sexual assault

Question 1

what is the timeline for forensic examination samples following sexual assault:

a) kissing/licking or biting
b) digital penetration
c) oral penetration
d) vaginal penetration
e) anal penetration

Answer 1

forensic samples should be taken within:-

a - kissing/licking or biting –> is within 48 hours or longer
b- digital penetration –> within 48 hours
c) oral penetration –> within 48 hours
d) vaginal penetration –> within 7 days (n.b if pre-pubertal up to 3 days)
e) anal penetration –> within 3 days

Question 2

If a patient presents to a sexual health clinic following an alleged sexual assault where is the best service to direct them to and why?

Answer 2

Direct them to SARC as they should consider having FME (forensic medical examination) first.
Anything we do in GUM (bloods/genital exam/oral or anal samples risk contaminating these areas and loss of DNA)
there is a short time frame for FME to be done.
Even if the patient is not sure if they want to prosecute then the FME samples can be stored for many years and available should they change their mind in the future

Question 3

Darcey presents to GUM following being sexually assaulted. She has not heard of SARC but is keen to pursue having a FME what should you advise her in regards to general measures such as washing in the meantime?

Answer 3

Advice not to wash or brush teeth, don’t wash clothes

don’t dye her hair (as they make take hair samples for toxicology)

Question 4

what is the timescale for toxicology from the alleged date of sexual assault
a) urine
b) blood tests
c) hair samples

Answer 4

urine - up to 5 days (can be up to 14 days in some cases)
bloods - up to 3 days
hair samples - up to 4-6 weeks

Question 5

when would you consider chain of evidence following a sexual assault?

Answer 5

If the patient informs you it is their first sexual exposure
sexually naive at that site of penetration e.g.
ano-rectal rape in a heterosexual male
Not been SA > 5 years

note - the evidence of finding a positive STI in a court could actually be detrimental to the case as court may see this as the patient being promiscuous

Question 6

What are the baseline bloods/ STI screen all patients should receive following a sexual assault?

Answer 6

HIV, Hep b and hep c
STS
CT/GC tripple site swabs dependent upon penetration
U&Es - LFTS if having PEPSE

Question 7

When would you recommend PEPSE following a sexual assault with an assailant from a high prevalence country or group e.g. MSM

Answer 7

receptive anal penetration –> RECOMMEND
insertive anal penetration –> CONSIDER
receptive/ insertive vaginal penetration –> generally not recommended

N.B if trauma/sexual assault, transgender community –> then this would increase the risk in a consider or generally not recommended category –> however the risk of HIV is considered to be very low…

and remember no good RCTS for PEPSE and ART is not licensced for this indication.

Question 8

if a patient accepts PEPSE when should you perform a follow up HIV blood test

Answer 8

45 days following the completion of the 28 course of PEPSE (so 73 days from the date of assault)

Question 9

in a female patient what is another consideration following sexual assault

Answer 9

need for EC + UPT and follow up UPT

Question 10

when should you consider hep B vaccine and within what time frame

Answer 10

consider Hep b vaccine for anybody presenting following SA where the assailant is from a high prevalence country or population e.g. MSM/transgender, IVDUs. multiple assailants, traumatic/ bleeding following SA, anal rape, assailant known to be a carrier of hep B

start hep b within 6 weeks following SA
- super accelerated (0,7,21 days + booster at 12 months or accelerated (0,1,2 months and booster at 12 months)

Question 11

when should f/u bloods be done

Answer 11

f.u HIV 45 days after SA
HEP b/c/ STS at 3 months
repeat ct/gc if present within the 2 week WP

Question 12

what is the name of the law that defines the four statutory non -consensual sexual offences

Answer 12

Sexual offences act 2003

Question 13

what are the four statutory non consensual sexual offences included in the Sexual Offences act 2003

Answer 13

Rape - must have had penile penetration at any orifice (oral, vaginal or anal penetration)

Sexual assault by penetration (e.g. digital penetration or penetration by another part of the body or object but excludes penile penetration

Sexual assault (touching)

Forcing someone to do something sexually they didn’t want to do (without consent)

note violence of threads of violence is NOT necessary

Question 14

if someone has been trafficked for modern slavery or sexual exploitation prior to 2015 which act/law would you apply

Answer 14

Sexual offences act 2003

Question 15

if someone has been trafficked for modern slavery or sexual exploitation 2015 or after which act/law would you apply

Answer 15

Modern slavery act 2015

Question 16

what does the law state in terms of sexual activity for someone aged under 13 years old?

Answer 16

Sex is illegal, a person aged under the age of 13 can not consent even if they think it was consensual

Question 17

what is the legal age in the UK that you can consent to have sex

Answer 17

age 16 and above (sex under the age of 16 is unlawful)

Question 18

what would happen if you have two teenagers under the age of 16 but over 13 years old having sex?

Answer 18

It is still illegal for anyone aged under the age of 16 to be having sex, however the law is not there to prosecute two people of similar age having sex so unlikely anything

Question 19

what is the name of the act that refers to statutory frameworks for sexual offences in the

a) England and wales
B) scotland
c) northern ireland

Answer 19

a) sexual offences act 2003
b) sexual offences act 2009
c) sexual offences order 2008

Question 20

what does the law state regarding sex with another person if you are in a position of power in regards to age of the other person?

Answer 20

If in a position of power it is illegal if you hold a position of power (e.g. teacher) to have sex with anyone under the age of 18, or a person with LD or a psychiatric illness

Question 21

what is the law regarding sexting

Answer 21

sexting is illegal under the age of 18, any sexy photo under the age of 18 is considered a padeophilic image in the eyes of the law

Question 22

In england and wales what is the legal definition of consent

Answer 22

Consent is agreement by choice with freedom and capacity to make that choice

note scotland is ‘free agreement’ emphasising the absence of coercion and control

Question 23

how can we as clinicians incorporate a trauma informed approach into our clinical practice?

Answer 23

trauma informed care is a way of adopting a consultation style to try and reduce the risk of re-traumatising a patient. Ways in which we can do this are: -

1. maintaining the trust that has been established by explaining confidentiality limitations early to avoid any perceptions or false promises
2. establishing and maintaining rapport including awareness of patients gender identity and using preferred pronouns
3. provide good amount of time and consultation free of interruptions to promote feeling of safety
4. enquire about safety when going home from the clinic in terms of pre-existing DA - ‘do you feel safe’
5. identify and acknowledge the patients priorities
6. explain options available to patients based upon their priorities and your clinical assessment
7. involve the patient in the management plan, empower them to make informed choices about onward management

Question 24

what are the principles of trauma informed care?

Answer 24

safety rather than threat, collaborative approach which provides the patient with choice rather than control, trust rather than betrayal

use the acronym Show Everyone That Comes Care to incorporate the 5 principles

Show = safety
Everyone =empowerment
That = Trust
Comes = Collaboration
Care = Choice

Question 25

what is the benefit to the patient if you adopt a trauma informed approach to your consultation

Answer 25

obviously lots but the main one is to aid recovery and prevent re-traumatisation

Question 26

What are the rules regarding confidentiality

Answer 26

information can be shared and confidentiality broken without patient consent if;-

• you are worried about the safety or wellbeing of a child,
  -other vulnerable individuals
  -or it is in the public interest
  -or required by law

Question 27

If a person under age of 16 discloses sexual abuse (even if historic) who should you make a referral to?

Answer 27

child social services as this would warrant “significant harm” slightly harder when child is aged between 16-18 as at age 16 and older children are considered to be able to have capacity to consent.

Question 28

when would hepatitis A prophylaxis be advised post SA

Answer 28

hep A prophylaxis (i.e hep A vaccine) would only be recommended within 2 weeks of contact with a confirmed case of hepatitis A or one week after the onset of jaundice in the index case.

opportunistic hep A vaccine might be recommended if falling into a high risk group e.g. MSM, PWID or those with hep B/C

Question 29

when do BASHH guidelines suggest we should offer PEPSE post SA?

Answer 29

when the risk of HIV transmission is > 1 in 1000

Question 30

In terms of hep B prophylaxis within what time frame ideally should hep B first vaccine be given following SA?

Answer 30

Ideally within 24 hours following exposure but up to 1 week. Beyond this timeframe it is unlikely to work as post exposure prophylaxis however unlikely to cause harm.

Question 31

when would HBIG be recommended following SA

Answer 31

HBIG (hepatitis B immunoglobulin) only recommended if known exposure to hepatitis B or in a known non responder to the vaccine . The vaccine should be offered simultaneously

Question 32

what are the preferred Hep B vaccination schedules and why in SA patients

Answer 32

all three schedules likely similar effectiveness as PEP but accelarated (0,1,2 and 12 months) or super accelerated (0,7,21 days and 12 months) are preferred as higher completion rates in addition to rapid development of immunity in those at ongoing risk and where compliance is an issue

Question 33

are SA patients routinely offered HPV vaccine?

Answer 33

no - not routinely offered but if eligible through current vaccination programme advised to seek HPV vaccine this way.

Question 34

what are the recommendations if medical notes are requested as evidence in a criminal trial

Answer 34

• follow local governance protocols regarding sharing of information and inform caldecott guardian
• use caldicott principles (8 in total)
  -redact any third party names apart from the suspect and any other unnecessary information
  -consider consulting with the legal department where you work and your medical defence union