EFTA00156817

TILAU14A. VIOLENCE & ABUSE I.IS Responding to Delayed Disclosure taThe Author(%) 2016 RAVWS and nommen sagcpubconqourndinermaneasnar of Sexual Assault in Health Settings: DC. 101I77/152d0S0146$9464 rasageptincon A Systematic Review OSAGE Stephanie Lanthierl '2, Janice Du Mont i '2, and Robin Masonl '2 Abstract Few adolescent and adult women seek out formal support services in the acute period (7 days or less) following a sexual assault. Instead. many women choose to disclose weeks. months. or even years later. This delayed disclosure may be challenging to support workers. including those in health-care settings. who lack the knowledge and skills to respond effectively. We con- ducted a systematic literature review of health-care providers' responses to delayed disclosure by adolescent and adult female sexual assault survivors. Our primary objective was to determine how health-care providers can respond appropriately when presented with a delayed sexual assault disclosure in their practice. Arising out of this analysis, a secondary objective was to document recommendations from the articles for health-care providers on how to create an environment conducive to disclosing and support disclosure in their practice. These recommendations for providing an appropriate response and sup- porting disclosure are summarized. Keywords sexual assault, adolescent victims, adult victims, reporting/disclosure, support seeking Sexual assault in adolescence and adulthood is a pervasive. estimated 28% of sexual assaults were reported to law enforce- violent crime that results in a significant trauma to victims, ment in 2012 (Truman. Langton. & Planty. 2013). with negative health impacts that can persist for appreciable However, research shows that the majority of survivors do amounts of time (Cahill, 2009). Although research has eventually disclose to someone (Ahrens, Stanscll, & Jennings, shown that men and transgendered persons experience sex- 2010; Golding, Siegel, Sorenson, Burnam, & Stein, 1989; ual assault (Du Mont, Macdonald, White, & Turner, 2013; Neville & Pugh, 1997). Disclosure most often occurs weeks. Mcdonald & Tijerino, 2013), it is women who continue to months, or years after the assault (Dunleavy & Slowik, 2012; be disproportionately impacted (World Health Organization, Esposito, 2006; Pilipas & Ullman, 2001; Lessing, 2005; Mon- 2013). roe et al., 2005; Plumbo, 1995; Ullman, 1996a) with fewer Women who have been sexually assaulted report poorer survivors disclosing in the acute period (7 days or less) when health and use medical services more frequently than those specialized sexual assault services (e.g., Sexual Assault Nurse who have not been sexually assaulted (Du Mont & White, Examiner programs) may be available in some jurisdictions 2007; Resnick et al., 2000). Negative health outcomes include (Du Mont & White, 2007; Resnick et al., 2000; Zinzow, immediate physical injuries, pregnancy, gynecological compli- Resnick, Ban, Danielson, & Kilpatrick, 2012). cations (e.g., vaginal bleeding, infection, pain during inter- Survivors most often choose to disclose to informal support course, chronic pelvic pain) and mental health consequences providers such as friends, family, or an intimate partner, with including depression, anxiety, and posttraumatic stress disorder (PTSD; Wathen, 2012). More severe sexual assaults have been associated with worse health outcomes than less severe assaults 'Women's College Research Institute. Wcmen's College Wapiti& Toronto. (Ullman & Brecklin, 2003; Ullman & Siegel, 1995). Ontario. Canada Despite its significant health impacts, sexual assault remains 'Della Lana School of Public Health. University of Toronto. Toronto. Ontario. underreported (Du Mont & White, 2007). Although more than Canada one third (39%) ofCanadian women report having experienced Corresponting Author a sexual assault (Statistics Canada, 1994), less than 10% of Stephanie Larithier. Women's Cane Research Institute. Women's College these assaults are reported to law enforcement (Statistics Hasped. 76 Grenville Street. Floor 6. Rm. 6443. Toronto. Ontario. Canada Canada, 1994). Underreporting of sexual assault is also a prob- MSS IB2- lem in the United States where it has been found that only an stephanielmduengmadutorontam 3502-017 Page 1 of 15 EFTA_00001476 EFTA00156817 2 TRAUMA, VIOLENCE, & ABUSE substantially fewer disclosing to formal support providers "disclosure," "self-disclosure," "self-reporting," "rape," including police, health-care providers, mental health profes- "sexual assault," "sexual violence," "sexual trauma," sionals, and rape crisis workers (Baker, Campbell, & Strut- "post-assault," "post-rape," "sex," "sexual," "post-trau- man, 2012). Although informal support providers are often a matic," "PTSD," "psycho-trauma," "social support," "social good source of social and emotional support for survivors, it is perception," "social adjustment," "patient acceptance of formal support providers who are well positioned to assist health care," "health services accessibility," "communication women in their recovery through the provision of services barriers," "health personnel," "health care facilities, man- that address the physical and mental health consequences of power, services," "primary health care," "general practice," sexual assault (World Health Organization, 2013). Health- "patient care," "support," "reaction," "barrier," "examiner," care providers in particular have the potential to play a central "clinician," "doctor," "provider," "nurse," "formal," role in assisting women in their recovery. In addition to pro- "informal," and "long term." viding health care in the aftermath of sexual assault, they are The search was limited to English language records pub- uniquely positioned to act as a gateway, providing referrals to lished between 1985 and 2013. In addition, we hand-searched counseling, social, and legal services (World Ilealth Organi- the reference lists of relevant articles. In total, we identified zation, 2013). 1,166 records. After removing duplicates, the total remaining Women who have experienced violence often seek out was 779 (see Figure 1). health care though they may not disclose sexual assault to their health-care providers (World Health Organization, 2013). Those who do disclose to health-care providers suggest that Selection of Included Articles too often they receive inappropriate responses to their disclo- In the first stage of the review, all three authors screened the sure (Baker et al., 2012; Borja, Callahan, & Long, 2006). Neg- titles of the 779 records. Articles were set aside for further ative responses from support providers, including health-care review if their titles contained the terms "rape," "sexual providers, have been associated with greater PTSD symptom assault," "sexual trauma," "sexual violence," or "unwanted severity, depression, and physical health symptoms, as well as sexual attention." Titles that contained the word "sexual predictive of maladaptive coping by survivors (Baker et al., abuse" were included if it was clear that the term referred to 2012; Borja et al., 2006; World Health Organization, 2013). the sexual abuse of adults or adolescents, or where it was Evaluations of acute sexual assault services are clear that sur- unclear whether the term referred to adults or adolescents. Any vivors positively rate providers trained to deliver an appropri- title that clearly referred to child sexual assault or abuse or ate response to sexual assault disclosure, one that sensitively sexual assault of adult males was excluded. Additionally, we addresses both their medical and social/emotional needs (e.g., excluded titles where it was apparent that the focus was solely Du Mont et al., 2014). Therefore, health-care providers who on acute sexual assault, as well as titles that focused on sexual come into contact with sexual assault survivors who delay offenders. Finally, we excluded identifiable dissertations, chap- disclosure also should know how to respond appropriately ters, book reviews, books, editorials, commentaries, conference (World Health Organization, 2013). proceedings, and any remaining non-English language articles. The purpose of this study was to examine health-care pro- The title screen yielded a total of 178 records. The abstracts viders' responses when presented with a delayed sexual for each of these records were subsequently screened for fur- assault disclosure by adult and adolescent female survivors ther review by two authors. Articles were set aside for further in their practice. Our primary objective was to determine how review if abstracts referred to responses to disclosure from health-care providers can respond appropriately to delayed formal sources of support (physicians, therapists, police, etc.), disclosure in health-care settings. Arising out of this analysis, formal and informal (friends or family) sources of support, and a secondary objective was to document authors' recommen- in instances where it was unclear whether disclosure was to dations for health-care providers on how to create an environ- formal or informal support persons. Abstracts that referred ment conducive to disclosing and support disclosure in their solely to disclosure to informal support sources were excluded, practice. To answer these questions, we conducted a systema- as were those which focused on acute sexual assault, child tic review of the literature centered on health-care providers' sexual assault or abuse, or routine screening for violence responses to the delayed disclosure of sexual assault. To our (although articles referring to "assessment" were included). knowledge, no best-evidence synthesis has been conducted in Also excluded were abstracts where disclosure was made this area to date. within the mental health-care system, as these professionals are assumed to have received specialized training. Dissertations, chapters, book reviews, books, editorials, commentaries, fact Method sheets, and conference proceedings were also excluded. The abstract screen yielded 49 articles for which a full Literature Search review was conducted by two authors. Articles were included In consultation with a medical librarian, we conducted a search in the final sample only if they included responses to disclosure of OVID Medlin, EMBASE, Psyclnfo, and PubMed using of sexual assault to a health-care provider. If the only health- combinations of the following terms: "truth disclosure," care provider included was a mental health professional, the 3502-017 Page 2 of 15 EFTA_00001477 EFTA00156818 !ambler et 3 Records identified through Additional records identified database search (N. 1162) through reference lists of key articles (N=4l Records after duplicates removed iN=779) Thies excluded (N=6011 Sexual Assault or Related Terms Not in Title (N=369) Childhood or Male Sexual Assault Titles assessed to eligibility (N=779) IN-169) Book Chapters, Dissertations, etc. (N=100) Focused on Offender (N=9) Not in English (N=7) ‘‘....Acute Sexual Assault (N=6) Abstracts excluded (N=129°) No Response to Disclosure (N=9811 Abstracts assessed for eligibility Book Chapters, Dissertations etc. (IS= 9) (N=178) Childhood Sexual Assault (N=12) Mute Sexual Assault (N=7) Informal Support Provider Only (N=5) Screening (N=11 J Full-text articles excluded (N=26) Full-text articles assessed for No Healthcare Provider (N=15) • Childhood Sexual Assault (N=4) eligibility (N=49) Mental Health Setting (N=4) Commentary, etc. (N=2) Mute Sexual Assault (N=1) Snicks included (N=23) 'Some records excluded based on more than one criteria Figure I. Roy/chart of search results. article was excluded as were any remaining articles focused on organized into themes, the most common of which are child sexual assault or abuse. reported in the text. Data Abstraction Results The final sample included 23 articles. From the articles, we extracted country, participants, disclosure recipients, meth- Characteristics of Included Articles ods, key findings, including helpful and unhelpful responses The articles included in the review examined women's experi- to sexual assault, and specific recommendations from the arti- ences of delayed disclosure to a range of health-care providers. cles for health-care providers to create a suitable environment Health-care providers included physicians (Ahrens, Campbell, for and improve their response to delayed disclosures of sex- Terrier-Thames, Vasco, & Sefi, 2007; Diaz et al., 2004; Fili- ual assault and organized the information in table format (see pas & Ullman, 2001; Golding et al., 1989; Mazza, Dennerstein, Table 1). Helpful and unhelpful responses, and recommenda- & Ryan, 1996; Popiel & Susskind, 1985; Starzynski, Ullman, tions to improve health-care provider responses, were Filipas, & Townsend, 2005; Sturza & Campbell, 2005; Ullman, 3502-017 Page 3 of 15 EFIA_00001478 EFTA00156819 Table I. Description of Included Articles. Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Ahrens et al. N= 103 women. Mixed Providing emotional support including supportive Blaming or doubting the survivor (2009) Generic medical methods listening, expressions of care and concern, and Treating the survivor differently United States providers assurances that the survivor is not to blame after disclosure Providing tangible aid Distracting the survivor Blaming and/or doubting reactions from medical Controlling the survivor personnel only when survivors interpreted this Doing nothing to help the response as trying to protect them from future survivor after disclosure harm Attempting to control the survivor's decisions if the survivor believes the support provider is reacting out of concern Having an egocentric reaction Ahrens et al. N = 102 women. Mixed Providing emotional support including listening to Blaming the survivor Train medical personnel on how to support (2007) Physicians methods the survivor, telling them it was not their fault. Doubting the survivor survivors United States providing reassurance Doing nothing to help the Consider incorporating sexual assault screening Providing tangible aid survivor after disclosure questions into medical intake procedures Maintaining a cold/detached demeanor Doing 'their job' bur failing to communicate any sympathy or concern for the survivor's well-being Having no reaction at all Ahrens et al. N = 103 women. Mixed Blaming the survivor Train formal support providers including health- (2010) Generic medical methods Taking control care providers about how to respond in a United States providers Treating the survivor differently positive manner and avoid responding in a after disclosure negative manner Distracting the survivor Diaz et al. N = 146 women. Quantitative Providing emotional support and responding in a Inquire directly about sexual assault victimization (2004) Physicians professional yec compassionate manner as part of routine assessment United States Ensuring survivor seeks the appropriate follow-up Use a series of concrete questions co elicit Clarifying misconceptions about sexual assault disclosure of a past sexual assault (e.g.. victim is to blame) Take time co build trust and help the survivor feel Informing survivors of services available to assist comfortable to disclose them with recovery Providing referrals (continued) EFTA00156820 Table I. (continued) Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Dunleavy and N = I woman. Qualitative Validating the disclosure and providing emotional Use a patient-centered approach to help establish Slowik Physical support using the simple statement: 'I am so trust and a feeling of safety that encourages (2012) therapists sorry that this has happened to you' disclosure and continuity of care United States Referring survivor to psychotherapy and Provide a confidential environment and do not community resources, providing support 'rush' che survivor without attempting to serve as a counselor or Have a heightened awareness of nonverbal stress psychotherapist responses during examinations Consider regular screening in health-care settings where many individuals are likely to have experienced sexual violence (e.g.. veterans) Esposito N = 43 women. Qualitative Providing compassionate and emotionally Criticizing the survivor Do not push the survivor to disclose (2006) Nurses supportive care Treating the survivor with Find another nurse to speak with the survivor, if United States Acknowledging the disclosure through statements contempt unable to respond appropriately and questions such as 'I'm so sorry chat Asking the survivor what they Use a nonjudgmental and culturally competent happened to you. were doing in that area or approach When did it happen?" "Have you ever spoken to telling the survivor 'they Discuss the sexual assault in a private, one-on-one anyone about it? Was that helpful?' and "You deserved it or "asked for IC setting are very brave co share that information Accusing the survivor of lying Have brochures or other materials about sexual Making referrals if needed Avoiding eye contact with the assault available in patient rooms survivor or changing the Ask the survivor how she can be most comfortable subject quickly during examination and explain the procedure Be sensitive to the survivor's behaviors during examination and allow the survivor to stop the examination if she wishes Assess for sexual assault using the approach recommended for intimate partner violence Fdipas and Ullman N = 323 women. Quantitative Providing emotional support Treating the survivor differently Educate formal support providers including health- (2001) Physicians Not blaming the survivor (e.g.. stigma) care providers about sexual assault and the United States Providing tangible aid Promoting rape myths negative impacts of "rape myths Providing informational support Blaming the survivor Validating or believing the disclosure Distracting the survivor Not distracting the survivor Having an indirect negative Sharing their own experience with the su or reaction (e.g.. comments Not treating survivor differently about sexual assault in general that survivors find hurtful Violating trust Golding et al. N = 447 women Quantitative Design interventions to change physicians negative (1989) and men. attitudes United States Physicians Train physicians on behaviors used by those with direct experience working with sexual assault survivors such as rape crisis workers (continued) EFTA00156821 P Table I. (continued) Participants and Key Findings Authors. Year. Disclosure Typef Country Recipients Method Helpful responses Unhelpful responses Recommendations Lasing N/A Nurses Literature Providing emotional support. nurturance. a feeling Create an environment that is conducive to disclosure (2005) review of safety Do not assume that the survivor will automatically United States Establishing safety. both physically and emotionally disclose sexual assault Providing appropriate referrals Conduct sexual violence screening as part of Recounting the events surrounding the sexual routine assessment assault until it is clear that the survivor knows Use an 'icebreaker to allow patients more comfort that the assailant is to be blamed for the assault in disclosing information by letting them know Document sexual assault in the survivors' own that others have experienced similar events words Be alert to signs and symptoms of sexual assault (e.g.. sleep disturbance, decreases in appetite. self-blame, decreases in self-esteem. relationship difficulties. phobias. motor behavior difficulties. suicidal and homicidal ideation. somatic reactions) Provide ongoing education for primary care providers co keep current on treating sexual assault Littleton N = 262 women. Quantitative Blaming or stigmatizing the Assess strength of survivor's social support networks (2010) Generic medical survivor Inquire about survivor's past disclosure United States providers Treating the survivor differently experiences Distracting the survivor Assist survivors with understanding and coping Taking control with negative disclosure reactions Proceed with caution when encouraging survivors co disclose Long. Ullman. N = 1.022 Quantitative Be sensitive to issues of sexual orientation when Long. Mason. women. providing care to survivors and Starzynski Generic medical Check that the survivor perceives your actions as (2007) providers supportive United States Nana a al. N = 2.181 Quantitative Assess for signs and symptoms of sexual assault (1996) women. Develop the skills co diagnose sexual assault Australia Physicians Have knowledge of local social services and legal options in order to make appropriate referrals Muganyizi et al. N = 50 women. Mixed Providing emotional support and coping Blaming the survivor Educate formal support providers including health- (2009) N=M methods information Using statements meant to care providers on responding to sexual assault Tanzania Nurses. N = Advising survivor to seek legal or medical degrade or shame the survivor 1.505 assistance Avoiding or segregating the Community Providing information on how to avoid sexual survivor members assault in the future Distracting the survivor Nurses Distracting the survivor (continued) EFTA00156822 Table I. (continued) Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Muganyizi N = ICI women. Qualitative Acting in an unprofessional Train health-care providers to improve caring and Nystrom. N = 20 manner communication skills Axemo. and Social supports Provide more sensitive care Emmelin Generic medical Understand how survivors cope with sexual (2011) providers assault Tanzania Plumbo (1995) N/A. Clinical Providing support and encouraging healing Dismissing the survivor Be empathic and open to encourage disclosure United States Nurse-midwives practice Acknowledging the sexual assault Not providing a referral when Assess the degree of support and counseling Reassuring the survivor that the decision to appropriate required disclose was appropriate Differentiate survivors who need referral from Using simple statements such as I'm so sorry this chose who do not has happened co you' and "I'm glad you told me Be sensitive to survivor's verbal and nonverbal about this' after disclosure behaviors Verifying that the survivor is not isolated Assess survivor's safety Listening to and supporting the survivor Educate the survivor about the physical and Assisting the surrivor to understand that she is in emotional symptoms of sexual assault charge of her recovery and that there are Provide advice that is brief. focused. and practical support systems available to her Ask the survivor to remember other difficult Providing referrals to survivors who have ahistoryof episodes in which she may have coped well abuse. ongoing difficulties with adult relationships. Ask the survivor about her support network substance we problems. suicidal ideation. and/or who express maladaptive sentiments identifying and acknowledging survivor's strengths and coping skills (e,g.. it cook a great deal of strength to deal with this event in your life. I'm glad you decided 43 share this with me today") Emphasizing that the survivor's reactions are normal Reinforcing that the survivor was a victim of a crime and not responsible for the sexual assault Popiel and N = 25 women. Quantitative Reassuring the survivor Feeling sorry for the survivor Provide training to the medical community to Susskind Physicians Taking time to talk with the survivor Making decisions for the survivor enhance communication skills (1985) Trying to understand what the survivor is going Talking about the sexual assault United States through Providing information and discussing options Encouraging the survivor to seek further assistance Starzynski et al. N= 1,084 Quantitative Be aware of and reject 'rape myths' (2005) women. Provide more positive and less negative reactions United States Physicians co disclosure (continued) EFTA00156823 Table I. (continue.* Participants and Key Findings Authors. Year. Disclosure Type/ Country Recipients Method Helpful responses Unhelpful responses Recommendations Sturza and N = 44 women. Mixed Giving the survivor a prescription Ensure physicians' offices are safe places for Campbell Physicians methods without acknowledging the women to disclose (2005) sexual assault or asking further Train physicians and nurses on how to respond United States questions appropriately to disclosure Dismissing or ignoring the Provide more responsive care with information survivor's disclosure about multiple treatment options Being cold or silent upon disclosure Refer survivors where appropriate to mental Appearing uncomfortable after health and social services the disclosure Not providing other options for dealing with the sexual assault ocher than medication Looking away from the survivor (not maintaining eye contact) Ullman N = 155 women. Quantitative Provide more positive and less negative reactions (1996a) Physicians to disclosure United States Provide education to improve medical personnel reactions to survivors Ullman N = 155 women. Quantitative Providing tangible aid/information support Blaming the survivor (1996b) Physicians Providing emotional support Being treated differently United States Providing validation Distracting/discouraging the Listening to the survivor survivor from talking Not blaming the survivor Taking control Ullman and Alipas N = 323 women. Quantitative Train medical professionals about sexual assault (2001) Physicians and common negative reactions to survivors United Scares Train formal support providers including health- care providers on the realities of sexual assault to help them to be more empathic and reduce their blaming responses Ullman and N = 969 women. Quantitative Providing tangible aidlinformational support Najd:iv/ski Generic medical (2009) providers United States Ullman and N = 155 women. Quantitative Providing emotional support Blaming the survivor Provide interventions for formal support providers Siegel Physicians Validating the disclosure Treating the survivor differently including health-care providers on how to (1995) Believing the survivor Distracting the survivor or support survivors in a helpful and effective way United States Listening to the survivor discouraging them from calking about the sexual assault Providing tangible aid Note. N/A = not applicable. EFTA00156824 Lanthier et al 9 I996a, 1996b; Ullman & Filipas, 2001; Ullman & Siegel, disclosed to their physician to access medication to deal 1995), nurses (Esposito, 2006; Lessing, 2005; Muganyizi with the sexual assault. et al., 2009), nurse-midwives (Plumbo, 1995), and physical Three empirical studies indicated reasons why women chose therapists (Dunleavy & Slowik, 2012). In six articles, the gen- not to disclose having been sexually assaulted to a physician. eric terms "medical personnel," "medical staff," or "health- Mazza, Dennerstein, and Ryan (1996) found that 53% of the care system" were used by the authors without specifying the women in their study had not disclosed to their physician type of provider (Ahrens, Cabral, & Abeling, 2009; Ahrens because they did not think it relevant to their consultation. et al., 2010; Littleton, 2010; Long, Ullman, Long, Mason, & Additional reasons for not disclosing sexual assault included Starzynski, 2007; Muganyizi, Nystrom, Axemo, & Emmelin, that their physician did not ask (27%), embarrassment (10%), 2011; Ullman & Najdowski, 2009). and lack of trust in their physician ( l%; Mazza et al., 1996). The articles varied widely in terms of their approach. Of the Ullman (1996b), as well as Sturza and Campbell (2005), further 23 articles, there were 21 empirical studies, I literature review, suggested that survivors fear of their physicians' response to and I clinical practice. The empirical studies included quanti- the disclosure was an important factor in influencing their tative methodologies (Diaz et al., 2004; Filipas & decision to not disclose. 2001; Golding et al., 1989; Littleton, 2010; Long et al., 2007; Golding, Siegel, Sorenson, Burnam, and Stein (1989) found Mazza et al., 1996; Popiel & Susskind, 1985; Starzynski et al., that 26% of survivors who experienced a stranger sexual 2005; Ullman, I996a, 1996b; Ullman & Filipas, 2001; Ullman assault told their physician, as opposed to only 5% of those & Nadjowski, 2009; Ullman & Siegel, 1995), qualitative meth- who experienced an acquaintance sexual assault. Survivors odologies (Dunleavy & Slowilc, 2012; Esposito, 2006; Muga- were more likely to tell their physician if the sexual assault nyizi et al., 2011), and mixed methods designs (Ahrens et al., involved penetration, physical or psychological threats, or if 2009; Ahrens et al., 2007; Ahrens et al., 2010; Muganyizi et al., they identified having experienced emotional consequences 2009; Sturza & Campbell, 2005). In all, 19 articles were U.S.- (Golding et al., 1989). based, 2 were from Tanzania, and I from Australia. The number of participants in the empirical studies ranged from I to 43 in the qualitative studies and up to 2,181 in the Helpful Responses to Disclosure quantitative studies. In all, 13 studies utilized the Social Reac- The most common helpful responses from formal support pro- tions Questionnaire, a self-report instrument developed by viders including health-care providers among the 13 articles Ullman (1996c, 2000) from earlier research on social support that provided data were validating the disclosure and providing and social reactions received by sexual assault survivors upon emotional support, and providing tangible aid. disclosure (Ullman, 2000). The instrument consists of48 items that are characterized as either positive reactions or negative Validating the disclosure andproviding emotional support Five arti- reactions to disclosure. Positive reactions fall into 2 categories cles indicated that having the provider acknowledge or validate including "emotional support/belief' and "tangible aid/infor- the disclosure was a positive response from formal support mation support," whereas negative reactions fall into five cate- providers generally (Ullman, 19966) and health-care providers gories including "victim blame," "treat differently," specifically (Dunleavy & Slowik, 2012; Esposito, 2006; "distraction," "take control," and "egocentric." Plumbo, 1995; Ullman & Siegel, 1995). Acknowledging or validating the disclosure was described as including simple statements such as "I'm so sorry that this has happened to you" Disclosure to Health-Care Providers and "I'm glad you told me about this" (Dunleavy & Slowilc, Eight empirical studies specified the precise proportion of sur- 2012, p. 346; Esposito, 2006, p. 76; Plumbo, 1995, p. 425). vivors in their sample who disclosed to a health-care provider. Twelve articles indicated that receiving emotional support Disclosure rates among sexual assault survivors to health-care from formal support providers including health-care providers providers in these studies were 6% (Golding et al., 1989), 9% was a positive response to disclosure (Ahrens et al., 2009; (Mazza et al., 1996), 10% (Ahrens et al., 2009), 11% (Littleton, Ahrens et al., 2007; Diaz et al., 2004; Dunleavy & Slowik, 2010), 17% (Starzynski et al., 2005), 19% (Ullman & Siegel, 2012; Esposito, 2006; Filipas & Ullman, 2001; Lessing, 1995), and 27% (Filipas & Ullman, 2001). One study, Ahrens, 2005; Muganyizi et al., 2009; Plumbo, 1995; Popiel & Sus- Campbell, Terrier-Thames, Wasco, and Sefi (2007), found that skind, 1985; Ullman, 1996b; Ullman & Siegel, 1995). Ahrens, only 5% of women chose their doctor as the first person to Cabral, and Abeling (2009) found that "emotional support whom to disclose. from medical staff was almost always considered healing" for Two empirical studies provided reasons why survivors survivors (p. 87). chose to disclose to a health-care provider. In Ahrens Emotional support included the health-care provider show- et al. (2007), some survivors indicated that they disclosed ing compassion for the survivor or providing nurturance (Espo- for medical reassurance. As one woman who disclosed to sito, 2006; Lessing, 2005), being empathic (Ahrens et al., 2007; her physician stated, "I wanted information, to know that I Plumbo, 1995; Popiel & Susskind, 1985), listening in an active was physically and emotionally all right" (Ahrens et al., and supportive manner (Ahrens et al., 2009; Plumbo, 1995; 2007, p. 4 I ). In Sturza and Campbell (2005), women also Ullman, 1996b; Ullman & Siegel, 1995), and acknowledging 3502-017 Page 9 of 15 EFIA_00001484 EFTA00156825 10 TRAUMA VIOLENCE, & ABUSE the survivor's skills in dealing with the sexual assault (Plumbo, Although blaming responses were generally experienced 1995). Telling survivors that they were not to blame for the negatively, two empirical studies found that such reactions sexual assault also was considered a key component of emo- from medical staff and other support providers' could be inter- tional support (Ahrens et al., 2009; Ahrens et al., 2007; Diaz preted positively if the survivor felt that the intention was to et al., 2004; Filipas & Ullman, 2001; Lessing, 2005; Plumbo, help them prevent another sexual assault from occurring 1995; Ullman, 19966). In a study conducted by Ullman (Ahrens et al., 2009; Muganyizi et al., 2009). For example, (1996b), 10% of women cited not being blamed as the most Ahrens et al. (2009) reported that while blaming responses helpful response they received from a formal support provider, were often considered hurtful by survivors when coming from including health-care providers. informal support providers, they were often considered healing when coming from medical personnel if they believed that the Providing tangible aid. Twelve articles indicated that "tangible provider was trying to help them avoid an assault in the future. aid" was a helpful response to disclosure from formal sources of support, including health-care providers (Ahrens et al., 2009; Minimizing, dismissing, and/or distracting responses. In nine arti- Ahrens et al., 2007; Diaz et al., 2004; Dunleavy & Slowik, cles that indicated negative responses to disclosure, minimizing 2012, Esposito, 2006; Filipas & Ullman, 2001; Lessing, and/or dismissing the sexual assault was cited as unhelpful 2005; Muganyizi et al., 2009; Plumbo, 1995; Popiel & Sus- (Ahrens et al., 2009; Ahrens et al., 2010; Filipas & Ullman, skind, 1985; Ullman, 19966; Ullman & Najdowski, 2009). 2001; Littleton, 2010; Muganyizi et al., 2009; Plumbo, 1995; Tangible aid is described by Ullman (2000) not only as assist- Sturza & Campbell, 2005; Ullman, 19966; Ullman & Siegel, ing the survivor to access medical care, providing them with 1995). Minimizing and dismissive responses included state- resources, particularly those that focus on coping with the after- ments or attempts to make the sexual assault seem less trou- math of sexual assault, and encouraging them to see a counse- bling than how the survivor perceived it, or suggesting to her lor or other mental health professional, but also encompassed that it was "not a big deal" or that she "stay silent." Ahrens clarifying misconceptions about sexual assault and assessing et al. (2009) found that such statements were taken by survivors safety (e.g., Diaz et al., 2004). to mean that the support provider did not care about them or Although across the articles, tangible aid was typically about what had happened to them. described as helpful and in some cases "healing" (Ahrens Three articles also noted that attempts by support providers, et al., 2009), Ahrens, Cabral, and Abeling (2009) found that including health-care providers, to distract the survivor were survivors could interpret tangible aid from formal support pro- considered unhelpful even when they were meant to be of viders (in this case legal workers) negatively if the tangible aid assistance (Ahrens et al., 2007; Filipas & Ullman, 2001; Ull- was not accompanied by validation or support. In another man, 19966). In one study, the results were mixed; Muganyizi study, receiving tangible aid from formal support providers was et al. (2009) reported that half their sample of sexual assault associated with poorer health outcomes for survivors who had survivors found distraction attempts to be helpful, whereas the experienced a severe sexual assault (Ullman & Siegel, 1995). other half described them as unhelpful. Distracting responses Ullman and Siegel (1995) suggested that this may have been from support providers, including health-care providers, because survivors who have experienced severe sexual assaults encompassed telling the survivor to stop talking or thinking are more likely to seek tangible aid from formal support pro- about the sexual assault or attempting to discourage them from viders such as physicians or the police, who have been shown further speaking about the sexual assault (Ullman, 19966). to react more negatively than other support providers. Treating survivor differently after disclosure. Eight articles indi- cated that being treated differently by the support provider after Unhelpful Responses to Disclosure the disclosure is unhelpful to survivors (Ahrens et al., 2009; The most common unhelpful responses from formal support Ahrens et al., 2010; Esposito, 2006; Filipas & Ullman, 2001; providers including health-care providers among the 13 articles Muganyizi et al., 2009; Popiel & Susskind, 1985; Ullman, that provided data were blaming the survivor, minimizing, dis- 19966; Ullman & Siegel, 1995). In fact, Ahrens et al. missing, and/or distracting responses; treating the survivor dif- (2009) found that every survivor in their sample who had ferently after disclosure; displaying a cold and/or detached disclosed having been sexually assaulted described being demeanor; and doubting the survivor. treated differently post-disclosure and that this was hurtful. Being treated differently after the disclosure included treating Blaming survivor for sexual assault. Identified in 10 articles, being the survivor with contempt (Esposito, 2006; Muganyizi et al., blamed for the sexual assault was the most commonly cited 2009), feeling sorry for the survivor (Popiel & Susskind, unhelpful response from formal support providers, including 1985), and avoiding or segregating the survivor (Muganyizi health-care providers (Ahrens et al., 2009; Ahrens et al., et al., 2009). Ullman (19966) found that physicians or police 2007; Ahrens et al., 2010; Esposito, 2006; Filipas & Ullman, were more likely to treat a survivor differently after disclosure 2001; Lessing, 2005; Littleton, 2010; Muganyizi et al., 2009; than either an informal support provider or a mental health Ullman, 19966; Ullman & Siegel, 1995). professional. 3502-017 Page 10 of 15 EFIA_00001485 EFTA00156826 !ambler et al. Displaying a cold and/or detached demeanor. Five articles sug- treating adolescents, specifically, Diaz et al. (2004) recom- gested that it was unhelpful to survivors when formal support mended that the health-care provider use a series of questions, providers, including health-care providers, displayed a cold rather than just one. Lessing (2005) cautioned that the and/or detached demeanor (Ahrens et al., 2009; Ahrens et al., health-care provider should not assume that the survivor will 2007; Esposito, 2006; Plumbo, 1995; Sturza & Campbell, automatically disclose information about the sexual assault, 2005), even when they "did their job" by providing the nec- whereas Esposito (2006) suggested "it would be inappropriate essary information and/or aid (Ahrens et al., 2007). A cold and or even harmful to push someone to disclose" (p. 71). detached demeanor included such reactions as not making eye contact with the survivor or asking another question unrelated Recognize indicators. Five articles suggested that it was impor- to the sexual assault in an effort to change the subject (Espo- tant for health-care providers to be aware of the signs and sito, 2006; Sturza & Campbell, 2005), ignoring the survivor symptoms of sexual assault (Dunleavy & Slowik, 2012; Espo- (Sturza & Campbell, 2005), not providing any emotional sito, 2006; Lessing, 2005; Mazza et al., 1996; Plumbo, 1995). assistance upon hearing the disclosure (Ahrens et al., 2009; Two articles indicated that the health-care provider should be Plumbo, 1995), and having no reaction at all (Ahrens et al., alert to signs and symptoms of distress or anxiety during rou- 2009; Ahrens et al., 2007). For example, in the Ahrens et al. tine examinations, particularly those that can be considered (2007) study, a survivor relayed that when she told her phy- invasive such as a Pap test (Dunleavy & Slowik, 2012; Espo- sician that she was sexually assaulted by her husband, "he sito, 2006). Esposito (2006) further suggested that during rou- didn't seem surprised ... he didn't really seem to give any tine examinations, the health-care provider should explain the reaction at all" (p. 43). procedure to the woman, be sensitive to any behaviors that An article by Sturza and Campbell (2005) reported that indicate that she is feeling distress, and allow her to stop the many women described their physicians as "cold" or "silent" examination if she appears to require a rest. upon disclosure and felt silenced when these physicians "got out their pad" to write a prescription as the sole response to the disclosure (Sturza & Campbell, 2005, p. 361). Half the women Create an erisSronment to support disclosure. The importance of in their sample using medications acquired them with a pre- being able to speak with the survivor in a private, safe, and scription given as a means of dealing with the sexual assault. supportive environment and "not rushing" them was indicated by the authors of five articles as particularly important in assist- Doubting the survivor. Three articles demonstrated that doubting ing survivors to disclose (Diaz et al., 2004; Dunleavy & Slo- the survivor's account of the sexual assault (Ahrens et al., wik, 2012; Esposito, 2006; Lessing, 2005; Sturza & Campbell, 2009; Ahrens et al., 2007), or accusing the survivor of not 2005). Diaz et al. (2004) suggested that having the time to help telling the truth (Esposito, 2006), constituted unhelpful the survivor feel comfortable and build mist with the provider responses. In particular, Ahrens et al. (2007) described sup- may also encourage disclosure. In addition, Esposito (2006) port providers including health-care providers, who ques- recommended having brochures or other media in examination tioned the accuracy of the survivors' account of the sexual rooms outlining information about sexual assault and the local assault or suggested that the sexual assault did not qualify as a services available to survivors. "real" rape. Use a patient-centered and culturally competent approach. Three articles recommended the use of a patient-centered and/or cul- Recommendations for Health-Care Providers turally competent approach when responding to delayed dis- The most common recommendations extracted from the arti- closure of sexual assault in health-care settings (Dunleavy & cles focused on improving formal support providers' including Slowik, 2012; Esposito, 2006; Long et al., 2007). Dunleavy and health-care providers' responses to sexual assault disclosure Slowik (2012) understood a patient-centered approach to were prompt for disclosure, recognize indicators, create an include viewing the patient as an active participant in their own environment supportive of disclosure, use a patient-centered care with the health-care provider listening and learning from and culturally competent approach, and enhance training. the patient about how their needs can best be met. Esposito (2006) further recommended that the health-care provider use a Prompt for disclosure. Four articles recommended direct inquiry "culturally competent" approach when supporting a survivor of all women for sexual assault as part of routine assessment after disclosure. Though not defined by Esposito, a culturally (Ahrens et al., 2007; Diaz et al., 2004; Esposito, 2006; Lessing, competent approach is described elsewhere as taking into 2005), with an additional study advocating for screening in account individual differences such as age, race, gender, socio- settings with large numbers of potential victims of physical economic status, and sexual orientation when discussing a trau- and psychological trauma (Dunleavy & Slowilc, 2012). Espo- matic event with a survivor (Roberts, Watlington, Nett, & sito (2006) suggested that when taking a sexual assault history Batten, 2010). A culturally competent health-care provider is as part of a routine assessment it is best to start the discussion sensitive to potential power differences between themselves by asking: "Ilas anyone ever touched you, or forced you to do and the survivor and shows a general level of sensitivity to something sexual that you did not want to do?" (p. 73). When diverse communities (Long et al., 2007; Roberts et al., 2010). 3502-017 Page 11 of 15 EFIA_00001486 EFTA00156827 I2 TRAUMA VIOLENCE, & ABUSE Enhance training. The authors of 11 articles suggested that for- providers, making it unclear if the results would have differed mal support providers including health-care providers require had these support providers been analyzed separately. For (further) training on how to sensitively respond to disclosures example, in one study that reported the proportion of survivors of past sexual assault (Ahrens et al., 2007; Ahrens et al, 2010; who disclosed to physicians, the remainder of the analyses Filipas & Ullman, 2001; Golding et al., 1989; Muganyizi et al., considered physicians along with a number of other formal 2009; Ivluganyizi et al., 2011; Popiel & Susskind, 1985; Sturza support providers as "other." & Campbell, 2005; Ullman, 1996a; Ullman & Filipas, 2001; Future research in the area should include specific and Ullman & Siegel, 1995). detailed information about the recipients of a disclosure, Ahrens, Stansell, and Jennings (2010) suggested that formal including profession (e.g., family physicians) as it is possible support providers including health-care providers require train- that some health professions provide more helpful responses ing focused on minimizing negative and increasing positive than others. It is also possible that certain responses may be social reactions. Starzynski, Ullman, Filipas, and Townsend considered helpful from one type of health-care provider, but (2005) recommended that becoming aware of rape myths will not another. There is some basis for this, with Ahrens et al. help formal support providers including health-care providers (2009) finding that the same reaction may be viewed differ- move beyond the notion that the only "real" sexual assaults are ently depending on who the support provider is (e.g., infor- those committed by strangers (Baker et al., 2012). Learning mal vs. formal, legal vs. medical). Additionally, little is about the realities of sexual assault was also emphasized by known about the specific characteristics of survivors who Ullman and Filipas (2001) who suggested this may assist in have disclosed past sexual assault (e.g., race, sexual orienta- reducing blaming responses. Finally, Golding et al. (1989) put tion, socioeconomic status, immigration status, lifestyle) and forward that it may be useful for health-care providers to learn how these characteristics may impact the health-care provi- helping behaviors used by those with direct experience work- ders' response. ing with sexual assault survivors such as rape crisis workers. The recommendation in four articles to inquire about sexual assault with every adolescent and adult woman as part of rou- tine practice (Ahrens et al., 2007; Esposito, 2006; Diaz et al., Discussion 2004; Lessing, 2005) has also been made by Probst, Thrchik, Although the research focused on delayed disclosure in health- Zimak, and Iluckins (2011). Although not much is known care settings is sparse, the evidence thus far suggests that about the impact of routine screening for sexual assault, within health-care providers respond both appropriately and inappro- the context of intimate partner violence, some research has priately to survivors' disclosures of past sexual assault. There shown there to be challenges and questionable benefit (Klevens appears to be a general consensus about what constitutes an et al., 2012; MacMillan et al., 2009; Wathen & MacMillan, appropriate response to the delayed disclosure of sexual 2012). This had led to some experts advising "a case-finding assault. Twelve of the 13 articles that included an examination approach to partner violence identification" (Wathen & Mac- of appropriate responses to delayed disclosure found the pro- Millan, 2012, p. 712). Research focused on routine screening vision of emotional support to be helpful. The evidence for the for sexual assault is required. Until we have such evidence, a provision of tangible aid/informational support (e.g., referrals) similar case finding approach which prompts for disclosure in was slightly more nuanced, with one study indicating that tan- the presence of signs and symptoms of sexual assault, may be gible aid was not helpful in the absence of emotional support. appropriate. Unhelpful responses were most commonly associated with There are limitations that temper the strength of these find- health-care provider "unprofessionalism" (Muganyizi et al., ings. Of the 23 articles, the findings of 4 empirical studies 2011), with blaming the survivor most frequently cited. appear to be based on data drawn from the same sample pop- Few articles examined delayed disclosure in health-care set- ulation (Ahrens et al., 2009, Ahrens et al., 2007, Ahrens et al., tings as their primary objective. Only 6 of the 23 articles 2010; Sturza & Campbell, 2005). Similarly, three other studies focused exclusively on health-care settings (Diaz et al., 2004; appear to draw on the same data set (Ullman, I996a, 19966; Dunleavy & Slowik, 2012; Esposito, 2006; Lessing, 2005; Ullman & Siegel, 1995). This effectively limited the number of Mazza et al., 1996; Plumbo, 1995) and named the practicing distinct women's perspectives included in this systematic health-care provider (i.e., nurse, nurse-midwife, physician, review. To draw stronger conclusions about helpful and physical therapist). Of these six articles, one was a literature unhelpful responses to disclosure, research with more (and review, one was a clinical practice, and two of the remaining more diverse) groups of women is required. Finally, six studies four articles were studies with relatively small sample sizes. In that met inclusion criteria focused primarily on outcomes that the 17 articles that did not focus exclusively on health-care were not associated with positive or negative responses from settings, II identified the health-care provider, whereas the health-care providers (Golding et al., 1989; Long et al., 2007; remaining 6 employed general terms such as "medical person- Mazza et al., 1996; Starzynski et al., 2005; Ullman, 1996a; nel" and "medical staff" (Ahrens et al., 2009; Ahrens, et al., Ullman & Filipas, 2001). 2010; Littleton, 2010; Long, et al., 2007; Muganyizi et al., The review itself may be limited by the search terms we 2011; Ullman & Najdowski, 2009). Further, some studies col- used as well as the way in which the search terms were com- lapsed health-care providers with other formal support bined. In addition, we restricted our search to four databases, 3502-017 Page 12 of 15 EFIA_00001487 EFTA00156828 Lanthier et at 13 which raises the possibility that articles not included in the Acknowledgment chosen databases could have been missed. However, to assist The authors gratefully acknowledge the support of medical librarian with minimizing this risk, we searched the reference lists of key Mona Frantzke. BSc, KILSc, from the Health Sciences Library at articles. We also included only scholarly articles published Women's College Hospital. after 1985 and only those articles which were written in the English language. Finally, we included some studies that did Declaration of Conflicting Interests not differentiate between those who disclosed sexual assault The author(s) declared no potential conflicts of interest with respect to immediately and those who delayed disclosure. the research. authorship. and/or publication of this article. Funding Conclusion The author(s) disclosed receipt of the following financial support for Ilealth-care providers are uniquely positioned to assist ado- the research, authorship. and/or publication of this article: Dr. Du Mont is supported in pan by the Atkinson Foundation. lescent and adult women survivors of past sexual assault by providing relevant health care and acting as an important gateway to other support services. As inappropriate or nega- References tive responses such as blaming can lead to secondary victimi- Ahrens. C. E.. Cabral. G., & Abeling, S. (2009). Healing or hurtful: zation, it is important that health-care providers are able to Sexual assault survivors' interpretations of social reactions from respond to survivors appropriately by validating the disclo- support providers. Psychology of Women Quarterly. 33,81-94. sure and providing emotional support and tangible aid. There Ahrens, C. E., Campbell. R., 'fernier-Thames, N. K., Wasco. S., & is strong agreement that to improve practice in this area, Sefl, T. (2007). Deciding whom to tell: Expectations and outcomes health-care providers need enhanced training on how to create of rape survivors' first disclosures. Psychology of Women Quar- an environment that supports disclosure, including use of a terly. 31, 38-49. patient-centered and culturally competent approach and, fur- Ahrens, C. E.. Stanse11,1., & Jennings. A. (2010). To tell or not to tell: ther, recognition of indicators of sexual assault when disclo- The impact of disclosure on sexual assault survivors' recovery. sure is not forthcoming. Violence and Victims, 25. 631-648. Baker. L. L. Campbell. M.. & Straatman, A. L. (2012). Overcoming barriers and enhancing supportive responses: The resvarch on sexual violenceagainst mown. Centre for Research & Education on Violence Implications for Practice, Policy, and Against Women and Children. Westem University. Retrieved from Research hupgAvww.vawlearningnetwork.caisitesileamingtoendabuse.ca.vaw Practice leamingnetworkifiles/LN_Overcoming_Baniers_FINAL.pdf • Enhance training for health-care providers on (a) creat- Bona. S. E., Callahan. J. L., & Long, P. J. (2006). Positive and neg- ing an environment that supports disclosure; (b) using a ative adjustment and social support of sexual assault survivors. patient centered and culturally competent approach; and Journal of Traumatic Stress, 19, 905-914. (c) recognizing indicators of past sexual assault. Cahill. A. (2009). Sexual violence and objectification. In R. J. Herbele & V. Grace (Eds.), Theorizing sexual violence (pp. 14-30). New • Respond to disclosures of past sexual assault with vali- York. NY: Routledge. dation, emotional support, medical care, information, Diaz. A.. Edwards, S., Neal. W. P., Ludmer, P.. Sondike, S. B.. Kess- and referral. ler. C..... Nucci. A. T. (2004). Obtaining a history of sexual victimization from adolescent females seeking routine health care. Poky The Mount Sinai Journal ofMedicine. 71, 170-173. • Include the care of sexual assault survivors in health- Du Mont. J.. Macdonald. S.. White, M.. & Turner. L. (2013). Male care professional practice guidelines. victims of adult sexual assault: A descriptive study of survivors' • Develop policies to ensure that health-care settings are use of sexual assault treatment services. Journal ofInterpersonal conducive to disclosure of sexual assault. Violence, 28. 2676-2694. Du Mont, J.. Macdonald, S., White. M.. Turner. L.. White. D.. Kaplan, Research S.. & Smith. T. (2014). Client satisfaction with nursing-led sexual assault and domestic violence services in Ontario. Journal of • Examine how characteristics such as gender, race, sex- Forensic Nursing, 10. 122-124. ual orientation, socioeconomic status, immigration sta- Du Mont, J.. & White. D. (2007). The uses and impacts of medico- tus, lifestyle, and assault characteristics impact the legal evidence in sexual assault cases: A global review. Geneva, responses the survivor receives upon disclosure to a Switzerland: World Health Organization. Retrieved from: http:// health-care provider. wwwsvri.orglmedico.pdf • Research routine screening for sexual assault to deter- Dunleavy, K.. & Slowik. A. K. (2012). Emergence of delayed post- mine its impact on diverse survivors. traumatic stress disorder symptoms related to sexual trauma: 3502-017 Page 13 of 15 EFIA_00001488 EFTA00156829 14 TRAUMA, VIOLENCE, & ABUSE Patient-centered and trauma-cognizant management by physical Popiel, D. A.. & Susskind. E. C. (1985). The impact of rape: Social therapists. Physical Therapy Journal. 92, 339-351. support as a moderator of stress. American Journal of Community Esposito. N. (2006). Women with a history of sexual assault: Health Psychology, 13.645-676. care visits can be reminders of a sexual assault. American Journal Probst, D. R., Turchik, J. A., Zimak, E. H., & Huckins, J. L. (2011). ofNursing. 106. 69-73. Assessment of sexual assault in clinical practice: Available screen- Filipas• H. H., & Ullman. S. E. (2001). Social reactions to sexual ing tools for use with different adult populations. Journal of assault victims from various support sources. Violence and Vie- Aggression. Maltreatment & Trauma• 20. 199-226. nna 16, 673-692. Resnick, H. S., Holmes. M. M.. Kilpatrick. D. G., Clum• G., Acierno. Golding, J. M.. Siegel, J. M., Sorenson, S. B.. Burnam. M. A.. & Stein. R., Best. C. L.. & Saunders. B. E. (2000). Predictors of post-rape J. A. (1989). Social support sources following sexual assault. Jour- medical care in a national sample of women. American Journal of nal ofCommunity Psychology, 17.92-107. Preventive Medicine. 19, 214-219. Klevens, J., Kee. R., Trick, W., Garcia, D.. Angulo• F. R.. Jones. R., & Roberts, S. T., Watlington• C. G.. Nett, S. D., & Batten. S. V. (2010). Sadowski• L. S. (2012). Effect of screening for partner violence on Sexual trauma disclosure in clinical settings: Addressing diversity. woolen's quality of life: A randomized controlled trial. The Jour- Journal of Trauma & Disassociation. 11, 244-259. nal ofthe American Medical Association• 308, 681-689. Surzynski, L. L.. Ullman, S. E.. Filipas. H. H., & Townsend, S. M. Lessing, J. E. (2005). Primary care provider interventions for the (2005). Correlates of women's sexual assault disclosure to informal delayed disclosure of adolescent sexual assault. Journal of Pedia- and formal support sources. Violence and Vicuna. 20.417-432. irk Health Care, 19. 17-24. Statistics Canada. (1994). Violence against women survey. 1993 [pub- Littleton, H. L. (2010). The impact of social support and negative lic use microdata file]. Ottawa, Ontario: Statistics Canada. disclosure reactions on sexual assault victims: A cross-sectional Stuna. M. L., & Campbell, R. (2005). An exploratory study of rape and longitudinal investigation. Journal of Trauma & Disassocia- survivors' prescription drug use as a means of coping with sexual tion. 11, 210-227. assault. Psychology of Women Quarterly., 29. 353-363. Long• S. M., Ullman, S. E.. Long. L. M.. Mason. G. E.. & Stanynski. Truman. J., Langton. L., & Planty, M. (2013). Criminal victimization. L. L. (2007). Women's experiences of male-perpetrated sexual 2012. U.S. Department of Justice. Retrieved from http:// assault by sexual orientation. Violence and Victims• 22.684-701. www.bjsgovicontentipublpdficv12.pdf MacMillan, H. L.. Walken, C. N., Jamieson• E..Boyle. M. H., Shannon. Ullman, S. E. (1996a). Correlates and consequences of adult sexual H. S., Ford-Gilboa M. F.. ... McNutt. L. A. (2009). Screening for assault disclosure. Journal of Interpersonal Violence, 11, intimate partner violence in healthcare settings: A randomizedtrial. 554-571. The Journal ofthe American Medical Association. 302.493-501. Ullman. S. E. (1996b). Do social reactions to sexual assault victims Mazza• D., Dennerstein, L., & Ryan. V. (1996). Physical, sexual and vary by support provider? Violence and Victims, II. 143-157. emotional violence against women: A general practice-based pre- Ullman. S. E. (1996e). Social reactions, coping strategies and self- valence study. The Medical Journal ofAustralia. 164, 14-17. blame attributions in adjustment to sexual assault. Psychology of McDonald. S., & Merino, A. (2013). Male survivors ofsexual abuse Women Quarterly. 20, 505-526. and assault: Their experiences. Research and Statistics Division, Ullman, S. E. (2000). Psychometric characteristics of the social reac- Department of Justice Canada. Retrieved from http://wonv.justi tions questionnaire: A measure of reaction to sexual assault vic- ce.gc.cdengirp-pricj-jpivictimirr 38.4713_8.pdf tims. Psychology of Women Quarterly. 24, 257-271. Monroe. L M., Kinney, L. M., Weist. M. D.. Dafeamekpor, D. S.. Ullman, S. E.. & Brecklin. L. R. (2003). Sexual assault history and Dantzler. J., & Reynolds. M. W. (2005). The experience of sexual health-related outcomes in a national sample of women. Psychol- assault: Findings from a statewide victim needs assessment. Jour- ogy of Women Quarterly. 27. 46-57. nal ofInterpersonal Violence• 20. 767-776. Ullman. S. E., & Filipas, H. H. (2001). Correlates of formal and Muganyizi, P. S., Hogan. N., Emmelin, M.. Lindmark• G., Massawe. informal support seeking in sexual assault victims. Journal of S.. Nystrom. L.. & Memo. P. (2009). Social reactions to rape: interpersonal Violence, 16. 1028-1047. Experiences and perceptions of women rape survivors and their Ullman, S. E., & Najdowski, C. J. (2009). Correlates of serious sui- potential support providers in Dar es Salaam. Tanzania. Violence cidal ideation and attempts in female adult sexual assault survivors. and Victims, 24. 607-626. Suicide and Life-Threatening Behavior. 39,47-57. Muganyizi, P. S., Nystrom• L., Memo. P.. & Emmelin. M. (2011). Ullman, S. E., & Siegel, J. M. (1995). Sexual assault, social reactions Managing in the contemporary world: Rape victims and supporters and physical health. Women's Health: Research on Gender. Beha- experiences of barriers within the police and the health care system vior, and Policy. 1. 289-308. in Tanzania. Journal of interpersonal Violence. 26. 3187-3209. Wathen, C. N., & MacMillan, H. L. (2012). Health care's response to Neville• H. A., & Pugh. A. O. (1997). General and culture specific women exposed to partner violence: Moving beyond universal factors influencing African American women's reporting patterns screening. The Journal of the American Medical Association. and perceived social support following sexual assault: An explora- 308, 712-713. tory investigation. Violence Against Women. 3.361-381. Wathcn, N. (2012). Health impacts of violent victimization on women Plumbo. M. A. (1995). Delayed reporting of sexual assault: and their children. Department of Justice Canada. Retrieved from Implications for counseling. Journal of Nurse-Midwifery. 40, http://www.justice.gc.calengirrp-pricj-jpirfv-vfirrr12_12frr12_ 424-427. 12.pdf 3502-017 Page 14 of 15 EFIA_00001489 EFTA00156830 Lanthkr a al. I5 World Health Organization. (2013). Responding to intimate partner Janice Du Mont is an applied psychologist and a scientist in the violence and sexual violence against hymen: WHO clinical and Violence and Health Research Program at Women's College policy guidelines. Retrieved from http://apps.who.intfiristbit Research Institute. She is also an associate professor at the Dalla stream/10665/85240/1/978924 I548595_eng.pdrua= I Lana School of Public Health at the University of Toronto. She Zinzow,H., Resnick, H..Barr, S,..Danielson,C.,& Kilpatrick,D.(2012). examines the impact of gender-based violence on women's health, with a particular focus on the medical and legal responses to sexual Receipt of post-rape medical care in a national sample of female assault. victims. American Journal ofPreventive Medicine. 43. 183-187. Robin Mason is a scientist in the Violence and Health Research Program at Women's College Research Institute and an assistant pro- fessor in the Dalla Lana School of Public Health and the Department Author Biographies of Psychiatry at the University of Toronto. In addition she is the Stephanie Lantbier is a PhD candidate in Social/Behavioral Health scientific lead of Women's Xchange, a women's health knowledge Sciences at the Dalla Lana School of Public Health. University of translation and exchange center at Women's College Hospital Toronto and a trainee in the Violence and Health Research Program designed to promote the development of women's health research at Women's College Research Institute. across the province. 3502-017 Page 15 of 15 EFIA_00001490 EFTA00156831