Know (Part II)

Recently, I discussed the basic importance of knowing resources in your area for women who have been sexually assaulted. If you have a woman walk in for a birth control visit, or a routine OB visit, or a pap smear, and she reports a sexual assault to you, do you know your local resources or the national hotline? Check it out. (It should be said that posts of this depth and nature are mostly self-serving: the review of information and research helps me as a provider, and my goal is that it is helpful to others. As a fellow provider, friend or family member to women, this is good information to know!)This week, let's talk about what to prepare for, if you have a woman who answers that yes, she has a history of sexual assault, or that she was recently assaulted. If you're going to screen, know how to follow-up with that if your screening tool turns up positive. (This also applies for depression screening in pregnancy, domestic violence, tobacco use, alcohol abuse, or interest in a methadone program. If you're going to ask the question, it's only appropriate practice to know how to follow-up if she answers, "Yes.") This post will not discuss the longer term effects of sexual assault, including sequelae during pregnancy. I have heard rave reviews about When Survivors Give Birth by Penny Simkin, if you would like to know more about that area specifically.If you are a Registered Nurse and have a particular interest in this area, the Sexual Assault Nurse Examiner (SANE) program is an amazing one. They are now offering online nursing education contact hours and application for qualification for clinical hours. The online portion is free, and likely contains wicked important information. Check. It. Out.Regarding how to prepare for a visit, I've scoured my current academic resources, and here is what the experts say.In "Primary Care of Women," (Editors Barbara Hackley, Jan Kriebs, and Mary Ellen Rousseau) section author Patricia A. Paluzzi provides a thorough history and resource list in the section "Rape or Sexual Assault." She importantly states that "Rape is a crime of violence and not of passion; the victim's behavior does not warrant this assault" (p. 197).  Items she includes that were missing from my own knowledge before re-reading this text were the list of concerns sometimes included in rape trauma syndrome, including "PTSD; depressive and anxiety disorders; other phobias; lowered self-esteem, social adjustment problems, and sexual dysfunction" (from Bell, et al., 1995; p. 198). Possible emotional stages women may work through include: (1) immediate shock, denial, crying; (2) feeling safe and sharing the experience; (3) calm and adjustment; and (4) triggers that bring back the event. "A client may present for care during any of these phases. Recognizing them and responding appropriately can assist the woman in getting the care she needs at that moment... Each client interaction will likely be different and what is most important is to offer the client appropriate referrals to meet her needs." Regarding assessment, I quote these words as a possible mantra pointing to the importance of creating a relationship with patients and providing a safe space for talking about this and any issues:"Recommendations are to screen every client during every annual visit as wells as every prenatal visit during pregnancy. A few studies have demonstrated that repeated assessment seems to be more effective for gaining disclosure, especially during pregnancy. Problem visits, especially if the client is presenting with an STD or repeated complaints of a pelvic problem, gastrointestinal problems, or other stress-related diseases should be used as a time for assessment. Because anyone can be abused and because repeated screening is more effective, universal screening is the preferred practice" (p. 202).YES.Patricia Paluzzi also points out the importance of language in these situations. Using the term "abuse" may be inappropriate, as not all women may consider their situation as such. Instead, asking if she "has ever been forced to participate in sexual activity that made her uncomfortable... if she is ever afraid of her partner" (p. 202).Important in this consideration of language is the subsection of sexual assault within established relationships, known as intimate partner violence (IPV). Sexual assault may be part of the violence a woman experiences in her partnership, and language around what activity is happening may be particularly important given the relationship of the person to her life. IPV is a very focused area of emotional, social, and physical violence, and can be considered jointly and separately in this situation. For this point, I will consider IPV mostly a separate issue, and will continue to speak about how to handle an acute or chronic sexual assault patient clinicians may see in clinic.Specific to marital sexual assault, authors Sheridan, Fernandes, Alden, Van Pelt and Campbell in the chapter "Intimate Partner Violence and Sexual Assault" from   "Women's Gynecologic Health," (Editors Kerri Durnell Schuiling and Frances E. Likis) provide some startling numbers. "Approximately 10-14% of all married women, and at least 40% of battered wives in the United States, have been sexually assaulted by their husbands (Campbell & Alford, 1989)... Spousal sexual assault is often more violent, repetitive, and less commonly reported, because of economic considerations as well as the humiliation and sense of marital failure that may accompany this form of sexual violence (Dupre et al.)" (p. 310). Know this.Back to "Primary Care of Women," Paluzzi points out that midwives may be the initial point of care for a woman who has experienced sexual assault, and thus should be prepared to explain what a sexual assault exam entails. I quote: "The midwife needs to counsel the client about the usefulness of having a sexual assault exam during which evidence can be collected. The client should be counseled that going through this type of exam does not mean that she must participate in legal activities but does have that option, should that be her decision... Anticipatory guidance for a [sexual assault] exam includes counseling that evidence collection can be done for up to 72 hours after the incident using a Physical Evidence Recovery Kit. This involves: collecting clothing worn at the time of the assault; combing through pubic and head hair to collect samples; taking swabs from all orifices that were involved in the assault; and perhaps performing a toxicology screen if the assailant used drugs" (p. 204). Written consent is required for the sexual assault exam, and a separate consent is needed to contact the police and turn over any evidence.If the assault happened more than 72 hours prior, the following can be considered:

• Evidence collected
• Baseline tests for pregnancy and STIs, including HIV
• Emergency contraception offered
• Six-week follow-up for pregnancy and STI screens
• Six-month follow-up for HIV (and, I would add, Syphilis and Hepatitis B)

If the client declines the sexual assault exam, the following can be accomplished:

• Assess and document injuries
• Perform baseline tests for pregnancy and STIs
• Offer emergency contraception
• Assess client's mental status and take appropriate measures
• Document all available details of the incident that might be used later if the client decides to pursue legal action, including using photos and/or a body map

All of this is available on pages 204-205 of the "Primary Care of Women" book, much of which I have quoted directly. The last two groups of bullets are important for any clinician, including those not trained in sexual assault exams. Additionally, asking the client about previous sexual abuse or assault provides an opportunity to fully document her history, her past disclosure to providers, and whether any further support may be indicated. Finally, Paluzzi includes vital information about safety planning, documentation and considerations about medical records potential for subpoena, marking charts or separating charts that should be considered separate of confidential, and self-care for providers caring for sexual assault victims on a regular basis.

Back to "Women's Gynecologic Health," Sheridan et al. review barriers that may prevent immediate care-seeking by a woman experiencing sexual assault. These include "fear of retaliation by the assailant, self-blaming, feeling humiliated, or inability to remember details of the assault due to drugs or alcohol" (p. 311). [NB: the woman I saw who reported assault months prior discussed all of these points - all the more important to provide the safe space, leave room to listen, and ask open-ended questions. These authors also quote Maryland research encouraging a sexual assault exam up to 120 hours rather than the regularly-used 72 hours. Importantly "Consent should be obtained from the sexual assault patient during each step of the medical investigation, including the history, physical examination, evidence collection, and photography (Petter & Whitehill, 1998). Asking consent for each aspect of the examination serves to help assaulted patients regain control and establish trust between the clinician and the patient" (p. 312).

Regardless of the level of sexual assault exam in which the clinician is trained, or that the client consents to, a detailed history (with consent obtained) would include the following (see p. 312):

• Age and identifying information for both the patient and the report assailant (if available)
• Date, time, and location of the reported assault
• Circumstances of the assault
• Details of the sexual contact - whether it was penile, digital, or object penetration of the vagina, oral cavity, or anus - as well as documentation of any ejaculation or urination by the assailant
• Type of physical restrained used, such as weapons, drugs, or alcohol
• Activities of the patient after the assault, such as change of clothing, bathing, douching, dental hygiene, urination, or defecation
• Focused gynecologic history - last menstrual period, contraceptive use, pregnancy history, last voluntary sexual encounter, and any recent episode of gynecologic infection or pelvic surgery (Petter & Whitehill, 1998)

Cynthia Ferguson, in her Journal of Midwifery and Women's Health article "Providing Quality Care to the Sexual Assault Survivor: Education and Training for Medical Professionals" (2006), she references adaptation of the Lynch model of TRACS documentation of assault from blunt force. (The entire article is worth reading, by the way. Find a friend with journal access, and get on that.)Williams Obstetrics also provides basic  what-can-you-do-right-then information regarding prophylaxis against STIs in victims of sexual assault. It's essentially the treatments for all STIs used as prophylaxis, but I've outlined it below with the updated gonorrhea criteria.

• Gonorrhea: Ceftriaxone 250mg IM x1 dose
• Chlamydia: Azithromycin 1g PO x1 dose
• BV: Metronidazole 500mg PO BID x7 days (I might also consider an available prescription for yeast which may develop from the assault or the antibiotic use above)
• Trichomonas: (covered by the BV treatment above)
• Hepatitis B: If not previously vaccinated, give first dose HBV vaccine, repeat at 1-2 and 4-6 months
• HIV: consider prophylaxis if risk for exposure is high

It is incredibly important to consider the level of preparation needed to appropriately provide care for a woman with an acute sexual assault. Schuiling and Likis' "Women's Gynecologic Health" includes a lengthy description of appropriate physical examination and evidence collection. However, Varney’s Midwifery includes minimal information about midwifery preparation for the physical exam of a patient presenting with acute or past sexual assault. However, in the chapter "Common Diagnoses in Women's Gynecological Health," Bill McCool and Dawn Durain explain its limited scope.“Midwives often have particular patience and skills in encouraging relaxation. This is a perfect opportunity to use those skills. The nature of the gynecologic examination may be particularly prone to retraumatizating the woman if her abuser and her health care provider are of the same gender. If abuse is known to the midwife or revealed during the visit, the midwife should offer the presence of another staff member or a support person for the examination… If the problem appears to be acute, the midwife should assess what type of examination other providers (e.g., Sexual Assault Nurse Examiner[SANE]) may need to do and limit the current examination to only those elements that are absolutely necessary for consultation or referral” (p 413).I happen to agree with Varney's belief that this is an area for which a highly trained SANE-RN or sexual assault examiner should be utilized. No one wants to mess up evidence collection, and we all want to support women in the best way that we can. If you are interested in this area, have not found a SANE-RN you can call or are comfortable with, or believe this should be an extension of continuity of care for your patients, check out the SANE-SART website or find local training resources in your area. Or, bring the SANE-SART expert to you for the 40-hour training:TO BRING A SANE TRAINING TO YOUR AREA...If interested in bringing a SANE-A training to your area, please contact Dr. Linda Ledray:Dr. Linda E. Ledray, PhD, RN, SANE-A, FAANDirector, SANE-SART Resource ServiceMMRF, Minneapolis, MNPhone: 612-347-0910Adult/Adolescent SANE Trainings ProvidedE-mail: Dr. Linda E. Ledray (linda@sane-sart.com)Whether for the benefit of family, friends, or clients, this information is incredibly important. Worth sorting through and getting one's brain around, for the sake of being prepared when she finds within you a safe space, and opportunity to disclose, and possibly, need for support.Need more? Here are two links to recent additional interesting research (with no attention to order or APA style)."Documenting Domestic Violence: How Health Providers Can Help Victims." National Institute of Justice, Research in Brief. Sarah V. Hart, Director. September, 2001."Acute Severe Pain Is a Common Consequence of Sexual Assault." McLean, et al. The Journal of Pain. August, 2012.