244节默克诊疗学第十八章妇科与产科对照版本

History and physical examination:A brief description of the assault indicates areas for medical investigation and treatment; recounting the events is often frightening for the patient, and a complete description may have to be deferred until immediate needs have been met. The reasons for the questions and for the examination procedure are not always clear to patients; eg, the female patient may need to be told that knowing when her last menstrual period was or if she uses a contraceptive helps determine the risk of pregnancy or that information about the time of the previous coitus helps establish the validity of sperm testing.
Psychologic assessment:Rape presents psychologic and social problems for the victims, who must handle their own feelings as well as face the often negative reactions (eg, judgmental, derisive) of friends, family, and officials. Patients should be viewed as undergoing posttraumatic stress disorder (seeCh. 187), which typically has an acute phase lasting a few days to a few weeks, followed by a long-term process of reorganization and recovery.
TABLE 244-1. EXAMINATION FOR ALLEGED RAPE
Whenever possible, the patient should be treated in a rape treatment center that is separate from the emergency department and staffed by trained, concerned support personnel.
Because these patients have experienced coercion, enlisting their cooperation and requesting permission for the examination are important. Details of the pelvic examination should be described and explained as it proceeds, and the results should be reviewed with the patient. Because being examined by a physician of the opposite sex may make the patient feel anxious, a nurse or volunteer of the patient's sex should be present to give support and to corroborate the procedures.
Rape is the illegal sexual penetration of any body orifice. The definition does not include touching without penetration, but in some jurisdictions, it includes penetration of body orifices by inanimate objects. Except when a child is seduced by offers of affection or bribes, rape is usually a criminal sexual act using threats or force against an unwilling person. Date rape is a variant of sexual assault in which the victim accepts a date, but the perpetrator (usually male) subsequently forces coitus on the victim without her consent. Statutory rape is sexual intercourse with a minor; the definition of "minor" varies by state.
In theUSA, 75,000 rapes of females are reported each year; estimates of unreported rape range from 2 to 10 times that number. About 90% of rapists attack persons of the same race; 50% are known to their victims and are often members of the extended family. This finding is important for preteen and teenage victims and has implications for follow-up and prevention of child abuse (see alsoCh. 264). Most rapes are planned (not impulsive), and more than half the attacks involve a weapon, usually a knife. About 50% of female rape victims have signs of physical trauma; > 10% require emergency treatment.
For both male and female perpetrators, rape is an expression of aggression, anger, or need for power; it is a violent more than a sexual act.
Although providing medical and psychologic care for the rape victim is the first concern, rape is a crime, and forensic medicine has certain requirements for medical evaluation and record keeping.Table 244-1is a guide for examination procedures and the medical record; it should be adapted to local requirements. Such a record is sometimes admissible in court and may aid recall if testimony is required later. Unless a subpoena is issued, the record should never be released without written consent of the patient.
Common intermediate reactions are fear and anger; patients' outward responses range from talkativeness, tenseness, crying, and trembling to shock and disbelief, with dispassion, quiescence, and smiling. The latter responses rarely indicate lack of concern; rather, they may be avoidance reactions or may reflect physical exhaustion or coping styles that require control of emotion. Usually, patients are severely frightened and embarrassed and feel degraded. The anger felt by many victims may be displaced onto hospital staff members, who should be aware of this process and not be troubled by it.
Some rape victims are males. Rape of males is not limited to those in prison. The male victim is more likely than the female to have physical trauma, to have been victimized by several assailants, and to be unwilling to report the crime. A few cases of female rapes of males have been reported.