ABSTRACT: Reproductive-aged victims of sexual assault are at risk of unintended pregnancy, sexually transmitted infections, and mental health conditions, including posttraumatic stress disorder. Health care providers should screen routinely for a history of sexual assault and offer victims both emergency contraception and sexually transmitted infection prophylaxis. The health care provider who examines victims of sexual assault has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits.
Sexual assault is a crime of violence and aggression, and encompasses a continuum of sexual activity that ranges from sexual coercion to contact abuse (unwanted kissing, touching, or fondling) to rape (1). The Federal Bureau of Investigation (FBI) has a newly revised, more comprehensive definition of rape to track statistics for the annual Uniform Crime Report. The old definition only recognized forceful vaginal penetration of a woman by a man’s penis as rape. For the first time ever, the new definition recognizes that rape victims and perpetrators may be female or male, and includes oral and anal penetration, as well as penetration with an object, as rape (2). Also, physical force is no longer a requirement of rape so that the definition includes vulnerable victims, those who are intoxicated or otherwise mentally or physically incapable of demonstrating a lack of consent (2). The FBI’s change does not affect definitions under federal or state criminal laws; the new definition only applies for statistical purposes, so that crimes under existing state laws will now be counted by the federal government. Because definitions vary among states, the term sexual assault is sometimes used interchangeably with rape. Sexual assault and rape are often further characterized to include acquaintance rape, date rape, statutory rape, child sexual abuse, and incest. These terms generally relate to the age of the victim and the relationship to the abuser.
Acquaintance rape and date rape refer to sexual assaults committed by someone known to the victim. When the perpetrator is a family member of the victim, the assault is defined as incest. Statutory rape refers to consensual sexual intercourse with an individual younger than a specific age. The age at which an adolescent may consent to sexual intercourse varies by state and is generally 16–18 years. Sexual assault that occurs in childhood, defined by most states as younger than 14 years, is considered child abuse. Childhood sexual abuse is further defined by the Child Abuse and Prevention Act as “the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other forms of sexual exploitation of children, or incest with children” (3). The scope of this Committee Opinion does not include childhood sexual assault. Please refer to the American College of Obstetricians and Gynecologists’ Committee Opinion Number 498, Adult Manifestations of Childhood Sexual Abuse, for more information (4).
Incidence and Prevalence
Methods of obtaining data influence estimates of the incidence and prevalence of rape and sexual assault. Data compiled from reports to law enforcement officials underestimate the incidence of sexual assault. Key findings of the National Intimate Partner and Sexual Violence Survey reveal that an estimated 1.3 million rape-related physical assaults occur against women annually (5). Approximately 18% of women surveyed reported that they had been victims of a completed or attempted rape during their lifetime (5). Nearly 80% reported that they were first raped before age 25 years, and 42% before age 18 years (5). Among female victims, 51% reported that at least one perpetrator was a current or former intimate partner, 41% reported an acquaintance, 13% reported a family member, and 14% reported a stranger (5). Female veterans experience increased rates of sexual assault during their time in the military as well as their time as a civilian and are eligible to receive lifetime care at any Veterans Health Administration facility for health problems related to military sexual assault (6).
Medical Consequences of Sexual Assault
Acute traumatic injuries of sexual assault can be relatively minor, including scratches, bruises, and welts. However, some women sustain fractures, head and facial trauma, lacerations, bullet wounds, or even death. The risk of injury increases for adult women rape victims in the following situations: the perpetrator is a current or former intimate partner; the rape occurs in the victim’s or perpetrator’s home; the rape is completed; harm to the victim or another is threatened by the perpetrator; a gun, knife, or other weapon is used during the assault; or the perpetrator is using drugs or alcohol at the time of the assault (7).
Sexual assault may lead to pregnancy. The national rape-related pregnancy rate is approximately 5% per rape among women aged 12–45 years, or approximately 32,000 pregnancies resulting from rape each year (8). Unintended pregnancy is especially high among adolescent assault victims because of their relatively low use of contraception. Adolescents are also more likely to be repeatedly assaulted and victimized in incestuous relationships (4). Other conditions that are diagnostic or suspicious for childhood sexual abuse include syphilis, human papillomavirus, and herpes simplex infection (9).
Various long-term health effects are associated with female sexual assault. Increases in patient-reported symptoms, diminished levels of function, alterations in health perceptions, and decreased quality of life are sequelae of childhood and adult sexual abuse (10, 11). Many women do not spontaneously discuss a history of sexual assault but may present with chronic pelvic pain, dysmenorrhea, and sexual dysfunction more often than those without such a history (12). Additional information on adult manifestations of childhood sexual abuse is available elsewhere (4).
Psychologic and Mental Health Consequences of Sexual Assault
A victim who is sexually assaulted loses control over her life during the period of the assault. After the assault, a rape-trauma syndrome often occurs. The acute, or disorganization phase, may last for days to weeks and is characterized by physical reactions such as generalized pain throughout the body, eating and sleeping disturbances, and emotional reactions such as anger, fear, anxiety, guilt, humiliation, embarrassment, self-blame, and mood swings (1, 13). The next phase, the delayed, or organization phase, is characterized by flashbacks, nightmares, and phobias as well as somatic and gynecologic symptoms. This phase often occurs in the weeks and months after the event and may involve major life adjustments (1, 13).
Posttraumatic stress disorder (PTSD) is a long-term consequence of sexual assault. Posttraumatic stress disorder is characterized by a symptom cluster involving reexperiencing the trauma, avoidance, and a state of hyperarousal (14). Symptoms may not appear for months or even years after a traumatic experience.
Alcohol abuse, including binge drinking, and illicit drug use and dependence have long-term associations with sexual assault. In a survey of women seeking substance abuse treatment, prevalence rates of completed rape or other types of sexual assault were 64.2% and 44.8%, respectively (15).
Roles and Responsibilities of Health Care Providers
The American College of Obstetricians and Gynecologists recommends that health care providers routinely screen all women for a history of sexual assault, paying particular attention to those who report pelvic pain, dysmenorrhea, or sexual dysfunction (16). Early identification of victims of sexual assault can lead to prevention of long-term and persistent physical and mental health consequences of abuse. When a history of sexual abuse is obtained, the clinician may expect that various health care procedures, such as pelvic, rectal, breast, and endovaginal ultrasonographic examinations, could trigger panic and anxiety reactions. Such reactions may stem from PTSD and may have a connection with more remote events. Clinicians should screen women with a history of sexual assault for substance abuse. Conversely, clinicians should screen for a history of sexual assault in women with a history of substance abuse. Counseling can help the woman to understand her psychologic and physical responses, thereby diminishing the associated symptoms (13).
Recently, many hospitals have implemented programs to provide acute medical and evidentiary examinations for sexual assault victims by sexual assault nurse examiners or sexual assault forensic examiners. In some settings, however, obstetrician–gynecologists remain the first point of contact for the evaluation and care of sexual assault victims. If called on to perform a sexual assault examination, the physician who has no experience or limited experience should consider requesting assistance to ensure appropriate evidence collection. Improper evidence collection, including a break in the chain of custody and incorrect handling of samples, virtually eliminates options to prosecute the case.
The health care provider conducting an evidentiary evaluation of a sexual assault victim must comply with state and local statutory or policy requirements involving the use of evidence gathering kits. If a sexual assault victim communicates with the health care provider’s office, emergency department, or clinic before evaluation, she should be encouraged to immediately go to a medical facility, and to not bathe, change her clothes, douche, urinate, defecate, wash out her mouth, clean her fingernails, smoke, eat, or drink. Many jurisdictions use a 72-hour cutoff time for collection of evidence in a sexual assault case, whereas some have extended the time to 1 week. When collecting evidentiary materials, health care providers should comply with the required time frame within that jurisdiction (17).
A history of obstetric and gynecologic conditions should be recorded, including current pregnancy or risk of pregnancy (1). A detailed examination of the entire body should be performed and injuries should be photographed or drawn. Rape and sexual assault are legal terms that should not be used in medical records. Rather, the health care provider should only report the findings and not state a conclusion. Using direct quotes or information from the patient for the history and detailed descriptions and photos of the physical findings are sufficient. Even terms such as “allegedly raped” should not be used as a diagnosis.
The health care provider should document the emotional condition of the woman as judged by direct observation and examination (1). If the woman is a minor or a vulnerable adult (those unable to care for their daily needs due to mental or physical disabilities), the health care provider should report the incident to the appropriate authorities as required by state law. Efforts should be made to involve a parent or caregiver unless that individual represents a security threat to the woman.
When the woman’s physical and medical–legal needs have been addressed, the health care provider should discuss with her the degree of injury and the probability of infection or pregnancy. Emergency contraception should be provided, requiring its immediate availability in hospitals and facilities where victims of sexual assault are treated. The most common sexually transmitted infections (STIs) reported in sexual assault victims include trichomoniasis, gonorrhea, and Chlamydia trachomatis (18). Prophylaxis for these STIs is recommended (19). Of particular concern is human immunodeficiency virus (HIV), where the status of the assailant is often unknown or unavailable. Multiple characteristics increase the risk of HIV transmission, including genital or rectal trauma leading to bleeding, multiple traumatic sites involving lacerations or deep abrasions, and the presence of preexisting genital infection or ulcers in the victim (20). The U.S. Department of Health and Human Services recommends that an individual seeking care within 72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infective body fluids from an HIV-positive individual receive a 28-day course of highly active antiretroviral therapy, initiated as soon as possible after exposure. If the assailant’s HIV status is unknown, clinicians should evaluate the risks and benefits of nonoccupational postexposure prophylaxis on a case-by-case basis. For individuals initiating care less than 72 hours after exposure (some guidelines restrict initiation of nonoccupational postexposure prophylaxis to within 36 hours following exposure) (21), clinicians may consider prescribing nonoccupational postexposure prophylaxis for exposures conferring a serious risk of transmission if, in their judgment, the unknown potential benefit of treatment outweighs the potential risk of adverse events from antiretroviral medications (22). The decision to prescribe nonoccupational postexposure prophylaxis should be made after a thorough risk assessment, taking into account the preference of the woman, the prevalence of HIV in the geographic area or institutional setting where the assault occurred, the estimated risk of infection in the perpetrator, and the nature of the exposure (17, 23). The local HIV specialist or the National Clinicians’ Consultation Center Post-Exposure Prophylaxis Hotline (1-888-448-4911) should be consulted before initiating nonoccupational postexposure prophylaxis. Low rates of medication completion have adversely affected the utility of the nonoccupational postexposure prophylaxis regimen. If the patient starts nonoccupational postexposure prophylaxis, a 2–5 day initial supply with a follow-up visit within several days helps increase continuation rates and allows for a comprehensive discussion after recovery from the attack. The patient’s HIV status should be tested within 72 hours of the initial assault and then repeated at 6 weeks, 3 months, and 6 months. Regardless of whether nonoccupational postexposure prophylaxis is initiated, the clinician should provide HIV risk reduction and primary prevention counseling.
Other health personnel, particularly those trained to respond to rape-trauma victims, should be consulted to provide immediate intervention if necessary and to facilitate counseling and follow-up. Health care providers are urged to assemble and maintain a list of individuals and other resources for patient referral.
Because of the emotional intensity of the experience, a woman may not recall all the information provided during an office visit. Therefore, it is helpful to provide all instructions and plans in writing. Generally, a visit for clinical and psychologic follow-up should take place within 1–2 weeks with additional encounters scheduled thereafter as indicated by results and assessments.
The American College of Obstetricians and Gynecologists recommends the following in the evaluation of sexual assault victims:
- Obtain informed consent
- Assess and treat physical injuries
- Obtain past gynecologic history
- Perform physical examination, including pelvic examination, with appropriate chaperone
- Obtain appropriate specimens and serologic tests for STI testing
- Provide appropriate infectious disease prophylaxis as indicated
- If the assailant’s HIV status is unknown, evaluate the risks and benefits of nonoccupational postexposure prophylaxis
- Provide or arrange for provision of emergency contraception as indicated
- Provide counseling regarding findings, recommendations, and prognosis
- Arrange follow-up medical care and referrals for psychosocial needs
- Provide accurate recording of events
- Document injuries
- Collect samples as indicated by local protocol or regulation
- Identify the presence or absence of sperm in the vaginal fluids and make appropriate slides
- Report to authorities as required
- Ensure security of chain of evidence
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- Federal Bureau of Investigation. Summary Reporting System (SRS) user manual version 1.0. Criminal Justice Information Services (CJIS) Division, Uniform Crime Reporting (UCR) Program. Washington, DC: FBI; 2013. Available at: http://www.fbi.gov/about-us/cjis/ucr/nibrs/summary-reporting-system-srs-user-manual. Retrieved November 25, 2013. ⇦
- Administration for Children and Families, Department of Health and Human Services. Definitions of child abuse and neglect. Available at: https://www.childwelfare.gov/can/defining. Retrieved November 25, 2013. ⇦
- Adult manifestations of childhood sexual abuse. Committee Opinion No. 498. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:392–5. [PubMed] [Obstetrics & Gynecology] ⇦
- Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, Merrick MT, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta (GA): Centers for Disease Control and Prevention; 2011. Available at: http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf. Retrieved November 25, 2013. ⇦
- Health care for women in the military and women veterans. Committee Opinion No. 547. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1538–42. [PubMed] [Obstetrics & Gynecology] ⇦
- Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. NCJ 183781. Washington, DC: U.S. Department of Justice, Office of Justice Programs; 2000. Available at: http://www.ncjrs.gov/pdffiles1/nij/183781.pdf. Retrieved November 27, 2013. ⇦
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*Many jurisdictions have prepackaged kits for the initial forensic examination of a rape that provide specific containers and instructions for the collection of physical evidence and for written and pictorial documentation of the victim’s subjective and objective findings. See www.rainn.org/get-information/sexual-assault-recovery/rape-kit for more information on rape kits.