Sexual violence is a profound public health crisis resulting in significant physical, emotional, and economic costs. Over half of all women have experienced some form of sexual violence involving physical contact during their lifetimes. Nurse practitioners in primary care settings have the unique opportunity to provide comprehensive care for women with whom they have established rapport. Care should include screening for sexual violence with a trauma-informed approach, and if indicated, providing treatment and coordinating care. Equipped with knowledge of screening and care management, nurse practitioners can provide a safe and trusting place for survivors of sexual violence to make disclosures and get the treatment and resources they need to recover and improve their health and wellbeing.

Sexual violence is common, nondiscriminate, and costly. Over half of women and one-third of men in the United States have experienced sexual violence involving physical contact over their lifetimes.¹ Sexual violence is a broad, nonlegal term that describes unwanted or harmful sexual acts including sexual assault, rape, and sexual abuse.² Anyone can experience sexual violence regardless of age, gender, sexual orientation, or socioeconomic standing. Women and certain racial and ethnic minority groups are disproportionately affected by sexual violence, with non-Hispanic American Indian/Alaska Native and non-Hispanic multiracial women having the highest prevalence.³ Approximately 33.5 million women in the US have been the victim of a completed or attempted rape. Sexual violence often starts early, with 80% of women reporting they were raped for the first time before age 25 and 14% (4.7 million) being victimized for the first time at age 10 or younger.³

Sexual violence is a profound public health crisis resulting in significant physical, emotional, and economic costs. Sexual violence has been linked to mental health conditions including depression, anxiety, post-traumatic stress disorder, and suicidal ideation and attempts.^4,5 The chronic physical consequences associated with sexual violence are many, with some of the most common being chronic pain, irritable bowel syndrome, HIV/AIDS, diabetes, hypertension, asthma, and headaches.^6–8 Other negative health consequences of sexual violence include the increased likelihood of engaging in risky sexual behaviors, smoking, abusing alcohol, and using drugs.¹ The trauma of sexual victimization may lead to difficulties maintaining existing and creating new personal relationships, completing daily activities, or carrying on with responsibilities at work or school. When the trauma results in taking time off from work, decreased productivity at work, or job loss, survivors of sexual violence and their dependents may be negatively impacted economically.¹

Emergency departments are often the initial point of contact for individuals following sexual assault, but it is estimated that about 80% of survivors will not seek any type of care specifically related to their assault.⁹ They may, however, seek care for other health issues that can provide an opportunity for screening and possible intervention. For nurse practitioners (NPs) working in primary care settings, there is a unique opportunity to provide comprehensive care for survivors of sexual violence. Primary care providers can offer a safe, familiar place for survivors to disclose their experiences when they are ready.
Understanding the scope and consequences of sexual violence can lead to the recognition of signs and the implementation of more thorough screening during regular office visits. Addressing sexual violence can be daunting to providers who are unfamiliar with how to approach a patient who has experienced or is experiencing sexual violence. The purpose of this article is to provide NPs in primary or ambulatory care settings with practical strategies and guidance to increase their confidence in caring for sexual violence survivors. The resources used for this article come primarily from literature focused on cis-gender women. Sexual violence affects individuals of all genders and sexual orientations. While much of the information is applicable beyond cis-gender women, providers should individualize care to the particular needs of each patient.

Screen routinely

The American College of Obstetricians and Gynecologists recommends screening all women for a history of sexual assault.¹⁰ Despite screening recommendations and the prevalence of sexual violence, it is often excluded from regular screening questions during office visits. In a study of college-age women, approximately two-thirds of the participants reported that they were not asked about sexual violence or intimate partner violence at their last healthcare visit.¹¹ Similarly, results from an online survey of women showed only 28% reported being screened for sexual assault by their healthcare providers.¹² In a systematic review of barriers to intimate partner violence screening in particular, provider-related barriers were more often reported than patient-related barriers.¹³ The most common provider-related barriers to screening were personal discomfort related to the issue, lack of knowledge, and perceived time constraints.¹³ Importantly, researchers have found that women respond favorably to screening, with 82% of respondents indicating they would disclose sexual assault if their healthcare provider asked while less than a quarter of respondents would disclose this voluntarily.¹²

Ideally, all women beginning in adolescence are screened for sexual violence during routine visits with their healthcare provider. Before the screening, providers should provide information about mandated reporting. In all states, if the abuse involves a child, a report must be made to Child Protective Services. Mandatory reporting laws for domestic violence/intimate partner violence vary depending on the jurisdiction. Healthcare providers should be familiar with mandatory reporting laws to ensure patients receive trauma-informed, transparent information prior to screening.¹⁴ Screening should occur in a private location when the woman is by herself. It should be incorporated into the medical history at the beginning of the visit rather than the end so that screening is universal rather than individualized or based on suspicion of abuse that may arise during the visit. Several screening tools have been validated and recommended for use in the primary care clinical setting.¹⁵ The Two-Question Screening Tool offers a quick and simple way of screening for intimate partner violence (“Have you ever been hit, slapped, kicked, or otherwise physically hurt by your partner?”) and sexual violence (“Have you ever been forced to have sexual activities?”).¹⁶ Healthcare providers should have one instrument they are familiar with and are comfortable using.

Recognizing experienced recent or past sexual violence through the lens of trauma-informed care

Trauma-informed care principles provide a framework for approaching all patients from a survivor-centered perspective. Healthcare guided by a trauma-informed framework shifts away from questioning “What is wrong with this patient?” to “What happened to this patient?”¹⁷ This approach allows the healthcare provider to see the multifaceted patient experience and creates space to address a broad range of factors affecting an individual’s health and wellbeing. To provide trauma-informed care is to approach the patient’s presenting concern from a holistic perspective, considering what may have happened in their life that could be impacting their current state of health and behaviors while acknowledging the prevalence of trauma. The overarching goal of trauma-informed care is to help the trauma survivor feel secure, safe, and empowered, and to support them as they move toward recovery.¹⁷ The four “Rs” are the key assumptions of the trauma-informed care approach:

Realize that trauma impacts individuals, families, communities, and organizations; the impact of trauma is widespread.

Recognize the signs and symptoms of trauma.

Respond by integrating knowledge about trauma into all areas of functioning.

Resist re-traumatization by recognizing how individual actions and/or organizational practices may affect someone with a history of trauma and changing those actions.¹⁷

Considering the health sequelae of sexual violence, the trauma-informed approach is particularly important for the primary care provider who will certainly see sexual violence survivors for other presenting concerns. The health-related consequences of sexual violence are extensive. Women who have experienced sexual violence may have short-term effects including acute injuries, sexually transmitted infections (STIs), pregnancy, increased anxiety, insomnia, and increased uptake of risk-taking behaviors.^18,19 Long-term effects may include, but are not limited to, post-traumatic stress disorder, depression, anxiety, substance use disorders, suicide, chronic pain syndromes, neurologic problems, headaches, and gastrointestinal and genitourinary complaints.²⁰ While the patient may present with chronic abdominal pain or headaches, considering trauma as a variable creates an opportunity for more comprehensive care provision.

Responding to delayed disclosure

In the primary care setting, initial disclosures of sexual violence will typically be delayed presentations. It is common for women to delay disclosure of sexual violence. Self-blame, fear, guilt, shame, embarrassment, and coerced silence contribute to delayed disclosure.^21–23 Trauma-informed care principles are critical when responding to disclosures of sexual violence. The manner in which healthcare providers respond has the potential to affect health outcomes for women who have experienced sexual violence. In a systematic review of healthcare providers’ responses to sexual violence disclosures, the most negative responses were: blaming the survivor; being dismissive, minimizing or distracting from the disclosure; treating the survivor differently after the disclosure; doubting the survivor; and reacting with a cold, distant demeanor.²¹

The most important and impactful way a healthcare provider can respond to a disclosure of sexual violence is to believe what the patient says. In the systematic review of healthcare providers’ responses to disclosures, helpful responses were: validating the disclosure, providing emotional support, and offering tangible aid in the form of resources.²¹ A response that acknowledges and validates what has been disclosed helps to create a safe space for the survivor to heal. Because self-blame is so common among women who have been sexually abused or assaulted, it is important to provide assurance that what happened is not their fault.^12,21 Next, the provider should ask how they can help. A selection of validating responses to disclosure is provided in Table 1.

After offering reassuring statements, the patient’s safety should be assessed. Physical injuries should be evaluated and managed according to the presentation. Providers should discuss with the patient whether they have someone they can call or a safe place they can go when they feel unsafe. Having resources readily available to give to patients with emergency hotlines, online support, and local support services is a way to provide tangible aid (Table 2). Also, it is appropriate to offer a referral for mental/behavioral health services. When distributing written information, assess whether the woman feels safe taking the information. If the abuse is happening within an ongoing relationship, having such information could put her at risk for increased violence if the abuser sees the material. If this is a concern for the individual, write the emergency phone number on a blank sheet of paper or give them the name of a website they can memorize and search for later. Finally, focus on the patient’s strengths (eg, “You showed a lot of courage by sharing this with me today.”) and promote resiliency with positive action steps the patient may take (eg, “What gives you strength during hard times?” Or “Tell me some ways you take care of yourself.”).²⁴ Ending the visit should include a plan for follow-up and support from the healthcare provider.

Acute sexual assault

Most women who decide to seek medical care following sexual assault will report to an emergency department, but some will present to primary care or contact the primary care provider. Caring for survivors of sexual assault in the community-based primary care setting offers the advantage of accessibility, familiarity with the provider, a more private setting for the patient, and possibly a staff and provider who are more connected in the community and understand the culture and language used by the survivor.¹⁴ The challenges in primary care are limited resources for care services, the need for possible transfer to the hospital, and time restrictions with appointments and regular business hours.¹⁴ Nevertheless, patients presenting to primary care should be assessed and cared for using a trauma-informed approach. The initial history should include assessing for safety and serious injuries. The provider should ascertain the approximate time the assault took place. The priority is safety and addressing acute medical needs. Referrals or transfers for evaluation, urgent stabilization and hospitalization, or surgery may be required based on the presentation. Strangulation injuries are concerning in that the seriousness or extent of the injury may be unrecognized by the survivor and many survivors who have been strangled will not have visible injuries to the neck.²⁵ Strangulation injuries can lead to a sequelae of events from sore throat, shortness of breath, laryngeal fracture, dissection of the carotid artery, stroke, coma, and even death.²⁵ Any patient who has experienced strangulation or sustained a head injury should be thoroughly evaluated and referred as indicated.²⁶

After assessing for and managing any serious injuries or other medical concerns, the patient should be informed of the option for a forensic exam with or without evidence collection. Typically, evidence can be collected within 120 hours of the assault.¹⁴ The time frame for evidence collection varies based on state protocols and individual hospital policies. The forensic exam is not required and is completed at the discretion of the patient. If the individual chooses to have a forensic exam, it should be performed by a trained medical professional (sexual assault nurse examiner [SANE] or sexual assault forensic ex-aminer [SAFE]). If the patient is being transferred from the primary care location to a designated facility for a forensic exam, the provider should take special care in coordinating the transfer so the care transition is as seamless as possible to reduce further trauma to the patient.¹⁴ Once care is transferred, the sexual assault clinician will complete the plan of care to meet the patient’s needs.

If the patient decides to not have the forensic exam and does not want to see a specialized provider, the primary care provider should attend to the needs of the patient following best practices in caring for sexual assault survivors. Pregnancy and STI screening tests should be offered to survivors. All survivors of childbearing age should be offered emergency contraception within the appropriate time frame. The Centers for Disease Control and Prevention recommends prophylactic treatment for chlamydia, gonorrhea, and trichomonas at the initial presentation to the healthcare facility following the assault. Providers should not wait for test results to treat for STIs.²⁷ The healthcare provider should assess the need for post exposure hepatitis B vaccination with or without hepatitis B immune globulin (HBIG) and HPV vaccination. The CDC provides an algorithm for evaluation and treatment for possible HIV exposure.²⁷

Nurse practitioners (NPs) who want to learn more about caring for sexual assault survivors and want to expand the care they can provide to their patients can become SANEs. SANEs provide acute care to sexual assault survivors and have special training to take a complete history and conduct a forensic medical exam with evidence collection. Additionally, they are trained in photographic documentation of injuries and can provide consultation and testimony in civil and criminal legal proceedings. When a SANE is involved, patients are more likely to receive recommended care including emergency contraception and prophylactic STI treatment.²⁸ Patients also are more likely to be offered and accept a forensic exam with evidence collection if a SANE is providing the care.²⁸ SANEs have improved patient care experiences, helped to decrease crowding in emergency departments, and have contributed to increased rates of perpetrator conviction.^29,30 Nurse practitioners working in rural and medically underserved communities where access to trained sexual assault examiners in hospitals or sexual assault centers is limited or absent may consider becoming SANEs to meet the healthcare needs of survivors in their communities. The International Association of Forensic Nurses offers information on how to become a SANE (https://www.forensicnurses.org).³¹

Conclusion

Sexual violence is prevalent with over half of all women experiencing some form of unwanted sexual activity in their lifetime and 1 in 5 women being raped in their lifetime.^1,32 Many women will never report sexual violence or will delay reporting it for months or years.^21–23 Nurse practitioners serving as primary care providers for women are uniquely equipped to provide comprehensive care for sexual violence survivors in an environment that is familiar and safe. Having established rapport and care continuity with patients allows for repeated opportunities for sexual violence screening that could lead to disclosures and opportunities to provide appropriate care and help. Adopting a trauma-informed care approach requires staff to be educated on best practices and committed to ensuring survivors of sexual assault are treated safely and with respect as they provide support for recovery.¹⁷ Receiving a disclosure of sexual violence has the potential to be disruptive to an NP practicing in a primary care setting with a set schedule with limited time per patient. Understanding how to respond in a sensitive and validating way, knowing recommended treatments for survivors of acute assault, and having resources readily available for survivors can make the experience of receiving a disclosure less overwhelming to the NP in primary care settings. Through sign and symptom recognition, screening, treatment, care coordination, and follow-up, NPs in primary care play a vital role in promoting healing and recovery and have the potential to greatly improve the health and wellbeing of women who are survivors of sexual violence.

Casey S. Hopkins is Assistant Professor of Nursing at Clemson University in Clemson, South Carolina, and a women’s health nurse practitioner in the Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, at Prisma Health-Upstate in Greenville, South Carolina. Dr. Hopkins is a trained sexual assault nurse examiner. Ellen Kennedy is the sexual assault nurse examiner coordinator at Prisma Health-Upstate in Greenville, South Carolina. The authors have no actual or potential conflicts of interest in relation to the contents of this article.

Womens Healthcare. 2024;12(1):25-30. doi: 10.51256/WHC022424

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KEY WORDS: sexual violence, primary care, sexual assault, intimate partner violence, women’s health nurse practitioners