Measuring the quality of medical care for women who experience sexual assault with data from the National Hospital Ambulatory Medical Care Survey

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.

Characteristics of acute sexual assault care in New England emergency departments

Objective

Interventions such as written protocols and sexual assault nurse examiner programs improve outcomes for patients who have experienced acute sexual assault. How widely and in what ways such interventions have been implemented is largely unknown. We sought to characterize the current state of acute sexual assault care in New England.

Methods

We conducted a cross-sectional survey of individuals acute with knowledge of emergency department (ED) operations in relation to sexual assault care at New England adult EDs. Our primary outcomes included the availability and coverage of dedicated and non-dedicated sexual assault forensic examiners in EDs. Secondary outcomes included frequency of and reasons for patient transfer; treatment before transfer; availability of written sexual assault protocols; characteristics and scope of practice of dedicated and non-dedicated sexual assault forensic examiners (SAFEs), provision of care in SAFEs' absence; availability, coverage, and characteristics of victim advocacy and follow-up resources; and barriers to and facilitators of care.

Results

We approached all 186 distinct adult EDs in New England to recruit participants; 92 (49.5%) individuals participated, most commonly physician medical directors (n = 34, 44.1%). Two thirds of participants reported they at times have access to a dedicated (n = 52, 65%, 95% confidence interval [CI], 54.5%-75.5%) or non-dedicated (n = 50, 64.1%; 95% CI, 53.5%-74.7%) SAFE, but fewer reported always having this access (n = 9, 17.3%; 95% CI, 7%-27.6%; n = 13, 26%; 95% CI, 13.8%-38.2%). We describe in detail findings related to our secondary outcomes.

Conclusions

Although SAFEs are recognized as a strategy to provide high-quality acute sexual assault care, their availability and coverage is limited.

Trends in US Emergency Department Use After Sexual Assault, 2006-2019

IMPORTANCE

Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality.

OBJECTIVE

To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation's Uniform Crime Reporting Program, which includes annual crime data from more than 18 000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022.

MAIN OUTCOMES AND MEASURES

Annual SA-related ED visits, subsequent hospital admissions, and associated patient-related factors (age, sex, race and ethnicity, income quartile, and insurance) were analyzed using descriptive statistics.

RESULTS

Data were from 120 to 143 million weighted ED visits reported annually from 2006 through 2019. Sexual assault-related ED visits increased more than 1533.0% from 3607 in 2006 to 55 296 in 2019. Concurrently, admission rates for these visits declined from 12.6% to 4.3%. Female, younger, and lower-income individuals were more likely to present to the ED after SA. Older and Medicaid-insured patients were more likely to be admitted. Overall, the rate of ED visits for SA outpaced law enforcement reporting.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that US adult SA ED visits increased from 2006 through 2019 and highlighted the populations who access emergency care most frequently and who more likely need inpatient care. These data can inform policies and the programming needed to support this vulnerable population.

Emergency Contraception Administration, Toxicology Kit Use, and Postassault Reporting: A Comparison of Sexual Assault Nurse Examiner (SANE) and Non-SANE Medical Providers

Sexual assault nurse examiners (SANEs) are specially trained to meet the postassault medical forensic needs of sexual assault patients. However, there remains a dearth of literature comparing directly postassault service provision and action in cases treated by SANEs as compared to non-SANE medical providers. In this study, we compare rates of emergency contraception administration, toxicology kit use, reports to police at the time of examination, and mandatory child abuse reports among n = 3,969 sexual assault cases treated by SANEs and non-SANE medical providers. Compared to cases treated by non-SANE medical providers, cases treated by SANEs were significantly more likely to have emergency contraception administered, less likely to have a toxicology kit collected, less likely to have a police report filed at the time of examination, and more likely to have a mandatory child abuse report filed. Observed patterns suggest that non-SANE medical providers may find it difficult to balance the needs of the criminal justice system with those of their patients, whereas SANEs provide a tailored, comprehensive first response. We discuss the importance of consistent, accurate documentation and clearly defined protocols in the medical forensic response to sexual assault patients.

Sexual Assault in an Adolescent Female: A Pediatric Simulation Case for Emergency Medicine Providers

INTRODUCTION

Many emergency medicine (EM) physicians have limited training in the care of sexual assault patients. Simulation is an effective means to increase the confidence and knowledge of physicians in such high-stakes, low-frequency clinical scenarios as sexual assault. We sought to develop and implement a sexual assault simulation with a structured debriefing for EM residents and to determine its impact on resident learners' attitudes and knowledge skills in the care of patients with sexual assault.

METHODS

The simulation blended psychomotor skills (e.g., collecting forensic evidence), cognitive skills (e.g., ordering laboratory studies and medications), and communication skills (e.g., obtaining relevant patient history, responding to psychosocial concerns raised by team members and simulator). Our emergency department checklist was available as a cognitive aid for each step of the evidence collection process. A content expert answered questions in real time during the simulation and provided structured debriefing following the simulation. Trainees completed an anonymous survey within a week after the intervention and a follow-up survey within 8 months.

RESULTS

Nineteen EM trainees participated. Presimulation, 39% reported never having received training in the medical care of a patient with sexual assault. The proportion of trainees agreeing or strongly agreeing with the statement "I am comfortable and confident managing a case of sexual assault" increased from 21% to 74% following the simulation (p < .05).

DISCUSSION

This intervention was associated with EM trainees' increased confidence with and knowledge of medical and forensic evaluations for an adolescent with sexual assault.

Women's post-rape experiences with Guatemalan health services

We conducted a qualitative study to examine the critical pathways of 23 women survivors of sexual assault who navigated health care-based services in six states in Guatemala. We also captured the components of quality health care that were important to them, including the experience of the waiting room, being able to make active decisions, providing informed consent, and receiving emotional support. Our results from the in-depth, semi-structured interviews indicate the importance of creating and strengthening mechanisms for social support and trauma-informed, competent, and sensitive health services to accompany women as they move toward rebuilding their lives post-sexual violence.

Development and evaluation of sexual assault training for emergency department staff in Ontario, Canada

OBJECTIVE

The purpose of this evaluation was to assess the efficacy of a training in improving competence to address sexual assault among Emergency Department (ED) staff, as well as to compare in-person and online training modalities.

METHODS

A total of 1564 staff from 76 EDs in acute care hospitals across Ontario participated in either on-site (n = 828 staff) or online (n = 736 staff) training sessions, of whom 1366 (87%) completed both a pre- and post-training questionnaire. Mean pre- and post-training scores measuring perceived competence in responding to victims/survivors of sexual assault were compared using paired t-tests. The mean gain score for in-person and online training was then compared using the Mann-Whitney U test. Finally, in-person and online participants' ratings of the training content and delivery were compared using the Mann-Whitney U test.

RESULTS

There were significant improvements for all 16 self-reported measures of competence following training. The mean gain in knowledge and skills was higher for in-person training participants. Participants in the in-person modality more strongly agreed that the information they learned would help in providing care for sexual assault victims/survivors, and were more satisfied with the training overall. However, these participants less strongly agreed that there was an appropriate amount of time allotted for the scope of material presented.

CONCLUSIONS

Overall, the training led to immediate improvements in ED staff perceived understanding and ability to address the needs of victims/survivors of sexual assault, with particular advantages to the in-person training.

Rape Survivors' Experiences With the Legal and Medical Systems

This study used a naturalistic quasi-experimental design to examine whether rape survivors who had the assistance of rape victim advocates had more positive experiences with the legal and medical systems compared to those who did not work with advocates. Eighty-one survivors were interviewed in two urban hospitals about what services they received from legal and medical system personnel and how they were treated during these interactions. Survivors who had the assistance of an advocate were significantly more likely to have police reports taken and were less likely to be treated negatively by police officers. These women also reported less distress after their contact with the legal system. Similarly, survivors who worked with an advocate during their emergency department care received more medical services, including emergency contraception and sexually transmitted disease prophylaxis, reported significantly fewer negative interpersonal interactions with medical system personnel, and reported less distress from their medical contact experiences.

Sexual Assault Simulation Course for Healthcare Providers: Enhancing Sexual Assault Education Using Simulation

Patients who have been sexually assaulted disproportionately experience gaps in healthcare delivery. Ensuring that healthcare providers who care for this population are adequately prepared is one way of addressing this gap. At the Brigham and Women's Hospital, a 4-hour long interprofessional Sexual Assault Simulation Course for Healthcare Providers (SASH) was developed and conducted at the hospital's Simulation, Training, Research, & Technology Utilization System Center. The SASH is offered using a variety of teaching methodologies including didactics, skill stations comprising how to collect forensic evidence, simulation experience with standardized patient, and debriefing. Using simulation as an educational method allows healthcare professionals to gain hands-on skills in a safe environment. Ultimately, the goal of the SASH is to enhance collaborative practice between healthcare professionals and to improve knowledge, with the purpose of improving care for patients who have been sexually assaulted.

Clinical care for sexual assault survivors multimedia training: a mixed-methods study of effect on healthcare providers' attitudes, knowledge, confidence, and practice in humanitarian settings

Background

Sexual assault is a threat to public health in refugee and conflict affected settings, placing survivors at risk for unintended pregnancy, unsafe abortion, STIs, HIV, psychological trauma, and social stigma. In response, the International Rescue Committee developed a multimedia training tool to encourage competent, compassionate, and confidential clinical care for sexual assault survivors in low-resource settings. This study evaluated the effect of the training on healthcare providers’ attitudes, knowledge, confidence, and practices in four countries.

Methods

Using a mixed-methods approach, we surveyed a purposive sample of 106 healthcare providers before and 3 months after training to measure attitudes, knowledge, and confidence. In-depth interviews with 40 providers elaborated on survey findings. Medical record audits were conducted in 35 health facilities before and 3 months after the intervention to measure healthcare providers’ practice. Quantitative and qualitative data underwent statistical and thematic analysis.

Results

While negative attitudes, including blaming and disbelieving women who report sexual assault, did not significantly decrease among healthcare providers after training, respect for patient rights to self-determination and non-discrimination increased from 76% to 91% (p < .01) and 74% to 81% (p < .05) respectively. Healthcare providers’ knowledge and confidence in clinical care for sexual assault survivors increased from 49% to 62% (p < .001) and 58% to 73% (p < .001) respectively following training. Provider practice improved following training as demonstrated by a documented increase in eligible survivors receiving emergency contraception from 50% to 82% (p < .01), HIV post-exposure prophylaxis from 42% to 92% (p < .001), and STI prophylaxis and treatment from 45% to 96% (p < .01).

Conclusions

Although beliefs about sexual assault are hard to change, training can improve healthcare providers’ respect for patient rights and knowledge and confidence in direct patient care, resulting in more competent and compassionate clinical care for sexual assault survivors.

Substance use among women receiving post-rape medical care, associated post-assault concerns and current substance abuse: results from a national telephone household probability sample

OBJECTIVE

To examine post-rape substance use, associated post rape medical and social concern variables, and past year substance abuse among women reporting having received medical care following a most recent or only lifetime incident of rape.

METHOD

Using a subsample of women who received post-rape medical care following a most recent or only rape incident (n=104) drawn from a national household probability sample of U.S. women, the current study described the extent of peritraumatic substance use, past year substance misuse behaviors, post-rape HIV and pregnancy concerns, and lifetime mental health service utilization as a function of substance use at time of incident.

RESULTS

One-third (33%) of women seeking post-rape medical attention reported consuming alcohol or drugs at the time of their rape incident. Nearly one in four (24.7%) and one in seven (15%) women seeking medical attention following their most recent rape incident endorsed drug (marijuana, illicit, non-medical use of prescription drugs, or club drug) use or met substance abuse criteria, respectively, in the past year. One in twelve (8.4%) women reported at least monthly binge drinking in the past year. Approximately two-thirds of women reported seeking services for mental health needs in their lifetime. Post-rape concerns among women reporting peritraumatic substance use were not significantly different from those of women not reporting such use.

CONCLUSIONS

Substance use was reported by approximately one-third of women and past year substance abuse was common among those seeking post-rape medical care. Implications for service delivery, intervention implementation, and future research are discussed.

Minority women victims of recent sexual violence: disparities in incident history

AIMS

The aims of this descriptive study were to (1) describe assault and care characteristics and (2) determine differences in assault and care characteristics between black women and white women who sought emergency care following sexual violence.

METHODS

A retrospective, cross-sectional design was used to examine forensic examination data characterizing the incident history reported by women victims of sexual violence at the time of a forensic nurse examination. Examinations occurred at an urban university-affiliated hospital emergency department (ED) over a 2-year period.

RESULTS

Of the women (n = 173) seeking care in the ED, 58.4% were black and 41.6% were white. When compared with white women, black women were more likely to have weapons used in their assaults (42.6% vs. 16.7%, p < 0.00) and to be assaulted in the city rather than the suburbs (82.8% vs. 56.5%, p < 0.00). In general, substance use prior to the assault was reported to have occurred in 49.1% of the victims and 41% of the assailants; however, differences existed in the type and pattern of substance use by race/ethnicity. Black victims were more likely to report use of illicit drugs (28.7% vs. 12.5%, p = 0.01). White women were more likely than black women to report personal alcohol use prior to their assault, with significant differences for drinking by victims (47.2% vs. 23.8%, p = 0.01) or assailant use of alcohol (47.2% vs. 23.8%, p = 0.00). White women were more likely than black women to report both they and the assailant had used some type of substance (38.9 vs. 21.8, p = 0.01). Black women were more likely to arrive to the ED via EMS services (45.5% vs. 29.2%, p = 0.03). There were no reported differences in care characteristics by race.

CONCLUSIONS

Findings from this study suggest that differences exist in assault characteristics between black and white women. Use of substances, including alcohol, plays an important role in sexual violence in women and should be a focus of preventive intervention initiatives when conducting a forensic examination. Both coordinated responses and comprehensive, individualized care by specially trained providers are important in the emergency care of minority women who are victims of recent sexual violence.

Sexual assault nurse examiners' perceptions of the revictimization of rape victims

While Sexual Assault Nurse Examiner programs have improved the treatment of rape victims by offering more compassionate and thorough treatment, SANEs believe victims continue to face revictimization by the medical, criminal justice and legal systems. The purpose of this research is to explore SANEs' perceptions of the revictimization of rape victims by the police, legal system and medical system. Data from interviews with 39 Sexual Assault Nurse Examiners from four East Coast states reveal that most SANEs believe that the medical, criminal justice, and legal systems wield the power to revictimize rape victims. SANEs were more likely to cite the criminal justice system as a source of revictimization, followed by the medical system and legal system. According to SANEs, police contribute to victims' distress through failure to ask questions in a sensitive manner, failure to proceed with investigations, and by asking victim-blaming questions. Revictimization by the legal system results when charges are never filed, cases are postponed or dropped, plea bargains are unsatisfactory, and victims' character and credibility are questioned. Revictimization by the medical system is marked by long waits for medical attention.

Rape Survivors’ Agency Within the Legal and Medical Systems

Many rape survivors seek help from the legal and medical systems post-assault. Previous studies have examined how social system personnel treat survivors, but less attention has been paid to how survivors attempt to shape their interactions with these systems. The purpose of this qualitative study was to examine rape survivors’ agency—the active process in which they engaged to alter their experiences with the legal and medical systems. In-depth face-to-face interviews were conducted with 20 female rape survivors who had contact with the police and a Sexual Assault Nurse Examiner (SANE) program. Analytic induction was the guiding analytic approach. Findings indicate that this group of survivors engaged in three agentic processes in their interactions with the legal and medical systems: compliance in order to increase the likelihood their case would achieve what they deemed to be a successful outcome, defiance through noncompliance in order to protect themselves from further harm, and defiance by challenging the response to their case in order to alter the response to their case. Based on these findings, possible strategies for facilitating survivors’ participation and agency during their help-seeking experiences (e.g., systemic changes to empower survivors, improving the responsiveness of system personnel to survivors’ needs) are discussed. Implications may be of particular interest to rape-victim advocates and legal and medical personnel.

Conscientious Refusals by Hospitals and Emergency Contraception

Hospitals sometimes refuse to provide goods and services or honor patients’ decisions to forgo life-sustaining treatment for reasons that appear to resemble appeals to conscience. For example, based on the Ethical and Religious Directives for Catholic Health Care Services (ERD), Catholic hospitals have refused to forgo medically provided nutrition and hydration (MPNH), and Catholic hospitals have refused to provide emergency contraception (EC) and perform abortions or sterilization procedures. I consider whether it is justified to refuse to offer EC to victims of sexual assault who present at the emergency department (ED). A preliminary question, however, is whether a hospital’s refusal to provide services can be conceptualized as conscience based.

Care provided in visits coded for intimate partner violence in a national survey of emergency departments

PURPOSE

This article describes the health status of and care provided to patients in visits coded to intimate partner violence (IPV) victims in a national survey of emergency departments (EDs). Visits coded for IPV were defined by International Classification of Diseases, 8th edition-Clinical Modification (ICD-9-CM) codes.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey for 1997-2001 were analyzed. The sample consisted of 111 ED visits with ICD codes for IPV (or 12 IPV visits per 10,000 ED visits, and 21 female IPV visits per 10,000 female ED visits).

FINDINGS

The majority of visits coded to IPV were for patients who presented with mild to moderate pain (86%), physical or sexual violence (50%), and injuries to the body (38%). The majority of patients in visits coded to IPV received radiologic testing, wound care, and pain medications (odds ratios [ORs], 1.6, 3.3, and 2.3 respectively). Disposition was mostly referral to another physician or clinic (42%) or return to the ED when needed (20%), but much less to nonphysician services such as social services, support services, and shelters (14%). Uninsured IPV patients were more likely to receive radiologic testing and pain medications (ORs 5.1 and 3, respectively). Patients seen by nurses were 9 times more likely to receive wound care.

CONCLUSION

Caution should be exercised when interpreting the study results because they reflect only coded IPV visits in the ED and these might be the most obvious IPV cases. The results signal the need for further studies to evaluate access to and the quality of care for IPV patients and to improve screening, documentation, coding, and management practices.

HIV testing in US EDs, 1993-2004

OBJECTIVES

The aims of the study were to (1) estimate the incidence rates (IRs) of human immunodeficiency virus (HIV) testing among 13-year-old to 64-year-old patients in US emergency departments (EDs); (2) determine ED compliance with Centers for Disease Control and Prevention (CDC) recommendations for HIV testing for patients with nonsexual blood or body fluid exposures, sexually transmitted diseases (STDs), and sexual assaults; and (3) ascertain if HIV testing in EDs varies by patient demographic characteristics.

METHODS

The ED visits from the National Hospital Ambulatory Medical Care Survey databases (1993-2004) were analyzed. Visits for nonsexual blood or body fluid exposures, STDs, and sexual assaults were identified using diagnosis and cause codes. Incidence rates for HIV testing were estimated by year. Odds ratios (ORs) with 95% confidence intervals were estimated from multivariable logistic regression models using HIV testing as the outcome and demographic characteristics as covariates.

RESULTS

The average IR of HIV testing for 13-year-old to 64-year-old patients from 1993 to 2004 was 0.31%. Of all patients, 35.1% with nonsexual blood or body fluid exposures, 20.4% with sexual assaults, and 2.6% with STDs were tested for HIV. The HIV testing was more frequent among Hispanics (OR, 1.39 [1.06-1.81]), blacks (OR, 1.52 [1.19-1.94]), patients with Medicaid (OR, 2.35 [1.81-3.03]), Medicare (OR, 1.95 [1.20-3.16]), and self-pay/no charge/other type of insurance (OR, 1.74 [1.35-2.23]), and those visiting EDs in the northeastern United States (OR, 1.57 [1.04-2.38]).

CONCLUSIONS

The HIV testing rates are low in US EDs and have changed little for a 12-year period. Compliance with CDC recommendations for HIV testing is poor and not in accordance with risk for infection. Hispanics, blacks, and those without private health care insurance are being tested more frequently than other ED patients.

Compliance with mandated emergency contraception in New Mexico emergency departments

OBJECTIVE

New Mexico enacted a law in 2003 requiring that emergency departments (EDs) offer emergency contraception (EC) to survivors of sexual assault and that both doses be administered in the ED. This investigation sought to examine practices and knowledge of ED providers about EC in the setting of sexual assault.

METHODS

We visited hospitals in New Mexico from July 2005 to December 2005 and administered an 18-item questionnaire to three providers-a physician, a nurse, and a clerk-in the ED. The questionnaire included items related to characteristics of the hospital, knowledge of providers about EC and the law, and ED practices relevant to EC for sexual assault survivors as well as for women who had consensual unprotected intercourse.

RESULTS

Surveys were completed at 33 of 38 hospitals (87%). Overall, 52% of respondents reported that EC was routinely offered to sexual assault survivors, and 33% reported that both doses were administered in the ED. Forty-one percent of RNs, MDs, and clerks reported that EC was offered to sexual assault survivors who were minors regardless of age. Overall, 64% of respondents knew that EC may prevent pregnancy up to 72 hours after unprotected intercourse, and only 12% of respondents reported awareness of any requirements to offer EC to sexual assault survivors. Respondents reported that physicians in the ED more often routinely offered EC to sexual assault survivors (52%) than to women who requested it after consensual sex (20%). Thirty-three percent of respondents indicated parental consent was necessary for minors in the setting of sexual assault, although there is no requirement for parental notification in New Mexico.

CONCLUSIONS

EDs in New Mexico are not universally complying with the law. Better dissemination of the law and education about EC could improve care of sexual assault survivors in New Mexico.

Disparities in the provision of sexually transmitted disease and pregnancy testing and prophylaxis for sexually assaulted women in Rhode Island emergency departments

OBJECTIVES

To determine how often sexually assaulted adult female emergency department (ED) patients are being offered testing and prophylaxis for sexually transmitted diseases (STDs) and pregnancy and identify factors associated with the offering of tests and prophylaxis.

METHODS

This is a retrospective study of ED visits for adult female sexual assault in all Rhode Island EDs from January 1995 through June 2001. The percentage of patients offered testing and prophylaxis was calculated. Multivariable logistic regression was used to identify factors related to testing and prophylaxis use for women sustaining an anal/vaginal assault.

RESULTS

Of the 780 patients, 78.2% sustained anal/vaginal penetration, 5.0% genital touching only, and 3.7% oral sex only, and 13.1% did not know what happened to them. Of those women anal/vaginally assaulted, 83.8% were offered chlamydia/gonorrhea testing, 69.4% syphilis testing, 82.9% pregnancy testing, 77.0% chlamydia/gonorrhea prophylaxis, 47.6% emergency contraception, and 19.2% HIV prophylaxis. In multivariable logistic regression models, patients evaluated at the state's women's hospital instead of academic or community hospitals and those who sustained anal/vaginal assault instead of other assaults had a greater odds of being offered testing and prophylaxis. In some cases, older women were offered testing and prophylaxis less often than younger women.

CONCLUSIONS

Testing and prophylaxis for chlamydia/gonorrhea were used much more often than prophylaxis for emergency contraception and HIV, even for patients who were anal/vaginally assaulted. Disparities in testing and prophylaxis exist by type of hospital and, in some cases, by age. Educational campaigns should be instituted to ensure that all women receive adequate testing and prophylaxis commensurate with the exposure they sustained from a sexual assault.

Compliance in Rhode Island emergency departments with American Academy of Pediatrics recommendations for adolescent sexual assaults

OBJECTIVES

We assessed the offering of American Academy of Pediatrics-recommended tests and prophylaxes after sexual assault to adolescents who presented to Rhode Island emergency departments for 3 categories of sexual exposures: sexual assault, consensual sex, and suspected sexual abuse.

PATIENTS AND METHODS

This study entailed a retrospective review of visits for adolescent sexual exposures across 11 Rhode Island emergency departments between January 1995 and June 2001. Cases were identified through billing codes. Offering of each test and prophylaxis was compared by gender, category of sexual exposure, and type of sexual assault. Multivariable linear regression models were used to identify factors associated with the offering of a greater number of tests and prophylaxes after sexual assault.

RESULTS

The vast majority of emergency department visits for adolescent sexual exposures were by sexually assaulted girls (82.5%). Across the 3 sexual exposure categories, girls were offered tests and prophylaxes more often than boys (eg, chlamydia or gonorrhea testing and prophylaxis). Among sexually assaulted adolescents, 32.8% of girls and no boys were offered all recommended tests and prophylaxes. The multivariable linear regression found that vaginally and/or anally assaulted girls were offered, on average, 2.5 more tests and prophylaxes than patients with other types of sexual assaults. Girls presenting for care at the state's women's health care specialty hospital emergency departments were offered 1.7 more tests and prophylaxes than those evaluated in general hospital emergency departments.

CONCLUSIONS

Many adolescents did not receive American Academy of Pediatrics-recommended tests and prophylaxes after sexual assault. Boys received fewer tests than girls. Testing and prophylaxis varied by type of emergency department. Efforts are needed to improve and standardize emergency department medical management of adolescent sexual exposures.

Sexual assault victims in the emergency department: analysis by demographic and event characteristics

The objective of this study was to analyze demographic and event characteristics of patients presenting to the Emergency Department (ED) for evaluation after sexual assault, using a Sexual Assault Nurse Examiner standardized database. Data were prospectively collected as part of the Sexual Assault Nurse Examiner program at an urban teaching hospital. This study reviewed all ED patient records with a complaint of sexual assault between January 1, 2000 and December 31, 2004. Data were collected on 1172 patients; 92.6% were women, with a mean age of 27 years. The sample was 59.1% black, 38.6% white, and 2.3% "Other." Black victims of sexual assault were significantly more likely to be young (25 years or less) than Whites. Over half (54%) reported involvement of drugs or alcohol during the event. Fifty-three percent knew their assailant(s), and black and young patients were significantly more likely to know the perpetrator(s). Threats of force were common (72.4% of sample), and multiple assailants were uncommon (18.1% of sample). Physical evidence of trauma was present in more than half (51.7%), with increased rates among Whites and older persons. Multivariate analysis showed that race, age, threats, and substance use during the event were independent risk factors for evident trauma on physical examination. Survivors of sexual assault who present to the ED are overwhelmingly female, relatively young, often know the perpetrator of the event, and are likely to be threatened and show signs of physical trauma. Differences between patients according to demographic and event characteristics may have important implications for ED management and treatment plans.

Comprehensive medical care for victims of sexual assault: a survey of Illinois hospital emergency departments

BACKGROUND

Sexual assault is a major public health problem affecting 17 million women in the United States. Hospital emergency departments (EDs) are often the primary point of care for these women. We propose the concept of "comprehensive medical care management" (CMCM) at the primary point of care for victims of sexual assault. The objectives of this study were (a) to describe medical care services provided to sexual assault victims presenting at the EDs in Illinois hospitals, and (b) to identify the percentage of hospitals that always provide all 10 elements of CMCM.

STUDY DESIGN

This is a cross-sectional prevalence study. A 14-item phone survey was administered to 187 eligible EDs in Illinois from July to September 2004. Outcome measures were the percentages of EDs that provide the elements of CMCM: (a) acute medical care; (b) history and physical exam; (c and d) acute and long-term rape crisis counseling; (e and f) prophylactic and therapeutic sexually transmitted infection (STI) management; (g and h) prophylactic and therapeutic HIV management; and (i and j) counseling and provision of emergency contraception.

RESULTS

An 83% response rate of eligible emergency rooms provided the following data: while 100% of emergency rooms provide acute medical care upon presentation, two thirds provide rape crises counseling, two thirds provide STI management, 4 of 10 report counseling and provision of emergency contraceptives, and only 28.2% provide HIV management. About 1 in 10 (9.6%) provides all elements of CMCM.

CONCLUSION

Although there are recommendations from various medical organizations for all 10 elements of CMCM for victims of sexual assault, very few hospitals provide CMCM. Improvements must be made to provide quality comprehensive care for victims of sexual assault.

Patients' emergency contraception comprehension, usage, and view of the emergency department role for emergency contraception

Female Emergency Department (ED) patients were surveyed to determine their comprehension of the concept of emergency contraception (EC), to assess how often they had used EC in comparison to other forms of contraception, and to learn which patients want the ED to provide EC services. Most of the 761 respondents were aged < 35 years (62.1%), never married (42.9%), had been pregnant at least once (70.2%), had never had an abortion (76.1%), had never used EC (90.6%), and had sex with a man within the past month (70.7%). Respondents were 2.5 times more likely to have had an abortion than to have used EC; 85.3% could not correctly answer two questions that assessed comprehension of the concept of EC; 43.1% wanted the ED to offer EC, 55.6% to provide information about EC, and 52.6% to refer patients for EC. Younger patients, those who attended religious services infrequently, patients who had ever used EC, and those at risk of pregnancy were more likely to want the ED to provide EC services.

Emergency department care for victims of sexual offense

PURPOSE

Emergency department (ED) care for sexual offense victims was studied and compared with national treatment guidelines.

METHODS

This retrospective study analyzed data from the 2003 National Hospital Ambulatory Medical Care Survey. ED visits were selected based on the reason for the patient's visit, diagnosis, and cause of visit. ED visits were evaluated as two subgroups: rape or sexual assault and molestation or other sexual offense. Data were analyzed to determine whether certain screening procedures were performed, including pregnancy testing, HIV serology testing, urinalysis, cervical or urethral culture, and urine culture. Medication codes for each patient visit were examined to determine if antibiotics, antiretrovirals, emergency contraceptives, anxiolytics, analgesics, or antiemetics were provided.

RESULTS

In 2003, there were 251,762 ED visits for a sexual offense; 179,149 of these were for sexual assault or rape and 72,613 for molestation or other sexual offense. Nearly 70% of visits did not involve the prescribing of antibiotic therapy, and during only 6.7% of visits was appropriate antibiotic prophylaxis, as recommended by the Centers for Disease Control and Prevention, provided. For female victims age 12 years or older, pregnancy tests were performed during 36.7% of visits for sexual assault or rape and 6.7% of visits for molestation or other sex crimes. Only 13% of sexual assault or rape victims received HIV serology testing. Sufficient care was provided during only 20.4% of all visits for sexual offense victims.

CONCLUSION

The majority of victims of a sexual offense in the United States in 2003 did not receive sufficient care in the ED in accordance with national treatment guidelines.

National Estimates of Sexual Violence Treated in Emergency Departments

STUDY OBJECTIVE

There is little information about sexual violence cases treated in emergency departments (EDs). This study describes ED visits associated with sexual violence and considers the associated health care burden.

METHODS

A descriptive analysis was conducted using nationally representative data on nonfatal injury-related ED visits identified in the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) as sexual violence. To better understand these NEISS-AIP data, additional information about ED management of cases was collected, and additional information was collected from NEISS-AIP coders to determine the percentage of hospitals serving as designated examination facilities for sexual assault.

RESULTS

Of all assault visits to the ED, 4.2% were sexual assault related, which represents an estimated 143,647 ED visits for sexual assault in 2001 to 2002. The majority of sexual assault-related visits involved female and young patients. Nearly half of ED visits for sexual violence had missing perpetrator data. Additional data from hospitals revealed that in 77.8% of the 54 sexual assault cases, someone with specific training completed the examination, and the majority of the hospitals in this study serve as designated examination facilities for sexual assault.

CONCLUSION

Given the dearth of national data on sexual violence cases presented at US EDs, the data presented in this article are useful to understand the impact of sexual violence on the health care system at a national level. More complete documentation of sexual assault-related cases in EDs is needed to get a better estimate of the problem in future studies.

Why SANEs matter: models of care for sexual violence victims in the emergency department

This study examines models of SANE service in the ED and quality of care. Nurse managers of all 82 EDs in Virginia were surveyed (RR 76%). Five models emerged: 1) No SANE services (27.4%); 2) Victims transferred off-site for services (14.5%); 3) Partial coverage of services by ED SANEs (16.1%); 4) SANEs called in from off-site (6.5%); and 5) Full-coverage of services by ED SANEs (35.5%). Models 4 and 5 consistently provided a higher quality of care.

Responding to sexual assault victims' medical and emotional needs: a national study of the services provided by SANE programs

We measured the consistency with which a national random sample of 110 Sexual Assault Nurse Examiner (SANE) programs provided 17 services to sexual assault victims. SANE programs consistently offered forensic evidence collection, sexually transmitted infection (STI) prophylaxis, information on HIV, information on pregnancy risk, and referrals to community resources. Reasons programs did not routinely offer particular services (e.g., STI cultures, HIV testing/prophylaxis, emergency contraception (EC)) included financial constraints, difficulties balancing medical care with legal prosecution, and affiliations with Catholic hospitals.

Sexual Assault Nurse Examiner (SANE) Program Goals and Patient Care Practices

PURPOSE

To examine Sexual Assault Nurse Examiners (SANE) programs' goals and guiding philosophies and how they influence patient care practices for sexual assault victims.

DESIGN

Data were collected from a national random sample of SANE to examine whether programs differed significantly in their goals and patient care practices.

METHODS

Iterative cluster analysis was used to identify types of programs distinct in their stated goals.

FINDINGS

Three types of emphasis in SANE programs were identified: (a) prosecution of cases as a primary goal; (b) attending to patients' emotional needs, supporting feminist values, empowering patients, and changing the community response to rape; and (c) least importance on prosecution of cases and average importance on the other goals. Programs that were more focused on prosecution goals provided less comprehensive patient services.

CONCLUSIONS

Programs focused on prosecution as a primary goal were less likely to provide comprehensive services, especially those involving patient education. Such information is important for patients because their health concerns (e.g., pregnancy, STIs) have long-term implications for their well-being. Historical and structural differences among SANE programs might explain these different patient care practices. Researchers should examine the underlying processes in SANE programs that shape both their goals and patient care approaches.

Nonprescription Availability of Emergency Contraception in the United States: Current Status, Controversies, and Impact on Emergency Medicine Practice

In October 2004, the American College of Emergency Physicians Council joined more than 60 other health professional organizations in supporting the nonprescription availability of emergency contraception. This article reviews the history, efficacy, and safety of emergency contraception; the efforts toward making emergency contraception available without a prescription in the United States; the arguments for and against nonprescription availability of emergency contraception; and the potential impact nonprescription availability could have on the practice of emergency medicine in the United States.

Emergency contraception for sexual assault victims: an advocacy coalition framework

A bill was introduced into the Tennessee legislature in the 2005 session that would require emergency departments to offer and dispense emergency contraception to sexual assault survivors who are at risk of pregnancy. Several advocacy groups collaborated to form the Women's Health Safety Network for the purpose of communicating as one voice. The advocacy coalition framework of policy development is applied to the political system and is used as a model to discuss issues impacting policy development for this particular bill. Key actors, proponents, and opponents to this bill are presented along with constraints to policy acceptance. The challenge for emergency contraception advocates on a state and national level is to keep the focus on public health science, the health and well-being of women, and out of the abortion debate.

The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes

In sexual assault nurse examiner (SANE) programs, specially trained forensic nurses provide 24-hour-a-day, first-response medical care and crisis intervention to rape survivors in either hospitals or clinic settings. This article reviews the empirical literature regarding the effectiveness of SANE programs in five domains:(a) promoting the psychological recovery of survivors, (b) providing comprehensive and consistent post-rape medical care (e.g., emergency contraception, sexually transmitted disease [STD] prophylaxis), (c) documenting the forensic evidence of the crime completely and accurately, (d) improving the prosecution of sexual assault cases by providing better forensics and expert testimony, and (e) creating community change by bringing multiple service providers together to provide comprehensive care to rape survivors. Preliminary evidence suggests that SANE programs are effective in all domains, but such conclusions are tentative because most published studies have not included adequate methodological controls to rigorously test the effectiveness of SANE programs. Implications for practice and future research are discussed.

Sexual assault in Virginia: A population-based study

PURPOSE

Sexual assault is a serious social problem that affects the lives of many women, men, and children. Most sexual assaults are not reported to authorities and most victims do not seek services. As a result, accurate statistics on the prevalence and incidence of this problem are difficult to obtain. As in many states, the magnitude of sexual assault in Virginia is not known. This study was conducted to estimate the prevalence and determine the correlates of sexual assault among women in Virginia.

METHODS

A cross-sectional telephone survey was conducted among adult female residents of Virginia between November 2002 and February 2003. A total of 1,769 women aged 18 and older were interviewed using a random digit dialing method.

RESULTS

The lifetime prevalence of sexual assault in Virginia was 27.6%. The majority (65%) were rape victims with a prevalence of 17.8%. Approximately 78% of the victims reported that the sexual assault occurred for the first time when they were children or adolescents. Women who reported sexual assault were more likely to be between 35 and 44 years old (OR = 3.57; 95% CI = 2.06-6.15), divorced/separated/widowed (OR = 1.61; 95% CI = 1.13-2.30), consume alcohol four or more times a week (OR = 1.80; 95% CI = 1.01-3.21), ideate suicide (OR = 4.48; 95% CI = 3.23-6.23), and perceive their health status to be poorer (OR = 2.74; 95% CI = 1.30-5.83).

CONCLUSION

Sexual assault is a major public health problem in the Commonwealth of Virginia and children are disproportionately affected by the problem. Interventions and prevention programs should focus on children and adolescents.

Emergency contraception in emergency departments in Oregon, 2003

OBJECTIVES

We sought to learn about access to emergency contraception (EC) in Oregon emergency departments, both for women who are rape patients and for women who have had consensual unprotected sexual intercourse ("nonrape patients").

METHODS

We interviewed emergency department staff in 54 of Oregon's 57 licensed emergency departments in February-March 2003 (response rate = 94.7%).

RESULTS

Only 61.1% of Oregon emergency departments routinely offered EC to rape patients. Catholic hospitals were as likely as non-Catholic hospitals to routinely offer EC to rape patients. The hospitals most likely to routinely offer EC to rape patients had a written protocol for the care of rape patients that included offering EC (P = .02) and access to staff with specialized sexual assault training (P=.002). For nonrape patients, 46.3% of emergency departments discouraged the prescribing of EC. Catholic hospitals were significantly less likely than non-Catholic hospitals to provide access to EC for nonrape patients (P=.05).

CONCLUSIONS

Oregon emergency departments do not routinely offer EC to women who have been raped or to women who have had consensual unprotected sexual intercourse.

What really happened? A validation study of rape survivors' help-seeking experiences with the legal and medical systems

Much of what is known about rape survivors' experiences with the legal and medical systems has come from victims' accounts; rarely have researchers collected "the other side of the story" to find out what system personnel say did or did not happen in these interactions. In the current study, rape survivors who sought emergency medical care were interviewed before their hospital discharge about what services they received and how they were treated by social system personnel. Corresponding accounts were then collected from doctors, nurses, and police officers. There was significant interrater reliability between the survivors and legal and medical system personnel regarding what services were or were not provided ("service delivery") and if system personnel engaged in "secondary victimization" behaviors (i.e., statements/actions that could be distressing to victims). However, police officers and doctors significantly underestimated the impact they were having on survivors. Victims reported significantly more post-system-contact distress than service providers thought they were experiencing.

Sexual assault services delivered by SANEs

Sexual Assult Nurse Examiner (SANE) programs have become the standard of care for sexual assault victims in many urgent care settings. This study examines SANE clinical nursing practices at one Canadian sexual assault urgent care centre.

Acute Forensic Medical Procedures Used Following a Sexual Assault Among Treatment-Seeking Women

Despite the negative physical and mental health outcomes of sexual assault, a minority of sexually assaulted women seek immediate post-assault medical and legal services. This study identified the number and types of acute forensic medical procedures used by women presenting at a hospital-based urgent care centre between 1997 and 2001 within 72 hours following a reported sexual assault. The study also examined assault and non-assault factors associated with the use of procedures. It was hypothesized that assault characteristics resembling the stereotype of rape would be associated with the use of more procedures. The multiple regression indicated that injury severity, coercion severity, homelessness, and delay in presentation were significantly associated with the number of procedures received. Findings provide partial support for the hypothesis that post-assault procedures would be associated with the stereotype of rape, and highlight homeless women as a group particularly at risk for not receiving adequate medical treatment following a sexual assault.

Emergency department management of sexually transmitted infections in US adolescents

STUDY OBJECTIVE

Adolescents are at risk for developing a variety of sexually transmitted infections for many reasons. Many of these adolescents present to the emergency department (ED) for their care. We describe the management of adolescent sexually transmitted infections in US EDs.

METHODS

Data were obtained from the 1992 to 1998 National Hospital Ambulatory Medical Care Survey. All visits by adolescents aged 12 to 19 years were identified by any International Classification of Diseases, Ninth Revision code related to sexually transmitted infections. Treatment was reviewed and compared with existing guidelines from the US Centers for Disease Control and Prevention (CDC). Multivariate logistic regression was used to determine the independent association of each of the following variables on antibiotic prescribing rates: sex, race and ethnicity, hospital location, age, and insurance.

RESULTS

Eighteen thousand nine hundred ninety-nine records that represented 70,693,603 adolescent visits to US EDs were identified during the 7-year study period, of which 351 records representing 1.2 million visits were for a sexually transmitted infection. Mean age was 17.1 years, and 92% were female patients. Overall, 80% of patients diagnosed with a sexually transmitted infection were treated (received antibiotics or were admitted to the hospital); 91% of patients had pelvic inflammatory disease and 71% of patients had other sexually transmitted infections. Eight percent of patients diagnosed with pelvic inflammatory disease were admitted to the hospital. However, treatment for female patients with pelvic inflammatory disease was fully compliant with CDC recommendations in only 35% of cases (95% confidence interval [CI] 19% to 45%) and partially compliant in another 45%; 20% (95% CI 12% to 31%) of patients received either no treatment or treatment not in accordance with guidelines. Male patients were more likely to be treated for sexually transmitted infection (adjusted odds ratio [OR] 6.3; 95% CI 1.0 to 38.7), and Hispanic patients were less likely (adjusted OR 0.3; 95% CI 0.1 to 0.9) to be treated. Age, insurance type, and hospital location were not a factor in receiving antibiotics. For female patients who had a sexually transmitted infection, only 43% had a pregnancy test done, and of all adolescents diagnosed with a sexually transmitted infection, only 1 (0.3%) had an HIV test performed.

CONCLUSION

Significant numbers of adolescents sought care for sexually transmitted infections in US EDs. Evaluation and treatment of these adolescents is not optimal. Male patients are more likely to be treated for a sexually transmitted infection. Hispanic patients are less likely to be treated for a sexually transmitted infection. Pelvic inflammatory disease is not always treated with antibiotics, and few patients with pelvic inflammatory disease are admitted to the hospital. HIV testing was almost never done. Further study is necessary to explain these disparities and optimize care.

Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault

BACKGROUND

The medical response to adult sexual assault should comprise: the collection of forensic evidence, the treatment of injuries, and follow-up counselling. In the past, victims of sexual assault reporting directly to the police may not have received this total medical care. The Copenhagen Center for Victims of Sexual Assault at Rigshospitalet, Denmark offers a 24-h service. Medical treatment and psychosocial follow up is offered independent of police reporting. The aim of this study was to assess whether adult sexual assault victims who reported to the police differed from those who did not report to the police.

METHODS

Using clinical records, sociodemographics, characteristics of the assault, and type of preventive medical treatment received were obtained for 156 consecutive women consulting the Copenhagen Center (March 1st to December 31st 2000). Comparisons between characteristics of victims who reported to the police or not were determined.

RESULTS

Ninety-four (60.2%) of the women reported to the police. Women who sought services within 24 h of the assault, had experienced use of force, were subjected to assault outdoors, and among whom nongenital injuries were observed were more likely to report to the police (p < 0.05). However, in the multivariate model these associations fell below significance, and only the type of perpetrator remained significantly related to police reporting. The adjusted odds ratio for police reporting when the perpetrator was a friend was 0.4 (95% CI 0.17-0.94). There was no statistical difference between the victims who did or did not report to the police to request prophylactic antibiotics or emergency contraception.

CONCLUSION

Observed injuries and requests for prophylactic antibiotics or emergency contraception were not influenced by whether the woman did or did not report directly to the police. Hence the need for medical treatment appears to be similar in the two groups, and available specialized care for victims of sexual assault should not be restricted to those who immediately report to the police.