Management of Rape Victims Martin Donohoe Information within

Management of Rape Victims Martin Donohoe Information within does not constitute clinical advice regarding treatment – I recommend consulting contemporary medical references

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

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

Rape n n Annual incidence of at least 300, 000 women in US n Forcible rape every 6. 2 seconds (FBI) n 7% of all violent crimes n Additional 3. 7 million confronted with unwanted sexual activity Lifetime prevalence 13 -39% in women; 3% in men

Epidemiology of VAW n 2011 CDC study n 18% of women have been raped; 1. 4% of men n Women: 52% by partner; 41% by acquaintance n Men: 52% by acquaintance; 15% by stranger

Date Rape n 40% of college women report forced sexual contact, attempted rape, or completed rape nindependent of school demographics

Date Rape >25% of college males admit to using sexually coercive behaviors n 2/3 of college males report engaging in unwanted sexual intercourse n reasons: peer pressure, desire to be liked n

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

High Risk Groups n n n Prostitutes Military n See the “Women’s Health” and “War and Peace” pages of the Public Health and Social Justice website for other slide shows and articles covering: n Violence against women in the military n War, rape and genocide Homeless and runaways

High Risk Groups n n Gays, lesbians, bisexuals, transgendered Alcohol and drug users College students Persons under age 24

“High Risk” Perpetrators n. Male college athletes n. Fraternity n. Men members with restraining orders

Rape 5% chance of pregnancy n 25% chance of acquiring STD n GC = 6 - 12% n Chlamydia = 4 - 17% n Syphilis = 0. 5 - 3% n

Rape 5% chance of pregnancy n 25% chance of acquiring STD n GC = 6 - 12% n Chlamydia = 4 - 17% n Syphilis = 0. 5 - 3% n

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

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

Rape n n 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

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

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

The Physician’s Duties in Caring for Victims of Sexual Assaults n Medical n medical history n evaluate and treat physical injuries n cultures n treat pre-existing infections NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

The Physician’s Duties in Caring for Victims of Sexual Assaults n Medical n offer post-exposure HIV prophylaxis n offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) n arrange medical followup n provide counseling n NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

Physical Examination of Sexual Assault Victims n n Collection of clothing External/internal evaluation n abrasions, lacerations, ecchymoses, bite marks; colposcopy, toluidine blue staining Oral cavity n secretions, injuries, cultures Note: time limits for evidence collection vary by state (72 -120 hrs) n NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

Physical Examination of Sexual Assault Victims n n Genitalia n hair combing, hair sampling, vaginal secretions, injuries, cultures Rectum n injuries, cultures NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

Prophylaxis for Adult Victims of Sexual Assault Antibiotic Prophylaxis Ceftriaxone (250 mg IM) or cefixime (2 g po) PLUS n Doxycycline (100 mg po bid x 7 d) or Azithromycin (1 g po x 1) PLUS n Metronidazole ( 2 g po x 1) n

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy n 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%)

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy n n 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 n Nearly 100% effective

HIV Post-Exposure Prophylaxis for Adult Victims of Sexual Assault n HIV Prophylaxis n Consult ID n start up to 72° after rape n Baseline HIV test and referral to experienced clinician within 72 hours of starting PEP

Hepatitis B Post-Exposure Prophylaxis for Adult Victims of Sexual Assault n n n Offender HBs. Ag-positive: administer Hep B vaccine and HBIG Offender’s HBs. Ag 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

Ensure Victim’s Safety Social worker involvement n Restraining order n Phone numbers of shelters, hotlines n Safe place to go n

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

Domestic Violence Shelters Woefully underfunded n Average length of stay = 14 days; most allow 30 day max stay n Over 50% of all homeless women and children are fleeing domestic violence n

Contact Information Public Health and Social Justice Website http: //www. phsj. org martindonohoe@phsj. org