Resources for healthcare providers

Sexual violence refers to any sexual act that occurs without consent. This includes a wide range of assaults, including rape, attempted rape, sexual battery, incest, molestation, spousal rape, and statutory rape. Intimate partner violence, or domestic violence, takes many forms, including: sexual, emotional, verbal, financial, psychological, spiritual, digital, and physical. Visit our Intimate Partner Violence and Sexual Assault/Abuse pages for more detailed information.

Intimate partner violence is associated with increased morbidity and mortality. Recent studies show that sexual assault/abuse and intimate partner violence have short-term and long-term effects on survivors’ health even when they haven’t sustained physical injuries.

Findings from the National Intimate Partner and Sexual Violence Survey (2010)(1) reveal that survivors can experience mental health consequences—like depression, anxiety, suicidality— as well as physical health consequences like gastrointestinal disorders, sexually transmitted infections, and peripartum and postpartum complications. Sexual assault/abuse and intimate partner violence are public health concerns, as recognized by the World Health Organization.

Survivors commonly experience headaches, stomachaches, depression, anxiety, post-traumatic stress disorder (PTSD), sleep disturbances, and many other physical and psychological ailments.

Survivors are:

• 60% more likely to have asthma

• 70% more likely to have heart disease

• 80% more likely to have a stroke

• Twice as likely to be a current smoker

• Twice as likely to suffer from depression and headaches

Healthcare providers are in a unique position to provide care and referrals for ailments caused by violence and abuse. As healthcare providers can sometimes be the only outside person to interact with a survivor, up-to-date training and trauma-informed care are key components of delivering care.

In addition to mandating screening for intimate partner violence during intake interviews, the Affordable Care Act also greatly expands support and insurance coverage for survivors. Exclusions based on pre-existing conditions, such as a history of intimate partner violence, are prohibited. The law exempts survivors from penalties for not having insurance, requires coverage for mental health and substance abuse treatment and increases support for Native American survivors.

Visit the Department of Health and Human Services’ Division of Family Violence Prevention and Services webpage for more information.

A trauma-informed care approach is strengths-based and grounded in an understanding of the impact of trauma. Such an approach:

• Recognizes that trauma exposures are pervasive through both individual and collective experiences.

• Emphasizes the physical, psychological, and emotional safety of both providers and survivors and focuses on creating opportunities for communication, support, and safety at all levels of an organization.

• Is culturally sensitive and person-centered and expands on a foundation of patient autonomy and choice to ensure that an individual’s unique trauma history is as integral a component to care as the patient’s concerns, preferences, and values.

• Responds to disclosures with understanding and recognition of the effects of all kinds of trauma (childhood exposure to violence, sexual violence, historical trauma, etc.) by building trust and providing a safe environment for receiving services.

• Actively avoids re-traumatization. Conversations around past trauma as well as physical exams should take into consideration any triggers the patient/survivor might have.

This information was adapted with permission from FUTURES Without Violence.

The goal of trauma-informed care is to help survivors rebuild a sense of control and empowerment. People experience trauma through physical and sexual violence, racism, structural violence, poverty, homophobia, transphobia, witnessing violence, health inequity, war or natural disaster, emotional abuse and neglect, and more.

Visit the Safe Place webpage for information on implementing trauma-informed care in your clinic.

Routine assessment as part of preventative health care screenings should be incorporated into clinical settings. The CDC is a resource for assessment instruments that can be used in healthcare settings. The two-question screening tool is a validated tool that can be used in primary care settings. The Danger Assessment can be used to determine a person’s risk of homicide after experiencing violence. When talking to your patients, keep in mind that disclosing can only come when the patient/survivor is ready.

Many clinics and hospitals are updating their intake forms and electronic health records to include questions about sexual assault/abuse and intimate partner violence.

Lumina Alliance encourages providers to use the evidence-based CUES assessment method and the safety cards developed by Futures Without Violence to talk to their patients about healthy and unhealthy relationships. To request safety cards, email Contact@LuminaAlliance.org.

CUES stands for the following protocol:

• Confidentiality: Disclose your limits of confidentiality. Always see the patient alone for at least part of every visit to ensure a safe space to discuss relationship violence.

• Universal Education & Direct Inquiry: Give the patient a safety card that educates on how relationships can affect health. Reiterate that you are a safe person to speak with.

• Support: Know that disclosure is not the goal. Survivors get to decide if or when they are ready to share their experience. If your patient discloses that they have been in or are currently in a physically or emotionally abusive relationship, before anything else, start by believing and thanking them for their courage in disclosing. Offer to call an advocate from Lumina Alliance. Treat any injury or illness without fear of “tampering with evidence.”

• Warm Referral & Follow-Up Visit: Assess your patient’s level of risk for future violence, provide resources, and make a warm referral to Lumina Alliance. Advocates can accompany patients to forensic medical exams and can meet patients at any clinic or hospital to inform them of their rights, reporting options, and services available including safety planning, temporary restraining orders, counseling, and emergency shelter. Schedule a follow-up visit to check their injuries and ask about their relationship again. This shows support and empathy for your patients, increases their sense of safety and security and may contribute to improved health outcomes.

Treat these patients as you would any other patient, addressing their presenting physical ailments first and foremost. Note that physical exams might be triggering for anyone who has experienced sexual assault or physical violence. Many healthcare providers are fearful of interfering with forensic evidence, but your primary role is to ensure the health of your patients. You do not have to, nor should you attempt to, act as a detective or trauma counselor.

Appointment times will vary depending on the patient. Healthcare providers often have busy schedules with very little flexibility, but it’s recommended you give your patients time, support, and privacy after they disclose. Work with your clinic’s administrators to establish a trauma-informed procedure for these patients. If possible, reserve a private room for these patients, establish a protocol that enlists point people to help with the reporting process, and call an advocate to support you and your patient.