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Medical Examination of the Rape Victim

By

Erin G. Clifton

, PhD, University of Michigan

Last full review/revision Jul 2022
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Topic Resources

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 should be evaluated for injury, sexually transmitted infections, pregnancy, and acute or posttraumatic stress disorders; they are asked to give permission for an examination to collect evidence. Treatment includes infection prophylaxis and mental health care.

Sexual assault includes rape and sexual coercion; it may involve physical force or threats of force, or the attacker giving the victim drugs or alcohol.

Although legal and medical definitions vary, rape is typically defined as penetration, no matter how slight, of the vagina or anus with any body part or object or oral penetration by another person's sex organ without the consent of the victim ( 1 Pearls & Pitfalls Pearls & Pitfalls ). People under the age of consent cannot give consent to sexual activity with an adult.

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.

Rape and other forms of sexual assault, including childhood sexual assault, are common; the estimated lifetime incidence for both ranges from 2 to 30% but tends to be about 15 to 20%. However, actual incidence may be higher because rape and sexual assault tend to be underreported.

Females have the highest rates of rape and sexually assault; however, victims include people of all genders. 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.

General reference

Symptoms and Signs of Rape

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 physical violence that occurs during the sexual assault. Evidence indicates that a lifetime experience of rape is also related to long-term physical health problems; for example, risk of developing asthma, irritable bowel syndrome, frequent headaches, or chronic pain is higher for rape victims than for people who are not victims of rape [ 1 Symptoms and signs 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 ]).

Immediately after an assault, patient behavior can range from talkativeness, tenseness, crying, and trembling to shock and disbelief with dispassion or quiescence. 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 or family members.

For acute stress disorder to be diagnosed, symptoms must be present for 3 days to 1 month after the assault.

Friends, family members, and officials may be supportive or react judgmentally or in another negative way. Negative reactions can impede recovery after an assault.

Long-range effects of rape may include PTSD, particularly among women. PTSD is a trauma-related disorder; symptoms of PTSD include

  • Re-experiencing the trauma (eg, flashbacks, intrusive upsetting thoughts or images)

  • Avoidance (eg, of trauma-related situations, thoughts, and feelings)

  • Negative effects on cognition and mood (eg, persistent distorted blame of self or others, inability to experience positive emotions)

  • Altered arousal and reactivity (eg, sleep difficulties, irritability, concentration problems)

Symptoms and signs reference

  • 1. Basile KC, Smith SG, Chen J, Zwald M: Chronic diseases, health conditions, and other impacts associated with rape victimization of U.S. women. J Interpers Violence 36; 23–24; 2021.

Evaluation of the Rape Victim

Goals of medical evaluation after rape are

  • Medical assessment and treatment of injuries and assessment, treatment, and prevention of pregnancy and STIs

  • Collection of forensic evidence

  • Psychologic evaluation

  • Recommendation of crisis intervention and psychologic support

If patients seek advice before medical evaluation, they are told not to throw out or change clothing, wash, shower, douche, brush their teeth, clip their fingernails, 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]). Some areas in the US have a sexual assault response team (SART), which includes members from health care, forensics, the local rape crisis center, law enforcement, and the prosecutor's office. 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. Patients may feel more comfortable with a clinician of the same sex; all patients should be asked about their preference before the examination. 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 evidence collection kit) is used to record legal evidence and medical findings (for typical elements in the form, see table Typical Examination for Alleged Rape Typical Examination for Alleged Rape 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.

Table

History and examination

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 reporting forms include most or all of these questions (see table Typical Examination for Alleged Rape 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.

Testing and evidence collection

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:

  • At 1 week: Gonorrhea, chlamydial infection, and trichomoniasis in patients who refused prophylactic treatment

  • At 2 weeks: Pregnancy

  • At 4 to 6 weeks: Syphilis and HIV infection

  • At 3 months: Syphilis, hepatitis, and HIV infection

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 Typical Examination for Alleged Rape ); 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

  • If available, semen

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.

Evaluation reference

Treatment of the Rape Victim

  • Psychologic support and/or crisis intervention

  • When indicated, postexposure hepatitis B and human papillomavirus (HPV) vaccination

  • Possibly HIV postexposure prophylaxis

  • Possibly emergency contraception

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.

Physical injuries are treated conservatively.

Prophylaxis for STIs as needed. Vaginal lacerations may require surgical repair.

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.

Prevention or treatment of infections

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

  • Ceftriaxone 500 mg IM in a single dose or for patients weighing ≥ 150 kg, 1 g of ceftriaxone (for gonorrhea and chlamydia infections) AND

  • Doxycycline 100 mg orally 2 times a day for 7 days (for chlamydial infection)

  • For females, metronidazole 500 mg orally twice a day for 7 days (for trichomoniasis and bacterial vaginosis)

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.

  • Anal penetration

  • Bleeding (assailant or victim)

  • Male-male rape

  • Rape by multiple assailants (eg, male victims in prisons)

  • Rape in areas with a high prevalence of HIV infection

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

Prevention of pregnancy

Emergency contraception Emergency Contraception Commonly used emergency contraception regimens include Insertion of a copper-bearing T380A IUD within 5 days of unprotected intercourse Insertion of a 52-mg levonorgestrel-releasing IUD, which... 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.

Treatment reference

  • 1. Welch J, Mason F: Rape and sexual assault. BMJ 334 (7604): 1154–1158, 2017. doi: 10.1136/bmj.39211.403970.BE

Key Points

  • Sexual assault is any type of sexual activity or contact that a person does not consent to.

  • Nongenital or genital injury, sexually transmitted infections, and pregnancy may occur.

  • In the short term, most patients experience fear, nightmares, sleep problems, anger, embarrassment, and other psychologic symptoms; although most patients eventually recover; some develop posttraumatic stress disorder (PTSD).

  • Explain the benefits of a rape evaluation, which the patient can consent to or decline; ask the patient's permission before each step of the evaluation, and explain what each step involves and why it is being done.

  • Check for injuries, test for pregnancy and sexually transmitted infections, collect evidence that can provide proof of rape (eg, smears of the buccal, vaginal, and rectal mucosa), and maintain chain of custody.

  • Provide psychologic support for the patient and the patient's family, provide prophylaxis for sexually transmitted infections, and offer emergency contraception.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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