Chapter 51 Sexual Assault

The U.S. Department of Justice defines rape as “[f]orced sexual intercourse including both psychological coercion as well as physical force. Forced sexual intercourse means penetration by the offender(s). This definition includes attempted rapes, male as well as female victims, and both heterosexual and homosexual rape. Attempted rape includes verbal threats of rape.”¹ While each state has its own definition of rape, all states include in their definition the element of force and lack of consent. Although the terms “rape” and “sexual assault” are frequently used interchangeably, the Rape, Abuse, and Incest National Network (RAINN)² refines this definition, classifying sexual assault as unwanted sexual contact that stops short of rape or attempted rape. Most state statutes currently define rape as “nonconsensual oral, anal, or vaginal penetration of the victim by body parts or objects using force, threats of bodily harm, or by taking advantage of a victim who is incapacitated or otherwise incapable of giving consent.”³

Although the total number of sexual assaults has dropped nearly 60% in the United States in the past decade ², the incidence is still staggering. It is estimated that one in six American women will have been the victim of an attempted or completed rape some time in her life and that someone is sexually assaulted in America every 2 minutes.² In 2010, there were 188,380 incidents of rape or sexual assault.⁴ A 2006 study noted that 22% of women report having been forced to do “something sexual” in their lifetimes.⁵ According to the 2000 National Violence Against Women Survey,⁶ a very conservative estimate of the number of female rape victims treated by emergency department (ED) personnel in the 12 months preceding the survey was almost 129,000.

General Approach

Given these statistics, it is nearly inevitable that an emergency nurse will be responsible for the care of a sexual assault survivor at some time during his or her career. The emergency nurse is a key member of the treatment team and is instrumental in coordinating the multiple activities necessary to ensure that the simultaneous goals of compassionate emergency care and forensic evidence collection are met.⁷ The Emergency Nurses Association (ENA) advocates that these at-risk victims “receive appropriate and sensitive care that addresses their medical, emotional, and legal needs.”⁷ It is important to recognize that sexual assault is a crime of violence, not of sexual gratification⁸ and, as such, can cause concomitant physical injuries as well as long-lasting detrimental effects on the survivor’s psychological well-being and future interpersonal relationships. Because the ED is the first point of contact for many of these survivors, emergency nurses play a key role in their care, not only as that of health care provider but as that of evidence collector as well.⁹ As such, it is imperative that the emergency nurse approach the patient as well as the examination from an integrated, holistic psychological-social-legal perspective.

The Sexual Assault Nurse Examiner

Because of the intensely personal needs and legal implications inherent in the care of the sexual assault survivor, many EDs have adopted the Sexual Assault Nurse Examiner (SANE) model of care. SANE programs grew out of a need recognized by health professionals who care for sexual assault victims. These professionals recognized that the services provided in the ED to sexual assault victims were not at the same standard of care as for other populations of emergency department patients.¹⁰ The first SANE programs were established in Memphis, Tennessee, in 1976 and they have grown in number from 3 in the 1970s to more than 600 as of June 6, 2010.¹¹ In addition, 17 schools offer forensic nurse degree programs at this time.

The benefit of SANE services was evidenced in a retrospective analysis of sexual assault victims presenting to a pediatric ED in a study by Bechtel, Ryan, and Gallagher.¹² They found that patients whose care was directed by a SANE as compared to those whose care was not were more likely to have a full genitourinary examination documented. They were also more likely to have had appropriate testing for sexually transmitted infections, to have received pregnancy prophylaxis treatment, and to have been referred to a rape crisis center.¹² Research has shown that additional benefits of a SANE program include the following:

Triage

In addition to any physical pain from injuries incurred during the assault, patients presenting for treatment following sexual assault are in extreme emotional pain. Using a five-tier triage system that the ENA and American College of Emergency Physicians (ACEP) jointly recommend,¹³ these patients should be assigned a triage category of 2 on a scale of 1 to 5 (with 1 meaning resuscitation). These patients warrant a level 2 categorization because of the time-sensitive nature of their required treatment as well as the severity of their psychological pain.¹⁴ Following identification of the chief complaint, these patients should bypass the remainder of the triage process and be taken to a private treatment room if at all possible. This provides them with the maximum amount of privacy and assists in the preservation of forensic materials. In EDs with access to SANE services, the SANE should be notified at this time.

Each sexual assault survivor is not only a crime victim but a crime scene as well.