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Rape is a violent crime, most often perpetrated by men against women. Largely because of the women's movement, popular misconceptions and attitudes toward rape and rape victims have been slowly changing. In addition, crisis intervention centers have developed better support systems and more sophisticated evaluation techniques to help victims of sexual assault.
To receive help at most rape intervention centers, a victim must report the assault to many people-police detectives, physicians, nurses, rape counselors-in addition to her immediate social circle of husband or lover, children, parents, and friends. Thus, the clinician must offer professional services with compassion and respect for the patient and remember that rape is ultimately an intensely personal crisis.
Although the long-term effects of rape need further study, insight-oriented psychotherapy can be a vital part of long-term recovery (Rose, 1986). This chapter reviews the various aspects of emergency care of the rape victim and discusses supportive psychological interventions.
When the patient’s chief complaint is sexual assault, obtain a history of the event through direct but sensitive questioning, but allow the woman to talk spontaneously about what happened. The patient may have either acute or delayed symptoms, depending on when the attack occurred. To provide adequate physical care, you will have to inquire about particular details of the attack (such as oral or anal penetration) if the victim does not provide them. Alternate between open- and close-ended questions. For example, if a woman enters the emergency service and says, "I was raped today. I feel like I'm going to die," your first question should be open-ended: "Can you tell me what happened, from beginning to end?" When events are not clear, ask close-ended questions: "Were you threatened with a weapon?" or "Were you forced to perform oral sex on the attacker?" Remain calm and empathetic when asking these questions. When the chief complaint includes suicidal thoughts, ask direct questions: "Are you thinking about ending your life right now?" or "Have you tried to kill yourself since this attack occurred?"
Occasionally, the history and mental status examination of a patient who complains of sexual assault clearly point to an acutely manic or paranoid psychosis. The history may be unreliable and erratic because of the patient's thought disorder. In these cases. treat the psychosis first and complete the routine protocol for rape victims when the patient is more coherent. Patients who are acutely psychotic and disorganized may be at higher risk for becoming victims of rape and other violent crimes. Between 70% and 80% of psychiatric inpatients have been victims of physical or sexual assault (Jacobson and Richardson, 1987). These patients may quickly incorporate the actual traumatic event into a paranoid delusional system (for example, ideas of persecution).
The patient may consciously conceal or unconsciously repress sexual trauma. Although a patient may come to a crisis center or outpatient psychotherapy session with symptoms of delayed posttraumatic stress disorder, she does not spontaneously reveal that she has been raped. Several cases of self-cutting have been reported as the primary symptom after rape (Greenspan and Samuel, 1989). As a result, you should routinely include sensitive questioning about the possibility of sexual assault as part of any emergency psychiatric interview. And because the rape victim may be a drug or alcohol abuser, you should ask all patients about substance abuse and order drug screens if appropriate.
Concentration and judgment may be somewhat impaired secondary to the victim's shock. Suicidal ideation, gestures, or attempts are more likely than homicidal or aggressive acts. Dissociative states may develop later. Prominent findings in the delayed stage include disorientation, confusion, derealization (severe feeling of detachment), and depersonalization.
Rape trauma syndrome, a variant of post-traumatic stress disorder, has acute and delayed stages. The acute stage begins within24 hours of the assault and may last for several weeks. Although rape victims may seek help during the acute stage, many victims report the attack weeks or months later. Psychological symptoms can range from numbness, disbelief, panic, severe anxiety, anger. self-blame, humiliation, and depression to outer calmness, compliance, glibness, and talkativeness.
The delayed stage usually begins several weeks after the assault and can persist for months or years. Symptoms include anxiety. nightmares, flashbacks, guilt, depression, anger, disinterest in sex. anorgasmia, and suicidal ideation. The intensity and duration of symptoms vary greatly among patients. Much depends on the woman's coping skills, social supports, and preassault level of functioning. Because the details and nature of the assault are of great importance, assess the extent of violence, the type of sexual attack, the number of attackers, and the availability of safety after the assault. This information can help you anticipate post-traumatic symptoms.
Many victims are threatened with another attack or with death if they report the rape. In these situations, continued reminders of the traumatic assault in the victim's everyday life complicate recovery.
Conduct a comprehensive and detailed physical examination of the victim, documenting locations and dimensions of all injuries-bruises, fractures, lacerations, scratches, and inflammation of soft tissue and mucosae. All rape victims must have a pelvic examination. A female nurse should stay in the room with the patient during the examination, especially if the examiner is male. As much as possible, avoid what has been called a "second rape" of the victim - potentially invasive and subjectively threatening aspects of the emergency department (ED) examination. (See Protocol for examining a rape victim, pages 190 and 191, for more detailed information on the examination.)
Appropriate laboratory tests are discussed in Protocol for examining a rape victim, pages 190 and 191.
The differential diagnosis for rape is not complex. Most rape victims enter the ED with a clearly stated chief complaint, which leaves few other diagnoses to rule out. Alternative diagnoses are delusional disorder (as part of schizophrenia, bipolar affective disorder, or a toxic psychosis) and dissociative disorder. Concurrent diagnoses of alcohol or substance abuse can occur.
The clinician should be supportive but not intrusive with the patient who has just been raped and should view the interaction with the rape victim as psychotherapeutic, from gathering the history to arranging follow-up care. When possible, interview the rape victim in a safe and quiet place. Recovery from the assault begins almost immediately. Facilitating and supporting this recovery is the responsibility of the physicians, nurses, and counselors in the ED.
Staff members should not pass judgment on a patient who reports a rape. A disapproving or negative attitude directly affects the victim's level of comfort in discussing the rape. More important, a judgmental or uncaring attitude may block the woman's natural expression of emotions or intensify her feelings of self-blame, guilt, and helplessness.
Familiarity with the typical range of responses to trauma can facilitate interpersonal interventions. For example, the question "Do you blame yourself for this attack?" can lead to a discussion of the patient's guilt and shame. Keep in mind that issues addressed in the first encounter cannot be resolved immediately, but discussing the problems openly sets the stage for continued work and offers the woman hope of gaining control over her reactions to the traumatic event. Avoid exploring areas that are neither relevant nor helpful to the woman. Questioning a rape victim about sexual fantasies or gathering a complete history of sexual partners is inappropriate during the initial interview. These issues can be covered later in the patient's recovery, if appropriate.
| Protocol for Examining a Rape Victim | |
| Most crisis centers have a medical protocol for clinicians who examine rape victims. This protocol outlines the details of the examination for medicolegal purposes, along with appropriate tests and treatments for sexually transmitted diseases and pregnancy. Whether victims should be screened for human immunodeficiency virus is debatable; the value of immediate testing has not been established. The standard protocol of Thomas Jefferson University Hospital in Philadelphia is presented here: | |
| · | A gynecologist (6 p.m. to midnight, 7 days a week) or the emergency medicine resident (all other times) should respond when a rape victim age 14 years or older arrives in the emergency department (ED). A pediatrician (8 a.m. to 5 p.m., Monday through Friday) or the emergency medicine resident (alt other times) should respond for children younger than age 14. The emergency medicine resident should examine mate rape victims age 14 or older. Consider hospitalizing a child if she would be placed in jeopardy by returning home. Sexual assault is a form of child abuse. |
| · | A registered nurse must be present during the examination and treatment to serve as a witness (preferably the support person, to maintain continuity). Police officers should not be present during the examination and treatment. |
| · | Obtain a gynecological history if appropriate. Document the physical examination on the history and sexual assault form and the ED form. Record pertinent medical history (last menstrual period, contraceptive use, presence of venereal disease) on the ED form. |
| · | Perform a general examination, documenting the patient's general physical appearance and demeanor, marks on her body or clothing, bleeding, and physical trauma. Record any physical trauma reported by the victim and any symptoms of emotional trauma. |
| · | Perform a vaginal examination, which is essential to determine injury. Use a non-lubricated, water-moistened speculum (a small speculum for a victim whose tissues are especially sensitive). Inspect the vulva for evidence of trauma and the cervix and vaginal walls for lacerations, contusions, or abrasions. Obtain appropriate specimens. Then perform a bimanual examination to determine the size of the uterus and ovaries. Note that a speculum examination may not always be necessary or appropriate. The examiner may choose to collect specimens with swabs or saline washes. For male victims, complete a full genital and anal examination. |
| · | Order appropriate laboratory tests, which can detect untoward consequences of sexual contact (sexually transmitted diseases, pregnancy) and provide evidence for possible assault charges. Using the department's rape kit, collect necessary specimens, which will be processed by the police crime laboratory. If the crime occurred in the last 7 days, relevant specimens include a blood sample; saliva sample; two swabs from the areas of alleged penetration (vagina, rectum, mouth), placed in a red-top tube; hair samples when they are obviously out of place (pubic hair forced into the vagina, hair in the pubic area of children, hair a different color from that of the patient); any extraneous fibers or particles (paint, wood, blood, semen), which should be placed on a sheet of dean paper, folded to hold the sample, put in an envelope, and sealed; and the victim's clothing, especially undergarments, if soiled, torn, or containing material that could be used as evidence. Seal all evidence with tape and keep it in the refrigerator until delivered to the police. Always test the patient for venereal disease regardless of when the assault occurred. Draw a blood sample for a rapid plasma reagin test, and obtain cultures from the cervical canal, throat, or rectum, as appropriate. Pregnancy testing can be done at the examiner's discretion. |
| · | Treat all life-threatening injuries first. All victims should receive preventive therapy against urethral, cervical, anal, and oral gonorrhea: 125 mg I.M. of ceftriaxone (Rocephin) in patients who weigh less than 100 Ib (45 kg) and 250 mg I.M. for those who weigh 100 Ib or more. If the patient is allergic to penicillin, 40 mg/kg of spectinomycin (Trobicin) I.M. (maximum dose, 2 g) should be given in a single dose. Both drugs must be followed by either 500 mg of tetracycline (Bristacycline) four times daily for 7 days or 100 mg of doxycycline (Vibramicin) twice daily for 7 days (adults only). Although pediatric victims can be treated prophylactically with either ceftriaxone or spectinomycin, the clinician should wait for positive culture results before initiating drug therapy. |
| Source: Zeccardi, 1988. Adapted courtesy of Thomas Jefferson University Hosptal. | |
If the rape victim is female and the perpetrator male, a female counselor should conduct the interview, if possible. In most EDs. a female nurse is present even when the examining physician is a woman, since the pelvic examination is potentially distressing. If the rape victim expresses a preference for a female physician, her request should be respected, if possible.
Most rape victims identify at least one person-husband, lover, parent, or friend—to whom they can turn for social support. The counselor should offer significant support to this person, especially by providing information about rape trauma syndrome. However, maintain confidentiality about the specifics of the sexual assault, and release no details without the patient's consent.
Before administering any medication to a rape victim, the clinician must obtain her informed consent. Minor tranquilizers are the most commonly used pharmacologic agents in the psychiatric emergency treatment of sexual assault. Psychotropic medications are rarely used. The primary indication for a minor tranquilizer is severe anxiety or panic that does not respond to supportive psychological intervention. Recommended doses are alprazolam (Xanax) 0.25 to 0.5 mg by mouth or lorazepam (Ativan) 1 to 2 mg by mouth. One dose is usually enough to make the patient feel calmer and more in control. When the patient has an underlying diagnosis of schizophrenia, bipolar affective illness, or another psychotic disorder, the clinician may need to administer a dose of the patient's standard neuroleptic medication. Neuroleptic agents should be given if the patient is agitated or hallucinating or has disorganized thoughts.
Educate the patient about the typical emotional responses to trauma (see "Mental status findings" above). Because a sense of isolation commonly accompanies the rape victim's panic and shock, learning that others have undergone the same experience can be reassuring. This premise is the basis for the follow-up support groups offered by many rape counseling centers.
Most rape victims can be allowed to return home after examination and treatment. Try to ensure that the patient has a supportive person at home, and refer the woman to an appropriate follow-up agency (medical clinic, rape counseling center, or psychiatric service).
Laws regarding notification of authorities vary from state to state. Most rape intervention centers have written protocols that detail these requirements. Clinicians and other staff members are obligated to notify the police of any injury that occurred as the result of a crime. In cases involving children, the clinician must make a full report to the child welfare division of the state government. A telephone hotline is usually available for this purpose.
Medical information about the sexual assault can be released only with the written consent of the patient or by a subpoena or court order. When recording the history, do not describe the events with the assumption that a rape has or has not taken place. Always refer to the sexual assault as "alleged," and clearly indicate descriptions or direct quotations from the patient as such. Medical personnel do not determine whether a crime has occurred; that determination is left to the judicial system.
The clinician and the crisis counselor are responsible for accurately describing their findings. When no one has witnessed the rape, the clinician's observations and recognition of trauma are the only corroborating evidence for a criminal investigation and trial. Careful notation of all signs of physical and sexual assault must be made in the medical record. The likelihood of medical personnel being subpoenaed by the court is lessened if medical documentation is thorough and complete.