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Hampton,
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We recently completed a national survey of 102 residencies in emergency medicine to evaluate existing sexual-assault curriculums. Of the 67 programs that responded, only 45 percent included education about sexual assault as part of the orientation of new residents. Sixty-two percent offered less than one hour of training on the collection of evidence, and 66 percent included less than one hour on psychosocial sequelae of assault. Sixty-three percent provided less than four hours of additional training during the subsequent years of residency.
In our experience, care is best provided after an assault by a multidisciplinary team involving nurses, social workers, counselors, and advocates, as well as physicians.3 The average length of stay in the emergency department for victims of sexual assault is 4.3 hours.2 This period gives the opportunity for a multidisciplinary effort to begin that addresses the complex psychosocial issues surrounding the assault, as well as fulfilling the medical and legal requirements of the complete examination as described by Dr. Hampton. Nonetheless, in our national survey only 48 percent of academic emergency departments described having a response team that is prepared to intervene in cases of women who have been raped.
Sexual assault remains a major public health problem, most frequently presenting to the emergency department, that requires a coordinated multidisciplinary response and thorough inclusion in the curriculum of residency-training programs if its victims are to receive optimal care.
Gail D'Onofrio, M.D.
Barbara Herbert, M.D.
David L. Levine, M.D.
Boston City Hospital
Boston, MA 02118
References
I also question the oft-cited recommendation to obtain specimens for culture for sexually transmitted diseases routinely from "all" sexual-assault survivors. It seems that the need for such tests should be evaluated in the same way as that for other diagnostic or screening tests — How will the results of the test affect treatment? In the case of a survivor who has received prophylaxis against sexually transmitted disease (which means treatment), the answer would be not at all. Furthermore, how might a positive culture be used in court? Although the presence of a sexually transmitted disease in a child may be useful evidence, in an adult it serves little evidentiary purpose and may even be used against the victim to suggest promiscuity.
Nancy J. Sugarek, R.N.C., M.S.N.
University of Texas Health Science Center at San Antonio
San Antonio, TX 78284-7879
References
Confirmation of negative antibody status, which may require a laboratory turnaround time of several days, is only a cost-effectiveness concern and is not mandatory. Since hepatitis B immune globulin may be more efficacious when given sooner rather than later (ideally, within 24 hours of exposure),3 empirical administration is warranted, especially to persons without specific risk factors for prior hepatitis B infection.
Steven Leiner, F.N.P., P.A.
University of California, San Francisco
San Francisco, CA 94143
References
To the Editor: Ms. Sugarek correctly notes that 125 mg of ceftriaxone is the dose recommended by the CDC as prophylaxis against gonorrhea in an adult rape victim. The smallest dose of ceftriaxone currently marketed is a vial containing 250 mg. Instead of discarding half a vial of costly antibiotic, I believe that most practitioners administer the full 250 mg rather than 125 mg.
Ms. Sugarek questions the practice of obtaining cervical cultures in rape victims. Since sexually transmitted diseases may already be established in sexually active adolescents and adult rape victims, screening becomes an important public health issue.1 Thus, when rape victims have disease that is already established, their partners can be treated and reinfection prevented. Legislation protects such victims from harassment with regard to their sexual histories. We must not compromise health care out of fear that a positive test would lead to legal disadvantages.
I agree with D'Onofrio et al. that treatment for sexual assault is best managed by a multidisciplinary team. When this is not possible, the primary caretaker must commit time and energy to support the patient and complete the forensic examination.
Finally, my appreciation to Mr. Leiner for correcting my omission of the need for hepatitis B immune globulin (0.06 ml per kilogram) to be given as short-term prophylaxis against hepatitis B.
Harriette L. Hampton, M.D.
University of Mississippi School of Medicine
Jackson, MS 39216
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