Forcible rape is recognized as a violent crime rather than a sex act and has been placed in the same category as other violent crimes, such as robbery, assault, and the ultimate act of aggression, homicide. The word rape comes from the Latin rapere, which means “to take by force.” It is usually defined as the crime of having sexual intercourse with a woman or girl forcibly and without consent. Another meaning is “the act of seizing and carrying away by force.” Although these definitions imply violence, until the decade of the 1970s when the women's movement began to publicize the crime, most people believed sexual motives were involved and blamed the victims for enticing the offenders.

Traditionally, the legal definition of rape is carnal knowledge (vaginal penetration) of the female without her consent and with force or the threat of force. Statutory rape is the crime of having sexual intercourse with a girl under the age of consent. This age varies from state to state; in Florida, for example, the age of consent is 12 years.

The term rape is gradually being replaced by the more inclusive phrase sexual battery. The laws vary from state to state, but many states are accepting this concept and are changing their statutes to those that provide for “degrees” of sexual battery and that are similar to the structure of the law dealing with homicide. The severity of the sentence varies with the degree of the crime. For example, the Florida law defines sexual battery as follows: “ ‘Sexual battery’ means oral, anal or vaginal penetration by or union with the sexual organ of another or the anal or vaginal penetration of another by any other object; however, sexual battery shall not include acts done for bona fide medical purposes” (Florida law 794.011). Therefore, this definition includes fellatio and sodomy, for example. Consent is a key word and contact is sufficient. Penetration is no longer necessary. Few states recognize marital rape, and any cases that would fit this category are usually prosecuted as assault and battery.

As stated in the 1992 Uniform Crime Reports (UCR), forcible rape is the fastest-growing violent crime in the the United States.¹ In 1992, 102,069 rapes were reported to law enforcement—a rate of 84/100,000. This is a 2% increase from 1991 and an 18% increase from 1988. Eighty-six percent were rape by force, and the rest were attempted rape. These figures do not include rape homicides, male victims, or sexually abused children. Statistically, one forcible rape occurs every 5 minutes; it is estimated that one rape occurs every 2 minutes.

Law enforcement agencies recognize that victims are often too embarrassed and in many instances are too terrified of their attackers to report the crime; male victims seldom report the crime. It is thought that, at best, only 1 in 5 rapes is reported; perhaps, in reality, it is only 1 in 10.

In the country as a whole, more forcible rapes occur in the summer months than during any other time of the year. In South Florida, however, rapes occur throughout the year, and there is no clear seasonal pattern.

More rapes occur in large metropolitan areas than in the smaller cities, and rural areas have the fewest number.

If people are to understand that rape is a crime, they must be aware of some facts about the sex offender.² Rape is a crime of violence and is the expression of anger, power, hostility, and aggression, not sex. It is generally acknowledged that rape is a pseudosexual act and that sexual gratification is not the motivation for sexual assault. Rape is now recognized to be a form of sexual deviance.

Sex offenders come predominantly from the lower and middle classes, but all socioeconomic groups and all educational levels are represented. The tendency toward sexually deviant behavior begins to manifest itself before or during adolescence and gradually increases in the degree of seriousness. Rapists tend to “burn out” around 35 years of age, but other sex offenders such as child molesters may continue to commit these crimes until they are elderly. It is significant that the majority of sex offenders were themselves the victims of sexual battery during childhood.

Until recently, the “nuisance offenders,” the voyeurs (Peeping Toms), and the exhibitionists were thought to be “harmless,” but it is now known that these men often progress to rape as they become older and more aggressive. This has been well documented by people working in the sex offender programs that exist within the penal systems. Law enforcement personnel are now taking these offenses more seriously than they did in the past and, in addition to arresting these offenders, are seeking psychologic help for them.

Rape is a repetitive crime, and some men rape as frequently as once a week. Rapists plan the rape carefully, although they may not have picked out the victim, and each has a rigid modus operandi that usually can be identified by the police even though they may not know the name of the man committing the crime.³ When a rapist is caught, he has usually committed 14 rapes that have gone undetected.

Aggression in the sexual act is frequently acted out when sexual inadequacy exists.⁴ The victim may be a substitute for the mother figure or may be just someone who has not responded adequately to him. In both situations the violence becomes the primary focus of the relationship and seems to overshadow the sexual elements involved.

It has been found that the rapist's behavior is frequently linked with his childhood socialization process within the family unit. The family scenario may be as follows: a strong maternal encouragement of dependent behavior and a father who is sexually promiscuous, an excessive drinker, and a brutal disciplinarian. Other theorists claim that the rape is a compensatory sadistic reaction to feelings of inadequacy toward women. By being aggressive to them, the rapist can mask these feelings and satisfy his need to dominate. Humiliating the victim makes her inferior and degrades her. This allows the rapist to feel masculine and powerful, and thus he expresses, proves, tests, and gains his image of masculinity and his dominance over women.

The crime of rape can be divided into three categories: power rape, anger rape, and sadistic rape.² The offender may progress from one category to the other. At one time this was thought not to occur, but it has since become apparent during discussions with the offenders.

The Power Rape

About 55% of the reported rapes fall into the category of the power rape. These men are usually younger than those in the other groups, and they are often under 18 years of age. This may make it difficult to prosecute them because they are “juveniles.” The assault is premeditated, and the rapist may stalk the victim. The attack is preceded by rape fantasies. The object of the rape is sexual intercourse, but it is not sexual gratification the offender is seeking. The rapist uses whatever force is necessary to get control of a victim, but it is not his intent to injure her physically, although this may occur. This man is anxious and questions his own ability and virility. He aims to control the victim. In many cases, the victim is kidnapped and held for a period of time during which she is assaulted repeatedly. The encounter seldom lives up to his fantasy, and he tells himself that although this victim “did not understand, the next one will.” The so-called date rape is included in this category. These cases are often plea bargained down to a charge of breaking and entering and are not reported as forcible rapes.

The Anger Rape

The category of the anger rape comprises about 40% of all rapes. These men are more dangerous than the power rapists but less dangerous than the sadistic type; their rapes are more impulsive and episodic than the first group. More physical force is used than in the power category, and the victim usually suffers multiple bruises. This rapist is much more aggressive than the previous type and uses more physical force than necessary. His aim is to humiliate, degrade, and hurt his victim. He feels that rape is the worst thing he can do to a woman, and he uses the penis as a weapon. These assaults are not as premeditated as that of the power rapist but are triggered by sudden stress, such as an argument with his wife or girlfriend or an incident in which he felt he had been wronged. The victim is an “object,” a “thing,” and is often unknown to the man; she was just there when he exploded.

Sadistic Rape

The most violent rape occurs in the sadistic rape category; fortunately, only 5% are of this type. Rape-homicides are included in this group. These assaults are calculated and preplanned, and the physical force is eroticized. They are often ritualistic and may involve bondage, torture, and acts designed to humiliate and debase the victim. There is usually severe trauma to the sexual areas of the body, possibly including mutilation. These assaults are premeditated and are designed to punish and even destroy the victim.

Many of these men will show cruelty in other areas: spouse abuse, child abuse, cruelty to animals, and frequent fights. Some are psychotic and frequently give little indication of the “Jekyll and Hyde” personality they have.

This rapist symbolically eliminates the female. These are the most traumatic assaults, and the victim has a difficult time returning to her former psychologic state and needs a great deal of help.

Rape is a repetitive crime, and the rapist tends to return to it after a term in prison. He uses the same modus operandi and often goes back to the same area. Because of this and because most offenders do not realize that violence and not sex is the motivation, a sincere effort has been made to treat these men in a rehabilitation program. The length of these programs is about 3 years, and the criminally insane are not accepted.

In some instances, the rehabilitation programs have been very effective. Unfortunately, not all sex offenders can benefit from this intensive psychotherapy, and they may never learn to control their behavior. The Sex Offender Rehabilitation Program at South Florida State Hospital, for example, has an overall rearrest rate of 6%, and when corrected for recidivism for a sex crime, the rate is 1%.⁵ This is much better than the rate after routine incarceration in prison. There are few rehabilitation programs for convicted sex offenders in the prison system, and the recidivism rate after release from prison is 73%. Many law enforcement personnel feel that it is closer to 90%.

From an economic standpoint, the average cost of treatment for each man in the hospital is about $15,000 a year. Overall, it is far less expensive in both money and damage to victims to treat these men than to simply “warehouse” them within the prison system.⁶

All sexual battery victims should have a physical examination, appropriate medical treatment, and psychologic counseling to help them overcome the trauma. The way in which they are managed determines the rapidity with which they recover from the experience and the degree of recovery they will attain. No one who is judgmental should come into contact with a patient of sexual assault.⁷

Once the victim enters the hospital, she should be treated as a patient and must be given all the empathy and confidentiality that the word patient encompasses. All those who care for her should realize that rape is a crime and that she is not the guilty party. It is vital that they understand that rape is a crime of violence, not of sex.

Few rape patients are hysterical; most are exhausted and sit quietly. They should be treated as emergencies because they are in a crisis situation. They should be taken to an area apart from the confusion of the emergency room, and the word rape should never be used in their presence. These patients are extremely sensitive and feel “marked.” They need expert medical care and counseling and should be examined as soon as possible after their arrival at the hospital.⁸

All those working with the rape patient must have empathy; sympathy can be degrading. In most cases, the sex of the personnel caring for the patient is not important. In fact, although a female nurse should be present, dealing with a normal empathic male is usually psychologically therapeutic for a female patient. Male rape patients readily accept a female nurse, but most of them are far more relaxed with a male physician.

The nurse is usually the first person to see the patient, and she should be supportive and empathic. Although the patient should be allowed to talk freely, no history should be extracted. Only the information necessary to generate a chart should be obtained at this time. The patient should sign the necessary consent forms so that she may be examined and so that specimens may be collected and pictures taken, if indicated. In Florida, for example, it is not necessary that the crime be reported to the police for the adult patient. However, if the patient is under the age of consent, the assault must be reported to the authorities. It is wise to get the permission of a parent or guardian if the patient is a minor, although this is not absolutely necessary because in some states procedures vary.

If the patient wishes to talk about the experience, this is fine, but no pressure should be put on her at this time. It is essential for her mental health that she be given control of her life as soon as possible after the attack, and being asked to tell and retell the story at this time can be extremely damaging psychologically.

The physician should arrive as soon as possible and conduct the necessary examinations. If the police are there, the physician may want to get a skeleton history from the police. Most details of the crime are not needed for the medical chart and should not be included there. The medical history should include only those facts needed for the proper medical care of the patient and for the collection of evidential specimens. Too detailed a history may jeopardize the case when it goes to trial. It is especially necessary for the physician to ask about fellatio and sodomy, for example, because the patient is often too embarrassed to tell anyone but the physician about these things. This is especially true of the older patient and of the young teenager. The history should be accurate but not detailed and, whenever possible, should be written in terms the lay person can understand. The reports will be read by police officers and attorneys, not by medical personnel.

It is obvious that the rape patient must be stable before the usual history and physical examination are done. Those patients with severe physical injuries should be taken directly to the trauma area of the emergency room. The examinations, photographs, and tests for the sexual battery may be done there; if indicated, these procedures may be performed in the operating room with the patient under anesthesia.

Only the doctor and the nurse should be in the room during the examination, unless the patient requests the presence of someone else. Police officers, regardless of their sex, should never be in the examining room.⁸

The date and time of the examination as well as the date, time, and location of the assault should be documented on the chart (Fig. 1). This will help the physician correlate the findings of the physical examination and the laboratory results. Foreign material found on the body of the patient (e.g., sand, grass, dried semen) may substantiate the history.

A past history is helpful. The patient should be asked if she has any allergies. Any hepatic disease or blood clotting problems may influence postcoital treatment. In addition, the last menstrual period, gravidity, parity, and the method of contraception, if any, should be documented. The date of the last consensual intercourse is essential because sperm from this encounter may still be present in the vaginal canal and cervix and confuse the issue. Whether or not she has had any recent gynecologic surgery may be significant if blood is present. The patient should be asked if she has ever had hepatitis or venereal disease. If so, she should be asked if she was treated for it, when she was treated for it, and what medication was used. It is also important to learn if the patient has douched, voided, defecated, or bathed since the attack.

The history of the attack should include the presence or absence of violence. If there was physical abuse, of what type and how severe was it. If a weapon was used, what kind was it. The presence of a weapon can explain the lack of physical trauma to the patient, because few patients will fight if the attacker has a knife or a gun . . . and rightly so. The patients with the most severe trauma are often the “fighters.” Was the patient restrained? If so, what was used? These facts are significant because they tell the physician what to look for (e.g., discolorations on the skin, rope burns, and abrasion).

How many attackers were present? What did they look like (e.g., color, race, language)? Did the victim know the assailant? Was he a relative? These latter bits of information are needed so that some of the myths about rape can be dispelled. The patient's own words should be used as much as possible and be put into quotation marks in the report.

A general statement about the emotional state of the patient should be documented. Again, a too-detailed interpretation of her behavior can be prejudicial. A blood screening test for alcohol or drugs is not necessary unless requested by the police.

The general inspection of the patient should be done in a good light so that injuries can be seen more easily. Some of the materials necessary to perform a proper physical examination are shown in Figure 2. It is not necessary to document findings not related to the rape. These findings may prejudice a jury. Although physical trauma is often not present, any ecchymoses, abrasions, contusions, scratches, and lacerations must be described accurately. The size of these lesions should be measured in inches so that the jury can appreciate it; at the present time the metric system is a mystery to many lay people, and they cannot visualize lesions that are measured in centimeters. Ecchymoses from gripping by the fingers of the offender are commonly found on the neck, upper arms, breasts, and medial aspects of the thighs.

Any bite marks should be carefully documented and, whenever possible, a forensic dentist should be called for more accurate interpretation of the marks; teeth marks may absolutely identify the attacker.

If there was a struggle, the fingernails should be inspected and scrapings taken from underneath them; there may be blood or skin from the attacker under the nails. Any broken nail should be clipped and saved; it may match some evidence found at the scene. The scrapings and piece of nail should be put into a clean paper envelope and sealed.

Dry seminal stains on the skin appear as pale yellow glistening areas and will fluoresce under a Wood's lamp (filtered ultraviolet light). Any areas suspicious for semen that has dried on the skin should be swabbed with cotton applicators moistened with saline. Moistened filter paper may also be used to “lift” semen from the skin. Any positive findings should be described and documented on the chart.

The examination of the genital area is usually the most important part of the examination. The pubic hair should be combed for foreign material (e.g., hair from the offender, twigs or debris from the location of the rape, and dried semen). Any evidence should be collected and placed in a clean envelope and sealed. Anything unusual about the vulvar area should be documented and diagramed. The area should be inspected for semen as well as for trauma.

The hymenal area and fourchette should be inspected carefully. Any erythema, abrasions, or lacerations should be noted. A statement about the state of the hymen should be made. The word marital should be avoided: words such as remnants, parous, old scarring, or nonviolated are preferable. Bleeding is usually present if the laceration has been recent.

In the case of young children, if a finger has been forced into the vagina, the bleeding may be from a laceration at the top of the vault caused by a fingernail; lacerations of the lateral walls are common. A small child must never be held down during examination of the genital area: this is tantamount to sexually assaulting the child and will intensify the trauma. When indicated, the child should be taken to the operating room and anesthetized so that proper assessment and treatment can be done.

In the adult, after the inspection is complete, a Pederson speculum should be inserted into the vaginal canal. The smaller speculum is desirable because only water can be used for lubrication: jelly will interfere with the forensic tests. There is usually no physiologic lubrication of the vagina during a rape because the primary emotion of the rape victim is fear; therefore, many patients are very tender. The cervix and the vaginal walls and vault should be inspected, and any laceration should be noted. Any secretions in the vaginal vault should be described. Nonabsorbent cotton swabs should be used to obtain specimens of these fluids, which are then placed in sterile glass tubes. Air-dried smears should be made.

Two millimeters of normal saline is injected into the vaginal vault, retrieved, and labeled “vaginal aspirate.” The pipette and bulb should be a single disposable unit so that there can be no contamination from previous examinations. Usually, forensic specimens should not be taken from the endocervical canal because sperm will remain motile much longer in the cervical mucus than it will in the acidity of the vagina itself.

A Papanicolaou smear should be obtained; it may provide a permanent record of sperm. Testing should be done for sexually transmitted diseases, especially gonorrhea and Chlamydia trachomatis. The material for these tests is obtained from the endocervical canal and inoculated on the proper media. Some laboratories are now doing DNA probes for these organisms instead of cultures.⁹ Although either method should be acceptable, it is best to ask law enforcement if the DNA results will be admissible or if the local courts recognize only culture results.

A bimanual pelvic examination should be done to check for pre-existing conditions (e.g., pregnancy or uterine, tubal, or ovarian pathology) and for tenderness in the lower abdomen that may be secondary to the rape trauma.

If there has been fellatio, the mouth and pharynx should be swabbed with nonabsorbent cotton swabs, and a smear should be made similar to that made of the vaginal material. A culture for gonorrhea should be taken from the nasopharynx.

If there was sodomy, the perirectal area should be inspected carefully, and any indication of lubricant or forced entry is recorded. Saline washings from the rectum are difficult to obtain, but the attempt should be made. Swabs and a smear may be made successfully; however, they must be free of feces. A gonorrhea culture should be taken from the rectum. The rectum should be explored with a finger, and an anoscope is used when appropriate.

A specimen of the patient's saliva should be collected routinely. The forensic laboratory can use this to check the secretor status of the victim. About 80% of people are secretors, and ABO antigens can be found in their body fluids; the other 20% are nonsecretors. Sperm can be typed for ABO if the offender is a secretor. The sample may be obtained by having the patient chew a small square of cloth or a piece of filter paper. No one but the patient may touch the sample at any time or the specimen will be contaminated. The specimen is put into a clean container, sealed, and identified.

Venous blood samples should be drawn and placed in tubes with color-coded tops appropriate for the tests ordered. A serologic test for syphilis should be sent to the laboratory, and tubes should be sent to the forensic laboratory for examination.

If the patient wishes to be tested for the human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), blood may be drawn at this time and sent to the laboratory. If the test is negative, it should be repeated in 3 months. In our area, a test for HIV may be done only if the patient agrees, and both pre- and post-test counseling must be offered.

Examinations and tests are done as indicated by the history of the individual attack. It is not necessary to do every procedure in every case.

Sophisticated testing should be done by a forensic laboratory, but the preliminary testing of the vaginal aspirate can be done easily by the examiner using the high power of a microscope; inspection of a wet mount will readily identify sperm, if present, and will determine motility or the lack of it. Sperm usually will remain motile in the vaginal canal for an average of 4 to 6 hours. However, sperm remains motile much longer in a specimen taken from the endocervical mucus. If the aspirate is contaminated by red blood cells, a drop of Sedistain (a commercial urine stain) may be added to the slide; the sperm will stain bright blue and can be easily identified under the microscope.

Acid phosphatase is an enzyme from prostatic glandular secretion and is present in huge quantities in seminal fluid.⁹ Although acid phosphatase is also found in the vaginal fluids, the concentration is relatively low. A high level of this enzyme in the vaginal washings is considered to be an indication of the presence of semen. The test is qualitative and is considered positive only when a deep blue-purple color develops within 10 seconds of the addition of the dye to the unknown solution.

Although using DNA for absolute identification of an offender is still not approved by all states, DNA testing is being used more and more by forensic laboratories and is becoming more accepted by law enforcement and the courts as documentation of its accuracy accumulates.¹⁰

All specimens must be handled properly if the chain of evidence is to be preserved, and this chain must be intact if the evidence is to be valid in the courtroom. The specimens must be labeled with the patient's name, the date they were taken, and the initials of the personnel obtaining the samples. The cultures and the blood samples should be sent to the appropriate laboratory as soon as possible. The other specimens are sent to the forensic laboratory.

The specimens for the forensic laboratory must be placed in properly labeled containers, initialed by the examiner, put in a paper bag, and sealed. This bag then should be handed directly to a police officer. A property receipt should be obtained. If it is not possible to hand the specimens directly to a police officer, they must be kept in a locked refrigerator until they can be taken to the crime laboratory. If signatures are obtained each time the specimens are transferred from one person to another, the chain will be preserved, and the evidence will be valid at trial.¹¹

Photographs are invaluable evidence and, whenever possible, should be taken by police identification units so that there will be no doubt about who took the photographs, where they were developed, and who has had possession of them since they were taken; again, the chain of evidence remains intact.

Any clothing that will become evidence should be handled as little as possible by the hospital personnel, properly identified, and sealed in a paper bag. Plastic bags should never be used because the moisture that collects inside a plastic bag will allow overgrowth of mold and bacteria, and this will destroy any seminal stains. Clothing stored in plastic bags will be useless as evidence.

Rape is a legal term, not a medical diagnosis, and it is not the duty of the physician to determine whether or not this was a case of sexual battery. That is the work of the police officers. If physicians remember this, they may be less reluctant to examine and treat rape victims. Rape is a crime, not a medical condition. Many cases have been jeopardized and even lost in the courtroom because the medical testimony was very detailed (and wrong), thereby putting a doubt in the minds of the jury.¹² Even the term alleged rape should not be written because the jury may interpret it to mean disbelief of the patient's story. The only conclusion the physician can reach is that the findings are “consistent with” or “not consistent with” the history given by the patient. A diagnosis of rape cannot be made by medical personnel.

All rape victims need medical and psychologic care if they are to survive the attack without permanent damage. This care must be offered to the victim, not forced on her. She should be urged to accept it, but she must be allowed to make the final decision.

Medical

PREVENTION OF SEXUALLY TRANSMITTED DISEASES.

Although the risk of contracting syphilis from a rape is said to be approximately 1 in 1000, and that of contracting gonorrhea is 1 in 30, prophylaxis for these diseases should be offered.

Because the incidence of penicillin-resistant gonorrhea is almost 50% in South Florida, ceftriaxone sodium (Rocephin) 250 mg for adults and 125 mg for children given intramuscularly is the drug of choice in our center. This will prevent incubating syphilis and will treat gonorrhea. If this is not available, probenecid, 1 g orally followed by 4.8 million U aqueous penicillin given intramuscularly, half in each buttock, may be used. If the patient is allergic to these medications, spectinomycin (Trobicin) 2 g intramuscularly may be used to prevent gonorrhea. A regimen of doxycycline 300 mg by mouth followed in 1 hour by a second 300-mg oral dose may be used for prophylaxis.

If the patient is reliable, oral doxycycline 100 mg twice a day for 7 days, will be effective for Chlamydia as well. Azithromycin 1 g orally in a single dose is also effective for Chlamydia trachomatis prophylaxis.¹³

PREVENTION OF PREGNANCY.

If the patient is not using contraception, she should be told that the risk of pregnancy post-rape is believed to be about 1%, and the “morning after pill” usually prevents conception if given within 72 hours of exposure. Treatment should be withheld, however, if the patient is adamant against termination of the pregnancy should the medication not be effective, because the fetus may be at risk. If pregnancy is suspected, a pregnancy test should be performed before any medication is given. A quantitative beta subunit assay for chorionic gonadotropin is preferred because it will diagnosis an early pregnancy.

The medication most commonly used is a combination of ethinyl estradiol and norgestrel (Ovral): 2 tablets given orally at the time of the examination and 2 tablets in 12 hours. Compliance is usually good because only one dose of medication must be taken after the patient leaves the examination area, and there are usually no side effects. Diethylstilbestrol (DES), 25 mg twice a day for 5 days, and ethinyl estradiol (Estinyl), 0.5 mg a day for 5 days, may also be used. Compliance is not as good with these medications because of the length of treatment and because side effects are common. An antiemetic may be needed to control the nausea.¹⁴

If the medication fails to prevent conception, a menstrual extraction may be performed within 2 weeks of the missed menses. A legal abortion may be done later.

ADDITIONAL TREATMENT AND FOLLOW-UP.

Tetanus toxoid should be offered to the patient when appropriate. A follow-up examination is scheduled for 6 weeks after the initial treatment, although the patient may be examined sooner if she is symptomatic or misses her menstrual period. During this visit, the appropriate cultures for gonorrhea and the serologic test for syphilis should be repeated. A pregnancy test should be done if indicated. This visit gives the staff an excellent opportunity to reassess the victim's psychologic adjustment, especially if she has not kept the counseling appointments given her.

Psychologic

The rape victim is in a crisis situation, and her psychologic reactions fit within the crisis theory framework.¹⁵ Therefore, if one is to understand these victims, a knowledge of crisis intervention techniques is essential.

A crisis is a turning point and produces a period of disequilibrium. It occurs when a person faces a problem that she cannot solve by those methods previously used to solve her problems. It is a stressful event that poses a threat to her. Whether it be real or imagined is of no consequence; her tension increases, and a period of disorganization occurs. New methods must be found to solve the problem.

The elements necessary to modify the effects of the crisis are authority, not force, and immediate action. It is essential to act as soon as possible because the patient builds her defenses as time passes.

If rape is considered to be the ultimate invasion of privacy, the actual invasion of the body without the permission of the individual, the trauma to the victim can be better understood. It increases her sense of helplessness and intensifies her conflicts about dependence and independence. This experience generates self-criticism and guilt, and these in turn are followed by depression.¹⁵

The rape victim, as opposed to the male victim of sexual assault, has the added burden of the cultural myths that have long been associated with this crime. The victim needs understanding from those around her if she is to survive psychologically.

A crisis intervention scheme for victims of rape was described in 1972 by Fox and Scherl.¹⁶ They divided the reaction of rape victims into three predictable and sequential phases that represent a normal cycle of emotional responses by victims of sexual assault:

1. The acute reaction
   
2. The outward adjustment
   
3. The integration and resolution of the experience.
   

Burgess and Holmstrom, in 1974, identified a rape trauma syndrome that defined the cluster of symptoms experienced by rape victims.¹⁷ They divided the syndrome into two phases: the immediate or acute phase and the long-term process, the reorganization period. Essentially these designs are the same.

Rape is a victim crisis and a social crisis because not only the individual but also the significant others in her life will be affected. Responses vary with the age and situation of the victim, but in general they all fit into this framework. Young single females are particularly vulnerable.

ACUTE PHASE.

The victim's immediate feelings after the attack include shock and disbelief, followed by anxiety and fear. Her emotions may be controlled, or she may express them freely. It is during this period that she must deal with the practical concerns. Will she report to the authorities? Will she seek medical attention? Does she need a place to stay? Is her home safe? Does she need money?

OUTWARD ADJUSTMENT PHASE.

During this period, the victim seems to be adjusting to the trauma she suffered. She resumes her normal activities and does not seek counseling. The patient should be supported and not challenged during this time. Her emotional reactions should be allowed to run their course. It is during this time that denial and rationalization appear.

INTEGRATION PHASE.

It is during the integration period that the patient is often depressed. She is ready now to talk about her experience and will accept counseling. She must be guided so that she may work through her feelings about herself and her feelings about the offender. She must be allowed to reach her own conclusions and integrate the experience. Only after this is accomplished will the patient be able to resume her usual patterns. Until then, she will be emotionally handicapped.

Forcible rape is a violent crime, and sexual gratification is not the purpose of the rapist. To degrade, humiliate, and hurt the victim is his aim. Few of these victims will have serious physical injuries, but all will suffer psychologic trauma that will affect their lives and the lives of those around them. If they are to adjust and take their place in society without major problems, they all need medical care, psychologic counseling, and understanding.¹⁸

Incest is a problem that has existed over the ages. In Europe in the sixteenth, seventeenth, and eighteenth centuries it was common practice to have sexual contact with youngsters. In some cultures, sexual contact with children is not taboo, and an article in Time magazine in 1980 contained a statement that incest was beneficial to the child.

Although the figures have not been reliable, recent estimates have suggested that at least 400,000 children are molested each year, and it is thought that 1 of every 4 girls and 1 of every 6 boys has been sexually molested to some degree before they reach the age of 18 years. By definition, incest is any sexual contact or interaction between family members who are not marital partners. This is a broad-based definition and includes sexual molestation and sexual assault as well as forcible rape—any variety of sexual contact. In our culture, this problem denotes a dysfunctional family, especially in the case of father-daughter incest. During the past decade, there has been a significant increase in reporting and awareness. This has led to increased interest in the issue and the resulting interest in developing appropriate treatment methods. As in the case of forcible rape, the criteria for incest are in the area of the legal and not the medical profession.^19,20

In the early 1890s, Freud expressed the belief that many cases of hysteria had a basis in childhood incest. Later he expressed a different view, but he never totally repudiated his original seduction theory. At the present time, we have become aware that incest is often a forerunner of subsequent borderline personality disorder (BPD) and that all the clinical manifestations of BPD can be related to the prior incest experience.²¹

Incest experiences are overwhelming to the child and have an impact on the formation of their identity. There is great anxiety and feelings of helplessness and powerlessness. There is a lack of support from the mother. It limits individual self-perception and leads to weakness of the ego. Psychotherapy is essential because the victim must validate and integrate the trauma before recovery can take place.²²

The fact that in earlier times the child was not believed and could not talk to anyone about the incidents intensified the problem. Because adults now believe the stories, this will improve the long-term results, and these victims will have fewer personality disorders as they reach adulthood.

1. U.S. Department of Justice, Federal Bureau of Investigation: Uniform Crime Reports on Crime in the United States. Washington, DC, 1992

2. Groth N: Men Who Rape. New York, Plenum Press, 1979

3. Boozer G, Director, Sex Offender Rehabilitation Program, South Florida State Hospital: Personal communication, 1976

4. Amir M: Patterns in Forcible Rape, p 126. Chicago, University of Chicago Press, 1971

5. Samek W, Former Director, Sex Offender Rehabilitation Program, South Florida State Hospital: Personal communication, 1981

6. Samek W, Former Director, Sex Offender Rehabilitation Program, South Florida State Hospital: Personal communication, 1981

7. Hicks DJ, Weisberg MP: Sensitive emergency management of rape victims. Emerg Med Rep 9, 1988

8. Hicks DJ: Rape, sexual assault. Am J Obstet Gynecol 137: 931, 1980

9. Gomez RR, Wunsch CD, David JH, Hicks DJ: Qualitative and quantitative determinations of acid phosphatase activity in vaginal washings. Am J Clin Pathol 64: 432, 1975

10. Evett IW: A guide to interpreting single locus profiles of DNA mixtures in forensic cases. Forensic Sci Soc 31 (1): 47, 1991

11. Bureau of Crime Victims Rights, State of Florida Department of Legal Affairs: Evidence collection protocol for sexual assault, 1991

12. State's Attorney, Dade County, Florida: Personal communication, 1976

13. Center for Disease Control: MMWR 42(14), 1993

14. Porter J, Jones W: Postcoital contraception. Med J Aust 68 (1): 85, 1981

15. Hilberman E: The Rape Victim. Washington, DC, American Psychiatric Association, 1976

16. Fox SS, Scherl DJ: Crisis intervention with victims of rape. Soc Work 37: 37, 1972

17. Burgess AW, Holmstrom LL: Rape, Victims of Crisis. Bowie, MD, Robert J. Brady, 1974

18. Moscarello R: Post traumatic stress disorder after sexual assault: Its psychodynamics and treatment. J Am Acad Psychoanal 19 (2): 235, 1991

19. Price M: The impact of incest on identity formation in women. J Am Acad Psychoanal 21 (2): 213, 1993

20. Green AH: Child sexual abuse: Immediate and long-term effects and intervention. J Am Acad Child Adolesc Psychiatry 32 (5): 890, 1993

21. Stone MH: Incest, Freud's seduction theory, and borderline personality. J Am Acad Psychoanal 20 (2): 167, 1992

22. Kinzl J, Biebl W: Long-term effects of incest: Life events triggering mental disorders in female patients with sexual abuse in childhood. Child Abuse Negl 16 (4): 567, 1992