Be aware of issues commonly faced by patients from specific populations

It is important to realize that for some patients, certain personal characteristics (e.g., culture, language skills/mode of communication, disability, gender, and age) may strongly influence their experiences in the immediate aftermath of a sexual assault and during the exam process. Education for responders on issues facing a specific population may serve to enhance care, services, and interventions provided during the exam process. Responders should identify different populations that exist in their jurisdiction and determine what information they should have to help them serve patients from these populations. Building understanding of the perspectives of a specific population may help increase the likelihood that the actions and demeanor of responders will mitigate victim trauma. However, do not assume that patients will hold certain beliefs or have certain needs and concerns merely because they belong to a specific population. And, as pointed out earlier, recognize that patients’ experiences are affected by a plethora of other personal and external factors. 
 
Develop policies and plans.  Involved agencies and SARTs should develop policies and plans to meet the needs of specific patient populations (e.g., to obtain certified interpreters for Deaf and hard-of-hearing patients). When creating these plans, consider what barriers exist for patients from different populations to receiving a high-quality exam and what can be done to remove these barriers. Also, consider what equipment and supplies might be needed to assist persons from specific populations (e.g., a hydraulic lift exam table may be useful with victims who have a physical disability). Relevant responders need to have access to and know how to use such equipment or supplies. 
 
Partner with those who serve specific populations.  Involved responders should seek expertise from and collaborate with organizations and leaders that serve specific populations. Not only may they be willing to provide information and training on working with victims from the population they serve, but they also may be a resource before, during, and after the exam process. If responders may be involved in the immediate response to victims, they should be trained on the dynamics of sexual victimization and procedures for getting help for victims and work with the multidisciplinary response team to clarify their roles and procedures for response.
 
Explore the needs of specific populations.  To gain a basic understanding of potential issues and concerns facing different groups of sexual assault victims, this section explores several specific populations.[1] Clearly, this exploration is not inclusive of all populations of victims, but a more comprehensive discussion on this topic is beyond the scope of this document. 
 
―Victims from various cultural groups and those with limited English proficiency 
  • Understand that culture can influence beliefs about sexual assault, its victims, and offenders. It can affect health care beliefs and practices related to the assault and medical treatment outcomes. It can also influence beliefs and practices related to emotional healing from an assault. In addition, it can impact beliefs and practices regarding justice in the aftermath of a sexual assault, the response of the criminal justice system, and the willingness of victims to be involved in the system.[2] 
  • Understand that some victims may be apprehensive about interacting with responders from ethnic and racial backgrounds different from their own. They may fear or distrust responders or assume they will be met with insensitive comments or unfair treatment. They may benefit from responders of the same background or at least who understand their culture. 
  • Be aware that cultural beliefs may preclude a member of the opposite sex from being present when victims disrobe. Also, it may be uncomfortable for victims from some cultures to speak about the assault with members Understand that victims may not report or discuss the assault because the stigma associated with it is so overwhelmingly negative. In some cultures, for example, the loss of virginity prior to marriage is devastating and may render victims unacceptable for an honorable marriage. Even discussing an assault or sexual terms may be linked with intense embarrassment and shame in some cultures.  
  • Recognize that some cultures (e.g., Indian tribes) may have their own laws and regulations to address sexual assault, in addition to or in place of applicable jurisdictional laws. Responders should be familiar with procedures for coordinating services and interventions for victims from these communities. 
  • Be aware that beliefs about women, men, sexuality, sexual orientation, race, ethnicity, and religion may vary greatly among victims of different cultural backgrounds. Also, understand that what helps one victim deal with a traumatic situation like sexual assault may not be the same for another victim. 
  • Help victims obtain culturally specific assistance and/or provide referrals where they exist.[3]
  • Be patient and understanding toward victims’ language skills and barriers, which may worsen with crisis. 
  • Make every attempt to provide interpretation services and translated materials for victims who do not speak English. Use certified interpreters when possible and not victims’ families or friends.[4] Take the victim’s country of origin, acculturation level, and dialect into account when responding or arranging interpretation.[5] Remember to speak directly to victims when interpreters are used. 
  • Train interpreters about issues related to sexual assault, confidentiality, and cultural concerns whenever they are needed to facilitate communication in these cases. 
―Victims with disabilities 
  • Understand that victims with disabilities may have physical, sensory, or mental disabilities, or a combination of disabilities. (For a more detailed explanation, see “Use of Terms”.) Make every effort to recognize issues that arise for victims with disabilities (both in general and in relation to their specific disability) and provide reasonable accommodations when working with them. 
  • Be aware that the risk of criminal victimization (including sexual assault) for people with disabilities appears to be much higher than for people without disabilities. People with disabilities are often victimized repeatedly by the same offender.[6] Caretakers, family members, or friends may be responsible for the sexual assault.
  • Respect victims’ wishes to have or not have caretakers, family members, or friends present during the exam. Although these individuals may be accustomed to speaking on behalf of persons with disabilities, it is critical that they not influence the statements of victims during the exam process. If aid is required (e.g., from a language interpreter or mental health professional), ideally those providing assistance should not be associated with victims. 
  • Follow exam facility and jurisdictional policy for assessing vulnerable adults’ ability to consent to the exam and evidence collection and involving protective services. Again, note guardians could be offenders. (For a more detailed discussion on seeking informed consent of patients, including consent by victims from specific populations, see A.3. Informed Consent.) 
  • Speak directly to victims with disabilities, even when interpreters, intermediaries, or guardians are present.
  • Assess a victim’s level of ability and need for assistance during the exam process. Explain exam procedures to victims and ask what help they require, if any (e.g., people with physical disabilities may need help to get on and off the exam table or to assume positions necessary for the exam). Do not assume they will need special aid. Also, ask for permission before proceeding to help them (or touch them, handle a mobility or communication device, or touch a service animal[7]).  
  • Note that not all individuals who are Deaf or hard-of-hearing understand sign language or can read lips. Not all blind persons can read Braille. Communication equipment that may be beneficial to victims with sensory disabilities include TTY machines, word boards, speech synthesizers, anatomically correct dolls, materials in alternative formats, and access to interpreter services. Responders should familiarize themselves with the basics of communicating with an individual using such devices.[8] Be aware that victims with sensory disabilities may prefer communicating through an intermediary who is familiar with their patterns of speech. 
  • Recognize that individuals may have some degree of cognitive disability: mental retardation, mental illness, developmental disabilities, traumatic brain injury, neurodegenerative conditions such as Alzheimer’s disease, or stroke. Note that not all developmental disabilities affect cognitive ability (e.g., cerebral palsy may result in physical rather than mental impairment). Be aware that victims with cognitive disabilities may be easily distracted and have difficulty focusing. To reduce distractions, conduct the exam in an area that is void of bright lights and loud noises. Speak to victims in a clear and calm voice and ask very specific and concrete questions. Be exact when explaining what will happen during the exam process and why. It may also be helpful if examiners and others present in the exam room refrain from wearing uniforms with ornamental designs and jewelry. 
  • Keep in mind that victims with disabilities may be reluctant to report the crime or consent to the exam for fear of losing their independence. For example, they may have to enter a long-term care facility if their caretakers assaulted them or may need extended hospitalization to treat and allow injuries to heal. 
  • Recognize that it may be the first time victims with disabilities have an internal exam. The procedure should be explained in detail in language they can understand.[9] They may have limited knowledge of reproductive health issues and not be able to describe what happened to them. They may not know how they feel about the incident or even identify that a crime was committed against them.
  • Some victims with disabilities may want to talk about their perceptions of the role their disability might have played in making them vulnerable to an assault. Listen to their concerns and what the experience was like for them.[10] Assure them that it was not their fault they were sexually assaulted. If needed, encourage discussion in a counseling/advocacy setting on this issue as well as on what might help them feel safer in the future,.
  • Recognize that the exam may take longer to perform with victims with disabilities. Avoid rushing through the exam—such action not only may distress victims, it can lead to missed evidence and information. 
―Male victims[11]
  • Help male victims understand that male sexual assault is not uncommon and that the assault was not their fault. Many male victims focus on the sexual aspect of the assault and overlook other elements such as coercion, power differences, and emotional abuse. Broadening their understanding of sexual assault may help reduce their self-blame. 
  • Because some male victims may fear public disclosure of the assault and the stigma associated with male sexual victimization, emphasis may need to be placed on the scope of confidentiality of patient information during the exam process. 
  • Offer male victims assistance in considering how friends and family members will react to the fact that they were sexually assaulted (e.g., by a male offender or a female offender). 
  • Male victims may be less likely than females to seek and receive support from family members and friends, as well as from advocacy and counseling services. Their ability to seek support may vary according to the level of stigmatization they feel, the circumstances of the assault, the sensitivity of care they initially receive, and the appropriateness of referrals provided.
  • Encourage advocacy programs and the mental health community to build their capacity to serve male sexual assault victims and increase their accessibility to this population.
  • Requests by male victims to have an advocate of a particular gender should be respected and honored if possible.[12] 
―Adolescent victims[13]
  • Adolescents may be brought to the exam site by their parents or guardians. The presence of parents or guardians creates an additional challenge for those involved in the exam process because they are often traumatized by their child’s victimization. 
  • Understand that parents or guardians may blame victims for the assault if the victim disobeyed them or engaged in behaviors perceived as increasing risk for victimization. 
  • Health care providers must assess the physical development of adolescent victims and take their age into consideration when determining appropriate methods of examination and evidence collection.[18] Involved professionals should be well versed in jurisdictional policies related to response to minor victims. 
  • Be aware of jurisdictional laws governing minors’ ability to consent to forensic exams and medical treatment. Follow exam facility and jurisdictional policy in obtaining appropriate consent. (For a more detailed discussion on seeking informed consent of patients, including consent by victims from specific populations, see A.3. Informed Consent.) 
  • Recognize that the sexual assault medical forensic exam may be the first time an adolescent female victim has an internal exam. There may be a need to go into detail when explaining what to expect.[14] 
  • Adolescence is often a time of experimentation. Reassure these victims that regardless of their behavior (e.g., using alcohol and drugs, engaging in illegal activities, or hitchhiking), no one has the right to sexually assault them, and they are not to blame for the assault.
  • Ideally, attending health care providers should gather information from adolescents without parents or guardians in the room, subject to victims’ consent. The concern is that parents or guardians may influence or be perceived as influencing victims’ statements.
  • Inform victims, particularly those who do not involve parents or guardians in the exam process, of facility billing practices (e.g., that their parents may get a bill or statement of services provided).[15] 
―Older victims
  • Keep in mind that the emotional impact of the assault may not be felt by older victims until after the exam when they are alone and become aware of their physical vulnerability, reduced resilience, and mortality.[16] Fear, anger, and depression can be especially severe in older victims who are isolated, have little support, and live on a meager income. [17] 
  • Be aware that caretakers may sexually assault their older dependents. Offenders may bring victims to the exam site, and jurisdictional and facility policies should be in place to provide guidance on how staff should screen for and handle situations that are threatening to patients or facility personnel. 
  • Note that older victims are generally more physically fragile than younger victims and thus may be at risk for tissue or skeletal damage and exacerbation of existing illnesses and vulnerabilities.[18] 
  • Hearing impairment and other physical conditions attendant to advancing age, coupled with the initial reaction to the assault, may render older victims unable to make their needs known, which could result in prolonged or inappropriate treatment.[19] Do not mistake this confusion and distress for senility.
  • Health care personnel should follow facility policy for assessing a vulnerable adult’s ability to consent to the exam and evidence collection, as well as involving adult protective services.
  • Some older victims may want to talk about their perceptions of the role their age and physical condition might have played in making them vulnerable to an assault. Listen to their concerns and what the experience was like for them.[20] Assure them that it was not their fault they were sexually assaulted. If needed, encourage further discussion on this issue in a counseling/advocacy setting. 
  • Older victims may be reluctant to report the crime or seek treatment because they fear the loss of independence. Although sometimes relatives wish to place older victims in an assisted living situation after an assault occurs, such an action is not always necessary or useful to a victim’s recovery. When a change in living environment is truly needed, assist victims and their relatives in making plans that maximize independence yet enhance safety.[21]
  • Encourage use of followup medical, legal, and nonlegal assistance. Older victims may be reluctant to seek these services or proceed with prosecution. For example, they may rely on family members for transportation and may not want to burden them by asking to be taken to postexam followup appointments. 
[1] This section was adapted partially from Connecticut’s Technical Guidelines for Health Care Response to Victims of Sexual Assault, 1998, pp. 12–14, and from Iowa’s Sexual Assault: A Protocol for Forensic and Medical Examination, 1998, pp. 1–4.
[2] Bullet drawn from A. Blue, The Provision of Culturally Competent Health Care, from the Web site of the Medical University of South Carolina College of Medicine (www.musc.edu/fm_ruralclerkship/culture.html). 
[3] For example, to raise their level of hope and comfort during the exam, some patients may benefit from talking about culturally specific models of healing (where they exist) and their application to recovery from sexual assault. To facilitate such a discussion, they may wish to speak with a religious or spiritual healer from their culture.
[4] Consult with jurisdictional statutes and policies regarding the use of community-based advocates as interpreters—such a dual role may jeopardize their confidentiality with victims.
[5] For example, a Cuban interpreter may encounter language and trust obstacles when trying to communicate with a victim from rural Mexico. (L. Zarate, Suggestions for Upgrading the Cultural Competency Skills of SARTs, Arte Sana Web site, www.Arte-sana.com, 2003.)
[6] The above two sentences are drawn from the Office for Victims of Crime, First Response to Victims of Crime Who Have a Disability, 2002, p. 1.
[7] Examples of service animals include guide dogs and hearing-assistance dogs, and therapy dogs.
[8] Note that individuals may have their own assistive devices, but words needed to communicate may have to be programmed.
[9] Drawn from A. Conrad, SANE/SAFE Organizing Manual, 1998, p. 7, developed for the New York State Coalition Against Sexual Assault.
[10] Drawn from L. Ledray, SANE Development and Operation Guide, 1998, pp. 82–85.
[11] Drawn partially from L. Ledray, SANE Development and Operation Guide, 1998, p. 79.
[12] A national resource for male patients is Male Survivor: The National Organization Against Male Sexual Victimization. Contact information: PMB 103, 5505 Connecticut Avenue, NW, Washington, DC 20015–2601, 800–738–4181, www.malesurvivor.org.
[13] Adapted partially from the West Virginia Protocol for Responding to Victims of Sexual Assault, 2002, p. 11.
[14] For example, the size of the speculum used with adolescent female victims and exam positions of victims may vary.
[15] Drawn from A. Conrad, SANE/SAFE Organizing Manual, 1998, p. 7, developed for the New York State Coalition Against Sexual Assault.
[16] Drawn from L. Ledray, SANE Development and Operation Guide, 1998, p. 98.
[17] Drawn from Iowa’s Sexual Assault: A Protocol for Forensic and Medical Examination, 1998, p. 3.
[18] Ibid.
[19] Older women are at an increased risk for vaginal tears and injury when they have been vaginally assaulted. Decreased hormonal levels following menopause result in a reduction in vaginal lubrication and cause the vaginal wall to become thinner and more friable. Because of these physiological changes, a Pedersen speculum, which is longer and thinner than the Graves speculum, should be used during the pelvic exam for evidence collection. Special care should also be taken to assess for intravaginal injury. In some older women, examiners will need to simply insert the swabs and avoid the trauma of inserting a speculum. If there are external tears in , internal injuries must also be considered. The recovery process for older victims also tends to be longer than for younger victims. (Drawn from L. Ledray, SANE Development and Operation Guide, 1998, p. 86–87.)
[20] Drawn from L. Ledray, SANE Development and Operation Guide, 1998, p. 87.
[21] Drawn from L. Ledray, SANE Development and Operation Guide, 1998, p. 82–85.
[22] Ibid.


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