EFTA00156728.pdf

The Journal of Enargency Medicine. Vol. 36. No. 4. pp. 417-42.1. 2009 Copyright 0 2009 Elsevier Inc. Primed in the USA. AU neat mewed 0736-1679/09 S-see front flat. doi: I 0.1016/j.jentermed.2007.10.077 Violence: Recognition, Management and Prevention WHY WOMEN DON'T REPORT SEXUAL ASSAULT TO THE POLICE: THE INFLUENCE OF PSYCHOSOCIAL VARIABLES AND TRAUMATIC INJURY Jeffrey S. Jones. mo.' Carmen Alexander, SSW Barbara N. Wynn. 'An't Unda Rossman. MSN t and Chris Dunnuck, hISN't 'Spectrum Health Hospital - Butternorth Campus and tYWCA Nurse Examiner Program. Grand Rapids MERC/Mchgan &ate University Program in Emergency Medcine. Grand Rapids. Michigan Repnat Address: Jeffrey S. Jones. MD. Department of Emergency Medcine. Spectrum Health Buttenvorth Campus, 100 Michigan Street NE. Grand Reads. Ml 49503-2560 Abstract—The purpose of this study was to identify the variables that acutely influence reporting practices in fe- male sexual assault victims presenting to an urban clinic or Emergency Department. We conducted a cross-sectional survey of consecutive female victims during an 18-month study period. Patient demographics assault characteristics. and injury patterns were recorded in all eligible patients using a standardized classification system. At the comple- tion of the forensic examination, victims were asked to complete a psychosocial questionnaire designed to deter- mine specific reasons why women reported or did not re- port their sexual assault to police. During the study period. 424 women were eligible to participate in the study: 318 (75%) reported the sexual assault to police. One hundred six (25' 1 did not file a police report, but consented to a medical-legal examination. Women not reporting sexual assault were typically employed, had a history of recent alcohol or drug use, a known assailant, and prolonged time intervals between the assault and forensic evaluation 1p < 0.004 There were no differences in the extent of non- genital injuries or anogenital injuries between the two groups. Thirty-six percent (152/424) of the eligible popula- tion agreed to complete the questionnaire. Only three of the 20 psychosocial variables examined were found to he sig- nificantly different in women not reporting sexual assault compared to reporters. The reasons for not reporting were Presented at the American College of Emergency Physicians Research Forum. Seattle. Washington. October 2002. primarily environmental factors (prior relationship with as- sailant) rather than internal psychological barriers (shame. anxiety, fear). C) 2009 Elsevier Inc. K Keywords—sexual assault: anogenital injuries: report- ing; psychosocial: medical-legal INTRODUCTION Accurate estimates of the incidence of sexual assault are difficult to obtain. One national study reported that fe- male lifetime prevalence rates of sexual assault in the general population were 18% (I). Feldhaus and col- leagues recently reported that 51% of women presenting to their Emergency Department (ED) had a history of completed or attempted sexual assault at some point during her life (2). Despite these rates. it is widely recognized that a significant percentage of these assaults are not reported to police or social agencies. The Na- tional Crime Victimization Survey estimates that only 38% of sexual assaults occurring in 2005 were reported to police (3). Sexual assault is treated as a violent crime in all jurisdictions. The legal definition includes a wide range of victimizations that include acts of unwanted sexual contact between the offender and victim. as well as threats and attempts to commit sexual assault (4). How- REauvm: 3 November 2006: Fomt. SUBMISSION Recovan: 25 September 2007: Acceprm: 30 October 2007 417 Downloaded fin Anon)ntous Use (Maim Libraryof the Wall MCfral Collegarignell Utuversmy Ilona ClanicaKey com by Eberier an December I M. 2017 For personal Ise only. No other uses without permanco Copyright 02017. Sane Inc. All righis. reserved. 3502-011 Page 1 of 8 EFIA_00001387 EFTA00156728 418 J. S. Jones et al. ever, social definitions of sexual assault are diverse, and one's personal conception of rape can inhibit reporting (5.6). Reporting can also be hindered by the perceived outcomes of dealing with the police and criminal justice system. impaired cognitive processing, and the victim/ offender relationship (2.7-9). Much of the literature on sexual assault reporting is outdated or based on retrospective population surveys. telephone questionnaires, or studies of specific popula- tions (e.g.. date rape) (1,2,6.10). The present study ex- amined data from a community-based population of women presenting to a sexual assault clinic or ED. Our purpose was to identify the variables that acutely influ- ence reporting practices and to compare the frequency and types of traumatic injuries in women who do and do not report. METHODS Study Design This was a cross-sectional survey of consecutive female patients presenting to an urban sexual assault clinic or local ED during an 1S-month study period. The study was designed to explore the primary reasons why women decline to report sexual assault to the police. A secondary objective was to identify any differences in demograph- ics, assault characteristics, or injury patterns in those who do and do not report. The study protocol was ap- proved by the Institutional Review Board at Spectrum Health. Grand Rapids, Michigan. Study Setting The Nurse Examiner Program (NEP) is a community- based clink that provides 24-h comprehensive response to adolescent and adult victims of sexual assault. It is located in downtown Grand Rapids. in the YWCA build- ing. The NEP is associated with a university-affiliated Emergency Medicine residency program and works closely with local law enforcement agencies and the existing domestic/sexual assault programs of the YWCA (II). The vast majority of referrals come from law en- forcement dispatch and crisis line contacts. Those sexual assault victims presenting directly to the three downtown EDs are referred to the NEP for evaluation after triage and initial assessment. Transportation is provided if needed or requested. Approximately 3-5 ED patients each year are too severely injured to be evaluated at the YWCA (II). Nurse examiners have completed a creden- Elating process that allows them to go into the hospital and perform the evaluation and collection of evidence in the ED. Education of the nurse examiner consists of approximately 40 h of training in all aspects of caring for this population, including physical examination, forensic preservation of evidence. documentation, and courtroom testimony. Participant Selection All female sexual assault victims aged 13 years or older who presented to local EDs for treatment or the YWCA Nurse Examiner Program for treatment between Novem- ber 1.2001 and April 30, 2003 ( IS months) were eligible for the study. Women who could not complete the ques- tionnaire (e.g.. non-English speaking). refused forensic examination, or could not remember the sexual assault (e.g.. intoxication) were excluded from participation. Study Protocol Demographic data, sexual assault history, and clinical findings were prospectively obtained on eligible patients and entered into a Microsoft Excel database (version 2003: Microsoft Inc.. Redmond. WA). Abstraction forms were used to guide data collection. It is the policy of the NEP to conduct a complete evidentiary examination for all sexual assault victims who come to the clinic within 72 h of an assault, even if no police report is made. This rationale allows for the collection of evidence without putting pressure on the victim to report the assault if she is not ready to make that decision. Anogenital trauma is documented at the NEP using colposcopic examination with nuclear staining and dig- ital photography. The following nine anatomic sites are routinely evaluated and photographed for the presence and type of injury: the labia minors, labia majors, pos- terior fourchette. fossa navicularis. hymen. vagina, cer- vix. perineum, and perianal area. Anoscopy was per- formed at the examiner's discretion. For the purposes of this study. the type and location of anogenital injuries were recorded using a standardized classification system (12.13). Definitions of findings used by the nurse exam- iners were those listed in Sexual Assault: The Medical Legal Eramination (4). At the completion of the forensic examination per- formed at the NEP. victims were asked to voluntarily complete the study questionnaire. The survey instrument consisted of 20 questions designed to determine specific reasons why women reported or did not report their sexual assault to police. The questions were adapted from previous studies on sexual assault, and from anec- dotal reports heard by clinicians from their clients (2,6,10). Information was also collected regarding pit- I>mmloaded fos Atanymcat set (Nap al Lb ay of the Weill Mcocal ColkietCornell Mummy from ClancalKey corn by Ebcner on Demmber Is. 20 I 7 For personal use only. No other user without ftmusuco.Copyngtri 02017. Usenet Inc. All nstrb reused 3502-011 Page 2 of 8 EFTA_00001388 EFTA00156729 Influence of Psychosocsal Variables on Reporting Sexual Assail 419 Table 1. Demographics and Reporting Practices in Female Sexual Assault Victims Not Reposing (n - 106) Reporting (n - 318) Age of victim (mean years ± SD) Age range (years) 252 .1 5.7 13-54 23.31 6.5 13-76 Ethnicity (94 white) 89 (84%) 254 (80%) Marital status (% single) 92(87%) 251(79%) Employment status 73(60%) 171(54%) (% employed)' Alcohol or drug use < 24 h' 74(70%) 162(51%) No prior history sexual intercourse 8(8%) 38 (12%) Last consensual intercourse < 29(27%) 95(30%) 72 h Time interval to examination (mean hours ± SD) 202 ± 12.6 11.3 1 9 History of previous sexual assault 46 µ3%) 156 (49%) • Indicates significance at the p < 0.01 level. vious sexual assaults, prior experience with police, and support systems available to the victim. The question- naire was pretested on a select group of sexual assault victims presenting to the NEP in September 2001. After revisions were made, the questionnaire was offered to all female sexual assault victims beginning in November 2001. The questionnaire was handed out by the nurse examiner, who explained its purpose and answered any questions. Patients were assured that the questionnaire would remain anonymous and confidential. Outcomes Measured The primary outcome of interest was to identify reasons that women decline to report sexual assault to the police. The secondary outcome was to identify any differences in demographics. assault characteristics, or injury pat- terns in those who do and do not report. We hypothesized that women suffering the most seven assaults would be more likely to report to the police, and that women not reporting might have suffered less severe injury and hence might have less need of medical treatment. Data Analysis A power analysis determined that at least 40 patients were needed in each group (reporters vs. non-reporters) to detect a 20% difference in categorical variables with a power of 0.8 and an alpha of 0.05. Analyses were per- formed using SPSS statistical software (version 14.0. SPSS Inc., Chicago. IL). Descriptive statistics were used to describe the demographic variables, perpetrator fac- tors, and assault characteristics. The mean number of documented anogenital and non-genital injuries for each group was determined, as were the typical locations and type of anogenital injury (abrasion, laceration. erythema. ecchymosis. edema). Discrete variables were analyzed with the use of chi-squared tests: unpaired mests were used for comparisons of two means. Odds ratios (ORs) with 95% confidence intervals (CIs) were then calculated for the association between survey responses and the women's decision to report sexual assault to police. Due to the number of variables compared. we chose a p-value < 0.01 for statistical significance (14,15). RESULTS During the I8-month study period. 337 adult women presented directly to the Nurse Examiner Program: 114 were triaged in one of four local EDs and transferred to Table 2. Sexual Assault Characteristics Not Reposing (n — 106) Reporting (n — 318) Multiple assailants Age of assailant. mean (SD) Ethnicity of assailant (% white) Relationship to victim• Stranger Known assalant Acquaintance/date 13(12%) 25.4 ± 7.0 50(47%) 14(13%) 92(87%) 76(71%) 41(13%) 25.91 6.0 146(46%) 102(32%) 216(68%) 180(56%) Previous boyfriend/spouse 8(8%) 19(6%) Current spouse/partner 1(1%) 8(3%) Relative 5 (5%) 5 (2%) Employer/authority figure 2 (2%) 4(1%) Time of assault Midnight-5:50 am. 52(49%) 146(46%) 6:00 axn.-11:59 a.m. 11(10%) 48(15%) Noon-5:59 p.m. 13(12%) 35(11%) 6:00 p.m.-11:59 p.m. 31(29%) 89(28%) Type of sexual assault Vaginal 99 (93%) 267 (84%) Oral 21(20%) 02 (29%) Anal 35(33%) 83(26%) Digital 37 (35%) 02 (29%) Location of assault Victim's home 42(40%) 146(46%) Assailant's home 33(31%) 73(23%) Vehicle 16 (15%) 57 (18%) Outdoor 6 (6%) 41 (13%) Other 19(18%) 38(12%) Type of coercion Verbal threats 52(49%) 143(45%) Physical force 30(28%) 108(34%) Victim sleeping/drugged 26 V5%) 73(23%) Use of weapons 13(12%) 54(17%) Non-genital injuries 43(41%) 143(45%) Anogenital injuries 78(74%) 248(78%) Mean no. genital injuries 1.5 ± 1.0 1.7 ± 1.3 - Indicates significance at the p < 0.01 level. DotmlimInf for Anonym:cc User (War at Library of the Weill Medical ColkselComell Um•cn.ny from ClinicalKey corn by 6besur on Dmember Ix. 2017. For personal use only. No other user *idiom rxemassion. Copyngto 02017. Elsevier Inc. All astir,. reserved 3502-011 Page 3 of 8 EFIA_00001389 EFTA00156730 420 J. S. Jones et al. Table 3. Psychosocial Variables Associated with Reporting Sexual Assault Not Reporting (n — 41) Reporting (n 111) Odds Ratio (95% CS I an reluctant to report rape because .. . I do not want the assailant going to fair 27 (66%) 10(9%) 19.47 (7.79-48.68) Police would be insensitive or blame me' 21 (51%) 17 (15%) 5.81 (2.61-12.94) I know the assailant' 22 (54%) 26 (23%) 3.79 (1.78-8.04 I was involved in illegal activity during assault 19 (46%) 27 (24%) 2.69 (1.27-5.70) I am afraid of going to courVtrial 25 (61%) 46 (41%) 2.21(1.06-4.59) Some people will not believe me 20 (49%) 34 (31%) 2.16 (1.04-4.49) I have no support from rnenda/family 2 (5%) 3 (3%) 1.85 (0.30-11.47) I have had a bad experience with police in past 17(42%) 32 (29%) 1.75 (0.83-3.68) My family or friend(s) will be upset 6 (15%) 10(9%) 1.73 (0.59-5.11) It would be just his word against mine 26 (63%) 58 (52%) 1.58 (0.76-3.31) Other people will think I am responsible 30 (73%) 71 (64%) 1.54 (0.70-3.39) Concerned that others will (rid out about assault 33 (80%) 81 (73%) 1.52 0.64-3.68) The details of the assault are unclear 24 (59%) 54 (49%) 1.49 (0.72-3.04 I feel partially responsible 27 (66%) 64 (58%) 1.43 (0.67-2.99) I have a criminal record or am on probation 3 (7%) 6 (5%) 1.38 0.33-5.80) I feel ashamed or embarrassed 32 (78%) 80 (72%) 1.38(0.59-322) I feel anxious 18 (44%) 42 (38%) 1.29 (0.62-2.66) I am afraid of the assailant 9 (22%) 21 (19%) 1.21(0.50-2.90) I have been raped/assaulted before 6 04%) 19 (17%) 0.83 (131-225) FriencVfamily told me not to report 1(2%) 3(3%) 0.90(0.09-891) • Indicates significance at the p < 0.01 level. the NEP: and 15 patients were evaluated in the hospital by NEP staff due to the severity of their injuries. Of these 466 women. 42 (9%) were excluded from the study for the following reasons: could not recall details of the sexual assault due to intoxication (n = 21). refused forensic examination (n = 9). intercourse was consen- sual (n = 7). and missing or incomplete documentation (n = 5). Seventy-five percent (318/424) of the women eligible to participate in the study reported the sexual assault to law enforcement. Women not reporting sexual assault were more often employed, with a history of recent alcohol or drug use, a known assailant, and a prolonged time interval between assault and forensic evaluation (p < 0.031). There were no other significant differences in race, marital status. perpetrator factors. Or assault characteristics between the two patient groups (Tables 1. 2). A large percentage of women in both groups had a previous history of sexual assault. Eighty-three percent of known assailants (2561308) were described as acquaintances: 12% (36/308) were current or previous boyfriends or spouses: 3%(10/308) involved other family members (Table 2). Eighty percent of incestuous assaults (8110) occurred among victims aged 13 to 15 years of age; the majority (64%) of acquaintance rape (164/256) was documented in young adults aged 16 to 25 years of age. Among the older victims (>31 years of age) who knew their assailants. 23% (22/97) were assaulted by current or previous boyfriends or spouses. Women victimized by known assailants were less likely to file a police report (70% vs. 88%, p <.001). There were no differences in the extent of non-genital injuries or anogenital injuries between the two groups (Table 2). Seventy-seven percent (326/424) had docu- mented anogenital injuries. A total of 23% (751326) had single and 77% (251/326) had multiple sites of trauma. The pattern of anogenital injuries was similar in both groups of adult patients with the majority of injuries (80%) occurring at one of three anatomical sites: labia minors, fossa navicularis. and posterior fourchette. Su- perficial lacerations and erythema were the most com- mon types of injuries documented in women reporting sexual assault as well as those not reporting assault (Figure Of the 424 women eligible to participate in the study. 152 (36%) agreed to complete the psychosocial question- naire. There were no significant differences in demo- graphics. perpetrator factors, or assault characteristics between those who completed the survey and those who refused. Seventy-three percent (111/152) of the women who completed the survey reported the sexual assault to police. Table 3 details the responses of women to the psy- chosocial questionnaire. A majority of women in both groups felt partially responsible for the assault, were concerned about public exposure. and were ashamed or embarrassed by the assault. However, these internal psy- chological barriers (i.e., shame. anxiety. fear) were not significantly associated with reporting sexual assault to police. The three most common reasons for not reporting sexual assault included: not wanting the assailant to go to Dotmloa‘lcd for Aoonynbect, Uses (Nat n Lb ay of the weal Mccbcal ColkseCornell Utuvenaty Iron ClaocalKcy coin by El>c•Ict to Demmber Is. 2017 For personal use only. No other uses witboui pcmassico.Cctynchi 02017. Et.cvscr Inc. All nstax monad 3502-011 Page 4 of 8 EFIA_00001390 EFTA00156731 Influence of Psychosocial Variables on Reporting Sexual Assail 421 • • A - • Figure 1. 1. Types of genital trauma in sexual assault victims with anogenital findings (n = 326). jail (OR 19.47.95% CI 739-48.68), a prior relationship with the assailant (OR 3.79, 95% CI 1.78—8.05). and feeling that the police would blame the victim or be insensitive (OR 5.81. 95% CI 2.61-12.94). Seven per- cent of women not reporting sexual assault (3141) had a criminal record or were on probation: however, 42% (17/41) reported a "bad experience" with police in the past or were involved in illegal activity during the assault (19/41). This illegal activity generally involved underage drinking or recent drug use. DISCUSSION These results show that in a community-based urban population, one-quarter of women presenting to a sexual assault clinic or ED chose not to report the rape to police. This rate is consistent with a previous study in Minne- apolis that reported that 24% of sexual assault victims treated in an ED by nurse examiners refused to file a police report (16). During the past three decades, women have become more likely to report rapes and auempted rapes-particularly those involving known assailants-to police 13). But the fact remains that less than half of such crimes are reported (1.3). In fact, law enforcement offi- cials consider sexual assault to be the most underreported violent crime in America (17). It is apparent that the majority of rape survivors who seek post-assault health care in community clinics or EDs have already made the decision to involve the police (7.16.18). The simple act of seeking medical help may in turn lead a woman to define a situation as rape and report it. For those victims who have not decided whether or not to report the assault, trained examiners, when available. can discuss the survivor's fears and concerns about re- porting and provide the information necessary to make an informed decision (16). A recent study by Crandall and Helitzer examined the legal outcomes for sexual assault cases seen at the University of New Mexico's Health Sciences Center. After inception of a Sexual Assault Nurse Examiner (SANE) program, approxi- mately 28% of rape victims declined to report the assault to the police. compared with 50% before the SANE program was launched in their community (19). It has been hypothesized that women suffering the most severe assaults are more likely to report to the police, and hence might access medical care through the police (18.20.21). It follows that women not reporting might have suffered less severe assaults and hence might have less need of medical treatment. Although the majority of our study population had documented physical injuries, we found no differences in the frequency or severity of injuries between reporters and non-reporters. In addition, we found that the use of force and the pattern of anogenital injuries were similar in both groups. Therefore, although the severity of phys- ical injuries may cause the rape survivor to seek appro- priate medical care, it does not significantly influence their decision to report. These findings are consistent with a recent Danish study of women presenting to a sexual assault center in Copenhagen. They also con- cluded that the severity of the assault or the documenta- tion of injuries did not influence police reporting (20). Since 1970. social scientists have investigated a num- ber of possible reasons why women don't report rape. ranging from fears, beliefs, and characteristics of the women themselves. to the nature of the relationship between the victim and the assailant. and the character- istics of the particular rape. The usefulness of these studies in determining the relative importance of these factors is limited by the research methodologies used and the populations studied. The only way clinicians can really determine why sexual assault victims do not report to police is to ask the victims themselves. The current study was designed to accomplish this goal within a community-based sample of women presenting for med- ical care after an assault. The results of this study iden- tified six distinct factors associated with not reporting sexual assault to law enforcement. Age. marital status, and ethnicity were not associated with police involvement; however, employment status differed significantly between non-reponers and those reporting sexual assault (69% vs. 54%. respectively). Some rape victims likely chose to avoid the notoriety and stigma attached to rape prosecution, or they feared re- jection by friends and co-workers (17,20). More than half of the women we surveyed felt partially responsible for the assault (60%). were concerned about public ex- posure (75%). and were ashamed or embarrassed by the Dovallossdoi for Arranymoos User (alai a: Libray of the Weal Mcdscal ColleseComell Unnersoly from CluoicalKe) cool by Elsesser on December IS.1017 For penonal use only No (Ace uses *idiom fventosom Copyngbi 02012 Elscescr Inc All nEho reserved 3502-011 Page 5 of 8 EFIA_00001391 EFTA00156732 422 J. S. Jones et al. assault (74%). Practical issues may also be involved—a victim may not have the time to participate in a criminal prosecution. especially if she is employed (22). Seventy-three percent of sexual assaults in our study This is consistent with other studies such as the National Crime Victimiza- tion Survey, which reported that approximately two- thirds of rape victims knew their assailant (3). Our results also demonstrate that women assaulted by a known as- sailant are significantly less likely to report the crime compared to those assaulted by a stranger. Not surpris- ingly. the response on the psychosocial survey that had the greatest association with non-reporting was: "I do not want the assailant going to jail" (OR 19.47. p < 0.001). The complex nature of the victim-assailant relationship is known to influence perceptions of the seriousness and sequelae of the sexual assault (23). It also is clearly the most important factor influencing a victim's decision to report (1820-22). Sexual assault victims having experienced acquain- tance rape are typically young adults, 16 to 25 years old. Sex-role socialization encourages this type of assault victim to see herself as a possible contributor to her own victimization (22). In a survey of high school students. teenage girls who had experienced forced sex believed that consensual sex play provoked the non-consensual intercourse and therefore felt they were at fault, not the perpetrator who ignored pleas to stop (23). Moreover. intoxication in the context of a dating relationship can lead to the misinterpretation of friendly cues as sexual invitations, diminished coping responses. and the wo- man's inability to ward off a potential attack (24). At least one-half of all violent crimes involve alcohol or drug use by the perpetrator, the victim, or both (3,24). Sexual assault certainly fits this pattern. Alcohol, mari- juana. cocaine, and other illicit drugs were used by 56% of all the women in our population. Although not statis- tically significant. almost half of our respondents did not report rape because they were involved in illegal activity at the time of the assault. This illegal activity generally involved underage drinking or recent drug use and prob- ably contributed to victim's feelings of fear. guilt. em- barrassment. and blame. In addition. intoxication was likely the key reason that 51% of our respondents stated that "the details of the assault are unclear." Another significant reason for not reporting assault was the belief that police would be insensitive or blame the victim (OR 5.81. p < 0.001). Only 7% of non- reporters had a criminal record or were on probation; however, a considerable number of these women re- ported a "bad experience with police in the past" (42%) or were "involved in illegal activity during assault" (46%). Previous research has shown that victims may were committed by known assailants. also lack confidence in the ability of the criminal justice system to apprehend or punish the assailant (22.24). According to Williams. most people think of rape as a sudden. violent attack by a stranger in a deserted. public place. after which the victim is expected to pro- vide evidence of the attack and of her active resistance (22). These characteristics, then, constitute what is re- ferred to as the classic rape situation. When an individual is confronted with a situation that does not conform to the stereotypical concept rape. she may be reluctant to report the incident or seek medical care (7). This reluc- tance is aptly demonstrated by the prolonged time inter- val between assault and forensic evaluation among non- reporters (20 h vs. II h. p < 0.001). Any delay in presentation is troublesome in light of previous studies that suggest that the timing of the examination is the most significant predictor of abnormal anogenital find- ings in both children and adult victims of sexual assault (2526). For example. the frequency of anogenital lacer- ations and abrasions may decrease from 50% at C 24 h to 13% at > 96 h after the assault (26). LIMITATIONS There were several limitations in our study. We could not control for the clinical evaluations by different examin- ers. It may be that documentation was not uniform. although the nine nurse examiners had a similar level of training and experience. The findings of the examiners were recorded on state-mandated reporting forms and were taken as the most accurate representation of the actual physical findings. Over half of all patients had been exposed to alcohol or illicit drugs during the time of the assault. It is unknown what impact this might have had on the accuracy of the history or the degree of anogenital injuries. However, the documented history of the sexual assault by forensic nurses is quite detailed and considered accurate by legal authorities. In addition. women were excluded from participating in the survey if the nurse examiner felt they were still clinically intoxicated. This study, like all studies of rape victims, is vulner- able to sample or selection bias. Previous research sug- gests that many victims of rape are not likely to seek medical care or even to identify themselves as rape victims (2). In fact, the desire to avoid using the term "rape" is frequently very high. It should also be noted that this study considered women who reported to the police, the NEP. or a local ED. If all women experienc- ing sexual assault who neither reported to the police nor came to the NEP/ED were included, the results might have been different. Of the 424 women eligible to participate in the study. 152 agreed to complete the psychosocial questionnaire. Damao:Wed for Anonymous User Oda; a: Library of the Weill MoliCJICollescreornell Mummy fmm ClinicalKe) corn by Ebc%wr on Drcember IS. Ylll. For personal use only No mho c.c. *idiom peenussion Copyrighi 0200 ESC ssa Inc All nEhri reserved 3502-011 Page 6 of 8 EFIA_00001392 EFTA00156733 Influence of Psychosoaal Vadat.les on Reporting Sexual Assail 423 for a response rate of 36%. This limited response rate was understandable because, in many cases, subject re- cruitment took place within hours of the sexual assault and women were not compelled to participate. There were no significant differences in demographics. perpe- trator factors, or assault characteristics between those who completed the survey and those who refused. How- ever, the small sample size and the more stringent level of significance (p < 0.01) made for a less robust study. Over the past two decades, there have been a number of initiatives aimed at improving the legal treatment of sexually assaulted women (27). Rape crisis centers and victim assistance programs offer crisis intervention. emotional support, counseling, and advocacy to women who have been sexually assaulted. Hospital-based sexual assault care and treatment programs have been estab- lished, providing victims with around-the-clock support and crisis counseling, medical care, referrals to local service providers, and forensic evidence collection for potential court use. Although one of the goals of these initiatives was to increase the proportion of women re- porting sexual assault, results from retrospective studies evaluating their effectiveness have been mixed and have not captured the complexity of factors that may influence women's post-assault decisions. Qualitative, in-depth in- terviews with women who have been sexually assaulted hold unique promise for evaluating treatment programs and enhancing women's interaction with the criminal justice system (27). Moreover, given that women do not constitute a unified and homogeneous group. future re- search may want to employ more sophisticated measures of age. ethnicity, culture, education, and assault charac- teristics to examine their collective impact on reporting practices. CONCLUSIONS In a community-based urban population. one-quarter of women presenting to a sexual assault clinic or ED chose not to report the sexual assault to police. These results suggest that women who are employed, raped by a known assailant, have a history of recent alcohol or drug use, and prolonged time intervals between the assault and forensic evaluation are more reluctant to involve the police. No differences were found in the extent of non- genital injuries or anogenital injuries between reporters and non-reporters. When surveyed, the reasons given by assault victims for not reporting to police were primarily environmental factors (e.g.. relationship with the assail- ant) rather than internal psychological barriers (e.g.. shame, anxiety. fear). Further study is needed to identify the policies or practices that encourage reporting and to apply those practices elsewhere. Such a strategy might. in turn, increase the chance of arrest and prosecution and. ultimately. the deterrent effect of the criminal justice system. Acloundedgments-The authors acknowledge the suggestions and statistical assistance of Dr. Diann Reischnum. Grand Rapids Medical Education and Research Center for Health Professions. REFERENCES I. Toden P. Thoennes N. Prevalence. incidenx. and consequences of violence againtr women: findings from Ile National Violence against Women Sooty (NCI 183781). Washington. DC: National firritute of linnet: November 2030. AvaibI4c at: hugfiwwwnars.orgipdililes I/ ni/111.3781.pdf. 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