UBC Objectives: Women's Health, UBC Objectives: Care of Men, & Priority Topic: Rape/Sexual Assault

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate how to counsel (and examine if required) a woman who has been sexually assaulted, including referral for forensic examination and counseling as appropriate (ex: local sexual assault team, post-exposure prophylaxis and counselors)
• Demonstrate how to counsel (and examine if required) a man who has been sexually assaulted including referral for forensic examination and counselling as appropriate (ex: local sexual assault team, post-exposure prophylaxis and counsellors)
  

Key Feature 2: Apply the same principles of managing sexual assault in the acute setting to other ambulatory settings (i.e. medical assessment, pregnancy prevention, STI screening/treatment/prophylaxis, counselling).
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 3: Limit documentation in sexual assault patients to observations and other necessary medical information (i.e., avoid recording hearsay information).
Skill: Clinical Reasoning, Professionalism
Phase: History

Key Feature 4: In addition to other post-exposure prophylactic measures taken, assess the need for human immunodeficiency virus and hepatitis B prophylaxis in patients who have been sexually assaulted.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 5: Offer counselling to all patients affected by sexual assault, whether they are victims, family members, friends, or partners; do not discount the impact of sexual assault on all of these people.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 6: Revisit the need for counselling in patients affected by sexual assault.
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

I have yet to encounter a patient disclose to me that they have been sexually assaulted. At least not acutely, as some women have shared with me a a past history of being sexually assaulted. Even then, this has been very few, and never with a man. I imagine this is partly because I do not probe, because as a resident I generally still have fleeting relationships of care. I expect this will change as I build rapport with a panel of patients and develop a zone of comfort where patients may feel more comfortable to disclose these experiences. At this time, it would at best be insensitive and at worst retraumatizing without having a relationship in which I could continue to support the patient physically, mentally, emotionally, and spiritually.

When a patient discloses that they have  been sexually assaulted, regardless of whether they disclose this in the outpatient setting or in a more urgent care setting, a number of things need to be arranged by the health care provider. First and foremost, patients need a comprehensive medical assessment and thorough documentation including a history and physical examination as indicated. They then may require a series of investigations including STI testing. Possible steps in management include emergency contraception, empiric treatment of STIs, and prophylaxis for possible transmitted infections such as as PEP for HIV or Hepatitis B vaccination and immunoglobulin (if not on PrEP and if not already immunized against Hepatitis B). Some treatment options may only be able to be provided in certain treatment facilities (ex: rapid access to PrEP), and in any case I think it is best to connect with a local sexual assault team for guidance on navigating important steps that must be taken fairly urgently and that may vary on a case-by-vase basis. These teams also provide assistance with forensic examination as may be necessary. Beyond immediate care of the physical state, generally with assessment and management that is fairly time sensitive, a patient must be supported more holistically with counseling and other forms of social support, ideally through longitudinal relationships of care.

There are of course many different forms of sexual assault and harassment. It is important not to make assumptions. Even if a patient has not been raped, they may still be suffering undue harm from an encounter that occurred without their consent. Likewise, patients may suffer vicarious harm if they have witnessed or cared for someone who has experienced sexual harassment. Check out one of my absolute favourite videos on consent.