Guidelines Updated on Care for Sexually Assaulted Teens CME/CE
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.
Release Date: August 6, 2008; Valid for credit through August 6, 2009
Physicians – maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians – up to 0.25 AAFP Prescribed credit(s) for physicians;
Nurses – 0.25 nursing contact hours (None of these credits is in the area of pharmacology)
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.
Physicians should only claim credit commensurate with the extent of their participation in the activity.
August 6, 2008 — The American Academy of Pediatrics (AAP) has updated its 2001 guidelines on care for teens who have been sexually assaulted. The revised recommendations are published in the August issue of Pediatrics.
“Many terms have been used to describe sexual assault, including rape, statutory rape, acquaintance or date rape, sexual abuse, molestation, and incest,” write Miriam Kaufman, MD, and the AAP Committee on Adolescence. “There is great overlap and some confusion in the definitions of nonconsensual sex acts….Sexual assault includes situations in which there is sexual contact with or without penetration that occurs because of physical force or psychological coercion or without consent, including situations in which the [assaulted adolescent] would be unable to consent because of intoxication, inability to understand the consequences of his or her actions, misperceptions because of age, and/or other incapacities.”
Since the previous AAP policy statement on sexual assault was issued in 2001, additional evidence has been published concerning sexual assault and rape in adolescents and regarding the treatment of the adolescent who has been sexually assaulted. The purpose of the updated guidelines, which highlight the evaluation and care of sexually assaulted adolescents, is to offer new information to update clinicians.
Specific recommendations for prophylactic treatment are as follows:
- Gonorrhea: Ceftriaxone, 125 mg intramuscularly once, for oral and/or anogenital penetration. An alternative option suitable for anogenital but not for oral penetration is cefixime, 400 mg orally, once.
- Trichomonas species: Metronidazole, 2 g orally once.
- Chlamydia: Azithromycin, 1 g orally once, or doxycycline, 100 mg orally twice daily for 7 days.
- Hepatitis B: Immunization should be completed, if this was not done previously.
- Human papillomavirus: Immunization should be completed, if not done before the assault.
- Pregnancy prevention or emergency contraception: 2 orally administered 0.75-mg levonorgestrel tablets, given 12 hours apart.
- HIV: Although HIV prophylaxis is not universally recommended, it should be considered when there is oral, vaginal, or anal mucosal exposure. Pertinent factors include repeated abuse or multiple perpetrators; oral, vaginal, or anal trauma; HIV status of the perpetrator, if known; presence of a genital lesion in the assaulted teen or in the perpetrator, if known; and prevalence of HIV in the geographic area where the sexual assault occurred. If rapid testing of the assailant is available, prophylaxis can be initiated and then stopped if the test result is negative.
Specific recommendations for treatment of adolescents who have been sexually assaulted, as well as recommendations designed to prevent such abuse, are as follows:
- Clinicians should routinely initiate a discussion with their adolescent patients concerning the potential for sexual and physical violence, including that occurring within relationships. In addition to helping prevent sexual assault, this discussion may reduce the stigma associated with reporting sexual assault should it occur.
- Clinicians should be knowledgeable concerning the current reporting requirements for sexual assault and the laws that protect the confidential rights of adolescents to receive care at rape crisis care centers in their state.
- Clinicians should be aware of relevant community resources, including sexual assault and rape evaluation services. They should know when and where to refer adolescents for a forensic medical examination and sexual assault care, and they should have appropriate referral information for services provided to adolescents with disabilities.
- Adolescents, including those with disabilities, should be routinely screened for a history of sexual violence. Clinicians should specifically address the potential of dating violence and sexual assaults.
- Teenagers with positive histories of sexual assault should undergo timely and appropriate screening, prophylaxis, and treatment of sexually transmitted infections, including referrals for care and potential sequelae when indicated.
- Within 120 hours of the assault, female adolescents who have experienced a sexual assault should be offered emergency contraception. Because emergency contraception is safe, it should be made available even if the adolescent is unsure whether penetration occurred. At the time of the evaluation, pregnancy status should be documented with either a blood or urine sample.
- Sexual assault is associated with the potential for long-term psychological consequences. Therefore, clinicians should be ready to offer psychological support or referral for counseling, and they should be able to refer sexually assaulted adolescents to appropriate community services providing management, examination, and counseling.
Follow-up care at 1 week should evaluate injury healing and ensure that counseling has been arranged. Reassessment for STIs may be indicated. Pregnancy testing can be performed at 2 weeks. The Centers for Disease Control and Prevention recommend repeated syphilis testing after 6 to 12 weeks and HIV testing 3 to 6 months after the assault, if initial test results were negative and if infection could not be ruled out in the assailant.
“Physicians should be aware that sexual assault is common and need to be prepared to counsel their adolescent patients to avoid high-risk situations,” the authors conclude. “Screening of adolescents for sexual victimization should be part of visits for psychological problems, sexuality issues, contraception or substance abuse, and health supervision. Physicians should include information about ways to prevent sexual assault as part of anticipatory guidance with adolescents with and without disabilities, tailored to cognitive abilities to understand.”
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
- Define adolescent sexual assault and variations on its definition.
- Describe risk factors and management strategies for acute sexual assault of adolescents.
Many terms have been used to describe sexual assault including rape, statutory rape, acquaintance or date rape, sexual abuse, molestation, and incest. There is overlap and some confusion about the definitions of nonconsensual sexual acts with variations in the age of consent in US states, with 18 years being the most common definition of age of consent. The term sexual assault refers to any forced or inappropriate sexual activity without consent, including contact with or without penetration; situations of intoxication, misperception, and other incapacities; and can include “touching sexual or intimate parts.” Certain state laws require reporting of sexual contact between a minor and his or her sexual partner, and clinicians need to be aware of these laws and their changes, available through the Child Welfare Information Gateway.
This is a summary of risk factors for adolescent acute sexual assault and management strategies for treatment and follow-up, provided by the Adolescent Committee of the AAP.
- Teens and young adults have the highest rates of rape and other sexual assaults of any age, with rates ranging from 1.2 to 1.7 per 1000 persons for both girls and young women and boys and young men and more than 10 times more female than male adolescents affected.
- Two thirds of sexual assaults are perpetrated by an acquaintance or relative.
- Those with developmental disabilities (in particular, mental retardation) are at higher risk for acquaintance or date rape with a 1.5 to 2 times higher risk than the general population.
- Services for physical examination of those with physical disabilities should be identified.
- Teens vs young adults are more likely to have used drugs or alcohol (reported by 40%) associated with sexual assault and to delay care.
- Multiple assailants, weapons, and forced oral assaults are more common in assaults of male than female adolescents.
- Clinicians should routinely discuss the potential for sexual and physical violence with their teen patients and screen those with disabilities for a history of sexual violence.
- Clinicians should be knowledgeable about an appropriate forensic medical examination and services available in the community.
- Some states require reporting of assault even if the teen does not consent to the reporting.
- A forensic medical examination includes history, documentation of biological and physical findings, collection of evidence from the patient, and additional evidence gathering.
- With DNA amplification, a forensic examination can be useful for at least 4 days after the assault.
- As many as 32% of teens may show signs of intercourse after the acute period, and video colposcopy may be beneficial during the physical examination.
- Clinicians should document screening, prophylaxis, and treatment of sexually transmitted infections in patients with positive histories and offer emergency contraception to female adolescents within 120 hours of the assault, even if it is uncertain if penetration has occurred.
- Prophylactic treatment of chlamydia and gonorrhea should be recommended to adolescents who have been assaulted vaginally or anally or orally based on recommendations from the Centers for Disease Control and Prevention.
- Documentation of pregnancy status should occur at presentation with a urine or blood sample.
- Pregnancy prevention may be offered as 2 tablets of 0.75 mg of levonorgestrel taken at once.
- Clinicians should be familiar with collecting an unbroken chain of evidence.
- Serum samples should be taken at baseline for HIV and syphilis testing, and syphilis tests should be repeated at 6 to 12 weeks, whereas HIV tests should be repeated at 3 to 6 months.
- HIV infection from a single episode of sexual assault is rare, and adherence to triple HIV prophylaxis is low.
- Where significant risk for HIV infection exists, prophylaxis should be offered within 72 hours of exposure with use of 3 medications.
- Hepatitis B immunization should be initiated or completed as appropriate as well as the human papillomavirus vaccine.
- Follow-up can include a visit 1 week after the first visit to assess injury healing and reassess sexually transmitted infections.
- At 2 weeks, pregnancy testing can occur.
- The teen’s emotional status should be assessed, including sexual identity, posttraumatic stress disorder, and the risks for suicide and self-harm.
- Up to 80% of sexually assaulted teens experience posttraumatic stress disorder.
- Rape trauma syndrome is an initial phase lasting for days to weeks, with anxiety, fear, and guilt, followed by a reorganization phase for months to years.
- Trauma-focused behavioral therapy has been shown to be useful, and referral to a sexual assault center should be considered.
Pearls for Practice
- Teen sexual assault refers to any forced or inappropriate sexual activity without consent, including contact with or without penetration; situations of intoxication, misperception, and other incapacities; and can include “touching sexual or intimate parts.”
- Clinicians should be aware of teen risk factors for sexual assault, procedures for documentation, treatment, prophylaxis, management, referral and follow-up of assault; and the state and local laws about reporting sexual assault in teens.
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- August 7, 2008 / 12:26 pm