Alex Coolman and David Eisenman, Sexual Assault: A Critical Health Care Issue, Correct Care, Fall 2003.

When Colorado inmate Robin Darbyshire returned from a transport trip between two corrections facilities, she was nervous and dehydrated. She kept taking showers over and over. Finally, a fellow inmate asked her if she was okay, and her story came out: Robin had been sexually assaulted by the driver of the private transport van. Correctional medical practitioners examined Robin, diagnosed her with post-traumatic stress disorder, and helped start an investigation that eventually led to a successful civil lawsuit against her assailant.

Robin's case points to the critical role that health care practitioners can play in dealing with sexual assault in detention - and the possibility that assaults may go undetected in the absence of pro-active steps to understand inmates' situations. The recently passed Prison Rape Elimination Act of 2003 (PREA) provides an opportunity for healthcare providers in prisons and jails to take those steps, enhancing their detection, treatment, and prevention of prison sexual assault.

The PREA will fund a nationwide prevalence study of sexual assault that will give corrections officials and health care providers a better understanding of the significance of this problem. While we await this data, we can learn from the results of previous work.. One study of Midwestern prisons reported that among male inmates - who are most likely to be assaulted by fellow inmates - 21% had experienced "pressured or forced sexual contact." Female inmates, who, like Robin, are more likely to be victimized by male employees, also report significant rates of assault. In one study, rates of forced sexual contact ranged from 7% to 27%.

Importantly, the PREA creates increased scrutiny of the efforts of corrections facilities to prevent and respond to this problem - a factor that makes it more relevant than ever for health care practitioners to understand the patterns of victimization and effective tools for dealing with incidents when they occur. Federal guidelines mandated by the new law, for example, will address the physical and psychological treatment of victims, referrals to long-term care, post-rape prophylaxis, and the reduction of HIV transmission.

Some basic facts about the problem are already known: Among male inmates, sexual assault victims tend to be young, physically small, nonviolent, first-time offenders who are not "street smart." Transgender inmates, gay men, and inmates who are simply perceived to be gay, are also at increased risk. A study of one institution reported that 41% of gay inmates had been sexually assaulted, a rate that was more than four times higher than that of the institution as a whole. Lesbian, gay, bisexual, and transgender (LGBT) inmates often face institutional apathy when attempting to report abuse, as their sexual identity is incorrectly interpreted as an indication that they must have "wanted" to be victimized.

When a new male inmate is successfully sexually attacked - or "turned out" - it is often taken as an indication that the inmate is fair game for repeat victimization. In some cases, these initial attacks take the form of brutal gang rapes, while the mere threat of such violence is employed in other situations to coerce sex from victims.

Female inmates, too, may face threats of violence or, alternatively, may be offered special treatment and privileges in exchange for sex. Women inmates who are mentally ill or disabled are often targets of sexual misconduct.

For health care practitioners, inmate secrecy, shame and lack of awareness about appropriate sexual boundaries may be an obstacle to addressing sexual assault. Male rape victims may feel intense guilt about the fact that they have "allowed" themselves to be attacked, and have a sense that they have lost their masculinity. One third of female inmates have been raped at some point in their lives prior to incarceration, according to the U.S. Department of Justice, and this history of abuse can make for its own set of complex and painful responses to trauma behind bars.

While part of the burden for overcoming these barriers rests with the administrators of detention facilities, health care practitioners can help inmates overcome some of these obstacles by actively including sexual assault in the range of issues discussed with them. Sexual assault should be considered as a differential factor in cases of trauma, STDs, hepatitis, pregnancy, chronic pain syndromes, and mental health problems, for example. Speaking candidly and specifically with inmates about behavior, and steering clear of jargon or stigmatized terms like "coercion" and "rape" is also an important component in eliciting an honest response from an individual who may not feel comfortable describing his or her experience. Practitioners should strive to ask frank, straight-forward questions about sexual incidents without shaming inmates or displaying embarrassment about the subject matter.

Clinics should have a protocol in place to respond when sexual assault is suspected. This means not only having a procedure for treating injuries, but also having policies for reporting abuse when appropriate, screening for STDs, providing counseling for victims and thorough follow-up care, and ensuring that forensic evidence is collected either onsite or outside of the facility. In at least some cases, what begins as a medical issue may evolve into a criminal investigation. A good protocol should help this process happen while protecting inmates from the potential threat of retaliation.

In an effort to help, Stop Prisoner Rape (SPR), a national non-profit organization based in Los Angeles, works with corrections professionals from around the country to implement sounds measures in their facilities to address sexual assault. SPR is now specifically seeking new opportunities to collaborate with correctional health professionals to address this problem.

Health care practitioners' awareness of sexual assault risks and their response to instances of abuse can contribute to a safer, more humane institutional atmosphere for everyone. As attitudes toward this issue evolve - and as legal oversight increases - health care practitioners have both an opportunity and an obligation to create comprehensive, forward-looking policies to address sexual assault.