Additionally, some of the more dangerous abusers may not be appropriate candidates for offender intervention programs. It is also important to realize that research suggests that simply going to court and being monitored may account for a significant proportion of the deterrent effect. Treatment is best offered in a community-based setting backed by the courts, in a program that is both certified and also long enough to be potentially successful. Many certified abuser intervention programs have treatment programs lasting up to 48 weeks. Other counseling programs may also be helpful for abusers who have PTSD from child abuse or from warfare, however, the therapist needs to know that there is violence in the relationship and be knowledgeable about IPV dynamics as well as PTSD treatment. Recent evidence-based data reveals that perpetrator intervention best occurs within system change through a local coordinated community response– not exclusively on an individual level. 50 Couple counseling is generally contraindicated. There are a few programs specifically designed for low-level violence between couples that have been shown to be effective, but few communities have these models in place, and regular marital counseling can be dangerous for the survivor. Generally, the focus must be on ending the violence first, with any couples-focused work waiting until the survivor is no longer afraid of being attacked if they speak candidly about issues within the relationship. At each point, it is important that the offender and the survivor are assessed separately and treated separately, and that no couple’s counseling occurs until the survivor requests it and there is no longer a danger of physical violence. The delay between the offense and the start of treatment should be as minimal as possible to make sure that there are sanctions for noncompliance. Knowledge that an offender will either go to jail or go back to court and suffer a stiffer penalty can be an important motivator for change. Steps should be taken to provide for the survivor’s safety while the offender is going through court-ordered intervention. It is important that the survivor has realistic expectations and not assume false hopes. The abused individual needs to have a protection plan in place while the offender is going through treatment. Perpetrator intervention offers offenders a chance at rehabilitation, but it cannot work with those who do not attend or complete the program. ASSESSING PATIENTS FOR SEXUAL VIOLENCE* Sexual violence is a common experience in the lives of women and men 55 . People who have been sexually victimized are more likely to suffer from chronic physical and mental health problems than those who have not been victimized, and believe that their health is fair or poor 56 . Female survivors of sexual violence visit the doctor more often than women who have not been victimized 57 .
Given the high rates of sexual violence and potential health impacts, it is therefore likely that most healthcare providers will come into contact with victims of sexual violence. A variety of tools and guidelines have been created to address the need for screening patients for histories of sexual violence. This guide aims to build on those tools and encourage healthcare providers to conduct full assessments with patients to encourage interventions that provide adequate treatments and recommendations for survivors of sexual violence. Assessing patients While studies have shown that most female patients want to be asked about their experiences with sexual violence by their healthcare providers 58 , few medical professionals screen any patients, female or male, for such trauma. 59 This may be due to a lack of training, time, or comfort on the part of the healthcare provider. 60 However, doctors’ offices can be safe, confidential places to address sexual violence in which survivors can feel comfortable disclosing and confident in receiving the care and services they need. Many prominent health organizations recommend that providers screen their patients for violence, including the American Medical Association, the World Health Organization, the American College of Obstetricians and Gynecologists, the American Academy of Pediatricians, and the American Nurses Association. 61 Although most of the current research and recommendations regarding screening patients for sexual violence focuses on women, some programs have begun screening both male and female patients with promising results. The Veterans Health Administration recently implemented a universal screening program for male and female veterans, providing free care for patients experiencing conditions resulting from military sexual trauma. 62 Screening patients is only one step in the process. A full assessment requires that healthcare providers also develop plans and protocols for what to do when a patient discloses incidents of sexual victimization. Developing assessment protocols Healthcare providers should develop protocols that ensure consistent, effective practices for providing care to patients that experience sexual violence. One promising tool that can aid providers in these efforts is the SAVE method, which was developed by the Florida Council Against Sexual Violence (2003). • Screen all of your patients for sexual violence • Ask direct questions in a non-judgmental way • Validate your patient’s response • Evaluate, educate, and make referrals
How to discuss sexual violence
Normalize the Topic I need to ask you some personal questions. Asking these questions can help me care for you better. Since I am your doctor, we need to have a good partnership. I can better understand your health if you would answer some questions about your sexual history.” I ask all of my patients this question because it is important for me to know what has gone on in their lives. Provide context to your questions We know that sexual violence is common in the lives of many women, men, girls, and boys. Connect sexual violence to the patient’s physical health and well being Sexual violence can affect a person’s health. Ask about sexual experiences that were unwanted or made the person feel uncomfortable Have you ever been touched sexually against your will or without your consent? Have you ever been forced or pressured to have sex? Do you and your partner ever disagree about sexual things? Like what? How do you resolve these conflicts? Do you feel that you have control over your sexual relationships and will be listened to if you say “no” to having sex?
(Pennsylvania Coalition Against Rape [PCAR], 2005)
Healthcare providers should avoid • Asking patients about their victimization when other people are present • Only asking patients who “seem” like victims about their experiences • Using the term “rape,” as some survivors may not label their experience as rape 64 • Using formal, technical, or medical jargon 61 • Only asking about specific types of violence or recent violence 63 • Expressing value judgments If a patient discloses sexual violence Clearly describe to patients what your reporting requirements are and what information might be included in their medical records so that they can make informed decisions about what they disclose. Demonstrate through body language that you are listening to your patient’s response. Respond with validating messages that allow the patient to feel heard and believed.
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