Sexually related trauma

Many men and women practice a broad range of voluntary sexual activities, most of which are harmless. The only erotic activities that have an unacceptable risk for injury are vaginal insufflation during pregnancy, and fist fornication. Many minor injuries of the genital, oral, and anal areas do occur but most require only symptomatic therapy. Vaginal lacerations focus primarily around the posterior fourchette, although the few most serious ones tend to be high in the vault. Following anal sex, minor rectal bleeding from anal fissures or small mucosal tears is neither uncommon nor serious. Although retained rectal foreign bodies may present a challenge to the physician's imagination, most can be removed in the Emergency Department, and laparotomy rarely is required. Rectal perforations and sphincter injuries are uncommon but may be caused by foreign objects. Rape is a common crime of violence in which a man uses sex as a weapon. A post-traumatic psychological syndrome, with both short-term and long-term dysfunctional elements, almost uniformly follows the attack. Oral and anal sex are part of the assault in many cases. Nongenital injuries may be documented in 40 per cent, but only 4 per cent are serious, and fewer than 1 per cent require hospitalization. Genital injuries can be found with special staining in almost 50 per cent of cases, but only 1 per cent will need repair. Men represent only 5 per cent of the adult sexual assault cases, but they tend to suffer more physical injury. Both rape and sexual child abuse are grossly underreported. Sexual misuse of children has a family focus and is appallingly common. The emotional impact on the child is largely a function of the family's reaction. When strangers are involved in the abuse there is more chance of injury. Significant fresh injury will be found in only 8 per cent and is most likely to be anogenital. Findings of chronic sexual abuse will be present in one third, however. Boys are the victims in 15 per cent of cases. Physicians must be educated and vigilant for sexually related injuries because people frequently will delay treatment and then provide misleading histories because of embarrassment.