Determining “best” practices in responding to delayed disclosure by

female sexual assault victims in health care settings

A Systematic Literature ReviewStephanie Lanthier, Janice Du Mont and

Robin Mason

1

2

Image: http://projectunbreakable.tumblr.com/

Background: Disclosure of Sexual Assault

3

• Sexual assault is a pervasive yet underreported violent crime (Du Mont & White, 2007). Less than 10% of sexual assaults are formally reported to the police (Brennan & Taylor Butts, 2010; Sinha, 2013).

• Research shows that the majority of women do eventually disclose to someone (Ahrens et al., 2010; Golding et al., 1989; Neville & Pugh, 1997).

• Disclosure often occurs weeks, months or years after the assault (Dunleavy 2012; Esposito, 2006; Filipas & Ullman, 2001).

Background: Health Consequences

and Health Seeking

4

• Sexual assault victims report poorer health and use medical services more frequently than non-victims (Golding et al., 1989; Resnick et al., 2000; Ullman & Brecklin, 2003; Ullman & Siegel, 1995).

• They can present with a variety of physical, uro-gynaecological, obstetric and/or mental health issues (Taylor et al., 2012).

• It is important that health care providers in a variety of settings are able to respond appropriately to the delayed disclosure of sexual assault.

Purpose

To determine “best” practices in responding to delayed disclosure of sexual assault by examining helpful and unhelpful responses by health care providers.

5

Image: The Awareness Center Inc.

Methods: Search Strategy(April 2013)

Key Terms• “sexual assault”,

“disclosure”, “social support”, “post assault”, “reaction”, “clinician”, “provider”, “formal” etc.

Databases• OVID Medline• PubMed• PsycINFO• Embase

6

Limited search to 1985-present; English

Methods: Analysis

Title Screen

Abstract Screen

Full Article Review

7

Records identified through database searching and reference lists of key articles (N=1166)

Duplicate records (N=383)

Title screen (N=779)

Titles excluded (N=601)

Abstracts assessed for eligibility (N=178)

Abstracts excluded (N=129)

Full-text articles assessed for eligibility (N= 49)

Studies included (N=24)

Full-text articles excluded (N=25)

Methods: Exclusion Criteria

Titles Excluded (N=601)Sexual Assault or Related Terms Not in Title (N=369)Childhood or Male Sexual Assault (N=169)Acute Sexual Assault (N=6)Book Chapters, Dissertations etc. (N=100)Focused on Offender (N=9)Not English (N=7)

Abstracts Excluded (N=129)Childhood or Male Sexual Assault (N=12)Acute Sexual Assault (N=7)Book Chapters etc. (N= 9)No Response to Disclosure (N=98)Informal Support Provider Only (N=5)Screening (N=1)

Full Text Articles Excluded (N=25)Childhood Sexual Assault (N=4)No Healthcare Provider (N=15)Mental Health Setting (N=4)Fact Sheet, Commentary etc. (N=2)

9

Results: Summary

10

24 Studies

Country 20 USA2 Tanzania1 Australia1 N/A

Sample Size Range = 1 to 3026

Methods Questionnaire, Case Report, In-Depth Interview, Survey, Systematic Review

Health Care Providers Physicians, Nurses, Midwives, Physical Therapists.Medical Personnel, Medical Staff, Health Care System

Disclosure Rates to Health Care Providers

Range = 9 to 27.1%

Results: Responses

11

Unhelpful Responses

Blaming the SurvivorMinimizing, Dismissive or Distracting ResponsesDisplaying a Cold and/or Detached DemeanorTreating the Survivor Differently

Results: Helpful Responses

12

Helpful Responses DescriptionTangible aid (N=13) • Providing medical care

• Giving information about sexual assault and community resources

• Providing referrals to counsellors or mental health professionals

Providing emotional support (N=13)

• Showing concern• Being empathetic• Listening in an active and supportive manner• Telling the survivor that they are not to blame

Acknowledging or validating the disclosure (N=5)

• Using simple statements such as “I’m so sorry that this happened to you” or “I’m glad you told me about this”.

Results: Unhelpful Responses

13

Unhelpful Response Description

Blaming the survivor for the assault (N=7)

• Holding the survivor responsible for the assault

• Doubting the survivor’s account of the assault

• Accusing the survivor of not telling the truth

Minimizing, dismissive or distracting responses (N=6)

• Statements or attempts to make the assault seem less troubling than how the survivor perceived it

• Telling the survivor to stop talking or thinking about the assault

• Attempting to discourage survivor from further speaking about the assault.

Results: Unhelpful Responses

14

Unhelpful Response DescriptionHealth care provider displaying a cold and/or detached demeanor (N=6)

• Not making eye contact• Asking a question unrelated to the sexual

assault in an effort to change the subject• Ignoring the survivor• Not providing any assistance upon hearing

the disclosure• Having no reaction at all• Giving a prescription without asking further

questions

Treating the survivor differently after disclosure (N=5)

• Treating the survivor with contempt• Treating the survivor as if she is not able to

take care of herself• Avoiding the survivor

Summary: “Best” Practices

Providing a safe and supportive environment

Being aware of the indicators of past

sexual assault

Direct questioning if patient presents

with indicators of a past sexual assault

Validating the disclosure

Providing emotional support

Providing appropriate

referrals

15

Implications: Practice• Health care providers

require more training on recognizing indicators of past sexual assault and knowing how to respond to delayed disclosure in a helpful way.

• Implementing “best” practices is a first step in achieving this improved response.

After receiving a sympathetic reaction from her doctor, one survivor said: “It made me feel good, like I, wow, it’s not the end you know?” (Ahrens et al., 2009)

16

Acknowledgements

Special thanks to:

Mona Frantzke, BSc, MLSc, Medical Librarian, Health Sciences Library, Women’s College Hospital

17

ReferencesAhrens, C.E. (2006). Being silenced: The impact of negative social reactions on the disclosure of rape. American Journal of Community Psychology, 38, 263-274.

Ahrens, C.E., Cabral, G. & Abeling, S. (2009). Healing or hurtful: Sexual assault survivors’ interpretations of social reactions from support providers. Psychology of Women Quarterly, 33, 81-94.

Ahrens, C.E., Campbell, R., Ternier-Thames, N.K., Wasco, S. & Sefl, T. (2007). Deciding whom to tell: Expectations and outcomes of rape survivors’ first disclosures. Psychology of Women Quarterly, 31, 38-49.

Ahrens, C.E., Stansell, J. & Jennings, A. (2010). To tell or not to tell: The impact of disclosure on sexual assault survivors’ recovery. Violence and Victims, 25, 631-648.

Diaz, A., Edwards, S., Neal, W.P., Ludmer, P., Sondike, S.B., Kessler, C., Medeiros, D. & Nucci, A.T. (2004). Obtaining a history of sexual victimization from adolescent females seeking routine health care. The Mount Sinai Journal of Medicine, 71(3), 170-173.

Dunleavy, K. & Slowick, A.K. (2012). Emergence of delayed posttraumatic stress disorder symptoms related to sexual trauma: Patient-centered and trauma-cognizant management by physical therapists. Physical Therapy Journal, 92(2), 339-351.

Esposito, N. (2006). Women with a history of sexual assault: Healthcare visits can be reminders of a sexual assault. American Journal of Nursing, 106(3), 69-73.

Filipas, H.H. & Ullman, S.E. (2001). Social reactions to sexual assault victims from various support sources. Violence and Victims, 16(6), 673-692.

Ullman, 1996aUllman, 1996bUllman & Filipas, 2001Ullman & Najdowski, 2009Ulllman & Siegel, 1995

18

ReferencesGolding, J.M., Siegel, J.M., Sorenson, S.B., Burnam, M.A. & Stein, J.A. (1989). Social support sources following sexual assault. Journal of Community Psychology, 17, 92-107.

Lessing, J.E. (2005). Primary care provider interventions for the delayed disclosure of adolescent sexual assault. Journal of Pediatric Health Care, 19, 17-24.

Littleon, H.L. (2010). The impact of social support and negative disclosure reactions on sexual assault victims: A cross-sectional and longitudinal investigation. Journal of Trauma & Disassociation, 11, 210-227.

Long, S.M., Ullman, S.E., Long, L.M., Mason, G.E. & Starzynski, L.L. (2007). Women’s experiences of male-perpetrated sexual assault by sexual orientation. Violence and Victims, 22, 684-701.

Mazza, D., Dennerstein, L., & Ryan, V. (1996). Physical, sexual and emotional violence against women: A general practice-based prevalence study. The Medical Journal of Australia, 164, 14-17).

Muganyizi, P.S., Hogan, N., Emmelin, M, Lindmark, G., Massawe, S., Nystrom, L., & Axemo, P. (2009). Social reactions to rape: Experiences and perceptions of women rape survivors and their potential support providers in Dar es Salaam, Tanzania. Violence and Victims, 24(5), 607-626.

Muganyizi, P.S., Nystrom, L., Axemo, P. & Emmelin, M. (2011). Managing in the contemporary world: Rape victims and supporters experiences of barriers within the police and the health care system in Tanzania. Journal of Interpersonal Violence, 26(16), 3187-3209.

19

ReferencesPlumbo, M.A. (1995). Delayed reporting of sexual assault: Implications for counseling. Journal of Nurse-Midwifery, 40(5), 424- 427.

Popiel, D.A. & Susskind, E.C. (1985). The impact of rape: Social support as a moderator of stress. American Journal of Community Psychology, 13(6), 645-676.

Starzynski, LL., Ullman, S.E., Filipas, H.H., Townsend, S.M. (2005). Correlates of women’s sexual assault disclosure to informal and formal support sources. Violence and Victims, 20(4), 417-432.

Sturza, M.L. & Campbell, R. (2005). An exploratory study of rape survivors’ prescription drug use as a means of coping with sexual assault. Psychology of Women Quarterly, 29, 353-363.

Ullman, S.E. (1996a). Correlates and consequences of adult sexual assault disclosure. Journal of Interpersonal Violence, 11(4), 554-571.

Ullman, S. E. (1996b). Do social reactions to sexual assault victims vary by support provider? Violence and Victims, 11(2), 143-157.

Ullman, S.E. & Filipas, H.H. (2001). Correlates of formal and informal support seeking in sexual assault victims. Journal of Interpersonal Violence, 16(10), 1028-1047.

Ullman, S.E. & Najdowski, C.J. (2009). Correlates of serious suicidal ideation and attempts in female adult sexual assault survivors. Suicide and Life-Threatening Behavior, 39(1), 47-57.

Ullman, S.E. & Siegel, J.M. (1995). Sexual assault, social reactions and physical health. Women’s Health: Research on Gender, Behavior, and Policy, 1(4), 289-308.

20

Questions?

Image: http://www.shutterstock.com/