Course:SOWK551/2021/Sexual Assault and the Medical System
Literature review of the psychological impacts of revictimization in the healthcare systems and care approaches to minimize revictimization and support sexual assault survivors.
December 10, 2022
Sexual Assault (SA) is a pervasive public health issue that can happen to anyone regardless of age, gender, income, ethnicity or sexuality (Patel et al., 2008; Rape Victim Support Network, 2022). For this literature review, SA will be defined “as an assault of a sexual nature that violates the sexual integrity of the victim” (Edmonton Police Services, 2019, para. 1). The hospital emergency department (ED) can often be the first point of contact between the survivor and medical professionals after someone has been sexually assaulted (Patel et al., 2008). Unfortunately, the medical system may treat survivors in a way which leads to revictimization and traumatization instead of providing proper support (Campbell, 2008). This paper will explore the psychological impact of SA on the survivor, subsequent revictimization from the medical system, SA care approaches that support and uplift survivors as well as implications for social work practice.
Articles for this literature review were found in the UBC online library database. Terms searched included: ‘sexual assault’ along with ‘medical system’, ‘social work’, ‘healthcare’, and ‘SANE’. A total of fifteen academic journal articles published between 2002 and 2022 were selected and reviewed.
The Psychological Impact of Sexual Assault
For those who have experienced SA, a range of psychological impacts and mental health issues can emerge after the incident (Patterson et al., 2009). A common theme in the literature for SA survivors was experiencing self-blame and guilt (Patterson et al., 2009; Patel et al., 2008; McMahon & Schwartz, 2011; Campbell, 2008). Studies conducted by Campbell (2008) and Patterson et al. (2009) on SA survivors had consistent findings regarding participants feeling embarrassed, ashamed, blamed and doubting themselves, which resulted in many survivors not reaching out for formal support from the medical, legal or mental health systems.
SA survivors’ mental health is also significantly impacted, with McMahon & Schwartz's (2011) review of social work literature on SA finding post-traumatic stress disorder (PTSD) as the most cited mental health issue. The long-term effects of PTSD, depression and psychological harm caused by SA can increase the survivor’s risk of depression, substance use, suicidality and revictimization (Patel et al., 2008; McMahon & Schwartz, 2011; Campbell, 2008).
Victimization and Traumatization by the Medical System
A survivor’s experience with the medical system can greatly depend on their interaction with medical professionals. Unfortunately, much of the literature found that medical professionals still subscribe to stereotypes and misguided perceptions about SA survivors which leads to revictimization and traumatization (Maier, 2008; Campbell, 2008; Ahrens, 2006; Chalmers et al., 2022; Anderson & Quinn, 2009). As Campbell (2008) stated, “[a] survivors’ post-rape distress may be due not only to the rape itself but also to how they are treated by social systems after the assault” (p. 711).
Anderson & Quinn (2009) conducted a study of medical students’ attitudes toward SA victims. Their findings showed that male students had lower levels of empathy for SA survivors, compared to their female colleagues. The study further found that among all genders of medical students, there were more negative views of male survivors compared to female survivors. Chandramani et al. (2020) also found that male medical students were more likely to view SA patients as “taking time away from more critical patients”, with 56% of medical students agreeing with the quote (p. 6).
This theme was echoed in literature with Maier’s (2008) research finding that medical professionals in the ED want to “get the bed back” so they will often rush the process with a SA survivor which leads to re-victimization (p. 797). Due to these attitudes, SA survivors may have to wait a long time before being seen, which can be very traumatic due to the fact they are often not allowed to eat or use the bathroom to preserve evidence (Campbell, 2008). When a SA survivor is finally seen, they may have to deal with intrusive, judgmental and inappropriate questions regarding their sexual history and behaviour prior to the assault (Maier, 2008; Campbell, 2005). If a survivor is seen by a doctor in the ED (compared to nurses), many doctors were unaware of the secondary victimization the survivor felt during their interactions which points to a need for better self-awareness among medical staff (Campbell, 2005).
There is also a lack of training and understanding of the complex care and needs of SA survivors amongst healthcare professionals, with many ED professionals feeling unprepared, uneducated and uncomfortable with providing care to SA survivors (Chandramani et al., 2020). Their research went on to find ED medical professionals were unaware of what laws and/or policies applied to SA survivors and many were also unsure of how to properly complete a forensic exam (Chandramani et al., 2020). Similarly, Hendriks et al.’s (2018) study of health professionals found that many didn’t understand the theoretical knowledge and gender-based differences surrounding SA which resulted in care that wasn’t inclusive or tailored to meet the survivors' needs.
The research conducted by Maier (2008), Monroe et al. (2005) & Patterson et al. (2009) brought up the concept of “stereotypical” rape, which means a SA is done by a stranger in a violent way that usually includes a weapon. Therefore, if a survivor had been sexually assaulted by a family member/someone they knew or they didn’t have visible injuries they were less likely to seek support (Monroe et al., 2005; Patterson et al., 2009). The “stereotypical” rape also means that the SA survivor shouldn’t have been under the influence of drugs/ alcohol, wouldn’t have been engaging in sex work and would have contacted the police immediately after the incident (Maier, 2008).
Therefore, when a survivor doesn’t fit the “real” victim profile, medical staff can project their misconceptions, stereotypes and judgements onto the patient when they do seek support (Chalmers et al., 2022). For example, Maier’s (2008) research found that one doctor stated “If you don’t remember if something was put inside you then I am not doing the rape kit” to a woman who didn’t fully remember the SA (p. 796). Another doctor wouldn’t administer a rape kit after hearing the SA happened while the woman was doing sex work. The long-term impact of these comments and misconceptions on a survivor not only leads to higher rates of PTSD, but also results in a survivor being less likely to engage with any type of social system (ex. medical or legal) throughout their lifetime which can result in lower health outcomes (Chalmers et al., 2022).
Approaches that Support Sexual Assault Survivors
Despite the traumatization and harm caused by the medical system, research has found programs and methods which can improve how SA survivors are supported within the medical system. One specific program that was cited in the literature was the Sexual Assault Nurse Examiner (SANE) program which has significantly improved the experience for SA survivors in the hospital (Chandramani et al., 2020; Maier, 2008; Stermac & Stirpe, 2002). The SANE program includes specially trained nurses who provide forensics exams and SA support in a trauma-informed and empathetic way (Chandramani et al., 2020). This approach recognizes how traumatic the forensic exam and retelling the story of the assault can be for the survivor, so the utmost effort is made to make sure the patient feels heard, supported and cared for. Research has also found that other medical services such as STI testing and emergency contraceptives were offered more through SANE compared to untrained ED nurses and doctors (Chandramani et al., 2020).
Another potential benefit of SANE was that the forensic exam and wait period to see a medical professional was shorter for patients who received care through SANE compared to an ED doctor (Stermac & Stirpe, 2002). This could be attributed to several factors with Stermac & Stirpe (2002) finding SANE nurses had fewer interruptions compared to ED doctors, while Maier (2008) found that SANE nurses were more knowledgeable and showed more empathy when completing the forensic exam compared to ED doctors. These findings may also be due in part to the above-mentioned issue in which some doctors view SA survivors' needs as not critical. Therefore, they may prioritize and leave to assist other patients which could add to the higher rate of interruptions.
Outside of SANE, research has identified other factors which mitigate the risk of traumatic interaction with the medical system. Some of these factors include: integral respect, safety, autonomy and control, reassurance, transparency through information, expert advice and support extended beyond the hospital setting (Ericksen et al., 2002). Research by Ericksen et al. (2002) highlighted the need for medical staff to feel comfortable in their role, as well as having two main workers support a SA survivor. Through this approach, one healthcare practitioner provides the forensic exam (if the survivor consents), while the other can provide emotional support and information. Notably, their research showed that the use of touch can be an effective tool, with one survivor stating that having a nurse hold their hand reminded them of what their own mom would have done (Ericksen et al., 2002). However, Patterson et al. (2009) found that many survivors avoided the medical system due to not wanting to be touched as it would cause emotional distress. Therefore, the way touch is used and by whom appears to have the potential to cause either harm or healing, with future research needing to explore this more.
Applications to Social Work Practice
Social workers who work within the ED, sexual assault care centres or other similar departments, should not take lightly the positive or negative impact they can have on a SA survivor. It is in this critical period a SA survivor’s initial interaction with the medical system can determine if they will reach out for support in the future (Chalmers et al., 2022). Maier’s (2008) research into the role and benefits of victim advocates can be translated to the work social workers can do with SA survivors. For example, some of the most beneficial things advocates do are “ to relay to the victim that they believe [their] story, stress to [them] that the rape was not [their] fault, reinforce that [they] have the power and control to make [their] own decisions, and provide information that assists [them] in doing so” (p. 800). At the macro level, social workers can advocate for more specialized and mandatory trauma-informed training for staff who work in the ED along with implementing SANE programs in all EDs. Additionally, social workers can push for more community SA resources and programs that provide more long-term therapy and support compared to acute care which can help bridge the gap between hospital and community so survivors can get continued care.
Lastly, Clemans’ (2004) research into the impact on those who work with SA survivors should not be ignored. She identified issues such as social workers having secondary traumatic stress, feeling more vulnerable and changes in their behaviour due to feeling more fear around things such as walking home late at night or getting into a taxi. Therefore, social workers who work with SA survivors must develop coping strategies such as reminding oneself why they are doing this work, the greater impact it has, having strong relationships and camaraderie with coworkers doing similar work and using humor as a way to manage stress (Clemans, 2004).
Gaps in Literature
Campbell (2008) and Hendriks et al.’s (2018) research highlighted the many identities that are excluded in most literature which include the voices of transgender, male, lesbian and immigrant SA survivors. Campbell’s (2008) critique of the literature shows that it is mostly the voices of women (who most likely come from a certain degree of privilege) that are featured rather than the above-mentioned groups. Another notable gap was the lack of social work literature in relation to SA (McMahon & Schwartz, 2011). Most research surrounding SA and the medical system came from doctors and nurses, despite social workers playing a pivotal role in supporting and advocating for SA survivors (McMahon & Schwartz, 2011). Therefore, more social work research needs to be conducted in this area to highlight the important interventions and work social workers can do to empower and support SA survivors.
In order to provide trauma-informed, empowering care for SA survivors, a shift within the medical system must occur in which all healthcare professionals must examine and change the misconceptions, negative beliefs and stigma they hold about SA. Through proper training, implementing programs such as SANE and allocating more specialized staff and resources to supporting SA survivors within the medical system, the hospital can start to be seen as the first step towards healing rather than an institution which further propagates survivors' trauma and victimization.
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Anderson, I., & Quinn, A. (2009). Gender differences in medical students' attitudes towards male and female rape victims. Psychology, Health & Medicine, 14(1), 105-110. https://doi.org/10.1080/13548500802241928
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