The Ethics of Rape Reporting and Examination
“Consider what it might be like to be a victim of sexual assault who has come to a health care facility for a medical forensic examination. Sexual assault is a crime of violence against a person’s body and will. Sex offenders use physical and/or psychological aggression to victimize, in the process often threatening a victim’s sense of privacy, safety, and well-being. Sexual assault can result in physical trauma and significant mental anguish and suffering for victims. Victims may be reluctant, however, to report the assault to law enforcement and to seek medical attention for a variety of reasons. For example, victims may blame themselves for the sexual assault and feel embarrassed. They may fear their assailants or worry about whether they will be believed. A victim may also lack easy access to services. Those who have access to services may perceive the medical forensic examination as yet another violation because of its extensive and intrusive nature in the immediate aftermath of the assault. Rather than seek assistance, a sexual assault victim may simply want to go somewhere safe, clean up, and try to forget the assault ever happened. It is our hope that this protocol will help jurisdictions to respond to sexual assault victims in the most competent, compassionate, and understanding manner possible.”
This is the first paragraph of the September 2004 “A National Protocol for Sexual Assault Medical Forensic Examinations (Adults/Adolescents)” from the United States Department of Justice Office on Violence Against Women.
The reason I started this thread on a socio-medical issue is to learn from my visitors how they look at rape and its consequences both to the victim and to society but in terms of the ethics and ethical responsibilities of both the victim and those in the medical and justice system.
For example, what ethical responsibility does the victim of rape have to herself but also to the social community to report the rape to authorities and be subjected to examination and later participate in legal proceedings against the accused? Should privacy concerns, modesty and embarrassment by the victim ever be considered to be sufficient reasons to hinder investigation of a crime or if indicated prosecution of the suspected criminal?
The Protocol sets informed consent by the victim as a basis for allowing history taking, physical examination, photography and specimen removal and testing. Is “informed consent “obtained in an atmosphere of acute emotional and physical trauma a fair and just consent? If not, what are the alternatives? Any ideas on this topic? ..Maurice.
Graphic: Illustration from U.S. Government DNA Initiative and modified by me for this topic with Picasa 3.
posted by Maurice Bernstein, M.D. @ 11:48:00 AM
6 comments
6 Comments:
I don't think anyone should be forced to have examination after sexual assault….. that would not help him or her at all. Those in the area of social work and counseling might have a viewpoint on the emotional state of those after an attack. To simply state that retrieving sperm or other physical evidence against a perpetrator is a reason to perform medically sanctioned abuse (from an unwilling patient) is ridiculous and unethical.
Dr. Bernstein,
I read the document cover to cover, and impressed with it's primary focus on the patient/assault victim's wishes and degree of consent. At every step it emphasizes the patient's right to decide what tests, exams, pictures, etc. they will allow. Fully informed consent is stressed throughout, as it should be, and any procedures should be carried out with maximum consideration to the patient's modesty and wishes. Yes I think it can be done with properly trained examiners and advocates whose clear primary interest and focus is supporting the patient. They must be the patient's advocate first and foremost.
One statement in particular stands out:
"In all cases, the medical forensic examination should never be done against the will of patients. Responders should not touch patients or otherwise perform exam procedures without their permission."
IMHO the needs and wishes of the patient/victim must always take priority, and any societal or prosecution interests must always be secondary.
Hexanchus
Suzee left the following comment today. I edited out a commercial advertisement and comments dealing with rape protection and which were not pertinent to the issue of the ethics of rape reporting and examination. ..Maurice.
It is devastating enough for anyone to experience a sexual assault and the trauma of going through the rape examine is reason enough for many victims not to report the crime. Unfortunately, even after all of the forensic evidence is analyzed and presented, the predators aren't convicted because there isn't enough "evidence." If the victim doesn't come forth because of humilation and embarrassment, the predator is free to attack again and again until someone has the courage to speak up. Until laws against domestic violence are reformed and tougher penalties are enforced, sexual assault in this country will continue to increase.
Individuals most vulnerable to sexual crimes are girls and women. Recent Statistics reveal 1 in 6 women will be a victim of sexual assault in their lifetime. College age women are 4 times more likely to be sexually assaulted. 60% of sexual assaults are not reported to the police. Approximately 73% of rape victims know their assailants.
Only 6% of rapists will ever spend a day in jail.
True, the standard in medical forensics for sexual assault is victim centered care. Nurse examiners and lay advocates are trained to place the needs of the victim before any evidence collection. However, until Jan 1, 2009, hospitals who received Violence Against Women Act funds to cover the costs of the exam were REQUIRED to get authorization by a police officer before the forensic exam could be performed. Victims would have to endure a police interview in a traumatized state. Some officers were sensitive, some were not... In some cases, if the officer did not believe the victim, she might be threatened with a lie detector test.
Now, a delayed reporting option can be offered to victims who are unsure about reporting. The victim supposedly can choose to get the exam w/o police involvement and has 30 to 90 days (depending on jurisdiction) to decide whether or not to report to police. The evidence is labeled with a number only, and stored until/if the victim wants to report. Medical care(very important!) without the evidence collection is always offered whether or not the victim wants to report. Keep in mind that evidence disappears if not collected within a tiny window of time. The huge gap in informed consent IMO is a victim's knowledge of likely outcomes. Few rapists are convicted and/or jailed. Many times the alleged assailant is only briefly questioned pending the results of the lab report. The lab report can take months! Its not like on TV. For the victim it often becomes a matter of subjecting oneself to invasion of privacy in the "hope" that some level of inconvenience/embarrassment/threat of charges to the assailant will be a deterrent, or at least the victim feels she is "doing the right thing" or by following through with court procedures she is proving to others that the rape really happened and was not consensual. Most rapes occur by someone a woman knows, not the stranger in an alley. This said, there can be a healing element in reporting despite the retraumatizing aspects. Staying silent, while it may seem the easier course at the time, can cause long-standing problems on top of the effects of the assault itself. There is no perfect answer. Victims of all crimes need better resources for sorting these issues out...
Paloma
Paloma, thanks for the VAWA update. This change will allow the victim time to deal with the acute emotional trauma before deciding regarding formal reporting. Still for some, even the process of obtaining specimens might be itself too traumatic if it is necessary to obtain them within a short period after the rape.
Also, regarding the matter of truly informed consent, do the examiners or lay advocates really tell the victim the full, realistic statistics of the legal outcomes? I would doubt the police authorities do since that information provided to the victim might easily make a barrier for accomplishing their professional goal. ..Maurice.
Statisics are very helpful and interesting, but the statistics that matter most are rarely included in the reasons why women don't report.
These women are strong enough survive the "embarrassment" and loss of "privacy". It is however, a hugh saftey issue. Not for themselves as many would assume, but for their children, family and sometimes even friends.
Many times these women are trying to protect everyone, and it is tricky and dangerous. We all know that the legal system is not capable of protecting everyone, nor should we expect that they can. Women need to weigh the consequenses of reporting..it's that simple.
One thing women will probably never tell anyone...you report or leave when you feel like it's safe for your family. As far as yourself? You really don't expect to survive it long, if at all.
In short, leave it up to the person without guilt or possible interferrance. They know what their facing...who...and the safty of navigating these waters.
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