Introduction
Sexual violence is a critical global issue that affects millions of people worldwide, claiming a victim every 45 seconds according to the American Medical Association [1]. EMS personnel are certain to encounter sexual assault victims, and are often the first to interact with the victim after the assault. It is crucial that EMS physicians and personnel, as well as EMS medical directors, understand the psychosocial, medical, and legal aspects of sexual assault.
Sexual violence has been defined as any form of sexual activity with another person without her or his consent. The assault may include forced kissing, fondling, attempted or completed penetration, forced masturbation by the victim or to the assailant, forced participation in or looking at sexually explicit photos, sexual harassment, exhibitionism, and voyeurism [2]. Both women and men can be victims of sexual assault; however, the majority of assaults are perpetrated by men against women and children [3]. Therefore, for ease of pronoun use, she or her will be used here in any reference to a victim.
The National Intimate Partner and Sexual Violence Survey reports that nearly one in five women (18.3%) and one in 71 men (1.4%) in the United States have been raped at some time in their lives, including completed forced penetration, attempted forced penetration, or alcohol/drug-facilitated completed penetration [4]. It is important to note that sexual assault is one of the most underreported crimes. Fewer than one in ten victims report the crime to the police [5]. Most women will confide in family, friends, co-workers, doctors, and/or nurses [6].
Reasons for not reporting include embarrassment, fear of being blamed or not being believed, and fear of reprisal from the assailant or court proceedings. Sexual assault is often attributed to overwhelming sexual desire. It is anything but. All forms of sexual assault are the misuse of power and control over another person with the intention of abusing and humiliating the victim [7].
Myths
Myths are used to condone or deny sexual assault. Accepting myths as reality contributes to the way society responds to and may influence the reporting of sexual assault. Some of the widely held myths are:
- the only way a rapist can really force a woman to have intercourse is by using a weapon
- women who do not actually physically fight back have not been raped
- if the attacker is drunk at the time of the assault, then he cannot be accused of rape.
Providers should understand that sexual assault can affect anyone (including males, children, and the elderly) and is not typically accompanied by physical injury or signs of trauma.
Male sexual assault
Use of weapons and brutality are reported more often in male sexual assault. Therefore, males may sustain more physical trauma than females [10]. The most common forms of assault that males experience are receptive anal and/or oral intercourse and forced manual genital stimulation [10]. The male patient may feel guilty about having been assaulted because of a belief that males are supposed to be able to protect themselves. This feeling can be compounded if the male also experienced an erection and/or ejaculation during the assault. Both these responses can occur as involuntary reactions to extreme stress. A male does not have to be sexually aroused to have an erection [10].
Given that most assaults committed against men are perpetrated by other males, a common misunderstanding for assaulted heterosexual males is that he will become homosexual after the assault.
Psychological care of the patient
Many victims of sexual assault do not suffer life-threatening injuries; however, they do experience psychological trauma. Therefore, after assessment for and management of physical injuries, support becomes the EMT’s priority. During a sexual assault, power and control are taken away from the person; care should be directed at restoring the person’s self-determination through decision making with respect to her care. Sexual assault is the only crime in which the victim is often considered to have some responsibility and have contributed to the assault by the way she dressed, spoke, or acted, or her location at the time of the assault. No one asks or deserves to be sexually assaulted: EMTs should always treat patients with respect. The patient will experience a multitude of emotions, including but not limited to shock, disbelief, confusion, guilt, self-blame, terror, anger, and lack of trust. These emotions may be evident or the patient may be very composed. The patient may even block out the events if they are too much for her to cope with at the time [10]. The type of response she receives from the first person to whom she discloses can affect how she views her situation and subsequently deals with it.
Some of the most important things an EMT can do in the initial interaction is to connect with the patient through introducing himself or herself, using the patient’s name, maintaining eye contact, and using a calm, even tone when speaking. It is important that the EMT proceed on the presumption that an assault has occurred; it is not the EMT’s role to decide whether or not an assault occurred. Responses to the patient should be non-judgmental and intended to reassure the patient that she is safe and that the assault was not her fault. Many victims buy into the myths surrounding sexual assault, and it is thus important to be able to help the patient distinguish between myth and reality.
People respond to crisis in a variety of ways, from crying to being calm and cooperative to laughing nervously. All are normal responses and it is important to help the patient understand this if she is concerned about how she is responding. A controlled response from a patient does not mean that the assault did not happen. She may also be concerned that she did not do enough to resist the assault; therefore, she should be reassured that she did what was necessary to prevent any further harm. If she is alone, the EMT should ask her if she would like a support person to be called.
