CHAPTER 32. Sexual Violence
Victims and Offenders
Linda E. Ledray
One of the first researchers to systematically study the impact and needs of the sexual assault survivor was a nurse, Dr. Ann Burgess (Burgess & Holmstrom, 1974). She and her colleague, Linda Holmstrom, a social worker, identified a two-stage syndrome of response, which they referred to as rape trauma syndrome (Burgess & Holmstrom, 1974). Considerable additional research has occurred since that time, however, and has identified specific symptoms rather than a pattern of response. As a result of this more recent research, posttraumatic stress disorder (PTSD) resulting from sexual assault has become the term used to describe the symptom response following rape (American Psychiatric Association, 1994 and Faigman et al., 1997). The American Psychiatric Association (APA) first referred to PTSD in 1980.
Nurses, including Burgess, have remained active in furthering the understanding of victim response and developing services for sexual assault survivors. The efforts of these pioneering nurses have led to the development of a new role for nurses, the forensic nurse examiner (FNE). Today, the FNE functions in a variety of roles, including clinical forensic nurse, nurse coroner, forensic investigator for the medical examiner, forensic psychiatric nurse, correctional nurse, domestic violence nurse examiner, and sexual assault nurse examiner (SANE).
This chapter focuses on the largest group of forensic nurse examiners, the SANE. It will look at the history and development of the SANE role, the impact of sexual assault, and the treatment needs of sexual assault survivors, as well as how the SANE functions today to meet these needs as a member of the sexual assault response team (SART).
SANE History and Role Development
Although men are raped too, most victims of sexual and personal violence are women. Because women are so often victims of violence, emergency department (ED) nurses have learned that whenever women present to an ED for even minor trauma, the etiology of their trauma must be thoroughly evaluated. ED staff must be aware of the types of injuries most likely resulting from violence, and the victim must be carefully questioned about the cause of the trauma to determine if it is the result of violence (Sheridan, 1993). When violence such as rape is identified, further evaluation may be necessary, including proper evidence collection and maintaining the chain of custody. Further care, beyond basic medical care, is also essential when rape is identified and will be discussed.
Only recently have our healthcare facilities begun to recognize their responsibility to have trained staff available to provide this specialized service for victims of sexual assault. Treating injuries alone is not sufficient. In 2000, a rape victim successfully sued a New York City hospital when she came to the medical facility after a sexual assault and a sexual assault evidentiary examination was not accurately performed. She was made to wait three hours before being examined, and then potentially significant evidence, her underwear and vaginal swabs, were lost. The New York Department of Health investigation also found that the hospital failed to provide complete care. It did not provide her with medication to prevent pregnancy. The authorities believed that if correct evidence collection and chain of custody had occurred, the evidence obtained may have been useful to secure a conviction against the serial sex offender charged with her rape. As a result, New York passed the Sexual Assault Reform Act requiring New York State to develop specialized sexual assault (SANE) evidence collection programs in 2001 (Chivers, 2000). Since 1992, the guidelines of The Joint Commission (TJC) has required emergency and ambulatory care facilities to have protocols on rape, sexual molestation, and domestic abuse (Bobak, 1992). By 1997 they also stated healthcare facilities should develop and train their staff to use criteria to identify possible victims of physical assault, rape, other sexual molestation, domestic abuse, and abuse or neglect of older adults and children (TJC, 1997). TJC expectations concerning hospital care of the sexually assaulted patient were once again raised in 2004 with the expectation that medical care and assessment “must be conducted within the context of the requirements of the law to preserve evidentiary materials and support future legal actions” (TJC, Standard PC 3.10.10, 2004).
At the 1996 International Association of Forensic Nurses (IAFN) meeting in Kansas City, Geri Marullo, executive director of the American Nurses’ Association (ANA), predicted that within 10 years TJC would require every hospital to have a forensic nurse available (Marullo, 1996). Even though TJC still does not require a FNE or SANE to be available to do the evaluation, it is no longer optional for medical facilities to identify and provide appropriate and complete services to victims of rape and abuse. In addition, TJC survey teams have begun to ask hospitals multiple questions about sexual abuse policies and procedures and whether they have a SANE program in place to respond. This TJC emphasis has effectively set the stage for the further development of forensic nursing as an important new nursing specialty.
Many healthcare facilities have recognized that the implementation of the FNE role is an optimal way to meet this expectation of a higher level of care and that it is an effective community marketing tool for the medical facility as well. The benefits of the FNE or SANE to the victim, other ED staff, the police, and the prosecutor have been the most effective impetus to SANE role development and utilization. The availability of funding for program development has also been an important impetus.
The landmark Violence Against Women Act (VAWA) of 1994, introduced by Senator Joseph Biden of Delaware, was signed into law on September 13, 1994, as Title IV of the Violent Crime Control and Law Enforcement Act of 1994. In addition to doubling the federal penalties for repeat offenders and requiring that date rape is treated the same as stranger rape, this act made $800 million available for training and program development over a six-year period, with $32 million appropriated for the first year. This funding has had a significant impact on changing the availability of services to rape victims today. It was initially used by the existing rape crisis centers to hire paid staff and to professionalize their organizations, and more recently it has provided funding to establish SANE programs and SARTs across the United States.
The VAWA 2005 reauthorization has additional forensic compliance mandates. This reauthorization requires that states ensure all teen and adult victims do not have any out-of-pocket expenses associated with the provision of sexual assault forensic examinations and that victims are provided these forensic medical exams without being required to report to law enforcement, cooperate with law enforcement, or participate in the criminal justice system (42 USCA S.3796 gg-4 (d) (1)). Although many jurisdictions have been meeting these mandates for more than 20 years, under this reauthorization, states and territories were given until January 5, 2009, to certify that they are in compliance. States have several options available to meet these mandates. The evidentiary exam may be completed, the evidence collected and held by the medical facility, maintaining chain of custody, for a specific period of time, giving the victim the option of making a delayed report before the evidence is destroyed. Or the victim may be given the option of making an anonymous “Jane Doe,” or blind, report in which a police report is made without disclosing the victim’s identity, so the evidence can be turned over to law enforcement for storage.
Demonstrating the need for sane programs
The initial impetus to develop SANE and SART programs began with the individuals who were working with rape victims in hospitals, clinics, and other settings across the country. These workers primarily included nurses, other medical professionals, counselors, and advocates. It was obvious to these individuals that services to sexual assault victims were inadequate and were not being provided at the same high standard of care being given to other medical clients (Holloway and Swan, 1993 and O’Brien, 1996). When rape victims came to the ED for care, they often had to wait as long as 12 hours in a busy, public area; their wounds were seen as less serious than the other trauma victims, and they competed unsuccessfully for medical staff time with the critically ill (Holloway and Swan, 1993, Sandrick, 1996 and Speck and Aiken, 1995). They were often not allowed to eat, drink, or urinate while they waited, for fear of destroying evidence (Thomas & Zachritz, 1993). The medical professionals who eventually did care for them were often not sufficiently trained to do medicolegal examinations, and many were also lacking in their ability to provide expert witness testimony (Lynch, 1993).
When staff was trained, they often did not complete a sufficient number of examinations to maintain their level of proficiency (Lenehan, 1991, Tobias, 1990 and Yorker, 1996). Even when the victim’s medical needs were met, his or her emotional needs all too often were overlooked (Speck & Aiken, 1995), or even worse, the survivor was not believed or the ED staff blamed the survivor for the rape (Kiffe, 1996). All too often, the rape survivor faced a time-consuming examination by a succession of healthcare professionals, some with only a few hours of orientation, many with little experience, and most not comfortable doing the examination or concerned that they would be called to testify in court.
Services were inconsistent and problematic. Often the only physician available to do the vaginal examination after the rape was male (Lenehan, 1991). Approximately half of rape victims in one study were unconcerned with the gender of the examiner, but for the other half this was extremely problematic. This study found even male victims often preferred to be examined by a woman, as they too are most often raped by a man and experienced the same generalized fear and anger toward men that female victims experienced (Ledray, 1996a).
More recently, male RNs who wanted to be SANEs have been trained and, likely as a result of their empathetic and nonjudgmental approach, victims have successfully accepted them. The forensic nurse response team in Houston, Texas, had three men on the team in 2004, and in more than 600 cases performed by the three combined, only one instance in which a patient preferred a female examiner was reported (Rooms, 2004). After having power and control over one’s body ripped away by a male, having a male restore a sense of control by gaining consent before talking, touching, or examining the patient is often cited as restoring a more positive image of men in general. Men in nursing who specialize in domestic violence cases have also cited this benefit. It has been noted that the ability of the examiner to convey genuine concern, empathy, and return power and control is a more important characteristic than gender. Whether it is the responding law enforcement officer, paramedic, triage nurse, physician, or SANE, men should be encouraged to understand the psychodynamics of sexual assault and attempt to quash the myth that men have nothing to offer the sexual assault patient (Rooms, 2004).
There are also many reports of physicians being reluctant to do the examination. This reluctance was the result of many factors, which included an awareness of their lack of experience and training in forensic evidence collection and not wanting to do something they knew was extremely important and that they were concerned they would not do well (Bell, 1995, Lynch, 1993 and Speck and Aiken, 1995).
The lengthy evidentiary examination takes the physician away from other medically urgent or critically ill patients in a busy ED (Frank, 1996). In addition, whenever the physician is involved in evidence collection, there is always the expectation that the doctor will later be subpoenaed and be taken away from working in the ED to testify in court and be questioned by a sometimes hostile defense attorney (Frank, 1996, Speck and Aiken, 1995 and Thomas and Zachritz, 1993). All too often, such concerns resulted in evidence collection being rushed, inadequate, or incomplete. In rare instances, physicians even refused to do the examination, and the rape victim was sent home from the hospital without having an evidentiary examination completed because no physician could be found to collect the evidence (DiNitto et al., 1986 and Kettleson, 1995). Unfortunately, many of these same problems continue today in major medical centers in the United States (Chivers, 2000).
As research with this population continued, the importance of this initial medicolegal examination for these survivors became clear, as did the need to provide the most comprehensive care possible during the initial ED visit (Gray-Eurom et al., 2002 and Lenehan, 1991). For as many as 75% of sexual assault victims, the initial ED visit was the only known contact they had with medical or professional support staff regarding the sexual assault, and it had a significant impact on their medical and psychological recovery (Ledray, 1992). Additional research confirmed that the proper collection and documentation of evidence by the ED staff had a significant impact on the successful prosecution of these cases and the lack of evidence could harm the likelihood of prosecution (Chivers, 2000, Frazier and Haney, 1996, Gray-Eurom et al., 2002, Ledray, 2002 and Tintinalli and Hoelzer, 1985). This confirmed the importance of ED physicians either being properly trained themselves to collect the evidence or supporting the development and utilization of a SANE program to provide the service for them (Gray-Eurom, et al., 2002; Wears, 2002).
Sane program development
As a result of this identified goal to better meet the needs of this underserved population, SANE programs were established in Memphis, Tennessee, in 1976 (Speck & Aiken, 1995), Minneapolis, Minnesota, in 1977 (Ledray, 1993 and Ledray and Chaignot, 1980), and Amarillo, Texas, in 1979 (Antognoli-Toland, 1985). Unfortunately, these nurses worked in isolation, unaware of the existence of similar programs until Gail Lenehan, editor of the Journal of Emergency Nursing (JEN), recognized the importance of this new role for nurses and published the first list of 20 SANE programs (Emergency Nurses Association, 1991). This facilitated communication, collaboration, and further SANE program development.
As a result of the collaboration fostered by the Journal of Emergency Nursing, 72 individuals from 31 programs across the United States and Canada came together for the first time in 1992 at a meeting hosted by the Sexual Assault Resource Service and the University of Minnesota School of Nursing in Minneapolis. It was at that meeting that the International Association of Forensic Nurses (IAFN) was formed (Ledray, 1996b). Membership in IAFN surpassed the 1000 mark in 1996 (Lynch, 1996). By January 2009, the number of members had grown to more than 3300 (personal communication with Kim Day, IAFN, February 18, 2009). Although initial SANE development was slow, with only three programs operating by the end of the 1970s, development today is progressing rapidly. In the past few years, IAFN has, however, concentrated more efforts on strengthening and sustaining the SANE programs in operation rather than developing new programs.
After years of effort on the part of SANEs and other forensic nurses, the American Nurses Association (ANA) officially recognized forensic nursing as a new specialty in 1995 (Lynch, 1996). At the October, 1996, IAFN annual meeting held in Kansas City, the SANE council voted overwhelmingly to use the title SANE, sexual assault nurse examiner, to define this new forensic nursing role. SANE is still the largest subspecialty of forensic nursing.
A SANE is a registered nurse (RN) who has advanced education in forensic examination of sexual assault victims. IAFN has recommended a 40-hour didactic SANE training program, with specified content, plus clinical experience for a nurse to function as a SANE (Ledray, 1999). At the 1996 annual meeting of IAFN, the SANE council also voted and adopted the first SANE standards of practice. The standards include goals of sexual assault nurse examiner programs, a definition of the practice area, a conceptual framework of SANE practice, evaluation, documentation, forensic examination components, and minimum SANE educational qualifications (IAFN SANE Standards, 1996). In April 2002, the first national certification examination was given to 80 nurses. Of those 80 nurses, 70 (87.5%) passed and were the first to carry the SANE-A designation after their name, for sexual assault nurse examiner—adults and adolescents. That was followed in 2007 with the designation of SANE-P for SANEs who specialize in the care of pediatric victims. Both certifications are offered through IAFN. Although SANE-A or SANE-P certification certainly identifies that the SANE has additional expertise and may be helpful in establishing credibility when testifying in court, it is not a requirement for a nurse to work as a SANE or to testify as an expert witness in court.
Sexual Assault Impact and Treatment Needs
The physical impact of a sexual assault on the victim includes genital and nongenital trauma as well as fear of contracting a sexually transmitted infection (STI), general health risk, fear of pregnancy, substance abuse, and all too often sexual dysfunction. The psychological impact can last for years after a sexual assault and typically includes depression, anxiety, fears, posttraumatic stress disorder (PTSD) symptoms, self-blame, and shame.
Nongenital physical injury
Most studies indicate that significant physical injury resulting from sexual assault is rare (3% to 5% across studies, with less than 1% of victims needing hospitalization). Even minor injury usually occurs in only about one third of the reported rapes. Injuries, when they do occur, are more common in stranger rapes and rapes by someone the victim knows intimately (domestic violence) than in date rape or acquaintance rape (Kilpatrick et al., 1992, Ledray, 1999, Marchbanks et al., 1990 and Tucker et al., 1990). Also, much like nongenital injuries, anogenital injuries include a variety of tears, bruising, scraping, irritation and redness, swelling, and cuts. These may all occur from consensual and nonconsensual sexual contact (Keller & Nelson, 2008).
In one study, the rate of physical injury for male rape victims (40%) was found to be higher than for female victims (32%). Although 25% of the men and 38% of the women in this study of 351 rape victims sought medical care after the rape for their physical injuries, only 61% of them told the treating physician they had been raped. The women expressed a strong preference for medical treatment and counseling by a woman. The male victims were less likely to express a gender preference (Petrak, Skinner, & Claydon, 1995). A more recent study of 1076 sexual assault victims, of which 96% were female, found nongenital trauma more often, 67% of the time. Physical force was, however, reported during the sexual assault in 79.6% of this population (Riggs, Houry, Long, et al., 2000).
Strangulation
Although we do not have statistics indicating the percentage of sexual assault victims who are strangled or smothered during the assault, we do know that in domestic violence (DV) cases, when a victim is strangled she is nine times more likely to be killed by her abuser than one who is not, and she is likely to be killed soon afterward (Battered Woman’s Justice Project and the Family Justice Center, 2004; Strack et al., 2004). Because most women do not report strangulation or smothering unless they are asked, it is important that in addition to looking for signs and symptoms of strangulation, we ask all victims if anything was placed around their neck or over their nose and mouth that prevented them from breathing or speaking. Clues to look for at the time of the exam or by history would include sore throat, vocal changes such as hoarseness, neck bruising, redness, or swelling, shortness of breath, wheezing, signs of aspiration such as a cough or emesis, hyperventilation, marks on the neck or chest from a ligature or hands, scratches on the neck, petechiae to conjunctiva, mouth, face, or neck (remember, petechiae may also be in the brain and be life threatening hours or days later), bruising or petechiae behind the ears, subscleral hemorrhage, agitation, confusion, seizure, loss of bowel or bladder function, or visual changes. Whenever strangulation or smothering is suspected, additional evaluation is indicated, which may include pulse oximetry, chest or soft tissue x-ray, CT or MRI of the neck or brain, carotid Doppler ultrasound, or laryngoscopy (Adkinson, Karasov 2007; Battered Women’s Justice Project and the Family Justice Center, 2004; OPDV Bulletin, 2003; Vignola, 2009).
Anogenital trauma
When evaluating the genital area for trauma, it is important to remember that the genital area is elastic and very vascular. As a result, it can withstand penetration without tearing, and injuries that do occur heal rapidly without scarring. Most injuries are identified in exams completed within the first 48 hours after the assault (Carter-Snell, Olson, Jensen, Cummings, & Wiebe, 2007). This is one of many reasons why the evidentiary examination should be completed as soon as possible, as anogenital injuries are seen more frequently when there is a shorter interval between the assault and examination and why it is important to remember that the absence of visual trauma does not rule out forceful, unwanted penetration (Adams, Girardin, & Faugno, 2001).
Studies indicate the likelihood of genital trauma identification without the use of a colposcope or camera equipped with a macro lens to magnify the trauma is similar to that of nongenital trauma; 1% have severe injury, and 10% to 30% have minor injury across studies. In reported studies, the injury was always accompanied by complaints of vaginal pain, discomfort, or bleeding (Cartwright et al., 1986, Cartwright et al., 1986, Geist, 1988 and Tintinalli and Hoelzer, 1985).
In one study, Adams et al. (2001) reported that the number of genital injuries correlated greatly with the number of other nongenital injuries (p = 0.003), suggesting that some assaults are more violent in many aspects. Although they do not specifically indicate if a colposcope was used on examination, Riggs et al. (2000) found genital trauma more often, in 52% of the cases reviewed. It is uncertain if this is the result of more violence resulting in injury in their population or more careful and consistent injury evaluation by experienced examiners. Other researchers report finding more anogenital injuries in sexual assault victims who are virgins than in victims who were sexually active (Jones, Rossman, Wynn, Dunnuck, & Schwartz, 2003).
The literature also suggests that colposcopic examination is often extremely useful to visualize genital abrasions, bruises, and tears, because these injuries are often so minute they cannot be seen with the naked eye (Frank, 1996 and Slaughter and Brown, 1992). These minor injuries are likely the result of tightened pelvic muscles and a lack of pelvic tilt or lubrication during the forced penetration. This minor injury usually heals completely within 48 to 72 hours. With colposcopic examination, genital trauma has been identified in up to 87% (N = 114) of sexual assault cases (Slaughter & Brown, 1992).
Another often quoted study comparing vaginal trauma in sexual assault survivors to women who had consenting sexual contact found 68% of 311 sexual assault victims had genital trauma, where as only 11% (n = 8) of the 57 women in the study who had consenting sex had genital trauma (Slaughter, Brown, Crowley, & Peck, 1997). Unfortunately, this study has not yet been replicated and is problematic, as women who recanted the sexual assault were included in the control group. The findings do not indicate if they did or did not have vaginal injuries. Although they did indicate the site of genital trauma, unfortunately they did not link the trauma to time of exam or the mechanism of injury (e.g., penile, digital, or penetration by an object). The most common sites of injury were the posterior fourchette, labia minora, hymen, fossa navicularis, and anus, followed by the cervix.
Another study looking at site of injury, but not connecting the mechanism of injury, compared 766 women ranging in age from 13 to 82. They found the most common sites of injury for the adolescents were the fossa navicularis, hymen, labia minora, and posterior fourchette. Nearly twice as many adolescents (10%) had cervical injury than did adult women. Eighty-three percent of the adolescents had anogenital injuries compared to 64% of the adult women (Jones, et al., 2003).
Both the colposcope and anoscope have been shown to improve the identification of rectal trauma; however, the colposcope may be less helpful than the anoscope. In a study of 67 male rape victims, all examined by experienced forensic examiners, 53% had genital trauma identified with the naked eye alone. This number only increased slightly, 8%, when the colposcope was used, but the positive findings increased a significant 32% when an anoscope was used. The combination of naked eye, colposcope, and anoscope resulted in total positive findings in 72% of the cases (Ernst, Green, Ferguson, et al., 2000).
We have more recently become aware of the importance of considering skin color in forensic evaluations. Unfortunately, little is known about anogenital injury prevalence and skin color. One study used experienced sexual assault examiners to evaluate 63 black and 57 white women after consensual sexual intercourse. They used colposcopes with digital imaging, and toluidine blue dye application. They found 55% of the total sample had at least one anogenital injury, with a significant difference between the groups. Injury was identified in the white women 68% of the time and only 43% of the time in the black women (p = .003). They concluded that dark skin color rather than race was a primary predictor for a decrease in injury detection (Sommers, Fargo, Baker, Fisher, Buscher, & Zink, 2009, in press).
Because rape victims often fear vaginal trauma, it is also important when they seek a medical examination that the extent of the trauma, or the lack of trauma, is explained to them after the forensic examination is completed (Ledray, 1999). When a video colposcope is available, it can be helpful to turn the screen so that the survivor can also view the genital area.
The ability of the examiner to identify anogenital trauma has improved considerably with the utilization of SANEs who are better trained in trauma identification and who are more likely to use a colposcope, anoscope, or a camera with a macro lens. However, the issue has now shifted and the question raised by defense attorneys is how can one be certain that anogenital trauma is the result of a sexual assault and not “rough” consenting sexual contact. Although this has become a clearly relevant focus of study by clinical researchers, unfortunately, sufficient scientific information does not yet exist that determines if the trauma identified is the result of consenting or nonconsenting sexual contact. What is known is that anogenital trauma does not prove rape, and the absence of trauma does not prove consent (Hilden et al., 2005, Jones et al., 2003, Jones et al., 2003, Sommers and Buschur, 2004, Slaughter and Brown, 1992 and Sommers et al., 2005). There is indeed a need for additional studies that look for a pattern of injury, tied to the time from exam to penetration and the type of penetration, in consenting and nonconsenting sexual contact.
The literature suggests that a number of factors impact the likelihood of finding anogenital injuries after a reported sexual assault. These include the time between the exam and the assault, methods of examination (gross visualization, colposcopy, or the use of a digital camera), the experience and skill of the examiner, and the past sexual history of the victim. It is also important to remember that there can indeed be genital trauma from consenting sexual contact. Trauma does not result solely from nonconsenting sexual contact or sexual assault. It does, however, appear that trauma is more likely and multiple sites of trauma are more likely as a result of sexual assault than from consenting sexual contact.
Anogenital injury heals rapidly. Anogenital trauma can result from consenting sexual contact. Trauma does not result solely from nonconsenting sexual contact or sexual assault. Both trauma and multiple sites of trauma are more likely to occur as a result of sexual assault than from consenting sexual contact.
Sexually transmitted infections
Sexually transmitted infections (STI) and HIV concerns have been identified as a significant reason why victims seek medical care after a sexual assault. While one study found 36% of the rape victims coming to the ED stated their primary reason for coming was concern about having contracted an STI (Ledray, 1991), the actual risk is much lower. The Centers for Disease Control and Prevention (CDC) estimates the risks of rape victims getting gonorrhea is 6% to 12%, chlamydia infection is 4% to 17%, syphilis is 0.5% to 3%, and HIV is much less than 1% (Centers for Disease Control and Prevention, 1993 and Centers for Disease Control and Prevention, 1998). The specific STI risk will, of course, vary from community to community, and it is important that the forensic examiner is aware of local rates so that this information can be provided to concerned sexual assault victims.
From a forensic and clinical perspective, treating prophylactically for STIs following the current CDC guidelines is preferable to culturing. Culturing is expensive and time consuming for the survivor who must return two or three times for additional testing, and, unfortunately, most victims do not return (Blair & Warner, 1992). In addition, STI cultures have not proved to be useful in court in adult and adolescent cases. It is still recommended in ongoing child sexual abuse cases, however, and can be useful evidence. As a result, most clinicians and forensic examiners recommend prophylactic treatment for adult and adolescent victims (American College of Emergency Physicians, 1999, Centers for Disease Control and Prevention, 1998, Frank, 1996 and Ledray, 1999; OVW, 2004).
In a national study, researchers found only 58% of sexual assault victims were screened or treated for sexually transmitted infections (Amey, 2002). Fortunately, victims seen by SANE programs are more likely to have this need addressed. In a study of 61 SANE programs across the United States, 90% offered prophylactic treatment for STIs, although 54% of these programs did not offer HIV testing (Ciancone, Wilson, Collette, & Gerson, 2000).
Since the early 1980s, HIV has been a concern for rape survivors, even though the actual risk still appears to be very low with only a few published cases of HIV transmission following sexual assault (CDC, 2005). The first case in which seroconversion, from HIV negative to HIV positive, suspected to be the result of a rape occurred in 1989 (Murphy, Harris, Kitchen, & Forester, 1989). Claydon Murphy, Osborne, et al. (1991) reported four more cases in which researchers believe a rape resulted in a subsequent HIV seroconversion. Even though these numbers are extremely low considering the number of rapes that occur every year, the impact for the individual victims is, of course, extremely significant.
In a study of 412 Midwest rape victims with vaginal or rectal penetration tested for HIV in the ED at three months after rape and again at six months after rape, not one seroconverted. Because 95% of individuals who are going to seroconvert will do so by three months after exposure and 100% will do so by six months, the researchers did not recommend routine HIV testing or prophylactic care. The study also found, however, that even if the survivor did not ask about HIV in the ED, within two weeks it was a concern of theirs or their sexual partner. Based on the recommendations of the rape survivors surveyed in this study, the researchers recommend that even if the survivor does not raise the issue of HIV or AIDS in the ED, the SANE or medical professional should, in a matter-of-fact manner, provide them with information about their risk, testing, and safe sex options (Ledray, 1999).
Determining the actual risk of HIV exposure following a sexual assault is extremely difficult because of the time period and other factors that could account for any seroconversion that may occur. How to best deal with the issue of HIV is complicated and controversial (Blair & Warner, 1992). If the offender is HIV infected, the probability of a rape victim contracting HIV from a sexual assault will depend on the type of sexual contact, the presence of trauma in the involved orifice, if there was exposure to ejaculate, the viral load of the ejaculate, and the presence of other STIs (CDC, 2002). In most instances, it is impossible to determine the HIV status of the offender in a timely fashion. In the Minnesota study described earlier, two assailants told the rape victims that they were positive. However, when one was apprehended and tested for HIV, he was found to be negative (Ledray, 1999). The likely risk of an offender being HIV-infected varies from state to state, because the general rates of HIV infection vary from state to state and community to community. The forensic examiner must, of course, know the local infection rates.
The risk following a single receptive penile-anal exposure is 0.5% to 3.2%, and following receptive penile-vaginal exposure 0.05% to 0.15% (Downs and deVincezi, 1996, DeGruttola et al., 1989 and Katz and Gerberding, 1998; Mastro & deVincenzi, 1996; Wiley, Herschkorn & Padian, 1989). No data are available on the risk of oral sexual transmission.
Because good data are not available on the actual risk of HIV transmission following a sexual assault, the CDC recommends postexposure antiviral prophylaxis (PEP) should be considered, or recommended, based on the risk of the rape combined with the HIV prevalence in the specific geographic area (CDC, 2005). A rape would be considered a high-risk rape if it involved rectal contact or vaginal contact with vaginal tears or existing vaginal STIs that have caused ulcerations or open sores disrupting the integrity of the vaginal mucosa. It would also be considered high risk if the victim had some reason to know or suspect that the assailant was an intravenous drug user, HIV positive, or bisexual.
As with other STIs, the risks, symptoms, and treatment options, including the impact of the HIV antiviral drug regimen, and follow-up recommendations, should be explained to the victim so he or she can make an educated decision (Ledray, 1999; US Department of Justice Office on Violence Against Women (OVW), 2004).
Pregnancy
The risk of pregnancy from a rape is the same as the risk of pregnancy from any one-time sexual encounter, estimated to be 2% to 4% (Yuzpe, Smith, & Rademaker, 1982). Unfortunately, perhaps from a lack of education, understanding, or personal religious beliefs, many healthcare providers still do not routinely discuss emergency contraception with sexual assault victims, even though the California Court of Appeals clearly articulated in the case of Brownfield v. Daniel Freeman Marina Hospital that a woman who did not receive complete postrape counseling and the right to choose a postrape antipregnancy treatment has standing to sue the hospital that provided the inadequate care (Calif. State Court of Appeals, BO32109, 1989).
The National Victim Survey found only 40% of rape victims were given information about emergency contraception (EC) (National Victim Center, 1992). Similar results were found in a more recent study completed by the National Research Center for Women and Families (2006) that reported less than half of sexual assault victims seen in the ED are offered EC. However, another national survey of hospitals found as few as 20% of rape victims were given EC (Amey & Bishai, 2002). Fortunately, as with STI prophylaxis, most (97%) of SANE programs offer EC to women at risk of becoming pregnant following a sexual assault (Ciancone et al., 2000). Most rape survivors are now offered this option when they are seen within five days of the rape and have a negative pregnancy test in the ED.
One SANE program operating at a Catholic hospital went as far as to get special permission from the diocese to administer Ovral (ethinyl estradiol) (Frank, 1996). The National Conference of Catholic Bishops has agreed that “A female who has been raped should be able to defend herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medication that would prevent ovulation, or fertilization” (National Conference of College Bishops, 1995, p. 16). Unfortunately, even with this directive only 5% of hospitals with Catholic affiliations will prescribe EC when requested (Amey & Bishai, 2002).
The importance of offering complete care to sexual assault victims, including care to prevent pregnancy when requested by the victim, was further strengthened by the successful lawsuit against the New York City hospital that did not ensure that a victim receive a full birth control prescription to prevent pregnancy (Chivers, 2000). Many states have state laws requiring all hospitals that see sexual assault victims to offer them pregnancy prevention medications. This is a significant change in responsibility. Even though as of August 24, 2006, EC is now available over the counter (U.S. Food and Drug Administration, 2006), it is still important for hospitals to provide the EC to rape victims in the ED. This is essential to avoid a delay in their getting the medication, because the longer they wait the less effective it will be in preventing a pregnancy. It is also possible that if victims are only given a prescription, they will not fill the prescription for EC because of cost, stress from the assault, or embarrassment (Womack, 2008).
Sometimes referred to as “the morning-after pill,” oral contraceptives such as Ovral or Lovral were initially used for EC. The Yuzpe regimen using a combined oral contraceptive is currently the most common emergency contraceptive (Yuzpe, et al., 1982). A more recently available progestin-only contraceptive, levonorgestrel 0.75 mg (plan B), is today the EC of choice and is widely used. Plan B is slightly, but nonsignificantly, more effective in reducing the risk of pregnancy. When started within 72 hours of unprotected intercourse, 85% of pregnancies were prevented in one study, compared to 57% using the Yuzpe regimen (Task Force on Postovulatory Methods of Fertility Regulation, 1998). The effectiveness of both methods decreases as the time between the assault and the first dose increases. When given within the first 24 hours, plan B reduced the risk of pregnancy by 95%, but only by 61% when given between 48 and 72 hours after unprotected intercourse. Because there is some continued preventive efficacy for up to five days, plan B is now given for up to five days after unprotected sexual contact. An advantage of plan B was in that the only side effect, nausea and vomiting, was significantly reduced to 23.1%, from 50% with the Yuzpe method (Task Force on Postovulatory Methods of Fertility Regulation, 1998). This side effect can also be reduced by administering an antiemetic one hour before giving the pregnancy prevention. A more recent study found that it was as effective to give two tabs of levonorgestrel (75 mg) immediately, rather than as two doses (75 mg) 12 hours apart (Hertzen, Piaggio, Ding, et al., 2002).
General health risk
More medical professionals today are aware of the convincing evidence that sexual assault can have a significant and chronic impact on the general health of a sexual assault survivor.
The stress resulting from rape appears to suppress the immune system and increase susceptibility to disease, and it increases the survivor’s attention to subtle physical symptoms and concerns about general health (Cohen & Williamson, 1991).
Sexual assault victims interpret emotional reactions to the assault as physical disease symptoms (Koss, Woodruff, & Koss, 1990), or they may employ maladaptive coping strategies, such as an increased substance use and eating disorders that have a serious negative health impact (Felitti, 1991 and Golding, 1994). Increased sexual activity with multiple partners, which also sometimes follows rape, especially in a formerly inactive adolescent, may also result in increased exposure to disease (Ledray, 1994).
Rape victims often want to avoid remembering or talking about the assault and are more comfortable seeking medical care, which they see as less stigmatizing than psychological counseling. Kimerling and Calhoun found 73% of a sample of 115 sexual assault victims sought out medical services during the first year after a sexual assault, whereas only 19% sought out mental health services during the same time period (Kimerling & Calhoun, 1994). Poor social support was associated with higher use of medical services, and higher levels of social support were associated with better actual physical health and better health perception in this population. Koss et al. (1990) found that a statistically significant 92% of 2291 female crime victims sought medical care in the first year following the crime, and 100% sought medical care during the first two years. Those who had suffered more severe crime and victims of multiple crimes were the most likely to seek medical care. They, too, suggest that the stress of victimization may reduce resistance to disease by suppressing the immune system.
It is interesting that in their sample, Kimerling and Calhoun (1994) did not find a significant difference in the health service utilization of women who had sought out psychological services. Jones and Vischi (1980) even found a 20% decrease in medical service utilization in a sample of 87 rape victims who were in psychotherapy, stressing the importance of ensuring initial crisis intervention and follow-up counseling for victims of sexual assault.
Waigandt and Miller (1986) found that rape victims made 35% more visits to a medical doctor each year than nonvictims; however, the victims who continued to have psychological problems several years later made more visits and perceived their health as worse than the recovered victims. The recovered rape victims experienced only 12% of possible physical symptoms, and the victims with psychological problems experienced 28% of the symptoms, primarily female problems such as dysmenorrhea and incontinence. These victims also exhibited twice the number of maladaptive health behaviors such as smoking, excessive alcohol use, and overeating.
Walker, Katon, Hansom et al. (1995) found women with chronic pelvic pain were significantly more likely than women with no pelvic pain to be victims of sexual abuse, even though only 1 out of 10 were found to have an organic condition. The chronic pain groups were also more likely to be depressed and to have substance abuse problems, phobias, and sexual dysfunction. Eleven percent of the primary care visits were related to the chronic pelvic pain, at an average cost of $1816 per patient.
Rape disclosure can have a significant and positive impact on a woman’s health.
A 49-year-old woman experienced intermittent, severe, longstanding hypertension for which no biological cause could be identified. After a routine health visit to check her blood pressure (BP), she disclosed she had been having nightmares and was beginning to recall being raped by her sister’s boyfriend when she was 14 years old. Immediately after the disclosure her BP went from 240/150 mm Hg to 150/105 mm Hg. The next morning she reported a good night’s sleep, no more nightmares, and her BP was recorded at a normal 120/85 mm Hg (Mann & Delon, 1995).
Felitti (1991) compared a sample of 131 medical patients who had a history of sexual abuse to a group of matched control subjects. The majority (90%) had never before disclosed the abuse. Decades later, Felitti found the sexual assault victims to be significantly more depressed (83%) and experiencing physical symptoms of depression such as despondency, chronic fatigue, sleep disturbance, and frequent crying spells. Sixty percent had gained more than 50 pounds, and 35% had gained more than 100 pounds. Chronic unexplained headaches were common in the victim group (45%), as were recurrent gastrointestinal disturbances (64%). Another study of 100 women concluded that women with a history of sexual abuse were 60% more likely to have unexplained pelvic pain, abnormal bleeding, and more gynecological surgery than women without a sexual assault history (Chapman, 1989). Chapman (1989) found that sexual abuse victims had five times the number of hysterectomies and three times the number of pelvic and gynecological surgeries than a nonvictim control group and cautions that unexplained pain in women with a history of sexual abuse may not be removed by a surgical procedure when pain alone is the criteria for the procedure.
Koss, Koss, and Woodruff (1991) found severity of victimization was a more effective predictor of total yearly visits to a physician and outpatient costs than was age, ethnicity, self-reported symptoms, or actual injury. They found that rape victims were twice as likely to seek the help of a physician than nonvictims, and visits increased 56% in victim groups compared to 2% in nonvictim groups.
In a study comparing sexual assault (n = 99) and life-threatening physical abuse victims (n = 68) on physical health status 10 years later, Leserman, Drossman et al. (1997) found overall poor physical health status was directly associated with sexual assault, especially with physical injury during the assault, multiple perpetrators, and the victim’s life being threatened during the assault. Golding (1994) also found women with a history of sexual assault were more likely to complain of six or more medically unexplained somatic symptoms (29% versus 16% of nonrape victims) and to have a severe chronic disease such as diabetes, arthritis, difficulty in walking, paralysis, or fainting as well as having functional limitations (27% versus 16% of the nonrape victims). The increased incidence of overall explained and unexplained somatic symptoms of rape victims in this population was 60%, compared to 36% of the nonvictims.
Sexual Dysfunction
Considering the nature of sexual assault, it is not surprising that studies have found sexual dysfunction is a common reaction, and often a chronic problem, following a sexual assault. The sexual dysfunction often includes loss of sexual desire, inability to become sexually aroused, slow arousal, pelvic pain associated with sexual activity, a lack of sexual enjoyment, inability to achieve orgasm, fear of sex, avoidance of sex, intrusive thoughts of the assault during sex, or abstinence. Sexual dysfunction such as avoidance, loss of interest in sex, loss of pleasure from sex, painful intercourse, and actual fear of sex are mentioned repeatedly in the literature (Abel and Rouleau, 1995, Becker et al., 1986, Burgess and Holmstrom, 1979, Frazier, 2000, Kimerling and Calhoun, 1994, Koss, 1993, Ledray, 1994 and Ledray, 1999). It is important to note that even though rape victims may become sexually active again within months of the assault, they may still not enjoy sex years later. Celibacy may be a coping strategy.
Substance Abuse
In one of the first large samples of 6159 college students surveyed by Koss (1988), 73% of the assailants and 55% of the victims reported using alcohol or other drugs before the sexual assault. Rape victims are clearly more vulnerable to being raped as a result of substance abuse, which leads to intoxication and an increased vulnerability. Because one study identified that 47% of the rape victims seen reported some form of sexual victimization in the past, vulnerability is clearly an issue (Ledray, 2001).
The use of alcohol and other substances prior to a sexual assault is often identified in the literature (Abbey, 2002, Kaysen et al., 2006, Ledray, 1999 and Logan et al., 2002Messman-Moore & Long, 2002). Studies indicate at least 50% to 74% of rape victims used alcohol or drugs immediately before a sexual assault (Abbey, 2002 and DuMont et al., 2003; Kilpatrick, Resnick, Ruggiero, Conoscenti, & Mc Cauley, 2007; Littleton & Breitkopf, 2006; Logan, Cole, & Capillo, 2006).
It is important to remember, and it has long been recognized, that rape also can result in substance abuse, possibly as an attempt to dull the memory and avoid thinking about the rape (Goodman et al., 1993, Koss, 1993 and Ledray, 1994). In a national sample of 3006 survivors, both alcohol and drug use was significantly increased after a sexual assault, even for women with no prior substance use or abuse history (Kilpatrick, Acierno, Resnick, et al., 1997).
Healthcare providers have been found to be hesitant to identify and address alcohol-related problems in any patient seen in the ED (Thom, Herring, & Judd, 1999). This is true of advocates and SANEs who have historically been hesitant to discuss the role of alcohol and other drugs in sexual assault, because we do not want to appear to be blaming the victim for complicity in a crime that was perpetrated against them. This is especially true when we are treating the victim in the ED, even though, as we have already identified, at least 50% to 74% of rape victims are intoxicated at the time of the assault and in one study 90% of them reported being so intoxicated they could not have legally consented to the sex (Resnick, personal communication, February 25, 2007; Kilpatrick, Acierno, Resnick, et al., 1997). Even if the individual is not alcohol dependent, clearly binge drinking, all too common on our college campuses and with the younger populations groups most often included in sexual assault statistics, is a vulnerability issue. Because we also have previously identified that this is often our only known contact with the rape victim, perhaps it is time to reconsider the unwritten policy to not address the alcohol issue, as it clearly is not helpful to our patients (Ledray, 2008).
The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends all medical patients be screened for unhealthy alcohol use (National Institutes of Health, NIAAA, 2005). Although we certainly need to do so in a manner that will in no way sound to the victim that we are blaming her for the assault, brief screening and intervention in the medical setting has been identified as feasible and effective in limiting unhealthy alcohol use. It has been shown effective with other ED populations, and it could result in the victim being vulnerable to another assault (D’Onofrio et al., 2002, Gentilello et al., 1999 and Spirito et al., 2004). Clearly this is an opportunity for nursing to identify and address alcohol-related problems with this population and once again take the lead in providing more comprehensive care to sexual assault victims (Ledray, 2008).
Psychological impact
There is considerable agreement among researchers that rape victims experience more psychological distress than do victims of other crimes. Fear, anxiety, depression, and symptoms of PTSD are the most frequently recognized and documented reactions to sexual assault (Burgess and Holmstrom, 1974, Calhoun et al., 1982, Frazier, 2000, Kilpatrick and Veronen, 1984, Ledray, 1994, Resick and Schnicke, 1990 and Resick and Schnicke, 1990).
Anxiety
Anxiety is also frequently recognized and documented in the literature as an immediate reaction to a sexual assault (Abel and Rouleau, 1995, Burgess and Holmstrom, 1974, Calhoun et al., 1982, Kilpatrick and Veronen, 1984, Ledray, 1994, Littel, 2001 and Resick and Schnicke, 1990). In one study, 82% of rape victims met the Diagnostic and Statistical Manual (DSM) criteria for generalized anxiety disorder (GAD) compared to 32% of nonvictims (Frank & Anderson, 1987). Some studies of long-term anxiety have found differences between victim and nonvictim groups (Gidycz et al., 1993, Gidycz and Koss, 1991 and Gold et al., 1994), and others have not (Frazier and Schauben, 1994, Frazier and Burnett, 1994, Riggs et al., 1992 and Winfield et al., 1990). Studies also report that rape victims were more likely to meet the criteria for panic disorder several years after the rape (Burnam et al., 1988 and Winfield et al., 1990).
Fear
Fear of death is the most common fear during the assault, and continued generalized fear after the assault is a very common response to rape (Dupre et al., 1993 and Ledray, 1994). Fear after a rape can be specifically related to factors associated with the sexual assault, or it can be widely generalized to include fear of all men (Ledray, 1994). Because fear is subjective, it is generally evaluated using self-report measures. Although evidence of the duration and type of fear varies, reports of long-term fear following rape is common, with up to 83% of victims reporting some type of fear following a sexual assault (Frazier, 2000 and Nadelson et al., 1982). Girelli, Resnick, Marhoefer-Dvorak, et al. (1986) found the subjective distress of fear of injury or fear of death during rape was more significant than the actual violence as a predictor of more severe postrape fear and anxiety. It is thus important to recognize that the threat of violence alone can be psychologically devastating (Goodman, Koss, & Russo, 1993).
As might be expected, rape victims are consistently found to be generally fearful and experiencing hyperalertness to potential danger during the first year following a sexual assault. During the acute stage, up to 80% of rape victims report being generally fearful, afraid of violence, or afraid of being alone. Nearly as many, 75%, report a fear of being indoors, outdoors, or in a crowd, and 70% report a fear of death (Becker, et al., 1986). Although fear of retaliation by the assailant is a persistent and long-term result of a sexual assault, except in domestic violence rapes, retaliation by the assailant when a victim reports is, fortunately, an extremely rare occurrence (Ledray, 1994).
Depression
Depression is one of the symptoms most commonly identified following a sexual assault. Depression is easily, reliably, and quickly measured by standardized self-report measures, such as the Beck Depression Inventory (Adkinson and Karasov, 2007, Atkeson et al., 1982, Frazier, 2000, Ledray, 1994 and Kilpatrick and Veronen, 1984).
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