Protocols for managing the victims of sexual assault

As doctors, we will undoubted meet people who have been sexually assaulted and this requires specialist care. Emma Wall and Jan Welch explain how to manage victims of rape

Rape is common and victims may present in any number of medical settings (box 1). As well as victims' need for good medical care, evidence collection should be considered so that rapists can be identified and convicted. Throughout most of the United Kingdom, services for people who have been sexually assaulted are uncoordinated, of poor quality, and conviction rates are low. This is beginning to change as more specialist sexual assault referral centres are developed, which can provide care tailored to individual needs and concerns (box 2).

The attitudes of doctors have been found strongly to influence outcomes,^w8 indicating that the management of those who have been raped should be covered during medical training. A non-judgmental stance is essential with optimal treatment enabling the victim to regain control and be involved in decisions regarding their care. By considering forensic, medical, and psychosocial aspects of care separately, the care of complainants of rape may appear less daunting.

Forensic examination

Only a minority of victims of rape report to the police. They may be more willing to do so if supported, or alternatively they may only wish to have their healthcare needs met. Good note keeping is essential in all cases as it may be needed for subsequent reports, for example for applications for criminal injuries compensation. Pending police involvement, early evidence kits can be used to collect mouth samples (for the assailant's DNA) and urine (for drugs) and other potential evidence such as clothing should be retained.

In the United Kingdom, of the 20% of rapes which are reported to the police, only about a fifth result in a trial and 7.5% in a conviction.^{w9 w10} Since DNA evidence on or in the body degrades in 2-10 days,^w11 prompt forensic examination should be encouraged to aid later prosecution and should precede medical care beyond what is urgently required.

The person examining the complainant should be a clinician with specialist training and you should check whether they want to see a male or female doctor. The doctor should document details of the assault, sexual history, and all injuries using body diagrams. Samples for DNA and other material such as hairs should be taken from relevant skin areas and orifices--these may be used to identify the perpetrator and prove sexual contact, although this is not necessary for conviction. Drugs are implicated in an increasing number of rapes and a urine sample can be sent for toxicological analysis when this is suspected. Depending on the nature of the assault, complainants should be advised not to eat, drink, wash, or urinate until samples have been taken. Samples are usually given to the police to submit for forensic science analysis. The care of those younger than 16 should involve a paediatrician and child protection team.

Medical management

Complainants referred by the police are already likely to have spent time recalling the event and having a forensic examination, which a doctor should bear in mind in their subsequent care. Careful questioning should elicit the time and place of the assault, orifices involved, whether ejaculation occurred, and current symptoms or injuries. Additional details required include any sexual activity before and since the incident, and a menstrual and contraceptive history. Pelvic examination should only be carried out if necessary, and by someone who is specially trained to do so.

Physical injuries

Physical violence occurs in about half of reported rapes,^w12 although complainants may be unable to give an accurate indication of injuries because of the emotional impact of the assault. Non-genital injuries are often abrasions or lacerations--doctors should consider giving tetanus prophylaxis--or fractures to the head, neck, or extremities. Less than 5% of complainants of sexual assault need hospital admission for treatment.^w13 Genital injuries are found in 24-53%^{w2 w5 w12 w14}; but most require no specific treatment. In about a fifth of women no injuries are found--but this does not mean that a rape has not occurred.^w14

Pregnancy and contraception following rape

After a rape, an estimated 5% of women of reproductive age become pregnant,^w15 and so consideration of emergency contraception is crucial. Hormonal emergency contraception (levonorgestrel) is most effective the sooner it is given, although may be of value up to five days after unprotected sex.^{w16 w17} An intrauterine device is even more effective although perhaps less acceptable, and may be inserted within five days of the earliest expected date of ovulation--doctors should consider antibiotic cover with this.^w17

BILDERBERG/PHOTONICA

Sexually transmitted infections

Sexually transmitted infections are found in between 4% and 56% of complainants of rape,^w18-w20 and it is unusual to find multiple infections. Although many STIs will be pre-existing, a significant number will result from the assault.^w20-w22

Sexually transmitted infections resulting from rape reflect those prevalent locally such as chlamydia, gonorrhoea, and trichomoniasis. Complainants should be encouraged to attend for screening for sexually transmitted infections about two weeks after the assault, allowing for the incubation period of newly acquired bacterial infections. Those declining examination or unlikely to return for follow up should be offered prophylactic antibiotics to cover chlamydia and gonorrhoea, for example with single doses of azithromycin and cefixime.

Screening should include swabs and cultures for gonorrhoea and chlamydia from all sites of penetration and vaginal samples for trichomoniasis; baseline syphilis serology may be tested with a further test at three months to exclude infection as a result of the assault. Doctors should also take serum and save it from those who are to be followed up for viral hepatitis and HIV. Nucleic acid amplification tests are increasingly used for chlamydia and gonorrhoea, although their forensic use is not yet established, they are likely to be more acceptable since they can be performed on urine or perineal swabs. If amplification tests are used, positive results should be confirmed.

Infection with hepatitis B after rape is uncommon, however doctors should consider giving vaccination especially when the risk appears to be high--it may be effective up to six weeks after the assault.

Contracting HIV from rape is unlikely in areas with low prevalence, such as the United Kingdom, but the risks are higher if there has been genital trauma including loss of virginity, anal rape, or multiple assailants, especially if assailants are from high prevalence areas or have other risk factors, such as being gay or bisexual men or injecting drug users. Victims considered to be at significant risk should be offered post-exposure prophylaxis following the same guidelines as for occupational exposure.^{w23 w24} Testing for viral hepatitis and HIV may be carried out at three to six months after pre-test counselling. If an infection is found, a further test on the baseline serum saved will clarify the timing of acquisition.

Psychosocial care

Victims of sexual assault show various emotions. They may be expressive and tearful, quiet and controlled, intoxicated, shocked, or in denial.^{w26 w27} In these circumstances, a safe and supportive environment is essential. However, formal counselling is inappropriate and in those self referring may discredit future statements should police involvement occur later.

Other problems include anxiety, depression, and sexual and relationship problems.^w27-w30 Individuals who report greater social support tend to have lower levels of psychological morbidity, whereas poorer adjustment is found in those who try to hide the assault from family or partners, and those who have previously been sexually victimised.^{w18 w30--w33}

At the time of presentation social circumstances, including personal safety and support, should be assessed, with intervention offered as necessary. Written information should be provided regarding both medical and psychosocial follow up. The complainant's general practitioner is often able to provide invaluable medical care and support to those who have been sexually assaulted, including referral for counselling. Some people will decline further services, while others may not wish to access them until much later, and these wishes must be respected

Emma Wall fourth year medical student, Guy's King's, and St Thomas's School of Medicine, London
Email: emma.wall@kcl.ac.uk

Jan Welch clinical director, The Haven Camberwell, King's College Hospital, London
Email: jan.welch@kingsch.nhs.uk


studentBMJ 2004;12:177-220 May ISSN 0966-6494

1. Home Office. Protecting the public. www.protectingthepublic.homeoffice.gov.uk/PTP_Final.pdf (accessed 25th February 2004).
2. Bowyer L, Dalton ME. Female victims of rape and their genital injuries. British Journal of Obstetrics and Gynaecology 1997;104:617-620.
3. Petter LM, Whitehill DL. Management of female sexual assault. American Family Physician 1998;58:920-6.
4. Magid DJ, Houry D, Koepsell TD, Ziller A, Soules MR, Jenny C. The epidemiology of female rape victims who seek immediate medical care: Temporal trends in the incidence of sexual assault and acquaintance rape. Journal of Interpersonal Violence 2004;19:3-12.
5. Grossin C, Sibille I, Lorin de la Grandmaison G, Banasr A, Brion F, Durigon M. Analysis of 418 cases of sexual assault. Forensic Science International 2003;131:125-130.
6. The Haven. Report with monthly figures & charts: May 2000-2003.
7. King MB. Male rape. British Medical Journal 1990;301:1345-6.
8. Popiel DA, Susskind EC. The impact of the rape: social support as the moderator of stress. American Journal of Community Psychology. American Journal of Community Psychology 1985;13:645-676.
9. Myhill A, Allen J. Rape and sexual assault of women: Findings from the British Crime Survey. London, Home Office. www.homeoffice.gov.uk/rds/pdfs2/r159.pdf (accessed 25th February 2004).
10. Her Majesty’s Crown Prosecution Service Inspectorate. A report on the joint inspection into the investigation and prosecution of cases involving allegations of rape. Her Majesty’s Inspectorate of Constabulary. April 2002. www.homeoffice.gov.uk/hmic/CPSI_HMIC_Rape_Thematic.pdf
11. Mein JK, Palmer CM, Shand MC, Templeton DJ, Parekh V, Mobbs M, Haig K, Huffam SE, Young L. Management of acute adult sexual assault. Medical Journal of Australia 2003;178:226-30.
12. Kerr E, Cottee C, Chowdhury R, Jawad R, Welch J. The Haven: A pilot referral centre in London for cases of serious sexual assault. British Journal of Obstetrics and Gynaecology 2003;110:267-71.
13. Knox I. Sexual Assault. In: P Cameron, G Jelinek, A Kelly, L Murray, J Heyworth, Textbook of Adult Emergency Medicine. 1st ed. London: Churchill Livingstone, 2000. Pp 525-530.
14. Riggs N, Houry D, Long G, Markovchick V, Feldhaus KM. Analysis of 1076 cases of sexual assault. Annals of Emergency Medicine 2000;35:358-62.
15. Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: Estimates and descriptive statistics from a national sample of women. American Journal of Obstetrics and Gynecology 1996;175:320-4.
16. Rodrigues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected intercourse. American Journal of Obstetrics and Gynecology 2001;184:531-7.
17. Faculty of Family Planning and Reproductive Healthcare (FFPRHC). Emergency Contraception (April 2003) (updated June 2003). www.ffprhc.org.uk/clinical_effect/EC%20revised%20PDF%2019.06.03.pdf (accessed 25th February 2004).
18. Harrison JM, Murphy SM. A care package for managing female sexual assault in genitourinary medicine. International Journal of STD & AIDS 1999;10:283-9.
19. Lamba H, Murphy AM. Sexual assault and sexually transmitted infections: an updated review. International Journal of STD & AIDS 2000;11:487-91.
20. Jenny C, Hooton TM, Bowers A, Copass MK, Krieger J, Hillier SL, Keviat N, Corey L, Stamm WE, Holmes KK. Sexually transmitted diseases in victims of rape. New England Journal of Medicine 1990;322:713-6.
21. Clinical Effectiveness Group (Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). 2001 National Guidelines on the Management of Adult Victims of Sexual Assault. www.bashh.org/guidelines/sexassault%2006%2001.pdf (accessed 27th February 2004).
22. Blackmore CA, Keegan RA, Cates W Jr. Diagnosis and treatment of sexually transmitted diseases in rape victims. Reviews of infectious diseases 1982;4 Supplement 877-82.
23. Limb S, Kawsar M, Forster GE. HIV post-exposure prophylaxis after sexual assault: the experience of a sexual assault service in London. International Journal of STD & AIDS 2002;13:602-5.
24. HIV Post-Exposure Prophylaxis: Guidance from the UK Chief Medical Officer’s Expert Advisory Group on AIDS, Department of Health, July 2000.
25. Rothbaum BO, Foa EB, Murdock T, Riggs DS, Walsh W. A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress 1992;5:455-75.
26. Ullman SE, Filipas HH. Predictors of PTSD symptom severity and social reactions in sexual assault victims. Journal of Traumatic Stress 2001;14:369-89.
27. Moscarello R. Psychological management of victims of sexual assault. Canadian Journal of Psychiatry 1990;35:25-30.
28. Rose DS. Worse than death: psychodynamics of rape victims and their need for psychotherapy. American Journal of Psychiatry 143;817-24.
29. Schwartz IL. Sexual violence against women: prevalence, consequences, societal factors and prevention. American Journal of Preventative Medicine 1991;7:479-89.
30. Santiago JM, McCall-Perez F, Gorcey M, Beigel A. Long-term psychological effects of rape in 35 rape victims. American Journal of Psychiatry 1985;142:1338-40.
31. Sales E, Baum M, Shore B. Victim readjustment following assault. Journal of Social Issues 1984;40:117-36.
32. Filipas HH, Ullman SE. Social reactions to sexual assault victims from various support sources. Violence and Victims 2001;16:673-92.
33. Frank E, Anderson BP. Psychiatric disorders in rape victims: Past history and Current Symptomatology. Comprehensive Psychiatry 1989;28:77-85.