Audit on the management of complainants of sexual assault at an emergency department

Objective

Proper medical management should be offered to rape complainants, including systematic investigation for sexual transmitted diseases, prophylactic antibiotics, a pregnancy test, emergency contraception, and psychological and medical follow up. We conducted an audit on the medical management of complainants of sexual assault in a public university hospital with a high referral of rape complainants.

Study design

Retrospective study of rape complainants, based on medical records (n = 356) including women admitted at the emergency department between January 1, 2002 and December 31, 2007.

Results

Most complainants were Caucasian (median age: 25 years, range: 15-79 years). About 82% of the assaults were committed by one assailant only, and almost two-thirds of the rapes were characterized by vaginal penetration. In 8% of the patients, no blood sample to screen for sexually transmitted disease had been taken and in 38% of the patients, no cervical smear for C. trachomatis had been done. Prophylactic antibiotics were provided to 40% of the patients. Eighty percent of the complainants who were not using contraception received an emergency contraceptive treatment. Respectively, 10%, 16% and 11% of the complainants were seen at a gynecological, infectious diseases or psychological support follow-up visit.

Conclusion

Only about 20% of the complainants received optimal care. Different steps were taken to improve the medical management, including a specific computerized checklist and involvement of a social nurse for the follow up. These steps aim at reducing psycho-affective and medical morbidity of rape complainants.     

Providing quality care to the sexual assault survivor: education and training for medical professionals

One in every six women in the United States will be the victim of an attempted or completed rape over the course of their lifetime.³ Health care providers trained in sexual assault examination procedures are not available in all clinical settings. CNMs/CMs have most of the requisite training to provide this service, and they are ideally poised to help women who report sexual abuse. We can assist persons who have been sexually assaulted by becoming educated in sexual assault care, attending specialty training as sexual assault examiners, joining SARTs, and serving as sexual assault response coordinators in our communities. Education about sexual assault care in midwifery programs can facilitate the ability of CNMs/CMs to provide physical assessments and forensic examinations to sexual assault victims.Once training has been obtained, it is essential to stay current about topics such as emergency contraception, STI treatments, and new methods of forensic evidence collection. Sexual assault examiners must have a knowledge of available referral sources and local resources where the person reporting these crimes may receive assistance as needed. Providing medical and forensic care for women who are victims of sexual violence should be considered a core practice within the midwifery scope of practice. CNMs/CMs need to be well prepared to care for sexual assault patients by receiving proper education and training. Specific instruction concerning care for victims of sexual and domestic violence, along with an introduction to serving as an expert witness, should be an integrated into midwifery education programs as part of the core curriculum.     

Post-traumatic Stress Disorder After Sexual Abuse in Adolescent Girls

The sexual assault of girls and women in this country is estimated at approximately 20%. The development of post-traumatic stress disorder (PTSD) after sexual abuse and assault is one of the potential lingering aftereffects. In this article we describe PTSD after sexual abuse and its effect on presenting complaints, such as sexually transmitted infections, contraception, and chronic pain, for the pediatric and adolescent gynecology (PAG) clinician. Treatment approaches, including the use of antidepressants and anxiolytics, as well as evidenced-based psychotherapies, are highlighted. In addition, this article will assist the PAG clinician in identifying trauma-related concerns during clinic visits and will cover specific screening tools to aid in identification of PTSD. A better understanding of PTSD after sexual abuse will allow PAG providers to deliver better care to their patients.     

Fertility control in the under 16 year old

Providing contraception and sexual health to under 16 year olds remains a controversial and emotive issue despite clear guidance and the fact that 20–30% of young people report having had their first experience of sexual intercourse by the age of 16 years old.Competent under 16 year olds have the ability to consent to medical treatment and the duty of confidentiality owed to them is as great as to any other individual. Contraception can be provided to under 16 year olds without parental consent provided certain criteria are met.Health professionals should maximise all opportunities they have to develop a relationship of trust with a young person and explore their contraception and sexual health in an open, non-judgemental and confidential manner.Effective hormonal methods combined with condoms, to prevent sexually transmitted infections, should be promoted and the realities of teenage sexual behaviour acknowledged if the UK high rate of teenage pregnancy is to be reduced.     

Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault

BACKGROUND: The medical response to adult sexual assault should comprise: the collection of forensic evidence, the treatment of injuries, and follow-up counselling. In the past, victims of sexual assault reporting directly to the police may not have received this total medical care. The Copenhagen Center for Victims of Sexual Assault at Rigshospitalet, Denmark offers a 24-h service. Medical treatment and psychosocial follow up is offered independent of police reporting. The aim of this study was to assess whether adult sexual assault victims who reported to the police differed from those who did not report to the police. METHODS: Using clinical records, sociodemographics, characteristics of the assault, and type of preventive medical treatment received were obtained for 156 consecutive women consulting the Copenhagen Center (March 1st to December 31st 2000). Comparisons between characteristics of victims who reported to the police or not were determined. RESULTS: Ninety-four (60.2%) of the women reported to the police. Women who sought services within 24 h of the assault, had experienced use of force, were subjected to assault outdoors, and among whom nongenital injuries were observed were more likely to report to the police (p < 0.05). However, in the multivariate model these associations fell below significance, and only the type of perpetrator remained significantly related to police reporting. The adjusted odds ratio for police reporting when the perpetrator was a friend was 0.4 (95% CI 0.17-0.94). There was no statistical difference between the victims who did or did not report to the police to request prophylactic antibiotics or emergency contraception. CONCLUSION: Observed injuries and requests for prophylactic antibiotics or emergency contraception were not influenced by whether the woman did or did not report directly to the police. Hence the need for medical treatment appears to be similar in the two groups, and available specialized care for victims of sexual assault should not be restricted to those who immediately report to the police.     

Intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes

OBJECTIVE: To describe the characteristics and consequences of sexual assault within intimate relationships specific to racial or ethnic group, compare the findings to a similar group of physically assaulted-only women, and measure the risk of reassault after victim contact with justice and health services. METHODS: A personal interview survey of 148 African-American, Hispanic, and white English- and Spanish-speaking abused women seeking a protection order. Extent of sexual assault, prevalence of rape-related sexually transmitted diseases and pregnancy, symptoms of posttraumatic stress disorder (PTSD) and depression, and risk of reassault after treatment were measured. RESULTS: Sixty-eight percent of the physically abused women reported sexual assault. Fifteen percent of the women attributed 1 or more sexually-transmitted diseases to sexual assault, and 20% of the women experienced a rape-related pregnancy. Sexually assaulted women reported significantly (P = .02) more PTSD symptoms compared with nonsexually assaulted women. One significant (P = .003) difference occurred between ethnic groups and PTSD scores. Regardless of sexual assault or no assault, Hispanic women reported significantly higher mean PTSD scores compared with African-American women (P = .005) and White women (P = .012). The risk of sexual reassault was decreased by 59% and 70% for women who contacted the police, or applied for a protection order, after the first sexual assault. Receiving medical care decreased the woman's risk of further sexual assault by 32%. CONCLUSION: Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of reassault is decreased if contact is made with health or justice agencies.     

The Use of Reproductive Health Services by Young Women in Australia

Summary: Retrospective analysis of clinical data from 8 State/Territory Family Planning Organizations (FPO) was conducted to determine the reproductive health services used by young women. Between July, 1996 and June, 1997, a total of 185, 879 client visits were recorded at FPO clinics, of which 72,303 (39%) were by young clients. The results showed that young women tended to use a combined oral pill, postcoital pill and spermicides more than those older than 25 years (p < 0.05). Young women were also more likely to use services for management of sexually transmitted disease (STD), counselling for HIV, STD and sexual assault (p < 0.05). However, there were considerable differences among the 3 groups of women: Aboriginal clients, those who did not speak English at home, and those who were born outside Australia. This study confirms that young women are using FPO services especially for emergency/postcoital contraception, STD screening and counselling. FPOs need to continue their existing role of providing reproductive and sexual health services catering to the need of this special segment of the population.     

Injury in adult female sexual assault complainants and related factors

Objective

This study was undertaken to document physical injuries and ascertain associated variables in female complainants of sexual assault.

Study design

164 cases of sexual assault between 2002 and 2006 in Belfast were included. 162 women consented to body examination and 153 to genital examination. Data for the study were obtained from the contemporaneous notes of a forensic doctor who examined the victims.

Results

Of 164 females, 44% were less than 20 years of age, mean age was 24.2, range 13–74 years; two-thirds reported alcohol consumption prior to assault. Non-genital (body) injury was observed in 61%, genital injury in 39%, both in 20% and 18% had no injury. Body injury was associated with time to examination (OR = 4.0, p < 0.01), alcohol intake prior to assault (OR = 3.33, p < 0.001), assault occurring outdoors (OR = 3.45, p < 0.01), previous sexual intercourse (OR = 3.19, p < 0.01) and genital injury (OR = 2.24, p < 0.05). Genital injury was related to acquaintance assault (OR = 2.33, p < 0.05), time to examination (OR = 3.70, p < 0.05), reported virgin status (OR = 3.03, p < 0.01) and absence of hormonal contraception (OR = 2.04, p < 0.10).

Conclusion

Almost half the victims of sexual assault were less than 20 years old and injury was detected in over 80%. Time to examination and prior sexual experience were related to genital and body injury. Assault occurring outdoors and alcohol intake were associated with body injury. Genital injury was more frequent in acquaintance assault and victims not using hormonal contraception. Young females drinking alcohol are at a very high risk for sexual assault.     

Sexually transmitted disease among women attending a family planning clinic in Zaria, Nigeria

Three types of sexually transmitted infections were investigated among 150 family planning clients using different methods of contraception and 50 controls. For oral contraception, intrauterine contraceptive device, medroxyprogesterone acetate (depo-provera) and controls, the incidence of trichomonas was 0%, 6%, 8% and 4%; for gonorrhoea it was 0%, 8%, 2% and 6%; for syphilis it was 4%, 34%, 16% and 12%. Only the difference in prevalence of syphilis among intrauterine contraceptive users and control was statistically significant (P less than 0.3).     

Contraceptive use and associated factors among Swedish high school students.

OBJECTIVES: To investigate self-reported sexual experiences, abortions, sexually transmitted infections (STIs), use of contraception and possible influencing factors on contraceptive use among Swedish high school students. METHODS: An anonymous classroom survey was distributed to a random sample (n = 924) of 18-year-old high school students in a medium-sized Swedish city. The response rate was 78% (n = 718). RESULTS: Three out of four students had experienced intercourse and the majority of them stated that they were satisfied with their sexual life. Few students reported having had an abortion (5%) or a STI (4%). Alcohol use appeared the most important contributing risk factor for non-use of contraception in relation to both first and latest intercourse, and the young men reported more unprotected latest intercourse than the young women did. CONCLUSION: The fact that young men appear less inclined to use contraception is disturbing, and must be addressed in sexual education and individual counseling to promote a better sexual health for adolescents.     

Gynecological clinical study in girls and adolescent victims of sexual abuse

In spite of a very important under-registration, sexual abuse represents a social and public health problem worldwide. In Mexico, estimated prevalence of sexual abuse in women is 17.3%, half of them in youngsters under 15 years old. Most of cases have a late gynecological evaluation, due to a delay in a formal complaint. Gynecologist or pediatrician are the specialists who most frequently perform the genital examination of girls suspected of sexual abuse, due to this a complete knowledge of the topic is necessary in order to make an accurate diagnosis, register the physical findings and give prompt medical and psychological treatment as well as follow up to the patient. Despite the low risk of acquiring a sexually transmitted infection, it is important to evaluate the use of prophylactic treatment and the prevention of unwanted pregnancy with emergency contraception. Big efforts are being made by preventive programs on sexual abuse, sexually transmitted infections and unwanted pregnancy, all of which are serious problems in Mexican children and youths, and should constitute a fundamental part of the public politics on sexual health.     

Female victims of rape and their genital injuries

Objective A minority (some report < 10%) of women report sexual assault. Of those that negotiate the police process, only a minority will come to a court hearing. It is thought that the courts still rely upon medical evidence, in particular evidence of genital injury to 'prove' the rape. This study aimed to ascertain the incidence of genital injury in victims of alleged rape
Design Retrospective review of case records of women who reported they had had been raped, provided by women doctors on the Northumbrian Police Doctors scheme.
Sample Case records from Newcastle, North and South Tyneside, Sunderland and Northumbria.
Methods Analysis of records in the standardised booklet used by police surgeons to examine women reporting rape.
Main outcome measures Presence of genital injury, presence of other physical injuries.
Results A minority of women had genital injuries (22/83); the majority had some form of physical injury (68/83), although most of these were minor.
Conclusion The study shows that only a minority of women examined by specifically trained police doctors show evidence of genital injury. The absence of genital injury does not exclude rape.     

Sexual assault: review of a national model protocol for forensic and medical evaluation. New Hampshire Sexual Assault Medical Examination Protocol Project Committee.

A national hospital/community model protocol was developed for the forensic and medical examination of victims of sexual assault. This review is designed to assist states in the development of sexual assault protocols. Controversial issues were addressed, including the collection of hair evidence, the importance of semen, mandatory reporting, pregnancy testing and prophylaxis, and sexually transmitted diseases including human immunodeficiency virus. The current role of DNA profiling is reviewed. These issues at the interface of medicine, forensic science, victim advocacy, and the law are analyzed. Representatives of the medical, legal, law enforcement, victim advocacy, and forensic science communities contributed to the development of the protocols at the national and state levels. The importance of a collaborative effort is emphasized. The broad protocol goals are to minimize the physical and psychological trauma to the victim while maximizing the probability of collecting and preserving physical evidence for potential use in the legal system.     

General sexually transmitted diseases

This review discusses current trends in sexually transmitted diseases. Topics include treatment and prevention of syphilis and gonorrhea, as well as the association of sexually transmitted diseases with sexual assault. Also discussed are the various organisms that cause vulvitis, including Trichomonas, Candida, and Gardnerella species, along with a discussion of vulvar lesions that are especially difficult to diagnose and treat. Diagnosis, sampling, pathogenesis, and treatment of Chlamydia trachomatis are also covered. A discussion of the various degrees of protection offered by different forms of contraception encourages use of barrier methods and oral contraceptives for teenagers as well as postponement of sexual activity. Detection, treatment, and vaccination against genital herpes are covered, along with diagnosing anogenital warts in children as either skin or genital wart virus types, and the relationship between human papillomavirus and cancer.     

Advance provision of emergency contraception for pregnancy prevention: a meta-analysis

OBJECTIVE: Advance provision of emergency contraception can circumvent some obstacles to timely use. We performed a meta-analysis to summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors. DATA SOURCES: In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE, a specialized emergency contraception article database, and contacted experts to identify published or unpublished trials. METHODS OF STUDY SELECTION: We included randomized controlled trials comparing advance provision to standard access, defined as any of the following: counseling (with or without information about emergency contraception) or provision of emergency contraception on request at a clinic or pharmacy. TABULATION, INTEGRATION AND RESULTS: Two reviewers independently assessed study quality. We performed a meta-analysis using Review Manager software. Eight randomized controlled trials met inclusion criteria, representing 6,389 patients in the United States, China, and India. Advance provision did not decrease pregnancy rates, despite increased use (single use, odds ratio [OR] 2.52, 95% confidence interval [CI] 1.72-3.70; multiple use: OR 4.13, 95% CI 1.77-9.63) and faster use (weighted mean difference -14.6 hours, 95% CI -16.77 to -12.4 hours). Advance provision did not increase rates of sexually transmitted infections (OR 0.99, 95% CI 0.73-1.34), unprotected intercourse, or changes in contraceptive methods. Women who received emergency contraception in advance were as likely to use condoms as other women. CONCLUSION: Advance provision of emergency contraception did not reduce pregnancy rates and did not negatively affect sexual and reproductive health behaviors and outcomes compared with conventional provision. LEVEL OF EVIDENCE: III.     

Swedish adolescents' knowledge of sexually transmitted diseases and their attitudes to the condom

In an attempt to assess the risk of AIDS infection in teenagers in Sweden a survey of adolescent sexual behaviour was conducted in Uppsala. Two hundred and nine students in the first form of an upper secondary school completed a questionnaire at the beginning of a lesson on family life. Half the female and 45% of the male students reported having had sexual intercourse. Forty per cent had not used contraception at their first intercourse and 23% reported no use of contraceptive at their most recent intercourse. The students considered that they had only a low risk of contracting a sexually transmitted disease. The use of condoms was relatively low and this has implications for the students' potential to contract a sexually transmitted disease.     

Young Women's Beliefs About the Terms Sexually Transmitted Disease and Sexually Transmitted Infection

Objective: To determine whether young women differentiate between the terms sexually transmitted disease and sexually transmitted infection and if they do whether their reasons are consistent with those of health care providers.
Design: Secondary analysis of cross-sectional, survey data.
Setting: Four women's health clinics and one university classroom.
Patient/Participants: Three hundred and two women aged 18 to 24.
Methods: The women completed a survey that measured beliefs about seven sexually transmitted diseases, a demographic and sexually transmitted disease health information questionnaire, and a single item assessing whether the terms sexually transmitted disease and sexually transmitted infection were interchangeable.
Results: Fifty-seven percent ( n =155) responded that sexually transmitted disease and sexually transmitted infection do not mean the same thing, 28% ( n =76) responded that sexually transmitted disease and sexually transmitted infection mean the same thing, and 15% ( n =42) responded they do not know. Beliefs about sexually transmitted disease stigma and symptoms were not related to sexually transmitted disease terminology; beliefs about curability were related but not in the hypothesized direction.
Conclusions: A majority of the young women do differentiate between the terms sexually transmitted disease and sexually transmitted infection; however, the rationale for doing so is not consistent with the rationale used by health care providers. Professionals should clarify their use of the terms sexually transmitted disease and sexually transmitted infection when talking with patients as a means to improve health communication and subsequently improve sexually transmitted disease health care.