Telehealth Triage of Sexual Assault
Sexual violence is a very traumatic experience that may have both acute and long-lasting effects (physical, psychological, and emotional). More than 1 in 3 women and 1 out of 4 men have faced sexual violence in their lives (CDC). Sexual violence is linked to negative impacts on overall health and unhealthy behaviors (increased smoking, alcohol or drug misuse, risky sexual behavior).
Knowledge of sexual assault care will help you triage more effectively. Your goal as a telehealth triager is to provide a safe and supportive space when talking with those impacted by sexual violence. Consider the following priorities to promote patient-centered care.
• Ensure physical and emotional safety: Triage injury symptoms and refer to the appropriate level of care. Approach with gentleness and a non-judgmental manner.
• Inform about health care choices: A child or adult has the right to decline any part or the entire forensic (scientific tests used in crime detection) exam. Reinforce this right with a caller or parent who may be uncertain about an exam.
What Concerns and Fears Do Patients Have?
Triagers should recognize that people who have been victims of sexual assault have a number of concerns and fears.
• Becoming pregnant
• Bringing shame to family
• Costs of medical care
• Cultural factors, including loss of virginity and acceptability for marriage
• Getting a sexually transmitted infection (STI)
• Getting HIV
• Law enforcement involvement might result in a report to immigration authorities and deportation
• Loss of home, children, citizenship, income - especially if assault by an intimate partner
When Is the Best Time for an Exam After a Sexual Assault?
A forensic exam (sexual assault exam) as soon as possible after the assault is best!
Some “date rape” drugs become untraceable around 12 hours after ingestion.
HIV prophylaxis is ideally started within a 72-hour timeframe.
Emergency contraception is effective up to 5 days after intercourse.
Assessment and treatment of injuries in a timely manner is best for proper healing and pain management.
Referral for supportive care is essential after an assault.
However, the focus of sexual assault referral to an Emergency Department has shifted. The type of care provided, instead of the timeline for evidence collection, is the principal concern.
Why Is the Emergency Department Usually Recommended for Evaluation and Management?
The Emergency Department (ED) has the resources (trained staff and equipment) to assess, document, treat and refer a patient that has been sexually assaulted. The ED serves as an access point 24 hours/day for sexual assault evaluation and counseling services.
Emergency contraception can be initiated.
Injuries can be evaluated and treated.
Medicines can be given to prevent sexually transmitted infections and HIV.
A forensic exam can be completed by a SANE nurse (Sexual Assault Nurse Examiner) or a trained emergency department doctor (or NP/PA). There are about 1000 U.S. hospitals that provide a SANE nurse or “SART” (Sexual Assault Response Team). Forensic evidence can be collected.
The ED can arrange counseling and address important psychological needs (an advocate is typically contacted). Further, law enforcement can assist in providing a report and help in other ways if requested.
If a prolonged period of time (weeks, months) has passed since the sexual assault, a triager may use their judgment and knowledge of other local sources of care to best address a victim's needs and wishes. Alternate sources of care might include the primary care doctor (or NP/PA), a local agency like Planned Parenthood, or a Federally Qualified Health Center (FQHC). Still, the ED may be the best place to send these individuals.
As a Triager, Am I Mandated to Report Sexual Assault?
People less than 18 years and vulnerable adults: The triager is mandated to report suspected or actual sexual abuse.
Adults 18 years and older: The patient, not the healthcare worker, has the option of whether or not to report a sexual assault to the police.
Triagers should know the mandated reporting laws for the state (or province) where the sexual assault occurred. Refer to your call center policies or reference materials.
What Are the Evidence Collection Timelines?
Some jurisdictions use 72 hours after the assault as the standard cutoff time for collecting evidence from a sexual assault examination. Many jurisdictions have extended the standard cutoff time to 7 days. Improving DNA testing technologies may extend this timeframe further.
What Telehealth Triage Guidelines Are Available for Decision Support?
• Sexual Abuse Suspected (Pediatrics)
• Sexual Assault or Rape (Pediatrics)
• Sexual Assault or Rape (Adult)
How Should I Handle Follow-Up Calls?
While uncommon, you may talk with a patient or family that has experienced some type of sexual violence in the distant past or has already had a full medical evaluation and forensic exam. Refer and encourage patients to be seen to help address medical, emotional, and psychosocial needs and promote healing and recovery. Active listening, knowledge, and compassion will prepare you to best support these callers!
Internet Resources
The National Sexual Violence Resource Center (NSVRC): Available online at http://www.nsvrc.org/. Phone 877-739-3895.
Rape, Abuse & Incest National Network (RAINN): RAINN has a hotline that victims of sexual assault can call: 1-800-656-HOPE. Available online at http://www.rainn.org/. RAINN also has a search engine for locating a local counseling center for a victim of sexual assault. Available online at: http://www.rainn.org/.
A National Protocol for Sexual Assault Medical Forensic Examinations. U.S. Department of Justice. Available online at http://www.safeta.org/.
U.S. Department of Defense Sexual Assault Prevention and Response (DoD SAPRO): "Each person covered under DoD SAPR policy who reports a sexual assault is offered the assistance of a Sexual Assault Response Coordinator (SARC) or Victim Advocate (VA). who addresses safety needs, explains the reporting options, services available, and assists with navigating the military criminal justice process. SARCs and SAPR VAs offer expertise to prepare victims for the road ahead and will advocate on behalf of a victim along the way." Available online at https://www.sapr.mil/victim-assistance.
U.S. DoD Safe Helpline: The Safe Helpline provides confidential crisis intervention, support and information to Service members of the U.S. DoD community who have been sexually assaulted. The 24-hour a day phone number is 877-995-5247. Available online at https://www.safehelpline.org/.
U.S. Office of Civil Rights and Title IX Reporting: Available online at www2.ed.gov/about/offices/list/ocr/docs/tix_dis.html.
Here are some additional resources about emergency contraception.
The Emergency Contraception Website: http://ec.princeton.edu. This is a very useful website with answers to many FAQS. This website also lists physicians and clinics in the United States and Canada that provide emergency contraceptive pills.
Canadian Paediatric Society Adolescent Health Committee position statement: https://www.cps.ca/en/documents
Author:
Cheryl Patterson, RNC-TNP, BSN Nurse Editor, Adult Telehealth Triage Guidelines, STCC
Co-Authors:
Jeanine Feirer, RN, MSN Nurse Editor, Adult Telehealth Triage Guidelines, STCC
David Thompson, MD Senior Medical Editor, Adult Telehealth Triage Guidelines, STCC