In the past few years, campus sexual violence has gone from being a matter of private pain to a matter of national scandal as news stories, films and lawsuits have exposed the vast extent of the issue. Colleges around the nation are now required by newly enacted legislation and public outcry to develop comprehensive programs to prevent and respond to sexual violence on their campuses.
It’s estimated that 1:5 college women and 1:16 college men will be sexually assaulted before graduation.1 Twenty-one percent of college students reported they’ve faced dating violence at the hands of a current romantic partner while almost one-third have experienced abuse in past relationships.2
Although we talk of college campuses as ivory towers safe from “real-world” problems, the reality of sexual violence can’t be ignored. With the awareness of campus sexual violence as an epidemic comes the critical need for campus EMS to understand and train to respond to this unique type of trauma.
DIFFERENT EXPERIENCES
The term “rape” conjures images of armed strangers in dark alleys and overwhelming physical force. College sexual violence is much different than these horror stories. Eighty percent of women who experience college sexual violence know their attackers. In 90% of cases, perpetrators don’t have weapons.2 Typically, college sexual assault is facilitated by alcohol and, less commonly, other drugs that leave the victim incapacitated and unable to remember exactly what happened.3
Because the experience of college sexual violence is so different from the ways rape is commonly portrayed, survivors often fail to realize that what they experienced was, in fact, criminal behavior.
College students who were sexually assaulted while they were unconscious sometimes describe what happened to them as “bad hookups”–not rape. Many of the survivors interviewed for this article blamed themselves. They thought it was their fault because they got drunk, believed “he was a nice guy” (who then turned out to be a “creeper”), or were too scared to fight when they were physically forced to have sex. So these survivors told no one what happened, and instead, blamed themselves for “allowing” the sex to occur.
For a long time, this discrepancy between real and stereotypical acts meant that campus EMS was rarely dispatched to cases of sexual violence in the immediate aftermath. Now, as more survivors come forward and challenge these myths, EMS squads can help their patients, peers and campus communities respond to rape.
The cases that closely follow the stereotypes of “real” rape–the assaults perpetrated by a stranger, with a weapon, resulting in significant physical trauma– are the cases most likely to be immediately reported to police or EMS.
This skewed reporting perpetuates the idea that these factors are common denominators in assault cases. As a result, survivors and responders may not recognize sexual violence as it most often presents itself on college campuses.
Survivors also fear what happens after a report. They’re afraid no one will believe them and their reputations will be ruined. Many fear getting punished for underage drinking and being revictimized by criminal or college justice systems. For all of these reasons, it’s estimated that less than 10% of college sexual assaults are reported to the authorities.1 EMS providers need to be trained to identify and respond to the real signs of college sexual violence, even when the symptoms aren’t obvious.
It’s also important for EMS providers to understand that it’s very rare for reports of sexual violence to be unfounded. Although stories of “angry exes” filing false reports or “crying rape” have surfaced, the overwhelming majority of reports of sexual violence are supported by the facts.4 All reports or indications of sexual violence need to be carefully documented using the patient’s own words in quotations. Responders must consider these points as the interview and assessment continue.
SCENE MANAGEMENT
Positioning below the patient’s line of sight can make providers less intimidating to victims.
When responders are dispatched to reported assaults, law enforcement officers often accompany and, in many systems, secure scenes before the arrival of EMS. However, because many acts of campus sexual violence aren’t reported as such, responders may find themselves on scenes that aren’t only unsecured, but endangered by potential perpetrators mingling in with other bystanders.
These threats to patients and responders may not be immediately apparent and seemingly safe scenes can become dangerous before EMS providers have a chance to recognize threats and retreat. Violent partners can appear to be devoted loved ones who cling to the patient’s side, even when they get in the way of care and are asked to leave.
In these situations–particularly when a possible perpetrator is answering for the patient, or demanding treatment without transport– providers may need to use their imaginations to notify law enforcement and get their patient out of harm’s way. One crewmember can step outside, under the guise of retrieving equipment, and call for assistance on the phone (to avoid the perpetrator hearing the request over the radio of the partner still providing care).
Providers could also declare the need for a medical procedure, such as sutures or X-rays, which can’t be performed at the scene.
The important point is to get the crew and patient to safety. If these creative solutions are unsuccessful or unviable and a potential perpetrator issue escalates, responders’ first priority must be to protect themselves.
As soon as a scene becomes unsafe, retreat and request law enforcement. If it’s safe for all parties, the responders should take the patient with them as they leave.
PATIENT-PROVIDER TRUST
Effective and therapeutic communication between patients and providers is an essential aspect of the treatment of stable survivors. Because the patient has recently experienced chaos, fear and violation, EMS professionals must present themselves as advocates and confidants. Survivors are beginning a lengthy process of evaluations, discussions, and possible campus and/or criminal investigations. Providers make this bearable by maintaining a calm and supportive demeanor.
Providers start trust-building by introducing themselves as soon as they arrive on the scene. They must let patients know why they’re with them (e.g., “We came because your residence hall assistant called. She said you were upset and couldn’t stop crying.”). Providers should first gently ask for permission to approach survivors. They must also wait for their patient to accept their help. This can seem like a delay until providers remember that sexual violence, at its core, is an enormous loss of control.
Sexual assault and dating violence may be difficult to recognize because survivors present symptoms in so many different ways. Often, past experiences and rape myths prevent EMS providers from recognizing mechanisms of injury stemming from sexual assault. Patients may be unable to speak or explain their situations, seemingly “frozen” in time and place. They can be impaired by alcohol or other drugs, completely calm, or hysterical. In cases of extreme emotional distress, especially panic attacks and severe alcohol intoxication, responders should rule out sexual violence as a routine part of the initial interview.
Survivors may not be able to verbalize the exact events prior to the arrival of EMS, so asking open-ended questions and allowing patients to expand upon their answers can provide the most information.
Although survivors of sexual assault often don’t present with visible injuries, responders must seek explanation for obvious wounds. In order to protect perpetrators, patients may make up stories about “accidents” to explain their injuries. This makes interviewing difficult. EMTs and paramedics can’t accuse patients of dishonesty, yet they must ask directed questions if they suspect assault. For instance, “You said you fell and hurt your face, but I see what looks like a handprint on your neck. How did that happen?” By focusing on obvious signs of trauma, providers can prompt disclosure of other injuries and discussion of possible abuse.
TREATMENT IS A TWO-WAY STREET
Caring for survivors of sexual assault or dating violence can be difficult. As always, life-threatening illnesses and injuries should be immediately addressed in compliance with local and regional protocols.
Taking care to preserve evidence while caring for patients is also an integral role of EMS professionals, but lifesaving interventions should always be the priority.
When responding to campus sexual violence in the presence of other students, such as in group housing (on- or off-campus) or at parties, removing bystanders from the scene may be challenging. Involve local or campus police as early as possible.
Allowing survivors of campus sexual violence as many decision-making opportunities as possible helps them regain control of their lives after losing power during victimization. Providers help victims by calmly reinforcing the idea that they–the survivors–are now in a position to decide exactly what will and will not happen. Pressuring stable survivors to accept treatment can feel like another assault. Providers should explain, in advance, each and every move they’re making. (See Figure 1, below.)
Once permission is granted, providers must address disclosed injuries, check for signs of strangulation (which is common in both sexual assault and dating violence), and allow patients to disclose as much information as they’re comfortable relaying. Each time providers move and initiate another intervention, they must provide an explanation to the patient, explain the purpose of the movement, and wait for consent.
Providers should take caution to not undress patients or remove clothing, unless articles of clothing directly prohibit essential treatment. This will not only serve to make the patient feel less exposed, but will also preserve evidence. EDs will have more resources to collect and preserve evidence, should the survivor later decide to pursue criminal or other charges against the perpetrator.
Providers should avoid making remarks or using terminology from their field of practice that may be unfamiliar to their patent. Remember that survivors may be feeling deeply ashamed of what they’ve experienced and could interpret side conversations or technical language as passing judgment on their experience or the narrative they’ve given. Use common language for all equipment and procedures you describe.
College-based responders may know their patients because of the close-knit nature of many campus communities. When this happens, survivors should be given the option of having someone else provide care. Fulfilling this request should be a priority, as long as injuries aren’t life-threatening and the patient won’t be harmed by the delay in getting another responder. If it’s acceptable to the patient, the first provider can give emotional support, evaluate vital signs and provide assurance the survivor’s privacy will be maintained under all circumstances.
Typically, victims of trauma take comfort from having familiar faces and friends around them. For survivors of sexual violence, having friends and acquaintances nearby can increase their sense of embarrassment or shame. Asking friends and other bystanders to leave the immediate scene–unless the patient specifically asks that they be present–should be part of the scene management.
Whenever possible, encourage survivors of campus sexual violence to accept transport to the hospital, even if there are no visible signs of physical trauma. EDs have the resources to provide prophylactic treatment for potential pregnancy, sexually transmitted infections, and perhaps, more importantly, screen and provide referrals for follow-up for mental health problems. Survivors of sexual violence are at a significantly increased risk of psychological problems–including depression and suicide–compared to the general population and even victims of other crimes. Mental health care and counseling are essential elements in treating sexual violence.
ABUSE AFFECTS EVERYONE
College sexual violence may not initially look like trauma. Patients often present with alcohol or drug intoxication, depression or panic attacks.
It makes sense that abuse, which is traumatizing for survivors, is also challenging for responders. Sexual violence can make people question the security of their communities and loved ones. Providers know patients may never completely recover. Perpetrators can also be people responders may know or respect. This may make responders question their own judgment. EMS agencies and responders often overlook self-care, but the toll of vicarious trauma can’t be ignored. Too many compassionate and talented providers neglect their own needs until they reach a point of being unable to care for anyone–even themselves.
Acute defusing skills and critical incident stress management (CISM) tend to be reserved for headline-grabbing tragedies; however, sexual violence wounds everyone it touches. Standard operating procedures should acknowledge the needs of providers by making CISM readily available and deployable for a vast array of cases, including those involving sexual violence.
Managers and supervisors should check in and consider defusing with crews prior to their departure from shifts involving abuse. Responders also need to take responsibility for their own well-being, and consider themselves out of service if they’re too affected by the situation they’ve just faced.
CONCLUSION
Responders, by nature, are helpers. Although calls involving sexual violence require exceptional skill, they also offer unique opportunities to assist people in rebuilding their lives when they’re most in need of compassion, guidance and a person to trust. Using these techniques and the information provided as tools in the EMS arsenal will make providers better equipped to respond to cases of sexual violence and improve campus safety for everyone.
REFERENCES
1. Krebs CP, Lindquist CH, Warner TD, et al. (2007.) The campus sexual assault (CSA) study. National Criminal Justice Reference Service. Retrieved Nov. 29, 2015, from www.ncjrs.gov/pdffiles1/nij/grants/221153.pdf.
2. National Coalition Against Domestic Violence. (2007.) National statistics. Retrieved Nov. 29, 2015, from www.ncadv.org/learn/statistics.
3. National Institute of Justice. (2008.) Drug-facilitated rape on campus. Retrieved Nov. 29, 2015, from www.nij.gov/topics/crime/rape-sexual-violence/campus/pages/drug-facilitated.aspx.
4. National Sexual Violence Resource Center. (2012.) False reports. Retrieved Dec. 3, 2015, from www.nsvrc.org/sites/default/files/Publications_NSVRC_Overview_False-Reporting.pdf.
RESOURCES
- Bogler D. (n.d.) 9 things to know about Title IX. Know Your IX. Retrieved Feb. 12, 2016, from www.knowyourix.org/title-ix/title-ix-the-basics/.
- End Violence Against Women International. (2016.) Retrieved Feb. 12, 2016, from www.evawintl.org.
- Harning A. Reported sexual assault: Emotional first aid & the facilitation of justice. JEMS. 2015;40(10)50—53.
- Horn J. Behavioral health: The new NFFF Initiative 13 works to change traumatic incident response stigma. JEMS. 2014;39(7)64—69.
- White House Task Force to Protect Students from Sexual Assault. (2014.) Not alone. Retrieved Feb. 12, 2016, from www.notalone.gov/assets/report.pdf.
