Identification of current practices and barriers to care for patients seeking abortion after sexual assault
Awarded 2013
Complex Family Planning Fellowship Research
Rachel Perry, MD
University of Illinois

One in six women in the United States experiences rape or attempted rape in her lifetime. Clinicians play an important role in the immediate care of sexual assault survivors, including treatment of injury, prevention and treatment of sexually transmitted infection, prevention of pregnancy through provision of emergency contraception, collection of forensic evidence for prosecution of the assailant if the woman chooses, and coordination of mental health care. Most women will not seek emergency care after an assault, and may not receive these important services. Among the possible consequences of assault, particularly for women who do not receive emergency contraception, is pregnancy. If pregnancy does occur following an assault, the survivor may seek an abortion. Thus, her first contact with the health care system may be with the abortion provider. Our research sought to understand the current practices of abortion providers in the United States regarding care of women who have become pregnant after a rape, the experiences of women who have terminated pregnancies resulting from rape, and the experiences of professionals involved in the care of rape survivors. 
We used two methods to achieve our research aims: 1) A national survey of clinicians involved in abortion care 2) Interviews with women who terminated pregnancies resulting from rape and with abortion providers, social workers, and rape crisis center advocates, all in the Chicago area (termed “key stakeholders”). We conducted this research project over one year, collected 279 survey responses and did 21 interviews. Our survey results showed that half of abortion providers have a “screen” for pregnancies resulting from rape, that is, they have a question or process that asks women whether rape is the reason for choice to terminate. However, only 22% of survey respondents reported that their center has a specific protocol for care of sexual assault survivors. The majority (81%) are able to refer to support services (such as counselors) if a history of sexual assault is disclosed. 
The major themes to arise from the patient interviews included that there are five important opportunities created by sexual assault disclosure which fall into two domains: interpersonal (explaining abortion decision-making in context of rape, receiving belief and caring from providers) and structural (receiving Medicaid coverage as a Hyde Amendment exception, opportunity to prosecute, and opportunity to access mental health services). No patient in our study chose to access all the opportunities, but all felt it was important to offer them. For instance, none of the patients decided to press charges against their assailants, but they felt it was important to offer the opportunity to collect tissue from the pregnancy for DNA evidence. About half of the patients had decided to pursue support services such as group or individual counseling. Patients overwhelmingly felt that the most important consequence of disclosure was having their accounts of the rape believed by providers and feeling cared for in the clinic. Key stakeholders discussed the importance of having accessible support services (some had counseling available in the clinic setting, others were frustrated that patients were not able to afford or schedule appointments for counseling). They generally appreciated the ease with which the state of Illinois funds abortions for pregnancies resulting from assault, and felt that lifting this financial burden relieved a major stressor for women recovering from the trauma of assault. 
In summary, many clinics are employing some form of screening for pregnancies resulting from assault, and though most are able to refer to support services, only a small number have a specific protocol for care of assault survivors. Because the abortion care setting may be the survivor’s first contact with medical care, a protocol for care may be important to assure that the patient receives all aspects of appropriate post-assault care, and this could be an area of future research. Abortion care settings should make environments conducive to disclosure, consider development of care protocols, and consider the interpersonal and structural opportunities they can offer patients when disclosure occurs.