Office of the Attorney General Washington, D.C. 20530
Dear Friend:
October was recognized by the President as Domestic Violence Awareness Month. The month gave all of us an opportunity to gather information, hold discussions, and increase awareness about domestic violence. However, if we are going to be successful in putting an end to violence against women, we must keep the issue at the forefront all year long.
Violence against women is perpetrated in all types of intimate relationships and crosses economic, education- al, cultural, racial, and religious lines. Nearly one-third of women murdered each year in the United States are killed by their current or former intimate partners. Approximately 1 million women are stalked each year, and 1 in 36 college women is a victim of an attempted or completed rape in each academic year. As a result, across the country, women live in constant fear that they will be attacked at home, at work, at school, or in public places. Few women walk home alone at night without being concerned for their safety.
To assist communities and individuals engaged in activities to end violence against women, we are pleased to announce the development of the Web-based Toolkit To End Violence Against Women. The Toolkit was devel- oped by the National Advisory Council on Violence Against Women, a council that is chaired by the U.S. Department of Justice and the U.S. Department of Health and Human Services. The recommendations and information contained in the Toolkit were the result of input from leaders and practitioners around the country with expertise in domestic violence, sexual assault, and stalking. Input was also provided by key individuals working in the areas of criminal justice, health, sports, faith, the media, the military, and entertainment. As you know, to end violence against women we must change our culture, and all facets of society need to play a role.
The Toolkit comprises 16 chapters that provide recommendations for strengthening prevention efforts and improving services for victims. Each Toolkit chapter focuses on a particular audience and includes recom- mendations for a range of professionals. The format is designed to help readers quickly pinpoint topics of interest, and each chapter is relevant to more than one group of individuals. We encourage you to consult all chapters of the Toolkit for instruction, guidance, and inspiration.
The Toolkit will be available beginning November 1, 2001, at the following Internet address: http://toolkit.ncjrs.org. We consider the Toolkit to be a “living” document that will evolve as the issues sur- rounding violence against women continue to grow. We encourage your feedback and look forward to work- ing with you to eradicate violence against women and to make this country a safer one for all individuals.
Sincerely,
John Ashcroft Tommy Thompson Attorney General Secretary U.S. Department of Justice U.S. Department of Health and Human Services Communities Identify gaps in servicesIdentify gaps for Collaborate with community Ensure that staff and volunteers of sexual Ensure that staff and volunteers Adequately fund sexual assault and domestic Develop a range of mechanisms to ensure sur- a range Develop Support leadership development for women from for women Support leadership development Expand efforts to educate local and state policymakers Expand the services offered to survivors of sexual assault, dat- Target funds for strategies and services developed by and for under- strategies and services funds for by developed Target groups that are interested in integrating response to violence against women response to violence against that are interested in integrating groups into their work. may Ensure that informal that women neighborhood networks turn to for support and are adequately informed women about violence against community resources. available capacity. Increase organizational to ensure their stability and effectiveness. violence programs Inform policymakers. Build partnerships with community groups. vivor involvement in the design, involvement vivor evaluation, and enhancement of outreach strate- gies and services. and survivors Support role of victim advocates the leadership in coordinated community responses, councils, coordinating task forces, and entities. other collaborative specific competent and culturally of culturally Expand the availability services. served and marginalized communities and populations. Develop new leadership. and confidentiality. Protect privacy all necessary take assault and domestic violence programs steps to protect the of their communications with victims,confidentiality and privacy including safe- guarding files and records and the informed of confidentiality. use of written waivers been have who about the impact of proposed policies and legislation on women sexually assaulted, battered, or stalked, survivors in these efforts. and involve Seek and use survivor input. and linguistic competence of community programs. Increase the cultural With community partners, of sex- network responsive commit to building a more and services.ual assault and domestic violence programs Institute hiring and recruitment policies and practices to ensure that staff reflect the communities are serving.they underserved and marginalized populations to increase their participation in efforts women. to end violence against Ensure that all victims have a safe place to turn. a safe place have Ensure that all victims assault,all victims of sexual dating and domestic violence, and stalking. Educate the public, legislators, community leaders. and to strategies Develop of core crisis services exist. none where increase the availability Expand services. ing and domestic violence, and stalking, including more long-term counseling, assistance with housing and employment, and culturally specific services. Chapter 1. Strengthening Community-Based Services and Advocacy for Victims for Advocacy and Services Community-Based 1. Strengthening Chapter What Communities Can Do To Make Make To Do Can Communities What a Difference Chapter 1 Strengthening Community-Based Services and Advocacy for Victims
Ensure Quality Services in Dual began in the early 1970s against domestic violence and established the model for community-based Programs organizations providing services and advocacy to women and their children. Initially, sexual assault eeting the needs of all survivors of vio- and domestic violence advocates focused on creat- lence against women requires collabora- ing crisis hotlines, support groups for victims,1 and M tion and information sharing between “safe homes” and emergency shelters for battered sexual assault and domestic violence service women. As advocates helped individual women providers. Many communities have created dual negotiate the courts, health care, and social service programs that address both sexual assault and systems, disturbing patterns emerged—e.g., insti- domestic violence. However, sexual assault serv- tutional responses that were biased, uncoordinated, ices are often disproportionately understaffed, and confusing; blamed victims for their assault or underfunded, and unable to provide even core abuse; and too often endangered women and chil- services to the community. dren. The need for systemic change was identified, and public policy advocacy took on new urgency. If communities are considering developing dual programs or combining sexual assault and domes- Advocates effectively worked with federal and tic violence services into the same agency, they state elected officials to pass and implement more should first investigate the potential benefits, pit- effective sexual assault, dating and domestic vio- falls, and unintended consequences of merging or lence, and stalking laws; increase funding for serv- maintaining separate programs. In communities ices; and provide better training for those involved where only one program provides sexual assault in ensuring safety, recovery, and justice for sur- and domestic violence services, measures must be vivors. More than 1,300 sexual assault programs taken to ensure that sexual assault programming is and more than 1,900 domestic violence programs equitable and fully developed. Policies and proce- now exist in communities across the nation; the dures should be carefully structured and monitored number of victim advocacy programs offering sup- to ensure that sexual assault intervention and pre- port and protection to women who have been vention activities receive equitable support. stalked is also growing. Sexual assault and domes- tic violence coalitions exist in every state; national organizations also offer comprehensive training, Strengthen Services and technical assistance, and systems advocacy on Advocacy for Victims and violence against women issues. Survivors Although funding has expanded in the past 10 years for both sexual assault and domestic vio- The antirape movement organized in the late lence programs, and justice agencies have 1960s laid the political foundation for work that enhanced their ability to protect victims, the
| 1 availability of services has lagged behind the Provide More Comprehensive pressing needs that women and children face.2 Rural communities, communities of color, tribal Services and Advocacy reservations, immigrant and refugee groups, incar- cerated women, older women, women with dis- Research and practice have provided a more com- abilities, and others too often remain marginalized plete understanding of the incidence, prevalence, and have benefited far less by the advocacy efforts forms, and impact of sexual assault, acknowledg- of the past 30 years than women in the main- ing the pressing need for a greater range of servic- stream. As programs develop, increased attention es and broader expertise. Increases in the number is focused on recognizing and responding to of child sexual assault and acquaintance rape sur- women’s diverse interests and concerns. A chal- vivors reaching out for help have placed new lenge facing all community-based sexual assault, demands on sexual assault programs. Similarly, domestic violence, and stalking programs is to domestic violence advocates are challenged by the provide support and leadership while respecting complexity of issues facing battered women. and learning from the women and communities Different resources and staff/volunteer skills are with whom these programs are working. needed to provide appropriate services and advo- cacy for immigrant or migrant battered women, poor women, women with substance abuse or Ensure That All Women Have a mental health problems, and women requiring long-term support. Place To Turn Still, most women who are sexually assaulted, bat- Many states have three times as many counties to tered, or stalked do not reach out to sexual assault serve as sexual assault and domestic violence pro- or domestic violence programs. They may not grams to serve them. The problem is particularly know such programs exist, be able to access them, acute in rural areas, but many large cities also face recognize that what has happened to them is a chronic shortages of emergency shelter beds and crime, or find the services provided relevant to crisis services for battered women and their chil- their needs or experiences. New outreach strate- dren. Most sexual assault programs struggle to gies must include building new alliances between provide core services such as hotlines, medical victim advocacy programs and other community and legal system advocacy, and crisis counseling groups that bring services and support closer to to women in their communities. Few communities the women who need them. have developed services specifically designed to assist stalking victims outside the context of sexu- Appreciation has deepened in regard to the diver- al assault or domestic violence. sity of women’s experiences with sexual and phys- ical violence and the differences in the women’s However, more women are reaching out for serv- circumstances, resources, and interests. Advocates ices than ever before.3 As the criminal justice, understand the need to tailor responses to the par- health, welfare, and social service systems more ticular needs of each woman, respecting and sup- regularly identify sexual assault, dating and porting her decisions and increasing her domestic violence, and stalking victims and refer understanding of options, and to her sense of con- them to community-based services, the demand trol. This approach is more responsive to the for these programs’ services has increased signifi- complexity of women’s lives and more likely to cantly. Public education and awareness efforts enhance women’s safety, recovery, and well- have also informed more women how to access being.4 services and have encouraged them to seek help.
2 | Toolkit To End Violence Against Women Enhance Services and Programs Ensure that every intervention is grounded in being responsive to victim needs and interests for Marginalized and and holds offenders accountable for their Underserved Women and behavior. Communities Encourage communication, coordination, prob- lem solving, and collaboration among institu- Culture has a tremendous impact on the way indi- tions, community agencies, and the community vidual women experience and interpret violence, as a whole. how and where they look for help, and how they respond to and use formal and informal service Help develop a vision and plan for ending vio- systems. Sexual assault and domestic violence lence against women in the community. programs must continue to make services more relevant and accessible to all women and more Meeting the needs of all women dealing with vio- culturally appropriate and specific to the commu- lence also requires collaboration and information nities they serve. Additionally, marginalized and sharing between sexual assault and domestic vio- underserved communities are encouraged to create lence service providers, advocates, and experts.5 services and programs that are by and for their members. Often, organizations that have tradition- To fulfill these roles, community-based sexual ally provided services to specific populations assault and domestic violence programs require (regardless of whether those services specifically adequate resources, leadership development targeted violence against women) are in a better opportunities, and technical assistance from within position to serve women from that community. the advocacy movement and support from the jus- tice, health, social service, and other systems. Many victims of sexual assault and domestic vio- lence require a continuum of responses and servic- Similarly, state coalitions and national sexual es. Sexual assault or domestic violence programs assault and domestic violence organizations, alone cannot provide all of the services, support, including national hotlines and resource centers, and protection needed by survivors and their chil- play a critical role in advocating on behalf of dren. The effort must be communitywide. women’s interests by fostering collaboration; bringing new partners into the movement to end violence against women; changing systems, poli- Increase Organizational cies, and laws to protect victims; providing train- ing and technical assistance to guide program Capacity To Provide Responsive development and public education efforts; and guiding and leading prevention efforts. These Services and Community national and state organizations also struggle to Leadership secure adequate resources to meet the demands of their work. Although many sexual assault and domestic vio- lence programs are currently understaffed and Outlined on the following pages are specific underfunded, they are increasingly being urged to actions that local communities, private funding address a broader and more complex range of sources, sexual assault and domestic violence pro- issues and to assume key leadership roles within grams, state coalitions, and state and national sex- coordinated community response efforts. ual assault and domestic violence organizations Community-based sexual assault and domestic can take to eliminate violence against women. violence programs have been assigned several critical tasks:
Chapter 1. Strengthening Community-Based Services and Advocacy for Victims | 3 Ensure That All Women Have a 3. Get and use survivors’ input in design, evaluation, and enhancement of program policies and practices. Place To Turn Develop various mechanisms to ensure ongoing survivor input into policy analysis, program 1. Increase availability of core advocacy and support development, systems change, program evalua- services, such as crisis hotlines, information and refer- tion, and public education activities. rals, support groups and counseling, emergency shel- ters, and legal, medical, and economic advocacy. Solicit input from survivors through surveys, focus groups, intake and exit interviews, and Identify unserved and underserved areas within other strategies designed to obtain broad feed- each state and county, focusing on both rural back from diverse women. and urban areas. Target additional resources to areas with the most pressing needs. Invite survivors to participate in analyzing the information and discussing its implications Establish new sexual assault and domestic vio- and its applications to policy and program lence programs in unserved communities or development. counties. Ensure that funding for dual programs ade- 4. Work collaboratively with other community agencies quately supports the provision of core services to create an emergency assistance fund to be admin- to sexual assault survivors. istered by local and statewide sexual assault or Expand the capacity of existing sexual assault domestic violence agencies. and domestic violence programs to establish Provide resources to cover emergency expenses outreach or satellite offices. resulting from victimization, including emer- Increase transportation networks to enable more gency relocation and housing costs, transporta- women access to existing services. tion, short-term food and clothing expenses, Train specialized staff to work on violence respite care for children and other dependents, against women issues in other community- emergency medical care including health care based organizations serving underserved areas. evaluations immediately after an assault, and other crisis costs facing victims.
Provide More Comprehensive 5. Enhance sexual assault advocacy and services and their responsiveness to the needs of women who have Services and Advocacy been sexually assaulted. 2. Use advocacy, service delivery, counseling, and Expand the types of services offered, including safety planning approaches that acknowledge the enhanced legal and medical advocacy (such as diversity of each woman’s circumstances, resources, helping survivors secure forensic exams and and interests. long-term evidence storage, treatment for sexu- Provide advocates with the necessary orienta- ally transmitted diseases, and legal accompani- tion, skill training, and ongoing support to ment), long-term counseling, housing and build respectful partnerships with victims and employment advocacy, community outreach survivors. and education, grassroots organization, and more effective use of information technology to Analyze the range of relevant risks and needs reach survivors and the community. each woman faces, as well as options and resources, and offer the most responsive serv- Increase program capacity to respond to victims ices and advocacy. of different forms of sexual assault, including adult and child survivors of child sexual abuse Prepare to assist battered women in strengthen- and survivors of acquaintance rape, rape within ing and effectively implementing ongoing safe- marriage or cohabiting relationships, and drug- ty plans. facilitated and same-sex sexual assault.
4 | Toolkit To End Violence Against Women Provide services that are responsive to survivors 7. Enhance collaborative relationships among sexual who have emergency housing needs, live in assault, domestic violence, and stalking programs remote areas, have been prostituted or traf- within the same community. ficked, have chronic mental health needs, have Provide cross training for sexual assault, been raped in the context of war, or have also domestic violence, and stalking program staff been stalked—including victims whose stalkers and volunteers on violence against women, the have used the Internet to harass or threaten services and advocacy provided by other pro- them. grams, and appropriate referral strategies. Remove barriers to current services or provide When appropriate, share staff to best meet the alternative services in special situations. Ensure needs of women seeking assistance. For exam- that services are available to women who may ple, an interpreter for hard-of-hearing victims or require them for longer than is typically a substance abuse counselor may not be needed allowed, speak languages other than English, full time at any single agency but might be have mental health problems or substance abuse shared among several. histories, or face criminal charges; undocument- ed women; women living with HIV/AIDS; and 8. Expand efforts to educate local and state policy- women with disabilities. makers about the impact of proposed policies and legislation on women who have been sexually assault- 6. Enhance domestic violence advocacy and services ed, battered, or stalked; involve survivors in these and their responsiveness to needs of battered women. efforts. Expand the range of services offered to battered As resources allow, monitor and document the women, such as welfare, housing, education, response of criminal and civil justice, health employment, medical and legal advocacy, serv- care, welfare, and other systems to violence ices and advocacy for nonsheltered women, against women, and report both positive and transitional housing, and followup services to negative results to the community. sheltered women and their children. Provide appropriate referrals to every woman 9. Investigate and carefully expand the use of new information and communications technology to who seeks emergency shelter but is turned away improve services, outreach, and education related to because of lack of space or because her needs violence against women. fall outside program capacity. Expand emer- gency housing options in communities by sup- Institute appropriate safeguards to address 6 plementing beds available through battered privacy and confidentiality concerns. women’s shelters, including hotels/motels, “safe Explore how the Internet and distance-learning homes,” hospital beds, and other emergency approaches can provide training and education housing programs. Develop appropriate operat- of survivors and advocates. ing and referral policies to ensure that such options are responsive and safe. 10. Protect the confidentiality and privacy of staff/ volunteer communications with victims, including safe- Ensure that shelter and services are available to guarding files and records and the informed use of writ- women who may require longer stays than are ten waivers of confidentiality. typically allowed, have older children or male children of any age, speak languages other than Provide regular and comprehensive training to English, have mental health problems or sub- all staff and volunteers to ensure they are ade- stance abuse histories, face criminal charges, or quately prepared to maintain confidentiality of are former sex workers or prostituted undocu- communications and records under existing state mented women; women living with HIV/AIDS; statutes and program policies and procedures. women with disabilities or who have children Reflect a commitment to women’s confidential- with disabilities; and survivors of lesbian ity and privacy in all program descriptions, in battering.
Chapter 1. Strengthening Community-Based Services and Advocacy for Victims | 5 oral and written information, with third parties, Focus on victim concerns and safety within and in educational materials. existing collaborations addressing violence Help women protect their privacy with private against women, such as state, county, and local post office boxes, unlisted phone numbers, councils. blocking of caller identification, and flagged records in credit bureau and child support Increase Responsiveness to databases. Develop and implement privacy safeguards for Marginalized and Underserved programs with an online presence. Women and Communities Develop or expand policies within coordinated community responses to protect the confiden- 12. Increase the cultural and linguistic competence tiality of survivors and appropriately regulate of sexual assault, domestic violence, and stalking the flow of information. programs. Inform community partners about existing laws Engage staff and volunteers at every level of related to confidentiality and victims’ rights, an organization to discuss the meaning and and ensure that information is exchanged in importance of cultural sensitivity and compe- accordance with applicable laws. tence; commit to building a more responsive organization. 11. Build community partnerships to provide survivors Recruit and hire staff, volunteers, and board with needed services; initiate, participate in, and pro- members who reflect the composition of the vide leadership to multidisciplinary community-based community the program is responsible to serve. efforts addressing violence against women. Articulate in organizational documents a com- Designate staff with the responsibility and time mitment to serve victims and survivors from to strengthen collaborative efforts with other diverse backgrounds; challenge oppression sectors of the community. based on race, ethnicity, socioeconomic status, Build new collaborative relationships with pro- and other factors. Review all policies and prac- grams addressing child abuse, teen pregnancy, tices, and modify those that contain bias or cre- homelessness, poverty, mental health, alcohol ate barriers to accessing services. and drug abuse (including those providing resi- Provide ongoing training for staff about the dential substance abuse or mental health servic- populations the program is responsible to serve; es and those working with communities of provide constructive forums for staff to address color); people with psychiatric, developmental, the reality and impact of racism, sexism, and physical disabilities; the lesbian, gay, bisex- homophobia/heterosexism, and biases related ual, and transgender communities; men and to age, disability, geographic isolation, and reli- boys; and religious, spiritual, and faith-based gious beliefs. organizations. Assume responsibility for understanding and Convene representatives from all systems that speaking out against other forms of oppression affect survivors’ lives, and coordinate the provi- and incidents involving discrimination or bias. sion of wraparound services that minimize vic- tim trauma. 13. With community women and other partners, identi- Partner with academic and research organiza- fy natural sources of information and support used by tions to ensure that policy and practice is women in the community, and help ensure that these informed and strengthened by research evalua- sources are adequately informed about violence tion and that research and evaluation initiatives against women and available services. are informed by and responsive to current poli- Support organizations, groups, and individuals cy and practice issues and community needs. already working within local communities—
6 | Toolkit To End Violence Against Women such as migrant health clinics, senior centers, approaches can include expanded definitions lesbian service agencies, disability rights organ- of core services, nontraditional response or izations, neighborhood watches, faith-based prevention strategies, and services delivered groups, and parent-teacher associations—to through nontraditional entry points. incorporate an understanding and response to violence against women in their work in the community. Increase Organizational Collaborate with leaders from diverse commu- Capacity To Provide Responsive nities to develop culturally and linguistically appropriate brochures, videos, public service Services and Community announcements, posters, and other materials; Leadership distribute them through trusted organizations and community leaders. 16. Ensure program staffing that is adequate, well- trained, and reflective of the community. 14. Support the leadership development of women Provide adequate staff compensation and bene- and men from underserved and marginalized commu- fits packages, ongoing staff and volunteer nities and groups to facilitate their ability to fully par- development, programs and support to address ticipate in efforts to end violence against women. secondary trauma and “burnout,” safe working Incorporate the expertise, perspectives, and conditions, and staff access to specialized con- leadership of underrepresented communities, sultants, including legal, medical, and mental including communities of color and people with health specialists, as necessary to meet commu- disabilities, in the design and implementation of nity needs. services and individual advocacy, outreach, Institute staff hiring and volunteer recruitment public education, training, policy advocacy, and and retention policies that result in staffing evaluation activities of programs. reflective of the community the organization is Increase representation and leadership on pro- responsible to serve. gram boards and within membership structures of national, state, and local sexual assault and 17. Increase state funding for state sexual assault and domestic violence organizations, and ensure domestic violence coalitions. meaningful opportunities for participation in Expand provision of technical assistance, train- policy and program development, planning, and ing, policy advocacy, public education, and priority setting. organization activities by state sexual assault Work collaboratively with government and pri- and domestic violence coalitions. vate funders to expand support for community, state, and nationwide networks, organizations, 18. Increase local and state support for local-, state-, and alliances of communities of color to end tribal-, and national-level meetings, working groups, sexual assault and domestic violence. and conferences. Provide advocates and allies with more oppor- 15. Expand current efforts to develop culturally com- tunities to meet, network, coordinate advocacy petent and specific services for victims, and target and policy work, devise methods to improve funds for programs, services, and new approaches to intervention and prevention efforts, and address address violence against women. emerging policy and practice issues. Ensure that services are designed and imple- mented by and for underserved and marginal- ized populations and communities. These new
Chapter 1. Strengthening Community-Based Services and Advocacy for Victims | 7 Resources National Resource Centers and Advocacy Organizations National Hotlines Family Violence Prevention Fund Victim Services Helpline (assistance and referral) 383 Rhode Island Street, Suite 304 National Center for Victims of Crime San Francisco, CA 94103–5133 2000 M Street NW., Suite 480 Phone: 415–252–8900 Washington, DC 20036 Fax: 415–252–8991 Phone: 1–800–FYI–CALL Web site: www.fvpf.org TTY: 1–800–211–7996 The Family Violence Prevention Fund works to Fax: 202–467–8701 end domestic violence and help women and chil- Web site: www.ncvc.org/infolink/main.htm dren whose lives are affected by abuse. The Web The National Center for Victims of Crime’s site offers free online catalogs, articles and infor- (NCVC’s) mission is to help victims of crime and mation on abuse and violence, press releases and their families rebuild their lives. NCVC works story archives, information on public policy with local, state, and federal agencies to enact leg- efforts, and other resource materials. islation and provide resources, training, and tech- nical assistance. The NCVC Web site provides Institute on Domestic Violence in the African relevant statistics, links to publications, and refer- American Community rals to participating attorneys. 180 McNeal Hall University of Minnesota National Domestic Violence Hotline 1985 Buford Avenue P.O. Box 161810 St. Paul, MN 55108–6142 Austin, TX 78716 Phone: 1–877–643–8222 Phone: 512–453–8117 Web site: www.dvinstitute.org Hotline: 1–800–799–SAFE The Institute on Domestic Violence in the African TTY: 1–800–787–3224 American Community promotes public awareness Fax: 512–453–8541 through public outreach, dissemination of related Web site: www.ndvh.org information and resources, publication of a bi- The National Domestic Violence Hotline uses a annual newsletter, and coordination of conferences nationwide database to provide crisis intervention, and training forums. referrals, information, and support in many lan- guages for victims of violence against women. National Alliance of Sexual Assault Coalitions c/o Connecticut Sexual Assault Crisis Services, Inc. Rape, Abuse, and Incest National Network 110 Connecticut Boulevard 635–B Pennsylvania Avenue SE. East Hartford, CT 06108 Washington, DC 20003 Phone: 860–282–9881 Phone: 202–544–3059 Fax: 860–291–9335 Hotline: 1–800–656–HOPE Web site: www.connsacs.org/alliance.html Fax: 202–544–3556 The National Alliance of Sexual Assault Web site: www.rainn.org Coalitions Web site provides a listing of sexual The Rape, Abuse, and Incest National Network assault coalitions across the country, with contact (RAINN) offers a toll-free hotline for free, confi- information, URLs, and e-mail links for each. The dential counseling and support 24 hours a day for site includes an online library of relevant articles victims of rape, abuse, and incest. and information that includes research materials as well as fiction and poetry.
8 | Toolkit To End Violence Against Women National Latino Alliance for the Elimination of National Sexual Violence Resource Center Domestic Violence 123 North Enola Drive 1730 North Lynn Street, Suite 502 Enola, PA 17025 Arlington, VA 22209 Phone: 1–877–739–3895 Phone: 1–800–342–9908 TTY: 717–909–0715 Fax: 1–800–600–8931 Fax: 717–909–0714 Web site: www.dvalianza.com Web site: www.nsvrc.org The National Latino Alliance for the Elimination The National Sexual Violence Resource Center of Domestic Violence (the Alianza) includes (NSVRC) is a clearinghouse for resources and Latino advocates, community activists, practition- research about all forms of sexual violence. ers, researchers, and survivors of domestic vio- NSVRC works with its partner agency, the lence working together to eliminate domestic University of Pennsylvania, to provide new violence in Latino communities. The Alianza policies for establishing sexual violence interven- serves as a national forum for ongoing dialogue, tions and prevention programs. education, and advocacy. Publications and the Web site are offered in English and Spanish. Stalking Resource Center National Center for Victims of Crime National Network to End Domestic Violence 2000 M Street NW., Suite 480 666 Pennsylvania Avenue SE., Suite 303 Washington, DC 20036 Washington, DC 20003 Phone: 202–467–8700 Phone: 202–543–5566 Fax: 202–467–8701 Fax: 202–543–5626 Web site: www.ncvc.org Web site: www.nnedv.org The National Center for Victims of Crime’s The National Network to End Domestic Violence (NCVC’s) mission is to help victims of crime and (NNEDV) is a membership organization for state their families rebuild their lives. The Stalking domestic violence coalitions that offers advocacy, Resource Center provides resources, training, and information, referrals, technical assistance, train- technical assistance to criminal justice profession- ing, and other opportunities for advocates across als and victim service providers to support locally the country. NNEDV publishes a quarterly coordinated, multidisciplinary antistalking newsletter and the Web site includes an “On The approaches and responses. Hill” page that tracks the latest legislation and government actions on domestic violence. Endnotes National Resource Center on Domestic Violence Pennsylvania Coalition Against Domestic Violence 1. Some victims and survivors chose to identify 6400 Flank Drive, Suite 1300 themselves using one of these two terms. For Harrisburg, PA 17112 clarity, we use “victim” through most of this Phone: 1–800–537–2238 document. TTY: 1–800–533–2508 Fax: 717–545–9456 2. Schechter, Susan (1996). Improving the Web site: www.pcadv.org Response to Domestic Violence: Recommendations The National Resource Center on Domestic to Federal Agencies. Iowa City, IA: University of Violence (NRC) is a valuable source for informa- Iowa, School of Social Work and Injury tion, training, and technical assistance regarding Prevention Research Center. p. 11. domestic violence issues. NRC is also a clearing- house for domestic violence resources and statis- 3. One example of this is the increase in calls to tics that may be used to enhance policies and the National Domestic Violence Hotline over the publications. past 4 years. In the year 2000, the hotline received
Chapter 1. Strengthening Community-Based Services and Advocacy for Victims | 9 an average of 11,000 calls per month, up from 6. For example, sexual assault and domestic vio- 5,000 calls less than 3 years ago. Most calls are lence programs with an online presence should from battered women seeking help, although many develop and implement safeguards that preclude calls are from family and friends of someone the discovery of survivor research and/or contact being abused to request information they can online through information stored on the sur- pass on. vivor’s computer. Sexual assault and domestic vio- lence Internet sites should prevent and eliminate 4. Davies, J., Lyon, E., and Monti-Catania, D. the caching of pages and their content and avoid (1998). Safety Planning With Battered Women: the use of “cookies” whenever possible. Users Complex Lives/Difficult Choices. Thousand Oaks, should be offered warnings and instructions about CA: Sage Publications. clearing the cache and the navigational history and the potential dangers of using “bookmarks” or 5. Promising Practices: Improving the Criminal “favorites.” Users should be encouraged to use pri- Justice System’s Response to Violence Against vate e-mail, and sexual assault Internet sites Women, compiled by the STOP Violence Against should offer links to sites where survivors can set Women Grants Technical Assistance Project up private e-mail accounts. (1998). Washington, DC. p. 11. For a copy, con- tact the National Criminal Justice Reference Service at 1Ð800Ð851Ð3420 or askncjrs.org and reference NCJ 172217.
10 | Toolkit To End Violence Against Women Health Care Create Fully inte- Create measures for evaluating vic- Create measures for evaluating Establish sexual assault, dating and domes- Enact statutes, policies, and procedures that Require that institutions identify, document, assess, Examine and amend state statutes regarding domestic regarding Examine and amend state statutes Encourage the use of standard chart the use of prompts,Encourage documenta- and respond to sexual assault and domestic violence victims’ needs as part of routine licensing and credentialing procedures. as response to violence tim health and mental health status improvement is enhanced. women against Dedicate increased federal, state, and local funds to improving the health and mental health care systems’ women. responses to violence against funding streams and earmarkingInclude exploring the creation of new specific funding within state and local health department budgets. Create oversight and accreditation requirements for sexual assault and Create oversight and accreditation requirements for sexual assault domestic violence care. Establish health care outcome measures. Protect victim health records. victims, discrimination against prevent safety and privacy, enhance victim and information. victims to restrict access to their patient allow Ensure that mandatory reporting requirements protect the safety and health status of adult victims. women. Create incentives for providers to respond to violence against reimbursement codes and mechanisms, quality assurance procedures, and service for domestic violence,packaged programs provision and implement the by sexual assault as recommended toward strategies specifically geared national sexual assault task force. Educate all health care providers about violence against women. care providers about violence against Educate all health guidelines for health care facilities,Create protocol and documentation and disseminate widely. tion forms, reference materials on sexual assault and dating and and provider domestic violence. violence mandatory reporting to require victim consent before reporting in cases adult victims unless the injuryinvolving is gunshot-related or life threatening. Conduct public health campaigns. Conduct public health tic violence, national,as serious public health issues through and stalking state, health and mental health departments, by and local campaigns and health medical associations, health care institutions. and information grate on the prevention, detection, treatment of sex- and appropriate curriculumsual assault and domestic violence into at all health and mental continuing education programs.health care professional schools and Encourage on domestic violence training to provide group every health plan and provider screening, intervention, documentation, and referral. Chapter 2. Improving the Health and Mental Health Care Systems’ Care Health and Mental Health the 2. Improving Chapter to Responses Women Against Violence What the Health and Mental Health Care Health and Mental the Health What a Difference Make To Can Do Systems Chapter 2 Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women
illions of women are victims of sexual Sexual assault victims are more likely than other assault, dating or domestic violence, or crime victims to attempt suicide.2 More than one- M stalking at some point in their lives, and third of sexual assault victims and battered women the traumatic effects of this violence have a experience symptoms of depression.3 Forty-six tremendous impact on survivors’ physical and percent of domestic violence victims have symp- mental health. Too many victims never discuss toms of anxiety disorder.4 Victims of both sexual incidents of violence with anyone or approach the assault and domestic violence experience symp- health and mental health care, criminal justice, or toms consistent with posttraumatic stress disorder.5 other system for assistance. However, most Persistent sexual victimization occurring early in women come to health care settings for regular childhood can lead to a range of disorders that can exams, for treatment of specific problems both arise anytime after the traumatic event and last caused by and independent of the abuse, and for indefinitely until appropriate treatment is received. the care of their children and other family mem- Resulting behaviors, such as drug abuse or prosti- bers. Health care providers may be the first and tution, may be deemed criminal and may result in only professionals who see a battered woman or the person being punished. Numerous studies sexual assault victim. This makes the health and nationwide consistently show prevalence rates of mental health care systems crucial points for early sexual abuse histories at 22Ð54 percent among intervention and prevention for women who have women receiving case management mental health survived or are experiencing violence. services and 50Ð70 percent among women in inpa- tient psychiatric facilities.6 The health effects of violence against women are extensive. In addition to possible acute injuries Unfortunately, many health and mental health care sustained during sexual assault or dating or providers still do not view sexual assault, dating domestic violence, physical, sexual, and psycho- and domestic violence, and stalking as public logical abuse are linked to numerous adverse health issues and lack the knowledge, skills, and chronic health conditions. These include arthritis, incentives to intervene appropriately. For example, chronic neck or back pain, frequent migraines or only 9Ð11 percent of the primary care physicians other types of headaches, visual problems, sexual- in California routinely screen patients for domestic ly transmitted infections, chronic pelvic pain, violence during new patient visits, periodic check- increased gynecological symptoms, peptic ulcers, ups, and prenatal care.7 One study in which partic- and functional or irritable bowel disease.1 ipants represented patients and physicians in both a private and a public hospital concluded that both Violence against women is also directly related to patients and physicians favored the practice of adverse mental health effects. Sexual assault trau- doctors inquiring about physical and sexual ma and domestic violence are often life-altering abuse—yet 89 percent of the physicians never experiences resulting in numerous emotional and made such inquiries.8 behavioral responses.
| 1 Sexual Assault and Domestic When primary or secondary prevention strategies are not implemented or are ineffective, tertiary Violence as Overlapping but prevention—a strategy that limits the impact of an Distinct Health Issues injury or disability once it has become serious—is needed. For this discussion, it is important to understand Until recently, the health care system has the interconnections and distinctions between sexu- addressed sexual assault and domestic violence al assault and domestic violence and their implica- predominantly through tertiary prevention strate- tions for health and mental health care system gies. Sexual assault programs handle crisis calls intervention. Medical treatment differs dramatically from victims and survivors; shelters provide tem- for survivors of sexual assault and domestic vio- porary housing for women and children seeking lence. Although competent medical treatment is refuge from abuse. The criminal justice system critical for both, it must occur immediately—from reacts to violent incidents with sanctions for per- the moment a sexual assault survivor or domestic petrators. Similarly, health and mental health care violence victim arrives at a health care facility. In professionals treat the presenting problem (sutur- cases of sexual violence, a victim may have con- ing lacerations, setting broken bones, and prescrib- tracted a sexually transmitted disease as a result of ing antidepressants) usually without exploring the her assault, and pregnancy is often an overwhelm- underlying problem. In one study of 476 consecu- ing and genuine fear. Therefore, immediate and tive women seen by a family practice clinic in the continued access to a full range of reproductive Midwest, 394 (82.7 percent) agreed to be sur- health care services is particularly important for veyed. Of these patients, 22.7 percent had been sexual assault victims. Long term, the followup physically assaulted by their partners within the care for victims of sexual assault and dating and last year, and 38.8 percent of them endured life- domestic violence may involve different types of time physical abuse. However, only six women treatment, referrals, and support. Factors such as said they had ever been asked about the occur- duration of abuse, unreported history of earlier vic- rence of domestic violence by their physician.9 timization, ongoing safety concerns, and cultural influences are just some of the needs to consider. If violence against women is to be stopped, screening and intervention in the health care set- ting must be supplemented with broad-based pub- Primary and Secondary lic education efforts that inform and address Prevention of Violence Against deep-seated attitudes and give people tools for action in the communities in which they live. Women Despite some gains, far too many Americans con- tinue to hold attitudes that can be construed as Health problems of the magnitude described above excusing the sexual abuser or batterer for his require a broad public health approach with com- behavior or blaming victims for precipitating the prehensive prevention strategies and commitment violence. These attitudes contribute to pervasive to ongoing evaluation. When such strategies are social norms that tolerate and permit abuse. effective, they can prevent health problems (pri- mary prevention) or identify a problem in its earli- Recent public health initiatives to reduce AIDS, est stages (secondary prevention). In this way, smoking, and drunk driving have yielded promis- harm to individuals is reduced, and the long-term ing results and significant lessons that can be used adverse impact on a patient’s health (including to help end violence against women. A campaign mental health) is minimized. For example, early sponsored by The Advertising Council encouraged detection programs for breast, cervical, and people to speak to their doctors about colon can- prostate cancer can identify and treat these prob- cer. Widespread response showed that public lems before the disease reaches advanced stages.
2 | Toolkit To End Violence Against Women health communication of this kind can be an eliminates many opportunities for early inter- effective tool for addressing topics people feel vention and prevention. By asking simple and uncomfortable discussing (as many people do with direct questions regarding abuse and sexual sexual assault and domestic violence). Not only assault, trained health care providers engage in did The Advertising Council successfully increase vital prevention and early intervention by send- awareness of the problem of colon cancer in just ing a message to women that violence against 6 months of advertising, it also increased the them is a health issue, that they are not alone, number of people discussing the issue with their and that health care providers know and care physicians. about sexual assault and domestic violence. Documenting violence against women. Acute incidents of sexual assault and domestic vio- Clinical Response: Improving lence should be documented accurately, non- the Standard of Care judgmentally, and in detail in the medical record. Documentation of sexual and domestic Virtually every clinical health and mental health violence improves both continuity and quality care provider treats victims of sexual assault and of care by allowing the provider to understand domestic violence, although most are unaware that the impact of violence on current and future their patients have formerly or recently been health problems or injuries. Proper documenta- abused. Historically, health care providers have tion also facilitates reimbursement and referral viewed violence against women as a social/legal to additional services, but confidentiality must issue or even as a private family problem, outside be maintained throughout the process. Detailed their purview and inappropriate to address in a documentation in the medical record also serves clinical setting. Only recently has the situation as compelling evidence when a victim seeks begun to change. At the clinical care level, health legal recourse. On a system level, a large num- and mental health care institutions and systems are ber of documented abuse and sexual assault encouraged to implement changes designed to cre- incidents justifies the allocation of additional ate comprehensive standards of care for victims of dedicated services for victims in the medical violence against women. The standards should and mental health care setting. However, more include study is needed to determine the best approach to documenting an adult patient’s history of Access to health and mental health care. Basic, child sexual abuse and adult nonacute sexual quality, affordable services should be available assault, given how prejudicial such information to all women regardless of age, geographic or can be if used improperly. language barriers, sexual orientation, or ability Intervention/referral. Once abuse is identified to pay. and documented, an appropriate response Routine screening by trained health care should ensue. This response may vary depend- providers. All adult and teenage women should ing on the internal and community-based be screened routinely for intimate partner vio- resources of the health care facility and the lence following a screening protocol that desires of each survivor. Multidisciplinary pro- ensures patient privacy, safety, and confidential- tocols that incorporate the roles and responsibil- ity. Resources must be invested to develop and ities of all staff who interact with victims of test sexual assault screening instruments and to violence against women can ensure that victims train providers across all health specialties on receive the support and services they need. the use of these tools and appropriate referrals. Although some health care facilities have Screening for violence based on observed in-house advocates to provide victims with injuries alone does not account for the toll of resources and support, such as safety assess- psychological abuse or unseen injuries and ment and planning or counseling, others might need to partner with local sexual assault and
Chapter 2. Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women | 3 domestic violence victim advocates and refer have often lacked the organizational support nec- appropriately. Regardless of the setting, whether essary to continue to respond to victims. urban or remote rural environments, health care providers must develop culturally competent, Those striving to improve the health care system’s creative, and effective strategies to assist vic- response to domestic violence began by training tims. Development of a coordinated and collab- multidisciplinary teams consisting of nurses, orative system of referral, followup care, and physicians, advocates, social workers, and admin- onsite services is critical in improving the istrators. By organizing and training a range of safety, recovery process, and health status of stakeholders in an institution, awareness and victims. response was more widespread, consistent, and longlasting. These teams met with more success in Clinical interventions should be tailored to screening and assisting victims through their poli- respond to the range of racial, ethnic, and socio- cy change efforts, creating a multidisciplinary economic characteristics of patients, as well as response, and instituting new clinical tools, but the address the particular needs of women with dis- demands of the increasingly complicated health abilities and women of all ages and sexual orienta- care system, as well as staff turnover, still make tion. Literacy levels should also be considered routine screening and response difficult. when developing screening questions and patient information. To address the particular needs of sexual assault victims who sought medical assistance soon after an assault, a multidisciplinary response was devel- Integrating Response in All oped, coordinating crisis intervention services and professional forensic evidence collection when the Levels of the Health Care victim wanted to report the assault to law enforce- System ment. For these victims, a new area of medical specialization has evolved, the sexual assault The clear lesson of the past two decades of efforts examiner (SAE), also known as SANE (sexual to improve health care’s response to violence assault nurse examiner) or SAFE (sexual assault against women is that the system must be engaged forensic examiner). SAEs are trained medical pro- at every level to ensure that meaningful public fessionals who have advanced education and clini- health efforts and effective sustainable clinical cal preparation in the forensic examination of interventions occur. Early efforts focused on creat- sexual assault victims and who partner with local ing protocols to guide the care of victims of victim advocates to provide support during the domestic violence. Although the Joint Commis- forensic exam and coordinate followup services. sion on Accreditation of Healthcare Organizations When a victim wants to report an assault to law (JCAHO) mandated that individual health care set- enforcement, existing relationships between the tings develop written protocols on identifying and SAE, victim advocate, and police department responding to sexual assault and domestic vio- facilitate a victim-centered response. Some com- lence, protocols unaccompanied by other strate- munities have established sexual assault response gies did not improve screening and intervention. teams to coordinate these efforts. Efforts shifted to supplementing protocols with Protocols and individual and team training are all training for individual providers on the dynamics crucial, but they must be joined by broader of and responses to sexual assault and dating and reforms of institutions and policies that affect domestic violence. Training, along with increas- health care delivery and inform public health ingly strengthened JCAHO requirements, success- strategies. fully raised individual provider awareness of and sensitivity to the issue. Single providers, however,
4 | Toolkit To End Violence Against Women Addressing Health Care Policy nature of the abuse and perpetrators. Although cli- nicians can use the general preventive medicine Issues codes to bill for domestic violence screening per- formed in the context of a comprehensive preven- Confidentiality of health records. An essential tive medicine assessment and preventive medicine corollary to documentation of abuse in medical counseling codes for domestic violence safety records is the confidentiality of these medical assessment and referral processes, there are many records. Women who have been sexually assault- compelling reasons to develop procedural codes ed, abused, or stalked share with many other specific to domestic violence screening and health care consumers concerns about inappropri- intervention. ate access to and use of medical record informa- tion by insurance companies, employers, and law First, a specific billing code would provide a enforcement agencies. In addition, victims of direct financial incentive to reward clinicians for domestic violence have the added concern of the time spent screening and intervening in cases potential perpetrator access. Few laws exist to pre- of domestic violence. Second, specific codes vent spousal access to medical records. would facilitate the process of evaluating how fre- quently screening is being performed. Third, spe- Removing barriers to forensic sexual assault cific codes for screening and intervention would exams and related treatment. One problem is the make it easier for population-based delivery sys- practice of conditioning medical or forensic serv- tems to provide feedback to medical groups and ices to requirements that the victim report to law individual clinicians on how well they are per- enforcement agencies or participate in court pro- forming compared with national standards and/or ceedings. Such practices compromise sexual peers. For example, a review of specific coding assault survivors’ access to the emergency health might reveal how many women per 1,000 were care services they may need and may place them screened in cases of domestic violence or what at further risk. percentage of screened women received an inter- vention. Measured performance can be tied to both Mandatory reporting to law enforcement by health financial and nonfinancial incentives to drive more care providers. With increased recognition that rapid improvement. Finally, specific codes for violence against women is a public health issue, domestic violence screening and intervention some jurisdictions have instituted policies that would indicate to the health care community that require a health care provider to report domestic these services are as valuable as other services for violence, and sometimes sexual assault, to law which specific codes already exist. enforcement authorities. Growing evidence sug- gests that mandatory reporting may not improve a Appropriate use of existing diagnostic codes can patient’s health and safety and may discourage be an important source of data about domestic vio- some victims from seeking medical care. More lence and can be used by health plans and other research is needed on the unintended conse- population-based delivery systems to track inci- quences of these policies and how they affect vic- dence, associated costs, utilization patterns, and tims’ safety and health before they are established effectiveness of interventions. This type of admin- in any more institutions. istrative data can also be used by researchers to answer many important questions about how to Creating reimbursement mechanisms, coding, and design programs that will improve the health care other incentives to provide care for victims of vio- system’s response to victims of domestic violence. lence against women. Currently, no specific As documentation and coding for domestic abuse Current Procedural Terminology (CPT) codes for and dating violence is improved, issues concerning domestic violence screening or intervention exist. confidentiality of the information must be rigor- However, diagnostic codes (995.80Ð995.85) and ously addressed. e-codes capture additional information such as the
Chapter 2. Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women | 5 Financial and nonfinancial incentives that promote Communicate the serious consequences that evaluation and intervention services for victims of violence against women has on all aspects of domestic violence at all levels of the health care health and mental health so that the public no system must be developed and implemented. longer minimizes the problems or views them Purchasers, health plans, and other insurers may as solely private or criminal justice issues. be motivated to “buy” or implement comprehen- Encourage public health leaders, including the sive domestic violence programs if they are pre- Secretary of Health and Human Services, the sented with the business case for such programs. Surgeon General, and state and local public health figures, to continue to identify sexual In addition to being paid for delivering domestic assault, dating and domestic violence, and violence services, clinicians should be encouraged stalking as serious public health issues and call to improve performance. Institutions must priori- for comprehensive responses. tize the creation of comprehensive packaged serv- Emulate campaign strategies that addressed ices for victims of dating and domestic violence. other health issues that were considered largely Models that require multifaceted responses includ- private or social in nature. Consider those that ing medical care, counseling, assessment, case man- resulted in greater willingness of individual agement, and mental health counseling and referrals providers to screen and intervene and in patient should be used to create systems that encourage willingness to turn to health care providers for response to dating and domestic violence. assistance. Campaigns to discourage smoking Creating appropriate measures of health out- or to promote safe sex are good examples. comes. Much of the contemporary health care Integrate messages about violence against delivery is shaped by health outcome measures. women into other health education campaigns. Many health issues have obvious means to meas- Look for opportunities to include information ure successful treatment or intervention. For about sexual assault, dating and domestic vio- example, the treatment of high blood pressure lence, and stalking into education that targets can use simple outcome measures of established behavior often associated with the aftereffects ranges of healthy blood pressure to assess the of sexual assault, including but not limited to course of treatment and its success. Effective out- teen pregnancy, unsafe sex, sexually transmitted come measures must be established to guide care diseases, and alcohol and other drug use. delivery to victims of violence against women. Target funds to develop campaigns that respond to a wide range of factors, such as race, ethnici- Outlined below are specific actions that health ty, socioeconomic level, age, disability, and lit- care professionals; mental health professionals; eracy level. Research shows that linguistically victim service providers; advocacy groups; public and culturally appropriate campaigns are signif- and private health care funders; federal, state, and icantly more effective. local government researchers; and others can take to help end violence against women. Improve the Standard of Clinical Care
Increase Understanding of Violence 2. Educate all health care providers and public health Against Women as a Critical Public professionals on violence against women. Health Problem Because violence affects so many aspects of physical and mental health and women enter 1. Conduct public health campaigns about violence the health care system through various types of against women at the same level as other large-scale providers, institutions, government health pro- public education campaigns. grams, and managed care systems, engage
6 | Toolkit To End Violence Against Women every type of provider, institution, and system Target primary care, reproductive health, emer- in education efforts. gency, mental health, pediatric, and other spe- cialty organizations that see women regularly. 3. Develop professional school curriculums that Integrate violence against women into associa- address violence against women. tion member recognition and honors. Fully integrate information on violence against Increase the availability of technical assistance women into standard curriculums at all health and training for health care providers who want care and public health professional schools. to become SAEs and professionals who want to Include information on the dynamics, epidemi- improve multidisciplinary responses to sexual ology, and direct and indirect effects of sexual assault. assault, dating and domestic violence, and Follow recommendations of the International stalking, as well as clinical skills such as Association of Forensic Nurses, which requires screening, documentation, and response. the completion of 40 contact hours approved Although specialized sections on specific issues through a recognized continuing education are necessary, integrate information about vio- body or offered through a college or university. lence against women throughout course work Participate in continuing education and ongoing whenever appropriate. training to maintain proficiency with new tech- Offer specific modules on improving the cultur- nologies and research findings. al and linguistic competence of practices for all levels of providers. Integrate examples of cul- 5. Engage all types of providers and institutions. turally and linguistically competent practices Primary care settings offer opportunities for and cases that deal with various patient popula- early intervention, and even primary prevention, tions in training that addresses violence against by identifying sexual or domestic abuse as a women. health issue in its early stages or before it begins. 4. As part of continuing education for providers, offer Mental health professionals are key points of specific modules on violence against women, and rec- ognize achievements in the field. contact who see victims for problems of anxi- ety, depression, posttraumatic stress disorder, Ensure that training related to violence against suicide attempts, and other psychological prob- women is a component providers receive to lems highly associated with violence against become or remain licensed to practice. women. Involve sexual assault and domestic violence Obstetricians, gynecologists, women’s health advocates and survivors in the development and nurse practitioners, and nurse midwives are implementation of continuing education on vio- important players because sexual assault sur- lence against women. vivors often experience anxiety about pelvic Include questions related to both the dynamics examinations and because data suggest that the and effects of violence against women and onset of abuse is often associated with pregnancy. appropriate clinical responses on licensure and Pediatricians and pediatric nurse practitioners certification examinations. can identify victims of domestic violence and Provide training and promote effective clinical offer the resources and support necessary to guidelines and standards of care that reflect stop the abuse before it takes its toll on the routine screening, documentation, appropriate mothers and children they are treating.10 assessment, intervention, and referral. SAEs see victims of sexual assault as well as Create associationwide member awareness cam- victims of domestic violence. paigns around sexual assault, dating and domes- Dentists and oral surgeons may see women for tic violence, and stalking. treatment of oral injuries, such as fractured
Chapter 2. Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women | 7 jaws, and for regular checkups, during which Provide increased funding and technical assist- abuse can be identified by routine screening ance to support program development in under- even in the absence of acute injuries. They may served areas, in collaboration with local and also have patients who have specific fears or state sexual assault programs and coalitions. reactions concerning their dental care because of a history of sexual assault. 7. Design mental health services to respond to the Substance abuse counselors see many women needs of victims and survivors of sexual assault, dat- who are victims of sexual assault and domestic ing and domestic violence, and stalking. violence and who use alcohol or other drugs as Designate funds to provide quality mental a way of coping with the trauma. Research has health services for treating the traumatic seque- shown victimization to be a risk factor for sub- lae of abuse for victims of sexual assault, dating stance abuse. and domestic violence, and stalking, including Specialists such as orthopedic and plastic sur- adult survivors of child sexual abuse living in geons, radiologists, and home health care nurs- rural areas. es and attendants each have an important stake Develop collaborative models for addressing the in identifying and responding to abuse among social and advocacy needs and the psychologi- their patients. Pain management centers may cal needs of survivors of sexual assault, dating see many women who suffer from chronic pain and domestic violence, and stalking. due to abuse. Designate program and training resources to Inpatient health care settings, such as psychi- improve quality of care in public mental health atric facilities and nursing homes, are urged to systems to address trauma and its sequelae work with community sexual assault and across the lifespan. domestic violence programs to provide training Provide training for community mental health and develop policies and services that respond centers to address sexual assault and domestic to the needs of patients who enter with a history violence for women diagnosed with serious of assault or who are assaulted while in the mental illness and for women who are experi- institution. encing other mental health sequelae of sexual All types of health care organizations must be assault, dating and domestic violence, and engaged, including community health centers; stalking. home health and visiting nurses agencies; man- Provide resources for sexual assault and domes- aged care organizations; private hospitals and tic violence victim advocacy programs to pro- practices; alternative healing centers; Indian vide onsite services and develop contractual Health Services; military health entities; arrangements with mental health providers and Women, Infants, and Children and Medicaid agencies to address the mental health sequelae programs; and state and federal public health of violence against women. Foster greater col- departments and agencies. laboration between mental health professionals, Businesses and other health care purchasers can sexual assault victim advocates, alcohol and create the institutional support and incentives other drug abuse treatment providers, and crim- that promote training and an improved response inal justice personnel. by their providers and insurers. Develop curriculums and training materials for mental health providers (e.g., psychiatrists, psy- 6. Expand SAE programs to all communities through- chologists, social workers, and marital and fam- out the country. ily therapists) to address issues faced by women Increase the capacity of existing SAEs to who are being or have been sexually, emotion- address the complex health and forensic needs ally, or physically abused. of victims, including the domestic violence vic- tims experiencing forced sex by their partners.
8 | Toolkit To End Violence Against Women 8. Develop and support the widespread use of provider Implement safeguards, under federal, tribal, and institution clinical tools that respond to sexual and state laws, to ensure that health records of assault and domestic violence. victims of sexual assault, dating and domestic Develop patient charts, new-patient intake violence, and stalking are not accessed inappro- forms, and other clinical tools that support priately by insurance companies, employers, or appropriate screening, documentation, and spouses/partners. Protect privileged medical and response to victims of sexual assault, dating mental health information from discovery and and domestic violence, and stalking. other legal actions during the course of a crimi- Include prompts for providing sexual assault nal proceeding. victims with information on available forensic Build into current policy necessary protections medical examinations in sexual assault proto- for patients who may be endangered under rou- cols, and ensure access to appropriate equip- tine directory information, next of kin, and ment and staff training on its proper use. other practices in health care institutions. Post local, state, and national hotline telephone Allow victims to restrict access to their patient numbers for victims of sexual assault and information. domestic violence in all examination rooms Allow victims to request that bills and explana- and patient bathrooms. tions of benefits be sent to alternate addresses. Develop practitioner reference cards that Remove information regarding abuse from the address sexual assault, dating and domestic vio- records of victims and their children before lence, and stalking. Include sexual assault and releasing them to spouses or partners. Notify domestic violence information on Web sites victims before any required release of abuse- designed for health care provider and patient related information to facilitate their safety reference. planning. Equip examination rooms with body maps Allow minors who lawfully receive care on available for documenting injuries. Equip emer- their own to restrict access to records regarding gency departments, acute care centers, and abuse. other sites that see injuries caused by domestic violence with instant cameras. 11. Reduce or eliminate cost and reporting require- ments for victims needing forensic medical exams or Scrutinize all standard tools to ensure they related treatment after a sexual assault. include information about violence against women. Earmark state funds to cover costs of forensic medical exams for victims of sexual assault 9. Use funding, licensing, and credentialing mecha- without seeking reimbursement from the victim nisms to ensure that health care institutions have rele- or from any public or private health insurance vant response protocols for violence against women. under which the victim might otherwise be Require grantees to have policies, protocols, covered. training requirements, incentives, and other rel- Adopt current federal guidelines governing vic- evant responses to violence against women. tim compensation agencies, which permit reim- Create and strengthen guidelines regarding sex- bursement of examination costs to hospitals and ual assault, dating and domestic violence, and other medical facilities regardless of whether stalking, including guidelines for screening. the assault is reported to law enforcement authorities. Include care for acute symptoms and prophy- Address Health Care Policy Issues laxis for pregnancy, sexually transmitted disease 10. Fully protect the confidentiality of victims’ health transmission, and treatment for the hepatitis B records. virus when appropriate as part of emergency medical care associated with an assault.
Chapter 2. Improving the Health and Mental Health Care Systems’ Responses to Violence Against Women | 9 12. Amend mandatory reporting laws regarding adult Provide feedback on performance compared to victims of violence to ensure that the laws increase peers and national standards. victim safety and health status and do not deter Tie monetary rewards to attaining defined per- women from seeking care. formance goals with respect to screening and Require patient consent—except in cases of intervention. gunshot wounds or life-threatening injuries— Provide public recognition for high performers before health care providers report violent inci- (e.g., newspaper articles, plaques presented at dents to law enforcement agencies. medical society meetings). Increase awareness of the problems that arise Design and implement formal mechanisms to from mandatory reporting for women who are give providers feedback from patients who undocumented and the subsequent immigration value these services. problems. Support the clinician’s role in responding to 13. Create reimbursement mechanisms, coding, and sexual assault and domestic violence by devel- other incentives to provide quality care to victims of oping in-house services for victims of sexual violence against women. assault and domestic violence or by contracting with community organizations to provide onsite Educate clinicians and medical coders on the or on-call access to their specialized services. importance of including the existing Inter- national Classification of Diseases, Ninth 15. Prioritize the creation of comprehensive packaged Revision (ICDÐ9) codes for adult abuse and services for victims of sexual assault, dating and e-codes, particularly those that describe the domestic violence, and stalking. relationship of the perpetrator to the patient, either as primary or secondary diagnostic codes. Develop models for delivering multifaceted Failure to add an adult abuse code to the med- responses, including medical care, counseling, ical record means that information about the assessment, case management, and mental root cause of an injury or illness is not captured health counseling and referrals. and therefore may not be appropriately Examine Medicaid program models, similar to addressed in followup encounters. the State Medicaid Perinatal programs that Promote the use of existing ICDÐ9 codes, could reimburse health plans for the provision of including the use of e-codes to define the rela- patient education and case management, safety tionship of the perpetrator to the patient, assessment, and referrals in violence against through medical coder professional organiza- women cases in low-income communities. tions, national health care provider organiza- 16. Establish appropriate health outcome measures tions, state medical boards, and the use of related to improved health care response to violence federal and state government advisories. against women. Develop and implement at least two Current Convene a task force of leading advocates, sur- Procedural Terminology codes specific to vivors, health care providers, researchers, and domestic violence screening and intervention. federal representatives to create Health Plan Develop the business case for domestic vio- Employer Data and Information Set measures lence services in the health care setting. for sexual assault and domestic violence. Develop model incentive programs that reward Explore the full range of possible outcome purchasers, plans, other insurers, and clinicians measures, including decreased health care for domestic violence screening and intervention. use, fewer secondary health effects related to violence, and victim perception of improved 14. Provide incentives for individual health care physical and mental health status and safety. providers to address the violence against women issues of their patients.
10 | Toolkit To End Violence Against Women Develop and provide funds to implement a What are effective responses to perpetrators research agenda that establishes the medical who are not mandated to join batterer or sex evidence for effective intervention and offender treatment programs? improved health outcomes and increased safety. How can more culturally competent batterer and sex offender treatment programs be 17. Increase funding to improve the health and mental developed? health care systems’ response to violence against women. Explore the creation of new funding streams Pediatric Responses to Violence Against that can be dedicated to improving the health Women and mental health care systems’ responses to Although pediatricians clearly must respond to violence against women. domestic violence because of the documented Earmark specific funding within state and local effects of witnessing violence and the overlap of health department budgets for improving health child abuse and neglect, many questions remain care response to sexual assault and domestic unanswered. State and local agencies and health violence. care institutions should support pilot programs that 11 Provide funds for health care provider training, seek answers to these questions. institutional reform, patient education, and pub- How do providers navigate the complicated eth- lic health campaigns to reflect the prevalence of ical, legal, and reporting issues surrounding violence and its impact on health costs. child abuse and witnessing violence? How and when should screening of mothers Emerging Issues occur? How do child protective services and domestic Perpetrators of Violent Crimes Against violence advocates work together in health care settings to ensure the best care and health status Women for children and their mothers? The health and mental health care systems’ What role can a pediatrician take in responding responses to perpetrators of sexual assault, dating to abused women? and domestic violence, and stalking must be assessed. Outside of batterer and sex offender Another area for ongoing analysis and discussion treatment groups, often mandated by courts, virtu- is pediatric response to a mother, herself a sur- ally no programs exist that respond to perpetrators. vivor of child sexual abuse, being retraumatized State and local agencies, leaders in the sexual by discovery that her child is being sexually assault and domestic violence movement, abused. What training, screening, and response providers, and perpetrator experts must answer protocols are necessary? fundamental questions about the health and mental health care systems’ responsibility to intervene with perpetrators. Key questions include Resources