The Silent Victims

Physicians Can Help Detect Unreported Sexual Assaults  

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Cover Story -- October 2004  

By  Ken Ortolon
Senior Editor  

Christine Cramer was getting ready for work one morning in August 1996 when a stranger walked into her Houston home.

"The door had been left unlocked and he just walked in," Ms. Cramer said. "He initially asked for money and then ended up taking something else."

Ms. Cramer was sexually assaulted, but she managed to escape from her attacker. She fled naked to a nearby home, where a neighbor heard her screams and gave her shelter. The neighbor called the police and emergency medical services.

Several months later, the attacker was arrested, convicted, and sent to prison. And, with the help of counseling and a strong network of support from family and friends, Ms. Cramer was able to come to grips with what happened to her. She married three months after the attack and says her husband was "incredibly supportive."

"I like to think of myself as an example of someone who was really able to put my life back together," she said. "Of course, it's changed me, but it hasn't changed who I am, how I think about things."

But Ms. Cramer is not the typical sexual assault survivor. She did not hesitate to report the attack or to seek medical care and counseling. "Those were things to me that I knew should be done," said the 36-year-old sales manager, who now lives in Austin. "I know a lot of women don't react that way."

In fact, most sexual assault victims -- female or male -- never report the crime. Even fewer seek medical care after an attack.

Now, advocates for sexual assault victims here in Texas and in several states across the country are asking physicians to play a greater role in seeing that sexual assault victims get medical care and other services they may need.

Physicians can do that by screening all of their patients for sexual violence and providing referrals for appropriate services.

"With the enormous number of victims, both male and female, physicians are seeing victims, but these victims may never identify themselves to them," said Victoria Camp, director of operations for the Texas Association Against Sexual Assault (TAASA). "You can guarantee every doctor has treated a sexual assault survivor whether he knows it or not."

Confronting the Numbers  

Based on a survey funded by TAASA and the attorney general's office, TAASA estimates that as many as 2 million Texans -- one in five women and one in 20 men -- have been sexually assaulted. The survey of 700 adults aged 18 and older and 400 teenagers between ages 14 and 17 was conducted by The University of Texas School of Social Work and The Texas A&M University Public Policy Research Institute.

The survey also found that the public has a misconception about rape. "We found that if you ask people what they think of when they think of rape, they imagine somebody in a ski mask waiting on the jogging trail or in a shopping mall parking garage," said Chris Lippincott , TAASA's public affairs director. "The reality is a vast majority of sexual assaults are perpetrated by somebody known to the victim. About 80 percent of all sexual assaults are perpetrated by someone whom the victim knows as an acquaintance, a family member, coworker, or other trusted individual.

"Unfortunately, only about 20 percent of all rapes are ever reported to law enforcement," Mr. Lippincott said. "Only about 10 percent of rape survivors tell us they have received medical attention for their assault. People don't think to contact their physician. I think it folds into some of the broader anxieties that rape survivors have about telling anybody what happened to them."

TAASA Executive Director Annette Burrhus -Clay, MA, says a victim who does not report a sexual assault to police or doesn't tell anyone about it likely will not receive the help needed to cope with emotional and other issues after the attack.

"There may be safety concerns depending on who the person is who victimized them," she said. "A good many of these folks may be at risk of continued abuse, especially if you're talking about younger sexual assault victims. It may be happening in the home. Some of these folks may be marital rape victims."

Many victims also may be self-medicating with alcohol or drugs, she says. "They don't want to deal with or can't deal with what's happened to them and so they may have drug or alcohol problems. They may abuse prescription drugs. And there are other kinds of things that we would certainly like to see them get some help with."

Ms. Cramer attended group therapy sessions after she was attacked and says she witnessed firsthand how some victims struggle for years to deal with the emotional impact. "Just from my experience with the women in my group therapy sessions, there were so many women who didn't report it and were still struggling with self-esteem, guilt, and shame," she said.

One woman in the group was still having problems more than 25 years after being attacked. "It really angered me that she was still trying to deal with it, still struggling so much so many years later," Ms. Cramer said.

Asking the Right Questions  

Ms. Burrhus -Clay says physicians are in a unique position to help these victims because of the trust and respect most patients have for their doctor. She says physicians should screen all patients for sexual assault.

But that's not as easy as it sounds.

"The difference between sexual assault and domestic violence and other types of crime victimization is that it frequently takes a rape survivor a good period of time to get to the point of telling someone," Ms. Burrhus -Clay said. "It's not something they're likely to blurt out. The reality is that physicians tend to be rushed. They've got a huge caseload, so the kind of time it may take for them to make someone feel comfortable enough to disclose the abuse may be more time than a lot of them feel like they have." Asking someone point-blank if they have been raped may cause them to shut down, she says.    

There are ways to ask if an assault has occurred. "For instance, if you ask a question like, 'Has anyone ever forced you to have sexual intercourse against your will?' someone may say yes to that, while they would say no if you ask them if they have been raped. This may be especially true in situations of marital rape," Ms. Burrhus -Clay said.

"Getting doctors to ask certain screening questions might take the stigma away from sexual assault so that survivors can reach out to get the kind of help they need. If it's okay for their doctor to bring it up, then maybe it's okay for them to say something."

Gary M. Ackerman, MD, medical director of the Women's Intermediate Care Center at Parkland Hospital in Dallas, which treats about 700 sexual assault victims annually, supports screening. "It may make some other medical diagnoses and problems a bit more evident if they admit it," said Dr. Ackerman, who also is a professor of obstetrics and gynecology at UT Southwestern Medical Center.

The American College of Obstetricians and Gynecologists launched a campaign several years ago to get physicians to screen for family violence, he says.

Texas First Lady Anita Perry, who serves as a spokesperson for TAASA, learned the positive impact a physician can have by asking about sexual assault by watching her father, who was a rural physician.

"I can't tell you how many times I was in a room with him when he would pick up that something else was wrong than why that patient was in there," Ms. Perry said. "Usually he would look at me and I would know to leave the room, and he would ask, 'Now what else is bothering you?' I can't tell you how many times he has helped victims of sexual assault. If a physician would just take a moment and say, 'There's something else bothering you,' I think it would make a world of difference."

SAVE a Life  

In 2001, the Florida Council Against Sexual Violence (FCASV) launched the "Tell Me About It" campaign to train physicians and other health care professionals to screen patients for sexual assault.

"We've had a lot of favorable response from physicians and also from nurses, nurse practitioners, and allied medical professionals who know through their work with female patients that sexual assault is an important part of women's history and has many medical implications," said Debbie Rogers, FCASV program director.

"Screening is important to us and is shown to have a good impact in developing a relationship between patients and medical care providers, which can lead to intervention," she said. "But it's really, in our minds, a vehicle of public awareness. If physicians have in their minds that sexual assault is a part of women's medical life and needs to be addressed in some fashion, and if they're open to recognizing the signs and knowing how to talk to patients about sexual assault, then whether or not they screen per se, we're making an impact."

Part of the "Tell Me About It" campaign teaches health professionals to SAVE, which stands for:

  • S creen all of your patients for sexual violence;
  • A sk direct questions in a nonjudgmental way;
  • V alidate the response; and
  • E valuate, educate, and make referrals.   

The "Tell Me About It" materials include posters and buttons to encourage patients to talk with their health professionals about sexual assault, as well as instructional materials on how to screen for sexual violence and a list of rape crisis centers where patients can seek help. (See "How to Screen Your Patients for Sexual Assault.")

Ms. Rogers says it is hard to measure the true impact the campaign is having on getting sexual assault survivors into counseling or other support services. "But what we can measure and what's excited us the most about the project is that rape crisis centers have built stronger relationships with the medical professionals in their community by being a resource for training, by providing them with these good materials, and by providing follow-up."

Once physicians or other health professionals have identified sexual assault survivors, they need to take several steps, Ms. Rogers says. "One is to use that information to help decode the medical symptoms they're trying to interpret. Understanding a history of sexual assault might help them understand a woman's medical history or the things she might be at risk for. So they can more appropriately treat and understand any of those stress-related syndromes."

A second important step, she says, is making sure the victim's emotions and mental health are supported and to help him or her understand the options, which may include the rape crisis center, other community-based services or support groups, or perhaps private help.

"And then the third step, regardless of what they hear in the screening, is to provide prevention information to all patients to help them know the best ways to keep themselves safe and the best things to do should something happen to them."

Besides Florida, New York also promotes sexual assault screening, and advocacy groups in several other states are adapting the "Tell Me About It" materials.

Physicians interested in obtaining the "Tell Me About It" materials can request them through the FCASV Web site.

Getting SANE  

While screening for sexual assault is important, TAASA also encourages more physicians, especially emergency medicine specialists, to get involved in treating sexual assault victims who show up in the hospital emergency department.

"Physicians are reluctant to do so because, No. 1, they're not familiar with it," said Dr. Ackerman. "There's a completely different way of examining a sexual assault victim than examining anybody else."

Besides meeting a victim's immediate medical needs, physicians must follow proper protocols to ensure the victim gets protection against sexually transmitted diseases and pregnancy, that any injuries are documented in a manner that will hold up in court, and that a chain of custody is maintained for all physical evidence.

Ms. Burrhus -Clay says many physicians also are hesitant to perform sexual assault examinations because they may have to take time away from their practice to appear in court.

Certified sexual assault nurse examiners ( SANEs ) are trained to deal with sexual assault victims, but Texas has only about 200 of them.

"A trained SANE is certainly preferable in our eyes because of the amount of training they go through," Ms. Burrhus -Clay said. "But the reality is that as long as we have many more hospitals than we have certified SANEs , and I don't see that changing in the next several years, we still want to ensure a certain standard or level of care that survivors receive. And right now, lots of doctors are incredibly hesitant to do a rape exam."

Parkland Hospital has one of the oldest sexual assault programs in the nation but does not employ SANEs , Dr. Ackerman says. Instead, all sexual assault exams are performed by residents and faculty members. Dr. Ackerman says Parkland has a close working relationship with local law enforcement agencies, the crime laboratory, and the district attorney's office, which has helped minimize hassles for physicians and cut the amount of time they spend in court.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.  


How to Screen Your Patients for Sexual Assault

The Florida Council Against Sexual Violence offers these tips, which are endorsed by the Texas Association Against Sexual Assault, to help physicians talk to patients about sexual assault:

Screen all of your patients for sexual violence
Any person could be the victim of sexual violence. Make sure you are alone with the patient when asking about violence. Make direct eye contact and listen actively to responses.

Ask direct questions in a nonjudgmental way
Do not use formal, technical, or medical language. Begin by normalizing the topic. For example:

  • "I know we just met and yet I have to ask you personal questions. Let me explain why. My asking you these questions can help us know how to take care of you."
  • "Because I am your doctor we need to have the best sort of partnership. It will help me understand your health if you could answer my questions about your sexual history."
  • "I ask all of my patients this question because it is important to me to know what has gone on and what is going on in their lives."

            Next ask the patient directly:

  • Have you ever been touched sexually against your will or without your consent?
  • Have you ever been forced or pressured to have sex?
  • Do you feel that you have control over your sexual relationships and will be listened to if you say "no" to having sex?

Validate the response
Be sure to document the patient's responses in the medical record. Continue in the following manner:

  • "Thank you for speaking so honestly about a difficult topic."
  • "I'm sure that was hard for you to tell me about. It's very good you told me."
  • "Rape is devastating in many ways. Let's talk about some of the ways you need support."

Evaluate, educate, and make referrals
If the answer to a question about sexual assault is "yes," immediately evaluate the current level of danger, other instances of violence, psychological and physical symptoms, or drug or alcohol use, and mention the disclosure of the sexual violence again during another visit.

If the answer is "no," go ahead and offer education and prevention information and provide follow-up at the next visit.

If the answer is "not sure," evaluate the patient's experience(s), educate the patient about violence and consent, and offer all survivors a referral for someone to talk to, including the local rape crisis hotline.

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