No hard, fast rules on reporting sexual abuse

Best option is to develop a case-based approach

Susan, a 31-year-old, married mother of three, has been seen in your reproductive health services’ clinic three times in the past two years. Each time, she has required repeat treatment for different sexually transmitted infections. She reports that although she is faithful to her husband, he continues to have extramarital relationships and frequently forces her to have sexual intercourse. Because she is financially dependent upon him, she does not feel able to leave the relationship and does not want to confront him about the infections.

Should your clinicians report the husband for spousal abuse? Contact him about receiving treatment? Or, should they honor Susan’s request for treatment for her existing infection, not tell her husband, and remain silent about the abusive situation?

Alicia, 15, presents in your hospital emergency department complaining of chronic abdominal pain and pain during sexual intercourse. She is subsequently diagnosed with chlamydia and pelvic inflammatory disease. During her visit, she states that her current boyfriend is older, age 19, and doesn’t like to use condoms. She fears losing him if she asks him to be tested for chlamydia or insists on safer sexual practices.

In your state, Alicia’s boyfriend could be charged with second-degree sexual assault for having intercourse with a minor under the age of 17. Should you report the relationship to the police?

The two situations mentioned above are common occurrences for many health care professionals who provide reproductive health services. Although deciding whether to report abuse or illegal activity is an ethical dilemma faced by providers in many settings, laws requiring the reporting of cases of sexually transmitted diseases (STDs), abuse, and sexual contact with minors make clinical dilemmas in reproductive health even more complicated.

Where do you draw the line between patient confidentiality and protecting public health? Is it ever appropriate to honor a patient’s request for a specific medical intervention and allow other health problems to go unacknowledged? What if maintaining patient confidentiality and safety requires you to violate state law?

Many providers are so confused about how to handle those situations that they end up choosing to work with blinders on, experts say, preferring not to deal with the underlying personal issues that may be contributing to the patients’ medical problems.

"There is really nothing out there that says, if a person comes in and is being abused, you do X, Y, and Z — not really," says Jane Dimmitt Champion, PhD, FNP, CS, assistant professor in the department of family nursing at the University of Texas Health Science Center in San Antonio. "I think that clinicians everywhere are struggling with a lot of these issues and have decided on their own how they will handle certain situations. But I know a lot of them are really interested in finding some organized system of looking at things."

Particularly when care involves reproductive health services to adolescents, many providers are so concerned about damaging their patients’ access to care and trust in the providers that they are opposed to delving into issues of possible abuse or coercion, says Steven C. Matson, MD, associate professor of pediatrics and director of the Milwaukee Adolescent Health Program at the Medical College of Wisconsin.

"In many cases, providers aren’t even attempting to identify it," he says. "It is a combination of factors. There is a key group of people who are advocates for adolescents and their control of their sexual behavior and for getting confidential reproductive health services to kids. So they try to deliver these services to them and then don’t delve into things in a real deep manner. Then, there is another group of providers who just feel that they are too busy, so they deal with the issue at hand [the STD or other reproductive health matter] and move on."

However, statistics have shown that adolescents, particularly adolescent girls, involved in relationships with older partners are more likely to engage in unwanted sexual contact, and less likely to practice safe sex,1,2,3 says Matson. "In my mind, you provide these services in the context of a sort of paternalistic kind of approach to health care," he states. "If you are going to provide these services to kids, you still need to do it in a safe sort of way. You make sure that if they are sexually active, that they are engaging in appropriate adolescent sexual behavior, that it is consensual, and there is no violence or coercion involved."

Reproductive health providers do not "treat and street" patients, as some people sometimes assume, says Champion. They have a responsibility to address issues in patients’ lives that put their health at risk. "Some people do think that we just treat the person and send them back out," she says. "I think if you are really doing that, it is the worst possible thing. It just doesn’t work. You are not really addressing the problem."

Although some states do have laws requiring health care providers to report cases of domestic abuse and statutory rape or sexual assault, many of the laws are vaguely worded and difficult to enforce. In Wisconsin, for example, "sexual contact and sexual intercourse" with a person under the age of 13 is a Class B felony, and sexual contact and/or intercourse with a minor under the age of 16 is a Class B/C felony, but the statute does not define "sexual contact," says Margaret Flood, MSW, a social worker and forensic child abuse interviewer with the Child Protection Center of Children’s Hospital of Wisconsin.

Sexual contact and/or intercourse with a person 16 or 17 years of age is a Class A misdemeanor. Following the letter of the law, two 15-year-olds who have sexual intercourse are guilty of a class B or C felony. "Most statutory rape laws throughout the country are unenforceable because, if they really meant to arrest every 15-year-old that was having sex, it would inundate the system," says Matson.

State law also requires health care providers to report occurrences to child protection authorities, unless they are providing reproductive health services, Flood adds. The exceptions to this rule are: the sex partner is a caregiver, relative, or adult authority figure to the minor; the minor reports being forced to have sex or promised gifts or money for sexual contact; the minor reports being under the influence of drugs or alcohol when sex occurred; or the minor is cognitively delayed or disabled.

However, many providers are not asking enough questions of their patients to know whether the sexual relationships meet any of the exception criteria for required reporting by reproductive health providers, says Flood. "You should be screening for, basically, exploitation — someone taking advantage of the kid because [he or she is] mentally or emotionally disabled, or they are getting [him or her] drunk to have sex," she says. "But we did a survey of our local ERs and family planning clinics in our community just to find out what they were doing in terms of screening. Pretty much no one could produce anything that showed they even had a policy of asking these types of questions to teen-agers."

Develop a consensus-based approach

Health care providers actually have an opportunity to come together and develop a consensus on what kinds of sexual activity with and among minors should be reported, even though enforcement of existing laws is spotty, says Matson. "Most people aren’t reporting these cases anyway," he says. "But if we could get health care providers to agree on parameters for what is normal adolescent sexual behavior, we could develop criteria that would determine which cases really need to be reported."

Providers should try to come together to decide, based on their experience, which cases may violate the letter of the law, but are not truly harmful and patient confidentiality should be maintained. Conversely, providers should agree when a relationship is harmful and violating patient confidentiality is in the minor’s best interest, say Flood and Matson.

Flood and Matson have proposed such criteria and developed the Adolescent Sexual Violence/ Abuse Screening Tool (AVAST). (To see chart and policy, click here.) The tool is a guided set of questions to be asked of adolescent patients in reproductive health settings, says Flood. It’s designed to assist providers in deciding whether a minor is involved in a relationship that violates state law and, if so, whether clinicians providing reproductive health services still should report it.

"We hashed these out in long discussions, both taking into account the law, but also what would be reasonable in the health care setting," she says. For example, they came up with a guideline of reporting a sexual relationship with a person under 16 whose partner is five or more years older. "We felt that was reasonable to report, whereas the general feeling is that two 14-year-olds having sex or two 15-year-olds having sex was not inappropriate," she says.

The tool also provides a way for providers to document which cases they report, which they don’t, and how the decision is made, says Matson. "Lots of times, for example, we have not been able to document why we didn’t report a particular situation," he says. "This, at least, allows you to show that you considered these things: there is not a greater than five-year age difference; there doesn’t seem to be coercion, the contact seems wanted; and there doesn’t seem to be any violence. So in our best effort, we are going to uphold confidentiality here because it seems like a reasonable relationship. You can really say you made a serious attempt to do the best you could to ensure the relationship was safe and protective."

One size does not fit all

Providers also need an organized approach to dealing with adults who present for reproductive health services and in whom partner abuse is either suspected or confirmed. "Right now, there are so many new laws, with regard to reporting individuals involved in violent situations, and when you add on top of all of that reporting requirements for sexually transmitted diseases, partner treatment, access-to-care issues — especially in poor and/or rural areas, issues get very complicated," she says.

It would be very difficult to develop a one-size-fits-all policy to apply in every situation and still meet the needs of the patient, Champion believes. Using the ethics-based approach — or case-based reasoning — makes more sense in these situations. "Sometimes, if you take a principles-based approach’ and say, Well, I need to do this,’ and then you examine what is actually going to happen to your client, you know you can’t do it," she says.

Champion relates the story of co-workers in a rural area who were caring for a woman in a situation similar to "Susan’s" in the first paragraph. The woman was involved in an abusive marriage. Though she was repeatedly reinfected with an STD by her husband, she did not want her husband to stop having extramarital affairs because he was less abusive and did not force her into sexual contact as often, says Champion. Fearing negative consequences from her husband, the client could only visit the clinic nurse surreptitiously and could not be contacted at home about her care.

The woman also did not feel that she had the financial resources to live on her own and support her child. Gradually, over the period of a couple of years, Champion and other co-workers were able to obtain financial aid for the woman when she was ready to leave the relationship. In the meantime, however, they treated her for her STD, provided treatment for her husband without telling him he had an STD, and arranged for the health department to document the case without independently contacting the husband.

"Case-based reasoning takes into account all the aspects of the patient’s life and how you can resolve the problem without hurting them," she says. There are four basic components to consider:

1) the medical indications of the patient’s condition and how it needs to be treated;

2) patient preferences, what the patient himself or herself wants to do;

3) quality of life — what does the patient currently feel about his or her quality of life;

4) contextual features — this is the component that considers the social and environmental factors that influence the decision.

All four components should be considered and balanced to make a decision for that individual. "Contextual features, which in most of these cases have to do with violence and STDs, is very important in making the decision," says Champion. "You have to examine what will be the overall outcome for that particular patient if we make a certain decision."

In many cases, a "principles-based" approach doesn’t work in a case in which abuse is involved because the wishes of the people involved may vary so dramatically. "You have to be very careful that you are not imposing your views on the patient," says Champion. "We may look at a relationship and feel that it is abusive and the client may just not see it that way. Or we may assume that because a patient is in an abusive relationship that they necessarily want that relationship to end, and that is not always the case."

Although you may not handle all situations in the same way, you are still taking a consistent approach to addressing the relevant issues in the patient’s life, she adds. "You need an ethical basis for examining how to achieve a good outcome and get to that point without causing harm to the individual," she says.

Providers also must follow up to see how their policies and guidelines really are affecting the care they provide, particularly when it comes to reporting cases of abuse, says Matson. "When we do report, we still need to look at how damaging that report is to the client-provider relationship," Matson says. "What is the actual outcome of our intervention? Did something good actually happen? Or, did nothing happen and you just made everyone mad? We do need to be held to that standard if we are going to intervene."

References

1. Landry DJ. Age of fathers in the National Maternal and Infant Health Survey, 1991. Fam Plann Pers 1995; 27:159.

2. Leitenberg H. First intercourse for females and partner age differences. Arch Sex Behav 2000; 29:3.

3. Centers for Disease Control and Prevention. National Center of Health Statistics. National Survey of Family Growth. Atlanta; 1995.

Recommended reading

• Arras JD. Getting down to cases: The revival of casuistry in bioethics. J Med Philos 1991; 16:29-51.

• Arras JD. Principles and particularity: The role of cases in bioethics. Indiana Law Journal 1994; 69:1,075-1,104.

• Artnak K, Dimmitt J. Choosing a framework for ethical analysis in advanced practice settings: The case for casuistry. Arch Psychiatr Nurs 1996;10:16-23. 

Sources

Jane Dimmitt Champion, PhD, FNP, CS, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284.

Margaret Flood, MSW, Children’s Hospital of Wisconsin, 1020 N. 12th St., Room 5030, Milwaukee, WI 53201.

Steven Matson, MD, Medical College of Wisconsin, 1119 W. Kilborn Ave., Second Floor, Milwaukee, WI 53233.