(Adapted from the Crisis Management Handbook: A Guide for Overseas Staff, Peace Corps Volunteer Safety Council)

A) PURPOSE

To establish procedures for the appropriate medical and legal management of students who have been sexually assaulted.

B) BACKGROUND

Sexual assault is defined as any non-consentual sexual act and is a form of violent crime. Rape, attempted rape, or any unauthorized contact with genitals, breasts, or mouth should be reported to the Resident Director and managed as a sexual assault.

Victims of sexual assault do not always present at the time of the incident, but may present at a later date with incident-related symptoms (e.g. anxiety/depression, pregnancy, STD.) Individuals (men and women) who report that they have been sexually assaulted should be treated in a compassionate, non-judgmental manner (see "Sexual Assault: Counseling.")

It is estimated that one in every six women is raped during her lifetime. It is the court's responsibility to decide if the legal definition of rape applies in a particular case. The responsibilities of the designated medical doctor when managing a reported rape should be to:

• Assure the victim's physical safety.
• Document the pertinent history.
• Perform a careful physical examination.
• Promptly treat physical injuries.
• Inform the Resident Director of the assault.
• Maintain medical confidentiality.
• Contact the US home institution doctor.
• Provide and /or arrange psychological support (see "Sexual Assault: Counseling".)
• Prevent sexually transmitted disease.
• Prevent unwanted pregnancy.
• Collect legal evidence.

C) CLINICAL MANAGEMENT

Students who have been sexually assaulted should be encouraged to go to a hospital/clinic as soon after the assault as possible. Students reporting rape should be asked not to urinate, defecate, rinse their mouths, or clean under their fingernails before examination, if possible. Inform the student that this request is to help obtain evidence which might later be used in court and is not in itself for medical reasons.

The designated doctor should tend, first and foremost, to the well-being of the student. The student should be taken to a quiet, comfortable, safe area and not be left alone. The student may prefer to be accompanied by a friend. Male doctors should arrange for a female chaperon when examining women. Consent must be given before examination and treatment. This also allows the student a sense of control over the examination.

Information should be carefully recorded in the student's medical record, with the history reflecting only the victim's account of the incident. For serious sexual assault or rape, a comprehensive history and examination are required (see below), with special attention to physical injuries, emotional distress, and the collection of appropriate evidence for future legal proceedings (see section 6.)

MANAGEMENT OF SERIOUS SEXUAL ASSAULT

SUBJECTIVE

History should include:

• Age and identifying information of the victim and the alleged assailant (if known)
• Date and time of the assault and examination
• Circumstances of the assault
• Details of the sexual contact (oral, vaginal, or anal intercourse, ejaculation or urination by the assailant)
• Type of physical abuse (use of weapons or restraints, drugs, alcohol)
• Victim's activities after the assault (change of clothing, bathing, douching, urination or defecation)
• Gynecological history:

Last menstrual period
Pregnancy history
Recent gynecological surgery or infections
Last voluntary sexual experience

Examination (see section 6 for more detail)

Carefully examine the entire body. Take photographs or make drawings of injured areas.

External (total body):

• Cuts
• Bruises
• Bite marks

Oral cavity:

• Secretions
• Injuries resulting from oral penetration

Genitalia:

• Hair combing
• Hair sample
• Vaginal secretions
• Check for gynecological pathology, trauma, and foreign objects

Rectal:

• Examine for trauma

Culture for chlamydia (cervix) and gonorrhea (cervix, rectum, and/or pharynx, as appropriate) when possible. Non-culture testing is of limited benefits.
Test for syphilis and repeated in 3 months
Counsel and test for HIV; repeat in 6 months
Perform pregnancy test

Assess the need for:

• Medical treatment/medevac
• Pregnancy prevention
• Hepatitis B prevention
• Psychological/psychiatric care. Medevac is generally recommended, but may not be immediately accepted by the student.

• Do not leave victim alone
• Notify US home institution doctor
• Arrange for medical treatment/medevac
• Provide STD & pregnancy prevention
• Arrange for close follow-up; continue to offer medevac (in most cases) and monitor for sequelae.
• Arrange subsequent periodic visits
• Arrange an emergency contact and support person
• Schedule follow-up at 3 months for syphilis testing and 6 months for HIV testing.

D) PREVENTION OF PREGNANCY

Pregnancy occurs as a result of rape in about five percent of female victims. Treatment to prevent pregnancy should be offered to victims, and prescribed only after a pregnancy test has been performed to rule out prior pregnancy. Following are the recommended doses of oral contraceptive pills to be taken within 72 hours of the alleged rape.

Protocol for post-coital contraception
(must be taken within 72 hours of intercourse, obtain a negative pregnancy test first)

Two doses of two (2) contraceptive tablets containing 50mcg estrogen 12 hours apart or Two doses of three (3) oral contraceptives tablets containing 35mcg estrogen , 12 hours apart.

AND PROVIDE

Promethazine (Phenergan) 25mg suppositories (2)
Or
Tigan 200mg suppositories (2) (to be used every 3-4 hours for nausea, if required.)

E) PREVENTION OF SEXUALLY TRANSMITTED DISEASES AFTER RAPE

Few studies are available which predict the risk of acquiring a STD as a result or rape.

E.1. CHLAMYDIA, GONORRHEAS, AND TRICHOMONAS

Treatment for the prevention of chlamydia, gonorrhea, and trichomonas is indicated.

Recommended regimen to prevent gonorrhea, chlamydia, and trichomonas

Ceftriaxone 125mg IM in a single dose
AND
Doxycycline 100mg orally 2 times a day for 10 days
Or
Azithromycin 1 gm orally in a single dose
AND
Metronidazole 2 gm orally in a single dose
Or
Trinidazole 2gm orally in a single dose

E.2 Prevention of Hepatitis B

Rape victims who are non-immune to hepatitis B should receive prophylaxis against hepatitis B. Unless the student has received a complete hepatitis B vaccine series or is immune due to prior hepatitis B infection (serologically confirmed), vaccination should be provided. Hepatitis B vaccine, when started within 14 days of exposure, is effective. Hepatitis B Immune Globulin .06ml/kg IM (HBIG human) can be given if available and offers additional protection.

Recommended post exposure immunization for hepatitis B (within 14 days of exposure, no prior immunity).

Hepatitis B vaccine 1.0 ml IM (deltoid) at months 0,1,6

E.3 HIV

The risk of acquiring HIV infection as a result of rape depends on the likelihood of the assailant having HIV, the sexual acts performed, and other factors (associated trauma, presence of other STD's, etc.) The estimated risk of HIV transmission in sexual assault by an HIV infected person (vaginal or anal intercourse, or exposure to ejaculate) is about 2 per 1000. The risk is higher if other factors are present.

No preventative treatment is available.

F) COLLECTING FORENSIC EVIDENCE

Physical evidence useful during legal proceedings includes the presence of semen, genital and other injuries, and pubic hair obtained from medical examinations. Evidence should be collected and handled in a manner acceptable to local courts. Procedures standard in the U.S. for handling evidence are generally acceptable (see below.) However, doctors should be familiar with local laws and procedures and should adapt U.S. procedures to conform with local ones.

Following are standard procedures for collecting evidence during a rape examination:

• Maintain a log of evidence collected. Anyone who handles the evidence should sign and date the log indicating when they had possession of the item and how it was stored.
• Avoid contamination by allowing only the victim to handle her clothing. Send all of the victim's clothing (if she has not changed) to crime laboratory in sealed and labeled paper bags.
• Prepare careful and complete photographs and /or drawings of the physical findings.
• Examine the perineal and thigh area with a Wood's lamp to detect semen stains.
• Comb the pubic hair over a sheet of paper (for possible material traceable to the assailant), and pluck and store a few of the victim's pubic hairs.
• Perform a vaginal examination with speculum lubricated only with water. Note the condition of the hymen and examine the vaginal walls and cervix for lacerations and abrasions.
• Aspirate or collect vaginal secretions on a saline-soaked swab. Sperm remain motile for about three hours after ejaculation. Non-motile sperm may be found for up to 72 hours.
• Swab areas involved in oral and anal intercourse, if appropriate. Spermatozoa have been recovered from the mouth up to six hours after the event-even after the victim had brushed her teeth or used a mouthwash.
• Carefully seal and date all specimens collected.

References

Hampton, H.L. (1995) Care of the Woman Who Has Been Raped. New England Journal of Medicine. 332, 234-7.

ACOG Technical Bulletin Number 172-September 1992. International Journal of Gynecology and Obstetrics, 1993: 42; 67-72.

Memorandum

To: Resident Directors

From: Administrator, Study Abroad Office

Subject: Medical Confidentiality

It is important to clarify the role of the Resident Director with respect to medical confidentiality. The Resident Director is responsible for the safety and security of students and the medical professional in the host country is responsible for the health and well-being of the student.

Medical confidentiality is important so that students can feel safe to discuss their medical problems openly with the medical professional. Thus, for routine student health care the medical professional shall not share medically confidential information with study abroad staff. However, because the Resident Director is responsible for overall program management to ensure a safe and secure environment for students, he or she has a need to know certain information students safety, security or programs. When such information is given to the Resident Director, he or she is bound by the Privacy Act and rules of medical confidentiality.

The Privacy Act protects information about individuals which is maintained in an agency system of records, including medical information and medical records. The Act provides a serious criminal and civil penalties for the unauthorized release of information contained in a protected file.

The Privacy Act authorizes the release of certain information by the keeper of the record to another agency employee on a need to know basis. The Resident Director has a legitimate need to know certain information in order to properly perform his or her duties.

For example, in the case of any physical or sexual assault, the Resident Director must be given timely notification that an incident has occurred, the type of assault, where it occurred, the date and time of day it occurred, whether the assailant was known, whether there was more than one assailant, whether any weapons were involved, and any other information which pertains to the safety and security of that student or other students. This is an extension of medical confidentiality to the Resident Director based on a need to know in order to carry out his or her responsibilities.

There are no circumstances in which extension of medical confidentiality to the Resident Director may be appropriate. These include situations in which there is a serious threat to student health and safety. Examples of these situations may include life threatening communicable diseases; child or spouse abuse; drug use; potential suicide or psychotic or violent behavior; alcohol abuse if it impairs the students health, safety, or ability to perform effectively; or any other condition or situation that would prevent a student from attending class. Only information that affects the well-being, safety, and security of the student or other students needs to be shared with the Resident Director.

(Adapted from the Crisis Management Handbook: A Guide for Overseas Staff, Peace Corps Volunteer Safety Council)