Emergency Psychiatry: Emergency Interventions for Rape Victims

The arrival of a rape victim in the emergency department initiates a system of medical, mental health, and forensic interventions with the overall goal of supporting the victim's adjustment to the trauma of rape (1,2,3). The urgency of the patient's medical requirements may preclude early mental health interventions; however, for most rape victims, the medical and forensic needs afford an opportunity to assess the patient's psychological status and provide early mental health interventions.

Usually the victim of rape or sexual assault is psychologically overwhelmed on arrival in the emergency department and requires immediate interventions, including triage to a private, quiet area and initiation of psychological support. Family members or friends, with the patient's consent, should be contacted to provide additional support. If the patient is unwilling to have family or friends contacted, the clinician should explore the reasons, because rape frequently induces shame that may prevent the use of family and community support.

Acknowledgment of this nearly universal response and the need for ongoing support may help the patient allow support from family or friends. The mental health clinician must assess the ability of the family member or friend to provide support and to make the interventions necessary to maximize his or her ability to provide support (4). Additionally, a sensitive exploration of the patient's reluctance may help to determine whether a family member or partner was the perpetrator.

Psychological interventions

As described by Osterman and Chemtob (4), a patient's clinical presentation in the emergency department will be characterized by one of three persisting "survival-mode" functions that manifest as anxiety (flight), anger (fight), or dissociation (freeze). Because persistence of survival-mode functioning may complicate the forensic evaluation and medical treatment, establishing psychological safety is essential so that the patient will consent to and cooperate with these examinations. The five-step emergency intervention described by Osterman and Chemtob for acute traumatic stress involves restoring the patient to psychological safety, providing information, correcting misattributions, restoring and supporting effective coping, and ensuring social support. This approach can be adapted to the treatment of rape by including the relevant medical and forensic examinations.

Psychological safety can be restored by helping the patient to recognize that he or she is in the hospital and is safe. Patients may be sensitive to power and control issues, so a calm, respectful approach will help them to develop a sense of safety. Patients with dissociation typically appear calm and unaffected by their trauma, yet they have a high risk of developing posttraumatic stress disorder (4,5,6). These patients need additional interventions, including grounding strategies such as touching items in the hospital (4).

Once a sense of safety is achieved, it is essential to provide information to the rape victim about his or her current medical status and to address fears of future health problems, including pregnancy, sexually transmitted diseases, and HIV infection. Information must be given about the legal system, the role of the police, and the need for evidence collection, because the victim may choose to pursue charges at some point (1,7).

The rape victim's concerns and need for information provide an opportunity for sensitive discussions of the medical and forensic examinations and the need for psychological support during the examinations. The clinician must acknowledge the patient's fears of being touched and undergoing vaginal and rectal examinations and should discuss the potential for these examinations to trigger flashbacks or intrusive memories of the rape or sexual assault. Informing the patient that a reexperiencing of the trauma might occur will prevent the patient from feeling as if he or she is "going crazy" if a flashback occurs. The presence of a trusted family member or friend and the psychological support of the clinician will help the patient to cope with the examinations.

Victims of rape or sexual assault commonly blame themselves for what happened and often develop fears of a catastrophic nature, such as a belief that being out in the dark or out alone is dangerous. Helping the patient to recognize the catastrophic nature of his or her postrape beliefs, correct misattributions, and define the rape experience more realistically decreases anxiety, guilt, and anger.

Psychoeducation about normal responses and common symptoms after rape, such as irritability, problems with arousal, sleep problems, intrusive thoughts, nightmares, avoidance, and numbing, helps to restore psychological competence and allay possible fears on the part of family, friends, and the patient that he or she is "crazy" or has "lost control" (4). A discussion of the impact of rape on intimacy and the potential for sexual touching to trigger a survival-mode response helps the patient and his or her sexual partner to understand that these postrape responses are common and do not reflect on the partner. Such a discussion may prevent the partner from responding to perceived rejection with an angry retort, thus preventing an escalation of posttraumatic symptoms.

The patient should be active in determining her or his medical and mental health care. A referral for crisis intervention should be made, and, if possible, the patient should speak with the aftercare clinician at the crisis center to maximize adherence to aftercare treatment. If the patient is having difficulties managing his or her feelings, physical symptoms, or postrape adjustment, he or she should return to the emergency service or the crisis center.

The SANE program

Many emergency services use the Sexual Assault Nurse Examiner (SANE) program developed in 1976 by Ledray (1,2,7) through collaboration with nurses, physicians, hospital administrators, district attorneys, local police, and rape crisis advocates. Although the central focus of the SANE program is on proper evidence collection, the broader goal is to facilitate the return of the victim to his or her pretrauma functioning status and to involve the victim in medical decisions. SANE aims to strengthen the victim by serving as an advocate and providing evidence if the victim wants to pursue criminal charges. Collection of forensic evidence, expert testimony, treatment for sexually transmitted diseases, pregnancy prevention, and psychological counseling are components of the SANE program (1). If the SANE program is not used, the rape treatment team should be trained in the proper collection of evidence, as required by state laws, and be familiar with the standard rape evidence kit.

Medical and forensic examinations

The accepted time interval between the rape or sexual assault and the collection of evidence is determined by the state's legal standards; if these time standards have been exceeded, only the medical examination is performed (1,7). The patient's history is part of his or her legal statement and must include the patient's detailed account of the rape or sexual assault. If there is a language barrier, a hospital interpreter is required, because the use of a family member or friend in this capacity is inappropriate and violates state evidence-collection rules. General medical information, including information on physical illnesses, past or present psychiatric disorders, allergies, current pregnancy status, and date of last menstrual period, if applicable, should be documented. A family history of psychiatric disorders is important, because such a history may be predictive of postrape mental health sequelae (8).

It is important to describe the examination and ascertain that the patient understands the examination procedures and is capable of providing informed consent. After the patient has given informed consent, the patient's clothing is collected and a general medical evaluation is completed; attention is given to signs of physical trauma (1,2,3,7). Samples of sperm and seminal fluid are collected as evidence by means of oral, anal, and vaginal examination. Additional evidence is collected from fingernail scrapings, swabs of blood, and saliva and from seminal fluid, hair, and fibers from the victim's body or clothing. The victim's blood, saliva, and hair are collected for comparison. If symptoms of reexperiencing or psychological distress are noted, psychological support is provided to help the patient recognize that he or she is not back at the scene of the rape and is not alone but is safe in the hospital and having a physical examination.

Date or acquaintance rape may be complicated by the use of amnesic drugs, such as flunitrazepam and gamma-hydroxybutyrate, leaving the victim without memory of the rape. In addition, alcohol and other drugs of abuse may be associated with rape. Screening for these agents should be part of the medical and forensic examinations (9).

Prophylactic medical treatment of sexually transmitted diseases varies according to treatment center protocols. If the victim's hepatitis B status is unknown, a first dose of the hepatitis B vaccine should be given, along with instructions for follow-up doses (1,3). Because the risk of pregnancy as a result of rape is estimated to range from 2 percent to 5 percent, female patients of childbearing age may be offered medications for prophylaxis after current pregnancy status has been determined (3, 11). Patients should be informed that this treatment is 75 percent effective and that a repeat pregnancy test should be performed if menstruation does not occur within 21 days.

Prophylactic emergency treatments for HIV should be administered. Because the protocols for such treatments are likely to continue to be refined as more is learned about this virus, it is essential that the rape treatment team consult with an HIV or infectious disease expert.

When the examinations have been completed, the mental health clinician should assess the patient's psychological status and provide necessary interventions. The patient's coping status and plans for follow-up treatments—both physical treatment and mental health care—should be reviewed.

Conclusion

The emergency mental health treatment of rape is complex because rape is not only an individual physical and psychological trauma but is also a crime. The required evidence collection and medical treatment may trigger symptoms of reexperiencing or shifts to survival-mode functioning, requiring ongoing psychological assessment and interventions to maintain psychological safety and effective coping skills. Psychoeducation about normal responses after rape and the need for ongoing community and family support will help to promote recovery.

Dr. Osterman is director of residency training and medical student programs in psychiatry and assistant professor of psychiatry at the Boston University School of Medicine, 850 Harrison Avenue, Dowling 7 South, Boston, Massachusetts 02118 (e-mail, [email protected]). Ms. Barbiaz is a psychiatric nurse specialist at Lawrence Memorial Hospital in Medford, Massachusetts. Dr. Johnson is vice chair for clinical services at Boston Medical Center and assistant professor of psychiatry at the Boston University School of Medicine. Douglas H. Hughes, M.D., is editor of this column.