The Case

You are working a Saturday night when a 21-year-old female comes in for alcohol intoxication. Her vital signs are stable, and she appears visibly intoxicated. She appears withdrawn and tearful, and shortly after evaluation, she confides in you that she was raped at a college party. She doesn’t want the police called but does want a rape kit collected. She continues to insist on no police involvement. You are unsure about collecting a kit without law enforcement involvement and do not have a sexual assault nurse examiner (SANE) team at your hospital. What do you do?

It’s Not Unusual

Sexual assault is a common complaint in the emergency department. A 2010 study showed that one in five women and one in 71 men will experience rape, which the authors defined as “forced attempted or completed penetration.”¹ The rates of sexual violence other than rape, including being forced to penetrate another person, sexual coercion, unwanted sexual contact, and non-contact unwanted sexual experiences, are experienced by one in two women and one in five men sometime during their life.¹ And these national statistics do not adequately reflect the experience of populations in which rape and sexual violence occur in much higher numbers.

How patients are cared for in the emergency department can have profound effects on their physical, psychological, and emotional healing. Well-functioning, victim-centered programs utilizing SANE teams have been perceived as helpful, caring, compassionate, and supportive by sexual assault victims. Survivors are left feeling supported, believed, heard, respected, safe, reassured, in control, informed, and well cared for post-assault.^2–4 In contrast, a negative ED experience following sexual assault produces the opposite effects.

What Does the Law Require?

Emergency physicians are often held to federal and/or state laws when caring for victims of crime, including sexual assault survivors. Several of these laws come into play in the above case as well as in the overall care of intoxicated sexual assault patients.

First, many state statutes mandate law enforcement notification when patients who are victims of certain crimes present to the emergency department. These include gunshot wounds, stab wounds, battery, assaults with weapons, child abuse, elder abuse, domestic abuse, and sexual assault. For these crimes, ED personnel are classified as mandated reporters.

But just because a state law mandates reporting does not mean the patient has to speak to police. It is well within the rights of the patient to refuse to cooperate with law enforcement. Police understand this discrepancy between the law and the victim’s autonomy. Police officers may also be able to better explain to the patient all of their options regarding sexual assault reporting and investigation as well as the benefits and potential downsides of reporting. Sometimes officers develop a rapport with patients and may convince them to report the crime.