Sexual violence resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:

Overview

Sexual violence is a public health issue as well as violation of human rights. It has many forms,for example rape, sexual assault, sexual coercion, sexual harassment, sexual exploitation,sexual battery. It occurs without the consent of the victim or when the victim refuses or is unable to give a consent due to age, intoxication, illnesss or any other reasons.It is a common problem that may be seen in primary care.It is important for physicians to identify if a person has suffered any type of sexual violence and take care of their safety.Though the evaluation and treatment of sexual assault victims are mostly limited to female and pediatric patients a few of the guidelines being applicable to male victims. Most of the post-examination follow-up guidelines focus on the factors affecting female survivors. There is limited studies focusing on male and homosexual survivors and factors affecting their treatment and follow-up.

Causes

Common Causes

• Aggressive nature, including hostility against women
• Rape-supportive attitudes
• Alcohol use
• Nonsexual delinquency
• Lack of parental monitoring
• Poor emotional bond between caregiver and child is also associated with sexually aggressive behavior
• Peer pressure to engage in sexual activity
• Pornography use
• Substance abuse

Diagnosis

Shown below is an algorithm summarizing the diagnosis of sexual violence.

Patient with history of sexual violence

Take complete history

Ask the following questions about the complaint

Ask the following questions about circumstances of attack, including : ❑When did it happen,tell me the date, time, and location. ❑ Is the location familiar to you? ❑ Can you provide any information about assailants (number, name if known, description) ❑Did they use any weapon ❑Did you get any threats recently? ❑ Type of sexual contact (vaginal, oral, rectal) ❑ Did they use condom? ❑Was there any extragenital injuries sustained? ❑Occurrence of bleeding (patient or assailant) ❑Did they ejaculate, if yes, where did they ejaculate?

Ask the following questions about activities of the patient after the attack: ❑Did you douch or take a bathe ❑Did you use a tampon or sanitary napkin ❑Did you urinate or defecate ❑Is there a history of use of toothpaste, mouthwash, enemas, or drugs

Ask the following questions about menstrual history if female patient: ❑Last menstrual period ❑Date of previous coitus and time, if recent ❑Contraceptive history for example oral contraceptives, intrauterine device

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

Do physical examination

Physical examination and evidence collection: ❑ Look for general (extragenital) trauma or injury to any area ❑ Examine genitals to look for trauma to the perineum, hymen, vulva, vagina, cervix, or anus ❑Collect any foreign material for example stains, hair, dirt, twigs on the body ❑perform examination with Wood’s lamp or colposcopy when available ❑Collect any small samples of clothing, including an unstained sample, should be collected and examined ❑Collect hair samples, including loose hairs adhering to the patient or clothing, semen-encrusted pubic hair, and clipped scalp and pubic hairs of the patient. Try to collect at least 10 of each for comparison. ❑ Check the condition of clothing, check if it is damaged, stained, or if there is any foreign material attached to any part of body ❑Take semen from the cervix, vagina, rectum, mouth, and thighs ❑Take blood from the patient ❑Look for any dried samples of the assailant’s blood taken from the patient’s body and clothing ❑Collect urine, saliva, and smears of buccal mucosa ❑Collect fingernail clippings and scrapings ❑Collect other specimens, as described by the history of the patient or physical examination

Do the following investigations

Laboratory tests: ❑ Do Acid phosphatase to detect the presence of sperm. This test is very helpful if the assailant had a vasectomy, is oligospermia, or used a condom, which may cause sperm to be absent. If the test cannot be done immediately, a specimen should be placed in a freezer ❑Saline suspension from the vagina to look for sperm motility. This is helpful if t can be done immediately on time to spot the motile sperm ❑Semen analysis for sperm morphology and presence of A, B, or RH grouping substances ❑Tests for STDs. ❑Blood typing ❑Urine testing, including drug screen for example drug screening for flunitrazepam (the date rape drug) and gamma-hydroxybutyrate should be considered and pregnancy tests

Order the follow-up tests: ❑Tests for STDS at 6 weeks: Gonorrhea, chlamydial infection, human papillomavirus infection (initially using a cervical sample from a Papanicolaou test), syphilis, and hepatitis ❑At 12 weeks: HIV infection ❑At 6 months: Syphilis, hepatitis, and HIV infection

Treatment

Shown below is an algorithm summarizing the treatment of

Patient comes with history of sexual violence

Non-pharmacological treatment and psychologic support

Pharmacological treatment

•Stress Inoculation Training (SIT) • Prolonged Exposure Therapy (PE) • Cognitive Processing Therapy (CPT) • Cognitive therapy • Eye Movement Desensitization Reprocessing (EMDR) • Supportive Counseling

• Medications for PTSD •Medications for prevention of infections • Contraceptives for unwanted pregnancy

Further care: ❑ Give the patient the opportunity to raise their questions and concerns ❑ Reassure the patient that she did not deserve to be sexually assaulted and that the assault was not her fault ❑Teach patients how to properly care for any injuries they have sustained ❑ Explain how injuries heal and describe the signs and symptoms of wound infection ❑Teach proper hygiene techniques and explain the importance of good hygiene. ❑Discuss the signs and symptoms of STIs, including HIV, and the need to return for treatment if any signs and symptoms should occur. ❑ Stress the need to use a condom during sexual intercourse until STI/HIV status has been determined. ❑ Explain the importance of completing the course of any medications given. ❑ Discuss the side effects of any medications given. ❑Explain the need to refrain from sexual intercourse until all treatments or prophylaxis for STIs have been completed and until her sexual partner has been treated for STIs, if necessary. ❑Explain rape trauma syndrome and the range of normal physical, psychological and behavioral responses that the patient can expect to experience to both the patient and (with the patient’s permission) family members and/or significant others. Encourage the patient to confide in and seek emotional support from a trusted friend or family member. ❑Inform patients of their legal rights and how to exercise those right

Assess safety of the patient

Ask about safety: ❑ Ask if it is not safe for the patient to return home ❑ Make appropriate referrals for shelter or safe housing, or work with her to identify a safe place that she can go to ❑ Discuss strategies that may help prevent another assault ❑ If it is a case of domestic violence, ask if there is a gun at home ❑ Ask if they are afraid of their partner ❑Screen for depression ❑Reassure and tell the patient that she can telephone or come into the health care facility at any time if she has any further questions, complications related to the assault, or other medical problems.

Follow up visits

Follow up visit at 2 week: ❑ Examine any injuries for proper healing and take pictures of the injuries if indicated to document healing, comparisons in court ❑Check that the patient has completed the course of any medications given for STIs ❑ Obtain cultures and draw blood to assess STI status, especially if prophylactic antibiotics were not given at the initial visit ❑ Discuss results of any tests performed ❑Make follow-up appointments ❑Assess the patient’s emotional state and mental status, and encourage the patient to seek counseling if they have not yet done so Follow up at 3 months: ❑Test for HIV. Make sure that pre and post-testing counseling is available or make the appropriate referral ❑Draw blood for syphilis testing if prophylactic antibiotics were not given previously. ❑Discuss any results available ❑Assess patient’s emotional state and mental status and encourage the patient to seek counselling if they have not yet done so. Follow up visit at 6 months: ❑Test for HIV. Make sure that pre and post-testing counseling is available or make an appropriate referral. ❑ Discuss results. ❑ Administer the third dose of the hepatitis B vaccine. ❑ Assess the patient’s emotional health and refer as necessary.

Referrals: ❑Patients should be given both verbal and written referrals for support services such as •Rape crisis centers •Shelters or safe houses •HIV/AIDS counseling •Legal aid •Victim-witness programs •Support groups •Therapists •Financial assistance agencies •Social service agencies

Non-pharmacological treatment of sexual violence:

Treatments for sexual assault victims include treatment of PTSD, fear, and anxiety, and/or depression

Stress Inoculation Training (SIT)

Includes: ❑ It is used to treat the victim with elevated fear and anxiety and specific avoidance behaviors. ❑ Psychoeducation to explain and normalize fear and avoidance behaviors ❑Exposure assignments to target rape-related phobias such as strange men, darkness. ❑ Training in behavioral and cognitive-behavioral coping strategies, specifically thought stopping, guided self-dialogue, muscle relaxation, controlled breathing, covert modeling, and role playing

Prolonged Exposure Therapy

Includes: ❑ It aims to decrease anxiety associated with rape memories, thus allowing victims to reevaluate meanings associated with the memories and construct a more organized trauma story. ❑ Psychoeducation ❑Breathing training ❑Development of a fear and avoidance hierarchy for in vivo exposures ❑ Imaginal reexposure to the assault by asking the victims to relive the rape scene and describe it aloud as they are imagining it, using present tense and vivid detail. This may be done several times during one session. The victim's retelling of their rape is audio-recorded and daily homework of listening to the account is assigned for further exposure

Cognitive Processing Therapy (CPT)

Includes: ❑Helps people with PTSD. ❑ Exposure occurs through writing assignments in which the victim describes her rape and its meaning and rereads her trauma and writes about the impact of the trauma multiple times to incorporate new understandings and reevaluations. ❑ Other part of the therapy focuses on victims' beliefs about the meaning and implications of their trauma. ❑Through cognitive restructuring worksheets,questioning, and discussion, one theme—safety, trust, power/control, esteem, or intimacy—is addressed in the final five sessions

Non-pharmacological treatment

Eye Movement Desensitization Reprocessing

Includes: ❑helpful in treating PTSD. ❑ A scene is used to represent the entire rape trauma and the patent imagines the scene and recites words related to the scene, while the therapist is moving her/his finger back and forth in front of her.The finger movement is hypothesized to facilitate the processing of the trauma memory through the dual attention required to attend to the therapist's finger (an external stimulus) and the trauma scene (an internal stimulus). After the client's anxiety related to the scene exposure has decreased, patient rehearses a new, adaptive belief until the new belief “feels true”

Cognitive therapy

Includes: ❑Here patient's fear and anxiety is acknowledged and substituted with positive thoughts

Supportive Counseling

Includes: ❑It shows significant pre-post improvement in PTSD, anxiety, and fear, and depression. ❑Explain that counseling and social support will help to facilitate recovery •Listen carefully to the history of the event, ask about his concerns, and address them appropriately •Explain to him that he did not deserve to be sexually violated •Reinforce that the assault was not his fault •Stress that sexual violence is an issue of power and control ❑It helps to decrease the isolation that victims often feel •It provides a supportive atmosphere •Victims are encouraged to share their experiences •It helps victims to establish their own support network

Pharmacological treatmnent:

Empiric prophylaxis for STDs consists of

First line pharmacotherapy
Medication	Recommended dosage	Disease
Ceftriaxone Or	125 mg IM in a single dose	Gonorrhea
Ciprofloxacin Or	500 mg orally in a single dose
Cefixime	400 mg orally in a single dose
Metronidazole	2 g orally in a single dose	Trichomoniasis and bacterial vaginosis
Doxycycline	100 mg orally 2 times a day for 7 days	Chlamydial infection
Azithromycin	1 g orally once
Azithromycin+Metronidazole	2g both as a single dose	covers Gonorrhea and Chlamydial infection
Benzathine penicillin G Or	2.4 million IU IM in a single dose	Syphilis
Doxycycline Or	100 mg orally twice a day for 14 days
Tetracycline	500 mg orally 4 times a day for 14 days
Hepatitis B vaccination	0 and then 1 and 6 months after the first dose	To prevent Hepatitis B if the patient is not vaccinated before
Combination of zidovudine (ZDV) 300 mg and lamivudine (3TC)	50 mg is given orally 2 times a day for 4 weeks in low-risk cases If risk is higher Protease Inhibitor is added	Prophylaxis for HIV infection is best begun < 4 hours after penetration and should not be given after > 72 hours HIV prophylaxis is required in the following circumstances: Anal penetration Bleeding (assailant or victim) Male-male rape Rape by multiple assailants (male victims in prisons) Rape in areas with a high prevalence of HIV infection
Contraception Emergency oral contraceptive Progestin-only ECPs Combined estrogen-progesterone pills Intrauterine device	A single dose for progestin-only pills. To doses, 12 hours apart and within 72 hours of the assault for combined pills.	It is offered to all women with a negative pregnancy test. Oral contraceptives are used. If used > 72 hours after a rape, they are much less likely to be effective. An antiemetic may help if nausea develops. An intrauterine device may be effective if used up to 10 days after the rape.

Do's

• Make sure the victim is not left alone.
• Provide emotional support and reassure the victim that they are not at fault for what happened.
• If the victim has been raped, a doctor will use a rape kit to collect hair, semen, clothing fibers, and other evidence of the attacker's identity
• Even if the victim is not sure they want to report about the violence, it is important to collect and preserve evidence so it can be accessed at a later date, if required.

• If the victim wishes to report about the violence, the staffs of the hospital will call the police from the emergency room.
• Victims should be treated for sexually transmitted diseases (STDs)
• Victims should be told about emergency birth control. It is important to receive birth control and treatment for STDs within 72 hours of the assault for maximum effectiveness. Although victims can get emergency contraception up to 5 days after but it will be less effective.

Don'ts

• To preserve evidence, the victim should not take a bathe, go to the bathroom, comb their hair, or change clothes until they have received a medical examination.
• Do not clean up anything at the site of the assault.

References

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