A Physician Guide to Supporting Sexual Assault Survivors

A decade ago, I believed it utterly unthinkable that anyone could advocate for rape or incest survivors carrying an unwanted pregnancy to term. I was wrong.

I’ve witnessed this extremism firsthand while walking by my local Planned Parenthood, the site of a mural that I wanted to see in person. There, I was accosted by a lone protester who insisted that a raped teenager seeking an abortion was “perpetrating the violence done to her on an innocent.” When I asked her to leave me be, she followed me aggressively, shouting into a microphone. And I was only there for the artwork — imagine if I were a rape survivor, traumatized and trying to regain some modicum of control over my life and body?

Physicians in any specialty will inevitably treat patients who have experienced sexual assault. Whether or not the assault results in pregnancy, the medical community should be prepared to provide appropriate and supportive care. Here, I offer a clinical framework to support sexual assault survivors delineated by an attending physician on the Inpatient Medicine in Psychiatry Service at my institution.

While state laws, regional practices, and available resources will differ, clear guidelines can provide a universal service for patients who have survived a horrific and senseless violation and can unify us as a profession.

A Guide to Supporting Sexual Assault Survivors

If your patient discloses sexual assault, listen to the patient empathetically and genuinely believe them. Emphasize that they did not cause this to happen, and ask them what they need from you right now. Explain your process to them and ask permission. Emphasize that they can decline any part of the evaluation. Restore their sense of agency as much as possible.

Assess whether an emergency department (ED) visit is warranted. Reasons for an ED visit include:

• Presence of physical injuries requiring an emergency department visit.
• Patient desires to have forensic evidence collected, if presenting within the appropriate window. This time window varies from state-to-state.
• Note: if you determine the patient should be sent to the ED, your questions and evaluation should stop here in order to minimize the number of times the patient is asked to relive the experience. You should still create a follow-up plan with the patient.

Assess whether the assault is reportable:

• Vulnerable/disabled patient
• Minor patient: call child protective services

If continuing the encounter, take a thorough history, assessing all areas involved in the assault, and perform a relevant physical exam. You are not collecting forensic evidence; you are performing the required physical exam to inform appropriate workup and treatment. If physical injuries are present, ask whether the patient wants photographs for their chart.

Perform sexually transmitted infection (STI) screening and provide empiric treatment.

Perform pregnancy testing; provide emergency contraception if the patient presents within 5 days of the assault.

Offer resources for counseling and legal support; provide resources for pregnancy termination within the scope of the law, if the patient expresses that this is a choice they wish to pursue:

• Local resources will differ across institutions; we recommend compiling relevant lists of available resources to offer patients.
• In general, we recommend first determining whether the patient can safely take paper resources home. If not, inform the patient that they can always return to the clinic, or offer them your local hotline for social and crisis services.
• We also recommend offering a list of free clinics that provide STI testing in the event that the perpetrator still has access to the patient and the patient does not want the perpetrator to have access to their disclosure inadvertently through hospital billing.

Carefully document the history and physical exam in the medical record. Be sure to document in a no-share note, and discuss with the patient who may have proxy access to their chart.

Follow up with the patient 2 weeks later, or sooner as needed.

What not to do:

• Don’t ask why the victim did not seek care earlier.
• Don’t push the patient to report to the police or seek legal assistance if they do not want to do so.
• Don’t give tips on what to do if this happens again.
• Don’t blame the victim in any way for the assault.
• Don’t push the victim to share more than they are comfortable sharing.

It is crucial that we, as physicians, offer support, clarity, and empathy in the face of callous apathy towards all survivors of sexual violence.

A Changing Response to Sexual Assault Resulting in Pregnancy Post-Roe

All victims of sexual assault deserve high-quality care, including those who become pregnant as a result of the assault. While the latter cases have always been especially complicated, they have become even more challenging in the aftermath of the Dobbs decision.

Several politicians have casually dismissed pregnancy from rape, from claiming that pregnancy rarely can result from rape to categorizing these violations as “opportunities” for the rape victim to raise a child. As recently as February, the Missouri Senate voted to ban abortions in cases of rape or incest, with some senators even arguing that carrying a pregnancy from rape is “healing” for the victim.

When reports surfaced of a 10-year-old rape survivor needing to leave her home state of Ohio for an abortion, conservative politicians and pundits responded with outrage — not at the egregious violation of a child, but at “politically timed disinformation.” Rather than defending her and mitigating her pain, they chose to persecute and punish her physician and slander the reports as untrue. The reports were true. Those voices remained unapologetic, doubling down on their rhetoric. The general counsel for the National Right to Life stated explicitly that she should have carried her pregnancy from rape to term, despite the well-known, severe risks and the fact that the victim was a little girl.

To say that the overturn of Roe has angered and disappointed me would be an understatement; I was raised in a Christian conservative household, and I find myself increasingly jaded with legislators’ professed commitment to protecting life and their antithetical actions, tantamount to a declaration that women’s lives and dignity are expendable. I feel hopeless at times, especially when I see medical students avoiding the extreme states. I fully understand their hesitation, but my heart breaks for women whose access to good reproductive healthcare narrows even further.

But my faith in human compassion and resilience, however fragile, persists. An attending physician once told me, “Doctors are more than our job; I believe our role is to model ethical behavior and to be a support for our communities.”

So, let’s be that unconditional, compassionate community support for our vulnerable patients. All victims of sexual assault deserve our support.

Special thanks to Lalita Movva, MD, for mentoring me and for providing guidelines on supporting sexual assault survivors in the clinical setting.

The Rape, Abuse, and Incest National Network (RAINN) provides a breakdown of relevant laws state-by-state, runs the national sexual assault hotline, and offers other critical supports to assault survivors: https://www.rainn.org/. 24/7 hotline: 1-800-656-4673

Chloe Nazra Lee, MD, MPH, is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York.