Original Article
A Comparative Analysis of Victims of Sexual Assault With and Without Mental Health Histories: Acute and Follow-up Care Characteristics Rebecca Brown, BSc1, Janice Du Mont, EdD2,3, Sheila Macdonald, RN, MN4,5,6, and Deidre Bainbridge, NP-PHC, BScN4,5
ABSTRACT Sexual assault is a common and serious health issue that is underreported and has low follow-up rates. The myriad of psychological sequelae of sexual assault are well documented; however, there is a dearth of literature on the prevalence of preexisting mental health issues in survivors of sexual assault. This exploratory study compares victims seen at a sexual assault treatment center with and without preexisting self-reported mental health histories. The rates of preexisting mental illness in sexual assault victims are significant. Implications for clinical practice and research are discussed. KEY WORDS: follow-up; mental health; rape; sexual assault
T
he World Health Organization (WHO, 2002) World Report on Violence and Health recognizes interpersonal violence, which includes sexual violence, as a highly prevalent and important global health and human rights issue; interpersonal violence is responsible for 30% of the 700,000 deaths due to violence worldwide (WHO, 2002). Although most victims of sexual assault survive, as compared to some other forms of violence, the negative psychological sequelae of rape include, but are not limited to, suicide ideation/attempts (Kilpatrick et al., 1985), major depressive episodes, substance abuse, and post-traumatic
Author Affiliations: 1Faculty of Medicine, University of Toronto, 2 Women’s College Research Institute, Women's College Hospital, 3 Dalla Lana School of Public Health at the University of Toronto, 4 Sexual Assault/Domestic Violence Care Centre at Women’s College Hospital, 5Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto, and 6Sexual Assault/Domestic Violence Treatment Centres in Ontario. The authors declares no conflict of interest. Correspondence: Rebecca Brown, BSc, Faculty of Medicine, University of Toronto, 790 Bay Street, Toronto, Ontario M5G1N6 Canada; E-mail: [email protected]. Received August 18, 2012; accepted for publication November 28, 2012. Copyright © 2013 International Association of Forensic Nurses DOI: 10.1097/JFN.0b013e31828106df
76
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stress disorder (PTSD; Hanson et al., 2008; Kilpatrick, Edmunds, & Seymour, 1992; Kilpatrick et al., 2003). Furthermore, the WHO estimates that rape and domestic violence account for 5%–16% of healthy years of life lost in women of reproductive age (Kilpatrick et al., 1992). Lifetime prevalence for sexual assault in North American adult women has been reported to be between 12% and 18% (Elwood et al., 2011; McCall Hosenfeld, Freund, & Liebschutz, 2009), although these figures are likely conservative due to underreporting. Despite the potential severity of the psychological and physical impact on victims, reporting rates remain low (Ackerman, Sugar, Fine, & Eckert, 2006), as exemplified by the International Violence Against Women Survey, which found that less than one third of women reported their assault to the police (The European Institute for Crime Prevention and Control [HEUNI], 2008). Similarly, studies have shown that follow-up care rates for victims of sexual assault are as low as 26%–35.5% (Ackerman et al., 2006; Holmes, Resnick, & Frampton, 1998). The relationship between mental health and sexual assault is both considerable and complex. Epidemiological and hospital-based studies have consistently associated certain demographic characteristics with sexual assault. These include gender (female; Avegno, Mills, & Mills, Volume 9 • Number 2 • April-June 2013
Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article 2009; Ingemann-Hansen, Sabroe, Brink, Knudsen, & Charles, 2009; Kilpatrick et al., 1992), age (young adults; Avegno et al., 2009; Du Mont & McGregor, 2004; Elwood et al., 2011), previous victimization (Acierno, Resnick, Kilpatrick, Saunders, & Best, 1999; Elwood et al., 2011), and an active diagnosis of PTSD (Acierno et al., 1999). A positive association has been reported between lifetime prevalence of gender-based violence and other mental health disorders, such as anxiety disorders, mood disorders, and substance use (Rees et al., 2011). A review article describing the effects of trauma on women with serious mental illnesses points also to a positive association with HIV-related risk behaviors, substance abuse, homelessness, and an increase in psychiatric symptoms (Goodman, Rosenberg, Mueser, & Drake, 1997). Although the mental health impacts of sexual assault are well documented, little is known about preexisting mental health problems in victims of sexual assault. The relationship between background mental health history, trauma exposure, and subsequent mental health sequelae were investigated in a study of 977 primary care patients interviewed using the Mood Disorders Questionnaire, the PTSD Checklist-Civilian Version, and the Medical Outcomes Study 12-Item Short Form Survey (Neria et al., 2008). It was found that patients with a background history of bipolar disorder (n = 92) were 2.6 times more likely to report a history of physical or sexual assault and 2.9 times more likely to have comorbid active PTSD. A recent study from a sexual assault referral center in England reported a background prevalence of psychiatric history of 20% (Campbell, Keegan, Cybulska, & Forster, 2007). However, this study did not examine how this subpopulation might differ from other victims of sexual assault. As well, more health-related data from sexual assault care centers is needed to shed light on other important characteristics of this subpopulation. In general, there appears to be a dearth of specific guidelines for acute and follow-up care of victims with preexisting mental health issues. This exploratory retrospective study uses the Sexual Assault/Domestic Violence Care Centre (SA/DVCC) client database at Women’s College Hospital (WCH) in the province of Ontario, Canada, for two main purposes: (a) to characterize the victims of sexual assault seen at a hospital-based center by a sexual assault nurse examiner (SANE) and (b) to compare the following characteristics of sexual assault victims with and without preexisting self-reported mental health issues: client demographics, health history, criminal justice reporting characteristics, sexual assault characteristics, acute care characteristics, and on-site follow-up care characteristics.
▪
Method
Ethics approval for this study was obtained from the WCH Research Ethics Board in December 2011. Journal of Forensic Nursing
Setting The SA/DVCC is located at WCH, and emergency service is available 24 hours a day, 7 days a week through the Urgent Care Centre. The SA/DVCC also provides on-site medical follow-up and counseling by appointment for continuity of care. Services are offered to women, men, transgender, and intersex victims of sexual assault and/or intimate partner abuse, for clients 14 years of age and older. Clients are initially triaged by the Urgent Care Centre staff, and the SANE is contacted. Emergency care includes crisis intervention and support, physical examination, and medical history taking including documentation of any preexisting physical or mental illnesses, documentation of injuries, provision of emergency contraception, prophylactic treatment for sexually transmitted infections (STIs) including HIV and hepatitis B, drug testing for suspected drug-facilitated sexual assault, safety planning, and referral to another agency where appropriate. In Ontario, victims can choose whether or not to report sexual assault to police. For patients who report to police, the Sexual Assault Evidence Kit (SAEK) is often completed. If the person is undecided about reporting to police, the SAEK can be frozen and stored at the hospital for a limited time (3 months) while the person decides what to do. An anonymous Third Party Report can also be completed and forwarded to the police. At the completion of the emergency visit, the SANE informs the client of on-site follow-up services and arranges an appointment and/or a follow-up phone call. The follow-up telephone call is made by a SANE within 1–3 days to all consenting clients in order to enquire about their coping, needs, resources, supports, the status of any police investigation, medication tolerance and adherence, and to arrange a follow-up appointment if one has not already been made. Reminder calls are made to patients 24 hours prior to their follow-up appointment. For the client who comes to the follow-up clinic, care may include examination and injury redocumentation; supportive counseling; HIV postexposure prophylaxis monitoring and side effect management; STI, HIV, hepatitis B and C, and pregnancy testing; and referral to individual and group counseling. On-site counseling services are available on a short-term basis for up to 20 sessions.
Study Population The target population for this study was persons seen at the SA/DVCC who had been sexually assaulted. Inclusion criteria were clients who were entered in the SA/DVCC database, who were seen at WCH between January 2010 and June 2011, and who reported having been sexually assaulted. This sample included 479 individuals, 12 of whom had presented for sexual assault during the study period more than once; in these cases, only the first assault was collected for statistical purposes, giving a final study population of 467 individuals. Within this target population, the www.journalforensicnursing.com
Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
77
Original Article study focused on two subgroups for comparison: persons with and without a preexisting history of mental illness.
Database The SA/DVCC database is a standardized electronic documentation tool. Information from the patient health record generated during the emergency service visit is entered into the database by the SANE subsequent to the visit. All follow-up care is entered directly into the database and is used to create the nursing documentation for that visit, which is then added to the patient health record. Data were extracted from the SA/DVCC database across six domains: (1) Client demographics, (2) Health history, (3) Criminal justice reporting characteristics, (4) Sexual assault characteristics, (5) Acute care characteristics, and (6) On-site follow-up care characteristics.
Variables Self-reported mental health history was extracted from the “Medical History” section of the electronic form and was collected as a dichotomous yes/no variable; the types of mental health issues reported in the Medical History section were also collected as string variables (e.g., depression, generalized anxiety disorder). Other variables across the six domains extracted from the database and coded for analysis were (1) Client demographics (age and gender), (2) Health history (prescription medication use, type of prescription medication(s) used, pregnancy prior to assault, birth control use), (3) Criminal justice reporting characteristics (completion of the SAEK and police reporting), (4) Sexual assault characteristics (vaginal, oral, and anal penetration; drug-facilitated sexual assault), (5) Acute care characteristics (any medical interventions administered [prophylactic antibiotics, emergency contraception, HIV postexposure prophylaxis, hepatitis B immunization]), and (6) Follow-up care characteristics (client gave telephone number, counseling referrals, completion of a follow-up phone call, completion of a follow-up visit, HIV-related follow-up including testing and prophylaxis).
Data Analysis The statistical package for Social Sciences (SPSS) was used to analyze the data. Discrete nominal scales were used to encode the categorical data. Continuous data were collected as such and converted to categorical data using intervals as needed for analysis. Means and standard deviations were calculated for continuous variables, and frequency counts and proportions were generated for categorical variables. Bivariate analyses using chi-square and Fisher’s exact tests when appropriate were used to compare those with selfreported mental health histories to other sexual assault victims and generate p values. Results with a p value of less than 0.05 were reported as statistically significant. 78
www.journalforensicnursing.com
▪
Results Description of the Whole Study Population
Between the months of January 2010 to June 2011, 467 individuals presented to the SA/DVCC following a sexual assault. Their ages ranged from 16 to 80 years old; 205 (43.9%) were young adults (16–24 years old) and 255 (54.6%) were older adults (>24 years old). Almost all the victims were female (n = 440, 94.2%); 21 (4.5%) were male and 6 (1.3%) were identified as transgender. Of the women and those who were identified as transgender (female-to-male), 10 (2.1%) were pregnant at the time of assault and 45 (9.6%) were on a form of hormonal birth control, such as an oral contraceptive pill or had an intrauterine device. Eight (1.7%) individuals were identified as having an intellectual disability. Three (0.6%) of the victims were HIV positive. Psychiatric medications (including antidepressants, antipsychotics, antiobsessionals, hypnotic/sedatives, and mood stabilizers) accounted for the most sizeable (41.5%) category of the prescription medications used prior to presenting for sexual assault care. Fewer victims were taking reproductive/ sexual health medications, such as hormonal contraception, antiandrogens, and estrogen replacement therapy (10.7%); respiratory/allergy medications, including COPD/asthma therapy and antihistamines (10.1%); analgesics/anti-inflammatory medications (9.5%); neurological medications, including antiepileptics, anticonvulsants, antispasmodics, central nervous system stimulants, anticholinergics, antiparkinsonians, and migraine therapies (9.1%); endocrine/metabolic medications, including thyroid hormone, hypoglycemic agents and bone metabolism regulators (5.9%); gastrointestinal medications, including antiemetics, laxatives, stool softeners, H2 receptor blockers, and proton pump inhibitors (4.0%); cardiovascular medications, including antihypertensives, cholesterol-lowering agents, calcium channel blockers, diuretics, angiotensin receptor blockers, and antianginals (3.4%); and medications for infectious causes, including antibiotics, antiretrovirals, HIV protease inhibitors, antifungals, and antivirals (3.4%). Finally, 2.7% of victims were taking medications that were classified as other, including acne therapy, smoking cessation aids, medical marijuana, and antileukemics. One third (n = 154, 33.0%) of victims completed a SAEK, and 213 (45.6%) involved police. Most gave a telephone number (n = 420, 89.9%); however, fewer indicated that the SANE could leave a message (n = 322, 69.0%), and in fewer cases still, the SANE able to complete a follow-up call (n = 299, 64.0%). Only half (n = 233, 49.9%) of victims came in for at least one follow-up visit.
Description of the Subpopulation With Positive Mental Health Histories A total of 158 (33.8%) of the 467 victims of sexual assault reported at least one preexisting mental health Volume 9 • Number 2 • April-June 2013
Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
FIGURE 1. Frequency of different types of preexisting mental health problems.
issue. Figure 1 depicts the breakdown of mental health issues present in the population into six major categories: The largest category was anxiety (n = 61, 13.1% of study population), followed by depression (n = 59, 12.6% study population), then bipolar spectrum disorders (n = 33, 7.1% study population), substance abuse and addiction problems (n = 24, 5.1% study population), the psychotic spectrum disorders (n = 20, 4.3% study population), self-harm/suicidal ideation (n = 11, 2.4% study population), eating disorders (n = 10, 2.1% of study population), and finally other mental health issues (n = 8, 1.7% study population), wherein “other” was comprised of borderline personality disorder and dissociative identity disorder.
Comparison of Persons With Mental Health Histories to Other Victims of Sexual Assault Table 1 shows the results of the bivariate analyses across sociodemographic characteristics. Victims with mental health histories were significantly less likely than other
TABLE 1. Sociodemographic Characteristics of Sexual Assault Victims No mental Mental health health history, n (%) p history, n (%) Gender Female
148 (93.7)
292 (94.5)
Male
7 (4.4)
14 (4.5)
Transgender
3 (1.9)
3 (1.0)
56 (35.9)
149 (49.0)
100 (64.1)
155 (51.0)
0.701
Age (years) 16–24 25 *p < 0.05.
Journal of Forensic Nursing
0.007*
sexual assault victims to be young adults (w2 [1, n = 460] = 7.17, p = 0.007). Health history characteristics are shown in Table 2. Victims reporting mental health histories were significantly more likely than other victims to be taking prescription medications in general (w2 [1, n = 467] = 89.88, p < 0.001) and, in particular, to be using psychiatric medications (w2 [1, n = 467] = 201.77, p < 0.001). As seen in Table 3, for criminal justice reporting characteristics, there were no significant differences found in completion of a SAEK or police reporting. As reported in Table 4, significant differences were found across sexual assault characteristics. Compared with other sexual assault victims, those with mental health histories were more likely to be vaginally penetrated (w2 [2, n = 428] = 7.13, p = 0.028), orally penetrated (w2 [2, n = 449] = 12.51, p = 0.002), and anally penetrated (w2 [2, n = 449] = 9.41, p = 0.009). In contrast, they were less likely to have
TABLE 2. Health History of Sexual Assault Victims No mental Mental health health history, n (%) p history, n (%) Pregnant before assault
4 (2.6)
6 (2.0)
0.678
Using birth controla
14 (9.3)
31 (10.5)
0.681
Taking prescription medication
116 (73.4)
85 (27.5)
A Comparative Analysis of Victims of Sexual Assault With and Without Mental Health Histories: Acute and Follow-up Care Characteristics Rebecca Brown, BSc1, Janice Du Mont, EdD2,3, Sheila Macdonald, RN, MN4,5,6, and Deidre Bainbridge, NP-PHC, BScN4,5
ABSTRACT Sexual assault is a common and serious health issue that is underreported and has low follow-up rates. The myriad of psychological sequelae of sexual assault are well documented; however, there is a dearth of literature on the prevalence of preexisting mental health issues in survivors of sexual assault. This exploratory study compares victims seen at a sexual assault treatment center with and without preexisting self-reported mental health histories. The rates of preexisting mental illness in sexual assault victims are significant. Implications for clinical practice and research are discussed. KEY WORDS: follow-up; mental health; rape; sexual assault
T
he World Health Organization (WHO, 2002) World Report on Violence and Health recognizes interpersonal violence, which includes sexual violence, as a highly prevalent and important global health and human rights issue; interpersonal violence is responsible for 30% of the 700,000 deaths due to violence worldwide (WHO, 2002). Although most victims of sexual assault survive, as compared to some other forms of violence, the negative psychological sequelae of rape include, but are not limited to, suicide ideation/attempts (Kilpatrick et al., 1985), major depressive episodes, substance abuse, and post-traumatic
Author Affiliations: 1Faculty of Medicine, University of Toronto, 2 Women’s College Research Institute, Women's College Hospital, 3 Dalla Lana School of Public Health at the University of Toronto, 4 Sexual Assault/Domestic Violence Care Centre at Women’s College Hospital, 5Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto, and 6Sexual Assault/Domestic Violence Treatment Centres in Ontario. The authors declares no conflict of interest. Correspondence: Rebecca Brown, BSc, Faculty of Medicine, University of Toronto, 790 Bay Street, Toronto, Ontario M5G1N6 Canada; E-mail: [email protected]. Received August 18, 2012; accepted for publication November 28, 2012. Copyright © 2013 International Association of Forensic Nurses DOI: 10.1097/JFN.0b013e31828106df
76
www.journalforensicnursing.com
stress disorder (PTSD; Hanson et al., 2008; Kilpatrick, Edmunds, & Seymour, 1992; Kilpatrick et al., 2003). Furthermore, the WHO estimates that rape and domestic violence account for 5%–16% of healthy years of life lost in women of reproductive age (Kilpatrick et al., 1992). Lifetime prevalence for sexual assault in North American adult women has been reported to be between 12% and 18% (Elwood et al., 2011; McCall Hosenfeld, Freund, & Liebschutz, 2009), although these figures are likely conservative due to underreporting. Despite the potential severity of the psychological and physical impact on victims, reporting rates remain low (Ackerman, Sugar, Fine, & Eckert, 2006), as exemplified by the International Violence Against Women Survey, which found that less than one third of women reported their assault to the police (The European Institute for Crime Prevention and Control [HEUNI], 2008). Similarly, studies have shown that follow-up care rates for victims of sexual assault are as low as 26%–35.5% (Ackerman et al., 2006; Holmes, Resnick, & Frampton, 1998). The relationship between mental health and sexual assault is both considerable and complex. Epidemiological and hospital-based studies have consistently associated certain demographic characteristics with sexual assault. These include gender (female; Avegno, Mills, & Mills, Volume 9 • Number 2 • April-June 2013
Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article 2009; Ingemann-Hansen, Sabroe, Brink, Knudsen, & Charles, 2009; Kilpatrick et al., 1992), age (young adults; Avegno et al., 2009; Du Mont & McGregor, 2004; Elwood et al., 2011), previous victimization (Acierno, Resnick, Kilpatrick, Saunders, & Best, 1999; Elwood et al., 2011), and an active diagnosis of PTSD (Acierno et al., 1999). A positive association has been reported between lifetime prevalence of gender-based violence and other mental health disorders, such as anxiety disorders, mood disorders, and substance use (Rees et al., 2011). A review article describing the effects of trauma on women with serious mental illnesses points also to a positive association with HIV-related risk behaviors, substance abuse, homelessness, and an increase in psychiatric symptoms (Goodman, Rosenberg, Mueser, & Drake, 1997). Although the mental health impacts of sexual assault are well documented, little is known about preexisting mental health problems in victims of sexual assault. The relationship between background mental health history, trauma exposure, and subsequent mental health sequelae were investigated in a study of 977 primary care patients interviewed using the Mood Disorders Questionnaire, the PTSD Checklist-Civilian Version, and the Medical Outcomes Study 12-Item Short Form Survey (Neria et al., 2008). It was found that patients with a background history of bipolar disorder (n = 92) were 2.6 times more likely to report a history of physical or sexual assault and 2.9 times more likely to have comorbid active PTSD. A recent study from a sexual assault referral center in England reported a background prevalence of psychiatric history of 20% (Campbell, Keegan, Cybulska, & Forster, 2007). However, this study did not examine how this subpopulation might differ from other victims of sexual assault. As well, more health-related data from sexual assault care centers is needed to shed light on other important characteristics of this subpopulation. In general, there appears to be a dearth of specific guidelines for acute and follow-up care of victims with preexisting mental health issues. This exploratory retrospective study uses the Sexual Assault/Domestic Violence Care Centre (SA/DVCC) client database at Women’s College Hospital (WCH) in the province of Ontario, Canada, for two main purposes: (a) to characterize the victims of sexual assault seen at a hospital-based center by a sexual assault nurse examiner (SANE) and (b) to compare the following characteristics of sexual assault victims with and without preexisting self-reported mental health issues: client demographics, health history, criminal justice reporting characteristics, sexual assault characteristics, acute care characteristics, and on-site follow-up care characteristics.
▪
Method
Ethics approval for this study was obtained from the WCH Research Ethics Board in December 2011. Journal of Forensic Nursing
Setting The SA/DVCC is located at WCH, and emergency service is available 24 hours a day, 7 days a week through the Urgent Care Centre. The SA/DVCC also provides on-site medical follow-up and counseling by appointment for continuity of care. Services are offered to women, men, transgender, and intersex victims of sexual assault and/or intimate partner abuse, for clients 14 years of age and older. Clients are initially triaged by the Urgent Care Centre staff, and the SANE is contacted. Emergency care includes crisis intervention and support, physical examination, and medical history taking including documentation of any preexisting physical or mental illnesses, documentation of injuries, provision of emergency contraception, prophylactic treatment for sexually transmitted infections (STIs) including HIV and hepatitis B, drug testing for suspected drug-facilitated sexual assault, safety planning, and referral to another agency where appropriate. In Ontario, victims can choose whether or not to report sexual assault to police. For patients who report to police, the Sexual Assault Evidence Kit (SAEK) is often completed. If the person is undecided about reporting to police, the SAEK can be frozen and stored at the hospital for a limited time (3 months) while the person decides what to do. An anonymous Third Party Report can also be completed and forwarded to the police. At the completion of the emergency visit, the SANE informs the client of on-site follow-up services and arranges an appointment and/or a follow-up phone call. The follow-up telephone call is made by a SANE within 1–3 days to all consenting clients in order to enquire about their coping, needs, resources, supports, the status of any police investigation, medication tolerance and adherence, and to arrange a follow-up appointment if one has not already been made. Reminder calls are made to patients 24 hours prior to their follow-up appointment. For the client who comes to the follow-up clinic, care may include examination and injury redocumentation; supportive counseling; HIV postexposure prophylaxis monitoring and side effect management; STI, HIV, hepatitis B and C, and pregnancy testing; and referral to individual and group counseling. On-site counseling services are available on a short-term basis for up to 20 sessions.
Study Population The target population for this study was persons seen at the SA/DVCC who had been sexually assaulted. Inclusion criteria were clients who were entered in the SA/DVCC database, who were seen at WCH between January 2010 and June 2011, and who reported having been sexually assaulted. This sample included 479 individuals, 12 of whom had presented for sexual assault during the study period more than once; in these cases, only the first assault was collected for statistical purposes, giving a final study population of 467 individuals. Within this target population, the www.journalforensicnursing.com
Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
77
Original Article study focused on two subgroups for comparison: persons with and without a preexisting history of mental illness.
Database The SA/DVCC database is a standardized electronic documentation tool. Information from the patient health record generated during the emergency service visit is entered into the database by the SANE subsequent to the visit. All follow-up care is entered directly into the database and is used to create the nursing documentation for that visit, which is then added to the patient health record. Data were extracted from the SA/DVCC database across six domains: (1) Client demographics, (2) Health history, (3) Criminal justice reporting characteristics, (4) Sexual assault characteristics, (5) Acute care characteristics, and (6) On-site follow-up care characteristics.
Variables Self-reported mental health history was extracted from the “Medical History” section of the electronic form and was collected as a dichotomous yes/no variable; the types of mental health issues reported in the Medical History section were also collected as string variables (e.g., depression, generalized anxiety disorder). Other variables across the six domains extracted from the database and coded for analysis were (1) Client demographics (age and gender), (2) Health history (prescription medication use, type of prescription medication(s) used, pregnancy prior to assault, birth control use), (3) Criminal justice reporting characteristics (completion of the SAEK and police reporting), (4) Sexual assault characteristics (vaginal, oral, and anal penetration; drug-facilitated sexual assault), (5) Acute care characteristics (any medical interventions administered [prophylactic antibiotics, emergency contraception, HIV postexposure prophylaxis, hepatitis B immunization]), and (6) Follow-up care characteristics (client gave telephone number, counseling referrals, completion of a follow-up phone call, completion of a follow-up visit, HIV-related follow-up including testing and prophylaxis).
Data Analysis The statistical package for Social Sciences (SPSS) was used to analyze the data. Discrete nominal scales were used to encode the categorical data. Continuous data were collected as such and converted to categorical data using intervals as needed for analysis. Means and standard deviations were calculated for continuous variables, and frequency counts and proportions were generated for categorical variables. Bivariate analyses using chi-square and Fisher’s exact tests when appropriate were used to compare those with selfreported mental health histories to other sexual assault victims and generate p values. Results with a p value of less than 0.05 were reported as statistically significant. 78
www.journalforensicnursing.com
▪
Results Description of the Whole Study Population
Between the months of January 2010 to June 2011, 467 individuals presented to the SA/DVCC following a sexual assault. Their ages ranged from 16 to 80 years old; 205 (43.9%) were young adults (16–24 years old) and 255 (54.6%) were older adults (>24 years old). Almost all the victims were female (n = 440, 94.2%); 21 (4.5%) were male and 6 (1.3%) were identified as transgender. Of the women and those who were identified as transgender (female-to-male), 10 (2.1%) were pregnant at the time of assault and 45 (9.6%) were on a form of hormonal birth control, such as an oral contraceptive pill or had an intrauterine device. Eight (1.7%) individuals were identified as having an intellectual disability. Three (0.6%) of the victims were HIV positive. Psychiatric medications (including antidepressants, antipsychotics, antiobsessionals, hypnotic/sedatives, and mood stabilizers) accounted for the most sizeable (41.5%) category of the prescription medications used prior to presenting for sexual assault care. Fewer victims were taking reproductive/ sexual health medications, such as hormonal contraception, antiandrogens, and estrogen replacement therapy (10.7%); respiratory/allergy medications, including COPD/asthma therapy and antihistamines (10.1%); analgesics/anti-inflammatory medications (9.5%); neurological medications, including antiepileptics, anticonvulsants, antispasmodics, central nervous system stimulants, anticholinergics, antiparkinsonians, and migraine therapies (9.1%); endocrine/metabolic medications, including thyroid hormone, hypoglycemic agents and bone metabolism regulators (5.9%); gastrointestinal medications, including antiemetics, laxatives, stool softeners, H2 receptor blockers, and proton pump inhibitors (4.0%); cardiovascular medications, including antihypertensives, cholesterol-lowering agents, calcium channel blockers, diuretics, angiotensin receptor blockers, and antianginals (3.4%); and medications for infectious causes, including antibiotics, antiretrovirals, HIV protease inhibitors, antifungals, and antivirals (3.4%). Finally, 2.7% of victims were taking medications that were classified as other, including acne therapy, smoking cessation aids, medical marijuana, and antileukemics. One third (n = 154, 33.0%) of victims completed a SAEK, and 213 (45.6%) involved police. Most gave a telephone number (n = 420, 89.9%); however, fewer indicated that the SANE could leave a message (n = 322, 69.0%), and in fewer cases still, the SANE able to complete a follow-up call (n = 299, 64.0%). Only half (n = 233, 49.9%) of victims came in for at least one follow-up visit.
Description of the Subpopulation With Positive Mental Health Histories A total of 158 (33.8%) of the 467 victims of sexual assault reported at least one preexisting mental health Volume 9 • Number 2 • April-June 2013
Copyright © 2013 International Association of Forensic Nurses. Unauthorized reproduction of this article is prohibited.
Original Article
FIGURE 1. Frequency of different types of preexisting mental health problems.
issue. Figure 1 depicts the breakdown of mental health issues present in the population into six major categories: The largest category was anxiety (n = 61, 13.1% of study population), followed by depression (n = 59, 12.6% study population), then bipolar spectrum disorders (n = 33, 7.1% study population), substance abuse and addiction problems (n = 24, 5.1% study population), the psychotic spectrum disorders (n = 20, 4.3% study population), self-harm/suicidal ideation (n = 11, 2.4% study population), eating disorders (n = 10, 2.1% of study population), and finally other mental health issues (n = 8, 1.7% study population), wherein “other” was comprised of borderline personality disorder and dissociative identity disorder.
Comparison of Persons With Mental Health Histories to Other Victims of Sexual Assault Table 1 shows the results of the bivariate analyses across sociodemographic characteristics. Victims with mental health histories were significantly less likely than other
TABLE 1. Sociodemographic Characteristics of Sexual Assault Victims No mental Mental health health history, n (%) p history, n (%) Gender Female
148 (93.7)
292 (94.5)
Male
7 (4.4)
14 (4.5)
Transgender
3 (1.9)
3 (1.0)
56 (35.9)
149 (49.0)
100 (64.1)
155 (51.0)
0.701
Age (years) 16–24 25 *p < 0.05.
Journal of Forensic Nursing
0.007*
sexual assault victims to be young adults (w2 [1, n = 460] = 7.17, p = 0.007). Health history characteristics are shown in Table 2. Victims reporting mental health histories were significantly more likely than other victims to be taking prescription medications in general (w2 [1, n = 467] = 89.88, p < 0.001) and, in particular, to be using psychiatric medications (w2 [1, n = 467] = 201.77, p < 0.001). As seen in Table 3, for criminal justice reporting characteristics, there were no significant differences found in completion of a SAEK or police reporting. As reported in Table 4, significant differences were found across sexual assault characteristics. Compared with other sexual assault victims, those with mental health histories were more likely to be vaginally penetrated (w2 [2, n = 428] = 7.13, p = 0.028), orally penetrated (w2 [2, n = 449] = 12.51, p = 0.002), and anally penetrated (w2 [2, n = 449] = 9.41, p = 0.009). In contrast, they were less likely to have
TABLE 2. Health History of Sexual Assault Victims No mental Mental health health history, n (%) p history, n (%) Pregnant before assault
4 (2.6)
6 (2.0)
0.678
Using birth controla
14 (9.3)
31 (10.5)
0.681
Taking prescription medication
116 (73.4)
85 (27.5)
