Victim Centered Care (cont 3)
- Help male victims understand that male sexual assault is not uncommon and that the assault was not their fault. Many male victims focus on the sexual aspect of the assault and overlook other elements such as coercion, power differences, and emotional abuse. Broadening their understanding of sexual assault may help reduce their self-blame.
- Because some male victims may fear public disclosure of the assault and the stigma associated with male sexual victimization, emphasis may need to be placed on the scope of confidentiality of patient information during the exam process.
- Offer male victims assistance in considering how friends and family members will react to the fact that they were sexually assaulted (e.g., by a male offender or a female offender).
- Male victims may be less likely than females to seek and receive support from family members and friends, as well as from advocacy and counseling services. Their ability to seek support may vary according to the level of stigmatization they feel, the circumstances of the assault, the sensitivity of care they initially receive, and the appropriateness of referrals provided.
- Encourage advocacy programs and the mental health community to build their capacity to serve male sexual assault victims and increase their accessibility to this population. Requests by male victims to have an advocate of a particular gender should be respected and honored if possible.2
- Adolescents may be brought to the exam site by their parents or guardians. The presence of parents or guardians creates an additional challenge for those involved in the exam process because they are often traumatized by their child’s victimization.
- Understand that parents or guardians may blame victims for the assault if the victim disobeyed them or engaged in behaviors perceived as increasing risk for victimization.
- Health care providers must assess the physical development of adolescent victims and take their age into consideration when determining appropriate methods of examination and evidence collection.4 Involved professionals should be well versed in jurisdictional policies related to response to minor victims.
- Be aware of jurisdictional laws governing minors’ ability to consent to forensic exams and medical treatment. Follow exam facility and jurisdictional policy in obtaining appropriate consent. (For a more detailed discussion on seeking informed consent of patients, including consent by victims from specific populations, see A.3. Informed Consent.)
- Recognize that the sexual assault medical forensic exam may be the first time an adolescent female victim has an internal exam. There may be a need to go into detail when explaining what to expect.4
Adolescence is often a time of experimentation. Reassure these victims that regardless of their behavior (e.g., using alcohol and drugs, engaging in illegal activities, or hitchhiking), no one has the right to sexually assault them, and they are not to blame for the assault.
Ideally, attending health care providers should gather information from adolescents without parents or guardians in the room, subject to victims’ consent. The concern is that parents or guardians may influence or be perceived as influencing victims’ statements.
Inform victims, particularly those who do not involve parents or guardians in the exam process, of facility billing practices (e.g., that their parents may get a bill from the medical facility for medical treatment provided or an explanation of benefits from their insurance provider).6
Be aware of mandatory reporting laws regarding minor victims and explain to the victim any mandatory reporting obligations.
- Keep in mind that the emotional impact of the assault may not be felt by older victims until after the exam when they are alone in the days, weeks, and months following an attack. Older victims may feel common trauma reactions such as being physically vulnerable, reduced resiliency, and mortality.Fear, anger, and depression can be especially severe in older victims who are isolated, have little support, and live on a fixed or limited income.
Be aware that caretakers may sexually assault older adults. Older adults may be dependent on these sexual offenders for emotional or financial support or housing. Offenders may bring victims tot he exam site. Some offenders may be charming to staff while others may be threatening or menacing. Jurisdictional and facility policies should be in place to provide guidance on how staff should screen for and handle situations that are threatening to patients or facility personnel.
- Note that older victims may be more physically fragile than younger victims and thus may be at risk for tissue or skeletal damage and exacerbation of existing illnesses and vulnerabilities.8
Hearing impairment and other physical conditions attendant to advancing age, coupled with the initial trauma reaction to the assault, may render some older victims unable to make their needs known,which could result in prolonged or inappropriate treatment. 9
Do not mistake disabilities (such as hearing loss or aphasia) or acute stress reaction following assault for senility. Use of appropriate communication remedies, for example, a personal listening device, may enable an older adult with a severe hearing loss to communicate effectively. Also, be aware that older adults typically process information more slowly than younger adults and take longer to put their thoughts into words. This is a normal age-related change and should not be viewed as evidence of lack of mental capacity. Health care professionals treating elders need to speak slowly and clearly and give elders ample time to process information provided and formulate responses. If questions about the victim’s capacity arise, contact trained experts to conduct an assessment.
If a forensic medical exam has been requested by a law enforcement officer, guardian, or other authority, it is still important to obtain the victim’s consent and cooperation to forensic evidence gathering procedures. Those making the request may argue that evidence collection may be especially important because the victim may be unable to provide a statement or testify. However, when victims lack capacity and are unable to provide consent and cooperation, they should not be forcibly examined or subjected to forensic procedures that are not necessary for their own health and safety.
Health care personnel should follow facility policy for assessing a vulnerable adult’s ability to consent
to the exam and evidence collection, as well as involving adult protective services.
Some older victims may want to talk about their perceptions of the role their age and physical condition might have played in making them vulnerable to an assault. Others may be traumatized by being harmed sexually by a family member or trusted caregiver. Listen to their concerns and what the experience was like for them.10 Assure them that it was not their fault they were sexually assaulted. If needed, encourage further discussion on this issue in a counseling/advocacy setting.
Some older victims may be reluctant to report the crime or seek treatment because they fear losing their independence. Some older sexual assault victims may need a significant amount of time to recover from injuries that are the result of the abuse or attack. When a change in a living environment, such as placement in a residential facility, is truly needed, older victims who have not been adjudicated as lacking mental capacity and requiring guardians have the legal right to make their own decisions regarding choice of residence. Health care providers must avoid colluding with relatives who want to force older adults into unwanted lifestyle changes subsequent to assault.
Older adults who have been sexually assaulted in care facilities often experience intense feelings of vulnerability in those facilities following sexual assault and desperately want to be relocated. Elders who rely upon others for care are likely to need the assistance of relatives and involved professionals in being safely relocated.
Encourage use of follow-up medical, legal, and nonlegal assistance. Older victims may be reluctant to seek these services or proceed with prosecution. If barriers to accessing services or ongoing health care exist, such as lack of transportation, work with local service providers to identify potential remedies.
|Table of Contents||Victim Centered Care (cont 4)|
1 Drawn partially from L. Ledray, SANE Development and Operation Guide, 2000, p. 79. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf. 2 A national resource for male patients is Male Survivor: The National Organization Against Male Sexual Victimization. Contact information: PMB 103, 5505 Connecticut Avenue, NW, Washington, DC 20015–2601, 800–738–4181, http://www.malesurvivor.org. 3 Adapted partially from the West Virginia Protocol for Responding to Victims of Sexual Assault, 2011, pp. 26–27. http://www.fris.org/Resources/PDFs/Books/WVProtocol.pdf. 4 For example, the size of the speculum used with adolescent female victims and exam positions of victims may vary. 5 Drawn partially from L. Ledray, SANE Development and Operation Guide, 2000, p. 7. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf. 6 Drawn partially from L. Ledray, SANE Development and Operation Guide, 2000, p. 98. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf. 7 Ibid.
8 Older women are at an increased risk for vaginal tears and injury when they have been vaginally assaulted. Decreased hormonal levels following menopause result in a reduction in vaginal lubrication and cause the vaginal wall to become thinner and more friable. Because of these physiological changes, a Pedersen speculum, which is longer and thinner than the Graves speculum, should be used< during the pelvic exam for evidence collection. Special care should also be taken to assess for intravaginal injury. In some older women, examiners will need to simply insert the swabs and avoid the trauma of inserting a speculum. If there are external tears in the introitus, internal injuries must also be considered. The recovery process for older victims also tends to be longer than for younger victims. (Drawn partially from L. Ledray, SANE Development and Operation Guide, 2000, p. 86-87. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf.) 9 Drawn partially from L. Ledray, SANE Development and Operation Guide, 2000, p. 87. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf. 10 Drawn partially from L. Ledray, SANE Development and Operation Guide, 2000, pp. 82-85. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf.