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PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1476-1479
Sexual assault is a broad-based term that
encompasses a wide range of sexual victimizations, including rape.
Since the American Academy of Pediatrics published its last policy
statement on this topic in 1994, additional information and data have
emerged about sexual assault and rape in adolescents, the adolescent's
perception of sexual assault, and the treatment and management of the
adolescent who has been a victim of sexual assault. This new
information mandates an updated knowledge base for pediatricians who
care for adolescent patients. This statement provides that update, focusing on sexual assault and rape in the adolescent population.
ABSTRACT
Top
Abstract
Recommendation
References
Understanding the definitions of the terms sexual assault,
rape, acquaintance rape, date rape, molestation, and statutory rape are
important in the identification, treatment, and management of the
adolescent victim. Sexual assault is a comprehensive term that includes multiple types of forced or inappropriate sexual activity. Sexual assault includes situations in which there is sexual
contact with or without penetration that occurs because of physical
force or psychologic coercion. This includes touching of a person's
"sexual or intimate parts or the intentional touching of the clothing
covering those intimate parts."1
The term molestation is applied when there is noncoital
sexual activity between a child and an adolescent or adult. Molestation can include viewing of sexual materials, genital or breast fondling, or
oral-genital contact.1
From legal and clinical perspectives, rape is defined as
"forced sexual intercourse" that occurs because of physical force or psychologic coercion. Rape involves vaginal, anal, or oral penetration by the offender. This definition also includes incidents in
which penetration is with a foreign object, such as a bottle, or
situations in which the victim is unable to give consent because of
intoxication or developmental disability.1,2 The terms
acquaintance rape and date rape are applied to
those situations in which the assailant and victim know each other.
Statutory rape involves sexual penetration by a person 18 years or older of a person under the age of consent.1
Statutory rape laws are based on the premise that, until a person
reaches a certain age, he or she is legally incapable of consenting to sexual intercourse. The age of consent varies from state to state. In
some states, there are new statutory rape laws mandating that sexual
intercourse and sexual contact must now be reported if certain age
differences exist between a minor (usually defined as younger than 18 or 21 years) and his or her sex partner (whether minor or adult), even
if the sexual act was voluntary and consensual. There is concern that
the new laws and mandated reporting statutes can have a significant
impact on the interaction between the health care provider and the
patient. Adolescents and health care providers may have concerns
regarding medical or social history, access to care, and
confidentiality, and some adolescents may refuse to seek care or refuse
to disclose personal risk information because of possible reporting of
sexual partners.3-5
National data show that adolescents continue to have the highest
rates of rape and other sexual assaults of any age group. Annual rates
of sexual assault per 1000 persons (males and females) were reported in
1998 by the US Department of Justice to be 3.5 for ages 12 through 15 years, 5.0 for ages 16 through 19 years, 4.6 for ages 20 through 24 years, and 1.7 for ages 24 through 29 years.6 There are
significant gender differences in adolescent rape and sexual assault,
with female victims exceeding males by a ratio of 13.5:1.6
National Crime Victimization Survey statistics reported 308 569 rapes
and sexual assaults in females 12 years or older and 21 519 rapes and
sexual assaults in males 12 years or older in 1998.6 This
represents a decrease from peak rates of rape and sexual assault
reported in 1992.6,7 The US Department of Justice reported that more than half of all rape and sexual assault victims in 1998 were
females younger than 25 years.6
Studies have demonstrated that two thirds to three quarters of all
adolescent rapes and sexual assaults are perpetrated by an acquaintance
or relative of the adolescent.8-11 Older adolescents are
most commonly the victims during social encounters with the assailants
(eg, a date). With younger adolescent victims, the assailant is more
likely to be a member of the adolescent's extended family. Adolescents
with developmental disabilities, especially those in the mildly
retarded range, are at particular risk for acquaintance and date
rape.12
Adolescent rape victims are more likely than adult victims to have used
alcohol or drugs and are less likely to be physically injured during a
rape, as the assailants in adolescent rape tend to use weapons less
frequently.8,9 Adolescent female victims are also more
likely to delay seeking medical care after rape and sexual assault and
are less likely to press charges than adult women.8,9
Male victims are less likely to report a sexual assault than are female
victims.13,14 Studies of sexual assault of males have
demonstrated that up to 90% of perpetrators are male. Sexual assault
of males by females is more commonly reported by older adolescents or
young adults, compared with children or young
adolescents.12 Male perpetrators of male sexual assault
more commonly identify themselves as heterosexual than homosexual, and
there is lack of clarity in the literature whether adolescent and young
adult victims are more commonly heterosexual or
homosexual.13-14 The rate of perpetration by an
acquaintance of the victim is similar for male and female victims, but
multiple assailants, use of a weapon, and forced oral assaults are more
common in assault of males than females.14
Alcohol or drug use immediately before a sexual assault has been
reported by more than 40% of adolescent victims and adolescent assailants.15 The recent increase in the rate of
adolescent acquaintance rape has been associated with the illegal
availability of flunitrazepam (Rohypnol, manufactured by Roche
Pharmaceuticals Inc, outside of the United States). This
so-called "date rape drug" is a benzodiazepine sedative/hypnotic.
The effects of flunitrazepam begin 30 minutes after ingestion, peak
within 2 hours, and can persist for up to 8 to 12 hours. Drug effects
include somnolence, decreased anxiety, muscular relaxation, and
profound sedation. There may also be amnesia for the time that the drug
exerts its action. This drug can go undetected if added to any drink,
thus increasing the risk of sexual assault, especially in the
adolescent population.16-19
Exploring the perceptions and attitudes of adolescents regarding
rape and other forced or unwanted sexual encounters is important. The
acquaintance rape phenomenon raises issues of victim credibility, because there may have been voluntary participation until the assault
occurred. Aggressive behavior on the part of a male perpetrator may be
seen by some adolescents as normative in this
context.20-23 One study demonstrated that male and
female adolescents who viewed a vignette of unwanted sexual intercourse
accompanied by a photograph of the victim dressed in provocative
clothing were more likely to indicate that the victim was responsible
for the assailant's behavior, more likely to view the male's behavior
as justified, and less likely to judge the act as rape.24
Exploration of unwanted sexual experiences and rape from the
adolescent's perspective can lead to additional insight into health
behaviors and outcomes.21,22,25,26 A large survey of
unwanted sexual experiences among middle and high school students
indicated that 18% of females and 12% of males reported
having had an unwanted sexual experience.26 In 1 study,
this led to unexpected gender-reversed patterns of behavior, including
the internalizing behavior, bulimia, in males and externalizing
behaviors, such as fighting, in females.27 Other studies
of female adolescents have found rape during childhood or adolescence
to be associated with younger age of first voluntary intercourse, lower
internal locus of control, higher depression scores, increased seeking
and receipt of psychologic services, increased rate of pregnancy, and
greater amounts of illegal drug use as well as evidence of physical
abuse and negative mental health states.28,29
The pediatrician who is involved in the management of adolescents
who are the victims of sexual assault should be trained in the forensic
procedures required for documentation and collection of evidence or
should refer to an emergency department or rape crisis center where
there are personnel experienced with adolescent rape victims. New
colposcopic procedures allow examiners to better document genital
trauma, including microtrauma, seen in rape cases, with a growing body
of literature demonstrating the patterns of genital injury in sexual
assault victims.30-32
It is essential that the forensic examination be performed by a person
who can ensure an unbroken chain of evidence and accurate documentation
of findings.133-38 Details of the required examination
and documentation are presented in a handbook by the American College
of Emergency Physicians, Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient.39
Pediatricians who treat sexually abused or assaulted patients need to
be aware of the legal requirements, including completion of appropriate
forms and reporting to appropriate authorities, specific to their
locale. Pediatricians should also be aware that the availability of DNA
amplification technology now used to more accurately identify
assailants allows for performance of a forensic examination beyond the
72-hour period that was previously considered the cutoff for such
examinations.3640-41
The diagnosis and management of sexually transmitted diseases (STDs) is
an important component of treatment of the assault victim.42 Blood and tissue specimens should be obtained from appropriate sites (as identified in the history) to detect Neisseria gonorrhea and Chlamydia trachomatis.
Vaginal secretions should be microscopically examined for
Trichomonas species. Specimens should be tested for herpes
virus if there is a clinical indication (eg, vesicles). Serum samples
should be obtained to test for syphilis, hepatitis B virus (HBV), and
human immunodeficiency virus (HIV). These tests serve as a baseline
indicating the presence of any STDs in the victim before the assault
but are considered controversial by some authorities who prefer
performing the initial STD tests 2 weeks after the assault. All
authorities agree that the syphilis and HBV tests should be repeated in
6 weeks and that the HIV test should be repeated in 3 to 6 months.136-39,42
Pregnancy prevention and postcoital contraception should be addressed
with every adolescent female rape and sexual assault victim. This
discussion should include risks of failure and options for pregnancy
management. A baseline urine pregnancy test should be performed. This
is important because the adolescent could be pregnant from sexual
activity that occurred before the assault.136-39
Current recommendations are to provide prophylactic treatment for
Chlamydia infection and gonorrhea to adolescent sexual
assault victims and to provide prophylaxis for pregnancy
prevention.136-39,42 HIV prophylaxis is not universally
recommended but should be considered when there is mucosal exposure
(oral, vaginal, or anal). Factors to consider include the risks and
benefits of the medical regimen, whether there was repeated abuse or
multiple perpetrators, if the perpetrator is known to be HIV-positive,
or if there is a high prevalence of HIV in the geographic area where
the sexual assault occurred.136-39,43 HBV vaccination is
recommended for those who have not received a complete HBV series or
who have a negative surface antibody despite previous
vaccination.36-39
Posttraumatic stress disorder occurs in up to 80% of rape
victims.44 Rape trauma syndrome is described as consisting of an initial phase lasting days to weeks during which the victim experiences disbelief, anxiety, fear, emotional lability, and guilt
followed by a reorganization phase lasting months to years during which
the victim goes through periods of adjustment, integration, and
recovery.37,45 Counseling designed to specifically address
these issues as well as additional psychologic trauma that results from
date or acquaintance rape should be available. Psychotropic
medications may be required in some instances. The pediatrician should
be knowledgeable about services available in the community to address
these issues and should provide initial psychologic support.
Other victim reactions to rape can include the feeling that his or her
trust has been violated, increased self-blame, less positive
self-concept, anxiety, alcohol abuse, and effects on sexual activity
(including younger age at first voluntary sexual activity, poor use of
contraception, greater number of abortions and pregnancies, STDs,
victimization by older partners, and sexual dissatisfaction).28,3446-49 Adolescent victims may feel
that their actions contributed to the act of rape and have confusion as
to whether the incident was forced or consensual.50-52
Because responses to rape can vary, it is important for pediatricians
to not only manage the physical needs of the victim but also be
sensitive to the psychologic needs of the adolescent. Pediatricians
should be aware that self-blame, humiliation, and naiveté may
prevent the adolescent from seeking medical care. Effective screening,
referral, and follow-up allow for support of the adolescent rape victim
and appropriate delivery of health care services. Because patients
treated in emergency departments often do not return for follow-up
care,53 it is important that the emergency treatment team
refer the assaulted adolescent back to his or her medical home. Thus,
pediatricians should be prepared to provide such services as follow-up
STD testing, completion of the HBV vaccination series, treatment of
injuries, screening for mental health problems, and management of
substance use issues.
Adolescent rape exists in a sociocultural context in which issues
of male dominance, appropriate gender behaviors, female victimization,
and power imbalances in relationships are highly visible. Prevention
messages for adolescents need to be designed for males and
females.33,3454-56 Adolescents need to be able to
identify high-risk situations and should be encouraged to seek medical
care after a rape. Factors that may increase the likelihood of assault
(eg, late night use of drugs or alcohol) and strategies to prevent rape
should be discussed, and associated educational materials should be
distributed.33,3454-56
Screening of adolescents for sexual victimization should be part
of a routine history. Adolescents should be asked direct questions
regarding their past sexual experiences. These questions should include
those that explore age of first sexual experience, unwanted voluntary
or forced sexual acts, and a description of events. Exploration of
gender roles and relationship parameters (eg, exploitative,
nonconsensual vs healthy) are critical. The patient needs the
opportunity to describe the experience in his or her own
words.30-34
DEFINITIONS
EPIDEMIOLOGY
ADOLESCENTS' PERCEPTIONS AND ATTITUDES REGARDING SEXUAL ASSAULT
AND RAPE
TREATMENT AND MANAGEMENT
ADOLESCENT REACTIONS TO RAPE
SEXUAL ASSAULT AND RAPE PREVENTION STRATEGIES
RECOMMENDATIONS
Top
Abstract
Recommendation
References
Committee on Adolescence, 2000-2001
David W. Kaplan, MD, MPH, Chairperson
Ronald A. Feinstein, MD
Martin M. Fisher, MD
Jonathan D. Klein, MD, MPH
Luis F. Olmedo, MD
Ellen S. Rome, MD, MPH
W. Samuel Yancy, MD
Liaisons
Paula J. Adams Hillard, MD
American College of Obstetricians and Gynecologists
Diane Sacks, MD
Canadian Paediatric Society
Glen Pearson, MD
American Academy of Child and Adolescent Psychiatry
Section Liaison
Barbara L. Frankowski, MD, MPH
Section on School Health
Staff
Tammy Piazza Hurley
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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STDs, sexually transmitted diseases; HBV, hepatitis B virus; HIV, human immunodeficiency virus.
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REFERENCES |
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Top
Abstract
Recommendation
References
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The following policy statement is a revision:
This article has been cited by other articles:
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  M. Kaufman and and the Committee on Adolescence Care of the Adolescent Sexual Assault Victim Pediatrics, August 1, 2008; 122(2): 462 - 470. [Abstract] [Full Text] [PDF]
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P. J. O'Malley, K. Brown, S. E. Krug, and and the Committee on Pediatric Emergency Medicine Patient- and Family-Centered Care of Children in the Emergency Department Pediatrics, August 1, 2008; 122(2): e511 - e521. [Abstract] [Full Text] [PDF]
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 C. A. Gidycz, L. M. Orchowski, C. R. King, and C. L. Rich Sexual Victimization and Health-Risk Behaviors: A Prospective Analysis of College Women J Interpers Violence, June 1, 2008; 23(6): 744 - 763. [Abstract] [PDF]
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R. C. Merchant, E. T. Kelly, K. H. Mayer, B. M. Becker, S. J. Duffy, and D. L. Pugatch Compliance in Rhode Island Emergency Departments With American Academy of Pediatrics Recommendations for Adolescent Sexual Assaults Pediatrics, June 1, 2008; 121(6): e1660 - e1667. [Abstract] [Full Text] [PDF]
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N. Kellogg and and the Committee on Child Abuse and Neglect The Evaluation of Sexual Abuse in Children Pediatrics, August 1, 2005; 116(2): 506 - 512. [Abstract] [Full Text] [PDF]
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 Protecting Adolescents: Ensuring Access to Care and Reporting Sexual Activity and Abuse AAP News, November 1, 2004; 25(5): 250 - 251. [Full Text] [PDF]
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B. Geiger, M. Fischer, and Y. Eshet Date-Rape-Supporting and Victim-Blaming Attitudes Among High School Students in a Multiethnic Society: Israel J Interpers Violence, April 1, 2004; 19(4): 406 - 426. [Abstract] [PDF]
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 M Kawsar, A Anfield, E Walters, S McCabe, and G E Forster Prevalence of sexually transmitted infections and mental health needs of female child and adolescent survivors of rape and sexual assault attending a specialist clinic Sex. Transm. Inf., April 1, 2004; 80(2): 138 - 141. [Abstract] [Full Text] [PDF]
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