CHAPTER 3: SEXUALLY TRANSMITTED INFECTIONS IN …



CHAPTER 4: MEDICAL ADVOCACY ISSUES WITH VICTIMS OF SEXUAL ASSAULT

This chapter covers some of the issues related to medical advocacy with victims of sexual assault. The following topics are covered in this chapter:

• Medical Rights of the Survivor

• Sexual Assault Survivor’s Emergency Treatment Act

• The Rights of Minors

• Sexually Transmitted Infections

• Emergency Contraception and Abortion

• Drug-Facilitated Sexual Assault

Again, it is not necessary for a volunteer to commit all of the factual information in this chapter to memory. In providing support to victims of sexual assault, however, it is helpful to have a general working knowledge of some of those issues. It will also be important to know how to obtain additional information, and to have access to written materials to share with victims. As a volunteer, you should always have the support and guidance of a trained, experienced sexual assault worker in responding to the medical needs of sexual assault victims.

Medical Rights of the Survivor

As the field of sexual assault survivor advocacy has matured, consensus has developed as to a common set of accepted rights that apply to all sexual assault survivors. Some of these rights represent a shared understanding among rape crisis workers. Others are actually specified in the legal codes of many states, including Illinois.

Rights of the Survivor

The anti-rape movement is based on the belief that all survivors of sex crimes deserve the following rights. Rape crisis workers, especially advocates, work to ensure these rights are recognized and respected. Some of the rights are provided through the law and others are understood as best practice guidelines.

In the Emergency Department, the victim has the right to:

• Be treated with respect by medical personnel, regardless of race, gender, sexual orientation, religion, ethnicity, age, level of physical/mental ability, lifestyle or occupation;

• Call the victim’s personal physician, in addition to medical services offered in the Emergency Department;

• Refuse the collection of medical evidence;

• Have a private space for the collection of evidence;

• Request that law enforcement personnel leave the exam room;

• Request that a friend, family member, or other support person accompany the victim into the exam room;

• Have each procedure, test and form explained in detail before completing it;

• Request copies of medical reports. Processing of this request may have to wait for regular business hours; and

• Granted strict confidentiality.

Minor teens have the right to undergo the examination and consent to healthcare without a parent or guardian present.

At the rape crisis center, the victim has the right to:

• Be treated with respect by rape crisis personnel, regardless of race, gender, sexual orientation, religion, ethnicity, age, level of physical/mental ability, lifestyle or occupation;

• Be treated in a non-judgmental and supportive manner by all rape crisis center personnel;

• Be granted protection under the Confidentiality of Statements Made to Rape Crisis Personnel Act;

• Receive timely follow-up from rape crisis personnel;

• Meet privately with rape crisis personnel; and

• Determine her course of recovery.

Sexual Assault Survivor’s Emergency Treatment Act (SASETA)

The Sexual Assault Survivors Emergency Treatment Act, often referred to as SASETA, is an Illinois law governing the health care and evidence collection procedures for hospitals responding to sexual assault victims. Under SASETA, hospitals are classified as either treatment hospitals (those certified by the Illinois Department of Public Health (IDPH) to provide comprehensive medical and forensic response to sexual assault victims) or transfer hospitals (those authorized only to determine that the victim is medically stable and to transfer her to a treatment hospital). Treatment hospitals are required to file a plan with IDPH outlining the methods that they will use to provide emergency services to sexual assault survivors. IDPH reviews all plans submitted and approves those which comply with the rules and ensure adequate services for rape victims.

SASETA Requirements

SASETA mandates that the treatment hospital meet the following requirements:

• A private exam room must be provided. If the room is not ready, the patient should be shown to a private waiting area.

• An appropriate medical and gynecological exam is to be done.

• An evidence collection exam is to be completed using the Illinois State Police Evidence Collection Kit.

• A victim is to be tested for sexually transmitted diseases, pregnancy (if applicable) and any other tests deemed medically necessary.

• Oral and written information is to be given to the patient concerning the possibility of infection, sexually transmitted diseases (STDs) and pregnancy.

• Oral and written information concerning “accepted medical procedures” and possible contraindications for prevention and treatment of infection of STDs is to be provided to the victim.

• Medications to prevent STDs and pregnancy are to be made available to the patient in the Emergency Department.

• The patient is to be provided with written and oral instructions describing the need for a second blood test 6 weeks after the sexual assault to assess the presence or absence of STDs.

• The patient is to receive “appropriate counseling as determined by the hospital, by trained personnel designated by the hospital.”

• The patient will receive information about emergency contraception, including where and how she can get it.

• Services may be provided for a minor without the consent of a parent, guardian or legal custodian.

The patient should never receive a bill for any services provided in the Emergency Department. If the patient has health insurance or is a Public Aid recipient, the hospital will first attempt to collect payment from them. If the patient does not have health insurance, or the health insurance company will not pay all costs, the Illinois Department of Public Aid will reimburse the hospital for procedures, medications and follow-up tests.

The Rights of Minors

Special attention must be paid to the rights of victims of sexual assault who are legally considered minors. Their ability to consent to medical treatment, be tested for sexually transmitted diseases, make decisions about reproductive health care, crisis counseling and releasing information are all covered below.

Consent to Medical Treatment

1. Minor Victims – When a minor is the victim of sexual assault or abuse, she can consent to any medical care related to the treatment of an injury arising from the assault without consent of her parent or guardian.

2. Emergency Care – In an emergency situation, when a hospital, doctor or dentist provides emergency treatment or first aid to a minor, parental consent for the treatment is not required if the provider believes that obtaining consent is not reasonably feasible without adversely affecting the minor’s health.

3. Minor is Parent, Married or Pregnant – A minor who is a parent, who is married, or who is pregnant has the same legal rights and responsibilities as a person who is of legal age. She can consent to all medical procedures as if she were 18 years of age or older.

4. Minor’s Rights Regarding Testing for Sexually Transmitted Infections/HIV

• Medical Treatment – Illinois laws allow for a minor age 12 or older to consent to medical treatment for STD and HIV/AIDS treatment and alcohol and drug treatment. No parental consent is necessary.

• HIV/AIDS Testing – HIV/AIDS testing and treatment can be done in Illinois without parental consent as long as the minor is above the age of 12. If a minor is found to be HIV+, the physician will speak to the minor about telling her parents, but parental notification is not required. Minors also can consent to treatment on their own, but often minors will need financial assistance from someone in order to pay for the high costs of Post Exposure Prophylaxis (PEP).

5. Emancipated Minor – A court may find that a minor 16 years of age or older is of sound mind and has the capacity and maturity to manage her own affairs and therefore is considered an emancipated minor. An emancipated minor has the legal right to make decisions. An emancipated minor must have an order from a court reflecting this finding.

Sexually Transmitted Infections

One of the fears faced by survivors is the fear of sexually transmitted infections. It is helpful to be educated on the types of infections, their symptoms, and the treatment available so you can be a helpful resource to survivors.

There are a number of sexually transmitted infections that must be considered in patients who have been sexually assaulted. Bacterial vaginosis, trichomoniasis, chlamydia, and gonorrhea are the most frequently diagnosed infections in adult victims. However, other diseases are also transmitted through unprotected sex. HIV, hepatitis, herpes, human papilloma virus, pelvic inflammatory disease and syphilis are all infections you need to be aware of in your role as advocate. Reliable, useful information is critical for survivors of sexual assault so they can make informed decisions about their medical health.

There is no single test for all sexually transmitted infections – separate tests are needed. Some infections may be detected during a physical exam, others may require a blood test and still others are tested for in urine samples. Different types of fluid and tissue samples may also be required depending on the infection for which one is testing.

Sexually transmitted infections found in children present additional issues. The Center for Disease Control states, “the identification of a sexually transmissible agent from a child beyond the neonatal period suggests sexual abuse.” In most cases, the diagnosis of a sexually transmitted infection in a child is considered “credible evidence” for child protective services (in Illinois, the Illinois Department of Children and Family Services) to indicate a case of sexual abuse and, therefore, must be reported immediately.

Specific information regarding symptoms, diagnosis and treatment are included below for several different sexually transmitted infections. For more information, contact Planned Parenthood or visit their website at .

Bacterial Vaginosis (BV)

Bacterial vaginosis is a condition caused by a change in the balance of different kinds of bacteria in the vagina. Most women will get BV at some point in their reproductive years. When there are symptoms, they often appear as a form of vaginitis – an irritation of the vagina often associated with a vaginal discharge. BV is not always due to sexual contact. However, women who are sexually active run a high risk of developing the condition. It can develop when an external factor, such as sexual contact, disrupts the balance between bacteria that protect the vagina from infection and those bacteria that do not.

Untreated BV is associated with premature delivery, low birth weight, and pelvic inflammatory disease. It can also increase the risk for HIV infection. Pregnant women with BV run a higher risk of miscarriage, especially in the first trimester.

Common symptoms:

• Strong, unpleasant vaginal odor

• Vaginal discharge

However, many women do not have any symptoms.

How BV is spread:

• Vaginal intercourse

Diagnosis:

• Pelvic exam

• Examination of vaginal fluid

• Microscopic examination of vaginal tissue

Treatment:

• Antimicrobial creams

Trichomoniasis (Trich)

Trich is a condition caused by a protozoan – a microscopic, one-cell animal. It is a common cause of vaginal infection. Up to five million Americans develop trichomoniasis every year.

Common symptoms

• Frothy, often unpleasant-smelling discharge

• Itching in and around the vagina

• Blood spotting in the discharge

• Swelling in the groin

• Urinating more often than usual – often with pain and burning

Only rarely do men have symptoms. Sometimes women have no symptoms. It takes from three to 28 days for symptoms to develop.

How Trichomoniasis is spread:

• Vaginal intercourse

• Mutual masturbation if fluids from one partner are passed to the genitals of the other

Diagnosis:

• Microscopic examination of vaginal discharge

Treatment:

• Drugs called 5-notroimidazoles are successful for both partners

Chlamydia

Chlamydia is a sexually transmitted bacterium. It can cause sterility in women and men. In women, it infects the cervix and can spread to the urethra, fallopian tubes, and ovaries. It can cause bladder infections and serious pelvic inflammatory disease, ectopic pregnancy, and sterility. In men, chlamydia infects the urethra and may spread to the testicles, which can cause sterility.

Chlamydia can also lead to reactive arthritis – especially in young men. One in three men who develop reactive arthritis becomes permanently disabled. In infants, chlamydia can cause pneumonia, eye infections, and blindness. Chlamydia is the most common and most invisible sexually transmitted bacterial infection in America. At least three million American men and women become infected every year.

Common symptoms:

• Discharge from the penis or vagina

• Pain or burning while urinating, frequent urination

• Excessive vaginal bleeding

• Painful intercourse for women

• Spotting between periods or after intercourse

• Abdominal pain, nausea, fever

• Inflammation of the rectum or cervix

• Swelling or pain in the testicles

Symptoms appear in 7-21 days – if they appear. If your partner is a man, and he has a urinary tract infection, you may have chlamydia. Seventy-five percent of women and 50 percent of men with chlamydia have no symptoms.

How Chlamydia is spread:

• Vaginal and anal intercourse

• From the birth canal to the fetus

• Rarely, from the hand to the eye

Diagnosis:

• Can be confused with gonorrhea and other conditions. Examination of tissue samples or urine is necessary for correct diagnosis.

Treatment:

• Both partners can be treated successfully with antibiotics. Follow-up testing may be suggested three to four months after treatment.

Gonorrhea

Gonorrhea is a bacterium that can cause sterility, arthritis, and heart problems. In women, gonorrhea can cause pelvic inflammatory disease (PID), which can result in ectopic pregnancy or sterility. During pregnancy, gonorrhea infections can cause premature labor and stillbirth. About 650,000 new cases of gonorrhea are reported every year in the U.S.

Common symptoms:

For women:

• Frequent, often burning, urination

• Menstrual irregularities

• Pelvic or lower abdominal pain

• Pain during sex or pelvic examination

• A yellowish or yellow-green discharge from the vagina

• Swelling or tenderness of the vulva; and even arthritic pain

For men:

• A pus-like discharge from the urethra

• Pain during urination

Eighty percent of the women and 10 percent of the men with gonorrhea show no symptoms. If they appear at all, symptoms occur in women within 10 days. It takes from one to 14 days for symptoms to appear in men.

How gonorrhea is spread:

• Vaginal, anal, and oral intercourse

Diagnosis:

• Microscopic examination of urethral or vaginal discharges; cultures taken from the cervix, throat, urethra, or rectum. Urine tests are also available.

Treatment:

• Both partners can be successfully treated with oral antibiotics. Often people with gonorrhea also have chlamydia. They must be treated for both infections at the same time.

Human Immunodeficiency Virus (HIV)

HIV infections weaken the body's ability to fight infection and can cause acquired immune deficiency syndrome (AIDS) – the most advanced stage of HIV disease. HIV is the most dangerous sexually transmitted infection, and it affects people of all ages. It is now the fifth leading cause of death for American women and men between 25 and 44 years old. It is believed that at least 40,000 Americans become infected each year. Like many other viruses, HIV remains in the body for life.

Common symptoms:

• Constant or rapid, unexplained weight loss, diarrhea or lack of appetite

• Fatigue, persistent fevers, night sweats, dry cough

• Lightheadedness, headaches, mental disorders

• A thick, whitish coating of yeast on the tongue or mouth — "thrush"

• Severe or recurring vaginal yeast infections

• Chronic pelvic inflammatory disease

• Purplish growths on the skin

There may be no symptoms for 10 years or more.

How HIV is spread:

• Blood, semen, vaginal fluids, and breast milk

• Anal and vaginal intercourse – less commonly transmitted through oral sex

• Sharing contaminated needles for injecting IV drugs

• Transfusion of contaminated blood products

• Childbirth

• Breast-feeding

• Accidental pricks with contaminated needles in the course of health care

Diagnosis:

• Blood, urine, and saliva tests detect HIV antibodies. Diagnosis of AIDS is based on the presence of one or more of a variety of conditions and “opportunistic” infections related to HIV infection.

Treatment:

• No cure or vaccine exists. HIV infection and many AIDS-related conditions can be managed to some extent with different treatments. However, at this time, no one has recovered from AIDS. Although people with AIDS are living longer, it is still considered fatal.

Hepatitis (HBV)

HBV is a common sexually transmitted infection that can be prevented with vaccination. About 120,000 Americans get HBV every year because they have not been vaccinated. There are now about 417,000 people with sexually acquired HBV in the U.S. Sexual transmission of the hepatitis A virus (HAV) is less common. Unlike most sexually transmitted infections, a person with HAV also develops immunity against re-infection. Although 90-95 percent of adults with HBV recover completely, the virus can cause severe liver disease and death. Unless they are treated within an hour of birth, 90 percent of the infants born to women with HBV will carry the virus. Pregnant women who may have been exposed to HBV should consider being tested before giving birth so that their babies can be vaccinated at birth or treated if they become ill. Like many other viruses, HBV remains in the body for life.

Common symptoms:

• Extreme fatigue, headache, fever, hives

• Lack of appetite, nausea, vomiting, tenderness in the lower abdomen

Later symptoms: more abdominal pain, dark urine, clay-colored stool, yellowing of the skin and white of the eye – jaundice. Hepatitis may be invisible during its most contagious phases.

How HBV is spread:

• Semen, saliva, blood and urine

• Intimate and sexual contact, from kissing to vaginal, anal, and oral intercourse

• Use of unclean needles to inject drugs

• Accidental pricks with contaminated needles in the course of health care

How HAV is spread:

• Oral contact with fecal matter through oral/anal sex play or other kinds of sex play

• Sharing needles with intravenous drug use

Hepatitis A and B are very contagious. However, HAV infection is contagious for only a short period of time.

Diagnosis:

• Blood test

Treatment:

• None. In most cases, the infection clears within four to eight weeks. Some people, however, remain contagious for the rest of their lives.

Herpes

The two forms of genital herpes are herpes simplex virus-1 and herpes simplex virus-2. Although herpes-1 is most often associated with cold sores and fever blisters, both forms of herpes may be sexually transmitted. In fact, most adults have herpes simplex virus (HSV), either type 1 or type 2, or both. During pregnancy, herpes may cause miscarriage or stillbirth. If active herpes infections are present during childbirth, newborn infants may suffer serious health damage, including developmental disabilities and, rarely, death. Transmission to a newborn is more common during the first episode of the herpes infection and less common during recurrent herpes outbreaks. More than 45 million Americans have been diagnosed with genital herpes. At least one million new cases are diagnosed every year. Like many other viruses, the HSV remains in the body for life.

Common symptoms:

• A recurring rash with clusters of itchy or painful blistery sores appearing on the vagina, cervix, penis, mouth, anus, buttocks, or elsewhere on the body

• Painful ulcerations that occur when blisters break open

• The first outbreak may cause pain and discomfort around the infected area, itching, burning sensations during urination, swollen glands in the groin, fever, headache, and a general run-down feeling

Symptoms usually appear from two-20 days after infection, but it may be years before an outbreak occurs.

How HSV is spread:

• Touching, sexual intimacy – including kissing

• Vaginal, anal, and oral intercourse

HSV may be passed from one partner to another or from one part of the body to another, whenever contact is made with an active herpes virus.

HSV is most contagious from the time the sores are present until they are completely healed and the scabs have fallen off. Some people may be contagious at various times when they have no symptoms. Mucous membranes of the mouth, anus, vagina, penis, and the eyes are especially susceptible to infection.

Diagnosis:

• Definitive diagnosis is possible by laboratory culturing of fluid samples taken from the sores or by blood test

Treatment:

• No cure exists for HSV. Symptoms can be relieved and the number of recurrences reduced with drugs.

Human Papilloma Virus

There are more than 100 different human papilloma viruses (HPVs). They cause a variety of warts and other conditions and can remain in the system for life. Studies suggest that as many as three-quarters of adults in the U.S. have been infected with at least one type of HPV. Thirty of these HPVs are genital and affect sexual and reproductive organs. A few cause genital warts, but most genital HPV infections are not visible and have no symptoms. Some of these cause cancer of the cervix, vulva, or penis. Every year, more than five million Americans are newly infected with genital HPVs – about 20 million women and men are now infected.

Common symptoms:

• Warts appear on the genitals, in the urethra, in the anus, and, rarely, in the throat

• Genital warts are soft to the touch, may look like miniature cauliflower florets, and often itch

• Untreated genital warts can grow to block the openings of the vagina, anus, or throat and become quite uncomfortable

It usually takes two to three weeks after infection for warts to develop. Genital warts grow more rapidly during pregnancy or when other infections are present.

How genital HPVs are spread:

• Vaginal and anal intercourse

• Very rarely, to the fetus during childbirth

• Oral sex

Diagnosis:

• Microscopic examination of tissue or fluid samples

• Clinical evaluation of warts during a physical or gynecological exam

• Special magnifiers can detect genital HPVs that cannot be seen with the naked eye during pelvic exams

• Pap tests may reveal pre-cancerous conditions caused by genital HPVs – early treatment prevents cancer of the cervix

Treatment:

No cure exists for HPV. Though they may recur, genital warts can be treated in a number of ways. Clinicians offer other treatments, including:

• Application of acid

• Standard surgery

• Laser surgery (vaporizing the wart with a beam of high-powered light)

• Cryosurgery (freezing the wart with liquid nitrogen)

• Injection of interferon

Pelvic Inflammatory Disease (PID)

PID is a progressive infection that harms a woman's reproductive system. PID occurs throughout the pelvic area, in the fallopian tubes, the uterus, the lining of the uterus, and in the ovaries. Treated or untreated, PID can lead to sterility, ectopic pregnancy, and chronic pain. The more episodes of PID a woman has, the greater are her chances of becoming infertile. PID is not always the result of a sexual transmitted infection, but in most cases it is. The sexually transmitted infections that most commonly cause PID are gonorrhea and chlamydia. More than 1,000,000 U.S. women have an acute episode of PID every year. It is believed that millions of other cases go undiscovered.

Common symptoms:

• Unusually long or painful periods, and unusual vaginal discharge

• Spotting and pain between menstrual periods or during urination

• Pain in the lower abdomen and back

• Fever, chills

• Nausea, vomiting

• Pain during intercourse

Diagnosis:

• Pelvic exam

• Microscopic examination and/or culture of vaginal and cervical secretions

• Laparoscopy – an optical instrument is inserted through a small cut in the navel to look at the reproductive organs

Symptoms can be confused with those of appendicitis and other infections. Diagnosis can be difficult if patients are too embarrassed to admit sexual activity.

Treatment:

• Antibiotics

• Bed rest

• Sexual abstinence

• Surgery may be required to remove abscesses or scar tissue, or to repair or remove reproductive organs

Syphilis

Untreated, the syphilis organism can remain in the body for life and lead to disfigurement, neurological disorder, or death. There are 70,000 new cases each year in the U.S.

Common symptoms:

Syphilis has several phases that may overlap one another. They do not always follow in the same sequence. Symptoms vary with each phase, but there are no symptoms most of the time.

• Primary Phase: Painless sores or open, wet ulcers – chancres – often appear from three weeks to 90 days after infection. They last three to six weeks. They appear on the genitals, in the vagina, on the cervix, lips, mouth, or anus. Swollen glands may also occur during the primary phase.

• Secondary Phase: Other symptoms often appear from three to six weeks after the sores appear. They may come and go for up to two years. They include body rashes that last from two to six weeks – often on the palms of the hands and the soles of the feet. There are many other symptoms, including mild fever, fatigue, sore throat, hair loss, weight loss, swollen glands, headache, and muscle pains.

• Latent Phase: No symptoms. Latent phases occur between other phases.

• Late Phase: One-third of untreated people with syphilis suffer serious damage to the nervous system, heart, brain, or other organs, and death may result.

How syphilis is spread:

• Vaginal, anal, and oral intercourse

• Kissing

• To the fetus during pregnancy

Syphilis is especially contagious when sores are present early in the disease – the liquid that oozes from them is very infectious. People are usually not contagious during the latent phases of the first four years of syphilis infections. Untreated syphilis remains latent for many years or a lifetime, but can be spread from a pregnant woman to her fetus. The effect of syphilis on a fetus is very serious. If untreated, the risks of stillbirth or serious birth defects are high. Birth defects include damage to the heart, brain, and skeleton as well as blindness. It is very important for pregnant women to consider testing for syphilis early, and, sometimes, throughout their pregnancies. Pregnant women with syphilis can be treated to prevent damage to the fetus.

Diagnosis:

• Microscopic examination of fluid from sores

• Blood tests

• Examination of spinal fluid

Treatment:

• Antibiotics are successful for both partners, but damage caused by the disease in the later phases cannot be undone.

Emergency Contraception And Abortion

Survivors of sexual assault obviously may fear pregnancy as well as sexually transmitted infection. It is one of your roles as a volunteer to provide them with factual information about their options regarding emergency contraception, and if necessary, alternatives for an unplanned pregnancy, including abortion. Hospitals are required by law to give sexual assault victims information about emergency contraception.

Emergency contraception can reduce the risk of pregnancy after unprotected intercourse. Emergency contraception is most often provided through the use of emergency contraception (EC). EC pills contain hormones. Some ECs are combination pills containing both estrogen and progestin-synthetic hormones like the ones a woman’s body makes. Other ECs are progestin-only pills. There are now two products approved by the FDA and marketed specifically as emergency contraception – Plan B (a progestin-only pill) and Previn (a combination pill). Both products require the user to take pills in two doses twelve hours apart.

Although emergency contraception pills (ECs) are effective in reducing the risk of pregnancy when used up to 120 hours after unprotected vaginal intercourse, they work best when taken within 96 hours. When taken within 96 hours of unprotected intercourse, combination ECs, such as Previn, reduce the risk of pregnancy by 75%. When initiated within 24 hours of unprotected intercourse, progestin-only ECs have been found to reduce the risk of pregnancy by 95%.

Emergency contraception can be obtained in the hospital setting and from pharmacies. In Illinois, ECs can also be obtained online from Planned Parenthood affiliates. You can contact Planned Parenthood at 1-800-230-PLAN (7526) for a Planned Parenthood center nearest you, or call 1-888-NOT-2-LATE for a list of providers in your area. ECs can be ordered online at or . Providers can also be located by going to ec.princeton.edu.

It is important to understand that emergency contraception is not abortion, in that it cannot end an existing pregnancy. Emergency contraceptive pills are not effective if the woman is pregnant. They act by delaying or inhibiting ovulation, fertilization, and/or implantation, therefore preventing pregnancy. Abortion is covered in more detail in the next section.

Abortion

Abortion is a way to end pregnancy. Sometimes, an embryo or fetus stops developing and the body expels it. This is called spontaneous abortion or “miscarriage.” A woman can also choose to end a pregnancy. This is called induced abortion. There are three ways it can be done – with medicine, vacuum aspiration, or surgery.

Medical abortion involves the use of medications that can induce abortion. There are currently two drugs available in the U.S. for this purpose: mifepristone, most commonly known as RU-486, and methotrexate. There is considerable public confusion about the difference between emergency contraception and medical abortion because of misinformation disseminated by anti-choice groups. Much of this confusion has centered on RU-486. RU-486 (mifepristone) is not used to prevent pregnancy. Rather, it is used to terminate early-term pregnancies. Mifepristone can be taken up to 63 days after the first day of the last menstrual period and methotrexate can be taken up to 49 days after the first day of the last menstrual period. Both drugs are taken in conjunction with another drug (misoprostol) that completes the abortion.

Vacuum aspiration and surgical abortions can be performed at clinics, doctors’ offices and hospitals. Most abortions – nearly 90 percent – are provided in the first trimester, the first three months of pregnancy. Fewer than 11 percent take place in the second trimester. Abortion is very rare and only done for serious health reasons after six months.

If a survivor finds herself in a position of wanting to terminate a pregnancy, earlier is better. Earlier abortions are easier and safer than abortions later in pregnancy. They also cost less. Her health care provider or an organization like Planned Parenthood can provide the survivor with more detailed information about the specific options available to her.

Minors’ Rights Regarding Reproductive Health Care

1. Birth Control – According to Illinois law, minors do not need parental consent to get birth control if failure to provide the services would result in a serious health hazard or if the minor is referred by a doctor, clergy person or Planned Parenthood agency. In reality, minors are almost always able to obtain birth control without parental consent.

2. Abortion Services – Illinois lawmakers have enacted laws that require parental consent for abortion, but so far each version of this law has been found to be unconstitutional. This means that while the law says minors must get consent for abortion services, these laws cannot be enforced. Planned Parenthood can provide abortion services without notifying the minor’s parents, although they are required to discuss with the minor the option of telling her parents on her own. Minors of all ages are included.

3. Evidence – Minors 13 and over can release medical evidence with the consent of a parent or guardian. For minors under 13, evidence can be released by a parent or guardian, law enforcement or DCFS.

Drug Facilitated Sexual Assault

Victims raped while under the influence of alcohol and drugs generally will remember little or none of the actual assault. Therefore, these victims may have special needs and concerns as they seek to recover from the sexual assault.

Even if the survivor remembers a few, fragmented pieces of the assault, she may be uncertain about what exactly happened and who the perpetrator(s) was/were. This can cause tremendous anxiety. Survivors assaulted while sedated may become very focused on trying to recall exactly what happened to them. Like all survivors, those victimized by an assailant using drugs will feel an extreme sense of loss of control; this may be the biggest barrier to their recovery. Advocates need to be aware of the following possible reactions from a survivor raped with the use of date rape drugs:

• She has incomplete recall of events surrounding the rape.

• She does not fully know what sexual activity was forced upon her.

• She may feel enhanced guilt or shame and blame herself for “letting” herself be vulnerable to date rape drugs.

• She may feel a particularly strong sense of loss of control.

• She may have great difficulty coping with the reality that she may never be able to fill in the missing pieces.

• She may feel great anxiety about the “unknowns,” for example, she may wonder if multiple offenders were involved or if there was videotaping or photographing of the sexual assault.

• She may feel concern over the possibility of circulation of videos or photographs of her in the underground pornography industry or on the Internet.

• She may express the feeling that, if she does not even know what actually occurred during the rape, no one will or should believe that an actual rape took place.

• She may be worried that if the case is prosecuted, she will be unable to testify effectively.

• She may express the feeling that because of all the “unknowns,” she can never truly deal with her assault and, consequently, will never recover.

The ease of illicit administration and the almost immediate incapacitating effects of some drugs make them extremely appealing to sexual offenders. Research indicates that most acquaintance rapes are planned in advance and are not the impulsive result of “runaway sexual urges.” An offender intent on finding a victim can go to a crowded party, slip a crushed tablet into a woman’s drink, escort her away from the party and sexually assault her while she is in a drug-induced stupor. Sometimes offenders work together. Gang rapes of drug-incapacitated victims are not uncommon. Since amnesia is a common side effect, the drug provides an almost perfect cover for sexual perpetrators. Although the victim may never consciously know what happened to her, she may nevertheless suffer many serious, even life-threatening, after-effects, including injury, sexually transmitted infections and/or pregnancy.

Drugs Used to Facilitate Sexual Assault

Rohypnol

The most well-known date rape drug, Rohypnol, is a central nervous system depressant, in the same class of drugs as Valium, but far more powerful. Slang terms for the drug include rophies, roofies, ruffies, R2, roofenol, Roche, roachies, la rocha, rope, and rib. Rohypnol is legally prescribed in Europe and Mexico to treat severe insomnia; however, it is neither made nor approved for sale in the U.S.

Rohypnol is used both to induce a high and to mitigate the effects of withdrawing from heroin or cocaine. Usually Rohypnol is taken orally in tablet form, but it may also be snorted. Rohypnol is one of the “club drugs” found at “rave” dances (late-night dance parties usually located in clubs, bars and similar settings). Drugs are often used extensively at raves in order to enhance the dancers’ sensory experiences and to provide the energy needed to dance for hours.

When combined with alcohol, Rohypnol produces both disinhibition and amnesia. Rohypnol also does not show up on standard drug tests.

The drug’s effects start within a half-hour of ingestion and may last as long as 8 hours. According to the package insert provided by the manufacturer, “Some patients may have no recollection of any awakenings occurring in the 6 to 8 hours during which the drug exerts its action.” The person on the drug almost instantly starts to feel intoxicated and sleepy, and may show signs such as slurred speech, problems in walking and poor judgment. Other effects include blackouts that can last up to a full day, respiratory distress, lowered blood pressure, hallucinations, dizziness, confusion, and headaches. Rohypnol can be lethal if taken in large quantities, especially if mixed with alcohol.

In response to the growing concern about Rohypnol, in 1996, Congress enacted the Drug-Induced Rape Prevention and Punishment Act of 1996, which makes it a crime to give someone a controlled substance without their knowledge and with the intent to commit a violent crime. Rohypnol’s manufacturer has also reformulated the drug in order to make it more detectable in liquids, and to slow down the rate at which it dissolves. This change does not affect counterfeit drugs, as they are not produced by the manufacturer. Therefore, counterfeit drugs are still not easily detectable in liquids.

GHB

Another similar but lesser known date rape drug is gamma-hydroxybutyrate (GHB). GHB was first sold by health food stores to help body builders enhance their performance. GHB is also a central nervous system depressant, and has many of the same characteristics as Rohypnol. It comes in a tablet which can be crushed and mixed into liquids, produces intoxication followed by deep sedation, and affects the person almost immediately. GHB has a high potential for lethal overdoses, especially when combined with alcohol and other drugs.

Ecstasy

Ecstasy, or MDMA, is another very well-known club drug. Slang names include E, X, XTC, Adam, Eve, Clarity, Essence, Lover’s Speed, and the hug drug. It is usually prepared in pills that look like candy or vitamins, making it easy to camouflage. It is derived from methamphetamine, and may be used as a diet aid. It has numerous effects on the user, including feelings of pleasure, increased energy and closeness to others. High doses can lead to hallucinations, paranoia and violence. As a club drug, some Ecstasy users have danced themselves into severe dehydration and heat exhaustion, resulting in death.

Alcohol

There are alarming statistics on the relationship between alcohol and sexual crimes. Alcohol is cheap, legally available and is not just tolerated, but encouraged among adolescents and young adults. For these reasons, it is extremely important to understand the connection between alcohol and sexual assault.

According to researchers, as many as half of all rapes are committed by men who have been drinking. Similarly, about half of the women who are raped have also been drinking. Often both parties have consumed alcohol when a rape occurs. Although four out of five sexual assaults happen between people who know one another, rapes involving alcohol tend to take place between two people who do not know each other at all or know each other only slightly.

It is well known that alcohol is related to aggressive behavior. It is related to half of all violent crimes, not just sexual assaults. Similar to Rohypnol, alcohol acts on the brain to release inhibitions, suspend judgment and interrupt higher brain functions. A woman who is drunk may be feeling free, released from normal constraints and not as aware as usual of risks and vulnerability. One of the most important research implications is the possibility that completed rapes are more likely when alcohol is involved. This is a very significant finding, because completed rapes have far more serious consequences for the victim than attempted rapes.

It is critical to recognize that drinking does not cause sexual violence. It may be that men who want to commit sexual offenses drink in order to gain “liquid courage” and to have an excuse for their behavior. It may also be that women who drink, especially those who drink in bars or similar settings, are viewed as more sexually available and more deserving of forced sexual activity. Sexual predators may deliberately facilitate a woman’s drinking in order to increase her vulnerability. Since women who were sexually abused as children are more likely to heavily consume alcohol as a way to cope with unresolved trauma, they may unknowingly become vulnerable to further sexual victimization in adulthood.

Rights Regarding Date Rape Drug Testing

1. The victim has the right to be tested for the presence of controlled substances and the right to refuse such a test.

2. If the victim decides to be tested for the presence of controlled substances, such a test will disclose all controlled substances, including prescription medications, alcohol and illegal drugs such as cocaine and marijuana.

3. If the victim thinks she might want to be tested for the presence of date rape drugs, she should give a urine sample as soon as possible. If she is uncertain about whether to be tested, medical personnel will explain to her that a sample can be taken now and she can make the decision to test or not to test the sample during the next 30 days.

4. If the victim gives a urine sample, she has 30 days after giving the sample to make a final decision about having the sample tested. If she decides to have the sample tested, she may sign the consent form at the hospital or at the law enforcement agency within 30 days of giving the sample. If she is unable to travel to the law enforcement agency, law enforcement personnel will bring the form to her. If she does not sign the consent form within 30 days of giving the sample, the sample will not be tested.

5. If the victim signs the consent form and then decides within 30 days of giving the sample that she does not want the urine to be tested, she may revoke consent. To do so, she must return to the law enforcement agency and sign the revocation of consent form. If she is unable to travel to the law enforcement agency, law enforcement personnel will bring the form to her.

Revocation of Consent

Signing at the Hospital

1. If the victim decides while still at the hospital to have the urine sample tested for the presence of controlled substances, she may sign the “Consent to Toxicology Screen” form at the hospital.

2. A witness, preferably medical personnel at the hospital, must also sign the form and indicate the time at which she signed it, to confirm that it was signed within 30 days of the sample being taken.

Signing Later

1. If the victim is unsure whether to have the urine tested for the presence of controlled substances, she may wait up to 30 days after the sample is taken to make the decision. During the waiting period, the law enforcement officer keeps the consent form. The urine sample will be kept at the State Crime Laboratory during the wait period.

2. If she decides to have the urine tested, she must return to the law enforcement agency within the 30-day waiting period to sign the form. If she is unable to travel to the law enforcement agency during that time, the law enforcement officer will take the form to her for her signature.

3. A witness, preferably a law enforcement officer, must also sign the form to confirm that it was executed within 30 days of the sample being taken.

Revocation of Consent

In the event that the victim consented in writing to having the urine screened, she may revoke that consent by doing the following:

1. Within 30 days after the sample is taken, the victim must go to the law enforcement agency (or if she is unable to travel, request that the law enforcement agency bring the form to her) to complete the “Revocation of Consent to Toxicology Screen” form.

2. The victim and a witness (preferably a law enforcement officer) must sign the form.

Chapter 4: Medical Advocacy Issues

Chapter Questions

Instructions: Write a brief answer to each question and be prepared to discuss your responses with the training facilitator.

1. List at least three mandates of treatment hospitals under SASETA.

2. What type of test(s) is/are required in determining if a sexually transmitted infection is present and what are the most common infections transmitted through sexual assault?

3. What is the difference between emergency contraception and abortion?

4. In what form is emergency contraception provided and how effective is it?

5. How does a victim obtain emergency contraceptives?

6. List at least five specific concerns a victim of a drug-facilitated rape may have.

7. What substance is most commonly used in drug-facilitated rape?

8. Why is it important for victims of drug-facilitated rape to know a drug test will reveal all drugs in their system?

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