This lecture is going to cover direct medical care for the survivor of gender based violence. The objectives are to describe the preliminary, non-forensic assessment of clinical needs. We also will explain how to obtain consent from an adult as well as minor patients. We're also going to demonstrate how to conduct a patient-centered assessment and describe appropriate documentation of the assessment process. So we'll start with preliminary clinical needs assessment. Sexual assault should always be considered a priority, regardless of whether physical injuries are present. We should always make sure that we use a private area for intake as well as assessment, and always see that patients are alone when we're able to see them. We must be flexible and inquisitive about this however, because there's always going to be some sort of requests that need to be weighed to understand the benefit for the patient. So we're going to accommodate any requests for a trusted friend or family member to stay with the survivor. And then we're going to make sure that we verify in private that the survivor truly wants to be accompanied by that person. I'd like to take the time to acknowledge that male victims are certainly a piece of this survivor piece of puzzle. Triage and assessment for male victims is essentially going to be the same as female victims and that provider should be aware of potential or personal discomfort with serving male victims. Often as providers we're more comfortable with the notion that women may be characterized as victims rather than men. However, it's really important that we acknowledge that men can also be victims. Our goal as providers, as a reminder, is to provide the same compassionate, empathic, and non judgmental care to men as we do to women. Safety is imperative, we must assess safety upon the survivor's arrival to the healthcare setting. So a question we may want to ask is, did the assailant accompany a survivor to the clinic? Because remember that we're not always dealing with people that have been assaulted by someone that they do not know, it's not always a stranger. Most often it's actually going to be someone that they know. In that case there is a potential that the survivor has been accompanied by the assailant. We also want to make sure that our clinical setting has developed and implemented protocols to identify and address threatening situations that could occur. Advocacy is a very big component to providing care to the survivor of gender based violence. We'll want to contact an advocate if one is available in your area. What is an advocate? An advocate is a specially trained, mostly a lay person, or it could be a mental health provider, a pastoral counselor, or someone else that has the special skills and have been trained in providing trauma-informed care. One of the most important aspects of trauma informed care is preserving the victims confidentiality. Best practice includes systematically contacting advocates for support, regardless of who is presenting as a survivor in your office. And also allowing survivors to decided if, when, or how much they have contact with the advocate. So the advocate can become more of an adjunct to the care that you're providing and can be a real support. But it's important to realize that not all survivors are going to feel comfortable having an advocate work with them. In terms of triaging response we're going to want to respond to acute needs first. Any kind of injury, trauma care, or any safety that needs to be done, needs to be attended to first. The initial health exam should be conducted according to your agency's protocol. All of this work is to manage and stabilize those acute problems and then we're also going to address the survivor's pain if possible. If a forensic exam is available, we're going to ensure that protocols are developed and implemented in your organization. Evidence should be preserved if possible, but not at the expense of attending to acute medical needs, or the comfort of the survivor. Forensic examiners may be able to collect evidence while survivors are being stabilized and treated. It's very important to think about how best to maintain the comfort of the survivor while she's being examined. Particularly because many different people will need to be interviewing her at the same time. In the next section we'll talk about obtaining consent. All survivors should provide consent for medical treatment according to the usual protocol in your healthcare setting. We would like for you to give clear explanations about procedures that require consent, ensuring that you make clear that medical treatment is separate from the forensic examination. Obtaining consent throughout the examination is preferable, clarifying that survivor can refuse any part of the exam at any time and can revoke consent at any point during your care. We're going to include a discussion of confidentiality. And that includes the limits that local laws may require for mandatory reporting. Consent from minors requires special protocols. So, if you're caring for anyone under 18, you must know your local laws and regulations that pertain to the treatment of people that are younger than 18. If parental consent is required for the medical procedure that you're doing, assent from the minor is also required. The primary responsibility is to the survivor throughout the exam. So even though the minor is under 18, if the survivor does not desire the exam, you should not perform it, even if the parent is insistent and wishes that the exam be performed. The parental wishes do not override those of the minor. It's important that you develop a protocol with your team to address these issues, so that your medical team does not have to try to discern whether or not, or how to give care to someone 18 or under. Next we'll talk about patient-centered assessment and some good history taking strategies. One of the most important things that you can do as a provider is ensure that the environment in which you are treating the survivor is as comfortable as possible. One way you can do that is to conduct the interview while the survivor is clothed. This allows you to build rapport with that person, and to really gain their trust and hear what their story is. You're going to allow the advocate or trusted friend or family member to remain in the exam room with you, if she wishes. Ask these persons, however, to not interrupt or to join in the story. The should purely be observers and supporters of the survivor. But you can reiterate that by joining into the story, they're not allowing the survivor to tell her story which is the most important. It's important to check local laws governing witnesses, because those persons that are in the room, if they're an advocate, may be subject to consequence if they remain in the room and hear the story. If multiple interviews are required by multiple persons such as the forensic examiner, the doctor, a nurse, law enforcement, one thing that you can do as a provider is to try to coordinate those interviews as much as possible. So that you don't have the survivor in the exam room for a long period of time having to repeat the same story over and over again. That can add to the trauma that she's already experienced. Listen to the survivor and allow for breaks it if she needs it, if she needs to. Remember that the purpose of the interview is to guide examination and treatment, not investigation. You are the medical provider and you're providing care. If possible, make sure that you conduct the exam in the same language that the survivor feels most comfortable. And it's important to recognize that responses to trauma are going to vary. They can range from anger to being tearful, to being quiet and withdrawn or to appear to be unaffected at all. Be sensitive and demonstrate empathy. And be prepared that survivors may talk about being embarrassed, they may talk about being ashamed and they also may have difficulty finding the words to describe what happened. Therefore it's very important that you are patient and allow the survivor to develop the story as she remembers it. Reassure the survivor that assault is not her fault. Allow enough time to talk. And then make eye contact as appropriate in your culture. These can be steps for making the interview be smooth as well as trustworthy. You'll also want to understand that survivors may not remember everything in the order that it occurred. So, be prepared to gently clarify things, don't ask very probing questions like why, because that can feel like you're blaming the survivor. And if a another person is present, allow the survivor out a few minutes at the end to speak to you alone. At this time you'll want to make sure that everything is clear and that the survivor has felt that they've been able to speak freely to you during the interview. Some examples of comforting things that you can say to a survivor during the exam are, you're safe here. You were smart to seek help. You have choices about what we are going to do here today. So these are reassuring statements that can help to build trust with the survivor. Also, say that must have been frightening for you. And you're not to blame. The person who assaulted you is at fault. And really important is to tell her that we care about you and that we believe your story. These are going to be very important particularly in those first hours or days after an assault has occurred. Also during the interview you're going to start with a general medical history, including past medical history, any medications, or allergies. Make sure you find out the last menstrual period, as well as any current contraceptive method that they're using. That will help guide your care and options that you'll provide to the survivor. Next, you'll want to obtain a history of assault. Has this occurred to this person before? Ask only what you need to guide your assessment and treatment however. So it's not important that you get into the details of any past assault, but it is important for the context, for your care to understand the person's exposure to any kind of assault or trauma in the past. This builds the opportunity for you to provide a truly trauma informed care. And you may also want to use this information for evidence collection if it's necessary. So as you're talking to the survivor about the assault that she's presenting for that day, you're going to make sure to ask the date as well as the time of the assault. This will help guide your exam as well as to offer the options that are necessary for the survivor. If a forensic exam with physical evidence and DNA collection will occur, you'll need to ask the following. Any recent consensual sexual activity? You're also going to want to confirm what activities the survivor did after the assault occurred. Did she urinate? Did she go to the bathroom? Did she defecate? Did she use any menstrual products? Any kind of showering, washing, brushing her teeth. Did she smoke? Did she change clothes? Any vomiting? These can all provide evidence for what can occur next and can be passed on for the forensic examination. And you're also going to want to know about the suspect information, as much information as possible in terms of the gender of the suspect, age, race. If there were multiple suspects you'll want to find that out. In all cases, you should also ask if there was any memory loss, loss of consciousness, vomiting, pain, bleeding, any non genital injury, anal or genital injury as well. When confirming the nature of the assault, find out the location, If there were any weapons used, whether or not they were used or not but they could have been used as a threat. What types of violence was involved with the assault? Did the assailant bite the victim or did the survivor hit the assailant? Was the survivor strangled at all? Was there any burning with cigarettes? What other kind of injuries could've occurred to the assailant? This will all be information that can be passed on to law enforcement. When describing the assault that actually occurred, you'll want to find out exactly what type of penetration occurred, whether it was genital, oral, or anal. Any other oral contact with the genitals. And you need to clarify whether it occurred from the survivor to the assailant or the assailant to the survivor, or both. Any non-genital acts such as kissing, sucking, biting that may have occurred from the assailant. Did the assailant use any objects during the assault? You'll also want to find out whether or not the assailant ejaculated or not. If they did, did they use a condom? Where did they ejaculate? And clarify if there was any contraception used, any lubricants or any condoms. Finally, let's talk about documentation. How do we make sure that all of this information is maintained and useful for going forward. Document information per protocols of your setting. Forensic examinations should be documented separately from the medical aspects. So it's very clear that those two things must be separate documentation. Throughout the examination and while you're documenting you're going to be objective and thorough. Never document that an assault or a rape occurred or did not occur. It is not your job to decide what occurred. It is your job to document only what the patient describes or you observe. Your opinion does not matter in this case. Reassuring the survivor that their decision to seek care was the right thing is a positive way to continue to build trust and ensure that the survivor feels that she did the right thing. Remind the survivor that the assault is not her fault. Reassure that they are safe in your care, and allow the survivor to control the course of the assessment, that includes how fast you conduct the assessment on the exam. What parts of the exam that she participates in and the content of what is performed. That ends this lecture, thank you very much my contact information is included here.
