Screening for Sexual Assault
There are many reasons that clinicians do not screen for sexual assault. They lack training, fear approaching sensitive subjects, lack time to screen, or do not have private facilities for screening. Most do not screen because they do not know how to ask questions and/or how to respond when the victim discloses. Clinicians may also have experienced sexual violence in their own lives, either directly or in a family member. In such cases, the clinician should seek help to resolve his/her own distress to avoid a countertransference response.
When properly screened, victims can disclose their abuse and receive the care and services they need. The "telling" alone provides meaning to their experience and helps to better manage emotions. Not asking reinforces the victims' silence.
Screening should take place during routine wellness exams and during episodic illness exams when symptoms are suspicious for sexual assault. Red flags include: anxiety; depression; sudden-onset sleep disorders; stress-related complaints; requests for pregnancy testing, emergency contraception, or testing for sexually transmitted diseases; pelvic area trauma; and bruising that may be from restraints. Clinicians should keep in mind that victims vary in response to sexual assault, ranging at one end to showing no response and at the other end to showing significant emotional or physical symptoms.
The National Sexual Violence Resource Center recommends the following:
Normalize the subject by including it within the sexual history
Provide context by connecting the subject to the patient's health and well-being
Be nonjudgmental
Be direct but avoid using terms like rape and sexual assault
Validate the patient's responses
Ask about sexual experiences that were uncomfortable or unwanted:
Have you been touched without your consent?
Have you ever been pressured or forced to have sexual contact?
Do you feel that you have control over your sexual relationships?
Allow the patient to verbalize and be heard
Clinicians should develop a protocol to ensure that all patients are screened adequately and consistently. Protocols should ensure privacy in both the interview, which should take place when victims have their clothing on, and the documentation.
For example, the SAVE screening protocol developed by the Florida Council against Sexual Violence in 2003 focuses on the following 5 points:
Screen all of your patients: anyone can be a victim
Ask direct questions: be nonjudgmental, make eye contact, stay calm, do not blame the victim or dismiss what the victim discloses even if the victim minimizes the event
Validate their response: believe the victim, tell them they are not alone, support their courage to disclose, assure them there is help and that their disclosure is the first step toward healing
Evaluate, educate, and refer: assess whether there is current danger, identify the perpetrator, assess for suicidal and homicidal ideation/attempts, obtain a substance use history
Some patients will not disclose when first asked. Thus, screening should take place with each visit. Some may also not be sure whether what happened to them was sexual violence, giving the clinician an opportunity to discuss it further. Some patients, including males who were abused by other males, may not want to talk to a male provider and may need referral to a female provider.