Barbara returned to her apartment at 2 AM, after an evening out with friends. She placed her key in the outside door that led to the foyer of the apartment complex. When she entered, a man approached her from the mailbox area and threatened her with a knife. In an attack that lasted between five and 10 minutes, but seemed like hours, the stranger raped her at knifepoint.

A phone call summoned the police, who took Barbara to a local hospital where she was greeted by a sexual assault nurse examiner. A law enforcement officer and the nurse interviewed her. With the help of a sexual assault advocate, Barbara painstakingly described the nature of the attack. The nurse examiner collected forensic evidence and gave her medications to prevent pregnancy and sexually transmitted diseases. After the exam, when the nurse and the police were gone, Barbara told the sexual assault advocate that she wanted to go to her parents’ home, not to her apartment. Arrangements were made for her to visit her parents. Follow-up counseling was arranged via a rape crisis center. Barbara left with her mother as the day dawned and never returned to her apartment. Barbara also quit her job. In fact, she didn’t return to the town where the attack occurred.

Barbara attended many counseling sessions at a rape crisis center near her parents’ home. She had concerns about her safety. She especially didn’t feel safe when she was alone. She didn’t sleep well. She had no appetite and often felt nauseated. She worried about developing HIV. In time, Barbara took a job near her parents’ home. She continued to live in her childhood bedroom as she started the new job. Nights out with friends became different —  less spontaneous and never in bars or clubs. She rarely dated; when she did, it was with “friends of the family.”

Barbara had follow-up medical appointments as suggested by the sexual assault nurse examiner. She didn’t become pregnant, and she didn’t develop a sexually transmitted disease. Her weight stabilized, and she developed normal sleep patterns about a year after the attack. But her concern for personal safety persists today.

Legal aspects

Rape and sexual assault are legal terms defined by legislation in every state. Rape is legally defined by penetration, sometimes limited to vaginal penetration. Sexual assault is an all-encompassing term that includes sexual activity with or without penetration. Sexual assault, as a wider category of crimes, includes statutory sexual assault.

Laws in all states require healthcare providers to report rape or sexual assault of children. States vary as to mandatory reporting of adult victims. When to report to law enforcement and how to proceed when a victim of these crimes presents to hospital personnel requires consultation with experts on sex crimes. Nurses can find experts via a sexual assault response team, which consists of forensic examiners who collect evidence from the victim’s body and provide nursing care, law enforcement personnel who investigate sex crimes, prosecutors who bring legal action against the offenders, and rape crisis advocates who provide counseling and support.¹

Sexual assault response teams take action in the immediate aftermath of the crime. If the assault occurred within 72 hours to 90 hours of reporting, the entire team will respond to the victim. If a report is delayed, advocacy and law enforcement will respond. Nurses should encourage victims of sex crimes to report to a team. Encouraging reporting allows for evidence collection, law enforcement investigation of the crime, and counseling from an advocacy group. These experts can help the victim with physical, psychological, and legal concerns that arise after sexual assault.

The scope of the crime

U.S. Department of Justice statistics for 2005 show that for persons age 12 and older, 191,670 rapes and sexual assaults were reported to law enforcement.¹ Thirty percent were found to occur between 6 PM and midnight, and four out of 10 assaults occurred in the homes of the victims.¹ Thirty-five percent of all victims of rape or sexual assault who reported the crime to police were between the ages of 12 and 19 years. Thirty-five percent of victims of reported rape or sexual assault were between the ages of 20 and 34.¹

Rape is a devastating crime, and no one actually knows how often it occurs. No valid statistics for rape and sexual assault exist because of underreporting. Many people, unlike Barbara, do not report the crime of rape. And without reporting, evidence is not collected, medications to prevent pregnancy and sexually transmitted diseases are not given, and counseling does not occur. These people do not receive help from a sexual assault nurse, an advocate, or a law enforcement officer. The crime never becomes a statistic in the town in which it occurs, and perpetrators of these crimes do not account for their actions when the crimes are not reported.

The assaulted people are left to their own resources for dealing with the aftereffects of the crime. For many victims, dealing with the aftermath is very difficult and dealing with the assault can creates symptoms that interfere with their daily lives and even the integrity of their health.

Why would a woman fail to report rape?

One Saturday night, Tracey went to a bar near her college with her friends to relax and have fun. She met a stranger, Alex, who bought her drinks and shot pool with her all evening. Alex was handsome, charming, and friendly. Tracey thought that he might be someone she would like to date. At 2 AM as the bar was closing, Alex asked Tracey for a ride home, and she obliged.

Alex lived close to the bar, and the ride to his apartment was short and uneventful. When he invited Tracey into his apartment for a nightcap, she agreed. Once inside, Alex locked the door behind him and demanded that Tracey undress and perform oral sex on him. This was followed by forced penile-vaginal and rectal penetration. Alex threatened Tracey with physical harm if she did not comply. During the assault, he slapped her twice, holding her down on the floor while he penetrated her. When he was done, Alex pulled Tracey from the floor and ordered her to dress and go home.

Tracey arrived home safely despite tears while she drove. She didn’t tell anyone about the assault. Her face, arms, and genitals were sore, but what hurt even more was the anger, the sense of betrayal, and the feelings of shame and of being used.

Tracey went to class the next day, but she had difficulty focusing on her work. She graduated from college two years later and moved to another state. She never dated while in college after the rape. She had difficulty sleeping throughout those last two years. Nightmares woke her often. She also developed an eating disorder —  many foods nauseated her.

She met Steve, whom she married, at her first job after college. Tracey has sexual dysfunction within her marriage. Sex is always uncomfortable for her, and sometimes it’s painful.

Uncertainty about how to respond to an assault is common among women. Barbara’s initial response after the attack was to call the police. Not all women respond that way. Tracey did not report the crime because she felt embarrassed and ashamed. Other women do not report rape because they’re afraid or distrustful of the healthcare and/or legal systems. They fear being “victimized again” by the medical or law enforcement communities. They fear not being believed as they give an account of the attack. In the past, grassroots movements of both rape advocacy groups and sexual assault nurse examiner groups grew out of recognition that victims of sex crimes felt revictimized by law enforcement and the healthcare system.

Women also fear retaliation by the attacker if they “tell.” A common threat used by perpetrators of sex crimes is that the attacker will return and hurt the victim if she reports it.

A recent national crime victimization survey conducted by the Department of Justice revealed that only 38.3% of victims of rape or sexual assault reported the crime to law enforcement; 61.7% of victims did not report to police.²

Symptoms of unreported rape

Every nurse has seen this note on the chart of ambulatory female patients:

“Lost to follow-up.” Documentation might indicate that nurses and other healthcare personnel have made telephone calls and sent letters, but the patients have not responded. We, as nurses, worry about patients who are lost to follow-up. Many of them have serious health-related problems that require treatment — HIV-positive women with no follow-up after abnormal Pap smears, patients with medically complicated pregnancies who do not return for prenatal care, women with suspicious breast masses who fail to go for mammography, and those with infections that remain unresolved.

Some women come reluctantly to the healthcare system. Most nurses have seen notes on women’s charts that state “uncooperative” or “difficult to examine” when describing a pelvic examination. Nurses have worked with women who deliver their babies without the benefit of prenatal care. Who are these women who do not follow-up or conform to usual expectations, and how can we encourage them to stay in the healthcare system?

Some of the women described above are victims of rape or sexual assault. Reluctance to enter or remain in the healthcare system is related to unresolved symptoms associated with the sex crime(s). Understanding the crime and victim’s responses gives nurses useful information about how to reduce the fear associated with the healthcare system and specifically with pelvic examinations and how to assist in labor and delivery after a rape or sexual assault. Understanding these crimes and their effect on victims can help nurses assist survivors of sex crimes no matter when they are detected within the healthcare system. Incorporating information about victim responses to rape and sexual assault helps nurses identify victims, become sensitive to their needs, and make appropriate referrals.

Very little is known about male rape and failure to report. Sexual assault response teams believe that male rape is widely under-reported. Overall violence against females is more likely to be reported to law enforcement than is violence against males.¹

The rape experience

Females are more likely than males to be the victims of rape or sexual assault. Also, eight out of 10 rape/sexual assault victimizations involve a single offender.¹ During a rape or sexual assault, the sexual offender controls the victim and the experience. Gaining control of the victim is the first important component of the crime. The offender can gain control of the victim through the use of weapons and threats. In Barbara’s case, a knife was used to control her. In some cases, a gun is used. In other cases, such as Tracey’s, the perpetrator uses verbal threats and/or physical assault to control the situation. Another common way to gain control is “talking” or “conning” the victim. In these cases, the victim is encouraged to go to a site where there are no witnesses, such as a car, an apartment, or a bedroom. Asking a woman for a “ride home,” as with Tracey, is a common “con.”

The victim probably knows (on some level) the sexual offender. In fact, national interview statistics show that offenders known to the victim commit 70% of reported rapes.² The victim may have known the sexual offender for a short time, for instance, through a chance meeting at a bar or party, or she may have known him for months or years. Unlike stranger rape, this type of perpetrator cons the woman into being alone with him. He often does this with flattery, charm, and wit.

What happens during the attack depends on the fantasy of the offender. Rape is the playing out of a sexual fantasy. Every victim of rape has experienced a method of gaining control, followed by a playing out of the offender’s fantasy. The sexual fantasy may involve the offender’s speaking to the woman as though they were on a date, when cooperation by the victim is important to the fantasy. Another type of offender has little or no conversation during the attack. Some offenders are sadistic and find sexual excitement in inflicting pain. The sex acts themselves also depend on the fantasy of the offender. Some offenders incorporate oral sex or rectal sex into their fantasy, and some do not. Serial rapists repeat the pattern of sex acts and other behaviors involved in the crime. Law enforcement officials profile sexual offenders by examining behavior and the crime scene and by gathering information from or about the victim.³

The victim’s response is often dependent on components of the crime itself, such as how the offender gains control, the crime scene, the sex acts involved, what the offender says, the use of threats, how the offender escapes, and injuries sustained in the assault. The victim stores in her or his memory the sights, sounds, smells, and touches, as well as the pain and fear associated with the assault. Everyday experiences, such as smelling a particular scent noted during the rape or revisiting the assault setting, can remind her or him of the crime and make her or him anxious. If the attack happened in a car or an elevator, the victim may have difficulty entering similar places. Victims remember the sounds experienced during the attack and recall the offender’s voice. They may be sensitive to any contact with the pelvic region, which may remind them of the assault and generate anxiety.³

People who were victims of sexual abuse as children also have memories of the experience, often recalling the sounds and other sensory qualities of the abuse. According to the Department of Justice, one in six children (less than age 12) in the U.S. becomes the victim of a sex crime.¹ Five percent to 10% of those exposed to sex with an adult as a child experienced penetration; the remaining women experienced sexualized behavior that did not involve penetration.⁴ Victimization of a child is repeated by the offender many times. Sex offenders who find young girls or young boys sexually attractive are typically men who gain access to their victims by gaining their confidence. They victimize girls and boys that they know. The girls or boys are relatives, neighbors, or members of a group to which offenders have access. Typically, the girl or boy is gradually persuaded into sexual behavior. The sexual experiences between young girls or boys and offenders vary greatly; there is no one typical sexual encounter. (For more information about child abuse, see CE 185, “Child Abuse,” in the online self-study modules section of www.nurse.com/ce.

Treatment of rape or sexual assault

Each victim processes the psychological trauma associated with rape or sexual assault differently. However, patterns emerge in the responses. After an assault, a victim is alarmed inappropriately. She or he startles easily. She or he develops a traumatic association with the event(s). Visual, auditory, and olfactory stimulation, and/or touching can trigger images of the event and create responses that seem inappropriate to the current situation. Women or men who are raped or sexually assaulted experience symptoms related to the events of the assault itself. Therefore, women or men may respond to any stimuli that bring back memories of the event.

The limbic system in the brain holds traumatic memory. It’s the alarm center and the center for arousal, sleep and rest, sexual response, and attachment. Victims of rape often report difficulties related to these processes. They can’t sleep or they sleep too much; they are hypo- or hypersexual.⁵

Therapy after sexual assault begins with helping the victim to feel safe and strengthening his or her resources. Intervention is required for victims to process the trauma associated with the assault. For that to happen, the sensory, perceptual, and cognitive memory of the event has to be “unlinked” and transferred to past memory. The victim must regain control of her or his responses to stimuli associated with the attack. The psychological and physical toll on the victim is devastating over time if this ability is not achieved.⁵ The trauma will persist for months, years, or forever.

Identify and refer

People who have been raped or sexually assaulted enter the healthcare system through many avenues. Nurses may encounter them in the ED or in obstetric or primary care settings. These patients may be found in pain clinics; in specialty centers for GI, genitourinary (GU), or neurological workups; or in gynecological or urologic settings, as they move from specialty to specialty, seeking a medical diagnosis of their symptoms. Common symptoms of the untreated victim population are physical discomfort, skeletal muscle tension, GI irritability, and GU disturbance.⁶ Victims can come to the system with vague complaints that cannot be linked to medical diagnoses.

Lack of control in a rape or sexual assault creates special needs in victims. Female victims may need to feel in control of a pelvic examination or a vaginal delivery. Any hint of lack of control can trigger an uncooperative, difficult, or anxious response, and they may become lost to follow-up. Giving as much control as possible to these women in clinical situations, within safety guidelines, may greatly increase their comfort level.

An important role for nurses is to identify victims of sexual assault. Asking patients about sexual assault should be a routine question when collecting information about sexual history during a patient assessment. Questions such as “Have you ever had sex that you did not want?” “Have you had sex without your consent?” or “Have you ever been forced to have sex when you didn’t want to?” are good questions. If the person answers positively, refer her or him to a rape crisis center for specialized counseling and follow-up. Other questions might include, “Have you told anyone about your assault?” or “Would you like to discuss this with someone in more detail?”

Never too late to report

People who were raped long before the sexual history is taken can still benefit from referrals for counseling. The effects of this crime can last a lifetime, and appropriate intervention can be successful at any time. The patient can call a rape crisis hotline 24 hours a day. If a patient does not wish to call, and you know or believe that she or he is a victim who is not yet ready to reveal herself or himself as such, talk to her or him about what you have observed. A possible response is: “I know that many people have unwanted sex. In fact, it’s so common that I ask all my patients if this has happened to them. Do you want to talk about any sexual experiences that were against your will?” The person may wish to discuss the assault(s) or she may not. If you believe that a person is a victim who chooses not to reveal, you should indicate caring and concern, be nonjudgmental of the person’s decision, and offer a return visit at a time of her or his choosing.

In an ideal situation, rape or sexual assault is reported within 72 hours to 90 hours of the event, and a sexual assault forensic examiner takes action. Forensic examiners are not only highly skilled in collecting evidence and testifying, but they are frequently successful in encouraging women to report the crime to law enforcement. They treat victims with dignity and respect, empowering them to report the crime and begin the healing process. Immediately after the assault is the best time to report the crime. Following a prompt complaint, health-related concerns are addressed in the immediate aftermath, and follow-up care is initiated. A connection to a rape care advocate is made, and the investigation and legal process begin.

Ten percent of forcible rape cases are unfounded versus 2% of all other index crimes.⁷ Unfounded does not mean that the rape did not occur; it means that the case has been reported, but something impeded the investigation. Common reasons for unfounded sexual assault cases are that the victim or assailant cannot be located, the victim repeatedly changed her or his account of the event, or the victim recants or chooses not to prosecute. However, changing the account may occur because the victim recalls additional data; and victims may recant out of fear of the assailant. Trained examiners, working with advocates and police as part of a sexual assault response team, can begin effective intervention that may reduce the number of unfounded cases of rape and sexual assault.

If the assault occurred at an interval longer than 90 hours, even months or years before, the person should be referred to a rape crisis center, which provides a wide range of services, including court accompaniment and individual and group counseling. The government funds rape crisis centers that employ advocates who counsel and refer for medical follow-up. Rape crisis centers maintain a hotline that can be reached 24 hours a day. Any time a nurse has a question about rape or sexual assault, rape crisis center counselors are appropriate people to call. These advocates are the experts in victim responses to sex crimes.

Nurses can provide an important link between the experts on sexual assault and the victims seen every day in many settings. Identifying victims of sexual assault, no matter when the assault occurred, can make an important difference to many people. Understanding the crime and the response to it can help nurses identify victims of sexual assault. Once identified, referral to sexual assault specialists in the form of a sexual assault response team or a rape crisis center can make a special difference in the lives of victims of rape and sexual assault.