By Rebecca Bowers

EXECUTIVE SUMMARY

The American College of Obstetricians and Gynecologists has issued updated guidance to aid clinicians with screening protocols and providing resources in caring for sexual assault survivors.

  • Approximately one in five women in the United States experience completed or attempted rape in their lifetime. It is estimated that 1.47 million rape-related physical assaults against women occur annually.
  • Results of a new study indicate that in midlife, women who have been assaulted are almost three times more likely to experience symptoms consistent with major depression and more than two times more likely to experience increased anxiety.

The American College of Obstetricians and Gynecologists (ACOG) has issued updated guidance to aid clinicians with screening protocols and resources in caring for sexual assault survivors.1

Approximately one in five women in the United States experience completed or attempted rape in their lifetime.2 It is estimated that 1.47 million rape-related physical assaults against women occur annually.2

For sexual assault survivors, the emotional complexity and vulnerability related to issues discussed and exams performed during reproductive healthcare visits may be difficult, says Serina Floyd, MD, MPH, committee opinion author. The new guidance offers a framework to approach sexual assault screening and care in a compassionate and comprehensive fashion, she states.

Women’s experiences of sexual harassment and sexual assault can affect their physical and mental health significantly. In a recent study,
researchers examined the relationship between a history of sexual assault or verbal or physical sexual harassment in the workplace and measures of physical and mental health. These factors included blood pressure, sleep, mood, and anxiety.3 Data were drawn from 304 women between 40 and 60 years of age who initially were recruited as part of a larger study evaluating the relationship between menopause and cardiovascular health.

The researchers found that women who had been assaulted were almost three times more likely to experience symptoms consistent with major depression and were more than two times more likely to experience increased anxiety. Both sexual harassment and sexual assault were associated with a twofold higher likelihood of poor sleep that was consistent with clinical insomnia. The associations remained true even when researchers considered demographics, socioeconomic status, medical history, and medication use.3

“We know that sexual harassment and assault are prevalent in our society and can cause significant harm,” says Rebecca Thurston, PhD, professor of psychiatry, clinical and translational science, epidemiology, and psychology at the University of Pittsburgh and lead author of the paper. “If you are a healthcare provider, recognize that these experiences can have implications for your patient’s health.”

Screen All Women for a History of Assault

Women’s healthcare providers should conduct screening of all patients for a history of sexual assault, paying attention in particular to those who report dysmenorrhea, pelvic pain, or sexual dysfunction, advises the new ACOG guidance. Use the SAVE protocol:

• Screen all patients for sexual violence. Because patients need to feel safe to talk, ask patients about sexual violence without parents, partners, friends, or children in the room. Conduct the screening discussion in a room that has a door closed for privacy.

• Ask direct questions in a nonjudgmental manner. Approach the subject in a normal manner. One way to introduce the subject is to say something like, “I am starting to ask all my patients about sexual assault because it is such a big problem in women’s lives and it can hurt them in so many ways. I want you to tell me about anything in your past that may have confused or hurt you so that I can help you in the right way.”

Once the subject has been introduced, ask the following three questions, allowing time for the patient to answer between each question:

  1. Have you ever been touched sexually against your will or without your consent?
  2. Have you ever been forced or pressured to have sex?
  3. Do you feel that you have control over your sexual relationships and will be listened to if you say “no” to having sex?
  • Validate the patient. If the patient answers in the affirmative to any of the three questions, let her know that you believe her and that her disclosure is important for her healthcare.
  • Evaluate, educate, and refer. If a patient answers in the affirmative to any of the three questions, a clinician will need to ask the following questions to determine further steps:
  • What type of violence occurred? Who was the perpetrator, and when did the violence take place?
  • Is the patient in any present danger from the perpetrator?
  • How does the patient feel this is affecting her now physically and psychologically (in addition to any symptoms you are aware of)?
  • Has the patient had any suicidal ideation/attempts?4

Clinicians must be ready to provide resources for victims of sexual violence. These services include psychological, legal, social, and crisis services; support groups and hotlines; and housing and other community support services.

There are complex legal and evidentiary protocols surrounding care for sexual assault survivors at their first point of contact following an assault. These protocols vary from state to state, so providers should familiarize themselves with the specifics of their state and local requirements and resources. The guidance includes resources from the United States Department of Justice and the International Association of Forensic Nurses to guide clinicians toward pertinent information. (Access the guidance at: https://bit.ly/2FXUxrN.)

Make Your Office Survivor-Friendly

Let your patients know that the topic of sexual violence is important to you and your staff. How can you do this? Be sure to have information in the office about the issue. The following visual cues will let patients know that sexual violence is a topic that is discussed freely as part of a routine visit:

  • Display posters and distribute educational material. These printed items let patients know that you are aware of how sexual violence affects women’s lives.
  • Have staff wear buttons that say something about sexual violence. By seeing such buttons, patients will know that staff members are sensitized to the subject and are open to talking with patients about it.
  • Display informational material about sexual violence in public areas as well as in private places, such as the bathrooms, where patients can take it without being seen.
  • Maintain referrals that can be accessed easily by patients, such as those that are low-cost or free, accessible to transportation, and available in multiple languages. (Check out the resources listed on the Centers for Disease Control and Prevention’s Violence Prevention website at https://bit.ly/2Xpaj2B. ACOG also has identified additional resources that may be helpful for healthcare providers and patients; visit https://www.acog.org/More-Info/SexualAssault.)4

As public discourse advances toward a more open and robust discussion about the prevalence of sexual assault, it is important to develop resources to support survivors and strategies to prevent such violence, states the ACOG guidance.

“When it comes to sexual harassment or sexual assault, our study shows that lived experiences may have a serious impact on women’s health, both mental and physical,” said Thurston in a press statement. “This is an issue that needs to be tackled with urgency, not just in terms of treatment but in terms of prevention.”

REFERENCES

  1. [No authors listed]. ACOG Committee Opinion No. 777: Sexual assault. Obstet Gynecol 2019;133:e296-e302.
  2. Smith SG, Chen J, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017.
  3. Thurston RC, Chang Y, Matthews KA, et al. Association of sexual harassment and sexual assault with midlife women’s mental and physical health. JAMA Intern Med 2019;179:48-53.
  4. Florida Council Against Sexual Violence. SAVE (Screening Your Patients for Sexual Assault). Tallahassee, FL; 2012.