Sexual Violence

Essentials of Diagnosis

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

• The term "sexual violence" is used by the Centers for Disease Control and Prevention and will be used here instead of "rape"

• Sexual violence is sometimes committed by a stranger, but more commonly is 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

• 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 as required by law are essential for clinicians evaluating possible victims of sexual violence and IPV

General Considerations

• The legal definition of rape varies state and geographic location

• 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

• 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

Symptoms and Signs

• Each patient will react differently to this personal crisis, but anxiety disorders and posttraumatic stress disorder (PTSD) are common sequelae

Rape trauma syndrome

• 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

• Late or chronic (weeks or months later)

  • The individual's lifestyle and work patterns change

  • Sleep disorders or phobias often develop

  • Loss of self-esteem can rarely lead to suicide

Laboratory Tests

• Culture the vagina, anus, or mouth (as appropriate) for Neisseria gonorrhoeae and Chlamydia

• Perform a Papanicolaou smear of the cervix, a wet mount for Trichomonas vaginalis, a baseline pregnancy test, and VDRL test

• A confidential test for HIV viral load or antibody is recommended (with the patient's consent); antibody testing is 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 suspected or forced ingestion or injection of drugs or alcohol

Diagnostic Procedures

• The clinician who first sees the alleged victim of sexual violence should be empathetic and prepared with appropriate written and/or video materials regarding evidence collection and treatment recommendations

• 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 as well as personnel who are trained in interviewing and examining victims of sexual violence

• 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

• If police are to be notified, do so, and obtain advice on the preservation and transfer of evidence

• 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 last menstrual period, 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

• Have the patient disrobe while standing on a white sheet

  • Hair, dirt, and 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

• 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

• 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

• Perform appropriate laboratory tests

• 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

Medications

• Give analgesics or sedatives if indicated

• Administer tetanus toxoid if deep lacerations contain soil or dirt particles

• 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

Therapeutic Procedures

• Prevent pregnancy by using one of the methods discussed in Contraception, Emergency, if necessary

• Vaccinate against hepatitis B

• Offer HIV postexposure prophylaxis

• Make sure the patient and her family and friends have a source of ongoing psychological support

Follow-Up

• Clinicians and emergency department personnel who deal with victims of sexual violence should work with sources of ongoing psychological support and counseling

Complications

• All victims suffer some psychological aftermath

• Some victims of sexual violence may acquire sexually transmissible disease or become pregnant

When to Refer

• All women who seek care for sexual assault should be referred to a facility that has expertise in the management of victims of sexual assault and is capable of performing expert forensic examination