Are sexual assault victims getting the proper treatment in your ED?
June 1, 1999 13 minutes read
Are sexual assault victims getting the proper treatment in your ED?
These patients require biological, psychological, and social services
ED nurses play a major role in the healing process of sexual assault victims, says Patricia Speck, MSN, RN, FNP, CS, nurse coordinator for Memphis (TN) Sexual Assault Resource Center.
"In many communities, the ED is the only resource for these patients," she explains. "His or her needs are biological, psychological, and social. ED nurses are in the best position to evaluate the patient holistically on all three levels."
Every sexual assault victim has at least five needs, says Linda Ledray, PhD, RN, FAAN, director of the Sexual Assault Resource Service in Minneapolis.
"These include documentation of and caring for any injuries, collection of forensic evidence, dealing with STD and pregnancy concerns, crisis intervention, and follow-up services," she stresses. "These must be addressed for every rape victim who comes into the ED."
More than 95% of all sexual assault victims do not sustain physical injuries requiring emergent medical attention, says Eileen Allen, RN, coordinator of the Monmouth County Sexual Assault Nurse Examiner (SANE) program in Freehold, NJ. However, these patients are in need of a full range of assessment, treatment, and follow-up services, she stresses.
Often victims feel they have been stripped of any sense of control. "It is important for the ED nurse to recognize a rape victim’s needs and ensure the patient’s dignity and confidentiality throughout the exam and treatment process," emphasizes Allen. Offer the victim as many opportunities as possible to regain control, by informing him or her about choices regarding treatment and services, she advises.
Meeting the victim’s needs
Biased, poor, or negligent care in the ED by the nurse or physician can have a lifelong effect on health-seeking behaviors in the victim, notes Speck.
"Research has shown that victims who receive therapeutic care in the hours and weeks following the assault have a reduced incidence of post-traumatic stress disorder by 50%," she reports.1
Here are ways to meet the unique needs of sexual assault victims in the ED:
• Expect a wide range of behaviors. "A victim’s demeanor can range from agitated and angry to very calm and composed," notes Allen. "There is no one correct way for a victim to react or behave. Most of the time, he or she is not physically injured, but may react in any manner of ways. Be ready to deal with any type of reaction."
• Ensure the privacy of victims. "There are stories of victims being left waiting in the main ED waiting room in the company of a police officer for hours, making them vulnerable to questions from friends or acquaintances who may happen to walk through the area," says Allen.
If your ED does not have a private waiting area that is separate from the main ED waiting room, find another space, Allen recommends. "Utilize an area already designated as a family waiting room for trauma patients, or find another private, underutilized space, such as a conference room," she says.
• Know local and state laws regarding sexual assault reporting. "The victims should be asked if they have notified police or if they wish to do so. In New Jersey, reporting rape is not mandatory. As an ED nurse, I am not allowed to report it without the victim’s permission," says Allen. "However, in other states, it is mandatory [to report the crime to authorities]."
• Involve victims in the decision-making process. Advises Allen, "Say, Have you notified the police? In our state, it’s up to you. Have you reached out for any support services?’"
• Offer victims options throughout the assessment and treatment process. "Ask them if they would like to have anyone present while you document the history of the assault," says Allen. "Explain the evidence collection procedures, and assure the victim that he or she can ask questions throughout the procedure."
• Explain that the patient can refuse any steps in the procedure that he or she doesn’t wish to undergo. "I briefly explain why we do this, and how we do it, and then I ask the victim if it’s okay if we go ahead and do that. I never assume that an initial consent for treatment is a blanket consent for all steps in the procedure." Allen says.
• Provide privacy. "Whenever possible, patients should be assessed and treated behind closed doors instead of behind a pulled curtain," says Allen. "During the assessment and information gathering, the examiner will be asking very specific questions about the details of the assault itself. It’s very stressful, both for the examiner and for the victim, to try and carry on this conversation with patients and visitors in the cubicle next door."
Paperwork should also be kept private, stresses Suzanne Brown, RN, CEN, sexual assault nurse examiner at Inova Fairfax Hospital in Falls Church, VA. "I am appalled when I hear stories of patients getting seen after a sexual assault, and as soon as they leave everyone looks at the medical record. Patient confidentiality includes that record," she says. "In our program, the patient’s medical record goes, in a sealed envelope, from the nurse who is seeing the patient to medical records."
• Be willing to testify. "Nurses need to know how to be a competent witness in court, and have a responsibility to do that," Ledray emphasizes. "One study found that out of 97 kits collected, 14 had absolutely no identifying information as to who collected it, which is suspicious.2 It’s an understandable concern that it’s a time commitment to be called to testify, but it’s an important part of the nursing role."
• Know policies on victims’ rights. "Victims may be afraid to report the crime because their name will be in the paper. You need to know if that’s true so you can let them make an educated decision," says Ledray. "You also need to know if prosecutors will force the victim to testify if he or she changes his or her mind later, or if he or she can just report [the crime] and make the decision about prosecuting later."
• Don’t worry about saying the wrong thing. "It’s not so crucial what you say, because it’s highly unlikely you’re going to say the wrong thing," says Ledray. "A study showed that just having a caring nurse in the room, who said nothing through the rest of the exam, was very beneficial and helpful to the patient. Nonverbal communication can make a significant difference."3
• Don’t be afraid of talking to the victim about the assault. "The stigma is diminished the more they talk about it," says Speck.
• Start with less-invasive procedures. "Do the oral first, then perianal, anal, and vaginal specimens," recommends Ledray. "If your routine is to draw blood first, change it, because it’s not the best way to deal with a rape victim. Draw blood last because it’s most painful and invasive."
• Work with law enforcement. "You need to work with police, prosecutors, advocates, and sexual assault response teams. You will be able to accomplish a lot more if you know what evidence is useful in court," says Ledray. (See story on evidence collection tips on p. 106.)
ED Representatives met with the local sex crimes unit to discuss evidence collection, says Ledray. "For instance, our crime lab kit doesn’t ask for additional blood for drugs and alcohol. But we are still drawing an extra tube that can be held and used, because assailants were claiming the victim had exchanged sex for drugs. With that extra tube of blood, we can prove it wasn’t true," she explains.
Remain professional with patients
• Don’t sound accusatory. At triage, avoid questions that sound like accusations, says Brown. "Stay away from why’ questions, such as, Why were you walking down that street at midnight?’ or Why were you drinking?’" she advises. "Instead, say something like, I understand you were drinking tonight, we all go out for drinks, about how much did you have?’"
• Be conscious of your own prejudices. "You need to deal with your own issues about sexual assault. If you feel you’ll be judgmental about drinking, then you shouldn’t be taking care of that patient," says Brown. "If you can’t offer the patient the morning after pill, your judgmental feelings will come across. Check your attitude at the door."
• Don’t get too personal. "If you have been a victim of sexual assault, don’t talk to the patient about that. You need to remain professional," advises Brown. "Otherwise, your comments will be brought up in court against you to show bias. Be empathetic, instead of sympathetic."
• Know which equipment is needed. In most non-SANE programs, the exam is done visually, which doesn’t pick up all the injuries the patient has, says Brown. "Most SANE programs use a colposcope or med scope," she notes. "These are devices which aid in visualization, to magnify and photograph the area. This is starting to become a standard of care for a rape victim. You can also [use this to] photograph physical injuries from child abuse or domestic violence, or even to look at edges of wounds."
Toluidine blue dye adheres to injuries that have occurred within approximately three days, says Brown. "The dye highlights injuries you don’t see with your naked eye," she explains. "The naked eye picks up about 10% of injuries, with the dye you pick up about 50%. The dye only adheres while that injury is fresh so, once [the injury] starts to heal, it won’t adhere. If the victim claims an injury happened two days ago, and the dye adheres, it shows that it’s likely it did happen in that time frame."
• Put all instructions in writing. "Everything needs to be written down for a patient. You may have told her 10 times during an exam, but she won’t remember most of what you say. Victims are often in a state of shock," says Brown. "Provide detailed, written instructions, such as, Take this medicine at this time. Call me at this number if you have questions. Follow up with this doctor on this date.’"
• Know resources. Ask victims about their need for support services, advises Allen. "Include services from a rape care advocate or someone from the social services department," she says. "The triage nurse needs to be educated as to what services are available in his or her facility and community."
Victims need a counselor who is comfortable dealing with sexual assault issues, Brown advises. "Hospital social workers know what resources are out there. You can also put together a sexual assault resource book with names and numbers, so you are not reinventing the wheel every time a patient comes in."
• Be sensitive to needs of male sexual assault patients. Male victims of sexual assault usually have more trauma associated with their assault and may require the care of a surgeon, says Susan McDaniel Hohenhaus, RN, CEN, FNE, coordinator, Emergency Medical Services for Children at the North Carolina Office of Emergency Medical Services in Raleigh, NC. "The most common form of sexual assault reported by males is forced anal intercourse," she notes.
Only about 12% percent of men report sexual assault to the police and another 12% report it to medical personnel, more often in a primary care setting than in an ED setting, Hohenhaus reports.
"If a male patient presents with signs of physical assault, especially by multiple assailants, the clinician should suspect sexual assault," she says. "Unfortunately, men report rape even less frequently than women, especially teenagers," she notes.
Boys tend to be victimized by a known assailant, particularly a family member, and report that victimization occurs most often around age 11, Hohenhaus notes. "Clinicians should question children in this age range regarding unwanted sexual contact," she advises.
Men may experience anxiety over their physical response to the assault, notes Brown. "A male does not have to be sexually aroused to have an erection. Some men do have an erection and even ejaculation, but these are both considered to be involuntary reactions," she explains.
Medical attention should be a priority
• Don’t overlook immediate medical needs. "At triage, ask the patient, Are you hurt anywhere physically that I need to look at right now?’ Because the majority of sexual assault victims don’t have physical injuries that require immediate medical attention, there is a tendency to overlook this possibility. Medical stability is always the No. 1 priority," says Brown.
In some cases, medical injuries were completely overlooked, reports Speck. "Victims were put in rooms for privacy and never checked on by the nursing or medical staff until the SANE nurse arrived, and then it was nearly too late for some," she says. "In one case, the patient’s vagina was traumatically lacerated and punctured her abdominal cavity following the rape. By the time the I was called, the patient had a rigid abdomen and was spiking a 104° F temp."
The delay resulted in a bad outcome, Speck recalls. "I went to surgery to collect evidence (a successful collection), but the patient lost one-third of her vagina and her female reproductive organs," she says. "Before she was released, she had two other surgeries to remove the infection in her peritoneal space. That may have been prevented if she had been appropriately triaged for bleeding and subsequent hypovolemia."
• Make patients feel safe. "Safety is a big issue with victims. Let patients know we are here to help them, that they are safe with us," says Brown. "At triage, tell the patient, We commend you for coming in here; it’s a big step for you to take, and we will keep you safe while you are here. We’ll also try and help you with your emotional trauma.’"
• Ask where the rape occurred. "It needs to be investigated in the jurisdiction where it happened," says Brown. "For example, in northern Virginia we have 22 jurisdictions, so we need to know which county to call to report the rape."
• Ask patients what would make them more comfortable. "One woman was sexually assaulted over a couple of days. When she came in, she wasn’t sure if she could go through with the exam," recalls Brown. "I asked her, Is there something I can do to make this experience easier for you?’ She said, If I’m home and get stressed, I usually have a cup of tea.’ So I said, Let me do a couple of swabs from mouth and then we’ll get you a cup of tea, then we’ll do the rest of the exam.’ And she was fine."
• Don’t always take what patients say at face value. "They have just been through a life-threatening ordeal, so the way they’re saying things may not be what they really mean," Brown says. "Ask, How can I help you with this?’ instead of just taking it as a refusal of the exam."
During the exam, patients may become distressed due to a specific concern, Brown reports. "You need to be aware of subtle movements or body language. If you notice a patient is becoming upset, say, Obviously something is bothering you.’ The patient may tell you, I just thought about pregnancy.’ Address it right then and there, so you decrease the anxiety at that moment."
• Establish a good rapport with the patient. "You need a good rapport with the patient to get the best evidence collected. If you go in the room and go right to the vaginal swabs, the patient might not tell you there was also contact with the breast," Brown explains. "Anywhere that there has been any type of transfer of any type of body fluids, we swab."
• Tell patients that their account of the rape is essential to conducting a thorough exam. Brown says, "I joke with patients a lot by saying, You’re fortunate because you got the best nurse, but I’m only as good as the information you give me. I know it’s hard to bring up these issues, but I need your help.’"
• Address self-blame and shame of the patient. "Provide a statement of sympathy, such as, I’m sorry that happened to you,’ and dispel myths voiced by the victim," advises Speck. "Assess the assimilation of the trauma both psychologically and socially, then plan for medical evaluation of post-trauma syndromes such as pelvic pain syndrome."
• Word questions so that it doesn’t sound as if the victim is at fault. "Instead of saying, Did you put your mouth on him anywhere?’ ask, Did he make you put your mouth on him anywhere?’ This is a way to give control back to the victim, and can make a big difference," Brown explains.
• Address STDs and pregnancy. Patients should be offered both medication to prevent STDs and emergency contraceptives, recommends Brown. "It’s a patient’s choice; he or she can also have one and not the other," she says. "In our program, all meds are available so the patient doesn’t need to go to the drugstore. That gives you more compliance, but it also provides more confidentiality. This way, she doesn’t have to deal with the pharmacist looking at her and thinking, she must have been raped."
Sexual assault patients should be treated prophylactically for STDs, not tested, Hohenhaus recommends. "What you are testing at this time is the victim. If they are positive at the time of the exam, this may be discovered at court and may be used against her," she says. "By the time a search warrant is obtained for the assailant to be tested, he can have been tested and treated confidentially."
Instead, refer patients to a private doctor or the health department for further testing, Hohenhaus advises. "The CDC still does not recommend HIV prophylaxis for victims of sexual assault unless there is a known infected perpetrator," she notes. "This applies to adult victims."
• Emergency contraception is offered to all patients, and all are tested for pregnancy. "Generally speaking, we offer two tablets of Ovral at the exam with two to be taken 12 hours later," says Hohenhaus. "We also give them something to keep them from vomiting, as we have had women tell us they often can’t keep the second dose down, especially after all of the meds we give for STD prophylaxis."
References
1. Resnick HS, Acierno R, Kilpatrick DG. Health impact of interpersonal violence: Medical and mental health outcomes. Behav Med 1997;23:79-85.
2. Ledray L, Simmelink K. Efficacy of SANE evidence collection: A Minnesota study. J Emerg Nurs 1997;23:75-77.
3. Ledray L. November 1984 dissertation. The impact of rape and the relative efficacy of guide to goals and supportive counseling as treatment models for rape victims.
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