BY: MARGARET BARRON, MD
Providence Hospital, Washington, DC
It never occurred to me that offering emergency contraception to rape victims
could be controversial. It wasn't until I was called a few years ago by a researcher
doing a survey that I learned that this is an issue. I thought that emergency
contraception was the standard of care, like offering thrombolytic therapy to
a patient having a myocardial infarction. Therefore, I welcomed the opportunity
to comment on the article by Drs. Hamel and Panicola. I am grateful that this
subject is being discussed in a reputable forum.
I have been an emergency medicine physician for 20 years. Day in and day out
I see the horrors inflicted on my patients by my fellow human beings. Rape is
one of the worst of these horrors. Despite seeing large numbers of victims,
I have never gotten "used to" these patients. I can dissociate myself from a
patient with a gunshot wound. When I step into the vortex of a trauma resuscitation,
there is amazingly little interpersonal exchange between the patient and myself
before he is whisked away to the operating room or the morgue. But with a rape
victim, there is nowhere to hide. I have to take a history that is painful to
listen to. I have to perform a physical exam that, besides being painful, is
humiliating (taking swabs of the throat, vagina, and anus; collecting fingernail
scrapings; plucking hair samples, etc.). After this, I have a frightening conversation
about the risks of HIV transmission and sexually transmitted diseases. I discuss
the patient's personal sexual history and the terrifying possibility of becoming
pregnant as a result of this violent act. After all this, I test for an existing
pregnancy. If this test is negative, I offer the patient pregnancy prophylaxis
and treatment to prevent a sexually transmitted disease. I arrange for counseling
and discharge the patient.
If I had to use the Peoria Protocol, it would be impossible
for me to offer prophylaxis at the time of this visit. In most
hospitals, there is no such thing as receiving "stat" progesterone
level information. This is a complicated assay that is usually
sent out to a reference lab and has a turnaround time of several
days. This puts the patient well past the effective therapeutic
window for prophylaxis. Even if I could get the result back
in a day, the patient would need immediate gynecological follow-up.
Try arranging that at 3 am on a Saturday morning.
The LH urine test is even more problematic. It is not accurate in patients
taking corticosteroids, such as those with asthma. It is not accurate in patients
taking certain antibiotics. It is not accurate if the patient's urine is dilute
(a common effect of alcohol, which is often involved in rape). It is not accurate
in perimenopausal women or in those with polycystic ovary syndrome. Do I deny
this large group of women the option of prophylaxis because I cannot trust the
results of the LH test?
The Peoria Protocol is neither a practical option nor a medically or scientifically
valid approach. Requiring its use would effectively eliminate my ability to
treat my rape patients at an acceptable standard of medical care. Maybe my thinking
is simplistic, but to me, this is a no-brainer. We clinicians need to do the
right thing, and that is to follow the Centers for Disease Control and Prevention
and the American College of Obstetrics and Gynecology guidelines for the treatment
of women who have been raped. Failing to do so will leave us vulnerable to sensationalistic
attacks that will in turn give rise to legislation with far-reaching mandates
that most of us would abhor.
Copyright © 2002 by the Catholic Health Association of the United States
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