Health care utilization by women sexual assault survivors after emergency care: Results of a multisite prospective study

Trauma- and Violence-Informed Empowering Care for Sexual Assault Survivors

BACKGROUND

Forensic nurse examiners, including sexual assault nurse examiners, provide care for survivors holistically through healthcare, emotional support, connection to follow-up care, safety planning, and, if desired, evidence collection to aid in the prosecution of sexual assault. There is increasing recognition that trauma-informed care must also include an understanding of the impacts of structural violence on minoritized patients to ensure health equity.

AIM

To help address this guidance gap, we expanded Campbell and colleagues' empowering care model using a trauma- and violence-informed care (TVIC) lens.

METHODS

We used an iterative discussion-based process that included five joint meetings between a seven-member transdisciplinary research team and a five-member nurse advisory board.

RESULTS

In a TVIC-informed empowering care model, we propose behavioral examples for forensic nurses for each of Campbell et al.'s five key domains of empowering care for forensic nurse examinations (i.e., build rapport and establish trust, show compassion, provide patient-directed care, convey professionalism, and provide resource referral and follow-up).

CONCLUSIONS

These behavioral examples for nurses can help guide forensic nurse training and practice to reduce disparities in treatment and follow-up support. Structures and systems are needed that enable forensic nurses to provide trauma- and violence-informed empowering care to survivors of sexual assault and, over time, increase the accessibility of forensic nurse examinations and improve patient outcomes.

Web-Based Screening, Brief Intervention, and Referral to Treatment for Traumatic Stress and Alcohol Misuse Among Survivors of Sexual Assault and Intimate Partner Violence: Usability and Acceptability Study

BACKGROUND

Recent survivors of intimate partner violence (IPV) and sexual assault (SA) are at a high risk for traumatic stress and alcohol misuse. IPV and SA survivors face barriers to services for traumatic stress and alcohol misuse and have low service utilization rates. One way to increase access to services for this population is the use of web-based screening, brief intervention, and referral to treatment (SBIRT), an evidence-informed approach for early identification of traumatic stress and alcohol and drug misuse and connecting individuals to treatment.

OBJECTIVE

This study aims to assess the usability and acceptability of a web-based SBIRT called CHAT (Choices For Your Health After Trauma) tailored to address traumatic stress and alcohol misuse following past-year IPV, SA, or both.

METHODS

Phase 1 involved gathering feedback about usability and acceptability from focus groups with victim service professionals (22/52, 42%) and interviews with past-year survivors of IPV, SA, or both (13/52, 25%). Phase 2 involved gathering feedback about the acceptability of an adapted version of CHAT in an additional sample of recent survivors (17/52, 33%). Survey data on history of IPV and SA, posttraumatic stress disorder symptoms, alcohol and drug use, and service use were collected from survivors in both phases to characterize the samples. Qualitative content and thematic analyses of the interviews and focus group data were conducted using a coding template analysis comprising 6 a priori themes (usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance).

RESULTS

Six themes emerged during the focus groups and interviews related to CHAT: usability, visual design, user engagement, content, therapeutic persuasiveness, and therapeutic alliance. Phase 1 providers and survivors viewed CHAT as acceptable, easy to understand, and helpful. Participants reported that the intervention could facilitate higher engagement in this population as the web-based modality is anonymous, easily accessible, and brief. Participants offered helpful suggestions for improving CHAT by updating images, increasing content personalization, reducing text, and making users aware that the intervention is confidential. The recommendations of phase 1 participants were incorporated into CHAT. Phase 2 survivors viewed the revised intervention and found it highly acceptable (mean 4.1 out of 5, SD 1.29). A total of 4 themes encapsulated participant's favorite aspects of CHAT: (1) content and features, (2) accessible and easy to use, (3) education, and (4) personalization. Six survivors denied disliking any aspect. The themes on recommended changes included content and features, brevity, personalization, and language access. Participants provided dissemination recommendations.

CONCLUSIONS

Overall, CHAT was acceptable among victim service professionals and survivors. Positive reactions to CHAT show promise for future research investigating the efficacy and potential benefit of CHAT when integrated into services for people with traumatic stress and alcohol misuse after recent IPV and SA.

Acceptability of a smartphone-based intervention targeting anxiety sensitivity among women receiving emergency care after sexual assault: A pilot uncontrolled trial

Anxiety sensitivity (AS), defined as the fear of anxious arousal, is a promising therapeutic target to reduce posttraumatic stress disorder (PTSD) symptom development after trauma exposure. Computerized AS interventions have been shown to be acceptable to individuals with PTSD symptoms and effective in achieving symptom reduction; however, to our knowledge, no research has examined AS interventions initiated in the immediate aftermath of trauma. We evaluated the feasibility, acceptability, and credibility of a brief (i.e., ∼75 min of psychoeducation, ∼2 hr of ecological momentary intervention) smartphone-based AS intervention in a pilot study. Participants were 12 women who presented for emergency care after sexual assault with high levels of peritraumatic PTSD symptoms. Most women who started the intervention completed the majority of it and reported using the techniques provided. Results indicated that participants perceived the intervention as logical and believed it would help in reducing their symptoms. Qualitative feedback was mostly positive but also indicated concern regarding intervention length. Although not the purpose of the study, results indicated medium-to-large, statistically significant decreases in AS, g = 0.74, and PTSD symptoms, g = 1.20. Overall, these preliminary findings suggest that this novel smartphone-based intervention targeting AS was feasible, acceptable, and credible in this small sample of women receiving emergency care following sexual assault. Treatment outcome data must be considered in the context of natural recovery; however, these promising preliminary feasibility, acceptability, and credibility data support continuing to pilot the feasibility and potential efficacy of the intervention to reduce AS and prolonged PTSD symptoms.

Adolescent Female Victims of Sexual Violence: Analysis of Loss of Follow-up after Emergency Care and Outpatient Follow-up

OBJECTIVE

 To assess the loss to follow-up after emergency care and during 6-months of outpatient follow-up, and the associated variables, among adolescent sexual violence survivors.

METHODS

 This is a retrospective study with review of the medical records of 521 females, aged 10 to 18 years, who received emergency care in a referral service in São Paulo, Brazil. The variables were sociodemographic; personal history; characteristics of abuse, disclosure, and reactions triggered after abuse (physical and mental disorders as well as social changes), psychotropic prescription needs, and moment of abandonment: after emergency care and before completing 6 months of outpatient follow-up. To compare groups of patients lost to follow-up at each time point, we used the Chi-square and Fisher exact tests followed by multiple logistic regression with stepwise criterion for selection of associated variables. We calculated the odds ratio with confidence interval (OR, CI 95%). The level of significance adopted was 5%.

RESULTS

 A total of 249/521 (47.7%) adolescents discontinued follow-up, 184 (35.3%) after emergency care and 65 (12.4%) before completing outpatient follow-up. The variables of living with a partner (OR = 5.94 [CI 95%; 2.49-14.20]); not having a religion (OR = 2.38 [CI 95%;1.29-4.38)]), having a Catholic religion [OR =  2.11 (CI 95%; 1.17-3.78)]; and not disclosing the abuse [OR = 2.07 (CI 95%; 1.25-3.44)] were associated with loss to follow-up after emergency care. Not needing mental disorder care (OR = 2.72 [CI 95%; 1.36-5.46]) or social support (OR = 2.33 [CI 95%; 1.09-4.99]) were directly associated with loss to outpatient follow-up.

CONCLUSION

 Measures to improve adherence to follow-up should be aimed at adolescents who live with a partner and those who do not tell anyone about the violence.

Variation in rates of sexual assault crisis counsellor usage during forensic examination in California: an observational study

OBJECTIVES

A critical asset to post-assault care of survivors is support from sexual assault crisis counsellors (SACCs). We sought to elucidate variation in implementation between California counties in SACC accompaniment during Sexual Assault Forensic Examination (SAFE).

METHODS

SACC attendance data from 2019 was obtained from the California Governor's Office of Emergency Services (CalOES). To assess SACC attendance rates during SAFEs, we requested SAFE quantity data from sheriffs and public health departments, the State Forensic Bureau, and the California Department of Justice (DOJ), but all requests were unanswered or denied. We also sought SAFE data from District Attorneys (DAs) in each county, and received responses from Marin and Contra Costa Counties. To estimate numbers of SAFEs per county, we gathered crime statistics from the Federal Bureau of Investigation's (FBI's) Uniform Crime Reporting Program and OpenJustice, a transparency initiative by the California DOJ. For each data source, we compared SACC attendance to SAFE quantities and incidences of sexual assault statewide.

RESULTS

At the state level, data on SACC attendance per CalOES and DOJ archival data on sexual assault were used to approximate relative rates of SACC accompaniment at SAFEs; 83% (30 of 36) of counties had values <50%. The joint sexual assault crisis centre for Contra Costa and Marin Counties reported that 140 SACCs were dispatched in 2019, while DAs in Contra Costa and Marin reported completion of 87 SAFEs in 2019, for a calculated SACC accompaniment rate of 161%. Proxy data sourced from FBI and DOJ crime statistics displayed significant inconsistencies, and DOJ data was internally inconsistent.

CONCLUSIONS

SACC accompaniment at SAFEs appears to be low in most California counties, however, limited data accessibility and data discrepancies and inaccuracies (e.g., rates over 100%) prevented reliable determination of SACC accompaniment rates during SAFEs. Substantial improvements in data accuracy and transparency are needed to ensure survivors' adequate access to resources.

Mental health of sexual assault victims and predictors of their use of support from in-house psychologists at Belgian sexual assault care centres

BACKGROUND

Sexual assault (SA) can induce a negative impact on victims' mental health. Specialised SA services generally offer medical care and a forensic examination to SA victims. However, there is a large variation in how these services provide mental health support.

OBJECTIVE

This study aims to assess mental health problems of SA victims attending the Belgian Sexual Assault Care Centres (SACCs) and identify predictors for victims' use of support from in-house psychologists.

METHOD

Health records of victims ≥ 16 years who presented within one week post-SA to one of the three Belgian SACCs between 25 October 2017 and 31 October 2019 were reviewed. An AIC-based stepwise backward binary logistic regression was used to analyse the association between victim, assault, service use and mental health characteristics and follow-up by a SACC-psychologist.

RESULTS

Of the 555 victims, more than half had a history of mental health problems. Of those assessed, over 70% showed symptoms of posttraumatic stress disorder (PTSD), depression and/or anxiety disorder. One in two victims consulted a SACC-psychologist. Victims with a mental health history (OR 1.46, p = .04), victims accompanied by a support person during acute care (OR 1.51, p = .04), and victims who were assaulted by an acquaintance in comparison to those assaulted by a stranger (OR 1.60, p = .039) were more likely to attend their appointment with the SACC-psychologist.

CONCLUSION

The study reaffirms the high mental health burden among victims attending specialised SA services, stressing the need to provide effective mental health interventions at these services and improve their longer-term use by victims. Prescheduling of appointments with an in-house psychologist in combination with phone reminders may improve the uptake of such services. Health care providers must be vigilant about potential barriers faced by victims without a mental health history or social support in attending appointments with mental health professionals.

Perceived Barriers and Facilitators to Treatment for Alcohol Misuse Among Survivors and Victim Service Professionals Following Sexual Assault and Intimate Partner Violence

Survivors of sexual assault (SA) and intimate partner violence (IPV) report high rates of alcohol misuse and often receive services from community agencies. We conducted a qualitative study to examine barriers and facilitators to treatment for alcohol misuse after experiences of SA/IPV among survivors (N = 13) and victim service professionals (VSPs; N = 22) at community-based agencies using semi-structured interviews and focus groups. Survivors discussed seeking treatment for alcohol misuse when alcohol is being used to cope with SA/IPV-related distress and when alcohol use becomes problematic. Survivors identified that stigma and acknowledgment of alcohol misuse are individual-level barriers and facilitators to treatment. System-level factors were also described including having access to treatment and sensitive providers. VSPs also discussed individual (e.g., stigma) and system (e.g., availability and quality of services) level barriers and facilitators to treatment for alcohol misuse. Results indicated several unique barriers and facilitators to treatment for alcohol misuse following SA/IPV.

Sexual Assault Nurse Examiners Lead to Improved Uptake of Services: A Cross-Sectional Study

Introduction: Sexual Assault Nurse Examiners (SANE), who are trained to provide comprehensive and compassionate specialty care to sexual assault survivors, are increasingly used in the emergency department (ED), but there is little published literature to support their benefit. In this study we aimed to compare services offered and received by sexual assault survivors in the ED when care was provided by a SANE vs those with traditional care teams, hypothesizing that SANE utilization will be associated with improved uptake of recommended services. Methods: This was a retrospective review examining all patient encounters in which a sexual assault was disclosed in a large, urban, adult ED between June 1, 2019-June 30, 2022. We extracted timeline information from the ED encounter, demographic information, resources offered to and accepted by the patient, clinical care data, and continuity of care data from the medical record. We used unadjusted and adjusted analyses to compare patient demographics and services offered and accepted between SANE and non-SANE encounters. Results: We included a total of 182 encounters in the analysis, of which 130 (71.4%) involved SANEs. Demographics were similar between groups, except there was a larger proportion of cisgender men in the non-SANE group (14.0% vs 5.5%), and the timing of visits differed, with non-SANE visits more common during the overnight shift. All recommended testing, prophylaxis, and resources were offered more frequently during SANE visits, and all but one were more frequently accepted by patients during SANE visits, although not all comparisons reached statistical significance. Conclusion: Patients who received care from a SANE were more often offered recommended services and resources and more frequently accepted them. Making SANE care available at all times to these vulnerable patients would both improve patient outcomes and allow hospitals to meet required quality metrics. States should consider expanding legislation to encourage and fund SANE coverage for all hospitals to support access to vital resources in the ED for survivors of sexual assault.

A preliminary examination of sexual and physical victimization 6 months after recent rape

One in four US women will experience a completed or attempted rape in their lifetime, and more than 50% of survivors will experience two or more rapes. Rape and physical violence also co-occur. Multiple experiences of sexual and physical violence are associated with elevated mental and physical health problems. This secondary analysis examined the prevalence and correlates of experiencing sexual or physical violence within 6 months of a sexual assault medical forensic exam (SAMFE). Between May 2009 and December 2013, 233 female rape survivors aged 15 and older were enrolled in a randomized controlled trial during a SAMFE in the emergency department (ED). Demographics, rape characteristics, distress at the ED, and pre-rape history of sexual or physical victimization were assessed. New sexual and physical victimization was assessed 6 months after the SAMFE via telephone interview. Six months after the exam, 21.7% reported a new sexual or physical victimization. Predictors of revictimization during follow-up included sexual or physical victimization prior to the index rape, making less than $10,000 annually, remembering the rape well, life threat during the rape, and higher distress at the ED. In adjusted models, only pre-rape victimization and making less than $10,000 annually were associated with revictimization. Factors assessed at the ED can inform subsequent victimization risk. More research is needed to prevent revictimization among recent rape victims. Policies to provide financial support to recent rape victims and/or targeted prevention for those with pre-rape victimization at the SAMFE could reduce revictimization risk. TRIAL REGISTRATION: NCT01430624.

"I Want to Be Heard": Rape Victims' Encounters With Swedish Police

Interactions with police are vitally important to victims' ability to process their trauma. This study focused on the experiences of victims who reported a rape to police in Sweden. Thirteen women participated in interviews; the material was analyzed using inductive thematic analysis. Findings include lack of information and the role of luck in finding an understanding officer; some found comfort, and some felt violated once again. Long processing times bound participants to their trauma. Findings highlight the need for improved knowledge of trauma among police, victims' needs for information and rights to support, and structural barriers that need to be addressed.

Impact of Sexual Assault Survivor Identity on Patient Care in the Emergency Department

Interactions between emergency department (ED) staff and sexual assault (SA) survivors can be a source of retraumatization for survivors, increasing their risk of posttraumatic stress and decreasing utilization of longitudinal medical care. Little is known about nationwide trends in ED staff attitudes and behaviors toward survivors, including the impact of survivor identity. We conducted a survey to determine if survivor identity influenced ED staff behaviors. A nationwide survey of SA patient advocates was conducted between June and August 2021. Advocates are volunteers or staff dispatched from rape crisis centers to support survivors during ED care. Advocates participated in an online survey to determine the frequency of observing six potentially retraumatizing provider attitudes and behaviors. Adaptive questioning was used to explore the impact of survivor identity on each attitude or behavior and which identity groups were more likely to be affected. Three hundred fifteen advocates responded to the survey. Less than 10% indicated that ED staff often or always convey disbelief or blame to survivors. Almost 75% of advocates indicated that they often or always observe ED staff showing empathy to survivors. Disparities were found in provider attitudes. Over 75% of advocates observed that survivors' mental health status or substance use impacted conveyed belief from providers. Patients who were intoxicated when assaulted, had psychiatric disorders, were Black, Hispanic/LatinX, or indigenous, or were not cis-females were more likely to experience disbelief. Patients who were white and/or cis-gender females were more likely to be pressured by ED staff to complete the forensic exam and/or report to the police. Our study documents disparities in ED staff behavior towards SA survivors according to survivor identity. Given that post-assault ED interactions are critical turning points in survivors' future medical processes, disparities in ED care may be linked to larger disparities in healing from trauma.

Traumatic Life Experience and Pain Sensitization: Meta-analysis of Laboratory Findings

OBJECTIVES

Psychological trauma often co-occurs with pain. This relationship has been explored using laboratory pain measures; however, findings have been mixed. Previous studies have limited operationalization of trauma (eg, posttraumatic stress disorder) or pain (eg, pain thresholds), which may contribute to conflicting results. Further, prior reviews likely underrepresent trauma experiences among people who are not receiving clinical care, limiting generalizability.

MATERIALS AND METHODS

We systematically reviewed the existing literature on the relationship between psychological trauma (eg, car accidents, sexual assault, childhood abuse, neglect) and laboratory pain (ie, quantitative sensory testing measures of pain threshold, intensity, summation, modulation), using inclusive criteria. The direction of the relationship between psychological trauma and pain sensitivity was evaluated, and moderation by purported pain mechanism (ie, pain detection, suprathreshold pain, central sensitization, inhibition) was explored.

RESULTS

Analyses were conducted using 48 studies that provided 147 effect sizes. A multivariate random-effects model with robust variance estimation resulted in a small but statistically significant overall effect size of g=0.24 (P=0.0002), reflecting a positive association between psychological trauma and enhanced laboratory pain sensitivity. Upon examination of mechanistic moderators, this relationship appears driven by effects on pain detection (g=0.28, P=0.002) and central sensitization (g=0.22, P=0.04). While effect sizes were similar across all moderators, effects on suprathreshold pain and inhibition were not statistically significant.

DISCUSSION

Findings demonstrate an overall pattern of trauma-related pain enhancement and point to central sensitization as a key underlying mechanism.

Distinctive impacts of sexual trauma versus non-sexual trauma on PTSD profiles in highly trauma-exposed, Black women

BACKGROUND

Prior findings suggest that psychopathology following interpersonal trauma or assaultive violence may present differently from prototypical posttraumatic stress disorder (PTSD). However, whether this is true for sexual trauma (ST) in the context of other salient lifetime traumatic experiences is yet unknown. We predicted that ST exposure may result in higher avoidance and numbing symptoms and blunted fear responses, relative to non-sexual trauma (NST), particularly if ST occurred during childhood.

METHODS

Participants were n = 5163 Black women recruited in an urban public hospital. We investigated effects of ST on PTSD symptoms, fear-potentiated startle (FPS) response (n = 285), and amygdala reactivity and habituation to social threat cues with fMRI (n = 95).

RESULTS

ST was associated with greater PTSD symptoms (p = 2.64 × 10^-21), but this was observed across all symptom clusters. Women who experienced repeated ST in both childhood and adulthood showed greater PTSD (p = .0009) and numbing symptoms (p = .002). In the FPS paradigm, the ST group startled more on all blocks and stimulus types than the NST group (p = .004). Developmental timing of ST did not influence startle magnitude. ST was not associated with amygdala habituation or reactivity.

LIMITATIONS

Generalizability is limited to Black women with a high trauma burden. Associations are cross-sectional, limiting causal conclusions.

CONCLUSION

While survivors of ST may present with more severe PTSD symptoms, their profiles are not characteristically different from similar NST controls. Childhood sexual abuse exposure alone did not result in a unique symptom profile. ST represents a uniquely high-burden stressor with likelihood for more severe posttraumatic outcomes.

Prevalence and risk factors for acute stress disorder in female victims of sexual assault

Sexual assault is one of the most traumatic events a person can experience. Despite this, information regarding the risk factors associated with the development of Acute Stress Disorder (ASD) in sexual assault victims is scarce. A follow-up prospective cohort study was designed to examine the prevalence and risk factors of ASD in women exposed to a recent sexual assault. A total of 156 women were treated at the Emergency Department of a university general hospital shortly after sexual assault. Sociodemographic, clinical and sexual assault-related variables were collected. The Acute Stress Disorder Interview was used to estimate the prevalence of ASD at three weeks post-SA. From the 156 victims, 66.6% (N = 104) met ASD diagnosis using DSM-5 criteria, whereas 59.6% (N = 93) met ASD diagnosis using DSM-IV criteria. The risk factors associated with the development of ASD were nationality, psychiatric history, peritraumatic dissociation and type of assault. In conclusion, the prevalence of ASD in female victims of recent sexual assault was high, affecting approximately two thirds of them. The recognition of the risk factors associated with ASD development, like peritraumatic dissociation or type of assault, may aid in the prompt detection of vulnerable women that require early and specific interventions shortly after trauma.

"I still feel so lost": experiences of women receiving SANE care during the year after sexual assault

OBJECTIVE

Emergency caregivers provide initial care to women sexual assault (SA) survivors. An improved understanding of the issues facing this population can aide emergency care practitioners in providing high quality care. The goal of this study was to share the experiences of women SA survivors with the emergency care practitioners that care for them.

METHODS

English-speaking adult women (n = 706) who received SA Nurse Examiner (SANE) evaluation within 72 hours of SA at 1 of 13 geographically distributed sites were enrolled in a prospective, longitudinal multi-site observational study. We qualitatively analyzed responses to the open-ended question: "What do you think is most important for researchers to understand about your experience since the assault?" asked 1 week, 6 weeks, 6 months, and 1 year after enrollment.

RESULTS

Themes from responses (n = 1434) from 590 women (84% of study sample) fell into 12 broad categories: daily life, justice, medical, and social services, mental health, physical health, prior trauma, recovery, romantic relationships, safety, self, shame, and social interactions. Responses demonstrated that the assault permeates many aspects of assault survivors' daily lives.

CONCLUSIONS

Qualitative analyses of open-ended responses from a large cohort of women SA survivors receiving SANE care highlight the challenges for survivors and can increase understanding among the emergency care practitioners who care for them. The authors propose a brief acronym to help emergency care practitioners recall important messages for SA survivors.