Section 22. Women's Health Issues

Chapter 253. Violence Against Women

Topics: Introduction | Domestic Violence | Rape

Rape

Rape is typically considered to be unwanted penetration of the victim's vagina, anus, or mouth. In victims younger than the age of consent, such penetration--whether wanted or not--is considered rape (statutory rape). Sexual assault is a broader term, including the use of force and threats to coerce sexual contact. The reported percentage of women who have been raped during their lifetime varies widely: from 2% to almost 30%. The reported percentage of children who are sexually abused is similarly high (see Section 23, Chapter 288). Reported percentages are probably lower than the actual percentages, because rape and sexual abuse are less likely to be reported to the police than are other crimes.

Men are also raped. For men as for women, injuries may occur and the psychologic effects can be devastating.

Symptoms

Physical injuries resulting from a rape may include tears in the upper part of the vagina and injuries to other parts of the body, such as bruises, black eyes, cuts, and scratches.

The psychologic effects of a rape are often more devastating than the physical. Shortly after a rape occurs, almost all women have symptoms of posttraumatic stress disorder (which can occur after any stressful event (see Section 7, Chapter 100)). Women feel fearful, anxious, and irritable. They may feel angry, depressed, or guilty (wondering whether they may have done something to provoke the rape or could have done something to avoid it). They may have intrusive, upsetting thoughts about or mental images of the assault, and they may relive the rape. Or they may stifle thoughts and feelings about the rape. They may avoid situations that remind them of the rape. Difficulty sleeping and nightmares are common. These symptoms may last for months, interfering with social activities and work. However, for most women, symptoms lessen substantially over a period of months.

In addition to her own feelings, the rape victim may have to handle negative, sometimes judgmental or derisive reactions of friends, family members, and officials. These reactions can interfere with the victim's recovery.

After a rape, there is a risk of infection with sexually transmitted diseases (such as gonorrhea, chlamydial infection, and syphilis) and hepatitis B and C. Infection with the human immunodeficiency virus (HIV) is a particular concern, even though the chances of acquiring it in a single encounter are low. Rarely, a woman becomes pregnant.

Evaluation

Having a thorough medical evaluation after a rape is important. Whenever possible, women who have been raped or sexually assaulted are taken to a sexual assault evaluation treatment center that is separate from the emergency department and that is staffed by trained, concerned support personnel.

After a rape, doctors are required by law to notify the police and to examine the victim. The examination provides evidence for prosecution of the rapist and is necessary before medical care of the victim can begin. The best evidence is obtained when the rape victim goes to the hospital as soon as possible, without showering, without changing clothes, and, if possible, without even urinating. The medical record resulting from this examination is sometimes admissible in court as evidence. However, the medical record cannot be released unless the victim gives her consent in writing or a subpoena is issued. The record may also help the victim recall details of the rape if her testimony is required later.

Immediately after a rape, a woman may be afraid of undergoing a physical examination. If possible, a female doctor examines the woman. If not, a female nurse or volunteer is present to help allay any anxiety the woman may be feeling. Before beginning the examination, the doctor should ask the woman's permission to proceed. The woman should feel no pressure to consent, although consent is generally in her best interest. The woman can ask the doctor to explain what will happen during the examination so that she knows what to expect.

The doctor asks the woman to describe the events to help guide the examination and treatment. However, talking about the rape is often frightening for the woman. She may request to give a complete description later, after her immediate needs have been met. She may first need to be treated for injuries, to clean up, and to have some time for calming down. The woman, if she wishes, is provided with bathroom facilities so that she can wash.

To help determine the likelihood of pregnancy, the doctor asks the woman when her last menstrual period was and whether she uses a contraceptive. To help interpret the analysis of any sperm samples, the doctor asks the woman if she recently had sex before the rape and, if so, when.

The doctor notes physical injuries, such as cuts and scrapes, and may examine the vagina for injuries. Photographs of injuries are taken. Because some injuries such as bruises become apparent later, a second set of photographs may be taken later. A swab is used to take samples of semen and other body fluids for evidence. Other samples, such as samples of the perpetrator's hair, blood, or skin (sometimes found under the woman's nails), are collected. Sometimes DNA testing of the samples is performed to identify the perpetrator.

If the woman consents, blood tests are performed to check for infections, including HIV infection. If the initial test results for gonorrhea, chlamydial infection, syphilis, and hepatitis are negative, the woman is tested again within 6 weeks. If results for syphilis and hepatitis are still negative, tests are repeated at 6 months. Blood tests for HIV infection may be repeated after 90 and 120 days.

Usually, a pregnancy test (to measure the level of human chorionic gonadotropin in the urine (see Section 22, Chapter 257)) is performed within a few days and again within 6 weeks. If the woman may have been pregnant before the rape, the urine test is performed during the initial examination. The test cannot detect a pregnancy that has just occurred. Thus, performed at this time, the test would detect a preexisting pregnancy, but not one that resulted from the rape.

Treatment

Most physical injuries are easily treated. Severe injuries may require surgery. For preventing infections, the woman is given antibiotics, typically one dose of ceftriaxone injected into a muscle, one dose of metronidazole given by mouth, and doxycycline given by mouth for 7 days. If test results for HIV were positive, treatment for HIV is started immediately (see Section 17, Chapter 199).

If pregnancy is a concern, emergency contraception may be used. A high dose of an oral contraceptive is given immediately, then repeated 12 hours later (see Section 22, Chapter 255). This treatment is 99% effective if given within 72 hours of the rape. If the woman may have been pregnant before the rape, the oral contraceptive is given only if results from the pregnancy test do not detect pregnancy. If pregnancy results from the rape, abortion can be considered.

Common psychologic reactions to the rape (such as excessive anxiety or fear) are explained to the woman. As soon as feasible, a person trained in rape crisis intervention meets with her. The woman is referred to a rape crisis team if one is located in the area. This team can provide helpful medical, psychologic, and legal support. For the woman, talking about the rape and her feelings about it can help her recover. If symptoms of posttraumatic stress disorder persist, psychotherapy or antidepressants can be effective (see Section 7, Chapter 100). If necessary, the woman can be referred to a psychologist, social worker, or psychiatrist.

Family members and friends may have some of the same feelings as the victim: anxiety, anger, or guilt. They may irrationally blame the victim. Family members or close friends may benefit from meeting with a member of the rape crisis team or sexual assault evaluation unit to discuss their feelings and how they can help the victim. Usually, listening supportively to the victim and not expressing strong feelings about the rape are most helpful. Blaming or criticizing the victim may interfere with her recovery. A support network of health care workers, friends, and family members can be very helpful to the victim.