Sexual assault (rape) is a violent crime directed predominantly against women. Under Kenyan laws rape is defined as carnal knowledge of a woman without her consent or by use of force, duress or pretence. A girl below 14 years of age in Kenya is not legally deemed to be able to give consent. Neither are mentally retarded or psychiatric women.

Clinical Features

These will range from none or mild to very severe injuries that may be life threatening. The medical personnel must approach the rape victim with great understanding, respect and concern for her well being. The patient may appear deceptively calm, and is usually withdrawn and detached. Careful history and medical record is important because this will be required in court. If the patient has eaten, drunk, bathed or douched, this may affect the outcome of laboratory test. History must be taken to evaluate the risk of acquisition of sexually transmitted disease and pregnancy.

During physical examination, document location, nature and extent of external trauma to face, neck, breast, trunk, limbs, the genitalia, vagina and cervical trauma must also be documented. Clothes and attire are retained as exhibits. Psychological trauma is evaluated.

Investigations

• Swabs for microscopy and culture:

- vagina

- throat

- rectum

- urethra

• Swab the cervix for sperm microscopy

• Pubic hair combings and clippings

• Scrapping of finger nails for DNA studies for purposes of identification of the assailant

• Blood is taken for baseline RPR and HIV serology then after 3 months

• Urine for baseline pregnancy test and repeat after 4 weeks.

Management

• All cases should be reported to the police

• Treat physical injuries that may require surgical repair of tears

• Tetanus toxoid for soiled lacerations

• Give prophylactic treatment to prevent pregnancy after ruling out already existing pregnancy. This is ethynyl oestradiol 50 mg + norgestrel 0.5 mg 2 tabs orally on examination and 2 tabs 12 hrs later, e.g. Eugynon or Neogynon

• Give prophylactics against sexually transmitted disease [see 2.5.-2.11. STIs]

• Examination and sperm collection of the rapist follow the same guidelines

• Post exposure prophylaxis (see 2.1.-2.4 AIDS/HIV).

Refer If

• Psychological and psychiatric review is important. The patient may be put on tranquillisers e.g. diazepam 5 mg TDS or sedatives phenobarbitone 30 mg TDS

• Long term psychological and psychiatric care may be required.