Care of the female adolescent rape victim

TARGET AUDIENCE This CME activity is intended for physicians, including pediatricians, pediatric emergency physicians, emergency physicians, family practitioners, and emergency department nurses, who provide care for the adolescent rape victim. LEARNING OBJECTIVES After completion of this article, the reader will Be able to discuss the epidemiology of adolescent rape. Be familiar with the acute evaluation of the adolescent rape victim. Be familiar with collecting forensic evidence from the adolescent rape victim. Be aware of the latest recommendations for prophylaxis of sexually transmitted diseases and pregnancy in the adolescent rape victim. INTRODUCTION Unfortunately, female adolescents are frequent victims of sexual assault and rape. The incidence of rape in the United States peaks among young women 16 to 19 years of age (1). The reported incidence of rape and sexual assault reflects a fraction of the actual frequency of this crime (1). The National Victim Center estimates that almost 700,000 women are raped each year, and that 61% of the rape victims are under the age of 18 (2). A survey of US high school students revealed that nearly 20% had one episode of forced sexual contact. However, only half of these students ever reported the assault to authorities (3). The reasons for not reporting these assaults include fear of public humiliation, perceived negative social stigma of rape, thinking that the event was a “matter of privacy,” and fear of “what happens next”—particularly the emergency department (ED) evaluation. A similar survey of female adolescents showed that 23% had experienced at least one episode of unwanted sexual contact (4). Nearly 25% of women sampled who were 17 to 19 years of age had reported unwanted sexual intercourse. The majority (84%) stated that they knew their assailant, and that many of these attacks (57%) occurred during a date (5). Male victims account for 5% of reported sexual assaults (6). Any sexual act performed by one person on another without that person’s consent defines a sexual assault (7). The use or threat of force, the inability of the victim to give appropriate consent, or both is an important component of this definition. Sexual assault in adolescents includes incest, acquaintance rape (ie, rape in which the assailant and the victim know one another), and stranger rape (rape in which the assailant and the victim do not know one another) (7). Rape has historically been defined under standard common law as “the unlawful carnal knowledge of a women by a man, forcible and against her will, or without her consent” (8). A more current definition of rape is “a sexual assault in which the penis of an assailant is introduced into the victim’s genitalia, either without consent or by threat of force or compulsion” (7). The age at which a person can grant consent for sexual intercourse varies with state law, which defines statutory rape. Thus, statutory rape has occurred even in “consensual intercourse” when one party is not of “legal age” according to the state law. As with other forms of child abuse, appropriate social service authorities need to be involved in all cases of suspected statutory rape. Female adolescents are at high risk for becoming victims of acquaintance rape or “date rape.” Studies have shown that the highest incidence of acquaintance rape occurred in grade 12 and during the freshman year of college (5,9). Of the 25% of college women surveyed who reported having had unwanted sexual intercourse, 84% knew their assailant, 57% of the episodes occurred on dates, and 41% of the women stated that they were virgins at the time of the assault (5). Again, this is probably an underestimation of the true incidence of date rape. There is an association between the high incidence of alcohol and drug abuse on college campuses and date rape (10). In addition, drug-facilitated sexual assault has received widespread media coverage in the past few years (11). At least 20 drugs have been documented as having been used in drug-facilitated sexual assaults and rapes (12). In a study of 1179 specimens collected from victims of sexual assault nationwide, 38% were positive for alcohols; 18% for tetrahydrocannabinol; 8% for benzodiazepines, including flunitrazepam (Rohypnol; Hoffman-LaRoche, Nutley, NJ), which is also known as the “date rape drug”; and 4% for gamma-hydroxybutyrate (12). These drugs are thought to be readily available at college campuses, bars, discos, and clubs. They produce disinhibition and relaxation of the voluntary muscles and cause victims to have retrograde amnesia for events that occur under the influence of the drugs (13–16). As with most sedatives, alcoholic beverages potentiate the effects. Female adolescents who have been raped will present to the pediatric ED. The initial ED management of these patients includes documentation of pertinent history, careful physical examination and collection of forensic evidence, prompt recognition and treatment of physical injuries, psychosocial support with arrangements for follow-up counseling, prevention of venereal diseases, and prevention of pregnancy (17). A standardized approach to the initial management of the young woman who has been raped is warranted (Table 1). This type of approach provides a consistent process of evaluation, treatment, and collection of forensic evidence. Examples of standardized protocols are available (18,19).TABLE 1: Physician’s role in the care of the adolescent rape victimOBTAINING THE HISTORY Adolescent victims of rape should be immediately identified in triage and quickly and quietly escorted to a private, secluded area. Their privacy should be respected, but they should not be left alone. In many states, physicians are required to report all cases of sexual assault to law enforcement agencies. Other state legal statutes may require parental notification of a minor’s sexual assault. These statutes may override the confidentiality issues of the adolescent. If the adolescent is agreeable, parental notification should be encouraged. After assurance that no severe physical injuries warrant immediate evaluation, a careful history should be obtained in a sensitive, nonjudgmental fashion and documented in a clear and concise manner. Pertinent historical information should include general demographic information; the name of the alleged perpetrator and relationship to the victim; the circumstances of the assault, such as location, particular sexual acts, physical violence, ejaculation, and physical and behavioral symptoms; any relevant medical history, such as menarche, last menstrual period, previous consensual sexual activity, possibility of preexisting pregnancy, previous history of sexually transmitted diseases (STDs); and the use of alcohol or drugs by the patient or the assailant before the assault (Table 2). Other components of the medical history, such as history of chronic illnesses, immunization history, current medications, and allergies, should not be overlooked.TABLE 2: Important history in the evaluation of the adolescent rape victimSome adolescents may feel that specific questioning about the actual event is awkward and difficult and is a further invasion of their privacy. Initially, some individuals may be hesitant to answer truthfully, whereas others may welcome the chance to express their feelings and tell authorities exactly what has occurred to them. Questions should be specific, clear, and focused to avoid any ambiguity in responses. All historical information should be recorded carefully in the medical record. Because the determination of rape is made in a court of law, the wording of the history should reflect the patient’s report of the incident, and her exact words should be used as often as possible (20). PHYSICAL EXAMINATION AND FORENSIC EVIDENCE COLLECTION After ensuring the patient’s comfort, the physician should perform a meticulous physical examination. Some health care professionals feel that informed consent should be obtained before the physical and forensic evaluation. In addition to fulfilling legal requirements, consent allows the victim a sense of control over the examination (21). As with all adolescent examinations, a female chaperone should be present. The adolescent patient should also be provided the opportunity to designate a family member or friend to remain in the room during the examination. The examiner should provide a succinct explanation to prepare the patient for the examination. All interactions with the victim should be in a deliberate, considerate manner with respect for the patient’s modesty. As with any other patient seen in the pediatric ED, any concerns with the patient’s airway, breathing, or circulation should be immediately addressed. Five percent or more of rape victims have major nongenital injuries (22). In one study of adolescent victims, as many as 27% had extragenital sites of injury (23). An initial assessment for unstable vital signs, altered consciousness, peritoneal injury, and pain will alert the physician to severe lacerations, fractures, or internal injuries. As with any patient with trauma, treatment should follow appropriate resuscitation measures and diagnostic studies. One percent of sexual assault victims sustain nongenital injuries severe enough to require hospitalization (24). A recent study reported that of the severe nongenital injuries, 50% involved the face, head and neck; in 0.1% of assaulted women, the injuries are fatal (21). One review of fatal sexual assaults in adults reported the actual causes of death (in descending order of frequency) as mechanical asphyxiation, beating, lacerations, drowning, and gunshot wounds (25). Genital trauma is possible even in rape victims who are asymptomatic on presentation to the pediatric ED (26). One study of adult rape victims showed that up to 63% of women who were sexually assaulted had some type of genital injury compared with 11% of women who were examined after consensual intercourse. The most common types of genital injury reported were abrasions in the posterior fourchette, labia minora, hymen, and the fossa navicularis (27). Therefore, a careful pelvic examination should be performed to detect signs of trauma or injuries. If anal penetration is suspected or if signs of trauma exist, a rectal evaluation should be performed. The patient’s general appearance, clothing stains, and emotional status during the physical examination and the presence of any injuries must be clearly documented (24). The physician should identify edema, ecchymoses, abrasions, bite marks, and lacerations on the face, neck, torso, buttocks, and extremities. Presuming the presence of the assailant’s saliva, the central portion of all bite marks should be swabbed with swabs moistened with sterile saline and placed in the appropriate envelope in the rape kit. Photographs of major injuries should be taken, and an outline drawing of the injuries on the body is helpful for documentation. Although immediate medical care of the patient is of the highest priority, forensic evaluation fulfills important obligations to the victim, the criminal justice system, and society by attempting to document that a sexual assault has occurred and by aiding in the identification of the assailant (19). Necessary equipment for the collection of forensic specimens from the rape victim is contained in standard rape kits, which are available in most EDs. A forensic evaluation should be performed within 72 hours of the sexual assault; however, the sooner the examination and specimen collection, the more likely that the forensic analysis will yield useful information with regard to markers that prove sexual assault or identify the assailant (19). As with any other evaluation, the examining physician has a role in determining which forensic sample is the most appropriate to collect on a case-by-case basis. The physician should try not subject the victim to unnecessary specimen collection, which may serve only to exacerbate the victim’s feelings of being secondarily violated. Local law enforcement should be notified immediately upon disclosure that an assault occurred. This ensures rapid investigative response and a timely evaluation of the victim. Familiarity with the rape kit is important to ensure that all specimens are collected properly and efficiently, thereby subjecting the victim to the minimal amount of discomfort. It is important to remember that this forensic evidence will not be available to the clinician to be used in the acute management of the patient. Generally, it has been taught that the patient’s clothing should initially be examined with a Woods lamp to help in the detection of any seminal stains. However, a recent study concluded that the use of a Woods lamp is unreliable in the detection of semen. Furthermore, the correct identification of semen may be complicated by the presence of previously existing ointments and creams, some of which may be iatrogenically introduced (28). Clothing should be handled only by the victim and collected in a large bag after the patient disrobes over a clean sheet. Separate containers should be used for undergarments. A recent study in prepubescent victims of sexual abuse concluded that the victims’ clothing yielded a significant amount of evidence and should be retained if at all possible (29). Conclusive data as to the of the adolescent victim’s are A envelope and is provided for the collection of and should be from the victim’s and placed in the appropriate analysis from victims’ and may prove useful in a suspected and swabs should be collected and placed in the appropriate sterile collect and are (21). If the victim the the victim’s should be examined The victim’s should be with the provided in the rape kit to that in the for seminal collection should be moistened with saline for (21). of the should document the of or and It is important to use only saline for for of the is that other may evidence and (28). A and collection are provided for These specimens should be for seminal and seminal and by the forensic (21). A with of sterile saline may the of detection of this important evidence The presence of in sexual contact within the few hours The physician should the examination and specimen collection before the examination. A of the may in the detection of after the assault The collection of forensic is by the use of clearly and the collection of evidence is made more by with the rape kit. analysis also the analysis of specimens to identify and from the has been in the up to hours after intercourse and seminal up to hours after current the presence of semen may be by the of which in for up to hours after intercourse in the for to in the and for an amount of time in the which in the and for up to hours and in the for up to 17 or seminal a specific to the which within hours is by it is more difficult to occurred in the on the or has been reported to be present for up to hours after the (21). In of the are in saliva, and Therefore, a sample of the victim’s is and placed in the appropriate provided in the rape kit. After the victim’s status has been are and to the assailant forensic including of and are becoming more widespread and and their are as evidence in many The use of in the evaluation of adolescent rape victim Some physicians that is not in the evaluation of the adolescents who have been sexually They that most pertinent physical examination can be seen without or with a and is an unnecessary Other health care professionals support the use of in the evaluation of the adolescent rape victim of evidence that it in the detection of abrasions, lacerations, and other physical examination and documentation of these injuries may of which may be useful to identify abrasions and of the with A large of women who have been raped do not have physical evidence of trauma Studies of female rape victims have that the incidence of is It is to tell a female adolescent has had previous sexual intercourse by examining the to the of the adolescent is and can penetration without In addition, trauma can that are not after a few after the assault In many sexual assault response have been to the of the for rape victims in the ED The these is to ensure that rape victims consistent medical treatment and examinations, emotional and appropriate for further medical and are in whereas others are by to provide Sexual assault examiner and sexual assault response are of such forensic examination to a of This documentation of all the specimens and careful of each in the evidence from collection to the (19). All medical professionals specimens must identify on the or specimens are and forms are which document the of the evidence to the The and of the forensic evidence in court is by the use of meticulous and documentation and by ensuring of adolescent victims of rape initially and They may to for the assault, if drugs or alcohol were or if the victim had voluntary sexual activity before the assault (21). of acquaintance rape or date rape may a of of their previous social with the (7). that adolescents be to discuss their of the assault, it is an important in (21). Rape victims may of the Rape a by and the acute is one of The victim and the rape. may initially in in the patients and and often during the and in the the patient and and the patient to express her This can last from to a few should either and provide appropriate support and the is a process in which the victim may include of This may last a few to a year, or on the patient. recent have documented a to rape that has of This is by the the event by or an of previously an of the or the rape and an state of to with and The patient should be made aware of the common to rape, including in and should be made for a rape social or health patients should have to after the initial medical evaluation. 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The for this is that even the risk of in rape is not known the status of the assailant is often not the of must be in consensual intercourse of the of rape The treatment includes or and They also that further are to the risk of after sexual assault and document a of the of that physicians prophylaxis for on In that are of a high risk the assailant is known to be the is with a experienced pediatric and with for Again, of after to by sexual assault in adolescent rape victims have not been performed. for and should be obtained from all sites of such as the or and and are also are the legal standard and in some are the only that are as evidence diagnostic for are and appropriate treatment should be after are is for the adolescent victim of sexual assault in a in a or in a a for or in a or in a immunization at the time of initial examination if not on the If the patient is known to have been at the time of the assault, or may be for the and should be only after the prophylaxis should be to The risk for pregnancy as a of sexual assault is as high as 5% The risk of pregnancy is by at what in the victim’s menstrual the rape occurred. intercourse before has been shown to in pregnancy of the intercourse to before in pregnancy of the and intercourse on the of in pregnancy of the time of a pregnancy and the status of the last menstrual at the time of medical evaluation should be It should be to the patient that the pregnancy is more for pregnancy at the time of the assault and not pregnancy as a of the assault. A recent study by documented that of that were a of sexual assault were from known to the victim. The concluded that of as a of sexual assault are with of and family In and introduced a for emergency of and to be within 72 hours of intercourse. A to be 12 hours is also have that the of within 72 hours of the assault and 12 hours will the risk of pregnancy by to At the of the for emergency in rape of 12 hours or of 12 hours The the are after intercourse for emergency the more likely they are to be of this include and a of is Because the risk of pregnancy prophylaxis the patient should be to have a pregnancy to to detect any such as to the victim’s in with is also to the of the has been to have a of and an of pregnancy prevention to the of the patient to The and has which of The current is to one as as possible after the event 72 and the other 12 hours in adolescent rape victims have to be performed. known as the will another in pregnancy prophylaxis in adolescent rape The has it as an in the United and it can be as a it is only available in a which is a that required for emergency according to Studies have shown to be more as a However, as of are no as to use as an emergency in adolescent rape Rape is not in the adolescent patient. sexual assault has and for the victim and for Because the initial care a rape victim has been shown to influence her physicians should these patients with and should use the latest recommendations in their