Judith A. Linden, MD, associate professor of emergency medicine at Boston University School of Medicine (BUSM) and vice chair for education in the department of emergency medicine at Boston Medical Center (BMC), has written an review article on the treatment of adult victims of sexual assault in an acute care setting that will run in the Sept. 1 issue of the New England Journal of Medicine. The article, which utilizes a clinical vignette to illustrate evaluation and treatment protocols, was written to educate primary care and emergency physicians about the best practice models of treating individuals presenting with sexual assault.
Linden, who has been a certified sexual assault examiner for the Commonwealth of Massachusetts for more than ten years, conducted an extensive analysis and assessment of literature on providing care to sexual assault victims. By incorporating national guidelines, as well as areas of controversy in the field, Linden presents a comprehensive educational tool that practitioners can reference in order to provide state of the art care for victims of sexual assault.
The clinical vignette depicted a 20 year-old woman who presents to the emergency department, where she gave her account of being sexually assaulted 24 hours earlier by a man she met at a campus party. She was vaginally assaulted and had not yet reported her assault to law enforcement.
To provide the most comprehensive care, Linden recommends that the woman first be evaluated for acute traumatic physical injuries by an emergency physician. The patient should then be evaluated and treated by a team, including a trained sexual assault examiner (if available at that center) and a social worker/rape crisis advocate. If the victim presents within the time limits for evidence collection (within 120 hours after vaginal assault and 24 hours after oral and rectal assault, per Massachusetts guidelines) and consents, she should be offered evidence collection. During the evaluation, which could take up to six hours, a trained sexual assault examiner should ask the woman to give a verbal account of what happened during the assault and collect evidence (both physical and DNA, which should be done in accordance with state protocols).
The examiner should document findings and take photographs (if appropriate) that could later be used in a court of law. The woman should be offered treatment for sexually transmitted infections (STIs) and pregnancy prevention (if appropriate). Throughout the process, the rape crisis advocate or social worker should provide the emotional support necessary to help the patient get through the evaluation. If the victim suspects that she was involved in an alcohol- or drug-facilitated sexual assault (AODFSA), a full toxicology screen may be sent to a crime lab. If the victim has not yet contacted the police, one of the health providers should offer to do so (with the patient's consent). In Massachusetts, a victim can have evidence collected, even if they do not want to report immediately to the police. They then have up to 6 months (longer if they are a minor) to decide if they want to report the assault.
Once all these steps are taken, the providers should ensure that the victim has medical and psychiatric follow-up appointments prior to discharge. According to the one major study, sexual assault survivors are at an increased lifetime risk for developing Post-Traumatic Stress Disorder, major depression (30 percent), and contemplating (33 percent) and attempting (13 percent) suicide.
While not as common, male sexual assault victims may also present to the emergency department and, in those cases, the same guidelines are applicable.
"Caring for a victim of sexual assault is truly complex and can involve a host of psychological, medical and legal issues," said Linden. "I hope that this article will help demystify and clarify the issues for emergency and primary care practitioners and help standardize care models so that we can deliver optimal care to victims of sexual assault."
Linden addressed areas of controversy, including the use of HIV Prophylaxis after sexual assault when the perpetrator is not known or suspected to be HIV positive. HIV Prophylaxis, with an antiretroviral agent, can be administered within 72 hours of the assault, but given the low risk of HIV transmission from sexual assault and the complex side effects of the treatment, this must be determined on a case by case basis. Linden also provided information for readers about where to find more information and guidelines on caring for victims of sexual assault, including the United States Department of Justice and the World Health Organization.