Caring for victims of sexual violence is often a challenge for medical professionals.
They need to tend to the victim's medical needs as well as gather evidence for law enforcement. Above all, they need to do it with sensitivity and compassion.
Ralph J. Riviello, recently named the chair of emergency medicine at Crozer-Keystone Health System in Delaware County, has long focused on the needs of sexual assault victims.
Among his other associations, he is on the board of Women Organized Against Rape, where he received the Bridge to Courage Award for his work toward ending sexual violence. He has served on the Pennsylvania Sexual Assault Evidence Collection Committee, the Pennsylvania Violent Crime Death Reporting System Advisory Panel, and the City of Philadelphia Sexual Assault Advisory Committee. He also serves as medical director of the Philadelphia Sexual Assault Response Center.
We spoke with him recently about his work.
What prompted your interest in sexual violence?
In 1999, I was working at the University of Virginia, and we had a sexual assault nurse examiner program. They needed a medical director. I didn't really know much about it, but I agreed to do it because I knew of the work they did. I took a course on how to perform the medical forensic examination. When I moved to Philadelphia, I took over a similar program at Thomas Jefferson University Hospital. I have continued developing expertise on the subject — doing research, lecturing, and doing national committee work related to various aspects of the medical care of victims of sexual violence.
Personally, I have seen how devastated the victims of sexual violence can be. There's a lot we can do for them in the emergency department. But there's also a lot we could do wrong. I didn't want to be one of those people who did it wrong. And I didn't want to work in a place that did it wrong. These are very vulnerable individuals. They don't need to be hurt again. They don't need to be let down.
What is sexual violence, and how do you deal with it in the emergency room?
Sexual violence is a big umbrella. It includes what most people would think of as rape. It also can involve things like unwanted touching or forced oral intercourse. There are other things, such as forced prostitution, forced sexual work, forced pornographic work, child pornography, explicit photographs, and sexual harassment.
From a health-care perspective, we see adults and children who have been affected by forms of sexual violence that may leave physical evidence or injuries that would require evaluation, treatment, and documentation. Someone who was out with friends, got drugged and then sexually assaulted and maybe beaten up, is going to have a lot of medical, forensic, and psychological needs that can be taken care of in an emergency department.
The process is very extensive. It starts like any other medical encounter, with a detailed medical history. Then, a detailed history of what happened during the sexual assault. Often, those questions get very personal. Sometimes, the victim doesn't know what actually happened, perhaps because they were drugged or given alcohol. But a lot of times, the body's response to the trauma of being assaulted causes problems with memory.
After that, we move into the examination phase. We conduct a head-to-toe examination, looking for any physical or biological evidence. We look for injuries, such as cuts and scrapes and bruises, or perhaps something more serious. With anything that appears to be evidence-related, we'll collect samples.
The last part of the exam focuses on the genital or anal area, where you would expect penetration to occur. For women especially, it involves a thorough examination of the outside of the genital area, looking for injuries or foreign debris. A speculum exam is done. We take specimens from inside the vagina and inside the cervix. Then, depending on what happened during the assault, an anal/rectal exam is performed. Often, articles of clothing are collected as evidence.
This process can be difficult for the victim and for caregivers. But people who do this kind of work — physicians and nurses — see it as a necessary function. Several studies have shown that providing a good examination, one that's very victim-centric, helps the victim begin a healing process. The patient is who matters most, and everything should be centered around them and made as easy as possible.
Are there any misconceptions you’d like to address?
It's not what the person wore or what they said or what they did or where they went or who they went with. Clearly, sexual violence is all the responsibility of the perpetrator. The victim is never at fault. I like to extend that to say that any of the victim's actions afterward don't impact the veracity or truth of what happened to them.
People who are well-versed in taking care of sexual violence patients know that the response of every person is different. Not everyone is going to be crying. Some may be withdrawn. Some may report immediately. Some may report a day or two later. Some may never report, and we find out years later that it has been harboring in their memory. We see patients who will report to law enforcement; others don't want to. All those things don't negate or discredit what happened to them.
You were involved in setting up an innovative program in Philadelphia. Tell us about that.
Emergency departments are usually the best settings because they deliver care 24/7. But in Philadelphia, we changed that model. We designed and implemented a medical office space within the Special Victims Unit at Police Headquarters. Examination and care of the patient takes place in a private office setting. Several agencies are located there, including the Philadelphia Children's Alliance, which does forensic interviews with children who are victims. Then there are the abuse investigation division of the Department of Children's Services, Women Organized Against Rape [WOAR], and the Philadelphia District Attorney's Office.
If victims don't have acute medical needs that require hospitalization, they could be taken there directly from the scene of the crime to be examined, have a police interview, be linked to a rape crisis advocate, and so on. They have everything done right then and there.
One of the reasons we chose this model was the number of cases in Philadelphia. We would handle 400 to -450 cases a year involving victims ages 16 and older.
The groups involved were the Sexual Assault Response Team for Philadelphia, which included police, the district attorney, and other agencies, plus WOAR and the Drexel University School of Medicine, where I was at the time. We started putting it together in 2010 and opened in April 2011.
What changes would you like to see going forward?
Victims should get the best possible care. It should be care that is victim-centered and trauma-informed.
A lot of the stereotypes and misinformation — how the victim acted, for instance — need to be out of the vocabulary, especially out of the vocabulary of health care workers and other professionals who take care of the patients.
The ultimate future for caring for victims of sexual violence starts with education and research communities. We really need to look at what are the best practices for caring for patients. What are the best practices for recovering evidence and documenting findings, for example.
A lot of what we do is anecdotal. The best practice is what it is because we've done it this way and it works. But is that really the best way? There has to be a commitment to research so that we actually know that what we are doing will make a difference and will matter to victims.