ASSESSING PATIENTS FOR SEXUAL VIOLENCE A GUIDE FOR HEALTH CARE PROVIDERS This project was supported by Grant Number 2009-TA-AX-K042, awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. The content of this publication may be reprinted with the following acknowledgement: This material was reprinted, with permission, from the National Sexual Violence Resource Center’s publication entitled Assessing patients for sexual violence: A guide for health care providers. This guide is available by visiting www.nsvrc.org © National Sexual Violence Resource Center 2011. All rights reserved. ASSESSING PATIENTS FOR SEXUAL VIOLENCE A GUIDE FOR HEALTH CARE PROVIDERS Sexual violence is a common experience in the lives of women and men. Current estimates suggest that one in six women and one in 33 men will experience attempted or completed rape (i.e., forced oral, anal, or vaginal penetration) in his or her lifetime (Tjaden & Thoennes, 1998). People who have been sexually victimized are more likely to suffer from chronic physical and mental health problems than those who have not been victimized, and believe that their health is fair or poor (Golding, Cooper, & George, 1997). Female survivors of sexual violence visit the doctor more often than women who have not been victimized (Rosenberg et al., 2000). Given the high rates of sexual violence and potential health impacts, it is therefore likely that most health care providers will come into contact with victims of sexual violence. A variety of tools and guidelines have been created Many prominent health organizations recommend to address the need for screening patients for that providers screen their patients for violence, histories of sexual violence. This guide aims including the American Medical Association, the to build on those tools and encourage health care World Health Organization, the American College providers to conduct full assessments with patients of Obstetricians and Gynecologists, the American to encourage interventions that provide adequate Academy of Pediatricians, and the American treatments and recommendations for survivors Nurses Association (Stevens, 2007). of sexual violence. A variety of tools and guidelines have been created to address the need for screening patients for histories of sexual violence. this guide aims to build on those tools and encourage health care providers to conduct full assessments with patients to encourage interventions that provide adequate treatments and recommendations for survivors of sexual violence. Assessing Patients While studies have shown that most female pateients want to be asked about thier experiences with sexual violcne by their health care privders (Littleton, Berenson, & Breitkopf, 2007), few medical professionals screen any patients, female or male, for such trauma (McAfee, 1995). This may be due to a lack of training, time, or comfort on the part of the health care provider (Stayton & Duncan, 2005). However, doctors' offices can be safe, confidential places to address sexaul violence in which survivors can feel comfortable disclosing and confident in receiving the care and services they need. Many prominent health organizations recommend that providers screen their patients for violence, including the American Medical Association, the World Health Organization, the American College of Obstetricians and Gynecologists, the American Academy of Pediatricians, and the American Nurses Accosiation (Stevens,2007). Although most of the current research and recommendations regarding screening patients for sexual violence focuses on women, some programs have begun screening both male and female patients with promising results. The Veterams Health Administration recently implemented a universal screening program for male and female veterams that provides free care for any patient experience conditions resulting from military sexual trauma (Kimerling, Street, Gima, & Smith, 2008). The program found that both men and women who screened positive for military sexual trauma were more likely to seek out mental health care after being screened than those who screened negative. How to discuss sexual violence Normalize the Topic I need to ask you some personal questions. Asking these questions can help me care for you better. Since I am your doctor, we need to have a good partnership. I can better understand your health if you would answer some questions about your sexual history.” I ask all of my patients this question because it is important for me to know what has gone on in their lives. Provide context to your questions We know that sexual violence is common in the lives of many women, men, girls, and boys. Connect sexual violence to the patient’s physical health and well being Sexual violence can affect a person’s health. Ask about sexual experiences that were unwanted or made the person feel uncomfortable Have you ever been touched sexually against your will or without your consent? Have you ever been forced or pressured to have sex? Do you and your partner ever disagree about sexual things? Like what? How do you resolve these conflicts? Do you feel that you have control over your sexual relationships and will be listened to if you say “no” to having sex? (Pennsylvania Coalition Against Rape[PCAR], 2005) Screening patients is only one step in the process. A full assessment requires that health care providers also develop plans and protocols for what to do when a patient discloses incidents of sexual victimization. Developing assessment protocols Health care providers should develop protocols that ensure consistent, effective practices for providing care to patients that experience sexual violence. One promising tool that can aid providers in these efforts is the SAVE method, which was developed by the Florida Council Against Sexual Violence (2003). -Screen all of your patients for sexual violence -Ask direct questions in a non-judgmental way -Validate your patient’s response -Evaluate, educate and make referrals Protocols should stipulate that patients be assessed regularly (e.g., annually), as this will give patients multiple chances to disclose victimization and allow time for the patient to develop a trusting relationship with the provider (Stevens, 2007). Medical providers are encouraged to consider their professional ethics and organizational policies in order to form protocols which safeguard the privacy of victims and survivors in every aspect of their practice, including documentation and information sharing with other providers. The decision to document disclosures of sexual violence, in particular, should be carefully considered. Trainings and consultations for medical providers on this topic are available through sexual violence prevention and services centers and state coalitions against sexual violence. Health care providers should avoid • Asking patients about their victimization when other people are present • Only asking patients who “seem” like victims about their experiences• Using the term “rape,” as some survivors may not label their experience as rape (Pittsburgh Action Against Rape, 2007) • Using formal, technical, or medical jargon (Stevens, 2007) • Only asking about specific types of violence or recent violence (PCAR, 2005) • Expressing value judgments If a patient discloses sexual violence Clearly describe to patients what your reporting requirements are and what information might be included in their medical records so that they can make informed decisions about what they disclose. Demonstrate through body language that you are listening to your patient’s response. Respond with validating messages that allow the patient to feel heard and believed. Some examples: “I’m really sorry that happened to you.” “That sounds like it was a terrifying experience.” “I’m really glad you had the courage to tell me.” “I want you to know it wasn’t your fault.” When documenting responses in a medical chart, use the patient’s own words. Evaluate the patient’s needs -Is the patient in current danger? -If the assault happened recently, does the patient want a forensic exam to be performed? -If the assault happened within the past 120 hours, and the patient is female, does the patient want emergency contraception? -Does the patient need or want prophylaxes for HIV or other sexually transmitted infections? -Does the patient have acute injuries that need medical attention? -Do special accommodations need to be made to make the patient feel safe? -Does the patient need to schedule a follow-up appointment? -Does the patient wish to speak with a sexual assault advocate? Provide education (verbally and in writing) about violence and health issues Make referralsy The Rape, Abuse, and Incest National Network (RAINN) offers a hotline (1-800-656-HOPE) which refers victims to local rape crisis centers. -The NSVRC’s Directory of Sexual Assault Centers in the United States, contains contact information for sexual assault crisis centers and state, territory, and tribal coalitions in the United States and its territories. www.nsvrc.org or 877-739-3895. -Crime victim compensation programs are often able to provide financial support to victims of violence for medical expenses and other costs that arise as a result of the crime. A directory of these programs is available online at http://www.ovc.gov/ publications/infores/intdir2005/welcome.html (Office for Victims of Crime, 2005). If the patient does not disclose sexual violence Offer education and prevention information and provide follow-up at next visit. Collaborating with community partners Collaborating with local sexual violence experts is key to successful assessment and support for victims. Each program in such collaborations can provide the others with referrals, professional in-services, trainings, public education/outreach, and specialized services. For example, state sexual violence coalitions and community-based sexual violence prevention and services centers are often able to provide publications that can help health care providers educate patients about sexual violence. Collaborations can ensure that sexual violence assessments are effective while strengthening the community effort to identify and respond to victims of sexual violence. Selected assessment instruments The CDC has compiled a list of instruments that can be used to screen for sexual violence entitled Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Health care Settings (Basile, Hertz, & Back, 2007). Instruments outlined in this document include: -Abuse Assessment Screen (AAS) - Five items that assess physical, sexual, and emotional abuse. -Screening Tools-Sexual Assault - Five items that assess sexual assault and knowledge of risk reduction strategies. -Sexual and Physical Abuse History Questionnaire - Six of the items in this scale assess sexual abuse. -Two-Question Screening Tool - One of two items assesses sexual violence. -Universal Violence Prevention Screening Protocol - Five items that assess recent physical, sexual, and emotional abuse. -Victimization Assessment Tool - Five items that assess a variety of kinds of violence, including sexual violence. Resources for providers -Screening Patients for Sexual Violence, a CD tutorial program http://www.pcar.org/long-term- health-effects-sexual-assault-and-rape -Put down the chart, pick up the questions: A guide for working with survivors of sexual violence, http://www.pcar.org/sites/default/files/ file/healthcare/put-down-the-chart.pdf -National Sexual Violence Resource Center, www.nsvrc.org -Centers for Disease Control and Prevention, www.cdc.gov REFERENCES Basile, K. C., Hertz, M. F., & Back, S. E. (2007).Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare settings: Version 1. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/ncipc/dvp/IPV/IPVandSV-Screening.pdf Florida Council Against Sexual Violence. (2003). SAVE: Screening Your Patients for Sexual Assault. Tallahassee, FL: Author. Golding, J. M., Cooper, M. L., & George, L. K. (1997). Sexual assault history and health perceptions: Seven general population studies. Health Psychology, 16, 417-425. doi:10.1037//0278-6133.16.5.417 Kimerling R., Street, A. E., Gima, K., & Smith, M. W. (2008). Evaluation of universal screening for military-related sexual trauma. Psychiatric Services, 59, 635-40. doi:10.1176/appi.ps.59.6.635 Littleton, H. L., Berenson, A. B., & Breitkopf, C. R. (2007). An evaluation of health care providers’ sexual violence screening practices. American Journal of Obstetrics & Gynecology, 196, 564e1-564e7. doi:10.1016/j.ajog.2007.01.035 McAfee, R. (1995). Physicians and domestic violence: Can we make a difference? JAMA, 273, 1790–1791. doi:10.1001/ jama.1995.03520460072039 Office for Victims of Crime. (2005). Directory of international crime victim compensation: 2004-2005. Washington, DC: U.S. Department of Justice, Office of Justice Programs. Retrieved from http://www.ovc.gov/publications/infores/ intdir2005/welcome.html Pennsylvania Coalition Against Rape. (2005). Put down the chart, pick up the questions: A guide to working with survivors of sexual violence. Enola, PA: Author. Retrieved from http://www.pcar.org/sites/default/files/file/healthcare/ put-down-the-chart.pdf Pittsburgh Action Against Rape. (2007). Screening patients for sexual violence: An accredited curriculum for nurses in Pennsylvania. Enola, PA: Pennsylvania Coalition Against Rape. Retrieved from http://www.pcar.org/sites/default/files/ file/healthcare/Screening-Patients-for-Sexual-Violence.pdf Rosenberg, H. J., Rosenberg, S. D., Wolford, G. L., Manganiello, P. D., Brunette, M. F., & Boyton, R. A. (2000). The relationship between trauma, PTSD, and medical utilization in three high risk medical populations. International Journal of Psychiatry in Medicine, 30, 247-259. Stayton, C., & Duncan, M. (2005). Mutable influences on intimate partner abuse screening in healthcare settings: A synthesis of the literature. Trauma, Violence, & Abuse: A Review Journal, 6, 271-285. doi:10.1177/1524838005277439 Stevens, L. (2007). Screening for sexual violence: Gaps in research and recommendations for change. Harrisburg, PA: National Online Resource Center on Violence Against Women. Retrieved from http://new.vawnet.org/Assoc_Files_ VAWnet/AR_ScreeningforSV.pdf. Tjaden P., & Thoennes, N. (1998). Prevalence, incidence and consequences of violence against women: Findings from the National Violence Against Women Survey. Washington, DC: U.S. Department of Justice, National Institute of Justice. Retrieved from http://www.ncjrs.gov/pdffiles/172837.pdf