Self-Learning Training Powerpoint Presentation

1. Clinical Indicators of Sexual Violence in Corrections

1. Training Presentation

1. This purpose of this presentation is to train all necessary personnel on the purpose and procedures of the clinical indicators of sexual violence in custody project.

 

1. Background

1. We will first discuss the background of the project.

 

1. Male rape in correctional facilities

• •Few studies 

• •Estimates of sexual assault <1% to 14% 

• •Estimates of sexual coercion up to 22%  

• •Vulnerable populations 

• • –Inmates with drug addiction 

  • –Inmates with mental health issues 

  • –Inmates who are homosexual or bisexual 

  • –Inmates with little experience with corrections 

1. There are very few studies looking at male rape in correctional facilities.  

   There are varied estimates of the prevalence of sexual assault in corrections – some studies report less than 1% of inmates are assaulted, other studies report up to 14% of inmates are assaulted.

   Studies also report that up to 22% of inmates experience sexual coercion while incarcerated – forcing someone to engage in sexual acts in a way that might not be violent, possibly through the use of threats or exchange sex.

   These studies generally find certain groups of inmates to be more vulnerable to sexual violence than others: those with drug addiction, those with mental health issues, those who are homosexual or bisexual, or those inmates who are new to the corrections environment.

 

1. Prison Rape Elimination Act of 2003

• •Purposes of the Act: 

• • –Establish a zero-tolerance standard 

  • –Make the prevention of prison rape a top priority 

  • –Develop and implement national standards for detention, prevention, reduction, and punishment of prison rape 

  • –Increase available data 

  • –Standardize the definitions used for data collection 

  • –Increase the accountability of prison officials 

  • –Protect the Eighth Amendment right of prisoners 

     

1. The Prison Rape Elimination Act of 2003 was established with several goals in mind.

   To establish a zero-tolerance standard for the incidence of prison rape in the US.

   To make the prevention of prison rape a top priority in each system.

   To develop and implement national standards for the detection, prevention, reduction, and punishment of prison rape.

   To increase the available data and information on the incidence of prison rape, consequently improving the management and administration of correctional facilities.

   To standardize the definitions used for collecting data on the incidence of prison rape.

   To increase the accountability of prison officials who fail to detect, prevent, reduce, and punish prison rape.

   To protect the Eighth Amendment rights of Federal, State and local prisoners.

 

1. A multi-measure, multi-mode strategy

 

 

 

 

 

1. As part of the act, the Bureau of Justice Statistics was charged with collecting data from current and former inmates to determine the incidence and prevalence of sexual violence in corrections.

   The National Inmate Survey utilized Audio Computer-Assisted Self Interview (ACASI) technology to gather data directly from inmates in adult facilities.

   This same technology was used for the Juvenile survey.  The results of this survey were released in early January.

   The administrative records survey gathered data on the frequency of sexual violence reported to officials in adult and juvenile facilities.  It was administered to a sample of at least 10% of the nearly 8,700 correctional facilities in the US.

   The former prisoner study provides estimates based on interviews with former state prison inmates.  These results will be released in early 2010.

   The Clinical indicators surveillance project is another component of data collection that should provide another angle in understanding the issue of sexual violence in corrections.

 

1. BJS Reports

• •Reports available on the BJS website (http://bjs.ojp.usdoj.gov/): 

• • –Sexual Violence Reported by Correctional Authorities (2004, 2005, 2006) 

  • –Sexual Victimization in State and Federal Prisons Reported by Inmates (2007) 

  • –Sexual Victimization in Local Jails Reported by Inmates (2007) 

  • –Sexual Violence Reported by Juvenile Correctional Authorities (2005-2006) 

  • –Sexual Victimization in Juvenile Facilities Reported by Youth (2008-2009) 

1. The data that has been collected by BJS are compiled into reports that are available publicly:

   Sexual Violence Reported by Correctional Authorities (2004, 2005, 2006)

   Sexual Victimization in State and Federal Prisons Reported by Inmates (2007)

   Sexual Victimization in Local Jails Reported by Inmates (2007)

   Sexual Violence Reported by Juvenile Correctional Authorities (2005-2006)

   Sexual Victimization in Juvenile Facilities Reported by Youth (2008-2009)

 

1. Clinical Indicators Surveillance Project

• •Medical surveillance 

• • –Are there clinical conditions that are indicative of sexual assault? 

1. We are about to start the Clinical Indicators Surveillance Project.  The motivation for these data collection efforts is to find out if there are clinical conditions indicative of sexual assault in corrections.

   The thought is, if inmates are being assaulted while incarcerated, the injuries that are sustained during the assault would be coming through the medical departments in the facilities.

   Is it feasible to monitor sexual violence in corrections through medical?

 

1. BJS administrative records study – 2005

1. Types of injury

• •Bruises, black eye, sprains, 

1.         cuts, scratches, swelling                11.0%

• •Anal tearing                                  6.1% 

• •Broken bones                                 0.3% 

• •Teeth chipped/knocked out         0.3% 

• •Knocked unconscious                 0.3% 

1. In 2005, BJS looked at the impact on victims and perpetrators in substantiated incidents of inmate-on-inmate sexual violence in all facilities.  

   They found that 11.0% of the victims sustained bruises, black eyes, sprains, cuts, scratches or swelling.  

   6.1% experienced anal tearing

   0.3% experienced broken bones

   0.3% experienced teeth being chipped or knocked out

   0.3% were knocked unconscious

 

1. BJS jail inmate survey – 2007       

1. Types of injury

• •Bruises, cuts, scratches                15.8% 

• •Teeth chipped/knocked out         8.9% 

• •Knocked unconscious                 7.8% 

• •Anal tearing                                  6.3% 

• •Internal injuries                         6.3%         

• •Broken bones                                 3.3% 

• •Knife or stab wounds                 2.1%         

1. Similar findings were shown in the jail inmate survey of 2007.

   15.8% of victims reported bruises, cuts or scratches

   8.9% had teeth chipped or knocked out

   7.8% were knocked unconscious

   6.3% experienced anal tearing

   6.3% experienced internal injuries

   3.3% had broken bones

   2.1% had knife or stab wounds

 

1. Clinical Indicators of
   Sexual Violence in Custody

1. Goal

   To develop a sensitive, specific, and

   sustainable data collection system to measure

   the occurrence of clinical indicators of

   sexual violence in correctional facilities.

1. Our goal for this study is to develop a sensitive, specific, and sustainable data collection system to measure the occurrence of clinical indicators of sexual violence in correctional facilities.  

 

1. Proposed conditions

1. Unexplained rectal bleeding

   Rectal or anal tears or fissures

   Bruises, scratches, or abrasions on buttocks

   Genital bruising

   Nipple injuries

                           OR

   Allegation of sexual violence

                           OR

   Clinician suspects sexual violence

                          

1. From research and consultation with physicians, CDC developed a short list of conditions that are indicative of sexual violence.  These conditions are unexplained rectal bleeding, rectal or anal tears or fissures, bruises, scratches, or abrasions on buttocks, genital bruising, or nipple injuries.  ***Unexplained rectal bleeding means bleeding due to unknown causes – not bleeding from hemorrhoids, constipation, Crohn’s disease, etc.***

   Obviously, this is not an exhaustive list of the injuries that can be sustained during sexual assault.  Additionally, not everyone who is assaulted will be injured.  However, this list represents the most common injuries, as well as those most suggestive of sexual assault.

   This list of 5 conditions will be used as ‘trigger conditions’ to complete the data collection form.  If these injuries come through medical, then a form should be completed.

   In addition to the five ‘trigger conditions’, there are two other methods through which the data collection form should be completed.  

1. 1. When an inmate makes an allegation of sexual violence against another inmate or staff member. 

2. 2. If the clinician has a suspicion of sexual violence during a routine medical examination.  This will allow the form to be completed in the instance that a different type of injury occurred (like an oral injury, for example).  The system relies on the expertise and professional training of the medical staff. 

 

1. Syndromic surveillance

1. Surveillance using health-related data that

   precede diagnosis and signal a sufficient

   probability of a case or an outbreak to warrant

   further public health response.

1. This type of data collection falls under the umbrella of “syndromic surveillance”.  Syndromic surveillance is surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response.

   In other words, syndromic surveillance monitors certain indicators that serve as a proxy for a certain issue.  

   For example, a local health department may monitor a variety of syndromes to detect foodborne outbreaks: emergency department visits, over-the-counter anti-diarrheal medication sales, sales of electrolyte formulations and worker absenteeism.  When there is an increase in these syndromes, this may indicate a foodborne outbreak.

   In another example, flu-like symptoms, including fever, muscle aches, chills, headaches, and fatigue are monitored as a method of detecting flu incidence.

   Similarly, the proposed conditions for this data collection aren’t perfectly sensitive AND specific, but will hopefully provide insight into those incidents of sexual violence that are going unreported.

 

1. Surveillance

 

1. Surveillance

 

1. Data Collection

1. Now, we will walk through the specifics of the data collection.

 

1. When does the form get filled out?

• •If an inmate makes an allegation of sexual violence 

• •If a clinician has a suspicion of sexual violence 

• •If an inmate has any of the following conditions diagnosed as part of a medical examination:  

• • –Unexplained rectal bleeding 

  • –Rectal or anal tears or fissures  

  • –Bruises, scratches, or abrasions on buttocks  

  • –Genital bruising 

  • –Nipple injuries 

1. As we said earlier, the three ways for which a form should be completed are

1. 1.If an inmate makes an allegation of sexual violence. 

2. 2.If you have a suspicion of sexual violence based on your expertise and professional training. 

3. 3.If an inmate has any of the following conditions as part of a medical examination. 

• 1. 1.Unexplained rectal bleeding 

  2. 2.Rectal or anal tears or fissures 

  3. 3.Bruises, scratches, or abrasions on buttocks 

  4. 4.Genital bruising 

  5. 5.Nipple injuries 

 

1. Which inmates qualify?

• •Male inmates ages 18 and older 

1. The initial data collection will be restricted to male inmates who are 18 and older.  

   Do not complete forms for younger inmates who are incarcerated in adult facilities.

   Based on what we find for this initial data collection, the Bureau of Justice Statistics hopes to expand the population to include juveniles and women.

 

1. Which staff members can complete the form?

• •Physicians 

• •Physician assistants (PA) 

• •Nurse practitioners (NP) 

• •Registered nurses (RN) 

• •Licensed practical nurses (LPN) 

1. Physicians, physician assistants, nurse practitioners, registered nurses, and licensed practical nurses are all eligible to complete forms.  

 

1. Which type of incidents get recorded?

• •Injuries that occurred during the current incarceration 

• •Allegations that are made about an incident that occurred during the current incarceration 

• •New onset of symptoms 

• • –Forms do not need to be completed for chronic conditions unrelated to sexual violence 

1. There are some restrictions to note:

1. 4.We are only interested in injuries that occurred during the current incarceration.  If an inmate is treated for something that occurred prior to incarceration, do not fill out a form. 

2. 5.Additionally, only fill out forms for allegations of sexual assault that occurred during the current incarceration.  If an inmate alleges he was assaulted during a previous incarceration, at this facility or any other, do not fill out a form. 

3. 6.We are only interested in new onset of symptoms.  For example, if an inmate suffers from chronic rectal bleeding due to hemorrhoids or Crohn’s Disease (not an exhaustive list), a form should not be filled out.  In the same way, inmates who suffer from chronic anal fissures should not have forms completed for their condition. 

 

1. Completing the form

 

1. Form Identification Number

 

1. Date of encounter

 

1. Indicators of Sexual Violence

1. Part A records indicators of sexual violence.  It is necessary to answer all parts of A.1 and A.2.

   In A.1, record whether or not the inmate made an allegation of sexual violence.

   In A.2, record whether or not the inmate presented with any of the following injuries: unexplained rectal bleeding, rectal or anal tears or fissures, bruises, scratches, or abrasions on the buttocks, genital bruising, or nipple injuries.  Record “Don’t know” if your routine examination did not include a check for one of these injuries.  Again, remember that you are not expected to examine every inmate for these injuries when they seek medical care.  Also, record the occurrence of these injuries whether or not there is an allegation.

 

1. Indicators of Sexual Violence

1. IF YOU ANSWERED ‘NO’ TO EVERY ITEM IN A.1 AND A.2, THEN ANSWER A.3.  

   A.3 SHOULD BE LEFT BLANK IF ‘YES’ IS MARKED IN ANY PART OF A.1 OR A.2.

   The form should be filled out if a clinician has a suspicion of sexual violence.  A.3 is on the form for the purpose of incidents that occur where other types of injuries could suggest sexual violence.  Again, this is based on your professional training and expertise.

 

1. Inmate Demographics

1. In Section B:

   Record current age in years.

   Record current height (in feet and inches) if measured during examination or most recent height documented.

   Record current weight (in pounds) if measured during examination or most recent weight documented.

   Record race/Hispanic origin documented in medical record, by inmate self-report, or clinician identification.  Check all that apply.

 

1. General Injury Assessment

1. In the general injury assessment, mark any areas of the body where you observed bruises or scratches.  A separate exam for each of these areas is not required; only injuries that are discovered as part of your routine examination.

 

1. General Injury Assessment

1. In C.2, mark if the inmate had defensive injuries to the arms, hands or fingernails, broken bones, bite wounds, teeth chipped or knocked out, or bruises or cuts in or near the mouth.  Again, only record injuries that are discovered as part of your routine examination.

 

1. Behavioral Observations

1. In Part D, behavioral observations should be recorded based on your interaction with the inmate during the exam.  A separate examination by a mental health professional is not required.  However, if additional sources of information are available for your use, such as mental health notes in a chart or a conversation with a mental health professional that may have recently seen the inmate, it is recommended to complete this section using all possible resources.

   Record high levels of anxiety in D.1.  This would be evident from an inmate appearing agitated or usually upset during the examination, fidgeting, crying, appearing to startle easily, trembling, or reporting that he’s having trouble sleeping.

 

1. Behavioral Observations

1. In D.2, record if the inmate appears emotionally withdrawn.  This would be evident if the inmate appears detached from others or in a daze, has difficulty concentrating, has difficulty attending to the exam, or appears lost in his own thoughts.

 

1. Behavioral Observations

1. Item D.3 is for situations where the inmate did not make an allegation of sexual violence.  There is a box to check if the inmate DID make an allegation.  

   If he did not make an allegation, record if the inmate has an extreme emotional reaction (anger, sadness, etc.) at the suggestion of sexual assault.  You should not change your routine practice regarding discussion of sexual assault with inmates.  In other words, you are not being asked to suggest sexual violence if it wouldn’t be part of your routine practice.

 

1. Behavioral Observations

1. Item D.4 is also for situations where an allegation was not made.  

   Record whether or not the story matches the inmate’s injuries.  Does his explanation seem plausible or not?  Note the choices for response are:

• -Story does not match physical signs / no explanation 

• -Story matches physical signs 

• -Don’t know (if this was not part of the exam) 

• -Inmate made an allegation of sexual violence 

 

1. Referral

1. The next section, Part E, is asking about any recommendations or referrals the clinician made as a result of the exam.  You are asked to record “Yes” even if the inmate refuses the referral.  

   In E.1, record whether or not you referred the inmate for HIV or STD testing, including syphilis, gonorrhea, Chlamydia, hepatitis B or others.

 

1. Referral

1. In E.2, record whether or not you made a referral for a mental health examination.

 

1. Referral

1. In E.3, record whether or not you made a referral for the inmate to be seen by another clinician.

 

1. Referral

1. In E.4, record whether or not you recommend to have the inmate’s housing status changed through segregation, protective custody or transfer.

 

1. Referral

1. In E.5, record whether or not you recommended that an incident report be initiated.

 

1. Comments

1. The next section is a comments field where you can record any additional relevant information.  You should include any comments that would provide a clearer picture of the incident or anything else that you feel should be known about the situation.  Please remember to NOT include any potentially identifying information like an inmate ID number or an incident case number.

 

1. Visit Information

1. The last section contains questions about the visit.  Most of this information in this section is to help in determining if there is more than one completed form for a single injury.  The Reporter for the facility will be responsible for making sure that only one form per injury is sent to CDC, even if multiple forms are completed for the same injury.

   Record your level of training in F.1.

 

1. Visit Information

1. In F.2, record the method with which you came in contact with the inmate.  If the method is not listed, mark “Other” and fill in the blank space provided.

 

1. Visit Information

1. In F.3, record if the inmate has been seen for this injury/incident in the past 30 days.  If he has, record the date of the most recent visit.  Again, this will alert the Reporter that there may be a previous form completed for this injury.

 

1. Completed forms

• •The Reporter will be responsible for maintaining completed forms and will serve as the point of contact for the facility 

• •Forms will be sent to CDC on a monthly basis 

1. The Reporter will be responsible for maintaining completed forms and will serve as the point of contact for the facility.

   Forms will be sent to CDC on a monthly basis.

 

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Author	Elin Begley
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File Modified	2010-03-15
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