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Medical Examination of the Rape Victim_ Merck Manual Professional

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Medical Examination of the Rape Vi
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  Merck ManualHealth Care ProfessionalsGynecology and Obstetrics Medical Examination of the Rape Victim Although legal and medical definitions vary, rape is typically defined as oral, anal, or vaginalpenetration that involves threats or force against an unwilling person. Such penetration,whether wanted or not, is considered statutory rape if victims are younger than the age ofconsent. Sexual assault is rape or any other sexual contact that results from coercion,including seduction of a child through offers of affection or bribes; it also includes beingtouched, grabbed, kissed, or shown genitals. Rape and sexual assault, including childhoodsexual assault, are common; the lifetime prevalence estimates for both ranges from 2 to30% but tends to be about 15 to 20%. However, actual prevalence may be higher becauserape and sexual assault tend to be underreported.Typically, rape is an expression of aggression, anger, or need for power; psychologically, it ismore violent than sexual. Nongenital or genital injury occurs in about 50% of rapes offemales.Females are raped and sexually assaulted more often than males. Male rape is oftencommitted by another man, often in prison. Males who are raped are more likely thanfemales to be physically injured, to be unwilling to report the crime, and to have multipleassailants. Symptoms and Signs Rape may result in the following: Extragenital injuryGenital injuryPsychologic symptomsSexually transmitted diseases (STDs—eg, hepatitis, syphilis, gonorrhea, chlamydial infection,trichomoniasis, HIV infection [rarely])Pregnancy (uncommonly) Most physical injuries are relatively minor, but some lacerations of the upper vagina aresevere. Additional injuries may result from being struck, pushed, stabbed, or shot.Psychologic symptoms of rape are potentially the most prominent. In the short term, mostpatients experience fear, nightmares, sleep problems, anger, embarrassment, shame, guilt,or a combination. Immediately after an assault, patient behavior can range fromtalkativeness, tenseness, crying, and trembling to shock and disbelief with dispassion,quiescence, and smiling. The latter responses rarely indicate lack of concern; rather, theyreflect avoidance reactions, physical exhaustion, or coping mechanisms that require controlof emotion. Anger may be displaced onto hospital staff members.Friends, family members, and officials often react judgmentally, derisively, or in anothernegative way. Such reactions can impede recovery after an assault.Eventually, most patients recover; however, long-range effects of rape may includeposttraumatic stress disorder (PTSD—see Posttraumatic Stress Disorder ), particularly amongwomen. PTSD is an anxiety disorder; symptoms include re-experiencing (eg, flashbacks,intrusive upsetting thoughts or images), avoidance (eg, of trauma-related situations,thoughts, and feelings), and hyperarousal (eg, sleep difficulties, irritability, concentrationproblems). Symptoms last for > 1 mo and significantly impair social and occupationalfunctioning. Evaluation Goals of rape evaluation are Medical assessment and treatment of injuries and assessment, treatment, and prevention ofpregnancy and STDsCollection of forensic evidencePsychologic evaluationPsychologic support If patients seek advice before medical evaluation, they are told not to throw out or changeclothing, wash, shower, douche, brush their teeth, or use mouthwash; doing so may destroyevidence.Whenever possible, all people who are raped are referred to a local rape center, often ahospital emergency department(eg, sexual assault nurse examiners [SANE]). Benefits of a rape evaluation are explained,     Related SearchesSexual AssaultNursing Home AbuseVictims' RightsEmotional AbuseSexual AbuseDomestic ViolenceVictimsDomestic ViolenceLawsWomen Against RapeNational CrimeVictimization Survey BatBrowse Trust Rating 91 % merckmanuals.com    B  a   t   B  r  o  w  s  e   A   d  s      B  a   t   B  r  o  w  s  e   A   d  s Medical Examination of the Rape Victim: Merck Manual Professionalhttp://www.merckmanuals.com/professional/gynecology_and_obstetri...1 of 55/06/2014 11:07 PM  but patients are free to consent to or decline the evaluation. The police are notified if patientsconsent. Most patients are greatly traumatized, and their care requires sensitivity, empathy,and compassion. Females may feel more comfortable with a female physician; a female staffmember should accompany all males evaluating a female. Patients are provided privacy andquiet whenever possible.A form (sometimes part of a rape kit) is used to record legal evidence and medical findings(for typical elements in the form, see Table 1: Typical Examination for Alleged Rape ); it shouldbe adapted to local requirements. Because the medical record may be used in court, resultsshould be written legibly and in nontechnical language that can be understood by a jury. Typical Examination for Alleged Rape CategorySpecifics General informationDemographic data about the patientName, address, and phone number of theguardian if the patient is under ageName of police officer, badge number, anddepartmentDate, time, and location of examinationHistoryCircumstances of attack, including Date, time, and location (familiar to patient?)Information about assailants (number, name if known, description)Use of threats, restraints, or weaponType of sexual contact (vaginal, oral, rectal; use of condom?)Types of extragenital injuries sustainedOccurrence of bleeding (patient or assailant)Occurrence and location of ejaculation by the assailant Activities of the patient after the attack, such as Douching or bathingUse of a tampon or sanitary napkinUrination or defecationChanging of clothingEating or drinkingUse of toothpaste, mouthwash, enemas, or drugs Last menstrual periodDate of previous coitus and time, if recentContraceptive history (eg, oral contraceptives,intrauterine device)PhysicalexaminationGeneral (extragenital) trauma to any areaGenital trauma to the perineum, hymen, vulva,vagina, cervix, or anusForeign material on the body (eg, stains, hair,dirt, twigs)Examination with Wood's lamp or colposcopywhen availableData collectionCondition of clothing (eg, damaged, stained,foreign material adhering)Small samples of clothing, including anunstained sample, given to the police orlaboratoryHair samples, including loose hairs adhering tothe patient or clothing, semen-encrusted pubichair, and clipped scalp and pubic hairs of thepatient (at least 10 of each for comparison)Semen taken from the cervix, vagina, rectum,mouth, and thighsBlood taken from the patientDried samples of the assailant's blood takenfrom the patient's body and clothingUrineSalivaSmears of buccal mucosaFingernail clippings and scrapingsOther specimens, as indicated by the history orphysical examinationLaboratory testingAcid phosphatase to detect presence of sperm*Saline suspension from the vagina †  (for spermmotility)Semen analysis for sperm morphology andpresence of A, B, or H blood groupsubstances ‡ Baseline serologic test for syphilis in thepatient § Table 1 Related SearchesSexual AssaultNursing Home AbuseVictims' RightsEmotional AbuseSexual AbuseDomestic ViolenceVictimsDomestic ViolenceLawsWomen Against RapeNational CrimeVictimization Survey BatBrowse Trust Rating 91 % merckmanuals.com    B  a   t   B  r  o  w  s  e   A   d  s      B  a   t   B  r  o  w  s  e   A   d  s Medical Examination of the Rape Victim: Merck Manual Professionalhttp://www.merckmanuals.com/professional/gynecology_and_obstetri...2 of 55/06/2014 11:07 PM  Blood typing (using blood from the patient anddried samples of the assailant's blood)Urine testing, including drug screen ||  andpregnancy testsOther tests, as indicated by the history orphysical examinationTreatment, referral,physician's clinicalcommentsSpecifyWitness toexaminationSignatureDisposition ofevidenceName of the person who delivered theevidence and the person who received itDate and time of delivery and receipt *This test is particularly useful if the assailant had a vasectomy, is oligospermic, or used a condom,which may cause sperm to be absent. If the test cannot be done immediately, a specimen should beplaced in a freezer. † This test should be done by the examining physician if it can be done in time to detect motile sperm. ‡ In 80% of cases, blood group substances are found in semen. § This test is not recommended by all authorities because evidence of preexisting sexually transmitteddiseases may be used to discredit the patient in court. || Many authorities recommend not including comments or tests regarding the presence of alcohol ordrugs in the patient because evidence of intoxication may be used to discredit the patient in court. History and examination: Before beginning, the examiner asks the patient's permission.Because recounting the events often frightens or embarrasses the patient, the examinermust be reassuring, empathetic, and nonjudgmental and should not rush the patient. Privacyshould be ensured. The examiner elicits specific details, including Type of injuries sustained (particularly to the mouth, breasts, vagina, and rectum)Any bleeding from or abrasions on the patient or assailant (to help assess the risk oftransmission of HIV and hepatitis)Description of the attack (eg, which orifices were penetrated, whether ejaculation occurred or acondom was used)Assailant's use of aggression, threats, weapons, and violent behaviorDescription of the assailant Many rape forms include most or all of these questions (see Table 1: Typical Examination forAlleged Rape ). The patient should be told why questions are being asked (eg, informationabout contraceptive use helps determine risk of pregnancy after rape; information aboutprevious coitus helps determine validity of sperm testing).The examination should be explained step by step as it proceeds. Results should bereviewed with the patient. When feasible, photographs of possible injuries are taken. Themouth, breasts, genitals, and rectum are examined closely. Common sites of injury includethe labia minora and posterior vagina. Examination using a Wood's lamp may detect semenor foreign debris on the skin. Colposcopy is particularly sensitive for subtle genital injuries.Some colposcopes have cameras attached, making it possible to detect and photographinjuries simultaneously. Whether use of toluidine blue to highlight areas of injury is acceptedas evidence varies by jurisdiction. Testing and evidence collection: Routine testing includes a pregnancy test and serologictests for syphilis, hepatitis B, and HIV; if done within a few hours of rape, these tests provideinformation about pregnancy or infections present before the rape but not those that developafter the rape. Vaginal discharge is examined to check for trichomonal vaginitis and bacterialvaginosis; samples from every penetrated orifice (vaginal, oral, or rectal) are obtained forgonorrheal and chlamydial testing. If the patient has amnesia for events around the time ofrape, drug screening for flunitrazepam (the date rape drug) and gamma hydroxybutyrateshould be considered. Testing for drugs of abuse and alcohol is controversial becauseevidence of intoxication may be used to discredit the patient.Follow-up tests for the following are done: At 6 wk: Gonorrhea, chlamydial infection, human papillomavirus infection (initially using acervical sample from a Papanicolaou test), syphilis, and hepatitisAt 90 days: HIV infectionAt 6 mo: Syphilis, hepatitis, and HIV infection However, testing for STDs is controversial because evidence of preexisting STDs may beused to discredit the patient in court.If the vagina was penetrated and the pregnancy test was negative at the first visit, the test isrepeated within the next 2 wk. Patients with lacerations of the upper vagina, especiallychildren, may require laparoscopy to determine depth of the injury.Evidence that can provide proof of rape is collected; it typically includes clothing; smears ofthe buccal, vaginal, and rectal mucosa; combed samples of scalp and pubic hair as well ascontrol samples (pulled from the patient); fingernail clippings and scrapings; blood and saliva Related SearchesSexual AssaultNursing Home AbuseVictims' RightsEmotional AbuseSexual AbuseDomestic ViolenceVictimsDomestic ViolenceLawsWomen Against RapeNational CrimeVictimization Survey BatBrowse   Trust Rating 91 % merckmanuals.com    B  a   t   B  r  o  w  s  e   A   d  s      B  a   t   B  r  o  w  s  e   A   d  s Medical Examination of the Rape Victim: Merck Manual Professionalhttp://www.merckmanuals.com/professional/gynecology_and_obstetri...3 of 55/06/2014 11:07 PM  samples; and, if available, semen (see Table 1: Typical Examination for Alleged Rape ). Manytypes of evidence collection kits are available commercially, and some states recommendspecific kits. Evidence is often absent or inconclusive after showering, changing clothes, oractivities that involve sites of penetration, such as douching. Evidence becomes weaker ordisappears as time passes, particularly after > 36 h; however, depending on the jurisdiction,evidence may be collected up to 7 days after rape.A chain of custody, in which evidence is in the possession of an identified person at alltimes, must be maintained. Thus, specimens are placed in individual packages, labeled,dated, sealed, and held until delivery to another person (typically, law enforcement orlaboratory personnel), who signs a receipt. In some jurisdictions, samples for DNA testing toidentify the assailant are collected. Treatment Psychologic support or interventionProphylaxis for STDs and possibly hepatitis B or HIV infectionPossibly emergency contraception After the evaluation, the patient is provided with facilities to wash, change clothing, usemouthwash, and urinate or defecate if needed. A local rape crisis team can provide referralsfor medical, psychologic, and legal support services.Most injuries are minor and are treated conservatively. Vaginal lacerations may requiresurgical repair. Psychologic support: Sometimes examiners can use commonsense measures (eg,reassurance, general support, nonjudgmental attitude) to relieve strong emotions of guilt oranxiety. Possible psychologic and social effects are explained, and the patient is introducedto a specialist trained in rape crisis intervention. Because the full psychologic effects cannotalways be ascertained at the first examination, follow-up visits are scheduled at 2-wkintervals. Severe psychologic effects (eg, persistent flashbacks, significant sleep disruption,fear leading to significant avoidance) or psychologic effects still present at follow-up visitswarrant psychiatric or psychologic referral.Family members and friends can provide vital support, but they may need help from rapecrisis specialists in handling their own negative reactions.PTSD can be effectively treated psychosocially and pharmacologically (see Treatment ). Prevention of infections: Routine empiric prophylaxis for STDs consists of 125 mg IM in a single dose (for gonorrhea), 2 g po in a single dose (fortrichomoniasis and bacterial vaginosis), and either 100 mg po bid for 7 days or 1 g po once (for chlamydial infection). Alternatively, 2 g po(which covers gonorrhea and chlamydial infection) can be given with 2 g po,both as a single dose.Empiric prophylactic treatment of hepatitis B and HIV after rape is controversial. For hepatitisB, the CDC recommends hepatitis B vaccination unless the patient has been previouslyvaccinated and has documented immunity. The vaccine is repeated 1 and 6 mo after the firstdose. (HBIG) is not given. For HIV, most authoritiesrecommend offering prophylaxis; however, the patient should be told that on average, therisk after rape from an unknown assailant is only about 0.2%. Risk may be higher with any ofthe following: Anal penetrationBleeding (assailant or victim)Male-male rapeRape by multiple assailants (eg, male victims in prisons)Rape in areas with a high prevalence of HIV infection Treatment is best begun < 4 h after penetration and should not be given after > 72 h.Usually, a fixed-dose combination of (ZDV) 300 mg and (3TC) 150mg is given bid for 4 wk if exposure appears low risk. If risk is higher, a protease inhibitor isadded (see Postexposure prophylaxis (PEP) ). Prevention of pregnancy: Although pregnancy caused by rape is rare (except in the fewdays before ovulation), emergency contraception (see Emergency Contraception (EC) ) shouldbe offered to all women with a negative pregnancy test. Usually, oral contraceptives areused; if used > 72 h after rape, they are much less likely to be effective. An antiemetic mayhelp if nausea develops. An intrauterine device may be effective if used up to 10 days afterrape. If pregnancy results from rape, the patient's attitude toward the pregnancy andabortion should be determined, and if appropriate, the option of elective termination shouldbe discussed.ceftriaxonemetronidazoledoxycyclineazithromycinazithromycinmetronidazoleHepatitis B immune globulinzidovudinelamivudine Related SearchesSexual AssaultNursing Home AbuseVictims' RightsEmotional AbuseSexual AbuseDomestic ViolenceVictimsDomestic ViolenceLawsWomen Against RapeNational CrimeVictimization Survey BatBrowse Trust Rating 91 % merckmanuals.com    B  a   t   B  r  o  w  s  e   A   d  s      B  a   t   B  r  o  w  s  e   A   d  s Medical Examination of the Rape Victim: Merck Manual Professionalhttp://www.merckmanuals.com/professional/gynecology_and_obstetri...4 of 55/06/2014 11:07 PM
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