Every ninety-eight seconds a person somewhere in our country is sexually assaulted. One in five women and one in 71 men will be raped at some time in their lifetime.  Moreover, predators often target vulnerable populations making prevalence rates twice as high among individuals with disabilities.  The prevalence is even higher when considering gender; female autistics having 4 times higher odds of being sexually abused. These crimes often go unrecognized and unreported for multiple reasons: behaviors stemming from the sexual assault may be misattributed to their autism, victims may be easily manipulated, and/or they may be perceived as having difficulties in providing testimony or defending themselves. Unfortunately, in many of these cases, perpetrators are left free and, in a position, to continue abusing their helpless victim and to commit similar crimes with others.  In the meanwhile, the stressful experience leaves its victim vulnerable to substance use disorder, acquire posttraumatic stress disorder, and have worse pain outcomes.

Sexual abuse tends to occur in the midst of family problems, under limited supervision, in families with drug or alcohol problems, and where the spouse is not the biological parent.  Some behaviors indicative of sexual abuse include:

• An increase in nightmares and/or other sleeping difficulties
• Angry outbursts
• Anxiety/Depression
• Propensity to wander or run away (Note: See wondering prevention tips at https://www.autismspeaks.org/wandering-prevention-tips-our-community)
• Refusal to change for gym or to participate in physical activities
• Regressive behaviors depending on their age (e.g., return to thumb-sucking or bed-wetting)
• Reluctance to be left alone with a particular person or people
• Unusual and inappropriate sexual knowledge for the age of the child
• Withdrawn behavior

The Committee on Child Abuse and Neglect from the American Academy of Pediatrics (AAP) encourages physicians, “…to routinely ask adolescents, including those with disabilities, about a history of sexual violence, dating violence, and sexual assault.”  Prompt and proper action by the physician diminishes the likelihood of future assaults, reduces the stigma, decreases long-term negative outcomes, and provides appropriate medical, psychological, and supportive care.

The first contact by a physician is of importance, as it may be the only chance to interact with the patient.  Many victims chose not show up for follow-up appointments.   In an acute setting (within 72 hours of the assault), the victim should be taken to an emergency room to receive adequate health care and to collect forensic evidence.  The assault should be recorded verbatim and all injuries annotated (note: many sexual assault victims have no physical findings).  Recommended work-up includes:

• Baseline Labs: Pregnancy, wet prep, GC, CT, TV
• Baseline serology: Hep B, Hep C, syphilis, HIV (be careful, some people use the results as a way of victim blaming)
• Pregnancy Prevention: Emergency contraception (Plan B [morning-after pill] up to 72 hours, can be obtained over the counter with no age restrictions. Ella, another morning-after pill, can prevent contraception when used up to 5 days after sex. Ella is obtained by prescription only, but is covered by Medicare)

Treatment for sexually transmitted infections (STIs) prevention:

• Cefriaxone 250 IM
• Axithromycin 1 gm PO
• Flagyl 2 gm po x 1
• +/- HIV Pep
• Vaccines: Hep B, HPV

Be aware of juvenile sexual abuse and recovery centers in your area. This is the place police officers will take a child or disabled individual for interview and forensic exam.  The crisis center has individuals with training who can minimize the trauma of an interview to a child or disabled individual. They serve as patient’s advocates and can accompany the victims to police interviews.  Abuse and recovery centers are usually open 24 hours a day and have hotlines.   They offer individual and group therapy sessions, and in some instances, they may have a chaplain as part of the team.  Since some victims are substance abusers or have other medical problems, counselors are available to tackle these problems.  These services are free to its clients.  I urge autism support groups to include, as part of their annual activities, a lecture from their state juvenile sexual abuse and recovery center.  They will make you aware of local resources including those referrals for long term support in your area.  They will also provide you with information about the laws in your community and answer your medical concerns.