- Complaints of having been mugged
- Concerns about acquired immune deficiency syndrome (AIDS) or other sexually transmitted diseases
- Psychiatric symptoms include depression, anxiety, or a suicide attempt
- Somatic symptoms include disturbed sleeping and eating patterns, gastrointestinal irritability (with nausea predominating), musculoskeletal soreness, fatigue, tension headaches, and intense startle reactions
- Symptoms of vaginal irritation occur in more than 50% of victims
- Rectal pain and bleeding are frequent in patients subjected to anal penetration
- Gynecologic trauma
- Escape through the use of alcohol and drugs
Sexual assault is any sexual act performed by one person on another without the person's consent. Sexual assault includes genital, oral, or anal penetration by a part of the accused's body or by an object. It may result from force, the threat of force either on the victim or another person, or the victim's inability to give appropriate consent. Many states have now adopted the gender-neutral legal term sexual assault in favor of rape, which traditionally referred to forced vaginal penetration of a woman by a male assailant.
An estimated 700,000 to 1,000,000 American women are sexually assaulted every year. These estimates are higher than official crime reports because the majority of cases go unreported. According to one estimate, only 30% of rapes are reported to the police, and 50% of rape victims tell no one. At least 20% of adult women, 15% of college-age women, and 12% of adolescent girls have experienced sexual abuse and assault during their lifetime. Sexual assault occurs in all age, racial-ethnic, and socioeconomic groups, but its incidence may be higher for African American women and for adolescent females. In several studies, approximately one-fourth to one-half of the victims of sexual assault were younger than the age of 18 years. The very young, the elderly, and the physically or developmentally disabled may be particularly vulnerable to sexual assault.
Several variants of sexual assault deserve special mention. Marital rape is defined as forced coitus or related sexual acts within a marital relationship without the consent of a partner. Acquaintance rape refers to those sexual assaults committed by someone known to the victim. More than 75% of adolescent rapes are committed by an acquaintance of the victim. When the acquaintance is a family member, including step-relatives and parental figures living in the home, the sexual assault is referred to as incest. When the forced or unwanted sexual activity occurs in the context of a dating relationship, it is referred to as date rape. In this situation, the woman may voluntarily participate in sexual play but coitus occurs, often forcibly, without her consent. Alcohol use is frequently associated with date rape. “Date rape drugs” such as flunitrazepam (Rohypnol) and gamma-hydroxybutyrate (GHB) have also been used to diminish a woman's ability to consent or to remember the assault.
Statutory rape refers to sexual intercourse with a female under an age specified by state law (ranging from 14–18 years of age); the consent of an adolescent younger than this age is legally irrelevant because she is defined as being incapable of consenting. Child sexual abuse is defined as contact or interaction between a child and an adult when the child is being used for the sexual stimulation of that adult or another person. All 50 states and the District of Columbia mandate reporting of child abuse, including child sexual abuse. Nearly half of the states also require physicians to report statutory rape. Physicians should be familiar with the laws in their states; failure to report sexual assault against children may subject the physicians to fines and incarceration for up to 1 year.
Our society has many misperceptions about sexual assault. The victims are often blamed for having encouraged the assault by their behavior or dress, for not sufficiently resisting the assault, for being promiscuous, or for having ulterior motives for pressing charges. This misplaced culpability is often internalized by the victims, which (in addition to fear of retribution) may explain their reluctance to report the violent crime to the authorities. Another common misperception is that rape is an impulsive or aggressive extension of normal sex drive on the part of the rapist. The motivation for most sexual assault, however, seems not to be sexual gratification but rather degradation, terrorization, and humiliation of the victim. The assault is often a demonstration of power (power rape), anger (anger rape), or sadism manifested in ritualized torture or mutilation of the victim (sadistic rape) on the part of the rapist.
Much of this chapter addresses the role and responsibilities of the health care professional in caring for victims of domestic violence and sexual assault after they have occurred. One of the greatest challenges for health care and public health professionals working to improve women's health continues to be the epidemic of violence against women in our society and around the world. A great deal remains to be learned and done about the primary prevention of violence.
The majority of rape victims who come to emergency rooms do not openly admit to having been sexually assaulted. Instead, they may complain of having been mugged or may voice concerns about acquired immune deficiency syndrome (AIDS) or other sexually transmitted diseases. Others may present with psychiatric symptoms including depression, anxiety, or a suicide attempt. Unless the primary care physician, obstetrician-gynecologist, or psychiatrist obtains a sexual history, assault victims will remain unidentified as such and will be inadequately treated.
A “rape-trauma” syndrome often occurs after a sexual assault. The initial response (acute phase) may last for hours or days and is characterized by a distortion or paralysis of the individual's coping mechanisms. The initial outward responses vary from complete loss of emotional control (crying, uncontrolled anger) to an unnatural calm and detachment (although some physical signs such as shaking or lowered skin temperature are usually present). The latter behavior represents the victim's need to reestablish control over herself and her environment while simultaneously abandoning the defense mechanism of denial and allowing the renewed invasion of privacy represented by the questioning and examination. The initial reactions of shock, numbness, withdrawal, and denial typically abate after the first 2 weeks. However, studies suggest there is a period, occurring from 2 weeks to several months postassault, in which symptomatology returns and may intensify. It is at this time that the victim may begin to seek help for her symptoms, often without telling the health care provider of the sexual assault that precipitated these symptoms.
The next phase (delayed phase) may occur months or years after the sexual assault and is characterized by chronic anxiety, feelings of vulnerability, loss of control, and self-blame. Long-term reactions include anxiety, nightmares, flashbacks, catastrophic fantasies, feelings of alienation and isolation, sexual dysfunction, psychologic distress, mistrust of others, phobias, depression, hostility, and somatic symptoms. More than half of rape victims experience substantial difficulty in reestablishing sexual and emotional relationships with spouses or boyfriends. Thirty-three percent to 50% of victims report suicidal ideation; suicide attempts have been reported in nearly 1 in 5 rape victims who do not seek treatment.
PTSD is a common long-term sequela of sexual assault, characterized by psychic numbing, intrusive re-experiencing of the trauma, avoidance of stimuli associated with the trauma, and intense psychologic distress. Women with prior victimization histories often have more severe sequela. Women assaulted sexually by family members or dates experience as severe levels of distress as women assaulted by acquaintances or strangers.
Up to 40% of victims who are sexually assaulted sustain injuries. Although most injuries are minor, approximately 1% of the injuries require hospitalization and major operative repair, and 0.1% are fatal. Somatic symptoms are common during the acute phase and include disturbed sleeping and eating patterns, gastrointestinal irritability (with nausea predominating), musculoskeletal soreness, fatigue, tension headaches, and intense startle reactions. Symptoms of vaginal irritation occur in more than 50% of victims, and rectal pain and bleeding are frequent in patients subjected to anal penetration. Ongoing health concerns include gynecologic trauma, risk of pregnancy, and the potential for contracting infections or sexually transmitted diseases, including HIV. Victims may also seek to escape the pain of rape's effects through the use of alcohol and drugs.
Rape victims appear to be frequent users of medical services in the months and years after the assault. In one study, visits to physicians increased 18% in the year of the assault, 56% in the following year, and 31% in the year after, compared with previctimization levels. Reintegration of the self after sexual assault is a slow process that may take months to years as the victim works through the trauma and the loss of the event and replaces it with other life experiences. The prognosis for complete recovery is improved if health care professionals responsible for the victim's care have a supportive, nonjudgmental approach and a well-developed understanding and competent treatment of the emotional, as well as physical, consequences of sexual assault.
The physician evaluating the victim has both medical and legal responsibilities and should be aware of state statutory requirements. Such requirements may involve the use of sexual assault assessment kits, which list the steps necessary and the items to be obtained for forensic purposes. If personnel trained in collecting samples and information are available, it is appropriate to request their assistance.
Informed consent must be obtained before examining a sexual assault victim. A careful history and physical examination should be performed in the presence of a chaperon or victim advocate. The patient should be asked to state in her own words what happened and to identify or describe her attacker, if possible. The history should include inquiry about last menstrual period, contraceptive use, preexisting pregnancy and infection, and last consensual intercourse before the assault. The patient's activities in the interval between the assault and the examination—whether the patient has eaten, drunk, bathed, douched, voided, or defecated—might affect findings on physical examination; such activities must be recorded.
A careful physical examination of the entire body should be performed. The physician should search for bruises, abrasions, or lacerations about the neck, back, buttocks, and extremities. Bite marks should be noted, particularly about the genitalia and breasts. Injuries to the mouth and pharynx may result from oral penetration. Injuries should be documented with photographs or drawings in the medical record. Rape and physical assault are legal terms that should not be used in medical records. Instead, the physician should report findings as “consistent with the use of force.”
A pelvic examination should be performed. Injuries to the vulva, hymen, vagina, urethra, and rectum should be noted. Occasionally, foreign objects may be found in the orifices. The speculum must be moistened only with saline. Two milliliters of normal saline are injected into the vaginal vault. Nonabsorbent cotton swabs should be used to sample fluid from this vaginal pool and should then be placed in sterile glass tubes and refrigerated. Air-dried, nonfixed smears of this same fluid should be placed on glass slides. A Papanicolaou (Pap) test may also be obtained. Evidence of coitus will be present in the vagina for as long as 48 hours after the attack. Motile sperms may be noted in the vagina for up to 8 hours after intercourse, but may be present in the cervical mucous for as long as 2–3 days. Nonmotile sperm may be noted in the vagina for up to 24 hours and in the cervix for up to 17 days. Acid phosphatase is an enzyme found in high concentrations in the seminal fluid. Evidence of acid phosphatase should be sought by swabbing the vaginal secretions, even in the absence of sperm because the attacker may have had a vasectomy. DNA evaluation may also be performed from the vaginal swab. Nonmotile sperm may be found in the rectum for up to 24 hours after the assault, and acid phosphatase can also be detected in the rectum.
A wet mount or vaginal swab should be obtained to detect Trichomonas vaginalis. Testing for Neisseria gonorrhoeae and Chlamydia trachomatis should be performed from specimens from any sites of penetration or attempted penetration. A serum sample should be collected for subsequent serologic analysis if test results are positive. The risk of acquiring gonorrhea from sexual assault is estimated to be between 6 and 12%. Baseline serologic tests for hepatitis B virus, HIV, and syphilis should also be offered. The risk of acquiring syphilis from sexual assault is estimated to be 3%; the risk of acquiring HIV is undetermined.
An important part of the physician's legal responsibilities is to collect samples for forensic purposes. Pubic hair combings should be collected to look for pubic hair from the assailant. Fingernail scrapings should be obtained to look for skin or blood of the attacker. Skin washings and clothing should be investigated for the presence of blood or semen. A Wood light may be helpful because dried semen will fluoresce under its light. Saliva should be collected from the victim. Because seminal fluid is rapidly destroyed by salivary enzymes, identification of seminal fluid in the mouth after a few hours is difficult. Consequently, victims should be encouraged to come to a medical facility immediately after an assault, where they can be evaluated before they bathe, urinate, defecate, wash out their mouths, or clean their fingernails.
Proper processing and labeling of collected specimens is crucial. All collected specimens are placed in a larger sealed container and processed in a “chain of evidence” fashion. The person who collects the specimens verifies their completeness by signature on the sealed master container. The individual to whom they are transferred must verify by signature that all specimens were received in an untampered state. Thus each individual who has “custody” of the specimens during processing must verify that they were transmitted without alteration until they are turned over to the responsible law enforcement agency. The name of the law enforcement agent who receives the specimens should be noted in the medical record.
Treatment of physical injuries sustained at the time of assault should be initiated immediately; prophylactic medical treatment may be indicated for prevention of sexually transmitted infections and pregnancy. For prophylaxis against sexually transmitted infections, empiric recommended antimicrobial therapy for chlamydial, gonococcal, and trichomonal infections may be given. One such regimen consists of the following:
Alternative treatment may be given as recommended by the US Centers for Disease Control and Prevention. In addition, it is recommended that hepatitis B immunoglobulin be administered intramuscularly as soon as possible, but certainly within 14 days of exposure. It should be followed by the standard 3-dose active immunization series with hepatitis B vaccine at 0, 1, and 6 months, beginning at the time of passive immunization. Prophylaxis against HIV is controversial.
Emergency contraception can be offered as prophylaxis against pregnancy. The risk of pregnancy after sexual assault has been estimated to be 2–4% in victims who were not using some form of contraception at the time of the assault. A serum pregnancy test should be obtained before administration of emergency contraception to evaluate for preexisting pregnancy. Emergency contraception should be given within 72 hours of the assault, although it can still be effective up to 120 hours later. There are several different methods of emergency contraception. For many years, the most common method (Yuzpe method) involved the use of high-dose combined oral contraceptives within 72 hours of unprotected coitus, repeated 12 hours after the first dose. More recently, use of a progestin-only method has become popular. This method involves the use of levonorgestrel 0.75 mg, in 2 doses 12 hours apart, or a 1-time dose of 1.5 mg within 72 hours of unprotected coitus. A randomized study showed that this is more effective and better tolerated than the Yuzpe method. Levonorgestrel prevented 85% of pregnancies that would have occurred without treatment.
As most patients suffer significant psychologic trauma as a consequence of sexual assault, the physician must be prepared to provide access to counseling. It is preferable that follow-up psychologic counseling be provided by individuals who have extensive experience in the management of crisis response to rape. Even if the victim appears to be in control emotionally, she will probably experience aspects of rape-trauma syndrome at some time in the future. She should be made aware of the symptoms that she may experience and advised to seek help if and when these symptoms occur. No patient should be released from the facility until specific follow-up plans are made and agreed upon by the patient, physician, and counselor.
A follow-up visit should be scheduled approximately 2 weeks after the assault for repeat physical examination and collection of additional specimens. Testing for N gonorrhoeae, C trachomatis, and T vaginalis should be repeated unless prophylactic antimicrobials have been provided. Follow-up counseling should be discussed again at the second visit. Additional visits may be scheduled according to the victim's needs; an additional follow-up visit approximately 12 weeks after the sexual assault is advisable to collect sera for detection of antibodies against T pallidum, hepatitis B virus (unless vaccine was given), and HIV (repeat test at 6 months). During each of these visits, assessment of the patient's psychologic symptoms should be performed, and referrals for further counseling are made as indicated.
American College of Obstetricians and Gynecologists. Psychosocial risk factors: perinatal screening and intervention. ACOG Committee Opinion No. 343. Washington, DC: ACOG; 2006.
American College of Obstetricians and Gynecologists. Emergency oral contraception. ACOG Practice Bulletin No. 25. Washington, DC: ACOG; 2001.
Jina R, Jewkes R, Munjanja SP, Mariscal JD, Dartnall E, Gebrehiwot Y. Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynaecol Obstet
Jones RF 3rd, Horan DL. The American College of Obstetricians and Gynecologists: Responding to violence against women. Int J Gynaecol Obstet
Kaplan DW et al. Care of the adolescent sexual assault victim. Pediatrics
Patel M, Minshell L. Management of sexual assault. Emerg Med Clin North Am