WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Sexual violence occurs throughout the world. Coerced sex may result in sexual gratification on the part of the perpetrator, though its underlying purpose is frequently the expression of power and dominance over the person assaulted. Often, men who coerce a spouse into a sexual act believe their actions are legitimate because they are married to the woman. Rape of women and of men is often used as a weapon of war, as a form of attack on the enemy, typifying the conquest and degradation of its women or captured male fighter (1). It may also be used to punish women for transgressing social or moral codes, for instance, those prohibiting adultery or drunkenness in public. Women and men may also be raped when in police custody or in prison. Long-term effects of childhood sexual abuse are varied, complex, and often devastating. Women who are survivors of childhood sexual abuse often present with a wide array of symptoms. Frequently, the underlying cause of these symptoms is unrecognized by both the physician and patient. Although in most countries there has been little research conducted on the problem, available data suggest that in some countries nearly one in four women may experience sexual violence by an intimate partner, and up to one-third of adolescent girls report their first sexual experience as being forced (2). Many healthcare providers knowingly or unknowingly provide care to abuse survivors and should screen all women for a history of such abuse. Depression, anxiety, and anger are the most commonly reported emotional responses to childhood sexual abuse. Obstetricians and gynecologists can offer support to abuse survivors by giving them empowering messages, counseling referrals, and empathic care during sensitive examinations.
The purpose of this document is to provide understanding and recommendations of this neglected area of research. The evidence suggests that it is a public health problem of substantial proportions. While sexual violence can be directed against both men and women, the main focus of this chapter will be on adult manifestations of childhood sexual abuse. The lack of an agreed definition of sexual violence and the paucity of data describing the nature and extent of the problem worldwide have contributed to its lack of visibility on the agendas of policy-makers and donors. There is a need for substantial further research on almost every aspect of sexual violence the factors influencing recovery of health following a sexual assault. Survivors come from all cultural, racial, and economic groups.
Sexual assault is a crime of violence and aggression, not passion, and encompasses a continuum of sexual activity that ranges from sexual coercion to contact abuse (unwanted kissing, touching, or fondling) to forcible rape. Because definitions vary among states, sexual assault is sometimes used interchangeably with rape. Sexual assault, or rape, often is further characterized to include acquaintance rape, date rape, statutory rape, child sexual abuse, and incest. These terms generally relate to the age to victim and his/her relationship to the abuser.
Sexual violence is defined as: any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home or work. Coercion can cover a whole spectrum of degrees of force. Apart from physical force, it may involve psychological intimidation, blackmail or other threats – for instance, the threat of physical harm, of being dismissed from a job or of not obtaining a job that is sought. It may also occur when the person aggressed is unable to give consent – for instance, while drunk, drugged, asleep or mentally incapable of understanding the situation. Sexual violence includes rape, defined as physically forced or otherwise coerced penetration – even if slight – of the vulva or anus, using a penis, other body parts or an object. The attempt to do so is known as attempted rape. Rape of a person by two or more perpetrators is known as gang rape. Sexual violence can include other forms of assault involving a sexual organ, including coerced contact between the mouth and penis, vulva or anus (3).
Child sexual abuse is defined as any sexual activity with a child where consent is not or cannot be given. This includes sexual contact that is accomplished by force or threat of force, regardless of the age of the participants, and all sexual contact between an adult and a child, regardless of whether there is deception or the child understands the sexual nature of the activity. Sexual contact between an older child and a younger child also can be abusive if there is a significant disparity of age, development, or size, rendering the younger child incapable of giving informed consent. The sexually abusive acts may include sexual penetration, sexual touching, or non-contact sexual acts such as exposure or voyeurism (4). Legal definitions vary by state; however, state guidelines are available by using the Child Welfare Information Gateway.
Incidence and Prevalence:
Although the exact prevalence is unknown, it is estimated that 12-40% of children in the United States experience some form of childhood sexual abuse. Shame and stigma prevent many survivors from disclosing abuse. Incest, once thought to be rare, occurs with alarming frequency (5). Reliable information on national rates of sexual assault requires assembling information from a variety of sources. The method of obtaining data influences the estimates of the incidence and prevalence of rape and sexual assault. Approximately one in five women has experienced childhood sexual abuse (5). From 2006 to 2008, among females aged 18-24 years who had sex for the first time before age 20 years, 70% experienced non-voluntary first sex (6). 12% of girls in grades 9-12 reported they had been sexually abused; 7% of girls in grades 5-8 reported sexual abuse. Of all girls who experienced sexual abuse, 65% reported that the abuse occurred more than once, 57% reported that the abuser was a family member, and 53% reported that the abuse occurred at home (6).
The extent of human trafficking is staggering. According to the U.S. Department of State, there are many kinds of human trafficking, including forced labor, bonded labor, involuntary domestic servitude, sex trafficking, forced child labor, child soldiers, and child sex trafficking (7). By some estimates, nearly 1 million people in the world are trafficked across international borders each year, and approximately 14,500-17,500 people are trafficked into the United States each year (7). According to the most recent U.S. Department of State’s Trafficking in Persons report, trafficking is wide-spread across this nation and the year 2010 saw an increase in the number of female, foreign-born trafficking victims receiving services in the United States. This U.S. report identifies Thailand, India, Mexico, the Philippines, Haiti, Honduras, El Salvador, and the Dominican Republic as the most common countries of origin of persons trafficked into the United States. According to one report, the United States is second only to Germany with regard to the rate at which women and children are trafficked into sex work (8). One author notes that there are currently at least 100,000 victims of domestic minor sex trafficking in the United States and that there are as many as 325,000 additional youth at risk of being trafficked (9). Although there are many challenges in determining accurate prevalence estimates, the United States enacted the Victims of Trafficking and Violence Prevention Act in 2000 in response to this seeming epidemic. The Act subsequently was amended and reauthorized in 2003, 2005, and 2008. Additionally, the United States ratified the United Nations’ “Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children” in November 2005 (10).
Symptoms or behavioral sequelae are common and varied. More extreme symptoms can be associated with abuse onset at an early age, extended or frequent abuse, incest by a parent, or use of force. Common life events, like death, birth marriage, or divorce may trigger the return of symptoms for a childhood sexual abuse survivor. The primary after-effects of childhood sexual abuse include the following (11):
Medical Consequences of Sexual Assault:
Physical effects: The medical consequences of sexual assault can be considered as acute and chronic phenomena. Both categories can be characterized further as those of general medical significance and those of specific reproductive health consequence. Chronic and diffuse pain, especially abdominal or pelvic pain, lower pain threshold, anxiety and depression, self-neglect, and eating disorders have been attributed to childhood sexual abuse. Adults abused as children are four to five times more likely to have abused alcohol and illicit drugs. They are also twice as likely to smoke, by physically inactive, and may be severely obese (12). Acute, traumatic injuries reported can be relatively minor, including scratches, bruises and welts, but some women will sustain fracture, head and facial trauma, lacerations, or bullet wounds. The risk of injury is increased for adult female rape victims if the perpetrator is a current or former intimate partner; if the rape occurred in the victim’s or perpetrator’s home; if the rape was completed; if harm to the victim or another weapon was threatened by the perpetrator; if a gun, knife, or other weapon was used during the assault; of if the perpetrator was using drugs or alcohol at the time of assault. No relationship is found between the risk of injury and the victim’s race or age.
Sexual effects: Genital injury patterns have been described primarily in studies of emergency room populations. An analysis of 1,076 cases of sexual assault in an urban level I trauma center found that 52.7% of women had documented genital trauma; vaginal assault was the most common (13). In this series trauma types varied by vulvar site: tears were most often detected on the posterior fourchette and fossa, abrasions on the labia, and ecchymoses on the hymen. Sexual assault is associated with a risk of exposure to pregnancy and sexually transmitted diseases (STDs). Rape-related pregnancy contributes substantially to unintended pregnancy in the United States. Disturbances of desire, arousal and orgasm may result from the association between sexual activity, violation, and pain. Survivors are more likely to have had a sexually transmitted infection, and engage in risk-taking behaviors that place them at risk of contracting human immunodeficiency virus (HIV). Early adolescent and unintended pregnancy and prostitution are associated with sexual abuse (14). Gynecologic problems, including chronic pelvic pain, dyspareunia, vaginismus, and non-specific vaginitis, are common diagnoses among survivors (15). Survivors may be less likely to have regular gynecology examination, Pap tests and may seek little or no prenatal care.
Interpersonal effects: Adult survivors of sexual abuse may be less skilled at self-protection. They are more apt to accept being victimized by others. This tendency to be victimized repeatedly may be the result of general vulnerability in dangerous situations and exploitation by untrustworthy people (16).
Screening for Sexual Abuse:
It is strongly recommended that all women be screened for a history of sexual abuse. Patients overwhelmingly favor universal inquiry about sexual assault because they report a reluctance to initiate a discussion of this subject. Questions specifically related to obstetrics and gynecology patient populations might also include asking if anyone is forcing or pressuring the patient to do something she does not want to do, including having sex or performing sex acts with others. Importantly, as with intimate partner violence, interventions on behalf of an adult patient suspected or confirmed to be a victim of trafficking should be devised with the consent and input of the patient. One readily available resource is the National Human Trafficking Resource Center at 1-888-3737-888. This resource line is designed to assist the caller in determining whether a case of trafficking may exist and provide a list of local resources for further assistance. Within HIPAA privacy regulations, health care providers potentially could avail themselves of this service (17). The U.S. Department of Health and Human Services developed sample questions that healthcare providers can use in taking a history regarding possible trafficking.
In recent years, there has been a trend toward the implementation of hospital-based programs to provide acute medical and evidentiary examinations by sexual assault nurse examiners or sexual assault forensic examiners. In some parts of the country, however, healthcare providers will still be the first point of contact for the evaluation and care of patients after a sexual assault. Post traumatic stress disorder may be a long-term consequence of sexual assault. It is characterized by a cluster of symptoms involving re-experiencing the trauma, avoidance, and being in a state of hyper-arousal (18).
Victimization and abuse by partners are found to be equally prevalent among women with disabilities and women without physical disabilities about 62%. However, women with physical disabilities are more at risk for abuse by attendants or healthcare providers and more likely to experience a longer duration of abuse (19). Many women with physical disabilities rely on a relative, personal attendant, or other type of caregiver for their personal and household needs. This reliance may involve exploitative relationships that often are difficult to uncover. Women who need others for personal assistance may be reluctant to disclose their concerns for fear of retaliation or loss of essential services performed by the home or personal care provider. Abuse described by women with physical disabilities includes withholding of assistance or assistive devices. This type of abuse is not detected in standard abuse screening measures; however, a four question abuse assessment tool for those with physical disabilities has been developed (19). Some states have mandatory reporting requirements to adult protective services for individuals who are elderly or disabled and are living in an institutional setting. Other states require only that information about community resources be given. Healthcare providers should be familiar with their state laws, which can be obtained through the state department of social services.
Abuse Assessment Screen – Disability (AAS-D):
Role and Responsibility of Health Care Providers:
Physicians can encourage primary prevention of sexual assault by being involved in advocacy in professional, community, and educational arenas. In addition, The Women’s Health and Education Center (WHEC) recommends that health care providers routinely screen all patients for a history of sexual assault, paying particular attention to those who report pelvic pain, dysmenorrhea, and sexual dysfunction. Healthcare providers who routinely screen for a history sexual assault are better able to identify victims of sexual assault and thereby provide tertiary prevention of long-term and persistent physical and mental health consequences of sexual assault. If a history of sexual abuse has been obtained, the clinician needs to be aware that various health care procedures can be triggers for panic and anxiety reactions such as pelvic, rectal, breast, and endovaginal ultrasound examination. When these reactions are seen in clinical practice, it is important to consider that they may be caused by posttraumatic stress disorder and may have a connection with more remote events rather than the immediate practice situation. Clinicians should screen for substance abuse in patients with a history of sexual assault. Conversely, clinicians should screen for a history of sexual assault in patients with a history of substance abuse. Counseling can help the patient to understand her psychological and physical responses, thereby diminishing the associated symptoms (20).
In recent years, there has been a trend toward the implementation of hospital-based programs to provide acute medical and evidentiary examinations by sexual assault nurse examiners or sexual assault forensic examiners. In many parts of the world, however, obstetricians and gynecologists will still be the first point of contact for the evaluation and care of patients after a sexual assault. Often healthcare providers are called to perform evaluations, and if conducting screening for a history of sexual assault, will realize the importance this information in providing comprehensive health care. Therefore, all physicians should be familiar with the forensic examination procedure. If a healthcare provider is called to perform this examination and he or she has no experience or limited experience, it may be judicious to request assistance because any break in the technique in collecting evidence, or break in the chain of custody of evidence, including improper handling of samples or mislabeling, will virtually eliminate any effort to prosecute a case in the future. The healthcare provider conducting an evidentiary evaluation of a victim of sexual assault has a number of responsibilities, both medical and legal and should be aware of state and local statutory or policy requirements that may involve the use of assessment kits for gathering evidence.
The healthcare provider’s role in the evaluation of sexual assault victims is summarized below:
I. Medical Issues
II. Legal Issues*
The most common STDs reported in sexual assault victims are those most common in the general community and include trichomoniasis, gonorrhea, and chlamydia trachomatis infection (21). Prophylaxis of these STDs is recommended. WHEC recommendations for prophylaxis for these STDs is discussed on this website in detail at: Sexually Transmitted Diseases
An STD of particular concern among victims of sexual assault is HIV. The HIV status of the assailant in a sexual assault is often unknown or unavailable. There are multiple characteristics that increase the risk of HIV transmission if the perpetrator is infected, including genital or rectal trauma leading to bleeding, multiple traumatic sites involving lacerations or deep abrasions, and the presence of pre-existing genital infection in the victim (22). The U.S. Department of Health and Human Services recommends that an individual seeking care within 72 hours after non-occupational exposure to blood, genital secretions, or other potentially infective body fluids of an individual known to have HIV receive a 28-day course of highly active antiretroviral therapy, initiated as soon as possible after exposure. If the assailant’s HIV status is unknown, clinicians should evaluate the risks and benefits of non-occupational post-exposure prophylaxis on a case-by-case basis. For individuals initiating care more than 72 hours after exposure, clinicians might consider prescribing non-occupational post-exposure prophylaxis for exposures conferring a serious risk of transmission if, in their judgment, the diminished potential benefit of treatment outweighs the potential risk of adverse events from antiretroviral medications (23). Other health personnel, particularly those trained to respond to rape-trauma victims, should be consulted to provide immediate intervention if necessary and to facilitate counseling and follow-up. Healthcare providers are urged to assemble and maintain a list of these individuals and other resources for patient referral. Because of the emotional intensity of the experience, a woman may not recall all of what is said during an office visit. Therefore, it is helpful to provide all instructions and plans in writing. Generally, a visit for clinical and psychological follow-up should take place within 1-2 weeks and be scheduled thereafter as indicated by results and assessments at that time.
If a physician suspects abuse, but the patient does not disclose it, the healthcare provider should remain open and reassuring. Patients may bring up the subject at a later visit if they have developed trust in the healthcare provider. Not asking about sexual abuse may give tacit support to the survivor’s belief that abuse does not matter or does not have medical relevance and the opportunity for intervention is lost. Some guidelines are: make the question “natural”; normalize the experience; give the patient control over disclosure; if the patient reports childhood sexual abuse, ask whether she has disclosed this in the past or sought professional help; and many times it is wise to postpone examination until another visit. Once the patient is ready for an examination, questions about whether any parts of the breast or pelvic examination cause emotional or physical discomfort should be asked. For some survivors of childhood sexual abuse, there is minimal compromise to their adult functioning. Others will experience psychological, physical, and behavioral symptoms as a result of their abuse. An understanding of the magnitude and effects of childhood sexual abuse, along with knowledge about screening and intervention methods, can help healthcare providers offer appropriate care and support to patients with such histories. Traumatized patients generally benefit from mental health care. The healthcare provider can be a powerful ally in the patient’s healing by offering support and referral. Efforts should be made to refer survivors to professionals with significant experience in abuse-related issues.