> Table of Contents > Rape Crisis Syndrome
Rape Crisis Syndrome
Ravin V. Patel, MD
Dustin Creech, MD
image BASICS
DESCRIPTION
  • Definitions (legal definitions may vary from state to state)
    • Sexual contact: intentional touching of a person’s intimate parts (including thighs) or the clothing covering such areas, if it is construed as being for the purpose of sexual gratification
    • Sexual conduct: vaginal intercourse between a male and female, or anal intercourse, fellatio, or cunnilingus between persons, regardless of sex
    • Rape (which is a legal term, physician should use the phrase alleged sexual assault): any sexual penetration, however slight, using force or coercion against the person’s will
    • Sexual imposition: similar to rape but without penetration or the use of force (i.e., nonconsensual sexual contact, stalking)
    • Gross sexual imposition: nonconsensual sexual contact with the use of force
    • Corruption of a minor: sexual conduct by an individual age ≥18 years with an individual < 16 years of age
  • Most states have expanded rape statutes to include marital rape, date rape, and shield laws.
  • System(s) affected: nervous; reproductive; GI
EPIDEMIOLOGY
  • In the United States, 25% of women and 7.6% of men report being target of the definition of rape crisis syndrome listed above. The cost of this are estimated to exceed $5.8 billion annually.
  • Anyone can be sexually assaulted, but some populations are especially vulnerable.
    • Adolescents and young children
    • People with disabilities
    • Elderly
    • Low socio-economic status and homeless people
    • Sex workers
    • Those living in institutions/areas of conflict
  • Predominant age
    • The incidence of sexual assault peaks in those 16 to 19 years of age, with the mean occurring at 20 years of age
      • Adolescent sexual assault has a greater frequency of anogenital injuries.
  • Predominant sex: female > male
    • For males
      • 69% of male victims were first raped before age 18 years.
      • 41% of male victims were raped before age 12 years.
INCIDENCE
  • In the United States, approximately 1.5 million women and 834,700 men are sexually assaulted annually (1).
  • Estimated that only a fraction of sexual assaults are reported to law enforcement.
  • 18% of American women will be sexually assaulted during their lifetime (2).
    • Between 20% and 25% of females will experience rape/attempted rape during their college years.
  • 2-3% of American men will be sexually assaulted during their lifetime.
  • Most rape victims either know or have some acquaintance with their attacker.
RISK FACTORS
  • Chronologic age of adolescent and young adults 16 to 24 years incur sexual assault. Children living in household of sexual assault are increase risk of maltreatment and lifelong poor health.
  • Previous history of victimization (sexually or physically)
  • Alcohol consumption is estimated to be involved in 1/2 of sexual assault.
  • Illicit drug may also contribute to sexual assault.
GENERAL PREVENTION
  • The public health approach should include both prevention and avoidance of vulnerability factors and implementation of protective factors.
  • Females may benefit from assertiveness training and self-defense training.
  • U.S. Preventive Services Task Force found insufficient evidence to support general screening in all their patient (no evidence of harm in screening), but physician should discuss sexual assault and family violence with their patient in nonjudgement manner.
image DIAGNOSIS
  • In adults
    • History of sexual penetration
    • Sexual contact/conduct without consent and/or with the use of force
  • In children
    • Actual observation/suspicion of sexual penetration, sexual contact, or sexual conduct
    • Signs include evidence of the use of force and/or evidence of sexual contact (e.g., presence of semen and/or blood).
PHYSICAL EXAM
  • Use of drawings and/or photographs is encouraged; note that some states require specific forms for documenting physical exam.
  • Document all signs of trauma/unusual marks.
  • Document mental status/emotional state.
  • Use UV light (Wood lamp) to detect seminal stains on clothing/skin.
  • Obtaining the patient’s consent at each step of examination helps the patient regain a sense of control.
DIFFERENTIAL DIAGNOSIS
Consenting sex among adults
DIAGNOSTIC TESTS & INTERPRETATION
  • In females, obtain a serum or urine pregnancy test.
  • Record results of wet mount, screening for vaginitis, but also note the presence/absence of sperm and, if present, whether it is motile/immotile.
  • Drug/alcohol testing as indicated by history and/or physical findings
image TREATMENT
GENERAL MEASURES
  • Providing health care to victims of sexual assault/abuse requires special sensitivity and privacy.
  • All such cases must be reported immediately to the appropriate law enforcement agency.
  • With the victim’s permission, enlist the help of personnel from local support agencies (e.g., rape crisis center). When available, use of in-house social services is extremely helpful to victim and family.
  • SANE programs have been shown to be beneficial, especially in large cities and metropolitan areas with multiple emergency departments of varying capability and staff training/experience.
  • Give sedation and tetanus prophylaxis when indicated.
  • Discuss possible pregnancy and pregnancy termination with the victim. If hospital policy precludes such as discussion, then information about this option should be offered to the victim via follow-up mechanisms.
  • Discuss suspected HIV and hepatitis B exposure and testing with the victim in accordance with hospital, regional, and state policies/protocols. The initial HIV test should be completed within 7 days of the suspected exposure.
MEDICATION
First Line
  • Controversy exists regarding empiric antibiotic prophylaxis for victims of sexual assault. However, the Centers for Disease Control and Prevention (CDC) recommends empiric antibiotic prophylaxis of potential sexually transmitted infections (specifically, gonorrhea, chlamydia, trichomoniasis, and potentially syphilis), as many patients will not return for a follow-up visit and many patients prefer immediate treatment (5)[C].
  • Cultures are not required before initiating treatment but can be considered as part of routine evidence collection.
  • Gonorrhea: ceftriaxone 250 mg IM once. Note: Be aware that drug resistance is on the rise in several major cities. Quinolones are no longer recommended for treatment of gonorrhea.
  • Chlamydia: azithromycin 1 g PO single dose, or doxycycline 100 mg PO BID for 7 days, or erythromycin base 500 mg PO QID for 7 days, or erythromycin ethylsuccinate 800 mg PO QID for 7 days
  • Syphilis: benzathine penicillin G 2 to 4 million units IM once, or doxycycline 100 mg PO BID for 14 days.
    P.895

    Some suggest ceftriaxone 1 g/day, either IM/IV, for 8 to 10 days, but treatment failures have been reported in several geographic areas.
  • Trichomoniasis and bacterial vaginosis, if present (if cultures/wet mount were collected): metronidazole 2 g PO once, or metronidazole 500 mg PO BID for 7 days (consider single dose to maximize compliance), or metronidazole gel 0.75% 1 full applicator (5 g) intravaginally every day for 5 days; or clindamycin cream 2% 1 full applicator (5 g) intravaginally at bedtime for 7 days (considered less efficacious than PO metronidazole)
  • If pregnancy prophylaxis is indicated, use levonorgestrel 1.5 mg once (Plan B, progestin-only), efficacious for up to 5 days after the incident.
    • Levonorgestrel alone has proved more effective than the Yuzpe regimen, a method of emergency contraception.
    • Alternatively, ethinyl estradiol/levonorgestrel (Yuzpe) 100 &mgr;g/0.5 mg once and repeated in 12 hours can be used.
    • Alternatively, ulipristal acetate (Ella) 30 &mgr;g once can be used.
    • Alternatively, a copper intrauterine device can be inserted up to 5 days after the earliest predicted date of ovulation in that cycle (6)[C].
  • HIV: Currently, there is a low likelihood of HIV transmittance, but the CDC still recommends postexposure prophylaxis (PEP) for victims of sexual assault. Regimen is PEP for 3 to 7 days, with short-term follow-up for further counseling, with a specialist familiar with PEP regimens.
    • Most effective if started within 4 hours and could reduce transmission by as much as 80%; unlikely to be beneficial if started after 72 hours.
  • Hepatitis B: if prevalent in area or assailant known to be high risk: hepatitis B immunoglobulin 0.06 mL/kg IM, single dose, and initiate 3-dose hepatitis B virus immunization series. No treatment if the victim has had a complete hepatitis B vaccine series, with documented levels of immunity (7)[C].
Second Line
Pregnancy Considerations
Conduct baseline pregnancy test; discuss pregnancy prevention and termination with patient.
Pediatric Considerations
Assure the child that she or he is a good person and was not the cause of the incident.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Contact appropriate social services agency.
  • Most adult victims can be treated as outpatients, unless associated trauma (physical/mental) requires admission.
  • Most pediatric sexual assault/abuse victims will require admission/outside placement until appropriate social agency can evaluate home environment (8)[C].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Patient should be seen in 7 to 10 days for follow-up care, including pregnancy testing and counseling.
  • Close exam for vaginitis and treatment if necessary
  • Follow-up test for gonorrhea should occur in 1 to 2 weeks.
  • Follow-up testing for syphilis, HIV, and hepatitis B should occur at 6 weeks, 3 months, and 6 months.
  • Provide telephone numbers of counseling agency(ies) that can provide counseling/legal services to the patient.
  • Strongly consider SANE, if available (9)[C].
PATIENT EDUCATION
  • Local rape crisis support organizations
  • National Sexual Violence Resource Center, 123 Enola Drive, Enola, PA 17025; (877) 739-3895; www.nsvrc.org
  • National Domestic Violence Hotline at (800) 799-SAFE(7233) or TTY (800) 787-3224 or www.thehotline.org
PROGNOSIS
  • Acute phase (usually 1 to 3 weeks following rape): shaking, pain, wound healing, mood swings, appetite loss, crying. Also feelings of grief, shame, anger, fear, revenge, or guilt
  • Late/chronic phase (also called “reorganization”): Female victim may develop fear of intercourse, fear of men, anxiety or increase discomfort during Pap smears, nightmares, sleep disorders, daytime flashbacks, fear of being alone, loss of self-esteem, anxiety, depression, posttraumatic stress syndrome, and somatic complaints (e.g., nonspecific abdominal pain).
  • Recovery may be prolonged. Patients who are able to talk about their feelings seem to have a faster recovery. It is unclear if pharmaco- or psychotherapy results in better outcomes.
REFERENCES
1. Cronholm PF, Fogarty CT, Ambuel B, et al. Intimate partner violence. Am Fam Physician. 2011;83(10):1165-1172.
2. Tjaden P, Thoennes N. Extent, Nature, and Consequences of Rape Victimization: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice and the Centers for Disease Control and Prevention; 2006.
3. Linden JA. Clinical practice. Care of the adult patient after sexual assault. N Engl J Med. 2011;365(9):834-841.
4. U.S. Department of Justice, Office on Violence Against Women. A National Protocol for Sexual Assault Medical Forensic Examinations (Adults/Adolescents). 2nd ed. Washington, DC: U.S. Department of Justice; 2013.
5. Workowski KA, Berman S; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.
6. Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev. 2012;(8):CD001324.
7. Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part II: immunization of adults. MMWR Recomm Rep. 2006;55(RR-16):1-33; quiz CE1-CE4.
8. DeVore HK, Sachs CJ. Sexual assault. Emerg Med Clin North Am. 2011;29(3):605-620.
9. ACOG educational bulletin. Sexual assault. Number 242, November 1997 (replaces no. 172, September 1992). American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1998;60(3):297-304.
Additional Reading
&NA;
  • Centers for Disease Control and Prevention. Sexual Violence: Facts at a Glance. Atlanta, GA: Centers for Disease Control and Prevention; 2012.
  • National Consensus Guidelines of Identifying and Responding to Domestic Violence. San Franscisco, CA: Family Voilence Prevention Fund; 2002.
See Also
&NA;
Chlamydia Infection (Sexually Transmitted); Gonococcal Infections; Hepatitis B; Hepatitis C; HIV/AIDS; Posttraumatic Stress Disorder; Syphilis
Codes
&NA;
ICD10
  • T74.21XA Adult sexual abuse, confirmed, initial encounter
  • T74.22XA Child sexual abuse, confirmed, initial encounter
  • Z04.41 Encounter for exam and obs following alleged adult rape
Clinical Pearls
&NA;
  • Rape is a legal term, and the examining physician is encouraged to use terminology such as alleged rape or alleged sexual conduct.
  • Marital rape is a federal offense in all 50 states and the District of Columbia; in some states, also applies to unmarried cohabiting couples.
  • Because “consent defense” is common, documentation of evidence supporting the use of force or the administration of drugs/alcohol is imperative.
  • Use of a protocol is encouraged to assure every victim a uniform, comprehensive evaluation, regardless of the expertise of the examiner. The protocol must ensure that all evidence is properly collected and labeled, chain of custody is maintained, and the evidence is sent to the most appropriate forensic laboratory.
  • All medical records must be well documented and legible.
  • All medical personnel must be willing and able to testify on behalf of the patient.
The views expressed in this chapter are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government. Opinions, interpretations, conclusions, and recommendations herein are those of the author and are not necessarily endorsed by the U.S. Army.