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.
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.