A 24-year-old woman comes to the emergency department after being sexually assaulted 2 hours ago by a male coworker in their building's parking garage. She is tearful and avoids eye contact but can give a detailed account of the incident. The patient had no head trauma or loss of consciousness. She has no chronic medical conditions and takes no medications. Her last menstrual period was 2 weeks ago. The police are notified and present for the examination. There is bruising across the abdomen, around the neck, and on both wrists. Pelvic examination shows tender abrasions on the labia minora. A speculum examination is deferred, and evidence for the sexual assault kit is collected. A urine pregnancy test is negative, and emergency contraception is given. Which of the following is the best next step in management of this patient?
Postexposure prophylaxis for sexual assault | |
Infection | Medication |
Chlamydia | Doxycycline |
Gonorrhea | Ceftriaxone |
Trichomonas vaginalis | Metronidazole |
HIV | Multidrug regimen (eg, tenofovir-emtricitabine with raltegravir) |
Hepatitis B | Hepatitis B vaccine ± hepatitis B immunoglobulin |
Sexual assault is common, with a lifetime prevalence in women in the United States of approximately 20%, and perpetrators are often known to the patient (eg, coworker). Initial evaluation of patients who seek medical care after a sexual assault includes physical and forensic (eg, blood, semen) examination with detailed documentation of injuries (eg, bruising, abrasions).
Management of sexual assault includes empiric treatment for sexually transmitted infections because early treatment helps prevent morbidity (eg, pelvic inflammatory disease, infertility) associated with infection (Choice D). Therefore, all patients receive postexposure prophylaxis (PEP) against chlamydia (azithromycin), gonorrhea (ceftriaxone), and trichomoniasis (metronidazole). Patients who seek care within 72 hours of an assault may also benefit from HIV prophylaxis after individualized counseling on the risks and benefits of therapy. In addition to PEP, women with a negative pregnancy test are offered emergency contraception (eg, oral levonorgestrel [Plan B]).
(Choices A and C) Victims of sexual assault should be offered comprehensive psychosocial support, including mental health services, because they may experience complicated emotions (eg, anger, fear, shame) or develop anxiety, depression, or posttraumatic stress disorder. Inpatient psychiatric evaluation and antidepressant therapy are indicated for patients at immediate risk for suicide or homicide. However, tearfulness and avoiding eye contact (as in this patient) immediately after an assault are normal and do not necessarily mean that the patient is at risk of harming herself or others.
(Choice E) Reviewing risk factors for sexual assault immediately after a patient's assault is insensitive and places partial blame on the patient.
Educational objective:
Sexual assault victims are treated empirically for sexually transmitted infections, including chlamydia, gonorrhea, and trichomoniasis. Postexposure prophylaxis for HIV is individualized after counseling patients on the risks and benefits of therapy.