CAUSES AND SYMPTOMS

Rape is an act of violence; it is an expression of aggression and anger rather than a sexual motivation. A power imbalance usually exists, with the stronger of two individuals committing the assault. The typical victim of rape is a sixteen- to twenty-four-year-old woman; however, any male, female, or child can be raped. Sexual assault has a broader definition than rape. In addition to vaginal, anal, or oral penetration, sexual assault includes inappropriate touching as well as any physical contact, speech, or presentation of images that an individual finds objectionable. Many types of rape and sexual assault exist, including spousal, incest, child, elder, date, acquaintance, coworker, stranger, and same-gender. Cases of women raping women or men exist.

In the United States, the estimated lifetime prevalence of sexual assault is approximately 18 percent in females and 3 percent in males. The typical rapist is a twenty-five- to forty-four-year-old man who plans the attack and usually selects a woman of the same race. About 50 percent of the time, the victim knows the rapist through work, friends, family, or by living in the perpetrator’s neighborhood. More than 50 percent of rapes occur in the victim’s home. The rapist may break in or gain entry through a ruse, such as posing as a salesman. Compared with other men, rapists drink more heavily, begin having sexual experiences earlier, and are more likely to have been physically or sexually abused as children. Individuals who have been sexually assaulted as children are also more likely to be assaulted as adults. Many studies note that more than 50 percent of all physical and sexual assaults involve a perpetrator who was reported to have been drinking. Often, rape victims have also consumed alcohol before the incident (estimates run as high as 60 to 70 percent). Illegal drug use is a factor in many rapes. The perpetrator may be under the influence of drugs or administer them to the victim. Date rape occurs when a sexual assault occurs during a date. The rapist often gives the victim drugs or alcohol; the most common date rape drug is alcohol. Regardless of the circumstances, victims of sexual abuse are not at fault. For example, if the victim exhibits provocative behavior, the perpetrator should control his (or her) impulses. Most rapes are not reported to the police (80 to 90 percent by most estimates).

Immediately after a rape, the victim may exhibit the following symptoms: inappropriate behavior, confusion, crying, fear, nervousness, hostility, inappropriate laughter, sleep disturbances, anorexia, physical pain, and/or social withdrawal. Physical symptoms of rape include vaginal and rectal lacerations as well as injuries to other body parts. The presence of semen in the vagina or rectum, which can be subjected to DNA analysis for identification of the perpetrator, confirms the diagnosis of intercourse but not rape. Rape victims may suffer from posttraumatic stress syndrome, which may persist for years and have a marked impact on the victim’s life. Following a rape, some victims abuse alcohol and/or drugs; some become suicidal. More than 50 percent of rape victims develop difficulties with interpersonal relationships (such as with a husband or other partner).

TREATMENT AND THERAPY

Following a rape, the victim should proceed directly to a hospital without changing clothes, showering, douching, or urinating, as these activities may destroy evidence. Often, rape victims are referred to specialized centers that provide focused care and make certain that proper procedures are followed, including preserving the “chain of evidence.” Chain of evidence refers to the proper handling of evidence (semen, hair samples, and skin samples) from the time of collection throughout the legal process. Specimens collected for forensic evaluation include mucosal swabs, skin swabs, fingernail clippings, hair samples, blood samples, saliva samples, the victim’s clothes, and semen samples, if available. Sperm may be detected up to 72 hours after an assault in vaginal swabs, up to 24 hours in anal swabs, and are rarely detected in oral swabs. A complete evaluation of the victim may take up to six hours. In female victims, areas that should be carefully evaluated include the breasts, perineum, vagina, anus, and rectum. Nongenital trauma is commonly seen on the victim’s extremities, face, and/or neck, which may consist of bruising, abrasions, lacerations, and/or erythema. These are more likely to be present when the victim is examined within 72 hours of the assault, or if the perpetrator is a stranger. Colposcopy may be used to detect milder genital trauma and an ultraviolet (UV) light (ex: Wood’s lamp) may assist in detecting semen on the skin. In male victims, areas of concern include the penis, scrotum, prostate, anus, and rectum.

Immediate care includes medical and surgical treatment of injuries, which may be significant. The victim-and, if possible, the rapist-should be tested for sexually transmitted diseases (STDs). Minimal screening consists of testing for gonorrhea, chlamydia, trichomonas, bacterial vaginosis, and candidiasis. Necessity to screen for human immunodeficiency virus (HIV) hepatitis, and syphilis should be determined on an individual basis. Victims may opt out of testing for STDs if he/she consents to prophylactic treatment. Prophylactic treatment for STDs is recommended due to the poor follow-up visit rates. Postexposure Hepatitis B vaccination is considered adequate protection against Hepatitis B, unless the perpetrator is known to have Hepatitis B. Prophylactic antiviral medications are controversial after a sexual assault. The risk of HIV transmission after a single consensual episode of vaginal or anal intercourse is estimated to be 0.1-2 percent. Transmission after an assault is presumed to be higher, secondary to the trauma and bleeding. Risk and benefits should be discussed with the patient.

PERSPECTIVE AND PROSPECTS

From the days of ancient Greece through the American colonial period, rape was deemed to be a capital offense. Rapists were subjected to a wide range of punishments, including beatings, castration, and execution. However, in colonial America, the rape of Native American women was not deemed to be a crime because the women were “Pagan and not Christian.” Two centuries ago, rape was often not viewed as a type of physical assault; rather, it was deemed to be a serious property crime against the man to whom the woman belonged (her father or husband). The loss of virginity was a particularly serious matter. Under biblical law, if the father agreed, the rapist was required to marry his victim instead of receiving the civil penalty.

Anecdotal reports of rape during warfare have been described since antiquity-Greek, Roman, Persian, and Israelite armies reportedly engaged in rape. During the 1937 Nanking Massacre, it was reported that Japanese soldiers raped as many as 80,000 Chinese women over a six-week period. Anecdotally, by the end of World War II, Red Army soldiers were estimated to have raped approximately 2,000,000 German women and girls. During the 1994 Rwandan genocide, an estimated 500,000 women were raped. One study found that during Liberia’s thirteen-year-long civil war, 92 percent of the women interviewed had experienced sexual assault. Even today, rape is being used as a weapon of war in the Democratic Republic of Congo (DRC) to humiliate, dominate, and instill fear in the civilians of a community.

The medical literature contains numerous analyses of rape and sexual assault. In August 2009, researchers at St. Paul’s Hospital in Vancouver, British Columbia, published a study that evaluated the sexual assault of prostitutes. They found an “alarming rate” of violence against these women. They recommended that the following steps were crucial to stem violence against prostitutes: socio-legal policy reforms, improved access to housing and drug treatment, and scaled-up violence prevention efforts, including police-prostitute partnerships.

Although young adult women are the most frequent targets of sexual assault, physical abuse of older women has risen rapidly during the last decade. In October 2009, researchers with the Michigan State University Program in Emergency Medicine published a study comparing a group of postmenopausal victims of sexual assault with younger adult women (eighteen to thirty-nine years old). During the five-year study period, 1,917 adult sexual assault victims qualified for inclusion in the study; 84 percent of the victims were eighteen to thirty-nine years old, and 4 percent were postmenopausal women who were at least fifty years old. The 72 postmenopausal victims were more likely to be assaulted by a single perpetrator, usually a stranger (56 percent versus 32 percent); to be assaulted in their own home (74 percent versus 46 percent); and to have experienced more physical coercion (72 percent versus 36 percent). The younger women were more likely to have used alcohol or illicit drugs before the assault (53 percent versus 18 percent) and to have a history of sexual assault (51 percent versus 15 percent). Postmenopausal victims had a higher number of nongenital (2.3 percent versus 1.2 percent) as well as anal injuries (2.5 percent versus 1.8 percent). The authors concluded that postmenopausal women are not immune from sexual assault and that the epidemiology of sexual trauma in this age group is different from that of younger women.

Sexual harassment and assault are not uncommon at the workplace. A study published in August 2009, by the University of Southern Maine evaluated the frequency and impact of workplace sexual harassment on the health, work, and school outcomes on high school girls. They noted that sexual harassment has a significant impact on high school girls’ connections to work and school; it not only taints their attitudes toward work but also threatens to undermine their commitment to school. They added that as a consequence of sexual harassment experienced at work, teenagers may have their career development or career potential impeded or threatened because of school absence and poor academic performance. In addition, they noted, the physical safety of working students may be at risk under these circumstances, which would create a need for teenagers to receive training to deal with sexual assault and other types of workplace violence.

As it is in adults, alcohol is a frequent component of adolescent peer-on-peer sexual aggression. A study published in September 2009 by the Institute for Research on Women and Gender, University of Michigan, examined the characteristics of adolescents involved in alcohol-related and nonalcohol-related sexual assault of peers. The researchers conducted a Web-based survey of 1,220 students (grades seven through twelve) and found that adolescents who reported alcohol-related and nonalcohol-related sexual aggression had higher levels of impulsivity and more extensive histories of dating, early sexual activity, and alcohol consumption than adolescents who did not assault. Furthermore, perpetrators of alcohol-related assault had higher levels of alcohol use in the past thirty days as well as more alcohol- or drug-related problems than perpetrators of nonalcohol-related assault.

A particularly heinous form of sexual assault is one on a child. In October 2009, investigators at the Crimes Against Children Research Center, University of New Hampshire, Durham, published a study that strove to obtain national estimates of exposure to the full spectrum of childhood violence, abuse, and crime. The researchers conducted a cross-sectional national telephone survey that involved 4,549 children up to age seventeen. The authors found that a clear majority (60.6 percent) of the children had either experienced or witnessed victimization in the previous year. Almost half (46.3 percent) had experienced a physical assault in the study year, almost 25 percent had experienced a property offense, about 10 percent had experienced a form of child maltreatment, 6.1 percent had experienced a sexual victimization, and about 25 percent had been a witness to violence or experienced another form of indirect victimization in the year (including 9.8 percent who had witnessed an intrafamily assault). About 10 percent had experienced a victimization-related injury. More than one-third (38.7 percent) had been exposed to two or more direct victimizations (10.9 percent had five or more, and 2.4 percent had 10 or more) during the study year.

A 2010-2011 survey of adolescents, between the ages of fourteen and twenty-one, revealed that 1 out of 10 adolescents had been the perpetrator of a sexual assault. An association was found with perpetrators and a higher exposure to violent X-rated media. Up to the age of seventeen, the majority of the perpetrators were male. Among those older than seventeen, females and males had an equal representation as perpetrators.

See also Addiction; Alcoholism; Club drugs; Depression; Domestic violence; Ethics; Intoxication; Psychiatric disorders; Psychiatry; Psychiatry, child and adolescent; Psychiatry, geriatric; Psychoanalysis; Stress