1. SANEs and Victim Advocates
How multidisciplinary collaboration can improve patient care
Nancy and Deena… This is not a good title… open to suggestions

2. OBJECTIVES Define the purpose of the medical forensic exam.
Define the role of a community based confidential advocate in the medical forensic exam.
Review patient case studies that were impacted by the care of a forensic nurse and community based confidential advocate.

3. Memorial Hospital University of Colorado Health
2 Hospitals plus a Children’s Hospital; 771 beds

4. Memorial Hospital; University of Colorado Health Colorado Springs, CO
Forensic Nurse Examiner Program
Program initiated in 1995
Saw sexual assault patients of all ages
Worked as “on call”
In 2008 we expanded our services to care for more than sexual assault
Memorial Hospital; University of Colorado Health Colorado Springs, CO

5. Forensic Nurse Examiner Program Today:
Team of 10 nurses
“In house” 24/7
Provide medical care to victims of violence
Sexual Assault
Intimate Partner Violence
Child Abuse
Elder Abuse
Human Trafficking
Any strangulation or hanging patients

6. TRAINING OBJECTIVES
Understand the dynamics of sexual assault, different types of cases, and how those factors may affect patient care.
Learn the role of the victim advocate (within the multi-disciplinary team) in delivering excellent survivor patient care for individuals who present to the ED for sexual assault evidence collection and follow-up medical care.
Differentiate between the systems-advocates and community-based advocates in Colorado.
Karen
Nancy

7. PLEASE NOTE…
Colorado is a very diverse state, and policies and practices vary considerably across the state. Your facility should be a part of all multi-disciplinary efforts, to ensure a consistent, mutually-agreed upon response system is in place.

8. TYPES OF CASES RECEVING A MEDICAL FORENSIC EXAM
MEDICAL REPORT
LAW ENFORCEMENT REPORT
Cases in which the survivor reports the assault to law enforcement either prior to or at the time of the medical forensic exam.
The survivor seeks medical treatment services following a sexual assault, but elects not to participate in the Criminal Justice System at the time the Victim receives Medical Services.
Advocates can help with both & the content in this presentation will apply to both types of cases. However, there may be some differences in the advocate response, depending on the time of case and the victim’s wishes.
Karen– LE
Nancy-- Medical

9. SEXUAL ASSAULT DYNAMICS
How understanding sexual assault may assist with patient care
Nancy

10. What is sexual violence?
A sexual act is nonconsensual if it is inflicted upon a person who is
unable to grant consent or
if it is unwanted and compelled through the use of
Physical force
Manipulation
Coercion
Threats
Intimidation
Nancy
Can be completed or attempted.
Range of behaviors.

11. PREVALENCE OF SEXUAL VIOLENCE
Nearly 1 in 5 women (1 in 4 in Colorado) and 1 in 71 men in the U.S. have been raped at some time in their lives.
When other sexual crimes are added (unwanted sexual contact and other types of coercion), 1 in 2 women and 1 in 4 men in Colorado have experienced sexually violent crimes in their lifetime.
National Intimate Partner and Sexual Violence Survey, NISVS: 2010 Summary Report. Centers for Disease Control and Prevention, released 2011
Karen
NISVS – first national survey in a decade, how just based on LE reports, done in 2010 but released last year, b/c state definitions vary, not based on legal definitions.
We will talk more about age of victimization and populations more at risk as we move along.

12. WHO ARE VICTIMS? Victims: Can be anyone
They are chosen because they are:
Vulnerable or can be made so
Accessible or can be made so
And most often
Lacking in credibility or can be made to seem so
Karen
**The most highly victimized people are those who are lacking in credibility**

13. WHO ARE THE MOST VULNERABLE, ACCESSIBLE, AND LACKING IN CREDIBILITY?
Children
Adolescents
Women, especially women of color
People with developmental & physical disabilities
People with communication impairments
People who have a mental illness
ANY dependent, institutionalized or incarcerated person
Non-English speaking people
People who are undocumented
People who are poor, especially the homeless
People on the fringe of crime
People who are drunk or on drugs
People with non-dominant gender identity and/or expression
Nancy

14. WHO ARE VICTIMS?
Most sexual assault is first experienced in childhood and adolescence.
Most female victims of completed rape experienced their first rape before the age of 25 and almost half experienced their first completed rape before age 18.
Over one-quarter of male victims of completed rape experienced their first rape at or before the age of 10.
NISVS, 2010
Nancy

15. WHO ARE VICTIMS? Most victims of rape knew their perpetrators.
More than half (51.1%) of female victims of rape reported being raped by an intimate partner and 40.8% by an acquaintance.
For male victims, more than half (52.4%) reported being raped by an acquaintance and 15.1% by a stranger.
NISVS, 2010
Nancy

16. The younger the victim, and the closer the relationship…
AGE & RELATIONSHIP
The younger the victim, and the closer the relationship…
the less likely they will report.
Nancy
Offenders are not stupid… will contemplate where and how can they get access, create vulnerability, and ensure that there is less credibility.

17. WHO ARE VICTIMS?
Approximately 1 in 5 Black women and 1 in 7 Hispanic women in the United States have experienced rape at some point in their lives.
More than one-quarter of women (26.9%) who identified as American Indian or as Alaska Native and 1 in 3 women (33.5%) who identified as multiracial non-Hispanic reported rape victimization in their lifetime.
Nearly one-third of multiracial non-Hispanic men (31.6%) and over one-quarter of Hispanic men (26.2%) reported sexual violence other than rape in their lifetimes.
Approximately 1 in 3 Hispanic (36.1%) and Asian or Pacific Islander (29.5%) women reported sexual violence other than rape.
NISVS, 2010
Nancy
folks from racially marginalized communities are at higher risk.

18. WHO ARE VICTIMS?
Over 50% of transgender individuals are survivors of sexual violence. (FORGE, 2005)
Persons with a disability had an age-adjusted rate of rape or sexual assault that was more than twice the rate of persons without a disability. (US Bureau of Justice, 2009)
Nancy
Some more information about people who are more vulnerable and often seen as less credible in our society.
At higher risk, less access to help.

19. Victim Impact What Causes Trauma? Trauma Penetration Severity Weapon
Quantity
Trauma
Karen

20. VICTIM IMPACT Primary causes of trauma: Betrayal Extreme Fear/Terror
Blitz/Surprise Attack
Self-Blame
Lack of support
Invalidation
Karen
Jan Hindman called it “disastrous response.”

21. COMMON REACTIONS Humiliation Shame & self-blame Guilt Fear of people
Feeling a loss of control
Concern for the rapist
Grief
Depression
Denial/Anger and irritability
Belief in myths about sexual assault

22. IMPACT OF TRAUMA Trauma interferes with cognitive functioning
Thought processing
Concentration
Memory and specific recall
Realistic assessment of own situation
Decision making
Therefore, the victim’s ability to cooperate and work seamlessly with forensic nurses, law enforcement and/or advocates can be impaired.
Karen

23. Victims/Survivors who experience a supportive and compassionate response, regardless of the criminal justice outcome, have lower rates of post traumatic stress. Campbell, et al. (1999). “Community Services for Rape Survivors: Enhancing Psychological Well-Being or Increasing Trauma.”
Karen

24. MAJOR NEEDS OF VICTIMS The need to feel safe
The need to express emotion
The need for information about what will happen next1
Letting victims make decisions for themselves at this stage is critical to gaining a sense of control over their lives.2
Nancy
Woods, T. O. (2000). First Response to Victims of Crime. Washington, DC: U.S. Department of Justice: Office for Victims of Crime.
The Office of Justice (2001). Victim empowerment: Bridging the systems mental health and victim service providers. Washington, DC: U. S Department of Justice.

25. ADAPT THE EXAM PROCESS TO ADDRESS THE UNIQUE NEEDS OF EACH PATIENT
Patients’ experiences during the crime and the exam process, as well as their post-assault needs, may be affected by multiple factors:
Age
Gender and/or perceived gender identity/gender expression
Physical health history and current status
Mental health history and current status
Disability
Language needs for limited English proficient patients, Deaf and hard-of-hearing individuals, and those with sensory or communication disabilities
Ethnic and cultural beliefs and practices
Religious and spiritual beliefs and practices
Economic status, including homelessness
Immigration and refugee status
Sexual orientation
Military status
History of previous victimization
Past experience with the criminal justice system
Whether the assault involved drugs and/or alcohol
Prior relationship with the suspect, if any
Nancy

26. Adapt the exam process to address the unique needs of each patient
If the assailant who was in an authority position
If the assault was part of a broader continuum of violence and/or oppression (e.g., intimate partner and family violence, gang violence, hate crimes, war crimes, commercial sexual exploitation, sex and/or labor trafficking)
Physical injuries from the assault and the severity of the injuries
Illegal activities at the time of the assault (e.g., voluntary use of illegal drugs or underage drinking) or have outstanding criminal charges
Involvement in activities prior to the assault that traditionally generate victim blaming or self-blaming (e.g., drinking alcohol prior to the assault or agreeing to go to the assailant’s home)
Whether birth control was used during the assault (e.g., victims may already have been on a form of birth control or the assailant may have used a condom)
Level of support available from families and friends
Whether they have dependents who require care during the exam, were traumatized by the assault, or who may be affected by decisions patients make during the exam process
Community/cultural attitudes about sexual assault, its victims, and offenders
Frequency of sexual assault and other violence in the community and historical responsiveness of the local justice system, health care systems, and community service agencies
Nancy
Adapted from the National Sexual Assault Protocol, 2nd Edition, 2013

27. UNDERSTANDING ROLES
Law enforcement officials gather information and collect crime scene evidence to facilitate the investigation.
Health care personnel assess medical needs, offer treatment, and collect evidence from victims.
Advocates can offer a tangible and personal connection to a long-term source of support and advocacy.
Karen

28. WHAT IS ADVOCACY?
BEST PRACTICES FOR EFFECTIVE MULTIDISCIPLINARY COLLABORATIONS BETWEEN THE SANE AND Community-Based & system-based ADVOCAtes
Nancy

29. Each type of advocate has specific roles/responsibilities.
Broadly speaking, advocacy is supporting and assisting a victim/survivor to define needs, explore options, provide options, safety plan and ensure rights are respected within any systems with which the victim/survivor interacts.
Colorado has 3 types of advocates– community-based, law-enforcement, and victim/witness coordinators in DA offices.
Each type of advocate has specific roles/responsibilities.
What is Advocacy?
Nancy
Ideally, all 3 types of advocates are working well together, in the best interest of the victim.

30. In Colorado, there are different types of Victim Advocates
In Colorado, there are different types of Victim Advocates. A “Victim’s Advocate” with privileged communications is defined in state statute that explains who may not testify without consent.
According to the statute, a victim’s advocate is a person at a battered women’s shelter or rape crisis organization or a comparable community-based advocacy program for victims of domestic violence or sexual assault
A) Whose primary function is to render advice, counsel, or assist victims of domestic or family violence or sexual assault; and
B) Who has undergone not less than fifteen hours of training as a victim’s advocate or, with respect to an advocate who assists victims of sexual assault, not less than thirty hours of training as a sexual assault victim’s advocate; and
C) Who supervises employees of the program, administers the program, or works under the direction of a supervisor of the program.
What is an Advocate?
Colorado Revised Statute
(k)(II)
This Colorado statute details the qualifications of a community-based sexual assault advocate, who can protect the victim’s privilege.
Karen

31. UNDERSTANDING ADVOCATES
System-based Advocates are not covered under
this statute-- C.R.S. § (k)(II).
This means anything a victim says to or in front of a system-based advocate is not legally confidential.
Community-based Advocates are covered under
C.R.S. § (k)(II), therefore this type of advocate IS confidential.
Karen

32. UNDERSTANDING ADVOCATES
Being an advocate is not the same as being a counselor or a therapist. Professional counselors and therapists typically have advanced degrees in counseling, social work, or therapy and have unique licensing requirements.
This training will address a) community-based advocates, b) system-based victim advocates, c) advocates who provide both responsibilities, which may occur in some rural jurisdictions in Colorado.
Karen--- system based may be LE advocate or Victim/Witness Coordinator in DAs office

33. Rape victims who have assistance from victim advocates were significantly more likely to report the crime to law enforcement and were less likely to be treated negatively by law enforcement. They also report less distress after contact with the legal system. Campbell, Rebecca. Rape Survivors Experiences with the Legal and Medical Systems: Do Rape Victim Advocates Make a Difference? Violence Against Women 12, 2006.
Karen

34. COMMUNITY-BASED RAPE CRISIS ADVOCATES
Many colorado communities have non-profit
rape crisis centers.
Some of these programs solely address sexual violence, while other programs are dual agencies, addressing sexual violence and domestic violence
For a listing of colorado’s community-based programs, please visit
The state resources page has an interactive map!
Karen

35. RAPE CRISIS CENTER SERVICE PHILOSOPHY
Generally, the rape crisis center service philosophy is based on social justice models.
This work grew out of the anti-violence movement and holds the belief that clients are inherently well people, but it helps to get some support after a devastating event such as sexual violence.
Karen
Not all the agencies, but some examples… community-based, sometimes college-based

36. VICTIM-CENTERED APPROACH
Rape Crisis Centers typically espouse a Victim-Centered Approach in service provision.
The Principles of a Victim-Centered Approach:
Consider the needs and wants of the victim first
Listen and promote victim self-advocacy
Coordinate and collaborate in the victim’s interest
Promote Victim Safety
Hold self and other accountable
Seek just solutions for all
Nancy

37. CORE RAPE CRISIS SERVICES
24-hour Crisis Intervention (oftentimes through a hotline)
May include information about the effects of sexual violence and possible reactions, general information about medical and legal issues, offering advocacy and information about other services available in the community, active listening and empathic responding and exploring options.
Legal Advocacy
Provides support during the client’s interaction with law enforcement and the civil or criminal justice system. Support may be provided through information, referrals, and requested accompaniments to any investigations, interviews, court hearings, and other proceeding related to the sexual victimization.
*In Colorado, the system-based advocates are more likely to provide advocacy through the Criminal Justice system.
While an advocate can provide guidance through the legal system, it is not the same as having an attorney.
Nancy
When explaining these slides, be sure to mention that services will vary across jurisdiction and geography.

38. CORE RAPE CRISIS SERVICES
General Advocacy
Trauma Informed Care
Case Management
Counseling/Therapy
Support Groups
Information/Referrals
Community Awareness
Prevention Education
Nancy
System-based advocates may provide some of these services as well.

39. MEDICAL ADVOCACY
Assistance and in-person support in making informed decisions about medical care and the preparations needed, including:
Coordination of victim transportation to and from the exam site
Referral for possible forensic exam
Information about medical care/concerns, including assistance with needed follow-up
Support at medical exams and appointments, to help cope with the trauma of the assault
Information and/or assistance with Crime Victim Compensation and other emergency assistance (SAVE Fund)
Nancy

40. WAYS A COMMUNITY-BASED ADVOCATE MAY SUPPORT A SURVIVOR
Promote the needs & choices of the victim
Provide accurate information/referrals
Increase access to services
Work toward the delivery of consistent, quality services
Crisis intervention
Bear witness
Believe the victim
Help navigate the systems (medical, law enforcement, and criminal justice)
Protect confidentiality of victim/survivor
Increase informed decision making
Intervene in victim-blaming/oppressive comments, actions and behaviors
Nancy
Accurate information and referrals: sometimes survivors can be given inaccurate information and it can be the job of the advocate to undo that.
Advocate without bias/judgement

41. Working with Community-Based Advocates with Cases Involving Minors
A Victim’s Advocate of a community-based program (sexual assault crisis center or domestic violence shelter) is entitled to privileged communication (C.R.S. § ).
Privileged communication applies to spoken and written communication—including notes, records, and reports.
However, privilege does not “trump” mandatory reporting requirements outlined in C.R.S. § In cases involving a minor, it is not uncommon for a teen to want to have a parent/guardian/friend present when speaking with a Victim Advocate.
It is a best practice for the Advocate to explain that having a third person in the room could potentially impact privacy. However, the Advocate can acknowledge that needing support is different than forgoing privileged communications.
It is important for the third party in the room to understand that the conversation involves private information.
There is Colorado case law which protects privileged conversations of minors when there is a third party in the room. For more information, please contact the Rocky Mountain Victim Law Center (
Working with Community-Based Advocates with Cases Involving Minors
Nancy

42. IN SUMMARY…. Community-Based Advocates:
Provide a range of services: hotlines, shelters, safety planning, counseling, referrals and communication with other agencies, etc.
Can respond to hospital to provide patient support
Can provide assistance and support regardless of law enforcement involvement
Will continue services after the conclusion of the justice process
Can protect victims’ privilege under Colorado law – this confidentiality can help establish trust and ensure safety of victim
Exceptions are child abuse, victim consent
Karen

43. LAW ENFORCEMENT ADVOCATES
Work in conjunction with Law Enforcement.
Provide a range of services: on scene response, interpreters, communication assistance with officers, safety planning, case updates, notification of case status, case management, referrals and support, etc.
Cannot protect victim privilege due to status as law enforcement employees and rules of discovery.
Karen
Therefore anything a victim says to or in front of this type of advocate is not legally confidential. In rural communities, LE advocates may do the court room advocacy for the DA's office.

44. LAW ENFORCEMENT ADVOCATES & MEDICAL ADVOCACY
Depending on the Jurisdiction, Law Enforcement Advocates May Provide Medical Advocacy as well.
Law Enforcement Advocates and Medical Professionals need to be aware that having a LE Advocate in the room, during an exam:
Jeopardizes a victim’s legal privilege
Could be in conflict with Crawford vs. Washington and negatively impact medical hearsay at time of trial (talk to your local DA office for more information)
This is why a mutually-agreed upon multidisciplinary protocol should follow national best practice, outlined in the National Sexual Assault Protocol.
Assistance and in-person support in making informed decisions about medical care and the preparations needed, including:
Coordination of victim transportation to and from the exam site
Referral for possible forensic exam
Information about medical care/concerns, including assistance with needed follow-up
Support at medical exams and appointments, to help cope with the trauma of the assault
Information and/or assistance with Crime Victim Compensation and other emergency assistance (SAVE Fund)
Karen
Contact CCASA for more information.

45. VICTIM/WITNESS COORDINATORS
Work in District Attorneys’ Offices
Provide a range of services: case management and support for the victim after the defendant has been charged, court preparation and court support, assist with victim impact statements, case status updates, victims compensation, communication assistance between DAs and victims, etc.
Cannot protect victim privilege due to status as law enforcement employees and rules of discovery.
Karen
Therefore anything a victim says to or in front of this type of advocate is not legally confidential.

46. SYSTEM-BASED ADVOCATES…
Provide support during the client’s interaction with law enforcement and the criminal justice system. Support may be provided through information, referrals, and requested accompaniments to any investigations, interviews, court hearings, and other proceeding related to the sexual victimization.
While an advocate can provide guidance through the legal system, it is not the same as having an attorney.
Don’t forget~ System-Based Advocates cannot protect confidentiality.

47. CAN AN ADVOCATE BE BOTH COMMUNITY-BASED & SYSTEM-BASED?!
Unique arrangements in Advocacy…
Karen

48. History of TESSA and Memorial Hospital Relationship:
Prior to 2008 TESSA Advocates responded to the hospital for any sexual assault patient 18 years or older
In 2008, Manager Jen Pierce-Weeks and TESSA Advocate Nancy Duke met and discussed expanding TESSA’s role as well
Nancy had Jen and the forensic nurses call for any patient that had advocacy needs
This started the documentation process for the NEED
Today, TESSA Advocates respond to the hospital for:
Sexual assault patients 15 years or older
Any intimate partner violence patient
In 2012 TESSA provided support to approximately 350 victims of sexual assault/domestic violence

49. HOW TO UTILIZE ADVOCATES
Utilize a system in which exam facility personnel, upon initial contact with a sexual assault patient, call the victim service/advocacy program and ask for an advocate to be sent to the exam site (unless an advocate has already been called).
Prior to introducing the advocate to a patient, exam facility personnel should explain briefly, in a language the patient understands, the victim services offered and ask whether the victim wishes to speak with the already onsite advocate.
If possible, victims should be allowed to meet with advocates in a private place prior to the exam.
Karen
Adapted from the National Sexual Assault Protocol, 2nd Edition, 2013

50. WORKING WITH ADVOCATES
Advocates can provide practical help at the hospital; but are not involved in collecting evidence. They can:
Prepare survivor for what to expect during an exam
Support survivor during the exam (with survivor’s permission)
Inform survivor s/he can stop the process at any time
Inform victim about the Victim Rights Act, Victim Compensation, and other referrals
Support friends and family
Know that Advocates will be involved with this survivor from the time she or he reports and throughout the court process. Community-based advocates may be involved for much longer, if the survivor utilizes the program for ongoing services.
When releasing evidence to law enforcement, an advocate is never involved in signing chain of custody.
Nancy

51. A team approach!
Work to develop good relationships with advocates through a multi- disciplinary team approach
Use multi-disciplinary team meetings to establish or explain hospital protocols, relevant laws, etc. Get to know one another
Hospital practice examination rules (who can be in room) survivor decides who is in the room during the exam
Consent forms and confidentiality: recognize that patients control the extent of personal information they share.
Have defined roles and know the roles: advocates (community-based & system-based), law enforcement, medical personnel
Advocates should inform you whether or not they can protect the patient’s privilege – if not, you should ask
Nancy

52. A TEAM APPROACH!
Multi-disciplinary agencies (and/or Sexual Assault Response Teams—SARTs) should develop policies and plans to meet the needs of specific patient populations (e.g., to obtain necessary interpreter services and translated documents for limited English proficient patients, qualified interpreters for Deaf and hard-of-hearing patients, and identify legal referrals for immigrant victims of sexual assault, domestic violence, dating violence, and stalking.)
Nancy

53. Obtaining Patient Feedback
Responders can benefit from survivors’ feedback about response to the crime.
After some time has passed, it can be useful to talk with victims about their experiences during the exam process, including the location of the exam, and explore how the process might be changed to better minimize trauma.
Advocates can help design a victim feedback system that is confidential, sensitive, does not harm victims, and has mechanisms to quickly link victims with appropriate victim services if needed.
Obtaining Patient Feedback
Adapted from:
A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents
Second Edition
April 2013
Karen

54. ADVOCATES & THE MEDICAL FORENSIC EXAM
With survivor permission, the advocate can stay with the victim throughout the exam and evidence collection process.
The priority of the community-based advocate is with the survivor, not the medical facility or the criminal investigation...
It’s national best practice to have a community-based advocate respond to cases in which the survivor is sure s/he wants to be a Medical Report only.
Karen
National best practice is that System-based advocates are typically not in the exam room, although this decision to an INFORMED victim. This is because the system based advocate then can become a witness and they aren’t protected under the advocate confidentiality statute. If the case goes to trial the victim's support person/advocate then may have to take the stand an testify. In rural communities, system based advocates do the court room advocacy for the DA's office.

55. THE ADVOCATE ROLE DURING THE EXAM
Advocates should be able to provide patient support and advocacy during the medical history, if desired by the patient. The presence of an advocate may help patients feel more comfortable answering questions and advocates may also assist patients in voicing their concerns about questions being asked and clarifying their needs during this time. Advocates should be careful not to answer questions asked of patients or otherwise influence their statements.
While documenting photographic evidence and during the exam, patients may want an advocate and/or a personal support person to be present.
Best practice is for the advocate to sit facing the patient, so that the advocate and patient can engage in conversation (if desired by the patient). The advocate should not, under any circumstances, assist with the exam.
Karen

56. What Forensic Nurses Need to Know about Working with Advocates:
Work to develop good relationships with advocates through a multi-disciplinary team approach
Use multi-disciplinary team meetings to establish or explain hospital protocols
Hospital practice examination rules (who can be in room)
Patient rights and confidentiality
Have defined roles and know the roles: advocates (community-based & system-based), law enforcement, medical personnel
Advocates should inform you whether or not they can protect the patient’s privilege – if not, you should ask

57. IAFN POSITION STATEMENT
International Association of Forensic Nurses (IAFN)
Position Statement :Collaboration With Victim Advocates
Effective Date: November 19, 2008
Status: New Position Statement
Originated by: IAFN Board of Directors
Adopted by: IAFN Board of Directors
IAFN Position Statement
IAFN supports patient centered and evidence based care for the victimized patient. IAFN recognizes the benefits to victims of violence when there is timely interaction with Victim Advocates. Furthermore, IAFN recognizes and supports the role of the Victim Advocate as part of a patient centered team approach to providing services to victims. IAFN encourages the creation of strong collaborative relationships between forensic nurses, advocates and other team members in order to provide rapid, compassionate, comprehensive, patient centered and evidence-based care to victims.
Karen

58. National protocol for sexual assault medical forensic examinations
The National Protocol for Sexual Assault Medical Forensic Examinations (2004),
developed by the U.S. Department of Justice, states, “Advocates can offer a tangible and personal connection to a long-term source of support and advocacy.”
The Protocol goes on to recommend that, in order for health care responders to facilitate a victim-centered approach they should ”understand the importance of victim (support) services within the exam process....(and) involve victim service providers/advocates in the exam process (including the actual exam) to offer support, crisis intervention, and advocacy to victims, their families, and friends.
National Protocol for Sexual Assault Medical Forensic Examination,
United States Department of Justice p. 34
Karen

59. In addition to the advocate, if possible, accommodate patients’ requests to have a relative, friend, or other personal support person (e.g., religious -and spiritual counselor/advisor/healer) present during the exam, unless considered harmful by responders.
Who is in the Room?
From:
A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescen ts
Second Edition
April 2013
Karen
Multidisciplinary teams need to discuss/share an understanding/formalize the issue of who is in the room at the MFE. Some communities will not allow anyone but the doctor or nurse in the exam room. However, they do discuss with the victim that the advocate will be right outside the door. Beforehand the doctor, nurse, victim advocate, and victim discuss what is going to happen with the exam and discuss what the victim needs to say if he/she needs to stop or needs a few minutes before continuing on with the exam, explain that the victim can refuse any component of the exam, etc.

60. They Ask the victim if it is OK for follow-up
Advocate Follow-up
Advocates Always inform the victim that they can provide follow-up calls
They Ask the victim if it is OK for follow-up
Advocates obtain a safe contact number for the victim and ask when would be a good time for contact
If the victim doesn’t want follow-up, the advocate will provide phone number or crisis line number
Nancy

61. Trauma-Informed Care
When providing trauma informed care remember that a victim will only remember a very small amount of the information provided.
Reassure the victim this is normal and s/he always has the option of calling the resources provided for answers to any questions.
Nancy

62. To Consider
When a victim reports, s/he may have to turn over clothing (some or all) for evidence. Work with your collaborative team to provide clothing for the victim when s/he leaves the hospital. This includes underwear, bra, pants, tops, sock, shoes, for men and women.
Also consider the need for toothbrushes, toothpaste, combs, brushes, shampoo, hair dryer, soap for the victim to be able to shower after the exam.
Nancy

63. VIOLENCE AGAINST WOMEN ACT (VAWA) FORENSIC COMPLIANCE
WORKING COLLABORATIVELY WITH ADVOCATES TO ADDRESS CASES IN WHICH THE VICTIM DOES NOT WANT TO PARTICIPATE IN THE CRIMINAL JUSTICE SYSTEM
Karen

64. Understanding Forensic Compliance
The forensic compliance laws (28 C.F.R.§ 90.2(b)(1)
& Colo. Rev. Stat. § ) mandate that sexual assault victims receive free medical forensic exams without required participation in a law enforcement investigation. In Colorado, victims have two reporting options:
Medical Reporting Victims - Victims who seek medical services following a sexual assault but elect not to participate in the criminal justice system at the time of receiving medical services.
Law Enforcement Reporting Victims - Victims who report the assault to law enforcement prior to, at the time of, or independent of a medical forensic exam.
Karen

65. Victims’ Right Not To Participate
A VICTIM HAS THE RIGHT NOT TO participate in the criminal justice system at the time of the mfe, but can also change her/his mind at a later date.
IT IS IMPORTANT FOR THE ADVOCATE TO EXPLAIN TO THE SURVIVOR THE TIME frames of how long EVIDENCE IS KEPT BY LAW ENFORCEMNT, how an individual could “convert” a medical report case to a law enforcement case, and follow-up services available.
Karen

66. Sexual Assault Victim Emergency (SAVE) Payment Program
To be eligible for the fund, the victim must have a sexual assault medical forensic examination in Colorado.
The Division of Criminal Justice (DCJ), Office for Victims Programs administers the SAVE Payment Program (starting July 1, 2013).
DCJ already administers the payment for forensic evidence collection and DFSA testing for sexual assault victims initially choosing to not participate in the criminal justice system.
Financial assistance through the fund are limited to the medical procedures related directly to the sexual assault (emergency room fees, physician fees, lab testing, medications, etc.,) with a cap per victim.
Karen

67. Questions?
Nancy
A special thank you to Karen Moldovan from CCASA for her assistance with the development of this presentation!!