SEXUAL ASSAULT AND RAPE

Rape is typically defined as oral, anal or vaginal penetration 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 of consent (18 years).

Sexual assault or any other sexual contact that results from coercion is rape, including seduction of a child through offers of affection or bribes; it also includes being touched, grabbed, kissed or shown genitals.

Clinical features

Rape may result in the following:

  • Extragenital injury
  • Genital injury (usually minor, but some vaginal lacerations can be severe)
  • Psychologic symptoms: often the most prominent
    • Short term: fear, nightmares, sleep problems, anger, embarrassment
    • Long term: Post traumatic Stress Disorder, an anxiety disorder; symptoms include re-experiencing (e.g., flashbacks, intrusive upsetting thoughts or images), avoidance (e.g., of trauma-related situations, thoughts, and feelings) and hyperarousal (e.g., sleep difficulties,
      irritability, concentration problems).
    • Symptoms last for >1 month and significantly impair social and occupational functioning.
    • Shame, guilt or a combination of both
  • Sexually transmitted infections (STIs, e.g., hepatitis, syphilis, gonorrhea, chlamydial infection, trichomoniasis, HIV infection)
  • Pregnancy (may occur)

Investigations

  • Pregnancy test
  • HIV, hepatitis B and RPR tests

Management

Whenever possible, assessment of a rape case should be done by a specially trained provider. Victims are traumatized so should be approached with empathy and respect. Explain and ask consent for every step undertaken.

The goals are:

  • Medical assessment and treatment of injuries
  • Assessment, treatment and prevention of pregnancy and STIs
  • Collection of forensic evidence
  • Psychologic evaluation and support

TREATMENT

  • Advise not to throw out or change clothing, wash, shower, douche, brush their teeth or use mouthwash; doing so may destroy evidence
  • Initial assessment (history and examination) – use standard forms if available
    • 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 of transmission of HIV and hepatitis)
    • Description of the attack (e.g., the orifices which were penetrated, whether ejaculation occurred, or whether a condom was used)
    • Assailant’s use of aggression, threats, weapons and violent behavior
    • Description of the assailant
    • Use of contraceptives (to assess risk of pregnancy), previous coitus (to assess validity of sperm testing)
    • Clearly describe size, extent, nature of any injury. If possible take photos of the lesions (with patient’s consent)
  • Test for HIV, RPR, hepatitis B and pregnancy, to assess baseline status of the patient
    • If possible test for flunitrazepam and gamma hydroxybutyrate (rape drugs)
  • Collect forensic evidence (with standard kits if available)
    • Condition of clothing (e.g., damaged, stained, adhering foreign material)
    • Small samples of clothing including an unstained sample, given to the police or laboratory
    • Hair samples, including loose hairs adhering to the patient or clothing, semen-encrusted pubic hair, and clipped scalp and pubic hairs of the
      patient (at least 10 of each for comparison)
    • Semen taken from the cervix, vagina, rectum, mouth and thighs
    • Blood taken from the patient
    • Dried samples of the assailant’s blood taken from the patient’s body and clothing
    • Urine, saliva
    • Smears of buccal mucosa
    • Fingernail clippings and scrapings
    • Other specimen as indicated by the history or physical examination
  • Prophylaxis for STD including:
    • Ceftriaxone 125 mg IM or cefixime 400 mg orally stat
    • Azithromycin 1 g stat or doxycycline 100 mg twice a day for 1 week
    • Metronidazole 2 g stat
    • HIV Post Exposure Prophylaxis if within 72 hours:Adults : TDF+3TC+ATV/r for 28 days

      Children: ABC+3TC+LPV/r

  • Hepatitis B vaccine if not already immunised
  • Emergency contraception if within 72 hours (but may be useful up to 5 days after)
    • Levonorgestrel 1.5 mg (double the dose if patient is HIV positive on ARVs)
  • Counselling: use common sense measures (e.g., reassurance, general support, non-judgmental attitude) to relieve strong emotions of guilt or
    anxiety
  • Provide links and referral to:
    • Long term psycho-social support
    • Legal counseling
    • Police- investigations, restraining orders
    • Child protection services
    • Economic empowerment, emergency shelters
    • Long-term case management

Notes

  • Because the full psychologic effects cannot always be ascertained at the first examination, follow-up visits should be scheduled at 2 week intervals
  • Reporting: Health facilities should use HMIS 105 to report Gender-Based Violence (GBV)

Harm classification for police reporting

  • Harm: any body hurt, disease or disorders, whether permanent or temporary
  • Grievous harm: any harm which amounts to a main or dangerous harm, or seriously or permanently injures health, or causes permanent disfigurement or any permanent injeury to any internal or external organ,
    membrane or sense
  • Dangerous harm: means harm endangering life
  • Main means the destruction or permanent disabling of any external membrane or sense