Hello, I'm Nancy Glass, professor at Johns Hopkins University School of Nursing. I'm going to focus today on providing confident, compassionate and confidential care to survivors of gender based violence. So the presentation will focus on the rights that survivors have when they enter the health care system. And how we as providers can assure their rights to care and access to services in the community. So let's talk about the right to health care. So survivors of gender based violence, they do have the right to high quality health care with competent health professionals. Meaning professionals that have training, that have worked with survivors and feel confident that they can provide informed care. And that also means establishing a setting where everybody who works in that setting can create a safe place for survivors. And survivors should not have to prove to the health care provider. That's not the role of the health care provider, is to require proof before they provide services. So what we hear often times from health care providers and other staff, is that they're concerned about taking action with the survivor if it's not really violence. So it's important to understand that if a woman comes in, or a man comes into your health care setting and reports violence, that you complete the assessment, provide the care and treatment, document what they've told you, and provide resources. It's the legal system that will determine if the violence occurred or not, they'll seek the proof. So also, I'm talking about the right to health care. It simply is not going to be all cases that are going to be prosecuted in court. But that doesn't mean that the impact, the long term impact. The mental and physical health, as well as the social consequences of being a survivor of gender based violence will remain. So our goal is to help those survivors minimize the long term consequences. And that oftentimes means providing early intervention and resources that are accessible to the survivor, and then sometimes their family members. So, survivors also have the right to non-discrimination. That means treating people without prejudice. So we don't treat or refuse treatment based on age, gender, sexual orientation, their tribal or community identification, religion, class or marital status. It's our responsibility as health care providers to provide equitable care to all groups who seek services. So survivors also have the right to information. Information about the process that they're going to go through if they're there to receive services related to their violence that they've experienced. For example, if they're going to have a forensic exam, if they've been sexually assaulted, they need to have all the information to make the decision if it's the right process for them. What are their options, what are the treatment options, and what are the available resources within the setting, and also in the larger community? So another critical right is to have this information that's needed, so urgently in some cases, in the language that they understand. So it's often in low resource settings, we use translators that are family members or children. This is important to minimize because it can certainly increase the risk of women experiencing future violence. For example if they report that their husband is abusive. And then she goes home and the child is then, was the translator, and the child then tells the parent, it could increase the violence for the woman, but also the children. And it's the same thing in the larger community. Making sure that the translators are trained and understand confidentiality and safety. Because if a woman reports, or a man reports, victimization, certainly we can't have that information being shared to the larger community, because that could result in revenge attacks on that person. So survivors need information about their rights, but they need it to be provided in a safe and private space. And creating that space in the clinic is critical. And they need to have this information documented. So, not every case will move forward. Not every case a survivor wants to take legal action, but in those cases that they do, that documentation could be critical. So the physician, the nurses, the social worker, the advocacy notes could be critical in those cases. So making sure that that information is secure in the health care setting and that she could have access to that information is important. And letting her know about her access. So certainly the right to privacy. Woman have a right to certainly have the information about what treatments are available, what services are available. But they also have the right to make sure that that information is not shared without their consent. So information that's going to be shared outside of the health care setting or team members that are not directly involved in the care, it's critical to have her informed consent. And that could be a release of information form and that could be developed by a clinic, as well as your partner agencies. And also it's important in creating a safe place for women and survivors to tell their story. It's to make sure that they're not required to move place to place and talk to multiple people to receive care. Having to tell their stories over and over can create a lot of stress and trauma. And they may just feel like they're being asked because they're not believed. And that may stop the process. So creating a team that's well trained, that knows how to ask questions and to minimize the stress and trauma in the process is critical. So it may mean that you will need to make follow up appointments and make referrals immediately, and then have the woman come back. The key is safety. It may not be that you can address all the needs in one visit. You may need to make follow up visits. So certainly confidentiality is one of the key principles as professionals and that the communication is privileged between the provider and the survivor. And as we talked about, that includes documentation. But it's important to think of specific cases where that might not be relevant. And it could be the case of abuse and neglect of a child or exploitation. So making sure you understand your legal requirements in reporting child sexual assault or child abuse and neglect within your context, and then working with the appropriate agencies in the community. And also making sure the child, if they're of the appropriate age, certainly talking them through what's happening. For example, if there's going to be an exam or if there's going to be a new person coming in to talk to them, helping them understand the process. And recognizing that a parent or a caregiver may be the perpetrator, so they may not be the one that can be there to provide that support. So making sure you have trained people available to that child is critical. So again, just to reiterate confidentiality, making sure that there's a plan within your clinic, and that people are all aware of that plan. And that means from the front desk to everybody working at the clinic, as well as the agencies you refer to. It's not required that the police receive the information on every case. Many cases for adult, mandatory reporting is not required. It's often up to the survivor to report that case. So working with the survivor and not pressuring the survivor, because she may well know that some of her partners or the perpetrator's desk colleagues work in the legal system or work at the place, and that may not be safe for her. So I think in critical for survivors is their right to self determination, meaning their autonomy in decision making. We all want to have the choices to make decisions without pressure. And that could be pressure from the health care provider but it also can be pressure from family and community members, to take a certain action. So we need to help survivors know their options, know what resources are available, understand those resources. And then help them think through, and then decide what is best for them. So the critical role of the health care provider is to explain the range of services that are available, but not pressure them to take one over the other. And so there's gotta be consent to those health care services. So if a woman or a child is going to have a forensic exam, for example, after a sexual assault, understanding what that means and providing consent to those services, and that could mean, for a child under age, consent from a care provider, or the state in some cases, is critical. And so it's not our responsibility to pressure/demand the survivor accepts any care. But to explain the potential benefits of that care, but also noting the risk of that care. Because there are often risk involved in the services that are provided, and helping them think through those risks, and balancing the benefits and risk is critical. So in summary, as health care providers, in providing competent and compassionate care, it's not our responsibility to solve the violence for the survivor. Our responsibility is to make sure that we provide the best care that is available in our context. That we make sure they know what resources exist in the community and their options for accessing those resources, and then to walk with them through that process. And the key for many women is safety. Many women don't have the option to leave the violence at that moment or leave a community. So helping them think through the best safety strategies is critical. And also, it's not your responsibility as a health care provider to determine, is this case legal, if this case will move through the legal process. If you think that it won't go through the legal process and then you provide care that doesn't meet the standard of high quality care, meaning you're not documenting the findings or you're not providing the services that are available, that can limit her options if she did want to go forward with legal cases. So your responsibility as a health care professional is to use the skills that you have. The ethical knowledge you've learned, and your responsibility to make sure that we provide confidential assessments for survivors, link them to care and resources, and then provide the follow up treatment as needed. So thank you very much.