Sexual violence resident survival guide
|Sexual Violence Resident Survival Guide Microchapters|
Sexual violence is a public health concern as well as violation of human rights. It has many forms which include rape, sexual assault, sexual coercion, sexual harassment, sexual exploitation, and 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, illness 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 from any type of sexual violence and take care of their safety. The evaluation and treatment of sexual assault victims are mostly limited to female and pediatric patients but a few of the guidelines are applicable to male victims as well. Though most of the post-examination follow-up guidelines focus on the factors affecting female victims, there are a few studies that focus on male and homosexual victims and factors affecting their treatment and follow-up.
While it is hard to pinpoint medical causes for sexual violence, many risk factors have been associated with the aggressor:
- 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
|Patient with history of Sexual violence|
|Take complete history|
|Ask the following questions about the complaint|
Ask details of the incident 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 or foreign objects?
❑ Did you get any threats recently?
❑ What was the type of sexual contact (vaginal, oral, rectal)
❑ Did they use a condom?
❑ Was there any extra-genital injuries sustained?
❑ Was there any occurrence of bleeding (patient or assailant)
❑ Did they ejaculate, if yes, where did they ejaculate?
|Do Physical examination|
Physical examination and evidence collection:
❑ Look for general trauma or injury anywhere in the body.
❑ Examine the genital area to look for trauma to the perineum, hymen, vulva, vagina, cervix, or anus.
❑ Collect any foreign material for example stains, hair, dirt on the body.
❑ Perform examination with Wood’s lamp or colposcopy.
❑ Collect the victim's clothing for examination and check its condition, note if it is damaged, stained, or if there is any foreign material attached to any part of body.
❑ Collect hair samples, including loose hairs adhering to the patient or their clothing, semen-encrusted pubic hair,clipped scalp and pubic hairs of the patient. Try to collect at least 10 of each for comparison.
❑ 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.
|Do the following investigations|
❑ Acid phosphatase test :
❑ Blood typing
❑ Urine testing, including drug screen for example drug screening for Flunitrazepam (the date rape drug) and gamma-hydroxybutyrate. Additionally, pregnancy tests should be done.
|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 and Reprocessing (EMDR)
• Supportive Counselling
|• Medications for PTSD |
• Medications for prevention of infections
• Contraceptives for unwanted pregnancy
❑ Let the patient raise their questions and concerns.
❑ Reassure the patient that she/he did not deserve to be sexually assaulted and that the assault was not their fault.
❑ Teach patients how to properly take care of any injuries they have sustained.
❑ Explain how injuries heal and describe the signs and symptoms of wound infection.
❑ Teach proper hygiene techniques and explain its importance.
❑ Discuss the signs and symptoms of STI, including HIV, and the need to return for treatment if any signs and symptoms should occur.
❑ Discuss 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 STI have been completed and until their sexual partner has been treated for STI, if necessary.
❑ Explain rape trauma syndrome and the physical, psychological and behavioral responses that the patient can expect to experience to both the patient and family members and/or significant others (if patient gives permission to share). Encourage the patient to open up and take emotional support from a trusted friend or family member.
❑ Inform the patient of his/her legal rights and how to exercise those right.
|Assess safety of the patient|
Ask about safety:
❑ Ask if it is safe for the patient to return home.
❑ Make appropriate referrals for safe housing, or work with them to identify a safe place that they 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 they can call or come to the health care facility at any time if they have any further questions, complications related to the assault, or other medical problems.
|Follow up visits|
Follow up visit at 2 week:
❑ Examine the injuries for proper healing and take pictures of the injuries if needed to document the healing process and for comparisons in court.
❑ Test for HIV. Make sure that pre and post-testing counseling is available or make the appropriate referral.
❑ Test for HIV. Make sure that pre and post-testing counseling is available or make an appropriate referral.
|Stress Inoculation Training (SIT)|
❑ 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|
❑ It aims to decrease anxiety associated with rape memories, thus allowing victims to re-evaluate meanings associated with the memories and construct a more organized trauma story.
❑ Breathing training.
❑ Development of a fear and avoidance hierarchy for in vivo exposures.
❑ Imaginal re-exposure 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)|
❑ Helps people with PTSD.
❑ Exposure occurs through writing assignments in which the victim describes their rape and its meaning and recites their trauma and writes about the impact of the trauma multiple times to incorporate new understandings and re-evaluations.
❑ Another part of the therapy focuses on the victim's beliefs about the meaning and implications of their trauma.
❑ Through cognitive restructuring worksheets, questioning and discussion one theme—safety, trust, control, esteem, or intimacy are gained in the final sessions.
|Non-pharmacological treatment||Eye Movement Desensitization Reprocessing|
❑ Helpful in treating PTSD.
❑ A scene is used to create the entire rape trauma and the patent imagines the scene and recites words related to the scene, while the therapist moves her/his finger back and forth in front of her/him. 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 patient's anxiety related to the scene exposure has decreased, patient rehearses a new, adaptive belief until the new belief feels real and true.
❑ It shows significant pre-post improvement in PTSD, anxiety, and fear, and depression.
|First line pharmacotherapy|
|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
|Azithromycin||1 g orally once|
|Azithromycin+Metronidazole||2g both as a single dose||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)||
||Prophylaxis for HIV infection is best if it is given < 4 hours after penetration and should not be given after > 72 hours|
Two 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.
- 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 staff 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, it will be less effective.
- To preserve evidence, the victim should not take a bath, 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.
- Tharp AT, DeGue S, Valle LA, Brookmeyer KA, Massetti GM, Matjasko JL (April 2013). "A systematic qualitative review of risk and protective factors for sexual violence perpetration". Trauma Violence Abuse. 14 (2): 133–67. doi:10.1177/1524838012470031. PMID 23275472.
- Maxwell, Christopher D.; Robinson, Amanda L.; Post, Lori A. (2003). "The Nature and Predictors of Sexual Victimization and Offending Among Adolescents". Journal of Youth and Adolescence. 32 (6): 465–477. doi:10.1023/A:1025942503285. ISSN 0047-2891.
- Ybarra, Michele L.; Mitchell, Kimberly J.; Hamburger, Merle; Diener-West, Marie; Leaf, Philip J. (2011). "X-rated material and perpetration of sexually aggressive behavior among children and adolescents: is there a link?". Aggressive Behavior. 37 (1): 1–18. doi:10.1002/ab.20367. ISSN 0096-140X.
- Basile, Kathleen C.; Smith, Sharon G.; Chen, Jieru; Zwald, Marissa (2020). "Chronic Diseases, Health Conditions, and Other Impacts Associated With Rape Victimization of U.S. Women". Journal of Interpersonal Violence: 088626051990033. doi:10.1177/0886260519900335. ISSN 0886-2605.
- Holmes MM, Resnick HS, Kilpatrick DG, Best CL (August 1996). "Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women". Am J Obstet Gynecol. 175 (2): 320–4, discussion 324–5. doi:10.1016/s0002-9378(96)70141-2. PMID 8765248.
- "Medical Examination of the Rape Victim - Gynecology and Obstetrics - MSD Manual Professional Edition".
- "www.who.int" (PDF).
- Vickerman KA, Margolin G (July 2009). "Rape treatment outcome research: empirical findings and state of the literature". Clin Psychol Rev. 29 (5): 431–48. doi:10.1016/j.cpr.2009.04.004. PMC 2773678. PMID 19442425.
- "Sexual Assault Infectious Disease Prophylaxis - StatPearls - NCBI Bookshelf".
- Saddichha S (April 2010). "Diagnosis and treatment of chronic insomnia". Ann Indian Acad Neurol. 13 (2): 94–102. doi:10.4103/0972-2327.64628. PMC 2924526. PMID 20814491.
- Meel BL (July 2005). "HIV/AIDS post-exposure prophylaxis (PEP) for victims of sexual assault in South Africa". Med Sci Law. 45 (3): 219–24. doi:10.1258/rsmmsl.45.3.219. PMID 16117282.
- Inciarte A, Leal L, Masfarre L, Gonzalez E, Diaz-Brito V, Lucero C, Garcia-Pindado J, León A, García F (January 2020). "Post-exposure prophylaxis for HIV infection in sexual assault victims". HIV Med. 21 (1): 43–52. doi:10.1111/hiv.12797. PMC 6916272 Check
|pmc=value (help). PMID 31603619.