Sexual Abuse, Assault and Intimate Partner Sex Voilence

Introduction Sexual assault accounts for 1% of all violent crimes reported in the 2003 United States Uniform Crimes Report. Most episodes of sexual assault are committed by a person known to the victim. Until recently, male sexual assault was underrecognized and underreported. The incidence in men is estimated to be 10% of all sexual assaults. Intimate partner violence and abuse (IPVA) is defined as a pattern of assaultive behavior that may include physical injury, sexual assault, psychological abuse, stalking, deprivation, intimidation, and threats. IPVA occurs in every race, ethnicity, culture, geographic region, and religious affiliation and occurs in gay, lesbian, and heterosexual relationships.

Clinical Features A brief, tactfully obtained history should include the following elements: (a) who (whether the assailant was known and the number of attackers), (b) what happened (including physical assault and injuries), (c) when (time since assault), (d) where (actual or attempted vaginal, oral, or anal penetration and whether ejaculation occurred; use of condoms or foreign bodies), (e) whether the patient has showered, douched, or changed clothes since the attack, and (f) suspicion of drug-facilitated sexual assault (whether there is a period of amnesia, intoxication greater than expected for the amount of alcohol consumed, or history of waking in a different location with genital pain). Past medical history pertinent to the sexual assault victim should include last menstrual period, birth control method, and last consensual intercourse (this may affect laboratory analysis of evidence). Allergies and prior medical history should be obtained for sexually transmitted disease (STD) and pregnancy prophylaxes and prior sexual assault. The history for the IPVA victim can be more difficult to obtain. Between 4% and 15% of women are seen in emergency departments (EDs) because of symptoms related to IPVA. Risk factors for IPVA include female sex, age between 16 and 24 years, low socioeconomic status, separated relationship status, and children younger than 3 years in the home. When a victim reveals a history of IPVA, it should be documented in the patient's own words. Recent and remote abuse, including dates, locations, details of abuse, and witnesses, should be documented. Injuries inconsistent with the patient's history, multiple injuries in various stages of healing, delay in the time of injury occurrence and presentation, a visit for vague complaints without evidence of injury, or suicide attempts should trigger suspicions of IPVA. Patients also may complain initially of chronic pain syndromes, gynecologic or psychiatric difficulties, and alcohol and substance abuse. The victim of IPVA also may appear frightened when the partner is present. Physical Examination The examinations for sexual assault and IPVA should include a general medical examination, including general appearance and demeanor. Patients who present to the ED may request only a forensic examination for sexual assault; however, trauma is present in 45% to 67% of cases, with genital injury in 9% to 45%. Injuries should be described and documented, including photographs of injuries, if available. In the sexual assault victim, a pelvic examination should include documentation of vaginal discharge, abrasions, cervical abrasions, and lacerations. The rectum also should be examined for lacerations and abrasions. Anoscopy has proven to be a better tool for detection of trauma. Toluidine blue can detect small lacerations by staining the deeper dermis; it can be applied with gauze and removed with lubrication before the speculum examination. A colposcope also increases documentation of genital injuries, especially to the posterior fourchette. In the IPVA victim, characteristic injuries include fingernail scratches, bite marks, cigarette burns, rope burns, and forearm bruising or nightstick fractures, suggesting a defensive posture. Central injuries to the head, neck, face, and thorax should be identified and documented. Abdominal injuries are common in the pregnant IPVA patient. Evidence Examination Evidence collection in sexual assault is credible only within the first 72 hours after the assault. After 72 hours, a history, physical examination, and documentation of injuries should be provided with STD prophylaxis. The evidence should be labeled clearly with the victim's name, type and source of evidence, date and time, and name of the examiner collecting the evidence.

Diagnosis and Differential Sexual assault is a legal determination, not a medical diagnosis. The legal definition contains 3 elements: carnal knowledge, nonconsent, and compulsion or fear of harm. Because of the legal considerations, careful documentation and evidence collection are important. Informed consent should be obtained, and a system to preserve the "chain of evidence" should be maintained. A prepackaged sexual assault, or "rape," kit with directions for sample collection should be used. Diagrams for documentation of genital and physical injuries can be useful. If a sexual assault kit is not available, smears from the vagina and cervix are made, labeled, and air dried. A wet mount from the same areas should be microscopically examined for sperm. A vaginal aspirate using 5 to 10 mL normal saline may be obtained and tested for acid phosphatase. Premoistened rectal and buccal swabs should be obtained to check for the presence of sperm. An ultraviolet light with a peak output around 490 nm wavelength (eg, Bluemaxx BM 500) can be used to examine for areas of fluorescence where semen may be collected on the body. The output of the typical Wood lamp (360 nm) does not fluoresce semen. If anal penetration occurred, a rectal aspirate and rectal swab should be taken and slides made, labeled, and air dried in the same manner as for the vaginal swabs. Additional forensic laboratory evaluation may include glycoprotein p30 testing and genetic typing.

Emergency Department Care and Disposition for Sexual Assault  The health care provider initially should address life-threatening injuries and the psychological needs of the sexual assault patient. Pregnancy Prophylaxis  A pregnancy test should be obtained. Up to 5% of all sexual assault victims will become pregnant as a result of the assault.  Postcoital prophylaxis reduces the risk of pregnancy by 60–90% if adequate doses of estrogen are used.  Options include: levonorgestrel 0.75 mg (Plan B) 1 tablet initially followed by 1 tablet in 12 hrs ethinyl estradiol and levonorgestrel 50 mcg/0.25 mg (Preven) 2 tablets initially followed by 2 tablets in 12 hrs ethinyl estradiol and norgestrel 50 mcg/0.5 mg (Ovral) 2 tablets initially followed by 2 tablets in 12 hrs. STD Prophylaxis Gonorrhea: The 2002 CDC guidelines are a single dose of: ceftriaxone 125 mg IM,  cefixime 400 mg PO,  ciprofloxacin 500 mg PO, or  ofloxacin 400 mg PO.  Ceftriaxone 125 mg IM is recommended in pregnancy. Chlamydia: Recommended regimens for prophylaxis are:  a single dose of azithromycin 1 g PO, doxycycline 100 mg PO bid for 7 days, erythromycin base 500 mg PO qid for 7 days, or amoxicillin 500 mg PO tid for 7 days. Trichomoniasis and bacterial vaginosis:  Recommended regimens for prophylaxis are:  a single dose of metronidazole 2 g PO, metronidazole 250 mg PO tid for 7 days, or  clindamycin 300 mg PO bid for 7 days.  If pregnant and symptomatic, metronidazole 2 g PO may be used with close follow-up.  Hepatitis B: Recommended treatment regimens for prophylaxis are:  vaccination at the time of initial evaluation  follow-up doses at 1 to 2 mos and at 4 to 6 mos. Prophylaxis or Counseling for the Human Immunodeficiency Virus  Rates of HIV are 0.008% to 0.032% from receptive, unprotected anal intercourse and 0.005% to 0.0015% from vaginal intercourse with HIV-positive assailants.  Circumstances should guide treatment with known assailant positivity, high viral load exposures, vaginal trauma, and ejaculate on membranes, which represent a moderate to high risk for HIV seroconversion  Postexposure prophylaxis:  Also should consider expense and side effects of the medications and the need to arrange follow-up with a primary physician with experience in HIV treatment.  Per CDC guidelines, treatment is currently "recommended" for victims with "moderate" risk exposures.  Routine prophylaxis is not recommended, and counseling and follow-up should be provided. Follow-Up Care  The patient should be counseled by a social worker or sexual assault counselor at the time of the assault.  Follow-up medical care is needed to reexamine physical injuries and to examine the effectiveness of pregnancy and STD prophylaxes.

Emergency Department Care and Disposition for the IPVA Victim  The first goal of treatment should be to address any life-threatening injuries to the patient while simultaneously ensuring the safety of the victim and any children involved while they are in the ED.  IPVA experts (trained social workers or IPVA advocates) can assist with providing information about IPVA and assisting the victims with available options for their families.  Safety assessment:  Should identify indicators of a potentially lethal situation.  Risk indicators include:  increasing frequency or severity of violence  the threat or use of weapons  obsession with the victim  taking hostages  stalking  homicidal or suicidal threats  substance abuse by the assailant, especially with crack cocaine or amphetamines.  The most dangerous period for victims is during the time of abuse disclosure and during an attempt to leave the relationship.  Hospital admission is an option in high-risk situations if a safe location cannot be established before discharge.