The challenge of providing medical follow-up for sexual assault victims: can we predict who will attend? A retrospective cross-sectional study
L. M. Healey
A * , J. L. Hutchinson B , M. N. Pfeiffer C , L. Garton A B , B. Hatten A , M. Dobbie C , L. Simpson D and D. J. Templeton A B C E
A Department of Sexual Health Medicine, Community Health, Sydney Local Health District, Sydney, NSW, Australia.
B The Kirby Institute, University of NSW Australia, Sydney, NSW, Australia.
C Sexual Assault Medical Service, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia.
D Sexual Assault Counselling Service, Community Health, Sydney Local Health District, Sydney, NSW, Australia.
E Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
Abstract
This study examined the impact of a pathway between a sexual assault service and a public sexual health service developed to improve rates of post-sexual assault medical follow-up. Follow-up attendances improved in the first 12 months of the pathway (2014) compared with attendances in 2013 (17.8% vs 9.6%, P = 0.01). Factors independently associated with attendance at follow-up were being prescribed HIV post-exposure prophylaxis and knowing the assailant. Those with physical injuries were less likely to attend. The prevalence of sexually transmissible infections in this cohort, 8% at the acute presentation and 5% at follow-up, suggests a need for alternatives to clinic-based follow-up.
Keywords: community health, gay men, HIV/AIDS, sexual violence, STIs.
Background
Testing for sexually transmitted infections (STIs) is strongly recommended after a person experiences sexual assault.1,2 Worldwide, small numbers of individuals present for follow-up sexual healthcare following an acute sexual assault presentation.3–6
This study examined the impact of a pathway developed between an inner-city sexual assault service and a public sexual health service on the same hospital campus, with the aim of improving the number of individuals attending post-sexual assault medical follow-up. The study also aimed to examine factors associated with attendance for follow-up care. The referral pathway, introduced in January 2014, consisted of the sexual assault forensic medical officer referring the victim to RPA Sexual Health (RPASH) for follow-up care, if agreed to. A sexual health counsellor then contacted the individual and invited them to attend medical follow-up using a trauma-informed approach.
Methods
A retrospective review was conducted of individuals attending Sydney Local Health District Sexual Assault Service (SAS) following a sexual assault between January 2014 and June 2016. The study population consisted of 440 individuals who presented to the service over the 30-month period. Chi-squared test was used to compare attendances before and after the pathway was introduced. Logistic regression was used to determine factors associated with attendance at RPASH for follow-up, among those who were referred. Penalised maximum likelihood estimation7 was used to reduce the small-sample bias of the maximum likelihood coefficients.
Results
In 2013, the 12-month period before the pathway was implemented, 240 individuals presented to SAS for acute sexual assault care. Twenty-three (9.6%) individuals attended RPASH for post-sexual assault medical follow-up. In 2014, the first year of the pathway, of the 219 total presentations to SAS, 84 (38.4%) accepted referral, of whom 39 (46.4%) attended medical follow-up; 17.8% of total presentations (17.8% vs 9.6%, P = 0.01). Following introduction of the pathway, over 30 months, 187 (42.5%) individuals accepted referral, of whom 98 (52%) attended medical follow-up; 22% of total presentations.
Thirty-seven individuals (8%) tested positive for an STI at the acute sexual assault presentation; most commonly chlamydia (n = 29, 7%). Five individuals who did not have an STI at the acute presentation, tested positive for an STI at the first follow-up visit. Four (4%) had chlamydia and one had pharyngeal gonorrhoea. Two women were treated for suspected pelvic inflammatory disease, but no pathogens were identified on laboratory testing.
Of those who accepted referral (n = 187) we compared those who attended (n = 98, 52%) with those who did not (n = 89, 48%). On adjusted analysis (Table 1) factors associated with attendance at medical follow-up were being prescribed HIV post-exposure prophylaxis (PEP) and knowing their assailant. The factor associated with a lower likelihood of attendance at medical follow-up was suffering physical injuries.
| Characteristic | OR | 95% CI | P-value | |
|---|---|---|---|---|
| Sex | 0.63 | |||
| Male | 0.70 | [0.17, 2.96] | ||
| Female | 1.00 | |||
| Age (years) | 0.53 | |||
| <25 | 0.71 | [0.36, 1.40] | ||
| 25–34 | 1.00 | |||
| ≥35 | 0.64 | [0.23, 1.74] | ||
| Know assailant | 2.25 | [1.20, 4.22] | 0.01 | |
| Received HIV PEP | 3.39 | [0.92, 12.58] | 0.05 | |
| Physical injuries | 0.59 | [0.32, 1.09] | 0.09 |
Nine excluded: two transgender women (small numbers), six missing physical injuries and one missing if HIV post exposure prophylaxis (PEP) was prescribed.
These associations persisted after analysis of only the 160 female participants. Women who knew the assailant were more likely to attend aOR [95%CI]: 2.76 [1.41, 5.41], P = 0.003, as were women who were prescribed PEP aOR [95%CI]: 4.82 [0.97, 24.05], P = 0.05. Those who sustained physical injuries were less likely to attend aOR [95%CI]: 0.46 [0.24, 0.89], P = 0.02.
Conclusion
The moderate improvement in numbers attending medical follow-up after sexual assault following the introduction of the pathway highlights the benefit of introducing a trauma-informed pathway between sexual assault and sexual health services. Many sexual health services are well placed to offer this proactive approach to individuals who have experienced sexual assault. The study found no modifiable characteristics associated with non-attendance for medical follow-up. The prevalence of chlamydia detected at follow-up suggests a need to look for novel ways to improve follow-up in this population, such as home testing8 or an opt-out rather than opt-in system of referral for victims of sexual assault.
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