Rape trauma syndrome

Rape trauma syndrome: Excerpt from Handbook of Diseases

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 after 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.

Incidence of reported rape is highest in large cities and is rising. However, more than 90% of assaults may still go unreported.

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 one out of seven reported rapes involves a prepubertal child.

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

Usually, 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

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.

A rapist usually has feelings of violence or hatred toward women or sexual problems, such as impotence or premature ejaculation. He may feel 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, or 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.

❑ Immediate reactions to rape differ. The patient may experience crying, laughing, hostility, confusion, withdrawal, or outward calm; in many cases, 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: Make sure your documentation is thorough. 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 whether she’s allergic to penicillin or other drugs, whether she has recently been ill (especially with venereal disease), or whether she was pregnant before the attack. Also ask the date of her last menstrual period and details of her obstetric-gynecologic history.

❑ Thoroughly explain the examination she’ll have, and tell her that 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 example, ask her whether 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 physician’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.

GENDER INFLUENCE: 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 phospate 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 doesn’t 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 in-valuable.

❑ 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” (norqestrel/ethinyl estradiol) 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 minor 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 may have nightmares in which she’s powerless; later dreams should 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 fear of intercourse or mistrust of men.

Special considerations

❑ Because cultures can’t detect gonorrhea or syphilis for 5 to 6 days after the rape, stress the importance of returning for follow-up venereal disease testing.

❑ If the patient receives DES, explain its adverse effects.

❑ Legal proceedings during this time force the victim to relive the trauma, leaving her feeling lonely and isolated, perhaps even temporarily halting her emotional recovery. To help her cope, encourage her to write her thoughts, feelings, and reactions in a daily diary.

CLINICAL TIP: Refer the victim to an organization such as Women Organized Against Rape or a local rape crisis center for assistance and counseling.

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

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