Rape and sexual assault

Who is sexually assaulted?

Anyone can be sexually assaulted but some people are especially vulnerable, such as adolescents and young women, people with disabilities, poor and homeless people, sex workers, and those living in institutions or areas of conflict.1 Consumption of alcohol is commonly linked with sexual assault,2 although covert administration of drugs seems to be unusual.3^w1 Perpetrators are usually one or more males known to the victim and often motivated by power and control; many women experiencing domestic violence also endure forced sexual activity.4 In Britain fewer than 20% of people who have experienced sexual violence report it to the police.4 People often seek medical help shortly or rather later after sexual assault, although they may not disclose the reason for their presentation.

Legal definitions of sexual offences vary internationally. Practitioners should be aware of local legislation and practice so that their actions do not compromise further investigations and court hearings. In England and Wales the law was comprehensively revised in the Sexual Offences Act 2003. Rape is defined as the non-consensual penetration of the vagina, mouth, or anus, by a penis; both sexes can be raped. Assault by penetration is the non-consensual, intentional insertion of an object other than the penis, into the vagina or anus. Specific offences relate to children.

What is the initial management?

Care should be guided by the individual's wishes and needs and provided sensitively in a coordinated and timely fashion to avoid the need for attendance at multiple services.5 Considerations after recent assault include treatment of injuries, preservation of evidence, prevention of unwanted pregnancies and sexually transmitted infections, and psychosocial support. Descriptive studies have found that most women and men reporting rape prefer to be examined by a woman.6

How can services be accessed?

Sexual assaults are often first reported to the police. Many forces have officers with specialist training who can provide excellent initial care and facilitate access to further services such as sexual assault centres: specialist services providing around the clock forensic examinations, other medical and psychological services, and aftercare in a secure and sensitive setting, thereby increasing access to support and services.7 8 As well as seeing people who have been referred by the police, sexual assault centres may also see people referred by other agencies and self referrals^w2 and can collect information and evidence anonymously to assist in identifying serial rapists.

Treatment of injuries

Descriptive studies have reported injuries in about half of people reporting sexual assault, with non-genital injuries more common than genital injuries.9 10^w3 The absence of genital injury does not imply consent or exclude penetration, even in women who deny previous sexual activity.10 Injuries are usually minor but should be documented and may need treatment. Major trauma—for example, head injury—is uncommon but may be life threatening and so its management takes precedence over forensic examination. Victims with significant vaginal or anal bleeding after penile penetration or assault with a foreign body should be assessed in an acute hospital setting with resuscitation facilities and where examination under anaesthesia and operative repair are possible.

Why and how should evidence be collected?

Good documentation and preservation of evidence are essential for assisting judicial processes necessary to prosecute perpetrators. People who have been raped should be asked whether they would like to report the assault to the police and undergo a forensic examination. Evidence dissipates rapidly in vivo and so even before forensic examination the collection and careful labelling of samples should be considered. Urine may provide information about drugs and alcohol. Mouth samples may yield spermatozoa for up to 31 hours^w4; ideally no drink or food should be consumed before samples are taken.11 Injuries may yield valuable evidence and cleaning or washing wounds should be deferred until forensic examination, unless clinically essential. Other samples that may provide crucial evidence are condoms and tampons, sanitary towels, panty liners, and chewing gum.

Why do a forensic examination?

If the person who has been assaulted wishes to report it to the police, or to a sexual assault centre, further evidence can be collected at forensic examination. This should be carried out promptly by a clinician with specialist training, ideally in a forensically secure environment to avoid DNA contamination. The examination should be detailed but sensitive to document all injuries (fig 1⇓)⇓ and to collect samples such as body fluids from the genitals and elsewhere on the body using swabs. In women DNA evidence is unlikely to be found later than seven days after the assault or three days in the case of men and children, but examination for injuries may still be worthwhile.11^w5

Fig 1 Recording injuries on a body diagram

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Contraception

The risk of pregnancy after rape is about 5%, with adolescents most at risk.12 A multicentre randomised trial showed that emergency contraception with a single 1.5 mg dose of levonorgestrol (Levonelle 1500; Schering Health Care) is effective up to five days after intercourse.13^w6 Alternatively an intrauterine device can be inserted up to five days after the earliest predicted date of ovulation in that cycle.

Sexually transmitted infections

The frequency and type of sexually transmitted infections acquired from sexual assault depend on their local prevalence and the nature of the assault. Chlamydia and gonorrhoea are common and may lead to pelvic inflammatory disease and infertility in women if untreated. Nucleic acid amplification tests for chlamydia and gonorrhoea can be carried out on urine samples rather than cervical swabs, minimising the need for intrusive examinations using a speculum.^w7 A positive test result should be confirmed by an additional test if used for medicolegal purposes.^{w8 w9} People who have been raped are often reluctant to attend for screening but one test alone may miss infections, especially if carried out too early. An alternative is to offer prophylactic antibiotics against bacterial sexually transmitted infections, often single dose treatment but advised by national or local protocols.14^w10 This is well tolerated,15 although its effectiveness has not been fully evaluated.14 An accelerated course of hepatitis B vaccine should also be considered.

Post-exposure prophylaxis against HIV

The risk of acquiring HIV depends on the local prevalence of the infection and the nature of the assault; although its prevalence is generally low in developed countries it may be much higher elsewhere, especially in areas of conflict.16 Risk assessment is subjective and difficult, as it is usually impossible to determine whether the alleged perpetrator is infected with HIV (fig 2⇓). Epidemiological studies indicate that high risk assaults are those including anal rape, trauma (including that resulting from sexual violence), bleeding, defloration, or multiple assailants, and that high risk assailants are those known to have HIV or risk factors such as injecting drug users, men who have sex with men, or those from a high prevalence area for HIV.17

Fig 2 Decision chart for post-exposure prophylaxis against HIV after sexual assault. Adapted from chart created by Martin Wiese, Leicester Royal Infirmary

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Evidence from a retrospective case-controlled study^w11 and prospective data^w12 suggest that post-exposure prophylaxis against HIV after sexual exposure could reduce the risk of HIV acquisition after sexual assault by about 80% if given as soon as possible—ideally within 24 hours—and continued for 28 days. Pathogenesis studies indicate that it is unlikely to be beneficial if started after 72 hours.17 Evidence for the relative effectiveness of different combinations is lacking, but safe and tolerable drugs are preferred.^w13 In the United Kingdom, generally three drugs are recommended,17 costing about £600 (€880; $1197). Treatment for 3-5 days can be provided initially as many people choose not to continue. Subsequent follow-up should be under the supervision of a clinician with experience of HIV and should include adherence and other support and follow-up testing for HIV.

What are the psychosocial factors associated with sexual assault?

The psychological and social impact of sexual assault can be profound. Elements contributing to post-traumatic responses include the personal meaning of the trauma, perception of (not actual) life threat, actual injury, being the victim of a completed rather than an attempted rape,18 and repeat traumatisation. Psychological reactions vary greatly, but overall people who experience rape are more likely to develop post-traumatic stress disorder than victims of any other crime.^w14

In the early weeks after sexual assault most people experience strong emotional reactions and express a range of post-traumatic symptoms. Other early symptoms include anxiety, tearfulness, self blame and guilt, disbelief, physical revulsion, and helplessness. About half19 recover from the acute psychological effects by 12 weeks but in many symptoms persist for years. About 17% develop disabling mental health and social problems.^w14 Longer term difficulties include post-traumatic stress disorder, generalised and phobic anxiety, depression,^w15 difficulties with social adjustment and sexual functioning,20 and substance misuse. Feelings of shame and humiliation are common and persistent and contribute to low self esteem and depression. Levels of suicidal ideation and attempted and completed suicide among people who have been raped are significant.21

Early intervention is often indicated for distress, although randomised controlled studies indicate that psychological debriefing may harm rather than benefit.22 23 Key elements are education (including written information); a space to ventilate and explore anger; reduction of shame and guilt; and consideration of coping mechanisms, sexual matters, and social support and integration. Support in a safe environment can be provided by sexual assault centres, victim support and rape crisis services, and general practitioners, as well as families, friends, and partners. Coordinated community based programmes, studied using a qualitative multiple case study design, have been found to benefit people who have been raped24 and may be more acceptable than health services for some.

Although most people recover spontaneously, treatment of clinically significant psychopathology is essential. General practitioners have an important role in identifying those requiring formal treatment and ensuring follow-up, given the risks outlined and frequency of avoidance symptoms. Management guidelines for post-traumatic stress disorder25 indicate that people should be offered trauma focused psychological treatment (cognitive behaviour therapy or eye movement desensitisation and reprocessing), regardless of the time since the trauma. If no noticeable improvement results, clinicians should consider an alternative psychological therapy or drugs. Antidepressants are indicated for prominent depressive symptoms or a distinct depressive illness. Short term use of hypnotics and anxiolytics may be beneficial for hyperarousal in the immediate aftermath. Management may be more complex in those with repeat traumatisation, when referral to a specialist centre should be considered.