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Helping Victims vs. Retraumatizing Them
By Michelle Gardner
"Grassroots" efforts can prevent rape victims from being
shortchanged in the ER.
Researchers at Johns Hopkins University in Baltimore determined that half of
all U.S. women who are sexually assaulted are not given recommended treatments
to prevent pregnancy or sexually transmitted diseases (STDs). Dr. David Bishai,
who helped lead the study, says this points to a need for emergency rooms to
develop better programs for medical management of sexual assault patients.
Annette Amey, the study's primary author, cites sexual assault as a
relatively rare event in any given emergency room in the country, which leaves
care providers ill-equipped to handle the situation. According to Amey, medical
management of sexual assault victims is largely a grassroots effort where a
community or hospital decides it will develop a specialized program like SAFE
(sexual assault forensic examiner) or SANE (sexual assault nurse examiner).
"Twenty percent of women getting emergency contraception (EC) is
low," states Amey. "It's even low in response to other articles
published by emergency rooms that developed specialized programs, which was
anywhere from 37 percent to 60 percent. We don't know whether the doctor tried
to offer it and it wasn't taken, or it was not offered in the first place. We
realized a number of women wouldn't need emergency contraception because of a
known fertility issue or they were already on a hormonal contraceptive. Even
when you adjust for that, roughly 45 percent of the women could have been
eligible. Still, less than half were recorded as getting EC."
That only 58 percent of patients were being screened for STDs or given drugs
to prevent infection also was surprising. "The tests are very simple and so
is the treatment," says Amey. "We thought maybe they were not recorded
as getting screened vs. being treated because they were receiving prophylactic
or preventive medication without a test. But even when you look at the total,
the numbers receiving treatment without screening didn't account for the
gap."
Advocating Care and Comfort
According to the New Jersey Uniform Crime Report, 1,623 rapes were reported
in 1998. There are 21 counties in the state, yet 19.3 percent of rapes were
reported in Essex County. The emergency department at University Hospital is the
designated county rape care program.
"We see in the vicinity of 300 sexual assaults a year in the county, a
majority of them are in the city of Newark," says Dr. Suzanne Atkin, MD,
New Jersey Medical School emergency department, Newark campus. "My program
is a domestic violence/sexual assault center called Safe & Sound. We do
counseling for domestic violence and sexual assault, and we have SANEs who may
look at other issues in addition to the medical evaluation of the rape victim,
plus they do forensic evidence collection. They treat the patient
prophylactically for STDs and HIV if appropriate, we give them treatment for
Chlamydia and gonorrhea and if the patient agrees, we will give them treatments
for pregnancy."
Atkin was on a state committee with experts from across the state to
determine what would go in to the standard rape kit. "There was a lot of
give and take for things we needed as clinicians, we collaborated with the
forensic people and developed a kit," she says. "It has packets with
test tubes, saline and things you need to collect samples, and a data collection
form with questions you need to ask the rape victim about the assault. There are
diagrams to indicate the location of injuries."
Atkin makes it clear that EC is always offered, whether or not the patient
chooses to take it, just as the rape kit is offered. "Victims are not
required to have forensic evidence collected," she says. "They are not
required to undergo an examination or even go to the emergency room. It varies
based on their personal experience and their perception of how the process may
help or not help them."
The emergency department at University Hospital will do a rape kit up to 72
hours after a sexual assault and save it for as long as it takes for a person to
make a decision to press charges. "In New Jersey, the victim has to seek
medical care, the victim has to allow forensic evidence collection and the
victim has to tell the police she wants to press charges," says Atkin.
"We have fallout every step of the way where there will be victims who go
no further. We try to have SANEs who can walk the victim through that difficult
situation emotionally and physically." The victim also is entitled to an
advocate who acts on behalf of the victim.
"An advocate is someone who provides comfort," shares Atkin.
"She is someone to talk to and who understands the legal process. She can
inform the victim of her legal rights, but is not a law enforcement officer. She
explains the rape exam while they are going through it and she helps the victim
choose for herself what she wants without the pressure of the police officer who
wants the evidence. The advocate is there to make sure the victim's needs are
met physically and emotionally."
The hospital has grant funding for one advocate and a community educator who
goes in to the school system to teach about sexual assault: the issues
surrounding sexual assault, how to say no and how to not put yourself in that
type of position.
"We need more grant funding," says Atkin. "I want to have
somebody here 24 hours a day, seven days a week to counsel, hold hands with and
support a victim. A lot of these programs are supported by volunteers and
volunteers are not easy to find. Women deserve to have a trained SANE who will
take care of them if they are raped. We should be able to have those resources
available when it happens."
A Worldwide Concern
Doctors for Sexual Abuse Care (DSAC) in Auckland, New Zealand, campaigns to
the Ministry of Health and the police its need of specialty services for victims
of sexual assault. DSAC provides training and education to doctors and nurses
who work in the area of sexual assault, but the responsibility of funding and
provision lies with the Ministry of Health and the police.
"All of our teaching and resources are based on internationally
recognized standards of best practice [according to] current international peer
reviewed literature," says Claire Hurst, NZRN and project coordinator for
DSAC. "We are not a research unit, although we audit and review sexual
assault examinations done by DSAC doctors throughout New Zealand to ensure
standards of practice."
According to Hurst, when a victim reports a sexual assault, the police
arrange for a medical examination. "Police policy states they must access a
doctor trained in the medical assessment of sexual assault. A victim support
person ensures the person is fully informed of her options in reporting and the
importance of a full medical examination."
With a focus on the medical management of sexual abuse, education is
important to DSAC. "We regularly organize seminars on the treatment of
survivors of sexual abuse by bringing in highly regarded researchers and
clinicians for one-day seminars," says Hurst. "We provide education to
a wider group of health professionals working in this area."
According to DSAC's 300-page manual addressing forensic medical management,
the responsibility of the doctor can be therapeutic or forensic. Therapeutic is
urgent, comprehensive medical care that includes treatment for physical and
psychological trauma. It includes: recognition and treatment of physical injury;
attention to the emotional trauma to the adult or child and family; its likely
sequelae; provision of appropriate counseling; prevention of pregnancy;
screening for STDs and prophylaxis or treatment when indicated; consideration of
patient safety with appropriate referral to the police; and provision of medical
follow-up to ensure adequate progress.
Forensic entails keeping detailed and exact records made at the time of the
examination; providing expert witness in a court of law when called; and
performing a careful examination to provide corroborative evidence in a claim of
sexual assault. Evidence is sought that may demonstrate: that a sexual assault
has taken place within the period of time claimed; that the victim did not
consent; the identity of the assailant; the parts of the body assaulted; and
where the assault took place.
Improving Community Response
In the 1990s, SANE programs sprang up in communities across the country to
address the inadequacy of the traditional model for sexual assault medical
evidentiary exams. According to the U.S. Justice Department Office for Victims
of Crimes (OVC)'s bulletin1, victims are often retraumatized when
they come to hospital emergency departments for medical care and forensic
evidence collection. Where they exist, SANE programs have made a profound
difference in the quality of care provided to sexual assault victims.
The bulletin highlights seven problems in the medical-legal response to
sexual assault victims.
- Emergency department staff frequently regard the needs of sexual assault
victims as less urgent than other patients because the majority of these victims
do not sustain severe physical injuries.
- Sexual assault victims often endure long waits in busy public areas (4- to
10-hour waits are not uncommon).
- Sexual assault victims often are not allowed to eat, drink or urinate while
they wait for a physician or nurse to conduct the evidentiary exam, to avoid
destroying evidence.
- Physicians or nurses who perform evidentiary exams often have not been
trained in forensic evidence collection procedures or do not perform these
procedures frequently enough to maintain proficiency.
- Some physicians are reluctant to perform evidentiary exams because they know
they might be called from the hospital to testify in court and their
qualifications to conduct the exam might be questioned due to a lack of training
and experience.
- Emergency department staff may not understand sexual assault victimization
and overlook the need to treat victims with sensitivity and respect.
- Emergency department staff may fail to gather and/or document all available
forensic evidence, particularly in nonstranger cases.
With the advent of SANE programs, it became possible for sexual assault
victims to consistently receive prompt and compassionate emergency care from
medical professionals who understand victimization issues. The quality of the
examination is usually improved because an experienced SANE is adept at
identifying physical trauma and psychological needs, ensuring that victims
receive appropriate medical care, knowing what evidence to look for and how to
document injuries and other forensic evidence, and providing necessary
referrals.
The Sexual Assault Resource Service (SARS) Web site at www.sane-sart.com
offers information and technical assistance to individuals and institutions
interested in developing new SANE programs and improving existing ones.
References:
1. Littel, Kristen. Sexual Assault Nurse Examiner (SANE) Programs:
Improving the Community Response to Sexual Assault Victims, for the Office
for Victims of Crime, April 2001.
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