| 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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