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Management of Rape Victims

Management of Rape Victims. Martin Donohoe Information within does not constitute clinical advice regarding treatment – I recommend consulting contemporary medical references. Rape. Unwanted, forced penetration (oral/vaginal/anal) Reported by 33 -46% of women who are physically abused.

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Management of Rape Victims

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  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 300,000women 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 • >25% 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 “Women’s 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 mother’s 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 Physician’s Duties in Caring for Victims of Sexual Assaults • Medical • medical history • evaluate and treat physical injuries • cultures • treat pre-existing infections NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

  20. The Physician’s 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; 332:234-7 and NEJM 2011;365:834-41

  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; 332:234-7 and NEJM 2011;365:834-41

  22. Physical Examination ofSexual Assault Victims • Genitalia • hair combing, hair sampling, vaginal secretions, injuries, cultures • Rectum • injuries, cultures NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

  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)

  24. Prophylaxis for Adult Victims ofSexual AssaultPrevention of Pregnancy • Most effective oral regimen: 1 dose of 30 mg ulipristal or 1.5 mg levonorgestrelwithin 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 • Offender’s 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 Victim’s 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@phsj.org

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