Medical Intervention of Rape Victims Flashcards
- Use of physical force, deception, or threat of bodily harm
- Lack of consent or inability to give consent
- Oral, vaginal, or rectal penetration with penis, finger, or object.
RAPE
Article 266 – A rape: When and How committed
Rape is committed:
1. by a man who shall have carnal knowledge of a woman under any
of the circumstances:
a. Through force, threat, or intimidation;
b. When the offended party is deprived of reason or otherwise unconscious
c. By means of any fraudulent machination or grave abuse of authority; and
d. When the offended party is <12 y.o. or is demented.
2. By any person by inserting his penis into another person’s mouth or anal orifice, or any instrument or object into genital or anal orifice
of another person.
Rape Law of 1997 (ACT NO. 8353)
What is forced coitus or related acts without consent but within marital relationship?
Marital rape
The woman may voluntarily participate in sexual play, but coitus is performed often forcibly, without her consent
Date rape
What are the types of rapists?
Anger rapists - 40%
Opportunistic rapists - 30%
Power rapists - 25%
Sadistic rapists - 5%
- Usually, batter the survivor and use more physical force that is necessary to overpower her
- Rape is episodic, impulsive, and spontaneous
- Rapist is angry or depressed and is often seeking retribution
Anger rapists – 40%
- Exhibit no anger toward the women they assault
- Usually use little or no force
- Rape is impulsive and may occur in the context of an existing relationship
- “Date” or Acquaintance Rape
Opportunistic rapists – 30%
- Do not intent to harm their victim but rather to possess or control her in order to gain sexual gratification
- Assaults are premeditated, repetitive, and may increase aggression over time
- Rape occurs over a period of time
- Rapist is usually anxious and may give orders to his victim, ask her personal questions or inquire about her response during the assault
- Are insecure about their virility and are trying to compensate for feeling of inadequacy
Power rapists – 25%
- Become sexually excited by inflicting pain on their victim
- Assault is calculated and planned
- Victim is often a stranger
- May involve bandage, torture, or bizarre acts
- Victim may be murdered
Sadistic rapists – 5%
What are the main motivating factors for rape?
Power, anger, dominance and
control
PHYSICAL EFFECTS OF RAPE
- PID
- Chronic pelvic pain
- Asthma
- Irritable bowel syndrome
- Partial or permanent disability
- Even delayed effects, such as arthritis, HPN, and heart disease
- Unwanted pregnancy including teenage pregnancy
- Teenage pregnancy resulting in pregnancy complications:
o Premature labor
o Miscarriage
o LBW babies with reduced chances of survival
o Maternal mortality from excessive bleeding - Infection: STDs, including HIV
- Death
PSYCHOLOGICAL EFFECTS OF RAPE
- Rape trauma syndrome
- Post-Traumatic Stress Disorders (PTSD)
- Injurious sexual/health behaviors
EMOTIONAL EFFECTS OF RAPE EFFECTS OF RAPE
- Humiliation
- Shame
- Embarrassment
- Self-blame
- Guilt
- Anger
- Helplessness
Most common injuries:
o Bruises and abrasions or head, neck, arms and genital injuries
accompanied by bleeding or pain
o Erythema, hematomas, lacerations, and edema of vulva, perineum and introitus
o Bite marks may be noted on breasts or genitalia
o Foreign objects injected into vagina, urethra, or rectum may be
found
Proper Collection of Evidences of Legal Purposes
- Examination with Wood’s light may help identify the semen, which will fluoresce
- Swabs of the vagina, mouth, and rectum may be obtained to test for presence of semen - Pap smear – useful to document the presence of sperm
- Vaginal secretions should be collected:
o for motile sperm, semen, or pathogens
o to test for the presence of acid phosphatase and DNA fingerprinting - Pubic hair should be combed over a sheet of paper
- Fingernail scrapping should be collected
- Order diagnostic tests (x-ray, CT scan, and ultrasound)
*(NOTES) To aid in the diagnosis of possible fractures, head and neck injuries, or abdominal trauma
LABORATORY TESTS
- Cultures of cervix, mouth, rectum for: o N. gonorrhea o C. trachomatis o H. simplex o Cytomegalovirus (CMV) - Serologic test for syphillis - Wet prep for trichomonas - Hep B surface antigen - HIV antibody - Pregnancy Test
Treatment should be directed to:
- Prevent possible pregnancy
2. Prophylactic treatment for STDs
PREG. PROPHYLAXIS:
Preexisting pregnancy should be ruled out by a sensitive hCG assay (pregnancy test)
- Post-coital contraception can be provided
o 2 tabs of combination OCP (50ug of ethinyl estradiol and 0.5mg, Norgestrel, FEMENALl) followed by two or more tabs, 12 hours later – effective within 72 hours
Postcoiltal contraception or emergency contraception
Combination or progestin-only oral contraceptives for EC should be offered to women who have had unprotected intercourse within 72 hours of intercourse, but it can be effective up to 120 hours later
Criteria for administering Emergency Contraceptive Pills (ECPs)
- There is a risk of pregnancy
- The patient consulted for treatment within 5 days of the assault and wishes to prevent pregnancy
- The patient is negative for pregnancy or definitive tests established that she is not currently pregnant
- If pregnancy cannot be ruled out, the ECP can still be prescribed as long as the patient is informed that the pills will not be effective if
she is already pregnant but neither will they affect the pregnancy nor harm the fetus
Common OCs use as emergency contraception: 2 does taking 12 hours apart
0.75 mg of levonorgestrel
Plan B
1st Dose: 1 pill
- 05 mg of EE
0. 25 mg of LNG
Preven, Nordiol
1st & 2nd Dose: 2 pills
- 03 mg of EE
0. 15 mg of LNG
Nordette
1st & 2nd Dose: 4 pills
400 to 600 mg
Danazol
1st & 2nd Dose: 2 pills
Treatment regimens for STI for women with sexual assault
For Gonorrhea:
- Ceftriaxone 125 mg, IM in a single dose or
- Cefixime 400mg, orally in a single dose
o If patient is allergic to Cephalosporins, Spectinomycin 2g IM may be used
For Chlamydia:
- Azithromycin 1 g, orally in a single dose or
- Doxycycline 100mg, orally 2 x a day for 7 days or
- Tetracycline 500 mg 4x per day for 7 days or
- Amoxycillin 500 mg , orally 3x a day for 7 days –for pregnant woman
Alternative Regimens for Chlamydia - Erythromycin base 500 mg, orally 4 times per day for 7 days or
- Erythromycin ethylsuccinate 800 mg, orally 4 times per day for 7 days or
- Ofloxacin 300 mg, orally 2x a day for 7 days
- Levofloxacin 500 mg, orally once daily for 7 days
For Bacterial Vaginosis:
- Metronidazole 500 mg, orally 2x daily for 7 days or
- Tinidazole 2 g, once a day for 2 days, or 1 g once daily for 5
- days or
- Metronidazole gel, 0.75% one full applicator (5g) intravaginally,
- once day for 5 days or
- Clindamycin cream, 2%, one full applicator (5g) intravaginally
- at bedtime for 7 days
Alternative regimens - Clindamycin 300 mg, orally 2x a day for 7 days or
- Clindamycin ovules 100 mg, intravaginally once at bedtime for 3 days
For Trichomoniasis:
- Metronidazole 2g, orally in a single dose or
- Tinidazole 2g, orally in a single dose
Alternative regimen: - Metronidazole 500mg, orally 2x a day for 7 days
For syphilis:
For Primary or Early Latent Syphilis:
- Benzathine penicillin G 2.4 million units, IM in a single dose.
For Late Latent Syphilis or Latent Syphilis of unknown duration:
- Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at weekly intervals.
GC.,SY, CHLAMYDIA
- Ceftriaxone (250 mg IM) or ( for GC)
Cefixime (400 mg. orally) followed by - Doxycycline (100 mg. BID) or (for Chlamydia)
Tetracycline (500 mg QID) x 7 or
Azithromycin (1 g orally) once only - Metronidazole (2 g orally) as single dose –(for Trichomoniasis and
BV)
If patient is allergic to Cephalosporins,
Spectinomycin 2 g IM may be used.
Alternative Tx for GC and Chlamydia - Azithromycin (2 g orally) as single dose –for GC and Chlamydial
infections - Metronidazole (2 g orally) as single dose –for Trichomoniasis and BV
For External Genital Warts
Patient applied:
o Podofilox 0.5 % solution or gel, apply 2x per day for 3 days, followed by four days of no therapy. This cycle may be repeated up to 4 cycles.
o Imiquimod 5% cream – apply once daily at bedtime 3 times per week for up to 16 weeks.
*(notes) The total wart area treated should not exceed 10 cm2, and the total volume of
podofilox should be limited to 0.5 ml per day. May use cotton swab or finger in applying.
For imiquimod- treatment area should be washed with soap and water 6-10 hrs after
application.
The safety of podofilox and imiquimod during pregnancy has not be established
For External Genital Warts
Provider administered:
o Cryotherapy with liquid nitrogen or cryoprobe.
o Podophyllin resin 10-25% in tincture of benzoin
o Trichloroacetic acid (TCA)
o Surgical removal- by excision, curettage or electrosurgery
o Laser surgery
o Intralesional interferon
Genital herpes – treated p.o for 7-10 days
- Acyclovir 400 mg 3 x per day or
- Acyclovir 200 mg 5 x per day or
- Famciclovir 250 mg 3 x per day or
- Valacyclovir 1 g 2x a day
Hep B prophylaxis
- Hepatitis Immuneglobulin o (HBIG) 0.06 ml/kg IM immediately followed by another dose 1 month later. - Another alternative: o single dose of HBIG & o initiation of Hep. B vaccination
HIV prophylaxis
- Tx is best begun <4 hrs. after penetration and should not be given at >72 hrs.
- Usually a fixed-dose combination of:
o Zidovudine (ZDV) 300 mg and Lamivudine (3TC) is given bid for 4 wks. - Usually a fixed-dose combination of:
o If the risk is higher, a protease inhibitor is added
HPV infection prophylaxis
- Vaccination is recommended
- Given at the time of initial evaluation after sexual assault
o female survivors – 9 to 26 years old
o male survivors – 9 to 21 years old - Second dose given 1-2 months after initial evaluation
- Third dose is given 6 months after initial immunization
- Stocks available are G2, G4, G9
MEDICAL MGT CONT.
- Tetanus prophylaxis (.5 ml IM) should be given.
- Repeat serologic tests (SY and Hep.) & STD cultures in 4 weeks.
- HIV test should be repeated in 6 & 12 mos.
Follow-up Care for Victims of Sexual Assault
- Approximately 2 weeks after the assault for repeat PE and collection of additional specimens.
- Additional visits would be every 2 weeks for 3 months and 6 months post-assault.
- HIV test if negative initially, the test should be repeated at 6, 12, and 24 weeks.
- Supportive counseling for the patient
- Should be referred to a sexual assault center therapist who specializes in the treatment of sexual assault survivor
