Partnering with Practitioners: Rape Care and Health CareJUNE 8, 2006
June Kiesel, EdD (Sexual Assault Program Coordinator, Coalition Against Rape & Abuse, Inc., Cape May County, NJ)
Many people are often surprised to hear the term "epidemic" used to describe sexual violence. But the 700,000 women in our nation over the age of 18 who are victims of sexual assault each year represent an epidemic, according to the Centers for Disease Control and Prevention (CDC). Available data underestimate the true magnitude of the problem. Rape continues to be the most underreported crime, with only 39% of rapes and sexual assaults reported to law enforcement in 2002, according to the Department of Justice. In a report to the nation, the National Victim Crime Center in 1992 found that not being believed or feeling that at some level she may have been to blame prevents more than half of all victims from seeking prosecution.
In 8 out of 10 rape cases, the victim knows the perpetrator and of people who reported sexual violence, 64% of women and 16% of men were raped, physically assaulted, or stalked by an intimate partner. This includes a current or former spouse, cohabitating partner, boyfriend/girlfriend, or date, reported Tjaden and Thoennes in a National Violence Against Women survey in 2000.
With such a prevalence of victims being assaulted by someone known to them, victims are often reluctant to identify that a rape has occurred. Embarrassment, shame, fear, feelings of discomfort and mistrust about the official to whom an assault is reported all add to the victim's reluctance to report. Rape by a stranger ("stranger rape") does not carry the level of stigma as does rape by a known perpetrator.
Victims must have the opportunity to reveal the assault. This becomes the first, most important step toward recovery, particularly regaining the ability to trust others and feel a sense of control over their own lives. Some may choose to report to law enforcement; others confide in friends, family, a trusted co-worker, or seek spiritual guidance from someone of their particular religious background.
Of those who decide to report, many more choose to remain silent. It is the silence that is the greatest obstacle impeding the healing process. In her book, Trauma and Recovery, J. Herman states, "The conflict between the will to deny horrible events and the will to proclaim them out loud is the central dialectic of trauma."
But in much of the available literature on sexual violence, very little is mentioned about a crucial partner on the road to healing: the health care professional. The trauma inflicted on the sexual assault victim often manifests in various physical, emotional, or psychological complaints that lead her to a health care facility. Research by Plichta and Falik in 2001 revealed that women who experienced sexual violence were more likely than other women to have had 8 or more doctor visits during the past year.
A visit to a health care provider is an appropriate time and opportunity for an assessment for violence. An American Medical Association study found that 87% of victimized women said it was their health care provider they wanted to tell about the violence in their lives.
Multiple studies conducted in 1996, 2000, and 2002 by Holmes et. al., Wingood et al., and Jewkes et al., respectively, found that consequences of sexual violence can and do have very harmful, lasting consequences for victims and their families. Over 32,000 pregnancies result from rape each year. Other life-altering, physical issues resulting from sexual violence include sexually transmitted diseases, chronic back pain, migraines, gastrointestinal disorders, and disability preventing work.
The American Medical Association reported in 1995 that approximately 80% of victims suffer a wide range of psychological disorders including fear, confusion, anxiety, nervousness, distrust of others, shock, symptoms of Post-Traumatic Stress Disorder, depression, attempted or completed suicide, or unhealthy eating behaviors.
Asking women patients who present with such disorders about past or present violence can clarify to providers the underlying reason for the patient's symptoms. It would save time, multiple office visits, money for unnecessary testing, and visits to specialists. Knowledge about the sequelae of sexual violence can alert providers to the possibility that a patient fits the profile of a survivor of a sexual assault.
In order to provide health care workers with the information needed to determine if, when, and how a patient may have been a victim of sexual violence, the Florida Council Against Sexual Violence (FCASV), in 2002, developed a guide for health care professionals (originally authored by Lynne Stevens, CSW, BDC) that can be used to assess patients.
The FCASV subsequently released their copyright allowing the New Jersey Coalition Against Sexual Assault (NJCASA) to adapt the materials for training purposes. The New Jersey project was made possible by a generous grant from The Healthcare Foundation of New Jersey, founded by the Jewish Community.
Edie Camel, Director of Public Education and Research for NJCASA offered, "There is now a movement in the sexual assault field to make health care professionals more aware of the issue of sexual violence in the lives of their patients; and we can give them the tools and the guidance to do just that." To date, professionals in 16 of New Jersey's 21 counties have received training from both NJCASA and their local rape crisis centers in order to make providers more comfortable in broaching the subject with patients and helping to make a difference in the lives of thousands of women.
Disclosure of sexual violence may take awhile since victims first need to develop trust in others. While the above summary is just that, much more can be done during an office visit to assist patients. A provider's attention to patients' disclosures and caring referrals to further help can make a profound difference in the well-being of each survivor.
States all around the country need to become more proactive in identifying victims of sexual assault. Already, many states are beginning to follow Florida's lead in order to bring the health care community onboard as a partner in working with people whose lives have been touched by sexual violence.
All local rape crisis centers around the country are equipped to provide information to anyone seeking assistance with sexual assault survivors, including the health care community. All members of that community can improve services to all patients by becoming part of the solution. Development and use of procedures and protocols will allow practitioners to feel comfortable asking the questions and allow patients to address their concerns, issues, and feelings with dignity. It should be noted that while the majority of the work in this field pertains to women as victims, sexual violence is also committed against men (Tjaden and Thoennes found that 78% of the victims of rape and sexual assault are women, 22% are men), and this warrants additional study as well as attention from clinicians.
The NJCASA screening protocol used to assess patients is simple. The
acronym S-A-V-E is an easy way to remember the steps used. The
information is summarized for purposes of this article.
S – SCREEN all your patients for sexual violence. Patients need to be asked before they will tell. Conduct the interview in a private setting, assuring confidentiality prior to asking questions.
A - ASK direct questions in a non-judgmental way. Practitioners need to remain calm, never blaming the patient or dismissing what she is sharing. Reminding the patient that many conditions can be a result of an assault, that many women are hurt in many ways due to an assault, and asking the patient to share anything in their past that they feel may be contributing to their condition or illness will put the woman at ease and develop trust.
V – VALIDATE the patient. If the patient discloses abuse, gently remind her that she is believed, that there is help available, that she was brave to discuss the issues, and the information will greatly improve the ability of the health care professional to provide the very best treatment. Offer empathy and understanding.
E – EVALUATE, educate, and refer. You need not hear the whole story to effectively treat the patient. But the provider needs to know how the patient is now feeling, and whether she is abusing drugs or alcohol or thinking of suicide. If the patient answers no to any of the initial questions, that does not always mean she is not a victim. Use it as an opportunity to provide information about sexual violence. Provide all patients with appropriate phone contacts, literature, and available support services.