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Female and Male Sexual Assault Lisa A. Moreno-Walton INTRODUCTION AND EPIDEMIOLOGY Sexual assault is a crime of violence, intended to dominate and humiliate the victim through the use of intimidation and fear.1 In many parts of the world, sexual assault is a tool for oppression, a weapon of war, and an act of genocide. Psychological trauma is a universal consequence of rape and sexual assault, but the absence of physical injury does not indicate that an assault did not take place. Sexual assault remains a major public health problem throughout the world, with case rates of police-recorded incidents as high as 92.9 per 100,000 in Botswana to a first-time record of 0.0 in Liechtenstein in 2010. 2 In the United States, the incidence of rape decreased from 1.6 cases per 1000 people in 2015 to 1.1 cases per 1000 in 2016 3; however, nearly one in five American women (18.3%) report being raped at some time during their lives. 4 Although males are less commonly victimized, studies estimate that between 0.6% and 22.2% of males have experienced sexual assaults. 5-7 According to the National Electronic Injury Surveillance System, sexual assaults accounted for >150,000 ED visits in 2001 in the United States. However, many sexual assault survivors do not report the assault to police or seek medical care. 9 The Department of Justice estimates that only 34.8% of sexual assaults are ever reported.10 Women are likely to seek treatment earlier for more severe assaults and injuries, and they are more likely to delay seeking assistance if assaulted by a known perpetrator. In most cases of rape in the United States, a single assailant is involved, and most often, the perpetrator is known to the victim. 11 Twenty-six percent of assailants are current or former partners, 38% are friends or acquaintances, and only 26% are strangers. 10 Force or coercion is used in most assaults, but a weapon is reported in only 11% of cases. 4 About half of female12 and male13 assault survivors have genital or rectal trauma on examination, and about two thirds have some evidence of bruising elsewhere.12 Injuries are more often found in female patients <20 years old or >49 years old, those who have experienced anal assault, and those who present within 24 hours of assault. Survivors age 12 to 17 years are more likely to have anogenital injuries than those age 18 to 49 years. HEALTHCARE RESPONSIBILITIES Care of the sexual assault victim is complex and can be time consuming. Responsibilities include obtaining the medical and forensic history; performing and documenting results of the medical examination; collecting forensic evidence and ensuring that material follows the proper chain of custody; treating potential sexually transmitted infections; treating other acute medical problems and injuries; assessing pregnancy risk and pro viding treatment options; providing referral for crisis intervention and medical follow-up; coordinating care with sexual assault advocates; and testifying in court if needed. 15 Although some hospitals provide sexual assault nurse examiners (see next paragraph) to aid in medical and forensic evaluation, in many institutions, emergency physicians will be expected to provide most of the care for sexual assault victims. Sexual assault nurse examiners (SANEs) provide expert assistance for sexual assault evaluation. SANEs are certified by examination through the Commission for Forensic Nursing Certification.

ic evaluation, in many institutions, emergency physicians will be expected to provide most of the care for sexual assault victims. Sexual assault nurse examiners (SANEs) provide expert assistance for sexual assault evaluation. SANEs are certified by examination through the Commission for Forensic Nursing Certification. Require ments before examination include an unrestricted registered nurse license, 2 years of nursing experience, 40 hours of coursework, and competency in supervised sexual assault examination. 16 Physicians, physician assistants, and nurses can also complete a separate course of training and receive certification as sexual assault forensic examin ers (SAFEs). The Department of Justice established national training standards for SAFEs in 2006. 17 Individuals, most often physicians and physician assistants, who complete the proscribed training and pass a standardized exam receive certification as a SAFE. There is little differ ence between SANE and SAFE training, but only registered nurses are eligible to train as SANEs, and the Commission for Forensic Nursing maintains authority over the certification of SANEs. Because SAFEs and SANEs are specially trained to perform the precise and sensitive history, physical and forensic examination, and to preserve evidence in a chain of custody, many U.S. hospitals have designated these individuals as part of sexual assault response teams (SART s). Local EMS personnel can transport survivors of sexual assault to SARTs as a matter of protocol.  CULTURAL DIFFERENCES AND MINORITIES Appropriate cultural competency skills often set the tone for the first steps toward healing. Some cultures consider rape a punishment or a consequence of aberrant sexual behavior. 18 Societies characterized by gender-based power disparities are often less likely to define sexual coercion and threats of violence as rape. Women from such cultures often present for care with other chief complaints or will give inconsis tent histories if they feel they are culpable or could have offered more resistance. 19 In countries with a history of slavery, indentured servitude, human property laws, and rigid caste or class systems, policies, tradi tions, and biases affect the treatment and adjudication of sexual assault. Survivors may be reluctant to report victimization if they fear a biased criminal justice system, do not think police will help, or anticipate being blamed by their family or community. 11,20,21 Fear of deportation may impact the decision of illegal aliens regard ing evidence collection, police reporting, and testifying in court. Before encouraging patients to make a police report, learn your state’s laws about illegal aliens who are crime victims. Women of color face more challenges than white women in obtain ing assistance after rape. Services for victims of diverse backgrounds are limited, and minority victims are often reluctant to contact rape crisis centers. 11 For black women survivors of sexual assault, poverty is a positive predictor of increased lifelong risk of depression and posttraumatic stress disorder. 11,22,23 Sexual minorities also suffer disproportionately. In September 2018, the Centers for Disease Control and Prevention published its National Intimate Partner and Sexual Violence Survey, documenting that 46% of bisexual women have been raped, in contrast to 17% of heterosexual women and 13% of lesbians. Although most large cities have good referral services and resources for providers, smaller communities may not have support services for minority and ethni cally diverse patients. The Substance Abuse and Mental Health Ser vices Administration National Council for Trauma-Informed Care provides excellent resources for institutions, providers, and patients, especially for referrals for continuing care.

smaller communities may not have support services for minority and ethni cally diverse patients. The Substance Abuse and Mental Health Ser vices Administration National Council for Trauma-Informed Care provides excellent resources for institutions, providers, and patients, especially for referrals for continuing care. THE SEXUAL ASSAULT EVALUATION  TRIAGE Triage sexual assault patients as a high priority, in accordance with Department of Justice recommendations. 15 Notify the SAFE or SANE on call, and place the patient in a private room, ideally one reserved for CHAPTER Abuse and Assault SECTION Tintinalli_Sec25_p1967-1978.indd 1967 8/2/19 1:50 PM

LT EVALUATION  TRIAGE Triage sexual assault patients as a high priority, in accordance with Department of Justice recommendations. 15 Notify the SAFE or SANE on call, and place the patient in a private room, ideally one reserved for CHAPTER Abuse and Assault SECTION Tintinalli_Sec25_p1967-1978.indd 1967 8/2/19 1:50 PM 1968 SECTION 25: Abuse and Assault the care of sexual assault victims. If a SAFE or SANE examiner is not in-house or if the hospital does not have a SART program, the triage nurse should notify the emergency physician of the patient’s presence in the department. Make sure the patient does not undress or change into a hospital gown, as all clothing must be properly removed and stored for forensic evaluation. Tell the patient not to wash, drink, or rinse the mouth. Provide appropriate medical care whether or not patients agree to evidence collection, police reporting, or assisting with criminal prosecution.  HISTORY Begin the interview with introductions, express regret about the assault, and provide reassurance that medical and psychological needs will be addressed. Maintain a professional, caring attitude. A patient’s response is affected by the physician’s attitude. A physician’s shock or outrage may increase the patient’s concern about physical injuries or cause the patient to feel marginalized. Questions perceived as critical or judgmental result in feelings of guilt and shame and interfere with the survivor’s ability to provide a thorough history. Calm reassurance will facilitate the history, examination, and collection of evidence. Ask open-ended questions about sexual history. For some women, sexual assault is the first sexual encounter, and for some lesbian patients, it may be the first sexual encounter with a male. Obtain a thorough past medical history and general assault descrip tion, and ask the patient about injuries. In some instances, the triage nurse will have obtained the past medical history. In EDs with SANE services, a detailed assault history, to help guide the evidentiary exami nation, will be obtained by the SANE. If there are no SANE services, but a sexual assault advocate, police representative, or social worker is available, have those individuals in the room during the history taking so that the patient does not have to repeat information. Details to gather about the assault and medical history are listed in Tables 293-1 and 293-2. Most authorities caution that the chances of finding forensic evidence >72 hours after the assault are slim, so a forensic examination is not necessary if >72 hours have elapsed since the assault, unless the specific state allows evidence collection up to 96 hours after the assault. Verify the policy in your state well in advance of the need to know.  CONSENT FOR FORENSIC EXAMINATION Have the patient sign the consent form for the forensic examination, collection of evidence, photography, and transfer of evidence to law enforcement authorities. Most hospitals have a prepackaged rape kit with equipment and directions. However, check with the police if you are unsure about the utility of your hospital’s kit, because some police departments may require use of a specific kit for their precincts. Hos pitals will usually allow the storage of a rape kit for a specified period of time while the patient decides whether or not she wishes to make a police report. In such a case, encourage the patient to consent to the forensic exam. Not every part of the forensic evidence kit needs to be used every time. Tailor the collection of evidence to the specifics of the assault.

t for a specified period of time while the patient decides whether or not she wishes to make a police report. In such a case, encourage the patient to consent to the forensic exam. Not every part of the forensic evidence kit needs to be used every time. Tailor the collection of evidence to the specifics of the assault. If >72 hours (or 96 hours, according to your hospital’s policy) have elapsed or the patient does not want an evidentiary examination, still perform a full history and physical examination, provide pregnancy and sexually transmitted disease prophylaxis, and refer for follow-up medi cal care and rape crisis counseling.  PHYSICAL EXAMINATION General Examination Record general information such as vital signs and mental status. After clothing is properly removed and stored, per form a head-to-toe inspection, and look for injuries. Focus on defensive injury areas such as the extremities, and carefully check potential areas of injury such as the oral cavity, the neck (for strangulation signs), and the breasts, thighs, and buttocks. Describe all injuries, and record all areas of tenderness, even if there is no outward sign of injury. Injuries, predominantly bruises, are often located on limbs (32%), face (23%), and torso (7%), with most assault survivors sustaining light (44%) or moderate (18%) injuries. 26 Other nongenital injuries include abrasions (40%), lacerations (4%), and bites and burns (1%).12  FORENSIC EXAMINATION The forensic examination includes collection of head and pubic hair and buccal swabs for DNA comparison, photographs of injuries, and vaginal and perineal examination, often with colposcopy. Tell the patient what the examiner is doing at each stage of the process. Tell the patient she can take a break at any point during the examination. (See Video: Sexual Assault.) Assemble all of the needed equipment for forensic examination. Throughout the examination, keep the patient’s body covered as much as possible. Have several pairs of gloves available for different parts of the examination—change gloves between the physical and the genital exam, and again between the genital and the anal exam. A detailed list of equipment and a demonstration of the examination and evidence collection are available. Take photographs of abrasions, bruises, contusions, TABLE 293-1 Assault History Who? •  Did  the assault survivor know the assailant? •  Was  it a single assailant or multiple assailants? •   Can the survivor recall any identifying features of the assailant (height, build, age, race, tattoos, scars, birthmarks, etc.)? (Document in the medical records.) What happened? •  Was  the patient physically assaulted? •  With  what (e.g., gun, bat, or fist) and to what part of the body? •  Was  there actual or attempted vaginal, anal, or oral penetration? •  Did  ejaculation occur? If so, where? •  Was  a foreign object used? •  Was  a condom used? •   Has alcohol been recently ingested? (Alcohol affects ED treatment with metronidazole or tinidazole.) •  Has  the victim been sexually assaulted before? •  Does  the victim have suicidal or homicidal ideation? When? •  When  did the assault occur? •  (Emergency  contraception is most effective when started within 72 h of the assault.) Where? •  Where  did the assault occur? •  (Corroborating  evidence may be found based on the location of the assault.) Suspicion of drug-facilitated rape? •  Was  there a period of amnesia? •  Is  there a history of being out drinking and then suddenly feeling very intoxicated? •  Is  there a history of waking up naked or with genital soreness? Douche, shower, or change of clothing? •   Did the patient douche, shower, or change clothing after the assault?

cilitated rape? •  Was  there a period of amnesia? •  Is  there a history of being out drinking and then suddenly feeling very intoxicated? •  Is  there a history of waking up naked or with genital soreness? Douche, shower, or change of clothing? •   Did the patient douche, shower, or change clothing after the assault? (Performing any of these activities prior to seeking medical attention may decrease the probability of sperm or acid phosphatase recovery, as well as recovery of other bits of trace evidence.) TABLE 293-2 Medical History •  Last  menstrual period? Birth control method? •  Last  consensual intercourse? •   If the patient has had consensual intercourse within the past 3 to 4 days, it may confuse laboratory analysis for sperm and acid phosphatase and genetic typing. •  Allergies,  medication history, and possible pregnancy? •  Medical  comorbidities •  Mental  health issues or substance use disorder history Tintinalli_Sec25_p1967-1978.indd 1968 8/2/19 1:50 PM

ercourse within the past 3 to 4 days, it may confuse laboratory analysis for sperm and acid phosphatase and genetic typing. •  Allergies,  medication history, and possible pregnancy? •  Medical  comorbidities •  Mental  health issues or substance use disorder history Tintinalli_Sec25_p1967-1978.indd 1968 8/2/19 1:50 PM CHAPTER 293:  Female and Male Se xual Assault      1969 lacerations, bite marks, burns, areas of erythema, hematomas, incisions, petechiae, and swelling. Document location, position of patient, and position of injury, using a clock face reference. Traditionally, when the patient is in lithotomy position, the pubic bone is at 12 o’ clock, the left hip is at 3 o’ clock, and the right hip is at 9 o’ clock. Begin the photographic series with a photograph of the patient’s face and end with a photograph of the patient’s hospital wrist band. If photography is not available, describe signs of trauma and areas of tenderness in detail using a body map. Begin the genital exam with combing of the pubic hair and extraction of hair samples. Patients can pluck their own hair, but make sure that the hair root is included. Examine the genital and rectal areas for inju ries and signs of trauma. Note any vaginal discharge, vaginal abrasions, cervical abrasions, and cervical lacerations. In some institutions, a topi cal application of toluidine blue dye is used to highlight microtrauma. Toluidine is a dye with affinity for DNA and RNA. 27 When placed on an area where the topical nonnuclear layer has been removed (as by abrading by injury), toluidine dye will be taken up by underlying cellular tissue. It is typically mixed for use by the hospital pharmacy. Toluidine is applied to the external vulva, especially the posterior fourchette, but not onto mucous membranes. If toluidine dye is used, do not perform a speculum examination until after the toluidine dye examination is completed, because the speculum examination itself may induce small abrasions that can be confused with injuries from the assault. 28 After examination, remove excess dye with a water-soluble lubricant. If the solution is not used soon after it is mixed, cover the bottle with alumi num foil, store at 4°C (39.2°F), and bring to room temperature before use. 29 An alternative to bottles of toluidine blue dye is the commercially available Forensic Blue Swabs® . Colposcopy detects injuries not visible to the naked eye. 13 In one study, only 34% of genital lesions were seen with the naked eye, 49% were seen with a colposcopy, and 52% were seen with toluidine blue dye. 28 If the colposcope is used to photograph injuries, document mag nification. If the patient reports anal penetration, examine the anus and rectum for abrasions or lacerations. Finally, darken the room and scan the entire body surface with a W ood’s lamp to detect traces of semen. Swab areas where the perpetrator made any oral contact, and swab areas that illuminate with the Wood’s lamp. Dry and label all swabs and add to the rape kit. After all evidence is collected, make sure to maintain chain of custody. Do not leave the kit unattended. Each party that releases and accepts the evidence kit must sign, date, and time the chain-of-evidence form. If the police are not present to receive the evidence, store the kit in a locked cabinet specifically designated for this purpose. Many rape kits contain elements that require refrigeration. In this case, when police are not available to accept the kit, store the entire kit in a locked refrigerator only used to store rape kits.  LABORATORY TESTING Obtain ancillary tests as clinically indicated. If there is high suspicion of drug-facilitated rape, a urine sample can be sent to a labora tory for toxicologic testing.

ase, when police are not available to accept the kit, store the entire kit in a locked refrigerator only used to store rape kits.  LABORATORY TESTING Obtain ancillary tests as clinically indicated. If there is high suspicion of drug-facilitated rape, a urine sample can be sent to a labora tory for toxicologic testing. Drugs that are typically thought of as “date rape” drugs, such as ketamine, flunitrazepam (Rohypnol), and γ-hydroxybutyric acid, are not detected on routine ED toxicology screening tests, and special “send out” tests must be ordered. Rohypnol can be detected in the urine for up to 72 hours, and γ-hydroxybutyric acid can be detected for 12 hours. Results, however, are not available for days. 30 Most SANEs typically send these tests when indicated and assume responsibility for checking the results. In some hospitals with SART programs, consent forms give the right to the prosecuting attor ney in the Special Victims Unit to receive the results. If these “send out” tests are ordered by the ED physician, develop a protocol for checking results and documenting results in the patient’s record. Guidance for appropriate ordering can be obtained from womenshealth.gov or by calling 800-994-9662. Obtain a urine or serum pregnancy test before giving emergency contraception. Testing for gonorrhea, chlamydia, and bacterial vagi nosis is not necessary, because treatment is provided at the ED encounter. However, do test for syphilis, hepatitis B and C, and human immunodeficiency virus (HIV). Obtain serum chemistry, liver function studies, and CBC for patients who will receive HIV postexposure prophylaxis. 31 Follow baseline HIV testing with repeat testing at 6 weeks and 3 and 6 months. TREATMENT Follow standard care protocols and also individually assess the needs of the survivor. 32,33 Treat physical injuries and provide immediate cri sis intervention if needed. Offer emergency contraception, sexually transmitted disease prophylaxis, tetanus and hepatitis B vaccination if needed, and prophylaxis against HIV infection (Table 293-3).  SEXUALLY TRANSMITTED INFECTION PROPHYLAXIS The prevalence of sexually transmitted infections in an adolescent urban population varies as follows by causative organism: Neisseria gonor rhoeae, 0.0% to 26.3%; Chlamydia trachomatis, 3.9% to 17%; Treponema pallidum, 0.0% to 5.6%; Trichomonas vaginalis, 0.0% to 19.0%; and human papillomavirus, 0.6% to 2.3%. 34 The regimens currently recom mended by the Centers for Disease Control and Prevention are provided in Table 293-4.  EMERGENCY CONTRACEPTION Obtain a pregnancy test on all women unless there is a history of hys terectomy. Offer pregnancy prevention to those who are not pregnant and of childbearing age. 35-40 The probability of a single act of intercourse within the fertile window is about 25%. 41 Also prescribe an antiemetic for nausea and vomiting. 39,40 Offer meclizine 50 milligrams, metoclopramide 10 milligrams, or ondansetron 4 milligrams.40 Four emergency contraceptive regimens are listed in Table 293-5.42 A fifth method of emergency contraception is the insertion of a copper intrauterine device, but this method is not commonly used after sexual assault or in the ED, there is little information on its effectiveness for emergency use, 43 and availability is limited. Provide emergency contraception as soon as possible following exposure; best results are within 3 days, and effectiveness is lower within 4 to 5 days. 44,45 Pregnancy after emergency contraception is 3.6 times more likely for obese women than for women with a normal body mass index.

use, 43 and availability is limited. Provide emergency contraception as soon as possible following exposure; best results are within 3 days, and effectiveness is lower within 4 to 5 days. 44,45 Pregnancy after emergency contraception is 3.6 times more likely for obese women than for women with a normal body mass index. Failure of emergency contraception TABLE 293-3 Centers for Disease Control and Prevention Guidelines for Postassault Prophylaxis •   If assailant status unknown and survivor not previously vaccinated, give postexposure hepatitis B vaccination without HBIG, and inform survivor that subsequent doses must be given at 1–2 and 4–6 mo after first dose.31 •   If the assailant is known to be HBsAg positive, unvaccinated survivors should receive hepatitis B vaccine and HBIG at the time of initial examination. •   For survivors previously vaccinated but who have not had postvaccination testing, give a single hepatitis B vaccine booster. •   HPV vaccination is recommended for female survivors age 9–26 y and male survivors age 9–21 y at the time of initial examination. Inform survivor that subsequent doses must be given at 1–2 mo and 6 mo after the first dose.16 •  Empiric  antibiotics for chlamydia, gonorrhea, and trichomoniasis (see Table 293-4). •  Tetanus  prophylaxis if needed. •  Offer  emergency contraception if the assault could result in pregnancy.31 •  Baseline  testing for syphilis, hepatitis C, and HIV. •   Obtain serum chemistries and liver function studies if HIV postexposure prophylaxis given. •  Provide  first follow-up at 1 week. Abbreviations: HBIG = hepatitis B immune globulin; HBsAg = hepatitis B surface antigen; HIV = human immunodeficiency virus; HPV = human papillomavirus. Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018. Tintinalli_Sec25_p1967-1978.indd 1969 8/2/19 1:50 PM

igen; HIV = human immunodeficiency virus; HPV = human papillomavirus. Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018. Tintinalli_Sec25_p1967-1978.indd 1969 8/2/19 1:50 PM 1970 SECTION 25: Abuse and Assault is more likely to occur with levonorgestrel than with ulipristal acetate; however, in all women, regardless of body mass index, the most signifi cant factor predicting failure is the cycle day of intercourse.46 Breastfeeding is not contraindicated following emergency contraception. Advise women that emergency contraception does not protect against HIV infection, other sexually transmitted infections, or subse quent unprotected intercourse. Recommend follow-up with a healthcare provider for all women and especially those with abnormal bleeding after cessation of emergency contraception. 40 Advise women who use emergency contraception to follow up with a regular provider to begin use of ongoing contraception in the form of oral contraception pills or copper intrauterine device to ensure successful prevention of pregnancy from subsequent unprotected intercourse. 45,46  HIV POSTEXPOSURE PROPHYLAXIS Viral load in the assailant is the most significant factor determining infectivity. 48 HIV seroconversion has occurred in persons whose only known risk factor was sexual assault or sexual abuse. 49 HIV transmission risk increases when bleeding occurs with vaginal, anal, or oral penetration; if viral load in the ejaculate is high; and if genital lesions are present in the assailant or the survivor. 31 Assistance in determining the advisability for postexposure prophylaxis can be obtained by calling the toll-free National HIV/AIDS Postexposure Hotline at 1-888-448-4911 (available 9 am to 8 pm Eastern time Monday through Friday, and 11 am to 8 pm Eastern time on weekends and holidays) or by accessing their website at http://nccc.ucsf.edu/ clinician-consultation/pep-post-exposure-prophylaxis/. There is also a Clinicians’ Warmline (1-899-933-3413) open 9 am to 8 pm Monday through Friday where clinicians may obtain answers to questions about caring for these patients. The Centers for Disease Control and Prevention recommendations for postexposure assessment of adolescents and adults are listed in Table 293-6. If postexposure prophylaxis is administered, follow the standard protocol recommended by your hospital’s infectious disease specialists. When prescribing HIV postexposure prophylaxis, ask about sulfa allergy. Truvada ® includes tenofovir, which has a sulfa moiety. DISPOSITION AND FOLLOW-UP Excellent care for survivors of sexual assault requires the coordination of clinical medicine with forensic science, law enforcement, and survivor advocacy. Once injuries are assessed and managed, offer counseling. This can be done by a dedicated rape counselor or trained social worker. If injuries are not severe, a rape counselor may be present prior to the physician’s assessment. Gaps in service and patient care have largely involved lack of treatment of sexually transmitted infections and lack of availability of pregnancy-related services. For patients with underlying mental health or substance use disor ders, recommend or arrange follow-up with their specific providers within a week. Sexual assault victims are more likely to have substance use disorders and previous mental health admissions, may be at risk for depression and even suicide, and have a strong need for mental health support.

health or substance use disor ders, recommend or arrange follow-up with their specific providers within a week. Sexual assault victims are more likely to have substance use disorders and previous mental health admissions, may be at risk for depression and even suicide, and have a strong need for mental health support. 51 However, even those without such underlying disorders should be encouraged to receive mental health support, because post traumatic stress disorder symptoms and depression are common.43 Prior to discharge, make sure that the patient has a safe place to go, a safe way to get there, and a plan for addressing absence from home or work. This conversation should include a discussion of if, to whom, and how she will reveal her assault for the present time. Cultural competency of the caregivers is essential throughout the delivery of healthcare ser vices to survivors of sexual assault, but it is critical at this juncture. If the team is not familiar with the cultural attitudes and practices surrounding sexual assault in the survivor’s religious, ethnic, or social group, ask the patient how his or her family, religious community, or social network may respond. Prior to discharge, provide the opportunity for bathing and oral care. Because clothing has been sequestered as part of the evidence kit, hospitals should provide fresh, packaged underwear and outerwear for the patient. Sweat suits are customarily provided at most SART hospitals. This is an appropriate time to raise the issue of returning to the home environment, since the patient will return in clothing that is not customary dress. Provide a headscarf for women who customarily wear head coverings in public. TABLE 293-5 Emergency Contraception Drug Dose Comments Levonorgestrel (Plan B® ) 1.5 milligrams once or 0.75 milligram at 1 and 12 h Prescribe antiemetics; less nausea than combined estrogenprogestin; available without prescription; 11–24/1000 estimated pregnancy risk Combined estrogenprogestin47 (Yuzpe® ) 100 micrograms ethinyl estradiol plus 0.50 milligram levonorgestrel, at 1 and 12 h Prescribe antiemetics; 29/1000 estimated pregnancy risk Mifepristone 25–50 milligrams PO as a single dose Menstrual delay most common side effect; 1–10/1000 estimated pregnancy risk Ulipristal acetate (Ella® /Fibristal® ) 30 milligrams PO as a single dose Prescribe antiemetics; possibly fewer pregnancies than with levonorgestrel Source: Data adapted from Shen J, Chey Y, Showell E, et al: Interventions for emergency contraception. Cochrane Database Syst Rev 8: CD001324, 2017. [PMID: 28766313] TABLE 293-6 Recommendations for Postexposure Assessment of Human Immunodeficiency Virus (HIV) Infection Risk for Adolescent and Adult Survivors Within 72 Hours of Sexual Assault •  Assess  risk for HIV infection in the assailant. •   Evaluate characteristics of the assault event that might increase risk for HIV transmission. Because recommendations vary with time and between institutions, consult with a specialist in HIV treatment for specific postexposure prophylaxis (PEP). •   If the survivor appears to be at risk for HIV transmission from the assault, discuss antiretroviral prophylaxis, including toxicity and lack of proven benefit. •   If the survivor chooses to start antiretroviral PEP, provide enough medication to last until the next return visit. Reevaluate the survivor 3–7 d after initial assessment and assess tolerance of medications. •   If PEP is started, perform CBC and serum chemistry panel at baseline. Do not delay PEP while awaiting laboratory results. •   Perform HIV antibody test at original assessment; repeat at 6 wk, 3 mo, and 6 mo.

xt return visit. Reevaluate the survivor 3–7 d after initial assessment and assess tolerance of medications. •   If PEP is started, perform CBC and serum chemistry panel at baseline. Do not delay PEP while awaiting laboratory results. •   Perform HIV antibody test at original assessment; repeat at 6 wk, 3 mo, and 6 mo. Repeat serologic assessment for syphilis can also be repeated at these times.31 Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018. TABLE 293-4 Centers for Disease Control and Prevention Recommended Regimens for Infection Prophylaxis •  Ceftriaxone,  250 milligrams IM, single dose Plus •  Azithromycin,  1 gram PO, single dose Plus •  Metronidazole, * 2 grams PO, single dose •  Tinidazole  *2 grams PO, single dose *If alcohol has been recently ingested or emergency contraception  is provided, metronidazole  or tinidazole  tablets can be given to the patient in the ED to take at home. Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018. Tintinalli_Sec25_p1967-1978.indd 1970 8/2/19 1:50 PM