Sexual assault—Intervention in primary care

Amanda Childress, codirector of the Sexual Assault Awareness Program at Dartmouth, stated in a telephone interview that intervention through prevention and education should occur much earlier than college age. She further advised that students be educated about predatory behaviors and be willing to intervene when they witness behaviors of concern. According to Childress, red flag predatory behaviors can include the following:

• Someone following one particular person around during a party or event (picking out a target), even if that person has made it clear he or she is not interested; predators usually plan their attacks
• Someone encouraging a specific person to increase consumption of a mind-altering substance, such as alcohol
• Backing someone against wall or into a corner, often putting an arm out to the wall or around the person to block an easy exit

A common misconception is that rape, especially on college campuses, is done by “basically good guys who, because of a combination of too much alcohol and too little clear communication, end up coercing sex upon their partners. This image is widely promulgated, but it is flatly contradicted by research.”¹⁶

A study published in the journal Violence and Victims in 2002 reported the identification of 120 self-reported rapists in a sample of 1,882 college students. These 120 rapists committed 1,045 acts of violence: 439 rapes and attempted rapes, 49 sexual assaults, 277 acts of sexual abuse against children, 66 acts of physical abuse against children, and 214 acts of battery against intimate partners.¹⁶ Of the 120 rapists, 76 of them averaged 14 victims each.¹⁶ Clearly, these are not acts of miscommunication, and the research shows that serial sexual predators are responsible for a large portion of sexual violence. Knowledge of this can help victims identify predatory behaviors and help them understand that nothing they did was responsible for the violence.

Amy was referred to a mental health specialist who helped her access multiple community resources, and she had regular follow-up visits with mental health providers. In addition, her sertraline dose was adjusted during her period of intense treatment and healing, and she has had regular clinic visits and communication from her medical provider as well.

The clinician’s role in sexual assault

What can we as health providers do to help?

• Education: Talk to patients starting in middle school or even before, though especially before they leave for college, and when they come in for routine visits while on school breaks. Include in your discussion the definition of assault and the definition of consent (“no” means “no”; ambiguous means “no”; and only fully conscious, alert consent means “yes”). Encourage them to look for available resources on and off campus in case of assault when they first enter college (as trying to find the resources in the midst of a crisis is more difficult), and encourage them to intervene on behalf of someone else when they see it is needed.
• Prevention: Encourage the buddy system—at all times—especially at parties and events. Encourage talking to their friends about predatory behaviors and to stand up and distract, discourage, and delegate (intervene) as needed. Teach that laughing at rape jokes, listening to inappropriate stories of conquests, or encouraging inappropriate behaviors helps camouflage predators and perpetuates the culture of sexual violence as socially acceptable.
• Recognition: Assess further if there are red flag symptoms, such as sudden onset of anxiety, depression, multiple somatic complaints, chronic pain, increased substance use, eating disorders, changing schools suddenly or moving back home; address the specific complaint, but consider precipitating factors. The provider should ask directly about a history of intimate partner violence or sexual assault at every visit, with every patient.
• Intervene: Provide multiple resources, counseling, support groups, crisis centers, and campus groups.
• Follow-up: Let the patient know you will continue to be a resource, provide contact information, and reach out—stay in touch via phone, email, and office visits on a regular basis.
• Education and prevention need to start early and should occur frequently. Intervention can be done at any time. It is never too late to address a sexual assault issue, and it is never too late to potentiate healing.

Jill Beyer Blodget, BSN, MSN, FNP, is a family nurse practitioner at Kaiser Permanente in Sacramento, Calif.