A 21-year-old woman attends you clinic requesting some tests for STIs. During routine clinical history taking she discloses that she was ‘forced to have sex’ yesterday by her ex-partner (male).
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1. What should your initial management be?
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Correct answer:
A sensitive approach should be taken during the consultation and it is vital that the woman feels safe and in control of the consultation. You should proceed at her pace, observing for signs of undue distress.
It is important to exclude any injuries requiring immediate medical attention e.g. head injury, lacerations.
Once these have been excluded you should proceed with history taking and concise documentation. The nature of the assault, including the time and place should be recorded.
She has attended within the timescale for FME so it is important to offer this and discuss police engagement. FME can take place in a SARC without police engagement. If she wishes FME this should be arranged as soon as possible.
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2. She doesn’t want police involvement or FME. How do you proceed?
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Correct answer: Immediate care should include the following:
- HIV-PEPSE: A risk assessment for HIV transmission should be undertaken and if indicated, PEPSE should be started as soon as possible. The alleged assailant is known to the complainant in this case therefore enquiry should be made about his personal BBV risk factors.
- HBV PEP: Hepatitis B vaccination can be commenced (very rapid schedule). If there is strong suspicion that the assailant has hepatitis B infection then HBV immunoglobulin should also be considered.
- Emergency contraception: undertake a pregnancy risk assessment and offer EC as indicated
- STI testing and prophylaxis: the pros and cons of testing at the time of presentation or delaying until after the window period should be discussed, along with the advantages and disadvantages of antibiotic prophylaxis. The nature of the assault will determine which anatomical sites require sampling.
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3. You enquire about her personal safety and what support she will have. She says that she will stay with her parents. She is worried about her future safety as the assailant told her he has assaulted other women recently. She is reluctant to report this to the police as she is fearful. Are there any other means of police involvement you should consider?
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Correct answer:
You should discuss anonymous ‘third-party reporting’. This information can be used by the police as intelligence to see if it matches other reports they may have had. You should obtain the complainants consent to undertake this.
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4. If she had disclosed a drug facilitated sexual assault (DFSA) and agreed to FME which additional samples should be taken?
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Correct answer:
Blood and urine samples should be collected within 3 and 4 days respectively. It is possible to carry out hair analysis in delayed presentation. Hair does not allow for as comprehensive a drug screen as blood and urine however it allows for assessment of exposure over longer periods of time. A sample of hair (usually from the head) should be taken at least 4 weeks after drug ingestion.
