Canadian Guidelines on Sexually Transmitted Infections

Supplementary statement for the management and follow-up of sexual assault in postpubertal adolescents and adults

October 2014

Key Issue

The Gonococcal Infections chapter has been revised in response to emerging antimicrobial resistance. As a result, the 2010 print and online versions of the Sexual Assault in Postpubertal Adolescents and Adults chapter of the Canadian Guidelines on Sexually Transmitted Infections are currently under review.

This statement is intended to provide clinicians with high level interim guidance to highlight key changes to screening, management and follow-up of sexually transmitted infections (STI) in cases of suspected or confirmed sexual assault until such time as updated guidance is available.

Age of Consent to Sexual Activity in Canada

  • Clinicians should refer to the Department of Justice website for information on age of consent in Canada and related exceptions.

Reporting Requirements

  • It is important for clinicians to advise victims of sexual assault that there is no statute of limitations for reporting.
  • Practitioners should consult Provincial/Territorial legislation or seek legal counsel if uncertain of reporting requirements.
  • Appropriate patient referral should be made as necessary and if available (e.g., sexual assault teams, local police/Royal Canadian Mounted Police, psychological support, local victim support organizations).

Assessment and Follow-up Recommendations

  • Assessment and follow-up of individuals suspected to be victims of sexual assault should be carried out with great sensitivity and in conjunction with local teams or services experienced in the management of victims of sexual assault. Of note, males and females of any age may be affected by sexual assault.
    • Clinicians should consult local sexual assault teams/or public health authorities for guidance whenever possible. In addition, where available, local and provincial/territorial guidelines should be consulted.
    • All specimens for forensic evidence should be collected by professionals experienced in these procedures, following established regional/local protocols.

Specimen collection considerations

  • Baseline screening for STIs should be done (refer to Table 1 of the 2010 chapter).
  • In addition to cervical swabs and urine, vaginal samples can be submitted for gonococcal, chlamydial and trichomonal infections by NAAT testing in some parts of the country; check with your local laboratory for availability of such testing.
  • If a positive NAAT may be used for medico-legal purposes then this should be confirmed:
    • for gonorrhea, ideally by collecting specimens for both culture and NAAT at the time of initial screening.
    • for gonorrhea and chlamydia by sending the positive NAAT samples to another laboratory where a second set of primers would be used; consult with your local laboratory regarding the availability of such testing.
  • Although no NAATs are currently licenced in Canada to detect rectal or pharyngeal infections, individual laboratories may offer NAATs after in-house laboratory validation. Positive specimens need confirmation with culture or a second NAAT which uses an alternate target and has been validated for rectal or oral specimens.

Prophylactic treatment considerations

  • Offer prophylaxis if:
    • unsure that the patient will be returning for follow-up;
    • it is known that the assailant is infected with a specific STI;
    • it is requested by the patient/parent/guardian; or
    • the patient has signs or symptoms of an STI.
  • As the literature suggests that sexual assault victims do not return for follow-up visits, it may be appropriate to routinely offer prophylaxis in situations where vaginal, oral or anal penetration has occurred.
  • For post-exposure prophylaxis recommendations, clinicians should refer to Table 2 in the 2010 chapter except for the treatment of gonorrhea; refer to the revised 2013 Gonococcal Infections chapter. Patients being treated for gonorrhea should optimally be treated with combination therapy in response to increasing antimicrobial resistance. This combination therapy also includes effective treatment for chlamydia.

Follow-up

  • Confirmed notifiable STIs should be reported to provincial/territorial authorities as appropriate.
  • Clinicians should consult the relevant chapters of the Guidelines for guidance on infection-specific management issues.
  • Where an STI is detected in a sexual assault victim, partner notification recommendations should follow the guidance provided in the relevant chapter of the Guidelines.
  • Clinicians should refer to the Follow-up section of the 2010 chapter for further suggested follow-up recommendations.
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