Additional Medical Concerns

General Medical Care and Treatment

  • The Technical Guidelines are intended to serve as a guide for the care and treatment of the sexually assaulted patient.
  • The medical care and treatment of sexual assault patients should be consistent with current professional guidelines and accepted medical practice.

Sexually Transmitted Infections (STIs)

  • Examiners should provide patients with information about the potential risk of transmission of sexually transmitted infections, along with the symptoms and treatment. Some factors affecting the transmission of STIs include the type and nature of the assault, the extent of the injuries, the number of assaults, the number of perpetrators, susceptibility of the patient, and known STI status of the perpetrator(s). A discussion should occur regarding baseline treatments options along with follow up care and referrals.
  • The need for baseline testing for STIs should be considered on a case by case basis by both examiners and patients. Testing at the time of the initial exam does not typically have forensic value if patients are sexually active and a STI could have been acquired prior to the assault. Testing at the time of the exam, however, provides examiners the opportunity to recommend specific treatment and allows patients the option of deferring treatment until it is needed. If baseline testing is performed, the guidelines outlined by the Centers for Disease Control and Prevention (CDC) should be followed. Obtaining specimens for STI testing should be performed immediately following forensic specimen collection.
  • Prophylaxis against STIs at the time of the exam should be discussed with patients, and may be indicated for those patients who decline baseline testing and for those patients who may not attend a follow-up appointment or referral. Patients who prefer prophylaxis generally do not require baseline testing. Prophylaxis may include medications for trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydial infections since they are the most frequently diagnosed infections among sexually assaulted women. Prophylactic treatment should additionally be based upon any clinical presentation that may suggest a preexisting STI. Therapy should be based upon CDC recommended medications and doses.

Hepatitis B Virus (HBV)

  • Examiners should provide patients with information regarding HBV. Patients who have completed a full Hepatitis B vaccination regimen prior to the assault are generally protected from HBV infection and may not require further doses. For those patients who have not received the vaccination regimen, have not completed the regimen or are unsure, the regimen should be initiated at the exam along with follow up referrals for two additional doses given at one to two months and again at four to six months following the initial dose. If perpetrators are suspected or known to have Acute Hepatitis B, it may be advisable to administer Hepatitis B Immunoglobulin. Treatment should be based upon CDC recommended doses.

Human Immunodeficiency Virus (HIV)

  • Health care personnel should provide patients with information regarding the risks of HIV, the risk of contracting HIV from the sexual assault, and options for baseline and follow-up testing. The risks of contracting HIV from sexual assault are affected by similar factors to those described above under Sexually Transmitted Infections.
  • If the assault is considered to be a high risk for HIV exposure, a baseline HIV status may be indicated and should be obtained as soon after the assault as possible. The patient should then be tested periodically as directed. HIV testing should be performed in settings where counseling can be offered to explain results and implications.
  • Written consent is not required for an HIV test. Patients can opt out of the test if it is offered.
  • Patients should be directed to testing services that are free, anonymous, and confidential. HIV testing should be performed in settings where counseling can be offered to explain results and implications. In some circumstances, HIV testing may be performed at the time of the initial sexual assault exam and evidence collection (see below for more information).
  • The need for HIV prophylaxis, a 28 day cycle of HIV medication that may help prevent the transmission of the virus, should be assessed by the examiner and discussed with the patient. When considering prophylaxis, clinicians and patients should assess how much time has passed since the exposure occurred, the probability that the assailant is HIV positive, the likelihood that transmission could occur from the assault, and the prevalence of HIV in the community in which the assault took place (e.g., a prison). The use of post-exposure therapy must balance the potential benefits of treatment with other factors including possible adverse side effects and toxicity, the need for frequent dosing and follow-up care, the importance of compliance with therapy, and the estimated costs of the medication and monitoring. If possible, an HIV specialist should be consulted. CDC recommendations should be utilized for medications and dosing.
  • If HIV prophylaxis is appropriate, the examiner may initiate a three-day course of medication until the patient is able to attend a follow-up appointment for further assessment for the continuation of the medication.
  • See Appendix J for more information about how to help patient’s access nPEP.

Baseline Testing Recommendations

  • Baseline testing for HIV that is done at the time of the examination or within a few weeks of the assault only tells a patient if she or he was infected with HIV prior to the assault. HIV antibodies will not be evident for 3 – 6 months after the time of infection.
  • Following a possible exposure to HIV, testing is recommended at 6 weeks, 3 months, and 6 months. All sexual assault patients should be told about the need for follow-up testing and provided with referral information at the time of discharge.
  • The decision to test for HIV at the time of evidence collection should be made on an individual basis and is not appropriate for all patients. The following factors impact the appropriateness of immediate testing and should be discussed with sexual assault patients:
      • Sexual assault patients typically present to a health care facility in a state of crisis. This could impact a patient’s ability to provide informed consent to the HIV test.
      • If HIV testing is done at the time of evidence collection, results could end up in the patient’s medical records and be billed through the patient’s insurance company.
      • HIV tests administered in hospital emergency departments are typically expensive and will not be paid for as part of the costs of collecting forensic evidence.
      • Some patients who present at a health care facility for evidence collection may have limited interactions with health care systems. For these patients, the time of evidence collection could be the best opportunity for them to learn their HIV status. The Centers for Disease Control (CDC) recommends routine, annual testing for all individuals between the ages of 13 – 64.
      • If the patient is exhibiting symptoms of HIV or another STI, testing should be done to diagnose and provide treatment.
      • Most emergency departments are not set up to provide appropriate pre- and post-test counseling. HIV tests should be administered in accordance with Connecticut law [CGS § 19a-582(c)], which requires counseling or counseling referrals that include:
      • Coping with the emotional consequences of learning the results
      • Discussion of the discrimination that could accompany disclosure of results
      • Behavior change to prevent transmission or contraction of HIV infection
      • Information about available medical treatments and medical services
      • Information about local or community-based HIV/AIDS support services agencies
      • Working towards the goal of involving a minor’s parents or legal guardian in decisions related to medical treatment
      • Regarding the need of the test subject to notify his partners and, as appropriate, provide assistance or referrals for assistance in notifying partners
      • The issue of baseline testing at the time of evidence collection is complicated and should be carefully discussed with the patient. For all patients, efforts should be made to ensure testing within 120 hours of the assault. If prophylaxis is prescribed, testing should be done within 72 hours.

Drug and Alcohol Testing

  • As a general rule, testing for the presence of drugs and/or alcohol in the system of a sexual assault patient is not suggested or required unless medically indicated.
    Examiners should be aware of the possible use of “date rape drugs” in sexual assaults. If a sexual assault patient states that s/he is unable to recall time/events related to the assault, consideration should be given to the appropriateness of testing for such drugs.

Click herefor more information about drug facilitated sexual assault, deciding when/whether to test for drugs, and consent for toxicology screening.

Pregnancy Risk Evaluation and Care

Examiners should provide information to patients regarding the risk of pregnancy. A pregnancy test should be conducted (with patient consent) with all patients of childbearing age to establish the patient’s present status.

Pregnancy prophylaxis, also known as Emergency Contraception (EC) should be discussed as a treatment option. Taking EC after a sexual assault decreases a woman’s chances of becoming pregnant.

EC pills should be started as soon as possible after the sexual assault at the facility.

  • The sooner a woman takes EC pills after a sexual assault, the more effective it is.
  • EC pills are most effective when taken in the first 12 hours.
  • The FDA has approved EC pills to be initiated up to 72 hours (3 days).
  • Recent research has shown EC pills initiated up to 120 hours are effective.

As of October 1, 2007, in accordance with Public Act 07-24 An Act Concerning Compassionate Care for Victims of Sexual Assault (See Appendix A) the standard of care for each licensed health care facility that provides emergency treatment to a victim of sexual assault shall promptly include:

  • Providing each victim of sexual assault with medically and factually accurate and objective information relating to emergency contraception;
  • Informing such victim of sexual assault of the availability of emergency contraception, its use and efficacy;
  • Providing emergency contraception to such victim of sexual assault at the facility upon the request of such victim, except that a licensed health care facility shall not be required to provide emergency contraception to a victim of sexual assault who has been determined to be pregnant through the administration of a pregnancy test approved by the United States Food and Drug Administration, and;
  • No licensed health care facility that provides emergency treatment to a victims of sexual assault shall determine such facility’s protocol for complying with the standard of care requirements on any basis other than a pregnancy test approved by the United States Food and Drug Administration.