How should I discuss a past assault with a patient?

How to Discuss a Past Assault with a Patient

Adolescents who have been sexually assaulted need the opportunity to describe the experience at their own pace and in their own words, with direct questions asked without parents present during routine screening visits. 1

Routine Screening Approach

Screen all adolescents routinely for sexual victimization during visits for psychological problems, sexuality issues, contraception, substance abuse, and health supervision. 1

• Ask direct questions without parents present about past sexual experiences, including age of first sexual experience, use of the Internet to find romantic or sexual partners, and unwanted or forced sexual acts 1
• Screening should be part of anticipatory guidance with all adolescents, including those with disabilities, tailored to cognitive abilities 1
• This routine discussion helps prevent assault and reduces the stigma of revealing such issues if violence occurs 1

Creating a Safe Environment for Disclosure

Allow the patient to describe the assault at their own pace and in their own words, without rushing or interrupting. 1

• Establish trust and clinician-patient rapport before performing sensitive examinations, as past discrimination, mistreatment, trauma, and dysphoria make physical exams distressing 1
• Wait to perform sensitive examinations until trust is established unless medically urgent and necessary 1
• Use a chaperone during sensitive exams to create a safer environment and act as another advocate for the patient 1

Taking a Trauma-Informed History

Perform a trauma-informed sexual health history that includes questions about unwanted sexual activity/sexual assault, genital dysphoria, sexually transmitted infections, and dysmenorrhea. 1

• Ask about symptoms warranting formal psychiatric assessment, including suicidal or homicidal ideation or other self-harm behaviors 1
• Screen immediately for depression, suicidal ideation, suicide attempts, self-mutilation, and eating disorders, as these are significantly elevated in sexual assault victims 1
• Explore gender roles and relationship parameters (exploitative, nonconsensual versus healthy) 1

Immediate Mental Health Assessment

If suicidal or homicidal ideation is present, refer the patient immediately to an experienced mental health professional—this cannot be delayed. 1

• Recognize that adolescent victims may feel their actions contributed to the assault and can be confused about whether the incident was forced or consensual 1
• Understand that reactions include feelings of violated trust, increased self-blame, negative self-concept, and anxiety 1
• If you are not comfortable performing psychiatric inquiry, refer the patient to a health care provider who is comfortable with such assessments and who can evaluate the patient immediately 1

Addressing Medical Consequences

Take a history of whether recent sexual contact occurred in addition to the reported assault to interpret physical findings in the correct context. 1

• Discuss pregnancy risk and emergency contraception with every adolescent female, including assault victims, within 120 hours of the assault 1
• Perform a baseline urine pregnancy test 1
• Address STI screening, prophylaxis, and treatment on a timely basis 1

Documentation Considerations

Be aware that clinical records generated after disclosure of sexual assault are routinely subpoenaed and reviewed by investigators and attorneys in possible criminal prosecution. 1

• Document carefully, recognizing the legal implications of your notes 1
• Physical findings may be consistent with penetrating sexual activity but cannot independently determine whether activity was consensual or nonconsensual 1

Long-Term Support and Referral

Prepare to offer psychological support or referral for counseling, and be aware of services in the community that provide management, examination, and counseling for sexual assault patients. 1

• Recognize that sexual assault is associated with long-term risky behaviors including younger age for first voluntary intercourse, poor contraception use, higher rates of pregnancies and abortions, higher STI rates, and increased victimization by older partners 1
• Understand that many chronic pain syndromes seen in assault victims may co-present with dysmenorrhea, menorrhagia, and sexual dysfunction 1
• Consider referral to trauma specialists, as a multidisciplinary approach addressing all contributors to symptoms is important 1

Common Pitfalls to Avoid

• Do not perform the interview with parents present, as adolescents need privacy to disclose sensitive information 1
• Do not rush the patient's narrative, as they need to describe the experience at their own pace 1
• Do not delay psychiatric assessment if warning signs are present, as suicidal or homicidal ideation must be addressed immediately 1
• Do not assume physical findings can determine consent, as both consensual and nonconsensual activity may result in similar or no physical injury 1