SPECIAL TOPICS IN BEHAVIORAL MEDICINE
Identifying and treating adult survivors of sexual assault Ashley Wellman, PhD
ABSTRACT About 18% of women and 3% of men report being a victim of sexual assault, but fewer than one-third of victims seek immediate medical attention or psychological counseling. Over time, victims may experience physical and emotional reactions and turn to primary care providers, who should be prepared to identify survivors of sexual assault and provide thoughtful referrals for long-term follow-up. Keywords: adult patients, sexual assault, victimization, posttraumatic stress disorder, rape trauma syndrome, cognitive processing therapy
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bout 18% of women and 3% of men report being a victim of sexual assault.1 Of these victims, fewer than one-third will seek immediate medical attention or psychological counseling for their injuries.1 Over time, most sexual assault victims will experience a host of physical and emotional reactions and may turn to primary care providers for personalized, long-term treatment. Few primary care providers will encounter patients who are seeking a forensic examination within the first 72 hours after their assault. However, healthcare providers, including physician assistants (PAs), are in a unique position to spend time with these patients, gain their trust, and provide thoughtful referrals for long-term follow-up care. This article describes indicators of past sexual assault and longterm treatment options for survivors. DIAGNOSIS Although some patients may share their personal history of sexual assault with medical professionals, most survivors are unlikely to disclose their experience out of fear of retaliation, embarrassment, lack of trust, denial of the event, or a desire to protect the offender.2 PAs may observe indicators of past sexual assault, including reports of pel-
Ashley Wellman is an assistant professor at the University of Central Missouri in Warrensburg, Mo. The author has disclosed no potential conflicts of interest, financial or otherwise. Roy A. Borchardt, PA-C, PhD, department editor DOI: 10.1097/01.JAA.0000446222.55059.92 Copyright © 2014 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
vic pain, dysmenorrhea, and sexual dysfunction.3 Patients with a history of sexual assault may also exhibit great emotional distress or adverse physical reactions to pelvic, genital, breast, or rectal examinations.4 In these cases, PAs should discuss incidents of sexual assault with patients, address mandatory reporting procedures, and remind patients that treatment is confidential and that they are in a safe environment to disclose abuse. Clinicians should avoid direct questions such as “Have you ever been raped?” and instead should ask less-threatening questions such as “Has there ever been a time when someone has unwantedly touched you in a sexual manner?” or “Have you ever been forced to participate in a sexual act that made you uncomfortable or that you did not want to do?” TREATMENT Regardless of whether they disclose the event or not, patients with a history of sexual assault are likely to experience physical and emotional complications. In a national selfreport telephone survey conducted by random-digit dialing, about 32% of the 8,000 women surveyed and 16% of the 8,005 men surveyed reported being injured during their most recent sexual assault.1 Although a patient may have healed from initial physical injuries such as vaginal tearing, anal fissures, bruising, and broken bones, victims of sexual assault face many long-term physical health risks. These patients should be examined and carefully monitored for pregnancy, sexually transmitted infections (STIs), HIV, and fertility health. PAs are more likely to encounter victims of sexual assault who are struggling with complicated emotional distress as a result of their trauma. Survivors of sexual assault are at increased risk for posttraumatic stress disorder (PTSD), rape trauma syndrome, depression, anxiety, addiction, and suicide.1,3-5 Victims of sexual assault are twice as likely as nonvictims to suffer from substance abuse, and may need inpatient treatment.5 Attending social groups such as Alcoholics Anonymous or Narcotics Anonymous may be beneficial to patients as an alternative or supplement to inpatient treatment. Clinicians can help patients understand treatment options by addressing the physical injuries and emotional distress associated with sexual assault victimization. Traditional medical care can address the physical maniwww.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
51
SPECIAL TOPICS IN BEHAVIORAL MEDICINE
festations of sexual assault. To prevent additional trauma, be sensitive to potential patient stimuli that may occur during routine checks, such as breast, pelvic, and rectal examinations. Female patients whose assault resulted in pregnancy should be informed of their medical and legal options, provided with prenatal care as appropriate, and referred to women’s support services. Medical facilities should develop and maintain a manual of social services resources because programs vary depending on location, and funding issues frequently affect local service availability. OPPORTUNITY FOR COLLABORATION The emotional effect of sexual assault is expansive and often long-term. Many options are available for patients who have emotional disorders and complications as a result of sexual assault. The most significant results are likely to occur when PAs and medical teams incorporate psychiatric care and local social services into patient care. Develop treatment and referral plans based on the patient’s needs: for some patients, social services will be the most immediate need; others may need immediate psychological care. Patients who are survivors of sexual assault are two times more likely to suffer from depression than patients who have not been abused.5 Talk to patients about options for combating anxiety and depression, and provide a referral to a professional such as a clinical psychologist, psychiatrist, counselor, or social worker who can further explore the treatment options. Often, patients’ mood symptoms will be treated with medication, such as selective serotonin reuptake inhibitors. Cognitive behavior therapy (CBT), one of the most researched and best-understood options available, is frequently used by clinicians to combat PTSD, and often is used to treat survivors of sexual assault. Slightly more tailored, cognitive processing therapy (CPT) was designed to specifically treat PTSD in victims of sexual assault. CPT focuses entirely on stimulating avoidance behavior and preventing future harm, using a combination of cognitive restructuring therapy and exposure therapy over 12 structured sessions.6 CPT helps patients resolve the conflict between pretrauma and posttrauma views of the world and restructure their understanding about the attack itself. Studies have found CPT to be one of the most successful methods for treating sexual assault victims, significantly reducing symptoms of PTSD, depression, and guilt.7 PAs who identify a sexual assault survivor should provide a referral for psychological care and educate patients about the available options and therapies, which may increase the probability that the patient will seek psychological care. If a patient appears resistant to more clinical therapies and traditional approaches to psychological health, PAs may recommend treatment options that embrace creativity, such as music, art, and equestrian therapy. Medical professionals, local women’s shelters, rape crisis organizations, employment services, and healthy 52
www.JAAPA.com
family organizations should network to better-serve patients. The Bureau of Justice Statistics reports that 60% to 90% of sexual assault victims were assaulted by an intimate partner, relative, friend, or acquaintance, decreasing the probability that they reported the crime and increasing the likelihood that patients will return to an environment that includes the perpetrator.8 Many survivors of sexual assault feel that they cannot escape their current living conditions based on a relationship with the offender, financial dependency, or children. To better aid survivors, PAs need to find out what resources are offered in their community, and form strong community partnerships to help provide patients with appropriate resources and options. CONCLUSION When fear, blame, and judgment are removed from the interaction with a clinician, patients are more likely to disclose details of their experience and be more upfront about their resulting medical complications. PAs must strive to create a safe and trusting environment when dealing with sexual assault survivors, as PAs often are key in identifying abuse and referring patients for proper treatment. Regardless of which treatment options are chosen, the patient should be in control of treatment decisions and play an active role in his or her recovery. PAs should work with other healthcare providers to develop a referral list of local services, support groups, and resources that might aid victims of sexual assault. JAAPA REFERENCES 1. Tjaden PG, Thoennes N. Extent, Nature and Consequences of Rape Victimization: Findings From the National Violence Against Women Survey. Washington, DC: National Institute of Justice; 2006. https://www.ncjrs.gov/pdffiles1/nij/183781.pdf. Accessed July 5, 2013. 2. DuMont JD, Miller KL, Myhr TL. The role of “real rape” and “real victim” stereotypes in the police reporting practices of sexually assaulted women. Violence Against Women. 2003;9: 466-486. 3. American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care: A Resource Manual. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007. 4. American College of Obstetricians and Gynecologists. Women’s Health Care Physicians: Committee Opinion–Sexual Assault. No. 499, August 2011. 5. World Health Organization. Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence. Geneva, Switzerland: World Health Organization Press; 2013. 6. Resick PA, Schnicke MK. Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park, CA: Sage Publishing; 1993. 7. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70(4):867-879. 8. Fisher BS, Cullen FT, Turner MG. The Sexual Victimization of College Women. Washington, DC: US Department of Justice, Bureau of Justice Statistics and National Institute of Justice; 2000:NCJ 182369. Volume 27 • Number 5 • May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Identifying and treating adult survivors of sexual assault Ashley Wellman, PhD
ABSTRACT About 18% of women and 3% of men report being a victim of sexual assault, but fewer than one-third of victims seek immediate medical attention or psychological counseling. Over time, victims may experience physical and emotional reactions and turn to primary care providers, who should be prepared to identify survivors of sexual assault and provide thoughtful referrals for long-term follow-up. Keywords: adult patients, sexual assault, victimization, posttraumatic stress disorder, rape trauma syndrome, cognitive processing therapy
A
bout 18% of women and 3% of men report being a victim of sexual assault.1 Of these victims, fewer than one-third will seek immediate medical attention or psychological counseling for their injuries.1 Over time, most sexual assault victims will experience a host of physical and emotional reactions and may turn to primary care providers for personalized, long-term treatment. Few primary care providers will encounter patients who are seeking a forensic examination within the first 72 hours after their assault. However, healthcare providers, including physician assistants (PAs), are in a unique position to spend time with these patients, gain their trust, and provide thoughtful referrals for long-term follow-up care. This article describes indicators of past sexual assault and longterm treatment options for survivors. DIAGNOSIS Although some patients may share their personal history of sexual assault with medical professionals, most survivors are unlikely to disclose their experience out of fear of retaliation, embarrassment, lack of trust, denial of the event, or a desire to protect the offender.2 PAs may observe indicators of past sexual assault, including reports of pel-
Ashley Wellman is an assistant professor at the University of Central Missouri in Warrensburg, Mo. The author has disclosed no potential conflicts of interest, financial or otherwise. Roy A. Borchardt, PA-C, PhD, department editor DOI: 10.1097/01.JAA.0000446222.55059.92 Copyright © 2014 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
vic pain, dysmenorrhea, and sexual dysfunction.3 Patients with a history of sexual assault may also exhibit great emotional distress or adverse physical reactions to pelvic, genital, breast, or rectal examinations.4 In these cases, PAs should discuss incidents of sexual assault with patients, address mandatory reporting procedures, and remind patients that treatment is confidential and that they are in a safe environment to disclose abuse. Clinicians should avoid direct questions such as “Have you ever been raped?” and instead should ask less-threatening questions such as “Has there ever been a time when someone has unwantedly touched you in a sexual manner?” or “Have you ever been forced to participate in a sexual act that made you uncomfortable or that you did not want to do?” TREATMENT Regardless of whether they disclose the event or not, patients with a history of sexual assault are likely to experience physical and emotional complications. In a national selfreport telephone survey conducted by random-digit dialing, about 32% of the 8,000 women surveyed and 16% of the 8,005 men surveyed reported being injured during their most recent sexual assault.1 Although a patient may have healed from initial physical injuries such as vaginal tearing, anal fissures, bruising, and broken bones, victims of sexual assault face many long-term physical health risks. These patients should be examined and carefully monitored for pregnancy, sexually transmitted infections (STIs), HIV, and fertility health. PAs are more likely to encounter victims of sexual assault who are struggling with complicated emotional distress as a result of their trauma. Survivors of sexual assault are at increased risk for posttraumatic stress disorder (PTSD), rape trauma syndrome, depression, anxiety, addiction, and suicide.1,3-5 Victims of sexual assault are twice as likely as nonvictims to suffer from substance abuse, and may need inpatient treatment.5 Attending social groups such as Alcoholics Anonymous or Narcotics Anonymous may be beneficial to patients as an alternative or supplement to inpatient treatment. Clinicians can help patients understand treatment options by addressing the physical injuries and emotional distress associated with sexual assault victimization. Traditional medical care can address the physical maniwww.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
51
SPECIAL TOPICS IN BEHAVIORAL MEDICINE
festations of sexual assault. To prevent additional trauma, be sensitive to potential patient stimuli that may occur during routine checks, such as breast, pelvic, and rectal examinations. Female patients whose assault resulted in pregnancy should be informed of their medical and legal options, provided with prenatal care as appropriate, and referred to women’s support services. Medical facilities should develop and maintain a manual of social services resources because programs vary depending on location, and funding issues frequently affect local service availability. OPPORTUNITY FOR COLLABORATION The emotional effect of sexual assault is expansive and often long-term. Many options are available for patients who have emotional disorders and complications as a result of sexual assault. The most significant results are likely to occur when PAs and medical teams incorporate psychiatric care and local social services into patient care. Develop treatment and referral plans based on the patient’s needs: for some patients, social services will be the most immediate need; others may need immediate psychological care. Patients who are survivors of sexual assault are two times more likely to suffer from depression than patients who have not been abused.5 Talk to patients about options for combating anxiety and depression, and provide a referral to a professional such as a clinical psychologist, psychiatrist, counselor, or social worker who can further explore the treatment options. Often, patients’ mood symptoms will be treated with medication, such as selective serotonin reuptake inhibitors. Cognitive behavior therapy (CBT), one of the most researched and best-understood options available, is frequently used by clinicians to combat PTSD, and often is used to treat survivors of sexual assault. Slightly more tailored, cognitive processing therapy (CPT) was designed to specifically treat PTSD in victims of sexual assault. CPT focuses entirely on stimulating avoidance behavior and preventing future harm, using a combination of cognitive restructuring therapy and exposure therapy over 12 structured sessions.6 CPT helps patients resolve the conflict between pretrauma and posttrauma views of the world and restructure their understanding about the attack itself. Studies have found CPT to be one of the most successful methods for treating sexual assault victims, significantly reducing symptoms of PTSD, depression, and guilt.7 PAs who identify a sexual assault survivor should provide a referral for psychological care and educate patients about the available options and therapies, which may increase the probability that the patient will seek psychological care. If a patient appears resistant to more clinical therapies and traditional approaches to psychological health, PAs may recommend treatment options that embrace creativity, such as music, art, and equestrian therapy. Medical professionals, local women’s shelters, rape crisis organizations, employment services, and healthy 52
www.JAAPA.com
family organizations should network to better-serve patients. The Bureau of Justice Statistics reports that 60% to 90% of sexual assault victims were assaulted by an intimate partner, relative, friend, or acquaintance, decreasing the probability that they reported the crime and increasing the likelihood that patients will return to an environment that includes the perpetrator.8 Many survivors of sexual assault feel that they cannot escape their current living conditions based on a relationship with the offender, financial dependency, or children. To better aid survivors, PAs need to find out what resources are offered in their community, and form strong community partnerships to help provide patients with appropriate resources and options. CONCLUSION When fear, blame, and judgment are removed from the interaction with a clinician, patients are more likely to disclose details of their experience and be more upfront about their resulting medical complications. PAs must strive to create a safe and trusting environment when dealing with sexual assault survivors, as PAs often are key in identifying abuse and referring patients for proper treatment. Regardless of which treatment options are chosen, the patient should be in control of treatment decisions and play an active role in his or her recovery. PAs should work with other healthcare providers to develop a referral list of local services, support groups, and resources that might aid victims of sexual assault. JAAPA REFERENCES 1. Tjaden PG, Thoennes N. Extent, Nature and Consequences of Rape Victimization: Findings From the National Violence Against Women Survey. Washington, DC: National Institute of Justice; 2006. https://www.ncjrs.gov/pdffiles1/nij/183781.pdf. Accessed July 5, 2013. 2. DuMont JD, Miller KL, Myhr TL. The role of “real rape” and “real victim” stereotypes in the police reporting practices of sexually assaulted women. Violence Against Women. 2003;9: 466-486. 3. American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care: A Resource Manual. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007. 4. American College of Obstetricians and Gynecologists. Women’s Health Care Physicians: Committee Opinion–Sexual Assault. No. 499, August 2011. 5. World Health Organization. Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence. Geneva, Switzerland: World Health Organization Press; 2013. 6. Resick PA, Schnicke MK. Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park, CA: Sage Publishing; 1993. 7. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70(4):867-879. 8. Fisher BS, Cullen FT, Turner MG. The Sexual Victimization of College Women. Washington, DC: US Department of Justice, Bureau of Justice Statistics and National Institute of Justice; 2000:NCJ 182369. Volume 27 • Number 5 • May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
