Study Points

Sexual Assault

Course #97022 - $15 • 3 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Among women in the United States, the prevalence of attempted or completed rape (at some time in life) is estimated to be

    EPIDEMIOLOGY

    Although victims of sexual assault are overwhelmingly adult women, the problem is encountered among persons of diverse age and gender. In 1995–1996, a national survey of 8,000 women and 8,000 men found that 1 in 6 women and 1 in 33 men had experienced an attempted or completed rape at some time in their lives [1]. One-half of the female victims reported they had been assaulted before their 18th birthday. Most rape victims indicated the assailant was someone they knew, and only 1 in 5 reported the assault to the police. Based on these data, the lifetime incidence of sexual assault in the United States was estimated to be 18% for women and 3% for men. Given the complexity of the problem and the limited methodology of reported studies, most of which were survey-based, the actual incidence was considered to be greater than indicated by these data [2].

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  2. Compared with the general population, the risk of sexual assault is higher in which of the following subgroups?

    EPIDEMIOLOGY

    Most victims of sexual assault are young, and population groups at increased risk are college students, children and adolescents, the mentally disabled, the homeless, and persons who are gay, lesbian, bisexual, or transgender [3,4]. The victimization of college students, often perpetrated by an acquaintance and frequently associated with the heavy use of alcohol by both victim and assailant, has become a national problem and public health concern [5].

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  3. Regarding persons presenting to an emergency department with the complaint of sexual assault, which of the following statements is FALSE?

    EPIDEMIOLOGY

    Victims of sexual assault are most likely to present to hospital emergency departments (EDs), public health and gynecology clinics, college infirmaries, and primary care offices. Published clinical series from urban EDs have helped define the scope and character of sexual assault injury [7,8,9]. Based on these clinical reports, it may be seen that victims of sexual assault presenting to an ED are predominantly female, relatively young, often know their assailant, and are likely to have been threatened with violence and to show physical signs of trauma.

    In one such study of 1,076 cases seen between 1992 and 1995, the age of victims ranged from 1 to 86 years (half were younger than 26 years of age) and 96% were women [7]. In 60% of cases, the assailant was someone known to the victim. Force was used in 80% and a weapon was present in 27% of incidents. Vaginal penetration was documented in 83% of cases, oral assault in 25%, and anal penetration in 17%. Signs of genital trauma were evident in 53% of cases, and extra-genital trauma was noted in 67% of victims. Similar results were found in an ED study of 1,100 patients published in 2009. In this study, 92% of victims were female, and the median age was 27 years. The majority of victims (57%) knew their assailant. Threat of force was used in 72% of cases, and physical trauma was evident in 52% of victims [8]. Alcohol consumption or drug use was involved in 54% of these assaults.

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  4. The evaluation and treatment of the patient who has been assaulted should include

    EVALUATION

    The evaluation and treatment of sexual assault victims should incorporate the following components [11,12]:

    • General assessment and treatment of physical injuries, with special attention to the genitalia

    • Forensic evaluation, where indicated and with informed consent

    • Pregnancy risk assessment and prevention

    • Evaluation, treatment, and prevention of STDs

    • Psychologic assessment, crisis intervention, and follow-up referral for counseling

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  5. With respect to non-genital bodily injury sustained in sexual assaults, all the following statements are true, EXCEPT:

    EVALUATION

    Non-genital bodily injury is seen in more than half of all rape victims presenting to EDs [7,8]. In one study of 162 women examined between 2002 and 2006, signs of bodily injury were found in 61% of patients, with genital injury present in 39% [13]. Most common were bruises (56%) and abrasions (41%), followed by lacerations, penetrating injury, and bites. Evidence of injury was higher in the 137 cases examined within 72 hours of assault (66% vs. 33%) and in cases in which the assaults occurred outdoors (79% vs. 52%).

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  6. All of the following statements concerning genital injury following sexual assault are true, EXCEPT:

    EVALUATION

    Signs of genital traumatic injury are not always found after sexual assault, and in such cases should not be taken as evidence that sexual assault did not occur [13]. When routine inspection is combined with additional examination techniques, such as colposcopy and toluidine blue staining, the rate for identifying genital injury approaches 70% [9]. Observed rates of genital injury are highest in women examined within 72 hours (40% vs. 7%), in those of virginal state (60% vs. 33%), and in cases involving assault by strangers or multiple assailants [14].

    The common types and location of genital injuries, and thus the areas to be examined most closely, are:

    • Bruises and abrasions to the labia, fossa navicularis, or perianal area

    • Ecchymoses, tears, or lacerations of the hymen

    • Abrasions and/or tears of the posterior fourchette

    • Tears/lacerations in the perianal area

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  7. The first step in preserving evidence is

    FORENSIC EVALUATION

    The first step in preserving evidence is identifying the precise nature of the assault, circumstances, and scope of injury to the victim. This helps to determine the direction of the investigation and the type of forensic evidence to be obtained during the course of the clinical and forensic evaluation. The time of the assault and the sequence of events following should be ascertained, as the quality of evidence often deteriorates over time. For example, DNA in saliva deteriorates especially rapidly, often in less than 48 hours. It is recommended that a sexual assault forensic exam be administered within 96 hours of an attack for the collection of trace evidence; however, bruises, bite marks, and other injuries are often still evident beyond this time frame [16,17].

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  8. For the purpose of photographic documentation of forensic evidence, it is considered good practice to

    FORENSIC EVALUATION

    Photo-documentation will typically proceed along with the physical examination and the collection of evidence. When an injury or other evidence (e.g., fluids, fibers) is found, it should be photographed. It is considered good practice to capture four images of each finding [15]. One should be an overall shot of the body and should include a clear anatomical reference (e.g., arm, hand, leg, foot), another should be a medium shot, and there should be two detailed shots of the finding. The wide and medium shots can be used to document multiple findings. Detailed shots of each finding should be taken before evidence collection, during manipulation, and after the evidence is swabbed or removed. If a lifesaving measure may disturb evidence, it is ideal to photograph the site/finding beforehand, if possible.

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  9. For post-exposure STD prophylaxis after suspected rape by an unknown assailant, all the following statements are true, EXCEPT:

    SEXUALLY TRANSMITTED INFECTION

    PREVENTIVE TREATMENT OF ADULTS AND ADOLESCENTS AFTER SEXUAL ASSAULT

    Condition Protocol
    PregnancyLevonorgestrel, 1.5 mg orally (single dose), preferably given within 12 hours of exposure if urine and/or serum pregnancy test is negative
    Sexually transmitted infections
    Gonorrhea, chlamydia, and trichomoniasisCeftriaxone, 250 mg IM, plus azithromycin (1 g orally in a single dose) or doxycycline, 100 mg twice daily for 7 days, plus metronidazole (2 g orally in a single dose) or tinidazole, 2 g orally (single dose)
    Hepatitis BVaccination protocol (unless known to be immune)
    HPVVaccination protocol for girls/women through 26 years of age and boys/men through 21 years of age
    HIVHIV combination antiviral therapy, 28-day course, initiated within 72 hours of exposure. The decision to treat (based on risk assessment) and the choice of drug regimen should be made in consultation with local infectious disease specialists
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  10. Discharge planning and one- to two-week follow-up for the assault victim are important for

    PSYCHOSOCIAL ASSESSMENT AND FOLLOW-UP CARE

    The patient should be seen in follow-up within one to two weeks. The purpose of this encounter is to assess clinical progress and compliance with medication, to check the adequacy of the patient's support system, and to offer counseling. A diagnostic evaluation for STDs may be performed as well, if this was deferred at the time of the initial evaluation.

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.