Victim Centered Care (cont)

Give sexual assault patients priority as emergency cases.

This includes a prompt medical screening exam. Recognize that every minute patients spend waiting to be examined may cause loss of evidence and undue trauma. Individuals disclosing a recent sexual assault should be quickly transported to the exam site, promptly evaluated, treated for serious injuries, and offered a medical forensic exam. (For more discussion on this topic, see C.2. Triage and Intake.) Have plans for what to do, if the examiner is not available right away. For example, is there a quiet, private place the patient can wait? Is there a phone available so the patient can talk to an advocate or a friend or family member while waiting? Jurisdictions should consider policies and training for facility staff and administration regarding what to do while sexual assault patients are waiting.

 

Provide the necessary means to ensure patient privacy

Exercise discretion to avoid the embarrassment for individuals of being identified in a public setting as a sexual assault victim. Some health care facilities use code plans to avoid inappropriate references by staff to sexual assault cases. Also, do not leave sexual assault patients in the main waiting area at the exam site. Instead, give them as much privacy as possible (e.g., a private treatment room and waiting area) and be cognizant of their sense of safety (e.g., do not examine suspects in same location at the same time). Make sure that the first responding health care providers attend to patients’ initial medical needs and arrange for an on-call advocate to offer onsite support, crisis intervention, and advocacy. It may be useful to give patients the option of speaking with an advocate via a 24-hour crisis hotline (if one exists) until an advocate arrives. Health care providers should provide patients with access to a phone to contact family members and/or support persons as desired, and should promptly contact law enforcement, if not already involved, if patients want to report the assault. Health care providers should explain, in a language the patients understand, the scope of confidentiality during the exam process and during communication with advocates. (For information on this topic, see A.4. Confidentiality.)

Adapt the exam process as needed to address the unique needs and circumstances of each patient.

Patients’ experiences during the crime and the exam process, as well as their post-assault needs, may be
affected by multiple factors, such as:

  • Age
  • Gender and/or perceived gender identity/gender expression.
  • Physical health history and current status.
  • Mental health history and current status.
  • Disability.
  • Language needs for limited English proficient patients, Deaf and hard-of-hearing individuals, and
    those with sensory or communication disabilities.
  • Ethnic and cultural beliefs and practices.
  • Religious and spiritual beliefs and practices.
  • Economic status, including homelessness.
  • Immigration and refugee status.
  • Sexual orientation.
  • Military status.
     History of previous victimization.
  • Past experience with the criminal justice system.
  • Whether the assault involved drugs and/or alcohol.
     Prior relationship with the suspect, if any.
  • Whether they were assaulted by an assailant who was in an authority position over them.
     Whether the assault was part of a broader continuum of violence and/or oppression (e.g., intimate
    partner and family violence, gang violence, hate crimes, war crimes, commercial sexual exploitation,
    sex and/or labor trafficking).
  • Where the assault occurred.
  • Whether they sustained physical injuries from the assault and the severity of the injuries.
  • Whether they were engaged in illegal activities at the time of the assault (e.g., voluntary use of illegal
    drugs or underage drinking) or have outstanding criminal charges.
  • Whether they were involved in activities prior to the assault that traditionally generate victim blaming
    or self-blaming (e.g., drinking alcohol prior to the assault or agreeing to go to the assailant’s home).
     Whether birth control was used during the assault (e.g., victims may already have been on a form of
    birth control or the assailant may have used a condom).
  • Capacity to cope with trauma and the level of support available from families and friends.
     The importance they place on the needs of their extended families and friends in the aftermath of the
    assault.
  • Whether they have dependents who require care during the exam, were traumatized by the assault,
    or who may be affected by decisions patients make during the exam process.
  • Community/cultural attitudes about sexual assault, its victims, and offenders.
  • Frequency of sexual assault and other violence in the community and historical responsiveness of
    the local justice system, health care systems, and community service agencies.

Clearly, the level of trauma experienced by patients can also influence their initial reactions to an assault and
to post-assault needs. While some may suffer physical injuries, contract an STI, or become pregnant as a
result of an assault, many others do not. The experience of psychological trauma will be unique to each
patient and may be more difficult to recognize than physical trauma. People have their own method of coping with sudden stress. When severely traumatized, they can appear to be calm, indifferent, submissive, jocular,angry, emotionally distraught, or even uncooperative or hostile towards those who are trying to help.1


Examiners should ensure they do not make credibility determinations based on myths or misconceptions about victim behavior.

In addition, patients’ fears and concerns can affect their initial reactions to the assault, their post-assault needs, and decisions before, during, and after the exam process. For example, female and transgender patients may be worried about getting pregnant. If they are already pregnant or have just given birth, they may be concerned about how the assault will affect their children. Patients may be concerned about being infected with HIV or another STI. They may not want anyone to know about the assault, or may be afraid that family members and friends will reject or blame them. They may fear bringing shame to their families or be concerned that family members will seek revenge against the assailant. They may fear perceived consequences of reporting to law enforcement. They may be concerned how their cultural background could affect the way they are treated by responders. They may wonder if the assailant will harm or harass them or their loved ones if they tell anyone about the assault. They may worry about losing their home, children,ability to remain in the United States, job, and other sources of income as a result of disclosure, particularly if an intimate partner assaulted them.2  They may be concerned about costs related to the exam and subsequent care of injuries.3

It is important to avoid making assumptions about patients, offenders, and the assault itself. Forms used during the exam process and discussions with patients should be framed in a way that does not assume they are of a specific background or gender identity and gender expression. Always ask questions and actively look and listen to understand patients’ circumstances and tailor the exam process to address their needs and concerns. Whatever the response, it should be respectful to patients and adhere to jurisdictional policies.

Recognize that patients control the extent of personal information they share. While it is useful for
responders to get a full picture of patients’ circumstances, it is up to patients to decide whether and to what
extent to share personal information. During the exam process, responders may ask patients to divulge
some data, such as age or whether they think the assault was alcohol- or drug-facilitated. Some information,
such as language needs, may be obvious. There is no reason for responders to question patients about
certain data, such as sexual orientation and gender identity, immigration status, or religious or spiritual
beliefs, beyond certain information that medical providers may need for appropriate care.

 Table of Contents Victim Centered Care
Culturally Responsive Care

1 Paragraph adapted from Iowa’s Sexual Assault: A Protocol for Forensic and Medical Examination, 1998, pp. 1–4.
2 Minors may fear being removed from their homes if suspects live with them. Persons living in residential settings, such as group
homes or nursing facilities, may fear being removed from their homes if they report an assault that occurred in that setting.
3 Paragraph partially adapted from the Ohio Protocol for Sexual Assault Forensic and Medical Examination, 2002, p. 2.