Medical Treatment of Victims of Sexual Assault and Domestic Violence and Its Applicability to Victims of Human Trafficking. Practices and Procedures for Medical Professionals Serving Victims of Domestic Violence and Sexual Assault and Their Applicability to Human Trafficking

03/30/2010

Screenings

Domestic violence, like human trafficking, is considerably under reported in healthcare settings (Sugg, Thompson, Thompson, Maiuro, & Rivara, 1999).  One important tool for proper identification is comprehensive screening practices.  Healthcare and social service providers working in the area of domestic violence generally agree that healthcare providers should employ universal screening for domestic violence.  They note that while universal screening is recommended for all healthcare providers, it is particularly important for those working in primary care, urgent care, ob/gyn and family planning, mental health, and inpatient settings.  (Family Violence Prevention Fund, 1999; Institute for Clinical Systems Improvement, 2006).  Unlike many survivors of sexual assault, victims of human trafficking may not initially enter medical facilities as a direct result of their sexual assault due to their inability to access medical care during their captivity (Zimmerman et al., 2006); therefore, screening by medical providers in all healthcare settings is important to ensure proper identification and service provision.

A number of tools and guidelines currently are available to assist providers in identifying and interviewing both adult and juvenile victims of domestic violence and sexual assault.  Some of these tools, such as the Family Violence Prevention Funds suggested screening questions[2] and the American College of Emergency Physicians guidelines for interviewing children[3] provide a good foundation from which to screen for domestic violence in general and could be modified to incorporate screening questions for human trafficking.

Guidelines for identifying victims of domestic violence note that, similar to human trafficking, victims can be men, women, transgender, or come from a variety of backgrounds and experiences (Institute for Clinical Systems Improvement, 2006).  While some guidelines for domestic violence put the minimum age for screening at 14 (Family Violence Prevention Fund, 1999), healthcare providers should be aware that victims of human trafficking can be much younger; according to Estes and Weiner (2001) the average age of entry into prostitution in the United States is 12-14.

Guidelines for domestic violence screening suggest posting signs and literature to supplement routine screening and reinforce the healthcare setting as a safe place to seek assistance.  They also recommend conducting all screenings in private settings away from perpetrators who may accompany victims to healthcare settings (Institute for Clinical Systems Improvement, 2006).  These guidelines can be adopted for victims of human trafficking who may be accompanied by either male or female traffickers.

Examinations

A limited number of evidence-based clinical practices exist for the examination and treatment of victims of sexual assault.  This is due, in large part, to the limited number of experimental or quasi-experimental studies evaluating current examination and treatment practices (Agency for Healthcare Research and Quality [AHRQ], 2003).

Despite significant efforts to standardize care for victims of domestic violence, protocols and standards for proper examination vary greatly across facilities and States, particularly in the following areas: comprehensiveness of standardized protocols, procedures, and rape testing kits; use of trained providers and expert consultants; quality of examination facilities and technology; and capacity for DNA and drug testing (AHRQ, 2003).  One example of disparity in standards is the fact that some hospitals have special areas and/or separate facilities to examine victims of sexual assault and abuse.  Some of these hospitals even have age-appropriate facilities for children, as well as clothing for victims whose clothing is removed for evidentiary processing (AHRQ, 2003).  However, other hospitals lack a sufficient number of private examination rooms to ensure the privacy of all victims.  Since a number of these protocols and standards affect all victims of sexual assault, they likely will affect victims of human trafficking.

While universal screening for domestic violence is recommended across the healthcare field, the majority of guidelines for examination of victims of domestic violence, family violence, and sexual assault focus on the importance of evidentiary examinations.  During evidentiary examinations, healthcare providers assess the medical needs of victims while collecting evidence for law enforcement purposes (AHRQ, 2003; American College of Emergency Physicians, 1999).  Evidentiary exams typically involve: attainment of a patients medical history and description of the crime; assessment of psychological functioning; performance of a physical examination; collection, documentation, and preservation of evidence; collection of lab samples; treatment for medical needs; and referral for medical and psychological services (Littel, 2001). Further research is needed to determine the effectiveness of evidentiary examinations on victims of human trafficking, especially since it can often take significant time for victims of human trafficking to perceive that they are victims of a crime and trust someone enough to disclose their victimization.

The DVSA Tool Assesses 12 Personal and Relationship Issues
Commonly Faced by Victims of Intimate Partner Violence
  1. Accessing help from friends, family, and organizations
  2. Self-identity
  3. Self-efficacy to be on ones own
  4. Feelings and emotional response to abuse
  5. Mental health, stress, depression, and PTSD
  6. Seeking medical care for stress and injuries
  7. Triggers of abusive incidents
  8. Actions to manage partner abuse
  9. Actions to seek legal sanctions
  10. Attachment to the relationship
  11. Views of the relationship and options
  12. Managing loyalty to norms and own beliefs

Some protocols for evidentiary examinations, however, appear appropriate for victims of human trafficking.  For example, it is recommended that victims of sexual assault be examined in a private room and by trained medical providers.  Protocols also stress the importance of having a rape crisis advocate, medical health professional, social worker, or pastoral caregiver trained in crisis intervention present (American College of Emergency Physicians, 1999).

As with screening, a number of tools have been developed to assist with the evaluation of domestic violence and sexual assault.  The Domestic Violence Survivor Assessment (DVSA) tool assists healthcare practitioners and patients in identifying psychological processing of the abuse as well as movement toward a violence-free life (Dienemann, Glass, Hanson, & Lunsford, 2007). This tool can be used for victims of sex trafficking whose relationship with their trafficker emulates that of intimate partner violence.  Additionally, this and other tools can be modified for successful use with all victims who experienced sexual assault while they were trafficked.

Evidentiary exams should only take place after all emergency needs have been met, including appropriate protective action for victims who are actively homicidal or suicidal (American College of Emergency Physicians, 1999; Institute for Clinical Systems Improvement, 2006; Littel, 2001).  The decision regarding whether to conduct an evidentiary exam is often based on State laws and whether law enforcement and prosecutors feel it will be useful in court; however, evidentiary exams are never to be conducted without the written consent of the patient.  As with other medical procedures, evidentiary exams should never be done against a patients will (Littel, 2001).  Additionally, evidentiary examinations, as well as all medical and mental health examinations, should be based in culturally competent practices that respond to the cultural needs of the victim.  Particular care should also be taken when conducting examinations on children (AHRQ, 2003).  As previously mentioned, little is known regarding the effectiveness of evidentiary exams on victims of human trafficking; therefore, while guidelines for sexual assault and domestic violence can inform healthcare efforts related to human trafficking, further research is needed to assess their effectiveness with the trafficking victim population.

Sexual Assault Nurse Examiners

When not done by specialized trained professionals, evidentiary examinations can retraumatize victims (Littel, 2001).  Recognizing this, the first Sexual Assault Nurse Examiner (SANE) program was established in 1977 to train registered nurses to specialize in forensic examination of sexual assault victims.  By March 2001, SANE had grown to more than 400 programs (Ledray, 2001).  This growth can be attributed, in part, to the fact that many physicians do not wish to examine victims of sexual assault because they feel they lack the specialized training required for evidentiary examinations (AHRQ, 2003; Littel, 2001).

The SANE program can be adapted for various regions and medical settings, including hospital-based and community-based settings (Littel, 2001).  SANEs receive classroom and clinical training as well as certification on sexual assault (AHRQ, 2003; Littel, 2001).  As part of their training, SANEs are taught the skills to provide assistance to patients from the initial evidence collection through prosecution (Littel, 2001).  They are also trained to present forensic evidence at trial (Office for Victims of Crime, 1998).  SANEs are not victim advocates; their training is in forensic examination of sexual assault.  However, SANEs often collaborate with advocates to ensure that necessary crisis intervention, safety planning, and referrals are provided (Littel, 2001).

SANE and Human Trafficking

Most SANEs operate as members of a Sexual Assault Response Team (SART).  SARTs utilize a multi-disciplinary approach, bringing together healthcare providers, law enforcement, prosecution, victim advocates, and public health organizations (AHRQ, 2003).  SARTs oversee coordination of and collaboration among service providers as they relate to the initial response after a sexual assault. The goal is to ensure victim-centered service delivery and prevent revictimization (American College of Emergency Physicians, 1999; Littel, 2001).  This model may be similarly beneficial for victims of human trafficking who also tend to be connected to multiple service providers, requiring a victim-centered service delivery approach.  For example, members of SARTs could respond to cases of human trafficking through the same basic guidelines that they use to respond to cases of other forms of sexual assault.  Case managers on SARTs could familiarize themselves with the local community-based agencies serving this population and act as a liaison between these service providers and the SARTs, similarly to their coordination of service delivery for victims of domestic violence.  Additionally, in communities that have specific law enforcement units focused on the crime of human trafficking, SARTs could invite representatives from these units to become members of the SARTs.  While all SARTs follow basic unifying guidelines and principles, each is unique in its structure and composition; therefore, communities will need to asses the best way to integrate human trafficking into their current response system on an individual basis.  Future research, however, can help to identify best practices for how SARTs can effectively integrate human trafficking into their service delivery models.

SANE programs and SART models have dramatically enhanced the services provided to victims of sexual assault in communities throughout the United States (AHRQ, 2003; Littel, 2001).  SANE programs have proven to be so successful that the Office for Victims of Crime has facilitated replication of SANE programs by funding the creation of the SANE Development and Operation Guide. Additionally, a Web site has been developed where SANE/SART programs can register and receive assistance with analyzing their program data (Littel, 2001).

Documentation

A crucial component of evidentiary examinations is documentation.  Written records are not only used to describe physical injuries but also to address the emotional impact of the abuse.  Evidentiary examinations must document injuries in an accurate, comprehensive, and objective manner that can be submitted to a court of law.  Written records should document the time between the abuse and the time the exam is conducted as well as describe the patients demeanor.  It is suggested that when working with victims of sexual assault patients words should be set off in quotation marks; should not use phrases implying doubt, such as patient alleges; should only use medical terms rather than legal jargon; should not summarize the patients report; and should not refer to the perpetrator of the abuse with terms that might be used by the patient, such as my boyfriend. (American College of Emergency Physicians, 1999; Isaac & Enos, 2001).  Written reports should always be supplemented by photographs documenting physical injuries and body maps identifying the extent and location of the injuries.  When observations conflict with a patients statement, healthcare providers should record reasons for the differences (Isaac & Enos, 2001).  For example, if a patients injuries are consistent with being struck by an object but the patient reports falling down stairs this should be recorded and medical providers should document the specific elements of the injury that are consistent with the impact of an object and inconsistent with a fall.  The impact of such documentation techniques on legal cases involving human trafficking is still unknown; therefore, until this issue has been further explored, medical professionals are encouraged to consult local district attorney offices to determine the form of documentation that best protects the victims they work with.

In the case of children, it is valuable to document their chronological age as well as the developmental changes related to sexual maturing (American College of Emergency Physicians, 1999).[4]  Since it may take years for a case of human trafficking to be heard in court, this documentation will accurately inform the court of the childs age and development at the time of the violence or exploitation.

Protocols and procedures for evidentiary examinations tend to focus on sexual assault in which there is one perpetrator and/or one incidence of sexual assault.  Victims of human trafficking, especially sex trafficking, have often been sexually assaulted multiple times by various perpetrators during their captivity.  Additionally, one study conducted in the United States found that 28 percent of Russian women who were trafficked into the United States and 46 percent of U.S. citizens trafficked internally reported childhood incestuous sexual abuse (Raymond et al., 2002).  Significant time may have elapsed between the time of childhood incest as well as the time of the assaults and the evidentiary examination, resulting in reduced physical ramifications of the assaults.  Therefore, particular attention should be paid to documenting the statements of these patients and their accounts of the assaults.

Proper training is essential since documentation often plays such an important role in ensuring that patients receive appropriate and effective medical services.  Factual information obtained in evidentiary exams may qualify victims for special status or exemptions in obtaining public housing, welfare, health and life insurance, victim compensation, and/or immigration relief.  Additionally, documentation also plays a critical role in criminal proceedings.  Medical providers who are not trained in proper documentation may actually hinder victims cases by trying to remain neutral and unintentionally using language that subverts the case (Isaac & Enos, 2001).

Informed Consent

Informed consent is imperative for treating sexual assault victims.  Allowing victims to make informed decisions regarding their care can be an empowering first step toward recovery.  Informed consent should be obtained prior to each component of an evidentiary examination: physical examination, medical treatment, evidence collection, and photodocumentation.  Additionally, informed consent should be obtained before reporting the crime to law enforcement and transfer of evidence.  In cases regarding children, local and State law should be consulted to assess the need for parental consent (American College of Emergency Physicians, 1999).  With youth and children, attaining patient consent can give the same important sense of empowerment that consent can provide for adults.

Medical records for evidentiary examinations should be kept separate from patients other medical records to ensure limited access by authorized personnel (American College of Emergency Physicians, 1999).  Findings from evidentiary examinations are only released to law enforcement when victims provide consent or when it is mandated by law (AHRQ, 2003; American College of Emergency Physicians, 1999).  While all States have laws regarding mandatory reporting of child abuse, States vary with regard to reporting sexual assault (American College of Emergency Physicians, 1999).  Healthcare providers should be well versed regarding laws related to mandatory reporting of sexual assault in their jurisdiction.  In cases where victims are uncertain whether they want to file a police report, evidence can be collected and maintained per State statutes without being shared with law enforcement (Littel, 2001).

Coverage

While all 50 States and the District of Columbia have victim compensation programs to cover the cost of emergency medical assistance not covered by private insurers or other medical benefits (Office for Victims of Crime, 1998), many States have also passed specific laws protecting victims from having to pay for medical evidentiary examinations (AHRQ, 2003).  Some of these State laws limit coverage to victims who are willing to file a police report and/or cooperate in prosecution, while other States provide coverage to all victims regardless of any decision pertaining to prosecution (AHRQ, 2003; Office for Victims of Crime, 1998).  Despite laws protecting victims anonymity and mandating that victims not be charged for the cost of evidentiary exams, cases have been reported where claims have been submitted to third-party insurance companies, breaching victims rights to privacy.  In some of these cases, victims who were not the primary insurance holders have been forced to disclose the assault to the primary persons covered.  Additionally, numerous studies have found reports of victims being directly billed for evidentiary exams despite laws explicitly prohibiting this practice (AHRQ, 2003).  Healthcare workers and facilities serving victims of human trafficking should familiarize themselves with local and State laws pertaining to coverage for victims of sexual assault to ensure compliance and assess applicability to victims of human trafficking.

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