Transcript Medical Concerns for Survivors

Medical Concerns for
Survivors
There are likely to be several medical
concerns for survivors of sexual assault.
They commonly include:
 pregnancy
 sexually transmitted infections
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Pregnancy
The risk of pregnancy following a sexual
assault is dependent upon the
 Nature of the assault,
 Time of the assault in relation to
menstrual cycle
 Current use of contraception
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Survivors should receive information,
counseling, and/or referral with regard to
all options.
Emergency Contraception
Emergency contraception prevents an egg
from being fertilized and/or implantation.
 EC will not affect a pre-existing
pregnancy. It is equivalent to a larger dose
of birth control pills.
 Ideally, it should be taken within 72 hours
of the sexual assault, and in some cases
can be taken up to five days (120 hours)
following an assault.
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Emergency Contraception
Emergency contraception, most commonly
“Plan B”, should be available as part of the
forensic exam, and is a covered expense
of the exam.
 Hospitals are required by law (RCW RCW
70.41.350 & WAC 246-320-370) to provide
EC to victims of sexual assault.
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Emergency Contraception
EC is also legally available without a prescription
from a pharmacist.
 For survivors who choose not to have a forensic
exam or seek other medical treatment, this is an
option.
 Advocates should be aware medical providers
may offer up unhelpful or harmful judgments or
statements when a survivor seeks EC.
 Survivors under the age of 17 will need a
prescription (Ella can be taken 5 days after
assault but requires a prescription for those
under 18.)
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Emergency Contraception
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Though emergency contraception is not abortion, some
medical facilities and some pharmacists have attempted
to refuse to provide certain treatment due to a moral
stance. Ralph’s and Bay View do not offer EC.
Legally, as long as the survivor has a prescription, the
pharmacist must provide EC if it is in stock (in
Washington.) It is legal to not stock EC.
The Washington State Department of Health has a
website devoted to emergency contraception. It has
factsheets and flyers:
http://www.doh.wa.gov/cfh/FPRH/EC.htm
Sexually Transmitted
Infections
While a survivor’s first medical concerns may be
directed at physical injuries and possible
pregnancy, there is also concern about the
possibility of STI’s.
 It may be a sensitive topic or the survivor may
know little about it. You may have to bring the
subject up, since exposure and prevention will
be an issue during the medical exam.
 STI’s are one of the most common kinds of
infections in American today. Every year more
than 10 million Americans get STI’s passed
primarily by sexual contact.
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Sexually Transmitted
Infections
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As part of the medical examination, the
examiner may prescribe STI prophylaxis.
Follow-up tests should be conducted for
gonorrhea culture in 3 to 8 days, a test for
syphilis in 6 to 8 weeks, and a HIV test in
3 months.
Measures Survivors Can Take
Self-examination for signs of possible
infection
 Going for screening tests at appropriate
intervals and
 Following any prescribed treatment when
diagnosed with an STI
 Making sure they have been cured by
getting tested during the follow-up after
treatment
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HIV/AIDS
Sexual assault victims should not be tested for
HIV during the forensic exam. An HIV/AIDS test
at this time would only provide information on
whether or not a victim already has HIV/AIDS,
not if she or he contracted HIV from the assault.
 Also, someone who has just been sexually
assaulted is most likely not in the proper mental
and emotional state to receive pre-test
counseling for HIV.
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HIV/AIDS
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A healthcare provider can help victims
assess immediate risks and whether HIV
prophylaxis is warranted. Post exposure
prophylaxis must be determined on an
individual basis. Be aware that
prophylactic medications for HIV are
highly toxic, and the regimen is difficult.
High risk factors for contracting
HIV
Anal rape
 Vaginal rape when other STDs are present
that would threaten the integrity of the
vaginal muscosa
 Vaginal rape with traumatic tearing injury
 Known or suspected HIV positive offender
 Known or suspected IV-drug use by the
offender
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Anonymous Testing
There are two common methods of HIV
testing: anonymous and confidential.
 Anonymous testing sites have no way of
connecting a person's name and address
with the test information. Those who
present for testing are given a code, which
has to be remembered in order to find out
the test results. (UCAN)
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Confidential Testing
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Confidential testing sites record the names and
addresses of those who are being tested.
This information is then documented in the person's
medical records.
Even if the test is negative, the medical file will still state
that an HIV test was performed.
However, no one can give out patient results without
permission, except as required by law. (Planned
Parenthood)
Anonymous testing is strongly recommended over
confidential testing in order to protect the survivor’s
privacy.
Crime Victim’s Compensation
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In all of the United States (VAWA 2007) a survivor is not
required to report the incident to the police, in order to
seek a forensic exam.
In the state of Washington, a victim should never be
billed for the forensic exam itself regardless of whether
he chooses to report the assault to law enforcement.
(RCW 7.68.170-No costs incurred by a hospital or other emergency medical facility for
the examination of the victim of a sexual assault, when such examination is
performed for the purposes of gathering evidence for possible prosecution, shall be
billed or charged directly or indirectly to the victim of such assault. Such costs shall
be paid by the state pursuant to this chapter. )
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The exam is performed, evidence is stored (duration
depends on several local factors), and a police report
can be made at a later time if the survivor chooses.
CVC
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Payment for services may be a major concern. Washington State’s
Crime Victim’s Compensation Act is a secondary insurer who will
cover expenses for the forensic exam even if there is no intention to
follow through with prosecution.
Crime Victim’s Compensation (CVC) covers the cost of all Sexual
Assault Forensic Exams in WA State. It is important for advocates to
know that survivors DO NOT need to complete a CVC application to
receive this benefit, it should be automatic.
The victim must file a CVC claim to have associated care covered.
For example, if I was raped and broke my arm CVC would pay for
the forensic exam but may or may not pay for the broken arm. A
separate claim would need to be filed.
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This can be done at a later time, when the survivor is
not in crisis. Be prepared to assist the victim with CVC
forms. If they are not available at the hospital, be sure
and have one on hand.
Separately and in addition to the forensic exam, the
Crime Victims Compensation (CVC) program may
provide financial assistance to eligible crime victims,
including medical bills, therapy, time loss, and vocational
rehabilitation.
The rate of approved claims and amount of coverage
varies year to year depending on the program’s budget.
CVC is a payer of last resort, meaning that all other
coverage options must be exhausted before the program
kicks in.
Eligibility Criteria for CVC
– Crime must occur in Washington State
– Must be gross misdemeanor or felony
– Crime must be reported to law enforcement within one year or
within 12 months of when it could have reasonably been
reported
– Claim must be filed with CVC within two years of reporting to
law enforcement or, with good cause, five years
– Victim must cooperate with law enforcement
– Injury cannot be result of consent; injury was not provoked
– Victim cannot be incarcerated
– Victim who has been convicted of a felony (violent crime or
crime against persons) within the last five years and has not
paid legal obligations
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For the latest eligibility criteria and
process, visit:
http://www.lni.wa.gov/ClaimsIns/CrimeVic
tims/About/default.asp
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These stipulations can be a challenge to survivors and
the denial rate may be a source of frustration to
organizations and individuals. It is important to talk
about the criteria for coverage, application process, and
other options for financial assistance.
Remember, the forensic exam is always automatically
covered and emergency contraception is included. The
law requires every hospital emergency room, regardless
of religious affiliation, give sexual assault victims truthful
information about emergency birth control (also known
as the morning-after pill) and give them the pills if they
request them, free of charge.
Advocacy Role Plays
After The Exam
The survivor may change clothes, receive
instructions, and get prescriptions.
 Be sure written instructions are received since
they are under extreme emotional stress and
may forget verbal instructions.
 Make notes on follow-up form so that SAAS
knows what they might want info about. What
do they feel their most important needs are?
What were most of their questions about? If the
SAAS knows then she can have info researched
and ready when she does follow-up.
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There may be difficulties in leaving the hospital.
The survivor may be afraid to leave, or may
have no transportation. St. Pete’s has cab
vouchers and can arrange this. Feel free to ask
the survivor if they would like you to inquire
about it with ER staff.
 Sometimes SP has cabs, bus tickets and gas
cards. Contact HelpLine or supervisor. You may
need to leave the survivor to pick up any of
these items for them and bring them back.
Never give a client a ride; it is SafePlace policy.
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As an Advocate You Can…
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Help the survivor sort through fears about leaving
Check to see what support base they can now turn to
Inform client of available and accessible support systems
in the community which may be needed
Make sure they know about Crime Victims Compensation
Set up a follow-up call in a few business days if they
want. Make sure you find out if it is okay to say
SafePlace when we call and to leave a message. If not
ask how they would like us to identify: doctor’s office,
counselor, friend?
Make sure they have and understand
information about sexually transmitted infections
 Make sure a client who could become pregnant
has made an informed choice about emergency
contraception
 Make sure there is a safe place for the survivor
to go
 Let the client know advocacy services are
available as needed
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Try not to overwhelm the survivor. Be
sensitive to the process they just went
through. Be careful to never give medical
advice or sharing any information you may
know about medicine.
Medical Advocacy with
Children
Locally, children are often taken to the Children’s
Advocacy Center (Monarch) by their caregivers
upon learning that sexual abuse has occurred,
regardless of when it happened.
 We use the name Monarch Children's’ Justice
and Advocacy Center even though we are really
talking about the Sexual Assault Clinic. Which is
housed in the same building. The SAC is a warm
and child-friendly office. The providers working
there have extensive training in child sexual
assault.
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The dynamics of working with a child can be
very different from working with adults.
Reassure the parent/caregiver that the medical
assessment children experience is similar to their
child’s regular medical exams.
 Monarch does not do internal evidence collecting
with any of their clients even if the survivor is an
older teen. They use a machine that magnifies
and records the medical examination which
allows medical providers to obtain the evidence
they need.
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Besides documenting the history, health status,
and injuries associated with the sexual
assault/abuse and identifying any potential
evidence, the exam is important to assure the
child themselves that they are not “broken” or
“damaged.”
 It is normal to be normal. Meaning, only about
20% of children have medical findings that
indicate sexual assault/abuse. This does not
mean sexual assault/abuse did not happen!
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There may be situations where it is
advisable to have an advocate for the
child (especially if they are 10 or older)
and a separate advocate for the
parent/caregiver. This can help ensure
that each survivor/secondary survivor
receives adequate support unique to their
needs.
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Many of the same objectives exist for the
teen victim of sexual assault as for the
adult victim in the medical setting:
– Support throughout the exam
– Discuss options around STIs and pregnancy
– Maintain appropriate records/paperwork as
directed by your agency’s protocols
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Initiate follow-up health care and
advocacy if appropriate
However, even with teens who can
consent to medical services, mandated
reporting is still obligatory, so some of the
dynamics will be different.
 There will be more systems to navigate –
law enforcement, child protective services,
hospital social workers, and parents.
 It is very important to become familiar
with your county’s child abuse protocols.
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Be upfront with your obligation to report
as soon as you know the survivor you are
supporting is under age. Tell them that
without identifying information, you are
not able to report and that they can
decline to give identifying information and
still receive support from advocates. (This
is harder in person but on the HelpLine is
very doable.)
When working with children/teens,
remember the assault was likely
perpetrated by someone they know – they
may be feeling guilty and sad.
 Help to alleviate fears and concerns. Keep
things age-appropriate. Stay calm.
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Parents, who are generally as traumatized
as the child, also need reassurance,
guidance and warnings not to magnify the
situation in front of the child. This is often
where we find ourselves spending most of
our time. It is EXTREMELY common for
parents to have been abused as children.
Examination of adolescents should not be done without
their consent unless there is a life-threatening
emergency.
 Teens 14 and over can provide consent for services
themselves. However, know the protocols of the
hospital/CAC doing the exams. Some will see younger
children under the “birth control services” exemption.
RCW9.02.100(1)(2)
 As a rule, the provider should not abdicate their
obligation on mandatory reporting to an employee from
a different agency.
 Sometimes the medical provider may contact law
enforcement or CPS prior to your arrival or without the
child’s or caregiver’s knowledge.
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Secondary Survivors
Many people may accompany the survivor to the
hospital. It is important for the advocate to
know who the survivor wants with them at the
forensic exam or medical assessment.
 This is stressful time for all involved. If the
secondary survivor is not acting in ways that are
supportive, an advocate can provide them with
resources and information which might help
them be more supportive. It can also be helpful
to model appropriate support.
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The survivor needs to be in control of when and
how family and friends are told.
 The secondary survivor may be a parent, lover,
partner, husband, sibling, roommate, friend,
employer or teacher. This person will influence
the recovery process so supporting the
secondary survivor is providing them with
resources to support the survivor.
 Secondary survivors, as well as primary
survivors, need to be counseled and supported.
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You must maintain confidentiality for whomever
you are an advocate for.
 Be cautious that the significant other may be the
perpetrator. For example, a man who has just
beaten and raped his daughter may take her to
the hospital.
 We provide support to significant others also, as
secondary victims. Sexual assault is like a bomb
going off. The survivor is the detonation point,
but those around are hit by the shrapnel,
causing trauma also.
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Make sure and address that secondary
survivor as a client too. Offer support and
follow-up. Often, this person wants
information and has questions. Offer
reading materials from SARP packet and
ask if they need additional support that
you can write down for the SAAS.