Throughout history, rape has been regarded as forced sexual intercourse. However, its classification as a crime has varied. Roman law apparently stated that it was a crime that could be committed only against virgins. Cultural and religious beliefs influence the assignment of culpability. In ancient Hebrew law, a married woman could be punished together with her rapist. Today there are still reports from some countries of the ‘honour killing’ of women who have been raped.
Sexual victimization may give rise to serious sequelae in the victim such as physical injury, infection and psychological problems. It also evokes powerful feelings of disgust and anger within the general population. We want to look after the victim and lock up the assailant, yet at the same time, society judges the person who has been sexually assaulted according to unconscious internal codes. For these reasons, people who have had such experiences often do not want to involve the police. Instead, they might present immediately or after a variable time interval to a variety of health care personnel. First disclosure often occurs within the genitourinary clinic setting when they seek screening for infection.
Definition of terms
The definition of terms used to describe particular types of sexual offences can still vary between countries.
In the UK, the Sexual Offences Act 2003 came into force in May 2004. It introduced new penalties for sex crimes and introduced new offences to make it easier for juries to make fair and balanced decisions on the question of consent. It has redefined ‘rape’, and created a new offence of ‘assault by penetration’.
Sexual victimization is under-reported; estimates of risk vary, with some suggesting that the lifetime risk may be as high as one in four for women. The British Crime Survey (BCS) found a 9.7% lifetime risk of any sexual victimization and a 4.9% risk of rape after the age of 16 years. In the year ending March 2003, the total number of sexual offences recorded by police in England and Wales was 48 654 — a 17% rise over the previous year. About 10% of reported sexual assaults are on men.
Society’s double sexual standards mean that the woman is often perceived to have been in some way responsible for an attack. Young women who dress fashionably can be seen by some groups as ‘leading men on’ by being sexually provocative. The woman herself often unconsciously subscribes to this belief system and therefore may believe that her experience was not ‘real rape’. This will contribute to the difficulty experienced in coming forward to report the offence.
Risks are highest for women living in inner city or urban areas and from low-income backgrounds.
Studies have shown that young single women between the ages of 16 and 24 are at most risk of sexual victimization, with students more likely to report an incident of sexual victimization. Younger women may be more at risk of acquaintance rape and of being specifically targeted by perpetrators, whereas older women are most affected by partner rape. Partner rape often overlaps with domestic violence, with the woman being caught up in a repetition of sexual and violent attacks. Less than one-third of these women tell anyone at all about the rape. Alcohol, cannabis and other recreational drugs are risk factors in sexual assault. A study in the US found these substances present in the urine of up to 40% of 1179 women victims of sexual assault. A survey of complainants attending a sexual assault referral centre (SARC) in London found that 11% reported recent recreational drug use and 30% had drunk two or more units of alcohol before the assault took place.
Women are most often sexually assaulted by men they know. The BCS found that most perpetrators were known to their victims in some way, as a friend, acquaintance or family member. It found that current partners were responsible for 45% of the rapes reported and 22% were by acquaintances. Strangers were only responsible for 8% of rapes but 23% of sexual assaults. These findings were not replicated by a London SARC, which reported that strangers or relative strangers had assaulted 52% of the clients seen. It is important to consider that when the victim knows the assailant, there may be fear of reprisals if they report the assault to the police. They may worry that their own family and friends will not believe them. These women often experience multiple incidents of sexual violence.
About three-quarters of reported rape incidents involve verbal threats as well as physical force or violence with a significant risk of physical injury. Partners who assault are most likely to inflict injury. Women are most likely to be raped in their own home, whereas sexual assault occurs more often in a public place.
Penovaginal penetration is the commonest form of assault on women. Anal intercourse is reported in between 6-26% of female complainants, but it is important to remember that there may have been a number of different sexual acts performed by the assailant, including irrumation (forced oral penetration) or cunnilingus.
Less than 7% of reported rapes of a female result in a conviction.
It is important to remember that although rare, women can be perpetrators as well. Women can also be accomplices to luring other unsuspecting victims into traps to be raped by others.
Rape is a violation of the body and the mind. Each individual responds according to their personal history, previous experience and to the type of assault. There is no one response that can be expected; some people appear to be cut off and controlled, whereas others are overwhelmed with fear, humiliation, guilt and shame. If the assailant is a partner or friend, feelings of betrayal of trust can be a major factor in long-term distress. The person who has been raped may suffer from significant psychological problems afterwards, such as anxiety, fear of being alone, panic attacks, depression, self-harm and suicidal ideation. There can be resulting relationship problems with particular difficulties in terms of sex, with up to 59% having a sexual dysfunction. The most common problem is the avoidance of sex.
Research has shown that post-traumatic stress disorder (PTSD) is the most common post-rape trauma psychopathology. It has been defined by the Diagnostic and Statistical Manual (DSM IV). One study has found that 94% of victims could be classified as suffering from PTSD at 1 week post-assault, with 47% still meeting the criteria at 3 months.
Physical violence occurs in about 50% of attacks, with studies reporting 31-82% of women having bodily injuries such as contusions, abrasions, choke-related injuries, lacerations and stab or gunshot wounds. Genital injuries have been found in 16-58%; these may range from minor abrasions to severe lacerations or penetrating injuries involving the perineum. The absence of genital injury does not exclude rape.
Pregnancy occurs in about 5% of women of reproductive age. Sexually transmitted infections are found in 4-56% of those screened and reflects the local prevalence. Infection with HIV following rape occurring in the UK is rare but must be considered. Risk of acquisition increases if the rape is of a man, if it is particularly violent or if it occurred in areas defined as high prevalence.
Following a disclosure of sexual assault, the clinician should establish the following details:
- • The time since the assault is important because forensic evidence cannot usually be gathered from the person after 1 week. Screening for sexually transmitted infections should be done ideally at 2 weeks post-assault. Hepatitis vaccination should be started within 3 weeks.
- • Have they or do they want to involve the police? If yes, do not continue with the examination.
- • Evaluate the relationship of the victim to the assailant and establish any known risk factors with regard to the assailant, if known, such as drug use. Ask whether there was more than one person.
- • It is important to establish in a sensitive manner what type of assault took place. If the patient does not want to describe the assault, it may be necessary to ask closed questions such as ‘Did he put his penis anywhere else?’
- • Take a pre- and post-assault sexual history. This may be relevant if any infection is found.
- • Establish risk of pregnancy by exploring current contraception, whether ejaculation occurred and if a condom was used.
- • Are there symptoms such as discharge, bleeding, pain etc.
- • Offer prophylaxis for common sexually transmitted infections such as chlamydia and gonorrhoea. Instigate rapid hepatitis vaccination if indicated.
- • Assess and discuss risk of HIV from this incident. Follow local guidelines if post-exposure prophylaxis (PEP) is indicated. The British Association for Sexual Health and HIV (BASHH) has produced guidelines on the administration of antiretrovirals following potential sexual exposure to HIV.
- • Instigate appropriate interventions and investigations for any physical injury.
- • Explore what support is available from family or friends and offer what local psychological support is available.
- • Establish whether there is any ongoing risk to the patient.
Detailed guidelines for the medical management of sexual assault can be found on the BASHH website
If the patient wishes to report the assault to the police they will be offered a forensic medical examination by an appropriately trained forensic examiner. The purpose of this is to gather evidence. The type of samples collected depends on the nature of the assault. Consideration must be given to time elapsed since the assault. This can be experienced as another traumatic event, so great care should be taken to allow the patient to feel in control. The examination includes:
- • A general examination to look for and document contusions or other injuries. Skin sampling is done if contaminated with bodily fluids. Head or pubic hair is sampled if contaminated. Fingernails are sampled if a history of scratching the assailant is obtained.
- • Saliva is collected by swabbing the buccal mucosa and rinsing the mouth with sterile water. Spermatozoa may persist for up to 6-31 hours, and persist longest in the gingival crevices.
- • Genital examination is done to look for and document local or internal injury.
- • Low and high vaginal swabs and endocervical swabs are taken during speculum examination of the vagina. Spermatozoa may be identified for up to 3-7 days.
- • If there has been anal penetration a proctoscopy examination may be performed and internal swabs taken. Spermatozoa have been identified 65 hours after rectal penetration.
- • Urine and blood should be obtained for toxicological analysis.
Sexual assault referral centres (SARCs)
SARCs are being developed across the UK and provide supportive and forensically secure environments. Support includes medical management as described above. People who have not involved the police can receive treatment, and if they so choose, can give information anonymously to the police regarding their assault. Forensic evidence can be taken and stored, giving the person time to consider whether they wish to make a complaint. They can access medical follow-up, counselling and support irrespective of police involvement.
It is hoped that in the future there will be one 24-hour national phone number that all people who have been sexually victimized could ring. The aim would be to offer medical evaluations and counselling in order to help that person to find the most appropriate care pathway.