"I still feel so lost": experiences of women receiving SANE care during the year after sexual assault.

OBJECTIVE: Emergency caregivers provide initial care to women sexual assault (SA) survivors. An improved understanding of the issues facing this population can aide emergency care practitioners in providing high quality care. The goal of this study was to share the experiences of women SA survivors with the emergency care practitioners that care for them.
METHODS: English-speaking adult women (n = 706) who received SA Nurse Examiner (SANE) evaluation within 72 hours of SA at 1 of 13 geographically distributed sites were enrolled in a prospective, longitudinal multi-site observational study. We qualitatively analyzed responses to the open-ended question: "What do you think is most important for researchers to understand about your experience since the assault?" asked 1 week, 6 weeks, 6 months, and 1 year after enrollment.
RESULTS: Themes from responses (n = 1434) from 590 women (84% of study sample) fell into 12 broad categories: daily life, justice, medical, and social services, mental health, physical health, prior trauma, recovery, romantic relationships, safety, self, shame, and social interactions. Responses demonstrated that the assault permeates many aspects of assault survivors' daily lives.
CONCLUSIONS: Qualitative analyses of open-ended responses from a large cohort of women SA survivors receiving SANE care highlight the challenges for survivors and can increase understanding among the emergency care practitioners who care for them. The authors propose a brief acronym to help emergency care practitioners recall important messages for SA survivors.

INTRODUCTION

Background

Sexual assault (SA) is common, with an estimated 19% of United States (US) women reporting rape and 43% reporting other forms of sexual contact during their lifetime. Approximately 100,000 US women present for emergency care after SA each year, yet opportunities to gain insights into the lives of women who present for emergency care after sexual assault (SA) are limited, both because such women rarely return for care or self‐identify when receiving further care, , , and because few studies have assessed the life experiences of women SA survivors after SA nurse examiner (SANE) care. Qualitative studies of SA have focused largely on the receipt of health care services, , , , , with less attention paid to survivors’ broader life experiences.

Importance

Understanding the patient experience is critical to providing high quality patient‐centered emergency care. , , Improved emergency care practitioner understanding of women receiving emergency care would be valuable because evidence suggests that emergency care practitioner misconceptions can create additional challenges for survivors. A better understanding of the types of challenges faced by these patients may also help emergency care practitioners to identify appropriate local referrals and outpatient resources for SA survivors receiving emergency care.

Objective

We sought to gain a better understanding of the lives of women SA survivors who are discharged to home after SANE evaluation and to characterize the issues important to women SA survivors during the year following assault. We performed a qualitative analysis of open‐ended free text survey responses obtained 1 week, 6 weeks, 6 months, and 1 year after SA from a large cohort of women presenting to 13 geographically distributed emergency care facilities. We used open‐ended questions because such questions allow individuals to share the experiences and issues most important to them. , ,

METHODS

Study design and setting

Data were collected between 2015 and 2020 as part of a prospective study of women SA survivors enrolled at 13 SANE programs (7 emergency department [ED]/hospital‐based and 6 community‐based) located across 10 US states and Washington D.C. Study design and methods have been described in detail elsewhere. The study was approved by UNC‐Chapel Hill's Institutional Review Board and the Institutional Review Board at each enrollment site.

Selection of participants

Participants were eligible if they were cisgender women at least 18 years old and presented to a study site within 72 hours of SA (unwanted sexual contact). Exclusion criteria included inability speak or read English, inability to provide informed consent, injuries requiring hospitalization, or living with the assailant. Study participants provided written informed consent at both the initial and 1‐week time points after being provided with a complete description of the study.

Assessment

After providing informed consent, participants completed web‐based self‐report computer surveys administered at a study site or in their home. Surveys were given 1 week (Wk1), 6 weeks (Wk6), 6 months (Mo6), and 1 year (Yr1) after SA. Participants were compensated for their participation at each time point.

Analysis

We analyzed responses to the following question asked at each time point: “What do you think is most important for researchers to understand about your experience since the assault?” The analysis sample included all enrolled participants and follow‐up data as of November 25, 2019. Data analysis was led by MB, an experienced qualitative researcher. To minimize bias, responses were coded by 2 team members (MB and EB) not involved in the study design or data collection. Incomplete and irrelevant responses were removed (Figure 1), after which a thematic analysis was conducted using an inductive analytic approach and methodological precedents for rigorous analysis of free‐text survey responses. , , , Emergent themes were identified, synthesized, and iteratively refined into 12 categories—daily life, justice, medical, and social services, mental health, physical health, prior trauma, recovery, romantic relationships, safety, self, shame, and social interactions—and a definition was developed for each code (Table 1). Coders then assigned code(s) to each response using an Excel spreadsheet; multiple codes could be applied to each response. Any discrepancies were discussed and resolved. Qualitative rigor was maintained through attention to the criteria of trustworthiness, including analyst triangulation to enhance credibility and dependability. ,

FIGURE 1

Screening process for inclusion in sub‐study

TABLE 1

Codes and definitions

Code	Definition
Daily life	Includes comments about how the assault has affected various aspects of everyday life, behaviors, functioning, and activities, including, but not limited to: housing, substance use, engaging in risky behaviors, employment, and income. Also includes generic comments about how the assault “changed my everyday life.”
Justice	Includes comments about the participant's experiences with police and the criminal justice system, including, but not limited to: disappointments or frustrations with legal proceedings, quality of interaction with police or detectives, and relationship between justice experiences and the recovery process.
Medical and social services	Includes statements about the participant's experience with and access to medical and social services, including inadequacies of such services, their benefits, and the financial burden of care.
Mental health	Includes any comments about the psychological, emotional, or cognitive dimensions of survivors’ experiences (eg, feelings, depression, anxiety, sensitivity, emotional numbness, suicidality, or generic psychological pain). Includes references to symptoms of trauma such as sleep disturbance, memory disruption, flashbacks, stress, etc. Also includes statements suggesting that the psychological pain is worse than the physical pain.
Physical health	Includes references to physical symptoms or embodied experience following assault (eg, pain, sexually transmitted infections, fatigue, weight loss, etc).
Prior trauma	Mentions of previous assault or other trauma and how that may have played a role in the participant's experience and recovery, including the suggestion that the participant is handling this assault better or worse due to previous traumatic experiences. (Excludes more generic reference to bad things/bad experiences.)
Recovery	Includes comments about barriers and facilitators of recovery, the temporal trajectory of recovery, the difficulty of recovery, and other factors associated with healing and recovery. Recovery includes broader references to getting better or being helped. May include statements about how the assault changed the person's life in good ways.
Romantic relationships	Includes any discussion of how the assault has affected the participant's romantic relationships and sexual activity, including those with preexisting partners, dating, and/or new relationships.
Safety	Includes any comments about the participant's sense of safety and security, including fears about leaving the home or moving due to safety concerns.
Self	Includes statements about one's sense of self and being a different person following the assault, feeling worthless, etc. Also include inverse statements (eg, “I am the same person”) and positive changes in sense of self (eg, “this made me stronger”).
Shame	Includes statements about self‐blame, shame, guilt, self‐doubt, etc. Also includes inverse statements (eg, “this isn't my fault”).
Social interactions	Includes general statements about how others respond to and treat the participant since the assault. A major sub‐theme is judgment/disbelief encountered from others. Feeling alone.

What is the impact of sexual assault on the lives of adult women in the year following assault? More than 1400 qualitative survey responses obtained from 590 women during the year after sexual assault describe a myriad of challenges, including mental distress, a profoundly altered sense of self, justice system inequities, financial difficulties, struggles with intimate relationships, isolation and anxiety, and healthcare access barriers.

RESULTS

Out of 1144 eligible patients, 49 declined to participate. An additional 389 individuals did not complete the 1‐week follow‐up because of study withdrawal (30), a determination of ineligibility following further screening (15), or loss to follow‐up (344). Therefore, the final sample included 706 participants. Follow‐up was completed in 630/706 (89%) at Wk6. Six‐month and 1‐year follow‐ups were still ongoing while these analyses were completed, therefore follow‐up rates at these time points were somewhat lower—554/706 (78%) and 510/706 (72%), respectively. Qualitative responses to the target question were provided by 670/706 participants (95%) at 1 or more follow‐up time points. After screening out extraneous and incomplete responses, 1434 responses from 590 participants remained (Figure 1). These 590 participants (“responders”) comprised the analysis sample, providing a median of 2 responses each (range 1–4). Mean age of responders was 28.3 (9.8), 68% self‐identified as white, and 69% had some education past high school. Responders did not differ significantly from non‐responders in age or educational attainment but were more likely to be white and to report more severe adverse childhood events (Table 2).

TABLE 2

Demographic characteristics of analysis sample compared to participants who did not answer the target question

Characteristics	Responders n = 116 (%)	Responders n = 590 (%)	P
Age (years): mean, [SD]	28.94 [9.5]	28.33 [9.8]	0.538
Education
Some college or higher	70 (61)	402 (69)	0.134
Race (select all that apply)
American Indian or Alaskan	12 (11)	64 (11)	0.869
Asian	5 (4)	14 (2)	0.240
Black or African American	25 (22)	91 (16)	0.104
Native Hawaiian/Pacific Islander	1 (1)	4 (1)	0.830
White	64 (56)	392 (68)	0.017
Other	22 (19)	94 (16)	0.423
Ethnicity
Hispanic or Latino	28 (25)	153 (27)	0.643
Assault characteristics
Assailant was a stranger	33 (28)	127 (22)	0.103
Contact with police occurred	5 (15)	52 (28)	0.122
Trauma history
Previous sexual assault	57 (50)	349 (59)	0.061
Adverse Childhood Events score 14 : mean [SD]	2.91 [3.2]	3.49 [2.9]	0.050
Health outcomes at 6 months
Clinically significant pain	35 (51)	299 (62)	0.072
Post‐traumatic stress (PCL‐5 score ≥33) 15	28 (42)	242 (50)	0.186
Depression (PROMIS) Depression 8b score ≥60 16	29 (42)	231 (48)	0.383

P values are for Student t test or χ2 test.

Post‐traumatic stress (PCL‐5 score ≥33)

Depression 8b score ≥60

Participant responses reflected 12 major themes: mental health (401/590, 68%), recovery (332/590, 56%), social interactions (264/590, 45%), daily life (165/590, 28%), self (115/590, 19%), justice (108/590, 18%), medical, and social services (102/590, 17%), physical health (84/590, 14%), shame (67/590, 11%), romantic relationships (60/590, 10%), prior trauma (37/590, 6%), and safety (35/590, 6%). Because the content and distribution of themes remained relatively stable over time (Supporting Information Table E1), responses were aggregated at the participant level. That is, each participant was classified as having expressed a particular theme if she mentioned it at 1 or more of the assessments. Descriptions of each theme are provided below. While thematic categories are useful for heuristic purposes, categories often intersected and overlapped. Extended exemplary responses are reported in Table 3 and complete responses are presented in the Supporting Information (Table E2).

TABLE 3

Key themes with illustrative examples

Theme (frequency)	Sample participant response a
Mental health (n = 401/590, 68%)	This has changed my life more than I could have every imagine, these question ask for a one to ten answer but no number could ever describe the panic of waking up screaming, the fear of leaving your house, the struggle to find the care to shower while drowning in depression, the physical ache I feel in my heart when I think about it, the loss of breathe I have when I hear the word “rape.” I just hope you all never forget that this is more than numbers. Thank you for looking into what happens after the night of. (5168, Yr1)
Recovery (n = 332/590, 56%)	That time SOMETIMES makes it easier for us to deal and come to terms with our assault but the thought will always linger with us. We are now scarred but its manageable. We will never forget our experiences, we just try to put them in the back of our minds and continue with our lives. Its a very hard process and some takes longer than others. Also, people who've never been through this, have no idea what our bodies and minds go through during this time and we as victims have to understand that sometimes people don't know how to deal with us while we are dealing with this. (5321, Yr1)
Social interactions (n = 264/590, 45%)	I just find that a lot people take it lightly or make jokes about it. I really think that until they experience it, they should keep their mouth shut. One bad experience can ruin you for a very long time. Every time you don't want to wake up in the morning but you have to. It really does affect the person. People don't care. My mother knew what happened and she didn't even help me. I had to go to a shelter. I had everything going for me. I worked at Golden Corral. What happened on me had a big impact on me. […] (8824, Wk6)
Daily life (n = 165/590, 28%)	[…] It took everything out of me and I lost everything I built up for my life in a matter of one night. I lost my amazing job, I lost my duplex, I lost my relationship, I started and luckily ended bad drug habits. I am lucky that I am still alive and hopeful today. But everyday it is still a battle. (7834, Yr1)
Self (n = 115/590, 19%)	I think it is best to know that I am not the same girl as I was prior to the assault. I was a super fun, bubbly, happy girl that was always ready to take on new adventures and now I just stick to my work and school schedule and sit in the house when I am not doing either of those 2 activities. I don't sleep well at night and am on edge during the day. (9266, Wk1)
Justice (n = 108/590, 18%)	I want to reiterate the police part. I debated if I wanted to call the police. I did because I thought sexual assault shouldn't happen and nothing is done with it. I think these cases should be given attention so more can be prevented in the future. But when I called and talked to the investigator, he told me a few days ago there was a similar case happened on my campus. He told me that victim girl and I were both Asian and he said he didn't believe her and I were innocent. I was totally shocked by what I heard and completely lost trust and confidence in the system. I honestly don't know which hurt me more, the assault or the disappointment from the police investigator. (2028, Yr1)
Medical and social services (n = 102/590, 17%)	The most important thing for researchers to understand about my experience is how difficult the healing process has been: my insurance doesn't offer coverage for counseling, I can't afford the out‐of‐pocket expenses to get the counseling I need to deal with the assault, the police didn't take my experience seriously, the police refused to believe a crime had occurred, and there are few low‐cost counseling services available. Further, all counseling services have extremely long wait lists. Initially when I was attempting to get some help, I was put on a wait‐list for a counseling service such that when an appointment became available, they would call me. After eleven weeks without any contact, I tried to call back to no avail. This was my experience with several facilities, and when I was finally able to schedule an appointment, I was told that counseling services are not covered by my insurance. My insurance isn't catastrophe‐only, by the way. So the whole situation is like trying to bale water out of a sinking boat. (7689, Mo6)
Physical health (n = 84/590, 14%)	I contracted herpes as a result of this rape, so now I can't forget about it. Not only is the pain nearly unbearable, it has changed my life, potentially my ability to have children and keep them free of this. The emotional pain I will carry for the rest of my life, because I have a continual reminder, that I must also explain to anyone I may be with.. if anyone chooses to ever be with me. The effects are medical and life lasting. (5407, Wk1)
Shame (n = 67/590, 11%)	It's really easy to blame myself for the whole thing. I keep doing questions, attacking myself on why I went to this concert. How did I become the target? Did I do something to attract this wrongful doing. Why does this happen to a 52, year old and the few people I told ask me if I was looking for it. Was I out looking for sex or to party? I was with my sister and my daughter on mothers day and went to a small venue to a concert. I cannot walk into these kind of venues without reliving, panicking and feeling like I am not safe. The police did nothing and this venue has no security cameras, yet still continues to do concerts. I guess, I feel like going to an inexpensive concert is not going to be something I can do again. I have not been to any concerts since this event. I hope to get past this, since music and live performances where such a big part of my life, before. (11644, Mo6)
Romantic relationships (n = 60/590. 10%)	[…] Also, researchers should investigate and understand more the effects of sexual assault and partner relationships, husband/wife, sexuality. In my case, my husband was not able to understand and accept my healing process and times, and unfortunately it led to separation and finally divorce. (8764, Mo6)
Prior trauma (n = 37/590, 6%)	[…] In some ways, being raped, having gone through a total loss of body autonomy before, helped me process the assault. I had something to compare it to. It wasn't nearly as bad as the first trauma. I was able to keep it together long enough to gather around friends and loved ones to support me. All in all, my life now is basically on the same track as it was before the assault. But the cynic in me wonders how long I'll have until I have to fill out a survey like this. And that is a terrible thought to have hanging over your head. (949, Yr1)
Safety (n = 35/590, 65)	how it Affects in the long term. I had to move 3 diffrent times to feel safe then ended up geting a roommate who stays awake while i sleep and sleeps when i am awake (1505, Yr1)

Spelling and grammatical errors have not been corrected, but some responses have been abridged due to space constraints. Excised material is represented with […].

Mental health

Most women commenting on mental health (n = 401) (Supporting Information Table E2) expressed mental distress or negative feelings or emotions resulting from SA (n = 310). Of these, 64 women mentioned anxiety (eg, “it's hard not to have an anxiety attack,” Wk1), 40 mentioned depression (eg, “this only increases my depression and loneliness,” Mo6), 14 explicitly mentioned “PTSD” (eg, “I've had moments of PTSD where I feel completely emotionally hijacked,” Wk1), 28 described intrusive thoughts (eg, “the thoughts never go away,” Mo6), 30 commented that the psychological pain is just as severe as the physical, and 26 commented on the cyclical nature of their emotions (eg,. “How I feel about the assault oscillates a million times a day,” Wk1).

Recovery

Women describing their recovery process (n = 332) (Supporting Information Table E2) frequently focused on barriers and facilitators. Women describing barriers to recovery (n = 80) described the unfair justice process, relationship challenges (eg, “I have had a hard time keeping relationships over the course of all of this,” Yr1; “I will always be afraid to be in a relationship again,” Mo6; “I worry that I use the assault as an excuse for my behavior when it comes to sabotaging relationships,” Mo6), financial impact of loss of income due to an inability to sustain paid employment, the burden of prior assault(s) (eg, “I have been assaulted before, so it is hard to realize that this time it happened again,” Wk6), and additional traumatic experiences after the assault. Facilitators to recovery (n = 88) included counseling (eg, “Therapy helped me A LOT,” Mo6), empathy and support from others (eg, “Anybody can move on if they know were being thought of and being able to turn to someone when help is needed,” Mo6), and staying busy (eg, “I have never been so busy in my life and it just helps keep my mind off of things,” Mo6). Some women described time as an asset to recovery (n = 68), and some stated that they had recovered (n = 32), and that recovery was associated with positive changes, such as inner strength or sobriety (n = 12). Other women highlighted the non‐linear nature of recovery and/or symptoms worsening over time (n = 33), or suggested that they would never recover (n = 6).

Social interaction

Most women highlighting social interactions (n = 264) (Supporting Information Table E2) reported negative effects on relationships or ability to interact with others (n = 73). Women frequently commented on the importance of having compassion for survivors and taking them seriously (n = 42, eg, “There needs to be a genuine warmth, more empathy, more understanding, more support,” Wk6). Many women described feeling alone, isolated, or not able to relate to others (n = 30). Women who referenced their support system most commonly indicated feeling supported by loved ones (n = 25, eg, “having people who care really helps,” Mo6), but other survivors expressed having little support (n = 17, eg, “people don't really understand or care,” Wk6). Some women emphasized that it is difficult or uncomfortable to discuss the assault (n = 29, eg, “I hate talking about it and have only told 3 people,” Wk1) and that others can react poorly (n = 30, eg, “I don't feel heard,” Yr1). Less frequently, women commented that talking about the assault was helpful (n = 17, eg, “even though it's painful it's needed for healing,” Yr1).

Daily life

Women commenting on their daily lives (n = 165) (Supporting Information Table E2) most commonly described the profound negative impact of the assault (n = 55, eg, “It affects you in every aspect of your life,” Wk1). Negative effects on daily life described included job or housing loss, increased engagement in risky behaviors, and constantly feeling on edge (n = 46). Many described difficulties in returning to normal activities (n = 39, eg, “returning back to life as normal is impossible and even small things seem more difficult than they should be,” Wk1), or wanting to get back to their normal life (n = 24).

Self

Many women commenting on their self‐identity (n = 115) (Supporting Information Table E2) described feeling like a different person, scarred, or not recognizing themselves (n = 49, eg, “It changes you as a person on so many levels you didn't know existed in the first place,” Wk1). Some women described feeling worthless, broken, or as if their assailant had taken their dignity or humanity (n = 28, eg, “I feel invalidated as a victim and worthless as a person since his life has gotten easier since the assault,” Mo6). Some women also reported that the assault had made them more cautious, less trusting, or fearful (n = 20). A smaller number of women made statements affirming their identity or self‐worth (n = 16, eg, “It didn't define who I was and who I was going to become,” Mo6), and some described personal growth (n = 17, eg, “I have a newfound strength about myself,” Wk1).

Justice

Comments about the justice system (n = 108) (Supporting Information Table E2) were overwhelmingly negative (105/108 (97%), eg, “I felt like it was a waste of my time to report,” Mo6). Disappointment in the justice system (n = 56) included concerns about some aspect of the criminal investigation process (n = 18, eg, “I do not think police should ask victims do an initiative text to the suspect of the assault,” Wk1), poor treatment by investigators (n = 6), the lengthy process (n = 9), or the failure to be updated about their case's progress (n = 4). Some women noted that negative experiences with the justice process exacerbated their mental health distress or interfered with recovery (n = 21), to the point where several women indicated that the justice system response was like a second assault (eg, “Being treated like it is our fault is being assaulted all over again,” Yr1).

Medical and social services

Many women commenting on medical and social services (n = 102) (Supporting Information Table E2) described challenges or barriers to receiving health care, such as the high cost or lack of sufficient reimbursement for health care services (n = 18). Other barriers to health care included difficulties identifying needed services, long waitlists, and the emotional difficulty of finding or following through with medical care (n = 17, eg, “I have anxiety when I even think about calling a psychiatrist to get help,” Yr1). Some women described negative experiences when trying to access care, such as being treated insensitively (n = 16, eg, “There was little communication or offering of support for disease testing, etc., after assault,” Wk6). Other women had positive experiences with care received: 22 emphasized that a service (primarily counseling) was helpful for recovery, and 12 offered praise for particular services or emergency care practitioners (eg, “The SANE nurse that I experienced was PHENOMENAL,” Wk6).

Physical health

Most women who commented on their physical health (n = 84) (Supporting Information Table E2) described negative effects of SA (n = 65, eg, “I feel like my body is overwhelmed and is much more sick than I have been in the past,” Wk1). Of these, 26 reported experiencing pain. Five women commented that they had contracted or were worried about contracting a sexually transmitted infection, and 8 attributed their physical health problems to the impact of SA on their mental health (eg, “My body isn't healing because my mind isn't,” Wk6).

Shame

Women who expressed shame (n = 67) (Supporting Information Table E2) commonly expressed guilt and responsibility, including assertions of self‐blame (n = 27, eg, “I will always feel somewhat responsible for what he did to me,” Mo6) and rejection of self‐blame (n = 25, eg, “No matter what happened it isn't your fault,” Wk1). A smaller number of women expressed feeling blame from others (n = 9), embarrassment, shame, or disgust (n = 8), or anger or self‐hatred (n = 5).

Romantic relationships

The most common subtheme regarding romantic relationships (n = 60) (Supporting Information Table E2) related to negative effects of SA (n = 23, eg, “The assault has definitely held me back when it comes to relationships,” Yr1). Women reported difficulty with initiating new romantic relationships after the assault (n = 14, eg, “They don't tell you you'll have to have the "rape talk" to anyone you could potentially get serious with,” Wk6). Ten women reported that they no longer trusted men, were afraid of men, or now hated men; 9 women reported decreased, or total loss of interest in sex; and 7 women stated that a romantic relationship had ended in the aftermath of the assault. Four women noted that their partners were also affected negatively by the assault (eg, “boyfriends are affected too,” Wk1).

Prior trauma

Of the women who mentioned a prior trauma (n = 37) (Supporting Information Table E2), 6 indicated that their response to this assault was worse because of their history (eg, “As someone who has been assaulted more than once, I'm trying to find the point,” Wk6). In contrast, 4 indicated that they were better equipped to respond to the current situation because they had developed coping resources (eg, “I have suffered extreme trauma in my life before, therefore I have a high tolerance to bad situations,” Wk1).

Safety

Most comments in this category (n = 35) (Supporting Information Table E2) related to feeling afraid (n = 12) or unsafe (n = 7) (eg, “the physical reactions that we still experience are reminders that we aren't safe,” Mo6). Some mentioned specific triggers that had not bothered them in the past, such as leaving the house, leaving window blinds open at night, or attending social events. A few women (n = 5) described actions they had taken to feel safe again, including moving or pursuing restraining orders against their assailants.

LIMITATIONS

This study has several limitations. The shortcomings of open‐ended survey questions include a tendency toward brief responses, the use of leading questions that may not adequately capture underlying patient views, and a negativity bias. , It is possible that the experiences of responders were more negative than those who did not respond to the target survey question. Such a tendency is suggested by the increased trauma history of respondents vs. non‐respondents. In addition, only cisgender women were included in the study, and the overwhelming majority of assailants were male. Consequently, findings may not be representative of all SA survivors. Participants interpreted the target question (“What do you think is most important for researchers to understand about your experience since the assault?”) in different ways, and some participants focused more on what they thought researchers should study than on their own personal experience. In addition, some responses seemed directed at specific features of the larger study. These limitations are offset by the breadth of data gathered from a large sample. Furthermore, study data meet criteria for richness in open‐ended free‐text response studies, including descriptions of particular social worlds, disclosure of otherwise inaccessible thoughts and feelings, and “thick” descriptions of context, emotion, personal meanings, and social relationships.

DISCUSSION

This study examined 1434 longitudinal comments from 590 adult women who presented for emergency care after SA and were asked to describe the most important thing for researchers to understand about their experience. Responses demonstrate the profound negative consequences of SA on many aspects of survivors’ lives. Survivors described a heavy burden and significant challenges as they navigated interactions with friends, family, romantic partners, medical emergency care practitioners, and investigators during the year after assault. Although many of the themes overlap with or relate to posttraumatic stress symptoms, a known sequela of sexual assault, other themes, such as difficulties with social interactions and major disruption of daily routines and activities, have not been well described.

Findings from this study have important implications for emergency care practitioners and future efforts to improve recovery after SA. First, these data underscore that recovery from sexual assault can be extremely challenging, and that every effort should be made by emergency care practitioners to provide referrals for mental and general health care. In addition, our findings demonstrate that survivors frequently face barriers to accessing care and services following assault, including financial barriers. Survivors need information regarding free or low‐cost treatment options at the time of emergency care. The many descriptions by survivors of struggling with profound feelings of shame and self‐doubt after SANE care emphasize the need for emergency care emergency care practitioners to convey a clear statement to every survivor that the assault was not their fault. Descriptions of the burden of posttraumatic stress symptoms experienced by survivors, and the sense of isolation and self‐doubt that these symptoms can bring, are consistent with recommendations that acute care practitioners inform survivors that such symptoms are common in the early aftermath of trauma, in order to reduce anxiety and promote recovery.

The development of emergency care‐based interventions to promote recovery and reduce posttraumatic neuropsychiatric sequelae following SA is in its infancy. Despite this, we believe that emergency care practitioners should communicate 4 things to every SA survivor, and that these messages can be communicated even within the time constraints imposed by a hectic ED shift. These 4 messages are summarized by the acronym SANE, and displayed in Figure 2.

FIGURE 2

“SANE” acronym summarizing important messages to communicate to sexual assault survivors at the time of emergency care

Experiences with the criminal justice system are profoundly negative for many survivors. Contributing factors frequently cited by SA survivors are readily addressable by detectives and prosecutors (eg, interacting with survivors in ways that make them feel supported and believed, providing regular case updates). Future studies should evaluate the effects of specific training and procedural changes on SA survivor experiences and outcomes within the criminal justice system.

Results suggest that recovery from SA is possible, but should not be equated with returning to how things were prior to the assault. A small number of participants (n = 32) acknowledged that they had recovered and moved on, or experienced positive changes after SA (n = 12) (eg, discontinuing risky behaviors, developing an improved sense of self‐worth). These findings lend cautious support to the possibility of posttraumatic growth following assault for a minority of survivors, in addition to adverse outcomes. Future research should investigate specific predictors of posttraumatic growth, to inform individual and systematic efforts to help recovery.

Strengths of this study include the large sample size and multi‐site prospective design. This study is the first, to our knowledge, to use qualitative methods to study a large number of SA survivors seen in US emergency care centers. Much of the qualitative research on SA in the United States has been collected from college students, , whereas this sample includes adult women of all ages. Additional strengths include the high overall response rate and the fact that responders differed from non‐responders only in terms of racial identity and trauma history. These qualities lend further support to the study's qualitative rigor. This study also demonstrates the utility and feasibility of analyzing open‐ended free‐text survey responses in patient outcomes research. Such questions are infrequently analyzed but can easily be added to study protocols and allow survivors to share the issues most important to them. , ,

In summary, these responses document in often searing detail the challenges faced during the year after assault, including mental distress, a profoundly altered sense of self, a justice system experienced as grossly unfair, financial difficulties due to assault‐related disability, burden of previous life trauma weighing more heavily, struggles with romantic relationships and interactions with others, experiences of isolation and anxiety, and difficulties with accessing healthcare. Survivor descriptions of the challenges they face after leaving the ED underscore the importance of simple messages to survivors at the time of emergency care. Although our results summarize themes and attempt to provide representative comments, a more complete conception of survivor experiences can be gained by reading the complete responses shared by participants (Supporting Information Table E2). For emergency care practitioners who care for women at the beginning of this journey, and for those who seek to gain a better understanding of the challenges facing survivors, improve services and societal responses, or develop improved secondary preventive interventions, we believe that reading the complete responses would be time well spent.

CONFLICTS OF INTEREST

The authors report no conflicts of interest.

AUTHOR CONTRIBUTIONS

SAM developed the overall study and research idea, collected data, and provided critical feedback on all drafts. MB, ERB, and AST conducted data analysis. MB, ERB, and SAM drafted the manuscript. TD, ML, KB, JB, JB, RR, JH, GR, MP, RR, CR, PN, and CP served as site PIs and collected data. KB, KDW, SLM, IL, and SAMR contributed to the overall study design and conduct. All authors provided feedback on the manuscript and approve of its submission for publication. SAM takes final responsibility for the manuscript as a whole.

Additional supporting information may be found online in the Supporting Information section at the end of the article.

Click here for additional data file.