Immediate Physical Injury

National representative samples have found that acute injuries are relatively uncommon in rape victims
The National Women's Study found that 70% of rape victims received no physical injury during the rape; 24% received minor injury, and 4% received serious injury (Kilpatrick, Edmunds, & Seymour, 1992).
The National Violence Against Women Survey found that 69% of the victims were not injured, while 31% did receive some injuries (Tjaden & Theonnes, 1998).
Treatment-seeking samples (i.e. Emergency room) have found slightly higher rates of injury with rates ranging from 40-50%.  (Geist, 1988, Cartwright, 1987).

Types of Injury

Nongenital Injury Perhaps because the low rates of injury have been reported in general samples, specific types of nongenital injury have been examined less often in rape samples.  However, Tjaden and Theonnes (1998) reported rates of nongenital injuries in their national sample of male and female rape victims. Female victims comprised the largest sample. They found 73% of injuries were scratches, bruises, and welts.

Genital Injury The type of genital injury associated with rape is associated with the type of penetration experienced during rape.  Findings from the first wave of assessments in the National Women’s Study revealed:

507 women reported some type of rape at some point during their lives.
Of all of the rapes reported, the most common type of penetration was vaginal (53%), followed by digital (24%), oral (15%), and anal (7%).
Rapes that included multiple types of penetration were not uncommon. The review of genital injuries may yield different rates of injury across studies because of differences in type of penetration.

Genital Injury Data

A study, (Lacy, 1990), examined types of genital injury in 47 women examined within 48 hours of the rape:

Forty-two percent of the women had genital injuries.
Thirty-six percent of the women had external vulvar bruising.
Genital injuries were more common when anal intercourse had occurred.  Anal tears and bruising were seen in 73% (8/11) of the women reporting anal rape.

Genital Injuries/Special Population/Elderly Women

A number of studies have consistently found that older rape victims experience significantly more severe genital injury than younger victims, even after controlling for the severity of nongenital injury.

 A study by Muram, Miller, and Cutler (1992) compared fifty-three older rape victims (average age 68.8 years) with fifty-three younger rape victims (average age 28.3 years).  Both the types of genital injuries and characteristics of the sexual assaults were examined.

A significantly greater number of older victims (50.9%) experienced genital injuries (i.e. 15 vaginal lacerations, 7 hematomas, 5 abrasions, and 2 anal injuries) compared with the younger victims (13.2%). Given that there were not significant differences in the frequency of nongenital injuries, these findings suggest that the increased rate of genital injury is not the result of increased use of force within the population of older rape victims (Muram, Miller, & Cutler, 1992).  

Sexually Transmitted Diseases/Overview

Rape victims are at risk for 15 sexually transmitted diseases (STDs) (Murphy, Munday, & Jeffries, 1990). The frequency of occurrence ranges from 3-30% of victims, depending on the sample.

Determining whether the disease occurred as a result of the assault or from consensual sexual activity can be difficult. It is important for women to have initial and follow-up sexual assault examinations. See section on Recommended Health Care Guidelines.

One report found higher rates of STDs among women raped in the previous year (38.7%) compared with demographically comparable non-victims (18.7%) (Irwin, Edlin, Wong, et al., 1995). 

HIV

The risk of rape-related Human Immunodeficiency Virus is thought to be relatively low compared with the risk of infection by other diseases. The estimated transmission rate from each instance heterosexual intercourse is approximately 1 in 500 (Gostin, Lazzarini, Alexander, Brandt, Mayer, & Silverman, 1994).

In spite of the relatively low risk of infection, rape should be considered as a possible source of exposure. Rape victims’ concerns about exposure are important and require attention. See section on Health-Related Concerns.

Pregnancy

A final health outcome associated with rape includes the risk of pregnancy.  Findings based on the National Women's Study (Holmes, Resnick, Kilpatrick, & Best, 1996) found that approximately 5% of reported rapes of women in childbearing years result in pregnancy.  Reviews of other studies (e.g. Goodman, Koss, & Russo, 1993) found comparable estimates.

Direct Health Effects Rape

Increased Stress and Concerns About Health
Rape not only increases a woman's risk of specific types of mental health problems, but also leads to general stress, anxiety and worry.  Chronic concerns can negatively affect health. (See section on Mental Health Outcomes).
Health-Related Concerns
The National Women's Study found that rape victims had concerns about their health related to rape.  Victims raped within the five years prior to the study (1985-1990) expressed the following concerns:

40% were concerned about contracting HIV/AIDS.
43% were concerned about getting a sexually transmitted disease
34% were concerned about getting pregnant.

Indirect Health Effects of Rape

Chronic Stress-Related Physical Complaints
Chronic health problems are persistent and caused by a number of factors. Chronic health complaints can arise from ongoing difficulties with acute physical injury, health problems associated with ongoing stress, other mental health difficulties, and harmful behaviors used to cope with emotional distress. These chronic health-related problems are reviewed in this section.

General Health Problems
Reports of physical injury are less common than general health complaints following sexual assault. Studies have found that sexual assault victims report more health symptoms (Kimmerling & Calhoun, 1994; Waigandt, Walace, Phelps, & Miller, 1990) and poorer perceptions of their health (Kimmerling & Calhoun, 1994; Koss, Woodruff, & Koss, 1990; Waigandt, Wallace, Phelps, & Miller, 1990) compared with nonvictims.

Examples of health complaints include: rapid or pounding heartbeat, tension headaches, nausea, back pain, allergies, skin disorders, menstrual symptoms, and sudden weight changes.

Chronic Stress-Related Physical Complaints
Focus on Sexual Health
There have been a number of studies examining the relationship between rape and sexual dysfunction.  Sexual dysfunction includes difficulties with sexual functioning, including disturbances in sexual desire, alterations in the sexual response cycle, difficulties with sexual arousal, orgasmic disorders, and sexual pain.

Victims are more likely than nonvictims to report at least one type of sexual dysfunction (Becker et al., 1986; Golding, 1996). Types of dysfunction associated with sexual assault include fear of sex and arousal dysfunction (Becker et al, 1986), pain, medically explained and unexplained, and lack of sexual pleasure (Golding, 1996).

There is emerging evidence that lingering mental health difficulties, such as depression and posttraumatic stress disorder, may play an important role in initiating and/or prolonging these sexual difficulties (Letourneau et al, 1996).

Health-Related Behaviors

The way people live their lives can play an important role in determining the quality of their health.  People may engage in particular behaviors that harm their health.  These behaviors, such as excessive use of alcohol and smoking, may be used to help cope with emotional distress.   

Health Damaging Behaviors
A large representative sample of college students (N = 4609) found that women who were raped were 1.5-2.7 times more likely than non-victims to engage in negative health behaviors including: drinking and driving in the 30 days prior to the survey, smoking cigarettes, episodic heavy drinking, marijuana use, and using alcohol or drugs the last time they had sexual intercourse (Brener, McMahon, Warren, & Douglas, 1999).

These increased rates continued to be significant even after controlling for the student's age, parent's education, race or ethnicity, and sorority membership.

Victims engaged in 50% more negative health behaviors, including lack of exercise, excessive caffeine or alcohol consumption, and cigarette smoking (Waigandt, Walace, Phelps, & Miller, 1990).

Health-Related Behaviors/General Functioning
Functional Impairment Acute or ongoing health problems can affect a person’s ability to function in everyday activities like adhering to work or school schedules and maintaining relationships. Using data from a series of sites in a large epidemiological study, Golding (1996) found that victims spent more days in bed and were more likely than non-victims to restrict activity.

Diminished functioning can prevent a person from maintaining gainful employment, reaching academic goals, and fulfilling potential. Inappropriate Overuse of Health Care Studies show that victims are more likely than nonvictims to make a greater use of health care services, particularly medical rather than mental health services (Golding et al., 1988; Koss, Koss, & Woodruff, 1991; Kimmerling & Calhoun, 1994).

While there are studies documenting overuse of health care by victims, there is also information that some victims avoid seeking appropriate health care, particularly important treatment like Pap smears (Springs & Friedrich, 1992).  This avoidance may be related to avoidance of distress or anxiety evoked by the medical exam.

Psychological/Physical Interaction

Research notes the association between psychological distress and difficulties with physical health. There are mental health factors that have been proposed as mediating negative physical health outcomes. They are reviewed in detail in Resnick, Acierno, and Kilpatrick (1997) and summarized below.

A traumatic event like rape has been directly associated with substance abuse, depression, and posttraumatic stress disorder. These disorders may be associated with victim's overall neglect of her health, such as avoiding adequate health care.

Disorders like substance abuse also have negative implications on health. These disorders also may negatively affect general functioning (e.g. social and occupational). Diminished functioning can lead to a spiral of poverty, unemployment, underemployment, and possible exposure to other high-risk situations.

Psychological distress can be misinterpreted as physical illness, particularly when certain types of psychological problems include physiological reactions. These misinterpretations can lead to inappropriate use of medical care and failure to receive appropriate treatment (figure one - Adobe Acrobat required to view or print this document).

Recommended Health Care Practices

Medical examination for STDs immediately after rape is recommended followed by preventative treatment. Examinations may also include counseling and emergency contraception in relevant cases (CDC, 1998). Follow-up examination is recommended to assess new infections, counsel victims about STDs and hepatitis B and to treat existing diseases.

CDC guidelines recommend offering follow-up care at two weeks after the assault for repeat STD testing and additional blood testing for syphilis and HIV. Follow-up care can be 6, 12, and 24 weeks.

Payment for follow-up care varies across states.  Sources for state or third party payment include sources such as Crime Victims Compensation. However, often these sources may be used only if victims report the assault to police. This provision excludes many victims from receiving subsidized medical care.

Model programs that provide follow-up by personnel trained in dealing with sexual assault have been developed. One of these programs is the Sexual Assault Follow-up Evaluation (SAFE) at the Medical University of South Carolina in Charleston, South Carolina. This program addresses the medical needs of victims and provides information about mental health and social service resources.

References

Becker, J., Skinner, L., Abel, G., & Cichon, J. (1986). Levels of postassault sexual functioning in rape and incest victims. Archives of Sexual Behavior, 15(1), 37-49.

Brener, N.D., McMahon, P.M., Warren, C.W., & Douglas, K.A. (1999). Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. Journal of Consulting and Clinical Psychology, 67(2), pp. 252-259.

Cartwright, P.S. (1987). Sexual assault study group. Factors that correlate with injury sustained by survivors of sexual assault. Obstetric and Gynecology, 7, pp. 44-46.

Centers for Disease Control and Prevention. (1998). Public Health Service guidelines for the management of health care worker exposurers to HIV and recommendations for postexposure prophylaxis. MMWR, 47 (RR-7):1,28.

Geist, R.F. (1988). Sexually related trauma. Emergency Medical Clinic of North America, 6, pp. 439-466.

Golding, J.M. (1996). Sexual assault history and limitations in physical functioning in two general populations samples. Reseach Nursing Health, 19, pp. 33-44.

Goodman, L.A., Koss, M.P., & Russo, N.F. (1993). Violence against women: Physical and mental health effects, Part 1: Research findings. Applied and preventive psychology, 2, pp. 79-89.

Gostin, L.O., Lazzarini, Z., Alexander, D., Brandt, A.M., Mayer, K.H., & Silverman, D.C. (1994). HIV testing, counseling, and prophylaxis after sexual assault. Journal of the American Medical Association, 271, pp 1436-44.

Holmes, M.M., Resnick, H.S., Kilpatrick, D.G., & Best, C.L. (1996). Rape-related pregnancy: Estimates and descriptive characteristics from a national sample of women. American Journal of Obstetrics and Gynecology, 175(2), 320-324.

Irwin, K.L., Edlin, B.R., Wong, L., Faruque, S., McCoy, H.V., Word, C. et al. (1995). Urban rape survivors: Characteristics and prevalence of human immunodeficiency virus and other sexually transmitted infections. Obstetrics and Gynecology, 85, pp. 330-336.

Kilpatrick, D.G., Edmunds, C.N., & Seymour, A.K. (1992). Rape in America: A report to the nation. Arlington, VA: National Victim Center & Medical University of South Carolina.

Kimerling, R., & Calhoun, K.S. (1994). Somatic symptoms, social support, and treatment seeking among sexaul assault victims. Journal of Consulting and Clinical Psychology, 62, pp. 333-340.

Koss, M.P., Woodruff, W.J., Koss, P.G. (1990). Relation of criminal victimization to health perceptions among women medical patients. Journal of Consulting and Clinical Psychology, 58, pp. 147-152.

Letourneau, E.J., Resnick, H.S., Kilaptrick, D.G., Saunders, B.E., & Best, C.L. (1996). Comorbidity of sexual problems and posttraumatic stress disorder in female crime victims. Behavior Therapy, 27, pp. 321-336.

Muram, D., Miller, K., & Cutler, A. (1992). Sexual assault of the elderly victim. Journal of Interpersonal Violence, 7(1), pp. 70-76.

Murphy, S., Munday, P.E., Jeffries, D.J. (1990). Rape and subsequent seroconversion to HIV [letter; comment]. British Medical Journal, 300(6717):118.

Resnick, H.S., Acierno, R., & Kilpatrick, D.G. (1997). Health Impact of Interpersonal Violence. Section II: Medical and mental health outcomes. Behavioral Medicine, 23(2), pp. 65-78 .

Spring, F.E. & Friedrich, W.N. (1992). Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clinic Proceedings, 67, pp. 527-532.

Tjaden, P. & Thoennes, N. (1998, Nov.) A prevalence, incidence, and consequences of violence against women: Findings from the National Violence Against Women Survey, @ p. 2&5. Research in Brief. Washington, DC: National Institute of Justice, U.S. Department of Justice.

Waigandt, A., Wallace, D.L., Phelps, L., & Miller, D.A. (1990). The impact of sexual assault on physical health status. Journal of Traumatic Stress, 3(1), pp. 93-102.