Doubt.

[The following is a composite description of a common scenario, and does not describe any individual patient.]



You are an emergency medical services provider. A woman walks into your facility stating that she's been raped.

There's a fairly extensive procedure for this. Immediate placement in a private room, contact the police, examine and treat injuries, do a rape kit, write a super-detailed report, treat everything as evidence and turn everything over to the police, and connect the victim to community resources to support her in the aftermath and recovery. And as a good provider, you want to follow this procedure to the letter and supplement it with as much victim advocacy and hand-holding as you can possibly spare time for. You know that your actions could make the difference between a rapist getting caught or going free, and between this woman being psychologically supported or devastated.

The problem is, the woman who says she's been raped is a psychiatric patient with numerous paranoid delusions. She's a "frequent flyer" at your facility and is well known for fabricating bizarre stories. Last week she was here because "the men are stealing my thoughts," the week before that she was here because "the CIA put a chip in my eyeball," and this week she says she's been raped.

The details she gives you are sketchy and inconsistent, but this is the case with everything she says, whether it's about the CIA or about where she sleeps at night. You know that mentally ill people are more vulnerable to rape, because they are less able to detect red flags and defend themselves--and because attackers know their stories will be doubted. But you also know that sexual abuse is a common paranoid delusion.

Taking a rape accusation seriously is, to be blunt, a huge pain in the ass. It'll cost tens of thousands of dollars that will never be paid back, and more importantly, it'll take up a tremendous amount of staff time--basically a nurse's entire shift and more than an hour of a doctor's time. This isn't your bon-bon eating time; this is coming out of the treatment of other patients. Every other patient in the facility, everyone suffering pain or distress or risk to their life, is going to have their care delayed because of this.

There's also tremendous staff resistance to playing along with delusions. The patient's assigned nurse argues that doing a rape kit (and all that entails) will encourage attention-seeking behavior and reinforce the patient's belief that her delusions are real. The nurse recommends the patient be evaluated for psychiatric treatment.

Last month, this woman came in claiming she was raped, you did a rape kit, and you found no evidence of rape and the police found no suspects. Doesn't mean she definitely wasn't raped then, just means there was no evidence. And now she's back again, with the same story.

What do you do?