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ESSENTIALS OF DIAGNOSIS

  • The legal definition of rape varies by state and geographic location. The term “sexual violence” is used by the CDC and will be used in this discussion. It can be committed by a stranger, but more commonly by an assailant known to the victim, including a current or former partner or spouse (a form of intimate partner violence [IPV]).

  • All victims of sexual violence should be offered emergency contraception, and counseled that this method does not induce abortion.

  • The large number of individuals affected, the enormous health care costs, and the need for a multidisciplinary approach make sexual violence and IPV important health care issues.

  • Knowledge of state laws and collection of evidence requirements are essential for clinicians evaluating possible victims of sexual violence, including IPV.

GENERAL CONSIDERATIONS

Rape, or sexual assault, is legally defined in different ways in various jurisdictions. Clinicians and emergency department personnel who deal with victims of sexual violence should be familiar with the laws pertaining to sexual assault in their own state. From a medical and psychological viewpoint, it is essential that persons treating victims of sexual violence recognize the nonconsensual and violent nature of the crime. About 95% of reported victims of sexual violence are women. Each year in the United States, 4.8 million incidents of physical or sexual assault are reported by women. Penetration may be vaginal, anal, or oral and may be by the penis, hand, or a foreign object. The absence of genital injury does not imply consent by the victim. The assailant may be unknown to the victim or, more frequently, may be an acquaintance or even the spouse.

“Unlawful sexual intercourse,” or statutory rape, is intercourse with a female before the age of majority even with her consent.

Health care providers can have a significant impact in increasing the reporting of sexual violence and in identifying resources for the victims. The International Rescue Committee has developed a multimedia training tool to encourage competent, compassionate, and confidential clinical care for sexual violence survivors in low-resource settings. They studied this intervention in over 100 healthcare providers, and found knowledge and confidence in clinical care for sexual violence survivors increased from 49% to 62% (P < 0.001) and 58% to 73% (P < 0.001), respectively, following training. There was also a documented increase in eligible survivors receiving emergency contraception from 50% to 82% (P < 0.01), HIV postexposure prophylaxis from 42% to 92% (P < 0.001), and sexually transmitted infection prophylaxis and treatment from 45% to 96% (P < 0.01). This training encourages providers to offer care in the areas of pregnancy and sexually transmitted infection prevention as well as assistance for psychological trauma.

Because sexual violence is a personal crisis, each patient will react differently, but anxiety disorders and posttraumatic stress disorder (PTSD) are common sequelae. The rape trauma syndrome comprises two principal phases. (1) Immediate or acute: Shaking, sobbing, and restless activity may last from a few days to a few weeks. The patient may experience anger, guilt, or shame or may repress these emotions. Reactions vary depending on the victim’s personality and the circumstances of the attack. (2) Late or chronic: Problems related to the attack may develop weeks or months later. The lifestyle and work patterns of the individual may change. Sleep disorders or phobias often develop. Loss of self-esteem ...

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