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Rape Trauma Syndrome

The term "rape" refers to illicit sexual intercourse without consent. It's a violent assault in which sex is used as a weapon. Rape inflicts varying degrees of physical and psychological trauma.

Rape trauma syndrome occurs during the period following the rape or attempted rape. It refers to the victim's short-term and long-term reactions and to the methods she uses to cope with this trauma.

In the United States, a rape is reported every 7 minutes (200 per day, 62,500 per year). Incidence of reported rape is highest in large cities and is rising. However, possibly more than 90% of assaults are never reported.

Known victims of rape range from age 2 months to 97 years. The age-group most affected is 10- to 19-year-olds; the average victim's age is 13½. About 1 out of 7 reported rapes involves a prepubertal child.

Over 50% of rapes occur in the home; about one-third of these involve a male intruder who forces his way into a home. Approximately half the time, the victim has some casual acquaintance with the attacker. Most rapists are ages 15 to 24. Usually, the attack is planned.

In most cases, the rapist is a man and the victim is a woman. However, rapes do occur between persons of the same sex, especially in prisons, schools, hospitals, and other institutions.

Children are also often victims of rape; most of the time these cases involve manual, oral, or genital contact with the child's genitalia. Usually, the rapist is a member of the child's family. In rare instances, a man or child is sexually abused by a woman.

The prognosis is good if the rape victim receives physical and emotional support and counseling to help her deal with her feelings. Victims who articulate their feelings are able to cope with fears, interact with others, and return to normal routines faster than those who don't.

Causes

Some of the cultural, sociologic, and psychological factors that contribute to rape include increasing exposure to sex, permissiveness, cynicism about relationships, feelings of anger, and powerlessness amid social pressures.

The rapist often has feelings of violence or hatred toward women or sexual problems, such as impotence or premature ejaculation. Often he feels socially isolated and unable to form warm, loving relationships. Some rapists may be psychopaths who need violence for physical pleasure, no matter how it affects their victims; others rape to satisfy a need for power. Some were abused as children.

Signs and symptoms

A physical examination (including a pelvic examination by a gynecologist) will probably show signs of physical trauma, especially if the assault was prolonged. Depending on specific body areas attacked, a patient may have a sore throat, mouth irritation, difficulty swallowing, ecchymoses, or rectal pain and bleeding.

If additional physical violence accompanied the rape, the victim may have hematomas, lacerations, bleeding, severe internal injuries, and hemorrhage, and if the rape occurred outdoors, she may suffer from exposure. X-rays may reveal fractures. The patient may have injuries severe enough to require hospitalization.

Assessment

• When a rape victim arrives in the emergency department, assess her physical injuries. If she isn't seriously injured, allow her to remain clothed and take her to a private room where she can talk with you or a counselor before the necessary physical examination.
• Remember, immediate reactions to rape differ and include crying, laughing, hostility, confusion, withdrawal, or outward calm; often anger and rage don't surface until later. During the assault, the victim may have felt demeaned, helpless, and afraid for her life; afterward, she may feel ashamed, guilty, shocked, and vulnerable, and have a sense of disbelief and lowered self-esteem.
• Offer support and reassurance. Help her explore her feelings; listen, convey trust and respect, and remain nonjudgmental. Don't leave her alone unless she asks you to.
• Being careful to upset the victim as little as possible; obtain an accurate history of the rape, pertinent to physical assessment.

CLINICAL TIP

Remember, your notes may be used as evidence if the rapist is tried.

• Record the victim's statements in the first person, using quotation marks. Also document objective information provided by others.
• Never speculate as to what may have happened or record subjective impressions or thoughts.
• Include in your notes the time the victim arrived at the hospital, the date and time of the alleged rape, and the time the victim was examined. Ask the victim about allergies to penicillin and other drugs, if she has had recent illnesses (especially venereal disease), if she was pregnant before the attack, the date of her last menstrual period, and details of her obstetric-gynecologic history.
• Thoroughly explain the examination she'll have, and tell her why it's necessary (to rule out internal injuries and obtain a specimen for venereal disease testing). Obtain her informed consent for treatment and for the police report. Allow her some control, if possible; for instance, ask her if she's ready to be examined or if she'd rather wait a bit.
• Before the examination, ask the victim whether she douched, bathed, or washed before coming to the hospital. Note this on her chart. Have her change into a hospital gown, and place her clothing in paper bags. (Never use plastic bags, because secretions and seminal stains will mold, destroying valuable evidence.) Label each bag and its contents.
• Tell the victim she may urinate, but warn her not to wipe or otherwise clean the perineal area. If the patient wishes, ask a counselor to stay with her through­out the examination. This examination is typically very distressing for the rape victim. Reassure her and allow her as much control as possible.
• Throughout the examination, provide support and reassurance, and carefully label all possible evidence. Before the victim's pelvic area is examined, take vital signs, and if the patient is wearing a tampon, remove it, wrap it, and label it as evidence.
• During the examination, make sure all specimens collected, including those for semen and gonorrhea, receive careful labeling. Include the patient's name, the doctor's name, and the location from which the specimen was obtained. List all specimens in your notes.
• If the case comes to trial, specimens will be used for evidence, so accuracy is essential. Most emergency departments have "rape kits" with containers for specimens. Carefully collect and label fingernail scrapings and foreign material obtained by combing the victim's pubic hair; these also provide valuable evidence. Note to whom these specimens are given.
• For a male victim, be especially alert for injury to the mouth, perineum, and anus. Obtain a pharyngeal specimen for a gonorrhea culture and rectal aspirate for acid phosphatase or sperm analysis.
• Photographs of the patient's injuries will also be taken. This may be delayed for a day or repeated when bruises and ecchymoses are more apparent.
• Most states require hospitals to report rape. The patient may not press charges and may not assist the police. If the patient does not go to the hospital, she may not report the rape.
• If the police interview the patient in the hospital, be supportive and encourage her to recall details of the rape. Your kindness and empathy are invaluable.
• The patient may also want you to call her family. Help her to verbalize anticipation of her family's response.

Treatment

The rape victim should receive supportive care and protection against venereal disease and, if she wishes, against pregnancy.

Antibiotics are given to prevent venereal disease. To prevent pregnancy as a result of the rape, the patient may be given the "morning-after pill" (Ovral) within 72 hours of the assault. If a pregnancy test is negative, two pills are given and the dose is repeated in 12 hours. Menses follows in 3 to 4 days. Or she may wait 3 to 4 weeks and undergo a dilatation and curettage or a vacuum aspiration to abort a pregnancy.

If the patient has vulvar lacerations and hair cuts, the area will be cleaned and the lacerations repaired after all the evidence is obtained. Topical use of ice packs may reduce vulvar swelling.

All victims of rape should be offered testing for human immunodeficiency virus infection and receive medical counseling and follow-up. Testing for hepatitis B and C should be considered and prophylaxis given.

Recovery from rape, which may be prolonged, consists of the acute phase (immediate reaction) and the reorganization phase. During the acute phase, physical aspects include pain, loss of appetite, and wound healing; emotional reactions typically include shaking, crying, and mood swings. Feelings of grief, anger, fear, or revenge may color the victim's social interactions.

Counseling helps the victim identify her coping mechanisms. She may relate more easily to a counselor of the same sex.

During the reorganization phase, which usually begins a week after the rape and may last months or years, the victim is concerned with restructuring her life. Initially, she often has nightmares in which she's powerless; later dreams show her gradually gaining more control. When she's alone, she may also suffer from "daymares" - frightening thoughts about the rape. She may have reduced sexual desire or may develop rear of intercourse or mistrust of men.