Health Care Provider Role in Prevention and Response to Sexual Assault in Correctional Facilities

1. Health Care Provider Role in Prevention and Response to Sexual Assault in Correctional Facilities Investigating Allegations of Staff Sexual Misconduct with Offenders National Institute of Corrections/ The Washington College of Law July 9-14, 2006 Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

2. Introduction • Role of Health Care Providers in Correctional Facilities • Role of Health Care Providers in Prevention and Response to Sexual Assault • Public Health Implications of Prison Rape Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

3. Role of Health Care Providers in Corrections • Primary responsibility to provide health care services to inmates • Establishment of a patient-provider relationship • Medical care provided with informed consent • Maintain medical confidentiality • Do not participate in disciplinary proceedings • “Do No Harm” Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

4. Role of Health Care Providers in Corrections • Health care staff are members of the correctional team • Support the security rules and regulations • Establish positive communication with correctional staff • In healthy institutions, mutual respect exists between correctional and medical staff Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

5. Dynamics of Staff/Inmate Interactions Inmates Tension Correctional Staff Advocacy Collaborative Health Care Staff Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

6. Comprehensive Approach to Prevent/Treat Prison Rape • Policies and Procedures • Interdisciplinary • Staff Training • Security, Medical, Mental Health, Counseling • Inmate Education • Zero tolerance • Institutional Leadership • Enforcing policies Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

7. Medical/Mental Health Policy • When to suspect sexual coercion/rape • Placing patient in safe environment • Interviewing patient in privacy • Informed consent • Assess/treat initial injuries • Arrange for collection of forensic evidence Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

8. Medical/Mental Health Policy • Evaluate/treat sexually transmitted infections • Address reproductive health issues • Facilitate mental health counseling • Confidentiality of health Information • Reporting Requirements Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

9. Health Care Role in Prevention/Treating Rape • Maintaining index of suspicion for coercive sexual behavior • Understanding victim/predator profiles • Identifying circumstances in which rapes are more likely to occur • Awareness of health conditions suggesting sexual activity (anorectal disorders and inmate requests for STD testing) Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

10. Spectrum of Sexual Activity Sex for Protection Sex through Intimidation Sex as Economy VoluntarySex ForcibleRape Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

11. References • National Protocol for Sexual Assault Medical Forensic Examinations – U.S. Department of Justice - September 2004 • Centers for Disease Control and Prevention Guidelines • Prophylaxis and Treatment of sexually transmitted infections, including HIV Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

12. National Protocol - Overarching Issues • Coordinated Team Approach • Victim-Centered Care • Informed Consent • Confidentiality • Reporting to Law Enforcement • Payment for examination under Violence Against Women Act (VAWA) Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

13. Coordinated Team Approach • Recognizes dual purpose of the medical forensic examination process • Addresses patient health care needs • Addresses the criminal justice system needs to hold offenders accountable • Identify key responders and roles • Develop QA measures to ensure effective immediate response Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

14. Victim-Centered Care • Give sexual assault patients priority as emergency cases • Address patient’s safety concerns • Provide patients with information that is easy to understand • Assess and respect patients’ priorities Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

15. Victim-Centered Care • Involve patient advocates/victim services if at all possible • Be aware of cultural issues • Inmate/patient may be labeled as a snitch and subject to further assault • Recognize and respect patients’ right to refuse examination and treatment Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

16. Informed Consent • Providers should seek informed consent throughout the examination process • Examinations should never be performed against the will of the patient • Providers must make patients aware of the impact of declining a particular procedure Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

17. Confidentiality • Responders must be aware of the scope and limitations of confidentiality • Policies should address confidentiality and reporting issues • Consider impact of Federal privacy laws • Seek to resolve intra-jurisdictional conflicts Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

18. Reporting Sexual Assault to Law Enforcement • Reporting to law enforcement • Provides opportunity to provide protection • Collect evidence from crime scenes • Investigate and prosecute cases • Hold offenders accountable • Reporting laws vary from state to state • Patients make decisions about reporting • Health care providers required to report Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

19. Payment for Examination - VAWA • Provides funding to pay for cost of medical forensic examinations • Examination should minimally include: • Examination for physical trauma • Determination of penetration/force • Victim interview • Collection and evaluation of evidence • Accessibility? Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

20. National Protocol-Operational Issues • Sexual Assault Forensic Examiners • Facilities • Equipment and Supplies • Sexual Assault Evidence Collection Kit • Timing Considerations for Evidence Collection • Evidence Integrity Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

21. Sexual Assault Forensic Examiners • Encourage the development of specific examiner knowledge, skills, and attitudes • Encourage advanced education and supervised clinical practice of examiners • Encourage certification for nurses who are examiners Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

22. Facilities, Equipment and Supplies • Correctional facilities should establish contracts with health organizations that recognize obligation to treat sexual assault victims • Ensure facilities to have necessary equipment and supplies • Role of Telemedicine Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

23. Sexual Assault Evidence Collection • Sexual assault evidence collection kits should be standardized and meet, or exceed, minimum guidelines • Ensure kits are available at the facility conducting examinations • Periodically review the kits efficiency and usefulness Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

24. Timing Considerations for Evidence Collection • Many jurisdictions use 72 hours as cutoff for evidence collection • New technologies (e.g., colposcopy) permit extension of time frame up to one week • Forensic history may identify and permit collection of other evidence Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

25. Evidence Integrity • Properly collecting, preserving, and maintaining the chain of custody of evidence is critical to criminal justice proceedings Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

26. Evidence Integrity • Handle evidence properly • Drying, packaging, labeling, and sealing evidence • Document the forensic medical history and examination findings • Maintain the chain of custody of evidence • Storage procedures maximize evidence preservation Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

27. National Protocol:The Examination Process • Initial Contact • Triage and Intake • Documentation by Health Care Personnel • Medical Forensic History • Photography • Exam and Evidence Collection Procedures Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

28. National Protocol:The Examination Process • Drug facilitated sexual assault • Sexually transmitted infection evaluation and care • Pregnancy risk and evaluation • Discharge and follow-up • Examiner court appearances Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

29. Initial Contact • May be any correctional staff member: • Correctional officer • Chaplain/Counselor • Health Care Staff • Address safety issues • Bring victim to medical staff immediately to conduct initial evaluation • Have contingencies for when medical staff are not available Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

30. Triage and Intake • Consider sexual assault a priority • Respond to injury, trauma care, and safety needs before collecting evidence • Patients should not wash, change clothes, urinate, defecate, smoke, drink, or eat until initially evaluated • Assess patients’ need for immediate mental health care Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

31. Documentation by HCP • Examiners document exam findings, the medical forensic history, and evidence collected in the medical forensic report • Examiners and/or other involved clinicians separately document medical care in the patient’s medical record • Ensure accuracy and objectivity of forensic reports Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

32. The Medical Forensic History • Obtain medical forensic history in a private setting • Attempt to minimize repetitive questioning • Advocates may be present for support but not participate when the forensic history is taken Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

33. The Medical Forensic History • The Medical Forensic History includes: • Date and time of the event • Location • Description and nature of the assault • Assailant (s) if known • Pertinent patient medical history (menses) • Recent consensual sexual activity • Patient activities since the assault (shower) Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

34. Photography • Photographic evidence of injury on the patient’s body can supplement the medical forensic history and document physical findings • Policy should address the extent of photographic evidence (injured vs. uninjured) • Obtain patient informed consent after explaining the purpose of the photos Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

35. Exam and Evidence Collection Procedures • Strive to collect as much evidence as possible • Prevent exposure to infectious materials and contamination of evidence • Document findings on body diagram form. With patient consent, use colposcope and anoscope as appropriate. • Keep medical specimens separate from forensic specimens Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

36. Sexually Transmitted Infections (STIs) Evaluation and Care • Offer patients information about the risk of STIs (including HIV) • Encourage patients to accept prophylaxis against STIs • HIV • Hepatitis • Syphilis, gonorrhea, chlamydia, trichomoniasis • Provide periodic testing and monitoring Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

37. Pregnancy Risk Evaluation and Care • Administer a pregnancy test to all women with reproductive capability • Discuss treatment options with patients including reproductive health services • Discuss the probability of pregnancy risk with female patients (2-5%) Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

38. Post-Assault Care and Follow-up • Discuss with patients what to expect following initial treatment: • Immediate safety and comfort needs • Mental health counseling • Medical follow-up for STDs (up to 6 months) • Investigative procedures Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

39. Examiner Court Appearances • Health care providers conducting the exam should expect to be called upon to testify in court: • Encourage education for examiners on testifying in court • Encourage pretrial preparation of examiners • Promote prompt notification of examiners • Provide examiners feedback to improve effectiveness Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

40. Public Health Implications of Prison Rape • Prisoners are at increased risk for sexually transmitted diseases (STDs): • Hepatitis B • HIV infection • Syphilis • Gonorrhea and chlamydia • Prison outbreaks of STDs have been documented in several states • Increases health care costs Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

41. Public Health Implications of Prison Rape • Extent of coercive sexual behavior impact upon STD transmission is unknown • Each correctional facility should establish disease surveillance system • Collaborate with local/state health departments when infections are reported • Understanding disease transmission assists in developing effective prevention strategies Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1

42. Public Health Implications of Prison Rape • Prevention of prison rape has a positive impact upon public health: • Reducing transmission of STDs • Reducing cycle of violence • Prevention of prison rape is one aspect of public health and safety Developed by Madeline LaMarre under NIC cooperative agreement 06S20GJJ1