EFTA00156817.pdf

TILAU14A. VIOLENCE & ABUSE I.IS Responding to Delayed Disclosure taThe Author(%) 2016 RAVWS and nommen sagcpubconqourndinermaneasnar of Sexual Assault in Health Settings: DC. 101I77/152d0S0146$9464 rasageptincon A Systematic Review OSAGE Stephanie Lanthierl '2, Janice Du Mont i '2, and Robin Masonl '2 Abstract Few adolescent and adult women seek out formal support services in the acute period (7 days or less) following a sexual assault. Instead. many women choose to disclose weeks. months. or even years later. This delayed disclosure may be challenging to support workers. including those in health-care settings. who lack the knowledge and skills to respond effectively. We con- ducted a systematic literature review of health-care providers' responses to delayed disclosure by adolescent and adult female sexual assault survivors. Our primary objective was to determine how health-care providers can respond appropriately when presented with a delayed sexual assault disclosure in their practice. Arising out of this analysis, a secondary objective was to document recommendations from the articles for health-care providers on how to create an environment conducive to disclosing and support disclosure in their practice. These recommendations for providing an appropriate response and sup- porting disclosure are summarized. Keywords sexual assault, adolescent victims, adult victims, reporting/disclosure, support seeking Sexual assault in adolescence and adulthood is a pervasive. estimated 28% of sexual assaults were reported to law enforce- violent crime that results in a significant trauma to victims, ment in 2012 (Truman. Langton. & Planty. 2013). with negative health impacts that can persist for appreciable However, research shows that the majority of survivors do amounts of time (Cahill, 2009). Although research has eventually disclose to someone (Ahrens, Stanscll, & Jennings, shown that men and transgendered persons experience sex- 2010; Golding, Siegel, Sorenson, Burnam, & Stein, 1989; ual assault (Du Mont, Macdonald, White, & Turner, 2013; Neville & Pugh, 1997). Disclosure most often occurs weeks. Mcdonald & Tijerino, 2013), it is women who continue to months, or years after the assault (Dunleavy & Slowik, 2012; be disproportionately impacted (World Health Organization, Esposito, 2006; Pilipas & Ullman, 2001; Lessing, 2005; Mon- 2013). roe et al., 2005; Plumbo, 1995; Ullman, 1996a) with fewer Women who have been sexually assaulted report poorer survivors disclosing in the acute period (7 days or less) when health and use medical services more frequently than those specialized sexual assault services (e.g., Sexual Assault Nurse who have not been sexually assaulted (Du Mont & White, Examiner programs) may be available in some jurisdictions 2007; Resnick et al., 2000). Negative health outcomes include (Du Mont & White, 2007; Resnick et al., 2000; Zinzow, immediate physical injuries, pregnancy, gynecological compli- Resnick, Ban, Danielson, & Kilpatrick, 2012). cations (e.g., vaginal bleeding, infection, pain during inter- Survivors most often choose to disclose to informal support course, chronic pelvic pain) and mental health consequences providers such as friends, family, or an intimate partner, with including depression, anxiety, and posttraumatic stress disorder (PTSD; Wathen, 2012). More severe sexual assaults have been associated with worse health outcomes than less severe assaults 'Women's College Research Institute. Wcmen's College Wapiti& Toronto. (Ullman & Brecklin, 2003; Ullman & Siegel, 1995). Ontario. Canada Despite its significant health impacts, sexual assault remains 'Della Lana School of Public Health. University of Toronto. Toronto. Ontario. underreported (Du Mont & White, 2007). Although more than Canada one third (39%) ofCanadian women report having experienced Corresponting Author a sexual assault (Statistics Canada, 1994), less than 10% of Stephanie Larithier. Women's Cane Research Institute. Women's College these assaults are reported to law enforcement (Statistics Hasped. 76 Grenville Street. Floor 6. Rm. 6443. Toronto. Ontario. Canada Canada, 1994). Underreporting of sexual assault is also a prob- MSS IB2- lem in the United States where it has been found that only an stephanielmduengmadutorontam 3502-017 Page 1 of 15 EFTA_00001476 EFTA00156817 2 TRAUMA, VIOLENCE, & ABUSE substantially fewer disclosing to formal support providers "disclosure," "self-disclosure," "self-reporting," "rape," including police, health-care providers, mental health profes- "sexual assault," "sexual violence," "sexual trauma," sionals, and rape crisis workers (Baker, Campbell, & Strut- "post-assault," "post-rape," "sex," "sexual," "post-trau- man, 2012). Although informal support providers are often a matic," "PTSD," "psycho-trauma," "social support," "social good source of social and emotional support for survivors, it is perception," "social adjustment," "patient acceptance of formal support providers who are well positioned to assist health care," "health services accessibility," "communication women in their recovery through the provision of services barriers," "health personnel," "health care facilities, man- that address the physical and mental health consequences of power, services," "primary health care," "general practice," sexual assault (World Health Organization, 2013). Health- "patient care," "support," "reaction," "barrier," "examiner," care providers in particular have the potential to play a central "clinician," "doctor," "provider," "nurse," "formal," role in assisting women in their recovery. In addition to pro- "informal," and "long term." viding health care in the aftermath of sexual assault, they are The search was limited to English language records pub- uniquely positioned to act as a gateway, providing referrals to lished between 1985 and 2013. In addition, we hand-searched counseling, social, and legal services (World Ilealth Organi- the reference lists of relevant articles. In total, we identified zation, 2013). 1,166 records. After removing duplicates, the total remaining Women who have experienced violence often seek out was 779 (see Figure 1). health care though they may not disclose sexual assault to their health-care providers (World Health Organization, 2013). Those who do disclose to health-care providers suggest that Selection of Included Articles too often they receive inappropriate responses to their disclo- In the first stage of the review, all three authors screened the sure (Baker et al., 2012; Borja, Callahan, & Long, 2006). Neg- titles of the 779 records. Articles were set aside for further ative responses from support providers, including health-care review if their titles contained the terms "rape," "sexual providers, have been associated with greater PTSD symptom assault," "sexual trauma," "sexual violence," or "unwanted severity, depression, and physical health symptoms, as well as sexual attention." Titles that contained the word "sexual predictive of maladaptive coping by survivors (Baker et al., abuse" were included if it was clear that the term referred to 2012; Borja et al., 2006; World Health Organization, 2013). the sexual abuse of adults or adolescents, or where it was Evaluations of acute sexual assault services are clear that sur- unclear whether the term referred to adults or adolescents. Any vivors positively rate providers trained to deliver an appropri- title that clearly referred to child sexual assault or abuse or ate response to sexual assault disclosure, one that sensitively sexual assault of adult males was excluded. Additionally, we addresses both their medical and social/emotional needs (e.g., excluded titles where it was apparent that the focus was solely Du Mont et al., 2014). Therefore, health-care providers who on acute sexual assault, as well as titles that focused on sexual come into contact with sexual assault survivors who delay offenders. Finally, we excluded identifiable dissertations, chap- disclosure also should know how to respond appropriately ters, book reviews, books, editorials, commentaries, conference (World Health Organization, 2013). proceedings, and any remaining non-English language articles. The purpose of this study was to examine health-care pro- The title screen yielded a total of 178 records. The abstracts viders' responses when presented with a delayed sexual for each of these records were subsequently screened for fur- assault disclosure by adult and adolescent female survivors ther review by two authors. Articles were set aside for further in their practice. Our primary objective was to determine how review if abstracts referred to responses to disclosure from health-care providers can respond appropriately to delayed formal sources of support (physicians, therapists, police, etc.), disclosure in health-care settings. Arising out of this analysis, formal and informal (friends or family) sources of support, and a secondary objective was to document authors' recommen- in instances where it was unclear whether disclosure was to dations for health-care providers on how to create an environ- formal or informal support persons. Abstracts that referred ment conducive to disclosing and support disclosure in their solely to disclosure to informal support sources were excluded, practice. To answer these questions, we conducted a systema- as were those which focused on acute sexual assault, child tic review of the literature centered on health-care providers' sexual assault or abuse, or routine screening for violence responses to the delayed disclosure of sexual assault. To our (although articles referring to "assessment" were included). knowledge, no best-evidence synthesis has been conducted in Also excluded were abstracts where disclosure was made this area to date. within the mental health-care system, as these professionals are assumed to have received specialized training. Dissertations, chapters, book reviews, books, editorials, commentaries, fact Method sheets, and conference proceedings were also excluded. The abstract screen yielded 49 articles for which a full Literature Search review was conducted by two authors. Articles were included In consultation with a medical librarian, we conducted a search in the final sample only if they included responses to disclosure of OVID Medlin, EMBASE, Psyclnfo, and PubMed using of sexual assault to a health-care provider. If the only health- combinations of the following terms: "truth disclosure," care provider included was a mental health professional, the 3502-017 Page 2 of 15 EFTA_00001477 EFTA00156818 !ambler et 3 Records identified through Additional records identified database search (N. 1162) through reference lists of key articles (N=4l Records after duplicates removed iN=779) Thies excluded (N=6011 Sexual Assault or Related Terms Not in Title (N=369) Childhood or Male Sexual Assault Titles assessed to eligibility (N=779) IN-169) Book Chapters, Dissertations, etc. (N=100) Focused on Offender (N=9) Not in English (N=7) ‘‘....Acute Sexual Assault (N=6) Abstracts excluded (N=129°) No Response to Disclosure (N=9811 Abstracts assessed for eligibility Book Chapters, Dissertations etc. (IS= 9) (N=178) Childhood Sexual Assault (N=12) Mute Sexual Assault (N=7) Informal Support Provider Only (N=5) Screening (N=11 J Full-text articles excluded (N=26) Full-text articles assessed for No Healthcare Provider (N=15) • Childhood Sexual Assault (N=4) eligibility (N=49) Mental Health Setting (N=4) Commentary, etc. (N=2) Mute Sexual Assault (N=1) Snicks included (N=23) 'Some records excluded based on more than one criteria Figure I. Roy/chart of search results. article was excluded as were any remaining articles focused on organized into themes, the most common of which are child sexual assault or abuse. reported in the text. Data Abstraction Results The final sample included 23 articles. From the articles, we extracted country, participants, disclosure recipients, meth- Characteristics of Included Articles ods, key findings, including helpful and unhelpful responses The articles included in the review examined women's experi- to sexual assault, and specific recommendations from the arti- ences of delayed disclosure to a range of health-care providers. cles for health-care providers to create a suitable environment Health-care providers included physicians (Ahrens, Campbell, for and improve their response to delayed disclosures of sex- Terrier-Thames, Vasco, & Sefi, 2007; Diaz et al., 2004; Fili- ual assault and organized the information in table format (see pas & Ullman, 2001; Golding et al., 1989; Mazza, Dennerstein, Table 1). Helpful and unhelpful responses, and recommenda- & Ryan, 1996; Popiel & Susskind, 1985; Starzynski, Ullman, tions to improve health-care provider responses, were Filipas, & Townsend, 2005; Sturza & Campbell, 2005; Ullman, 3502-017 Page 3 of 15 EFIA_00001478 EFTA00156819  Table I. Description of Included Articles. Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Ahrens et al. N= 103 women. Mixed Providing emotional support including supportive Blaming or doubting the survivor (2009) Generic medical methods listening, expressions of care and concern, and Treating the survivor differently United States providers assurances that the survivor is not to blame after disclosure Providing tangible aid Distracting the survivor Blaming and/or doubting reactions from medical Controlling the survivor personnel only when survivors interpreted this Doing nothing to help the response as trying to protect them from future survivor after disclosure harm Attempting to control the survivor's decisions if the survivor believes the support provider is reacting out of concern Having an egocentric reaction Ahrens et al. N = 102 women. Mixed Providing emotional support including listening to Blaming the survivor Train medical personnel on how to support (2007) Physicians methods the survivor, telling them it was not their fault. Doubting the survivor survivors United States providing reassurance Doing nothing to help the Consider incorporating sexual assault screening Providing tangible aid survivor after disclosure questions into medical intake procedures Maintaining a cold/detached demeanor Doing 'their job' bur failing to communicate any sympathy or concern for the survivor's well-being Having no reaction at all Ahrens et al. N = 103 women. Mixed Blaming the survivor Train formal support providers including health- (2010) Generic medical methods Taking control care providers about how to respond in a United States providers Treating the survivor differently positive manner and avoid responding in a after disclosure negative manner Distracting the survivor Diaz et al. N = 146 women. Quantitative Providing emotional support and responding in a Inquire directly about sexual assault victimization (2004) Physicians professional yec compassionate manner as part of routine assessment United States Ensuring survivor seeks the appropriate follow-up Use a series of concrete questions co elicit Clarifying misconceptions about sexual assault disclosure of a past sexual assault (e.g.. victim is to blame) Take time co build trust and help the survivor feel Informing survivors of services available to assist comfortable to disclose them with recovery Providing referrals (continued) EFTA00156820  Table I. (continued) Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Dunleavy and N = I woman. Qualitative Validating the disclosure and providing emotional Use a patient-centered approach to help establish Slowik Physical support using the simple statement: 'I am so trust and a feeling of safety that encourages (2012) therapists sorry that this has happened to you' disclosure and continuity of care United States Referring survivor to psychotherapy and Provide a confidential environment and do not community resources, providing support 'rush' che survivor without attempting to serve as a counselor or Have a heightened awareness of nonverbal stress psychotherapist responses during examinations Consider regular screening in health-care settings where many individuals are likely to have experienced sexual violence (e.g.. veterans) Esposito N = 43 women. Qualitative Providing compassionate and emotionally Criticizing the survivor Do not push the survivor to disclose (2006) Nurses supportive care Treating the survivor with Find another nurse to speak with the survivor, if United States Acknowledging the disclosure through statements contempt unable to respond appropriately and questions such as 'I'm so sorry chat Asking the survivor what they Use a nonjudgmental and culturally competent happened to you. were doing in that area or approach When did it happen?" "Have you ever spoken to telling the survivor 'they Discuss the sexual assault in a private, one-on-one anyone about it? Was that helpful?' and "You deserved it or "asked for IC setting are very brave co share that information Accusing the survivor of lying Have brochures or other materials about sexual Making referrals if needed Avoiding eye contact with the assault available in patient rooms survivor or changing the Ask the survivor how she can be most comfortable subject quickly during examination and explain the procedure Be sensitive to the survivor's behaviors during examination and allow the survivor to stop the examination if she wishes Assess for sexual assault using the approach recommended for intimate partner violence Fdipas and Ullman N = 323 women. Quantitative Providing emotional support Treating the survivor differently Educate formal support providers including health- (2001) Physicians Not blaming the survivor (e.g.. stigma) care providers about sexual assault and the United States Providing tangible aid Promoting rape myths negative impacts of "rape myths Providing informational support Blaming the survivor Validating or believing the disclosure Distracting the survivor Not distracting the survivor Having an indirect negative Sharing their own experience with the su or reaction (e.g.. comments Not treating survivor differently about sexual assault in general that survivors find hurtful Violating trust Golding et al. N = 447 women Quantitative Design interventions to change physicians negative (1989) and men. attitudes United States Physicians Train physicians on behaviors used by those with direct experience working with sexual assault survivors such as rape crisis workers (continued) EFTA00156821  P Table I. (continued) Participants and Key Findings Authors. Year. Disclosure Typef Country Recipients Method Helpful responses Unhelpful responses Recommendations Lasing N/A Nurses Literature Providing emotional support. nurturance. a feeling Create an environment that is conducive to disclosure (2005) review of safety Do not assume that the survivor will automatically United States Establishing safety. both physically and emotionally disclose sexual assault Providing appropriate referrals Conduct sexual violence screening as part of Recounting the events surrounding the sexual routine assessment assault until it is clear that the survivor knows Use an 'icebreaker to allow patients more comfort that the assailant is to be blamed for the assault in disclosing information by letting them know Document sexual assault in the survivors' own that others have experienced similar events words Be alert to signs and symptoms of sexual assault (e.g.. sleep disturbance, decreases in appetite. self-blame, decreases in self-esteem. relationship difficulties. phobias. motor behavior difficulties. suicidal and homicidal ideation. somatic reactions) Provide ongoing education for primary care providers co keep current on treating sexual assault Littleton N = 262 women. Quantitative Blaming or stigmatizing the Assess strength of survivor's social support networks (2010) Generic medical survivor Inquire about survivor's past disclosure United States providers Treating the survivor differently experiences Distracting the survivor Assist survivors with understanding and coping Taking control with negative disclosure reactions Proceed with caution when encouraging survivors co disclose Long. Ullman. N = 1.022 Quantitative Be sensitive to issues of sexual orientation when Long. Mason. women. providing care to survivors and Starzynski Generic medical Check that the survivor perceives your actions as (2007) providers supportive United States Nana a al. N = 2.181 Quantitative Assess for signs and symptoms of sexual assault (1996) women. Develop the skills co diagnose sexual assault Australia Physicians Have knowledge of local social services and legal options in order to make appropriate referrals Muganyizi et al. N = 50 women. Mixed Providing emotional support and coping Blaming the survivor Educate formal support providers including health- (2009) N=M methods information Using statements meant to care providers on responding to sexual assault Tanzania Nurses. N = Advising survivor to seek legal or medical degrade or shame the survivor 1.505 assistance Avoiding or segregating the Community Providing information on how to avoid sexual survivor members assault in the future Distracting the survivor Nurses Distracting the survivor (continued) EFTA00156822  Table I. (continued) Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Muganyizi N = ICI women. Qualitative Acting in an unprofessional Train health-care providers to improve caring and Nystrom. N = 20 manner communication skills Axemo. and Social supports Provide more sensitive care Emmelin Generic medical Understand how survivors cope with sexual (2011) providers assault Tanzania Plumbo (1995) N/A. Clinical Providing support and encouraging healing Dismissing the survivor Be empathic and open to encourage disclosure United States Nurse-midwives practice Acknowledging the sexual assault Not providing a referral when Assess the degree of support and counseling Reassuring the survivor that the decision to appropriate required disclose was appropriate Differentiate survivors who need referral from Using simple statements such as I'm so sorry this chose who do not has happened co you' and "I'm glad you told me Be sensitive to survivor's verbal and nonverbal about this' after disclosure behaviors Verifying that the survivor is not isolated Assess survivor's safety Listening to and supporting the survivor Educate the survivor about the physical and Assisting the surrivor to understand that she is in emotional symptoms of sexual assault charge of her recovery and that there are Provide advice that is brief. focused. and practical support systems available to her Ask the survivor to remember other difficult Providing referrals to survivors who have ahistoryof episodes in which she may have coped well abuse. ongoing difficulties with adult relationships. Ask the survivor about her support network substance we problems. suicidal ideation. and/or who express maladaptive sentiments identifying and acknowledging survivor's strengths and coping skills (e,g.. it cook a great deal of strength to deal with this event in your life. I'm glad you decided 43 share this with me today") Emphasizing that the survivor's reactions are normal Reinforcing that the survivor was a victim of a crime and not responsible for the sexual assault Popiel and N = 25 women. Quantitative Reassuring the survivor Feeling sorry for the survivor Provide training to the medical community to Susskind Physicians Taking time to talk with the survivor Making decisions for the survivor enhance communication skills (1985) Trying to understand what the survivor is going Talking about the sexual assault United States through Providing information and discussing options Encouraging the survivor to seek further assistance Starzynski et al. N= 1,084 Quantitative Be aware of and reject 'rape myths' (2005) women. Provide more positive and less negative reactions United States Physicians co disclosure (continued) EFTA00156823  Table I. (continue.* Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recomm