Health Promotion for Women - Prentice Hall

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lon23944_ch04.qxd 2/10/06 6:46 PM Page 95 up knowing that “no means no.” These young women are more cautious about potentially risky situations and more willing to express their wishes forcefully. Even more encouraging, in 2002 over half (53.7%) of sexual assaults and rapes were reported to the police (Rennison & Rand, 2003). This change is probably related to increased media attention and greater societal openness about the subject. No woman of any age or ethnicity is immune. However, statistics indicate that young, unmarried women, women who are unemployed or have a low family income, and students have the highest incidence of sexual assault or attempted assault. Why do men rape? Of the many theories put forth, none provides a completely satisfactory explanation. So few assailants are actually caught and convicted that a clear characteristic of the assailant has not been developed. However, rapists tend to be emotionally weak and insecure and may have difficulty maintaining interpersonal relationships. Many assailants also have trouble dealing with the stresses of daily life. Such men may become angry and overcome by feelings of powerlessness. They then commit a sexual assault as an expression of power or anger. Acquaintance rape, which occurs when the assailant is someone with whom the victim has had previous nonviolent interaction, is the most common form of rape. In fact, in 69% of the cases of rape or sexual assault, the assailant is known (Rennison & Rand, 2003). One type of acquaintance rape, date rape, which occurs between a dating couple, is an increasing problem on high school and college campuses. In some cases an assailant uses alcohol or other drugs to sedate his intended victim. One drug, flunitrazepam (Rohypnol), has gained notoriety as a date rape TABLE 4–3 Phases of Recovery Following Sexual Assault Phase Response Health Promotion for Women 95 drug because it frequently produces amnesia in its victims. In date rape situations, the male is usually determined to have sex and will do whatever he feels necessary if denied. Responses to Sexual Assault Sexual assault is a situational crisis. It is a traumatic event that the survivor cannot be prepared to handle because it is unforeseen. Following an assault the victim generally experiences a cluster of symptoms, described by Burgess and Holmstrom (1979) as the rape trauma syndrome, which last far beyond the rape itself. These phases are described in Table 4–3. Although the phases of response are listed individually, they often overlap, and individual responses and their duration may vary. A fourth phase—integration and recovery—has also been suggested (Holmes, 1998). Research suggests that survivors of sexual assault may exhibit high levels of post-traumatic stress disorder, the same disorder that developed in many of the veterans of the Vietnam War. Post-traumatic stress disorder is marked by varying degrees of intensity. Assault victims with this disorder often require lengthy, intensive therapy to regain a sense of trust and feeling of personal control. Care of the Sexual Assault Survivor Survivors of sexual assault often enter the healthcare system by way of the emergency department. Thus, the emergency department nurse is often the first person to counsel them. Because the values, attitudes, and beliefs of the caregiver necessarily affect the competence and focus of the care, it is essential that nurses clearly understand their feelings about sexual assault and assault survivors and resolve any conflicts that may exist. In many communities a specially trained sexual assault nurse examiner (SANE) coordinates the care Acute phase (disorganization) Fear, shock, disbelief, desire for revenge, anger, anxiety, guilt, denial, embarrassment, humiliation, helplessness, dependence, self-blame, wide variety of physical reactions, lost or distorted coping mechanisms Outward adjustment phase (denial) Survivor appears outwardly composed, denying and repressing feelings (e.g., she returns to work, buys a weapon); refuses to discuss the assault; denies need for counseling Reorganization Survivor makes many life adjustments, such as moving to a new residence or changing her phone number; uses emotional distancing; may engage in risky sexual behaviors; may experience sexual dysfunction, phobias, flashbacks, sleep disorders, nightmares, anxiety; has a strong urge to talk about or resolve feelings; may seek counseling or remain silent Integration and recovery Time of resolution; survivor begins to feel safe and be comfortable trusting others; places blame on assailant; may become an advocate for others
lon23944_ch04.qxd 2/10/06 6:46 PM Page 96 96 CHAPTER 4 of survivors of sexual assault, gathers necessary forensic evidence, and is then available as an expert witness when assailants are tried for the crime. The first priority in caring for a survivor of a sexual assault is to create a safe, secure milieu. Admission information is gathered in a quiet, private room. The woman should be reassured that she is safe and not alone. The nurse assesses the survivor’s appearance, demeanor, and ways of communicating for the purpose of planning care. Initially the woman is evaluated to determine the need for emergency care. Obtaining a careful, detailed history is essential. After the woman has received any necessary emergency care, a forensic chart and kit are completed. NURSING PRACTICE Strive to listen nonjudgmentally. Impartial listening can often make the difference in a victim’s readiness to disclose the full details of the assault and can also assist her in the recovery process. The woman is given a thorough explanation of the procedures to be carried out and signs a consent form for the forensic examination and collection of materials. Sexual assault kits contain all the necessary supplies for collecting and labeling evidence. The woman’s clothing is collected and bagged, swabs of stains and secretions are taken, hair samples and any fingernail scrapings are collected, blood samples are drawn, tissue swabs are obtained, and photographs are taken. Vaginal and rectal examinations are performed, along with a complete physical examination for trauma. The woman is offered prophylactic treatment for sexually transmitted infections. If the assailant’s HIV status is not known, the woman may be offered postexposure prophylaxis with HIV antiviral medications. In such cases, consultation with an HIV specialist is advised (CDC, 2002). The woman is also questioned about her menstrual cycle and contraceptive practices. If she could become pregnant as a result of the rape, she is offered postcoital contraceptive therapy. Throughout the experience the nurse acts as the sexual assault survivor’s advocate, providing support without usurping decision making. The nurse need not agree with all the survivor’s decisions but should respect and defend her right to make them. The family members and friends on whom the survivor calls also need nursing care. The reactions of the family will depend on the values to which they ascribe. Many families or mates blame the survivor for the assault and feel angry with her for not having been more careful. They may also incorrectly view the assault as a sexual act rather than an act of violence. They may feel personally wronged and see the survivor as devalued or unclean. Their reactions may compound the survivor’s crisis. By spending some time with family members before their first interaction with the survivor, the nurse can perhaps reduce their anxiety and absorb some of their frustrations, sparing the woman further trauma. Sexual assault counseling, provided by qualified nurses or other counselors, is a valuable tool in helping the survivor come to terms with her assault and its impact on her life. In counseling, the woman is encouraged to explore and identify her feelings and determine appropriate actions to resolve her problems and concerns. The counselor must avoid reinforcing the prevalent myth that the assault was somehow the woman’s fault. The fault lies with the assailant. The counselor also plays an important role in emphasizing that the loss of control the woman experienced during the rape was temporary and that the woman can regain a feeling of control over life. Prosecution of the Assailant Legally, sexual assault is considered a crime against the state, and prosecution of the assailant is a community responsibility. The survivor, however, must begin the process by reporting the assault and pressing charges against her assailant. In the past, the police and the judicial system were notoriously insensitive in dealing with survivors. However, many communities now have classes designed to help officers work effectively with sexual assault survivors or have special teams to carry out this important task. Many women who have sought to use the judicial process have had such a traumatic experience that they refer to it as a second assault. The woman may be asked repeatedly to describe the experience in intimate detail, and her reputation and testimony may be attacked by the defense attorney. In addition, publicity may intensify her feelings of humiliation, and, if her assailant is released on bail or found not guilty, she may fear retaliation. The nurse acting as a counselor needs to be aware of the judicial sequence to anticipate rising tension and frustration in the survivor and her support system. The woman needs consistent, effective support at this crucial time.
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Health Promotion for Women - Prentice Hall

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