Victim Centered Care (cont 5)
Accommodate patients’ requests to have a relative, friend, or other personal support person (e.g.,religious and spiritual counselor/advisor/healer) present during the exam, unless considered harmful by responders1
An exception would be if responders consider the request to be potentially harmful to the patient or the exam process.2 Patients’ requests to not have certain individuals present in the room should
also be respected (e.g., adolescents may not want their parents present). Examiners should get explicit consent from patients to go forward with the exam with another person present. When others are present,
appropriately drape patients and position additional persons. (It is also important to inform patients of
confidentiality considerations regarding the presence of support persons during the medical forensic history.
For a discussion of this topic, see C.4. The Medical Forensic History.)
Strive to limit the number of persons (beyond the patient, examiner, advocate, personal support person, and any necessary interpreters) in the exam room during the exam. The primary reason is to protect patients’ privacy, but also because exam rooms often cannot accommodate more than a few individuals. Law enforcement representatives should not be present during the exam. When additional health care personnel are needed for consultation (e.g., a surgeon), patients’ permission should be sought prior to their admittance. In cases in which examiners are supervising an examiner-in-training/licensed health care student, patients’ consent should be obtained prior to the student’s admittance to examine patients or observe the exam. It is inappropriate to ask patients to allow a group of nonlicensed medical students to view the exam. It is also inappropriate to ask patients about aspects of their health, body, legal status, or identity that are not related to the assault.
Accommodate patients’ requests for responders of a specific gender throughout the exam as much as possible.
For a variety of reasons, some patients may prefer to work with a male or female law enforcement official, advocate, and/or examiner.
Prior to starting the exam and conducting each procedure, explain to patients in a language the patients understand what is entailed and its purpose
In addition, it is important to explain the exam process and the purpose of the exam more generally (e.g., how the evidence may be used by the criminal justice system). A clear explanation is particularly important for individuals who may not previously have had a pelvic exam or medical care, or who have difficulty understanding what has happened and why they are being asked to undergo a medical forensic exam. Remember that some exam procedures may be uncomfortable and painful to patients, considering the nature of the trauma they have experienced. By taking the time to explain procedures and their options, patients may be able to better relax, feel more in control of what’s occurring, and make decisions that meet their needs. After providing the needed information, seek patients’ permission to proceed with exam procedures. (For a more detailed discussion on seeking informed consent of patients, see A.3. Informed Consent.)
Address and respect patients’ priorities
Although medical care and evidence collection may be encouraged during the exam process, responders should provide patients with information about all of their options and assess and respect their priorities. Integrate medical and evidentiary procedures where possible. Medical care and evidence collection procedures should be integrated to maximize efficiency and minimize trauma to patients. For example, draw blood needed for medical and evidentiary purposes at the same time. Also, coordinate information-gathering by health care and legal personnel to minimize the need for patients to repeat their statements. (For more information on coordination in information gathering, see C.4. The Medical Forensic History.) Consider the implications of the evolving law on hearsay exceptions when determining the level and nature of coordination. See Appendix C for more information on the relevant case law and how it relates to medical forensic examinations.
Address patients’ safety during the exam.
When patients arrive at the exam site, health care providers should assess related safety concerns. For example, a caretaker, partner, or family member who is suspected of committing the assault may have accompanied the patient to the facility. Some victims, including transgender people, may also fear assault or belittlement by health care professionals’ and/or law enforcement officials’ responses to their gender identity or expression and/or transgender body. Follow facility policy on response to this and other types of threatening situations. Also, exam sites should have plans in place to protect patients from exposure to potentially infectious materials during the examination. (See B.1. Sexual Assault Forensic Examiners.) Prior to discharge, assist victims in planning for their safety and well-being. Planning should take into account needs that may arise in different types of cases. For example, patients who know the assailants may not be concerned only about their ongoing safety but also about the safety of their families and friends. Local law enforcement may be be able to assist facilities in addressing patients’ safety needs. (See C.10. Discharge and Follow-up.)
Provide information that is easy for patients to understand, in the patient’s language, and that can be reviewed at their convenience.3
Information should be tailored to patients’ communication skill level/modality and language. This includes providing interpreter services and the translation of documents into languages other than English for limited English proficiency (LEP) patients. Developing material in alternative formats may be useful, such as information that is taped, in Braille, in large print, in various languages, or uses pictures and simple language.4 A victim booklet or packet that includes information about the following topics may be helpful:
The crime itself (e.g., facts about sexual assault and related criminal statutes).
Normal reactions to sexual assault (stressing that it is never the victim’s fault), and signs and
symptoms of traumatic response.
Victim support and advocacy services.
Civil, criminal, and immigration legal services.
Mental health counseling options and referrals.
Resources for the victim’s significant others.
The examination—what happened and how evidence/findings will be used.
Medical discharge and follow-up instructions.
Planning for the victim’s safety and well-being.
Examination payment and reimbursement information.
Steps and options in the criminal justice process.
Civil and immigration remedies that may be available to sexual assault victims.
Procedures for victims to access their medical record or applicable law enforcement reports.
Address physical comfort needs of patients prior to discharge.
For example, provide them with the opportunity to wash in privacy (offering shower facilities if at all possible5), brush their teeth, change clothes (clean and ideally new replacement clothing should be available); get food and/or a beverage,
and make needed phone calls. They may also require assistance in coordinating transportation from the exam site to their home or another location.
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1 Paragraph partially drawn from the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 15.
2 For example, in cases involving adolescents or vulnerable adults, caretakers should not be allowed in the exam room if they are suspected of committing the assault or of being otherwise abusive to the patient. 3 Many local sexual assault advocacy programs and state coalitions of sexual assault programs offer publications that speak to victims’ concerns in the aftermath of an assault. However, any involved agency, SART, or coordinating council could develop such literature. 4 For example, one sexual assault advocacy program offers a booklet “for those who read best with few words” designed for people with developmental disabilities who have been sexually assaulted. For more information on this publication, contact the Los Angeles Commission on Assaults Against Women by phone (213–955–9090) or e-mail email@example.com. 5 It would be useful for the exam room to have an attached bathroom with a shower.