Forensic Nurses Help Victims Get Past the Trauma of Sexual Assault
Wednesday September 5, 2007
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Psychological Trauma of Sexual Assault
Acute Phase — Disorganization
Impact reactions — within hours
Victims may present in a variety of ways:
- • Expressed style — feelings are shown in such behavior as crying, sobbing, smiling, restlessness, tension, joking.
• Controlled style — feelings are masked or hidden behind a calm, composed, or subdued affect.
Immediate effects — first weeks
Somatic manifestations:
- • Physical trauma
• Skeletal muscle tension
• Gastrointestinal irritability
• Genitourinary disturbance
Possible emotional reactions: shock, numbness, embarrassment, guilt, powerlessness, loss of trust, fear, anxiety, anger, disbelief, shame, depression, denial, disorientation
Short-Term Effects — Up to 3 to 4 Months
- • Generalized anxiety and fear
• Disturbance of eating, sleeping, thoughts, relationships
• Disruption to create safety — e.g., change of phone number
• Impaired social functioning
• Difficulty in maintaining or establishing relationships
• Guilt for not preventing assault
• Sudden change of residence or disappearance altogether
• Negative impact of legal process
Long-Term Reactions — Up to 4 Years
- • Anger toward offender, legal system, family, friends
• Diminished capacity for enjoying life
• Hypervigilance to potential danger
• Continued sexual dysfunction — decreased libido and arousal, experience of flashbacks
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To better support rape survivors in overcoming the trauma of rape and its aftermath, local facilities are employing specially trained forensic nurses to provide expert survivor care, collect evidence, and give testimony in court.
“Forensics is where nursing, medicine, and human behavior intersect with the law and can involve both living and deceased patients,” says Leslie Anderson, RN, BSN, FNE-A, program coordinator of the sexual assault forensic examiner (SAFE) program at Mercy Hospital in Baltimore.
Anderson says how survivors of rape are treated and how well evidence collection is completed will not only impact the prosecution process but also the way survivors cope with the sexual assault for the rest of their lives.
“For a trained, specialized nurse to be with them one-on-one in those initial hours after the rape means a lot to them,” she says.
Anderson says before the advent of definitive training for nurses as forensic examiners, nurses who cared for survivors (usually ED nurses) were not well-educated in how to care for or talk to these patients, who often suffer the effects of rape trauma syndrome (see sidebar, “Psychological Trauma of Sexual Assault”).
“These patients do not always show obvious signs of outward trauma, and their behavior can vary from giggling to withdrawn and uncommunicative to angry,” says Anderson. “Before specialized training,
caregivers probably did come across as not being
very empathetic.”
Survivors of sexual assault frequently experience feelings of a loss of control, which can be intensified in the healthcare setting as they undergo the elaborate process of physical exam, testing, and evidence collection.
Forensic nurses try to give back a sense of control to survivors by carefully asking their permission about as much as possible. Sometimes that means something as simple as giving them a choice of what to drink. With their permission, forensic nurses also try to hook them up with rape advocacy services as soon as possible.
“We want them to tap into counseling services while they’re here because once they leave the hospital, very few will seek them out on their own,” she says.
“It takes a lot of courage for survivors to seek treatment and pursue evidence, and it’s important for the community to have this service available,” says Gail Perkins, RN, SANE, forensic nurse coordinator, Mary Washington Hospital, Fredericksburg, Va.
Perkins says that, although forensic nurses are responsible for evidence collection, it’s not their job to determine if a rape really happened.
“That’s the job of the police,” she says. “However, you can’t take the nursing part out of us. We’re still caring and compassionate, and we can help survivors realize it wasn’t their fault, because we have the time to spend with them one-on-one.”
Perkins stresses it’s important to understand every survivor presents with different responses to sexual assault.
“There is no right or wrong response,” she says. “We let them know that however they are responding to it is OK, and if they’re giggling now, they may be crying later, and that’s normal.”
Qualifications in Virginia for becoming a SANE nurse include a five-day course, a ride-along with a police officer, and practical hours spent with detectives, victim witness directors, attorneys, and rape crisis professionals. SANE nurses must also complete 10 sexual assault exams with a preceptor.
In 2000, the Washington Rape Crisis Center established a SANE program for adult survivors of sexual violence. This program, developed in conjunction with the D.C. Metropolitan Police Department and the U.S. Attorney’s Office, operates out of Howard University Hospital’s ED. This multidisciplinary collaboration is called the sexual assault response team. These agencies work together to ensure a coordinated community response to sexual assault.
The team’s SANEs are often the first to touch the lives of sexual assault survivors during the exam and evidence collection process.
“The healing process needs to start right then and there,” says Pinn. “By the time I finish with them, they’re able to walk out of the hospital and feel more in control.”
Because as many as one out of three women will be raped in her lifetime, nurses in nearly any field will probably encounter a survivor sometime during their careers.
Dan Sheridan, RN, PhD, CNS, president of the International Association of Forensic Nurses, says all nurses can be effective caregivers for these special patients.
Here is what he suggests nurses do when encountering a survivor of sexual assault in their practice:
- • Don’t further victimize the survivor. Don’t blame him or her, and resist the temptation to pass judgment. Tell the patient, “I’m sorry this happened to you” and “It’s not your fault.”
• Say, “Thank you for sharing that” after a survivor has confided in you. Then gently say, “Tell me more about what happened.” Reassure the survivor that he or she is not alone and ask, “What would you like me to do with this information?” Offer further assistance by saying, “Let me help you get in touch with other professionals who can help.”
• Arm yourself with resources. Be aware of your state’s reporting requirements and know your local resources, such as victim advocate and counseling services and local EDs that complete sexual assault exams and evidence collection.
• Facilitate an evaluation by a sexual assault professional ASAP. To be most effective, sexual assault evidence collection procedures should be completed within 72 to 120 hours after an attack. In addition, most EDs and sexual assault programs offer victims “morning-after” pills (norgestrel, Ovral), which must be taken within 72 hours of the assault to prevent pregnancy. Testing and prophylactic treatment of possible sexually transmitted diseases are also best done as soon as possible.
• Preserve the evidence. Don’t disturb or throw away any possible evidence, including patients’ clothes and underwear. Tell them not to drink, eat, go to the bathroom, shower, or brush their hair or teeth until after the exam.
Catherine Spader, RN, is a freelance healthcare writer.
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