Epidemiology

Exact figures on the incidence of rape are unavailable because many rapes are not reported. Females exceed males as reported rape victims by nearly 10 : 1, but male rape may be more underreported than female rape. In the USA, the annual rates of sexual victimization per 1,000 persons were reported in 2008 by the U.S. Department of Justice, National Crime Victimization Survey to be 1.6 for ages 12-15 yr, 2.2 for ages 16-19 yr, and 2.1 for ages 20-24 yr. The highest annual rate of sexual victimization has continued to be among 16-19 yr old adolescents. Rape occurs worldwide and is especially prevalent in war. An estimated one fourth to one half million adolescent and older women were raped during the 1994 conflict in Rwanda. During the Balkan conflict, with teenage girls particularly targeted, at least 20,000 girls and women were raped. In East Timor, 23% of adolescent and adult women reported being sexually assaulted during the 1999 armed conflict, declining to 10% during the post crisis period. In the context of the war in the Democratic Republic of the Congo, there were 20,517 female rape survivors in the 3 yr period 2005-2007.

Female adolescents and young adults account for the highest rates of rape compared to any other age group. The normal developmental growth tasks of adolescence may contribute to this vulnerability in the following ways: (1) the emergence of independence from parents and the establishment of relationships outside the family may expose adolescents to environments with which they are unfamiliar and situations that they are unprepared to handle; (2) dating and becoming comfortable with one’s sexuality may result in activities that are unwanted, but the adolescent is too inexperienced to stop the unwanted actions; and (3) young adolescents may be naïve and more trusting than they should be. Many teens are computer competent, which gives sexual perpetrators access to unsuspecting vulnerable populations who were previously beyond their reach. Chat rooms represent a major risk for adolescents, resulting in correspondence with individuals unknown to them or protective family members, while simultaneously providing a false sense of security due to remote electronic communications. A determined perpetrator can obtain specific information to identify the adolescent and arrange for a meeting that is primed for sexual victimization.

Some adolescents are at higher risk of being victims of rape than others (Table 113-1).

Types of Rape

Acquaintance rape (by a person known to the victim) is the most common form of rape for victims between 16 and 24 yr of age. The acquaintance may be a neighbor, classmate, or friend of the family. The victim-assailant relationship may cause conflicting loyalties in families, and the teen’s report may be received with disbelief and/or skepticism by her or his family. Adolescent acquaintance rape differs from adult acquaintance rape because weapons are less often used, and victims are less likely to sustain physical injuries. Victims of acquaintance rape are also more likely to delay seeking medical care, may never report the crime (males greater than females), and are less likely to proceed with criminal prosecution even after reporting the incident(s).

Date rape (by a person dating the victim) is often drug facilitated and is prevalent in adolescent populations. Date rape drugs are pharmaceuticals administered in a clandestine manner to potential victims. γ-Hydroxybutyric acid (GHB), flunitrazepam (Rohypnol), and ketamine hydrochloride are the leading agents used for these illegal purposes (Chapter 108). The pharmacologic properties of these drugs make them suitable for this use as they have simple modes of administration, are easily concealed (colorless, odorless, tasteless), have rapid onsets of action with resulting induction of anterograde amnesia, and have rapid eliminations due to short half-lives. Detection of these drugs requires a high index of suspicion and medical evaluation within 8-12 hr, prompting specific testing because routine toxicology screening is insufficient.

Date rape victims are often new to a specific environment (college freshman, newcomer to a town) and lack strong social support. Victims may not be assertive in establishing boundaries or limits with their dates and may be intoxicated when the incident takes place. The date rape assailant may engage in more sexual activities than other men his age and often has a history of aggressive behavior toward women. He may interpret passivity as assent and deny the charge of coercion or force; he may also be intoxicated at the time of the assault.

A date rape victim often experiences long-term issues of trust, self-blame, and guilt. She may lose confidence in her judgment concerning men in the future. She is nearly always ashamed of the incident and is less likely to report the rape. She is reluctant to talk about the rape to family, friends, or a counselor and may never heal from the psychologic scars that ensue.

Male rape generally refers to same-sex rape of male teens by other males. Specific subgroups of young men are at high risk of being victims of rape (see Table 113-1). Male rape is most prevalent within institutional settings. Male rape that occurs outside of institutional settings typically involves coercion of the male teen by someone considered an authority figure, either male or female. Male rape victims often experience conflicted sexual identity whether or not they are homosexual. Issues of loss of control and powerlessness are particularly bothersome for male rape victims, and these young men commonly have symptoms of anxiety, depression, sleep disturbance, and suicidal ideation. Males are less likely than females to report rape and less likely to seek professional help.

Gang rape usually occurs when a group of young men rape a solitary female victim. This type of rape may be part of a ritualistic activity or rite of passage for some male group (gangs, college fraternity) or be displaced rage on the part of the assailants.

Female victims of gang rape may find it difficult to return to the environment in which the rape occurred for fear of confrontation with the assailants (college setting or place of employment) and may insist on moving away from the locale entirely.

Statutory rape refers to sexual activity between an adult and an adolescent under the age of legal consent, as defined by individual state law. Statutory rape laws are based on the premise that below a certain age, an individual is not legally capable of giving consent to engage in sexual intercourse. In some states in the USA, statutory rape laws apply to sexual contact or intercourse occurring between a minor and another individual with a specific age difference even when both are minors and both assert that the sexual act was voluntary (an 18 yr old male who has sexual intercourse with a 14 yr old female). The intent of such laws is to protect youths from being victimized, but they may inadvertently lead a teenager to withhold pertinent sexual information from a clinician for fear that their sexual partner will be reported to the law. A clinician must be familiar with the laws of the state or province in which they are practicing medicine.

Stranger rape occurs less frequently within the adolescent population and is most similar to adult rape. Such rapes frequently occur with an abduction, use of weapons, and increased risk of physical injuries. These rapes are more likely to be reported and prosecuted.

Trichomonas vaginalis and bacterial vaginosis* Metronidazole 2 g PO × 1 dose HIV^† Combivir 1 tab PO bid × 28 days Hepatitis B Complete immunizations Human papillomavirus Complete immunizations Emergency contraception^‡ Ovral 2 tabs (0.05 mg ethinyl estradiol, 0.50 mg norgestrel) and 2nd dose in 12 hr   Plan B 1 tab (0.75 mg levonorgestrel) and 2nd dose in 12 hr, or both pills together as one dose

* Prophylaxis is recommended for all three STIs.

^† HIV postexposure prophylaxis is provided for patients with penetration and when the assailant is known to be HIV positive or at high risk due to a history of incarceration, intravenous drug use, or multiple sexual partners. If provided, follow-up must be arranged.

^‡ Provided for patients with negative urine pregnancy screen. In addition, provide antiemetic (Compazine, Zofran) for patients receiving emergency contraception medication other than Plan B.

At the time of presentation, the clinician should address the need for follow-up care including psychologic counseling. Adolescent victims are at increased risk of post-traumatic stress disorder, depression, self-abusive behaviors, suicidal ideation, delinquency, substance abuse, eating disorders, and sexual revictimization. It is important for the adolescent victim and parents to understand the value of timely counseling services to decrease these potential long-term sequelae. Counseling services should be arranged during the initial evaluation, with follow-up arranged with the primary care physician to improve compliance. Counseling services for family members of the victim may improve their ability to provide appropriate support to the adolescent victim. Caution parents not to use the assault as a validation of their parental guidance, as it will only serve to place blame inappropriately on the adolescent victim.

Prevention

Primary prevention may be accomplished through education of preadolescents and adolescents on the issues of rape, healthy relationships, Internet dangers, and drug-facilitated rape. Prevention messages should be targeted to both males and females at high schools and colleges. Particular emphasis on prevention efforts during college orientation is highly recommended. High-risk situations that may increase the likelihood of a sexual assault (use of drugs or alcohol) should be discouraged. Secondary prevention includes informing adolescents of the benefits of timely medical evaluations when rape has occurred. Individual clinicians should ask adolescents about past experiences of forced and unwanted sexual behaviors and offer help in dealing with those experiences. The importance of prevention cannot be overstated since adolescents are disproportionately affected by rape and they are particularly vulnerable to long-term consequences.