1. Medical Concerns for Survivors

2. There are likely to be several medical concerns for survivors of sexual assault. They commonly include: There are likely to be several medical concerns for survivors of sexual assault. They commonly include: pregnancy pregnancy sexually transmitted infections sexually transmitted infections

3. Pregnancy The risk of pregnancy following a sexual assault is dependent upon the The risk of pregnancy following a sexual assault is dependent upon the Nature of the assault, Nature of the assault, Time of the assault in relation to menstrual cycle Time of the assault in relation to menstrual cycle Current use of contraception Current use of contraception

4. Survivors should receive information, counseling, and/or referral with regard to all options. Survivors should receive information, counseling, and/or referral with regard to all options.

5. Emergency Contraception Emergency contraception prevents an egg from being fertilized and/or implantation. Emergency contraception prevents an egg from being fertilized and/or implantation. EC will not affect a pre-existing pregnancy. It is equivalent to a larger dose of birth control pills. EC will not affect a pre-existing pregnancy. It is equivalent to a larger dose of birth control pills. Ideally, it should be taken within 72 hours of the sexual assault, and in some cases can be taken up to five days (120 hours) following an assault. Ideally, it should be taken within 72 hours of the sexual assault, and in some cases can be taken up to five days (120 hours) following an assault.

6. Emergency Contraception Emergency contraception, most commonly “Plan B”, should be available as part of the forensic exam, and is a covered expense of the exam. Emergency contraception, most commonly “Plan B”, should be available as part of the forensic exam, and is a covered expense of the exam. Hospitals are required by law (RCW RCW 70.41.350 & WAC 246-320-370) to provide EC to victims of sexual assault. Hospitals are required by law (RCW RCW 70.41.350 & WAC 246-320-370) to provide EC to victims of sexual assault.

7. Emergency Contraception EC is also legally available without a prescription from a pharmacist. EC is also legally available without a prescription from a pharmacist. For survivors who choose not to have a forensic exam or seek other medical treatment, this is an option. For survivors who choose not to have a forensic exam or seek other medical treatment, this is an option. Advocates should be aware medical providers may offer up unhelpful or harmful judgments or statements when a survivor seeks EC. Advocates should be aware medical providers may offer up unhelpful or harmful judgments or statements when a survivor seeks EC. Survivors under the age of 17 will need a prescription (Ella can be taken 5 days after assault but requires a prescription for those under 18.) Survivors under the age of 17 will need a prescription (Ella can be taken 5 days after assault but requires a prescription for those under 18.)

8. Emergency Contraception Though emergency contraception is not abortion, some medical facilities and some pharmacists have attempted to refuse to provide certain treatment due to a moral stance. Ralph’s and Bay View do not offer EC. Though emergency contraception is not abortion, some medical facilities and some pharmacists have attempted to refuse to provide certain treatment due to a moral stance. Ralph’s and Bay View do not offer EC. Legally, as long as the survivor has a prescription, the pharmacist must provide EC if it is in stock (in Washington.) It is legal to not stock EC. Legally, as long as the survivor has a prescription, the pharmacist must provide EC if it is in stock (in Washington.) It is legal to not stock EC. The Washington State Department of Health has a website devoted to emergency contraception. It has factsheets and flyers: http://www.doh.wa.gov/cfh/FPRH/EC.htm The Washington State Department of Health has a website devoted to emergency contraception. It has factsheets and flyers: http://www.doh.wa.gov/cfh/FPRH/EC.htm http://www.doh.wa.gov/cfh/FPRH/EC.htm

9. Sexually Transmitted Infections While a survivor’s first medical concerns may be directed at physical injuries and possible pregnancy, there is also concern about the possibility of STI’s. While a survivor’s first medical concerns may be directed at physical injuries and possible pregnancy, there is also concern about the possibility of STI’s. It may be a sensitive topic or the survivor may know little about it. You may have to bring the subject up, since exposure and prevention will be an issue during the medical exam. It may be a sensitive topic or the survivor may know little about it. You may have to bring the subject up, since exposure and prevention will be an issue during the medical exam. STI’s are one of the most common kinds of infections in American today. Every year more than 10 million Americans get STI’s passed primarily by sexual contact. STI’s are one of the most common kinds of infections in American today. Every year more than 10 million Americans get STI’s passed primarily by sexual contact.

10. Sexually Transmitted Infections As part of the medical examination, the examiner may prescribe STI prophylaxis. Follow-up tests should be conducted for gonorrhea culture in 3 to 8 days, a test for syphilis in 6 to 8 weeks, and a HIV test in 3 months. As part of the medical examination, the examiner may prescribe STI prophylaxis. Follow-up tests should be conducted for gonorrhea culture in 3 to 8 days, a test for syphilis in 6 to 8 weeks, and a HIV test in 3 months.

11. Measures Survivors Can Take Self-examination for signs of possible infection Self-examination for signs of possible infection Going for screening tests at appropriate intervals and Going for screening tests at appropriate intervals and Following any prescribed treatment when diagnosed with an STI Following any prescribed treatment when diagnosed with an STI Making sure they have been cured by getting tested during the follow-up after treatment Making sure they have been cured by getting tested during the follow-up after treatment

12. HIV/AIDS Sexual assault victims should not be tested for HIV during the forensic exam. An HIV/AIDS test at this time would only provide information on whether or not a victim already has HIV/AIDS, not if she or he contracted HIV from the assault. Sexual assault victims should not be tested for HIV during the forensic exam. An HIV/AIDS test at this time would only provide information on whether or not a victim already has HIV/AIDS, not if she or he contracted HIV from the assault. Also, someone who has just been sexually assaulted is most likely not in the proper mental and emotional state to receive pre-test counseling for HIV. Also, someone who has just been sexually assaulted is most likely not in the proper mental and emotional state to receive pre-test counseling for HIV.

13. HIV/AIDS A healthcare provider can help victims assess immediate risks and whether HIV prophylaxis is warranted. Post exposure prophylaxis must be determined on an individual basis. Be aware that prophylactic medications for HIV are highly toxic, and the regimen is difficult. A healthcare provider can help victims assess immediate risks and whether HIV prophylaxis is warranted. Post exposure prophylaxis must be determined on an individual basis. Be aware that prophylactic medications for HIV are highly toxic, and the regimen is difficult.

14. High risk factors for contracting HIV Anal rape Anal rape Vaginal rape when other STDs are present that would threaten the integrity of the vaginal muscosa Vaginal rape when other STDs are present that would threaten the integrity of the vaginal muscosa Vaginal rape with traumatic tearing injury Vaginal rape with traumatic tearing injury Known or suspected HIV positive offender Known or suspected HIV positive offender Known or suspected IV-drug use by the offender Known or suspected IV-drug use by the offender

15. Anonymous Testing There are two common methods of HIV testing: anonymous and confidential. There are two common methods of HIV testing: anonymous and confidential. Anonymous testing sites have no way of connecting a person's name and address with the test information. Those who present for testing are given a code, which has to be remembered in order to find out the test results. (UCAN) Anonymous testing sites have no way of connecting a person's name and address with the test information. Those who present for testing are given a code, which has to be remembered in order to find out the test results. (UCAN)

16. Confidential Testing Confidential testing sites record the names and addresses of those who are being tested. Confidential testing sites record the names and addresses of those who are being tested. This information is then documented in the person's medical records. This information is then documented in the person's medical records. Even if the test is negative, the medical file will still state that an HIV test was performed. Even if the test is negative, the medical file will still state that an HIV test was performed. However, no one can give out patient results without permission, except as required by law. (Planned Parenthood) However, no one can give out patient results without permission, except as required by law. (Planned Parenthood) Anonymous testing is strongly recommended over confidential testing in order to protect the survivor’s privacy. Anonymous testing is strongly recommended over confidential testing in order to protect the survivor’s privacy.

17. Crime Victim’s Compensation In all of the United States (VAWA 2007) a survivor is not required to report the incident to the police, in order to seek a forensic exam. In all of the United States (VAWA 2007) a survivor is not required to report the incident to the police, in order to seek a forensic exam. In the state of Washington, a victim should never be billed for the forensic exam itself regardless of whether he chooses to report the assault to law enforcement. (RCW 7.68.170-No costs incurred by a hospital or other emergency medical facility for the examination of the victim of a sexual assault, when such examination is performed for the purposes of gathering evidence for possible prosecution, shall be billed or charged directly or indirectly to the victim of such assault. Such costs shall be paid by the state pursuant to this chapter. ) In the state of Washington, a victim should never be billed for the forensic exam itself regardless of whether he chooses to report the assault to law enforcement. (RCW 7.68.170-No costs incurred by a hospital or other emergency medical facility for the examination of the victim of a sexual assault, when such examination is performed for the purposes of gathering evidence for possible prosecution, shall be billed or charged directly or indirectly to the victim of such assault. Such costs shall be paid by the state pursuant to this chapter. ) The exam is performed, evidence is stored (duration depends on several local factors), and a police report can be made at a later time if the survivor chooses. The exam is performed, evidence is stored (duration depends on several local factors), and a police report can be made at a later time if the survivor chooses.

18. CVC Payment for services may be a major concern. Washington State’s Crime Victim’s Compensation Act is a secondary insurer who will cover expenses for the forensic exam even if there is no intention to follow through with prosecution. Payment for services may be a major concern. Washington State’s Crime Victim’s Compensation Act is a secondary insurer who will cover expenses for the forensic exam even if there is no intention to follow through with prosecution. Crime Victim’s Compensation (CVC) covers the cost of all Sexual Assault Forensic Exams in WA State. It is important for advocates to know that survivors DO NOT need to complete a CVC application to receive this benefit, it should be automatic. Crime Victim’s Compensation (CVC) covers the cost of all Sexual Assault Forensic Exams in WA State. It is important for advocates to know that survivors DO NOT need to complete a CVC application to receive this benefit, it should be automatic. The victim must file a CVC claim to have associated care covered. For example, if I was raped and broke my arm CVC would pay for the forensic exam but may or may not pay for the broken arm. A separate claim would need to be filed. The victim must file a CVC claim to have associated care covered. For example, if I was raped and broke my arm CVC would pay for the forensic exam but may or may not pay for the broken arm. A separate claim would need to be filed.

19. This can be done at a later time, when the survivor is not in crisis. Be prepared to assist the victim with CVC forms. If they are not available at the hospital, be sure and have one on hand. This can be done at a later time, when the survivor is not in crisis. Be prepared to assist the victim with CVC forms. If they are not available at the hospital, be sure and have one on hand. Separately and in addition to the forensic exam, the Crime Victims Compensation (CVC) program may provide financial assistance to eligible crime victims, including medical bills, therapy, time loss, and vocational rehabilitation. Separately and in addition to the forensic exam, the Crime Victims Compensation (CVC) program may provide financial assistance to eligible crime victims, including medical bills, therapy, time loss, and vocational rehabilitation. The rate of approved claims and amount of coverage varies year to year depending on the program’s budget. CVC is a payer of last resort, meaning that all other coverage options must be exhausted before the program kicks in. The rate of approved claims and amount of coverage varies year to year depending on the program’s budget. CVC is a payer of last resort, meaning that all other coverage options must be exhausted before the program kicks in.

20. Eligibility Criteria for CVC –Crime must occur in Washington State –Must be gross misdemeanor or felony –Crime must be reported to law enforcement within one year or within 12 months of when it could have reasonably been reported –Claim must be filed with CVC within two years of reporting to law enforcement or, with good cause, five years –Victim must cooperate with law enforcement –Injury cannot be result of consent; injury was not provoked –Victim cannot be incarcerated –Victim who has been convicted of a felony (violent crime or crime against persons) within the last five years and has not paid legal obligations

21. For the latest eligibility criteria and process, visit: http://www.lni.wa.gov/ClaimsIns/CrimeVic tims/About/default.asp For the latest eligibility criteria and process, visit: http://www.lni.wa.gov/ClaimsIns/CrimeVic tims/About/default.asp http://www.lni.wa.gov/ClaimsIns/CrimeVic tims/About/default.asp http://www.lni.wa.gov/ClaimsIns/CrimeVic tims/About/default.asp

22. These stipulations can be a challenge to survivors and the denial rate may be a source of frustration to organizations and individuals. It is important to talk about the criteria for coverage, application process, and other options for financial assistance. These stipulations can be a challenge to survivors and the denial rate may be a source of frustration to organizations and individuals. It is important to talk about the criteria for coverage, application process, and other options for financial assistance. Remember, the forensic exam is always automatically covered and emergency contraception is included. The law requires every hospital emergency room, regardless of religious affiliation, give sexual assault victims truthful information about emergency birth control (also known as the morning-after pill) and give them the pills if they request them, free of charge. Remember, the forensic exam is always automatically covered and emergency contraception is included. The law requires every hospital emergency room, regardless of religious affiliation, give sexual assault victims truthful information about emergency birth control (also known as the morning-after pill) and give them the pills if they request them, free of charge.

23. Advocacy Role Plays

24. After The Exam The survivor may change clothes, receive instructions, and get prescriptions. The survivor may change clothes, receive instructions, and get prescriptions. Be sure written instructions are received since they are under extreme emotional stress and may forget verbal instructions. Be sure written instructions are received since they are under extreme emotional stress and may forget verbal instructions. Make notes on follow-up form so that SAAS knows what they might want info about. What do they feel their most important needs are? What were most of their questions about? If the SAAS knows then she can have info researched and ready when she does follow-up. Make notes on follow-up form so that SAAS knows what they might want info about. What do they feel their most important needs are? What were most of their questions about? If the SAAS knows then she can have info researched and ready when she does follow-up.

25. There may be difficulties in leaving the hospital. The survivor may be afraid to leave, or may have no transportation. St. Pete’s has cab vouchers and can arrange this. Feel free to ask the survivor if they would like you to inquire about it with ER staff. There may be difficulties in leaving the hospital. The survivor may be afraid to leave, or may have no transportation. St. Pete’s has cab vouchers and can arrange this. Feel free to ask the survivor if they would like you to inquire about it with ER staff. Sometimes SP has cabs, bus tickets and gas cards. Contact HelpLine or supervisor. You may need to leave the survivor to pick up any of these items for them and bring them back. Never give a client a ride; it is SafePlace policy. Sometimes SP has cabs, bus tickets and gas cards. Contact HelpLine or supervisor. You may need to leave the survivor to pick up any of these items for them and bring them back. Never give a client a ride; it is SafePlace policy.

26. As an Advocate You Can… Help the survivor sort through fears about leaving Help the survivor sort through fears about leaving Check to see what support base they can now turn to Check to see what support base they can now turn to Inform client of available and accessible support systems in the community which may be needed Inform client of available and accessible support systems in the community which may be needed Make sure they know about Crime Victims Compensation Make sure they know about Crime Victims Compensation Set up a follow-up call in a few business days if they want. Make sure you find out if it is okay to say SafePlace when we call and to leave a message. If not ask how they would like us to identify: doctor’s office, counselor, friend? Set up a follow-up call in a few business days if they want. Make sure you find out if it is okay to say SafePlace when we call and to leave a message. If not ask how they would like us to identify: doctor’s office, counselor, friend?

27. Make sure they have and understand information about sexually transmitted infections Make sure they have and understand information about sexually transmitted infections Make sure a client who could become pregnant has made an informed choice about emergency contraception Make sure a client who could become pregnant has made an informed choice about emergency contraception Make sure there is a safe place for the survivor to go Make sure there is a safe place for the survivor to go Let the client know advocacy services are available as needed Let the client know advocacy services are available as needed

28. Try not to overwhelm the survivor. Be sensitive to the process they just went through. Be careful to never give medical advice or sharing any information you may know about medicine. Try not to overwhelm the survivor. Be sensitive to the process they just went through. Be careful to never give medical advice or sharing any information you may know about medicine.

29. Medical Advocacy with Children Locally, children are often taken to the Children’s Advocacy Center (Monarch) by their caregivers upon learning that sexual abuse has occurred, regardless of when it happened. Locally, children are often taken to the Children’s Advocacy Center (Monarch) by their caregivers upon learning that sexual abuse has occurred, regardless of when it happened. We use the name Monarch Children's’ Justice and Advocacy Center even though we are really talking about the Sexual Assault Clinic. Which is housed in the same building. The SAC is a warm and child-friendly office. The providers working there have extensive training in child sexual assault. We use the name Monarch Children's’ Justice and Advocacy Center even though we are really talking about the Sexual Assault Clinic. Which is housed in the same building. The SAC is a warm and child-friendly office. The providers working there have extensive training in child sexual assault.

30. The dynamics of working with a child can be very different from working with adults. Reassure the parent/caregiver that the medical assessment children experience is similar to their child’s regular medical exams. The dynamics of working with a child can be very different from working with adults. Reassure the parent/caregiver that the medical assessment children experience is similar to their child’s regular medical exams. Monarch does not do internal evidence collecting with any of their clients even if the survivor is an older teen. They use a machine that magnifies and records the medical examination which allows medical providers to obtain the evidence they need. Monarch does not do internal evidence collecting with any of their clients even if the survivor is an older teen. They use a machine that magnifies and records the medical examination which allows medical providers to obtain the evidence they need.

31. Besides documenting the history, health status, and injuries associated with the sexual assault/abuse and identifying any potential evidence, the exam is important to assure the child themselves that they are not “broken” or “damaged.” Besides documenting the history, health status, and injuries associated with the sexual assault/abuse and identifying any potential evidence, the exam is important to assure the child themselves that they are not “broken” or “damaged.” It is normal to be normal. Meaning, only about 20% of children have medical findings that indicate sexual assault/abuse. This does not mean sexual assault/abuse did not happen! It is normal to be normal. Meaning, only about 20% of children have medical findings that indicate sexual assault/abuse. This does not mean sexual assault/abuse did not happen!

32. There may be situations where it is advisable to have an advocate for the child (especially if they are 10 or older) and a separate advocate for the parent/caregiver. This can help ensure that each survivor/secondary survivor receives adequate support unique to their needs. There may be situations where it is advisable to have an advocate for the child (especially if they are 10 or older) and a separate advocate for the parent/caregiver. This can help ensure that each survivor/secondary survivor receives adequate support unique to their needs.

33. Many of the same objectives exist for the teen victim of sexual assault as for the adult victim in the medical setting: Many of the same objectives exist for the teen victim of sexual assault as for the adult victim in the medical setting: –Support throughout the exam –Discuss options around STIs and pregnancy –Maintain appropriate records/paperwork as directed by your agency’s protocols Initiate follow-up health care and advocacy if appropriate Initiate follow-up health care and advocacy if appropriate

34. However, even with teens who can consent to medical services, mandated reporting is still obligatory, so some of the dynamics will be different. However, even with teens who can consent to medical services, mandated reporting is still obligatory, so some of the dynamics will be different. There will be more systems to navigate – law enforcement, child protective services, hospital social workers, and parents. There will be more systems to navigate – law enforcement, child protective services, hospital social workers, and parents. It is very important to become familiar with your county’s child abuse protocols. It is very important to become familiar with your county’s child abuse protocols.

35. Be upfront with your obligation to report as soon as you know the survivor you are supporting is under age. Tell them that without identifying information, you are not able to report and that they can decline to give identifying information and still receive support from advocates. (This is harder in person but on the HelpLine is very doable.) Be upfront with your obligation to report as soon as you know the survivor you are supporting is under age. Tell them that without identifying information, you are not able to report and that they can decline to give identifying information and still receive support from advocates. (This is harder in person but on the HelpLine is very doable.)

36. When working with children/teens, remember the assault was likely perpetrated by someone they know – they may be feeling guilty and sad. When working with children/teens, remember the assault was likely perpetrated by someone they know – they may be feeling guilty and sad. Help to alleviate fears and concerns. Keep things age-appropriate. Stay calm. Help to alleviate fears and concerns. Keep things age-appropriate. Stay calm.

37. Parents, who are generally as traumatized as the child, also need reassurance, guidance and warnings not to magnify the situation in front of the child. This is often where we find ourselves spending most of our time. It is EXTREMELY common for parents to have been abused as children. Parents, who are generally as traumatized as the child, also need reassurance, guidance and warnings not to magnify the situation in front of the child. This is often where we find ourselves spending most of our time. It is EXTREMELY common for parents to have been abused as children.

38. Examination of adolescents should not be done without their consent unless there is a life-threatening emergency. Examination of adolescents should not be done without their consent unless there is a life-threatening emergency. Teens 14 and over can provide consent for services themselves. However, know the protocols of the hospital/CAC doing the exams. Some will see younger children under the “birth control services” exemption. RCW9.02.100(1)(2) Teens 14 and over can provide consent for services themselves. However, know the protocols of the hospital/CAC doing the exams. Some will see younger children under the “birth control services” exemption. RCW9.02.100(1)(2) As a rule, the provider should not abdicate their obligation on mandatory reporting to an employee from a different agency. As a rule, the provider should not abdicate their obligation on mandatory reporting to an employee from a different agency. Sometimes the medical provider may contact law enforcement or CPS prior to your arrival or without the child’s or caregiver’s knowledge. Sometimes the medical provider may contact law enforcement or CPS prior to your arrival or without the child’s or caregiver’s knowledge.

39. Secondary Survivors Many people may accompany the survivor to the hospital. It is important for the advocate to know who the survivor wants with them at the forensic exam or medical assessment. Many people may accompany the survivor to the hospital. It is important for the advocate to know who the survivor wants with them at the forensic exam or medical assessment. This is stressful time for all involved. If the secondary survivor is not acting in ways that are supportive, an advocate can provide them with resources and information which might help them be more supportive. It can also be helpful to model appropriate support. This is stressful time for all involved. If the secondary survivor is not acting in ways that are supportive, an advocate can provide them with resources and information which might help them be more supportive. It can also be helpful to model appropriate support.

40. The survivor needs to be in control of when and how family and friends are told. The survivor needs to be in control of when and how family and friends are told. The secondary survivor may be a parent, lover, partner, husband, sibling, roommate, friend, employer or teacher. This person will influence the recovery process so supporting the secondary survivor is providing them with resources to support the survivor. The secondary survivor may be a parent, lover, partner, husband, sibling, roommate, friend, employer or teacher. This person will influence the recovery process so supporting the secondary survivor is providing them with resources to support the survivor. Secondary survivors, as well as primary survivors, need to be counseled and supported. Secondary survivors, as well as primary survivors, need to be counseled and supported.

41. You must maintain confidentiality for whomever you are an advocate for. You must maintain confidentiality for whomever you are an advocate for. Be cautious that the significant other may be the perpetrator. For example, a man who has just beaten and raped his daughter may take her to the hospital. Be cautious that the significant other may be the perpetrator. For example, a man who has just beaten and raped his daughter may take her to the hospital. We provide support to significant others also, as secondary victims. Sexual assault is like a bomb going off. The survivor is the detonation point, but those around are hit by the shrapnel, causing trauma also. We provide support to significant others also, as secondary victims. Sexual assault is like a bomb going off. The survivor is the detonation point, but those around are hit by the shrapnel, causing trauma also.

42. Make sure and address that secondary survivor as a client too. Offer support and follow-up. Often, this person wants information and has questions. Offer reading materials from SARP packet and ask if they need additional support that you can write down for the SAAS. Make sure and address that secondary survivor as a client too. Offer support and follow-up. Often, this person wants information and has questions. Offer reading materials from SARP packet and ask if they need additional support that you can write down for the SAAS.