Sexual assault is any form of non-consenting sexual activity, which encompasses all unwanted sexual acts ranging from fondling to penetration. Definitions of sexual assault vary from state to state.1 Sexual assault is a crime even if the victim knew the attacker, did not fight back, had intercourse with the attacker before the assault, or was intoxicated, drugged or unconscious. Anyone is a potential victim. This crime crosses all races and spans all ages.
Sexual assault represented 5.5 percent of all violent crimes reported in the United States during 1994.2 There were 97,464 forcible rapes reported in 1995 in the United States, and this number represented the lowest total since 1989.3 Nevertheless, one in every six women will be raped during her lifetime.4 Close to one half of all victims are adolescents. One in every 500 women has been assaulted during a pregnancy.5 Each year more than 60,000 rapes are committed against women older than 50 years of age.5
So few rapists are actually apprehended and convicted that a true character profile is not available. However, these criminals are generally not mentally delayed, psychotic or lustful. They usually are persons who have experienced failed social relationships, who harbor significant insecurities and who have low self-esteem. Rapists can be divided into three broad categories: the power rapist, the anger rapist and the sadistic rapist.1 Power rapists account for 55 percent of sexual assaults. They usually attack persons in their own age group. They function by premeditation, using intimidation to control the victim and, thus, minimal physical force is used. Anger rapists represent 40 percent of sexual assaults. In contrast to power rapists, they tend to target either very young victims or elderly victims. Tremendous force and restraints are used, resulting in physical injury to the victim. Sadistic rapists account for the remaining 5 percent. This crime is usually premeditated. These rapists derive erotic satisfaction from torturing their victims. Sadistic rapes are the most dangerous, and victims may not survive the attack.1,6 Rape homicides represent 1 percent of all sexual assaults.1
Obtaining the History of the Sexual Assault
Obtaining a history from a patient who has undergone sexual assault differs in many ways from a routine medical history. The setting will usually be the hospital emergency department, although the interview may take place in the physician's office. Preparation is the key. Provide a quiet and private environment (a room, not a cubicle with a drape). If a law enforcement officer is present, excuse him or her. Obtain the patient's consent during each step of the medical investigation: history taking, physical examination, evidence collecting and photographing. This consent is required by law in some states, but it also serves to help the victim regain control and establish trust. Write the phrase “alleged sexual assault,” or “sexual assault by history,” not “she/he was raped.” Rape is not a medical term7 but rather a legal term. In addition, be specific and state the facts as reported by the victim. Confine yourself to the medically relevant history. Details that are investigatory in nature may lead to apparent contradictions with police reports. Obtaining the history and performing the physical examination is time-consuming. Thirty to 60 minutes will be required in most cases. Listen carefully, do not hurry and do not place blame—the patient is not on trial.
The tailored medical history should include the following information: (1) age and identifying information for both the victim and the assailant (if available); (2) date, time and location of the alleged assault; (3) circumstances of the assault; (4) details of sexual contact, such as penile, digital or object penetration, and route, such as vaginal, oral or anal intercourse, as well as documentation of any ejaculation or urination by the assailant; (5) type of physical restraints used, such as weapons, drugs or alcohol; (6) activities of the victim after the assault, such as change of clothing, bathing, douching, dental hygiene, urination or defecation; and (7) gynecologic history—last menstrual period, contraceptive use, pregnancy history, last voluntary sexual encounter, any recent episode of gynecologic infection and pelvic surgery.4
Physical Examination of Assault Victims
The purpose of the physical examination is twofold: to assess the patient for physical injuries and to collect evidence for forensic evaluation and possible legal proceedings. Physical examination and evidence-collecting are done congruently. It is important to remember that evidence collected more than 48 to 72 hours after the assault often may be difficult to recover or may be invalid. Thus, it is not only imperative to document the time frame (from time of assault to medical examination), but also to encourage victims to proceed with evidence collection. Should the victim wish to pursue prosecution at a later date, evidence collected with the rape kit becomes a vital part of the case.
The use and contents of a rape kit are fairly universal throughout the United States, but variations do exist from state to state. A rape kit helps guide the clinician through the collection of forensic evidence and aids in preservation of evidence. Health professionals who have not used a rape kit should familiarize themselves with its contents. Table 1 lists the contents of a rape kit. Other necessary items include a speculum, sterile saline and a large paper bag. It is imperative that the step-by-step instructions for collection of evidence for a rape kit are followed. Once the kit is opened, the “chain of evidence” must be maintained. Evidence cannot be left unattended.1 An assistant will be necessary to aid in this process.
|Instructions and check-off sheet
|Large paper sheet
|Small paper bags
|Small cardboard boxes
|Red-topped and purple-topped tubes for blood sample collection
|History and physical documentation forms
|Patient discharge information form
Table 2 lists items and specimens to be collected. Clothing can be collected up to one month after the incident, provided the items have not been laundered. Only the victim should handle her clothes. Items of clothing should be placed in paper bags, not plastic bags, since plastic may promote bacterial growth on blood or semen stains.
|Fingernail scrapings, broken fingernail piece
|Air-dried swabs, separate envelope
|Separate envelope (include comb)
|Wet mount, air-dried smear
|Papanicolaou (Pap) smear
|Red-topped and purple-topped tubes
Start with a nonthreatening portion of the physical examination, such as the eyes, ears, nose and throat, to help in gaining the victim's trust. Swabbing the oral cavity should be done as part of evidence collection. If oral penetration took place, swab the oropharynx for gonorrhea testing8 and the mouth for semen. Sperm have been recovered from the oral cavity up to six hours after the assault, even if the teeth were brushed or mouthwash was used.9
Throughout the examination, observe the patient for signs of extragenital trauma, which occurs in 20 to 50 percent of cases of sexual assault.7 The most commonly injured extra-genital areas are the mouth, throat, wrist, arms, breasts and thighs.10 Document the presence, size and location of bruises, lacerations, bite marks and scratches. If the patient consents, photograph the area(s) of trauma. If consent is refused, use diagrams to accurately portray the physical condition of the victim.
The genital examination should follow examination of the head, lungs, abdomen and musculoskeletal system. Engorgement of the labia or clitoris may last for one to two hours after injury.7 Note the condition of the hymen and document any perineal trauma (i.e., erythema, abrasions, tears, bruising). If a Wood's lamp is available, examine the patient's thighs to look for fluorescing semen stains (urine and pus may also fluoresce). Swab any positive areas.
Pubic hair combing is performed to detect foreign hair. In addition, pubic hair samples (approximately 15 to 20 hairs) should be collected by the patient for reference. The speculum should be lubricated only with saline, since K-Y jelly may be spermicidal and may interfere with wet mount procedures and forensic evaluation. Examine the vaginal walls and cervix for abrasions, ecchymosis and lacerations. If a colposcope with photographic capabilities is available, it may aid in documentation of cervical-vaginal microtrauma. The cervix should be swabbed and cultures obtained for gonorrhea and Chlamydia trachomatis. A culture for herpes simplex virus is not routinely obtained.
One of the purposes of the wet mount is to check for the presence of sperm. Motile sperm can often be seen up to eight hours postcoitus,11 and nonmotile sperm may be detected beyond 72 hours.4 If sperm are present, document the number of sperm seen under high-power field. The absence of sperm does not exclude the possibility of sexual assault. The assailant may have undergone a vasectomy, and 50 percent of assailants experience impotence or ejaculatory dysfunction.4 The slide should also be examined for trichomonads, bacterial vaginosis and the presence of Candida species.12
Lastly, a bimanual and rectal examination should be performed to assess uterine size and to check for masses and tenderness. Swabbing of the rectal region for sperm, Chlamydia and gonorrhea testing should be performed only if the history indicates. In patients who have undergone anal assault, digital examination is recommended to assess for sphincter laxity or spasm. The presence of erythema, bleeding, mucosal tears and hematomas should be noted.1
Laboratory Examination of Assault Victims
A pregnancy test is recommended for all women of childbearing age who have undergone sexual assault. A β-human chorionic gonadotropin level should be determined at the time of initial examination to rule out established pregnancy. The risk of acquiring syphilis from a one-time sexual exposure is estimated to be less than 1 percent.6 A VDRL or rapid plasma reagin test should be obtained at the time of the initial visit and again three months later, based on local epidemiology. Hepatitis serology should be collected (hepatitis B surface antigen, antibody to hepatitis B core antigen, hepatitis B early antigen, antibody to hepatitis B surface antigen). Testing for hepatitis C is not routinely performed. The risk of acquiring hepatitis B or human immunodeficiency virus (HIV) infection from a one-time sexual encounter is less than 1 percent.6,13 Serology for HIV should be obtained at the initial visit, then repeated at three, six and 12 months after exposure. Antibodies develop within six months in 95 percent of persons who become infected after HIV exposure.4
Treatment of victims of sexual assault should include the following: care of physical injuries, pregnancy prophylaxis, prevention of sexually transmitted diseases and anticipation of psychosocial consequences.
Between 1 and 5 percent of sexual assaults result in pregnancy.7,8 Treatment for the prevention of pregnancy should be offered and discussed. Most postcoital pregnancy interventions are ineffective after 72 hours. Several management options exist. Repeating a pregnancy test six weeks after the last menstrual period is reasonable, although many victims of sexual assault experience late menses secondary to stress, tension and anxiety. This delay also may produce unnecessary anxiety. Therefore, pregnancy interruption is a commonly used alternative. The recommended treatment is high-dose oral contraceptive pills with 50 μg of ethinyl estradiol (example: Ovral), two tablets at the time of the initial visit and repeated 12 hours later.14 This treatment reduces the risk of pregnancy by 60 to 90 percent.8 Forewarn patients of the potential gastrointestinal side effects (i.e., nausea, vomiting). Treatment is recommended at the time of the initial visit to safeguard against unpredictable patient follow-up.
The overall risk of acquiring a sexually transmitted disease from a single sexual encounter is 5 to 10 percent.4 The Centers for Disease Control and Prevention treatment guidelines for postcoital prevention of sexually transmitted disease are as follows: prophylaxis should be offered if there is evidence that the assailant was infected or if symptoms of infection are present on examination, if poor follow-up is anticipated or if the patient requests prophylaxis. Treatment should include prophylaxis for gonorrhea, Chlamydia and syphilis. Trichomoniasis should be treated only if seen on the wet mount examination. If no prophylaxis is given, cultures for gonorrhea and Chlamydia should be repeated in two weeks and nontreponemal tests at 12 weeks. If prophylaxis was given and initial cultures are negative, no additional cultures are needed.7 If the patient was previously unimmunized, hepatitis B virus vaccine should be given at the acute care visit, then repeated at one and six months. Hepatitis B immune globulin should be reserved for use in patients who have been exposed within 14 days and who present with a high-risk exposure history, such as having an assailant who is a known intravenous drug user or having more than one assailant.
Pretest HIV counseling must be performed. The theory behind treatment is to prevent cellular infection by treating patients during a “window of opportunity.” Exposure risks for each patient will be unique. The probability of HIV transmission increases depending on the local prevalence rates, the assailant's serologic status, the number of assailants, the type of exposure (vaginal, anal, oral), the method of virus entry (directly into the victim's blood versus mucous membranes), the vaginal pH and the presence of other sexually transmitted diseases.15–17 If the assailant cannot be apprehended and tested, as in most cases, the victim's infection status may not be known for six to 12 months. Not only may this time delay foster anxiety and fear, but lifestyle changes may be necessary (need for condom use or abstaining from intercourse, postponing planned pregnancies, discontinuing breast feeding, etc.). Therefore, treatment must be made on a case-by-case basis, benefits must be weighed against lifestyle changes, and cost and potential drug toxicity must be considered.
Treatment may consist of two nucleoside analogs, zidovudine (Retrovir) and lamivudine (Epivir), given simultaneously for four weeks, or according to future treatment recommendations.13,15 Treatment should not be instituted beyond 72 hours from the time of exposure.13 Table 3 lists current medications for the treatment of HIV infection and other sexually transmitted diseases.
|Sexually transmitted disease
|400 mg orally in a single dose
|125 to 250 mg intramuscularly in a single dose
|500 mg orally in a single dose
|400 mg orally in a single dose
|100 mg twice daily for 7 days
|1 g orally in a single dose
|500 mg orally four times daily for 7 days
|500 mg orally twice daily for 7 days
|300 mg orally twice daily for 7 days
|Hepatitis B virus vaccine
|1 mL intramuscularly (deltoid) at 0, 1 and 6 months
|Hepatitis B immune globulin
|0.06 mL per kg intramuscularly in a single dose; within 14 days of exposure
|Human immunodeficiency virus
|200 mg orally three times daily for 4 weeks
|150 mg orally twice daily for 4 weeks
Psychologic Sequelae of Sexual Assault
The psychologic sequelae of sexual assault can be profound and long-term. Rape trauma syndrome is essentially similar to post-traumatic stress disorder. Phase I represents the acute phase (initial reaction), a period of disbelief, anxiety, fear, emotional lability and guilt. Phase II (reorganization phase) encompasses the stage of adjustment, integration and, finally, recovery. Patients who have been sexually assaulted do not necessarily present to the office with pelvic pain. Symptoms may be gastrointestinal, cardiac, respiratory, musculoskeletal or neurologic in origin. Victims may manifest phobias, panic disorder, obsessive-compulsive disorder, drug abuse and dependence.
Approximately 50 percent of victims experience depression during the first year following an attack.18 Sexual dysfunction has been reported in 24 to 40 percent of victims up to six years after the incident.18 One hundred percent of survivors surveyed reported that the experience continued to affect their lives five years later.18 Women with a history of sexual assault are significantly more likely than women without a sexual assault history to report poor health, chronic diseases and a variety of somatic symptoms.19 Visits to physicians' offices increase by 18 percent during the first year after a sexual assault and to 56 percent by the second year, and decline to 31 percent by the third year.5 The care a victim initially receives influences recovery. Therefore, it is imperative that proper support services be initiated at the time of initial evaluation and close follow-up be arranged. Support services may include hospital social workers, local rape crisis services, local departments of public health, the attorney general's office, the National Coalition Against Sexual Assault (NCASA; telephone: 717-728-9764), and the Rape, Abuse and Incest National Network (RAINN; telephone: 800-656-HOPE).
Sexual assault is a tragedy with long-term medical and emotional consequences. Victims of a sexual assault who perceive the physician and nurse to be concerned, kind and organized in their care are far more likely to return for follow-up counseling and treatment.20 Survivors of sexual assault have the right to medical treatment and to be treated in a humane manner. They have the right to report the assault to police and to be treated fairly and with dignity during the criminal justice process. As practicing family physicians, we can make a difference by including sexual assault in the differential diagnosis of patients who present with nonorganic etiology, by preparing and familiarizing ourselves with a rape kit and the laws that govern the state in which we practice, and by encouraging victims to report this crime.