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ACOG Issues Report on Sexual Assault

The American College of Obstetricians and Gynecologists (ACOG), under the auspices of the ACOG Committee on Educational Bulletins, has issued a report (ACOG Educational Bulletin No. 242) on the management of women who are victims of sexual assault. The report includes discussions on the incidence of sexual assault, psychologic impact, assault assessment kits, medical evaluation, legal concerns, counseling, follow-up and special circumstances regarding sexual assault. The following is information excerpted from the report.

According to ACOG, the annual incidence of sexual assault was 200 per 100,000 persons in 1994, an increase from 73 per 100,000 persons in 1987. In addition, many women do not report sexual assault because of embarrassment, fear of retribution, feelings of guilt or simply a lack of knowledge of their rights.

The Physician's Role in the Management of Sexual Assault The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Sexual assault occurs in all age, racial and socioeconomic groups. The physician evaluating a victim of sexual assault has a number of responsibilities, both medical and legal, and should be aware of state statutory laws. The table lists the medical and legal responsibilities of the physician.

Informed consent must be obtained before the examination of a sexual assault victim is begun and specimens are collected. After acute injuries have been determined and stabilized, a careful history and thorough physical examination should be performed. ACOG recommends that a third party be present during the history taking and physical examination to reassure and lend support to the victim. Photographs or drawings should be made of the injured areas.

A pelvic examination should be performed to determine the status of the reproductive organs, collect samples from the cervix and vagina, and to test for Neisseria gonorrhoeae and Chlamydia trachomatis. The risk of acquiring a sexually transmitted infection during sexual assault is not known, but ACOG notes that Trichomonas infections may be the most likely to be acquired. While the risk of acquiring human immunodeficiency virus (HIV) infection is generally thought to be low during a single act of heterosexual intercourse, the risk may vary among populations. Hepatitis B virus is more infectious than HIV during sexual intercourse, and the report recommends that hepatitis B immune globulin be given as soon as possible after a sexual assault. It should be followed by the standard three-dose immunization series with hepatitis B vaccine beginning at the time of hepatitis B immune globulin administration.

Emergency contraception can be offered if the patient is at risk of pregnancy. Counseling should be recommended if pregnancy is diagnosed.

After the physician has administered to the physical and medical-legal needs of the victim and carefully documented all of the circumstances of the attack, ACOG recommends that the physician discuss with the patient the degree of injury and the probability of infection or pregnancy. She should be encouraged to talk about her feelings and anxieties regarding the situation. The patient needs to know the general course of physical and emotional problems that may follow and how follow-up will be done.

ACOG emphasizes that other health care personnel, especially those trained to handle such cases, should be consulted to help the patient with the follow-up. Patients should not be released until they understand what follow-up plans will be made. The patient and everyone involved in her care should agree to the follow-up plan. ACOG stresses that it is important to anticipate that the patient will probably experience some aspects of rape-trauma syndrome sometime in the future. She should understand the symptoms she may experience and be advised to seek help if these symptoms occur.

More information about ACOG educational bulletins, ACOG committee opinions and ACOG technical bulletins may be obtained by contacting ACOG at 409 12th St., S.W., Washington, D.C. 20090-6920; telephone: 800-762-2264.

--VERNA L. ROSE

IOM Recommends Increased Calcium Intakes

The first in a series of reports on Dietary Reference Intakes (DRIs) by the Institute of Medicine (IOM) covers the nutrients associated with bone growth and osteoporosis. The report, "Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride," recommends intake levels for U.S. and Canadian individuals and population groups and, for the first time, sets upper level guidelines to reduce the risk of adverse health effects from consuming too much of a nutrient. The new guidelines have different age categories, nutritional measures and recommended intake levels. The most significant changes in the report were seen with calcium.

According to the new guidelines, Americans and Canadians should consume between 1,000 and 1,300 mg of calcium per day. Children and adolescents nine to 18 years of age and adults over the age of 50 years need calcium in the higher range (1,300 and 1,200 mg, respectively), a substantial increase from the amount recommended in previous guidelines for these age groups. The calcium recommendations were set at levels associated with maximum retention of body calcium, because bones that are rich in calcium are known to be less susceptible to fractures. In addition to calcium consumption, other factors that are thought to affect bone retention of calcium and risk of osteoporosis include high rates of growth in children during specific periods, hormonal status, exercise genetics and other diet components.

Dietary Reference Intake Values for Calcium* Age Adequate intake (mg per day) Up to six months 6 to 12 months 1 through 3 years 4 through 8 years 9 through 13 years 14 through 18 years 19 through 30 years 31 through 50 years 51 through 70 years Age 70 years and older 210 270 500 800 1,300 1,300 1,000 1,000 1,200 1,200 Pregnancy 18 years and under 19 through 50 years 1,300 1,000 Lactation 18 years and under 19 through 50 years 1,300 1,000 *--All groups exept "pregnancy" and "lactation" include males and females. Adapted from Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. National Academy Press, Washington, D.C., 1997.

The report recommends that individuals who wish to increase their calcium intake should do so through conventional foods, fortified foods, supplements or a combination of these three. Supplements are recommended for persons at high risk of health problems related to low calcium intake.

DRI values include recommended dietary allowance (RDA), adequate intake (AI), estimated average requirement (EAR) and tolerable upper intake level. In this first report in the series, RDAs were set for some nutrients. An AI was established if there was insufficient information to recommend an RDA. AI levels (see table) and a tolerable upper intake level were established for calcium. The upper limit for calcium is 2,500 mg per day for all persons one year of age and older. The upper limit figure is not intended by the IOM to be a recommended level of intake, and the IOM stresses that there is no established benefit for individuals to consume nutrients at levels above the RDA or AI. The tolerable upper intake level refers to total intakes from food, fortified food and nutrient supplements. The EAR is an intake that meets the estimated nutrient need of one half of the individuals in a specific group.

The DRIs were derived by a panel of experts appointed by the National Academy of Sciences who spent one year reviewing the scientific studies of the various nutrients associated with bone growth and osteoporosis. The panel considered the roles of these nutrients in decreasing the risk of chronic and other diseases and conditions and interpreted the current data on intakes in the U.S. and Canadian population groups. Subsequent reports will focus on at least six other nutrient groups, all of which will be managed by the IOM Food and Nutrition Board's Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. The six additional groups are folate and other B vitamins; antioxidants (e.g., vitamins C and E, selenium); macronutrients (e.g., protein, fat, carbohydrates); trace elements (e.g., iron, zinc); electrolytes and water; and other food components (e.g., fiber, phytoestrogens). The recommendations for folate and other B vitamins should be announced this spring.

The IOM recommendations have been given to various government agencies. It is planned that a subcommittee will be established to determine the uses of the DRIs in various settings.

The complete report can be ordered on the Internet site of the National Academy Press, at http://www.nap.edu. Copies may also be ordered by calling 800-624-6242 or 202-334-3313.

--VERNA L. ROSE

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