Care of the Adolescent Sexual Assault Victim - American ...
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CLINICAL REPORT
Care of the Adolescent Sexual Guidance for the Clinician in Rendering
Pediatric Care
Assault Victim
Miriam Kaufman, MD, and the Committee on Adolescence
ABSTRACT
Sexual assault is a broad-based term that encompasses a wide range of sexual
victimizations including rape. Since the American Academy of Pediatrics pub- www.pediatrics.org/cgi/doi/10.1542/
peds.2008-1581
lished its last policy statement on sexual assault in 2001, additional information
doi:10.1542/peds.2008-1581
and data have emerged about sexual assault and rape in adolescents and the
All clinical reports from the American
treatment and management of the adolescent who has been a victim of sexual
Academy of Pediatrics automatically expire
assault. This report provides new information to update physicians and focuses 5 years after publication unless reaffirmed,
on assessment and care of sexual assault victims in the adolescent population. revised, or retired at or before that time.
Pediatrics 2008;122:462–470 The guidance in this report does not
indicate an exclusive course of treatment
or serve as a standard of medical care.
Variations, taking into account individual
INTRODUCTION circumstances, may be appropriate.
Many terms have been used to describe sexual assault, including rape, statutory Key Words
rape, acquaintance or date rape, sexual abuse, molestation, and incest. There is sexual assault, victim, victimization,
great overlap and some confusion in the definitions of nonconsensual sex acts. adolescent, violence, dating violence
“Sexual assault” is a comprehensive term that includes any forced or inappropriate Abbreviations
GHB—␥-hydroxybutyrate
sexual activity. Sexual assault includes situations in which there is sexual contact STI—sexually transmitted infection
with or without penetration that occurs because of physical force or psychological NAAT—nucleic acid–amplification test
coercion or without consent, including situations in which the victim would be PEDIATRICS (ISSN Numbers: Print, 0031-4005;
unable to consent because of intoxication, inability to understand the conse- Online, 1098-4275). Copyright © 2008 by the
American Academy of Pediatrics
quences of his or her actions, misperceptions because of age, and/or other inca-
pacities. These situations can include touching of a person’s “sexual or intimate
parts or the intentional touching of the clothing covering those intimate parts.”1
The age of consent for sex varies from state to state. Reporting requirements to
child welfare agencies, parents, or the police are also variable, sometimes governed by local jurisdictions, and in flux.
In addition, in some states (eg, Texas and California), there are laws mandating that sexual intercourse and sexual
contact must be reported if certain age differences exist between a minor (usually defined as younger than 18 years)
and his or her sex partner (whether minor or adult), even if the sexual act was voluntary and consensual. Some
adolescents may refuse to seek care or disclose personal risk information because of possible reporting of sexual
partners.2–5
This report only addresses acute sexual assault in the adolescent age group and not sexual abuse that might be
chronic and identified long after the fact. For more information about sexual abuse, see the American Academy of
Pediatrics clinical report “The Evaluation of Sexual Abuse in Children.”6
Because of the differences between states and the likelihood of change, physicians need to be familiar with the
particular laws in their state and continue to be aware of any changes that may occur. This information is available
online through the Child Welfare Information Gateway.7
EPIDEMIOLOGY
National data show that teens and young adults have the highest rates of rape and other sexual assaults of any age
group. It is widely accepted that statistics on sexual assault reflect substantial underreporting, so the reported rates,
in all likelihood, are underestimates. Annual rates of sexual assault per 1000 persons (male and female) were
reported in 2004 by the US Department of Justice to be 1.2 for ages 12 through 15 years, 1.3 for ages 16 through 19
years, 1.7 for ages 20 through 24 years, and 1.6 for ages 24 through 29 years.8 There are significant gender differences
in reports of adolescent rape and sexual assault, with the 2005 National Crime Victimization Survey statistics
reporting 176 540 rapes and sexual assaults of females 12 years or older and 15 130 rapes and sexual assaults of males
12 years or older.9 This represents a significant decrease from peak rates of rape and sexual assault reported in this
group in 1992.9,10 These figures may not indicate a true decrease in the rate of rape but may reflect, instead,
methodologic differences in reporting rates over time. Studies have demonstrated that two thirds to three quarters
462 AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on February 8, 2020of all adolescent sexual assaults are perpetrated by an care professionals should inquire how to detect the pres-
acquaintance or relative of the adolescent.10,11 Older ado- ence of suspected drugs and collect the proper specimens
lescents are most commonly the victims during social en- from the victim.
counters with the assailants (eg, a date). With younger ␥-Hydroxybutyrate (GHB) is also used as a date-rape
adolescent victims, the assailant is more likely to be a drug. People who are given GHB in low doses are likely
member of the adolescent’s extended family. Adolescents to experience drowsiness, euphoria, increased libido,
with developmental disabilities, especially those with mild and passivity.22 In addition, at higher doses, they can
mental retardation, are at particular risk of acquaintance experience amnesia, intoxication, dizziness, and visual
and date rape.12 hallucinations. Medical complications of high doses in-
Adolescent rape victims presenting to emergency de- clude hypotension, bradycardia, severe respiratory de-
partments are more likely than adult victims to have pression, and coma. GHB acts quickly, usually within 15
used alcohol or drugs and are less likely to be physically minutes of ingestion. The effects last for 3 to 6 hours
injured during a rape, because assailants in adolescent when taken without alcohol and 36 to 72 hours when
rape tend to use weapons less frequently.11,13 Adolescent mixed with alcohol or other drugs. It is cleared quickly
female victims are also more likely to delay seeking and is undetectable in urine after only 12 hours or even
medical care after rape and sexual assault and are less earlier.23
likely to press charges (when given a choice) than are Ketamine effects include amnesia, delirium, vivid hal-
adult women.11,13 Male victims are less likely to report a lucinations, tachycardia and arrhythmias, mild respira-
sexual assault than are female victims.14–16 Studies of tory depression, confusion, irrationality, violent or aggres-
sexual assault of males have demonstrated that up to sive behavior, vertigo, ataxia, slurred speech, delayed
90% of perpetrators are male. Sexual assault of males by reaction time, euphoria, altered body image, analgesia, and
females is more commonly reported by older adolescents coma. Ketamine effects occur within 20 minutes. The ef-
or young adults, compared with children or young ado- fects last for less than 3 hours. Opinion varies on clearance,
lescents.14,16 Male perpetrators of male sexual assault with sources quoting detectability in urine from 24 to 72
more commonly identify themselves as heterosexual hours after ingestion.24,25
than homosexual.14 The rate of perpetration by an ac- Because all of these drugs are detectable for only a
quaintance of the victim is similar for male and female short time, if there is suspicion that 1 of them has been
victims, but multiple assailants, use of a weapon, and used, toxicology screening should be performed as soon
forced oral assaults are more common in assault of males as possible, perhaps even before finishing the history and
than of females.4 physical examination. The reference concentrations of
these drugs are not universally available, and referral to
SUBSTANCES AND SEXUAL ASSAULT a sexual assault center may be required for drug testing.
Alcohol or drug use immediately before a sexual assault In addition to these 3 drugs, common prescription
has been reported by more than 40% of adolescent benzodiazepines and over-the-counter antihistamines
victims and adolescent assailants.15 Adults have been are also being used to facilitate sexual assault, so testing
shown to significantly underreport voluntary drug use should be performed for these medications also.26
associated with sexual assault, but the same has not been Alcohol is still the most common date-rape drug, and
demonstrated in adolescents.17 Increasing rates of ado- adolescents should be warned of their increased vulner-
lescent acquaintance rape have been associated with the ability to assaults when drinking. If their friends are also
availability of illegal so-called date-rape drugs. The most drinking, they cannot count on them to notice that an
well known of these is flunitrazepam (Rohypnol, man- assault is taking place.
ufactured by Roche Pharmaceuticals Inc outside of the
United States), which is a benzodiazepine sedative/hyp- SEXUAL ASSAULT OF YOUNG PEOPLE WITH DISABILITIES
notic. The effects of flunitrazepam begin 20 to 30 min- Children and adolescents with disabilities are at signifi-
utes after ingestion, peak within 2 hours, and persist for cantly increased risk of sexual assault: 1.5 to 2 times
up to 8 to 12 hours if given without alcohol and up to 36 higher than the general population.27 Those who have
hours with alcohol. Drug effects include somnolence, milder cognitive disabilities are at the highest risk.28,29 A
decreased anxiety, muscular relaxation, and profound number of factors probably result in the increased risk,
sedation. There may also be amnesia for the time that including decreased ability to flee or fight off an attacker;
the drug exerts its action. Flunitrazepam can go unde- an expectation of increased compliance and tolerance of
tected by an adolescent if added to any drink, thus levels of physical intrusion not expected of people with-
increasing the risk of sexual assault, especially in the out disabilities; dependence on others for personal care;
adolescent population. Hypotension, visual distur- and, in general, ineffective safeguards.30
bances, dizziness, and urinary retention are all possible A number of factors apply to the reporting of sexual
medical complications. After ingestion, it can be found in abuse or assault by those with disabilities, including
the bloodstream for 24 hours and in urine samples for up what significance the victim attaches to the incident;
to 48 hours.18–21 Therefore, urine and blood samples can whether the victim has a means of communication;
be sent for toxicology screening, with every effort made whether they perceive there to be a trustworthy, capable
to ensure the chain of evidence. Date-rape drugs and person to whom the information may be disclosed; and
many other drugs of abuse are not included in standard issues of being believed and feeling safe.29,31,32 Some of
drug-screening panels. At the time of evaluation, health these factors uniquely affect individuals with disabilities,
PEDIATRICS Volume 122, Number 2, August 2008 463
Downloaded from www.aappublications.org/news by guest on February 8, 2020but others are shared by individuals without disabilities with adults by gynecologists.46 Counseling designed to
as well. specifically address these issues, as well as additional
Health care professionals should be familiar with psychological trauma that results from date or acquain-
counseling agencies, programs that specialize in child tance rape, should be available. Psychotropic medica-
abuse, and other services that are physically accessible tions may be required in some instances. The physician
and that have communication skills that are appropriate should be knowledgeable about services available in the
for teenagers using augmentative communication de- community to address these issues and should provide
vices or who are cognitively impaired. Services should be initial psychological support.
identified that can provide appropriate genital and pelvic Other victim reactions to sexual assault can include
examinations for victims having physical disabilities re- the feeling that his or her trust has been violated, in-
quiring mobility aids. creased self-blame, less-positive self-concept, anxiety, al-
cohol abuse, and effects on sexual activity (including
younger age at first voluntary sexual activity, poor use of
ADOLESCENTS’ PERCEPTIONS AND ATTITUDES REGARDING
contraception, greater number of abortions and preg-
SEXUAL ASSAULT
nancies, sexually transmitted infections [STIs], victim-
Exploring the perceptions and attitudes of adolescents
ization by older partners, erectile dysfunction in males,
regarding nonconsensual sexual encounters is impor-
and sexual dissatisfaction).41,47–52 Adolescent victims may
tant. Because there may have been voluntary participa-
feel that their actions contributed to the act of rape and
tion before the assault occurred, an adolescent might
have confusion as to whether the incident was forced or
think that he or she will not be believed. Teenagers may
consensual.53–55 Male victims also report fragility of their
be reluctant to report an incident because they feel
gender identity and sense of masculinity and confusion
guilty, are worried that their parents will restrict them
about their sexual orientation.50 All victims should be
from going to social events, or have little memory of the
screened for suicidal ideation and self-harm behavior.
assault because of the use of date-rape drugs. One study
demonstrated that male and female adolescents who
INVESTIGATIONS
viewed a vignette of unwanted sexual intercourse ac-
Adolescents may report a sexual assault to their physi-
companied by a photograph of the victim dressed in
cian, sometimes because they came to do so and other
provocative clothing were more likely to indicate that
times because the question has been asked. Depending
the victim was responsible for the assailant’s behavior,
on the patient’s current age, age at time of the event, the
more likely to view the man’s behavior as justified, and
identity and presence of the alleged perpetrator (such as
less likely to judge the act as rape than when the victim
an acquaintance, a relative, teacher/coach, or even
was in less-provocative clothing.33 Also, some aggressive
health care professional), and state law, the assault may
behavior on the part of a male perpetrator may be seen
have to be reported even if the teenager does not want
by some adolescents as normative.34–37
it to be reported. At the time of examination after acute
assault, an adolescent may have a hard time making a
ADOLESCENT REACTIONS TO RAPE decision to press charges and can be encouraged to have
Unwanted sexual experiences during adolescence are a forensic medical examination to assess for injury and
common, with a large survey of middle- and high-school infection and to collect forensic evidence. Before any
students indicating that 18% of females and 12% of forensic examination, victims should be advised not to
males have had an unwanted experience.38 Studies of wash their clothes, bathe, or shower until they have
female adolescents have found rape during childhood or been examined. These clothes should be stored in a
adolescence to be associated with increased risky behav- paper, not plastic, bag. In some facilities, adolescents
iors and mental health problems, including younger age may have the option of freezing forensic evidence if they
of first voluntary intercourse; higher rates of depression, are uncertain about filing charges for possible use in the
including suicidal ideation/attempts; and other self- future. A forensic medical examination includes a med-
harm behaviors such as self-mutilation and eating dis- ical forensic history, documentation of biological and
orders.34,35,37,39–42 When found in the gender less affected, physical findings, collection of evidence from the pa-
psychiatric or behavioral problems that are more preva- tient, and follow-up for additional evidence gathering.56
lent in the other gender (such as eating disorders in girls, With DNA-amplification techniques, a forensic exami-
fighting in boys) may be an indication that sexual assault nation can be useful for at least 4 days after the assault57
or abuse has occurred.40 and possibly longer.58–60 Between 4 and 7 days, local
Rape trauma syndrome is described as consisting of authorities should be contacted to determine if it is use-
an initial phase that lasts for days to weeks, during ful to collect evidence. After 1 week, examination, coun-
which the victim experiences disbelief, anxiety, fear, seling, and treatment can take place without need for
emotional lability, and guilt followed by a reorganization forensic collection. Unfortunately, not everyone pre-
phase that lasts for months to years, during which the senting with the same history may get the same forensics
victim goes through periods of adjustment, integration, and treatment, with homeless females being a group
and recovery.43,44 Part of rape trauma syndrome is post- that has been identified as getting less-than-adequate
traumatic stress disorder, which occurs in up to 80% of services.61 Decreased access to care is likely to lead to
rape victims.45 A 4-question screening tool for posttrau- increased rates of infections with STIs and their se-
matic stress disorder has been used with some success quelae, unwanted pregnancies, increased psychiatric
464 AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on February 8, 2020TABLE 1 Investigations According to Site62
Screening Throat Vagina Cervix/Urethra Anorectal Blood (Bodily Fluids,
Any Site)
Gonorrhea culture Yes No Yes Yes NA
Chlamydia culture No No Yes Yes NA
NAAT for chlamydia, gonorrhea No Yes Yes No NA
Microscopy for trichomoniasis, bacterial No Yes No No NA
vaginosis, candidiasis
HIV, hepatitis B, syphilis No No No No Yes
NA indicates not applicable.
complications, and poor reporting of sexual assault. The reporting to appropriate authorities specific to their lo-
Centers for Disease Control and Prevention’s treatment cale.
guidelines for STIs62 include a recommendation for com- Documentation of the history and physical examina-
prehensive clinical treatment of victims of sexual assault, tion is important. Value judgments should not be in-
including emergency contraception and HIV prophy- cluded, nor should interpretations of the meaning of the
laxis, if indicated. The evaluating health care profes- adolescent’s body language or facial expressions. De-
sional should ensure that specimens are available for scriptions should be exact, and terms such as “hymen
timely clinical care and that follow-up plans are com- not intact” should be avoided. The clinical records from
municated and feasible. both the referring physician and the assault center are
Before any examination, the health care professional likely to be subpoenaed if there is a prosecution. Again,
should address the adolescent’s immediate health con- there is more likelihood of the evidence being accepted if
cerns such as the likelihood of having contracted an STI, the examiner is an expert in handling cases of sexual
the possibility of pregnancy, and worries about acute assault. Any examination or treatment should be per-
and permanent physical injury/damage. A referral for formed only with the consent of the adolescent.
examination and treatment should be made to an emer- For an examination after acute assault, testing for
gency department or sexual assault treatment center STIs is somewhat controversial. There is a concern that a
where there are personnel experienced with adolescent speculum examination may be traumatic, especially for
assault victims. Physicians involved in the management a teenager who has not had one before, possibly leading
and forensic examination of adolescent victims of sexual to avoidance of pelvic examinations in the future. Find-
assault should be trained in the forensic procedures re- ing an STI, particularly Chlamydia trachomatis, may give a
quired for documentation and collection of evidence. defense lawyer an opportunity to introduce the victim’s
Colposcopic procedures allow examiners to detect and previous sexual history. However, many victims of as-
document genital trauma, including microtrauma, with sault have been reported to have positive culture results
a growing body of literature demonstrating the patterns and/or samples at the time of the acute evaluation.74–76
of genital injury in sexual assault victims.63–65 Physical Obviously, positive results may indicate an existing in-
examination is unlikely to yield evidence of penetration fection as a result of the victim’s history of consensual
that, other than the possible presence of seminal fluid, is sexual contact, but some cultures or samples may be
visible to the naked eye. After the acute period, it is positive as a result of the assault even when obtained
uncommon to find any indication of genital trauma,66 within 72 hours of the assault. Specimen collection
although as many as 32% of teenagers who have not should be discussed with the adolescent, who then can
previously had intercourse may show physical signs after choose whether to have cultures performed. If speci-
the acute period.67,68 Adolescents have reported that the mens are to be collected, the decision of which sites
experience of video colposcopy may be beneficial, with should be sampled should be based on possible contact
many accepting offers to watch their own examination with the perpetrator’s bodily fluids (see Table 1). Be-
on screen.69 cause some courts will only accept positive culture re-
It is essential that the forensic examination be per- sults for gonorrhea and chlamydia (as opposed to nucleic
formed by a person such as a physician who specializes acid–amplification tests [NAATs] and other indirect
in child abuse or a nurse with sexual assault care train- tests), cultures are preferable over NAATs for any case in
ing, who can ensure an unbroken chain of evidence and which there is likely to be prosecution. However, there
accurate documentation of findings.43,47,58,70–72 Details of may be an advantage to using an NAAT in addition to a
the required examination and documentation are pre- culture to detect chlamydia, because the high sensitivity
sented in a handbook published by the American Col- makes it more likely to detect before the end of the
lege of Emergency Physicians, Evaluation and Manage- incubation period.77 Vaginal secretions can be micro-
ment of the Sexually Assaulted or Sexually Abused Patient scopically examined for Trichomonas species and sent for
(available online).73 Physicians who treat sexually culture where available.
abused or assaulted patients need to be aware of the If prophylactic treatment is given, cultures do not
legal requirements, including completion of appropriate need to be performed at follow-up unless requested by
forms and maintaining the legal chain of evidence and the victim. If there is no prophylaxis prescribed, then
PEDIATRICS Volume 122, Number 2, August 2008 465
Downloaded from www.aappublications.org/news by guest on February 8, 2020TABLE 2 Prophylactic Treatment Recommendations Teenagers who have not initiated or completed im-
Condition Recommended Regimen munization against hepatitis B virus should be offered
the vaccine with completion of the series to be facili-
Gonorrhea Ceftriaxone, 125 mg intramuscularly once
tated. There are currently no recommendations regard-
(for oral and/or anogenital penetration) or
may use, if available, cefixime, 400 mg ing immunization against human papillomavirus infec-
orally once (for anogenital but not oral tions in the context of an acute sexual assault; however,
penetration) all adolescent female victims are within the recom-
Trichomonas species Metronidazole, 2 g orally once mended age group for receiving this immunization, so
Chlamydia Azithromycin, 1 g orally once, or doxycycline, depending on insurance coverage, immunization can be
100 mg orally twice daily for 7 d discussed at this time.
Hepatitis B Immunize, if not previously completed There are only a handful of cases in the literature of
Human papillomavirus Immunize, if not previously completed HIV being transmitted from a single episode of sexual
Pregnancy prevention or 0.75-mg levonorgestrel tablet: 2 tablets
assault.80–82 HIV prophylaxis is not universally recom-
emergency contraception orally, 12 h apart
mended but should be considered when there is mucosal
HIV See text
exposure (oral, vaginal, or anal). Factors to consider
include the risks and benefits of the medical regimen,
including whether there was repeated abuse or multiple
cultures are recommended 1 to 2 weeks after the as- perpetrators; if there is oral, vaginal, or anal trauma,
sault.77 including bleeding; if the perpetrator is known to have
Serum samples can be obtained for baseline testing HIV infection; or if either the victim or perpetrator has a
for syphilis and HIV in areas or populations in which genital lesion or if there is a high prevalence of HIV in
there is a high incidence of infection or if the victim the geographic area in which the sexual assault oc-
wishes for these tests to be performed (see below for HIV curred.43,58,62,72,73,83,84 If rapid testing of the assailant is
prophylaxis). Syphilis tests should be repeated after 6 to available, prophylaxis can be started and then stopped if
12 weeks, and HIV tests should be repeated after 3 to 6 the test result is negative. In 1 study, only 71 of 258
months.43,58,72,73 people who had been sexually assaulted agreed to HIV
prophylaxis, 29 continued with the treatment past 5
days, and only 8 completed the full course. Those at
MANAGEMENT
higher risk were more likely to complete treatment.85 A
Acute Care retrospective study found that uncertainties regarding
The examining physician should keep in mind that the exposure, high rates of psychiatric comorbidity, and low
young person may have nongenital injuries, the treat- rates of return for follow-up care were all factors in the
ment of which may be a priority depending on the low rates of adherence to postexposure prophylaxis.86
severity of the injury. Centers that specialize in treatment of sexual assault
Pregnancy prevention and emergency contraception victims often provide care without cost to their clients
should be addressed with every adolescent female rape and can advise about local resources when payment,
and sexual assault victim. The discussion should include confidentiality, and safety are concerns. No large studies
risks of failure and options for pregnancy management. examining different combinations of treatment have
Progestin-only emergency contraceptive pills have the been performed with sexual assault victims, but on the
most favorable mix of safety, with fewer adverse effects basis of current occupational-exposure guidelines, 2 nu-
and increased efficacy.78 A baseline urine pregnancy test cleoside reverse-transcriptase inhibitors and 1 of either a
should be performed. Emergency contraception should nonnucleoside reverse-transcriptase inhibitor or pro-
be offered to females who have been (or may have been) tease inhibitor for 4 weeks is recommended.87 In situa-
vaginally penetrated or who think that ejaculate has tions in which significant risk exists, prophylaxis with 3
come into contact with their genitalia.43,47,58,65,70,71 Al- medications should be offered only if the drugs can be
though package labels suggest a dosage of 0.75 mg of started within 72 hours of exposure.88
levonorgestrel taken twice, 12 hours apart, taking both
tablets at once is an easier regimen and is just as effective Follow-Up Care
without increasing adverse effects.79 Follow-up can include a visit within 1 week of presen-
Prophylactic treatment for chlamydia and gonorrhea tation to assess injury healing and to ensure that coun-
should be recommended to adolescent sexual assault seling has been arranged. Reassessment for STIs may
victims who have been vaginally or anally penetrated need to occur depending on medications given at the
(with or without ejaculation) or orally penetrated (with time of the initial evaluation and the intervening history
ejaculation). Current recommendations from the Cen- of consensual sexual activity.75 At 2 weeks, pregnancy
ters for Disease Control and Prevention are to treat with testing can be performed, along with discussion of test
125 mg of ceftriaxone intramuscularly, 2 g of metroni- results, assessment of adherence to any medications, and
dazole once orally, and either 1 g of azithromycin once the teenager’s emotional status. The Centers for Disease
orally or 100 mg of doxycycline twice daily for 1 week.62 Control and Prevention recommends that syphilis and HIV
If available, cefixime at a dose of 400 mg once orally can testing be repeated 6 weeks, 3 months, and 6 months after
be used instead of the ceftriaxone if only genital pene- the assault if initial test results were negative and infection
tration occurred (see Table 2). in the assailant could not be ruled out.62
466 AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on February 8, 2020Because responses to rape can vary, it is important for that may increase the likelihood of assaults (eg, use of
physicians to address both the physical and psychologi- drugs or alcohol) and strategies to prevent sexual as-
cal needs of the adolescent. Physicians should be aware saults (eg, “buddying up,” not drinking from anything
that self-blame, humiliation, lack of information (igno- that has been left unattended, abstaining from or mod-
rance), and naiveté might prevent the adolescent from erating alcohol intake, not accepting drinks from strang-
seeking medical care. Effective screening, referral, and ers) should be discussed, and associated educational ma-
follow-up allow for support of the adolescent rape victim terials should be available and distributed.47,70,91–93
and appropriate delivery of health care services. Because A survey of more than 600 young women in an urban
patients treated in emergency departments often do not setting showed that the vast majority thought that
return for follow-up care,89 it is important that the emer- young women should be screened and counseled by
gency treatment team refer the assaulted adolescent their health care professional regarding dating vio-
back to his or her medical home or a specialty treatment lence.94 Physicians should be aware that sexual assault is
center, if they have one and if the teenager consents to common and need to be prepared to counsel their ado-
his or her primary health care professional knowing lescent patients to avoid high-risk situations. Screening
about the assault. Contact with the primary health care of adolescents for sexual victimization should be part of
professional from the emergency department with the visits for psychological problems, sexuality issues, con-
information would relieve the teenager of the burden of traception or substance abuse, and health supervision.
introducing the topic and encourage follow-up. The ad- Physicians should include information about ways to
olescent should be encouraged to share information prevent sexual assault as part of anticipatory guidance
with a parent or other trusted adult. Although adoles- with adolescents with and without disabilities, tailored
cents may want confidentiality and have the right to it, to cognitive abilities to understand. Adolescents should
this is a time during which support from an adult is very be asked direct questions without their parents present
important, especially when teenagers are being treated regarding their past sexual experiences. These questions
in unfamiliar emergency department environments. In- should include those that explore age of first sexual
volving a support person may help ensure that the ad- experience, use of the Internet to find romantic or sex-
olescent gets supportive help and appropriate counsel- ual partners, and unwanted or forced sexual acts. Explo-
ing, particularly if he or she later becomes depressed and ration of gender roles and relationship parameters (eg,
lacks the ability to access help. Parents can be counseled exploitative, nonconsensual versus healthy) are critical.
and encouraged to focus on their teenager’s needs and Adolescents who have been sexually assaulted need the
not blame themselves or their son or daughter. opportunity to describe the experience at their own pace
Male victims’ concerns about their sexuality, in par- and in their own words.47,63–65,70
ticular their sexual orientation, should be addressed.
Physicians should be prepared to provide follow-up SUMMARY STATEMENTS
STI testing, completion of the hepatitis B virus and hu-
man papillomavirus immunization series, treatment of 1. Physicians are encouraged to routinely discuss with
injuries, screening for mental health problems, and their adolescent patients the potential for sexual and
management of substance use issues. physical violence, including relationship violence.
A number of studies have shown that trauma-focused The discussion may help prevent and/or reduce the
cognitive behavioral therapy is useful for adolescents stigma of revealing such issues if violence occurs.
who have been abused or assaulted,90 and a call or
2. Physicians are encouraged to be aware of the current
referral to a sexual assault care center may yield the
reporting requirements for sexual assault and laws
names of mental health professionals who are more
protecting the confidential rights of adolescents to
skilled in the care of victims and their families. Under
obtain care at rape crisis care centers in their state.
some circumstances, funding may be available to pay for
tests and treatments through the Victims of Crime Act 3. Physicians should be knowledgeable about sexual as-
(Pub L No. 98 – 473 [1984]). sault and rape evaluation services available in their
communities. This information should include when
SEXUAL ASSAULT AND RAPE-PREVENTION STRATEGIES and where to refer adolescents for a forensic medical
Adolescent rape exists in a sociocultural context, includ- examination and sexual assault care as well as for
ing some religious and ethnic values, in which issues of services appropriate for teenagers with disabilities.
male dominance, appropriate gender behaviors, victim- 4. Physicians are encouraged to routinely screen adoles-
ization, violence, and power imbalances in relationships cents, including those with disabilities, for a history of
are highly visible. Prevention messages for adolescents sexual violence, covering the potential of dating vio-
need to be designed for males and females.47,70,91–93 Ado- lence and sexual assaults.
lescents need to be able to identify high-risk situations
(such as attending parties with unknown people, meet- 5. For those adolescents with positive histories, appro-
ing people with whom they have had contact on the priate STI screening, prophylaxis, and treatment
Internet, walking alone at night, allowing themselves to should be available on a timely basis, including refer-
be photographed nude or in sexually explicit poses or rals for care and potential sequelae.
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