Sexual assault on women and girls

Rape: A Review Essay

This paper reviews two recent books, Against Our Will: Men, Women, and Rape and The Politics of Rape: The Victim's Perspective in the context of current research on rape. Though both books are nontechnical, their potential contribution to the focus and direction of rape research is discussed.

Microbial ecology of the lower genital tract in women with sexually transmitted diseases

Sexually transmitted diseases (STDs) in women are of great concern to all health-care providers since many of them are preventable and/or treatable conditions which, if left untreated, could have serious sequelae such as pelvic inflammatory disease, infertility, cervical cancer, systemic disease, etc. They may also become a major public health problem when dealing with diseases such as hepatitis, etc., or in people with human immunodeficiency virus. We present here a comprehensive review of the common causes of STDs and their treatment.

The medical and ethical aspects of photography in the sexual assault examination: Why does it offend?

This paper reviews the literature in respect to the photo-colposcopic examination of anogenital injury in the sexually assaulted child, considered to be the 'gold standard' of examination, and how this compares with gross visualisation, still the standard procedure in adult examinations. It then examines the claim that, because the presence of injury does not provide a distinction between consensual and non-consensual intercourse in adults, photo-documentation is unnecessary medically and constitutes an invasive procedure which is ethically unacceptable. The paper questions whether the unwillingness of forensic physicians to extend photo-colposcopy to the examination of adult victims is related more to political and gender issues than to claims made on ethical and medical grounds, and concludes that any move to ban anogenital photography in adult forensic examinations (currently under consideration in the author's own jurisdiction) would possibly constitute an interference with independent clinical judgment and an incursion into the patient's right to evidence-based medicine.

Injury in Women Who Are Raped

Sexual assault is considered the silent, violent epidemic. However, many critical care nurses are unaware of the injury patterns that may indicate that their patient has been sexually assaulted. In addition, critical care nurses are often uncertain how to proceed when caring for someone with a suspected sexual assault. This article provides both background information about sexual assault and guidance to critical care nurses on how to manage this difficult situation.

Retrospective study of alleged rape victims attended at Forensic Medicine Department of Dhaka Medical College, Bangladesh

Sexual assault is one of the fast growing violent crimes in Bangladesh. We carried out a retrospective study of 675 alleged rape victims out of total examined 1665 cases during 1994-2000. In the last seven years, 441 victims refused examination and a final report is pending in 2.4% cases due to non-availability of ancillary investigation reports. We found that 48.9% cases were sexually abused based on history, physical evidence and opinion of the examining doctor although high vaginal swab for spermatozoa was found to be negative in all cases. Out of 675 cases studied in this paper, 33.5% was in the 12-15 year age group, in 511 cases the assailant was known to the victims, 23.7% was reported and was examined within 72 h of occurrence, unmarried persons constituted 56.6% cases and 69.9% was literate. In 45.8% of the cases the victims were abused during the daytime. Non-genital violence was observed in 91 cases, 2.9% was admitted to the hospital, 2% reported with pregnancy, 0.4% reported with abortion and four cases had a history of previous abuse. Genital findings included hymenal rupture in 38.9% and 9.6% cases of forchette were found with recent tears. In 248 cases, opinion was negative due to delayed attendance, false charge and time-consuming procedures.

Epidemiologic issues of sexually transmitted diseases in sexual assault victims

The objective of this study was to investigate the epidemiologic aspects of sexually transmitted diseases (STDs) in victims of sexual assault and to discuss the methodological issues in determining risk of STD acquisition. We performed a comprehensive review of the medical literature to determine the prevalence of STDs in victims of sexual assault. A MEDLINE search and a search of bibliographies of published manuscripts was performed to discover relevant articles published in the English language. Studies were included in our review if they provided estimates of the prevalence of infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Trichomonas vaginalis, or human papillomavirus (HPV). The main outcome measure was prevalence rates of STDs in victims of sexual assault. It is difficult to determine the rate of newly acquired STDs from sexual assault. In the populations studied the prevalence of STDs can be summarized as follows: N. gonorrhoeae 0.0 to 26.3 percent; C. trachomatis 3.9 to 17 percent; T. pallidum 0.0 to 5.6 percent; T. vaginalis 0.0 to 19.0 percent; and HPV 0.6 to 2.3 percent. We conclude that prevalence estimates vary widely depending on the population studied and known risk factors for STDs. Given the limited follow-up rates in this population, preventive treatment for STDs in addition to emergency contraception should be offered in most instances.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to estimate the prevalence of STD transmission from an act of sexual assault, to describe the various types of STDs that a sexual assault victim is at risk for, and to explain the role of preventive therapy in this setting.

Who consults for rape? Sociodemographic characteristics of rape victims attending a medical rape trauma service at the Emergency Hospital in Oslo

OBJECTIVE

To consider the number of victims of rape and attempted rape in a city (Oslo) who sought treatment when medical help had been made available. To examine the sociodemographic characteristics of the patient group that applied for help.

DESIGN

Prospective study.

SETTING

A rape trauma service (RTS) established at the Emergency Hospital in Oslo. The service is free, open around the clock, and independent of police notification.

PARTICIPANTS

All patients attending RTS from 1 January to 31 December.

RESULTS

164 women and four men applied for medical treatment in 1987, four times as many as in 1985, before RTS was started. Their ages varied between 14 and 89 years, with a median of 27 years. Women aged 14-39 years were significantly over-represented in relation to the general female population of Oslo. Married women were significantly under-represented among the female patients, both married women raped by their spouses and married women raped by other men. 45 patients stated that they had been sexually assaulted on a previous occasion without reporting the incident or applying for help.

CONCLUSION

Compared with the police an available medical service for rape victims reached four times as many rape victims as in 1985, from a larger share of the population.

Rape victims--assaults, injuries and treatment at a medical rape trauma service at Oslo Emergency Hospital

OBJECTIVE

To describe assaults, injuries, and treatment in the 168 patients who attended the medical rape trauma service in 1987. To give an impression of the medico-legal documentation that is required.

DESIGN

Prospective study.

SETTING

A rape trauma service (RTS) established at the Emergency Hospital in Oslo. The service is free, open around the clock, and independent of police notification. RTS has standardized the medico-legal report used for rape victims.

PARTICIPANTS

All patients attending RTS from 1 January to 31 December.

RESULTS

Eighty-two (49%) patients reported the incident to the police. Two-thirds of the patients were assaulted by strangers, one-fifth by two or more assailants, and 16 were subjected to attempted rape. Weapons were used in 50 of the assaults. Eighty-one patients had physical injuries requiring documentation but no special treatment. Fourteen patients were infected with sexually transmitted diseases, three patients became pregnant. Seventy-eight patients returned for a medical follow-up. As many as 128 patients (76%) needed care from all parts of the emergency medical and psycho-social services.

CONCLUSION

RTS shows that primary health service can be responsible for the treatment of rape victims and for the medico-legal documentation of rape trauma.

Female sexual assault: medical and legal implications

STUDY OBJECTIVE

To assess the medical and legal effectiveness of this institution's existing adult female sexual assault protocol.

DESIGN

Retrospective review.

SETTING

Urban public hospital.

TYPE OF PARTICIPANTS

One hundred eighty-two adult female sexual assault victims undergoing evaluation within 36 hours of assault.

MEASUREMENTS AND MAIN RESULTS

Each case was reviewed with specific attention to associated injuries, sexually transmitted disease, compliance with medical follow-up, pregnancy, and legal outcome. Half of all cases had associated injuries. Nine percent of the women were found to have genital trauma on pelvic examination, although only 29% of these women had complaints of genital pain or bleeding. Ten percent of all women had positive gonorrhea cultures at initial examination. Thirty percent of the women completed the follow-up protocol. None of the women given postcoital estrogen therapy is known to have become pregnant. Only 53 of the 182 cases had the potential for successful prosecution with both a victim willing to cooperate in prosecution and an identified assailant. Thirty-four percent of these cases resulted in a successful prosecution. Evidence of genital or nongenital trauma was significantly associated with a successful legal outcome.

CONCLUSION

A physical and evidentiary examination, including pelvic examination and assays for sperm and acid phosphatase, is warranted in all cases of female sexual assault presenting within 36 hours of the assault. Institutions dealing with victims from a transient, lower socioeconomic population should offer prophylactic treatment for sexually transmitted disease and pregnancy rather than rely on compliance with follow-up schedules.

Incubating syphilis in an adolescent female rape victim

The risk of infection after rape is believed to be low. The use of presumptive treatment is, therefore, controversial. Some experts recommend treatment of all patients, and others suggest treatment if the doctor suspects infection, if the patient requests it, if follow-up examination of the victim cannot be ensured, or if the assailant has a known infection. No regimen will cover all possible pathogens. The Centers for Disease Control's empiric regimen for victims of sexual assault is effective against gonorrhea, chlamydia, and, most likely, syphilis. We present a case of incubating syphilis following rape, that did not respond to ceftriaxone.

Sexually transmitted diseases in rape victims

From 1 January 1986 to 1 September 1989 124 women presented to the Ambrose King Centre (the department of genitourinary medicine of the London Hospital) alleging rape. Sexually transmitted diseases were found in 36 (29%) women (excluding candidosis and bacterial vaginosis). The commonest organisms detected were Neisseria gonorrhoeae and Trichomonas vaginalis, each being present in 15 patients. Eleven women had genital warts. Chlamydia trachomatis was isolated in six patients, two had herpes simplex virus infection and one patient had pediculosis pubis. Serological evidence of past hepatitis B infection was detected in five women and one patient had antibodies to human immunodeficiency virus. Eighteen of the 36 women (50%) had multiple infections. Six women had abnormal cervical cytology smears, three being suggestive of cervical intraepithelial neoplasia grades II-III. Although it is rarely possible to attribute infection to an assailant, these patients require further counselling, treatment and review. Rape victims are thus a population at risk of having sexually transmitted diseases and screening should be offered.

Sexually transmitted diseases and rape: the experience of a sexual assault centre

Epidemiological data and rates of sexually transmitted diseases (STDs) are presented from a group of 90 women screened following rape. Forty-eight (53%) women knew their assailant. In 6 cases multiple assailants were involved. In 21 (23%) rapes weapons were used. Of 47 women examined within 48 hours of rape, 17 (36%) had evidence of genital trauma. Anal injury was common (8 of 11, 73%) in those reporting anal intercourse. Anal assault (17 of 90, 19%) and oral assault (16 of 90, 18%) commonly accompanied rape. STDs were diagnosed in 13 (14.4%) women, 3 having mixed infections. Neisseria gonorrhoeae was isolated in 2 women, Chlamydia trachomatis in 7, Trichomonas vaginalis in 6, genital warts in 2 and Pediculosis pubis in 2 women. Five of 16 cervical cytology results showed abnormalities, 2 were suggestive of CIN. Eleven of 13 women with an STD (84.6%) had been sexually active within the 3 months prior to the rape. Previous sexual activity may be the most relevant factor determining those most at risk of harbouring an STD.

Sexually transmitted diseases in victims of rape

The risk of acquiring a sexually transmitted disease as a result of rape is not known, in part because it is difficult to ascertain whether infections were present before the assault or acquired during it. To investigate this question, we examined female victims of rape within 72 hours of the assault and again at least one week after the assault. Of the 204 girls and women initially examined within 72 hours of the rape, 88 (43 percent) were found to have at least one sexually transmitted disease. These diseases included infections caused by Neisseria gonorrhoeae (6 percent of those tested), cytomegalovirus (8 percent), Chlamydia trachomatis (10 percent), Trichomonas vaginalis (15 percent), herpes simplex virus (2 percent), Treponema pallidum (1 percent), and the human immunodeficiency virus type 1 (HIV-1; 1 percent) and bacterial vaginosis (34 percent). Among the 109 patients (53 percent) who returned for at least one follow-up visit (excluding those who were found to be infected at the first visit or who were treated prophylactically), the incidence of new disease was as follows: gonorrhea, 4 percent (3 of 71); chlamydial infection, 2 percent (1 of 65); trichomoniasis, 12 percent (10 of 81); and bacterial vaginosis, 19 percent (15 of 77). There were no new infections with herpes simplex virus, cytomegalovirus, Trep. pallidum, or HIV-1, but follow-up serologic testing was performed in only 26 percent of the patients. On the basis of our assumptions that most venereal infections present within 72 hours of a rape were preexisting and that new infections identified 1 to 20 weeks later were acquired during the assault, we conclude that the prevalence of preexisting sexually transmitted diseases is high in victims of rape and that they have a lower but substantial additional risk of acquiring such diseases as a result of the assault.

Incidence of sexually transmitted diseases in rape victims during 1984

During 1984, 46 women attended the sexually transmitted disease (STD) clinic at St Mary's Hospital alleging that they had been raped. At presentation, 31 (67%) were asymptomatic. Evidence of STD was found in 14 (30%) women, mixed infections occurring in four. Chlamydia trachomatis and Trichomonas vaginalis were each detected in six (13%) patients and Neisseria gonorrhoeae in three (6%). The source of the infection could not confidently be traced to the alleged rapist. Two patients were found to have cervical cytological abnormalities suggestive of cervical intraepithelial neoplasia of grades II or III. One woman became pregnant as a consequence of the sexual assault. Investigations may unveil infection or other abnormalities, which are incidental to the rape but nevertheless require further investigation and treatment.

Clinical findings and legal resolution in sexual assault

Female sexual assault victims who received medical evaluation at Detroit Receiving Hospital from July to December 1980 and were seen by the Rape Counseling Center (RCC) were evaluated. Data were abstracted from the emergency department record, RCC file, and gynecology clinic; 372 patients were evaluated. One hundred twenty-seven patients (34%) were given DES, including 17 women who had been raped at least once before. Data regarding DES dosage were available only on 34 patients, with 27 stating they took the entire course; 5, an incomplete course; and 2 refusing to answer. DES is still approved for post-coital contraception in rape. However, if there is one major concern about its administration, it is that close follow-up be provided to anticipate or eliminate complications, especially those associated with inadvertent pregnancy. The extremely poor medical follow-up, the surprising lack of an "appropriate chief complaint" when follow-up does occur, the large number of sexual assault victim repeaters in an inner city population, and the socioeconomic and demographic characteristics of an urban, inner-city sexual assault victim population which make it impossible to determine the effectiveness of DES are strong arguments for the severe restriction of use of DES in the urban, inner city setting. There is no need for pretreatment GC cultures or VDRL assays. Patients should be treated in conformity with current CDC recommendations. Where a rape counseling center is available, it is suggested that the unit assume close and direct responsibility of directing patients for medical follow-up, regardless of emergency department treatment.

Sexual abuse of children

We review the characteristics of 843 cases of sexual abuse seen at the emergency department of the Hospital for Sick Children (HSC) in Toronto in 1962, 1967, and from 1970 to 1978. The children ranged in age from 23 days to 18 years, with a mean age of 9.8 years. Most (89.4%) were girls. The 174 cases seen from 1977 to 1978 were analyzed in detail. Among these, intercourse was the form of abuse in 70 (40%); molestation, in 41 (24%); and exhibitionism, in 36 (20%). Almost half (49%) of the offenses occurred in the child's or assailant's home.

Sexual abuse of children: clinical findings and implications for management

To increase understanding of childhood sexual abuse, we reviewed the hospital records of 113 girls and 17 boys who were the victims of sexual offenses. They were two to 16 years of age and seen in an 18-month period. Thirty had had medical or social problems. Four had previously been raped. Children under eight years old were more likely to know the assailant, to be victims of recurrent sexual or physical abuse, to report crimes without intercourse, and to present with an abused sibling (P less than 0.05). Incest victims were younger than other victims (P less than 0.05). Forty-three children had physical trauma. No pregnancies occurred, although diethylstilbestrol was not routinely used. Three girls had gonorrhea. Seventy-two patients were referred to hospital social services, and 41 to 17 other agencies. Victims and their siblings are at high risk of repeated abuse. Antibiotics and diethylstilbestrol are not routinely indicated. Follow-up may be best achieved by a central agency.