Handbook on Sexual Violence (100 page)

Forensic evidence collection is often the focus of hospital emergency department care, but rape survivors have other medical needs, such as information on the risk of sexually transmitted infections (STIs)/HIV and prophylaxis (preventive medications to treat any STIs that may have been contracted through the assault). The US Centers for Disease Control and Prevention (2002) and American Medical Association (1995) recommend that all sexual assault victims receive STI prophylaxis and HIV prophylaxis on a case-by-case basis after risk assessment. However, analyses of hospital records have shown that only 34 per cent of sexual assault patients are treated for STIs (Amey and Bishai 2002). Nevertheless, data from victims suggest much higher rates of STI prophylaxis: 57–69 per cent of sexual assault patients reported that they received antibiotics during their hospital emergency department care (Campbell 2005, 2006; Campbell
et al
. 2001; National Victims Center 1992). But not all victims are equally likely to receive STI-related medical services. Victims of non-stranger rape are significantly less likely to receive information on STIs/ HIV or STI prophylaxis (Campbell and Bybee 1997; Campbell
et al
. 2001), even though knowing the assailant does not mitigate one’s risk. In addition, one study found that Caucasian women were significantly more likely to get information on HIV than ethnic minority women (Campbell
et al
. 2001).

Post-assault pregnancy services are also inconsistently provided to rape

victims. Only 40–49 per cent of victims receive information about the risk of pregnancy (Campbell
et al
. 2001; National Victims Center 1992). The AMA (1995) and the American College of Obstetricians and Gynecologists (1998) recommend emergency contraception for victims at risk of pregnancy, but only 21–43 per cent of sexual assault victims who need emergency contraception actually receive it (Amey and Bishai 2002; Campbell and Bybee 1997; Campbell 2005, 2006; Campbell
et al
. 2001). To date, no studies have found systematic differences in the provision of emergency contraception as a function of victim or assault characteristics, but hospitals affiliated with the Catholic church are significantly less likely to provide emergency contraception (Campbell and Bybee 1997; Smugar
et al
. 2000).

In the process of the forensic exam, STI services and pregnancy-related care,

doctors and nurses ask victims many of the same kinds of questions as do legal personnel regarding their prior sexual history, sexual response during the assault, what they were wearing, and what they did to ‘cause’ the assault. For example, in instances of stranger rape, medical professionals may ask survivors if they had been out alone without ‘proper accompaniment’, whether they were dressed provocatively, or were engaged in other ‘risk-taking’ behaviours.

In situations of non-stranger rape, doctors and nurses often inquire whether survivors ‘led on’ the assailants (i.e., indicated that they did want sexual relations), sexually teased the assailants, or otherwise miscommunicated their intentions. Medical professionals may view these questions as necessary and appropriate, but rape survivors find them upsetting (Campbell and Raja 2005). It is important to keep in mind the broader context in which these questions are being asked. The rape exam is itself a highly invasive experience, including a lengthy vaginal and/or anal exam. To survivors, post-assault medical care can feel much like a second rape – a physical and emotional violation of their selves (Campbell
et al
. 2001).

Perhaps not surprisingly, experiences of secondary victimisation have a

demonstrable negative impact on victims’ mental health. Campbell (2005) found that as a result of their contact with emergency department doctors and nurses, most rape survivors stated that they felt bad about themselves (81 per cent), depressed (88 per cent), violated (94 per cent), distrustful of others (74 per cent), and reluctant to seek further help (80 per cent) (see also Campbell and Raja 2005). Only 5 per cent of victims in Ullman’s (1996) study rated physicians as a helpful source of support, and negative responses from formal systems, including medical, significantly exacerbate victims’ PTSD symptoma- tology (Filipas and Ullman 2001; Starzynski
et al
. 2005; Ullman and Filipas 2001a, b). Victims who do not receive basic medical services rate their experiences with the medical system as more hurtful, which has been associated with higher PTSD levels (Campbell and Raja 2005; Campbell
et al
. 2001). Specifically, non-stranger rape victims who received minimal medical services but encountered high secondary victimisation appear to be the most at risk: these women had significantly higher levels of PTSD symptoms than victims who did not seek medical services at all (Campbell
et al
. 1999).

If victims try to pursue criminal prosecution, their experiences with the

legal system are not markedly better. In the United States, case attrition is staggering: for every 100 rape cases reported to law enforcement, on average 33 would be referred to prosecutors, 16 would be charged and moved into the court system, 12 would end in a successful conviction, and seven would end in a prison sentence (see Campbell 2008 for a review). Successful prosecution is not random: it is more likely for those from privileged backgrounds and those who experienced assaults that fit stereotypic notions of what constitutes rape (see Campbell 2008 for a review). Younger women, ethnic minority women and women of lower socio-economic status are more likely to have their cases rejected by the criminal justice system (Campbell
et al
. 2001; Frohmann 1997a, b; Spohn
et al
. 2001; Spears and Spohn 1997; cf. Frazier and Haney 1996). Cases of stranger rape (where the suspect was eventually identified) and those that occurred with the use of a weapon and/or resulted in physical injuries to victims are more likely to be prosecuted (Campbell
et al
. 2001; Frazier and Haney 1996; Kerstetter 1990; Martin and Powell 1994; Spohn
et al
. 2001; Spears and Spohn 1997). Alcohol and drug use by the victim significantly increases the likelihood that a case will be dropped (Campbell
et al
. 2001; Spears and Spohn 1997; Frohmann 1997 a,b; cf. Frazier and Haney 1996).

These data suggest that the odds of a case being prosecuted are not good,

and the treatment victims receive from legal system personnel along the way is not much better. Across multiple samples, 43–52 per cent of victims who had contact with the legal system rated their experience as unhelpful and/or hurtful (Campbell
et al
. 2001; Golding
et al
. 1989; Filipas and Ullman 2001; Monroe
et al
. 2005; Ullman 1996). In qualitative focus group research, survivors described their contact with the legal system as a dehumanising experience of being interrogated, intimidated and blamed. Several women mentioned that they would not have reported if they had known what the experience would be like (Logan
et al
. 2005). Even victims who had the opportunity to go to trial describe the experience as frustrating, embarrassing and distressing, but they also took tremendous pride in their ability to exert some control in the process and tell what happened to them (Konradi 2007).

These experiences of secondary victimisation take a toll on victims’ mental health. In self-report characterisations of their psychological health, rape survivors indicate that as a result of their contact with legal system personnel, they felt bad about themselves (87 per cent), depressed (71 per cent), violated (89 per cent), distrustful of others (53 per cent), and reluctant to seek further help (80 per cent) (Campbell 2005; Campbell and Raja 2005). The harm of secondary victimisation is also evident on objective measures of PTSD symptomatology. Ullman and colleagues have found that contact with formal help systems, including the police, is more likely to result in negative social reactions, which was associated with increased PTSD symptomatology (Filipas and Ullman 2001; Starzynski
et al
. 2005; Ullman and Filipas 2001a, b). In a series of studies dealing directly with victim–police contact, Campbell and colleagues found that low legal action (i.e., case did not progress/was dropped) was associated with increased PTSD symptomatology, and high secondary victimisation was also associated with increased PTSD (Campbell
et al
. 2001; Campbell and Raja 2005). In tests of complex interactions, Campbell
et al
. (1999) identified that it was the victims of non-stranger rape whose cases were not prosecuted and who were subjected to high levels of secondary victimisation who had the highest PTSD of all – worse than those who chose not to report to the legal system at all. Interestingly, when victims who did
not
report to the police were asked why they did not pursue prosecution, they specifically stated that they were worried about the risk of further harm and distress; their decision was a self-protective choice to guard their fragile emotional health (Patterson
et al
. 2009).

If some survivors are
more
distressed after post-assault contact with the medical and legal systems, and indeed many describe the experience as something that sustains and prolongs the rape, then it begs the question of whether secondary victimisation should be viewed as part of Kelly’s continuum of sexual violence. Kelly (1988) offered the following definition of sexual violence:

Any physical, visual, verbal or sexual act that is experienced by the woman or girl at the time or later as a threat, invasion or assault that has the effect of hurting her or degrading her and/or takes away her ability to control intimate contact.

(p. 41)

The language of Kelly’s definition is the very language survivors use in their accounts of medical and legal system contact: invasion, invasive, hurt, hurting, degrading, lack of control (Campbell 2002, 2008). The semantic overlap cannot be ignored. The trauma of secondary victimisation is not the same in scope or magnitude as the assault itself, but consistent with the idea of a continuum, is somewhere far too close to the rape itself. The opportunity for help and healing is missed and instead, like a high-pitched musical note held far, far too long, to the point of discomfort or pain, the sustaining trauma becomes another violation to endure. Whereas not all survivors characterise their post- assault help-seeking as such, many do and indeed all are to some extent at risk for such treatment.

Changing the community response to rape: a SANE approach

Practitioners in the legal, medical and advocacy communities readily agreed that a new approach to post-assault care was needed, one that would attend to forensic legal issues as well as victims’ psychological and medical needs (Martin 2005). In response, sexual assault nurse examiner (SANE) programmes were created in the 1970s by the nursing profession, in collaboration with rape crisis centres/victim advocacy organisations. These programmes were designed to circumvent problems with traditional hospital ED care by having specially trained nurses, rather than doctors, provide 24-hour, first-response psychological, medical and forensic care to sexual assault victims/survivors. SANE programmes are staffed by registered nurses or nurse practitioners who have completed a minimum of 40 hours of classroom training and 40–96 hours of clinical training, which includes instruction in evidence collection techniques, use of specialised equipment, injury detection methods, pregnancy and STI screening and treatment, chain-of-evidence requirements, expert testimony and sexual assault trauma response (Department of Justice 2006; Ledray 1999). Most SANE programmes are hospital-based (e.g., emergency departments) (75–90 per cent), but some are located in community settings (10–25 per cent) (e.g. clinics or rape crisis centres) (Campbell
et al
. 2005b; Logan
et al
. 2007). Nearly all programmes serve adolescents and adults, and approximately half serve paediatric victims/survivors as well (International Association of Forensic Nurses (IAFN) 2010a).

SANE programmes strive ‘to minimize the physical and psychological trauma to the victim and maximize the probability of collection and preserving physical evidence for potential use in the legal system’ (Young
et al
. 1992: 878). To address victims/survivors’ psychological needs, SANEs focus on treating victims with dignity and respect to ensure that they are not retraumatised by the exam (Campbell
et al
. 2008). Many SANE programmes work with their local rape crisis centres so victim advocates can provide emotional support (Littel 2001; Taylor 2002). This delineation of roles is critical because rape victim advocates can offer victims/survivors confidentiality whereas SANEs may have to testify in court about their communications with survivors (Littel 2001). To attend to victims/survivors’ physical health needs, SANEs treat victims’ injuries, offer emergency contraception for those at risk of becoming

pregnant, and provide prophylactic antibiotics to treat STIs that may have been contracted in the assault (Campbell
et al
. 2006; Ledray 1999).

For the forensic evidence collection itself, most SANE programmes utilise specialised equipment, such as a colposcope, which is a non-invasive, lighted magnifying instrument used for examining the anogenital area for the detection of microlacerations, bruises and other injuries (Voelker 1996). A camera is attached to the colposcope to document anogenital injuries (Lang 1999). Toluidine blue dye can also be used for trauma identification by enhancing the visualisation of microlacerations (Ledray 1999). The forensic evidence collected by the SANEs is typically sent to the state crime lab for analysis. If a case is prosecuted, SANEs may provide expert witness testimony (Campbell
et al
. 2007).

SANEs provide extensive post-assault services for rape victims/survivors, but