Todd Akin and Sexual Assault Exams: A Nurse Practitioner Speaks Out
I put on my pink scrubs. I try for a visual distinction between me and the rest of the emergency department staff, dressed in grays and tans. This is a sexual assault exam. I need to convey to my patient that unlike my harried colleagues, I have all the time in the world for this.
I am a sexual assault nurse examiner practicing in a rural western community.
Our multi-county region does well in terms of high school graduation rates compared to the rest of the state, but we lead the state in teen pregnancy rates, smoking, and traffic fatalities. We have a low unemployment rate. We are about 150 miles from the nearest urban center, and about that far from the nearest Planned Parenthood office. If a woman is sexually assaulted and wants emergency contraception, she can see her own health care provider (none of whom is available weekends or holidays), or she can see me.
I enter the exam room, where the victim’s advocate is already chatting with my patient. I take a seat — another way to convey an unhurried attitude. I purposely maintain a very formal distance from the patient at first. She needs time and space to be comfortable telling her story to a stranger. We start with basic questions — her name, date of birth, any health problems, any medications or medication allergies.
I explain the purpose of this exam, which is not only to evaluate any injuries or medical needs, but to collect evidence that could be used to prosecute her assailant, if that person is apprehended. It is important that this woman knows that in this room, she is in charge. She calls the shots. If she wants me to stop at any point, she just needs to say so. This is about what she feels comfortable with, and what she believes is in her best interest. We can complete the exam whether she wants to press charges or not. Evidence collected today can be held, and if she later changes her mind about whether to prosecute or not, it’s OK.
The exam is more straightforward than many might imagine. It’s pretty much a head-to-toe physical, with a few twists. For instance, I collect head hair from the victim, for the purpose of DNA analysis. Because of this, it must be pulled out, root intact. Any marks or injuries obvious to the eye are photographed. Swabs of any potential DNA from the assailant are collected. There is a blood draw. There is a urine test for pregnancy for any woman of childbearing age. Our procedures are slightly different if the woman is pregnant. I do exams for men who have been victims of sexual assault. The only real difference in procedure for men is the urine pregnancy test.
I work on one uncovered part of the body at a time, preserving modesty as best I can. The victim’s advocate remains in the room, as a source of psychological comfort for the patient, but also as a witness to everything I have said and done. She can stay behind the drape, or hold the patient’s hand if desired. Often a patient will accept the offer to listen to music on the MP3 player the victim’s advocate brings with her. It’s a nice distraction.
At the conclusion of the exam, I explain the need for antibiotics to help prevent certain sexually transmitted diseases. In our area, prophylaxis for HIV/AIDs is not recommended, but a blood test is recommended to be certain about HIV status at the 6 month mark. Hepatitis B immunization is recommended, if it has not already been done. We also discuss the possibility of pregnancy following sexual assault.
Here’s where it gets interesting. A significant number of women in this situation refuse emergency contraception. Less than half, but probably one third. To be clear, I have not formally tracked this, and even if I had, that figure would only apply to my small area.
I go to some pains to clarify the whys and wherefore on this, because conceiving a child is absolutely a life-altering event. I explain that this is not "the abortion pill" and that emergency contraception does not interfere with an established pregnancy.
I have really never gotten an adequate answer from a woman who refused emergency contraception, when I have asked the reason for her refusal. It’s generally something along the line of "I just don’t think I need that."
And in my experience, in my little corner of the world, I am left to wonder why.
Does this woman feel guilty? That she is responsible in some way for being the victim of a crime? That she needs to accept whatever punishment might come her way, even if her assailant is apprehended and stands trial? Does she actually believe that emergence contraception equals abortion? Does the woman believe that if this was a “legitimate rape” her body will veto any possible conception? Is this some kind of modern day trial by fire?
I am left with many more questions than answers. The remarks made by Rep. Todd Akin earlier this week brought all this to my mind yet again.
If a member of the House Science Committee can be so wrong on basic facts of biology, can I expect a traumatized woman in my exam room to have a clearer understanding of the issue?