Management of Rape Victims

1
Management of Rape Victims

• Martin Donohoe
• Information within does not constitute clinical
  advice regarding treatment I recommend
  consulting contemporary medical references

2
Rape

• Unwanted, forced penetration (oral/vaginal/anal)
• Reported by 33 -46 of women who are physically
  abused

3
Rape

• Annual incidence ³ 80/100,000 women
• 7 of all violent crimes
• Lifetime prevalence up to 25
• 1/3 Native Americans/Alaskan Natives victims of
  attempted rape or rape
• Migrants, those in war zones and refugee camps at
  high risk

4
Rape

• Annual incidence of at least 300,000 women in US
• Forcible rape every 6.2 seconds (FBI)
• 7 of all violent crimes
• Additional 3.7 million confronted with unwanted
  sexual activity
• Lifetime prevalence 13-39 in women 3 in men

5
Epidemiology of VAW

• 2011 CDC study
• 18 of women have been raped 1.4 of men
• Women 52 by partner 41 by acquaintance
• Men 52 by acquaintance 15 by stranger

6
Date Rape

• 40 of college women report forced sexual
  contact, attempted rape, or completed rape
• independent of school demographics

7
Date Rape

• gt25 of college males admit to using sexually
  coercive behaviors
• 2/3 of college males report engaging in unwanted
  sexual intercourse
• reasons peer pressure, desire to be liked

8
Spousal Rape

• 10 - 15 of all marriages
• more violent, less frequently reported then
  non-spousal rape
• not illegal in many U.S. states/other countries

9
High Risk Groups

• Prostitutes
• Military
• See the Womens Health and War and Peace
  pages of the Public Health and Social Justice
  website for other slide shows and articles
  covering
• Violence against women in the military
• War, rape and genocide
• Homeless and runaways

10
High Risk Groups

• Gays, lesbians, bisexuals, transgendered
• Alcohol and drug users
• College students
• Persons under age 24

11
High Risk Perpetrators

• Male college athletes
• Fraternity members
• Men with restraining orders

12
Rape

• 5 chance of pregnancy
• 25 chance of acquiring STD
• GC 6 - 12
• Chlamydia 4 - 17
• Syphilis 0.5 - 3

13
Rape

• 5 chance of pregnancy
• 25 chance of acquiring STD
• GC 6 - 12
• Chlamydia 4 - 17
• Syphilis 0.5 - 3

14
Rape and HIV

• 1 -2/1,000 odds of acquiring HIV from HIV rapist
• 1-2/100,000 overall risk of HIV from vaginal
  penetration
• 2-3/10,000 from anal penetration

15
Rape and Pregnancy

• Noninvasive prenatal genetic testing through
  amplification of fetal alleles from maternal
  blood very accurate for identifying father
• Can be performed at 8-14 weeks gestation
• vs. amniocentesis and chorionic villus sampling
  (10-15 weeks, risks to mother and fetus)
• May assist mothers decision to carry vs.
  terminate pregnancy

16
Rape

• Underreported (16-38 notify law enforcement
  17-43 present for medical evaluation)
• Fewer than ½ of rape cases successfully
  prosecuted as few as 1 of rapists convicted

17
Rape

• Large backlog of untested rape kits (over
  180,000)
• H.R. 4114 and S.B 2736 (Justice for Survivors of
  Sexual Assault) bills pending in Congress

18
Rape

• Average prison time for those convicted
• rape 1 year
• armed robbery 3 - 5 years
• murder 8 years
• Chemical Castration Laws

19
The Physicians Duties in Caring for Victims of
Sexual Assaults

• Medical
• medical history
• evaluate and treat physical injuries
• cultures
• treat pre-existing infections
• NEJM 1995 332234-7 and NEJM 2011365834-41
  

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The Physicians Duties in Caring for Victims of
Sexual Assaults

• Medical
• offer post-exposure HIV prophylaxis
• offer post-coital contraception (vs. in utero
  paternity testing f/b selective abortion)
• arrange medical followup
• provide counseling
• NEJM 1995 332234-7 and NEJM 2011365834-41

21
Physical Examination ofSexual Assault Victims

• Collection of clothing
• External/internal evaluation
• abrasions, lacerations, ecchymoses, bite marks
  colposcopy, toluidine blue staining
• Oral cavity
• secretions, injuries, cultures
• Note time limits for evidence collection vary by
  state (72-120 hrs)
• NEJM 1995 332234-7 and NEJM 2011365834-41

22
Physical Examination ofSexual Assault Victims

• Genitalia
• hair combing, hair sampling, vaginal secretions,
  injuries, cultures
• Rectum
• injuries, cultures
• NEJM 1995 332234-7 and NEJM 2011365834-41

23
Prophylaxis for Adult Victims ofSexual
AssaultAntibiotic Prophylaxis

• Ceftriaxone (250 mg IM) or cefixime (2 g po)
• PLUS
• Doxycycline (100 mg po bid x 7d) or Azithromycin
  (1 g po x 1)
• PLUS
• Metronidazole ( 2 g po x 1)

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Prophylaxis for Adult Victims ofSexual
AssaultPrevention of Pregnancy

• Most effective oral regimen 1 dose of 30 mg
  ulipristal or 1.5 mg levonorgestrel within 120
  hours of unprotected intercourse (ulipristal
  twice as effective 0.9 pregnancy rate vs 1.7)

25
Prophylaxis for Adult Victims ofSexual
AssaultPrevention of Pregnancy

• Alternate regimen 2 doses of 100 mcg ethinyl
  estradiol plus 0.5 mg levonorgestrel taken 12
  hours apart (plus prn antiemetic)
• Most effective IUD implanted within 5 days
• Nearly 100 effective

26
HIV Post-Exposure Prophylaxis for Adult Victims
ofSexual Assault

• HIV Prophylaxis
• Consult ID
• start up to 72 after rape
• Baseline HIV test and referral to experienced
  clinician within 72 hours of starting PEP

27
Hepatitis B Post-Exposure Prophylaxis for Adult
Victims ofSexual Assault

• Offender HBsAg-positive administer Hep B vaccine
  and HBIG
• Offenders HBsAg status unknown administer Hep B
  vaccine
• Rx ideally within 24 hrs, but may be effective up
  to 14 days
• Complete Hep B vaccine series
• Tetanus booster if indicated

28
Ensure Victims Safety

• Social worker involvement
• Restraining order
• Phone numbers of shelters, hotlines
• Safe place to go

29
Domestic Violence Shelters

• Availability poor
• up to 70 - 80 of women and 80 of children
  turned away on any given night
• 4 times as many animal shelters as domestic
  violence shelters in U.S.

30
Domestic Violence Shelters

• Woefully underfunded
• Average length of stay 14 days most allow 30
  day max stay
• Over 50 of all homeless women and children are
  fleeing domestic violence

31
Contact Information

• Public Health and Social Justice Website
• http//www.phsj.org
• martindonohoe_at_phsj.org