Every 2 minutes, someone in the United States experiences a sexual assault. Sexual assault encompasses a number of acts ranging from inappropriate exposure or touching, to forced viewing of sexual encounters, to penetration. In addition to prevention, it’s important to know who and when to screen for sexual assault, how to screen, and what to do for people who have experienced a sexual assault. This article focuses on screening in the outpatient setting.
Universal screening is essential
Sexual assault crosses all socioeconomic, racial, and cultural boundaries. No one is immune, so it’s essential that nurses screen all patients. If we exclude patients for any reason, for example, we know the patient or the patient doesn’t look like someone we think would have experienced a sexual assault, we will miss the chance to intervene for a number of patients in need.
The American Congress of Obstetricians and Gynecologists (ACOG) and United States Preventative Services Task Force recommend routine screening for sexual abuse and violence during annual examination visits. Additional screenings should be conducted during episodic visits as appropriate. Because adolescents and pregnant women are more vulnerable, screening at each encounter may be warranted. Reasons why sexual assault screening doesn’t occur include lack of time, uncertainty in how to respond to positive findings, and, sometimes, a personal history of assault in one’s own life.
Asking the questions
Questions regarding sexual assault can be difficult for providers to ask and patients to answer. In fact, healthcare providers most often cite their discomfort in obtaining the information as a reason for not screening patients. However, many screening tools can help. The tools include written and computerized questionnaires for patients to complete and assessment questions for healthcare providers to ask.
The ACOG has developed a five question verbal screening tool for use by providers. Additional screening tools in verbal and written or computer-based formats can be accessed at http://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf
To maximize disclosure of sexual assault, use a combination of both written and verbal screening assessments. Carefully examine written screening tools before use to ensure the questions are written at an appropriate reading level for the intended population. Language should be gender neutral and free of heterosexual bias.
A combination of tools can help elicit information, but keep in mind that patients may be reluctant to disclose sexual assault. (See Why patients are reluctant.)
Why patients are reluctant
The comfort level of patients in disclosing a sexual assault varies greatly and is influenced by a number of factors. For example, some patients may be more comfortable in the lack of confrontation or seeming anonymity that a written questionnaire provides. Others may view written disclosure as less safe than verbal disclosure. Written information may be thought of as more easily discoverable, which would present a threat to one’s safety. The threat could be a perceived psychological threat or an actual physical threat. Actual physical threat may occur if the perpetrator has accompanied the patient to the healthcare encounter.
Adolescents, young adults, and partners listed as dependents on a policyholder’s insurance often fear disclosure of the information they share with healthcare providers. Healthcare providers have the responsibility to create a safe environment for patients. One of the ways to ensure this safety is to educate patients about the confidentiality of the patient-provider visit and the information disclosed during that visit.
Be sure to inform patients of reporting laws. All suspected and confirmed sexual assault involving minor patients must be reported to county welfare and local law enforcement agencies. Laws regarding the reporting of sexual assault involving adult patients vary from state to state. All healthcare providers should know the laws affecting the states where they practice.
Preface questions about sexual assault by explaining that there are some questions that all patients are asked to ensure their safety. First, ask about violence in general. The question may be phrased as, “Do you feel safe from violence at home? What about at school or work?”
Then assess for sexual assault by asking, “Has anyone ever forced you to do something sexually that you did not want to do?” The patient may respond by asking what is meant by that question. Be prepared to provide specific examples that are appropriate for the patient’s level of understanding. For example, a patient may not understand if you use the word genitals but will understand if you say the parts of your body that are covered by your underwear.
If a sexual history is a component of the patient visit, this would be the most appropriate place to begin the sexual assault screening. Ask the patient if he or she is sexually active. If the response is yes, then ask if the sex is consensual. Follow that question by asking if he or she has ever had any sexual activity that was not consensual. Be prepared to explain that consensual means not forced in any way. Assess for sexual activity while under the influence of drugs or alcohol. This is not done to convey judgment or imply blame, rather, as a teaching opportunity to explain that a person who is intoxicated is not capable of consenting.
Value of a protocol
If a patient indicates that nonconsensual sex has occurred, assess immediate welfare by asking, “Are you safe now?” If the response is no, the provider must act to provide for the patient’s safety. Developing a practice protocol for your particular setting will expedite care in these situations. As with any practice protocol, there should be allowance for individualization so that patient-specific needs are met.
To ensure the quality of care for sexual assault survivors across the country, the United States Department of Justice’s Office on Violence against Women developed a National Protocol for Sexual Assault Medical Forensic Examinations. The foundational basis of the protocol is twofold: meet the immediate needs of the survivor while providing for potential needs of the legal system. The protocol, which was updated in April 2013 to reflect the most recent scientific evidence in the care of survivors, can be accessed at http://www.justice.gov/ovw/selected-publications. The scope of this document may exceed services provided at individual outpatient settings. However, the comprehensive details of the sexual assault exam and survivors’ rights throughout the process will assist in the provision of anticipatory guidance for patients electing to undergo the exam. They can be helpful for developing protocols for your individual practice settings.
Identification and involvement of local resources are key components in follow-up care for survivors. If your community doesn’t have a sexual assault center, you’ll need to locate the nearest available resources. The Rape Abuse Incest National Network (RAINN) can assist in identifying local crisis centers that are either in or near your community.
Ideally, the development of a practice protocol should involve representation from all providers and staff who will be using it. Once the protocol is developed, plan an education session for everyone in the setting where the protocol will be implemented. Successful implementation depends on eliminating the knowledge and comfort barriers that exist for providers in the care of sexual assault survivors.
Education should cover the components of when to screen, how to screen, and what to do when a patient discloses sexual assault. Include scripts of how to phrase questions and responses and then have providers practice the scripts. Familiarity with potential clinical situations will decrease provider discomfort in initiating these discussions. After the protocol has been developed and implemented, schedule an annual protocol review to ensure continued accuracy and relevancy for your population.
Starting the healing process
Believing and supporting survivors are critical components in the healing process. This process starts with identification through appropriate screening and continues with supportive follow-up care. Ensuring that you and your colleagues have the knowledge and resources to provide these services will allow the healing process for sexual assault survivors to begin.
American College of Obstetricians & Gynecologists. Sexual assault. Committee Opinion 592; April 2014. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Sexual-Assault
American Congress of Obstetricians & Gynecologists. (n.d.) In American Congress of Obstetricians & Gynecologists (Eds.), Screening Tools – Sexual Assault. http://www.ncdsv.org/images/ACOG_ScreeningToolsSexualAssault.pdf
Basile KC, Hertz MF, Back SE. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings:
Version 1. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2007. http://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf
Office on Violence Against Women. In United States Department of Justice (Ed.), National Protocol for Sexual Assault Medical Forensic Examinations; April 2013. http://www.justice.gov/ovw/selected-publications
U.S. Preventive Services Task Force. Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: U.S. Preventive Services Task Force Recommendation Statement; January 2013. AHRQ Publication No. 12-05167-EF-2. http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderfinalrs.htm