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Appendices

Appendix A: Post-Assault Testing and Treatment

From the New York State Collaborative Efforts in Medical Evaluations of Child and Adolescent Sexual Offenses: Child and Adolescent Sexual Offense Post-Assault Testing and Treatment (printable PDF)


The need for an acute medical evaluation following a suspicion of sexual contact should be carefully considered. The health care provider should determine whether the child or adolescent should have an immediate examination in an Emergency Department or be referred to a Child Advocacy Center for an urgent appointment. The elapsed time since the assault is a key factor in this decision, and local availability may determine the most appropriate site for the examination. Whether the sexual assault was by a stranger or the result of ongoing familial abuse also affects treatment decisions. A mental health assessment and referral for treatment and support can be made any time after the assault.

The following explanation and accompanying chart will assist in examination decisions. These guidelines do not take the place of consulting an expert.

1. Acute and Follow-Up Examinations
Every child and adolescent suspected of sexual assault or abuse should have a complete physical examination. The timing of this exam depends on the nature of the abuse and the presence of symptoms. Visible physical findings are more likely to be seen on exam close to the time of sexual contact. Even when the potential for diagnostic physical findings is small, an examination is important for reassurance of physical well-being. Referrals to mental health agencies may be indicated. A listing of Rape Crisis Centers is available through the NYS Coalition Against Sexual Assault, http://nyscasa.org/ . Other informative internet sites include http://www.health.state.ny.us and http://www.nyscarcc.org . A post-assault follow-up exam may be necessary and should be scheduled one to two weeks after the acute examination.

2. Forensic Specimen Collection
The New York State Department of Health recommends the collection of forensic evidence within 96 hours of a sexual assault. In prepubertal children, it is rare to find forensic evidence beyond 24 hours. Collection of clothing and linens for analysis is more likely to result in positive findings. In all cases, weigh the benefit of collecting specimens based on the likelihood of a positive finding against the possible discomfort of the victim. Factors affecting the likelihood of identifying forensic evidence include time since the incident, bathing, age of the victim, and type of contact.

3. HIV Post-Exposure Prophylaxis and Testing
When the nature of the sexual assault has been determined to be of risk for HIV transmission, offer postexposure prophylaxis against HIV as soon as possible, preferably within one or two hours and up to 36 hours after exposure. Baseline HIV testing should be obtained. The actual interval after which no benefit exists is unknown, and initiating therapy after a longer interval may be considered for the highest risk exposures. Consult a pediatric infectious disease or HIV specialist before prescribing antiretroviral medication and obtain assurance that the child or adolescent will return for follow-up. Agency approval is required in situations involving children in foster care. For further information, check the NYS DOH website,www.hivguidelines.org/ . Follow-up testing should be done at four to six weeks, three months, and six months.

4. Pregnancy Prevention and Testing
Post-pubertal females with a history of exposure to semen are at risk for pregnancy and should be counseled regarding prophylaxis against pregnancy resulting from sexual assault (also known as emergency contraception or the "morning after pill"). Timely action is necessary as prophylaxis is most effective as soon as possible after the incident, optimally within 12 hours. Recommendations are to provide this treatment within 72 hours, however, treatment up to 120 hours has been shown to be effective. Obtain a serum ßhCG prior to treatment and one to two weeks after treatment.

5. STI Testing
When a prepubertal child with a history of or suspicion of sexual contact is seen within 96 hours, baseline STI testing is not necessary. In the pubertal victim, obtain baseline cultures if the patient is symptomatic for Neisserria gonorrhea (oral, vaginal/urethral, rectal) and Chlamydia trachomatis (vaginal/urethral, rectal). Test vaginal secretions for Trichomonas vaginalis and Candida species. The presence of vesicles or condyloma may indicate the need for herpes simplex virus (HSV) or human papillomavirus (HPV) testing. Baseline serum samples to test for syphilis (RPR) and bloodborne hepatitis viruses are needed if there is a history of previous exposure.

Follow-up cultures one to two weeks after the initial exposure are recommended. Follow-up testing for syphilis (RPR) and bloodborne hepatitis B (HBV) is recommended four to six weeks and three months after the initial exposure. Hepatitis C (HCV) testing is recommended at three months and six months after the exposure. Testing for STIs in cases of abuse where the incident was remote in time is predominantly based on symptoms, age of the victim, history of contact, and epidemiologic factors.

6. STI Treatment
It is currently recommended to provide adolescent sexual assault victims prophylactic treatment for Chlamydia infection and gonorrhea. HBV vaccination is recommended for those who have not received a complete HBV series or who have a negative surface antibody despite previous vaccination. Because of the low prevalence of STIs in the prepubertal victim of sexual abuse, prophylactic treatment is not usually warranted. Results of diagnostic testing and/or symptoms, such as those of pelvic inflammatory disease, guide treatment decisions. For CDC treatment guidelines see http://www.cdc.gov/std/ .

7. Drug Facilitated Sexual Assault Testing
If the victim’s history or symptoms indicate the possibility that drugs were used to facilitate the assault, and it is within 96 hours of the possible ingestion, collect evidence for the NYS Drug Facilitated Sexual Assault Kit. History or symptoms may include: memory loss or lapse, disheveled or missing clothing, dizziness, or intoxication that is disproportionate to the amount of alcohol reportedly ingested. The kit includes two gray top blood tubes, and a sterile urine specimen container. A consent form, which is included in the kit, should be completed. For further information see these web sites:
http://criminaljustice.ny.gov/ofpa/pdfdocs/dfsaalertsheet.pdf (PDF) and
http://www.criminaljustice.ny.gov/ofpa/evidencekit.htm .

 
 
 
Post-Assault Testing And Treatment Guidelines  



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Appendices  Appendix A: Post-Assault Testing and Treatment  Appendix B: A Sample Continuum of Medical History Questions and Confidence in the Responses  Appendix C: Body Diagrams  Appendix D: Burn Assessment - Rule of Nines  Appendix F: Common Types of Diaphyseal Fractures Seen in Childhood  Appendix G: Findings That May Be Confused with Abuse  Appendix H: Differential Diagnosis Table  Appendix I: List of Community Services  Appendix J: Supplemental Resources  Appendix K: Emergency Contraceptive Pills 

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