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性暴力被害者

著者: 奥田拓史 帯広第一病院 総合診療科

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2022/05/25
参考ガイドライン:
患者向け説明資料

概要・推奨   

  1. 性暴力被害者は、本人の同意なしに性的な虐待を受けた者である。
  1. 一般的に被害者は児童が多いが、実態はなかなか明らかにされにくい。
  1. 被害者自ら訴えをできないこともあるので、虐待を疑ったら性的虐待も念頭に置いて診察を行う。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
奥田拓史 : 特に申告事項無し[2022年]
監修:箕輪良行 : 未申告[2022年]

改訂のポイント:
  1. アメリカ心理学会の定義をもとに、改訂した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 性暴力被害者は、本人の同意なく性的な虐待行為を受けた者である。
  1. 実際の性的行為のみならず、わいせつな画像を強制的にみせられたりすることも、被害に含まれる。
  1. 一般的に児童が被害者になることが多いが、被害者は高齢者、配偶者(内縁関係を含む)、障害者など多岐にわたる。
  1. 広義には、強姦、セクシャルハラスメント、ストーカーなどが含まれる。
  1. 一般的に発覚は難しく、全性的虐待の10~15%程度しか発覚していないといわれている[1]
  1. 性的暴力の生涯有病率は、女性で18~19%、男性で2~3%と言われている[2]
  1. 性的暴力の多くのケースでは、アルコールや薬物が関係している[3]
  1. 性的暴力の被害者は、加害者と面識があることが多い[4]
  1. 性暴力被害者全体でみた場合、性感染症は5~8%とそれほど高くない割合である。しかし、女児の性暴力被害者においては、25%に膣分泌物に性感染症所見を認める、という報告があり、性感染症検査が性暴力被害の発見に有力な契機となり得る[5]
問診・診察のポイント  
 
  1. 詳細な問診が不可欠であるが、被暴力者は正直に訴えられないことが多いため、同行者である家族や関係者と離して、看護師や同性専門職を同席させて安全・安心を確保した上(この際、同行者の気持ちを逆なでしないよう注意が必要)で診察する、などの配慮が必要である。

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文献 

Jeffrey S Jones, Carmen Alexander, Barbara N Wynn, Linda Rossman, Chris Dunnuck
Why women don't report sexual assault to the police: the influence of psychosocial variables and traumatic injury.
J Emerg Med. 2009 May;36(4):417-24. doi: 10.1016/j.jemermed.2007.10.077. Epub 2008 May 7.
Abstract/Text The purpose of this study was to identify the variables that acutely influence reporting practices in female sexual assault victims presenting to an urban clinic or Emergency Department. We conducted a cross-sectional survey of consecutive female victims during an 18-month study period. Patient demographics, assault characteristics, and injury patterns were recorded in all eligible patients using a standardized classification system. At the completion of the forensic examination, victims were asked to complete a psychosocial questionnaire designed to determine specific reasons why women reported or did not report their sexual assault to police. During the study period, 424 women were eligible to participate in the study; 318 (75%) reported the sexual assault to police. One hundred six (25%) did not file a police report, but consented to a medical-legal examination. Women not reporting sexual assault were typically employed, had a history of recent alcohol or drug use, a known assailant, and prolonged time intervals between the assault and forensic evaluation (p < 0.001). There were no differences in the extent of non-genital injuries or anogenital injuries between the two groups. Thirty-six percent (152/424) of the eligible population agreed to complete the questionnaire. Only three of the 20 psychosocial variables examined were found to be significantly different in women not reporting sexual assault compared to reporters. The reasons for not reporting were primarily environmental factors (prior relationship with assailant) rather than internal psychological barriers (shame, anxiety, fear).

PMID 18462905
Steven Lawyer, Heidi Resnick, Von Bakanic, Tracy Burkett, Dean Kilpatrick
Forcible, drug-facilitated, and incapacitated rape and sexual assault among undergraduate women.
J Am Coll Health. 2010 Mar-Apr;58(5):453-60. doi: 10.1080/07448480903540515.
Abstract/Text OBJECTIVE: To examine the prevalence of drug-related sexual assaults, identify the frequency of assaults that occur following voluntary versus involuntary drug or alcohol consumption, and identify contextual correlates of drug-related assaults.
PARTICIPANTS: College-student females (n = 314).
METHODS: Volunteers reported experiences with forcible and drug-related sexual assaults in the spring semester of 2004. Follow-up queries regarding the most severe drug-related assaults determined whether the assaults followed voluntary or involuntary alcohol or drug consumption.
RESULTS: 29.6% (n = 93) of the respondents reported a drug-related sexual assault or rape; 5.4% (n = 17) reported a forcible sexual assault or rape. Voluntary incapacitation preceded 84.6% of drug-related assaults and involuntary incapacitation preceded 15.4% of drug-related assaults. The majority of drug-related assaults (96.1%) involved alcohol consumption prior to assault.
CONCLUSIONS: Drug-related sexual assaults on college campuses are more frequent than are forcible assaults and are most frequently preceded by voluntary alcohol consumption.

PMID 20304757
M-L Larsen, M Hilden, Ø Lidegaard
Sexual assault: a descriptive study of 2500 female victims over a 10-year period.
BJOG. 2015 Mar;122(4):577-84. doi: 10.1111/1471-0528.13093. Epub 2014 Oct 15.
Abstract/Text OBJECTIVE: To describe the victims of sexual assault and the circumstances in which the assaults occur.
DESIGN: Descriptive case study.
SETTING: Centre for Victims of Sexual Assault (CVSA), Rigshospitalet, Copenhagen, Denmark.
POPULATION OR SAMPLE: A total of 2541 women attending CVSA from 2001 to 2010.
METHODS: All women attending CVSA underwent a standardised data collection procedure. Descriptive bivariate analysis and logistic regression analysis were performed.
MAIN OUTCOME MEASURES: Associations between different assault characteristics and (1) the age of the victim and (2) the relationship between victim and perpetrator.
RESULTS: Two-thirds of the victims were aged 15-24 years. Seventy-five percent had met the perpetrator before the sexual assault and 70% reported the assault to the police. A physical injury was found in 53, and 27% sustained an anogenital lesion. Alcohol was involved in 60% of the cases. One-third of the victims had experienced a previous sexual assault(s). Women were more likely to report to the police when they were assaulted by a stranger (odds ratio [OR] 1.9, 95% confidence interval [95% CI] 1.3-2.6) and sustained a physical injury (OR 1.7, 95% CI 1.4-2.2) or anogenital lesion (OR 1.5, 95% CI 1.1-2.0). Women aged 45 years or older were more likely to sustain a physical injury (OR 2.0, 95% CI 1.2-3.2) or an anogenital lesion (OR 2.1, 95% CI 1.4-3.2).
CONCLUSIONS: Our results challenge the typical stereotype of a violent rape attack by a stranger, which is important in creating an environment where women are not reluctant to seek help after a sexual assault. Young age and drinking alcohol were risk factors for sexual assault, and we need to address this when considering preventive strategies.

© 2014 Royal College of Obstetricians and Gynaecologists.
PMID 25315463
Rebecca G Girardet, Sheela Lahoti, Laurie A Howard, Nancy N Fajman, Mary K Sawyer, Elizabeth M Driebe, Francis Lee, Robert L Sautter, Earl Greenwald, Consuelo M Beck-Sagué, Margaret R Hammerschlag, Carolyn M Black
Epidemiology of sexually transmitted infections in suspected child victims of sexual assault.
Pediatrics. 2009 Jul;124(1):79-86. doi: 10.1542/peds.2008-2947.
Abstract/Text OBJECTIVE: The objective of this study was to describe the epidemiology of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Treponema pallidum, HIV, and herpes simplex virus type 2 (HSV-2) infection diagnosed by culture or by serologic or microscopic tests and by nucleic acid amplification tests in children who are evaluated for sexual victimization.
METHODS: Children aged 0 to 13 years, evaluated for sexual victimization, who required sexually transmissible infection (STI) testing were enrolled at 4 US tertiary referral centers. Specimens for N gonorrhoeae and C trachomatis cultures, wet mounts for detection of T vaginalis, and serologic tests for syphilis and HIV were collected and processed according to study sites' protocols. Nucleic acid amplification tests for C trachomatis and N gonorrhoeae and serologic tests for HSV-2 were performed blinded to other data.
RESULTS: Of 536 children enrolled, 485 were female. C trachomatis was detected in 15 (3.1%) and N gonorrhoeae in 16 (3.3%) girls. T vaginalis was identified in 5 (5.9%) of 85 girls by wet mount, 1 (0.3%) of 384 children had a positive serologic screen for syphilis, and 0 of 384 had serologic evidence of HIV infection. Of 12 girls who had a specimen for HSV-2 culture, 5 (41.7%) had a positive result; 7 (2.5%) of 283 had antibody evidence of HSV-2 infection. Overall, 40 (8.2%) of 485 girls and 0 of 51 boys (P = .02) had >or=1 STI. Girls with vaginal discharge were more likely to test positive for an STI (13 [24.5%] of 53) than other girls (27 [6.3%] of 432; prevalence ratio = 3.9; P < .001), although 10 girls with STIs had normal physical examinations. Most girls (27 [67.5%]) with a confirmed STI had normal or nonspecific findings on anogenital examination.
CONCLUSIONS: The prevalence of each STI among sexually victimized children is <10%, even when highly sensitive detection methods are used. Most children with STIs have normal or nonspecific findings on physical examination.

PMID 19564286
Zoë D Peterson, Emily K Voller, Melissa A Polusny, Maureen Murdoch
Prevalence and consequences of adult sexual assault of men: review of empirical findings and state of the literature.
Clin Psychol Rev. 2011 Feb;31(1):1-24. doi: 10.1016/j.cpr.2010.08.006. Epub 2010 Aug 27.
Abstract/Text Male victims of adult sexual assault (ASA) are understudied as compared with female victims. Further, commonly-held myths about sexual assault suggest that men cannot be victims or that, if men are victims, they are relatively physically and emotionally unharmed by sexual assault. The goal of this paper was to systematically review the empirical literature on ASA among men to evaluate the veracity of these myths. This paper also sought to examine the methodological quality of the body of research in this area, identify limitations and gaps in the current literature, and suggest directions for future research. Eighty-seven relevant studies were identified through a systematic review of the literature. The reported prevalence of men's sexual aggression varied widely depending on the methods used and the population studied; some populations (e.g., veterans, prison inmates, and gay and bisexual men) reported higher rates of ASA than men in the general population. Few studies have systematically examined the consequences of male ASA; however, those that have suggest that ASA can have notable adverse physical and psychological consequences for some men.

Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID 21130933

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