Medical Examination of the Rape Victim

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

Many rape reporting forms include most or all of these questions (see table Typical Examination for Alleged Rape 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 before each step; the patient may refuse any part of the examination. 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 in females 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 secretions or urine is tested for trichomonal vaginitis and bacterial vaginosis; samples from every penetrated orifice (vaginal, oral, or rectal) are obtained for gonorrheal and chlamydial testing (1 Evaluation reference Sexual assault is any type of sexual activity or contact that a person does not consent to. Sexual assault, including rape, may cause physical injury or illness or psychologic trauma. Survivors... read more ). Patients may decline STI testing, possibly because empiric therapy is typically given to all patients.

Follow-up tests are done to check for pregnancy and STIs:

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.

Patients with severe 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 (see table Typical Examination for Alleged Rape Typical Examination for Alleged Rape ); it typically includes

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 hours; 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.

Clinicians should encourage patients to seek help with managing the effects of their trauma and with restoring their ability to function (crisis intervention) and to seek psychologic support.

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 of rape 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-week 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 (eg, gentle encouragement, reminders that the rape was not their fault), but they may need help from rape crisis specialists in handling their own negative reactions.

PTSD Treatment Posttraumatic stress disorder (PTSD) is a disabling disorder that develops after exposure to a traumatic event. It is characterized by intrusive thoughts, nightmares, and flashbacks; avoidance... read more can be effectively treated with psychotherapy and drug therapy.

Routine empiric prophylaxis for STIs for adults and adolescents consists of the following:

For hepatitis B, the Centers for Disease Control and Prevention (CDC) recommends hepatitis B vaccination unless the patient has been previously vaccinated and has documented immunity. The vaccine is repeated 1 and 6 months after the first dose. Hepatitis B immune globulin (HBIG) is not given.

HPV vaccination is given to females and males aged 9 to 26 years if they are unvaccinated or incompletely vaccinated. The vaccine is repeated at 1 and 6 months after the first dose. A 2-dose schedule (at 0 and 6 to 12 months) is recommended for unvaccinated patients who are starting HPV vaccination before age 15 years.

Counseling about empiric postexposure prophylaxis for HIV infection Postexposure prophylaxis (PEP) Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more is recommended. Most authorities recommend offering prophylaxis; however, risk factors should be considered, and the patient should be told that on average, the risk of HIV infection after rape from an unknown assailant is low (1 Treatment reference Sexual assault is any type of sexual activity or contact that a person does not consent to. Sexual assault, including rape, may cause physical injury or illness or psychologic trauma. Survivors... read more ). Risk may be higher with any of the following:

Prophylaxis for HIV infection is best begun < 4 hours after penetration and should not be given after > 72 hours.

Emergency contraception Emergency Contraception Emergency contraception may be used to prevent pregnancy for a short period of time after unprotected sex. Commonly used emergency contraception methods include Insertion of an intrauterine... read more should be offered to all women with a negative pregnancy test. Usually, oral medications are used; if used > 72 hours 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 5 days after rape.

If pregnancy results from rape, the patient should be counseled about options for obstetric care and elective termination.