| 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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