The courageous testimony of Dr. Christine Blasey Ford during the Senate Judiciary Committee hearing of Judge Brett Kavanaugh evoked a tidal wave of emotions for Americans—pride, anger, fear, and hope among them. However, for sexual assault survivors across the country, her testimony opened wounds that many thought had long healed. RAINN (Rape, Abuse & Incest National Network) reported that the number of calls to the National Sexual Assault Hotline more than doubled on the day of the trial.1 C-SPAN received calls from women and men, Democrats and Republicans, calling to share their experiences with sexual trauma. The message surrounding Dr. Ford's acknowledgement of an incident that had occurred more than three decades earlier was simple: sexual assault survivors are forever affected by the actions of their perpetrators.2 Numerous questions arose around her intent, her motive, and her recollection of events from so long ago. Some even boldly stated that her accusations were false because there was no police report filed. In actuality, an estimated two of every three sexual assaults go unreported.3 Although some Americans found it difficult to reconcile whether Judge Kavanaugh should be held liable for his actions during high school, others found it difficult to ascertain how a woman could be sure of events that occurred so many years ago. As physicians discussing the hearing, it became clear to us that despite our differing specialties of obstetrics and gynecology, psychiatry, and pediatrics, we have repeatedly experienced this same story in the context of our numerous patient encounters.
As a gynecologist, I have encountered patients almost daily who bear the scars of sexual assault, but there is one day that remains quite memorable because the juxtaposition of these two patients was jarring. The first adolescent patient clearly stated her own medical history and her reason for requesting hormonal contraception. Like many, her cycles were interfering with her ability to fully participate in academic and athletic endeavors. Her mother was present, but only as a bystander in the process as this young woman advocated for her own health care needs. Less than an hour later, I saw another patient, same age, same grade, yet the encounters were remarkably different. This adolescent avoided eye contact as she sat sullenly in front of me. Her mother recited similar needs for hormonal management because the young woman would not speak directly to me. I softly placed my hand on my patient's knee and, looking at the mom, voiced my concerns. This was not a vibrant, confident young woman, but one who seemed to exhibit very familiar signs of sexual abuse. Over the next half hour, the mother confided in me that the young woman had been sexually assaulted by her brother's teammate. After reporting the incident to the school administrators, this family experienced a horrid series of events that few could imagine. The brother was ostracized by his teammates, and my patient was tormented by the perpetrator's sisters, who also were students at the school. My patient learned the harsh lesson that speaking up brought grave consequences, and so she and her family had vowed never to speak of their trauma again.
According to the American College of Obstetricians and Gynecologists' Committee Opinion on sexual assault, acquaintance rape refers to sexual assaults committed by a perpetrator known to the victim.4 The term date rape has been replaced by the all-encompassing term acquaintance rape, which includes rape by current or former partners and any unwanted encounter by a perpetrator known to the victim.4 According to RAINN, 80% of female survivors know their perpetrators (Fig. 1).5 Adolescent sexual assaults have similarly staggering rates, with studies noting that approximately two thirds to three quarters of all adolescent sexual assaults are perpetrated by an acquaintance or family member of the adolescent.6,7 In a 2007 study of sexual assaults on college campuses, the perpetrator was known to the woman in nearly 80% of the cases.8 In our experience as physicians, the number of females (from young girls to accomplished women) who have been the victims of sexual assault is astounding. Even more shocking is the infinitesimal number of our female patients who reported filing a police report in cases of acquaintance rape. There are many overlapping factors affecting the decision to report a case of acquaintance rape. Adolescents may not initially perceive the assault as rape because of the mismatch between the actual encounter and a “rape script” that involves strangers or bodily harm.9 Many women in sexual assault situations fear they will not be believed. This concern over a false accusation is heightened when the two individuals already know each other, have spent time together, and may have even been intimate before. This added complexity may be confusing for young women who may think that, if consent is given once, it can never be withdrawn.10
The level of scrutiny around these circumstances is also heightened, often by peers—what was she wearing, was she drinking, has she flirted with him previously, did they engage in any romantic behavior, and, of course, did she willingly enter an enclosed space with him. These questions wrongfully bear significant weight in cases of acquaintance rape and may understandably decrease the rate of reporting by girls and women alike. This secondary victimization when women seek out medical, legal, or mental health assistance can leave women with unmet needs and can potentially exacerbate the trauma.11
Although white women comprise the majority of acquaintance rape victims, women of color face a higher lifetime risk of rape and attempted rape owing to higher frequency of rape and attempted rape in a smaller population. Studies indicate that white women and black women have a 17.7% and 18.8% risk, respectively, whereas American Indian and Alaskan women have nearly double that risk at 34.1%.12 Despite increased risk of being attacked, women in nonwhite groups may be less likely to report owing to their vulnerability to sexist and racist tenets that can make it more difficult for these groups to access support systems or receive fair treatment within the criminal justice system. Specifically, research has shown that black, Latina, and Asian-American women were more likely to believe the victim was “asking for it” or hold negative attitudes toward victims of sexual assault, even if they themselves had been a victim of sexual assault. Consistently, white Americans were more likely to hold negative attitudes toward nonwhite victims.13,14 These ethnicity-based sociocultural attitudes have been internalized. Although women of nonwhite ethnicity may be subjected to an experience that meets the legal definition of sexual assault, many will assert that they are not victims of rape and blame themselves.15,16
Medical organizations dutifully describe the role of physicians in providing care to patients who are survivors of sexual assault. The American College of Obstetricians and Gynecologists describes screening all women for a history of sexual assault and identifies pelvic pain, dysmenorrhea, sexual dysfunction, and posttraumatic stress disorder as potential long-term sequelae. Diagnosis and treatment of sexually transmitted diseases and unintended pregnancy are among the medical consequences discussed; thus, emergency contraception and sexual transmitted infection prophylaxis are stressed.4
The American Psychiatric Association considers trauma history an essential part of the initial psychiatric evaluation. Practice guidelines emphasize the effect that trauma history, including sexual trauma, can have on diagnosis, treatment planning, physical and mental health conditions, psychosocial functioning, and, importantly, patients' ability to form a therapeutic alliance—a factor that has been linked to clinical outcomes.17
The American Academy of Pediatrics encourages all providers to have an increased awareness about sexual assault.10 Asking such questions of teenagers can be challenging, so the H.E.A.D.S.S.S. assessment is a proven strategy that can be thought of as a comprehensive “review of systems” to guide these important conversations. During routine health maintenance visits with adolescents, using the acronym H.E.A.D.S.S.S., a provider can inquire about a teenager's experiences with home, education, employment, activities, drugs, sexuality, suicide, and safety.18 These questions should be asked without a parent or partner in the room to encourage open sharing of sensitive information. When asking about sex, it is critical to expand questions that a teenager may be expecting, such as “Have you ever had sex? How many sexual partners have you had?” to questions that examine the concept of assault, such as, “Has anyone ever touched you in a way that you did not want to be touched or forced you to do something that you didn't want to do?” It is important to note the range of varied reactions after an adolescent sexual assault, from mental health problems to risky behaviors.
Pediatricians should also guide and support parents as they have conversations about sex with their children. This communication has been shown to have a small protective role in the adolescents' behaviors regarding safer sex.19 Although parents are increasingly having these discussions, fewer are dialoguing about tougher topics, including dating abuse.20,21 The climate created from this early education about sex and sexuality may have an effect on the choice to disclose abuse or assault in the future.22 Messaging that either promotes or inhibits exploration and discussion can lead to similar contrasting outcomes after an assault.
The detailed guidelines for physicians cover important aspects of our responsibilities, including the medical, legal, and mental health aspects. However, the role of physicians should include another category called social responsibility. The first tenet of our social responsibility is prevention. We need to recognize acquaintance rape as the public health crisis it is. We adhere to universal screening for many conditions that are far less common and perhaps, less likely to result in the widespread, negative effect that acquaintance rape has on the lives and functioning of its survivors. Preventive medicine is a mainstay of clinical medicine and certainly should include prevention of sexual assault. Using the H.E.A.D.S.S.S. assessment as a psychosocial screening tool allows a provider to engage adolescents and potentially offer anticipatory guidance about sexual assault and, specifically, acquaintance rape. This same rubric could be applied beyond adolescents and young adults and incorporated into history-taking for women at routine visits. Health maintenance visits for women should include screening for many of the same topics identified in the H.E.A.D.S.S.S assessment, which would give adult health care providers a systematic way to offer anticipatory guidance and discuss preventative measures. We must educate young women about relationship violence, sexual harassment, and increased awareness of high-risk situations. Because the majority of sexual assaults are committed by men against women,23 sexual assault prevention also should include education for boys and men. Discussing the importance of sharing emotions, setting and respecting physical boundaries, and modeling appropriate behavior and speech are ways to cultivate a sense of respect and empathy for girls and women.24 We also must recognize that we are at risk of re-traumatizing women by virtue of the intimacy required by the routine medical histories we take and examinations and procedures we conduct. As such, failure to evaluate adolescent girls and women for trauma puts us at risk of violating the most basic medical ethical principle—First Do No Harm.
Our second social responsibility arises after a patient confides an experience of acquaintance rape. The appropriate response is, “I believe you.” Our role then continues to inquiring about the circumstances of the event. It is not enough for a physician’s response to be nonjudgmental, but rather, our initial reaction must be encouraging and supportive. Otherwise, we have the potential to silence a woman forever, which is an outcome that hinders recovery and compounds her risk of developing future physical and mental complications.11 Because of the high prevalence of sexual trauma, it is our responsibility as physicians to advocate for uniform adoption of trauma-informed care. Trauma-informed services approach the patient from the standpoint of the question “What has happened to you?” rather than “What is wrong with you?” Trauma-informed care adheres to the four Rs: 1) Realize the widespread effect of trauma and understand potential paths to recovery; 2) Recognize the signs and symptoms of trauma in patients, families, staff, and others involved in the system; 3) Respond by fully integrating knowledge about trauma into policies, procedures, and practices; and 4) seek to actively avoid Re-traumatization.25 From an individual account to the national stage, victim-blaming is the harsh reality for the survivors of sexual assault. We must not allow women to be repeatedly assaulted as they seek out assistance from the health care system.
Our third social responsibility as physicians is to provide a survivor of acquaintance rape with the knowledge about support resources available to her, because psychological trauma and social disruption are most likely to result when screening programs identify women who have been affected but fail to provide access to treatment.26 It is our responsibility to ensure that every woman knows her options, including police reporting and the newer availability of private and confidential reporting services. Callisto, for example, is a technological application that provides women with the option of private reporting; it uses a matching system to connect victims of the same perpetrator to identify repeat offenders.27
In cases of acquaintance rape, the complexity around future interactions between the victim and perpetrator in routine social settings often further complicates any future desire to report the encounter. These women suffer not just physically and emotionally, but in some cases financially, because they might avoid opportunities for advancement where they may encounter the perpetrator. Dr. Ford's testimony rang true to many women because it validated that, years later, as a successful and accomplished adult, a woman may still be tormented by the actions of a young and inebriated high school boy.
Creating a safer environment for women and girls starts by acknowledging the trauma caused in these situations, validating women and girls who bring forth credible claims, and teaching boys to understand and holding men to the ideal that no means no, whenever it is said. We as physicians must redirect the conversation away from the survivor's attitude, piety, sobriety, and chastity and instead hold boys and men accountable for their own behavior. Further, we must teach boys and men that they are responsible not only for their own actions with women, but also for the actions of those around them. If they see something untoward happening, they must say something, for staying silent is to be an accomplice to the assault. We must lead the charge in reframing the narrative around sexual assault.
As physicians in all specialties, we must vow to be diligent in exercising our social responsibility to inquire about sexual assault, including those affected by strangers as well as acquaintances. We must follow World Health Organization and American Medical Association recommendations to employ universal screening for sexual assault. The SAVE screening tool, developed by the Florida Council Against Sexual Violence, focuses on four points: 1) screen all of your patients; 2) ask direct questions; 3) validate their responses; 4) evaluate, educate, and refer to resources.28 Sexual assault affects all of our patients, regardless of our specialty, and it requires that we work across specialty lines to ensure that appropriate referrals are made.
Helping our patients clearly acknowledge the long-lasting effects of these assaults by acquaintances may support them in their lifelong journey to heal open wounds.
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