Resources for Healthcare Providers
Discussing sexual assault/abuse and intimate partner violence with your patients can feel daunting and intimidating. You might worry about being intrusive or maybe you’re unsure what to say to a patient who shares their experience of abuse with you. Perhaps you’re concerned about time constraints or making a report to law enforcement.
This webpage can help healthcare providers navigate these conversations with their patients and know what to do when their patients disclose abuse.
RISE toll-free 24-hour support line:855-886-RISE (7473)
contact@RISEslo.org (expect a response within 1-2 days)
Stand Strong 24-hour crisis line: (805) 781-6400
VIOLENCE, ABUSE, & HEALTH
What are sexual assault/abuse and intimate partner violence?
Sexual assault refers to a wide range of assaults including rape, attempted rape, sexual battery, incest, molestation, spousal rape, and statutory rape. Intimate partner violence, or domestic violence, takes many forms including sexual abuse, emotional or verbal abuse, financial abuse, psychological abuse, spiritual abuse, and physical abuse.
What is the connection between health and sexual assault/abuse and intimate partner violence?
Recent studies show that sexual assault/abuse and intimate partner violence have short-term and long-term effects on survivors’ health even when they haven’t sustained physical injuries. Survivors commonly experience headaches, stomachaches, depression, anxiety, post-traumatic stress disorder (PTSD), sleep disturbances, and many other physical and psychological ailments. Survivors are:
- 60% more likely to have asthma
- 70% more likely to have heart disease
- 80% more likely to have a stroke
- Twice as likely to be a current smoker
- Twice as likely to suffer from depression and headaches
Sexual assault/abuse and intimate partner violence are public health concerns. Healthcare providers need to be trained to provide care and referrals for ailments caused by violence and abuse.
How does the Affordable Care Act address sexual assault/abuse and intimate partner violence?
In addition to mandating screening for intimate partner violence during intake interviews, the Affordable Care Act also greatly expands support and insurance coverage for survivors. Exclusions based on pre-existing conditions, such as a history of intimate partner violence, are prohibited. The law exempts survivors from penalties for not having insurance, requires coverage for mental health and substance abuse treatment, and increases support for Native American survivors.
Visit the Department of Health and Human Services’ Division of Family Violence Prevention and Services webpage for more information.
What is trauma-informed care or response?
A trauma-informed care approach is strengths-based and grounded in an understanding of the impact of trauma. Such an approach:
- Recognizes that trauma exposures are pervasive through both individual and collective experiences.
- Emphasizes the physical, psychological, and emotional safety of both providers and survivors and focuses on creating opportunities for communication, support, and safety at all levels of an organization.
- Is culturally sensitive and person-centered and expands on a foundation of patient autonomy and choice to ensure that an individual’s unique trauma history is as integral a component to care as the patient’s concerns, preferences, and values.
- Responds to disclosures with understanding and recognition of the effects of all kinds of trauma (childhood exposure to violence, sexual violence, historical trauma, etc.) by building trust and providing a safe environment for receiving services.
The goal of trauma-informed care is to help survivors rebuild a sense of control and empowerment. People experience trauma through physical and sexual violence, racism, structural violence, poverty, homophobia, transphobia, witnessing violence, health inequity, war or natural disaster, emotional abuse and neglect, and more.
Visit the Safe Place webpage for information on implementing trauma-informed care in your clinic.
This response was adapted with permission from FUTURES Without Violence from “Who’s Got Your Back? A Guide for Addressing Sexual and Intimate Partner Violence in Campus Health Settings.”
How can I talk to my patients about health and sexual assault/abuse and intimate partner violence?
Many clinics and hospitals are updating their intake forms and electronic health records to include questions about sexual assault/abuse and intimate partner violence.
RISE encourages providers to use the CUES assessment method and the safety cards developed by Futures Without Violence to talk to their patients about healthy and unhealthy relationships. CUES stands for the following protocol:
- Confidentiality: Disclose your limits of confidentiality.
- Universal Education & Direct Inquiry:
- Support: If your patient discloses they have been in or are currently in a physically or emotionally abusive relationship, before anything else, start by believing and thank them for their courage in disclosing. Offer to call an advocate from RISE or Stand Strong. Treat any injury or illness without fear of “tampering with evidence.”
- Warm Referral & Follow-Up Visit: Assess your patient’s level of risk for future violence, provide resources, and make a warm referral to RISE or Stand Strong. Advocates can accompany patients to forensic medical exams and can meet patients at any clinic or hospital to inform them of their rights, reporting options, and services available including safety planning, temporary restraining orders, counseling, and emergency shelter. Schedule a follow-up visit to check their injuries and ask about their relationship again. This shows support and empathy for your patients, increases their sense of safety and security, and may contribute to improved health outcomes.
What if my patient discloses they are in a violent relationship or have been sexually assaulted? Can I still treat them?
Treat these patients as you would any other patient, addressing their presenting physical ailments first and foremost. Many healthcare providers are fearful of interfering with forensic evidence, but your primary role is to ensure the health of your patients. You do not have to, nor should you attempt to, act as a detective or trauma counselor.
How long will the appointment take?
Appointment times will vary depending on the patient. Healthcare providers often have busy schedules with very little flexibility, but it’s recommended you give your patients time, support, and privacy after they disclose. Work with your clinic’s administrators to establish a trauma-informed procedure for these patients. If possible, reserve a private room for these patients, establish a protocol that enlists point people to help with the reporting process, and call an advocate to support you and your patient.
REPORTING TO POLICE
How can I best document injuries suggesting sexual assault/abuse or intimate partner violence?
How you document your patients’ injuries can determine legal outcomes and recovery for your patients. The following tips can help you when documenting disclosed or suspected abuse or violence:
- With permission from your patient, objectively document injuries by taking photographs or by completing a body map that lists the location, number, type, and characteristics of the injuries.
- Use quotation marks to document your patient’s experience in their own words instead of paraphrasing. Identify the perpetrator(s) your patient describes in quotation marks such as “my husband” or “my mother.”
- Avoid legal jargon and personal conclusions about the case. For example, avoid phrases such as, “Patient alleges she is a battered woman experiencing intimate partner violence.” Instead, document injuries and record direct quotations from your patient. You can also record your own observations about your patient’s general appearance or demeanor.
For more information on best practices for documenting intimate partner violence, refer to the National Institute of Justice’s article “Documenting Domestic Violence: How Health Care Providers Can Help Victims.”
When do I have to make a mandated report? And what does the reporting process look like?
California law states all healthcare providers are mandated reporters. This means that healthcare providers are required to contact law enforcement if they are treating a physical injury resulting from disclosed or suspected violence. The following can help you when reporting:
- Before directly asking your patient about their experience, let them know that you are a mandated reporter. This allows your patient to make an informed decision about whether and how much to disclose, and prevents your patient from feeling blindsided should you be required to make a report.
- If a person accompanying your patient is under suspicion of perpetrating the assault, do not leave your patient alone with that person.
- Treat your patient’s injuries, address their health concerns, and provide emotional support.
- If your patient has experienced sexual assault/abuse or intimate partner violence, they have the right to an advocate. Explain an advocate’s role (to provide emotional support, information about patients’ rights and options, and referrals to local resources) and that they are available by phone or can come to your location. Offer to call RISE or Stand Strong.
- Explain your patient’s rights when disclosing or reporting, emphasizing they do not have to answer any questions and they are not required to stay.
- If needed, explain what a forensic medical or Suspected Abuse Response Team (SART) exam is. Your patient can contact RISE, law enforcement, Child Welfare Services, or the San Luis Obispo Public Health office to schedule an exam.
- Follow-up Care & Referrals: Refer your patient to RISE or Stand Strong for support services including safety planning, temporary restraining orders, counseling, and emergency shelter. Schedule a follow-up visit to check their injuries. Ensure your patient has a safe place to go prior to discharge.
- Depending on the situation or whether or not your patient wants to be involved in the reporting process, call law enforcement as soon as possible before or after your patient is discharged. Call the law enforcement agency in the jurisdiction where the abuse took place.
- Request and document the name and badge number of the assigned law enforcement officer(s) in the patient record.
- The report should include (A) the name of the injured person, if known, (B) the injured person’s whereabouts, if known, (C) the character and extent of the person’s injuries, and (D) the identity of any person(s) the injured person alleges inflicted the injury, if known. A report must be made even if the person has died, regardless of whether or not the injury contributed to their death, and even if evidence of the conduct of the perpetrator was discovered during an autopsy.
- Fill out a Suspicious Injury Report OES 2-920, Suspected Elder/Dependent Adult Abuse Report, or Suspected Child Abuse Report as appropriate within 48 hours of report filing and contact local law enforcement.
For more information about California mandated reporting laws and processes, review California’s Domestic Violence & Mandatory Reporting Law.
Where can I refer my patient to receive a forensic medical exam?
The San Luis Obispo Public Health Department houses the SART nursing office where forensic medical or Suspected Abuse Response Team (SART) exams are performed. Your patient can contact RISE, law enforcement, Child Welfare Services, or the San Luis Obispo Public Health office to schedule an exam.
Who can I call for help?
RISE toll-free 24-hour support line:855-886-RISE (7473)
contact@RISEslo.org (expect a response within 24 hours)
Stand Strong's 24-hour crisis line: (805) 781-6400
What community resources can I refer my patients to?
RISE and Stand Strong can assist your patients with safety planning, temporary restraining orders, individual and group counseling, and emergency and transitional housing. These agencies can also help connect your patients to many other community resources including long-term housing, health insurance, food assistance, and childcare.
Calling 2-1-1, which is free and confidential, or visiting 211slo.org can also connect you and your patients to information and community resources in San Luis Obispo County.
My patient’s partner will not leave the room. How can I talk to them alone?
RISE encourages all healthcare providers to have a policy that gives providers the opportunity to see their patients alone at some point in the visit. If your clinic does not have this policy, please contact RISE at contact@RISEslo.org to learn about clinic best practices and policies and to discuss ways for you and your patients to have confidential conversations about healthy and unhealthy relationships.
Where can I get more information?
Visit the Futures Without Violence Health webpage to learn more about the connections between health and sexual assault/abuse and intimate partner violence, watch informational videos about how to talk with patients about healthy and unhealthy relationships, and read articles about trauma-informed policies, procedures, and best practices.
Is there healthcare provider training for CEU credit?
Yes. RISE works with providers to ensure our in-person training sessions and meetings are eligible for CEU credit.
(1) Black, M. B. (2011). The National Intimate Partner and Sexual Violence Survey (VNVIS). Atlanta, CA: Center for Disease Control.