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sexual abuse

Risk factors: - pregnancy is a strong risk factor for sexual assault Epidemiology: 1) 20-27% of adult women, 15% of college women, 12% of adolescent girls have experience sexual assault 2) 1/8 of women in ongoing relationships has experienced sexual assault from her partner 3) 10% of men have experienced sexual assault [4] 4) 5-25% of children [8] - 8% of US high school girls [10] 5) 7% of women >= 15 years of age worldwide say they have been the victims of nonpartner sexual violence [9] History: 1) when possible, separate children from parents 2) use non-leading language when asking questions about potential abuse 3) 'It is not uncommon these days for people to have been emotionally, physically, or sexually victimized at some time in their life, & this can be related to various symptoms. Has this ever happened to you' 4) SAFE questions 5) Veterans Administration recommends screening all patients Clinical manifestations: - fear, anxiety, shame, anger, embarrassment Laboratory: - testing for sexually transmitted disease recommended for adults* - Neisseria gonorrhoeae nucleic acid - Chlamydia DNA - Trichomonas vaginalis nucleic acid - bacterial vaginosis (wet mount of vaginal secretions) - include genital, pharyngeal & rectal specimens; sites of penetration [15] - in children, test for genital infection with gonorrhea & chlamydia - HIV1 RNA, rapid plasma reagin, hepatitis B serology - consider hepatitis C serology [12] * nucleic acid amplification tests have higher sensitivity than culture and are much easier to use Complications: (associated disorders) 1) eating disorders (particularly obesity) 2) chronic abdominal complaints 3) somatization disorders 4) post-traumatic stress disorder 5) substance abuse 6) back pain 7) headache 8) sexual dysfunction 9) suicidal ideation Management: - sexual trauma counseling can be provided regardless of whether or not the incident was reported - cognitive processing therapy of benefit [7] - sexual assault resistance program may decrease risk of rape, attempted rape, & other forms of victimization among 1st-year university women [11] - treatment within 72 hours of sexual assault - gonorrhea, Chlamydia, trichomonas, hepatitis B, HIV1 prophylaxis - emergency contraception with levonorgestrel [14] - sexually transmitted disease prophylaxis for adults [12] - ceftriaxone 250 mg IM & azithromycin 1 g PO or doxycycline - metronidazole or tinidazole 2 g PO - routine sexually transmitted disease prophylaxis not recommended for children because follow-up is generally better than in adults, complications of delayed treatment are lower - postexposure HIV1 prophylaxis for mucous membrane exposures to infectious fluids from HIV1-positive individual - preferred regimen is tenofovir-emtricitabine & raltegravir - HIV1 transmission in children is less common - postexposure HIV1 prophylaxis in children is case-by-case - hepatitis B vaccine if vaccination status unknown - consider HPV vaccination for unvaccinated females 9-26 years & males 9-21 years [12] - document substance use related to the event [13] - offer levonorgestrel 1.5 mg single dose for emergency contraception [13] - pregnancy test 2 weeks after the assault [13]

Related

SAFE questions for domestic violence

Specific

rape

General

abuse domestic violence (includes intimate partner violence)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
  2. Journal Watch 21(18):144, 2001 Silverman et al, JAMA 286:572, 2001
  3. Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005 Aug;116(2):506-12. PMID: 16061610 http://pediatrics.aappublications.org/cgi/content/full/116/2/506
  4. Veterans Administration
  5. Floyed RL et al. Development of a screening tool for pediatric sexual assault may reduce emergency-department visits. Pediatrics 2011 Aug; 128:221. PMID: 21788216
  6. Justice Department Releases Updated Protocol to Improve Standards for Responding to Rape and Sexual Assault. Justice Department, April 24, 2013 http://www.justice.gov/opa/pr/2013/April/13-ag-466.html - U.S. Department of Justice. Office of Violence Against Women A National Protocol for Sexual Assault Medical Forensic Examinations. Adults/Adolescents. Second Edition. April 23, 2013 https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf
  7. Bass JK et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med 2013 Jun 6; 368:2182. PMID: 23738545 http://www.nejm.org/doi/full/10.1056/NEJMoa1211853
  8. Jenny C et al The Evaluation of Children in the Primary Care Setting When Sexual Abuse is Suspected. Pediatrics. July 29. 2013 PMID: 23897912 http://pediatrics.aappublications.org/content/early/2013/07/23/peds.2013-1741.full.pdf+html
  9. Abrahams N et al Worldwide prevalence of non-partner sexual violence: a systematic review. The Lancet, Early Online Publication, 12 February 2014 PMID: 24529867 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2962243-6/abstract
  10. Vagi KJ et al Teen Dating Violence (Physical and Sexual) Among US High School Students. Findings From the 2013 National Youth Risk Behavior Survey. JAMA Pediatr. Published online March 02, 2015 PMID: 25730143
  11. Senn CY et al Efficacy of a Sexual Assault Resistance Program for University Women. N Engl J Med 2015; 372:2326-2335. June 11, 2015 PMID: 26061837 - Basile KC. A comprehensive approach to sexual violence prevention. N Engl J Med 2015 Jun 11; 372:2350. PMID: 26061837
  12. Sena AC et al. Sexual assault and sexually transmitted infections in adults, adolescents, and children. Clin Infect Dis 2015 Dec 15; 61:S856 PMID: 26602623
  13. Crawford-Jakubiak JE, Alderman EM, Leventhal JM, COMMITTEE ON CHILD ABUSE AND NEGLECT, COMMITTEE ON ADOLESCENCE Care of the Adolescent After an Acute Sexual Assault Pediatrics Feb 2017, e20164243; DOI: 10.1542/peds.2016-4243 PMID: 28242861
  14. Linden JA Care of the Adult Patient after Sexual Assault. N Engl J Med 2011;365:834-41 PMID: 21879901 Free article https://www.nejm.org/doi/pdf/10.1056/NEJMcp1102869
  15. NEJM Knowledge+