CorrectCare

Sexual Abuse
What Is the Health Professional’s Role in Prevention and Response?

by Robert B. Greifinger, MD

• An estimated 12% of youth in state juvenile facilities and large nonstate facilities (representing 3,220 youth nationwide) reported experiencing one or more incidents of sexual victimization by another youth or facility staff in the past 12 months

• 4.5% of inmates report sexual victimization in the nation’s state and federal prisons

• 3.2% of inmates report sexual victimization in local jails

These shocking and shameful statistics come from the Bureau of Justice Statistics’ surveys of sexual violence (2007, 2008 and 2010), conducted as required by the Prison Rape Elimination Act of 2003. The findings leave no doubt about the extent of sexual victimization behind bars and vividly remind correctional health professionals of the importance of responding appropriately to it.

Although not yet binding, the standards recommended by the National Prison Rape Elimination Commission in June 2009 offer the best guidance. The basis for the NPREC standards is zero tolerance of sexual abuse of inmates, accomplished through the effective implementation of written policies for prevention, detection, response, reporting and monitoring by all correctional facilities. The standards delineate responsibilities for all staff as well as the particular responsibilities of correctional health professionals.

The NPREC standards have been submitted to the U.S. attorney general, who under PREA is required to issue final standards in June 2010. Correctional health professionals should not wait, however, as the NPREC standards articulate a set of best practices for responding to sexual abuse. Indeed, these practices are well worth adopting for any kind of medical urgency, whether it is sexual abuse, trauma or serious acute illness.

In a correctional facility, the health professional’s role is to provide timely access to appropriate medical and mental health care. Nothing differs for victims of alleged sexual abuse. We have high expectations for ourselves to act professionally, with sensitivity, insight and confidentiality. And we recognize the particular vulnerabilities of victims of sexual abuse behind bars: Not only do they suffer the physical and mental trauma itself, but their claims are too often dismissed, they are subject to retaliation for reporting abuse and the typical grievance process may not be the best route to a safe and effective response.

The NPREC standards outline a clear role and a set of policies and practices for correctional health professionals, including the following:

• Collaborate with the agency or facility executive team to develop and implement policies.

• Be trained in how to detect and assess signs of sexual abuse, preserve physical evidence, respond effectively and professionally to victims and know how to report allegations or suspicions of sexual abuse.

• Screen inmates during intake to assess their risk of being sexually abused by other inmates and their risk of being sexually abusive toward others. The screening should be guided by a written instrument tailored to the facility’s population (for example, by gender). The staff must obtain informed consent from inmates before reporting information about prior sexual victimization that did not occur in an institutional setting, unless the inmate is under the age of 18, where consent is not required.

• Participate in a coordinated response with first responders, investigators and facility leadership to ensure that victims receive all necessary immediate and ongoing medical, mental health and support services. This includes timely, unimpeded access to emergency medical treatment and crisis intervention services, the nature and scope of which are determined by medical and mental health practitioners according to their professional judgment.

• Communicate and coordinate with qualified forensic medical examiners. Where there is a need to collect forensic evidence, a recommended best practice is for evaluation and treatment, including examination, by community medical examiners, even if the facility has a forensic medical examiner on staff.

• Provide ongoing medical and mental health care as correctional health professionals deem appropriate and necessary in the exercise of their professional judgment, including help for victims of sexual abuse during their transition to the community. The abuser should also be assessed for mental health needs as the abuse may be related to mental illness, and be provided treatment accordingly.

• Report any alleged in-facility sexual abuse of inmates whether by staff or other inmates, unless otherwise precluded by law. This applies to knowledge gained in the lunchroom as much as it applies to direct information from patients. The duty to warn and protect your patient and other inmates overrides your patient’s privacy interest, in this unique circumstance. The reporting is on a need-to-know basis to preserve privacy. Mandatory reporting does not apply to reported sexual abuse prior to incarceration. Victims should be informed about the reporting at the outset of any interview or treatment so that they can know what information will be held confidential.

• Cooperate with investigations.

The NPREC standards for juveniles differ in several respects from those for adults. As an example, medical and mental health staff are required to inquire into sexual orientation and gender identity as well as prior victimization and participation in sexual abuse, tailored to the child’s age and developmental status. Reporting is mandatory for all sexual abuse, including prior abuse. Juvenile facilities must provide access to outside victim advocates for emotional support, in addition to on-site mental health support.

Be Mindful of Pitfalls
The pitfalls of effective prevention and response to alleged sexual abuse are confidentiality, continuity and coordination of care. Considering the three c’s will help correctional health professionals meet their duties.

First, confidentiality should not be used as a shroud to prevent reporting incidents of alleged sexual abuse. Reporting alleged abuse is critically important, as reflected in the NPREC standards, to protect the patient from further abuse or to protect other inmates. Hopefully, you will be able to obtain patient consent by convincing your patient that he or she will be safe and protected from unintended consequences of reporting, such as minimizing the allegation, rebuff with responses like “you didn’t fill out the proper form” or retaliation by staff or other inmates. If you believe your patients won’t be assured safety and treated with respect, you must still report—but you should also work with prison officials to change the institutional culture.

Second, emergency response and crisis intervention is not enough. Nor is a timely visit to the emergency department for a qualified forensic evaluation (e.g., when there has been penetration or there is forensic evidence to collect). Patients need continuity of care. On return to the facility, the victim may still have the emotional burden of the assault, fears for safety and wounds to heal. Follow-up laboratory testing is critical. Victims may have been tested for sexually transmitted infections, but it is important to remember the incubation periods of STIs and especially the period between contact and laboratory evidence of infection, which ranges from days to months depending on the organism. Diseases to consider are gonorrhea, chlamydia, syphilis, HIV, viral hepatitis and herpes. In cases of vaginal penetration, women should have laboratory testing for pregnancy several weeks after the assault.

Third, just because a victim appears fine emotionally does not mean there will not be late effects, such as anxiety disorders or PTSD. It is important for medical and nursing professionals to consider the victim’s mental status for months after an assault and to coordinate care with mental health staff, as needed. After an initial evaluation, mental health staff should follow up with their patients over time and coordinate care for their somatic complaints.

Meaningful Contribution

— About the author: Robert B. Greifinger, MD, is a physician consultant and college professor based in New York. He served as a member of the NPREC Standards Development Expert Committee.

[This article first appeared in the Winter 2010 issue of CorrectCare.]