Audit on the management of complainants of sexual assault at an emergency department

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Abstract

Objective

Proper medical management should be offered to rape complainants, including systematic investigation for sexual transmitted diseases, prophylactic antibiotics, a pregnancy test, emergency contraception, and psychological and medical follow up. We conducted an audit on the medical management of complainants of sexual assault in a public university hospital with a high referral of rape complainants.

Study design

Retrospective study of rape complainants, based on medical records (n = 356) including women admitted at the emergency department between January 1, 2002 and December 31, 2007.

Results

Most complainants were Caucasian (median age: 25 years, range: 15–79 years). About 82% of the assaults were committed by one assailant only, and almost two-thirds of the rapes were characterized by vaginal penetration. In 8% of the patients, no blood sample to screen for sexually transmitted disease had been taken and in 38% of the patients, no cervical smear for C. trachomatis had been done. Prophylactic antibiotics were provided to 40% of the patients. Eighty percent of the complainants who were not using contraception received an emergency contraceptive treatment. Respectively, 10%, 16% and 11% of the complainants were seen at a gynecological, infectious diseases or psychological support follow-up visit.

Conclusion

Only about 20% of the complainants received optimal care. Different steps were taken to improve the medical management, including a specific computerized checklist and involvement of a social nurse for the follow up. These steps aim at reducing psycho-affective and medical morbidity of rape complainants.

Introduction

The World Health Organization (WHO) has defined rape as physically forced or otherwise coerced penetration – even if slight – of the vulva or anus, using a penis, other body parts or an object [1]. Similarly, according to the Belgian law, every act of sexual penetration without consent of the victim constitutes a crime of rape. It is well known that data reporting rape largely underestimate its real prevalence. Nevertheless, in the United States, it has been estimated that one woman out of six has been, at least once in her lifetime, a victim of sexual assault and that about 30/10,000 women are raped every year by their partner [2], [3]. However, between 50 and 95% of sexual assaults are not reported to the police [4], [5], [6], [7], [8]. In Belgium also, very few data have been reported concerning the prevalence of sexual assault. According to police reports, there were in Belgium 2786 rapes during the year 2008. Bruynooghe et al. reported that 44% of Belgian women aged between 20 and 47 years have been confronted with sexual violence at some time in their lives [9]. Since 1989, it has been decided by the Belgian authorities to standardize the clinical examination procedure in searching for proofs of rape and to use a specific forensic tool called the “Sexual Assault Set (SAS)” [10], [11].

The CHU Saint-Pierre is a public university hospital located in downtown Brussels and is therefore one of the hospitals where the highest number of rape complainants are addressed. Based on Centre for Disease Control guidelines, the local protocol requires that proper medical management should be offered to the complainants (Table 1) [12]. This includes a systematic screening for sexual transmitted diseases and prophylactic antibiotic therapy, vaccination against Hepatitis B, and in some cases HIV tri-therapy, a pregnancy test and emergency contraception, as well as psychological and medical follow up. We conducted an audit on the medical management of complainants of sexual assault in a public university hospital with a high referral of rape complainants.

Section snippets

Materials and methods

We reviewed retrospectively all available charts of female patients older than 15 years of age who were managed using the SAS between January 1, 2002 and December 31, 2007 at the emergency department of the CHU Saint-Pierre. Only women who had reported the assault to the authorities were included in this study. All patients were examined by trainees (postgraduates) in obstetrics and gynecology or by trained gynecologists. We were able to identify 356 patients, among whom eight presented twice

Results

The principal demographic characteristics are presented in Table 2. The median age of the population was 25 years (15–79 years). Three hundred and thirty-six patients were younger than 50 years of age and 20 older than 50 years of age. Most of these patients (68%) were of Belgian, European or other Caucasian origin. Forty-two percent were not using contraception at the time of the rape. About 20% of the patients had a history of psychiatric disease (depression, suicide attempt, auto-mutilation,

Discussion

The principal aim of the study was to conduct an audit of the medical management, and to explore how it may be improved. Globally, this audit revealed that 90% of the patients did not receive optimal management. Even after August 2006, when a new protocol had been implemented, about 80% of the patients had still not been managed optimally. These data are alarming but not surprising since similar findings were observed by others, reporting that about 60–80% of patients who had suffered a sexual

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