To Nurse and Pro­tect

As more vic­tims of sex­ual as­sault seek treat­ment, E.R. staff must fig­ure out how to best care for them


As more vic­tims of sex­ual as­sault seek treat­ment, E.R. staff must fig­ure out how to best care for them. KATHER­INE LAID­LAW


FOR ABIDA DHUKAI, a nurse prac­ti­tioner, pre­par­ing to see a fe­male pa­tient al­ways starts the same way. First, she puts up an emo­tional wall. “I need to pro­tect my­self be­cause I don’t know what I’m go­ing to hear,” she says.

Then she men­tally runs through the many ques­tions she will ask if there’s abuse in­volved. “How safe do you feel?” “Do you have chil­dren?” “Are you fi­nan­cially in­de­pen­dent?” “Does your abuser know where you work?” She goes through these check­boxes, and more, so as not to get too close to the ris­ing tide of anger swelling within her.

Dhukai is a wiry woman of In­dian des­cent, with long, dark curly hair tied back in a bun. She speaks at the quick pace of a per­son who has places to be, and she usu­ally does. For nine years,

she has worked in Toronto’s Mount Si­nai Hos­pi­tal emer­gency depart­ment, see­ing pa­tients with ail­ments and in­juries that range from twisted an­kles to heart at­tacks. Af­ter a few years, she be­gan to fo­cus most on women’s health and be­came es­pe­cially in­ter­ested in tack­ling what she con­sid­ered a less-than-em­pa­thetic re­sponse to the women who re­ported they’d been sex­u­ally as­saulted.

In 2009, Dhukai be­gan tak­ing notes on her phone about her thoughts and feel­ings af­ter see­ing each of those cases. Her file is now hun­dreds of thou­sands of words long. When women re­ported that po­lice of­fi­cers had vic­tim-blamed them, she wrote it down. When women blamed them­selves, sug­gest­ing maybe they’d had too much to drink, she wrote it down. “As I saw more and more vi­o­lence, I felt more an­gry,” she says. “How can some­body do this to an­other hu­man be­ing?”

Re­flect­ing on her ex­pe­ri­ences made her re­al­ize that the hos­pi­tal needed stronger pro­to­cols for deal­ing with pa­tients suf­fer­ing from abuse. She ap­proached Chris­tine Bradshaw, a so­cial worker and the chair of the hos­pi­tal’s Vi­o­lence Against Women Aware­ness Com­mit­tee, and the two worked to­gether to im­ple­ment changes in how the emer­gency depart­ment re­ceives these pa­tients.

OVER TIME, DHUKAI and Bradshaw have in­no­vated. They’ve put into place pre­cau­tions to pro­tect a pa­tient’s iden­tity, are pro­vid­ing them with bet­ter re­sources and they now ask ev­ery woman who is ad­mit­ted into the hos­pi­tal’s depart­ment for women and in­fants whether any­body close to them is hurt­ing them phys­i­cally, sex­u­ally, emo­tion­ally or fi­nan­cially.

Uni­ver­sal screen­ing—the prac­tice of ask­ing ev­ery per­son who en­ters the emer­gency depart­ment whether or not they’re be­ing abused—isn’t manda­tory. In­stead, it’s left to in­di­vid­ual clin­i­cians to de­ter­mine when some­one’s story and symp­toms don’t match. Or, as Dhukai does, they can sim­ply put the ques­tion to ev­ery­one.

“When I first started out, I’d see one or two women a week who’d been sex­u­ally as­saulted,” Dhukai says. Lately she feels that this num­ber has in­creased and sug­gests the rise, which she first no­ticed around four years ago, is a re­sult of in­creased pub­lic con­ver­sa­tions around the is­sue.

For Dhukai, that uptick has taken a toll. One week­end in Fe­bru­ary 2017,



sur­rounded by the emer­gency depart­ment’s frenzy—peo­ple cough­ing, yelling, drunk—the nurse pro­cessed mul­ti­ple rape cases dur­ing one shift. Some­thing in her tipped fol­low­ing the last one. “I can still re­mem­ber her face,” Dhukai says.

For weeks af­ter, Dhukai was quiet and with­drawn. She took two weeks off work—she knew she needed space. But it’s not be­ing haunted by faces that makes her worry about her­self. It’s when they start to blend, when a patch­work of bruises on one pa­tient re­minds her of an­other.

“They mesh to­gether some­times,” she says. “It’s dis­turb­ing.”

AC­CORD­ING TO DATA re­leased by Sta­tis­tics Canada in July, there was a 13 per cent in­crease in po­lice-re­ported sex­ual as­saults na­tion­wide in just one year, to 24,672 in­ci­dents in to­tal. “The MeToo move­ment has sig­nif­i­cantly raised peo­ple’s aware­ness,” says Bradshaw. “And no­body wants to sit with this any­more. They want to talk.” In turn, an al­ready over­bur­dened health sys­tem must de­ter­mine how to best care for these trau­ma­tized pa­tients.

The emer­gency depart­ment plays a unique role in the so­ci­etal re­sponse to sex­ual as­sault: it’s of­ten the only place where nurses, so­cial work­ers and po­lice of­fi­cers con­verge to en­sure that a vic­tim is safe. It’s also some­times the only place where some­one who has ex­pe­ri­enced abuse will be alone with an­other per­son long enough to talk about it.

When some­one dis­closes abuse to her, Dhukai be­gins by ask­ing them how safe they feel. From there, the con­ver­sa­tion can take a num­ber of paths. If there are chil­dren in­volved, health­care pro­fes­sion­als run an in­ten­sive as­sess­ment and call the Chil­dren’s Aid So­ci­ety if nec­es­sary. Af­ter that, Dhukai will care­fully elicit the ex­act de­tails of the abuse and whether or not the vic­tim has ever con­sid­ered press­ing charges. She’ll ask if her pa­tient wants to be ex­am­ined by a sex­ual-as­sault nurse or, if it’s be­tween the hours of 8 a.m. and 10 p.m., if she wants to speak to the hos­pi­tal’s so­cial worker. Fi­nally, Dhukai of­fers in­for­ma­tion about shel­ters and a list of re­sources.

THE UNIQUE CHAL­LENGES of work­ing as a sex­ual-as­sault nurse come with a num­ber of oc­cu­pa­tional haz­ards. Be­cause they hear graphic nar­ra­tives ev­ery day, these work­ers can ex­pe­ri­ence dis­tur­bances with in­ti­macy, safety, trust and con­trol—in some in­stances as sig­nif­i­cantly as the vic­tims they treat, ac­cord­ing to a 2015 Jour­nal of Foren­sic Nurs­ing study.

They’re also more sus­cep­ti­ble to vi­car­i­ous trauma—the emo­tional residue that comes from em­pa­thet­i­cally en­gag­ing with peo­ple’s pain or fear—than most other kinds of nurses. This can lead to so­cial with­drawal, emo­tional numb­ing, night­mares and

a de­cline in sex­ual en­joy­ment. Fol­low­ing that, they may ex­pe­ri­ence burnout, com­pas­sion fa­tigue and even post­trau­matic stress dis­or­der.

At­tri­tion rates are high among sex­ual-health nurses, which can cre­ate dis­rup­tions in con­ti­nu­ity of ser­vice. One 2016 re­port from the United States Govern­ment Ac­count­abil­ity Of­fice noted that the state of Wis­con­sin had a .08 per cent re­ten­tion rate, with only 42 of 540 ex­am­in­ers still prac­tis­ing at the end of two years.

Although Cana­dian sta­tis­tics aren’t avail­able, for­mer sex­ual-as­sault nurse Amanda Pyper knows first-hand why burnout hap­pens here. When Pyper started work­ing at Women’s Col­lege Hos­pi­tal, she was 23 and just out of school. Right away, she was ad­min­is­ter­ing foren­sic ex­ams and of­fer­ing cri­sis coun­selling to women, many of whom ap­peared at the hos­pi­tal be­cause they’d been sex­u­ally as­saulted. “I was very stressed out,” she says. “I was con­stantly anx­ious about mak­ing mis­takes. I was the only health-care pro­fes­sional many of those peo­ple had con­tact with. I had a lot of au­ton­omy in terms of de­ci­sion­mak­ing and chang­ing the course of peo­ple’s care and lives.”

Over time, Pyper grew more com­fort­able in the role, but some parts of the job never grew eas­ier. Overnight shifts were es­pe­cially gru­elling, when sex­u­alas­sault nurses from Women’s Col­lege travel across the city, an­swer­ing pages from hospi­tals such as Sun­ny­brook, St. Michael’s and Mount Si­nai, as vi­o­lated and vul­ner­a­ble pa­tients wait for them to ar­rive.

Pyper says the hard­est part of that job, which she did on the side of her full-time po­si­tion at Mount Si­nai’s emer­gency depart­ment, was talk­ing with women search­ing for an­swers she couldn’t pro­vide. “A lot of peo­ple want to know, ‘Was I sex­u­ally as­saulted?’ Peo­ple come in want­ing an an­swer, yes or no,” she says. “I don’t think peo­ple fully ap­pre­ci­ate that there is no test for that.”

In the last few years, the de­mands of treat­ing sex­ual as­sault have in­creased dra­mat­i­cally. Pre­vi­ously, sit­u­a­tions ranged from stranger rape to dat­er­ape drugs, but the cases tended to be clear-cut. Now, as ed­u­ca­tion around con­sent and sex­ual as­sault has changed—in school, at home and in the me­dia—re­port­ing tends to be less straight­for­ward. Pyper saw a greater num­ber of sit­u­a­tions in­volv­ing peo­ple the vic­tims con­sid­ered friends or exes. And as more pa­tients come in with


cases in­volv­ing al­co­hol and am­bi­gu­ity, it makes fol­low­ing a me­thod­i­cal med­i­cal pro­to­col dif­fi­cult be­cause those cases re­quire so much more than a foren­sic test. “The big­gest thing peo­ple want is trauma coun­selling,” Pyper says. “I’m not trained in how to do that, so I was find­ing that I wasn’t pro­vid­ing them with the best care.”

Even­tu­ally, the de­mands of the job grew too great. Pyper left her role as a sex­ual-as­sault-cen­tre nurse last Oc­to­ber, re­turn­ing to work­ing solely at Mount Si­nai.

WHEN DHUKAI GETS home from a par­tic­u­larly dif­fi­cult shift, she sinks into bed and speaks to no one, let­ting the phone ring if some­one calls. Af­ter al­most a decade of this work, she has de­vel­oped rit­u­als that help her of­fer care at the stan­dard she ex­pects of her­self. She doesn’t watch the news. She ex­er­cises reg­u­larly, spend­ing an hour a day bik­ing or do­ing yoga, and prac­tises med­i­ta­tion. All this helps dis­pel the flashes of anger that rise up within her daily, anger at a so­ci­ety that doesn’t pro­tect women be­fore they be­come her pa­tients.

When their job feels over­whelm­ing, the nurses talk to each other, check­ing in to make sure they’re tak­ing care of them­selves. They can ac­cess the ser­vices of the hos­pi­tal’s so­cial work­ers, Dhukai says, but those col­leagues are over­worked, too. She has yet to find an out­side re­source who un­der­stands how over­whelm­ing the con­ver­gence of sex­ual-as­sault nar­ra­tives and an emer­gency depart­ment that op­er­ates at a break­neck pace can be.

Some­times the great­est chal­lenge of the job is qui­et­ing the voice in­side that com­pels Dhukai to save ev­ery woman who walks through the doors. “I wish I could just wrap them up in my arms and say, ‘Ev­ery­thing’s go­ing to be okay. Just come with me, my lit­tle duck­lings. I will take care of you,’” she says. “But I can’t.”

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