Overview of Domestic/Sexual Abuse in the Delta
We have the highest rate per capita for domestic violence and sexual abuse in the country, which is why we screen for it at every patient encounter. If you see suspicious bruises etc., make an effort to question the patient when they are alone so you can ask how it happened and assess for their safety. Encourage them to talk to Tundra Women’s Coalition, which is our local domestic violence shelter (543-3444).
If violence occurred while children were present, it is mandatory in Alaska to report it. If it occurred in Bethel, report it to Bethel Police Dept. (311). If it occurred in a village, report it to the State Troopers (543-2294). You must also report it to Office of Children Services (OCS 1-800-478-4444).
Per Alaska law, a person can choose not to report a domestic assault. As a provider, you must report the assault, even if the patient objects, if it involved a knife, a burn, firearm, strangulation, or if children were witnesses.
If you see a girl 16 years old or younger who has had sex with a partner three years older than her (you will probably discover this on a first prenatal visit), this is also reportable to OCS.
If you suspect child abuse or sexual abuse, use the same reporting system as described above.
In the ED we have a Sexual Abuse Report Team (SART) member who is available to collect evidence and offer support. If you see a patient who has been sexually abused/assaulted that day, or the day before, and they are interested in reporting, you can coordinate with the ED to make that happen. For children with possible abuse, please contact Bethel PD or State Troopers AND OCS.
If you suspect child physical or sexual abuse, use the same reporting system as described above. Please review the pediatric sexual assault guideline and how to proceed.
There is a Children’s Advocacy Center (CAC) at TWC that organizes the child’s interview, exam etc., to make it as painless as possible for the child. They tape the interview behind a one way mirror to make the child as comfortable as possible.
The Sexual Assault Response Team (SART) provides compassionate, comprehensive and culturally sensitive treatment for sexual assault victims through collaboration between the hospital, law enforcement agencies, forensic nurse specialists and sexual assault counseling advocates.
SART's goal is to counter the experience of sexual assault with a sensitive and competent multidisciplinary response, to support efforts to restore wellbeing to the victim, and to bring responsible person(s) to justice.
According to national statistics, one in six women are sexually assaulted during their lifetime. As disturbing as this statistic is, the number of victims is actually higher, as these reports do not include marital rape, or the many women and men who do not report sexual assault because of fear or shame. The 2017 Crime in Alaska Supplemental Report, which looks at felony level sex offenses, shows western Alaska (which includes the Yukon-Kuskokwim Delta region), with the highest rate of sexual assault crimes in Alaska at 410.1 per 100,000 people. The next highest rate is in the Anchorage area (the most populated city in Alaska) at 251.7 per 100,000 people. According to the Alaska Victimization Survey over half of adult women in the YK Delta have experienced intimate partner violence, sexual violence or both, in their lifetime. One out of every four adult women in the YK Delta had experienced sexual violence in their lifetime.
Traditionally, those who do report their assault are often forced to relive the trauma of their assault several times as they provide statements first to police, then hospital personnel, then advocates. They endure waiting in a busy emergency room and may have a health care provider who lacks training and experience in working with sexual assault victims and gathering forensic evidence.
SART's multi-disciplinary approach coordinates immediate and long-term medical care, advocacy, crisis counseling and criminal justice services to sexual assault survivors. SART eliminates repetitive or unnecessary questioning and ensures the proper collection of forensic evidence that often results in the successful conviction of sexual offenders. Participating nurse examiners are available to assist in the prosecution of sexual assault perpetrators by providing expert court testimony when required.
Sexual Assault/Abuse Presenting to the ER
Patients with complaints of a sexual assault who present to the ED will be triaged immediately to the SART room, or another ER room as appropriate. If significant injuries exist or if the patient requires stabilization for any reason, the patient will be seen in the ED first and later evaluated for sexual assault. If patient is stable, the triage nurse will obtain a full set of vital signs, pain score, and allergies. The SANE/SAFE On-Call should be notified via TigerText or SANE On-Call Phone that a sexual assault patient is in the Emergency Department. Triage nurse to document time that SANE was contacted.
If a patient discloses sexual assault to a medical provider in the ER or Clinic, the provider may contact the On-Call SANE at 907-545-4273 for guidance.
For Adult Patients
You may wonder why it is important to call the SANE on ALL sexual assaults.
- A patient may want to report to law enforcement. If the patient has not done this yet, the SANE will help guide them through this process and collect evidence for law enforcement as indicated.
- A patient may choose not to report. However, they still have the right to have an anonymous kit that will be stored at the state lab in the event that they change their mind at a later date. In these incidences, the evidence is collected and preserved. (Per Alaska law, a person can choose not to report a domestic assault. As a provider, you must report the assault, even if the patient objects, if it involved a knife, a burn, firearm, strangulation, or if children were witnesses.)
- A patient may choose not to report or have an anonymous kit collected. They still have the right to have an exam, STI Testing/Treatment, and Pregnancy Prophylaxis.
For Pediatric Patients
We have a procedure for suspected pediatric sexual abuse. This is especially important when you are doing RMTs. Following this procedure is extremely important to ensure that these children receive the most appropriate care. PLEASE DO NOT “SEND TO BETHEL FOR FURTHER EVALUATION” – Unless there is a medical emergency that needs to be addressed.
Please remember you cannot tell if someone has had sex or not based on any physical examination, and you certainly cannot tell if someone has touched a child inappropriately from an exam alone. We currently have a team of two providers and 3 SANE nurses that are trained in Pediatric SART Exams, but 92% of children who HAVE been sexually abused have normal exams. In addition, Bethel has the Child Advocacy Center which is a child-friendly, culturally respectful place where caring professionals work together, in one location, to help children and families cope with sexual abuse, severe physical abuse, and exposure to violence. Referrals are made to the center from the Bethel Police Department, AK State troopers, and Office of Children’s Services (OCS). The referring agency will then contact the center to make appointments for forensic interviewing, medical examinations and assessment for treatment services. The center provides a comprehensive multidisciplinary team (MDT) evaluation for child sexual or severe physical abuse concerns with the goal of reducing trauma to children. This may include a forensic interview, medical examination, victim advocacy, counseling support/referrals, and follow up for children and families. We have a clinic – The STAR (Surviving and Thriving while at Risk) Clinic - at the Child Advocacy Center that is able to provide these specialized medical exams in a child and family friendly manner.
The number of children presenting to the ER since we have started the STAR Clinic has significantly decreased; however, there may still be children that present to the ER due to concern for sexual abuse. In these situation, please contact the SANE On-call. They had all received specialized training in pediatric SART Cases, and have education on how to handle the situation if a child presents to the ER. It is possible that the patient will be scheduled for a CAC interview as soon as available and will have their exam at the CAC. There is a family advocate on call and may be able to assist in housing the patient overnight also with food and transportation. If law enforcement feel the child is too young for a forensic interview, they may be scheduled for a medical exam only. The SANEs have these phone numbers and are willing to handle making these arrangements; so, you, the ER staff, may continue to focus on other patient care. If any questions arise, you also have the option for contacting Child Abuse On-Call through TigerText.
Mandatory Reporters must make a report of suspected child abuse to law enforcement and OCS (follow the link for more details).
- Strangulation YKHC Wiki Page
- Role of Healthcare Provider in Child Abuse 2019 (PowerPoint Presentation by Dr. Jennifer Prince)
- TWC's Addressing Vicarious Trauma 2019 (PowerPoint Presentation)
- TWC's Sexual Assault Overview 2019 (PowerPoint Presentation)
- YKHC Clinical Guideline for Suspected Child Sexual Abuse Procedure
- YKHC Clinical Guideline for Suspected Child Physical Abuse Procedure