Laboratory analysis

Acute laboratory assessment includes a pregnancy test. If the test is positive, the victim will know that the father of the fetus is not the recent rapist.

Testing for N. Gonorrhea and C. Trachomatis should be considered. A wet mount should be analyzed for T. vaginalis. The Centers for Disease Control and Prevention (CDC) recommends a serum specimen for evaluation of human immunodeficiency virus (HIV), hepatitis B, and syphilis, but some authors disagree with this recommendation.[13, 14] The evaluator should keep in mind the possibility that a future defense attorney may use any positive result from these tests as a mechanism to promote a concept that the assault was consensual.

Drug-facilitated sexual assault is felt to be increasing.[15] In drug-facilitated rapes, the victims are incapacitated and unable to resist sexual contact. Memory may be impaired. Date rape drugs are often consumed with alcohol and their effects may be erroneously identified as alcohol intoxication. Rapid toxicological analysis is indicated; over fifty drugs have been known or suspected of involvement in drug-facilitated sexual assault.[16] If the provider is concerned about date rape drugs, a separate drug screen for such substances may be required. Traditional drug panels test for drugs of abuse; date rape drugs do not fit into this category.

Treatment

Components of treatment include post-coital contraception, sexually transmitted disease prevention and psychologic follow-up. The evaluator must confirm that the patient has a safe place to go upon discharge.

The national rape-related pregnancy rate is believed to be approximately 5% per rape among females aged 12–45 years.[17] Emergency contraception is available in multiple forms:

The levonorgestrel oral emergency contraceptive reduces a woman’s chances of pregnancy to 2.6% when used within 72 hours compared to the ulipristal acetate medication, which reduces a woman’s chances of pregnancy to 1.8% if used within 120 hours.[18]

Although it is difficult to quantify the risk of acquiring a new sexually transmitted infection after sexual assault, a literature review showed the risk of acquiring Neisseria gonorrhea infection after sexual assault is 0%–26%, while the rate of acquiring Chlamydia trachomatis infection is 4%–17%. Acquisition of Trichomonas vaginalis infection is 0%–19%.[19] Prophylaxis for Chlamydia trachomatis, Neisseria gonorrhea, and trichomonas vaginalis is recommended; three medications will be required. For Neisseria gonorrhea, the recommended treatment regimen is a single dose of ceftriaxone 250 mg IM or a single dose of cefixime 400 mg orally. For trichomonas vaginalis, a single dose of metronidazole 2 g orally should be given. For Chlamydia trachomatis, a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice a day for seven days is prescribed.[20]

Appropriate antibiotic prophylaxis is often omitted for sexual assault survivors; approximate treatment rates as low as 6.7% have been recorded.[21] Implementation of a standardized electronic order entry system for sexual assault victims in the emergency room has been show to improve adherence to CDC sexually transmitted disease prophylaxis guidelines.[11]

HIV seroconversion secondary to sexual assault has occurred but the frequency seems to be low for vaginal assault and slightly higher for rectal assault.[13] The risk of HIV transmission is estimated to be 1 or 2 cases per 100,000 for vaginal assault and 2 or 3 cases per 10,00 for anal assault.[14] If the perpetrator’s HIV status is known to be positive, the victim should be offered HIV prophylaxis. If the HIV status is unknown, the risks and benefits of nonoccupational post-exposure prophylaxis must be considered on a case-by-case basis.

Although a definitive statement of benefit cannot be made regarding post-exposure prophylaxis against HIV, post-exposure prophylaxis should be offered, in the author’s opinion, to those patients who request it. Additional risk factors that may encourage the use of HIV post-exposure prophylaxis include known high-risk behaviors by the assailant, multiple assailants, presence of mucosal lesions in the survivor or assailant, or the presence of lacerations or abrasions. If the survivor has been violated via receptive anal sex, HIV prophylaxis has been recommended.[22] Post-exposure prophylaxis to HIV within 72 hours of the assault is likely to be effective.[23]

Options for HIV prophylaxis after sexual exposure include:

HIV prophylactic medications can have varying and significant side effects including gastrointestinal upset, liver enzyme elevations, neutropenia, anemia, and renal toxicity.[14] These side effects may have a deleterious effect on patient completion of the prescribed regimen.

Acquisition of hepatitis after sexual assault has been reported.[24] Hepatitis B vaccination has been recommended and at minimum should be considered in areas where a high prevalence of this infection exists.[22, 25] A rapid course of vaccination may prevent acute hepatitis B infection if given for up to six weeks after exposure.[26] If the assailant is known to be at risk for hepatitis B, prophylaxis with immunoglobulin and subsequent rapid immunization may be considered.[12]

It seems reasonable to consider tetanus prophylaxis or a booster of tetanus toxoid if bodily abrasions or other wounds are present and the patient’s prior tetanus administration date is remote. The offering of a shower and provision of fresh clothes would be appropriate.

Due to the high emotional intensity of a sexual assault experience, patients may have difficulty remembering information provided by health-care providers. Instructions and plans should therefore be provided in writing and a visit for clinical and psychological follow-up should be scheduled in one to two weeks. Sexual assault treatment goals are summarized in Table 49-3.

Short-term medical follow-up

The patient must receive follow-up counseling. Follow-up medical evaluations provide opportunities to detect post-assault infections, complete hepatitis B immunization if indicated, confirm ongoing counseling, and monitor post-exposure prophylactic medication.

A follow-up pregnancy test three weeks after emergency contraception should be considered. If emergency contraception did not prevent the pregnancy, the patient should be offered the option of termination of pregnancy. Products of conception may have forensic significance.

Repeat examination for sexually transmitted diseases (C. trachomatis, N. gonorrhea, and T. vaginalis) is recommended in one to two weeks. Serologic testing for syphilis and HIV are recommended at six weeks, three months, and six months after the assault.[13]

The physician and legal responsibility

The health-care provider’s initial legal responsibilities are summarized in Table 49-4.

Less than 20% of rape victims report the assault to law enforcement, and less than half of these cases are successfully prosecuted.[1, 27, 28] On those occasions that a case goes to court, the examining health-care provider may be subpoenaed to testify about the evaluation. The health-care provider is usually a witness for the prosecution but on occasion may be subpoenaed as a witness for the defense.

In medico-legal cases such as prosecutions for sexual assault, the physician or other health-care provider’s responsibility is to the truth. In the author’s experience, defense attorneys have attempted to demonstrate a lack of competence on the part of the physician. It is the physician’s responsibility to do his or her part to ensure that the judge and/or jury receive complete and unprejudiced information. It is not the medical expert’s job to convict anyone.

It is reasonable for the physician to decline an invitation to meet with the defense attorney prior to the trial or deposition unless a representative from the prosecutor’s office is also present. If the physician is unfamiliar with the trial process, it is reasonable to request a meeting with the agency (usually the prosecutor’s office) that issued the subpoena prior to the court appearance in order to plan ahead for his/her responsibility.

In a survey of Sexual Assault Nurse Examiners (SANE), more than half of these knowledgeable professionals indicated that their most recent trial experience had been challenging. The challenges included (a) providing testimony was emotionally unnerving, (b) difficulties were present with the defense attorney regarding the victim, (c) difficulties with the defense attorney were present regarding the exam and/or evidence, (d) difficulty with the defense attorney were present regarding qualifications of the SANE examiner, and (e) the prosecutor was poorly prepared.[29]

Long-term consequences of sexual assault

Post-traumatic stress disorder may be a long-term consequence of sexual assault. The symptoms of this disorder include reexperiencing the trauma, avoidance, and a state of hyper arousal.[30] One-third of sexual assault survivors develop post-traumatic stress disorders; assault survivors are three times more likely than the general population of women to be currently experiencing a major depressive disorder.[27] Individuals who have been a target of sexual assault have an increased chance of attempted suicide compared to individuals who have not been sexually assaulted.[31] Not all unwanted sexual experiences are labeled as assaults by patients; labeling should not be considered as a criterion for determining who has experienced sexual victimization.[32]

After sexual assault, rape trauma syndrome is common. Rape trauma syndrome consists of an acute phase and long-term reorganization process that is seen after forcible rape or attempted forcible rape. The syndrome includes behavioral, somatic, and psychologic reactions to the life-threatening situation experienced by the survivor. The acute phase of the syndrome shows a disorganization of the patient’s lifestyle with a predominant feeling of fear. Self-blame may be a component. The second, or reorganization, phase is a longer-term process that can include phobic reactions, nightmares, and sexual dysfunction.[33]