Sexual Violence

Key Features

Essentials of Diagnosis

• The term "sexual violence" is used by the Centers for Disease Control and Prevention and is 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, and counseled that this method does not induce abortion

• 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 by 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

• "Unlawful sexual intercourse," or statutory rape, is intercourse with a female before the age of majority even with her consent

Clinical Findings

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)

  • Sexual violence survivors are at increased risk for developing several psychological and behavioral adverse effects, including PTSD, sleep disturbances, anxiety, depression, suicide attempt, and medication misuse

Diagnosis

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 (eg, rohypnol) or alcohol

Diagnostic Procedures

• The clinician who first ...