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Responding to a sexual assault call requires survivor-centered, culturally safe, trauma informed care. Paramedics need to address the physical and psychological trauma while ensuring the sexual assault survivor maintains their autonomy. Many survivors experience continued powerlessness, shame and guilt while accessing services due to insensitive treatment by health service workers. However, when treated with care, compassion, clear explanations and choice, survivors experienced positive associations with health care and can feel “humanized”. These positive interactions may be viewed as positive social support, which has been proven to diminish psychological impact of stressful life events.
Best practice for paramedics has been largely adapted from research on sexual assault nurse examiner programs with identified positive outcomes, the World Health Organization’s guideline, “Responding to Intimate Partner Violence and Sexual Violence Against Women,” and the British Columbia Ministry of Health Trauma-Informed Practice Guide.
In cases involving children, the survivor most often knows the perpetrator. Consider the safety of the patient and any other children or vulnerable individuals at the location of the incident. Follow mandatory reporting procedures (Appendix B).
Sexual Assault and Consent
Sexual assault is an act of violence. It is defined as any non-consensual sexual contact, as found in the Criminal Code of Canada, Section 271. The Criminal Code of Canada also notes that consent cannot be given if the individual is intoxicated, drugged, unconscious, asleep, or if they are incapacitated in any way. Consent must freely given, without coercion or threats. Consent can be revoked at any time and can be provided for one act, but not for another.
Trauma Informed Practice and Assessment Structure
Trauma informed practice (TIP) is a framework for understanding the effects of trauma in individuals. It provides physical, emotional, spiritual, and cultural support and safety by giving patients choice and control, allowing them to collaborate in their care planning and treatment. It allows the practitioner to see the patient’s reactions as a symptom of a trauma injury, rather than non-compliance or resistance.
Trauma is a psychological and emotional response to a terrible event that overwhelms an individual’s ability to cope. Examples include natural disasters, war, major accidents, and rape. One individual’s reaction to trauma may be different from another’s; some individuals may react expressively, while others may show no reaction at all. Sexual assault survivors may be sobbing and crying, or stoic, or anything in between – there is no “correct” or “right” reaction to trauma.
The re-telling of stories can be re-traumatizing for survivors, causing significant distress. The World Health Organization’s guidelines for responding to intimate partner violence, supported by extensive research, includes recommendations to reduce the number of services and providers a survivor has contact to, and where they must recount their story. In taking a clinical history, paramedics with trauma awareness should not press the survivor to tell their story, to exercise patience, and to understand regardless of the survivor’s reactions.
Sexual assault survivors
Survivors of sexual assault often experience a range of emotions following their assault. These emotions and feelings vary from individual to individual. Many survivors experience fear, shame, a loss of control, embarrassment, self-doubt, self-blame, grief, and confusion. Helpful words or phrases can include “I believe you,” and “this is not your fault.” “You are safe now” is also helpful, provided it can be guaranteed that the perpetrator will not have access to the patient.
In the assessment and treatment of sexual assault survivors, cultural safety requires acknowledging and addressing the power imbalances that exist between the practitioner and the patient, the patient and the health care system, and the patient and society. Cultural safety also requires self-reflection on the part of the practitioner, in an effort to identify and challenge personal biases, conscious and unconscious.
Without safety and trust, the patient may not allow paramedics to come close, or to touch them. Safety and trust can be established by ensuring practitioners introduce themselves, and explain their purpose. Paramedics should adapt their environment to help survivors feel safer. This might involve asking the patient if they would like to change locations for the assessment; it can also involve offering the patient a blanket to keep warm, or for protection from the elements. Paramedics should follow the survivor’s lead. To continue developing both safety and trust, paramedics must always clearly explain what they would like to do, and seek consent before performing any exam or intervention.
Offering choice and working collaboratively with survivors enhances feelings of safety and trust. Throughout the assessment process, paramedics should give the patient choice, and provide an opportunity to express their views on the types of treatment they might receive, and how it can be delivered. Some survivors will not want any assessment or treatment, wanting only to be taken to hospital. Paramedics must respect the patient’s autonomy over their body, and power over what happens in their care – control over the self was lost during the assault, and returning it can promote more safety and trust between paramedic and patient.
This also extends to the ambulance and transport. Patients must be given choices throughout the call. Paramedics must be aware that telling the patient to lie on the stretcher may trigger a negative reaction (the assailant may have told them something similar). Similarly, words or phrases such as “this will be easier if you let me do this” or “stop fighting,” or “you are going to the hospital no matter what” are unhelpful – these take away power and control, and mirror the experience of the assault.
Indigenous Survivors
Indigenous people of all genders have a rate of self-reported sexual assault that is nearly three times higher than non-Indigenous Canadians. Indigenous women with a parent who attended a residential school are 2.35 times more likely to be sexually assaulted compared to Indigenous women whose parents did not. Additionally, Indigenous women are specifically at much higher risk of violence, with self-reported rates of sexual assault that ranges from three times higher in the provinces, and six times higher in the territories, compared to their non-Indigenous counterparts. They are also twelve times more likely to be assaulted and suffer serious injuries.
The legacy of colonialism, racism, systemic and societal discrimination, intergenerational trauma, poverty, the continued impact of residential schooling and the 60s scoop, loss of individual and cultural identity, limited educational opportunities, poverty, isolation, and substance abuse all contribute to violence against Indigenous women, and affect the wellness of Indigenous people, their families, and communities. For Indigenous sexual assault survivors, cultural safety is of the utmost importance. Recognizing how these elements influence the survivor’s perception of care and treatment will assist paramedics in developing an approach to these patients.
Introduction to Indigenous Health: https://learninghub.phsa.ca/Courses/16926/introduction-to-indigenous-health
San’Yas Indigenous Cultural Safety training: https://learninghub.phsa.ca/Courses/11374/sanyas-indigenous-cultural-safety-training-ics-online
Physical Injuries
Survivors of sexual assault may not have immediate or apparent life-threatening injuries, and may only require minimal medical interventions in addition to emotional support and transportation. Paramedics should be aware of the possibility that survivors may have been drugged, strangles, or suffering from traumatic brain injuries; a high index of suspicion should be maintained when patients are disoriented, have disorganized thoughts, or an inconsistent story – though note that this can also be a trauma stress reaction. Traumatic brain injuries are under-recognized in cases of intimate partner violence; some studies cite the incidence of traumatic brain injury at over 90% of individuals with a history of interpersonal violence.
Signs and symptoms of a traumatic brain injury include headaches, nausea and vomiting, blurred vision, and memory problems. Traumatic brain injuries can produce physical, emotional, behavioural, and intellectual changes in patients. See CPG H04 for additional guidance on the management of traumatic brain injuries.
Patients who have been strangled often have symptoms with a delayed onset that can have sever consequences. Strangulation is a form of asphyxia resulting from external pressure on the neck, occluding blood vessels and the airway. Very little pressure on the jugular veins is needed to produce venous outflow obstruction, which leads to congestion of blood vessels, increased cerebral venous pressure, and elevated intracranial pressure. Stagnant hypoxia and cerebral edema can result. Occlusive pressure on the carotid arteries will result in loss of consciousness within 8 to 10 seconds; the obstruction of oxygen delivery to the brain can produce clots. Pressure on the carotid sinus can cause bradycardia, which may lead to cardiac arrest. The tracheal cartilage can also be fractured.
Early signs and symptoms of strangulation include:
Later signs and symptoms of strangulation:
Strangulation assessment tool for first responders: https://www.familyjusticecenter.org/wp-content/uploads/2018/09/Strangulation-Assessment-Card-v10.12.18.pdf
Forensic Evidence and Reporting
Many sexual assault programs collect forensic evidence samples up to seven days post-assault. Some forensic exams can take place beyond those seven days, depending on circumstances. The collection and documentation of forensic evidence requires continued consent from the survivor. A survivor cannot consent to the forensic collection if they are impaired or incapacitated. While at the hospital, the survivor has three options for care:
In all cases, the medical needs of the survivor take priority over the forensic examination and collection of evidence.
Survivors also have three options for police involvement in their case. They may or may not choose to report their assault to police, or they may elect for a third-party reporting (TRP) process, which allows the survivor to remain anonymous while still providing information about the assailant to police. Third party reporting is conducted through community-based victim services; as the survivor’s identity will be withheld from police, the Crown will not pursue the assailant in these cases. These reports may be made at any time – there is no time limit to reporting sexual assault.
Documentation
The documentation of any call is an important record of a patient’s care. In cases of sexual assault, paramedic (and other health care team) records can be requested and used in legal proceedings. Proper documentation can help the Crown with the laying of charges, and provide valuable evidence at trial.
Paramedics must ensure that notations and records represent objective observations. They should detail the size, location, and type of all injuries (new versus old and healing), any disclosures from the patient, and any “trigger words” and their reactions. Statements made by the survivor must be recorded verbatim.
Human Trafficking
Suvivors of sexual assault may also be victims of human trafficking. Warnings for trafficked patients include:
At scenes, be aware of:
If human trafficking is suspected, separate the patient from the “friend,” “boyfriend,” or handler. Move the patient to a safe space, such as the back of the ambulance, and assess using trauma informed practice. Avoid invasive questions; instead, listen to the patient’s statements. Many people who are trafficked do not perceive themselves as victims of trafficking. Concentrate on their immediate needs and any health or medical concerns. Transport the patient to hospital without escorts from the scene. If an interpreter is required, use PHSA Language Link, not an on-scene interpreter. Notify the triage nurse of suspicions.
Female Genital Mutilation
Female genital mutilation (FGM) is any procedure that involved the removal or cutting of some, or all, external female genitalia for non-medical purposes. It is practiced in many different cultures and countries, and is usually performed on minors, from infants to girls up to 18 years of age. FGM is internationally recognized as a gender-specific violation of human rights; it can be used to control women and girls’ sexuality, or it can be performed due to misinformation about female sexual organs. Regardless of the reason, FGM is fundamentally rooted in gender inequality. Because FGM does not involve sexual contact, it does not qualify as a sexual assault under the Criminal Code of Canada; instead, it is considered aggravated assault, under Section 268(3). It is also illegal to send children to another country for the purpose of undergoing an FGM procedure.
The prevalence of FGM in Canada is unknown. The diversity of Canada’s population, however, suggests that women and girls from countries where FGM are commonly practiced are living here; some of these women may have already had FGM, and younger girls may be at risk.
Female genital mutilation presents many immediate and long-term physical, psychological, and sexual health issues. Immediate complications include severe pain, hemorrhage, infection, sepsis, shock, and death. Over the longer term, problems include urinary tract infections, child birth complications, menstrual complications, chronic pain, depression, anxiety and low self-esteem.
Caution: consider sedation only in extreme circumstances (if the patient is a risk to themselves or others). Most sexual assault survivors can be calmed through verbal interactions, the provision of safe spaces, promotion of individual autonomy, and transported without medical sedation. Patients may still be emotionally distraught, but this agitation is rarely physical. Sedation can delay options in care, and inhibits the ability to consent to a medical forensic examination and evidence collection.
Vancouver Island Health Authority
Vancouver Coastal Health Authority
Fraser Health Authority
Interior Health Authority
Northern Health Authority
Northwest Facilities
Northern Interior Facilities
Northeast Facilities
The purpose of the Safety Plan is to assist the Survivor in being prepared should they decide to leave the potentially unsafe situation they are in. This can be used in situations of known to the Survivor perpetrator of sexual assault, Survivors of intimate partner violence, Survivors of Domestic Violence or any Survivor who fears the perpetrator will come back to their residence.
List Adapted from the Province of British Columbia Ministry of Justice “Creating a Safety Plan” booklet (2015). To see full version, visit: https://www2.gov.bc.ca/assets/gov/law-crime-and-justice/criminal-justice/victims-of-crime/vs-info-for-professionals/training/creating-safety-plan.pdf