Preventive Care for Adult Survivors of Sexual Violence
Ginny Moore
Definition
A.Preventive care—care provided to prevent pregnancy and/or STIs after sexual assault or rape.
B.Adult survivors—persons 18 years of age or older who have survived sexual violence.
C.Sexual violence includes sexual assault and rape. The legal definitions of each vary from state to state. The terms include the following:
1.Sexual assault—any sexual act performed on a person without consent.
2.Rape—penetration of a body orifice without consent.
Incidence
A.According to the Rape, Abuse and Incest National Network (RAINN), sexual violence has decreased over the past 20 years. Despite the decrease, it is estimated that every 98 seconds a person will experience sexual violence. One in six women and one in 33 men will be the victims of sexual violence in their lifetimes.
B.The incidence of sexual violence is highest, at 54%, in ages 18 to 34; declines to 28% in ages 35 to 64; and is lowest, at 3%, in ages 65 and up.
Predisposing Factors
A.Predisposing factors generally include genetic traits, lifestyle factors, and characteristics that may make an individual vulnerable to a certain condition:
1.Individuals who are sexually assaulted or raped are sometimes targeted by the perpetrator.
2.Others may be victims of the perpetrator’s convenience who are selected at random.
B.Although alcohol and prescription and recreational drugs are substances that may affect judgment and lead to unsafe choices, the voluntary ingestion of these substances does not imply that the survivor is responsible for sexual violence.
Common Complaints
Sexual violence survivors may present with explicit memory, much confusion, or no memory of the assault.
Other Signs and Symptoms
Survivors may report injuries associated with physical force during the assault.
Subjective Data
A.A detailed history of the body parts and actions involved in the assault is essential in guiding the physical examination and determining the management plan.
B.Regardless of how much time has elapsed, recounting details of the assault can be emotionally difficult for the survivor. To alleviate some of the discomfort, providers should explain how they will use information they are requesting. For example, if oral penetration occurred but there was no genital contact, the physical exam would be limited to the oral cavity.
C.Review a full medication history, asking specifically about the use of hormonal contraception and CYP3A4 inducers.
D.Review all allergies, including medications, latex, and copper (if desires intrauterine device [IUD] insertion).
E.Review medical history for any contraindications to contraception.
F.Review immunization history:
1.Human papillomavirus (HPV).
2.Hepatitis B virus (HBV).
3.Tetanus, if no history of immunization in the last 10 years of a booster is indicated.
G.Ask about current pregnancy or previous exposure for pregnancy. Previous exposure refers to consensual, unprotected sex within the past 72 to 96 hours.
H.Is the woman breastfeeding?
I.When was the patient’s last alcohol ingestion?
Physical Examination
The physical examination is limited to inspection of body parts involved in the assault.
Diagnostic Tests
A.Pregnancy testing:
1.Pregnancy testing should be offered if the survivor has had consensual, unprotected intercourse since her last menstrual period (LMP):
a.Urine pregnancy test—it is advisable to do pointof-care testing whenever possible due to the low rate of follow-up. The urine test provides results at the time of the examination.
b.Serum beta human chorionic gonadotropin (HCG) may be offered if earlier detection is essential.
2.Diagnostic testing for sexually transmitted infections (STIs), alcohol, and recreational drugs is controversial. If done in days after the acute assault, STI testing will only confirm the presence of prior infection, not infection resulting from the assault. All test results become a part of the medical record. Should the survivor choose to pursue legal prosecution of the assailant, it is possible that positive results prior to the assault may be used to discredit the survivor. Current infection status is not required to prescribe preventive treatment. Survivors should be provided with this information to make a fully informed decision regarding testing.
Plan
A.Emergency contraception (EC) options:
1.Levonorgestrel (LNG)—1.5 mg:
a.Available over-the-counter (OTC) in a singletablet regimen to anyone of any age.
b.Available behind-the-counter in a two-tablet regimen to persons ages 17 years and older.
c.50% efficacy if taken within 72 hours of exposure.
d.Efficacy may be decreased if body weight is greater than 165 lbs.
2.Ulipristal acetate (UPA)—30 mg:
a.Prescription only.
b.Limited product distribution to pharmacies. Online ordering may be necessary.
c.66% efficacy if taken within 120 hours of exposure.
d.Contraindicated with breastfeeding.
e.Concomitant use with CYP3A4 inducers or hormonal contraception may decrease effectiveness.
f.Efficacy may be decreased if body weight is greater than 195 lbs.
3.Copper IUD:
a.Must be inserted by trained professional.
b.Hormone free.
c.Contraindicated with copper allergy.
d.No drug interactions.
e.99% efficacy if inserted within 120 hours of exposure.
B.EC patient teaching:
1.The primary mechanism of action for LNG and UPA is to inhibit or delay ovulation.
2.The primary mechanism of action for the copper IUD is inhibition of fertilization through release of copper ions toxic to sperm.
3.LNG is a progestin. UPA is an anti-progestin. The two agents cannot be used together as they will negate effectiveness of the other.
4.Survivors using hormonal contraception regularly do not need EC. Survivors using hormonal contraception irregularly should be advised to use LNG not UPA for EC.
5.Survivors wanting to begin or resume hormonal contraception after UPA use should be advised to wait at least 120 hours.
6.The copper IUD may be left in place as contraception for up to 12 years after insertion.
7.Survivors with limited financial access to EC can find the nearest low-cost family planning
clinics by typing in their zip codes at this Health and Human Services sponsored site: opa-fpclinicdb.hhs.gov
8.If EC is declined, advise pregnancy testing 2 weeks after assault.
C.STI prophylaxis:
1.Chlamydia trachomatis (CT)—Azithromycin 1 g P.O. x 1.
2.Gonorrhea (GC)—Ceftriaxone 250 mg IM x 1.
3.Trichomoniasis—Metronidazole 2 g P.O. x 1 or Tindazole 2 g P.O. x 1.
4.HBV:
a.For survivors who started or completed immunization series but did not have confirmation titer for immunity, administer a single booster dose at time of exam.
b.For previously unvaccinated survivors, administer HBV immunization at time of exam with follow-up doses at 1 to 2 and 4 to 6 months after initial dose.
c.If assailant is known to be positive for hepatitis B surface antigen and survivor is unvaccinated, administer hepatitis B immune globulin along with initial dose of HBV immunization.
5.HPV:
For previously unvaccinated survivors, the Centers for Disease Control and Prevention (CDC) recommends initial dose at time of exam with follow-up doses at 1 to 2 and 6 months for the following groups:
a.Females ages 9 to 26 years.
b.Males ages 9 to 21 years.
c.Males who have sex with males through age 26 years.
6.HIV:
a.CDC recommends evaluation of risk status to determine need for post-exposure prophylaxis (PEP).
b.Due to the complexity of clinical management, collaboration with specialists is advised.
c.Call the National Clinician’s PEP Line (1 – 888 – 448 – 4911) for assistance with PEP-related decisions.
7.Syphilis—CDC does not recommend prophylaxis.
8.Herpes simplex virus (HSV)—CDC does not recommend prophylaxis.
D.STI prophylaxis considerations: Survivors have a low return rate for follow-up visits. Whenever possible, provide single-dose regimens of prophylactic treatments during time of exam.
E.STI patient teaching:
1.Advise sexual abstinence x 7 days after medication completion.
2.To avoid unpleasant side effects, wait 72 hours after last alcohol consumption before taking metronidazole or tindazole. After medication administration, wait 72 hours before consuming alcohol.
3.If STI prophylaxis is declined, advise STI testing (CT, GC, trichomoniasis) 2 weeks after assault.
Follow-Up
A.If lab testing was done during initial exam, return in 2 weeks for results.
B.Return for evaluation anytime if symptoms appear.
C.Additional lab testing as indicated.
D.Immunization doses as indicated.
Consultation/Referral/Individual Consideration
A.If an evidentiary or forensic examination is requested by survivor, call the National Sexual Assault Hotline at 1-800-656-4673 (HOPE) for locations of the nearest sexual assault providers.
B.Mandatory reporting requirements vary from state to state. A listing of individual state requirements can be found at www.rainn.org/public-policy-action.
C.All states require reporting if the sexual violence involved children (ages 17 and younger) or elderly (ages 60+).
D.To report sexual violence, call 911 or local enforcement. Information on individual state statutes on reporting can be found at www.rainn.org/public-policy-action.
E.It is essential survivors know support with trained professionals is available. Provide resources to all survivors during initial encounter.