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Rape's treatment gap

THE M.D.

October 06, 2008|Valerie Ulene | Special to The Times

Each year in the United States, according to the U.S. Department of Justice, more than 270,000 people are raped or sexually assaulted. The number is shocking enough. Also shocking is what happens afterward -- or what doesn't happen.

Too many of them don't get the medical care that they urgently need.

In a study published in June in the journal Contraception, researchers at the John H. Stroger Jr. Hospital of Cook County in Chicago identified 10 services they said should be offered to victims, usually women, after a sexual assault, such as rape crisis counseling and preventive treatment of sexually transmitted diseases. They then queried 187 emergency departments across Illinois (156 of which responded) and found that fewer than 1 in 10 routinely provided all of the services.

All of the emergency rooms provided medical care to assault victims, but just two-thirds offered rape crisis counseling and only 40% made emergency contraception available to their patients. Roughly two-thirds reported that they tested and treated for sexually transmitted infections, and less than one-third provided precautionary HIV treatment.

Other studies have shown similar results. A national study published in 2007 in the American Journal of Health-System Pharmacy looked at the treatment provided to almost 180,000 sexual assault or rape victims nationally in 2003. Antibiotic treatment to protect against sexually transmitted infections was provided in less than 10% of cases. A 2004 study of Pennsylvania emergency departments, published in the International Journal of Fertility and Women's Medicine, found that less than half routinely offered emergency contraception counseling.

"It's such a terrible event that happens in the lives of so many people in this country," says Dr. Ashlesha Patel, lead researcher in the Illinois study. "And it's simply not being taken care of in the way it should be."

Sexual assault victims require not just a careful forensic exam to obtain evidence for potential criminal proceedings, but also treatment for physical injuries and protection against pregnancy and infections such as HIV, gonorrhea, chlamydia and syphilis.

Rape crisis counseling is also crucial. Victims experience a variety of psychological reactions after an assault. Some grow fearful or anxious; others feel guilty or confused. All of them need an advocate -- often available through a rape crisis center -- to inform them of their medical and legal options, to support them through the treatment and reporting processes and to help them face their own reactions.

"Too often, the focus is on the forensic examination," says Dr. Astrid Heger, founder of the Violence Intervention Program at the USC School of Medicine. "Providers forget that there's a huge medical component that goes along with it."

The forensic part may be simpler to deliver because providers know exactly what's expected of them. In many states, including California, the forensic examination has been largely standardized.

When it comes to post-rape medical treatment, however, no one is holding healthcare providers to a particular standard. Although several medical societies and even the Department of Justice have issued loose guidelines, hospitals and rape centers are often left to develop and implement their own treatment plans.

Heger attributes some of the shortcomings to "money and time."

When it comes to emergency contraception, ethical considerations can also interfere with treatment. The risk of pregnancy resulting from one act of sexual intercourse is somewhere between 1% and 5%. When administered within 72 hours of a sexual assault, emergency contraceptive pills are extremely effective at preventing pregnancy. But at hospitals with a religious affiliation -- particularly Catholic hospitals -- such medication may not be offered.

Many emergency departments and rape crisis centers refer women to outside facilities to obtain services they don't provide, such as emergency contraception. To receive HIV medications, victims might be instructed to follow up in a medical clinic. For psychosocial counseling and support, they may be sent to a mental health clinic.

Although, in theory, this seems like a reasonable approach, many experts say that all services need to be offered on site. "Women won't go the next day to be followed up," says Heger. Some simply can't manage the logistics or don't have the financial resources to do it; others are mentally and emotionally incapacitated by what has happened to them.

In many respects, sexual assault victims are being victimized not once but twice: first by their assailant and then by the medical system that fails to care for them.

"We know what these women need," Patel says. "The challenge is getting healthcare providers to do it."

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Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. She can be reached at themd@att.net. The M.D. appears the first Monday of the month.

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