Medical Examination of the Rape Victim
Although legal and medical definitions vary, rape is typically defined as oral, anal, or vaginal penetration that involves threats or force against an unwilling person. Such penetration, whether wanted or not, is considered statutory rape if victims are younger than the age of consent. Sexual assault is rape or any other sexual contact that results from coercion, including seduction of a child through offers of affection or bribes; it also includes being touched, grabbed, kissed, or shown genitals. Rape and sexual assault, including childhood sexual assault, are common; the lifetime prevalence estimates for both ranges from 2 to 30% but tends to be about 15 to 20%. However, actual prevalence may be higher because rape and sexual assault tend to be underreported.
Typically, rape is an expression of aggression, anger, or need for power; psychologically, it is more violent than sexual. Nongenital or genital injury occurs in about 50% of rapes of females.
Females are raped and sexually assaulted more often than males. Male rape is often committed by another man, often in prison. Males who are raped are more likely than females to be physically injured, to be unwilling to report the crime, and to have multiple assailants.
Rape may result in the following:
Most physical injuries are relatively minor, but some lacerations of the upper vagina are severe. Additional injuries may result from being struck, pushed, stabbed, or shot.
Psychologic symptoms of rape are potentially the most prominent. In the short term, most patients experience fear, nightmares, sleep problems, anger, embarrassment, shame, guilt, or a combination. Immediately after an assault, patient behavior can range from talkativeness, tenseness, crying, and trembling to shock and disbelief with dispassion, quiescence, and smiling. The latter responses rarely indicate lack of concern; rather, they reflect avoidance reactions, physical exhaustion, or coping mechanisms that require control of emotion. Anger may be displaced onto hospital staff members.
Friends, family members, and officials often react judgmentally, derisively, or in another negative way. Such reactions can impede recovery after an assault.
Eventually, most patients recover; however, long-range effects of rape may include posttraumatic stress disorder (PTSD—see Posttraumatic Stress Disorder (PTSD)), particularly among women. PTSD is an anxiety disorder; symptoms include re-experiencing (eg, flashbacks, intrusive upsetting thoughts or images), avoidance (eg, of trauma-related situations, thoughts, and feelings), and hyperarousal (eg, sleep difficulties, irritability, concentration problems). Symptoms last for > 1 mo and significantly impair social and occupational functioning.
Goals of rape evaluation are
If patients seek advice before medical evaluation, they are told not to throw out or change clothing, wash, shower, douche, brush their teeth, or use mouthwash; doing so may destroy evidence.
Whenever possible, all people who are raped are referred to a local rape center, often a hospital emergency department; such centers are staffed by specially trained practitioners (eg, sexual assault nurse examiners [SANE]). Benefits of a rape evaluation are explained, but patients are free to consent to or decline the evaluation. The police are notified if patients consent. Most patients are greatly traumatized, and their care requires sensitivity, empathy, and compassion. Females may feel more comfortable with a female physician; a female staff member should accompany all males evaluating a female. Patients are provided privacy and quiet whenever possible.
A form (sometimes part of a rape kit) is used to record legal evidence and medical findings (for typical elements in the form, see Table: Typical Examination for Alleged Rape); it should be adapted to local requirements. Because the medical record may be used in court, results should be written legibly and in nontechnical language that can be understood by a jury.
Typical Examination for Alleged Rape
Before beginning, the examiner asks the patient’s permission. Because recounting the events often frightens or embarrasses the patient, the examiner must be reassuring, empathetic, and nonjudgmental and should not rush the patient. Privacy should be ensured. The examiner elicits specific details, including
Type of injuries sustained (particularly to the mouth, breasts, vagina, and rectum)
Any bleeding from or abrasions on the patient or assailant (to help assess the risk of transmission of HIV and hepatitis)
Description of the attack (eg, which orifices were penetrated, whether ejaculation occurred or a condom was used)
Assailant’s use of aggression, threats, weapons, and violent behavior
Description of the assailant
Many rape forms include most or all of these questions (see Typical Examination for Alleged Rape). The patient should be told why questions are being asked (eg, information about contraceptive use helps determine risk of pregnancy after rape; information about previous coitus helps determine validity of sperm testing).
The examination should be explained step by step as it proceeds. Results should be reviewed with the patient. When feasible, photographs of possible injuries are taken. The mouth, breasts, genitals, and rectum are examined closely. Common sites of injury include the labia minora and posterior vagina. Examination using a Wood’s lamp may detect semen or foreign debris on the skin. Colposcopy is particularly sensitive for subtle genital injuries. Some colposcopes have cameras attached, making it possible to detect and photograph injuries simultaneously. Whether use of toluidine blue to highlight areas of injury is accepted as evidence varies by jurisdiction.
Routine testing includes a pregnancy test and serologic tests for syphilis, hepatitis B, and HIV; if done within a few hours of rape, these tests provide information about pregnancy or infections present before the rape but not those that develop after the rape. Vaginal discharge is examined to check for trichomonal vaginitis and bacterial vaginosis; samples from every penetrated orifice (vaginal, oral, or rectal) are obtained for gonorrheal and chlamydial testing. If the patient has amnesia for events around the time of rape, drug screening for flunitrazepam (the date rape drug) and gamma hydroxybutyrate should be considered. Testing for drugs of abuse and alcohol is controversial because evidence of intoxication may be used to discredit the patient.
Follow-up tests for the following are done:
However, testing for STDs is controversial because evidence of preexisting STDs may be used to discredit the patient in court.
If the vagina was penetrated and the pregnancy test was negative at the first visit, the test is repeated within the next 2 wk. Patients with lacerations of the upper vagina, especially children, may require laparoscopy to determine depth of the injury.
Evidence that can provide proof of rape is collected; it typically includes clothing; smears of the buccal, vaginal, and rectal mucosa; combed samples of scalp and pubic hair as well as control samples (pulled from the patient); fingernail clippings and scrapings; blood and saliva samples; and, if available, semen (see Typical Examination for Alleged Rape). Many types of evidence collection kits are available commercially, and some states recommend specific kits. Evidence is often absent or inconclusive after showering, changing clothes, or activities that involve sites of penetration, such as douching. Evidence becomes weaker or disappears as time passes, particularly after > 36 h; however, depending on the jurisdiction, evidence may be collected up to 7 days after rape.
A chain of custody, in which evidence is in the possession of an identified person at all times, must be maintained. Thus, specimens are placed in individual packages, labeled, dated, sealed, and held until delivery to another person (typically, law enforcement or laboratory personnel), who signs a receipt. In some jurisdictions, samples for DNA testing to identify the assailant are collected.
After the evaluation, the patient is provided with facilities to wash, change clothing, use mouthwash, and urinate or defecate if needed. A local rape crisis team can provide referrals for medical, psychologic, and legal support services.
Most injuries are minor and are treated conservatively. Vaginal lacerations may require surgical repair.
Sometimes examiners can use commonsense measures (eg, reassurance, general support, nonjudgmental attitude) to relieve strong emotions of guilt or anxiety. Possible psychologic and social effects are explained, and the patient is introduced to a specialist trained in rape crisis intervention. Because the full psychologic effects cannot always be ascertained at the first examination, follow-up visits are scheduled at 2-wk intervals. Severe psychologic effects (eg, persistent flashbacks, significant sleep disruption, fear leading to significant avoidance) or psychologic effects still present at follow-up visits warrant psychiatric or psychologic referral.
Family members and friends can provide vital support, but they may need help from rape crisis specialists in handling their own negative reactions.
PTSD can be effectively treated psychosocially and pharmacologically (see Posttraumatic Stress Disorder (PTSD): Treatment).
Routine empiric prophylaxis for STDs consists of ceftriaxone 125 mg IM in a single dose (for gonorrhea), metronidazole 2 g po in a single dose (for trichomoniasis and bacterial vaginosis), and either doxycycline 100 mg po bid for 7 days or azithromycin 1 g po once (for chlamydial infection). Alternatively, azithromycin 2 g po (which covers gonorrhea and chlamydial infection) can be given with metronidazole 2 g po, both as a single dose.
Empiric prophylactic treatment of hepatitis B and HIV after rape is controversial. For hepatitis B, the CDC recommends hepatitis B vaccination unless the patient has been previously vaccinated and has documented immunity. The vaccine is repeated 1 and 6 mo after the first dose. Hepatitis B immune globulin (HBIG) is not given. For HIV, most authorities recommend offering prophylaxis; however, the patient should be told that on average, the risk after rape from an unknown assailant is only about 0.2%. Risk may be higher with any of the following:
Treatment is best begun < 4 h after penetration and should not be given after > 72 h. Usually, a fixed-dose combination of zidovudine (ZDV) 300 mg and lamivudine (3TC) 150 mg is given bid for 4 wk if exposure appears low risk. If risk is higher, a protease inhibitor is added (see Human Immunodeficiency Virus (HIV) Infection : Postexposure prophylaxis (PEP)).
Although pregnancy caused by rape is rare (except in the few days before ovulation), emergency contraception (see Emergency Contraception (EC)) should be offered to all women with a negative pregnancy test. Usually, oral contraceptives are used; if used > 72 h after rape, they are much less likely to be effective. An antiemetic may help if nausea develops. An intrauterine device may be effective if used up to 10 days after rape. If pregnancy results from rape, the patient’s attitude toward the pregnancy and abortion should be determined, and if appropriate, the option of elective termination should be discussed.