Determining “best” practices in responding
to delayed disclosure by female sexual
assault victims in health care settings
A Systematic Literature Review
Stephanie Lanthier, Janice Du Mont and
Robin Mason
Background: Disclosure of Sexual
• Sexual assault is a pervasive yet underreported
violent crime (Du Mont & White, 2007). Less than
10% of sexual assaults are formally reported to the
police (Brennan & Taylor Butts, 2010; Sinha, 2013).
• Research shows that the majority of women do
eventually disclose to someone (Ahrens et al., 2010;
Golding et al., 1989; Neville & Pugh, 1997).
• Disclosure often occurs weeks, months or years after
the assault (Dunleavy 2012; Esposito, 2006; Filipas &
Ullman, 2001).
Background: Health Consequences
and Health Seeking
• Sexual assault victims report poorer health and use
medical services more frequently than non-victims
(Golding et al., 1989; Resnick et al., 2000; Ullman &
Brecklin, 2003; Ullman & Siegel, 1995).
• They can present with a variety of physical, urogynaecological, obstetric and/or mental health issues
(Taylor et al., 2012).
• It is important that health care providers in a variety of
settings are able to respond appropriately to the
delayed disclosure of sexual assault.
To determine “best”
practices in responding
to delayed disclosure of
sexual assault by
examining helpful and
unhelpful responses by
health care providers.
Image: The Awareness Center Inc.
Methods: Search Strategy
(April 2013)
Key Terms
• “sexual assault”,
“disclosure”, “social
support”, “post
assault”, “reaction”,
“clinician”, “provider”,
“formal” etc.
• OVID Medline
• PubMed
• PsycINFO
• Embase
Limited search to 1985-present; English
Methods: Analysis
Title Screen
Abstract Screen
Full Article Review
Records identified through
database searching and reference
lists of key articles (N=1166)
Duplicate records (N=383)
Title screen (N=779)
Titles excluded (N=601)
Abstracts assessed for eligibility
Abstracts excluded (N=129)
Full-text articles assessed for
eligibility (N= 49)
Full-text articles excluded
Studies included (N=24)
Methods: Exclusion Criteria
Titles Excluded (N=601)
Sexual Assault or Related
Terms Not in Title (N=369)
Childhood or Male Sexual
Assault (N=169)
Acute Sexual Assault
Book Chapters,
Dissertations etc. (N=100)
Focused on Offender
Not English (N=7)
Abstracts Excluded
Childhood or Male Sexual
Assault (N=12)
Acute Sexual Assault
Book Chapters etc. (N= 9)
No Response to Disclosure
Informal Support Provider
Only (N=5)
Screening (N=1)
Full Text Articles
Excluded (N=25)
Childhood Sexual Assault
No Healthcare Provider
Mental Health Setting
Fact Sheet, Commentary
etc. (N=2)
Results: Summary
24 Studies
20 USA
2 Tanzania
1 Australia
1 N/A
Sample Size
Range = 1 to 3026
Questionnaire, Case Report, In-Depth Interview, Survey,
Systematic Review
Health Care Providers
Physicians, Nurses, Midwives, Physical Therapists.
Medical Personnel, Medical Staff, Health Care System
Disclosure Rates to
Health Care Providers
Range = 9 to 27.1%
Results: Responses
Unhelpful Responses
Blaming the Survivor
Minimizing, Dismissive or Distracting Responses
Displaying a Cold and/or Detached Demeanor
Treating the Survivor Differently
Results: Helpful Responses
Helpful Responses
Tangible aid (N=13)
• Providing medical care
• Giving information about sexual assault and
community resources
• Providing referrals to counsellors or mental health
Providing emotional
support (N=13)
Acknowledging or
validating the disclosure
• Using simple statements such as “I’m so sorry that
this happened to you” or “I’m glad you told me about
Showing concern
Being empathetic
Listening in an active and supportive manner
Telling the survivor that they are not to blame
Results: Unhelpful Responses
Unhelpful Response
Blaming the survivor for the
assault (N=7)
• Holding the survivor responsible for the
• Doubting the survivor’s account of the
• Accusing the survivor of not telling the truth
Minimizing, dismissive or
distracting responses (N=6)
• Statements or attempts to make the assault
seem less troubling than how the survivor
perceived it
• Telling the survivor to stop talking or
thinking about the assault
• Attempting to discourage survivor from
further speaking about the assault.
Results: Unhelpful Responses
Unhelpful Response
Health care provider displaying
a cold and/or detached
demeanor (N=6)
• Not making eye contact
• Asking a question unrelated to the sexual
assault in an effort to change the subject
• Ignoring the survivor
• Not providing any assistance upon hearing
the disclosure
• Having no reaction at all
• Giving a prescription without asking further
Treating the survivor differently
after disclosure (N=5)
• Treating the survivor with contempt
• Treating the survivor as if she is not able
to take care of herself
• Avoiding the survivor
Summary: “Best” Practices
Providing a safe
and supportive
Being aware of the
indicators of past
sexual assault
Direct questioning if
patient presents
with indicators of a
past sexual assault
Validating the
Providing emotional
Implications: Practice
• Health care providers
require more training on
recognizing indicators of
past sexual assault and
knowing how to respond
to delayed disclosure in a
helpful way.
• Implementing “best”
practices is a first step in
achieving this improved
After receiving a
sympathetic reaction
from her doctor, one
survivor said: “It made
me feel good, like I, wow,
it’s not the end you
know?” (Ahrens et al.,
Special thanks to:
Mona Frantzke, BSc, MLSc, Medical
Librarian, Health Sciences Library,
Women’s College Hospital
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