An updated AAP clinical report on how to assess and care for adolescents who have been sexually assaulted includes guidance on the importance of offering routine screening and prevention messages.
Teens and young adults ages 12-34 years have the highest rates of sexual assault, according to Care of the Adolescent After an Acute Sexual Assault from the AAP Committee on Child Abuse and Neglect and Committee on Adolescence. The clinical report is available at http://bit.ly/2kCPg9T and will be published in the March issue of Pediatrics.
A sexual assault includes any situation in which there is nonvoluntary sexual contact. An acute assault is defined as occurring within the past 72 hours (some jurisdictions go back as far as 10 days).
Talking to teens
The report notes that it is important for pediatricians to “have an increased awareness that sexual assault is a prevalent issue that can affect any of their patients, regardless of gender.” Teens — including those with disabilities — should be asked if they have any history of sexual violence, dating violence and sexual assaults.
During visits in the high school and college years, a H.E.A.D.S.S. assessment can help guide discussions on Home, Education/Employment, Activities, Drugs, Sexuality and Suicide/Depression.
When exploring substance use, for example, bring up the link between impairment and vulnerability to sexual assault. Adolescent victims (and perpetrators) of sexual assault are more likely than adult victims to have used alcohol or other drugs. However, voluntary use of these substances around the time of the assault “is common and should not influence the perceived legal status of the event or result in reductions in standards of care for presenting victims,” the report states.
General advice for teens on avoiding risky situations includes not walking alone at night, not attending social events with unknown people and not drinking from a glass that has been unattended. “Buddying up” can help friends watch out for each other.
A prime opportunity to bring up these safety issues is at the pre-college visit, according to Elizabeth M. Alderman, M.D., FAAP, a lead author of the report and member of the AAP Committee on Adolescence.
“As pediatricians, we are poised to provide anticipatory guidance not only around sexual assault itself but the fact that being cognitively impaired with alcohol and drugs puts someone at risk for being assaulted,” she said. “And no one is really immune — it happens to boys, too.
“I think you just need to give your patients the skills to keep them safe and encourage them … to keep their friends safe,” Dr. Alderman added.
Pediatricians should advise adolescents that if they are ever sexually assaulted, they should seek medical care immediately, even before changing clothes, bathing, eating/drinking, urinating, etc. The report emphasizes timely collection of toxicology samples, which usually occurs separately from collection of physical forensic evidence. It is critical to obtain the victim’s informed consent before toxicology sample collection.
Those who reveal an assault also should be questioned about commercial sexual exploitation.
Differences among victims
Compared with older adults who have been assaulted, adolescents are more likely to delay medical care, and they are less likely to press charges when given a choice — especially if they know the perpetrator.
Most victims do know their perpetrators. A younger victim’s assailant often is a member of the victim’s extended family, whereas most older teens know their perpetrator from a social encounter.
Only half of high school victims ever tell anyone about a sexual assault. Overall, as few as 10% of sexual assaults may be reported to authorities.
That reporting rate drops to 4% for teens with developmental disabilities, who have a much higher risk of sexual assault and acquaintance rape: As many as 68%-83% of these women are likely to be sexually assaulted in their lifetime.
Identification of a sexual assault may help lessen the likelihood of it happening again, reduce the stigma, and provide the victim with medical, psychological and supportive care, the report concludes.
Clinical guidance
- Routinely ask adolescents about any history of sexual violence, dating violence and sexual assaults. Those who disclose an assault should be questioned about commercial sexual exploitation.
- Know reporting requirements related to sexual assault and state laws ensuring the right of teens to obtain medical care at a sexual assault or rape crisis center.
- Be familiar with community resources and when/where to refer adolescents for forensic medical examinations and care after an assault.
- Clinicians who feel unqualified to care for such a patient should arrange for an immediate evaluation by an appropriate experienced health care professional.
- Screening for sexually transmitted infections, postexposure prophylaxis, treatment and follow-up should be provided per guidelines of the Centers for Disease Control and Prevention, http://www.cdc.gov/std/tg2015/sexual-assault.htm.
- Offer emergency contraception to female adolescents who disclose sexual assault if reported within 120 hours of the assault. Documentation of pregnancy status should occur at the time of evaluation and at follow-up.
- Consider that “date rape” drugs may have been used in the assault.
- Be prepared to offer emotional support and referral for additional counseling.
- Support evidence-based sexual violence prevention activities in local high schools, colleges and communities.
