A 27-year-old female patient, wearing a short, black skirt and revealing top, tells you she has asthma and a history of migraines. Giggling, she also reports smoking cigarettes and having several drinks last night.
Initially hesitating, now she tells you she was raped. What would your response be?
“If the first person you tell doesn’t respond positively, you might say, ‘The heck with this, I’m not telling anyone else,'” said Karen Carroll, RN, SANE-A, NY-SAFE, associate director of the Bronx Sexual Assault Response Team at North Central Bronx Hospital. “Imagine the courage it takes to tell someone, and they don’t believe you.”
Carroll has been a forensic examiner for 13 years, but also has been a victim herself. She first told a police officer that she had been assaulted and will never forget his positive response.
“The first thing he said was, ‘I’m so sorry this happened to you,'” Carroll said. “I’ll never forget the way he said that. It came out like he was breathing.”Barbara Ruvolo, RN
The Start by Believing Campaign, launched by End Violence Against Women International in early 2011, aims to get people to consider carefully how they would respond if a victim told them they had been raped.
Barbara Ruvolo, RN, BSN, CEN, SANE-A, nurse educator for emergency services and Sexual Assault Nurse Examiner coordinator for SAFE Center at North Shore University Hospital in Manhasset, N.Y., believes there still is a culture where people believe wearing a tight skirt, for example, can put a person at risk for sexual assault. “[The belief is] she asked for it because of the way she is dressed,” Ruvolo said about this common misconception. “It’s an absurd thought.”Sgt. Joanne Archambault
Sgt. Joanne Archambault, a retired San Diego police officer and executive director of EVAWI, plays a 911 tape during training sessions, in which 75% of people do not believe the victim.
“I’m not asking people to believe everything,” Archambault said. “I’m asking for objectivity — not to make a snap judgment.”
Victims may not present themselves in the way you think they should, but you still should do your job. “Because victims … feel judged, rape is one of the most underreported crimes,” said Linda Rinaldi, a prosecuting attorney who provided oversight to the New Jersey State SANE/Sexual Assault Response Team program for five years. “Victims feel it’s their fault and [that] nobody will believe them. Don’t start by thinking they are lying.”Linda Rinaldi
The Start by Believing Campaign website states if a rapist isn’t convicted, it could result in five more rapes. “Studies have shown rapists rape six to seven times before they get caught,” Rinaldi said. “I’m sure it’s pretty close to that — especially for cases where the victim and assailant know each other.”
If a victim even gets the slightest perception of distrust, they may not follow through with reporting the crime. After all, to prosecute the rapist, they would have to tell their story to several people and undergo a thorough evidentiary examination.
“I may have an opinion,” Ruvolo said in regard to believing the victim, “but I never express that to the patient.”
Eileen Allen, RN, MSN, FN-CSA, SANE-A, SANE-P, president of the International Association of Forensic Nurses and SANE/SART program coordinator in Monmouth County, N.J., is a supporter of the Start by Believing campaign. “Victims have a tremendous concern about people believing them,” Allen said. “It’s ingrained in our culture to blame rape victims unless they can show some ‘proof,’ such as a physical injury. Most victims don’t sustain injuries that require medical attention.”
Nurses may be confided in or involved in caring for a patient who has been a victim of sexual violence. Their response should include giving the respect every patient deserves.
“Some nurses may be afraid to say the wrong thing,” Carroll said. “So they choose not to say anything.”Eileen Allen, RN
Acknowledge the victim’s concerns and stay impartial. It is alright to say things such as “It took a lot of courage to tell someone;” “Thank you for trusting me to tell me;” “I’m so sorry this happened to you;” “You are safe now;” “We are here to help you;” and “This is not your fault.”
Outside of knowing the policies and procedures of the facility, nurses should be familiar with resources available to victims and their families in their communities, such as domestic violence coalitions, victim assistance programs and sexual assault crisis centers.
Nurses, especially in the ED, also should know the basic principles of forensic nursing, especially the importance of preserving evidence.
“Prior to a formal forensic/medical exam, [nurses] should leave clothing intact whenever possible, but if removed, clothing should be placed in a paper bag and labeled,” Allen said. “If there are wounds that must be treated, grab a camera and take a photo before the wound is treated or dressed. That can be helpful.”
If a facility does not have a protocol that includes access to a forensic nurse, be sure to provide an evidentiary medical examination and address sexually transmitted diseases and pregnancy concerns. Let the victim be your guide.
“Listen to where [the patient says] contact was made to the body,” Carroll said. “You will know where to examine and where to look for evidence.”
Document the examination and findings thoroughly, but do not document your personal opinion in the medical record.
“Treat the disclosure they are making as factual just like any other disclosure a patient makes as part of providing their history and reasons for seeking care,” Allen said. “Don’t show any change in the level of credibility.”