- Communication Tips for Caring for Survivors of Sexual Assault
- Article Sections
- KEY POINTS
- Helping a Friend
- Listen and Support
- Believe Your Friend
- Be Patient
- Respect Privacy
- Establish Safety
- Things you can say
- Get Support for Yourself
- But being there to listen, believe and support your friend in a positive way can greatly influence their healing process
- Helping a Survivor of Sexual Assault
- When a Friend is Sexually Assaulted
- Lopsided Relationships Following Sexual Assault
- Helping a Friend in Crisis
- Staying a Friend
- Campus and Community Resources
Communication Tips for Caring for Survivors of Sexual Assault
You can support your patients' recovery from sexual assault by interacting with them in an empowering, compassionate manner.
Michelle D. Sherman, PhD, ABPP, Stephanie Hooker, PhD, MPH, Anne Doering, MD, and Linda Walther, RN, SANE-A, SANE-P
Fam Pract Manag. 2019 Jul-Aug;26(4):19-23.
Author disclosures: no relevant financial affiliations disclosed.
This content conforms to AAFP CME criteria. See FPM CME Quiz.
The past few years have witnessed unprecedented disclosures of sexual assault, spanning public figures from business, politics, pop culture, and the media. The #MeToo movement has sparked tremendous interest, involving people openly sharing their sexual trauma experiences privately in health care settings and in public venues such as social media.
Physicians should be prepared for patient disclosures of sexual trauma to occur in the exam room and be ready to respond in an empowering and compassionate manner. This article focuses on effective communication methods for addressing sexual trauma with patients who have experienced sexual assault in adulthood.
The recommendations apply both to the immediate aftermath of the trauma and to working with survivors in the subsequent days, months, and years after the assault.
The medical and legal issues around working with survivors of sexual assault are beyond the scope of this article, but excellent resources are available (see “Resources”).
- Physicians need to be prepared for patients to disclose a history of sexual assault and respond to patients in an empowering, compassionate manner.
- How physicians respond to disclosure of sexual assault matters. You can be most helpful by providing emotional support, offering resources, and reassuring patients the assault wasn't their fault.
- Avoid using physical touch to comfort, as it's impossible to know how survivors will experience touch. Use your words, tone of voice, and body language to convey support.
According to the Centers for Disease Control and Prevention, the lifetime prevalence of contact sexual violence (defined as rape, being made to penetrate someone else, sexual coercion, or unwanted sexual contact) is 36 percent for women and 17 percent for men.1 Among female survivors, nearly half of their perpetrators are current or former intimate partners.1 Furthermore, more than half of women report being re-victimized sexually.2
Sexual assault has a clear impact on survivors' physical and mental health.
Women and men who have experienced sexual assault have a higher risk of health conditions such as asthma, irritable bowel syndrome, headaches, chronic pain, poor sleep, and overall poor physical health.
1 Mental health problems are also more common among sexual assault survivors, including post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, excessive feelings of shame and guilt, sexual problems, and others.1,3
How physicians respond to disclosure matters. Research has found that negative social reactions to sexual assault disclosure (e.g.
, blaming the victim, treating the victim differently, attempting to control the victim's actions, or focusing on one's own feelings rather than the victim's) are related to depression, substance abuse, and more severe PTSD symptoms among survivors.
4–6 On the other hand, positive social reactions (e.g., providing emotional support, offering resources, and explaining that it wasn't the victim's fault) are related to survivors having a greater perceived control over recovery, which is related to fewer PTSD symptoms.
Ullman suggests, “If we can teach people how to respond more positively to survivors' disclosures, then we can indirectly increase women's perceived control over recovery and adaptive social coping, and in turn potentially reduce PTSD symptoms.”4
The following suggestions may help you to respond effectively when patients share information about their sexual assault history:
1. Sit down. Move away from the computer, and make eye contact with the patient.
2. Listen nonjudgmentally. As with disclosures of other sensitive topics, your most important task when patients disclose a sexual assault history is to listen without judgment, express support, and avoid retraumatizing the survivor.
3. Choose words that support and empower. Using a gentle, receptive, and kind tone of voice may also help survivors feel comfortable talking about this difficult subject.
Although the specific words you use when responding will ly vary depending on the patient's situation, your relationship, the recency of the trauma, and the patient's emotional state, the overriding sentiment should be one of empathy, empowerment, respect for patient autonomy, and reduction of self-blame (especially if the survivor knows the perpetrator). (See “Messages to convey after a survivor discloses sexual assault.”)
Some well-intentioned providers make comments that survivors find judgmental, hurtful, and unsupportive.
Sexual trauma can involve feelings of grave personal violation, loss of control, fear, and humiliation, so routine instructions and questions may feel disrespectful and threatening.
Avoid trying to investigate the assault; the legal team can manage the detective work. Statements to avoid include the following:
- You should be over this by now.
- Why don't you remember everything that happened?
- You really need to report this to the police. (Note: It's OK to explore whether the patient has or wants to report it to the police, but empower survivors to make their own decisions.)
- You really need counseling.
- Why did you or didn't you (invite him over so late after you'd been drinking, fight back, call the police, etc.)?
Physicians should also use anatomical names of body parts when talking about the assault or subsequent health issues. Use of phrases such as “down there” may give the patient the message that the doctor is uncomfortable talking about sexual organs and may impede open communication.
4. Avoid using touch to comfort. Some empathic providers may feel the urge to offer reassurance to a distressed survivor through touch (e.g., a pat on the back or knee) or even by initiating a hug.
However, by definition, sexual assault involves someone exerting control by violating someone else's physical space and boundaries. Even if the physical expression of support is intended to be nurturing, it is impossible to know how the survivor will experience it.
Therefore, use words, tone of voice, and body language to convey support rather than physical touch.
5. Be prepared to offer resources and follow-up. Learn about your local community resources, and be prepared to offer referrals. Most large cities have organizations focused on helping survivors of sexual violence that offer 24/7 crisis phone lines and counseling.
At the national level, RAINN (Rape, Abuse & Incest National Network) offers a 24/7 website live chat and phone hotline (see “Resources”) and can also connect people with support services in their areas. Clinics and hospitals may also consider placing brochures and posters in their waiting rooms for local or national anti-sexual-assault organizations.
Also, adding a note to the patient's history can help remind you of the need to provide sensitive treatment during future visits to your office.
Physical exams can be triggering for people who have experienced sexual assault. Any procedures that involve touch or inserting an object into the patient's body — including pelvic exams, colonoscopies, endoscopies, and oral procedures — may elicit a reaction.
The power differential between the patient and physician or the process of removing clothing, being touched, or having one's sexual organs examined may also trigger reminders and feelings from the trauma. In response, the patient may feel overwhelmed, anxious, and scared.
The patient may suddenly be flooded with distressing memories of the trauma, and may even dissociate and feel detached from the present situation.
Notably, sexual assault survivors usually don't tell the doctor that the exam was upsetting or triggering.
However, due to previous negative experiences or fear of an intrusive exam, they may avoid doctors, minimize or deny symptoms, or refuse invasive tests.
Without knowing the patient's trauma history, the physician may be baffled and frustrated, and may even label the patient as “noncompliant.”
Although it may be impossible for you to prevent all forms of distress for sexual assault survivors during physical exams, there are steps you can take to help the patient feel more in control, present in the here and now, and less emotionally flooded. (See “Recommendations for physical exams with survivors of sexual assault.”)
Before the exam
Allow extra time so you're not rushed.
Before the patient disrobes, explain everything you plan to do (as well as the reasons for doing so).
Consider questions such as:
- “What part of this procedure is hardest or scariest for you?”
- “What could I do to be of support to you during the exam?”
- “How could you let me know if you need to take a break or stop? I want you to feel in control and safe here.”
Have resources and referrals available.
During the exam
Ask explicitly for the permission to touch.
Speak in a calm, matter-of-fact voice and avoid sudden movements.
Explain everything you're doing.
Talk about nonmedical, nonthreatening topics.
Check in regularly throughout the exam about how the patient is feeling and provide reassurance.
Offer a drink of water, an extra gown, or a warm or cold washcloth.
Offer to take a break or move with the patient into a different room to provide a change of environment, or reschedule the exam if needed.
Although physicians rarely raise the topic of sexual assault with their patients, many survivors believe that discussing sexual assault with their physicians can help them recover, and they are much more ly to disclose sexual assault if they are asked about it.
7 During an office visit, a physician's verbal and non-verbal communication skills can either help or hinder the elicitation of a disclosure.7 You can facilitate disclosures by establishing an open, supportive attitude, demeanor, and office environment.
7 Consider incorporating questions about sexual assault history in templates or patient surveys for new patient appointments, annual visits, or first obstetric visits. If you already screen for intimate partner violence, consider broadening the screening questions to also include questions about sexual assault.
We recommend addressing sexual assault history before performing an invasive exam, while the patient is fully dressed and when you and the patient are both seated.
To elicit sexual trauma history, some well-intentioned providers may ask broad questions such as, “Have you experienced any traumatic events?” However, patients who have experienced multiple traumas throughout their lifetimes may not know where to start or what you want to know. Therefore, a more direct approach may work best. We recommend the following phrasing: “I'm going to ask a few questions that will help me provide the best care for you. Many of my patients have experienced sexual violence. Has anything that ever been done to you?” Or, in follow-up to a screening instrument completed before the visit, you might say, “Many of my patients have experienced sexual violence, and I noticed you marked ‘yes’ on the screening questions. Is there anything I can do to help make the exam more comfortable or easier for you?”
This wording offers several advantages: First, it offers some context. It can be helpful for patients to know why you are asking about something so private — some patients may not see the connection between a history of sexual assault and their current well-being.
Second, it reminds patients that they are not alone and gives them permission to disclose if they feel comfortable and ready. Having the physician open the discussion may also enable survivors to disclose at a subsequent appointment if and when they feel safe to do so.
Third, this approach avoids the “Did sexual assault happen to you?” phrasing that is commonly employed. Sexual violence never “ just happens.” Someone made a conscious choice to sexually assault the survivor.
Small word choices can make a huge difference when talking with survivors.
Helping a Friend
Most survivors of sexual and relationship violence disclose the assault or abuse to at least one other person, usually a friend. You can't rescue your friend or solve their problems. But being there to listen, believe and support your friend in a positive way can greatly influence their healing process. The following suggestions/information can help you be a supportive friend.
Listen and Support
It's tough to be prepared when a friend tells you that they been the victim of sexual or relationship abuse. Faced with that situation, the worst thing you can do is nothing. Remember, you can't rescue your friends or solve their problems. You can only provide support.
- Support and understanding are essential. It takes a lot of courage for a survivor to share their experience;
- Try to provide a safe/non-judgmental environment, emotional comfort, and support for the survivor to express feelings;
- Let them know that they can talk with you. Listen. Don’t rush to provide solutions.
Believe Your Friend
The most common reason people choose not to tell anyone about sexual abuse is the fear that the listener won’t believe them. People rarely lie or exaggerate about abuse; if someone tells you, it’s because they trust you and needs someone to talk to.
- People rarely make up stories of abuse. It is not necessary for you to decide if they were “really hurt.” If the survivor says they were hurt, that should be enough;
- Believe what your friend tells you. It may have been difficult for them to talk to you and trust you.
- Sexual assault is NEVER the survivor’s fault. No one asks to be sexually assaulted by what they wear, say or do. Let the survivor know that only the perpetrator is to blame;
- The survivor needs to hear that fears, anxieties, guilt, and anger are normal, understandable and acceptable emotions;
- Remember, no one ever deserves to be abused or harassed.
- Don’t press for details – let your friend decide how much they want to share. Ask them how you can help;
- Survivors have to struggle with complex decisions and feelings of powerlessness, trying to make decisions for them may only increase that sense of powerlessness.
- You can be supportive by helping your friend to identify all the available options and then help by supporting their decision-making process.
- The survivor can’t just “forget it” or just move on. Recovery is a long term process and each individual moves at their own pace.
- Encourage the survivor to seek medical attention, report the assault, and or contact SHARPP. Remember, the survivor must ultimately make the decision as to what to do. They are the expert in their own lives. Don’t push. Remember, support your friend’s choices no matter what they decide.
- Don’t tell others what the survivor tells you. Let the individual decide who they will tell. It is important not to share information with others who are not involved;
- If you do need to share information for your friend’s safety, get permission by letting your friend know what you will share and with whom it will be shared;
- Don’t confront the perpetrator. Though you might want to fix the situation or get back at the abuser, this could make things worse, for you and your friend.
- An important part of helping the survivor is to identify ways in which the survivor can re-establish their sense of physical and emotional safety. You are a step in the process. Ask your friend what would make they feel safe and how you can help them accomplish this.
- If the stalking or harassment is ongoing, help your friend to develop a plan of what to do if they are in immediate danger. Having a specific plan and preparing in advance can be important if the violence escalates.
- SHARPP can assist with creating safety plans that are specific to the situation and individuals involved.
Things you can say
It is hard to know what to say to a friend when they confide in you. Refrain from asking a lot of questions, instead, support your friend with these phrases:
You may also find it helpful to share with your friend what you have learned about violence. This is also a good time to share with them your belief in the possibility to heal. Let your friend know that you believe that them and that they have strength and capacity to heal.
Get Support for Yourself
Sometimes the family and friends of victims can also feel the impact of the crime and experience emotional and physical reactions. This is called secondary victimization. Hearing about relationship abuse, sexual assault, and stalking can be upsetting. You may feel angry, sad, frustrated, and helpless.
If you have experienced crime or other traumatic events in the past, your friend’s experience might bring up memories and feelings of that time. You may want to talk about your feelings but also respect your friend’s privacy.
You too can contact SHARPP and speak to an advocate confidentially to get help for yourself.
If you have questions about any of the material on this page, please call SHARPP at (603) 862-3494 or reach out online via our webchat.
But being there to listen, believe and support your friend in a positive way can greatly influence their healing process
Helping a Survivor of Sexual Assault
This page discusses how to understand and help a friend who is in crisis. It focuses on the crisis caused by sexual assault, but many of the principles apply to helping any crisis.
In general, someone is in crisis when the stresses they are dealing with overwhelm their ability to cope. Stress can take the form of any challenge or hazard.
As such, stress is associated with growth and change; it is also associated with injury and loss. People deal with stress by problem-solving, social support, relaxation, and other coping skills.
Usually there is a balance maintained between the level of stress and one's coping efforts.
A crisis occurs when this equilibrium is disrupted.
a struggling swimmer who panics and grabs the lifeguard around the neck, or the depressed person who drinks more alcohol, a person in crisis often loses perspective and the ability to solve problems in organized and realistic ways.
A person in crisis needs extra support and a reduction in stress to re-establish their equilibrium. As a result, friends of the person in crisis often feel new demands and challenges in their relationships.
When a Friend is Sexually Assaulted
People who have been sexually assaulted often experience a range of emotions and reactions, and no two survivors of assault will feel exactly the same way about their experience. There are some «red flag» indicators that your friend has been sexually assaulted or is generally in crisis:
- Depressed or irritable mood
- Loss if interest in most activities
- Changes in sleep patterns (sleeping a lot, or difficulty sleeping)
- Changes in appetite or weight
- Changes in energy level, exhaustion
- Nightmares, flashbacks
- Fear for one's own safety
- Withdrawal from family and friends
- Excessive guilt, self-blame, or feelings of worthlessness
- Difficulty concentrating
- Thoughts of suicide
- Being excessively alert and easily startled
- General mistrust
These reactions are not unique to sexual assault; anyone in crisis may show some of these behaviors. They can be understood as indicators that your friend's general ability to cope has been thrown way balance and your friend is now struggling to manage trauma.
Many of these symptoms are common following any severe attack, loss, or injury. Your friend may have «flashbacks» (intrusive, vivid memories) about the assault.
Your friend may have specific fears and anxiety reactions related to the appearance of the assailant or the location where the attack took place. Problems in your friend's concentration, sleep patterns, and relationships can disrupt his or her daily functioning.
As a friend, you may also experience similar symptoms because your friend's difficulties may stress you directly and strike personal chords with crises you have had in your own life.
For some people, you will see no «visible» indications of crisis because all of their coping efforts are taking place inside of them.
In fact, some people cope by making an extra effort to «look normal» and only gradually let on that something terrible has happened to them. This coping strategy may be adaptive as long as it does not go on long.
Sexual assault experts have found that the best way of truly recovering from an assault is by acknowledging it to oneself and opening up about it to trusted people.
As a friend, you are a good judge of what emotions and behaviors are common for your friend. If your friend, for no apparent reason, begins to act in an atypical manner, don't be afraid to ask directly what is wrong. You may be the first person to respond to your friend's problem, and for a survivor of sexual assault, this is the starting point of recovery.
Lopsided Relationships Following Sexual Assault
Because you care about your friend, feel for your friend's pain, and want to help your friend through the current crisis, your relationship naturally changes. A friend in crisis is just a swimmer trying to stay afloat, and to some degree it is up to you to help.
Your friend's needs may suddenly come first. You may be giving more support and asking for less from your friend. You may feel and take more responsibility for your friend and there may be changes in the way power and control are shared in the relationship.
The more severe the crisis and the longer it lasts, the more lopsided the relationship can become. Some changes can «go too far» in various directions and ultimately threaten the friendship. Here are some characteristic ways good-intentioned people can get into lopsided roles when their friend is sexually assaulted.
- Paramedic: when you spend a lot of energy solving problems and «patching your friend up» immediately after the assault, then expect your friend to heal quickly and the crisis to be over soon.
- Chronic rescuer: when you repeatedly get caught up in your friend's problems and solutions which make sense at the time, only to have another problem appear shortly thereafter.
- Angel of mercy: when you will give any support, nuturance, and care that your friend seems to need without asking for anything in return.
- Tireless listener: when you will listen, accept, take in, and carry every feeling of pain and distress that your friend expresses.
- Avenging warrior: when you lead a counterattack against the person (or social issues) that injured your friend.
- Commander in chief: when you encourage, if not order, your friend to counterattack, press charges, become a vocal woman's advocate, or otherwise rise up in battle.
Taken too far, all of these roles are hazardous to your friend's recovery and hazardous to the friendship as well, because they change what was once a balanced relationship into something else. All are ly to generate new feelings of injury and anger, hurt and resentment, either on your part or your friend's.
Helping a Friend in Crisis
With the danger of lopsided roles in mind, here are some steps you can take to truly help your friend:
- Believe your friend unconditionally. Don't ask a lot of probing questions and don't express skepticism. Expect a friend in crisis to be confused and don't criticize.
- Let your friend know he or she is not alone. Offer support, offer your time, and remind your friend of available resources.
- Let your friend know it is not his or her fault. Don't blame your friend. Don't start searching for things your friend should have done differently.
- Empower your friend. Help your friend understand and consider options, let your friend make decisions, and offer to go along for support.
- Ask your friend what he or she wants from you. You don't have to guess or try to read your friend's mind; go ahead and talk about what kinds of support he or she needs. Keep talking about this because your friend's needs will change as he or she works through the crisis.
- Tell your friend directly when you see a serious problem. Your friend may have lost perspective or may be struggling to pretend that things are not that serious. When you have good evidence for your concerns, go ahead and share it with your friend. The additional information will probably help him or her consider more realistic options.
- Get outside help when needed. In a crisis, your friend needs more help, not less. A trained therapist may be essential to helping your friend work through the assault and resume more effective coping. Your friend may need other forms of support, dropping classes or changing his or her place of residence. Your friend may also need limits on self-destructive behavior following an assault, such as excessive drinking, risk-taking, or suicidal behavior.
- Don't exclude other people from helping your friend. Don't try to do the job of people who have training to do it (such as therapists). If you do all the problem-solving, your friend may miss opportunities to learn new ways of coping. He or she may also be reluctant to confront important but painful issues in therapy if they have already been discussed with you.
Staying a Friend
Only you can provide the opportunities for companionship, closeness, relaxation, and fun that your friend desperately needs. Affiliation helps anchor people and stabilize their perspective in a crisis.
Attachment and intimacy give people meaning; play and enjoyable activities offer respite and renewal. People who are depressed need «a break» from their depression. People in crisis feel alone and lost; they need a sense of connection and they need feedback.
By staying in the role of friend, you can help meet these needs. The following suggestions will help you stay an effective friend over time:
- Try to pace yourself so you can stick with your friend for the long run. Don't be one of those friends who disappears two weeks after the assault because you have taken on a role so lopsided that it cannot be sustained.
- Keep the rest of your life on track. For example, it is okay and necessary for you to keep up with your class and study obligations. You also have to keep up with other friends and relationships.
- Say «No» when asked to do things for your friend which are more than you can handle. You have a right to be taken care of yourself and you don't want to let your friend down by taking on responsibilities that you cannot sustain. Don't be afraid to redirect your friend to their therapist or other support person.
- Pay attention to your own needs and express them to your friend and others. Your friend's crisis doesn't automatically change who you are.
- Insist your friend seek help if the crisis escalates to the point of being worried about your friend's safety or long-term well-being.
- Seek support and outside help for yourself if you find yourself deeply affected by your friend's crisis.
- Try to get the lopsided relationship back on more even footing. Your friend needs a chance to listen to your concerns some of the time and to be a friend to you as well.
Campus and Community Resources
At William & Mary, the key resources include the Counseling Center, the Student Health Center, Residence Life, Dean of Students, Campus Ministries, and Campus Police. AVALON, the community sexual assault crisis center, offers individual and group counseling as well as trained rape companions to assist your friend.
If your friend refuses to seek help and the crisis appears to be worsening, you may have to seek resources. Often, people who have been in crisis look back with true appreciation to the friends who cared enough about them to get help when they needed it. As a friend, you cannot be faulted for seeking help when genuinely concerned.
In some ways, «a friend in need, is a friend in deed.»
- Campus Police, 911
- 24 Hour Helpline, (757) 258-5051
- Student Health Center, (757) 221-4386
- Counseling Center, (757) 221-3620
- Office of Residence Life, (757) 221-4314
- Dean of Students, (757) 221-2511
- AVALON Sexual Assault Companion Program, (757) 258-5051