It has been documented that 1 in 3 women will experience rape in her lifetime, and this is most common in women under the age of 25.\u00a0 Over 95% of victims of sexual assault are women worldwide, while in North America estimates place that at 85%.\u00a0 These are the assaults we know about \u2013 generous estimates say that, at most, 10% of rapes are reported to police or other authorities\/health care providers.\u00a0 2004 CDC statistics indicated there were 57,000 visits to US emergency departments for a presenting complaint of sexual assault \u2013 which is still a high number despite flawed methodology which likely vastly underestimated the numbers.\u00a0 To support this, a 2014 survey of patients in the emergency department found that half had experienced sexual assault in their lifetime.\u00a0 Sexual assault has an annual cost of over $2 billion in direct patient costs, lost wages and productivity (not including childhood sexual abuse).<\/p>\n
Sexual assault affects all domains of a victim\u2019s life, the physical and emotional, and extends out in a ripple effect to their surrounding relationships.\u00a0 This has been shown to be a key factor in the health of a person, exacerbating chronic complaints and contributing to new medical issues.\u00a0 It can be difficult for a patient to disclose their assault due to shame, guilt, feelings of responsibility and cultural norms.\u00a0 Instead, they can present with vague complaints which can be acute or chronic in nature \u2013 commonly headache, abdominal\/pelvic pain, anxiety, depression and substance abuse.\u00a0 We under-recognize sexual trauma, both acute and historical, as a key contributor to their current ED presentation.<\/p>\n
Assault is part of a patient\u2019s medical and life history, and should be taken into consideration during their clinical assessment.\u00a0 One way to identify these patients is to recognize pattern injuries such as bruising, swelling or abrasions that don\u2019t fit the story or fit a concerning pattern \u2013 we are very good at recognizing the hallmarks of child abuse, but don\u2019t translate it in our minds when outside the pediatric age group! Be mindful of \u201cbranding\u201d \u2013 tattoos such as bar codes or names that are used to identify a victim of human trafficking in a visible location such that those in the industry can recognize their \u201cproperty\u201d. \u00a0The ED is often the only point of refuge for those patients, and we have a unique opportunity to help them.\u00a0 Many of these patients are relieved to see a female physician.<\/p>\n
One of the major barriers that has been found to asking about sexual violence is not knowing what to do when someone discloses a history of sexual assault.\u00a0 What do you do? \u00a0After disclosure, there may be a variety of different emotional responses, much like any grief reaction.\u00a0 They may have tears, may be angry or may be numb.\u00a0 There are certain mandatory reporting requirements, such as the notification of Child Protection\/Children\u2019s Aid, and others that vary by jurisdiction.\u00a0 Care of these patients is complex, involving medical, forensic and emotional aspects.\u00a0 It is also a high stakes patient interaction as the legal case can hinge on quality of evidence collected, with very high standards for documentation and maintenance of chain of evidence for intersection with legal system.\u00a0 This is also time-consuming, typically taking hours to complete the medical and forensic care \u2013 which is impossible in a busy ED!\u00a0 Many EDs have direct linkages to specialized sexual assault care programs staffed with highly trained Sexual Assault Nurse Examiners (SANE) who can assume the care for these patients.<\/p>\n