877 SEXUAL ASSAULT (RAPE) The legal definition of rape varies from state to state, but for med- ical purposes, rape is physical assault or penetration of the geni- tal, oral, or anal cavities by the assailant’s body or foreign object with force or without consent of the victim. Thus, in medical envi- ronments, rape is better termed sexual assault. Sexual assault is perpetrated primarily against women or children. Far fewer rape victims are males. Rape is increasing, especially the number of eld- erly victims. Although it is a felony and the perpetrator is known to the victim in 80% of cases, only 20% of rapes are reported to the police. The relative lifetime risk that a woman will be raped is over 15%. Most rapes occur in the victim’s home (50%) or neigh- borhood (80%). Rape is perpetrated by men ,25 years old in 45% of cases. Many rapists have serious psychologic or sociologic problems and rape to terrify, humiliate, and degrade rather than to achieve sexual grat- ification (as evidenced by the high rate of nonejaculation). The av- erage rapist has committed many rapes before being apprehended. Rape can be divided into three categories: power rape (Ͼ50%), anger rape (40%), and sadistic rape (5%). Power rape is usually premeditated. Included in this category are multiple assailant rapes and date rape. The latter may involve the use of alcohol or the drug flunitrazepam (Rohypnol). Rohyp- nol is readily available as a “street drug” and affects the woman’s ability to anticipate or ward off an attack. Additionally, there is some amnestic effect. The perpetrator is often a young male who wants to show his dominance over the victim, occasionally resort- ing to kidnap and multiple assaults. Serious physical injury of the victim is not typical, but is more likely with multiple assailant rapes. 32 SEXUAL AND DOMESTIC ASSAULT CHAPTER Copyright 2001 The McGraw-Hill Companies. Click Here for Terms of Use. BENSON & PERNOLL’S 878 HANDBOOK OF OBSTETRICS AND GYNECOLOGY Anger rape is not usually premeditated and is often on impulse, but the victim is more likely to be injured than in power rape. The victim is subject to the assailant’s rage and may receive threats of death if the crime is reported. Sadistic rape frequently results in death or serious injury. The crime is most often premeditated, and torture or mutilation may en- sue. Sadistic rape assailants are more likely to be psychotic than other rapists and often have a history of abuse of a wife or child. The victim’s most common response during the attack is to sur- vive. Many do not fight for fear of being killed or seriously injured. Lack of resistance may lead to later guilt feelings because they did not try to protect themselves. Disorientation, isolation, anguish, and fear of a later attack are common reactions of victims. During med- ical evaluation and treatment, the victim may be reluctant to talk and try to establish self-control by appearing detached and calm. DIAGNOSIS Because the examining physician is a potential trial witness, the chart should include “findings consistent with the history obtained” or “alleged assault” rather than “rape,” which is a legal conclusion. Legally and medically, it is crucial to record the site, type, and ex- tent of the assault; the degree of physical injury; the risk of preg- nancy and possible acquisition of STD; and the treatment adminis- tered. Emotional aspects of the assault must be addressed because emotional trauma can be devastating, regardless of the degree of physical injury. Be empathetic. Begin with a statement such as, “This is a ter- rible thing that has happened to you. I want to help.” Medical per- sonnel should carefully avoid further emotional trauma to the rape victim. Show respect, support, and concern. Be aware of the im- pact of talking to co-workers. If the victim hears herself referred to as “the rape case in treatment room 1,” she will feel even more de- graded and shamed. HISTORY AND PHYSICAL EXAMINATION A brief gynecologic history, as well as full details of the assault, should be recorded. Activities between the assault and examination should be noted (e.g., bathing, douching, defecation, voiding, drink- ing, and eating). Because a meticulous pelvic examination is required, anesthe- sia may be required to enable patient cooperation. With witnesses present (and named in the records), inspect the perineum and vulva for abrasions, ecchymoses, and lacerations. Over 90% of victims will have trauma at one or more of four locations: posterior fourchette, labia minora, hymen, and fossa navicularis. Tears oc- cur most frequently on the posterior fourchette and fossa. The labia most often evidence abrasions and ecchymoses are most often seen on the hymen. Ideally, photographs of all external injuries should be taken, ac- companied by a written description and location of each. An ultra- violet or Wood’s lamp (fluorescence) should be used to check the patient and her clothing for semen. Positive areas should be blot- ted with saline-moistened filter paper, labeled, and packaged sepa- rately. Pubic hair should be combed, and both the comb and mate- rial obtained should be packaged together. Pubic hair cuttings should be obtained, as well as scrapings from under the fingernails. Each specimen should be packaged separately and labeled with source, patient’s name, and date. All assembled items should be sealed individually, then sealed in a large container to verify that they were unaltered during transfer to the law enforcement agency. The person who accepts the evidence should sign for the material, and this transfer should become part of the chart. In brief, the record should reflect the chain of evidence. The vaginal speculum should be moistened with saline only, and careful inspection of the vagina should be performed. Saline- moistened cotton swabs may be used to obtain fluid from the vagi- nal pool and the endocervix and placed in labeled, corked sterile glass tubes for culture for Neisseria gonorrhoeae. The same fluid should be applied to glass slides and air-dried but not fixed. Next, deposit 2 mL of saline in the vaginal vault, and with aspiration, search for motile sperm (often motile even 4–6 h after ejaculation). A cytologic (Pap) smear should be performed to show sperm if present. If the mouth or anus was invaded, similar cultures should be obtained. Blood should be drawn for VDRL and blood type. HIV, as well as hepatitis (B,C) testing at this time and later should be offered. A pregnancy test is advisable if the patient may have be- come pregnant during the assault. Proper labeling of all samples is essential. TREATMENT Treatment centers on treatment of physical injuries and prevention of STDs and pregnancy, together with the psychologic problems of the patient. Physical injuries should be treated as indicated. For prophy- laxis against STD (gonorrhea, syphilis, Trichomonas, Candida, and CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 879 BENSON & PERNOLL’S 880 HANDBOOK OF OBSTETRICS AND GYNECOLOGY bacterial vaginosis), follow standard treatment protocols. Tetanus prophylaxis is suggested for possibly contaminated external injury. Prevention of pregnancy should be discussed if pertinent. Endocrine postcoital pregnancy prophylaxis is effective if admin- istered Ͻ72 h after the assault, but before hormonal therapy is ini- tiated, one must determine whether or not the woman is pregnant. Several hormonal regimens are effective (i.e., ethinyl estradiol 50 m g and norgestrel 0.5 m g, 2 tablets at examination and 2 tablets 12 h later, is effective and has few side effects). Ethinyl estradiol 5 mg PO daily for 5 days also is effective, but antiemetics should be given also because 80%–90% will be significantly nauseated. Initiate follow-up emotional counseling and support of the victim. PROGNOSIS Physical recovery almost always precedes emotional recovery. Some women and children never fully recover emotionally. The acute phase reaction lasting days or weeks includes initial agitation or surprising calmness, followed by somatic complaints of sleep disturbances, nightmares, nausea, headache, or muscu- loskeletal pain (from tension). Emotional labiality is common, fluc- tuating from fear and guilt to anger and desire for revenge. Inabil- ity to concentrate and easy startle and fear reactions are frequent. Because a rape affects the attitude of friends and family as well as the victim, unexpected changes in interpersonal relationships are not unusual. The long-term reaction may be a permanent behavior modifi- cation of the victim. Changing jobs, home, telephone number, and city is typical. Some victims will fear isolation, and others will fear men or crowds. Sleep disturbances may persist. Reestablishing nor- mal sexual responses is difficult for 50% of victims. This negative effect is more pronounced in women who have never been sexu- ally active. Victims of sexual assault have an increased likelihood of substance abuse, suicide, neurosis, and psychosis. CHILD SEXUAL ABUSE In the case of children who are suspected of being victims of sex- ual abuse, written informed consent (witnessed) must be obtained from the child’s legal guardian, giving permission for examination, collection of evidentiary samples, photographs, release of informa- tion to the appropriate authorities, and treatment. The history should be obtained from the child, if possible, and recorded in the child’s own words. Note the type of injury sustained and who is the alleged perpetrator. The child’s behavior should be carefully detailed, as well as composure, mental state, and his or her responses. The examination should follow the techniques outlined in Chap- ter 18, with the addition of an ultraviolet (Wood’s lamp) examina- tion for semen on the skin and clothing. Collection of foreign ma- terials (e.g., hair, sand, grass) is essential with proper labeling as to site of removal. Fingernail scrapings should be obtained. Semen stains should be sampled in the same manner as with adult victims. Vaginal fluid should be obtained using sterile moistened cotton swabs for culture, wet preparation, cytology, and acid phosphatase determination. Cultures of the pharynx, anus, vagina, and urethra should be taken regardless of history. All specimens must be indi- vidually labeled, sealed, and stored in the same meticulous manner as with adult sexual assault to ensure a proper chain of evidence admissible in court. In suspected child sexual abuse, the local child advocacy or pro- tection agency should be contacted for temporary placement when a parent is suspected of sexual molestation until further investiga- tion can be effected. DOMESTIC VIOLENCE Violence against women affects at least 2–4 million women per year in the United States. This incidence of domestic violence is higher than the combined injuries from vehicular accidents, muggings, and rapes (by unknown assailants). One in ten women seen in emer- gency rooms (for any cause) are a victim of domestic abuse. Twenty- five percent of women who attempt suicide have a history of do- mestic violence. Spousal/partner abuse is defined as intentional violent or controlling behavior by someone who has been intimate with the victim and may or may not reside in the same home. Coercive behaviors take many forms and often include more than one of the following: sexual assault, physical assault, threatened physical assault, forced social isolation, psychological abuse (e.g., intimidation), threats or privilege removal, economic manipulation, and using children to manipulate. The abused woman may go through several phases. Initially, she may respond to abuse by increasing efforts to make the rela- tionship work and to prevent future abuse. Different strategies are often attempted to appease her partner, but eventually the futility of these efforts becomes apparent. At that point, she may begin to CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 881 BENSON & PERNOLL’S 882 HANDBOOK OF OBSTETRICS AND GYNECOLOGY tolerate the abuse, feeling partially responsible and grasping at the positive aspects of the relationship. The woman may cautiously seek outside assistance, but does not want to affect her partner’s social status, fearing for her safety or even simply feeling ashamed or hu- miliated that she is in this situation. Eventually, the woman realizes that she truly does not deserve the abuse she is receiving. Con- comitantly, she often realizes that she is in danger. This phase is often marked by her leaving and the returning to her partner sev- eral times. She may consider suicide or death of the abuser. At this time, she may be most receptive to proposed assistance. To recover, she must eventually maintain her separation from the abuser. Men who batter women may have been abused themselves as children or had male role models who were hostile to women. They may have not been raised in a loving or nurturing environment and possibly were exposed to alcoholism, racism, and oppressive behaviors as the norm. Most abusers blame the victim for making them angry enough to abuse. It is not unusual for the abuser to be contrite immediately after the violent episode and promise that it will not happen again. Unfortunately, the promise is rarely kept and the time periods of loving and nonviolence are ever more com- pressed between escalating episodes of abuse. Partners of alco- holics have almost a 50% risk of abuse. The astute health care provider looks for clinical clues of do- mestic violence in all female patients. One in seven women seen for general medical care in office practices have an abuse history. Often complaints are very vague and include: chronic pain, sleep and appetite disturbances, chronic headaches, fatigue, abdominal complaints, gynecological complaints (i.e., frequent vaginal and uri- nary infections, dyspareunia, and pelvic pain), panic or anxiety at- tacks, depression, and requests for tranquilizers or pain medication. Physical clues include multiple bruises in various stages of healing, repeated injuries, numerous injuries at multiple sites, contusions, abrasions, sprains, lacerations, and fractures. The extent of the in- jury often seems implausible given the woman’s explanation of how the injury occurred. The pregnant woman may be at increased risk for abuse. Commonly, the breasts, abdomen, and genital area are injured. Late or sporadic prenatal care may be a clue as well as “spontaneous” abortions and preterm labor. Short intervals between pregnancy and unintended or unwanted pregnancy increase the risk of domestic violence. Clues to domestic violence may also come from the woman’s partner. For example, suspicion should occur if the woman’s partner insists upon being present for the clinical visit, answers the questions directed at her, and minimizes any injuries seen. The patient may be reluctant to speak in front of her partner or blame herself for his outbursts of violence. Although medical providers for women should be in the best position to recognize signs of domestic abuse, they often fail to make inquiries or intervene on behalf of their patient. Simply ask- ing the question about domestic abuse causes discomfort for sev- eral reasons: fear of offending the patient, feeling powerless to help, frustration when the patient does not accept recommendations and change her situation, the fear that it will take up too much office time to address the issues fully, and the mistaken belief that it is not a common problem. The following series of questions from Salber and Taliaferro’s The Physicians Guide to Domestic Violence can be incorporated into a written health assessment. SCREENING QUESTIONS FOR DOMESTIC VIOLENCE ● Are you in a relationship in which you have been physically hurt? ● Have you ever been physically hurt in an intimate rela- tionship? ● Are you (have you ever been) in a relationship in which you felt you were treated badly? In what ways? ● Has your partner ever threatened to harm you or someone you love? ● Have you ever been forced to have sex when you did not want it? ● Have you ever been forced to participate in sexual practices that you didn’t want to do? If the patient answers “yes” to any of the above questions, the danger to the patient may be assessed by asking the following questions. ASSESSMENT QUESTIONS FOR DOMESTIC VIOLENCE ● Has he ever threatened you with a weapon? ● Has he ever used a weapon? Is there a gun in the house? ● Has he ever tried to choke you? Has he ever threatened to kill you? Have you ever been afraid you might die while he was attacking you? ● Does he use “upper” drugs such as amphetamines (speed), angel dust (PCP), cocaine, or crack cocaine? CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 883 BENSON & PERNOLL’S 884 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ● Does he get drunk every day or almost every day? ● Does he control your daily activities, such as where you can go, who you can be with, or how much money you can have? ● Were you ever beaten by him when you’ve been pregnant? ● Is he violent and constantly jealous of you? ● Has he ever used threats or tried to commit suicide in order to get you to do what he wants? ● Have you ever threatened or attempted suicide because of problems in the relationship? ● Are you thinking of killing yourself now? Do you have a plan? A weapon? ● Is he violent toward your children? ● Is he violent outside of your home? When a woman seeks medical attention for domestic violence, meticulous medical documentation is crucial. It should include dates and times, names of accompanying persons, description of the event in the patient’s words if possible, abuser’s name, description of the injuries (include photographs if applicable), names of treating per- sonnel, and the name and badge number of any law enforcement officer involved. The patient should be aware that her medical record can be used by her and only with her permission as evidence if legal action is undertaken. The health care provider should understand that simply giving information about domestic violence to victims is actually a thera- peutic intervention in and of itself. If the health care provider does not indicate how serious the situation truly is, the victim may be- lieve that the provider tacitly approves, or accepts the abuse. She must be respected in her attempts to make her own decisions, even when they seem inordinately delayed. Couple counseling is con- traindicated because the partners must be assessed and treated sep- arately. It is vital to offer her help in developing a safety plan be- fore she leaves the current setting, even if that includes referral to another person or organization with expertise in domestic violence. SAMPLE SAFETY PLAN ● If an argument seems unavoidable, try to have it in a room or area that has access to an exit and not in the bathroom, kitchen, or anywhere near weapons. ● Practice how to get out of your home safely. Identify which doors, windows, elevator, or stairwell would be best. ● Identify a neighbor that you can tell about the violence and ask that they call the police if they hear a disturbance com- ing from your home. ● Devise a code word to use with your children family, friends, and neighbors when you need the police. ● Use your own instincts and judgment. If the situation is very dangerous, consider giving the abuser what he wants to calm him down. You don’t deserve to be hit or threat- ened. You have the right to protect yourself until you are out of danger. ● Prepare a plan to leave even if you don’t think you will do it. ● Locate someone you trust that will shelter you (and your children) temporarily if you must leave in a hurry. If they cannot shelter you, ask them to safeguard your important items for pick up when needed. ● If there is no one available to provide shelter, locate and visit the nearest women’s shelter. It may be listed in the Yellow Pages under Crisis Intervention Services. Keep their number and sufficient change or a telephone card on you at all times. ● Pack a bag with a few clothes for you and the children, a spare set of keys to the car and house, as well as copies of important documents (e.g. birth certificates, driver’s license, green card, passport, social security card, immunization/ medical records, school records, welfare identification cards, and bank books), medications with dosing instructions, and money (in the form of traveler’s checks). Leave it with a person you trust. ● List the appropriate legal advocate to contact to receive a restraining/protective order and other legal advice, espe- cially for child custody and divorce. Keep the protective or- der with you at all times. Make sure that family and friends know that you have the protective order. ● Notify security at your place of work regarding your situa- tion. Have someone escort you to your car, bus, or train, if possible. ● If you are considering returning to a potentially abusive situation, discuss an alternative plan with someone you trust. ● To support yourself emotionally, attend a women’s or vic- tim’s support group for a minimum of 2 weeks. The Massachusetts Medical Society has devised an acronym (RADAR) to help physicians improve their response to victims of domestic violence. ● Remember to ask routinely about partner violence in your own practice. CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 885 BENSON & PERNOLL’S 886 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ● Ask directly about violence with such questions as, “At any time has a partner hit, kicked or otherwise hurt or frightened you?” Interview your patient in private at all times. ● Document your findings. Information about “suspected do- mestic violence” or “partner violence” in the patient’s chart can serve as a valuable function in court should the woman decide to seek legal redress. A physician’s documentation validates the woman’s position. ● Assess your patient’s safety. Is it safe for her to return home? Find out if any weapons are kept in the house, if the chil- dren are in danger, and if the violence is escalating. ● Review options with your patient. Know about the types of referral options (e.g., shelters, support groups, and legal advocates). . syphilis, Trichomonas, Candida, and CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 879 BENSON & PERNOLL’S 880 HANDBOOK OF OBSTETRICS AND GYNECOLOGY bacterial vaginosis), follow standard treatment protocols may begin to CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 881 BENSON & PERNOLL’S 882 HANDBOOK OF OBSTETRICS AND GYNECOLOGY tolerate the abuse, feeling partially responsible and grasping at the positive. of domestic violence. ● Remember to ask routinely about partner violence in your own practice. CHAPTER 32 SEXUAL AND DOMESTIC ASSAULT 885 BENSON & PERNOLL’S 886 HANDBOOK OF OBSTETRICS AND