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For further information on the two pilots contact Stop It Now! on office@stopitnow. org.uk

Chapter 21
‌

Changing the community response to rape: the promise of sexual assault nurse examiner (SANE) programmes

Rebecca Campbell

Meet Rebecca Campbell

Rebecca Campbell is a Professor of Community Psychology and Program Evaluation at Michigan State University, USA. She has been involved in the anti-violence movement since she was 19 years old. In her sophomore year of college, she did an internship at a battered women’s shelter and the experience changed her life. After that, she began training as a volunteer rape victim advocate in hospital emergency departments, a role she enjoyed for 15 years. Combining advocacy and research has always been a passion of Rebecca’s, and her academic scholarship examines how the legal, medical and mental health systems respond to the needs of rape survivors. For the past seven years, Rebecca has been studying alternative community interventions for improving post-assault care for rape victims.

Introduction

Sexual violence is a pervasive social problem: epidemiological data indicate that 17–25 per cent of women in the United States are raped in their adult lifetimes (Fisher
et al
. 2000; Koss
et al
. 1987; Tjaden and Thoennes 1998). Rape is one of the most severe of all traumas, causing multiple, long-term negative outcomes, such as post-traumatic stress disorder (PTSD), depression, substance abuse, suicidal ideation (and suicide) and chronic physical health problems (Koss
et al
. 2003). Rape victims have extensive post-assault needs and may turn to multiple social systems for assistance. Approximately 26–40 per cent of victims report the assault to the police and pursue prosecution through the criminal justice system, 27–40 per cent seek medical care and medical forensic

examinations and 16–60 per cent obtain mental health services (Campbell 2008). When victims reach out for help, they place a great deal of trust in the legal, medical and mental health systems as they risk disbelief, blame and refusals of help. How these system interactions unfold can have profound implications for victims’ recovery. If victims are able to receive the services they need, and are treated in an empathic, supportive manner, then social systems can help facilitate recovery. Conversely, if victims do not receive needed services and are treated insensitively, then system personnel can magnify victims’ feelings of powerlessness, shame and guilt. Post-assault help- seeking can become a ‘second rape’, a secondary victimisation to the initial trauma (Campbell and Raja 1999; Campbell
et al
. 2001).

Kelly’s (1988) concept of a ‘continuum of sexual violence’ revealed the wide

range of sexual violations women endure, and consistent with that conceptualisation, it appears that the help-seeking process is itself sometimes a point on that continuum as well. To be clear, secondary victimisation is not the same as rape and their traumas are not equivalent. That said, when survivors describe their experiences with the legal and medical systems as something so fundamentally hurtful that it feels as if they are once again being violated, it suggests that help-seeking is sometimes on that continuum of violence. At a time of tremendous vulnerability and need, rape victims turn to their communities for help and risk further hurt. The trauma of rape extends far beyond the actual assault, and intervention strategies must address the difficulties rape survivors encounter when seeking community help. Although prevention efforts to eliminate rape are clearly needed, it is also important to consider how we can prevent further trauma among those already victimised. The purpose of this
chapter is to review the extant research on rape victims’ help-seeking experiences and examine promising new interventions that seek to create more consistently positive post-assault help-seeking experiences for all survivors.

The community response to rape: helpful or hurtful?

When rape survivors seek community help after an assault, they are most likely to be directed to the medical system, specifically hospital accident and/or emergency departments (EDs) (Resnick
et al
. 2000). Although most victims are not physically injured to the point of needing emergency health care (Ledray 1996), survivors are sent to hospital anyway, primarily for forensic evidence collection (Martin 2005). The survivor’s body is a crime scene and due to the invasive nature of sexual assault, a medical professional, rather than a crime scene technician, is needed to collect the evidence. The ‘rape exam’ or ‘rape kit’ usually involves plucking head and pubic hairs; collecting loose hairs by combing the head and pubis; swabbing the vagina, anus and/or mouth to collect semen, blood or saliva; and obtaining fingernail clippings and scrapings in the event the victim scratched the assailant. Blood samples may also be collected for DNA, toxicology and ethanol testing (Martin 2005).

For decades, both researchers and rape victim advocates have noted numerous problems with this hospital ED-based approach to post-assault care

(Campbell 2008; Campbell and Bybee 1997; Campbell and Martin 2001; Martin 2005). Many ED physicians are reluctant to perform the rape exam, which results in long wait times for survivors, who spend on average four to ten hours in the ED before they are examined (Littel 2001; Martin 2005). During this wait, victims are not allowed to eat, drink or urinate so as not to destroy physical evidence of the assault (Littel 2001; Taylor 2002). Most ED personnel lack training specifically in forensic evidence collection and, as a result, many rape kits collected by ED doctors are done incorrectly and/or incompletely. Even ED physicians with forensic training usually do not perform forensic exams frequently enough to maintain their proficiency (Littel 2001).