Editorials

Management of people who have been raped

Needs special expertise, and more of it

Rape is common but under-reported, with an estimated lifetime risk of up to one in four for women.¹ Definitions vary between countries; in England and Wales the term refers to non-consensual vaginal or anal penetration by a penis, of a woman or a man. Serious sequelae include psychological problems, infection, and unwanted pregnancy. People who have been raped may present, immediately or later, to general practitioners or other clinicians, not all of whom may be familiar with such situations. Here we outline the care of people who present after sexual assault; we use the relatively neutral term clients, as suggested elsewhere.²

Optimal management depends on the client's wishes and needs, time since assault, and whether involvement of the police is requested. Meticulous medical notes are essential even if involvement of the police is declined initially, as reports may be required later for legal processes or compensation. Immediate considerations include safety, management of injuries, forensic examination, and emergency contraception. In situations of domestic violence or perpetrator's physical proximity a client might need alternative accommodation. Although genital injuries have been found in 16-58% of clients examined and non-genital injuries in 31-82%, ^{1 3 4} few are sufficiently serious to require hospital referral for suturing or further investigations.³

Forensic examination aims to collect evidence for use in criminal justice processes, including documentation of injuries and samples for DNA and toxicology. It involves a "top to toe" survey as well as genital examination and is ideally undertaken by a doctor or nurse with special training, such as a sexual offences examiner, whose sex is acceptable to the client.⁵ Retrieval of DNA is maximised by conducting the examination as soon as feasible after the assault, and advising the client not to wash, drink, or eat (depending on the orifices involved) until samples have been taken. Police officers can collect urine samples and mouth swabs, thereby minimising the client's discomfort while waiting as well as increasing the chance of detecting drugs excreted in the urine. If more than seven days have elapsed since the assault sampling for DNA is unlikely to be productive,⁶ but documentation of injuries may still be relevant.

In some areas the examination and other treatment can take place in dedicated sexual assault referral centres, ^{4 7} otherwise police can organise an examiner. Sexual assault referral centres provide supportive and forensically secure environments; clients who have not directly involved the police can also access them to receive treatment as well as possibly providing anonymous intelligence and evidence. Availability of specialist services, and hence quality of care, varies widely.⁸

Pregnancy following rape occurs in about 5% of women of reproductive age, and adolescents are most vulnerable.² Risk of pregnancy and views on contraception must therefore be explored. Progesterone only emergency contraception (Levonelle) can be taken up to 72 hours after the event; we believe that it should not be withheld after rape even if the woman had unprotected intercourse earlier in that cycle. An intrauterine device containing copper can be inserted up to five days after the earliest expected date of ovulation, or up to five days after assault in the absence of previous unprotected intercourse in that cycle.

The risk of sexually transmitted infections following rape is 4-56%⁷; infections found reflect those that are prevalent locally. Referral for assessment of sexually transmitted infections two weeks after the assault allows for incubation periods of gonorrhoea and chlamydial infection. A single genital screen misses up to 12% of infections,⁹ but repeatedor even initialexaminations may compound the invasion of the assault. Clients at high risk of sexually transmitted infections but unwilling to be examined further should therefore be offered prophylactic antibiotics² to prevent serious long term sequelae, such as pelvic inflammatory disease.

Acquisition of HIV infection following rape is rare in low prevalence areas such as the United Kingdom; risks are increased if assailants come from high prevalence areas, if there is trauma (including defloration), or if the rape victim is male. Postexposure prophylaxis with antiretrovirals given within hours of occupational exposure significantly reduces HIV acquisition,¹⁰ and is increasingly used after sexual exposure despite the lack of specific evidence.¹¹ The decision to start postexposure prophylaxis should be based on assessment of the individual risk and views of the clientlocal HIV services can advise further.

Psychological sequelae of rape are many including anxiety, depression, suicidal ideation, and problems related to relationships and sex.¹² The immediate risk of suicide must be assessed and referral arranged as appropriate. Advice on support and counselling services should be provided and a follow up appointment offered.

Sensitive and coordinated care for people who have been raped is crucial in promoting recovery and preventing later problems. It may also enable clients to participate in criminal justice procedures and thereby help reverse falling conviction rates.⁸ Optimal management recognises a client's multiple needs as well as the allegation of a crime, and is best provided by specialist services resulting from constructive collaboration between health services and police. Wider access to such services is badly needed.

Jantje Wilken, general practitioner and sexual offences examiner. 
Jan Welch, consultant. 

The Haven, Department of Sexual Health, King's College Hospital, London SE5 9RS (jan.welch{at}kingsch.nhs.uk)

Footnotes

Competing interests: None declared.