by David Page
Myth: A Woman Should Do What Her Husband Wants
Recognizing that rape is more than sexual assault has perhaps most meaning in the concept of spousal rape. Not only is the woman pressed to submit against her will sexually, she is attacked by force, thus confirming that rape is more than a simple sexual attack. It is a violent crime against the victim. And it is all the more repulsive in this instance because the marriage bond is built upon trust. When trust is tossed out, there can be little hope for the preservation of the bond.
Spousal immunity has been eliminated in many but not all states.
Myth: A Man Cannot Force Himself on a Woman
A clear difference now exists between consent and submission. The meaning of each is elaborated in the points presented below.
• Before the 1970s the victim was expected to "resist to the utmost" until overwhelmed and the rape consummated. This produced horrible genital and extragenital injuries.
• "Without her consent" implies that all force and energy to resist the assault was not used. This strategy avoids serious injury to the victim. Children and the elderly cannot resist anyway.
• "Against her will" implies the victim resisted in vain and was assaulted despite efforts to protect herself.
• Lack of physical injury in a sexually assaulted woman does not imply consent. Intimidation and physical threats cannot always be countered, especially when the attacker has a weapon or the physical size to carry out his threats.
Myth: "She Asked for It"—
Rape as a Spur-of-the-Moment Impulse
Rather than a lustful, salivating sex-crazy fool, the rapist is most often an angry man of low self-esteem who hates women. He is incapable of forming solid relationships with women and feels insecure in his activities of daily living. In a word, the rapist is a misfit who feels powerless to control his world.
Rape has been classified by motivation as follows.
• Power rape: 65 percent
• Anger rape: 35 percent
There's actually a difference in attack method between the two. The power rapist thinks out ahead of time who he wants to rape and how he will carry out the attack. Often the victim is about his own age, and, while he uses force in gaining control of his victim, the assaults are not violent. On the other hand, the angry rapist often attacks children and the elderly with little or no premeditation. Nongenital injuries are more common as the angry rapist uses more force than is needed to subdue his prey. At the outer limit of this repugnant behavior is the sadistic rape and sexual assault that results in the victim's death.
The rape victim carries her burden of guilt and shame for years. These initial emotions often mushroom into a variety of symptoms and behaviors, many also known as post-traumatic stress disorder. Included in the chronic illnesses seen in sexually assaulted adult women are:
• Depression
• Low self-esteem
• Development of an addictive personality
• Worry about overall poor physical health
• Development of functional limitations (unable to perform activities of daily living)
• Complaints of multiple chronic diseases
• Complaints about medically unexplained physical symptoms Other problems that may appear in assaulted women include:
• Pelvic infections; sexually transmitted diseases
• Chronic pelvic pain
• Pelvic trauma, e.g., abrasions, bruises and contusions of the mons and labia, lacerations of vagina or rectum
The Initial Examination of the Victim
Health care workers are concerned not only with identifying the extent of the victim's injuries but also with caring for her and with collecting information to convict the suspect. Therapy begins immediately. A rape victim may seek medical care in any of the following sites:
• Emergency room
• Private primary care doctor's office
• Gynecologist's office
• Hospital clinic
• "Doc-in-a-box" neighborhood walk-in clinic
• College or university health center
All victims of sexual assault should have a complete history, physical examination and evidential evaluation within thirty-six hours of the assault. The examining doctor must complete several duties during the initial evaluation. These include:
• Taking a general medical history as well as asking questions about the rape and what the victim did after the assault (all information documented in writing)
• Performing general and gynecologic examinations
• Collecting appropriate specimens for legal evidence using standard rape kit
• Providing emergency care and proper treatment of injuries
• Providing psychological support for victim at time of exam and arranging for follow-up therapy
• Providing advice regarding options on therapy to prevent pregnancy
• Giving appropriate antibiotics to prevent venereal disease and advising regarding option to be tested for AIDS
The physical examination is not easy for the victim. She feels violated, embarrassed. Her emotional status must be recorded and kept in mind as procedures are carried out in an orderly fashion. Not all injuries to rape victims are genital; 4 or 5 percent of these unfortunate victims require emergency surgery to repair lacerations and other bone and soft tissue disruptions.
The examiner must realize she is placing the victim in a situation similar to the rape: The doctor is in a position of control and can make the victim feel helpless. Therefore, the examiner must be objective, non-judgmental, kind and gentle. The doctor should ask permission before performing any part of the exam where touching or probing the victim is involved. The vaginal speculum should be warmed (no lubricant other than warm water) and inserted slowly as the examiner talks with the patient. Without a sensitive, caring practitioner, the victim may feel she's being raped all over again.
Evidence of recent sexual intercourse on examination includes:
• Engorgement of labia
• Engorgement of clitoris
• Redness of the posterior vaginal opening (fourchette)
• Presence of semen
• Presence of acid phosphatase
The time of the rape may be determined by the presence of several substances in semen:
• Motile sperm from the victim means the rape occurred within the last three hours.
• Acid phosphatase, an enzyme from the prostate, if present at a certain level in the vaginal washings (specimen), strongly suggests ejaculation occurred within the last twenty-four hours.
• P30, a prostate-specific protein found in semen, indicates ejaculation occurred within the last forty-eight hours.
Examination of the Sexual Assault Victim
History
■ Main complaint: What type of assault was it? What body orifices and parts are involved? What hurts? Is there bleeding? Is there evidence of severe injury requiring emergency (resuscitation) care?
■ Qualifying questions: Did ejaculation occur? Body penetration? What did the victim do after the assault? Shower? Change clothes? Take an enema? Douche? What is the victim's emotional state? Is she crying? Combative? Screaming? Huddling in fear? Noncommunicative? How many assailants? Did she ingest alcohol? Was the assailant drunk? Did the victim have consensual sex within seventy-two hours of assault? Obtain an explicit account of the sex act.
■ Past medical history: Is there a history of chronic illness such as heart disease, lung problems, diabetes or any other condition that may be worsened by the assault (chest pain, gasping, dizziness because of low blood sugar, etc.). Are medications in use? Pacemaker? Does the victim think she was pregnant before the attack? Is she using a method of birth control? Did she ever have tetanus prophylaxis?
Physical Examination
Performed with one or more attendants.
■ Have the victim disrobe on a clean sheet of paper that gets folded and sent to forensics with other specimens.
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■ Describe the victim's general appearance.
■ Describe the condition of her clothes. Are there stains? Tears in the fabric? Blood?
■ What is her emotional state?
■ Perform a general examination, and take photographs of any injuries, major or minor.
■ Perform gynecological examination, and document all injuries and the presence of any fluids or blood. Rarely use colposcope* and photodocumentation.
■ Use Wood's Lamp (fluorescent) to identify semen.
■ Use Rape Kit to collect:** —Semen
—Pubic hair (with collecting comb) —Head hairs (plucked, compared to pubic hair) —Saline swab of vagina —Saline swab of perianal skin when indicated —Swabs of vagina and anal area in sterile tubes for culture —Blood sample in appropriate tube —Saliva sample (filter paper inside plastic tube) * Colposcopy is an examination of the vagina and cervix using a special instrument with magnification and photographic capabilities. It's used infrequently.
**Material collected in the Rape Kit is sent to a forensic crime lab for expert evaluation.
Therapy is aimed at re-establishing a sense of worth and providing strategies to help the rape victim get on with her life. The goal is to assist her in beginning to cope with the trauma and to deal with the flashbacks, the feelings of shame and of lost self-worth. Frequently, multiple physical complaints arise. These include difficulty in sleeping, lack of concentration, irritability, eating disorders, gastrointestinal complaints, headaches and others. Studies confirm that these victims use medical care facilities much more frequently after the sexual assault than prior to it. Available to the victim are sexual assault response teams, victim assistance programs, rape crisis centers, psychological counseling and financial aid.
How Is a Rapist Identified?
DNA fingerprinting: This technique is still developmental, but highly specific. If a match from blood, saliva, hair or semen can be made, the likelihood the fluid was left by the assailant is high. ABO blood type antigens: They may be identified in saliva, blood or semen, and many additional antigens may be tested to narrow down the match with those identified in the fluids collected from the victim.
Sexual Assault Against Children
In children, the definition of sexual abuse includes any sexual activity between a minor child (less than eighteen years old) and a person who
Post-Traumatic Stress Disorder and the Rape Victim
■ Victim may have feelings of guilt, powerlessness, shame, fear, embarrassment, anger, feelings of stupidity, depression, anxiety, possible concern for the rapist.
■ Stress disorder may be expressed as bad dreams, flashbacks to the attack, difficulty concentrating, avoiding anything that reminds victim of the assault, loss of ability to relate emotionally to another, becoming easily annoyed.
holds power and authority over the child. Often sexual abuse of children is classified as either incest or extrafamilial.
Offenders may be under legal age themselves, and the criminal acts may include fondling, pornography, exhibitionism and/or penetration of the vagina, mouth or anus. No specific profile of a pedophile has been described but 98 percent of offenders in cases of child sexual molestation are male. Fifty percent of molested children are between ages six and twelve. Forty percent of the criminals are family members, and 20 percent are not known to the child. Almost half of these children are molested more than once. Ironically, children have a greater chance of being sexually assaulted at home.
So much for the myth of the stranger offering candy.
Incest refers to inappropriate sexual contact that involves members of a family with established relationships. It may include anyone in the family whom the child views as a caring, trustworthy adult. Stepparents and significant others who are acting as surrogate parents may become perpetrators as well as older stepbrothers and sisters.
The Child Sexual Abuse Scenario
To become abusive, the relationship between the child and the adult (or older child) must possess several features. Above all else the child must view himself as essentially helpless in the presence of the dominant and powerful adult. Most abusers know the child they select to sexually assault. At times, the assault is purely random.
Minor sexual contact may occur between an adult and a child. But when the true abuse scenario begins, the child feels that it is imperative to submit to the adult's authority. Rather than using threats and force, as in the adult sexual attack, the adult coerces the child with a steady stream of small gifts, compliments and perhaps extra attention. The adult must have access to the child, particularly when no one else is around.
One can imagine small talk, perhaps offhanded fondling and the first suggestion of exposing each other. Touching would follow as the child becomes drawn into the adult's powerful influence. Suggestions would be repeated that it's alright. They really like each other. No one's around. We enjoy this, don't we? And then the more overt sexual acts follow. Oral sex is often pressed on the child at first. Vaginal or anal sex may follow or "dry intercourse" where the adult rubs his penis against the child's genitals without penetration. Some sexual acts may cause the child minor genital irritation that's not easily detected. Others cause serious injury and leave lacerations and other evidence that would be a clear sign of trouble if only the child could reach medical care.
As time goes on, the adult reinforces the relationship's secret nature. At this point, the ever-powerful adult may suggest that the child was the one who actually started the intimate contact. With reinforcement the child begins to feel guilty. It's her fault. Who can she tell? Threats of physical injury to the child may be made now, and at times, real force is used to make the point.
Will the child reveal the secret? Most experts agree child sexual abuse is grossly underreported and often is revealed only later in life. How does the abusive relationship become known?
• The child confides in someone.
• Someone recognizes abnormal behavior in the child.
• An injury is evaluated by a doctor who suspects abuse and pursues
the diagnosis.
Evaluation of the Abused Child
Taking the history of a confused and frightened child is a little different than with adults. Because of the obvious difficulties with communication with a child, special techniques are used. These include the posing of open-ended questions, avoiding leading the child, and employing anatomically correct dolls. The dolls help to clarify something the child has said as well as enabling nonverbal children to communicate.
The physical examination can be performed in a doctor's office by a skilled clinician who is not rushed and who takes time to establish rapport with the victim. A caretaker may have made observations that suggest abuse and may help direct the physician's evaluation. A careful exam of the external genitals following standard steps and with the use of magnification permits the identification of small abrasions and cuts that would otherwise be missed. If major vaginal or anal injuries are seen on the initial examination, it is often necessary to take the child to a hospital where operating room facilities permit a thorough examination under anesthesia. If lacerations are discovered, they may be properly repaired at that time. More subtle are changes in the hymen such as notching or portions missing because of repetitive penetrating (stretching) trauma.
Several traps await the physician who examines a child for suspected sexual abuse. First, the evidence may have disappeared (small cuts and tears healed) by the time the child is examined. Also, youngsters scratch themselves, causing irritation and inflammation and leaving marks that could be misconstrued as abuse. Many reports on the relationship between the size of the hymenal opening and allegations of sexual abuse have been published and little agreement exists among experts. Overall, an opening of greater than one centimeter in a child is suggestive of abuse, as are recent or healed lacerations of the vagina or venereal disease. More conclusive is the presence of sperm. Finally, the last trap is to assume that the absenc
e of physical evidence of abuse means it didn't happen. It doesn't mean the child's story is suspect.
Treatment includes timely repair of physical injuries and the provision of emotional support for the victim and the family. Child sexual abuse cases are classified as acute when the child is evaluated soon after the assault and when forensic evidence must be collected (following similar guidelines as in adults). Major lacerations are treated surgically. The child may arrive in the ER or doctor's office complaining of genital or anal pain and bleeding. Less acute is the child assessed three or four days after the event. At this juncture, the child's safety is of paramount importance. As suggested above, some evidence may have already disappeared. Also, the children who come to medical evaluation even later are usually not severely hurt and are safe. But, as in the other scenarios, it is imperative that the child's safety be assured, particularly if the perpetrator lives with the child. Child protective services are available in most areas.
Long-term complications are common. Ongoing therapy is an essential part of the multidisciplinary approach to child sexual abuse. Sexually transmitted diseases are unusual in youngsters but should be treated if present. Girls who are menstruating must undergo pregnancy testing and should be offered medication to prevent pregnancy.
All states require the examining physician to report suspected cases of child sexual assault.
The Sexually Abused Adolescent
As adolescents struggle with an emerging, uncertain self-image, ideas about the role of people around them in their lives become focused and spiritual values are integrated into the young person's belief system. Interpersonal relationships are important, and communication with adults and other adolescents forms the basis of the adolescent's view of life. At this critical time when values and beliefs are being assessed and accepted as part of the person's self-concept, any disruption may prove to be overwhelming.
Lynn Rew, RN, Ed.D., and Pat Shirejian, MSN, RN, in the Journal of Psychosocial Nursing in 1993, describe the feelings, thoughts and behaviors of sexually abused adolescents that occur in the psychophysiologic, social and spiritual domains of their lives. Because they are not able to cope with the abusive event and the disastrous effect of the loss of trust in adults, these young adults become a setup for revictimization. Thus often begins the destructive relationship that leads to thoughts of betrayal, despair and the potential for violence.
