| Sexual assault is
reported to be the fastest growing violent crime
in the United States In 1988, rape affected 141,000
households in the United States, a 21.6 percent
increase over 1987 figures.(3) Statistics on rape
are often incomplete and underestimated because
of the hesitancy of many rape victims to report
the crime. A national crime survey estimates that
less than 40 percent of crimes, including rape,
are reported to the police. "The matter was
private or personal" was the reason most often
given for not reporting a violent crime.(4) Fear
of public humiliation and the social stigma attached
to rape often prevent women from seeking proper
medical care and reporting the crime.
Statistics indicate that 39 percent of rape victims
report having sustained physical injury; of those,
54 percent receive medical care. Most victims are
treated in a hospital emergency department. Although
80 percent of the injuries are minor, medical attention
is still needed.(5) Physician Responsibility
The physician's function is not to determine if
rape has occurred. Rape is a legal term, not a medical
term; whether a crime has been committed is to be
determined by the courts.(2,6)The physician's responsibilities
in an alleged rape involve the following: 1) documentation
of pertinent history, (2) careful physical examination,
(3) prompt treatment of physical injuries, (4) psychologic
support and arrangements for follow-up counseling,
(5) collection of legal evidence, (6) prevention
of venereal disease and (7) prevention of pregnancy,
if desired by the patient.
Emergency Department Management
On arrival at the emergency department, the patient
should be ushered to a private, quiet, comfortable
area. The patient's consent should be obtained before
beginning the history and during each phase of the
physical examination and collection of evidence.(2,7,8)
An explanation of each step of the examination process
is important, because it allows the patient some
control over her situation. The patient should be
reassured of her safety; if at all possible, she
should not be left alone. I Ideally, a rape crisis
counselor or specially trained social worker should
be called to stay with the victim throughout the
examination and arrange follow-up counseling. If
such persons are unavailable, the patient should
be allowed to select a friend or relative to wait
with her. This person should bring the victim a
change of clothing.
The questions asked while the history is being
taken should not be judgmental, moralistic or opinionated.(8)
victims of sexual assault may believe they caused
the assault. They need to be reassured that they
are victims and that what has happened was not their
fault.(7)
Some patients may feel that questioning is a further
invasion of their privacy and may be resistant;
others may welcome the chance to express their feelings.
The physician's questions should be specific, especially
when they refer to details that the victim might
be too embarrassed to mention.(9) Important historical
points to elicit are outlined in Table 1.
All information is carefully recorded in the patient's
medical record and/or in a rape evaluation flow
sheet (enclosed in rape kits). Because the determination
of rape is made in a court of law, the wording of
the history should reflect only the patient's report
of the incident. The wording should not be expressed
as statements of fact about the event.(10)
EXAMINATION
After assisting the patient to become as comfortable
as possible, a meticulous physical examination should
be performed. The purpose of the examination is
to assess and treat physical injuries, as well as
collect evidence submissible in court proceedings.
Even if the victim is undecided regarding criminal
prosecution of the alleged rapist, evidence collection
should be encouraged. Evidence not collected within
48 to 72 hours of the incident is often unrecoverable
or invalid.
The patient should disrobe while standing on examination
table paper to catch any falling debris, hair or
fibers.(8)To avoid contamination, only the victim
should handle her clothing, if possible. Clothes
should be placed in paperbags, not plastic bags.
Plastic may enhance the growth of bacteria on seminal
fluid or blood stains.(2,8) All of the victim's
clothes should be sent to a crime laboratory in
carefully labeled and sealed bags.
Next, the patient should be evaluated for abrasions,
bruises and lacerations. From 8 to 45 percent of
victims show evidence of external trauma. The most
common sites of extragenital trauma are the mouth,
throat, wrists, arms, breasts and thighs.(2) In
one study, trauma to these sites comprised 67 percent
of the injuries, while trauma to the vagina and
perineum accounted for 19 percent of the injuries."
Careful description of the findings, including diagrams
and photographs, is essential.
The perineal and inner thigh area should be examined
with a Wood's lamp to detect semen stains. Any areas
of fluorescence should be swabbed with saline-moistened
cotton swabs. Combing the pubic hair over a sheet
of paper may yield material that is traceable to
the assailant. (A sterile comb is provided in most
rape kits.) This material, along with the comb,
should be submitted as evidence. The patient's pubic
hairs may be clipped or plucked for further examination.
The vaginal examination should be performed with
a speculum lubricated only with water. Lubricants
may be spermicidal and may interfere with evaluation
of the wet-mount preparation. After noting the condition
of the hymen, the physician should examine the vaginal
walls and cervix for lacerations or abrasions. Vaginal
secretions should be aspirated or collected on cotton
swabs from the posterior fornices. If no secretions
are seen, normal saline can be instilled into the
vagina and aspirated.(2,8)
A wet-mount sperm examination is performed by suspending
some of the aspirate in warm saline. Motile sperm
are seen on the slide if less than three hours have
elapsed since ejaculation.(1,12)If sperm are seen,
their motility and number per high-power field should
be documented.(8) Nonmotile sperm may remain in
the genital tract for longer periods of time. Depending
on staining techniques, they may be demonstrated
even beyond 72 hours after intercourse.(1) Absence
of sperm does not exclude the possibility of sexual
assault; the alleged assailant may have had a vasectomy
or may have experienced sexual dysfunction during
the attack.(1) A high incidence of sexual dysfunction
during rape has been reported, with roughly 50 percent
of assailants experiencing impotence or ejaculatory
dysfunction. Penile penetration and ejaculation
in a body orifice occurred in only one-third of
sexual assaults evaluated in one large study.
The remaining vaginal aspirate should be sent to
a forensic laboratory to determine the presence
of acid phosphatase. High concentrations of this
enzyme are found in prostatic secretions, and the
presence of acid phosphatase is a good indicator
of recent coitus. Acid phosphatase activity decreases
with time and is usually absent after 24 hours.
Qualitative testing may reveal activity for a longer
period of time. (1,12)
If an undetermined amount of time has elapsed since
the sexual assault or if seminal fluid is scarce,
a semen-specific marker, p 3O, may still be detected.
This substance is a major plasma glycoprotein produced
in the prostate gland. Its presence indicates sexual
activity within a 48-hour period. The seminal fluid
of vasectomized men also contains a significant
p 3O level. Because semen may not be detected in
25 to 30 percent of sexual assaults, assays of p3O
and acid phosphatase are particularly important.(1,12)
Genetic typing of semen can help identify an assailant,
since semen contains high levels of three genetic
markers. Approximately 80 percent of the population
secrete block-group antigens into other body fluids,
and such analysis can be helpful.(1,12) A saliva
sample should be obtained from the victim to document
her secretor status.(2)
If oral or anal intercourse has occurred, these
areas should be swabbed for detection of sperm and
acid phosphatase. Spermatozoa have been recovered
from the oral cavity up to six hours after the event,
even after the victim brushed her teeth or usedmouthwash.(12)Cultures
for Neisseria gonorrhoeae and Chlamydia trachomatis
should be obtained from the cervix, rectum or oropharynx,
based on the assault history. Pelvic bimanual and
rectal examinations should be performed to assess
any masses or tenderness.
Pregnancy
Pregnancy as a result of rape occurs in about 5
percent of fertile female victims.(1) Preexisting
pregnancy should be determined, preferably by a
serum human chorionic gonadotropic beta subunit
assay, and treatment for the prevention of pregnancy
should be offered to the patient. Several pregnancy
prophylaxis options are listed in Table 2. The 1
percent failure rate and teratogenicity of postcoital
medications should be explained to the patient.(7)
Nausea may be controlled with any preferred antiemetic
agent. All postcoital pregnancy interventions are
ineffective after 72 hours."
Sexually Transmitted Disease
Detection and treatment of sexually transmitted
diseases are the responsibility of the physician.
Baseline syphilis serology should be determined
at the time of the examination, and the test should
be repeated three months after the sexual contact.(2)
Human immunodeficiency virus (HIV) testing is controversial
and should be discussed with the patient. If the
patient desires testing and baseline results are
negative, repeat testing is recommended in three
to six months. The risk of HIV transmission from
a single sexual encounter and the length of time
that a person is infected with HIV before antibody
is detectable are unknown. Data suggest that antibodies
develop within six months in 95 percent of persons
who become infected after HIV exposure.(15)
Current therapy recommendations for victims of
sexual assault are given in Tab le 3.16 The overall
risk of acquiring a sexually transmitted disease
as a result of rape is estimated to be 5 to 10 percent.
Chain of Evidence
All specimens collected during the examination
should be carefully sealed and dated. Evidence should
be kept in a locked box in the emergency department
until a police officer arrives. The officer should
transport the evidence to the nearest crime laboratory.
Blood tests and cultures can, in some cases, be
handled by the hospital laboratory, with the results
documented in the patient's chart.
Rape kits are available from forensic crime laboratories.
Contents of a standard rape kit are listed in Table
4. A "chain of evidence" must be maintained
to ensure that materials are not altered prior to
submission in a court of law. Each step of evidence
collection should be documented by the nurse, physician,
law enforcement officer and laboratory technician
who collect and handle the specimens.(1)
Rape Trauma Syndrome
In addition to medical treatment of the rape victim,
family physicians should be aware of the psychologic
aspects of rape. The rape trauma syndrome, as described
by Burgess and Holmstrom, (17) is a two phase process.
Phase 1-the acute phase-is one of disorganization.
The victim feels shock and disbelief regarding the
rape. Victims may initially react in two ways. (1)
In the expressed style, the patient displays anger,
fear and anxiety, often crying during the interview.
(2) In the controlled style, the patient remains
calm and composed, with little outward display of
emotion. The controlled patient needs permission
to express her emotions.(17)The first phase can
last from six weeks to a few months. Physicians
should anticipate either reaction and provide support
and encouragement.
Phase II-the reorganization phase is a long-term
process in which the victim develops coping mechanisms.
This phase may last for a few months to a year,
or indefinitely, depending on the patient.(14) Reorganization
may include stages of outward adjustment, personal
integration and, finally, recovery. Characteristics
of each phase are listed in Table 5.
There are emotional consequences of rape (Table
6). The patient should be made aware of the common
psychologic sequelae to rape.(1) Referral should
then be made for extensive counseling through a
rape crisis center, hospital social worker or mental
health facility.
Final Comment
Because of the high incidence of rape, medical
and social implications for victims, and increasing
prosecution of offenders, family physicians should
educate themselves about the appropriate management
of rape victims. The care a patient initially receives
influences her recovery from rape.(9)
REFERENCES
1. Hochbaum SR. The evaluation and treatmentof
the sexually assaulted patient. Emerg Med Clin North
Am 1987;5:601-22.
2. Kobernick ME, Seifert S, Sanders AB. Emer -
gency department management of the sexual assault
victim. J Emerg Med 1985;2:205-14.
3 . Rand MR. Households touched by crime, 1988.
Washington, D.C.: Department of Justice, Bureau
of Justice Statistics, 1989.
4. Bureau of Justice Statistics data report, 1988.
Washington, D.C.: Department of Justice, Bureau
of Justice Statistics, 1989.
5. Harlow CW. Injuries from crime. Washington,
D.C.: Department of Justice, Bureau of Justice Statistics,
1989.
6. Martin PY,. DiNitto DM. The rape exam: beyond
the hospital emergency room. Women Health 1987;12(2):5-28.
7. Beckmann CR, Groetzinger LL. Treating sexual
assault victims. A protocol for health professionals.
Female Patient 1989;14(5):78-83.
8. Hicks Dj, Minkin Mj, Solola A. Examining the
rape victim. Patient Care 1986;20(8):98-123.
9. Martin CA, Warfield MC, Braen GR. Physi - cian's
management of the psychological aspects of rape.
JAMA 1983;249:501-3.
10. Renshaw DC. Treatment of sexual exploitation.
Rape and incest. Psychiatr Clin North Am 1989;12:257-77.
11. Tintinalli JE, Hoelzer M. Clinical findings
and legal resolution in sexual assault. Ann Emerg
Med 1985; 14:447-53.
12. Enos WF, Beyer JC. Management of the rape victim.
Am Fam Physician 1978;18(3):97-102.
13. McGregor JA. Risk of STD in female victim of
sexual assault. Med Aspects Hum Sex 1985; 19(8):30,35-9,42.
14. Rosenberg MS. Rape crisis syndrome. Med Aspects
Hum Sex 1986;20(3):65-71.
15. Horsburgh CR Jr, Ou CY, Jason J, et al. Duration
of human immunodeficiency virus infection before
detection of antibody. Lancet 1989; 2(8664):637-40.
16. 1989 Sexually transmitted diseases treatment
guidelines. MMWR 1989;38(Suppl 8):I-43 [Published
erratum appears in MMWR 1989;38:6641.
17. Burgess AW, Holmstrom LL. Rape trauma syndrome.
Am J Psychiatry 1974; 131:981-6.
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