CHAPTER 53. Sexual Assault
Anita Ruiz-Contreras
Sexual assault can be defined as any type of sexual contact or behavior that occurs without the explicit consent of the recipient, including such activities as forced sexual intercourse, sodomy, child molestation, incest, fondling, and attempted rape. 18 Sexual assault is one of the most feared and least understood crimes. Of all the choices made in our lives, the most intimate choices are sexual. In a sexual assault, choice is taken away. Sexual assault is not a crime of passion. The perpetrator does not attack because of overwhelming lust. It is not the victim’s clothing or his or her perceived seductive behavior that causes the assault. The perpetrator’s sexual gratification is a myth.
In a classic study of more than 600 sex offenders, Amir1 was one of the first to describe rape as a crime of power and control. Groth11 interviewed more than 500 sexual “aggressors” and found power and anger described as motivating factors. Sex is used by the rapist as a tool to control and humiliate the victim.
Sexual assault is not defined by gender, social level, ethnic origin, religious affiliation, or cultural lines. 9 Anyone, male, female, young or old, can be a victim of sexual assault. Prostitutes who normally charge for sexual services can be raped. A wife, a husband, a boyfriend, or a girlfriend can be raped. One in six women describe being sexually assaulted in their lifetime. 15 Sixty percent of women are acquainted with their assailant. 17 Many victims, possibly as high as 61%, do not report the crime. 7
There are many factors that contribute to victims not reporting sexual assault. There is a perceived shame that the victim should have been able to prevent the event. There is concern about what others will say or think about the victim. In most states, health care professionals are mandated reporters and should speak honestly about this requirement. The patient has the right to report or not report as he or she sees fit.
Male sexual assault may be one of the most underreported of all groups. Myths surrounding male sexual assault include beliefs that these assaults only happen in prison or that homosexuality is a causative factor. Lipscomb et al, 9 in a study of 99 adult male victims of sexual assault, found no statistically significant difference between incarcerated and not incarcerated victims. All people are potential victims regardless of sexual orientation. Men are raped for the same reason women are raped: power, control, and humiliation. The male survivor needs the same level of compassion and recognition as any other patient who has been sexually assaulted.
SEXUAL ASSAULT PATIENTS ARE SURVIVORS
The term survivor has been used to identify patients who have been sexually assaulted. The patient who has experienced sexual assault has lived through a life-threatening, life-altering event. Use of the term victim may denote a person who is helpless and who feels hopeless. The term survivor has more of a positive, empowering connotation. Use of survivor as an identifying term can be helpful when counseling patients. However, there are some professionals working in the area of sexual assault treatment who do not use the term survivor because it is felt that it may minimize or take away from addressing the devastation of the actual event. In determining the terms to be used, the health care professional must consider the impact of his or her choice of words on the individual presenting for care.
MYTHS AND MISCONCEPTIONS
Common myths such as “victims are women wearing suggestive clothing” or “a woman cannot be raped by an acquaintance” have long ago been dispelled. Regrettably, other myths remain prevalent. The media often portray women as secretly wanting to be raped, which is the so-called rape fantasy. When an individual fantasizes, he or she selects the players, the setting, and the sexual acts. In sexual assault all choice is taken away. This myth confuses sex and rape. Sex becomes the tool used by the rapist to degrade and humiliate the victim. Emergency nurses can use their knowledge regarding myths and misconceptions when counseling patients and families to dispel these beliefs and help begin the process of healing.
The patient may arrive with expectations about the hospital and the staff that are based on misconceptions; law enforcement officers and emergency nurses may also have long-held beliefs based on misconception. It is important for health care professionals to examine their own attitudes regarding survivors of sexual assault. 10 Myths and misconceptions surrounding sexual assault harm the patient and hamper development of a trusting relationship with the emergency nurse.
RAPE-TRAUMA SYNDROME
In a landmark study of 94 rape victims, Burgess and Holmstrom3 first identified rape-trauma syndrome, a cluster of symptoms experienced by survivors of sexual assault. Symptoms include somatic, behavioral, and psychologic reactions. The framework of rape-trauma syndrome includes recognition of the long-term reorganization a survivor goes through when recovering from the assault. Reorganization may take weeks or even years. There is recognition of differences in lifestyle choices made by individuals, in which lifestyles are not judged but seen as normal for that person.
Rape-trauma syndrome is an approved nursing diagnosis and can be used to plan nursing care. The initial hospital experience can have a major effect on the acute phase of the sexual assault survivor’s recovery. When interacting with the sexual assault victim, it is essential for the emergency nurse to develop a trusting relationship. As with any patient, a calm, confident approach facilitates this process. Listen to the patient, and explain what will happen during the examination. Show concern for the patient’s experience. Specific questions that require the patient to relive the assault are not needed. Determining the presence of physical trauma that requires immediate treatment is the initial priority. The extent of emotional injury cannot be estimated. Each person’s response to a sexual assault is different. Individuals may laugh, cry, tell a joke, or become catatonic. Patients may blame themselves for fighting back or for not fighting back. Inform the patients that their actions helped get them through the ordeal, regardless of what action was taken. Patients may believe they caused the rape by accepting the ride or opening the door. Remind these patients that they did not cause the assault. Patients need to hear that they have the right to decide what to do with their own bodies and that no one has the right to hurt them.
THE SEXUAL ASSAULT SURVIVOR IN THE EMERGENCY DEPARTMENT
Evaluation of the sexual assault survivor in the emergency department (ED) requires planning, development of specific policies and procedures, and staff education. The goal is to provide sensitive, individualized care for each person in a manner that ensures adherence to legal and regulatory requirements. Staff should be knowledgeable about state laws and regulations regarding sexual assault. A standard documentation form or protocol may be required by local or state policy. For example, the California State Medical Protocol for the Examination and Treatment of Sexual Assault Victims must be used by all California hospitals and health care practitioners who perform examinations on survivors of sexual assault. 4 If hospitals do not wish to comply, they must develop a referral protocol with a hospital that does comply. For each case, a standard documentation form is used with copies for law enforcement, the criminalistics laboratory, and the hospital. The protocol outlines the steps of examination, including evidence collection, laboratory testing, medications, and follow-up care.
Sexual Assault Response Teams
For more than 20 years, specialized teams of nonphysician medical providers have been responsible for performing sexual assault medical and legal examinations. 2 The teams are identified as sexual assault response teams (SARTs) or suspected abuse response teams and consist of a nurse examiner, rape crisis advocate, and law enforcement personnel. Nurses with specialized training are identified as sexual assault/abuse nurse examiners (SANEs) or sexual assault forensic examiners (SAFEs). Some programs have started with the registered nurse serving as a patient care coordinator. This nurse assists the physician with the examination and follow-up. At the same time the nurse is learning how to perform examinations on his or her own. Other programs begin with adult patients and then progress to evidentiary examinations of pediatric patients as well. 16 The SANEs are usually on call and respond when a sexual assault victim arrives at an identified hospital/clinic. The SART programs train registered nurses to obtain patient histories, conduct evidentiary examinations, provide sexually transmitted infection (STI) prophylaxis, offer pregnancy prevention medication, and ensure follow-up care. The proliferation of these programs across the United States is evidence of their need and effectiveness. Most programs hold monthly case review meetings to ensure that all staff are kept up-to-date and there is consistent adherence to protocols. SANE personnel become the medical and legal experts in the field of sexual assault. The National Institute of Justice found that SART programs enhanced the quality of health care for women, improved the quality of forensic evidence, and increased the ability of law enforcement to collect information, file charges, and convict the assailant. 16 The International Association of Forensic Nurses reports that there are over 500 functioning sexual assault treatment programs (499 of these are in the United States—approximately 80% in hospitals with the remaining programs being community-based) (International Association of Forensic Nurses, personal communication, K. Day, March 9, 2009).
Development of a specialized team is the ideal; however, hospitals without specialized programs can treat sexual assault victims effectively. Individual hospitals can train all ED nurses or an identified number of nurses to care for sexual assault survivors during their work hours. Identified personnel may conduct the complete evidentiary examination independently or in conjunction with a physician. The nurse acts as a patient care coordinator, ensuring adherence to established protocols and procedures.
The Examination Begins
Sexual assault survivors should receive an emergent triage priority, only behind patients experiencing acute life-threatening events. The patient should be immediately placed in a safe, secure room. A medical screening examination should be performed to rule out an emergency medical condition. One nurse should be instructed to remain with the patient throughout the ED visit to provide continuity and decrease repetition of data collection. The patient should be allowed a support person such as a family member, friend, or representative from a rape crisis center. Asking “Whom can I call for you?” allows the patient to think of a name, whereas asking “Is there someone I can call for you?” is often followed by a “No” answer. Rape crisis advocates are an integral part of any sexual assault treatment program. If available, a rape crisis advocate should be part of the SART and be called to the hospital whenever the patient arrives. Law enforcement personnel should not be in the examination room during the examination.
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