This page has been printed from the Yarrow Place website http://www.yarrowplace.sa.gov.au

Many people are worried that they have been "damaged" as a result of a sexual assault. The reassurance of a thorough physical examination and information about the expected healing time of minor injuries can greatly allay these fears.

Provide information about options

As mentioned above give the person an explanation of their options in relation to medical care, legal action and counselling. If the person requests a Yarrow Place referral it is vital Yarrow Place be contacted to set up an appointment time.

Address concerns about pregnancy

For women who are not using reliable contraception, the emergency contraceptive pill (ECP) should be offered. There is now a marketed form of ECP available in Australia, Postinor-2. This is to be taken as a single stat dose of the two tablets. It is effective up to 5 days after unprotected sexual intercourse but is more effective when given as soon as possible after unprotected sexual intercourse. Postinor-2 is available without a prescription from chemists. However, it can cost around $25 and some chemists will not supply. Please check with local chemists and emergency departments for supply and cost.

A cheaper alternative for people on a concession card is to take 50 tablets of Microlut or Microval as a stat dose. This requires a prescription from a doctor.

Forensic paternity testing can be done on pregnancies diagnosed soon after a rape. Contact Yarrow Place for more information.

All women at risk of pregnancy should be encouraged to have a pregnancy test about 3 weeks after the sexual assault.

Address concerns about sexually transmitted infections (STI)

The probability of contracting an STI in South Australia is low, however it is important to encourage the person to return at appropriate intervals for STI testing. Also advise the person of safer sex practices until the results of testing taken at the appropriate intervals after the assault are available.

• Baseline testing: tests taken at the time of assault do not exclude infection and these tests need to be done at the appropriate times.
• Two to three weeks after the assault: test for chlamydia, gonorrhoea, trichomonas, bacterialvaginosis and candida. All sites involved should be tested.
• Three months after the assault test for HIV, Hepatitis B and C, Syphilis.

STI tests should only be taken after appropriate pre-test counselling and arrangements for results and post-test counselling are made.

STI Prophylaxis

The incidence of many STIs in South Australia is low. It is not considered necessary to give prophylactic medication for STI prevention as a matter of course, but people should be given information about prophylaxis and be allowed to make their own decision in relation to this. Prophylactic medication may be of more value in certain situations, for example, if:

• there were multiple assailants
• the person is very anxious about STIs
• the incidence of STIs in that particular community is known to be high
• the offender is known to have a STI
• the victim is unlikely to return for a follow up medical appointment and the risk of developing an STI is thought to by high

Treatment options for STI prophylaxis

If prophylactic antibiotics are to be used the following regime may be considered:

• Azithromycin 1gm orally once OR
• Doxycycline 100mgm b.d. orally for 10 days OR
• Erythromycin 800mgm b.d. orally for 10 days

This will cover chlamydia and to some extent gonorrhoea. It may also be appropriate to consider the use of an anti-fungal agent if the woman has a history of candida infections.

It there is a risk of contracting gonorrhoea, the following regime should be considered.

• Ceftriaxone 250mgm IM once

These options will cover pharyngeal, rectal and genital infections.

Post exposure hepatitis B prophylaxis

If the assailant is known to be a hepatitis B carrier, the following is recommended:

Consider checking the immune status of the victim.

• hepatitis B immunoglobulin 400IU (4ml) IM once, may be given up to 14 days after sexual exposure, and
• hepatitis B vaccination should be offered, although this is not an essential part of prophylaxis.

If the status of the perpetrator is not known and not able to be tested, the risk of developing a hepatitis B infection should be discussed.

• if the risk is thought to be high, hepatitis B immunoglobulin and consequent vaccination, should be considered.
• if the risk is not thought to be high, hepatitis B vaccination should be discussed as there is some evidence that this will give, in addition to long term protection some prophylactic protection.

Post exposure HIV prophylaxis

HIV post exposure prophylaxis has proven to be effective in the occupational setting and it is reasonable to think that it would be effective for sexual exposure. The incidence of HIV/AIDS in South Australia is low and post sexual exposure prophylaxis is not indicated for the majority of sexual assault victims. However, it should be discussed and if the risk is increased, for example if the alleged perpetrator is known to be HIV positive or comes from a community where the incidence of HIV/AIDS is high, HIV post exposure prophylaxis should be offered.

Post exposure prophylaxis is available through the Emergency Department at the Royal Adelaide Hospital in South Australia (phone: 8222-4000). The medical officer should contact either the Infectious Diseases registrar on call or the Emergency Department to organise the referral. There may be a cost for this.

It is important to be aware that some medications and their side effects can interfere with the action of the Emergency Contraceptive Pill. This needs to be considered when prescribing prophylactic medications and when possible, the medication should eitherbe delayed until ECP has been taken or a medication which does not interfere with the action of the ECP be prescribed.

Address concerns about the physical and psychological effects of the assault.

People who have been sexually assaulted may experience a variety of physical symptoms.

• sleep disturbances are very common and options for dealing with this should be discussed
• stress related symptoms, depression, suicidal thoughts, eating difficulties, concentration difficulties and anxiety are also problems that are commonly experienced
• substance abuse and eating disorders may become an issue for some people.

It is important to:

• do a risk assessment for suicidal ideation
• advise of possible physical effects that they may experience and options for coping with them
• acknowledge the traumatic nature of the assault and offer a sickness certificate for work/school/uni if required
• promote the concept of recovery from the effects of the assault
• encourage follow up medical care and counselling to aid the process of recovery.

Drugs, alcohol and sexual assault

Some people present with concerns that they have been drugged and sexually assaulted. A typical history is that a person has been out to a nightclub or party and feels intoxicated out of proportion to the amount of alcohol consumed. He/she may have no memory of events but wakes in a strange place and in circumstances that make him/her believe that he/she has been sexually assaulted.

In this situation people may request a medical examination and testing to determine whether or not they have been sexually assaulted. An examination should be offered but may not provide answers unless genital injuries are present. Testing for drugs and forensic testing for sperm and semen may be of value (but is not always conclusive) and should be offered. Note it is important to test for drugs as soon as possible after an assault. Contact Yarrow Place for more information.

Offer follow up medical care/counselling

Not all people who have been sexually assaulted will want follow up medical care, but it should be offered for pregnancy testing, STI testing, review of injuries and an opportunity, if not already in place, to organise counselling services.

If the person develops what is thought to be a seroconversion illness for HIV, diagnostic PCR testing can be done at that time. This testing is not to be done for screening purposes.

Mandatory notification

In South Australia, under the Children's Protection Act 1993, notification must be made to the Child Abuse Report Line (ph: 131478) for people who have been sexually assaulted under the age of 18 years. A report must also be made where there is a suspicion on reasonable grounds that the child has been abused.

The law does not require proof of harm, but a notification must be accompanied by a statement of the observations, information and opinions upon which the suspicion is based.

Mandated notifiers are assured of confidentiality and are immune from civil liability and from allegations of any breach of professional ethics for reporting their suspicions in good faith.