Panelists:William Alt, BSN RN Jessica Keith, PhD Lisa Nocera, MD Moderator:Aimee Sanders, MD MPH Acute Sexual Assault Statistics Myths about Sexual Assault Sexual assault is primarily a sexual crime. Sexual assault happens only to young women. Sexual assault is not possible within marriage. Women can incite men to rape. There is a right way to respond in a rape situation. False reporting of sexual assault is common. Ninas Arrival Sunday, 4:00 am 32yo female Veteran with a friend close by Avoiding eye contact Im not feeling well. I think I have a bladder infection. Tearfully, she discloses she was raped hours earlier The Silent Violent Epidemic Subtle Presentations of Acute Sexual Assault Ninas Triage Positive exchange from the beginning and from all involved Hemodynamically stable ESI = 2 Immediately place in private, gender-specific treatment room Allow support person, if desired Notify Charge Nurse and ED provider Compassionate Care Immediate Responsibilities Top Priority Address life-threats and serious injuries -Forensic evidence collection is secondary Remain mindful of any potential evidence while providing care Documented informed consent for: Reporting to law enforcement Physical examination Medical treatment Forensic examination* *signature consent Immediate Responsibilities Reporting Requirements Restore sense of control and safety Counsel on risks and benefits of proposed care Emphasize right to care even if chooses not to report Right to refuse any aspect of care and still receive desired treatment Immediate Responsibilities Know appropriate MH provider in advance Engage emergently if suicidal ideation or self-harm Acknowledge survivors have right to decline MH services Provide VA, private, and public resources Ninas Dilemma No physical injuries Non-mandatory reporting state Declines police involvement Ambivalent about evidence collection Friend is present Interested in MH Concerns: STI and preventing pregnancy Counseling on Reporting and Evidence Collection Survivor Decision-Making Documentation Use factual, clinical, non-judgmental language for descriptions Medically relevant information as reported Time and setting of the sexual assault Nature of assault (oral, vaginal, rectal penetration) Number of assailants Injuries, exposure to bodily fluids Threats, weapons and/or restraints used Post-assault activities (urinating, eating, bathing, etc.) Drug-Facilitated Sexual Assault Common drugs currently used Alcohol Most common Benzodiazepines (flunitrazepam) Ketamine Gamma hydroxybutyrate (GHB) Survivors of drug-facilitated sexual assault may present with Medical Exam and Clearance Precautions to preserve evidence Minimal handling of clothing Gloves (change when cross-contamination could occur) If clothing removed, undress over 2 sheets, place clothing/top sheet in paper bag Patient identification on all evidence collected Minimize transfers of evidence Counsel against activities that destroy evidence Use clinical judgment & common sense Transfer Process Facilitating Transfer Forensic Sexual Assault Exam All EDs & UCCs must have an exam kit in the event survivor is too unstable for transfer Head-to-toe exam with pelvic exam to document injuries and collect evidence Chain of custody for evidence collected Right to decline any portion and still have desired portions performed Transition and loss of therapeutic relationships can be stressful Ninas Decisions Declines transfer Declines forensic exam Requests medical treatment Ninas Decisions If the survivor declines transfer, providers should offer Ninas Care & Treatments Pregnancy prophylaxis Empiric STI treatment HIV testing Antiretroviral prophylaxis initiated Immunity to hepatitis B documented Psychiatrist and ED SW closely involved Follow-Up Recommendations Medical follow-up at 2, 6, 12 & 24 weeks - Injuries - STI - HIV - Pregnancy testing - Hepatitis B vaccine (at 1 month) Return if any concerning signs/symptoms Aftercare Instructions Arrange support presence Educate on common psychological responses PTSD-like symptoms Denial or repressive responses Normalize these responses Reassure responses will slowly diminish over time If they dont, VA services are available Safety Consider alternative arrangement if assailant is known to survivor Develop safety plan Make aware can return to ED/UCC Inquire if children in the home Follow state reporting laws Ninas Conclusion Key Points Non-Judgmental Approach Compassionate Care Informed Consent Survivors Rights Psychosocial Support Resources American College of Emergency Physicians. 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