She can recite the statistics and refer to the latest research studies, but what Dr. Kristi Mulchahey knows best are the teenagers that visit her office.
“It’s common for an adolescent to come in and announce she had sex for the first time,” said Mulchahey, an obstetrician and gynecologist with a private practice in suburban Atlanta. “Sometimes intuition tells me simply from the look on her face to ask questions about the circumstances.
“Then the teenager will describe the event to me and I’ll look at her to ask, `What would you say if I told you that was rape?’ They usually look back in disbelief.”
Believe it or not, sexual assault is a growing problem in this country. The traditionally conservative American Medical Association called it a “silent-violent epidemic” when releasing its first-ever sexual assault treatment guidelines in November.
According to the National Crime Center and Crime Victims Research and Treatment Center in Arlington, Va., more than 700,000 U.S. women are sexually assaulted each year. Roughly 80 percent are committed by boyfriends, other male friends, acquaintances or family members.
A lesser number of women are actually raped if the legal term of penetration is applied, though just how many fewer is a matter of debate (see accompanying story), as is the issue of psychological trauma caused by any attempted sexual assault. About 61 percent of rape victims are under age 18, and in such cases the probability is even greater the assailant will be a familiar face.
“Victims are scared silent by mistaken shame,” Dr. Lonnie R. Bristow, AMA president, said during the November press conference at the group’s headquarters in downtown Chicago. “Society is silent in its condemnation. And our health professionals and law enforcement colleagues have too often been silent and not asked the right questions to identify and treat the victims.”
Physicians like Mulchahey and Dr. Teresita M. Hogan, program director for emergency medicine at Resurrection Medical Center in Chicago, were specifically recruited to help the AMA begin to educate its membership on the effect of sexual assault on patients–and to urge doctors to feel more accountable for discovering any such trauma troubling their patients. The AMA is targeting both emergency rooms, where many women have their first encounter with people’s judgments after a sexual assault, and doctors’ offices.
“We had no national standard on how doctors should deal with patients,” said Hogan, who is also a professor at the University of Illinois at Chicago medical school. “This is a start. We want to communicate to rape victims and physicians how to best heal the emotional wounds left by the rape. Eighty percent of victims choose not to seek medical care and stay silent. We have to change that.”
One suggestion from Hogan and part of the new 38-page booklet sent to physicians is the availability of closed space for rape victims examined in the emergency room.
“It’s hard for the victim to reveal such details with only a thin curtain separating her from some guy on the next examining table,” explained Hogan. “A woman shouldn’t fear her secret will become public.”
The doctor’s demeanor in the ER can be critical to a women’s recovery process — or might discourage her from taking the important first step of admitting she was assaulted.
“Many women who come in hospitals don’t present with the primary problem,” said Hogan. “They say they are there for some secondary reason, then see how comfortable they feel. What doctors can learn is women are eager to share (their trauma) when there is a nurturing environment.”
True enough, according to women who are rape survivors.
“I was sexually assaulted 23 years ago,” said Barbara Engel, a local activist to prevent violence against women who has co-authored state legislation and co-founded the Chicago Sexual Assault Services Network. “An angry man with a knife changed my life in 10 minutes. I had years of nightmares and flashbacks before I could move from victim to survivor.”
Engel said her ER physician was “uncomfortable at best” when she informed him she was raped.
“He was kind of clueless but conscientious,” she said.
Engel said that is what’s encouraging about the AMA guidelines and an accompanying campaign to reach doctors in emergency rooms, primary practice offices and medical schools: Many doctors mean well but don’t know what will best comfort a woman.
“Simple human empathy and compassion is what’s needed,” said Martha Ramsey, author of “Where I Stopped: Remembering Rape at Thirteen” (G.P. Putnam’s Sons, $23.95). “My ER doctor prescribed a sedative, which I gladly took. But I’ve often wondered if my healing process would have been different if I wasn’t totally out of it the first night.
“A woman needs the presence of a caring human being to help her through it after you leave the hospital, which in my case was my mother. A doctor should first look for that person who can be present and supportive rather than hand out pills.”
The AMA guidelines have already attracted the attention of area doctors. Torrie Flink, executive director of the Lake County Council Against Sexual Assault, said her organization has received frequent inquiries from physicians during the last month.
“They are requesting information about our services and wondering how to refer patients to our various support groups,” said Flink. “I’m encouraged. It’s always wonderful when physicians are willing to do more than be technicians.”
Flink said the AMA’s campaign has clearly been developed with input from “rape support system advocates.” She is particularly pleased at the first-ever widespread effort to include primary-care physicians and make them feel more accountable for patients who might be silently suffering the physical, emotional and cognitive trauma of sexual assault.
“There are too many doctors who suspect something but don’t ask questions because they will then be mandated to report (to authorities),” noted Flink. “There’s paperwork involved, and often it means dealing with people such as parents, stepparents and other family members who might turn out to be the offenders.”
Nonetheless, the AMA guidelines provide plenty of advice on how to approach patients holding back dark secrets that may be affecting their health. For example, research shows chronic pelvic pain, especially in girls and younger women, can be directly related to untold sexual abuse.
According to the new booklet, doctors can help discover such traumatic events by “giving tacit permission for the patient to discuss sexual issues by initiating discussion about the patient’s sexual history.” Among the specific recommendations: Make sexual issues part of any routine personal history; emphasize that inquiries about past and present sexual health are an important part of ongoing medical care; be aware of any patients unusually withdrawn during gynecological exams; and routinely inquire about any unexplainable symptoms that might indicate sexual abuse, such as nightmares, chronic fatigue, withdrawal from intimate relationships and even alcoholism.
“This is long overdue,” said Engel. “Studies show people are more willing to talk with their physicians than anyone else. Doctors can ask about sexual life, whereas it seems like personal trespassing when friends or family members ask.”
