The Federal Bureau of Investigation (FBI) (2008) considers rape to be the second-most violent crime in a group of crimes that includes murder, robbery, and aggravated assault. Victims are traumatized, both physically and emotionally, and are often seen in health care settings. Nurses are instrumental in providing holistic care for those who have been sexually assaulted and also in helping to preserve evidence. Preservation of evidence can lead to the prosecution of a crime or the exoneration of a person of interest; therefore, it is essential that nurses be informed adequately about their roles and responsibilities with regard to providing both medical and legal care and ensuring that nursing policies and procedures effectively manage the care of sexual assault patients.

For the remainder of this chapter, victims of sexual assault will be referred to using the female pronoun in recognition of the fact that women are more frequently sexually assaulted; however, the principles discussed apply to anyone. In health care settings, victims of sexual assault are referred to as patients; advocacy groups use the term survivor; and legal systems use the term victim. Within this chapter, individuals will often be referred to as patients because those individuals are cared for in health care settings.

Epidemiology

Nearly 1 in 5 women and 1 in 71 men in the United States have been raped at some time in their lives (Black, et al., 2011). According to the National Intimate Partner and Sexual Violence Survey (NISVS) (2011), most female victims will experience their first rape before the age of 25, with 42.2% reporting a rape before the age of 18 years. More than one quarter of male victims experienced their first rape when they were 10 years of age or younger. Each year, women experience about 4.8 million intimate partner-related physical assaults and rapes (Centers for Disease Control, 2011).

Lifetime prevalence of rape is 18% among U.S. adult women, and few rape survivors seek immediate medical attention, even with serious injury (Tjaden & Thomas, 2008). For male victims, more than half (52.4%) reported being raped by an acquaintance and 15.1% by a stranger (Black et al., 2011). A male who is raped is more likely to experience physical trauma and to have been victimized by several assailants. Reports of male-to-male rape occur primarily in locked institutions, such as prisons and maximum-security hospitals. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment.

Race and ethnicity are important variables in rape statistics. The NISVS (2011) reports that approximately 22% of black women, nearly 19% of white non-Hispanic women, and about 15% of Hispanic women in the United States have experienced rape at some point in their lives. More than 25% of women who identify themselves as American Indian or as Alaskan Natives and about 33% of women who identified as multiracial non-Hispanic have reported rape victimization.

Precise estimates of sexual violence are impossible since this crime is greatly underreported, but there is reason for optimism. According to the 2011 FBI Uniform Crime Reporting Program, there was a decrease of about 5% for a majority of population groups. A reduction of sexual assault cases is part of an overall trend that may be due to several factors: policies that support longer sentences for perpetrators, mandatory sentences, and trained health care providers who specialize in caring for victims of sexual assault. Women and men today may be willing to report sexual violence, which may be a deterring factor.

Prevention efforts should include a multidisciplinary response in caring for victims of sexual violence. Nurses are often frontline health care providers who are needed to help coordinate these efforts. Men and women need to receive timely, competent care and help navigating both the health care and legal systems. Collective action is needed to help ensure short-term and long-term recovery as well as to prevent future adverse health consequences as a result of sexual victimization.

Sexual offenders and relationships with victims

While we often think of a stranger lurking in the shadows of parking lots as the typical sexual offender, this is not true. The terms spousal (or marital) rape and acquaintance (or date) rape describe the nature of the relationship between victim and rapist. In recent years, courts have recognized spousal (or marital) rape, in which the perpetrator (nearly always the male) is married to the person raped. In acquaintance (or date) rape, the perpetrator is known to, and presumably trusted by, the person raped. The psychological and emotional outcomes of rape seem to vary depending on the level of intimacy between the victim and the perpetrator. Sexual distress is more common among women who have been sexually assaulted by intimates, and fear and anxiety are more common in those assaulted by strangers. Depression occurs in both groups.

Females know their offenders in almost 70% of all violent crimes committed against them; males know their offenders 45% of the time (Truman & Rand, 2010). Acquaintance (or date) rape has increased in incidence in the United States in recent years, with drugs, often combined with alcohol, being used to commit sexual assault. Date-rape drugs may render a woman incapable of resisting the attack and are purported to facilitate acquaintance rape. Often these drugs are given to the unknowing victim. Once the drugs are ingested, victims lose their ability to ward off attackers, develop amnesia, and become unreliable witnesses. Because the symptoms mimic those of alcohol, victims are not always screened for these drugs. The increase in prevalence and incidence of drug-assisted rape led to the passage of the Drug-Induced Rape Prevention and Punishment Act in 1996. This law allows up to 20 years imprisonment and fines for anyone who intends to commit a violent crime by administering a controlled substance to an unknowing individual (U.S. Department of Justice, 1997). Table 29-1 provides information about date-rape drugs.

TABLE 29-1

DRUGS ASSOCIATED WITH DATE RAPE

DRUG, ALTERNATE NAMES, AND STATUS IN THE UNITED STATES	FORM, MECHANISM OF ACTION, AND ONSET	EFFECT ON VICTIM	OVERDOSE SYMPTOMS AND TREATMENT
GHB (γ-hydroxy-butyric acid) Also known as G, Georgia home boy, liquid ecstasy, salty water, and scoop Legal in the United States for narcolepsy Often made in home labs	Liquid, white powder, or pill with a salty taste Schedule III central nervous system depressant A metabolite of γ-aminobutyric acid Onset within 5-20 minutes; duration is dose related and from 1-12 hours	Produces relaxation, euphoria, and disinhibition Incoordination, confusion, deep sedation, and amnesia Tolerance and dependence exhibited by agitation, tachycardia, insomnia, anxiety, tremors, and sweating	Respiratory depression, seizures, nausea, vomiting, bradycardia, hypothermia, agitation, delirium, unconsciousness, and coma Intubation for severe respiratory distress; atropine for bradycardia, and benzodiazepines for seizure activity. Vomiting should be induced when possible.
Rohypnol (flunitrazepam)* Also known as forget-me pill, roofies, club drug, roachies, R2, and rophies Not legal in the United States	Pill that dissolves in liquids Schedule IV potent benzodiazepine; 10 times stronger than diazepam Impact is within 10-30 minutes and lasts 2-12 hours	More potent when combined with alcohol; causes sedation, psychomotor slowing, muscle relaxation, and amnesia Dependence and tolerance may develop	Overdose unlikely Airway protection and gastrointestinal decontamination
Ketamine Also known as black hole, bump, K, kit kat, purple, and Special K Legal in the United States for anesthesia	Comes as a liquid or a white powder An anesthetic frequently used in veterinary practice; also a hallucinogenic substance related to PCP (phencyclidine) Onset within 30 seconds intravenously and 20 minutes orally; duration only 30-60 minutes; amnesia effects may last longer	Causes dissociative reaction, with a dreamlike state leading to deep amnesia and analgesia and complete compliance of the victim May become confused, paranoid, delirious, combative, with drooling and hallucinations	Airway maintenance and use of anticholinergics such as atropine and benzodiazepines

^*Two other benzodiazepines, clonazepam (Klonopin) and alprazolam (Xanax), are also used.

Data from Lehne, R. A. (2010). Pharmacology for nursing care (7th ed.). Philadelphia, PA: Saunders; U.S. Department of Health and Human Services. (2008). Date rape drugs. Retrieved from http://www.womenshealth.gov/faq/date-rape-drugs.cfm.

Application of the nursing process

Assessment

According to the Centers for Disease Control and Prevention (2010), sexual assault represented 8% of all nonfatal violence-related injury visits to emergency departments for females in 2008. According to the U.S. Department of Justice, 32% of sexual assault victims seek help in a hospital emergency department. The attention the patient receives depends on the policy of the health care facility.

The U.S. Department of Justice (2004) publishes A National Protocol for Sexual Assault Medical/Forensic Examinations to assist health care facilities in establishing protocols in caring for adult and adolescent sexual assault patients. This protocol has been instrumental in guiding care toward a more comprehensive approach to sexual assault care. According to the protocol, the medical exam should include the following:

1. Information from the patient

2. An examination

3. Documentation of biological and physical findings

4. Collection of evidence

5. Follow-up as needed to document additional evidence

The Emergency Nurses Association (2010) position statement on care of sexual assault and rape victims suggests:

1. An individualized, multidisciplinary, multiagency approach.

2. A physical and social environment conducive to private, empathetic, and unbiased care by health care providers, family members, law enforcement officers, and members of the justice system.

3. A private and safe environment, with personnel limited to examining health care providers during sexual assault care. Translators must be available if needed. With the consent of the patient, a specially trained advocate also may be present.

4. Comprehensive, competent, and sensitive emergency health care.

5. Employment of SANE nurses in the emergency department is highly recommended.

6. Emergency nurses should collaborate to promote and establish ongoing community education focused on preparing the public and emergency nurses to better identify, prevent, care for, and report incidents of sexual assault and rape.

7. Emergency nurses should be involved in research concerning the identification, assessment, and treatment of victims of sexual assault and rape.

Historically, patients who were sexually assaulted and went to health care facilities for medical care and evidence collection had to wait for long periods of time to be evaluated. Often, they were not considered in need of acute care because they lacked visible physical injuries. Now, a patient who is sexually assaulted is considered a priority due to the intense psychological impact and potential hidden physical injury. Collecting legal evidence is also a priority, and delays may result in its destruction or contamination.

The care of sexual assault victims varies from facility to facility. In one Midwestern study, researchers found that virtually all emergency departments provided acute medical care (Patel et al., 2008); however, only two thirds of these agencies offered rape counseling and sexually transmitted infection management. Counseling and emergency contraceptives were provided by 40% of facilities, and HIV management was provided by 30% of the facilities. Just 10% of the emergency departments provided all of these services to victims of sexual assault.