Rape and the Adolescent

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Committee

on Adolescence

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738 PEDIATRICS Vol. 72 No. 5 November 1983

Rape

and the Adolescent

In recent years the problem of rape and sexual

abuse of young persons has begun to receive

appro-pniate medical attention. Nearly 50% of reported

nape victims are adolescents.”2 Whereas the vast

majority of offenses involve girls, the incidence of

sexual assaults on young males also appears to be

increasing.

Although community resources may vary

consid-erably, most metropolitan areas now have special

programs or facilities to assist the victims of sexual

assault. Such assistance usually includes advice as

to the management of the acute crisis as well as

guidelines for the collection of evidence and the

preparation for trial should legal action follow.

Be-cause so many of the victims are adolescents, they

are being seen with increasing frequency in

pedi-atnic emergency rooms.

The adolescent who is forcibly assaulted may

display a wide range of behaviors, such as hysterical crying or giggling, agitation, feelings of degradation,

anger and rage, helplessness, nervousness, and

rapid mood swings. Alternatively, the adolescent

may appear calm and controlled, masking internal

turmoil. She is often angry, confused, and filled

with self-blame. In cases of forcible assault,

long-term sequelae such as fears, nightmares, and sleep

disturbances, disturbed peer and sexual

relation-ships, and psychosomatic complaints may develop.

Some fear retaliation from their attacker and

de-velop ritualistic behavior as a defense. Some believe

their bodies to be permanently damaged, and may

even fear death as a consequence of the violent act

they have experienced.

For the victim, the circumstances of the initial

medical evaluation may be frightening and

stress-ful. Police interrogation, repeated questioning by

health professionals, and the physical examination

This statement is intentionally restricted in scope to the female adolescent. Readers interested in male rape as a separate entity may refer to a number of recent studies on that subject, in particular those ofDr Robert W. Deisher ofSeattle, Washington. This statement has been approved by the Council on Child and Adolescent Health.

itself all have the potential to add to the trauma of

the sexual assault. When the victim of an assault

is a child or an adolescent, it is frequently the

pediatrician who must intervene at this time of

crisis as health care provider, patient advocate, and trusted professional.

Pediatricians should be equipped to look after

the special needs of young victims of sexual assault.

Sexual violence toward a teenager is abhorrent to

the physician and can be emotionally devastating

to the family. Most pediatricians have had little

prior experience on training in managing such prob-lems, even though the pediatrician often works with both the police and the victim and his or hen family. The incidence of nape of adolescents is increasing. The victim’s reactions to such abusive experiences are greatly influenced by parental reactions and the

availability of appropriate support systems within

the community. Residency and continuing medical

educational programs should assist the pediatrician in developing the necessary skills and techniques for treating these patients in a sensitive and sup-portive manner. It is imperative that the pediatri-cian be taught to perform the appropriate physical

examination, to collect the necessary specimens,

and to provide sensitive and reassuring assistance to victims and parents.

The initial contact needs to be supportive. While

it is important to obtain a clear account of the

circumstances of an alleged nape, it is equally

essen-tial to minimize further psychological trauma that

might occur if the patient is immediately forced to

relive a very painful experience. Under such

cm-cumstances detailed history-taking may have to be

deferred. At all times the welfare of the adolescent

must be a primary consideration. The patient

should not become further victimized through

in-sensitive cane and unnecessary trauma. The patient

should always be told in understandable terms what

to expect in the way of tests or procedures, and

strong emotional support should be provided.

Es-tablished protocols and procedures are available in

most emergency room settings and in rape crisis

centers as an aid in the evaluation and care of the

patient who has been raped. Such protocols provide

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3. Mode of entry: police friend

family _ self-referral other

-B.

Date of assault _____________________________

C. Time of assault AM PM

D. Circumstances of assault (including postassault activity, changes of clothing, bathing, douching. Record evidence of torn clothing, bruises, blood or semen stains):

E. Menarche

F. Last menstrual period

G. Method of birth control

_________

H. Current medications: yes no

specify

II. Physical examination

A. General appearance (include the emotional state, behavior of patient. Document areas of obvious trauma by photograph or diagram):

B. T _ P_ BP Wt Pubertal stage

(Tan-ner)

C. Evidence of trauma: ______________________

D. Description of clothing: torn

blood-stained

________

semen-stained

normal ______________ E. Description of perineum: normal

laceration ___________ ecchymosis

bleeding F. Pelvic examination: vagina

cervix

_________

uterus ________

adnexa

rectum

_______

III. Laboratory evaluation Done Not

done

COMMITTEE ON ADOLESCENCE, 1982-1983

William A. Long, Jr, MD, Chairman

Richard C. Brown, MD

Anne Mare Ice, MD

Renee R. Jenkins. MD

Joe M. Sanders, Jr, MD

S. Kenneth Schonberg, MD

Liaison representatives

Luella Klein, MD, ACOG

Donald A. Dian, MD

Section on Adolescent Health Consultant

Sherrel L. Hammar, MD

APPENDIX

Sample Sexual Assault Data Sheet

I. History

A. Presentation in emergency room

1. Date seen _________________ 2. Time seen AM PM 0

Results

men

J. Hair combing of pubis K. Fingernail scrapings

AMERICAN ACADEMY OF PEDIATRICS 739

guidance in the collection of evidence, the obtaining of microbiologic cultures, the prophylaxis against venenal disease, and the prevention of pregnancy.

0 In institutions that have not yet developed such

protocols, it is the responsibility of the pediatrician, in collaboration with other health professionals, to

establish appropriate procedures prior to a crisis

situation.3 (See “Appendix”)

In addition to looking after the needs of the

victim, the physician must be sensitive to the

re-actions of the parents. Some will become angry and

blame the adolescent; others will be guilt-ridden.

Parents may exhibit reactions ranging from

help-less despair to extreme agitation. Often they require

as much support and reassurance as the victim; a

private interview with the parents will provide them an opportunity for open expression of their feelings.

With assistance and attention to their needs, most

parents will be able to support their teenager at this time of crisis.

Following the resolution of the immediate crisis,

most adolescents and their families will require

counseling, often separately and individually, in an effort to minimize the long-term effects of the rape and to assist in an early return to a normal living

pattern. These families may wish to obtain

profes-sional guidance from an established rape crisis cen-ten, but often they will feel more comfortable with

their pediatrician rather than seeking direction

0 from an unfamiliar resource. The pediatrician

needs to remain alert for those instances in which

the degree of disruption requires psychiatric

con-sultation or referral.

A. Wet preparation of vaginal fluid for motile sperm and T vaginalis

B. Vaginal washing for a. Acid phosphatase b. ABH agglutinogen C. Culture of vagina for

GC

D. Culture of anus for GC E. Culture of oropharynx

for GC

F. Culture of urethra for GC

G. Serologic test for

syph-ilis

H. Pregnancy test (pubertal females) I. Wood’s lamp for

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740 RAPE AND THE ADOLESCENT L. Serum sample frozen

and saved for future testing

IV. Therapy

A. Antibiotic prophylaxis (in accordance with current CDC

recommendations):

Tetracycline, 50 mg/kg/day for older children and 500 mg 4 times a day for adolescents, for 10 days. Should not be given to patients who are pregnant or those allergic to tetracycline.

OR

Doxycycline, 100 mg twice a day for

10 days (for adolescents). OR

Ampicillin, 3.5 g, or amoxicillin, 3.0 g

as a single dose, taken with 1.0 g of

probenecid, for adolescents.

Younger children can be given 50 mg/kg of either antibiotic, with 20-25 mg/kg of probenecid.

Contraindicated in patients allergic to penicillin.

B. Tetanus toxoid as indicated according to Public Health recommendations.

C. Pregnancy prevention for pubertal females: Ovral, 4 tablets in 2

divided doses 12 hours apart.

Dose given V. Reported to police: date

____

time

____

VI. Disposition and follow-up:

REFERENCES

1. Hayman CR, Lanza C: Sexual assault on women and girls.

Am J Obstet Gynecol 1971;190:380

2. Schiff AF: A statistical evaluation of rape. Forensic Sci

1973;2:332

3. American College of Obstetricians and Gynecologists: Al-leged Sexual Assault. ACOG Technical Bulletin No. 52, November 1978

ADDITIONAL RESOURCE MATERIAL

Felice M, Grant J, Reynolds B, et al: Follow-up observation of adolescent rape victims. Clin Pediatr 1978;17:311

Mann E: Self-reported stresses of adolescent rape victim. J Adolesc Health Care 1971;2:29

Morbidity and Mortality Weekly Report Supplement 1982;31:33-62

Sarles RM: Sexual abuse in the adolescent, in Moss AJ (ed):

Pediatric Update. New York, Elsevier, 1971, p 73 Sarles RM: Sexual abuse and rape. Pediatr Rev 1982;4:93

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CHILD ABUSE IN CEREBRAL-PALSIED CHILDREN

Of 86 cerebral-palsied children seen in one care center over a 12-month

period, 17 had been subjected to child abuse. Eight of these children’s cerebral palsy was a result of abuse. The findings suggest that there is a high incidence of child abuse among children with cerebral palsy. There is a “double indication” for abuse, both as a cause and a result of cerebral palsy.

Abstracted from L. J. Diamond and P. K. Jaudes: Child abuse in a cerebral-palsied population (Dev

Med Child Neurol 1983;25:169-174).

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1983;72;738

Pediatrics