Assisting Victims of Sexual Assault Through a Multidisciplinary Response
Dr. Patricia Speck, Sally Laskey  -  2006/4/7
http://ovc.ncjrs.gov/ovcproviderforum
 
 
Do you know of any DoJ programs and research addressing the role of "soft" and "hard" pornography triggering misogyny, sexual harssment and copy cat crimes in juveniles?
 
1.  S Laskey
 I am not aware of any specific Department of Justice funded research or programming that addresses the impact of pornography and juveniles. There is a body of research on adults, and one paper that might be of interest was recently published in the Canadian journal Sexual Abuse: A Journal of Research and Treatment April 2004 and showed that the use of pornography during childhood and adolescence were related to the development of deviant sexual preferences.
 
2.  Dr. Pat Speck
 The short answer is I am unaware of programs to address the listed issues. However, media violence, including your terms “soft” and “hard” pornography have been addressed. I have attached an internet site authored by the Surgeon General. This may help others find resources through the available links from this page and the bibliographies. Source: Surgeon General http://www.surgeongeneral.gov/library/youthviolence/chapter4/appendix4bsec2.html
 
 
Despite landmark cases involving sexual abuse of priests - They are still difficult cases to get police and prosecutors to arrest, charge, convict; and finding attorneys for the civil side in getting remedies and recovery from damages. Situation is the same related to sexual abuse by Army recruiters (probably other military personnel too). What professionals, attorneys, national agencies, and government agencies helping victims - are willing to handle such cases, especially when situation get complicated and the perpetrators/people helping the perpetrators are using strategies to cover-up/defeat the cases?
 
1.  S. Laskey
 Addressing sexual abuse by professionals is an important area that multidisciplinary teams must address. There are several national agencies that may be of assistance. SNAP - Survivors Network of those Abused by Priests, based out of Chicago is a self-help organization of men and women who were sexually abused by spiritual elders. The Victims Rights Law Center provides civil legal assistance http://www.victimrights.org/, the Sexual Assault Prevention and Response Office at the Department of Justice provides assess to support services and reporting options, http://www.sapr.mil/ and the Miles Foundation provides advocacy to victims that have been assaulted by military personnel http://hometown.aol.com/milesfdn/. You could also contact the National Sexual Violence Resource Center for specific referrals to local agencies that can help connect people to networks locally.
 
 
Even though we have a good SART Team working relationship, it seems that constant training of police & sheriff agencies is always needed, but not so welcomed. I'd like to know how other Victim Witness Units address this need in a successful way.
 
1.  Silvia Uribe
 That's a great resource, because i'm not only interested in regular training for all agencies involved, but also in learning more about SART protocols, and manuals, etc. I'll get in touch with your coordinator
 
2.  S Laskey
 Please contact our SART Resource Coordinator, Debbie Rollo for ideas about who to network with at drollo@nsvrc.org.
 
3.  Dr. Pat Speck
 FOURTH NATIONAL SEXUAL ASSAULT RESPONSE TEAM TRAINING CONFERENCE, May 30 - June 1, 2007, Tampa, Florida is an upcoming event for teams. Information can be located at http://www.sane-sart.com/ In addition, the International Association of Forensic Nurses annual meeting offers training not only for forensic nurses, but the topics should also be of interest to the advocacy and law enforcement communities. The information can be located at http://www.forensicnurse.org/events/default.html
 
4.  Silvia Uribe
 I'd like to know more about those who have teams of trainers, as well as what the training topics include, and how frequently they train participant agencies. Could you give me the contact information for a couple of them? I find that networking is the best approach, as oppose as to re-invent the wheel. Thanks for your assistance :o)
 
5.  S. Laskey
 You are absolutely right, and I would broaden your statement in that constant training is needed for all team members. In our national needs assessment work on SART in the US we found the high rates of staff turnover and the need for constant training to be a challenge across the board. Programs that seem to have fewer challenges use a training philsophy that ensures that team members are trained by members of the discipline they represent and therefore have more credibiliy or always to use teams of trainers in order to show the collaboration between disciplines. Secondly, we have found that when team members can view the content of the trainig as relevant to their work they are more interested in continued training. We have also seen many models that have emmense support from the local prosector or district attorney as very effective.
 
 
I have two questions: #1 - Have you encountered a professionally reviewed Sexual Assault Support Group curriculum. We have been using CalCASA materials for our groups, but wonder if someone has prepared an actual curriculum that is beneficial to SA support group participants. #2 - to provide assistance to SA victims, we need to reach them. We are a very rural area and our Law Enforcement agencies don't encounter many reported rapes. We are in the process of doing intense outreach to all community partners, but wonder if anyone has found a particular strategy to be more effective (or others that were less effective). \ Thank you for your time.
 
1.  Dr. Pat Speck
 Question #2: Yes, the federal government has several documents that address frameworks for program development and evaluation. These documents include the SANE-SART Development and Operations Guide and the Framework for Program Evaluation in Public Health (CDC, 1999). Together they can provide an approach to meeting your goal to be more effective with the interprofessional agencies. Source: SANE-SART Development and Operations Guide in http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf CDC source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm
 
2.  Dr. Pat Speck
 Question #1: I support Sally’s response and will add that a quick search of the social work literature revealed several models of care. VanDeusen and Carr (2004) describe a psycho-educational support group method that “takes place in a University setting and is free, confidential and easily accessible. The psychoeducational format allows survivors at various levels of healing to gain information about common sexual assault effects, rape myths, and coping strategies, and to explore their feelings and thoughts in a safe environment.”
 
3.  S. Laskey
 My first response is actually a question, what type of support group are you looking to utilize, are you implementing a therapy based model, psychoeducational model, peer support group model? Additionally, have you done an assessment of the current model you are using? Cris Sullivan and Suzanne provides some excellent assessment tools in Outcome evaluation strategies for sexual assault service programs : a practical guide. Once you have established your goals, then you can look to the literature for curriculum that are in line with those goals. The NSVRC has collected many models from around the country, and althought few have been evaluated in the way you are describing they may lead you to developing a program that you can evaluate in your community.
 
 
What would a multidisciplinary response look like for rural programs who do not have a local SANE program and who would make up the multidisciplinary team when there is limited numbers of advocates, law enforcement officers, etc.?
 
1.  S. Laskey
 With support from the Office for Victims of Crime, the National Sexual Violence Resource Center will be hosting the Fist Ever National Symposium for State/Territory/Tribal and Military SANE Coordinators in May 2006 and the first National Sexual Assault Response Team Toolkit in which we will be gathering promising practices around organizing regionally and specific recommendations for rural and tribal communities. The Wyoming Attorney General requested that a regional SART unit be established and their has been much success in their community. Additionally, West Virgina has developed a Mobile SANE unit that can provide all of us insight on how to work with limited resources. http://www.ojp.usdoj.gov/ovc/publications/infores/focuson/promisingpractices/pg2.html
 
2.  Dr. Pat Speck
 I presume that the local hospital would be responsible for the health care of the sexual assault or domestic violence victim. The SART would go to the local health care institution for health care and sexual assault kit collection. In these cases, the hospital is responsible for providing the standard of health care. The standards are available from professional organizations and in the evidenced based literature that guides health care practice. This would include the International Association of Forensic Nurses SANE Standards of Practice (1996, under revision to meet the new American Nurses Association format) and the American College of Emergency Physician document on the Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient (1999). In addition, the current literature about care of sexual assault victims would guide the health care response. Together with advocacy and law enforcement, the SART would need to meet to plan the response in their rural community. In Tennessee, this happened through the Department of Health when standards for SART in rural communities was addressed. In addition, the SANE-SART Development and Operations Guide provides insight into these issues in Chapters 4 & 5. Source: TN Department of Health (2000). Sexual assault response team: Best practice guidelines. Nashville, TN: Commissioner, Tennessee Department of Health SANE-SART Development and Operations Guide in http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf American College of Emergency Physicians (1999). Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient.
 
 
I am a surgeon who has developed a protocol to diagnose trauma pts who are victims of IPV. I want to know measurable predictors once a victims is identified to determine if intervention is working
 
1.  Dr. Pat Speck
 Here is the reference source: Gerlock, A.A. (2001). A profile of who completes and who drops out of domestic violence rehabilitation. Issues in Mental Health Nursing, 22 (4):379-400.
 
2.  Dr. Pat Speck
 Clearly the literature does not offer much information about intervention outcomes. In fact, the literature does not currently support the current prevention or intervention efforts. While I agree that there are intangibles that cannot be measured statistically, such as community education and legal accountability, the reality is that the majority of programs have difficulty in assisting victims who do not want to participate in the programs. One author in 2001 has reviewed why women drop out of intervention programs and a quote from the abstract states “Completers were more likely young, court-monitored, had lower levels of stress (SOS Inventory) and posttraumatic stress (PCL), and had higher levels of mutuality (MPDQ) in their relationships than non-completers.” My clinical experience tells me that among others, if the woman has other support systems outside her partner and economic independence, the chances of recovery are greater too. The evidence in the literature will be useful if you are designing a new tool for determining successes of your intervention. Good luck!
 
 
I have been an advocate for sexual assault victims for 25+ years, working in non-profits and law enforcement. Part of the role of the victim advocate is to respond to hospital to meet with a victim of sexual assault providing support, crisis intervention and referrals. I was very instrumental in organizing a SANE site at a local hospital. The SANE's are now refusing to have victim advocates in the room during the exam. This is occurring even at the request of the victim. Many of us fought this battle years ago with law enforcment. What suggestions do you have in helping us work as a team? What are your thoughts in having an advocate in the room during the exam?
 
1.  S. Laskey
 In our work building the National Sexual Assault Response Team Toolkit the concept of clearly defining the role of all team members has been a daily conversation. The role of SANE’s is related to comprehensive medical care and the role of the advocate is focused on providing psychological support and access to resources. The roles are different, but complimentary. As Nurses advocate for their patients medical care, advocates are able to focus on the long term follow up throughout a survivors healing. That being said, a victim-centered response is focused on the needs of the victim and it is only the victim that can choose who is present during the exam. It is the responsibility of all team members to provide information about the roles of the other members and provide them with options to receive those services. Enlist the support of law enforcement and other team members to try to bridge this gap in your area. I am wondering what might have caused this shift if philosophy and engaging all of the team members in the conversation may provide a new opportunity to create better access to services for victims of sexual assault.
 
 
What strategies do you recommend for addressing the jurisdictional issues frequently experienced in Indian Country?
 
1.  S. Laskey
 With the high rates of sexual violence against Native American women, this is a cruicial problem to address. Here are a few resources that can be used in your discussions locally, and it is that development of collaborative efforts that will break down those barriers. Public Law 280: Issues and Concerns for Victims of Crime in Indian Country http://new.vawnet.org/category/Documents.php?docid=292&category_id=291 Enforcing criminal law on Native American lands / by M. Wesley Clark. http://www.fbi.gov/publications/leb/2005/apr05leb.pdf Improving first response to domestic violence, sexual assault and stalking on Indian reservations. http://www.indianhealth.com/domesticviolence/PDF/Improving_First_Response.pdf Jurisdictional issues complicate response to sexual assault for tribes under PL280 status. http://www.nsvrc.org/publications/newsletters/fal_win_03.pdf For training issues you could reach out to the Federal Law Enforcement Training Center, National Center for state and Local training, US Department of Homeland Security.
 
2.  Dr. Pat Speck
 While I am not an attorney, I have responded to jurisdictional issues between states. In the public health model of planning interventions, all stakeholders have a responsibility to the community. The key is to recognize and respect the sovereignty of the Indian Nations by including the tribal leaders in the inter-professional response team planning where discussions about multi-jurisdictional issues will occur. Participation will not insure “by in” to the plan for response to sexual assault, but jurisdictional issues can be identified and addressed during the formation of program response or during evaluation of the program response by all. Resources include: http://toolkit.ncjrs.org/vawo_14.html and ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4811.pdf
 
 
Would you please address recommendations for addressing limited resources in rural or tribal communities and would you provide feedback on a regional concept to MDT's for rural or tribal communities?
 
1.  S Laskey
 The National Sexual Violence Resource Center is currently conducting a survey of states/territories and tribes regarding the variety of ways regional SANE programs are organized, we will be publishing innovative practices within the next year, please watch our website at www.nsvrc.org for updates.
 
2.  Dr. Pat Speck
 Regional SANE programs were first instituted in Memphis (1974) and Minneapolis (1977). These original programs provided services for multi-jurisdictional communities that were physically close to the regional service. For instance, the Memphis program accepts victims from a tri-state area. The SART historically includes victim advocacy, law enforcement and health care. In most cases, the health care is not mobile so the advocate and law enforcement come to the health care facility. However, mobile teams have been effectively used in cities and in rural areas, particularly on reservations. In addition, telemedicine equipment allows for experts to be available to the team during evaluation or through peer review process with the experts. The short answer is that interprofessional multidisciplinary teams work well and reflect a comprehensive approach to victim centered care. Resources include: Chapter 4 in http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf or Section A.1, A.2 and Section C.1 and C.2 in http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
 
 
I work in a university community. Often extreme alcohol intoxication is a factor in dealing with our sexual assault victims. It is so prevalent as to almost be the rule. How do you address this issue from a prevention/ prosecution/ support and treatment place?
 
1.  S. Laskey
 You are not alone in posing this question as you can see for the recent national needs assessment report that the National Sexual Violence Resource Center published.http://www.nsvrc.org/resources/strategies/OVCຈApprovedຈNeedsຈAssessmentຈReport.pdf. Your focus on a comprehensive response is a critical point. A multidisciplinary response that focuses on both prevention and intervention efforts is our best strategy. From our experience at the NSVRC working with Sexual Assault Response Teams and campus programs we have found that building this discussion into the regular workings of a SART or coordinated team is the first step. As a team, victim-centered policies can be developed that address the needs of the victim, criminal justice system and the community. There are many resources available to assist in creating policies and procedures around alcohol and sexual assault. Preventing Violence and Promoting Safety in Higher Education Settings: Overview of a Comprehensive Approach http://www.edc.org/hec/pubs/violence.pdf The American Prosecutors Research Institute provides training for prosecutors regarding voluntary intoxicated victims, training dates are available on their website and are fairly inexpensive http://www.ndaa.org/apri/index.html uccessfully investigating sexual assault, a national training manual for law enforcement provides relevant information that reframes the issue of intoxication as corroboration of a victim’s testimony to show heightened risk. http://www.evawintl.org/Downloads/NCWP/DrugFacilitatedMOD.pdf. The international Association of Chiefs of Police may also provide guidance on providing model policies.http://www.theiacp.org/. This will also be a focal point of the National SART Toolkit that the NSVRC is developing with support from the Office for Victims of Crime.
 
2.  Dr. Pat Speck
 There are two documents that will help you with each of these items – prevention, prosecution, victim support and treatment. They are: http://www.cops.usdoj.gov/mime/open.pdf?Item=269 http://www.cdc.gov/ncipc/factsheets/svfacts.htm
 
 
Sometimes the different ways in which law enforcement and victim advocates are trained to assist a rape survivor lead to conflict at the time the rape is reported at the hospital or elsewhere. VA's are trained to support the victim emotionally, while officers are trained to get an "untainted" story directly from the victim. This conflict has at times caused tension between law enforcement and victim advocates. Do you have any advice for resolving these types of conflicts or for avoiding them?
 
1.  S Laskey
 Teams that sit down together to "imagine" potential conflicts or discuss current challenges in a non-crisis situation are often able to build the respect that Dr. Speck mentions. Joint training and cross training can eliminate conflict by building trust and understanding of the value of each members role.
 
2.  Dr. Pat Speck
 Conflict among team members is expected, particularly when the roles overlap. The key is to sit the team members down at the same table and share their roles and restraints in a neutral environment. Resolution comes with respect and acceptance. The technical term is called “conflict resolution.” I have attached a source used in schools because the parents have forgotten how to teach their children and now the children are teaching the parents. Obviously, there is information here that can be applied to the SART members. Good luck and keep talking! Source: http://www.ncjrs.gov/pdffiles/conflic.pdf
 
 
Are there any statisitics that show SART teams help improve prosecution of sexual assault cases? If so, what are they?
 
1.  Dr. Pat Speck
 The public health literature does not at this time support evidence exams. However, the SART team offers choice to follow through with prosecution, not seen when law enforcement is the gate keeper of whether a case goes forward. The recent study “An evaluation of the Rhode Island Sexual Assault Response Team (SART)” is a comprehensive look at the multifaceted issues faced by communities trying to reduce this crime and improve outcomes for the victims. Source: http://www.ncjrs.gov/pdffiles1/nij/grants/210584.pdf
 
 
In working with victims of sexual assault, what are some ways in which we can better explain the process of reporting it to police, given the person is in such a traumatic state, so that they can make a more informed decision?
 
1.  S Laskey
 I agree that the crisis intervention model provides us needed guidance in supporting those who have experienced trauma. I have found having concise, linguistically appropriate resources in writing for survivors is a must have. Trauma often impacts a person’s ability to process information clearly and many communities have instituted anonymous reporting procedures so that evidence can be collected to increase their options if they choose to officially report at a later date. This victim centered approach has increased the amount of police reports in many areas while respecting the healing process of survivors. For more information on anonymous reporting at http://www.nsvrc.org/publications/newsletters/fal_win_01.pdf.
 
2.  Dr. Pat Speck
 First, while many victims will show the effects of the trauma immediately, utilizing a crisis intervention model, many victims can be therapeutically guided through a decision tree that addresses their health and the criminal justice process. Once the victim has made the decision to tell, the resources and time frame will guide the rest of the process, including reporting, participating in the evidentiary collection and physical evaluation, their counseling needs and aspects of the criminal justice process. The key to this is making sure it is victim centered AND within the confines of the services available. Many resources are available to SANE/SAFE providers, advocates and law enforcement to assist in their efforts to focus on the victims needs and a free one is listed here: Crisis Intervention Model in Child Abuse & Neglect – excellent models of care will apply to adults also located at http://nccanch.acf.hhs.gov/pubs/usermanuals/crisis/crisis.pdf
 
 
Hi Pat - we have a great team working here in Canada. One of the challenges we have had to iron out, however, was the role of each member esp as it comes to questioning the patient. We are often asked to seek details related to investigation vs medicolegal questions, but have evolved an understanding over time. Not only may it contaminate the investigation but it has significant impact on how often the patient has to tell the story and potential for retraumatizing. I expect this is not a unique challenge.
 
1.  Dr. Pat Speck
 Hi Cathy! Great observation and a task faced by SANEs daily in the US and Canada. As you know, the registered nurse in the U.S.A. is governed by state statute and national standards of practice. The standards are well developed for the registered nurse and will protect the nurse from boundary issues when they present in the care of the patient who has been sexually assaulted. They also provide the basis for the exception for hearsay in the states in that all information collected by the RN has the potential for medical diagnosis and treatment of the health effects in the patient. Even the make and model of a car used in abduction may need to be noted in the medical record if the patient is emotionally responding to that trigger. A nursing/medical plan of care will be developed to reduce the impact of the trigger in response to the nurse’s observation and conclusion about the car’s significance to the patient. The dialogue and research about traumatization and re-traumatization of the victim of sexual assault who tells her story over and over will continue among professionals and researchers. Sources: www.iafn.org and http://www.ncvc.org/ncvc/main.aspx?dbName=DocumentViewer&DocumentID=32366 and http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
 
 
Our University's Judicial Affairs system resists limiting ANY information that an accused student wishes to bring forth in a sexual assault hearing. They feel that the accused student would have the right to appeal, on the basis that the student was not allowed to present "evidence." This is upsetting, as accused students have presented information from public websites in an attempt to defame the character of the alleged victim. Of course, we know that this evidence is irrelevant to the question of consent. What are your thoughts about ways to approach this stand by the Judicial affairs system? Have you seen this elsewhere?
 
1.  S Laskey
 Over the last ten years campuses have been reacting to a series of court challenges that demand increased attention to accused students due process rights. Not surprisingly, recent studies and surveys have found that only 1 out of 10 campuses have "rape shield" protections for accused students and that while 60% of accused students have the right to have character witness, only 45% of complainants or accusers do. Please take a look at our campus resources webpage and consider reaching out the Penn State to discussion their process to improve their Judicial Affairs Program in regards to sexual assault. This is not an issue that can be solved in isolation and partnering with multidisciplinary team members, with leadership from students is the most effective strategy. http://www.nsvrc.org/resources/strategies/campus.html http://www.sa.psu.edu/ja/PDF/jamanual.pdf#page=71
 
2.  Dr. Pat Speck
 I have a question. Is this a legal process or a University policy? If it is a policy, they could try to change the policy to be more victim friendly. Sally will post the resource.
 
 
We recently had an inquiry from a public health nurse asking for any resources that could assist Public Health Nurses conducting well child exams to identify individuals who might need to be referred for further evaluation related to suspected sexual abuse.We would like suggestions on the most recent resources or protocols available. We are in a very remote and rural region with multiple barriers and special considerations.
 
1.  S Laskey
 This situation presents a great opportunity for prevention as Dr. Speck referenced. The International Associate of Forensic Nurses and the National Sexual Violence Resource Center have been working to engage public health professionals and forensic nurses in prevention efforts. Contact IAFN at www.iafn.org for more information.
 
2.  Dr. Pat Speck
 This is an excellent use of resources to detect abnormality in a rural population. Public health nurses have excellent skills and are many times the point of entry into a daunting health care system that is elusive to under-served or never-served communities/populations. In addition, the public health community is the link to violence prevention in communities and a source is located at http://www.cdc.gov/ncipc/dvp/SVPrevention.pdf . The public health community is the first to recognize the epidemiological effects of injury (intentional and unintentional). They are also the first to document stresses on the health care system. So it is logical that the public health nurse and epidemiological social worker become the team in the community not only to identify through routine screening, but to provide the prevention piece through education and environmental modification. These tools are critical if a reduction in morbidity and mortality are to be realized in remote communities; another source is http://www.cdc.gov/ncipc/dvp/bestpractices.htm#Download . The key to SART partnerships with the public health community is to insure that they know the SART is ready and willing to provide the support and intervention when a patient is identified and referred. The detail of the referral is a stakeholder meeting away. To learn more about the development of community problem solving, utilize the USDOJ Prevent Youth Violence Resources found at http://www.usdoj.gov/whatwedo/whatwedo_pyv.html and the Tool Kit to End violence Against Women found at http://toolkit.ncjrs.org/
 
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