Victim Centered Care (cont 5)

Lesbian, gay, bisexual, or transgender (LGBT) victims

  • Intake forms and other documents that ask about gender or sex should allow patients to write in a response, or include transgender and intersex options. Make sure questions appropriately distinguish between sexual orientation (the gender(s) someone is attracted to), gender identity (the internal sense of being woman, man, or gender non-conforming), and their sex.

  • Always refer to victims by their preferred name and pronoun, even when speaking to others. Ifunsure of what to call the person or what pronoun to use, ask.

  • Treat the knowledge that the person is LGBT as protected medical information subject to all
    confidentiality and privacy rules. Be aware that companions of LGBT victims may not know their gender identity or sexual orientation.


Additional suggestions specific to victims who are transgender or gender non-conforming:

  •  It is critical to not show surprise, shock, dismay, or concern when you are either told or inadvertently discover that a person is transgender. Be especially careful about your body language – gasping, sighing, a sharp intake of breath, or widening eyes can all be very upsetting to someone who may worry that you are making a judgment or assessment of their body.

  • Understand that transgender people have typically been subject to others’ curiosity, prejudice, and violence. Keep in mind that transgender victims may be reluctant to report the crime or consent to the exam for fear of being exposed to inappropriate questions or abuse. If the victim does consent to an exam, be especially careful to explain what you want to do and why before each step, and respect their right to decline any part of the exam.

  • Be aware that transgender individuals may have increased shame or dissociation from their body. Some use nonstandard labels for body parts, and others are unable to discuss sex-related body parts at all. Reflect the victim’s language when possible and use alternative means of communication (such as anatomically correct dolls or paper and pen for the victim to write or draw) if necessary.

  • Vaginas that have been exposed to testosterone or created surgically are more fragile than vaginas of most non-transgender women and may sustain more damage in an assault. There may be additional layers of psychological trauma for patients with a male identity or a constructed vagina when they have been vaginally assaulted.

  • Transgender male individuals who still have ovaries and a uterus can become pregnant even when they were using testosterone and/or had not been menstruating.

  • Transgender people may engage in self-harm as a coping mechanism. However, cutting and genital mutilations are also frequently part of anti-transgender hate crimes. Be nonjudgmental and careful when documenting such injuries.

  • Some transgender victims may want to talk about their perceptions of the role their gender identity might have played in making them vulnerable to an assault. Because of their value in possible prosecutions under hate crime laws, document any anti-transgender statements the victim says were made during the assault. Otherwise, listen to the victim’s concerns and what the experience was like for them. Assure them that it was not their fault they were sexually assaulted. If needed, encourage discussion in a counseling/advocacy setting on this issue as well as on what might help them feel safer in the future.

  • Ensure that all referrals given to a transgender victim have been trained on or have significant experience with the special needs of transgender survivors of sexual assault.
    Include opportunities for LGBT individuals to influence the development of sensitive responses for victims of sexual assault.


Recognize the importance of victim services within the exam process

In many jurisdictions, sexual assault victim advocacy programs and other victim service programs offer a range of services before, during, and after the exam process (see below for a description of typical services). Ideally, advocates should begin interacting with victims in a language the victims understand prior to the exam, as soon after disclosure of the assault as possible. Victims who come to exam sites in the immediate aftermath of an assault are typically coping with trauma, anticipating the exam, and considering the implications of reporting. Most responders that victims come in contact with are focused on objective tasks. Law enforcement officials gather information and collect crime scene evidence to facilitate the investigation. Health care personnel assess medical needs, offer treatment, and collect evidence from victims. Victims must make many related decisions that may seem overwhelming. Advocates1 can offer a tangible and personal connection to a long term source of support and advocacy. Community-based advocates, in particular, have the sole purpose of supporting victims’ needs and wishes. Typically, these advocates are able to talk with victims with some degree of confidentiality, depending on jurisdictional statutes, while statements victims make to examiners become part of the medical forensic report.2 When community-based advocates support victims, examiners can more easily maintain an objective stance.3 In addition, civil attorneys may be able to help victims assess legal needs and options, including privacy, safety, immigration, housing, education, and employment issues.

Be aware of the extent of services. Services offered by advocates during the exam process may include: 4

  • Accompanying the victims through each component (advocates may accompany victims from the initial contact and the actual exam through to discharge and follow-up appointments).

  • Serving as an information resource for victims (e.g., to answer questions; explain the importance of prompt law enforcement involvement if the decision is made to report; explain the value of medical and evidence collection procedures; explain legal aspects of the exam; help them understand their treatment options for STIs, HIV, and pregnancy; serve as a resource and follow-up point of contact for any future inquiries such as payment method for the exams; and provide referrals).

  • Assisting in coordination of victim transportation to and from the exam site.

  • Providing victims with crisis intervention5 and support to help cope with the trauma of the assault6 and begin the healing process.

  • Actively listening to victims to assist in sorting through and identifying their feelings.

  • Letting victims know their reactions to the assault are normal and dispelling misconceptions regarding sexual assault.

  • Advocating for victims’ self-articulated needs to be identified and their choices to be respected, as well as advocating for appropriate and coordinated response by all involved professionals; Supporting victims in voicing their concerns to relevant responders.

  • Responding in a culturally and linguistically sensitive and appropriate manner to victims from different backgrounds and circumstances and advocating for the elimination of barriers to communication.

  • Providing replacement clothing when clothing is retained for evidence, as well as toiletries.

  • Aiding victims in identifying individuals who could support them as they heal (e.g., family members, friends, counselors, employers, religious or spiritual counselors/advisors, and/or teachers).

  • Helping victims’ families and friends cope with their reactions to the assault, providing information,< and increasing their understanding of the type of support victims may need from them.

  • Assisting victims in planning for their safety and well-being.


Postexam, advocates can continue to advocate for victims’ rights and wishes; offer victims ongoing support, counseling, 7 information, and referrals for community services; assist with applications for victim compensation programs;8 and encourage victims to obtain follow-up testing and treatment and take medications as directed. They can also accompany victims to follow-up appointments, including those for related medical care and criminal and civil justice-related interviews and proceedings. They can work closely with the responders involved to ensure that postexam services and interventions are coordinated in a complementary manner and are appropriately based on victims’ needs and wishes.
Contact the victim service/advocacy program immediately. Utilize a system in which exam facility personnel, upon initial contact with a sexual assault patient, call the victim service/advocacy program and ask for an advocate to be sent to the exam site (unless an advocate has already been called).9 Prior to introducing the advocate to a patient, exam facility personnel should explain briefly, in a language the patient understands, the victim services offered and ask whether the victim wishes to speak with the onsite advocate. Note that some jurisdictions require that patients be asked whether they want to talk with an advocate before the advocate is contacted.10 If possible, victims should be allowed to meet with advocates in a private place prior to the exam. Ideally, a patient should be assisted by the same advocate during the entire exam process.11

Understandably, immigrant victims may be reluctant to discuss or report the victimization. It is inappropriate to ask patients about aspects of their health, body, legal status, or identity that are not related to the assault.It is, however, appropriate to ensure that all victims are provided with information regarding U-Visas, in the event that this relief would be appropriate.12

 Table of Contents Victim Centered Care Accommodation

 

1 To prepare them to competently provide sexual assault victim services, community-based advocates are typically trained according to the policies of the sexual assault advocacy agency where they are employed/volunteer and receive supervision related to their interactions with victims. In addition, many jurisdictions have specific requirements that community-based advocates must meet in order to fit within jurisdictional confidentiality or privilege laws. Advocates should meet these requirements. System-based advocates may be required to have specific credentials based on system and jurisdictional policies and laws.< 2 K. Littel, SANE Programs: Improving the Community Response to Sexual Assault Victims, 2001, p. 6. 3 Ibid. See also IAFN position statement Dated Nov 19, 2008: Collaboration with Advocates. 4 This bulleted section was drawn partially from Iowa’s Sexual Assault: A Protocol for Forensic and Medical Examination, 1998, p. 7, and the 1989 Volunteer Manual of Virginians Aligned Against Sexual Assault (VAASA).< 5 Crisis intervention counseling is short term in nature, aimed at returning individuals to their precrisis state through the development of adaptive coping responses. Broadly, it entails establishing a relationship with the individual in crisis, gathering information about what is occurring, clarifying the problem, helping the individual identify options and resources so that they are able to make an informed decision as to what, if any, actions will be taken. (Adapted from the 1991 Women Helping Women Volunteer Training Manual,< Cincinnati, Ohio.) Note: Crisis intervention is not intended to address longer term counseling and advocacy needs.< 6 See A. Burgess and L. Holmstrom, Rape Trauma Syndrome, American Journal of Psychiatry, 131: 981-986, September 1974, for a summary of the psychological, somatic, and behavioral impact of sexual assault on victims.
7 Many advocacy agencies offer ongoing support and advocacy to victims. Some also provide professional mental health counseling, but many refer victims to community or private agencies.
8 For more information on crime victim’s compensation, please see http://www.ovc.gov/publications/factshts/compandassist/welcome.html. 9 Use community-based sexual assault victim advocates where possible. If not available, victim service providers based in the exam facility, criminal justice system, social services, or other agencies may be able to provide some advocacy services if educated to provide those services. Patients should be aware that government-based service providers typically cannot offer confidential communication.< 10 In very small communities, patients may know some or all advocates (e.g., a small, close-knit community that speaks an uncommon dialect). Some patients may feel comfortable being supported by an advocate known to them while others may not. Patients concerned about anonymity should be provided with as many options as possible. For example, ask if they would like to speak with an on-call advocate on the phone prior to making their decision about whether they want an advocate present during the exam. Another option may be for the local advocacy program to partner with an advocacy program in a neighboring jurisdiction, so they can provide one another with backup to handle situations such as this one.
11 Continuity of advocates can be challenging when response by other professionals is delayed, the exam process is lengthy, or travel to< the exam site is considerable. Volunteers may or may not be able to continue providing services after the end of their on-call shift. 12 Legal Momentum has extensive resources available regarding U-Visas. See: http://www.legalmomentum.org/our-work/immigrantwomen- program/u-visa.html. Additionally, immigrant women are entitled to emergency medical and post-assault healthcare. For a stateby-< state breakdown of the benefits afforded see: http://www.legalmomentum.org/assets/pdfs/4_nilc_table_10.pdf.