18-14: Sexual Violence

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 have studied this intervention in over 100 healthcare providers and found that knowledge increased from 49% to 62% (P < 0.001) and confidence, from 58% to 73% (P < 0.001) in clinical care for sexual violence survivors 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. Rarely, loss of self-esteem can lead to suicide.

Clinicians and emergency department personnel who deal with victims of sexual violence should work with community rape crisis centers or other sources of ongoing psychological support and counseling.

The clinician who first sees the alleged victim of sexual violence should be empathetic and prepared with appropriate evidence collection and treatment materials. Standardized information and training, such as the program created by the International Rescue Committee, can be a helpful resource to the providers caring for these patients. Many emergency departments have a protocol for sexual violence victims and personnel who are trained in interviewing and examining victims of sexual violence.

1. Secure written consent from the patient, guardian, or next of kin for gynecologic examination and for photographs if they are likely to be useful as evidence. Although there are differences in state requirements, most states require health care providers to report sexual violence and physical abuse.

2. Obtain and record the history in the patient's own words. The sequence of events, ie, the time, place, and circumstances, must be included. Note the date of the LMP, whether or not the woman is pregnant, and the time of the most recent coitus prior to the sexual assault. Note the details of the assault such as body cavities penetrated, use of foreign objects, and number of assailants. Note whether the victim is calm, agitated, or confused (drugs or alcohol may be involved). Record whether the patient came directly to the hospital or whether she bathed or changed her clothing. Record findings but do not issue even a tentative diagnosis lest it be erroneous or incomplete.

3. Have the patient disrobe while standing on a white sheet. Hair, dirt, leaves, underclothing, and any torn or stained clothing should be kept as evidence. Scrape material from beneath fingernails and comb pubic hair for evidence. Place all evidence in separate clean paper bags or envelopes and label carefully.

4. Examine the patient, noting any traumatized areas that should be photographed. Examine the body and genitals with a Wood light to identify semen, which fluoresces; positive areas should be swabbed with a premoistened swab and air-dried in order to identify acid phosphatase. Colposcopy can be used to identify small areas of trauma from forced entry especially at the posterior fourchette.

5. Perform a pelvic examination, explaining all procedures and obtaining the patient's consent before proceeding gently with the examination. Use a narrow speculum lubricated with water only. Collect material with sterile cotton swabs from the vaginal walls and cervix and make two air-dried smears on clean glass slides. Wet and dry swabs of vaginal secretions should be collected and refrigerated for subsequent acid phosphatase and DNA evaluation. Swab the mouth (around molars and cheeks) and anus in the same way, if appropriate. Label all slides carefully. Collect secretions from the vagina, anus, or mouth with a premoistened cotton swab, place at once on a slide with a drop of saline, and cover with a coverslip. Look for motile or nonmotile sperm under high, dry magnification, and record the percentage of motile forms.

6. Perform appropriate laboratory tests as follows. Test the vagina, anus, or mouth (as appropriate) for Neisseria gonorrhoeae and Chlamydia. Perform a wet mount for Trichomonas vaginalis, a baseline pregnancy test, and VDRL test. A confidential test for HIV viral load or antibody can be obtained if desired by the patient. Antibody testing can be repeated in 2–4 months if initially negative. Repeat the pregnancy test if the next menses is missed and repeat the VDRL test in 6 weeks. Obtain blood (10 mL without anticoagulant) and urine (100 mL) specimens if there is a history of forced ingestion or injection of drugs or alcohol.

7. Transfer clearly labeled evidence, eg, laboratory specimens, directly to the clinical pathologist in charge or to the responsible laboratory technician, in the presence of witnesses (never via messenger), so that the rules of evidence will not be breached.

1. Give analgesics or sedatives if indicated. Administer tetanus toxoid if deep lacerations contain soil or dirt particles.

2. Give ceftriaxone, 250 mg intramuscularly plus azithromycin 1 g orally, to prevent gonorrhoea and chlamydia. In addition, give metronidazole, 2 g orally as a single dose to treat trichomoniasis. Incubating syphilis will probably be prevented by these medications, but the VDRL test should be repeated 6 weeks after the assault.

3. Prevent pregnancy by using one of the methods discussed under Emergency Contraception.

4. Vaccinate against hepatitis B.

5. Offer HIV prophylaxis (see Chapter 31).

6. Because women who are sexually assaulted are at increased risk for long-term psychological sequelae, such as PTSD and anxiety disorders, it is critical that the patient and her family and friends have a source of ongoing counseling and psychological support.

All women who seek care for sexual assault should be referred to a facility that has expertise in the management of victims of sexual violence and is qualified to perform expert forensic examination, if requested.