ADDRESSING
SEXUAL VIOLENCE THROUGH PREVENTIVE NURSING PRACTICE Denise Callahan Long
S
exual violence is a serious public health problem worldwide. Nearly one in five (19.3 percent) women report having been raped at some time in their life, with 8.8 percent reporting that the rape was committed by an intimate partner (Breiding et al., 2014). According to the Centers for Disease Control and Prevention (CDC), approximately 43.9 percent of women experienced other forms of sexual violence (Breiding et al., 2014). Abstract: Approximately 1 in 20 women will experience sexual violence at some point in her life. The negative health consequences to women can be serious and lifelong, prompting the Centers for Disease Control and Prevention and the World Health Organization to declare sexual violence a public health problem. Nurses, in their provision of care to individuals and communities, can contribute to improved outcomes related to the problem of sexual violence through the application of preventive care practices. DOI: 10.1111/1751-486X.12160 Keywords: intimate partner violence | public health | rape | sexual assault | sexual violence
DEFINITION OF SEXUAL VIOLENCE Sexual violence encompasses multiple behaviors, the key being any sexual activity where one party does not provide consent. Most people think of rape when they hear the term sexual violence. Rape can occur within a domestic or dating relationship, referred to as intimate partner violence (IPV). A stranger can be the perpetrator as well, but most people who experience rape are acquainted with the perpetrator, as is common among college students who might be victimized after alcohol or drug use (CDC, 2012). However, sexual violence can be defined more broadly as any nonconsensual sexual act, either completed or attempted, as well as abusive sexual contact or Denise Callahan Long, MSN, RN, WHNP-BC, CNE, is the women’s health nursing instructor at Our Lady of Lourdes School of Nursing in Camden, NJ. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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noncontact sexual abuse. Abusive sexual contact is defined as “intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thighs and buttocks” (Basile & Saltzman, 2002, p. 9). Noncontact sexual abuse includes experiencing sexual harassment, voyeurism or exposure (Basile & Saltzman, 2002).
INTERVENING IN CASES OF SEXUAL VIOLENCE Past research into the problem of sexual violence has identified factors that increase the risk of being a victim or perpetrator of sexual violence (see Boxes 1 and 2). Research has also identified many short- and long-term health consequences of sexual violence (see Box 3). Based on these findings, interventions have focused primarily on victims’ services after the fact. Prevention activities have also focused on victims, encouraging rape avoidance practices and self-defense training. This focus has placed the burden of preventing sexual violence on potential victims, and only benefits those who have received the education (DeGue, Simon et al., 2012). Improved prevention activities must address ways of decreasing the number of potential perpetrators of sexual violence. For this reason, the WHO and CDC suggest a need to use a public health approach to sexual violence. These organizations have recently released new recommendations (CDC,
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Fortunately, there has been a renewed focus on this issue in recent years. The CDC (2014a) uses a four-step method for addressing public health problems and has recommended that this approach be used to address the issue of sexual violence. The steps are as follows: (1) defining the problem, (2) identifying risk and protective factors, (3) developing and testing prevention strategies and (4) assuring widespread adoption of best practices. These steps have recently been applied by the World Health Organization (WHO, 2013) and the United States Preventive Services Task Force (USPSTF, 2013) in the development of new sexual violence guidelines for health care providers. Additional support comes from the U.S. government. President Obama recently promised to support increased efforts to decrease the incidence of sexual violence through the reauthorization of the Violence Against Women Act, which recently marked its 20th anniversary, and the development of a task force to focus on the issue (White House Council on Women and Girls, 2014). The task force’s work will be supported by improved funding for the development of specially trained, multidisciplinary sexual assault teams, new funding to support the development of the sexual assault nurse examiner (SANE) role and new protections for minority populations. Nurses and advanced practice nurses have a vital role to play in efforts to decrease sexual violence and its consequences, which can result in physical, psychological and reproductive health problems. The purpose of this paper is to provide an overview of the problem and contributing factors, update nurses on recent recommendations and review strategies that can assist nurses in addressing the issue of sexual violence.
2014b; WHO, 2013) to help direct future efforts focused on primary and secondary prevention interventions. The WHO (2013) guideline suggests a focus on four aspects: (1) provision of woman-centered first-line support in the postassault phase, (2) identification and care for survivors of IPV/sexual violence, (3) improved training of health care providers and (4) development of effective health and social policies to decrease sexual violence and improve outcomes for survivors. The CDC (2014b) suggests key principles to guide program planning.
Sexual violence can be defined more broadly as any nonconsensual sexual act, either completed or attempted, as well as abusive sexual contact or noncontact sexual abuse These are an emphasis on primary prevention, a commitment to the development of a rigorous science base and taking a cross-cutting, population-based approach. Nurses are well-poised to participate in these interventions through virtue of our education and our focus on improving health for individuals and communities. Unfortunately, many nurses feel unprepared to participate in sexual violence care. Studies have shown that nursing students, practicing nurses and advanced practice nurses are uncomfortable addressing the issue of sexual violence with patients (Beccaria et al., 2013; Ross et al., 2010). Reasons cited include fear of doing the wrong thing or of making things worse. Some nurses believed that they did not have sufficient time to address the issue if a woman was screened and responded affirmatively. Other nurses were concerned about being required to go to court. All the surveyed nurses believed that they needed more education on how to more effectively address concerns related to sexual violence. The WHO (2013) recommends that all preprofessional education of health care providers include education on how to offer first-line support to people who have experienced sexual violence. Health care providers who work with women should receive more detailed in-service training. This training should address basic knowledge of sexual violence, legal implications, where to access services and resolution of any negative attitudes, such as blaming victims. Skills training should include
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how and when to enquire about sexual violence, appropriate communication skills in questioning and how to respond to survivors, as well as how to collect forensic evidence, if indicated. A training guidelines toolkit from the CDC (Fisher, Lang, & Wheaton, 2010) can assist in the planning and implementation of educational programs.
PRIMARY PREVENTION— DECREASING INCIDENCE The primary aim of the CDC program is to reduce risk factors and increase protective factors. These include social factors that decrease one’s chance of becoming either a victim or perpetrator. Nurses can work as advocates who engage with individual clients. We should also advocate for social change in communities to decrease these factors. The WHO (2010) identifies coming from a supportive family, having achieved a higher education level, belonging to an association and being able to recognize risk as protective factors. Educating young men and women about avoidance of sexual violence has been a strong focus, especially on college campuses. Equipping people with knowledge, awareness and self-defense skills is one means of helping them avoid sexual violence (DeGue, Holt et al., 2012). However, review of the effectiveness of these programs has shown that only one program, “Safe Dates,” demonstrated effectiveness in a randomized controlled study (Fisher et al., 2010). The “Safe Dates” schoolbased program for early adolescents consists of 10 weekly 45- to 50-minute sessions. The curriculum is focused on improving students’ understanding of caring relationships, gender
BOX 1
Factors Placing Women at Risk for Sexual Violence Drug and/or alcohol abuse Young age (16 to 24 years old) Being disabled Sexual orientation (lesbian, gay, bisexual and transgender) Undocumented immigrant Incarceration Native American or Native Alaskan Societal norms and/or laws that support gender inequality Sources: CDC (2014a), WHO (2010).
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stereotypes and sexual assault issues. In a follow-up study conducted 4 years after program participation, participants reported 56 percent to 92 percent less violence perpetration and victimization compared to the control group (Blueprints for Healthy Youth Development, 2014). For this reason, the CDC encourages programs that help to promote healthful, respectful relationships among young persons, including their parents, peers and dating partners (Black et al., 2011). The CDC (2014b) suggests that program planners utilize prevention principles in the development of additional programs. VanderEnde, Yount, Dynes, and Sibley (2012) identify community factors that correlate with sexual violence. These factors include social disorganization, lack of social cohesion, acceptance of community violence and a hesitancy to get involved in other families’ domestic issues. Community gender norms, although mostly found in studies conducted in India where gender inequity is a greater issue than in the United States, may be relevant in immigrant communities (VanderEnde et al., 2012). Bystander response can be improved by addressing the beliefs, activities and messages in our society that condone, encourage or facilitate sexual violence (Black et al., 2011). Screening of communities to focus interventions can assist in planning. An excellent resource for this is available from the National Sexual Assault Coalition Resource Sharing Project and National Sexual Violence Resource Center (NSVRC). The NSVRC web site includes a toolkit called Listening to Our
Communities: Assessment Toolkit (NSVRC, 2014). The toolkit offers guidance on planning a community assessment. Topics cover the entire process from selecting who should participate and what to ask, through data collection and analysis (see Get the Facts box for this and other online resources). Use of community assessment can help nurses determine the community members’ perceptions, beliefs and preferred solutions, and strengthen providers’ relationships with the community (NSVRC, 2014).
SECONDARY PREVENTION— INITIAL CARE AFTER SEXUAL VIOLENCE The WHO refers to first-line support as “psychological first aid” (WHO, 2013, p. vii). This is defined as providing the minimum level of support and validation of the person’s experience. Health care providers should begin with full disclosure of privacy and the limits of confidentiality per state requirements (i.e., mandatory reporting). Consultation should be conducted in a private location and include the use of a trained language interpreter if indicated. This initial care requires being nonjudgmental and supportive, providing practical care that responds to a woman’s needs but doesn’t intrude and listening carefully but not pressuring. Providers should address issues specific to IPV, such as ways to increase safety for women and their children, and suggestions for how women can access legal and housing
BOX 2
Factors Associated With Perpetrators of Sexual Violence Male gender; 98 percent of perpetrators are male. Unhealthful home environment, including exposure to abuse, violence, hypermasculinity and hostility toward women.
Community factors, such as lack of employment opportunities and tolerance of violence in general. Societal factors, such as poverty, weak laws against sexual violence and societal norms that support gender inequality, male superiority and sexual entitlement. Sources: CDC (2014a), WHO (2010).
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Personal traits, such as substance abuse, impulsive tendencies and association with sexually aggressive/delinquent peers.
Providers should address issues specific to IPV, such as ways to increase safety for women and their children, and suggestions for how women can access legal and housing assistance and seek social support assistance and seek social support. Referral to mental health services should be included as indicated. Although the majority of the 22 studies on best care practices reviewed by the WHO had overall poor designs, it appears that cognitive behavioral therapy is most beneficial, while medication may be needed as an adjunct (WHO, 2013). Other WHO (2013) recommendations for clinical care include offering emergency contraception if a woman has presented within 5 days of the assault; postexposure prophylaxis for sexually transmitted infections (STI), such as gonorrhea, chlamydia and trichomoniasis; treatment for syphilis if in a high-prevalence community. Testing prior to postexposure prophylaxis isn’t necessary. In fact, providers who have cared for patients after assault were concerned that positive results, obviously not related to the assault, might reflect poorly on the victim should prosecution result (Campbell et al., 2006). Postexposure prophylaxis for human immunodeficiency virus (HIV) can be offered, especially in high prevalence areas, but only as a shared informed decision by the patient. Detailed algorithms and care pathways for use in the case of sexual violence are provided in the WHO (2013) report. There’s also a need to collect forensic evidence, if possible. National Institute of Justice studies have found that the quality of forensic evidence is better and prosecution rates are higher, when care is provided by a trained SANE. Crandall and Helitzer (2003) found health care services provided by SANEs to victims of sexual violence were of higher quality. All 50 states and the District of Columbia provide for financial coverage of the sexual assault forensic examination (SAFE) so that victims don’t incur costs related to the exam. Most states (32) cover the cost through a victim compensation program, with other states utilizing other programs. Thirty-three states also cover various health care needs related to the assault such as pregnancy and STI testing along with medications prescribed based on the exam (AEquitas: The Prosecutors’ Resource on Violence Against Women, 2012). The AEquitas report (2012) summarizes financial coverage by state.
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BOX 3
Potential Consequences of Sexual Violence Unplanned pregnancy Sexually transmitted infection Emotional distress—shock, guilt, fear, distrust Chronic pelvic pain, gastrointestinal/urogenitary complaints Migraine headaches Mental health issues—depression, suicide, posttraumatic stress disorder Engagement in unsafe activities, such as substance abuse and risky sexual behaviors Economic costs to society, which are estimated at $87,000 per victim for medical and legal costs (White House Council on Women and Girls, 2014, p. 2) Sources: CDC (2014a), WHO (2010).
TERTIARY PREVENTION— SCREENING FOR SURVIVORS As women’s health care providers, nurses might interact with survivors of sexual violence. The annual well-woman exam offers the opportunity to screen for various health conditions that could benefit from intervention. The WHO doesn’t recommend universal screening for sexual violence, since it doesn’t decrease the overall incidence of sexual violence. In fact, there’s concern that many women will find repeated inquiry difficult. For clinicians, adding another checkbox to standard forms for sexual violence screening could result in providers not giving the issue the serious consideration it requires. Also, considering the limited options available to women, the WHO feels it might be best to focus screening on those women who show signs or symptoms associated with violence. These include mental health issues, such as depression, anxiety, posttraumatic stress disorder or self-harm. Other conditions associated with sexual violence or IPV include substance abuse; unexplained chronic pain (gastrointestinal, urogenitary or pelvic); multiple unintended pregnancies or elective abortions; late entry to prenatal care; traumatic injuries, especially to the genitals, breasts or abdomen (especially if pregnant, since the growing abdomen can become a target for abuse) or a frequent user of health care services with no clear diagnosis. A partner who is intrusive or domineering during a clinical encounter might also indicate
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A women’s restroom, assuming privacy from male partners, is a good site for hotline information on small cards (to allow easier hiding from a partner) that women can take with them for possible future use Various screening tools are available. The USPSTF (2013) reviewed 15 studies measuring the effectiveness of 13 screening instruments. Five tools were identified with appropriate sensitivity and specificity to be used for screening in ambulatory care. Four of these tools are four-item questionnaires that can be either self-administered by the woman or completed by the provider. They are Hurt, Insulted, Threatened, Screamed at (HITS), Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/ OVAT), Humiliation, Afraid, Rape, Kick (HARK) and Woman Abuse Screen Tool (WAST). An additional instrument, Slapped, Threatened and Thrown (STaT), demonstrated effectiveness when used in an emergency room setting. Copies of these tools are available from the CDC (Basile, Hertz, & Back, 2007). ACOG, in conjunction with Futures Without Violence, has developed a useful guide for integrating screening into care
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based on the presenting problem of the woman. Appropriate responses if IPV and/or sexual violence are disclosed are offered. The toolkit (Futures Without Violence, 2013) includes helpful examples of scripts. A “framing” statement can be used to begin the discussion. For example, the statement, “We ask these questions of all our patients since we know that sexual abuse can have negative consequences on a woman’s health or pregnancy” may increase patient comfort. Any limits on confidentiality, such as mandatory reporting laws in certain states, should be explained. At a pregnancy test visit, providers can ask about whether or not women have felt pressured to become pregnant, and how their partners feel about using birth control. At an STI testing visit, questions about negotiation of condom use can be asked. At a visit about emergency contraception, questions about whether sexual activity is consensual can be asked. If a woman discloses abuse, clinicians should offer immediate and private access to an advocate either in person or by phone. If the woman requests, clinicians can notify police while in the office. Clinicians should clearly document findings in an objective manner. For example, appearance may be documented through the use of a body map drawing or photos, if the patient gives consent. Women’s statements should be documented, verbatim if possible. Documentation should also include all actions by the health care providers, including referrals (Chamberlain & Levenson, 2012). Both the WHO and ACOG advocate that culturally congruent written information be available in the waiting room. A women’s restroom, assuming privacy from male partners, is a good site for hotline information on small cards (to allow easier hiding from a partner) that women can take with them for possible future use. These
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a possible violence situation. A patient who has experienced sexual violence may demonstrate an exaggerated response to touch or show nonverbal discomfort with the gynecologic exam (Ross et al., 2010; WHO, 2013). The American College of Obstetricians and Gynecologists (ACOG, 2012) recommends universal screening for sexual violence at a woman’s annual well-woman check, as well as at visits that may suggest a need. The USPSTF (2013) didn’t find evidence to suggest a specific screening interval. If a provider is going to screen, the WHO (2013) recommends that the following minimum requirements be met: (1) assure that one is following a protocol/policy and has had training on how to ask questions and respond, (2) if screening identifies sexual violence, have a private setting to assure confidentiality and (3) have a system in place for referrals to other needed services.
materials can be ordered through the Futures Without Violence website (see Get the Facts).
DIRECTIONS FOR FUTURE RESEARCH Additional research is needed to develop and evaluate effective strategies and interventions to decrease the incidence and sequelae of sexual violence (CDC, 2014b). The WHO (2013) and USPSTF (2013) have conducted reviews of the current research and identified gaps in knowledge. More research is needed on the clinical and cost-effectiveness of screening based on indications versus universal screening in a variety of settings. There’s a need to look at the role of IPV, especially sexual coercion, on reproductive decision-making and reproductive health outcomes. There is little research on the role of support groups in survivor recovery. In the hopes of breaking intergenerational transmission of abusive behaviors, it’s suggested that research evaluate the effectiveness of mother-child home visitation programs. Determination of the most effective health care professional training programs should include the minimum content and duration of training. Finally, outcomes evaluation of programs, such as SANE-provided care, can promote best practices.
IMPLICATIONS FOR NURSES Nurses can increase their understanding of the scope and impact of sexual violence through reading articles such as this, attending continuing education and exploring national and local educational resources. Nurses can work toward primary prevention by discussing risk and protective factors with patients and community members. Nurses can enhance services for early identification of women who are at risk for or currently experiencing violence by talking to women about sexual violence, providing written materials in the office and integrating screening into care. Within a work organization, nurses can develop policies related to sexual violence, present in-service education to peers and serve on hospital committees to assure that sexual violence is addressed. Nurses can collaborate with other health care providers and sexual violence experts in their communities to establish a network of referral services. Finally, nurses can advocate for public policy changes by writing to or meeting with their legislators. Promoting awareness of the issue of sexual violence can include speaking to professional organizations or publishing articles during Sexual Assault Awareness Month, which is every April (NSVRC, 2014).
CONCLUSION Sexual violence results in serious short- and long-term health consequences. Recent recommendations from international, national and professional organizations encourage health care providers to apply a public health approach to address the issue. Increasing one’s knowledge of the problem and the factors that influence it is a start. Developing, implementing and evaluating best practices is a role for all nurses. Through these activities,
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Get the Facts AEquitas: The Prosecutors’ Resource on Violence Against Women
www.aequitasresource.org/Summary_of_Laws_ and_Guidelines-Payment_of_Sexual_Assault_ Forensic_Examinations_2.6.12.pdf CDC
www.cdc.gov/ViolencePrevention/ sexualviolence/ Futures Without Violence
www.futureswithoutviolence.org/ NSVRC
www.nsvrc.org/ Prevention Connection: The Violence Against Women Prevention Partnership
www.preventconnect.org/ USPSTF
www.guideline.gov/content.aspx?id=39425 WHO
www.who.int/reproductivehealth/topics/violence/sexual_violence/en/
nurses can contribute to a decreased prevalence of sexual violence and improved care for those who experience it. NWH
REFERENCES AEquitas: The Prosecutors’ Resource on Violence Against Women. (2012). Summary of laws & guidelines: Payment of sexual assault forensic examinations. Washington, DC: Author. Retrieved from www.aequitasresource.org/Summary_of_Laws_and_GuidelinesPayment_of_Sexual_Assault_Forensic_Examinations_2.6.12.pdf American College of Obstetricians and Gynecologists (ACOG). (2012). Intimate partner violence. Committee Opinion No.
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518. Washington, DC: Author. Retrieved from www.acog. org/Resources_And_Publications/Committee_Opinions/ Committee_on_Health_Care_for_Underserved_Women/ Intimate_Partner_Violence Basile, K., Hertz, M., & Back, S. (2007). Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare. Version 1. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Basile, K., & Saltzman, L. (2002). Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Beccaria, G., Beccaria, L., Dawson, R., Gorman, D., Harris, J. A., & Hossain, D. (2013, August). Nursing student’s perceptions and understanding of intimate partner violence. Nurse Education Today, 33(8), 907–911. Retrieved from dx.doi.org/10.1016/j. nedt.2012.08.004 Black, M., Basile, K., Beiding, M., Smith, S., Walters, M., Merrick, M., … Stevens, M. (2011). The national intimate partner and sexual violence survey (NISVS): 2010 summary report. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Blueprints for Healthy Youth Development. (2014). Safe dates. Boulder, CO: Author. Retrieved from www.blueprintsprograms. com/factSheet.php?pid=98fbc42faedc02492397cb5962ea3a3ffc 0a9243 Breiding, M., Smith, S., Basile, K., Walters, M., Chen, J., & Merrick, M. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National intimate partner and sexual violence survey, United States, 2011. Morbidity and Mortality Weekly Report, 63(ss08), 1–18. Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm Campbell, R., Townsend, S. M., Long, S. M., Kinnison, K. E., Pulley, E. M., Adames, S. B., & Wasco, S. M. (2006). Responding to sexual assault victims’ medical and emotional needs: A national study of the services provided by SANE programs. Research in Nursing & Health, 29(5), 384–398. Retrieved from dx.doi. org/10.1002/nur.20137 Centers for Disease Control and Prevention (CDC). (2012). Sexual violence: Facts at a glance. Atlanta, GA: Author. Retrieved from www.cdc.gov/violenceprevention/pdf/sv-datasheet-a.pdf
Crandall, C., & Helitzer, D. (2003). Impact evaluation of a sexual assault nurse examiner (SANE) program. Washington, DC: U.S. Department of Justice. DeGue, S., Holt, M. K., Massetti, G. M., Matjasko, J. L., Tharp, A. T., & Valle, L. A. (2012, January). Looking ahead toward community-level strategies to prevent sexual violence. Journal of Women’s Health, 21(1), 1–3. Retrieved from dx.doi.org/10.1089/ jwh.2011.3263 DeGue, S., Simon, T. R., Basile, K. C., Yee, S. L., Lang, K., & Spivak, H. (2012). Moving forward by looking back: Reflecting on a decade of CDC’s work in sexual violence prevention, 2000–2010. Journal of Women’s Health, 21(12), 1211–1218. Retrieved from dx.doi.org/10.1089/jwh.2012.3973 Fisher, D., Lang, K., & Wheaton, J. (2010). Training professionals in the primary prevention of sexual and intimate partner violence: A planning guide. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Futures Without Violence. (2013). Health cares about intimate partner violence: Intimate partner violence screening and counseling toolkit. San Francisco, CA: Author. Retrieved from www.healtcaresaboutipv.org National Sexual Violence Resource Center (NSVRC). (2014). Listening to our communities: Assessment toolkit. Retrieved from www.nsvrc.org/publications/nsvrc-publications-toolkits/ listening-our-communities-assessment-toolkit Ross, R., Draucker, C. B., Martsolf, D., Adamle, K., ChiangHanisko, L., & Lewandowski, W. (2010). The bridge: Providing nursing care for survivors of sexual violence. Journal of the American Academy of Nurse Practitioners, 22(7), 361–368. Retrieved from dx.doi.org/10.1111/j.1745-7599.2010.00519.x United States Preventative Services Task Force (USPSTF). (2013). Screening for intimate partner violence and abuse of the elderly and vulnerable adults: U.S. preventive services task force recommendation statement. AHRQ publication no. 12-05167-EF-2. Retrieved from www.uspreventiveservicestaskforce.org/uspstf12/ ipvelder/ipvelderfact.pdf. VanderEnde, K. E., Yount, K. M., Dynes, M. M., & Sibley, L. M. (2012). Community-level correlates of intimate partner violence against women globally: A systematic review. Social Science & Medicine, 75(7), 1143–1155. Retrieved from dx.doi. org/10.1016/j.socscimed.2012.05.027
Centers for Disease Control and Prevention (CDC). (2014a). Sexual violence. Atlanta, GA: Author. Retrieved from www.cdc.gov/ ViolencePrevention/sexualviolence/
White House Council on Women and Girls. (2014). Rape and sexual assault: A renewed call to action. Washington, DC: Author. Retrieved from www.whitehouse.gov/sites/default/files/docs/ sexual_assault_report_1-21-14.pdf
Centers for Disease Control and Prevention (CDC). (2014b). CDC Grand Rounds: A public health approach to prevention of intimate partner violence. Morbidity and Mortality Weekly Report, 63(02), 38–41. Retrieved from www.cdc.gov/mmwr/preview/ mmwrhtml/mm6302a4.htm?s_cid=mm6302a4_w
World Health Organization (WHO). (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: WHO Press. Retrieved from whqlibdoc.who.int/publications/2010/9789241564007_ eng.pdf
Chamberlain, L., & Levenson, R. (2012). Addressing intimate partner violence: A guide for obstetric, gynecologic, and reproductive health care settings (2nd ed.). San Francisco, CA: Futures Without Violence. Retrieved from www.futureswithoutviolence. org/userfiles/file/HealthCare/Reproductive%20Health%20 Guidelines.pdf
World Health Organization (WHO). (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva, Switzerland: WHO Press. Retrieved from www.who.int/reproductivehealth/publications/ violence/9789241548595/en/
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SEXUAL VIOLENCE THROUGH PREVENTIVE NURSING PRACTICE Denise Callahan Long
S
exual violence is a serious public health problem worldwide. Nearly one in five (19.3 percent) women report having been raped at some time in their life, with 8.8 percent reporting that the rape was committed by an intimate partner (Breiding et al., 2014). According to the Centers for Disease Control and Prevention (CDC), approximately 43.9 percent of women experienced other forms of sexual violence (Breiding et al., 2014). Abstract: Approximately 1 in 20 women will experience sexual violence at some point in her life. The negative health consequences to women can be serious and lifelong, prompting the Centers for Disease Control and Prevention and the World Health Organization to declare sexual violence a public health problem. Nurses, in their provision of care to individuals and communities, can contribute to improved outcomes related to the problem of sexual violence through the application of preventive care practices. DOI: 10.1111/1751-486X.12160 Keywords: intimate partner violence | public health | rape | sexual assault | sexual violence
DEFINITION OF SEXUAL VIOLENCE Sexual violence encompasses multiple behaviors, the key being any sexual activity where one party does not provide consent. Most people think of rape when they hear the term sexual violence. Rape can occur within a domestic or dating relationship, referred to as intimate partner violence (IPV). A stranger can be the perpetrator as well, but most people who experience rape are acquainted with the perpetrator, as is common among college students who might be victimized after alcohol or drug use (CDC, 2012). However, sexual violence can be defined more broadly as any nonconsensual sexual act, either completed or attempted, as well as abusive sexual contact or Denise Callahan Long, MSN, RN, WHNP-BC, CNE, is the women’s health nursing instructor at Our Lady of Lourdes School of Nursing in Camden, NJ. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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noncontact sexual abuse. Abusive sexual contact is defined as “intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thighs and buttocks” (Basile & Saltzman, 2002, p. 9). Noncontact sexual abuse includes experiencing sexual harassment, voyeurism or exposure (Basile & Saltzman, 2002).
INTERVENING IN CASES OF SEXUAL VIOLENCE Past research into the problem of sexual violence has identified factors that increase the risk of being a victim or perpetrator of sexual violence (see Boxes 1 and 2). Research has also identified many short- and long-term health consequences of sexual violence (see Box 3). Based on these findings, interventions have focused primarily on victims’ services after the fact. Prevention activities have also focused on victims, encouraging rape avoidance practices and self-defense training. This focus has placed the burden of preventing sexual violence on potential victims, and only benefits those who have received the education (DeGue, Simon et al., 2012). Improved prevention activities must address ways of decreasing the number of potential perpetrators of sexual violence. For this reason, the WHO and CDC suggest a need to use a public health approach to sexual violence. These organizations have recently released new recommendations (CDC,
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Opening photos © various photographers, all from thinkstockphotos.com. Photo thiis page © istock collection / thinkstockphotos.com
Fortunately, there has been a renewed focus on this issue in recent years. The CDC (2014a) uses a four-step method for addressing public health problems and has recommended that this approach be used to address the issue of sexual violence. The steps are as follows: (1) defining the problem, (2) identifying risk and protective factors, (3) developing and testing prevention strategies and (4) assuring widespread adoption of best practices. These steps have recently been applied by the World Health Organization (WHO, 2013) and the United States Preventive Services Task Force (USPSTF, 2013) in the development of new sexual violence guidelines for health care providers. Additional support comes from the U.S. government. President Obama recently promised to support increased efforts to decrease the incidence of sexual violence through the reauthorization of the Violence Against Women Act, which recently marked its 20th anniversary, and the development of a task force to focus on the issue (White House Council on Women and Girls, 2014). The task force’s work will be supported by improved funding for the development of specially trained, multidisciplinary sexual assault teams, new funding to support the development of the sexual assault nurse examiner (SANE) role and new protections for minority populations. Nurses and advanced practice nurses have a vital role to play in efforts to decrease sexual violence and its consequences, which can result in physical, psychological and reproductive health problems. The purpose of this paper is to provide an overview of the problem and contributing factors, update nurses on recent recommendations and review strategies that can assist nurses in addressing the issue of sexual violence.
2014b; WHO, 2013) to help direct future efforts focused on primary and secondary prevention interventions. The WHO (2013) guideline suggests a focus on four aspects: (1) provision of woman-centered first-line support in the postassault phase, (2) identification and care for survivors of IPV/sexual violence, (3) improved training of health care providers and (4) development of effective health and social policies to decrease sexual violence and improve outcomes for survivors. The CDC (2014b) suggests key principles to guide program planning.
Sexual violence can be defined more broadly as any nonconsensual sexual act, either completed or attempted, as well as abusive sexual contact or noncontact sexual abuse These are an emphasis on primary prevention, a commitment to the development of a rigorous science base and taking a cross-cutting, population-based approach. Nurses are well-poised to participate in these interventions through virtue of our education and our focus on improving health for individuals and communities. Unfortunately, many nurses feel unprepared to participate in sexual violence care. Studies have shown that nursing students, practicing nurses and advanced practice nurses are uncomfortable addressing the issue of sexual violence with patients (Beccaria et al., 2013; Ross et al., 2010). Reasons cited include fear of doing the wrong thing or of making things worse. Some nurses believed that they did not have sufficient time to address the issue if a woman was screened and responded affirmatively. Other nurses were concerned about being required to go to court. All the surveyed nurses believed that they needed more education on how to more effectively address concerns related to sexual violence. The WHO (2013) recommends that all preprofessional education of health care providers include education on how to offer first-line support to people who have experienced sexual violence. Health care providers who work with women should receive more detailed in-service training. This training should address basic knowledge of sexual violence, legal implications, where to access services and resolution of any negative attitudes, such as blaming victims. Skills training should include
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how and when to enquire about sexual violence, appropriate communication skills in questioning and how to respond to survivors, as well as how to collect forensic evidence, if indicated. A training guidelines toolkit from the CDC (Fisher, Lang, & Wheaton, 2010) can assist in the planning and implementation of educational programs.
PRIMARY PREVENTION— DECREASING INCIDENCE The primary aim of the CDC program is to reduce risk factors and increase protective factors. These include social factors that decrease one’s chance of becoming either a victim or perpetrator. Nurses can work as advocates who engage with individual clients. We should also advocate for social change in communities to decrease these factors. The WHO (2010) identifies coming from a supportive family, having achieved a higher education level, belonging to an association and being able to recognize risk as protective factors. Educating young men and women about avoidance of sexual violence has been a strong focus, especially on college campuses. Equipping people with knowledge, awareness and self-defense skills is one means of helping them avoid sexual violence (DeGue, Holt et al., 2012). However, review of the effectiveness of these programs has shown that only one program, “Safe Dates,” demonstrated effectiveness in a randomized controlled study (Fisher et al., 2010). The “Safe Dates” schoolbased program for early adolescents consists of 10 weekly 45- to 50-minute sessions. The curriculum is focused on improving students’ understanding of caring relationships, gender
BOX 1
Factors Placing Women at Risk for Sexual Violence Drug and/or alcohol abuse Young age (16 to 24 years old) Being disabled Sexual orientation (lesbian, gay, bisexual and transgender) Undocumented immigrant Incarceration Native American or Native Alaskan Societal norms and/or laws that support gender inequality Sources: CDC (2014a), WHO (2010).
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stereotypes and sexual assault issues. In a follow-up study conducted 4 years after program participation, participants reported 56 percent to 92 percent less violence perpetration and victimization compared to the control group (Blueprints for Healthy Youth Development, 2014). For this reason, the CDC encourages programs that help to promote healthful, respectful relationships among young persons, including their parents, peers and dating partners (Black et al., 2011). The CDC (2014b) suggests that program planners utilize prevention principles in the development of additional programs. VanderEnde, Yount, Dynes, and Sibley (2012) identify community factors that correlate with sexual violence. These factors include social disorganization, lack of social cohesion, acceptance of community violence and a hesitancy to get involved in other families’ domestic issues. Community gender norms, although mostly found in studies conducted in India where gender inequity is a greater issue than in the United States, may be relevant in immigrant communities (VanderEnde et al., 2012). Bystander response can be improved by addressing the beliefs, activities and messages in our society that condone, encourage or facilitate sexual violence (Black et al., 2011). Screening of communities to focus interventions can assist in planning. An excellent resource for this is available from the National Sexual Assault Coalition Resource Sharing Project and National Sexual Violence Resource Center (NSVRC). The NSVRC web site includes a toolkit called Listening to Our
Communities: Assessment Toolkit (NSVRC, 2014). The toolkit offers guidance on planning a community assessment. Topics cover the entire process from selecting who should participate and what to ask, through data collection and analysis (see Get the Facts box for this and other online resources). Use of community assessment can help nurses determine the community members’ perceptions, beliefs and preferred solutions, and strengthen providers’ relationships with the community (NSVRC, 2014).
SECONDARY PREVENTION— INITIAL CARE AFTER SEXUAL VIOLENCE The WHO refers to first-line support as “psychological first aid” (WHO, 2013, p. vii). This is defined as providing the minimum level of support and validation of the person’s experience. Health care providers should begin with full disclosure of privacy and the limits of confidentiality per state requirements (i.e., mandatory reporting). Consultation should be conducted in a private location and include the use of a trained language interpreter if indicated. This initial care requires being nonjudgmental and supportive, providing practical care that responds to a woman’s needs but doesn’t intrude and listening carefully but not pressuring. Providers should address issues specific to IPV, such as ways to increase safety for women and their children, and suggestions for how women can access legal and housing
BOX 2
Factors Associated With Perpetrators of Sexual Violence Male gender; 98 percent of perpetrators are male. Unhealthful home environment, including exposure to abuse, violence, hypermasculinity and hostility toward women.
Community factors, such as lack of employment opportunities and tolerance of violence in general. Societal factors, such as poverty, weak laws against sexual violence and societal norms that support gender inequality, male superiority and sexual entitlement. Sources: CDC (2014a), WHO (2010).
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Personal traits, such as substance abuse, impulsive tendencies and association with sexually aggressive/delinquent peers.
Providers should address issues specific to IPV, such as ways to increase safety for women and their children, and suggestions for how women can access legal and housing assistance and seek social support assistance and seek social support. Referral to mental health services should be included as indicated. Although the majority of the 22 studies on best care practices reviewed by the WHO had overall poor designs, it appears that cognitive behavioral therapy is most beneficial, while medication may be needed as an adjunct (WHO, 2013). Other WHO (2013) recommendations for clinical care include offering emergency contraception if a woman has presented within 5 days of the assault; postexposure prophylaxis for sexually transmitted infections (STI), such as gonorrhea, chlamydia and trichomoniasis; treatment for syphilis if in a high-prevalence community. Testing prior to postexposure prophylaxis isn’t necessary. In fact, providers who have cared for patients after assault were concerned that positive results, obviously not related to the assault, might reflect poorly on the victim should prosecution result (Campbell et al., 2006). Postexposure prophylaxis for human immunodeficiency virus (HIV) can be offered, especially in high prevalence areas, but only as a shared informed decision by the patient. Detailed algorithms and care pathways for use in the case of sexual violence are provided in the WHO (2013) report. There’s also a need to collect forensic evidence, if possible. National Institute of Justice studies have found that the quality of forensic evidence is better and prosecution rates are higher, when care is provided by a trained SANE. Crandall and Helitzer (2003) found health care services provided by SANEs to victims of sexual violence were of higher quality. All 50 states and the District of Columbia provide for financial coverage of the sexual assault forensic examination (SAFE) so that victims don’t incur costs related to the exam. Most states (32) cover the cost through a victim compensation program, with other states utilizing other programs. Thirty-three states also cover various health care needs related to the assault such as pregnancy and STI testing along with medications prescribed based on the exam (AEquitas: The Prosecutors’ Resource on Violence Against Women, 2012). The AEquitas report (2012) summarizes financial coverage by state.
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BOX 3
Potential Consequences of Sexual Violence Unplanned pregnancy Sexually transmitted infection Emotional distress—shock, guilt, fear, distrust Chronic pelvic pain, gastrointestinal/urogenitary complaints Migraine headaches Mental health issues—depression, suicide, posttraumatic stress disorder Engagement in unsafe activities, such as substance abuse and risky sexual behaviors Economic costs to society, which are estimated at $87,000 per victim for medical and legal costs (White House Council on Women and Girls, 2014, p. 2) Sources: CDC (2014a), WHO (2010).
TERTIARY PREVENTION— SCREENING FOR SURVIVORS As women’s health care providers, nurses might interact with survivors of sexual violence. The annual well-woman exam offers the opportunity to screen for various health conditions that could benefit from intervention. The WHO doesn’t recommend universal screening for sexual violence, since it doesn’t decrease the overall incidence of sexual violence. In fact, there’s concern that many women will find repeated inquiry difficult. For clinicians, adding another checkbox to standard forms for sexual violence screening could result in providers not giving the issue the serious consideration it requires. Also, considering the limited options available to women, the WHO feels it might be best to focus screening on those women who show signs or symptoms associated with violence. These include mental health issues, such as depression, anxiety, posttraumatic stress disorder or self-harm. Other conditions associated with sexual violence or IPV include substance abuse; unexplained chronic pain (gastrointestinal, urogenitary or pelvic); multiple unintended pregnancies or elective abortions; late entry to prenatal care; traumatic injuries, especially to the genitals, breasts or abdomen (especially if pregnant, since the growing abdomen can become a target for abuse) or a frequent user of health care services with no clear diagnosis. A partner who is intrusive or domineering during a clinical encounter might also indicate
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A women’s restroom, assuming privacy from male partners, is a good site for hotline information on small cards (to allow easier hiding from a partner) that women can take with them for possible future use Various screening tools are available. The USPSTF (2013) reviewed 15 studies measuring the effectiveness of 13 screening instruments. Five tools were identified with appropriate sensitivity and specificity to be used for screening in ambulatory care. Four of these tools are four-item questionnaires that can be either self-administered by the woman or completed by the provider. They are Hurt, Insulted, Threatened, Screamed at (HITS), Ongoing Abuse Screen/Ongoing Violence Assessment Tool (OAS/ OVAT), Humiliation, Afraid, Rape, Kick (HARK) and Woman Abuse Screen Tool (WAST). An additional instrument, Slapped, Threatened and Thrown (STaT), demonstrated effectiveness when used in an emergency room setting. Copies of these tools are available from the CDC (Basile, Hertz, & Back, 2007). ACOG, in conjunction with Futures Without Violence, has developed a useful guide for integrating screening into care
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based on the presenting problem of the woman. Appropriate responses if IPV and/or sexual violence are disclosed are offered. The toolkit (Futures Without Violence, 2013) includes helpful examples of scripts. A “framing” statement can be used to begin the discussion. For example, the statement, “We ask these questions of all our patients since we know that sexual abuse can have negative consequences on a woman’s health or pregnancy” may increase patient comfort. Any limits on confidentiality, such as mandatory reporting laws in certain states, should be explained. At a pregnancy test visit, providers can ask about whether or not women have felt pressured to become pregnant, and how their partners feel about using birth control. At an STI testing visit, questions about negotiation of condom use can be asked. At a visit about emergency contraception, questions about whether sexual activity is consensual can be asked. If a woman discloses abuse, clinicians should offer immediate and private access to an advocate either in person or by phone. If the woman requests, clinicians can notify police while in the office. Clinicians should clearly document findings in an objective manner. For example, appearance may be documented through the use of a body map drawing or photos, if the patient gives consent. Women’s statements should be documented, verbatim if possible. Documentation should also include all actions by the health care providers, including referrals (Chamberlain & Levenson, 2012). Both the WHO and ACOG advocate that culturally congruent written information be available in the waiting room. A women’s restroom, assuming privacy from male partners, is a good site for hotline information on small cards (to allow easier hiding from a partner) that women can take with them for possible future use. These
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a possible violence situation. A patient who has experienced sexual violence may demonstrate an exaggerated response to touch or show nonverbal discomfort with the gynecologic exam (Ross et al., 2010; WHO, 2013). The American College of Obstetricians and Gynecologists (ACOG, 2012) recommends universal screening for sexual violence at a woman’s annual well-woman check, as well as at visits that may suggest a need. The USPSTF (2013) didn’t find evidence to suggest a specific screening interval. If a provider is going to screen, the WHO (2013) recommends that the following minimum requirements be met: (1) assure that one is following a protocol/policy and has had training on how to ask questions and respond, (2) if screening identifies sexual violence, have a private setting to assure confidentiality and (3) have a system in place for referrals to other needed services.
materials can be ordered through the Futures Without Violence website (see Get the Facts).
DIRECTIONS FOR FUTURE RESEARCH Additional research is needed to develop and evaluate effective strategies and interventions to decrease the incidence and sequelae of sexual violence (CDC, 2014b). The WHO (2013) and USPSTF (2013) have conducted reviews of the current research and identified gaps in knowledge. More research is needed on the clinical and cost-effectiveness of screening based on indications versus universal screening in a variety of settings. There’s a need to look at the role of IPV, especially sexual coercion, on reproductive decision-making and reproductive health outcomes. There is little research on the role of support groups in survivor recovery. In the hopes of breaking intergenerational transmission of abusive behaviors, it’s suggested that research evaluate the effectiveness of mother-child home visitation programs. Determination of the most effective health care professional training programs should include the minimum content and duration of training. Finally, outcomes evaluation of programs, such as SANE-provided care, can promote best practices.
IMPLICATIONS FOR NURSES Nurses can increase their understanding of the scope and impact of sexual violence through reading articles such as this, attending continuing education and exploring national and local educational resources. Nurses can work toward primary prevention by discussing risk and protective factors with patients and community members. Nurses can enhance services for early identification of women who are at risk for or currently experiencing violence by talking to women about sexual violence, providing written materials in the office and integrating screening into care. Within a work organization, nurses can develop policies related to sexual violence, present in-service education to peers and serve on hospital committees to assure that sexual violence is addressed. Nurses can collaborate with other health care providers and sexual violence experts in their communities to establish a network of referral services. Finally, nurses can advocate for public policy changes by writing to or meeting with their legislators. Promoting awareness of the issue of sexual violence can include speaking to professional organizations or publishing articles during Sexual Assault Awareness Month, which is every April (NSVRC, 2014).
CONCLUSION Sexual violence results in serious short- and long-term health consequences. Recent recommendations from international, national and professional organizations encourage health care providers to apply a public health approach to address the issue. Increasing one’s knowledge of the problem and the factors that influence it is a start. Developing, implementing and evaluating best practices is a role for all nurses. Through these activities,
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Get the Facts AEquitas: The Prosecutors’ Resource on Violence Against Women
www.aequitasresource.org/Summary_of_Laws_ and_Guidelines-Payment_of_Sexual_Assault_ Forensic_Examinations_2.6.12.pdf CDC
www.cdc.gov/ViolencePrevention/ sexualviolence/ Futures Without Violence
www.futureswithoutviolence.org/ NSVRC
www.nsvrc.org/ Prevention Connection: The Violence Against Women Prevention Partnership
www.preventconnect.org/ USPSTF
www.guideline.gov/content.aspx?id=39425 WHO
www.who.int/reproductivehealth/topics/violence/sexual_violence/en/
nurses can contribute to a decreased prevalence of sexual violence and improved care for those who experience it. NWH
REFERENCES AEquitas: The Prosecutors’ Resource on Violence Against Women. (2012). Summary of laws & guidelines: Payment of sexual assault forensic examinations. Washington, DC: Author. Retrieved from www.aequitasresource.org/Summary_of_Laws_and_GuidelinesPayment_of_Sexual_Assault_Forensic_Examinations_2.6.12.pdf American College of Obstetricians and Gynecologists (ACOG). (2012). Intimate partner violence. Committee Opinion No.
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518. Washington, DC: Author. Retrieved from www.acog. org/Resources_And_Publications/Committee_Opinions/ Committee_on_Health_Care_for_Underserved_Women/ Intimate_Partner_Violence Basile, K., Hertz, M., & Back, S. (2007). Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare. Version 1. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Basile, K., & Saltzman, L. (2002). Sexual violence surveillance: Uniform definitions and recommended data elements. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Beccaria, G., Beccaria, L., Dawson, R., Gorman, D., Harris, J. A., & Hossain, D. (2013, August). Nursing student’s perceptions and understanding of intimate partner violence. Nurse Education Today, 33(8), 907–911. Retrieved from dx.doi.org/10.1016/j. nedt.2012.08.004 Black, M., Basile, K., Beiding, M., Smith, S., Walters, M., Merrick, M., … Stevens, M. (2011). The national intimate partner and sexual violence survey (NISVS): 2010 summary report. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Blueprints for Healthy Youth Development. (2014). Safe dates. Boulder, CO: Author. Retrieved from www.blueprintsprograms. com/factSheet.php?pid=98fbc42faedc02492397cb5962ea3a3ffc 0a9243 Breiding, M., Smith, S., Basile, K., Walters, M., Chen, J., & Merrick, M. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National intimate partner and sexual violence survey, United States, 2011. Morbidity and Mortality Weekly Report, 63(ss08), 1–18. Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/ss6308a1.htm Campbell, R., Townsend, S. M., Long, S. M., Kinnison, K. E., Pulley, E. M., Adames, S. B., & Wasco, S. M. (2006). Responding to sexual assault victims’ medical and emotional needs: A national study of the services provided by SANE programs. Research in Nursing & Health, 29(5), 384–398. Retrieved from dx.doi. org/10.1002/nur.20137 Centers for Disease Control and Prevention (CDC). (2012). Sexual violence: Facts at a glance. Atlanta, GA: Author. Retrieved from www.cdc.gov/violenceprevention/pdf/sv-datasheet-a.pdf
Crandall, C., & Helitzer, D. (2003). Impact evaluation of a sexual assault nurse examiner (SANE) program. Washington, DC: U.S. Department of Justice. DeGue, S., Holt, M. K., Massetti, G. M., Matjasko, J. L., Tharp, A. T., & Valle, L. A. (2012, January). Looking ahead toward community-level strategies to prevent sexual violence. Journal of Women’s Health, 21(1), 1–3. Retrieved from dx.doi.org/10.1089/ jwh.2011.3263 DeGue, S., Simon, T. R., Basile, K. C., Yee, S. L., Lang, K., & Spivak, H. (2012). Moving forward by looking back: Reflecting on a decade of CDC’s work in sexual violence prevention, 2000–2010. Journal of Women’s Health, 21(12), 1211–1218. Retrieved from dx.doi.org/10.1089/jwh.2012.3973 Fisher, D., Lang, K., & Wheaton, J. (2010). Training professionals in the primary prevention of sexual and intimate partner violence: A planning guide. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Futures Without Violence. (2013). Health cares about intimate partner violence: Intimate partner violence screening and counseling toolkit. San Francisco, CA: Author. Retrieved from www.healtcaresaboutipv.org National Sexual Violence Resource Center (NSVRC). (2014). Listening to our communities: Assessment toolkit. Retrieved from www.nsvrc.org/publications/nsvrc-publications-toolkits/ listening-our-communities-assessment-toolkit Ross, R., Draucker, C. B., Martsolf, D., Adamle, K., ChiangHanisko, L., & Lewandowski, W. (2010). The bridge: Providing nursing care for survivors of sexual violence. Journal of the American Academy of Nurse Practitioners, 22(7), 361–368. Retrieved from dx.doi.org/10.1111/j.1745-7599.2010.00519.x United States Preventative Services Task Force (USPSTF). (2013). Screening for intimate partner violence and abuse of the elderly and vulnerable adults: U.S. preventive services task force recommendation statement. AHRQ publication no. 12-05167-EF-2. Retrieved from www.uspreventiveservicestaskforce.org/uspstf12/ ipvelder/ipvelderfact.pdf. VanderEnde, K. E., Yount, K. M., Dynes, M. M., & Sibley, L. M. (2012). Community-level correlates of intimate partner violence against women globally: A systematic review. Social Science & Medicine, 75(7), 1143–1155. Retrieved from dx.doi. org/10.1016/j.socscimed.2012.05.027
Centers for Disease Control and Prevention (CDC). (2014a). Sexual violence. Atlanta, GA: Author. Retrieved from www.cdc.gov/ ViolencePrevention/sexualviolence/
White House Council on Women and Girls. (2014). Rape and sexual assault: A renewed call to action. Washington, DC: Author. Retrieved from www.whitehouse.gov/sites/default/files/docs/ sexual_assault_report_1-21-14.pdf
Centers for Disease Control and Prevention (CDC). (2014b). CDC Grand Rounds: A public health approach to prevention of intimate partner violence. Morbidity and Mortality Weekly Report, 63(02), 38–41. Retrieved from www.cdc.gov/mmwr/preview/ mmwrhtml/mm6302a4.htm?s_cid=mm6302a4_w
World Health Organization (WHO). (2010). Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: WHO Press. Retrieved from whqlibdoc.who.int/publications/2010/9789241564007_ eng.pdf
Chamberlain, L., & Levenson, R. (2012). Addressing intimate partner violence: A guide for obstetric, gynecologic, and reproductive health care settings (2nd ed.). San Francisco, CA: Futures Without Violence. Retrieved from www.futureswithoutviolence. org/userfiles/file/HealthCare/Reproductive%20Health%20 Guidelines.pdf
World Health Organization (WHO). (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva, Switzerland: WHO Press. Retrieved from www.who.int/reproductivehealth/publications/ violence/9789241548595/en/
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