management A pregnancy test must be performed and negative prior to administration It is offered within 120 hours of an assault with vaginal penetration or genital contact with ejaculation occurred Progestin-only emergency contraceptive pills are most favorable in terms of safety, adverse effects, and efficacy A total of 1.5 mg of levonorgestrel can be taken once, with or without ondansetron to mitigate nausea and/or vomiting Emergency contraception is up to 90% effective in pregnancy prevention No studies to date show untoward effects on the fetus should pregnancy occur; it does not disrupt an already implanted pregnancy Pregnancy testing should be repeated at weeks Reporting Physicians and other healthcare professionals are mandated reporters under U.S law, and therefore, are required to report suspected as well as known cases of child abuse ( Table 127.6 ) In many states, the suspicion of child sexual abuse as a possible diagnosis requires a report to both the appropriate law enforcement and CPS agencies For many children who present with complaints of sexual assault, CPS and the police may have already been involved; however, some children present prior to contact with these agencies Medical providers need to be aware of their mandated reporter status and the associated obligation to report any suspicions of child abuse The threshold for reporting is low; if there is a reasonable suspicion of sexual abuse, a report is indicated The CPS agency then has the responsibility to conduct a thorough investigation to determine whether the abuse has occurred Mandated reporters are protected against criminal or civil repercussions for any report made in good faith, no matter the eventual outcome of that investigation TABLE 127.6 GUIDELINES FOR MAKING THE DECISION TO REPORT SEXUAL ABUSE OF CHILDREN The majority of adolescent sexual assaults are perpetrated by an acquaintance or relative of the adolescent Depending on the patient’s age, the identity of the alleged perpetrator, and state law, the assault may have to be reported Statutory rape, defined as consensual sexual intercourse between an older person and a person younger than the state-mandated age of consent, continues to be a controversial issue In these cases, the assault may have to be reported, even if the adolescent does not want it to be reported Furthermore, sexual assault patients may also be victims of intimate partner violence and healthcare providers must be sensitive to this association and screen patients for associated physical and psychological abuse and address their safety An understanding of specific state statutes is important to properly determine reporting requirements under these circumstances The Digital Health Era—Teleconsultation Efforts to improve the quality of care delivered to the sexually assaulted patient have included the use of innovative telehealth technology to facilitate a teleconsultation for care at the bedside While asynchronous (store and forward) telehealth has been used for years in SART programs as a peer review process to ensure quality, synchronous (real-time) telehealth has been evaluated in child sexual abuse, and found to improve the quality of acute sexual assault care and the documentation of the care delivered In addition, patient- and caregiver attitudes and acceptance of telehealth as a tool in providing care to the child sexual abuse patient have been deemed very favorable as an acceptable approach to receiving high-quality, expert forensic care EDs and child abuse programs in the United States are developing systems to be able to expand the sexual assault forensic expertise to the ED with the use of telehealth solutions Clinical Indications for Discharge or Admission Disposition In most cases, the sexual assault victim may be discharged from the ED in the care of nonoffender caregivers On occasion, hospitalization is necessary for treatment or observation of injuries, exacerbation of pre-existing or new medical conditions; housing concerns, suicidal, homicidal, or other psychiatric emergencies If the patient is deemed medically stable for discharge and has a safe place to go once leaving the ED, plan for follow-up care with confirmed contact information should be obtained before final discharge instructions and appropriate referrals provided in both oral and written form Follow-Up Victims of sexual assault must be discharged with a specific plan of care that includes adequate follow-up with their primary care provider or child abuse specialist, child advocacy center, and accessible psychological/mental health services Patients should be counseled to follow-up with their primary care provider or child abuse specialist within week to assess healing and sooner, if symptoms occur Victims of sexual abuse are at risk for short- and longterm psychological disturbances, such as posttraumatic stress disorder, depression, and suicidality Law enforcement contact information should also be provided so that the patient can determine the status of their report Because infectious agents acquired through assault may not produce sufficient concentrations of organisms to be detected during initial testing, evaluation for STIs should be repeated within to weeks of the assault if treatment was not initially provided, and/or there is the onset of STI symptoms Serologic tests for syphilis are repeated to weeks, and then again at months after the assault if initial test results were negative and infection in the assailant cannot be ruled out Completion of the Hepatitis B vaccine series is also considered at to and to months after the first dose, if the patient was not previously vaccinated and had received the first dose during the initial evaluation If initial HIV testing was negative and a third-generation test (as described above) was performed, repeat testing should occur at weeks, months, and months; if a fourth-generation test was performed, repeat testing should occur at and 12 weeks Finally, if HIV PEP was initiated, follow up to monitor side effects and adherence to regimen is highly recommended