CHAPTER 16 Sexual assault is a violent crime. It is an act of violence, power, and hate, and sex is the weapon used by the perpetrator. Sexual violence most often results in devastating severe and long term trauma. Rape is a nonconsensual (or the individual is incapable of giving consent) vaginal, anal, or oral penetration that is obtained by force or threat of bodily harm. It is usually men who rape, and most individuals who are raped are women. However, women may also sexually assault other women. Male-on-male sexual assault is also more prevalent in prisons and in the military than in the general population. A male who is sexually assaulted is more likely to have physical trauma and to have been victimized by several assailants than is a female. Males experience the same devastating severe and long-lasting trauma as females. Long-term psychological effects of sexual assault include depression, dysfunction, and somatic complaints in many survivors. Incest victims might experience a negative self-image, self-destructive behavior, and substance abuse. All catastrophic events can result in posttrauma syndrome. Refer to chapter 6 for a fuller discussion of DSM-5 Posttraumatic Stress Disorder, and Posttrauma Syndrome. Rape-trauma syndrome is a variant of posttraumatic stress disorder (PTSD) and consists of two phases: (1) the acute phase, and (2) the long-term reorganization phase. Nurses may encounter a patient right after the sexual assault or weeks, months, or even years after the sexual assault. In either case, the individual will benefit from compassionate and effective nursing interventions. A positive history includes: 1. History of a previous sexual assault 2. History of incest within the family 3. Any signs and symptoms of PTSD Typical reactions to crisis reflecting cognitive, affective, and behavioral disruptions: • Shock, numbness, and disbelief • May appear calm and self-contained • May appear hysterical and/or restless • May cry a lot; or • May smile or laugh a lot • Complains of disorganization in his or her life • Complains of somatic symptoms Posttraumatic symptoms include: • Intrusive thoughts of the rape throughout the day and night • Flashbacks of the incident (reexperiencing the traumatic event) • Dreams with violent content • Insomnia • Increased motor activity (moving, taking trips, changing telephone numbers, staying with friends) • Mood swings, crying spells, depression • Fears and phobias can develop: • Fear of indoors (if rape occurred indoors) • Fear of outdoors (if rape occurred outdoors) • Fear of being alone • Fear of crowds • Fear of sexual encounters Questioning should be done in a very nonthreatening manner, using open-ended types of questions, for example, “It must have been very frightening to know that you had no control over what was happening.” 1. Assess physical trauma—document using a body map, and ask permission to take photos. 2. Assess psychological trauma—write down verbatim statements of patient. 3. Assess available support system. Often partners or family members do not understand about rape and might not be the best supports to rally at this time. 4. Assess level of anxiety. If patients are in severe to panic levels of anxiety, they will not be able to problem solve or process information. 5. Identify community supports (e.g., attorneys, support groups, therapists) who work in the area of sexual assault. 6. Encourage patients to tell their story. Do not press them to do so. Rape-Trauma Syndrome is the nursing diagnosis that applies to the physical and psychological effects resulting from a sexual assault. The diagnosis includes the acute phase of disorganization of the survivor’s lifestyle and the long-term phase reorganization. FORENSIC NOTE: Each emergency department (ED) or crisis center must have a protocol for the forensic examination of the sexual assault survivor. Most EDs and crisis centers have access to a sexual assault nurse examiner (SANE). As discussed in Chapter 15, SANEs are forensic nurses who have been certified to work with victims of sexual violence. Sexual assault response teams (SARTs) are also available in the United States to help survivors of sexual violence cope with the present and aftermath of sexual violence. Most emergency departments or crisis centers have their own rape kits available that facilitate collection of specimens such as blood, semen, hair, and fingernail scrapings. 1. Follow your institution’s protocol for sexual assault. 2. Do not leave the patient alone. 3. Maintain a nonjudgmental attitude. 4. Ensure confidentiality. 5. Encourage the patient to talk; listen empathetically. 6. Emphasize that the patient did the right thing to save his or her life. 7. Forensic issues • Physical trauma; note size, color, and distribution of trauma with a body map. • Ask permission to take photos. • Take verbatim statements as to the patient’s reaction to the rape. • Document the patient’s emotional status. 8. Explain everything you are going to do before you do it. 9. Ascertain that the forensic examination is done and that specimens are obtained with the patient’s written permission. 10. Alert the patient as to what he or she might experience during the long-term reorganization phase. 11. Arrange for support follow-up, for example: • Group therapy • Individual therapy • Crisis counseling
Sexual Violence
OVERVIEW
ASSESSMENT
Assessing History
Presenting Signs and Symptoms
Acute Phase of Rape-Trauma Syndrome (0 to 2 Weeks after the Rape)
Long-Term Reorganization Phase (PSTD) (2 Weeks or More)
Assessment Guidelines
Sexual Assault
NURSING DIAGNOSES WITH INTERVENTIONS
Discussion of Potential Nursing Diagnoses
Overall Guidelines for Nursing Interventions
Survivor of Sexual Assault
Selected Nursing Diagnoses and Nursing Care Plans
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