Acute Management of the Sexual Assault Victim Pedro A. Poma, MD Chicago, Illinois
Sexual assault victims usually seek emergency medical care at urban hospitals. The incidence of over 52,000 cases a year reported by the FBI does not include instances in which the victim died, cases of statutory rape (victim below the age of consent), or cases not confirmed by the police. It is well known that sexual assault is one of the most unreported crimes. The incidence of this crime in affluent communities is unknown. Rape occurs in any community but nonhospital professional services may be more easily available in some. The office practitioner may feel ill-equipped to deal with this kind of problem because such patients seldom come to a private office; although in a survey done in 1976, 33 percent of family practitioners stated that they see several rape victims each year. 1 The practitioner may be hesitant about getting involved in litigation. Experience indicates that by following the approach described and documenting facts clearly, physicians will prevent disruption of their busy schedules by unfamiliar court routines, and at the same time provide what society, the victim, and the alleged assailant expect of him as a member of the health care team. Rape is a violent crime. The penis may be considered as one of the weapons used. Besides psychological injury, rape is associated with physical trauma, disease, and pregnancy (when the victim is female). Most known victims are female; rarely will a heterosexual male report that he has been a victim of this kind of assault. The following refers to female victims, although in many instances it has applications for both sexes. The age of the victim ranges from months to over 90 years. The physical condition of the victim before the assault may include infirmity, even pregnancy. In other words, rape may occur to anyone at any place and any time. The courts are responsible for deciding whether or not the victim was able to give consent and if she did so. The reaction of the victim will de-
Requests for reprints should be addressed to Dr. Pedro A. Poma, Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center, California Avenue at 15th Street, Chicago, IL 60608.
pend on her psychological makeup and the way she handles stress situations. In many cases, she is sure only that she has been fighting for her life. Her reaction will depend on the amount and type of violence employed, whether or not she knows the assailant, any future threats, and the reaction of significant others (only five percent of alleged victims came to our hospital unaccompanied2). If available, the victim may choose a private practitioner's office to avoid the public acknowledgement that is implied in seeking help at the Emergency Room. Perhaps she is not planning to report the crime to the police; she may feel more protected, better understood and treated by her own physician. Thus, every physician must be familiar with the ancillary services and referral centers available in the community. The consent implied by her presence in the office does not suffice for the collection of specimens that could be used as evidence in court. In order to release the information obtained to the authorities, there is a need for specific consent. Evidence should be collected
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
even if she currently is unwilling to report her assault, in the event that she changes her mind. It must be clearly stated that no information will be given to anyone without her approval. Whether or not she is willing to report should offer no reason to doubt her history nor should it be a reason to delay or withhold appropriate management.
Management Health care workers must assume that the victim is telling the truth, even if she appears very calm. The task is divided into three main problems: medical, psychological, and legal. The medical problem is comprised of the evaluation of injuries and their management, prophylaxis of venereal disease and pregnancy, and appropriate follow-up. The psychological problem requires minimizing of stress, management of the acute episode and the reactions of significant others and the follow-up. The legal problem necessitates collection of legal evidence, maintenance of legal records, and protection of the chain of evidence. Health care workers should re589
member that rape is not a medical diagnosis and avoid the temptation to establish if rape really happened. This is a task of the judicial system and should be so stated to relatives, especially the parents, who are very anxious for a corroboration, particularly when the victim is young.
History Privacy is of utmost importance; a private examining room and early rapport with the victim's advocate establish a good beginning. Having a female nurse take the history will help ease some of the tension. The physician can review the history later. The history should be recorded in the alleged victim's own words. It should include time, place, characteristics of assailant(s), if known to her, circumstances surrounding the attack, type of threat, weapon used (if any), and any threats of further persecution and violence. The type of sexual activities should be noted. The presence of erection, place of ejaculation (if it occurred), the date of her last normal menstruation, contraception used, and the time of her last voluntary sexual contact. Other important points are: whether she changed her clothes, took a bath, had a douche or enema, gargled, and/or spontaneously voided or defecated. The use of drugs or alcohol also must be recorded. The victim's advocate is usually a female. An office assistant with some preparation and with the right attitude may attend to the victim's needs as soon as a woman identifies herself as a victim. In this author's experience, a male advocate can usually better help the relatives, especially the male relatives. In a hospital situation, the advocate should be immediately available, establish rapport with the victim, instruct her in the procedure that will follow, and explain the need for specific questions and procedures. The advocate helps to establish continuity with reality for the victim, reassures her about her present safety, allows her an opportunity to release her emotions, is present with her throughout the procedure if the victim is agreeable, establishes contact for follow-up, and considers the well-being and safety of the alleged victim after the procedures and treatment are over. The acute need for an advocate is diminished when the patient chooses to see her physician. By then, a good rapport had been established. 590
Physical Examination The attitude of the victim varies. She may appear very relaxed, but she may be aggressive. She, herself, should make the decision to go through with the examination. This enables her to feel she is once again in control. The fact that her physician is likely to be male may not help her present state of mind. The physician must continue to explain the process of examination, avoiding hasty remarks. Sometimes other pressing duties cause the physician to appear hurried. Alleged rape cases are emergency situations and should be given appropriate attention and priority. The physician should be ready to listen, allowing the patient to ventilate any feelings. In the office encounter, rapport is probably already established. The pressure of the alleged victim's relatives, if they are present, may be more evident. In an earlier study, about 42 percent of victims presented with injuries.2 Extragenital injuries were three times as common as genital injuries. Therefore, immediate examination involves evaluation of life threatening injuries and loss of consciousness. If there are no serious injuries, then a more methodical approach may be followed. Victims who choose the office setting do not usually present serious physical
injuries. The entire body should be evaluated for injuries and evidence of force or constraint, especially in the areas indicated by the victim. The general condition should be noted, including orientation, alcohol odor, condition of clothing, the presence of dirt and debris, and blood and/or semen stains. When photographs are not available, a simple drawing indicating this information is helpful. The condition of the hymen should be stated in writing (fourchette erythema is evidence of recent coitus). Lubricant should not be employed; warm water will facilitate speculum insertion. A cotton-tip applicator (salinemoistened, if needed) is employed to obtain samples. Irrigation with warm saline may also be used. Proper identification should be written on the slides. Dry slides for acid phosphatase and Papanicolaou stains are obtained; cultures are taken from endocervical canal, rectum, urethra, and pharynx when indicated. These should be streaked on Thayer-Martin medium to test for gonorrhea. Wet mounts for
semen motility should be prepared, preceded by bimanual examination and the recording of uterine size. VDRL, pregnancy, and other tests, such as for alcohol or drug levels when indicated, should be ordered if authorized by the patient. Pertinent consultations should be considered. If authorized by the patient, photographs may be obtained; the undeveloped film, stained clothing, combings of pubic hair, and fingernail scrapings (all of these require the patient's consent) should be given to authorities. Identify specimens and place of origin clearly. Specimens must be handled personally; the signature of the authorized person receiving them must be obtained, in order for the specimens to be accepted as evidence in court.
Therapy The presence of life-threatening conditions requires immediate and appropriate management, including hospitalization. In the author's experience, two to three victims annually require hospitalization. Some are admitted for surgery (often requiring blood transfusion), and others for acute crisis management through psychiatry. But, most cases can be managed in the Emergency Room or private office. The presence of injuries or the need for more appropriate examination in pediatric victims are indications for hospitalization. Often, the need to leave the home environment is also indicated because in approximately 80 percent of cases, the assailant is either a close relative or acquaintance. The attitude of physicians and other health care workers initiates the process of recuperation for these patients. The presence of an advocate, available patient literature, and the supportive reaction of significant others all contribute toward recovery. In adults, some lacerations can be repaired on an ambulatory basis, under local infiltration. If the patient has not had a tetanus booster during the last ten years, tetanus toxoid, 0.5 ml, should be
given. Procaine penicillin G, 4.8 million units intramuscularly, provides adequate prophylaxis against gonorrhea and even syphilis. Oral ampicillin, 3.5 gin, with probenecid, 1 gin, can also be employed. Tetracycline, 1.5 gin, stat, followed by 2 gm/day for four
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
days appears satisfactory for the allergic nonpregnant woman. For the allergic pregnant woman, 4 gm, intramuscularly, of spectinomycin is recommended. The risk of pregnancy resulting from an isolated intercourse is around one percent.34 In the author's experience about 75 percent of victims at risk of pregnancy were unprotected, ie, using no contraceptive method. The possibility of pregnancy resulting from the sexual assault, if ejaculation occurred at the genitalia, should be presented to the victim. The current medication commonly used, diethylstilbestrol, 25 mg BID, for five days, has many secondary effects and compliance is poor. About one half of patients complain of nausea and about one third complain of vomiting. Parenteral progestins (progesterone (Provera) 100- 150 mg) offers the advantage of administration before the patient leaves the premises, but these have been associated with congenital malformations when used during early pregnancy. Conjugated estrogens, 10-30 mg a day for five days, may be employed also. The prevention of pregnancy is a difficult aspect of the management of rape victims. The patient's morals and beliefs should be considered. Medications are not often satisfactory; there are, however, federal funds available for women with pregnancy resulting from a rape situation. Before the patient leaves, emphasize the need to keep in touch, and the need for follow-up (repeat VDRL, gonorrhea culture, and probably a pregnancy test). The discussion should include the secondary effect of any medication used and the kind of reactions she may expect. Instructions and explanations given in written form also help.
sexual stimuli; their responses are inappropriate. Most rapists are young and they usually choose a victim who appears weaker than themselves. There are rapists of all ages, health, and socioeconomic strata. Some sexual assaults occur when the victim is found while the assailant is committing another crime. Other rapists employ an elaborate process in the selection of a victim. Success in the crime encourages repetition. Many rapists are unable to relate adequately to a female, to express feelings, and to request behavior changes from other persons. Their sexual arousal results from forcing a victim. Many rapists have several forms of sexual dysfunction, ie, impotency and premature or delayed ejaculation. Twenty percent of compulsive rapists feel remorseful about their behavior and want to change. Previously, there was no alternative to prison for the few rapists who were convicted. Convicted rapists showed a great incidence of recidivism. There are currently programs employing aversion therapy and desensitization techniques to modify the rapist's vicious cycle and to enable him to have satisfactory intercourse with a consenting adult female.5 The incidence of recidivism is only five percent in the study cited, but the follow-up has been less than five years. The goals of this therapy are the establishment of rapport with the patient, establishment of his responsibility in the assault, a decrease of sexual arousal in rape-associated situations, an increase of sexual arousal with adult consenting females, the development, through training, of heterosexual social skills.
as well as rape hotlines available 24 hours a day. In some states, the past sexual experiences of the victim are not allowed in open court. A recent survey6 illustrates the change of nationwide public attitudes about rape. The majority (71-16) disagree with the statement that the victim provokes the attack; the majority (5128) agree that judges who make inappropriate statements about rape should be removed. A Wisconsin judge lost his bench in a recent election primarily because of his remarks in a rape case. In the survey, the majority agree that rape is a violent crime, that rapists are sick and that they do not have excuse for rape. Still many Americans believe some women sexually entice a man, then get scared and unfairly call it rape. Americans surveyed also agree that a hitchhiker is risking rape. The author feels that women have the right to change their minds even if initially they have consented to sex. Even a prostitute should have a right to choose her customers. Some states provide monetary compensation to the victim for injuries suffered during perpetuation of a crime. With the changes in traditional sex role models and the improvement in attitudes toward sex that society is experiencing, the author hopes that our children will come to live in a world where sexual assault is less prevalent.
The Future The Rapist Sexual assault cannot be eliminated but its incidence may be diminished by understanding the rapist and treating him. A rapist may commit hundreds of rapes. By treating just one rapist, a great deal of suffering may be eliminated. The motivation of a single rapist may differ from gang rape motivation. About 30 percent of victims treated at the author's hospital reported multiple attackers. Rapists demonstrate different degrees of response to aggressive or
If approaches such as the one described prove satisfactory and reproducible, the whole problem of rape might be ameliorated. The attitude of society, including health care workers, is improving. Reporting of this crime is becoming more likely. Legislation is improving court procedures. The following are some examples; in Illinois, the law (PA-79-564) establishes minimal standards for care of victims throughout the state, in hospitals that provide comprehensive emergency services. Large cities have developed sex squads composed of female offilcers
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
Literature Cited 1. McGuire LS, Stern M: Survey of incidence of and physician's attitudes toward sexual assault. Pub Health Rep 91:103, 1976 2. Poma PA, Stepto RC: Rape: A community hospital study. III Med J 154:25-28, 1978 3. Hayman CR, Lanza C: Sexual assault on women and girls. Am J Obstet Gynecol 109:480-486, 1971 4. Massey JB, Garcia CR, Emich JR: Management of sexually assaulted females. Obstet Gynecol 38:29-36, 1971 5. Rape. Sexual Medicine 1(3): November 1977 6. Harris L: Public has firm views about rape. Chicago Tribune, editorial. October 24, 1977
591
Sexual assault victims usually seek emergency medical care at urban hospitals. The incidence of over 52,000 cases a year reported by the FBI does not include instances in which the victim died, cases of statutory rape (victim below the age of consent), or cases not confirmed by the police. It is well known that sexual assault is one of the most unreported crimes. The incidence of this crime in affluent communities is unknown. Rape occurs in any community but nonhospital professional services may be more easily available in some. The office practitioner may feel ill-equipped to deal with this kind of problem because such patients seldom come to a private office; although in a survey done in 1976, 33 percent of family practitioners stated that they see several rape victims each year. 1 The practitioner may be hesitant about getting involved in litigation. Experience indicates that by following the approach described and documenting facts clearly, physicians will prevent disruption of their busy schedules by unfamiliar court routines, and at the same time provide what society, the victim, and the alleged assailant expect of him as a member of the health care team. Rape is a violent crime. The penis may be considered as one of the weapons used. Besides psychological injury, rape is associated with physical trauma, disease, and pregnancy (when the victim is female). Most known victims are female; rarely will a heterosexual male report that he has been a victim of this kind of assault. The following refers to female victims, although in many instances it has applications for both sexes. The age of the victim ranges from months to over 90 years. The physical condition of the victim before the assault may include infirmity, even pregnancy. In other words, rape may occur to anyone at any place and any time. The courts are responsible for deciding whether or not the victim was able to give consent and if she did so. The reaction of the victim will de-
Requests for reprints should be addressed to Dr. Pedro A. Poma, Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center, California Avenue at 15th Street, Chicago, IL 60608.
pend on her psychological makeup and the way she handles stress situations. In many cases, she is sure only that she has been fighting for her life. Her reaction will depend on the amount and type of violence employed, whether or not she knows the assailant, any future threats, and the reaction of significant others (only five percent of alleged victims came to our hospital unaccompanied2). If available, the victim may choose a private practitioner's office to avoid the public acknowledgement that is implied in seeking help at the Emergency Room. Perhaps she is not planning to report the crime to the police; she may feel more protected, better understood and treated by her own physician. Thus, every physician must be familiar with the ancillary services and referral centers available in the community. The consent implied by her presence in the office does not suffice for the collection of specimens that could be used as evidence in court. In order to release the information obtained to the authorities, there is a need for specific consent. Evidence should be collected
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
even if she currently is unwilling to report her assault, in the event that she changes her mind. It must be clearly stated that no information will be given to anyone without her approval. Whether or not she is willing to report should offer no reason to doubt her history nor should it be a reason to delay or withhold appropriate management.
Management Health care workers must assume that the victim is telling the truth, even if she appears very calm. The task is divided into three main problems: medical, psychological, and legal. The medical problem is comprised of the evaluation of injuries and their management, prophylaxis of venereal disease and pregnancy, and appropriate follow-up. The psychological problem requires minimizing of stress, management of the acute episode and the reactions of significant others and the follow-up. The legal problem necessitates collection of legal evidence, maintenance of legal records, and protection of the chain of evidence. Health care workers should re589
member that rape is not a medical diagnosis and avoid the temptation to establish if rape really happened. This is a task of the judicial system and should be so stated to relatives, especially the parents, who are very anxious for a corroboration, particularly when the victim is young.
History Privacy is of utmost importance; a private examining room and early rapport with the victim's advocate establish a good beginning. Having a female nurse take the history will help ease some of the tension. The physician can review the history later. The history should be recorded in the alleged victim's own words. It should include time, place, characteristics of assailant(s), if known to her, circumstances surrounding the attack, type of threat, weapon used (if any), and any threats of further persecution and violence. The type of sexual activities should be noted. The presence of erection, place of ejaculation (if it occurred), the date of her last normal menstruation, contraception used, and the time of her last voluntary sexual contact. Other important points are: whether she changed her clothes, took a bath, had a douche or enema, gargled, and/or spontaneously voided or defecated. The use of drugs or alcohol also must be recorded. The victim's advocate is usually a female. An office assistant with some preparation and with the right attitude may attend to the victim's needs as soon as a woman identifies herself as a victim. In this author's experience, a male advocate can usually better help the relatives, especially the male relatives. In a hospital situation, the advocate should be immediately available, establish rapport with the victim, instruct her in the procedure that will follow, and explain the need for specific questions and procedures. The advocate helps to establish continuity with reality for the victim, reassures her about her present safety, allows her an opportunity to release her emotions, is present with her throughout the procedure if the victim is agreeable, establishes contact for follow-up, and considers the well-being and safety of the alleged victim after the procedures and treatment are over. The acute need for an advocate is diminished when the patient chooses to see her physician. By then, a good rapport had been established. 590
Physical Examination The attitude of the victim varies. She may appear very relaxed, but she may be aggressive. She, herself, should make the decision to go through with the examination. This enables her to feel she is once again in control. The fact that her physician is likely to be male may not help her present state of mind. The physician must continue to explain the process of examination, avoiding hasty remarks. Sometimes other pressing duties cause the physician to appear hurried. Alleged rape cases are emergency situations and should be given appropriate attention and priority. The physician should be ready to listen, allowing the patient to ventilate any feelings. In the office encounter, rapport is probably already established. The pressure of the alleged victim's relatives, if they are present, may be more evident. In an earlier study, about 42 percent of victims presented with injuries.2 Extragenital injuries were three times as common as genital injuries. Therefore, immediate examination involves evaluation of life threatening injuries and loss of consciousness. If there are no serious injuries, then a more methodical approach may be followed. Victims who choose the office setting do not usually present serious physical
injuries. The entire body should be evaluated for injuries and evidence of force or constraint, especially in the areas indicated by the victim. The general condition should be noted, including orientation, alcohol odor, condition of clothing, the presence of dirt and debris, and blood and/or semen stains. When photographs are not available, a simple drawing indicating this information is helpful. The condition of the hymen should be stated in writing (fourchette erythema is evidence of recent coitus). Lubricant should not be employed; warm water will facilitate speculum insertion. A cotton-tip applicator (salinemoistened, if needed) is employed to obtain samples. Irrigation with warm saline may also be used. Proper identification should be written on the slides. Dry slides for acid phosphatase and Papanicolaou stains are obtained; cultures are taken from endocervical canal, rectum, urethra, and pharynx when indicated. These should be streaked on Thayer-Martin medium to test for gonorrhea. Wet mounts for
semen motility should be prepared, preceded by bimanual examination and the recording of uterine size. VDRL, pregnancy, and other tests, such as for alcohol or drug levels when indicated, should be ordered if authorized by the patient. Pertinent consultations should be considered. If authorized by the patient, photographs may be obtained; the undeveloped film, stained clothing, combings of pubic hair, and fingernail scrapings (all of these require the patient's consent) should be given to authorities. Identify specimens and place of origin clearly. Specimens must be handled personally; the signature of the authorized person receiving them must be obtained, in order for the specimens to be accepted as evidence in court.
Therapy The presence of life-threatening conditions requires immediate and appropriate management, including hospitalization. In the author's experience, two to three victims annually require hospitalization. Some are admitted for surgery (often requiring blood transfusion), and others for acute crisis management through psychiatry. But, most cases can be managed in the Emergency Room or private office. The presence of injuries or the need for more appropriate examination in pediatric victims are indications for hospitalization. Often, the need to leave the home environment is also indicated because in approximately 80 percent of cases, the assailant is either a close relative or acquaintance. The attitude of physicians and other health care workers initiates the process of recuperation for these patients. The presence of an advocate, available patient literature, and the supportive reaction of significant others all contribute toward recovery. In adults, some lacerations can be repaired on an ambulatory basis, under local infiltration. If the patient has not had a tetanus booster during the last ten years, tetanus toxoid, 0.5 ml, should be
given. Procaine penicillin G, 4.8 million units intramuscularly, provides adequate prophylaxis against gonorrhea and even syphilis. Oral ampicillin, 3.5 gin, with probenecid, 1 gin, can also be employed. Tetracycline, 1.5 gin, stat, followed by 2 gm/day for four
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
days appears satisfactory for the allergic nonpregnant woman. For the allergic pregnant woman, 4 gm, intramuscularly, of spectinomycin is recommended. The risk of pregnancy resulting from an isolated intercourse is around one percent.34 In the author's experience about 75 percent of victims at risk of pregnancy were unprotected, ie, using no contraceptive method. The possibility of pregnancy resulting from the sexual assault, if ejaculation occurred at the genitalia, should be presented to the victim. The current medication commonly used, diethylstilbestrol, 25 mg BID, for five days, has many secondary effects and compliance is poor. About one half of patients complain of nausea and about one third complain of vomiting. Parenteral progestins (progesterone (Provera) 100- 150 mg) offers the advantage of administration before the patient leaves the premises, but these have been associated with congenital malformations when used during early pregnancy. Conjugated estrogens, 10-30 mg a day for five days, may be employed also. The prevention of pregnancy is a difficult aspect of the management of rape victims. The patient's morals and beliefs should be considered. Medications are not often satisfactory; there are, however, federal funds available for women with pregnancy resulting from a rape situation. Before the patient leaves, emphasize the need to keep in touch, and the need for follow-up (repeat VDRL, gonorrhea culture, and probably a pregnancy test). The discussion should include the secondary effect of any medication used and the kind of reactions she may expect. Instructions and explanations given in written form also help.
sexual stimuli; their responses are inappropriate. Most rapists are young and they usually choose a victim who appears weaker than themselves. There are rapists of all ages, health, and socioeconomic strata. Some sexual assaults occur when the victim is found while the assailant is committing another crime. Other rapists employ an elaborate process in the selection of a victim. Success in the crime encourages repetition. Many rapists are unable to relate adequately to a female, to express feelings, and to request behavior changes from other persons. Their sexual arousal results from forcing a victim. Many rapists have several forms of sexual dysfunction, ie, impotency and premature or delayed ejaculation. Twenty percent of compulsive rapists feel remorseful about their behavior and want to change. Previously, there was no alternative to prison for the few rapists who were convicted. Convicted rapists showed a great incidence of recidivism. There are currently programs employing aversion therapy and desensitization techniques to modify the rapist's vicious cycle and to enable him to have satisfactory intercourse with a consenting adult female.5 The incidence of recidivism is only five percent in the study cited, but the follow-up has been less than five years. The goals of this therapy are the establishment of rapport with the patient, establishment of his responsibility in the assault, a decrease of sexual arousal in rape-associated situations, an increase of sexual arousal with adult consenting females, the development, through training, of heterosexual social skills.
as well as rape hotlines available 24 hours a day. In some states, the past sexual experiences of the victim are not allowed in open court. A recent survey6 illustrates the change of nationwide public attitudes about rape. The majority (71-16) disagree with the statement that the victim provokes the attack; the majority (5128) agree that judges who make inappropriate statements about rape should be removed. A Wisconsin judge lost his bench in a recent election primarily because of his remarks in a rape case. In the survey, the majority agree that rape is a violent crime, that rapists are sick and that they do not have excuse for rape. Still many Americans believe some women sexually entice a man, then get scared and unfairly call it rape. Americans surveyed also agree that a hitchhiker is risking rape. The author feels that women have the right to change their minds even if initially they have consented to sex. Even a prostitute should have a right to choose her customers. Some states provide monetary compensation to the victim for injuries suffered during perpetuation of a crime. With the changes in traditional sex role models and the improvement in attitudes toward sex that society is experiencing, the author hopes that our children will come to live in a world where sexual assault is less prevalent.
The Future The Rapist Sexual assault cannot be eliminated but its incidence may be diminished by understanding the rapist and treating him. A rapist may commit hundreds of rapes. By treating just one rapist, a great deal of suffering may be eliminated. The motivation of a single rapist may differ from gang rape motivation. About 30 percent of victims treated at the author's hospital reported multiple attackers. Rapists demonstrate different degrees of response to aggressive or
If approaches such as the one described prove satisfactory and reproducible, the whole problem of rape might be ameliorated. The attitude of society, including health care workers, is improving. Reporting of this crime is becoming more likely. Legislation is improving court procedures. The following are some examples; in Illinois, the law (PA-79-564) establishes minimal standards for care of victims throughout the state, in hospitals that provide comprehensive emergency services. Large cities have developed sex squads composed of female offilcers
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
Literature Cited 1. McGuire LS, Stern M: Survey of incidence of and physician's attitudes toward sexual assault. Pub Health Rep 91:103, 1976 2. Poma PA, Stepto RC: Rape: A community hospital study. III Med J 154:25-28, 1978 3. Hayman CR, Lanza C: Sexual assault on women and girls. Am J Obstet Gynecol 109:480-486, 1971 4. Massey JB, Garcia CR, Emich JR: Management of sexually assaulted females. Obstet Gynecol 38:29-36, 1971 5. Rape. Sexual Medicine 1(3): November 1977 6. Harris L: Public has firm views about rape. Chicago Tribune, editorial. October 24, 1977
591
