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This project was supported by Grant Number 2009-TA-AX-K042, awarded by the Office on Violence AgainstWomen, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed inthis 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 wasreprinted, with permission, from the National Sexual Violence Resource Center’s publication entitled Assessingpatients for sexual violence: A guide for health care providers. This guide is available by visiting National Sexual Violence Resource Center 2011. All rights reserved.

ASSESSING PATIENTSFOR SEXUAL VIOLENCEA GUIDE FOR HEALTH CARE PROVIDERSSexual violence is a common experience in the lives of women and men. Current estimates suggestthat one in six women and one in 33 men will experience attempted or completed rape (i.e., forcedoral, anal, or vaginal penetration) in his or her lifetime (Tjaden & Thoennes, 1998). People who havebeen sexually victimized are more likely to suffer from chronic physical and mental health problems thanthose 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 beenvictimized (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 createdto address the need for screening patients forhistories of sexual violence. This guide aimsto build on those tools and encourage health careproviders to conduct full assessments with patientsto encourage interventions that provide adequatetreatments and recommendations for survivorsof sexual violence.Assessing patientsWhile studies have shown that most femalepatients want to be asked about their experienceswith sexual violence by their health careproviders (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, orcomfort on the part of the health care provider(Stayton & Duncan, 2005). However, doctors’offices can be safe, confidential places to addresssexual violence in which survivors can feelcomfortable disclosing and confident inreceiving the care and services they need.Many prominent health organizations recommendthat providers screen their patients for violence,including the American Medical Association, theWorld Health Organization, the American Collegeof Obstetricians and Gynecologists, the AmericanAcademy of Pediatricians, and the AmericanNurses Association (Stevens, 2007).Although most of the current researchand recommendations regarding screeningpatients for sexual violence focuses on women,some programs have begun screening bothmale and female patients with promisingresults. The Veterans Health Administrationrecently implemented a universal screeningprogram for male and female veterans thatprovides free care for any patient experiencingconditions resulting from military sexualtrauma (Kimerling, Street, Gima, & Smith,2008). The program found that both menand women who screened positive for militarysexual trauma were more likely to seek outmental health care after being screened thanthose who screened negative.A Guide for Health Care Providers1

How to discusssexual violenceNormalize the TopicI need to ask you some personal questions.Asking these questions can help me care foryou better. Since I am your doctor, we need to have agood partnership. I can better understandyour health if you would answer somequestions about your sexual history. ” I ask all of my patients this question becauseit is important for me to know what has goneon in their lives.Developing assessmentprotocolsHealth care providers should develop protocolsthat ensure consistent, effective practices forproviding care to patients that experience sexualviolence. One promising tool that can aid providersin these efforts is the SAVE method, which wasdeveloped by the Florida Council Against SexualViolence (2003).Provide context to your questionsyyScreen all of your patients for sexual violence We know that sexual violence is common inyyAsk direct questions in a non-judgmental waythe lives of many women, men, girls, and boys. onnect sexual violence to the patient’sCphysical health and well being Sexual violence can affect a person’s health. sk about sexual experiences thatAwere unwanted or made the personfeel uncomfortable Have you ever been touched sexually againstyour will or without your consent? Have you ever been forced or pressuredto have sex? Do you and your partner ever disagree aboutsexual things? Like what? How do you resolvethese conflicts? Do you feel that you have control over yoursexual relationships and will be listened to if yousay “no” to having sex?(Pennsylvania Coalition Against Rape [PCAR], 2005)2Screening patients is only one step in the process.A full assessment requires that health careproviders also develop plans and protocols forwhat to do when a patient discloses incidents ofsexual victimization.Assessing Patients for Sexual ViolenceyyValidate your patient’s responseyyEvaluate, educate and make referralsProtocols should stipulate that patients be assessedregularly (e.g., annually), as this will give patientsmultiple chances to disclose victimization andallow time for the patient to develop a trustingrelationship with the provider (Stevens, 2007).Medical providers are encouraged to considertheir professional ethics and organizationalpolicies in order to form protocols whichsafeguard the privacy of victims and survivorsin every aspect of their practice, includingdocumentation and information sharing withother providers. The decision to documentdisclosures of sexual violence, in particular,should be carefully considered. Trainings andconsultations for medical providers on this topicare available through sexual violence preventionand services centers and state coalitions againstsexual violence.

Health care providersshould 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 judgmentsIf a patient discloses sexual violenceClearly describe to patients what your reportingrequirements are and what information mightbe included in their medical records so thatthey can make informed decisions about whatthey disclose.Demonstrate through body language thatyou are listening to your patient’s response.Respond with validating messages thatallow 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 needsy Is the patient in current danger?y If the assault happened recently, does thepatient want a forensic exam to be performed?y If the assault happened within the past 120hours, and the patient is female, does thepatient want emergency contraception?y Does the patient need or want prophylaxes forHIV or other sexually transmitted infections?y Does the patient have acute injuries that needmedical attention?y Do special accommodations need to be madeto make the patient feel safe?y Does the patient need to schedulea follow-up appointment?y Does the patient wish to speak witha sexual assault advocate?Provide education (verbally and in writing) aboutviolence and health issuesMake referralsy The Rape, Abuse, and Incest NationalNetwork (RAINN) offers a hotline(1-800-656-HOPE) which refers victims to local rape crisis centers.A Guide for Health Care Providers3

y The NSVRC’s Directory of SexualAssault Centers in the United States,contains contact information for sexualassault crisis centers and state, territory,and tribal coalitions in the United States and its territories. www.nsvrc.orgor 877-739-3895.y Crime victim compensation programsare often able to provide financial supportto victims of violence for medical expensesand other costs that arise as a result ofthe crime. A directory of these programsis available online at /welcome.html(Office for Victims of Crime, 2005).If the patient does not disclose sexual violenceOffer education and prevention informationand provide follow-up at next visit.Collaborating withcommunity partnersCollaborating with local sexual violenceexperts is key to successful assessment andsupport for victims. Each program in such collaborations can provide the others withreferrals, professional in-services, trainings,public education/outreach, and specializedservices. For example, state sexual violencecoalitions and community-based sexual violenceprevention and services centers are often ableto provide publications that can help healthcare providers educate patients about sexualviolence. Collaborations can ensure that sexualviolence assessments are effective whilestrengthening the community effort to identifyand respond to victims of sexual violence.4Assessing Patients for Sexual ViolenceSelected assessmentinstrumentsThe CDC has compiled a list of instruments thatcan be used to screen for sexual violence entitledIntimate Partner Violence and Sexual ViolenceVictimization Assessment Instruments for Use inHealth care Settings (Basile, Hertz, & Back, 2007).Instruments outlined in this document include:yy Abuse Assessment Screen (AAS) - Five itemsthat assess physical, sexual, and emotional abuse.yy Screening Tools-Sexual Assault - Five itemsthat assess sexual assault and knowledge ofrisk reduction strategies.yy Sexual and Physical Abuse HistoryQuestionnaire - Six of the items in this scaleassess sexual abuse.yy Two-Question Screening Tool - One of twoitems assesses sexual violence.yy Universal Violence Prevention ScreeningProtocol - Five items that assess recentphysical, sexual, and emotional abuse.yy Victimization Assessment Tool - Five itemsthat assess a variety of kinds of violence,including sexual violence.Resources for providersyy Screening Patients for Sexual Violence, a CDtutorial program -assault-and-rapeyy Put down the chart, pick up the questions:A guide for working with survivors of sexualviolence, hcare/put-down-the-chart.pdfyy National Sexual Violence Resource Center,www.nsvrc.orgyy Centers for Disease Control and Prevention,

REFERENCESBasile, K. C., Hertz, M. F., & Back, S. E. (2007).Intimate partner violence and sexual violence victimization assessmentinstruments for use in healthcare settings: Version 1. Atlanta, GA: Centers for Disease Control and Prevention, NationalCenter for Injury Prevention and Control. Retrieved from g.pdfFlorida 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 generalpopulation studies. Health Psychology, 16, 417-425. doi:10.1037//0278-6133.16.5.417Kimerling 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/, H. L., Berenson, A. B., & Breitkopf, C. R. (2007). An evaluation of health care providers’ sexual violencescreening practices. American Journal of Obstetrics & Gynecology, 196, 564e1-564e7. doi:10.1016/j.ajog.2007.01.035McAfee, R. (1995). Physicians and domestic violence: Can we make a difference? JAMA, 273, 1790–1791. doi:10.1001/jama.1995.03520460072039Office 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 /welcome.htmlPennsylvania Coalition Against Rape. (2005). Put down the chart, pick up the questions: A guide to working withsurvivors of sexual violence. Enola, PA: Author. Retrieved from hcare/put-down-the-chart.pdfPittsburgh Action Against Rape. (2007). Screening patients for sexual violence: An accredited curriculum for nurses inPennsylvania. Enola, PA: Pennsylvania Coalition Against Rape. Retrieved from senberg, H. J., Rosenberg, S. D., Wolford, G. L., Manganiello, P. D., Brunette, M. F., & Boyton, R. A. (2000). Therelationship between trauma, PTSD, and medical utilization in three high risk medical populations. InternationalJournal of Psychiatry in Medicine, 30, 247-259.Stayton, C., & Duncan, M. (2005). Mutable influences on intimate partner abuse screening in healthcare settings: Asynthesis of the literature. Trauma, Violence, & Abuse: A Review Journal, 6, 271-285. doi:10.1177/1524838005277439Stevens, 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 FilesVAWnet/AR ScreeningforSV.pdf.Tjaden P., & Thoennes, N. (1998). Prevalence, incidence and consequences of violence against women: Findings from theNational Violence Against Women Survey. Washington, DC: U.S. Department of Justice, National Institute of Justice. Retrieved from Guide for Health Care Providers5

123 North Enola Drive, Enola, PA 17025Toll free: 877-739-3895 resources@nsvrc.orgOn Facebook: On Twitter:

y Is the patient in current danger? y If the as sault happened recently, does the patient want a forensic exam to be performed? y If the as sault happened within the past 120 hours, and the patient is female, does the patient want emergency contraception? y Doe s the patient need or want prophylaxes for HIV or other sexually transmitted infections?

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