9.4: Sexual Abuse and Assault
By the end of this section, you will be able to:
- Summarize the definition of sexual abuse or assault, misinformation about it, and different types of sexual assaults
- Verbalize the characteristics of Rape Trauma Syndrome
- Describe the role of the nurse trained as a SANE and what the postassault exam entails
Any unwanted sexual behavior, such as touching, groping, or rape, that violates a person’s bodily autonomy and consent is considered sexual assault or sexual abuse . It can occur within relationships, in the workplace, or in institutions such as schools or care facilities. Survivors of sexual abuse often experience long-term psychologic and emotional trauma, as well as physical injuries. Sexual abuse is a criminal act in most countries and can result in serious legal consequences for the perpetrator.
Sexual assault comes in various forms, and many misconceptions surround these assaults. The rape victim will experience many physical and psychologic consequences of her attack. Survivors go through a process described as rape trauma syndrome and can experience PTSD. Nurses can be trained to assist in caring for rape survivors and collecting evidence to prosecute perpetrators.
Rape
Any vaginal or anal penetration, or oral penetration by a sex organ without consent is considered rape (U.S. Department of Justice, 2012). Signs of rape may be physical or psychologic. Physical signs of sexual abuse can include bruises around the breasts or genital area, unexplained STI, or unexplained vaginal or anal bleeding (Washington State Department of Social and Health Services, n.d.). Psychologic signs can be emotional distress, fear, anxiety , shame, and psychologic trauma, such as posttraumatic stress disorder (PTSD) or dissociative disorders. The person may report they have been sexually abused. If the nurse suspects sexual abuse, they should follow state and agency guidelines regarding reporting. Sexual abuse may require police reports, so it is essential to be aware of legally required steps nurses must take.
Types of Rape
The definition of rape by the U.S. Department of Justice (2012) does not mention gender when defining the victim and perpetrator, demonstrating that rape is not always male against female. It also states that rape can be performed with an object, not only a body part. Rape is penetration without consent; this lack of consent could be caused by drugs or alcohol, by mental or physical incapacitation, or by the victim’s age being below the age of consent (United States Department of Justice Archives, 2012).
Types of rape include date or acquaintance rape, intimate partner rape, diminished capacity rape, age-related rape, incest, aggravated rape, and other types of rape (Someplace Safe, n.d.; Tracy, 2021). Two-thirds of rapes are committed by someone the victim knows (Tracy, 2021). This type of rape is called date rape or acquaintance rape , which occurs between two people who know one another. When a partner or previous partner sexually assaults the other partner, it is called intimate partner rape . It can include physical assault, torture, perverse sexual acts, and power/control over the other partner (Tracy, 2021). When a person cannot consent to a sexual act because of physical or intellectual disability or intoxication, the sexual act is considered diminished capacity rape . Also known as statutory rape, age-related rape occurs when one sexual partner is below the age of consent, which is determined by each state (Tracy, 2021). Rape of a close family member (e.g., parent and child, uncle and niece or nephew, etc.) is considered incest . Rape that includes a threat of death or bodily harm is called aggravated rape . Other types of rape include gang rape or rape as part of a hate crime (Tracy, 2021).
Common Misinformation about Rape
Rape myth s are false beliefs about rape that are widely held and perpetuated (Tilton, 2022). According to Tilton (2022), these myths include denying the existence of rape, excusing the behavior, and denying that rape is a serious crime. She discusses the mistaken beliefs that women routinely lie about rape, that they could resist rape if they wanted to, and that consent cannot be withdrawn after it has been given. She further describes the myth that women who dress provocatively or who get drunk are “asking for it.” These myths blame the victim and overlook the role of the perpetrator. Other myths include that rape always involves physical force, always happens in dark alleys at night, is committed by strangers, and is committed by a person incapable of caring for women (Tilton, 2022). These myths are debunked by the facts that most rapes are committed by someone close to the victim and do not always involve physical force.
Purity Culture and Rape Myths
A study conducted by Owens et al. (2021) reviewed the relationship between the culture of valuing purity and culture members’ acceptance of rape myths. Purity culture was described as a Christian movement focused on preserving female virginity. The study listed six characteristics of purity culture :
- emphasis on virginity
- prohibition of physical affection
- need for modesty
- sexual gatekeeping
- denial of female bodily autonomy
- lack of education on sexual consent
These characteristics can be dangerous to women. Women in this culture are taught to dress modestly so that men will not “stumble in lust.” This places the burden of responsibility for men’s lust on the woman and causes her shame about her body. Women are taught sexual gatekeeping: that it is their job to deny sex to men, who “inherently have a reduced sexual self-control.” In purity culture, a woman’s body belongs to her future husband, and her worth depends on her virginity until marriage. The purity culture creates an environment where sexual consent is not discussed. Women are taught to refuse sexual encounters prior to marriage but to never refuse their husband’s desire for sex. The purity culture actually denies the existence of spousal rape or sexual assault.
Characteristics of Rapists
Characteristics of rapists are difficult to generalize; however, one study identified the following common characteristics among rapists: lack of empathy, narcissism, and feelings of hostility toward women (Aqel, 2020). Perpetrators use sexual assault to dominate women because rape is a crime of power and violence (Aqel, 2020). Rapists may see women as there to fulfill their sexual needs; women are objects instead of people. Rapists might believe that when a woman says no, they are just “playing hard to get” or challenging him but really mean yes (Aqel, 2020). Men called incels, “involuntary celibates,” believe they are entitled to a romantic or sexual relationship and are known for extreme misogynistic ideas and promotion of violence against women (Trotta, 2022). Several types of rapists exist: the rapist who loses self-control under the influence of drugs or alcohol; the sadist who wants to humiliate victims; the vindictive rapist who shows anger and aggression toward women, believing he has been rejected or wronged by past relationships with women; and rapists who deny rape and justify their actions (Aqel, 2020). The CDC (2021b) suggests the characteristics of an intimate partner perpetrator are low self-esteem, low income, heavy drug and alcohol use, anger and hostility, and having strict gender role ideas of male dominance.
Roles of Substances in Sexual Assault
Drug-facilitated sexual assault occurs when the use of a substance (drugs or alcohol) compromises the victim’s ability to give consent for sex. Intoxication of the partner allows the perpetrator to commit sexual acts with little resistance and can also prevent the survivor from remembering the rape. “Date-rape drugs” are used to incapacitate victims. Alcohol is the most common “date-rape drug” and is easily accessible (Rape, Abuse & Incest National Network [RAINN], n.d.). Other drugs include sleep aids, anxiety medications, muscle relaxers, tranquilizers, and street drugs such as GHB, Rohypnol, ecstasy, and ketamine (RAINN, n.d.). Warning signs that a person has unknowingly been given drugs include difficulty in breathing, feeling drunk when little to no alcohol has been consumed, loss of bladder or bowel control, nausea, sudden change in body temperature, dizziness, disorientation, blurred vision, and waking with no memory or missing large portions of memories (RAINN, n.d.).
Date Rape and Violence on the College Campuses
Sexual assault on college campuses is a common problem. One in five women in college experiences sexual assault, with the highest risk in the first few months of their first or second semester in college (U.S. Department of Health and Human Services’ Office on Women’s Health [USDHHS/OWH], 2021). Sexual assault includes any unwanted sexual activity, from unwanted touching to rape, and often involves alcohol or drugs. Nurses can teach college-aged persons to get to know someone prior to spending alone-time with them, to go to parties with friends instead of alone, to meet dates in public places, to be aware of alcohol or drug intake, to keep control of their drinks, to be aware of their surroundings, and to always have a plan for how to get home (USDHHS/OWH, 2021).
Rape in College Communities
Why is rape so common on college campuses?
- Alcohol and drugs: Assaults on campus many times involve alcohol and drugs. Many college students will experiment with substances for the first time in college. This can lead to incapacitation and rape.
- Lack of reporting sexual assault: Few college-aged women report assault. This allows perpetrators to go unpunished and continue to assault others.
- Peer pressure: College students may feel pressured to use substances, go to parties, and engage in sexual activities that make them uncomfortable.
(U.S. Department of Health and Human Services’ Office on Women’s Health, 2021)
Rape Trauma Syndrome
Rape trauma syndrome is the human reaction to a rape or sexual assault. There are three phases to this syndrome, which can be traversed in a forward and backward direction during the time of healing ( Rape trauma syndrome , 2020).
Phases of Rape Trauma Syndrome
The three phases of rape trauma syndrome include the acute phase, outward adjustment phase, and resolution phase. The acute phase occurs immediately after the assault, lasting a few days to several weeks ( Rape trauma syndrome , 2020). The person experiences three categories of reactions:
- expressed (the person is openly upset, cries, has anxiety attacks),
- controlled (emotionless, acts as if nothing happened), and
- shocked disbelief (strong sense of disorientation, difficulty in concentrating and making decisions, may have poor recall of the assault).
The person then experiences the outward adjustment phase. This phase occurs once the person appears to resume normal life but is experiencing extreme inner turmoil ( Rape trauma syndrome , 2020). The person uses minimization (“everything’s fine”), dramatization (the attack dominates their life and identity), suppression (refuses to discuss the attack), explanation (analyzes what happened), and flight (moving, changing appearance) as coping mechanisms ( Rape trauma syndrome , 2020). Nurses should be aware of the following symptoms of this phase: severe mood swings, fear, depression , rage, insomnia, eating difficulties, withdrawal from friends or family, difficulty in concentrating, and flashbacks.
The resolution phase occurs when the attack is no longer the person’s main life focus. The person has not forgotten the assault but has dealt with and accepted the rape as part of their life history ( Rape trauma syndrome , 2020). The person’s pain and symptoms lessen over time.
Posttraumatic Stress Disorder after Rape
Posttraumatic stress disorder (PTSD) can occur after a sexual assault, and women have a higher incidence of PTSD after rape than men do (Nöthling et al., 2022). Nöthling et al. (2022) found a lifetime PTSD prevalence rate of 36.2 percent in those who experienced rape. The study found that women who were younger and single and who had a lower level of education and lower income developed PTSD more often than those without these risk factors. Positive reliance (having a positive perspective of the world and oneself, positive beliefs about one’s coping mechanisms, positive perceived control over one’s emotional recovery) was found to be protective against developing PTSD. They also found that women with childhood trauma, depression, and alcohol use disorder also had a higher incidence of PTSD. Finally, the study suggested that the severity of the rape (multiple perpetrators, multiple sex acts, physical injuries, and longer duration of assault) can influence the degree of a survivor’s PTSD.
Care and Support of the Sexual Assault Survivor
Sexual assault survivors can experience a variety of adverse health consequences, such as mental health problems, suicidal ideation , PTSD, eating disorders, sexual and reproductive health problems, and chronic illnesses (Cannon et al., 2023). They also are at risk for STIs, pregnancy, and risky behaviors. Nurses help these persons cope with the health consequences of their assault by listening and by providing referrals for mental health providers, resources for support groups, and suicide hotlines.
Long-term effects of sexual abuse can be profound. Survivors may struggle with low self-esteem, trust issues, and difficulty in forming healthy relationships. They may also be at higher risk for developing mental health disorders, such as depression, anxiety , or substance misuse. In some cases, the impact of abuse can be so severe that it can lead to suicidal thoughts or behaviors.
It is essential for anyone who has experienced sexual abuse or assault to seek help and support from trained professionals, as well as from family and friends, to begin the healing process and move forward with their lives. With the right help and support, healing from sexual abuse is possible.
Start by Believing Campaign
Start by Believing (SBB) is a campaign created by End Violence Against Women International ( EVAWI ). EVAWI (n.d.) found that most survivors of sexual assault never report it to authorities due to the response they receive from friends and family. The SBB campaign focuses on preparing professionals and loved ones to respond appropriately to persons discussing their sexual assault. The EVAWI found that negative responses worsen the trauma to survivors and allow perpetrators to go unpunished for their crimes. By others believing the survivor’s story, the person is more likely to talk about their attack and feel heard. The survivor feels that someone believes them, which overcomes the myth that women lie about rape. Women might feel strong enough to report and prosecute the perpetrator if they know they have support. SBB was launched in 2011, and now 701 campaigns exist around the world. These campaigns teach everyone to believe and support the survivor.
Start by Believing emphasizes the importance of supporting survivors of sexual assault and provides guidance on what to say to someone who says they have experienced sexual violence.
Sexual Assault Nurse Examiner
Sexual assault nurse examiner ( SANE ), also known as forensic nurse examiner (FNE), programs were developed to improve services for rape survivors by training nurses to perform forensic exams with the focus on emotional, physical, and legal ramifications of sexual assault (Cannon et al., 2023). SANE programs provide psychologic support, comprehensive health care, forensic evidence collection, expert testimony, and coordination of multidisciplinary services. The SANE also recommends follow-up appointments at 7 to 15 days and again at 12 weeks after the assault. SANE professionals are considered mandatory reporters.
Nurses who wish to be trained as a SANE are drawn to helping adults and children who have experienced sexual violence. This website provides online training to become a SANE from the International Association of Forensic Nurses.
Detailed History
The SANE collects a detailed record of the person’s current health history, medications, social history, and family history. The SANE also takes a detailed history of the assault. Guidelines recommend the survivor seek care within 120 hours of the assault to ensure prevention of STIs, prescription for emergency contraception , and adequate evidence collection (Cannon et al., 2023).
Evidence Collection
Sexual assault nurse examiners perform a medical forensic exam, a thorough head-to-toe exam to document trauma to any part of the body for the purpose of treating trauma, treatment of possible STIs, referral for counseling and medical follow-up, and the collection of evidence to be used in legal proceedings (Paxton, n.d.). The SANE uses an evidence collection kit to gather physical evidence. Evidence collection usually takes place in a hospital emergency department by trained SANEs because it offers a safe environment and is open 24 hours a day. Some colleges and community centers provide SANE collection sites (Cannon et al., 2023). The SANE is trained in collecting the appropriate evidence, and studies have shown that prosecutors have increased the number of guilty pleas from perpetrators because of better evidence collection and evidence of force noted by SANEs (Ledray & Simmelink, 2020).
Preparing for the SANE Exam
A patient who has been raped may come to the emergency department in unstable condition. They may have injuries that need attending to prior to the SANE exam.
The nurse should:
- Assess if the patient has cuts or broken bones that need immediate care.
- Determine any language barriers or cultural considerations.
- Discuss consent for the SANE exam.
- Administer medications as ordered.
Prevention of Sexually Transmitted Infections
The evidence kit collected by the SANE includes testing for STIs. The most frequently diagnosed STIs are gonorrhea , chlamydia , and trichomoniasis; however, HIV, hepatitis B , and syphilis testing is also completed (Ragpa et al., 2019). Prophylactic antibiotics are given for gonorrhea, chlamydia, and trichomoniasis ; and postexposure prophylaxis for HIV is administered (Ragpa et al., 2019). Postexposure hepatitis B vaccination along with immune globulin is recommended in persons previously unvaccinated (Ragpa et al., 2019).
Prevention of Pregnancy
A pregnancy test is performed with the evidence collection. If the result is negative, emergency contraception will be offered to prevent pregnancy after a sexual assault. The nurse explains that emergency contraception is not an abortion pill; it delays ovulation to prevent fertilization of the egg. (See Chapter 5 Family Planning for more information on emergency contraception.)
Emergency Contraception
- Emergency Contraception: Ella
- Generic Name: ulipristal
- Trade Name: Ella
- Class/Action: emergency contraceptive/progesterone agonist-antagonist
- Route/Dosage: oral, 30 mg
- High Alert/Black Box Warning: none
- Indications: emergency contraception
- Mechanism of Action: binds to progesterone receptor, thereby inhibiting or delaying ovulation; alters endometrium, possibly preventing implantation
- Nursing Implications: Discuss side effects of headache, abdominal pain, nausea, dysmenorrhea, fatigue, and/or dizziness. The nurse should provide information on a contraceptive method if patient is not already using a method. The nurse should evaluate patient’s use of their typical contraception to determine if an alternative method would be more effective.
Prosecution of the Perpetrator
The U.S. Department of Justice refers to publications by the Rape, Abuse, & Incest National Network (RAINN) that state the rape survivor can make an initial report, and the police can decide to move forward with the investigation; however, only the state can decide to press charges (RAINN, n.d.). Even if the state does not press charges, reporting the crime can help shed light on the perpetrator for future crimes. If the case goes to trial, the survivor will most likely be asked to testify; however, every state decides on rules and resources to protect rape survivors. Advocates are usually assigned to survivors to help with this process.
Self-Care for Nurses of Rape Survivors
Caring for women surviving rape can result in nurses developing their own stress and trauma. Those nurses must engage in activities that will allow them to let go of stress and trauma caused by discussing assaults and performing rape exams. Self-care is the action of promoting physical, emotional, intellectual, and spiritual wellness. Nurses, especially those caring for women after rape, must practice self-care. Self-care includes caring for the mind, body, and spirit in an individual way that brings that person peace. Activities of self-care can be meditation, exercise, yoga, art, music, and so on. To care for others, nurses must care for themselves.