Introduction

 
• Women neither secretly want to be raped nor do they expect, encourage, or enjoy rape.  
• Rape is always a terrifying experience in which most victims fear for their lives.  
• The rapist is usually a hostile man who uses sexual intercourse to terrorize and humiliate a woman.

General Considerations

Rape, or sexual assault, is legally defined in different ways in various jurisdictions. Clinicians and emergency room personnel who deal with rape victims should be familiar with the laws pertaining to sexual assault in their own state. From a medical and psychologic viewpoint, it is essential that persons treating rape victims recognize the nonconsensual and violent nature of the crime. About 95% of reported rape victims are 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.

Rape represents an expression of anger, power, and sexuality on the part of the rapist. The rapist is usually a hostile man who uses sexual intercourse to terrorize and humiliate a woman. Women neither secretly want to be raped nor do they expect, encourage, or enjoy rape.

Rape involves severe physical injury in 5-10% of cases and is always a terrifying experience in which most victims fear for their lives. Consequently, all victims suffer some psychologic aftermath. Moreover, some rape victims may acquire sexually transmissible disease or become pregnant.

Because rape is a personal crisis, each patient will react differently. 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 can rarely lead to suicide.

Clinicians and emergency room personnel who deal with rape victims should work with community rape crisis centers whenever possible to provide ongoing support and counseling.

General Office Procedures

The clinician who first sees the alleged rape victim should be empathetic. Begin with a statement such as, “This is a terrible thing that has happened to you. I want to help.”

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

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, 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.

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. Culture the vagina, anus, or mouth (as appropriate) for N gonorrhoeae and chlamydia. Perform a Papanicolaou smear of the cervix, a wet mount for T vaginalis, a baseline pregnancy test, and VDRL test. A confidential test for HIV antibody can be obtained if desired by the patient and 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.

Treatment

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

Give ceftriaxone, 125 mg intramuscularly, to prevent gonorrhea. In addition, give metronidazole, 2 g as a single dose, and doxycycline, 100 mg twice daily for 7 days to treat chlamydial infection. Incubating syphilis will probably be prevented by these medications, but the VDRL test should be repeated 6 weeks after the assault.

Prevent pregnancy by using one of the methods discussed under Emergency Contraception, if necessary.

Vaccinate against hepatitis B. Consider HIV prophylaxis.

Preferences:
Make sure the patient and her family and friends have a source of ongoing psychologic support.

Linden JA: Sexual assault. Emerg Med Clin North Am 1999; 17:685.