What is the ob/gyn’s role in treating sexual assault survivors?

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A new American College of Obstetricians and Gynecologists (ACOG) committee opinion (#777) addresses the role of ob/gyns in evaluating and managing sexual assault survivors. The opinion replaces Committee Opinion Number 592 (April 2014) and includes model screening protocols and questions, relevant guidelines from other medical associations, and trauma-informed care.

The opinion notes that sexual assault (“a crime of violence and aggression and encompasses a continuum of sexual activity that ranges from sexual coercion to contact abuse to rape”) and rape (“the penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim”) are pervasive problems in the United States and an estimated 1.47 million rape-related physical assaults occur against women annually. 

Among the medical consequences that ob/gyns should look for in victims are acute traumatic injuries such as scratches, bruises, and welts, as well as traumatic injuries to the vulva or vagina severe enough to require surgical intervention. Approximately 5% of rapes among women between ages 12 and 45 lead to pregnancy and the incidence is particularly high among adolescent survivors due to relatively low contraception use. 

The committee opinion recommends that ob/gyns take a trauma-informed approach to care for victims of sexual assault. The key principles of this approach include ensuring physical and emotional safety, maximizing trustworthiness, prioritizing individual choice and control, empowering individuals, and encouraging peer support. 

Many women will not discuss a history of sexual assault spontaneously but may present with symptoms indicative of assault, including chronic pelvic pain, dysmenorrhea, and sexual dysfunction. The committee opinion, therefore, recommends that ob/gyns have a role and responsibility to screen all women for a history of sexual assault, paying particular attention to those who report these specific symptoms. Clinicians who evaluate sexual assault survivors must comply with certain medical and legal requirements. 

Ob/gyns should also be aware that various health procedures, such as pelvic, rectal, and breast exams, may trigger panic and anxiety stemming from post-traumatic stress disorder in survivors. When called on to perform a sexual assault examination, clinicians with little or no experience should request assistance from trained hospital personnel to ensure appropriate evidence collection. If trained personnel are unavailable, the committee opinion recommends using the protocol from the U.S. Department of Justice’s Office of Violence Against Women titled, “A national protocol for sexual assault medical forensic examinations of Adults/Adolescents.”

When sexual assault victims communicate with an ob/gyn’s office, emergency department or clinic before evaluation, the primary point of communication should encourage the patient to go to a medical facility immediately and provide instructions for not bathing, changing clothes, douching, urinating, defecating, wash out the mouth, cleaning fingernails, smoking, eating, or drinking. 

Jurisdictions vary in cutoff times for collecting evidence of a sexual assault case; many use 72 hours. However, if an assault is reported after the time limit, ob/gyns should still perform an examination and provide appropriate care and counseling. Ob/gyns must also be aware of jurisdictional policies in regard to evidence integrity; these policies include details on packaging, labeling, and sealing evidence and specifics on transfer, storage, management, and distribution of evidence.