Chapter 7

The Health Care Community

In 1985, former Surgeon General C. Everett Koop declared violence in
America to be a public health emergency and convened a historic conference
on violence and public health, involving physicians, nurses, public health
workers, researchers, policymakers, and advocates. Yesterdays emergency has
become todays epidemic, with some inner cities looking more like war zones
than urban communities. The costs to the U.S. health care system are
astounding:

 Three percent of U.S. medical spendingand 14 percent of injury-related
medical spendingis caused by interpersonal violence.2

 During 1994, U.S. hospital emergency department personnel treated an
estimated 1.4 million people for injuries from confirmed or suspected
interpersonal violence.3

 One insurer, Blue Cross/Blue Shield of Pennsylvania, estimated that more
than $32 million a year is spent in that state alone to treat domestic
violence injuries.4

 Gunshot violence in the United States costs $4.5 billion a year in
medical expenses alone.5

 Alcohol-related crashes cost $45 billion per year, with the average cost
per victim at $16,000.6

Whether looking at the cost of the expensive emergency surgery needed by
more than half of all gunshot victims, the permanent brain or spinal cord
damage suffered by a high percentage of the survivors, or the psychological
trauma and long-term health consequences endured by victims of relationship
violence and sexual assault, violence in America is both a major health
risk for individuals and an enormous drain on the nations health
resources.7

Dr. Koops urgent message challenged health care providers and the public to
seek out the root causes of violence and develop the best treatments. This
new focus for health professionals has been demonstrated at an
institutional level, from the U.S. Surgeon General and the American Medical
Association to local chapters of organizations like the American Academy of
Pediatrics, the American College of Physicians, and the American College of
Emergency Physicians.

Organizations such as the American Medical Association, the American Nurses
Association, the American Association of Emergency Nurses, and the American
Academy of Pediatrics, have taken a strong and visible role in efforts to
reduce violence and create a safer, healthier society. Many professional
organizations actively supported legislation such as the Brady Law, the
Assault Weapon Ban, the Violence Against Women Act, the Child Safety Act,
and laws to reduce drug distribution and handgun possession by juveniles.
Medical and public health research organizations, often funded by the
Centers for Disease Control and other Federal agencies, have examined the
risks of violence from many perspectives, greatly increasing the knowledge
base of criminal victimization. Physicians have established coalitions with
law enforcement personnel, social service workers, clergy, teachers,
parents, and government leaders to actively fight the epidemic of violence.
Their energy and commitment comes from seeing firsthand the consequences of
violence, from the gunshot wound in the trauma unit to the abused child in
the community clinic.

What happens in the clinical setting is paramount from the victims point of
view. Physicians must diagnose, treat, and mend victims of crime, while
also consoling and caring for them and their families. Treating patients
with sensitivity to their physical conditions, as well as to the
psychological impact of victimization, can help the overall physical and
mental healing process.

The Presidents Task Force on Victims of Crime recognized that the medical
community is often the first to come into contact with crime victims who
have experienced some form of injury. Because victims are understandably
fearful and insecure when they arrive at medical centers, the 1982 Task
Force recommendations focused on the clinical setting and the need for
hospital personnelfrom the emergency room to the billing departmentto be
sensitized to the emotional trauma of victimization and to treat the whole
patient, not just the physical manifestations of the criminal violence.8
The Final Report also recommended that hospitals should:

 develop and implement training programs for hospital personnel to
sensitize them to the needs of victims of violent crimes, especially the
elderly and those who have been sexually assaulted;

 provide emergency medical assistance to victims of violent crime without
regard to their ability to pay and collect payments from state victim
compensation programs;

 provide emergency room crisis counseling to victims of crime and their
families;

 encourage and develop direct liaisons with all victim assistance and
social service agencies; and

 develop, in consultation with prosecuting agencies, a standardized rape
kit for proper collection of physical evidence.

In the 15 years since the Task Force released its recommendations, changes
in professional norms, institutional resources, and clinical practice have
made it easier for the health care community to respond effectively to
crime victims. One of the most visible indicators of change in hospital
response is the adoption of standardized protocols for victim care, as well
as statutory requirements for victim services in many states. In addition,
the Joint Commission on Accreditation of Hospitals, the organization that
accredits these facilities, has added standards for victim response to its
review requirements.

Great strides have been made to sensitize health professionals to the signs
and symptoms of domestic violence and child abuse and educate them in
appropriate treatments. Hospital-based Sexual Assault Nurse Examiner (SANE)
programs are springing up around the country to assist rape victims in
supportive settings, and some hospitals have developed comprehensive social
services for crime victims, including individual and group counseling.

The medical community has responded slowly and inconsistently, however, to
the recommendations of the Task Force concerning training of all hospital
personnel, counseling in the emergency room, and referrals to victim
assistance organizations. The health care community is just beginning to
institute pilot projects to address the special needs of crime victims such
as adolescent gun violence victims, one of the fastest growing populations
of crime victims in the nation,9 and the hidden victims of family violence.
In the words of Donna E. Shalala, Secretary of Health and Human Services:

[W]e simply must do better. Because a battered woman may never call the
police... she may never contact a lawyer... she may never enter a shelter,
but, eventually even if its only for a routine check-up she will probably
visit a doctor, nurse, or community health worker. And we must be ready
when she does [W]e want to better reach out to health care professionals
strengthening our ability to screen, treat, and prevent violence against
women.10

Established Programs

Since the Presidents Task Force Final Report was released in 1982,
significant advances have been made in identifying and treating victims of
family abuse, providing supportive services for sexual assault victims, and
reimbursing crime victims for medical expenses.

Family Violence

The health care community has responded to family violence, which
encompasses abuse across the entire life cyclechildren, adults, and the
elderly. Coalitions of national health organizations have been established
to address family violence and develop protocols on recognizing and
treating family violence. The American College of Obstetricians and
Gynecologists (ACOG) became the first national medical organization to
address domestic violence in response to the high incidence of physical
abuse among pregnant women. ACOG collaborated with the National Coalition
Against Domestic Violence to publish bulletins and brochures about domestic
abuse for its members and their patients.

Another major health organization, the American Medical Association (AMA),
also has pushed the medical community to respond more forcefully to family
violence. In 1991, the AMA launched its Campaign Against Family Violence to
heighten physicians awareness of domestic violence, child abuse, and elder
abuse as public health problems. The campaign sought to improve physicians
ability to recognize the risk factors and symptoms of abuse and refer
patients for shelter and services when needed. The AMA has published a set
of diagnostic and treatment guidelines for physicians in the areas of child
physical abuse and neglect, child sexual abuse, domestic violence, and
elder abuse and neglect. Both the AMA and the American Nurses Association
have developed protocols for appropriate intervention and treatment of
family violence. The Joint Commission on Accreditation of Healthcare
Organizations now requires hospitals to develop protocols for the
identification and treatment of battered women.11 A couple of the more
successful hospitalwide protocols for assessing and intervening on behalf
of domestic violence victims are the Advocacy for Women and Kids in
Emergencies (AWAKE) program at Childrens Hospital in Boston, Massachusetts,
and WomanKind, a 24-hour case management, advocacy, crisis intervention,
hospital-wide training, support group, and outpatient assistance program
serving three Minnesota hospitals.

Sexual Assault

Beside providing immediate treatment for victims, medical staff are
required to collect relevant evidence to document an assault and to report
their findings. Appropriate documentation provides useful information for
prosecutors and victims when taking criminal and other legal action against
perpetrators. As the 1982 Presidents Task Force Report recommended, a
primary consideration is the use of appropriate evidence collection kits to
gather information in sexual assault and sexual abuse cases for later
evidentiary use at trial. This must be done sensitively, but competently,
so that the trauma of the rape examination is minimized and evidence is
collected accurately. Many hospitals have established protocol for the
comprehensive treatment of sexual assault victims, including the use of
specialized kits for forensic exams. However, one study found that such an
exam occurred in only 17 percent of all rape cases.12

Since 1990, the number of Sexual Assault Nurse Examiner (SANE) programs
across the country has doubled to 86.13 SANE programs offer an innovative
approach to handling the medical/evidentiary aspects of sexual assault and
child abuse cases through the use of technology, nurse examiners, and
specialized settings. Instead of having doctors handle these cases in busy
emergency rooms, SANE programs create a special environment for victims and
use trained nurse examiners to conduct the evidentiary medical examination
and present the forensic evidence at trial. According to the Tulsa Police
Department, the nationally recognized Tulsa SANE program has substantially
improved the quality of forensic evidence in sexual assault cases. The
Sexual Assault Resource Service of Minneapolis is developing a guidebook
for starting SANE programs for use by communities.

Compensation for Emergency Medical Care

Victim compensation programs in all 50 states, the District of Columbia,
and the Virgin Islands reimburse private and public hospitals for the cost
of emergency medical assistance to crime victims when that cost is not
covered by private insurance or other public medical benefits. In most
states, emergency medical assistance is reimbursed to the hospital in the
full amount of the cost billed. In others, state law or rule authorize
providing victim compensation programs to pay a percentage of the billed
amount, similar to the practice followed by private insurance carriers or
public medical programs such as Medicaid. For example, Delaware pays 80
percent of billed charges; Arkansas, California, and Maine pay 75 percent;
Florida covers 66 percent; and Louisiana pays 65 percent. A number of
states also ensure, by law, that victims are not held responsible for the
remaining amount of the bill.14

Promising Practices

Pilot programs linking victim services with health care settings are
increasingly being initiated across the country. These promising practices
bring together professionals from many disciplines to create victim
services that aid recovery without revictimizing patients or their
families.

Professional Education and Training

Education and training for physicians and other health care providers are
essential to ensure a sensitive and forensically sound response to criminal
injuries. Until a family violence curriculum becomes standard in all
professional schools for medical personnel and in postgraduate continuing
education programs, health care personnel are likely to overlook this form
of abuse, missing an important opportunity for early intervention and
support. Fortunately, excellent training protocols for responding to
victims have been developed, and they are being used by some hospitals
around the country.

 With funding from the U.S. Department of Health and Human Services and
several major foundations, the National Health Initiative on Domestic
Violence, a project of the Family Violence Prevention Fund (FVPF), has
developed, evaluated, and disseminated multidisciplinary training programs
to strengthen the medical communitys response to battering in a variety of
settings. The programs were tested in 12 California and Pennsylvania
hospitals in 1994 and 1995. In only 9 months, all 12 hospitals successfully
designed and implemented a comprehensive interdisciplinary emergency
department response to domestic violence, which includes physicians,
nurses, social workers, administrators, and community advocates. The model
is now being used in more than 130 hospitals and health care settings. FVPF
recently published a manual with step-by-step instructions to develop this
field-tested, low-cost model program, as well as a blueprint to create a
citywide health care response to domestic violence.15 In 1997, the
Initiative began its second phase, expanding into ten states to work with a
coalition of interested organizations to develop and implement a statewide
plan for a comprehensive hospital-based response to domestic violence.

A national conference, Domestic Violence and Health Care: Initiatives for
the New Millennium, was held in Washington, D.C., in November 1997 to flesh
out the steps necessary to expand and improve the U.S. health care response
to domestic violence.

 Individual hospitals are pioneering specialized victim services training
for physicians and mental health professionals. The Harborview Center for
Sexual Assault and Traumatic Stress at Harborview Hospital in Seattle,
Washington, one of the oldest victim service programs in the nation, has
been a national leader in developing comprehensive mental health services
for sexually abused children and adults. A medical training program at
Harborview, supported by state funds, provides training to physicians and
other health care providers who examine sexual assault victims. The program
also provides emergency department training in acute response, a mentorship
program for doctors, colposcopy16 slide review for quality assurance, and
protocols for administering tests for sexually transmitted diseases to
adolescent and adult patients reporting rape.

 At Childrens Hospital in San Diego, California, the Center for Child
Protection (CCP) was established in 1976 to address the prevention,
diagnosis, and treatment of child abuse and family violence. Its services
include intensive home visiting, assessment, and case management; support
for pregnant and parenting teens; assistance to women in identifying and
accessing resources to break the cycle of family violence; and individual,
group, and family therapy to victims of child abuse and their caretakers.
The success of these programs led to numerous requests for training and
technical assistance from other health care providers. In response, CCP
started a clinical training program that offers accredited continuing
education to physicians in conducting the medical evaluation of child
sexual abuse and to interview specialists in conducting forensically
defensible videotaped interviews of children. CCPs San Diego Conference on
Responding to Child Maltreatment and Summer Seminars by the Sea provides
state-of-the-art multidisciplinary education to 2000 professionals from
around the world each year.

 An interactive teleconference was used statewide in Alabama to train
public health department employees in domestic violence identification and
treatment. Developed through a partnership between the Alabama Coalition
Against Domestic Violence and the Alabama Department of Public Health, this
innovative training program used a talk-show format: an Alabama newscaster
was host, and a physician, shelter director, attorney, and three survivors
played the roles of talk show guests.17

 In its continuing effort to educate the medical profession about domestic
violence, the American College of Obstetricians and Gynecologists has
produced a slide lecture about the health care needs of domestic violence
victims. Target audiences include OB-GYN residents, third-year OB-GYN
medical students, first- and second-year medical students in courses such
as Introduction to Clinical Medicine, and other health care providers
including emergency department personnel, dentists, nurse midwives, nurse
practitioners, and mental health providers.

 In 1997, the Program Against Sexual Violence and the School of Dentistry
at the University of Minnesota received funding from the Office for Victims
of Crime to develop a comprehensive education model for dentists and dental
auxiliaries regarding family violence. The project will produce a training
videotape on the clinical and medical signs of family violence in the
dental setting; develop a curriculum for a six-hour seminar designed to
train dental professionals to recognize family violence and to implement
appropriate intervention; and design a comprehensive training packet which
will enable the dental team to easily apply the intervention model to their
own office setting.

 Victim Services in New York City has launched a 3-year pilot project with
HIP, the citys largest managed care health provider, to respond to victims
of domestic violence. The pilot has four components: physician and staff
training; universal screening of all female patients; care management of
identified domestic violence victims; and public education and outreach to
HIP members. Other goals of the pilot include developing models of
coordinated care between the mental health and primary care physicians,
developing outcome measures to track benefits of the intervention, and
developing actuarial data on the prevalence and cost of domestic violence
to HIP. Over 185,000 HIP members will be served by the project. The project
is funded by HIP, the Robert Wood Johnson Foundation, Chase Bank, and the
New York State Department of Health.

Multidisciplinary Approaches in Health Care Settings

Health care, mental health, religious, and social service agencies must
work closely with police officers and detectives, prosecutors, judges,
court personnel, correction professionals, and victim assistance providers
when assisting victims of crime. In the past, these professionals have not
necessarily shared the same goals, nor were they amenable to working
together. These allied professionals are beginning to recognize that they
must cooperate and understand each others functions when responding to
criminal victimization.

 The Violence Prevention Task Force of San Francisco General Hospital
(SFGH) was established in 1994 to build bridges between the many hospital
departments that interface with victims of violence, and between the
hospital and the community. Comprised of representatives from the hospitals
trauma, surgery, emergency services, psychiatry, nursing, pediatrics,
family medicine, social work, and administration departments, the task
force is facilitating institutional change in the way crime victims are
treated. They also seek to foster a culture of violence prevention at SFGH.
Members of the task force conduct staff training sessions to raise
consciousness about violence and sponsor annual educational fairs for
community victim service agencies to share resources and dialogue with
health care workers.

 The Center for the Vulnerable Child at the Los Angeles County-University
of Southern California Medical Center was founded in 1984 as one of the
first hospital-based family violence advocacy centers in the nation. The
state-of-the-art medical treatment and forensic documentation provided by
the center is complemented by a multidisciplinary approach, including
legal, social, and mental health services, to guarantee that all patients
are treated with dignity. The center uses new interactive computer
technology called telemedicine to consult with health providers in rural
areas on conducting examinations of abused children. In addition, the
center is using Office for Victims of Crime funding to develop a
hospital-based emergency shelter for victims of spousal abuse and their
children to serve as a laboratory and training site. The shelter will
assist victims of spousal assault by assessing the potential for repeated
violence to parents and children in a safe environment.

 The Childrens Advocacy Center in Niagara, New York, a service of Niagara
Falls Memorial Medical Center, is another example of a multidisciplinary
program in a hospital setting that offers a single child-friendly facility
for children who have been physically or sexually abused. Prosecutors,
police officers, social services workers, therapists, victim advocates, and
medical professionals work together to investigate allegations and to
reduce the trauma for these children. The center also provides training for
team members several times a year.

 The National Crime Victims Research and Treatment Center at the Medical
University of South Carolina provides specialized mental health services
while working closely with police agencies, the prosecutors office, the
local rape crisis center and battered womens shelter, the state crime
victim assistance network, and the crime victims compensation agency.
Physically injured crime victims hospitalized in the medical center are
provided with information about the justice system, crisis counseling, and
referrals for outpatient treatment.

 In the rural community of La Crosse, Wisconsin, the Gundersen Lutheran
Crime Victim Services and Victim Resource Center, a program of the
Gundersen Lutheran Medical Center, is testing a five-county crisis response
protocol for victims of traumatic crime. Supported by a Victims of Crime
Act subgrant, the program works to improve the accessibility of clinical
service resources to victims of serious crimes; increase victims access to
staff; enhance the skills of physicians, nursing staff, and clinicians for
crisis management response; and improve communication among law
enforcement, district attorneys offices, and clinical support services.

 The American Academy of Facial Plastic and Reconstructive Surgery
(AAFPRS), in partnership with the National Coalition Against Domestic
Violence, the umbrella group for the majority of domestic violence shelters
across the nation, provides free medical services to victims of domestic
abuse. Shelter counselors refer domestic violence victims who have received
injuries to the face, head, or neck to AAFPRS for consultation with a
surgeon, and suitable candidates are given reconstructive surgery at no
cost. Since July 1994, 614 victims have been referred to plastic surgeons.

Programs Assisting Adolescent Gunshot Victims

and Victims of Gang Violence

While multidisciplinary protocol are becoming routine for treating victims
of child abuse, sexual assault, and family violence, guidelines to address
the unique needs of violently injured adolescents did not exist until
recently. In November 1996, a Task Force on Adolescent Assault Victim Needs
convened by the American Academy of Pediatrics published a model protocol
for appropriate care of these victims from their arrival in the emergency
department to their discharge from the hospital. The work of the task force
was guided by the premise that comprehensive care of violently injured
adolescents must address their psychosocial needs as well as their physical
injuries. The protocol is designed to promote full recovery and to reduce
the risks of reinjury and reactive perpetration.18

The OVC Special Report, Victims of Gang Violence: A New Frontier in Victim
Services, released in October 1996, recommended that hospital-based
counseling and prevention programs be established in medical facilities
that provide services to gang violence victims. Several hospitals are
already testing pilot programs for children and adolescents that involve a
range of disciplines over time and across hospital, clinic, and community
settings. A few are highlighted below.

 The Teens on Target program at the Summit Medical Center in Oakland,
California, and at the Rancho Los Amigos Medical Center in Los Angeles has
been hailed nationwide as a model for hospital-based gang violence
intervention. It provides immediate and long-term assistance to teenage
victims, intervention with gang members who accompany victims to emergency
rooms, and gang prevention strategies for schools. The program uses trained
peer counselors, many of whom are in wheelchairs because they were victims
of gang violence, to give bedside support to injured teens and help them
find alternatives to violence.

 Project Ujima is a unique multidisciplinary collaboration of the
Childrens Hospital of Wisconsin, the Social Development
Commission/Milwaukee Youth Opportunities Collaborative, the Medical College
of Wisconsin, the Wisconsin Department of Health Education, and Family
Services of Milwaukee. The project was created to prevent violence and
improve the health of violently injured youth in the Milwaukee community.
To accomplish this, the projects partners established a network of medical,
psychological, and social support systems to provide emergency service for
young victims and their families. In the Childrens Hospital emergency
department, peer counselors, community-based staff, and a social worker
provide support and a sense of safety and trust. Following discharge, youth
and families are visited at home by service providers who provide them with
continued medical care and a complete health assessment as well as
integrated violence prevention services. Training sessions for hospital
staff focus on effective communication and sensitivity toward violently
injured youth of different races and ethnic backgrounds.

 KidStART is a Violent Injury Prevention Center for physical and
psychological healing of violent injuries that started in 1995 as a pilot
at the Childrens Memorial Medical Center in Chicago, Illinois. KidStART
counselors meet each week with an average of 21 young victims of violent
injury in the hospitals special art studio, where they paint, draw, make
masks, and sculpt in clay. Parents, siblings, and other hospital patients
may also participate. The program has had a visible impact on these
patients by allowing them to express and validate their feelings of fear,
frustration, and pain utilizing creative arts as their primary media.

 The Violence Prevention Club, established in 1991 by the Boston Violence
Prevention Program and now replicated at the Boston Medical Center, is
designed to provide guidance and support to young people with spinal cord
and other injuries caused by violence. Young gunshot victims in the
hospital have immediate contact with a member of the violence prevention
staff and are matched with peer counselors who also have sustained gunshot
injuries. The recovery period in the hospital and rehabilitation center
offers a window of opportunity for survivors to be exposed to supportive
resources and peer role models in the community. Once discharged, they are
encouraged to become advocates for prevention. Youth and adult staff of the
Violence Prevention Club have trained and assisted other spinal cord injury
units and city health departments across the nation in developing their own
violence and victimization intervention initiatives.

Recommendations from the Field for the Health Care Community

Health Care Community Recommendation from the Field #1

All professional schools that educate future health care professionals,
including schools of medicine, nursing, social work, rehabilitation,
hospital administration, and public health, should incorporate victim
issues into their curricula.

It is critical that the health care community learn about the
psychological, as well as the physical trauma caused by crime. At a
minimum, courses on the trauma of victimization, child sexual and physical
abuse, elder abuse and neglect, domestic violence, and sexual assault
should be a standard part of curricula for health care providers. The
objectives of a violence curriculum should be: to educate about risk
factors, indicators, prevalence, and consequences of violence; to increase
awareness of the prevalence of family violence; to emphasize the need to
screen all patients for alcohol and other drug abuse; to enhance
provider-patient communication skills, including how to take a violence
history; to foster a multicultural understanding and sensitivity; and to
expand knowledge of victims rights and available services to enhance
capability for quality and timely referrals.19 These topics should be
included in professional licensing examinations, and continuing education
programs throughout their careers.

Health Care Community Recommendation from the Field #2

All patients should be routinely assessed for indications of domestic abuse
or other history of violence, and any signs or symptoms of abuse should be
documented in their medical records.

State legislatures should consider following the lead of California, the
first state to mandate that all hospitals and licensed clinics routinely
screen patients for indicators of abuse,21 document such indicators in
their medical records, and refer patients to domestic violence assistance
resources.22 The law also requires all health care providers to complete
domestic violence course work or training as part of the licensure and
recertification process. Other states, such as Florida and New York,
require similar training for physicians licensed by the state. Whether
required by state law or not, health care responders should be instructed
and trained to gather evidence to document domestic violence injuries for
use later in criminal, juvenile, child protective, and civil proceedings.
Medical personnel should document the patients injuries and report in as
much detail as possible, using sketches or photographs and the exact words
the patient uses to describe the incident.23 Support systems for the
protection of health care professionals who report child abuse, neglect,
and child witnessing of violence should be strengthened.

Health Care Community Recommendation from the Field #3

Hospitals should establish training programs and protocols for all hospital
personnel about the rights and needs of victims of crime.

Annual mandatory training programs for hospital staff on victims needs
should include presentations by individual victims or victim panels on the
trauma of victimization and victims rights laws. The training should be
multidisciplinary and devote special attention to victims of sexual
assault, child abuse, domestic violence, elderly victimization, hate and
bias crimes, and catastrophically injured patients, including those injured
in drunk driving crashes. Protocol similar to those developed by the AMA
and American Nurses Association should be developed to ensure appropriate
procedures for collecting, preserving, and transmitting evidence and to
eliminate repeated interviews of victims by doctors, nurses, and social
workers.

Health Care Community Recommendation from the Field #4

Medical facilities including hospitals and rehabilitation and trauma
centers should serve as gateways to assist victims of crime. Response staff
should be available in these settings to provide onsite crisis counseling,
follow up with patients, and serve as links to in-house and community
resources.

The health care, social service, criminal and juvenile justice, and other
professional communities must integrate their response to violence if
victims are to be provided a safety net that functions effectively. Medical
settings should develop linkages with a variety of area resources including
victim service agencies. Special consideration of the needs of victims,
such as food, clothing, transportation, and the development of safety plans
should be taken into account in emergency rooms and trauma centers.
Programs should involve the family in aftercare and should educate them
about victims needs and rights before they leave the hospital. In all
cases, victims must be informed about options and be at the center of
decisions related to their aftercare.

Health Care Community Recommendation from the Field #5

Victims of sexual assault should be given emergency medical care, forensic
examinations, and testing for HIV and sexually transmitted diseases at no
out-of-pocket cost and in a supportive setting. More hospitals should
consider establishing Sexual Assault Nurse Examiner programs to respond
sensitively to the needs of sexual assault victims.

Specialized medical examinations for child and adult victims of sexual
assault have forensic, health, and psychological purposes. In these times
of dramatic changes in the health care delivery system and a shift to
managed care, it is especially important to ensure that victims receive the
full range of treatment they need including diagnosis and treatment of
injuries, and testing, counseling, and treatment for sexually transmitted
diseases. Financing these critical services could be accomplished through
government support of forensic practitioners, criminal or juvenile justice
system reimbursement for examination costs, or coverage by VOCA-funded
crime victim compensation programs. In federal sexual offense cases, the
Attorney General should provide for the payment of the cost of two
anonymous and confidential tests of the victim for the HIV virus and
sexually transmitted diseases, including gonorrhea, herpes, chlamydia, and
syphilis.24

HIV testing should be conducted at an anonymous testing site that provides
pre- and post-test counseling. Anonymous testing allows the victim to keep
his/her results private and avoids the potential for the results to be
discovered by defense attorneys or insurance companies when the test is
performed in a hospital setting. Any costs associated with the testing
should be covered by the medical community or by crime victim compensation.

Health Care Community Recommendation from the Field #6

Cultural competency guidelines should be developed to help health care
providers improve screening and intervention services for victims from
diverse backgrounds.

Detection, treatment, and prevention services for victims of domestic
assault, elder abuse, child abuse, and sexual assault are often
nonexistent, inadequate, or culturally inappropriate in rural, inner-city,
lower income, minority, and immigrant communities. Where these services do
exist, victims may be inhibited from seeking help because of cultural
barriers. Health care providers often compound these problems by their lack
of knowledge about options available to patients, by not discussing the
topic out of their own discomfort, and by insensitivity to the cultural
context of abuse. Imaginative approaches are needed to foster multicultural
understanding on the part of students in professional schools. For example,
where standardized patients are used as a teaching method, they should
represent the communitys racial, cultural, and linguistic groups.25

Health Care Community Recommendation from the Field #7

Medical personnel should be knowledgeable about and have policies in place
to ensure that statutory privacy protections are applied to medical
records, abuse reporting forms, and medical legal evidence. They should
respect the confidentiality and privacy needs of all victims of crime and
assist them in dealing with unwanted media attention, especially in cases
of sexual assault and assaults on children.

Although horrendous crimes may be of interest to the public, crime victims
do not have to share the details or their feelings with the public.
Hospitals and clinics should develop protocols for protecting the rights of
victim-patients in their care who do not want to be interviewed or
photographed. Victims of domestic violence, sexual assault, and gang
violence may need to be admitted under an alias to protect them from
further acts of violence. Security guards should be alerted when violence
or unwanted media attention is a possibility.

Health Care Community Recommendation from the Field #8

Counseling and prevention programs and/or a referral system to such
programs, should be established in medical facilities that treat
violence-related injury, including gunshot victims, to address the broad
spectrum of needs

of these victims.

The importance of counseling and prevention programs for victims of gang
violence was emphasized in the 1996 OVC Special Report, Victims of Gang
Violence: A New Frontier in Victim Services. Rehabilitation-based
intervention strategies to reduce adolescent acquaintance violence are
being used in major trauma centers across the country and should be
replicated, wherever possible.26

Health Care Community Recommendation from the Field #9

Protocols for appropriate security and safety procedures should be
developed to assist hospital personnel in responding to incidents of gang,
family, and other violence that might result in staff victimization.

Patient assaults on personnel in emergency rooms and other heath care
facilities threaten the welfare not only of the assaultive patient, but of
staff and visitors. Victims report intense emotional reactions as well as
physical injury. While risk management is widely recognized as an important
element of the management response, crisis intervention procedures and peer
counseling also should be established for emergency service personnel and
health care providers affected by assaultive incidents.27

Health Care Community Recommendation from the Field #10

Pediatricians, family practitioners, internists, and other health care
professionals treating young children should be educated about the effects
on children of witnessing domestic violence and violence in the community.

Several studies have documented that children are victims of and witnesses
to a significant amount of violence, including homicides and serious
assaults.28 It has also been estimated that at least 3.3 million children
witness physical and verbal spousal abuse each year, from insults and
hitting to fatal assaults with guns and knives.29 Pediatricians, pediatric
nurses, social workers, and others working in clinical settings need to be
able to recognize and treat both short-term and long-term consequences of
violence to children, including post-traumatic stress disorder, or ensure
appropriate referrals for counseling.

Health Care Community Recommendation from the Field #11

Technology should be utilized to improve medical services for crime
victims, especially in underserved and rural areas.

Many crime victims who live in underserved, rural, or remote areas do not
have access to physicians to conduct forensic and other needed medical
examinations. To help provide these crucial services, rural communities
should consider using new technology to link nurse practitioners to trained
physicians who can help them to conduct examinations and review procedures.
Web sites should be established to provide information and links to local
resources for families seeking help on victimization issues.

Health Care Community Recommendation from the Field #12

Statutes and policy should be adopted to prevent insurance companies from
discriminating against victims of crime by denying and/or canceling
coverage or by charging higher premiums for such coverage.

Some victims and their advocates report that it has become a practice among
some insurance carriers to deny claims made by individuals that resulted
from their criminal victimization. In addition, some insurers have either
refused to cover such victims or have attempted to charge victims
exorbitant premiums to obtain such coverage. As a matter of public policy,
insurers granted the privilege of doing business in the various states
should be required to provide victims with basic coverage much the same way
companies are required to insure high risk drivers.30

Health Care Community Recommendation from the Field #13

All health care professionals should be educated about sensitive death
notification techniques.

Death notification is rarely, if ever, addressed in medical schools,
although nursing journals, pastoral care journals, and some medical social
worker literature addresses it. OVC has funded the development of four
death notification seminars, one geared specifically toward health care
providers. The protocol presented are based, in part, on interviews with
hundreds of family members who had been notified of the deaths of their
loved ones.

Health Care Community Recommendation from the Field #14

Catastrophic physical injury victims, including assault and drunk driving
crash survivors with serious injuries, should receive specialized
neuro-psychological evaluation in health care facilities.

Emergency room professionals place primary importance on treatment of
injuries that are obvious or are detected by x-ray, CT scan, or MRI.
Victims who have been seriously injured should also be referred to
neuro-psychologists for evaluation of closed head injury and post-traumatic
stress disorder. Five to 45% of motor vehicle crash survivors who seek
medical attention will develop PTSD within the year following the crash and
an additional 15% to 30% will develop symptoms but not enough for the full
diagnosis.31

Endnotes

1 Koop, C.E., Foreword, in Violence in America: A Public Health Approach,
ed. M.L. Rosenberg and M.L. Fenley, New York: Oxford University Press,
1991.

2 Miller, T.R., M.A. Cohen, and B.Wiersema, Victim Costs and Consequences:
A New Look, National Institute of Justice, February 1996, NCJ 155282.

3 Rand, M.R., Violence-Related Injuries Treated in Hospital Emergency
Departments, Special Report, Washington, D.C.: U.S. Department of Justice,
Bureau of Justice Statistics, August 1997, NCJ 156921.

4 Flitcraft, A., Physicians and Domestic Violence: Challenges for
Prevention, Health Affairs, Vol. 12, Number 4, 1993:159.

5 Headden, S., Guns, Money & Medicine, U.S. News & World Report, July 1,
1996:34.

6 Miller, T.R., and L.J., Blincoe, Incidence and Cost of Alcohol-involved
Crashes, in Accident Analysis & Prevention, Vol. 26, Number 5,
1994:583-591.

7 There is increasing evidence that the impact of crime-related trauma
takes its toll on the long-term physical health of its victims. Dr. Dean
Kilpatrick, a national expert on victimization, notes that crime victims
have higher rates of health care utilization than nonvictims of crime.
Moreover, female crime victims have been found to have higher rates of
several prevalent health problems. Compared to nonvictims, crime victims
have higher rates of several behaviors that contribute to health morbidity
and mortality such as heavy alcohol and drug use, drunk driving, smoking,
bulimia, and obesity.

8 Presidents Task Force on Victims of Crime, Final Report, Washington,
D.C.: U.S. Government Printing Office, December 1982:89-94.

9 According to the Federal Bureau of Investigations 1995 Uniform Crime
Reports, juvenile gang killings

increased 38% over the last five years. Federal Bureau of Investigations,
1995 Uniform Crime Reports, Washington, D.C.: 1995:17.

10 Shalala, Donna, Remarks to the Family Violence Prevention Fund National
Conference, Domestic Violence and Health Care: Initiatives for the New
Millennium, Washington, D.C., November 3, 1997.

11 Information on pioneering research and program development by physicians
and nurses is contained in Best Practices: Innovative Domestic Violence
Programs in Health Care Settings, San Francisco, CA: Family Violence
Prevention Fund, February 1997.

12 Kilpatrick, D., Edmunds, C., and A. Seymour, Rape in America: A Report
to the Nation, Arlington, VA: National Victim Center and the Medical
University of South Carolina, National Crime Victims Research and Treatment
Center, 1992.

13 Data obtained from SANE program survey conducted by the Sexual Assault
Resource Service of Minneapolis under OVC Grant # 96-VF-GX-K012.

14 Florida law, for example, provides that the deductible or copayment
provision of any insurance policy shall not be applicable to a person
determined eligible pursuant to the Florida Crimes Compensation Act. . . .
FLA. STAT. ANN. 624.128.

15 Best Practices: Innovative Domestic Violence Programs in Health Care
Settings, published by the Family Violence Prevention Fund, 1997.

16 Colposcopy is the microscopic examination of the cervix.

17 This program is described along with a sampling of other innovative
health care domestic violence programs in Best Practices: Innovative
Domestic Violence Programs in Health Care Settings.

18 American Academy of Pediatrics, Adolescent Assault Victim Needs: A
Review of Issues and a Model Protocol, Pediatrics, Vol.98, No.5, 1996:991-
1001.

19 Alpert, E.J. and S. Cohen, eds., Educating the Nations Physicians about
Family Violence and Abuse, Academic Medicine, Supp.72, January 1997:1;
Thurston, W.E. and L. McLeod, Teaching Second-Year Medical Students About
Wife Battering, Womens Health Issues, Vol.7, No.2, 1997:92-98.

20 Shalala, D., Domestic Violence and Health Care: Initiatives for the New
Millennium, Remarks to the Family Violence Prevention Fund National
Conference, Washington, D.C., November 3, 1997.

21 According to Dr. A. Heger, Medical Director of the Violence Intervention
Program at L.A. CountyUSC Medical Center, 28% of emergency room visits are
related to family violence.

22 Wests Ann. CAL. HEALTH AND SAFETY CODE 1233.5 (West). Patient screening
to detect spousal or

partner abuse.

23 McAfee, R.E., M.D., Medical Records, in The Impact of Domestic Violence
on Your Legal Practice, American Bar Association Commission on Domestic
Violence, 1996.

24 Violence Against Women Act of 1994, tit. IV of the Violent Crime Control
and Law Enforcement Act of 1994, Pub. L. No. 103-322 (September 13, 1994)
codified at 42 U.S.C. 13701, at  40503.

25 Pinn, M.T., V.W. Chunko, The Diverse Faces of Violence: Minority Women
and Domestic Abuse, Academic Medicine, Supp., January 1997:72.1.

26 See, e.g., De Vos, E. , D. Stone, Evaluation of a Hospital-based Youth
Violence Intervention, American Journal of Preventive Medicine, Supp.
Vol.12, No.5 1996:101-108.

27 Lanza, M.L., Nurses as Patient Assault Victims: An Update, Synthesis,
and Recommendations, Archives of Psychiatric Nursing, VI:3, 1992:163-171.

28 See Silent Victims, Children Who Witness Violence, Commentary, Journal
of the American Medical Association, Vol.269 No.2, 1993:262- 264.

29 Osofsky, J.D., Children Who Witness Domestic Violence: The Invisible
Victims, Social Policy Report, Vol.IX No.3, 1995:2-3.

30 Under current federal law (Kennedy-Kassenbaum legislation) it is illegal
for insurance companies to discriminate based on a pre-existing condition
when a person transfers from one insurance plan to another. Abuse cannot be
considered a pre-existing condition. In addition, Senator Paul Wellstone
(D-MN) and Representative Bernard Sanders (I-VT) have introduced
legislation that would effectively prevent discrimination of insurance
carriers against victims of crime. Called the Victims of Abuse Insurance
Protection Act, it would prohibit insurers and health carriers from making
coverage determinations on the basis that the applicant or insured is or
has been the victim of domestic abuse. It would also prohibit insurers from
using or disclosing information about the persons abuse history, with
limited exceptions. S. 467, H.R. 1117.

31 Hickling, E.J., and E.B. Blanchard, Post Traumatic Stress Disorder and
Motor Vehicle Accidents, Journal of Anxiety Disorders, Vol. 6,
1992:283-304; Green, M.M., McFarlane, A.C., C.E. Hunter, & W.M. Griggs,
Undiagnosed Post Traumatic Stress Disorder Following Motor Vehicle
Accidents, The Medical Journal of Australia, Vol.159, 1993: 529-534.