Sexual Assault management in emergency department

Update on sexual assaults

1. Background Effects of sexual assault Forms of sexual assault Risk factors to sexual violence Protocol for rape management Malawi-Reproductive Health Rights references

2. Sexual assault is defined as: “a ny sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women’s sexuality, using coercion, threats of harm or physical force, by any person, regardless of the relationship with the victim, in any setting, including but not limited to home, school, prison, the streets and at work’. (World Health Organisation 2003)

3. Statistics: › Nearly 1 in 5 (18.3%) women and 1 in 71 men (1.4%) reported experiencing rape at some time in their lives. › Approximately 1 in 20 women and men (5.6% and 5.3%, respectively) experienced sexual violence other than rape, such as being made to penetrate someone else, sexual coercion, unwanted sexual contact, or non- contact unwanted sexual experiences, in the 12 months prior to the survey. › 4.8% of men reported they were made to penetrate someone else at some time in their lives. › 13% of women and 6% of men reported they experienced sexual coercion at some time in their lives. ( CDC)

4. Malawi: › 24% of all school children aged 9-18 years old have been forced to have sex, mostly at home and at school One stop center on average a case is reported everyday

5. › unwanted pregnancy › Sexual dysfunction › unsafe abortion › Infertility › STIs including HIV/AIDS › Pelvic pain and urinary tract infections › Post traumatic stress disorder › Self harm › Suicide › Flashbacks › Eating disorders › depression › Substance abuse

6. Rape: › “physical forced or otherwise coerced penetration – even if slightly – of the vulva or anus, using a penis, other body parts or an object” (World Health Organisation 2003) Sexual harassment: › Intimidation, bullying or coercion of sexual nature, or unwelcome or inappropriate promise or rewards in exchange of sexual favors. Groping › Touching or fondling of another person in sexual way without that person’s consent Elderly sexual assault : › Sexually victimization of elderly individual (60) Child sexual abuse: › Involves an adult or order adolescent sexualy abusing a child(asking or pressuring a child to engage in sexual activeities, indesent exposure of genitals to a child) Domestic violence:

7. Who are the victims? › Women › Children › Orphans › men

8. perpetrators: › Family members › Neighbors › Strangers › seniors

9. CDC › In a nationally representative survey; Among female rape victims, perpetrators were reported to be intimate partners (51.1%), family members (12.5%), acquaintances (40.8%) and strangers (13.8%). Among male rape victims, perpetrators were reported to be acquaintances (52.4%) and strangers (15.1%). Among male victims who were made to penetrate someone else, perpetrators were reported to be intimate partners (44.8%), acquaintances (44.7%) and strangers (8.2%).

10. Women being victimized › being young; › consuming alcohol or drugs; › having previously been raped or sexually abused; › having many sexual partners; › involvement in sex work; › becoming more educated and economically empowered; › poverty.

11. Diagnosis › History Record details of the events before and after the assault, drugs taken voluntarily or involuntarily, force and/or weapons used, condom use, timing and sequence of events, specific events of the assault and post assault hygiene. Ask about LMP, current hormonal contraception and previous intercourse.

12. Physical examination › Visualize entire body to draw a detailed body map. Mark abnormalities (i.e. contusions, bites, ligature marks, old and new trauma), distinguishing features (i.e. tattoos, piercings, scars) and areas where swabs were obtained. Include pertinent negatives. For the pelvic exam, visualize before using a speculum. Other common areas of injury include head/neck and anus/rectum. Note tenderness, tears, ecchymosis, abrasions, erythema and oedema . Lack of findings does not mean that the exam is inconsistent with history of sexual assault.

13. Investigations › Time dependent specimens include sperm/semen, foreign material, swabs of body secretions and fingernail scrapings. Blood and hair from the head or pubic area are NOT time dependent. Also do the following: › HIV test — Pregnancy test

14. Management  Step 1: › Assess and treat serious injuries first › Obtain verbal consent to conduct physical examination › Take full history and document all findings › Conduct full physical examination and document all findings › Document all facts regarding the assault Step 2: › Manage physical effects of the assault such as wounds and bruises – including antibiotics to prevent wound infection, tetanus booster if required, medication for pain relief or anxiety Step 3: › Provide emergency contraception if the victim has started menarche and presents within 72 hours post-assault › Postinor-2 – take 1 tablet orally, to be repeated after 12 hours or › Lo-Femenal 4 tabs to be repeated after 12 hours

15. Step 4: › Treat presumptively for STIs (or conduct laboratory investigations if available): › Benzathine Penicillin < 25 kg: 600,000 IU stat (if >25 kg, then 1,200,000 IU stat) › Gentamycin 6mg/kg single dose › Erythromycin 12.5mg/kg every 6 hours for 7 days › Metronidazole 5mg/kg every 8 hours for 7 days Step 5: › Provide HIV Testing and Counseling › Conduct an HB baseline reading (if available ) › If the victim presents within 72 hours of penetrative assault, and is HIV negative upon initial testing, and consents to PEP treatment, provide PEP treatment with Duovir BD x 30 days. › o If the victim has HB ≤ 8 g/dl Duovir must be replaced with LamivirS BD x 30 days › Malawi Obstetrics & Gynaecology Protocols Page 102

16. Step 6: › Provide counseling on post-traumatic stress to victim and guardian › Assess safety of the victim › Refer to other support services, such as the Victim Support Unit in the Police Step 7: › Advise on dates for follow up visits › Record Findings and treatment in “Examination Record” and provide copy to the victim for submission to the police, if appropriate › Record all findings and treatment in health passport

17. WHO Plan malawi Malawi medical journal Obstetrics & Gynecology Protocols and Guidelines; taulo et el CDC Clinical gynecology 3 rd edition tf Kruger, mh Botha www.rainn.org