PANCE Blueprint Reproductive System (7%)

Sexual assault

Patient will present as → a 24-year-old G1P0 female at 16 weeks gestational age is in your office for a routine prenatal visit. When performing an antenatal psychological health assessment the patient admits that over the past six weeks her boyfriend has been increasingly violent towards her. On two occasions he has grabbed her forcefully and pressured her to perform oral sex against her will. When she spoke to a friend about this she was told to let it go, and that her boyfriend was just "under a lot of stress." She is visibly upset and asks you what she should do.

Sexual assault is any involuntary sexual act in which a person is coerced or physically forced to engage against their will or any non-consensual sexual touching of a person

  • Physical contact need not occur to be considered assault (eg, forced to watch a sexual act)
  • 1 in 3 women will be sexually assaulted in her lifetime
  • Because of the stigma associated with sexual assault, only 1 in 10 victims seek help
  • National sexual assault hotline: 800-656-4673

Rape constitutes both a psychiatric emergency and a legal situation; all procedures should be documented, clothing saved, and samples taken

  • Explain to the patient the purpose of all procedures, and inform him or her of what is being done before doing it. This provides the patient with a feeling of some control
  • A rape kit, which has instructions regarding questions to include in the history, how specimen samples are to be collected and under what conditions, and how samples should be handled after collection, is valuable and ensures that the proper evidence is secured.
  • Cultures from the vagina, the anus, and usually, the pharynx for gonorrhea and Chlamydia, RPR for syphilis, hepatitis antigens, HIV, urinalysis, pregnancy test for menstrual-aged women (regardless of contraceptive status)

Prophylactic antibiotic therapy should be initiated

  • Rocephin 250 mg followed by oral doxycycline twice daily x 7 days
  • Tetanus toxoid if indicated
  • The patient should be given the option of emergency contraception
  • Counseling: As soon as possible after the event, and preferably before leaving the emergency department, the patient should talk to a mental health professional and follow-up counseling should be scheduled

Follow up within 24-48 hours after discharge, all victims should be contacted by phone

  • One-week visit - a general review of the patient's progress
  • Six-week visit - repeat cultures for STIs and repeat RPR
  • 12-18 week visit may be indicated for repeat HIV titers
Question 1
A 23-year-old female PA student presents to the emergency department stating that she was sexually assaulted 3 hours earlier. Appropriate initial medical professional intervention for the patient should be
A
Provide acute medical care
B
Prophylaxis therapy for sexually transmitted infections and pregnancy
Hint:
Although providing prophylaxis therapy for sexually transmitted infections and prevention of pregnancy be offered, this would not be the first step in treating this patient.
C
Referral to local authorities
Hint:
A consult with the local sexual assault agency should be made and it is up to the victim to report the crime unless child abuse or human trafficking is suspected.
D
Referral to counseling services
Hint:
See A for explanation
Question 1 Explanation: 
One in six women in America will be a victim of sexual assault in their lifetime and will often present to the emergency room for help. As a medical provider, the initial point of contact is to ensure the patient is stable and provide acute medical care. Often victims have been beaten or injured. Although providing prophylaxis therapy for sexually transmitted infections and prevention of pregnancy be offered, this would not be the first step in treating this patient. A consult with the local sexual assault agency should be made and it is up to the victim to report the crime unless child abuse or human trafficking is suspected.
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