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Rape, or the sexual assault of children, women, and men, is a common act.
any sexual act performed by one person on another without that person's
consent

Very young
Mentally and physically handicapped
Very old are
Homeless
*Although the perpetrator may be a stranger, he or she is often an individual well
known to the victim.

Marital Rape - involves forced coitus or related acts without consent but within the
marital relationship

Date Rape - the woman may voluntarily participate in sexual play, but coitus is
performed, often forcibly, without her consent; often not reported because the victim
may believe she contributed by partially participating.

Statutory Rape - consent is irrelevant because the female is defined by statute as

being incapable of consenting.

Victim deserves it
Indication of basic promiscuity of victim
Victim lied

Rape Trauma Syndrome (burgess and holmstrom)

1. Immediate (acute phase)
Lasts from hours to days
Associated with a paralysis of the individual's usual coping
mechanisms
Victim may demonstrate manifestations ranging from complete loss
of emotional control to a well-controlled behavior pattern
Actual reaction may depend on a number of factors:
relationship of the victim to the attacker
whether force was used
length of time the victim was held against his or her will

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Comb pubic hair for hair samples

Collect fingernail scrapings where appropriate
Collect saliva for secretion substance

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Turn specimens over to forensic authorities and receive receipts for chart

Discuss degree of injury, probability of infection, and possibility of pregnancy

Discuss general course that can be predicted
Consult with rape-trauma counselor
Arrange follow-up visit for medical and emotional evaluation in 14 weeks
Reassure as far as possible

Treat injuries
Diagnose and treat STD

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Prevent pregnancy
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Collect vaginal (rectal and pharyngeal) samples for sperm

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Collect articles of clothing

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2.

- fear, mood swings, irritability, guilt, anger,

depression, and difficulties in concentrating. Frequently, the victim will
complain of flashbacks to the attack
Second Phase (reorganization phase)
Flashbacks and nightmares may continue, but phobias may also
develop; directed against members of the offending sex, the sex act
itself, or nonrelated circumstances, such as a newly developed fear of
crowds or heights
May institute a number of important lifestyle changes, including job,
residence, friends, and significant others
major complications such as the contraction of a sexually
transmitted disease (STD) or a pregnancy occur, resolution may be more
difficult
may last from months to years and generally involves an attempt on
the part of the victim to regain control over his or her life
During this time medical care and counseling must be
nonjudgmental, sensitive, and anticipatory
When the physician realizes that the patient is contemplating a
major lifestyle change during this period, it is probably appropriate to
point out to the patient why the change is being contemplated and the
complicating effects it may have on the patient's overall well-being.

Examine patient thoroughly and specifically note injuries

- specific injuries or general complaints of soreness,

eating problems, headaches, and sleep disturbances

Document history carefully

is important to obtain informed consent before examining the patient and

collecting specimens
it helps the victim to regain control over her body and her life.
It is important to have a chaperone present during the taking of the history
and the performance of the examination and specimen collection to reassure
the victim and to provide support.
presence of such a third party probably reduces feelings of vulnerability on
the part of the victim
history of previous gynecologic conditions, particularly infections and
pregnancy, use of contraception, and the date of last menstrual period,
should be recorded

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Pharynx 6 hr

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Up to 8 hr

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Vagina

Up to 79 days Variable (Up to 48 hr)

Unknown

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HepB vaccination and tetanus prophylaxis are given when appropriate

follow-up visits the patient should again be investigated for signs and
symptoms of the STDs, and appropriate repeat cultures and serologies
should be obtained.
Prophylactic antibiotics are useful in acute rape management when the
patient is concerned about contracting an STD or knows the assailant to be
high risk

RPR, rapid plasma reagin.

Candidapotassium hydroxide preparation

Trichomonassaline preparation

Condyloma virusstudy lesion

Cytomegalovirusserology

HIVserology

Hepatitis Bscreening serology

Herpes simplexculture lesion or serology

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SyphilisRPR

Chlamydia trachomatisculture

meaningful, medicolegal material must be collected shortly after the assault

takes place and definitely within 96 hours
evidence for coitus will be present in the vagina for as long as 48 hours after
the attack
but in other orifices the evidence may last only up to 6 hours
and
are legal terms, they should not be stated as

diagnoses; rather the physician should report findings as consistent with use
of force.
Nonmotile sperm may be present as well if the attack occurred 12 to 20
hours previously
motile sperm will be noted for as long as 2 to 3 days in the endocervix
It is difficult to ascertain whether ejaculation occurred in the mouth, because
residual seminal fluid is rapidly destroyed by bacteria and salivary enzymes,
making documentation of such an event difficult after more than a few hours
have passed.
Seminal fluid may be found staining the skin or the clothing several hours
after the attack, and this should be looked for
Medicolegal Responsibilities:
1. careful documentation of history
2. thorough examination of the patient and specific noting of all
injuries
3. collection of articles of clothing
4. collection of vaginal, rectal, pharyngeal samples
5. combing of pubic hair
6. collection of fingernail scraping
7. collection of saliva
8. submission and receiving of receipts of specimens to forensics

Gonorrheaculture for Neisseria gonorrhoeae

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If the patient is at risk for pregnancy at the time of the assault, an

appropriate emergency contraception or morning after prophylaxis can be
offered as long as the pregnancy test was negative

patient's menstrual history, birth control regimen, and pregnancy status

should be assessed

[*]

Rectum Undetermined 20 to 24 hr

100 IU

Cervix

Similar to vagina

Up to 5 days

Up to 17 days

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are terms referring to violence occurring between

partners in an ongoing relationship even if they are not married.
Violence between individuals within a relationship regardless of marital
status (current or former spouse, live-in, boyfriend, girlfriend, dating partner)
Actual or threatened
Physical, sexual and/or psychological
Most common sites for injury are the head, neck, chest, abdomen, breast,
and upper extremities
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Physical complaints involving several organ system

Chronic and bladder problems
Chronic fatigue

Context of child sexual abuse

Sexual abuse of children may be divided into two types:
- first in which the child is victimized by a stranger
- a family member or friend is the perpetrator
In the case of child sexual abuse involving a stranger, the act is usually a
single episode and is usually reported to the authorities.
Child is capable in most instances of clearly stating what happened, and the
act may involve any form of sexual activity and may have taken place
because of enticement, coercion, or physical force
Child should be interviewed carefully and allowed to tell what happened
Police or protective services should be notified, and, where appro-priate, the
techniques used in evaluating a rape victim should be applied.
Appropriate prophylaxis against infection should be employed, and
counseling should be arranged with a mental health care worker, who should
see the child immediately and also take the responsibility for planning longterm follow-up.

start investigation ASAP

Appropriate questioning
Detailed and discrete injury
Reassurance
Appropriate referrals
Appropriate counseling

guilt feelings
fearful that withdrawing from the relationship will destroy the family
shame and humiliation
weak ego and self image
difficult relationships later on
poor interpersonal relationships and chaotic families in the future
abnormal psychological development
psychiatric symptoms

removal of the clitoral prepuce

excision of the clitoris
removal of the clitoris and labia minora.
labia majora is also partially removed and the vagina partially sutured closed
procedures are often performed between early childhood and age 14 and
frequently without anesthesia under unsterile conditions by untrained
practitioners
complications often occur, including infection, tetanus, shock, hemorrhage,
and death
Long-term problems include chronic infection, scar formation, local
abscesses, sterility, and incontinence
depression, anxiety, sexual dysfunction, obstetric complications, and the
psychosomatic conditions associated with sexual abuse may be seen

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Families in which incestuous activity is taking place may appear normal, but
family members frequently have limited contact with the outside world.
Family relationships are often chaotic, including problems such as alcohol
and drug abuse and severe mental illness.
fatherdaughter incestuous relation-ships the father is frequently a passive,
introspective person who experiences a weak sexual relationship with the
child's mother

each case the child should be carefully told that

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Discussion with patient the degree of injury, likelihood of infection and

pregnancy
Reassurance stress to the patient that she is a victim and is not at fault
Follow-up plans within 1-4 weeks for reevaluation of the patients overall
condition
Appropriate referral
*Stress that the patient is a victim and is not responsible for the assault

breast and abdomen

escalation postpartum
significant correlates: anxiety, depression, housing problems, inadequate
prenatal care, substance abuse

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Frequent crying
Often accompanied by male partner

Associations abuse of children or elderly in the same household

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history of childhood abuse

raised in single parent household
early/teenage marriage
pregnancy before marriage

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head
neck
chest
abdomen
breast
upper extremity

Injuries

pushing
slapping
kicking
hitting
beating

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Passivity

verbal abuse, threats

throwing objects
threatening or use of a weapon
mental abuse
intimidation

Jumpiness

Drug or alcohol abuse (often overdose)

Evasiveness

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Intimate Partner Violence - the CDC's currently preferred term because it allows for
males or females to be the victim and intimate partners can be the same or opposite
sex
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Other signs and symptoms

Embarrassment

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Chest, back, or pelvic pain

Battered Wife Syndrome - defined as a symptom complex occurring as a result of

violence in which a woman has at any time received deliberate, severe, or repeated
(more than three times) physical abuse from her husband or significant male partner
in which the minimal injury is bruising

Hyperventilation

Shyness

Insomnia

Battered Woman - defined as any woman over the age of 16 with evidence of physical
abuse on at least one occasion at the hands of an intimate male partner

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Headaches

Choking sensation

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Upper extremities may be fractured as the woman attempts to defend

herself
Murder and suicide are frequent components of the domestic violence
problem
There is a strong relationship between spouse battering and child abuse
Physical abuse in pregnancy

Tension building
Tension between the couple gradually escalates manifested by discrete acts
that cause family friction
Name calling, intimidating remarks, meanness, and mild physical abuse such
as pushing are common

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Change clothes, other necessities in a suitcase left with a trusted friend or

relative
Cash, checkbook left with a friend
ID and other important papers
Toy, book, favorite or special thing for each child
Available financial records
Where to go
Asks neighbors to call police
Remove weapons
Teach kids to call for help

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Stress gravity of situation

Evaluate patients overall condition
Evaluate patients assessment of her situation and readiness to take action
Appropriate referrals
Assessment of community resources
Handle domestic violence
The doctors job is to recognize the problem and offer or get counseling for
the victim so that she understands her rights and alternatives and learns to
protest and her children from future harm

The incidence of sexual abuse of women in the United States was

estimated to be 73/100,000, accounting for 6% of all violent crimes.
Sexual assault happens to people of all ages, races, and socioeconomic
groups, but the very young, the mentally and physically handicapped, and
the very old are particularly susceptible.
Two phases of the rape-trauma syndrome occur. The first is the immediate
or acute phase and lasts hours to days. The second, the reorganization
stage, lasts months to years.
In caring for rape-trauma victims, the physician's responsibilities are
medical, medicolegal, and supportive.
About 12% to 40% of victims who are sexually assaulted have injuries.
Rape-trauma victims should always be treated as victims. At no time
should guilt be implied.

First Phase increases in length and intensity

Second Phase becomes more severe
Third Phase decreases in duration and intensity

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batterer apologizes, asks forgiveness, and frequently shows kindness and

remorse, showering the victim with gifts and promises
gives the victim hope that the relationship can be saved and that the violence
will not recur
Batterers are often charming and manipulative, offering the victim
justification for forgiveness

represented by an uncontrollable discharge of tension that has built up

through the first phase
attack may take the form of both verbal and physical abuse
the victim is often left injured

Dissatisfaction and hostility are often expressed by the batterer in a

somewhat chronic form
Victim may attempt to placate the batterer in hopes of pleasing him or
calming him
She may actually believe at this point that she has the power to avoid
aggravating the situation. She may not respond to his hostile actions and may
even be successful from time to time in apparently reducing tensions
Tension phase builds, the batterer's anger is less controlled, and the victim
may withdraw, fearing that she will inadvertently set off explosive behavior.

About 10% of all child abuse cases involve sexual abuse.

As many as half a million children are sexually abused each year in the
United States.
Incestuous activity may be experienced by as many as 15% to 25% of all
women and approximately 12% of all men.
Approximately 80% of all cases of sexual abuse of children involve a family
member.
Fatherdaughter incest accounts for about 75% of reported cases;
however, brothersister incest may be the most common type, although it
may not be reported often.

An estimated 2 million cases of domestic violence are reported in the

United States each year.
In 93% of the cases, the wife is the victim of the violence.
More than half of the men who abuse their partners also abuse their
children.
About 10% of antepartum clinic patients may be victims of battering.
Victims of battering demonstrate multiple somatic complaints.
Two thirds of batterers who carry out violent acts are under the influence
of alcohol, but this may be the excuse rather than the reason.

If the male batterer has not undergone a violence elimination program, a

referral of the family for family counseling should
be made because it
may raise issues that exacerbate the violence.
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As many as 25% of women treated for injuries in an emergency room are

likely to be victims of wife battering. Diagnosis of this by a physician is rare.

Between 500,000 and 2.5 million cases of abuse of the elderly reportedly
occur in the United States each year.