Category: Sexual Assault

Apologies for missing the 1st half of the week, but I had my hands full with our Leadership Training and Lobby Day, which was a fantastic couple of days. And now, seeing as April is Sexual Assault Awareness Month, a totally appropriate posting for the 1st one I’m managing this #SAAM2017. And featuring my friends, no less. OVCTTAC is sponsoring a Q&A with Susan Chasson and Jennifer Pierce-Weeks on building an effective SANE program. The session will be held April 19th at 2pm ET.  From the registration:

Providing comprehensive health care to survivors of sexual assault is critical to minimizing the long-term consequences of this traumatic experience. That is where a Sexual Assault Nurse Examiner (SANE) can help. This session will focus on how to start or improve a SANE program in your community with OVC’s SANE Program Development and Operation Guide. Now available online at https://www.ovcttac.gov/saneguide.

Understanding the landscape of sexually transmitted infections in your community is a critical part of effectively caring for sexual assault patients. National treatment guidelines are well and good, but if the clinical picture is different where you are, then adapting those guidelines becomes a necessity. To that end, Indian Health Services has an upcoming webinar that should be helpful for those providing care in Indian Country–Sexually Transmitted Infections: Epidemiology in Indian Country and Screening and Treatment Recommendations. The session will be held April 14th at 3pm ET. CEs are available for nurses.

Outcomes:

At the end of this presentation, participants will be able to:

1. Summarize the epidemiology of STIs in Indian Country.
2. Apply appropriate standard screening and treatment recommendations for STIs to help increase screening rates in Indian Country.
3. Identify the special populations and their different STI testing needs to increase case finding in those populations and in turn reduce total STI burden.

The National Criminal Justice Training Center has a webinar coming up, Best Practices in Communicating with Survivors of Sex Trafficking. The session will be held March 23rd at 2pm ET. The session will:

…[provide] an overview of trauma-informed techniques for communicating with victims and survivors of sex trafficking. Gather strategies for building rapport and fostering open communication for the various professionals that victims of sex trafficking interact with in justice, advocacy, and recovery.

Register for the webinar here.

SAFEta has a webinar coming up in May (bless you, Kim for your advanced planning and scheduling)–Informed Consent for Sexual Assault Exams: It Is Not Just a Signature, It’s a Process. The session will be held May 2nd at 2pm ET. From the announcement:

Sexual assault victims must provide informed consent for a medical forensic exam. Although the concept of informed consent is a term that healthcare providers are very familiar with, there are additional legal implications associated with consent for the exam that providers need to understand. Victims need relevant information on the impact of participating in or declining each component of the exam.

Register here.

PreventConnect has a webinar coming up, Public Health Approach to Preventing Human Trafficking. The session will be held 23 March from 2-3:30 pm ET. Their webinars tend to fill, so if you’re interested I would encourage you to register quickly.  From their site:

A recently published book, Human Trafficking Is a Public Health Issue: A Paradigm Expansion in the United States, is the first book of its kind, with a comprehensive look – from a public health perspective – at human trafficking in the US. This web conference will explore the problematic nature of human trafficking in our communities through the public health lens and how it is linked to sexual violence and domestic violence. We will identify fundamental types and essential elements of human trafficking to consider and incorporate while developing primary prevention programs. We will also highlight examples of anti-human trafficking prevention work being pursued by community health organizations and discuss strategies and actionable goals to create programs to prevent human trafficking in your communities.

You can register here.

NSVRC has a new research translation available (PDF) that summarizes a CDC study on sexual identity and health-related behaviors of high school students. The report found that students who identify as gay, lesbian, or bisexual face significant health disparities. This is a critical issue in our work, as we evaluate the healthcare needs of our patients at the time of the exam and as part of the discharge and referral process. And NSVRC has made it easier to understand and apply the research–here are some other research translations if you’re interested:

Key Findings from Sexual Violence Victimization and Associations with Health in a Community Sample of African American Women

Key Findings on Sexual Violence from the “Global status report on violence prevention 2014”

And while this isn’t a research translation, it is a research brief to which I still refer folks (even though it’s from 2012) since the information is still relevant:

Sexual Violence and Health: Research Brief (PDF)

{Related: new JAMA Pediatrics article, Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts (Full-Text)}

A reader recently asked about the risk of STDs in cases where the patient reported only oral penetration. She wanted to know what the recommendations were around counseling patients, and which infections, in particular, were concerning. The CDC actually has a fact sheet on this issue (that includes where the research is lacking), and while the information is meant for the lay public, it does a nice job of providing an overview of the issue that would certainly be useful to clinicians, as well. And you know I do love me a good references section, which this one has. So if nothing else, check it out for a deep dive on the STD literature. Recently updated, too.

In case you missed the release of this a couple weeks ago, the Office on Violence Against Women published a white paper, Sexual Assault Kit Testing and Non-investigative Kits (PDF). Per their description: “This report presents reasons why the Office on Violence Against Women cautions against submitting sexual assault kits to forensic laboratories if the person from whom the kit was collected has not chosen to report a sexual assault to law enforcement and has not otherwise consented to its submission.” Many communities are debating the issue of how to handle untested kits right now, so it’s worth your time to both read and share with members of your SART for an upcoming meeting. It’s well articulated and well-referenced, and best of all, it’s relatively brief.

The US Department of Health and Human Services, Office on Trafficking in Persons has been offering their SOAR to Health and Wellness training to clinicians, social workers and public health professionals, and the next healthcare provider session will be on March 9th.

Contrary to the rather nonspecific name, this training specifically [E]quips professionals with skills to identify, treat, and respond appropriately to potential victims and survivors of human trafficking.

By applying a public health approach, SOAR seeks to build the capacity of communities to identify and respond to the complex needs of victims and survivors of human trafficking and understand the root causes that make individuals, families, and communities vulnerable to trafficking.

After attending SOAR training, you will be able to:

• Stop – Describe the scope of human trafficking in the United States
• Observe – Recognize the verbal and non-verbal indicators of human trafficking
• Ask – Identify and interact with victims and survivors of human trafficking using a victim-centered and trauma-informed approach
• Respond – Respond effectively to potential human trafficking in your community by identifying needs and available resources to provide critical support and assistance

The sessions are held online and in person, but to my knowledge tey are not archived, so if you want the training it must be done on the date offered. Registration is not yet available, but keep checking back for the link.

OJJDP is hosting a webinar, Understanding the Complexities of Commercial Sexual Exploitation, January 30th from 2-3:30pm ET. From the announcement:

In support of National Slavery and Human Trafficking Prevention Month in January 2017, OJJDP, in conjunction with MANY and the Wichita State University Center for Combating Human Trafficking (CCHT), will present an interactive webinar to deepen participants’ understanding of commercial sexual exploitation.

This 90-minute workshop will discuss specific circumstances that put individuals at risk of victimization and what helps them survive, and even thrive, despite experiences of abuse and exploitation.

Participants will have the opportunity to consider the pervasive impacts (biological, physical, psychological, and spiritual) on persons affected by commercial sexual exploitation and celebrate the resiliency evident in the journey from victim to survivor. Participants also will learn about tangible, intentional, and responsible actions that can be taken to support those affected.

You’ll also want to check out this recently published article from the AMA Journal of Ethics (FULL-TEXT)

The Tribal Forensic Healthcare project has 2 free, upcoming webinars: Funding for Forensic Exams–VAWA 2013 Requirements and VOCA (2/13); and Evidence Integrity–Keeping It Safe (3/14). They will both be archived if you aren’t available on those dates. CEUs/CMEs are available for both.

Register for Funding for Forensic Exams

Register for Evidence Integrity

{Once again, let me preface this by saying I am not the definitive authority on this topic. I am one woman with an opinion who provides care to adult and adolescent domestic violence and sexual assault patients. At the end of the day, you need to decide the best course of action to take for your practice and patient population. Hopefully, this spurs some discussion, where needed, as that is its intent.}

So I was asked by an FHO reader if I would comment on the best way to document the narrative portion of the history. That is, the history of the patient’s chief complaint. Always up for stepping into the abyss, I said, sure–why not? After all, it comes up in pretty much every single testimony workshop I teach.

Perhaps the best way to begin this discussion is by saying, I don’t necessarily believe there is one right way to document the narrative history of the assault. Some of you out there write down everything the patient says, verbatim. I think that’s weird, but I don’t necessarily think it’s wrong.

Why do I think it’s weird? Because I personally can’t listen to a patient and also transcribe everything the patient says. When I do that, I miss all the rich, non-verbal communication that happens, and that impacts patient care. But that’s just me. Also, most people aren’t terribly accurate at capturing every single word the patient says, which I imagine defeats the purpose of choosing that method in the first place. So for me, it feels like a missed opportunity to connect with a patient as a person (and not a crime scene or a complainant), and begin the process of assessing their well-being.

My preference is to summarize, except where my summary couldn’t possibly do justice to the patient’s account of events or state of mind (threats, fear, etc.). Then I add quotes. This gets me where I need to be to take care of this patient in the most comprehensive way possible. And since the purpose of obtaining the narrative history of the assault is to guide my exam process, focus any sample collection the patient may desire, and inform the patient-specific discharge and follow-up plan, I don’t feel like I could more effectively accomplish any of that if I wrote down what the patient said verbatim.

I do think there are some wrong ways to approach narrative documentation, though (and I see them all in my travels):

1. Having the patient write it out for you (and even worse, having them sign it). This is not medical documentation. And doing this says that the end goal is litigation rather than good quality patient care. If you want to tell me it’s to avoid inconsistencies between what the patient reported to law enforcement and what the patient tells us, I’m going to call BS on that right now–1.) not all of our patients even engage with law enforcement, and some will do so long after the exam; and 2.) I challenge people under duress to write down details of a traumatic event and then several hours later, in a different environment with different people looking over your shoulder, do it again–now see how many inconsistencies are there.
2. Obtaining the narrative history of the assault from law enforcement rather than the patient. Except in extraordinary circumstances (e.g. patient is brought in unresponsive and you take a report from the police) I can’t come up with a justification for this approach.There are reasons patients tell healthcare providers different details than they tell law enforcement–they may feel more comfortable with us; they may believe there’s a different purpose for providing the info (and there is); we don’t have a gun on our hip at the time we’re caring for them. Also, how many times have you gone into a patient’s room to get a history, and then had them provide totally different information when another physician or nursing colleague went in to see them? Exactly. People are not machines. Different questions elicit different responses, even when focused on the same event. Inconsistencies are both expected and explainable.
3. Never having it (and the rest of the medical-forensic documentation) peer-reviewed. Some sort of quality assurance/quality improvement process is a must. How do you know you are providing comprehensive, appropriate care and hitting identifiable benchmarks for quality if your work is never reviewed?

So if I was going to summarize, I’d say this: if you have a clinical rationale for documenting in your particular style, you’re probably just fine (assuming your work is also being peer-reviewed). If your approach to documentation of the narrative history is dictated by any non-clinician professionals (e.g. law enforcement or prosecutors like you to document in a certain way), or you see its purpose as being primarily for the investigation and prosecution of the reported crime, I think that’s problematic. And if your approach simply doesn’t resemble healthcare at all, well, it may be time to reassess.

OVCTTAC has a revamped website with a dedicated section to SANE-SART resources. It includes the SANE Program Development and Operation Guide, among other resources. It is a multimedia site, so there are videos, as well as archived webinars on a variety of topics. Worth perusing for sure.

The Battered Women’s Justice Project has an upcoming webinar, Nonconsensual Pornography: Circulating Sexual Violence Online. The session will be held January 24th from 2-3:30pm CT. From the website:

Pornography, much like sexual violence, is pervasive, especially in online spaces and has evolved to include content that is both consensually produced and disseminated as well as that which is not. Accordingly, in this webinar, presenter Amber Morczek will define nonconsensual pornography (often referred to as ‘revenge porn’), how it impacts victims, what is being done to address it, and how it relates to rape culture.

Register for the webinar here. Note: space is limited.

I received a question from a reader about choosing a training for prospective members of her SANE team. She had heard that there were some trainings out there that didn’t meet eligibility requirements for SANE certification and wanted to avoid them, but wasn’t sure what to look for. I agree that not only is it important to identify training that meets certification eligibility criteria, it’s also important to have some sense about quality in general (I promise you–not all SANE trainings are equal). So I encourage everyone to refer back to this guest post from 2009, which is as relevant today as it was more than 7 years ago (make sure to read the comments, too). Considering the sheer number of new subscribers we’ve had just in the past 2 months, it’s probably worth posting again, regardless. Enjoy!

{Post edited to update links.}

EVAWI just put out a bulletin on the neurobiology of trauma (PDF) that, while geared toward investigators, can serve as a good primer on the issue for clinicians, as well. From the email announcement:

…[T]his 38-page document provides basic information about the brain and explores the impact of trauma on behavior and memory. It then highlights the implications for law enforcement interviews conducted with victims of sexual assault and other traumatic crimes.  

The training bulletin was written by Dr. Chris Wilson, Dr. Kim Lonsway, and Sgt. Joanne Archambault (Ret.), with contributions by Dr. Jim Hopper. It was reviewed by experts from a variety of professional disciplines, including psychology, law enforcement, and prosecution. We hope you find it to be a useful resource, to enhance your understanding of these critical issues. 

With an understanding of how the brain responds to trauma, and an appreciation for how trauma affects memory encoding, storage and recall, we now have the potential to become truly “trauma informed” in our interviewing practices.  

I think the reference section is particularly useful for clinicians, especially those testifying as an expert on this issue. However, to be clear, I am very skeptical of most forensic nurses testifying as experts on this topic unless they know the science backward and forward–that means being able to speak to the literature that challenges some of these ideas, as well as the literature that supports it. (I feel like I’m pretty well-versed in this issue; I do not provide expert testimony on it.) Reading a monograph like this, or attending a training, does not make one an expert. It’s useful information to help understand patient behavior and the workings of the brain in the face of trauma, but proceed cautiously with how you use it in court.

Don’t forget we have a giveaway going on this week. See all the details here.

The National Resource Center on Justice Involved Women has a webinar coming up next week: The Intersection Between Prostitution, Human Trafficking, and Victimization Among Justice Involved Women. The session will be held November 1st from 2-3:30pm ET.

From the site:

It is estimated that 90% percent of justice involved women have experienced some form of victimization in their lifetime. As a result of this trauma, women may engage in behaviors that are criminalized, such as drug use or prostitution, and may be less commonly seen as “victims” by the justice system. What’s more, their vulnerability may expose them to further victimization, trauma, and exploitation — such as human trafficking.

The NRCJIW, in partnership with the Center for Court Innovation, will conduct a webinar on November 1 to explore the nexus between prostitution, human trafficking, and victimization among justice involved women. The webinar will discuss strategies that justice system stakeholders can take to identify women who may be victims of exploitation and human trafficking, address their needs, and improve their response to these women.

Register now for this informative webinar to take place on Tuesday, November 1 from 2:00 – 3:30 pm Eastern.