sexual assault Flashcards
what are immediate needs for patients presenting following alleged sexual assault?
safety treatment of injuries baseline sti screening consider prophylaxis for sti baseline hiv test or safe serum pepse if <72h hep b vaccine hep b immunoglobulin if assailant known hepbsag carrier EC referral offered for forensic assessment safeguarding self harm risk assessment
what are medium term needs post sexual assault?
eow sti screen
PT if indicated
assess for PTSD
psychosocial support
what is the definition of rape?
intentional penetration of the penis into the vagina, mouth or anus without their consent
if the person is <13, consent is irrelevant
what is the definition of sexual assault by penetration?
if person intentionally penetrate the vagina or anus of another person with another part of their body or anything else without their consent
what is the definition of sexual assault?
unwanted sexual behaviour or touching of another person without their consent
can be with part of their body
or anything else
or through clothing
may include forced acts or oral sex or forcing someone to watch porn or masturbation
what are the most common STIs identified in women with a history of sexual assault?
GC, chlamydia and TV
what are the disadvantages of abx prophylaxis in sexual assault?
unnecessary treatment
reinforce belief they have an sti
anxiety
no PN
what are the advantages of abx prophylaxis for sexual assault ?
reduce the need for tests
reduce chance of missing sti if they default
decrease the chance of detecting an sti
if patient may default, wants an emergency IUD which abx would be recommended?
cover GC, CT and TV
What are the options for non police SARC forensic referral?
Testing of anonymous forensic samples
Storage of anonymous forensic samples without testing
Release of police intelligence information with the samples
Release of police intelligence information without samples
Independent trained police officer advice
Revisiting decisions regarding testing and/or reporting
Forensic timescale for digital penetration?
12 hours
Forensic timescale for anal penetration?
72 hours
What advice should be given to a patient prior to forensic medical examination?
Preserving forensic evidence if possible by avoiding
bathing/washing clothes
brushing teeth or drinking liquids prior to an FME
Preservation of sanitary pads, tampons and clothes (particularly underwear) worn at the time of the assault and immediately after the assault.
If DFSA is suspected, advise not to dye hair as this interferes with toxicology results in hair
What aspects should be covered in forensic history?
Date, time, location
Number of perpetrators
Perpetrator characteristics (stranger, partner, ex-partner, acquaintance)
Physical violence
Presence of injuries (new and old)
Sexual acts (vaginal, oral, anal, penile/digital penetration)
Ejaculation and condom use
Some will not disclose forced oral or anal penetration without being directly asked, due to embarrassment.
Pre- and post-assault sexual history
Presenting symptoms Eg: vaginal/anal pain or bleeding
Risk of viral infections (HIV, Hepatitis B and C) in the perpetrator, if known
Past medical, surgical, gynaecological, obstetric history and mental health history Menstrual and contraceptive history
Prescription and non-prescription medication and allergies
Post sexual assault, would you offer STI testing if within the window period for GC/CT?
If the client presents within 2 weeks of the assault, consider STI screening at baseline using Nucleic Acid Amplification Tests (NAATs) if appropriate and repeat tests 2 weeks after exposure
High rate of default from subsequent appointments, so a pragmatic approach to management may have to be taken.
What tests to offer in symptomatic women post sexual assault
Vaginal wet slides for microscopy for yeasts, BV and TV.
If available, culture for TV
Gram stained slides for microscopy for gram negative diplococci
Cultures for Neisseria gonorrhoea and NAAT tests for Chlamydia trachomatis/GC from any site of penetration or attempted penetration (vagina: urethra, cervix; rectum, throat)
What are the risk factors for HIV transmission in sexual assault?
Assailant from high risk group
Background local prevalence of HIV in the community
HIV status of the assailant
The assailant is thought to come from a high prevalence area
Type of assault
“Stranger” versus “known” assailant
Presence of other STIs in the assaulted individual
Genital injuries
Multiple assailants
Multiple risk factors
What are the side effects to mention if PEPSE considered?
nausea, vomiting and diarrhoea
Which supportive treatments may be offered to take with PEPSE?
Domperidone 10 mg tablet TDS PRN
Loperamide 2 mg tablet 2 tablets if diarrhoea then 1 PRN (Maximum of 8 tablets in 24 hours)
What should be advised with regards to DDI if patient is given Kaletra® (Lopinavir and Ritonavir)
Kaletra® (Lopinavir and Ritonavir) reduces the effect of the contraceptive pill through induction of hepatic enzyme activity.
Additional barrier contraception such as condoms should be advised to those on
the combined oral contraceptive pill, patch, an implant (Implanon®) or a progesterone only pill.
The dose of a combined oral contraceptive pill should be adjusted to provide 50 micrograms or more of ethinylestradiol.
What should be considered with regards to risk of Hepatitis B infection in sexual assault?
Acquisition of Hepatitis B following sexual assault in the UK is very rare.
BASHH guidelines recommend that Hepatitis B vaccine may be considered in those who give a history of a sexual assault up to 6 weeks.
When should hepatitis B immunoglobulin be considered?
Immunoglobulin should be considered within 48 hours and no later than 7 days after a known infectious contact and may be given to a non-immune contact after a single unprotected sexual exposure, if the assailant is known or strongly suspected to have Hepatitis B
Does hepatitis B vaccination precent infection post exposure?
There is a theoretical possibility that a very rapid course of Hepatitis B vaccination given within 6 weeks of sexual exposure, apart from offering long term protection, will prevent the development of Hepatitis B infection in those at risk
How is Hepatitis B immunoglobulin given?
Immunoglobulin 500 i.u. IM (best within 48 hours) no later than 7 days of an known infectious or strongly suspected contact to non-Hepatitis B immune individuals
What hepatitis B vaccine regime can be offered?
Hepatitis B vaccination 1 ml IM in adults and adolescents > 13 yrs of age within 6 weeks of exposure ( Engerix B 3 x 20 mcg; HBvaxPro 3 x 10 mcg)
Very rapid course of Hepatitis B vaccination given at 0, 7 and 21 days post exposure
Or an accelerated course at baseline, 1 month and 2 months post exposure followed by a booster at one year, is recommended.
What are the options for EC in women post sexual assault?
Oral EC or IUD
A copper IUD, due its low failure rate and its potential for use as an ongoing method of contraception, ought to be discussed with all women presenting within 5 days after an episode of unprotected sexual exposure
Can Oral EC be given if on PEPSE?
UPA and levonelle can be given with Truvada and raltegravir. (or alternative PEPSE- zidovudine and lamivudine- depending on what 3rd agent is - beware if ritonavir booster)
No need for double dosing
Can oral EC be given if on enzyme inducers?
The dose of Levonelle should be doubled (ie: 3 mg) for those taking liver enzyme- inducing drugs.
Those starting HIV PEPSE at the same time should use condoms.
The issue of emergency contraception and simultaneous administration HIV PEPSE raises questions about efficacy and toxicity.
Some clinicians would choose to use a double dose of emergency contraception in case Ritonavir reduces levels.
Liverpool interaction says weak association with ella one and levonelle and ritonavir and unlikely to be clinically significant
What are the options in pregnancy post sexual assault?
Continuing with the pregnancy
Termination of pregnancy
Paternity testing
Using products of conception as evidence
Which groups are at at higher risk of sexual assault?
Young and elderly Those with mental health problems Learning difficulties/disability Victims of domestic violence Ethnic minorities Trafficked women/ commercial sex workers Those misusing alcohol and/or recreational drugs.
In which groups do you need to ensure that they are Gillick competent?
Gillick competence in everyone who is under 16 years of age or under 18 with learning difficulties.
How should you proceed if you are concerned that the patient is not GIllick competent?
If not Gillick competent, seek consent to examine the child from a person with parental responsibility or legal guardian.
What % of violence against women is domestic?
Domestic violence is strongly linked to rape. Almost 85% of violence against women crimes are domestic violence
What % of violence against women is sexual?
5% are rape and 11% sexual offences.
What is the association between sexual assault and developing MH problems?
In one study, 20% of those who reported that they had been sexually assaulted gave a history of mental health problems
What might increase risk of developing PTSD post sexual assault?
Previous history of sexual victimisation
history of mental health difficulties including self-harm
Lack of social support
Sense and/or evidence of ongoing threat e.g. domestic violence
Post-trauma life events.
What is the most common type of trauma that people who have been raped/sexually assaulted develop?
People who have been raped or sexually assaulted are much more susceptible to develop PTSD than any other trauma
What is the Criminal Injuries Compensation Authority?
The Criminal Injuries Compensation Authority is a government body responsible for administering the UK Criminal Injuries Compensation Scheme.
It provides a free service to victims of violent crime who may be interested in applying for financial compensation.
