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Am Fam Physician. 1999;59(1):213-214

“There's a ‘72’ downstairs. You up to it?” Those were the familiar words of one of the senior rape counselors on the phone, a little after 3:00 p.m. that day. “I'm on my way,” I replied, grabbing a clipboard, a blank case file report and a sealed state-issued sexual assault examination kit. As on most days, I had just reported for volunteer work at the rape crisis center at a major urban hospital.

Walking to the elevator, I prepared by quickly reviewing the checkpoints discussed during many hours of training and role-playing. Even though I had only completed my first year of medical school, I felt somewhat prepared for this summer internship, having already been a volunteer on the rape crisis center hotline. The long hours I had spent talking to survivors on the hotline had made me feel more comfortable discussing many of the issues surrounding sexual assault. This summer, however, promised new challenges, because it was my first time receiving the “call” to provide hospital support of a rape survivor during the invasive medical evidence collection examination. Volunteer rape counselors were present in this hospital around the clock to respond to the high volume of survivors seeking post-assault care. We slept lightly in a souped-up resident call room, waiting to be awakened with news of the arrival of a “72.” We were trained to support, to educate and to offer our hand to distract the patient from the dual pain of the speculum and the memories.

This was not my first call of the summer. Still, I couldn't shake the feelings I had each time I pulled into the parking lot. I would hope the emergency department wouldn't call “72” and that the very people I had volunteered to support would not come to the hospital that day. Current statistics estimate that one woman is raped about every four seconds in this country. One in four women can expect to be assaulted at some point in her life, and almost 85 percent of the time the perpetrator is someone the victim knows. After an assault, a survivor has only 72 hours to have potentially supportive legal medical evidence collected, with the viability of the evidence decreasing linearly with time, a shower, even a change of clothes. However, survivors are still encouraged to see a physician even if 72 hours has elapsed, to guard against injury, pregnancy and sexually transmitted diseases (STDs).

I had reached the point at which I wasn't dreading the opening of the elevator doors on the emergency floor. I was now unfazed by the overworked emergency department staff, the police officers, the family members, and the often slow-moving folks in the pharmacy where I went for the patients' prophylactic STD medicines and “morning-after” pills. As I entered amongst the bustle of the Women's Emergency Care Center, a familiar nurse spotted me. “She's back in ‘observation,’ ” she said briskly. “Do you know anything about her story?” I asked. “Not much, except that she's beat up pretty bad. She's been over in general emergency all day.”

A rape survivor receiving care in more than one section of the emergency complex was not unusual. Any systemic injuries were attended to before the patients came over to us for the “rape kit.” Just the day before I had worked with a woman who had been stabbed during her escape.

Back in observation, I approached my patient in the corner bed; she lay with her back toward me, her small frame nearly invisible amid the white sheets. “I'm Andréa, from the crisis center upstairs. I'm here to support you in any way I can,” I said softly, placing my hand on her shoulder. She turned slowly to face me, voicing small painful groans with each slight movement. Gauze and bandage covered almost all of her swollen forehead. One eye was blackened and swollen shut. Bruises covered the arm visible from under the sheets. Although she spoke not a word for the first few minutes, her silence communicated her pain, her fear and her anger.

I know that women of all ages, races and appearances are assaulted. However, dealing with this 65-year-old woman more than underscored that chilling reality. I tried to conceal my horror as she related how her throat was grabbed from behind with a rope. The gash on her forehead was from the impact of a dirty brick. She had been knocked unconscious, and the blood from the lacerations indicated repeated sexual assaults.“I'm so old,” she kept telling me.“I'm not cute. I was just walking to the store for cigarettes. What did he see in me?” As we waited for the resident, I explained to her that rape is not about sexual attraction; rather, it is a crime of power and control. I emphasized that she was not alone. I offered my hand as the resident applied the utmost care to perform the various specimen collections. I helped her with a cool drink and offered her a change of clothes as her own were packaged as legal evidence. Finally, I waved as she was wheeled away to be admitted for her internal injuries.

As I drove home that day, my thoughts returned to her. It is only natural to be disturbed and disgusted by this example of man's inhumanity to man, but I do not tell this story for sympathy. I intend it as a call to action. Often, when colleagues learn of my continued work with sexual assault survivors, many respond with distanced admiration or sympathetic references about how depressing my experiences must be. However, the work is anything but reserved for a talented select few. Too many of us feel that the problem is either too great or possibly nonexistent in the population with whom we work. Rape extends beyond all boundaries of sex, economic status and race. As physicians, students and citizens, we must fight our tendency to categorize sexual assault based on a person's background or circumstance. Even when unaccompanied by physical violence, and whether the victim is a prostitute in a dark alley or a college student on a date, rape is a crime of violation.

Although the statistics of rape may seem overwhelming, so do those of heart disease, depression and diabetes. Just as we, physicians in all levels of training, persevere against those conditions in our clinics and offices daily, we should persevere against sexual assault. We should become familiar with local sexual assault services. We should interview our patients about abuse without judgment, with an affirming ear and a list of resources for further support. We can take proactive steps to emphasize respect and sexual responsibility in routine visits, particularly with adolescents. We can help young people to understand that sex is not something to be demanded or coerced. We can strive to understand the dynamics of sexual crimes and advocate for strong prevention efforts.

Although I've worked with many sexual assault survivors before and after I saw this particular victim, I'll never forget that frail woman wrapped in the crisp hospital sheets. She is our grandmother, our mother, our sister, our friend, our patient and our neighbor. Rape touches us all. Just before this patient was wheeled away, she whispered to me, “I know he knew me. I know because he called me what all the kids on my block have called me for 35 years. He whispered,‘Don't scream, Miss Annie. Don't scream.’ ”

This quarterly department features essays written by medical students and family practice residents. Contributing editors are Amy Crawford-Faucher, M.D., a family practice resident at the Fairfax (Va.) Family Practice Residency Program, Sumi Makkar, M.D., resident representative to the Family Practice Editorial Board and Terrence J. Joyce, student representative to the editorial board.

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Copyright © 1999 by the American Academy of Family Physicians.

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