Emergency Management of the Adult Female Rape Victim

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.