Nursing care for rape victims

Barbara N Talento, RN, Judith C Fernandez, RN

Nursing care for rape victims Rape is a traumatic experience for the victim, her family, and her friends. It is also a crisis for the care givers and agencies charged with treating rape victims. Rape is a crime that we as nurses must learn to cope with on several levels-as health care professionals who may be treating rape victims, as private citizens concerned about society’s attitudes toward rape victims, and as individuals who may need to protect ourselves from possible attack. Nurses are often the first care givers in the hospital the rape victim sees during this crisis. If the nurse can communicate as a helping, caring person, the victim may perceive that help for her is possible. The first step in coping with rape is understanding our own feelings about Barbera N Talento, RN, MSN, is an instructor at California State University, Fullerton. She received her associate degree from Fullerton (Calif) College, her BSN from California State University, Fullerton, and her M S N from California State University, Los Angeles. She is on the board of directors of the Rape Crisis Clinic in Fullerton. Judith C Fernandez, RN, MSN, is an instruc-

tor in nursing at California State University, Fullerton. She received her associate degree from Mount San Antonio College in Walnut, Calif, her BSN from California State University, Fullerton, and her MSN from California State University, Los Angeles. 1408

rape as well as our attitudes and values about human sexuality in general. Failure to understand our own beliefs can lead us, as nurses, to nursing care mismanagement, which interferes with a helping, caring relationship with the rape victim. Unidentified strong feelings and prejudicial attitudes may alter and affect the use of knowledge and skills needed to treat and care for this victim. Rape involves force, humiliation, and degradation of a woman by a man. In our myths about rape, the male is frequently depicted as a virile “he-man” who regards the woman as a sex object to be used and abused. Perhaps some of these stereotypes come from the mass media, which too frequently encourage such roles. Cultural myths, absorbed by us in the process of socialization from early childhood on, underlie our individual feelings. The myths are internalized and become part of our beliefs, values, and attitudes. Children acquire cultural values via the family and significant others about these attitudes, values, beliefs, and judgments about the roles men, women, and children are expected to assume in the family and in t h e community outside t h e home. Within this larger socialization process, we develop attitudes toward human sexuality and rape. Ideally, our socialization process helps us develop a healthy sexuality.

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This healthy sexuality should integrate the emotional, intellectual, somatic, social, and ethical aspects of sexual being and behavior t h a t enhance the development of love, interpersonal relationships, and personality.’ Human sexuality encompasses all of our being, and our concept of the totality of human sexuality involves ideas, attitudes, beliefs, and values. This concept of socialization also operates i n the development and acceptance of rape myths. The concept of rape often seeps into our childhood awareness by imperceptible degrees. According to Brownmiller, women are indoctrinated into a victim mentality.2 This leads to the formation and continuation of such rape myths as “all women want to be raped,” “no woman can be raped against her will,” and “women by their manner, appearance, or way of dress in some subtle way invite rape.” If you think you are free of such myths, take an imaginary walk down a street. Approaching you is a pretty young woman wearing a tight pair of shorts and a T-shirt. She is obviously braless. Are you thinking or have you ever thought, “Boy, she’s asking for it”? That is one of the myths of rape. Suppose you read that this young lady was indeed raped. Would you think, “Well, she deserved it”? That is yet another myth of rape. When a large segment of society accepts these myths, then society rejects the victim. This in turn leads to a sense of isolation within the rape victim. Another theory about society’s rejection of rape victims has been proposed by See, who says we are subject to a “blaming-the-victim ideology.” This means that the more society feels at a loss to eliminate a social problem (such as rape), the more society turns on the victim as a s cape goat.^ According to the Federal Bureau of 1410

Investigation (FBI) Uniform Crime Reports, there were an estimated 51,000 forcible rapes in the United States in 1973. This was an increase of 10%over 1972 and 62% over 1968.The 1974 FBI Uniform Crime Reports points out that 85% of all rapes occur in the victim’s home, and one rape is committed every 11 minutes in t h e United States. According t o projected figures, 1 of every 2.5 women will be raped. In Orange County, Calif, the youngest victim of rape was 7 months old and the oldest, 93 years old. Given these statistics, one of the first concerns is to protect ourselves as well as other women against rape. Start by examining your own feelings. How do you react in a time of crisis? Try to remember how you reacted when you have been most frightened. Did you keep your wits about you? Could you talk coherently? Could you scream? Were you capable of doing violence to another? Examine your daily habits to see if you are putting yourself at risk. For instance, where do you park your car at night? You should always choose a well-lighted spot, clearly visible to others. Make certain your hospital parking lot is well lighted during the hours of darkness. If not, demand that lights be installed. Walk with others t o the parking lot, o r ask your hospital security guard to walk you to your car. Keep your car locked at all times and have your keys in your hand before you leave a building to keep from fumbling at the last moment. Keep a police whistle on your key chain. If you need to call for help, yell “Fire!” because most people will respond. Lastly, obtain from your police department a booklet entitled Lady Beware, which gives many suggestions on primary prevention. To become more involved i n your community, determine how rape victims are treated and which agencies

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etermine how rape victims are treated in your community.

work with rape victims. Find out what your state laws are regarding the victim within the legal system. Is the victim’s past sexual activity admissible in court as evidence in your state? Remember that the assailant’s past is never admissible under normal court procedures. These same rights should apply for the victim. Write your representatives in the state legislature asking about laws regarding rape and find out their opinions about the laws. Remember that in most states, rape is “carnal knowledge of a woman by a man, but not her husband.” This means t h a t a husband under law cannot rape his wife because the wife is considered the property of her husband. Visit your police department and ask them the following questions. 0 Do you have specially trained officers to assist rape victims? 0 Is one of these officers a woman? 0 Do you routinely submit the victim to a polygraph test? 0 Does the police department use female police officers to take the necessary photographs? If the answers to these questions are negative, convince your police department to institute changes. Assess the hospitals in your area. Call or visit their emergency rooms. Ask if they have a protocol for the care and treatment of rape victims. If a protocol is not available, ask the following questions. 1412

Is the victim given information on venereal disease? Is the victim treated prophylactically for possible venereal disease? How is the possibility of pregnancy established? Is there follow-up? If it is determined at a later date that the victim is pregnant, what is she advised to do? How is she treated? When is the victim given treatment? Is she treated first or after all other patients are treated? Who treats the victim, any physician or a specialist? What kind of follow-up is provided for the victim? How are financial arrangements handled? Is crisis counseling done? Who does it? Is the victim referred to a rape crisis center? The University of California Irvine Medical Center i n Orange County adopted a formal protocol following a study by John Ryan, MD.5This protocol recommends a team composed of an obstetrics-gynecology resident, a trauma specialist who is a physician (if needed), a registered nurse, and a social worker. The registered nurse, preferably female, stays with the victim from admission t o discharge from t h e emergency room. Appointments are made for t h e victim to r e t u r n for follow-up visits and to see the social worker, Additionally, the victim is supplied with a printed list of support

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groups available in the community, eg, regional mental health offices and crisis line telephone numbers. Also included are the names and work telephone numbers of the registered nurse and the social worker. In our research, we found that some hospitals and physicians refuse t o treat rape victims. There are several reasons for this. First, many hospitals lack a specific protocol t o assist the on-call physician in the collection of physical evidence. Second, many physicians are reluctant to become involved legally because every instance of rape is a potential court case and the physician can expect to be subpoenaed to justify his observations of the victim. The American College of Obstetricians and Gynecologists (ACOG) has published a bulletin, “Suspected rape,” which lists the proper procedures for the protection of patient and physician as well as in the interest of justice in cases of alleged or suspected rape or sexual molestation.6 This suspected rape protocol provides the following guidelines: consent, cautions, history, examination, laboratory specimens, clothing and photographs, objective statements, care of a child, prevention of disease, prevention of pregnancy, and follow-up for the victim. In Orange County, a rape kit has been developed by the Sheriff’s Department for use by emergency room personnel. The rape kit contains instructions about the “chain of possession,” stating that each piece of evidence must be clearly labeled and initialed by every person touching it. This chain of possession must be kept intact from the moment the evidence is collected to the moment it is introduced at the trial. The rape kit contains a small envelope for evidence found on or near the external genitalia, such as hair, fabric, or fiber; slides, mailer, swab, and test tube for obtaining cultures from inside

the vaginal vault, anus, or oral cavity; test tube for vaginal vault aspirations; comb and plastic bag for pubic hair combings; small envelope for representative sample of victim’s pubic hair; edetic acid (EDTA) blood vial for comparison of blood type; and cotton swabs for saliva samples for genotyping. In Los Angeles, the Community Task Force on Rape Guidelines has developed the Guiklines for the Hospital Emergency Department in Treating the Alleged Sexual Assault Patient. These guidelines prescribe the effective and sensitive approach to treatment that the sexual assault patient needs. The guidelines describe the legal, emotional, and physical considerations required for the victim’s benefit. At a personal level, we believe that a helping relationship can be established by any care giver for victims of rape. We also believe that any person interested in helping can learn and use the steps and methods of crisis intervention. To establish a humanistic, caregiving relationship requires of the care giver an expression of the worth and dignity of each individual; it also requires that the care giver willingly enter into a dynamic interpersonal relationship with the victim. The most important aspect of this helping process is to show and share your concern about the victim’s plight with the victim. The very fact that someone cares and understands will often help to establish a supportive relationship and open the door to further expression of feelings. Any care giver in any setting can use the methods of crisis intervention when working with victims of rape. Of primary importance is facilitating the expression of feelings by the victim. Crisis intervention can be used to help a victim cope with severe emotional stress. Crisis intervention, according to one study, focuses on acute situational reactions characterized by temporary but to 1416

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risis intervention is initiated by the nurse.

intense emotional upset. If unrelieved, these reactions could lead to serious disorders affecting not only the victim but also a larger circle of family and others intimately involved.8 A person in crisis is usually more amenable to help if it is offered at the right time and right place. This means during the throes of a crisis before maladaptive resolution of a crisis has begun. Contrary to methods taught most nurses, crisis intervention is initiated by the nurse. One does not wait for the victim to ask for help. The following steps may be useful for any nurse to employ. Assessment. During this first step, the care giver actively tries to obtain an assessment of the event t h a t precipitated the crisis. In the instance of rape, there has been a threat to the life goals of the victim. Life goals can be such things as good health, emotional security, a job, or a marriage. Nurses can begin by assisting the victim t o gain an intellectual understanding of her crisis. It may be helpful at this point to help the victim face the possible feelings of guilt and shame. Share with the victim your knowledge that rape is a crime of violence, not one of sex initiated by the victim. Planning intervention. This step overlaps the first step. Here you attempt to identify previous coping patterns of the victim. Ask the victim to tell you how she has coped with problems in the past. 1416

Did these coping behaviors work? If they did not work, what other behaviors did she use? Intervention. At this point, help, encourage, and assist the victim t o bring into the open her present feelings and continue to assist her to gain an intellectual understanding of the crisis. The most prevailing feeling after rape is fear; then comes anger, guilt, and shame. Ask the victim such questions as “Can you talk about what you are feeling?” or “How are you feeling right now?” Continue to explore coping behaviors; if old ones are not effective, suggest new behaviors such as crying, talking, and seeking out significant others. Reopen the social world by talking about significant others who can be called on t o be supportive. The nurse may make telephone calls to the family o r friends for the victim. Have a referral list of people or groups that can help available and talk about what help is available in the community. Anticipatory guidance. Discuss with the victim her feelings about her husband, boyfriend, dating, men in general, and sexual relations. Foreknowledge of the physical and emotional changes that can happen is useful to the victim so that she is not frightened when they occur. It does not take highly specialized training to begin crisis intervention. Many nurses, through the development of warm, empathetic relationships,

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have succeeded w i t h n o f o r m a l therapeutic training. The k e y t o helping i s caring. That k e y applies t o t h e entire problem of rape. Summary. Rape i s a brutal, h u m i l i a t ing, life-threatening, and psychologically traumatic event for t h e victim. Indeed, she has lost something o f herself t h a t w i l l never be recovered. We believe it is imperative t h a t nurses in a l l w o r k settings become aware and actively involved in the treatment as w e l l as prevention of rape. E a r l y crisis intervent i o n should be provided during acute shock r e a c t i o n t o rape.s A d e q u a t e follow-up should be done for medical complications that would greatly add t o the emotional stress o f t h e victim. Finally, it i s imperative that care givers become aware o f and identify t h e i r own attitudes, values, and beliefs regarding human sexuality so that they m a y be b e t t e r p r e p a r e d t o offer humanistic n u r s i n g care t o the rape victim. Notes 1 . Harold I Lief, Tyana Payne, “Sexualityknowledge and attitudes,” American Journal of Nursing 75 (November 1975) 2026. 2. Susan Brownmiller, “Do you believe the myths about rape,” Family Circle (October 1975) 38-42, adapted from Against Our Will: Men, Women and Rape. 3. Carolyn See, “Rape: No woman is immune,” Today’s Health (October 1975) 38. 4. Clarence Kelly, FBI Uniform Crime Reports, 1973 (Washington, DC: US Government Printing Office, issued Sept 6, 1974) 13. 5. “Proposed protocol for medical procedures in the cases of alleged rape,” University of California lrvine Medical Center, Orange County, Calif, 1974. 6. American College of Obstetricians and Gynecologists, “Suspected rape,” 14 ACOG Technical Bulletin (July 1970). 7. The Community Task Force on Rape Guidelines, Guidelines for the Hospital fmergency Department in Treating the Alleged Sexual Assault Patient, Hospital Council of Southern California and Los Angeles County Department of Health Services, Preventative Health Services, May 1, 1976. 8. Donna C Aguilera, Janice Messick, Crisis lntervention Theory and Methodology, 2nd ed (St Louis: C V Mosby Co, 1974) 67-105.

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9. Ann Wolbert Burgess, Lynda Lytle Holmstrom, “Rape trauma syndrome,” American Journal of Psychiatry 131 (September 1974) 981 -985; Ann Wolbert Burgess, Lynda Lytle Holmstrom, “The rape victim in the emergency ward,” American Journal of Nursing 73 (October 1973) 1288-1291; Ann Wolbert Burgess, Lynda Lytle Holmstrom, “Crisis and counseling requests of rape victims,” Nursing Research (May-June 1974) 196-202.

AHA supports fluorocarbon-€0 use Hospitals must be allowed to continue use of fluorocarbon-ethyleneoxide mixture as the safest, most cost-effective method of medical device sterilization, the American Hospital Association (AHA) said during joint hearings of the Environmental Protection Agency, the Food and Drug Administration, and the Consumer Product Safety Commission on a proposal to ban fluorocarbon 12. AHA said it would cost US hospitals more than $100 million to convert present sterilizers. Another $70 million would be spent to replace nonconvertible sterilizers. Fluorocarbon 12 is used an an additive to ethylene oxide in sterilizing certain medical devices and patient care products, which are either reusable or purchased in a nonsterile state. Although steam is used in sterilizing many hospital products, special sterilizing techniques are needed for items such as cardiac catheters; plastic orthopedic prostheses, which cannot withstand heat; and delicate microsurgical instruments, which are eroded by steam. In its testimony, AHA said the mixture of ethylene oxide with fluorocarbon 12 produces a nonflammable, highly effective sterilization agent uniquely applicable to hospital needs. Although the pure form of ethylene oxide is highly flammable, the US Department of Agriculture has found that when mixed with fluorocarbon 12, flammability is virtually eliminated. Fluorocarbon 12 in mixture with ethylene oxide has inherent safety factors because it can be used under low pressure, is nonflammable, less toxic to personnel, and appears to be less hazardous to the atmosphere.

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