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 primarily environmental factors (prior relationship with as- variables that acutely influence reporting practices in fe- sailant) rather than internal psychological barriers (shame. male sexual assault victims presenting to an urban clinic or anxiety, fear). C) 2009 Elsevier Inc. Emergency Department. We conducted a cross-sectional survey of consecutive female victims during an 18-month ❑ Keywords—sexual assault: anogenital injuries: report- study period. Patient demographics assault characteristics. ing; psychosocial: medical-legal 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 INTRODUCTION complete a psychosocial questionnaire designed to deter- mine specific reasons why women reported or did not re- Accurate estimates of the incidence of sexual assault are port their sexual assault to police. During the study period. difficult to obtain. One national study reported that fe- 424 women were eligible to participate in the study: 318 male lifetime prevalence rates of sexual assault in the (75%) reported the sexual assault to police. One hundred six (25' 1 did not file a police report, but consented to a general population were 18% (I). Feldhaus and col- medical-legal examination. Women not reporting sexual leagues recently reported that 51% of women presenting assault were typically employed, had a history of recent to their Emergency Department (ED) had a history of alcohol or drug use, a known assailant, and prolonged time completed or attempted sexual assault at some point intervals between the assault and forensic evaluation 1p < during her life (2). Despite these rates. it is widely 0.004 There were no differences in the extent of non- recognized that a significant percentage of these assaults genital injuries or anogenital injuries between the two are not reported to police or social agencies. The Na- groups. Thirty-six percent (152/424) of the eligible popula- tional Crime Victimization Survey estimates that only tion agreed to complete the questionnaire. Only three of the 38% of sexual assaults occurring in 2005 were reported 20 psychosocial variables examined were found to he sig- to police (3). nificantly different in women not reporting sexual assault compared to reporters. The reasons for not reporting were 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 Presented at the American College of Emergency Physicians contact between the offender and victim. as well as Research Forum. Seattle. Washington. October 2002. 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 IM. 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 the ED. Education of the nurse examiner consists of one's personal conception of rape can inhibit reporting approximately 40 h of training in all aspects of caring for (5.6). Reporting can also be hindered by the perceived this population, including physical examination, forensic outcomes of dealing with the police and criminal justice preservation of evidence. documentation, and courtroom system. impaired cognitive processing, and the victim/ testimony. offender relationship (2.7-9). Much of the literature on sexual assault reporting is outdated or based on retrospective population surveys. Participant Selection telephone questionnaires, or studies of specific popula- tions (e.g.. date rape) (1,2,6.10). The present study ex- All female sexual assault victims aged 13 years or older amined data from a community-based population of who presented to local EDs for treatment or the YWCA women presenting to a sexual assault clinic or ED. Our Nurse Examiner Program for treatment between Novem- purpose was to identify the variables that acutely influ- ber 1.2001 and April 30, 2003 ( IS months) were eligible ence reporting practices and to compare the frequency for the study. Women who could not complete the ques- and types of traumatic injuries in women who do and do tionnaire (e.g.. non-English speaking). refused forensic not report. examination, or could not remember the sexual assault (e.g.. intoxication) were excluded from participation. METHODS Study Protocol Study Design Demographic data, sexual assault history, and clinical This was a cross-sectional survey of consecutive female findings were prospectively obtained on eligible patients patients presenting to an urban sexual assault clinic or and entered into a Microsoft Excel database (version local ED during an 1S-month study period. The study 2003: Microsoft Inc.. Redmond. WA). Abstraction forms was designed to explore the primary reasons why women were used to guide data collection. It is the policy of the decline to report sexual assault to the police. A secondary NEP to conduct a complete evidentiary examination for objective was to identify any differences in demograph- all sexual assault victims who come to the clinic within ics, assault characteristics, or injury patterns in those 72 h of an assault, even if no police report is made. This who do and do not report. The study protocol was ap- rationale allows for the collection of evidence without proved by the Institutional Review Board at Spectrum putting pressure on the victim to report the assault if she Health. Grand Rapids, Michigan. is not ready to make that decision. Anogenital trauma is documented at the NEP using colposcopic examination with nuclear staining and dig- Study Setting ital photography. The following nine anatomic sites are routinely evaluated and photographed for the presence The Nurse Examiner Program (NEP) is a community- and type of injury: the labia minors, labia majors, pos- based clink that provides 24-h comprehensive response terior fourchette. fossa navicularis. hymen. vagina, cer- to adolescent and adult victims of sexual assault. It is vix. perineum, and perianal area. Anoscopy was per- located in downtown Grand Rapids. in the YWCA build- formed at the examiner's discretion. For the purposes of ing. The NEP is associated with a university-affiliated this study. the type and location of anogenital injuries Emergency Medicine residency program and works were recorded using a standardized classification system closely with local law enforcement agencies and the (12.13). Definitions of findings used by the nurse exam- existing domestic/sexual assault programs of the YWCA iners were those listed in Sexual Assault: The Medical (II). The vast majority of referrals come from law en- Legal Eramination (4). forcement dispatch and crisis line contacts. Those sexual At the completion of the forensic examination per- assault victims presenting directly to the three downtown formed at the NEP. victims were asked to voluntarily EDs are referred to the NEP for evaluation after triage complete the study questionnaire. The survey instrument and initial assessment. Transportation is provided if consisted of 20 questions designed to determine specific needed or requested. Approximately 3-5 ED patients reasons why women reported or did not report their each year are too severely injured to be evaluated at the sexual assault to police. The questions were adapted YWCA (II). Nurse examiners have completed a creden- from previous studies on sexual assault, and from anec- Elating process that allows them to go into the hospital dotal reports heard by clinicians from their clients and perform the evaluation and collection of evidence in (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 to describe the demographic variables, perpetrator fac- Sexual Assault Victims tors, and assault characteristics. The mean number of Not Reposing Reporting documented anogenital and non-genital injuries for each (n - 106) (n - 318) group was determined, as were the typical locations and type of anogenital injury (abrasion, laceration. erythema. Age of victim (mean 252 .1 5.7 23.31 6.5 years ± SD) ecchymosis. edema). Discrete variables were analyzed Age range (years) 13-54 13-76 with the use of chi-squared tests: unpaired mests were Ethnicity (94 white) 89 (84%) 254 (80%) Marital status (% single) 92(87%) 251(79%) used for comparisons of two means. Odds ratios (ORs) Employment status 73(60%) 171(54%) with 95% confidence intervals (CIs) were then calculated (% employed)' for the association between survey responses and the Alcohol or drug use < 24 h' 74(70%) 162(51%) women's decision to report sexual assault to police. Due to No prior history sexual 8(8%) 38 (12%) intercourse the number of variables compared. we chose a p-value < Last consensual intercourse < 29(27%) 95(30%) 0.01 for statistical significance (14,15). 72 h Time interval to examination 202 ± 12.6 11.3 1 9 (mean hours ± SD) History of previous sexual 46 µ3%) 156 (49%) assault RESULTS • Indicates significance at the p < 0.01 level. 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 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 Table 2. Sexual Assault Characteristics victims presenting to the NEP in September 2001. After Not Reposing Reporting revisions were made, the questionnaire was offered to all (n — 106) (n — 318) female sexual assault victims beginning in November 2001. The questionnaire was handed out by the nurse Multiple assailants 13(12%) 41(13%) Age of assailant. mean (SD) 25.4 ± 7.0 25.91 6.0 examiner, who explained its purpose and answered any Ethnicity of assailant (% white) 50(47%) 146(46%) questions. Patients were assured that the questionnaire Relationship to victim• would remain anonymous and confidential. Stranger 14(13%) 102(32%) Known assalant 92(87%) 216(68%) Acquaintance/date 76(71%) 180(56%) Previous boyfriend/spouse 8(8%) 19(6%) Current spouse/partner 1(1%) 8(3%) Outcomes Measured Relative 5 (5%) 5 (2%) Employer/authority figure 2 (2%) 4(1%) Time of assault The primary outcome of interest was to identify reasons Midnight-5:50 am. 52(49%) 146(46%) that women decline to report sexual assault to the police. 6:00 axn.-11:59 a.m. 11(10%) 48(15%) The secondary outcome was to identify any differences Noon-5:59 p.m. 13(12%) 35(11%) 6:00 p.m.-11:59 p.m. 31(29%) 89(28%) in demographics. assault characteristics, or injury pat- Type of sexual assault terns in those who do and do not report. We hypothesized Vaginal 99 (93%) 267 (84%) that women suffering the most seven assaults would be Oral 21(20%) 02 (29%) Anal 35(33%) 83(26%) more likely to report to the police, and that women not Digital 37 (35%) 02 (29%) reporting might have suffered less severe injury and Location of assault hence might have less need of medical treatment. 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%) Data Analysis Type of coercion Verbal threats 52(49%) 143(45%) A power analysis determined that at least 40 patients Physical force 30(28%) 108(34%) Victim sleeping/drugged 26 V5%) 73(23%) were needed in each group (reporters vs. non-reporters) Use of weapons 13(12%) 54(17%) to detect a 20% difference in categorical variables with a Non-genital injuries 43(41%) 143(45%) power of 0.8 and an alpha of 0.05. Analyses were per- Anogenital injuries 78(74%) 248(78%) Mean no. genital injuries 1.5 ± 1.0 1.7 ± 1.3 formed using SPSS statistical software (version 14.0. SPSS Inc., Chicago. IL). Descriptive statistics were used - 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 There were no differences in the extent of non-genital by NEP staff due to the severity of their injuries. Of these injuries or anogenital injuries between the two groups 466 women. 42 (9%) were excluded from the study for (Table 2). Seventy-seven percent (326/424) had docu- the following reasons: could not recall details of the mented anogenital injuries. A total of 23% (751326) had sexual assault due to intoxication (n = 21). refused single and 77% (251/326) had multiple sites of trauma. forensic examination (n = 9). intercourse was consen- The pattern of anogenital injuries was similar in both sual (n = 7). and missing or incomplete documentation groups of adult patients with the majority of injuries (n = 5). Seventy-five percent (318/424) of the women (80%) occurring at one of three anatomical sites: labia eligible to participate in the study reported the sexual minors, fossa navicularis. and posterior fourchette. Su- assault to law enforcement. perficial lacerations and erythema were the most com- Women not reporting sexual assault were more often mon types of injuries documented in women reporting employed, with a history of recent alcohol or drug use, a sexual assault as well as those not reporting assault known assailant, and a prolonged time interval between (Figure assault and forensic evaluation (p < 0.031). There were Of the 424 women eligible to participate in the study. no other significant differences in race, marital status. 152 (36%) agreed to complete the psychosocial question- perpetrator factors. Or assault characteristics between the naire. There were no significant differences in demo- two patient groups (Tables 1. 2). A large percentage of graphics. perpetrator factors, or assault characteristics women in both groups had a previous history of sexual between those who completed the survey and those who assault. refused. Seventy-three percent (111/152) of the women Eighty-three percent of known assailants (2561308) were who completed the survey reported the sexual assault to described as acquaintances: 12% (36/308) were current or police. previous boyfriends or spouses: 3%(10/308) involved other Table 3 details the responses of women to the psy- family members (Table 2). Eighty percent of incestuous chosocial questionnaire. A majority of women in both assaults (8110) occurred among victims aged 13 to 15 years groups felt partially responsible for the assault, were of age; the majority (64%) of acquaintance rape (164/256) concerned about public exposure. and were ashamed or was documented in young adults aged 16 to 25 years of age. embarrassed by the assault. However, these internal psy- Among the older victims (>31 years of age) who knew chological barriers (i.e., shame. anxiety. fear) were not their assailants. 23% (22/97) were assaulted by current or significantly associated with reporting sexual assault to previous boyfriends or spouses. Women victimized by police. known assailants were less likely to file a police report The three most common reasons for not reporting (70% vs. 88%, p <.001). sexual assault included: not wanting the assailant to go to Dotmloa‘lcd for Aoonynbect, Uses (Nat n Lbay 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 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. ••A -• Although the majority of our study population had Figure 1. Types of genital trauma in sexual assault victims with anogenital findings (n = 326). 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 jail (OR 19.47.95% CI 739-48.68), a prior relationship force and the pattern of anogenital injuries were similar with the assailant (OR 3.79, 95% CI 1.78—8.05). and in both groups. Therefore, although the severity of phys- feeling that the police would blame the victim or be ical injuries may cause the rape survivor to seek appro- insensitive (OR 5.81. 95% CI 2.61-12.94). Seven per- priate medical care, it does not significantly influence cent of women not reporting sexual assault (3141) had a their decision to report. These findings are consistent criminal record or were on probation: however, 42% with a recent Danish study of women presenting to a (17/41) reported a "bad experience" with police in the sexual assault center in Copenhagen. They also con- past or were involved in illegal activity during the assault cluded that the severity of the assault or the documenta- (19/41). This illegal activity generally involved underage tion of injuries did not influence police reporting (20). drinking or recent drug use. 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 DISCUSSION women themselves. to the nature of the relationship between the victim and the assailant. and the character- These results show that in a community-based urban istics of the particular rape. The usefulness of these population, one-quarter of women presenting to a sexual studies in determining the relative importance of these assault clinic or ED chose not to report the rape to police. factors is limited by the research methodologies used and This rate is consistent with a previous study in Minne- the populations studied. The only way clinicians can apolis that reported that 24% of sexual assault victims really determine why sexual assault victims do not report treated in an ED by nurse examiners refused to file a to police is to ask the victims themselves. The current police report (16). During the past three decades, women study was designed to accomplish this goal within a have become more likely to report rapes and auempted community-based sample of women presenting for med- rapes-particularly those involving known assailants-to ical care after an assault. The results of this study iden- police 13). But the fact remains that less than half of such tified six distinct factors associated with not reporting crimes are reported (1.3). In fact, law enforcement offi- sexual assault to law enforcement. cials consider sexual assault to be the most underreported Age. marital status, and ethnicity were not associated violent crime in America (17). with police involvement; however, employment status It is apparent that the majority of rape survivors who differed significantly between non-reponers and those seek post-assault health care in community clinics or reporting sexual assault (69% vs. 54%. respectively). EDs have already made the decision to involve the police Some rape victims likely chose to avoid the notoriety and (7.16.18). The simple act of seeking medical help may in stigma attached to rape prosecution, or they feared re- turn lead a woman to define a situation as rape and report jection by friends and co-workers (17,20). More than it. For those victims who have not decided whether or not half of the women we surveyed felt partially responsible to report the assault, trained examiners, when available. for the assault (60%). were concerned about public ex- can discuss the survivor's fears and concerns about re- 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 also lack confidence in the ability of the criminal justice victim may not have the time to participate in a criminal system to apprehend or punish the assailant (22.24). prosecution. especially if she is employed (22). According to Williams. most people think of rape as Seventy-three percent of sexual assaults in our study a sudden. violent attack by a stranger in a deserted. were committed by known assailants. This is consistent public place. after which the victim is expected to pro- with other studies such as the National Crime Victimiza- vide evidence of the attack and of her active resistance tion Survey, which reported that approximately two- (22). These characteristics, then, constitute what is re- thirds of rape victims knew their assailant (3). Our results ferred to as the classic rape situation. When an individual also demonstrate that women assaulted by a known as- is confronted with a situation that does not conform to sailant are significantly less likely to report the crime the stereotypical concept rape. she may be reluctant to compared to those assaulted by a stranger. Not surpris- report the incident or seek medical care (7). This reluc- ingly. the response on the psychosocial survey that had tance is aptly demonstrated by the prolonged time inter- the greatest association with non-reporting was: "I do not val between assault and forensic evaluation among non- want the assailant going to jail" (OR 19.47. p < 0.001). reporters (20 h vs. II h. p < 0.001). Any delay in The complex nature of the victim-assailant relationship presentation is troublesome in light of previous studies is known to influence perceptions of the seriousness and that suggest that the timing of the examination is the sequelae of the sexual assault (23). It also is clearly the most significant predictor of abnormal anogenital find- most important factor influencing a victim's decision to ings in both children and adult victims of sexual assault report (1820-22). (2526). For example. the frequency of anogenital lacer- Sexual assault victims having experienced acquain- ations and abrasions may decrease from 50% at C 24 h tance rape are typically young adults, 16 to 25 years old. to 13% at > 96 h after the assault (26). Sex-role socialization encourages this type of assault victim to see herself as a possible contributor to her own LIMITATIONS victimization (22). In a survey of high school students. teenage girls who had experienced forced sex believed There were several limitations in our study. We could not that consensual sex play provoked the non-consensual control for the clinical evaluations by different examin- intercourse and therefore felt they were at fault, not the ers. It may be that documentation was not uniform. perpetrator who ignored pleas to stop (23). Moreover. although the nine nurse examiners had a similar level of intoxication in the context of a dating relationship can training and experience. The findings of the examiners lead to the misinterpretation of friendly cues as sexual were recorded on state-mandated reporting forms and invitations, diminished coping responses. and the wo- were taken as the most accurate representation of the man's inability to ward off a potential attack (24). actual physical findings. Over half of all patients had At least one-half of all violent crimes involve alcohol been exposed to alcohol or illicit drugs during the time of or drug use by the perpetrator, the victim, or both (3,24). the assault. It is unknown what impact this might have Sexual assault certainly fits this pattern. Alcohol, mari- had on the accuracy of the history or the degree of juana. cocaine, and other illicit drugs were used by 56% anogenital injuries. However, the documented history of of all the women in our population. Although not statis- the sexual assault by forensic nurses is quite detailed and tically significant. almost half of our respondents did not considered accurate by legal authorities. In addition. report rape because they were involved in illegal activity women were excluded from participating in the survey if at the time of the assault. This illegal activity generally the nurse examiner felt they were still clinically intoxicated. involved underage drinking or recent drug use and prob- This study, like all studies of rape victims, is vulner- ably contributed to victim's feelings of fear. guilt. em- able to sample or selection bias. Previous research sug- barrassment. and blame. In addition. intoxication was gests that many victims of rape are not likely to seek likely the key reason that 51% of our respondents stated medical care or even to identify themselves as rape that "the details of the assault are unclear." victims (2). In fact, the desire to avoid using the term Another significant reason for not reporting assault "rape" is frequently very high. It should also be noted was the belief that police would be insensitive or blame that this study considered women who reported to the the victim (OR 5.81. p < 0.001). Only 7% of non- police, the NEP. or a local ED. If all women experienc- reporters had a criminal record or were on probation; ing sexual assault who neither reported to the police nor however, a considerable number of these women re- came to the NEP/ED were included, the results might ported a "bad experience with police in the past" (42%) have been different. or were "involved in illegal activity during assault" Of the 424 women eligible to participate in the study. (46%). Previous research has shown that victims may 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 ESCssa 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 in turn, increase the chance of arrest and prosecution and. was understandable because, in many cases, subject re- ultimately. the deterrent effect of the criminal justice cruitment took place within hours of the sexual assault system. and women were not compelled to participate. There were no significant differences in demographics. perpe- trator factors, or assault characteristics between those Acloundedgments-The authors acknowledge the suggestions who completed the survey and those who refused. How- and statistical assistance of Dr. Diann Reischnum. Grand Rapids ever, the small sample size and the more stringent level Medical