| Not Reporting(n=41) | Reporting(n=111) | Odds Ratio(95% CI) |
| I am reluctant to report rape because... |
| I do not want the assailant going to jail* | 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(1.78-8.05) |
| I was involved in illegal activity during assault | 19(46%) | 27(24%) | 2.69(1.27-5.70) |
| I am afraid of going to court/trial | 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 friends/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 find 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(0.72-3.08) |
| 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(0.59-3.22) |
| 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(14%) | 19(17%) | 0.83(0.31-2.25) |
| Friend/family told me not to report | 1(2%) | 3(3%) | 0.90(0.09-8.91) |
* Indicates significance at the $p < 0.01$ level.
the NEP; and 15 patients were evaluated in the hospital by NEP staff due to the severity of their injuries. Of these 466 women, 42 (9%) were excluded from the study for the following reasons: could not recall details of the sexual assault due to intoxication (n = 21), refused forensic examination (n = 9), intercourse was consensual (n = 7), and missing or incomplete documentation (n = 5). Seventy-five percent (318/424) of the women eligible to participate in the study reported the sexual assault to law enforcement.
Women not reporting sexual assault were more often employed, with a history of recent alcohol or drug use, a known assailant, and a prolonged time interval between assault and forensic evaluation ($p < 0.001$). There were no other significant differences in race, marital status, perpetrator factors, or assault characteristics between the two patient groups (Tables 1, 2). A large percentage of women in both groups had a previous history of sexual assault.
Eighty-three percent of known assailants (256/308) were described as acquaintances; 12% (36/308) were current or previous boyfriends or spouses; 3% (10/308) involved other family members (Table 2). Eighty percent of incestuous assaults (8/10) occurred among victims aged 13 to 15 years of age; the majority (64%) of acquaintance rape (164/256) was documented in young adults aged 16 to 25 years of age. Among the older victims (>31 years of age) who knew their assailants, 23% (22/97) were assaulted by current or previous boyfriends or spouses. Women victimized by known assailants were less likely to file a police report (70% vs. 88%, $ p < .001$).
There were no differences in the extent of non-genital injuries or anogenital injuries between the two groups (Table 2). Seventy-seven percent (326/424) had documented anogenital injuries. A total of 23% (75/326) had single and 77% (251/326) had multiple sites of trauma. The pattern of anogenital injuries was similar in both groups of adult patients with the majority of injuries (80%) occurring at one of three anatomical sites: labia minora, fossa navicularis, and posterior fourchette. Superficial lacerations and erythema were the most common types of injuries documented in women reporting sexual assault as well as those not reporting assault (Figure 1).
Of the 424 women eligible to participate in the study, 152 (36%) agreed to complete the psychosocial questionnaire. There were no significant differences in demographics, perpetrator factors, or assault characteristics between those who completed the survey and those who refused. Seventy-three percent (111/152) of the women who completed the survey reported the sexual assault to police.
Table 3 details the responses of women to the psychosocial questionnaire. A majority of women in both groups felt partially responsible for the assault, were concerned about public exposure, and were ashamed or embarrassed by the assault. However, these internal psychological barriers (i.e., shame, anxiety, fear) were not significantly associated with reporting sexual assault to police.
The three most common reasons for not reporting sexual assault included: not wanting the assailant to go to
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Figure 1. Types of genital trauma in sexual assault victims with anogenital findings (n = 326).
jail (OR 19.47, 95% CI 7.79–48.68), a prior relationship with the assailant (OR 3.79, 95% CI 1.78–8.05), and feeling that the police would blame the victim or be insensitive (OR 5.81, 95% CI 2.61–12.94). Seven percent of women not reporting sexual assault (3/41) had a criminal record or were on probation; however, 42% (17/41) reported a “bad experience” with police in the past or were involved in illegal activity during the assault (19/41). This illegal activity generally involved underage drinking or recent drug use.
## DISCUSSION
These results show that in a community-based urban population, one-quarter of women presenting to a sexual assault clinic or ED chose not to report the rape to police. This rate is consistent with a previous study in Minneapolis that reported that 24% of sexual assault victims treated in an ED by nurse examiners refused to file a police report (16). During the past three decades, women have become more likely to report rapes and attempted rapes—particularly those involving known assailants—to police (3). But the fact remains that less than half of such crimes are reported (1,3). In fact, law enforcement officials consider sexual assault to be the most underreported violent crime in America (17).
It is apparent that the majority of rape survivors who seek post-assault health care in community clinics or EDs have already made the decision to involve the police (7,16,18). The simple act of seeking medical help may in turn lead a woman to define a situation as rape and report it. For those victims who have not decided whether or not to report the assault, trained examiners, when available, can discuss the survivor's fears and concerns about reporting 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, approximately 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.
Although the majority of our study population had 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 force and the pattern of anogenital injuries were similar in both groups. Therefore, although the severity of physical injuries may cause the rape survivor to seek appropriate medical care, it does not significantly influence their decision to report. These findings are consistent with a recent Danish study of women presenting to a sexual assault center in Copenhagen. They also concluded that the severity of the assault or the documentation of injuries did not influence police reporting (20).
Since 1970, social scientists have investigated a number of possible reasons why women don’t report rape, ranging from fears, beliefs, and characteristics of the women themselves, to the nature of the relationship between the victim and the assailant, and the characteristics of the particular rape. The usefulness of these studies in determining the relative importance of these factors is limited by the research methodologies used and the populations studied. The only way clinicians can really determine why sexual assault victims do not report to police is to ask the victims themselves. The current study was designed to accomplish this goal within a community-based sample of women presenting for medical care after an assault. The results of this study identified six distinct factors associated with not reporting sexual assault to law enforcement.
Age, marital status, and ethnicity were not associated with police involvement; however, employment status differed significantly between non-reporters and those reporting sexual assault (69% vs. 54%, respectively). Some rape victims likely chose to avoid the notoriety and stigma attached to rape prosecution, or they feared rejection by friends and co-workers (17,20). More than half of the women we surveyed felt partially responsible for the assault (60%), were concerned about public exposure (75%), and were ashamed or embarrassed by the
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assault (74%). Practical issues may also be involved—a victim may not have the time to participate in a criminal prosecution, especially if she is employed (22).
Seventy-three percent of sexual assaults in our study were committed by known assailants. This is consistent with other studies such as the National Crime Victimization Survey, which reported that approximately two-thirds of rape victims knew their assailant (3). Our results also demonstrate that women assaulted by a known assailant are significantly less likely to report the crime compared to those assaulted by a stranger. Not surprisingly, the response on the psychosocial survey that had the greatest association with non-reporting was: “I do not want the assailant going to jail” (OR 19.47, $p < 0.001$).
The complex nature of the victim-assailant relationship is known to influence perceptions of the seriousness and sequelae of the sexual assault (23). It also is clearly the most important factor influencing a victim’s decision to report (18.20–22).
Sexual assault victims having experienced acquaintance rape are typically young adults, 16 to 25 years old. Sex-role socialization encourages this type of assault victim to see herself as a possible contributor to her own victimization (22). In a survey of high school students, teenage girls who had experienced forced sex believed that consensual sex play provoked the non-consensual intercourse and therefore felt they were at fault, not the perpetrator who ignored pleas to stop (23). Moreover, intoxication in the context of a dating relationship can lead to the misinterpretation of friendly cues as sexual invitations, diminished coping responses, and the woman’s inability to ward off a potential attack (24).
At least one-half of all violent crimes involve alcohol or drug use by the perpetrator, the victim, or both (3,24). Sexual assault certainly fits this pattern. Alcohol, marijuana, cocaine, and other illicit drugs were used by 56% of all the women in our population. Although not statistically significant, almost half of our respondents did not report rape because they were involved in illegal activity at the time of the assault. This illegal activity generally involved underage drinking or recent drug use and probably contributed to victim’s feelings of fear, guilt, embarrassment, and blame. In addition, intoxication was likely the key reason that 51% of our respondents stated that “the details of the assault are unclear.”
Another significant reason for not reporting assault was the belief that police would be insensitive or blame the victim (OR 5.81, $p < 0.001$). Only 7% of non-reporters had a criminal record or were on probation; however, a considerable number of these women reported a “bad experience with police in the past” (42%) or were “involved in illegal activity during assault” (46%). Previous research has shown that victims may
also lack confidence in the ability of the criminal justice system to apprehend or punish the assailant (22,24).
According to Williams, most people think of rape as a sudden, violent attack by a stranger in a deserted, public place, after which the victim is expected to provide evidence of the attack and of her active resistance (22). These characteristics, then, constitute what is referred to as the classic rape situation. When an individual is confronted with a situation that does not conform to the stereotypical concept rape, she may be reluctant to report the incident or seek medical care (7). This reluctance is aptly demonstrated by the prolonged time interval between assault and forensic evaluation among non-reporters (20 h vs. 11 h, $ p < 0.001 $ ). Any delay in presentation is troublesome in light of previous studies that suggest that the timing of the examination is the most significant predictor of abnormal anogenital findings in both children and adult victims of sexual assault (25,26). For example, the frequency of anogenital lacerations and abrasions may decrease from 50% at $ < 24 \mathrm{~h} $ to 13% at $ > 96 \mathrm{~h} $ after the assault (26).
## LIMITATIONS
There were several limitations in our study. We could not control for the clinical evaluations by different examiners. It may be that documentation was not uniform, although the nine nurse examiners had a similar level of training and experience. The findings of the examiners were recorded on state-mandated reporting forms and were taken as the most accurate representation of the actual physical findings. Over half of all patients had been exposed to alcohol or illicit drugs during the time of the assault. It is unknown what impact this might have had on the accuracy of the history or the degree of anogenital injuries. However, the documented history of the sexual assault by forensic nurses is quite detailed and considered accurate by legal authorities. In addition, women were excluded from participating in the survey if the nurse examiner felt they were still clinically intoxicated.
This study, like all studies of rape victims, is vulnerable to sample or selection bias. Previous research suggests that many victims of rape are not likely to seek medical care or even to identify themselves as rape victims (2). In fact, the desire to avoid using the term "rape" is frequently very high. It should also be noted that this study considered women who reported to the police, the NEP, or a local ED. If all women experiencing sexual assault who neither reported to the police nor came to the NEP/ED were included, the results might have been different.
Of the 424 women eligible to participate in the study, 152 agreed to complete the psychosocial questionnaire,
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for a response rate of 36%. This limited response rate was understandable because, in many cases, subject recruitment took place within hours of the sexual assault and women were not compelled to participate. There were no significant differences in demographics, perpetrator factors, or assault characteristics between those who completed the survey and those who refused. However, the small sample size and the more stringent level of significance ($p < 0.01$) made for a less robust study.
Over the past two decades, there have been a number of initiatives aimed at improving the legal treatment of sexually assaulted women (27). Rape crisis centers and victim assistance programs offer crisis intervention, emotional support, counseling, and advocacy to women who have been sexually assaulted. Hospital-based sexual assault care and treatment programs have been established, providing victims with around-the-clock support and crisis counseling, medical care, referrals to local service providers, and forensic evidence collection for potential court use. Although one of the goals of these initiatives was to increase the proportion of women reporting sexual assault, results from retrospective studies evaluating their effectiveness have been mixed and have not captured the complexity of factors that may influence women’s post-assault decisions. Qualitative, in-depth interviews with women who have been sexually assaulted hold unique promise for evaluating treatment programs and enhancing women’s interaction with the criminal justice system (27). Moreover, given that women do not constitute a unified and homogeneous group, future research may want to employ more sophisticated measures of age, ethnicity, culture, education, and assault characteristics to examine their collective impact on reporting practices.
## CONCLUSIONS
In a community-based urban population, one-quarter of women presenting to a sexual assault clinic or ED chose not to report the sexual assault to police. These results suggest that women who are employed, raped by a known assailant, have a history of recent alcohol or drug use, and prolonged time intervals between the assault and forensic evaluation are more reluctant to involve the police. No differences were found in the extent of nongenital injuries or anogenital injuries between reporters and non-reporters. When surveyed, the reasons given by assault victims for not reporting to police were primarily environmental factors (e.g., relationship with the assailant) rather than internal psychological barriers (e.g., shame, anxiety, fear). Further study is needed to identify the policies or practices that encourage reporting and to apply those practices elsewhere. Such a strategy might,
in turn, increase the chance of arrest and prosecution and, ultimately, the deterrent effect of the criminal justice system.
Acknowledgments—The authors acknowledge the suggestions and statistical assistance of Dr. Diann Reischman, Grand Rapids Medical Education and Research Center for Health Professions.
## REFERENCES
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