Interpersonal Violence: SAFE and SANE Nursing

• The presentation discusses interpersonal violence including abuse, neglect, and assault.
• Stephanie DeRedin, MBA, BSN, RN, SANE-A/P, ME-SAFE-A/P, a SAFE Nurse at St. Joseph Healthcare, St. Joseph Hospital in Bangor, Maine presents the information.

Objectives:

• Define SAFE/SANE and discuss their roles, sexual violence, and domestic violence.
• Understand the prevalence of violence in Maine, dynamics of relationships, and medical-forensic exam processes at the hospital.
• Identify red flags, vulnerabilities, and necessary medical assessment, care, and treatment.
• Discuss the nurse's role and how to provide help.

SAFE and SANE Definitions

• SAFE (Sexual Assault Forensic Examiner) is a healthcare provider trained to give comprehensive care to sexual assault patients.
• SAFE demonstrates competency in forensic exams and can serve as an expert or fact witness in court.
• SANE (Sexual Assault Nurse Examiner) is a registered nurse, nurse practitioner, physician assistant, or physician.
• SANEs require board certification from the International Association of Forensic Nurses (IAFN).

State of Maine SAFE Program

• In Maine, the SAFE program operates under the Department of Health and Human Services (DHHS), Office of Child and Family Services.
• The SAFE Advisory Board makes recommendations for healthcare providers to:
• Promote specialized skills for comprehensive, quality medical-forensic care for sexual assault/abuse victims.
• Ensure training in evidence collection, documentation, and management during medical-forensic exams.
• Prepare healthcare providers to testify in legal proceedings.

Comprehensive Violence Program

• The SAFE program at St. Joseph Hospital cares for all crime victims including forms of interpersonal violence.
• There is a dedicated ER department with full-time and per diem SAFE/ER nurses and on-call hours, working towards a 24/7 model of care.
• Trauma-informed care is 100% patient driven and is the standard of care for sexual assault survivors and standard for all health care especially for intimate examinations.

Trauma Informed Care Principles

• Realize
• Recognize
• Respond
• Resist
• Safety
• Trustworthiness & transparency
• Peer support
• Collaboration & mutuality
• Empowerment, voice & choice
• Cultural, historical, & gender issues

Trauma Informed Approach

• Stay neutral and consistent
• Empathy and compassion
• Recognize complexity of trauma and validate coping skills
• Collaborate with the survivor and follow their lead
• Reflect language
• Create welcoming space

Sexual Violence

• Sexual violence occurs when someone forces or manipulates another into unwanted sexual activity without their consent.
• Consent is freely given, reversible, informed, enthusiastic, specific and sober.
• Forms of sexual violence can include: rape or sexual assault, child sexual assault and incest, intimate partner sexual assault, unwanted sexual contact or touching, sexual harassment, sexual exploitation, showing one's genitals or naked body without consent, masturbating in public, watching someone in a private act without their knowledge or permission.

Sexual Violence Nationally

• Sexual violence is common and affects both genders.
• 1 in 3 women and 1 in 4 men have experienced sexual violence with physical contact in their lifetimes.
• Sexual violence often starts early.
• 1 in 3 female rape victims first experienced it between 11-17 years old and 1 in 8 before age 10.
• Nearly 1 in 4 male rape victims first experienced it between 11-17 years old and about 1 in 4 before age 10.
• Most rape victims, both female and male, knew the person who raped them.

Sexual Violence in Maine

• One in five Mainers will experience sexual assault in their lifetime.
• Each year, approximately 14,000 Mainers will experience sexual violence.
• In 2017, 448 rapes or attempted rapes were reported to Maine law enforcement, 514 in 2019 and 468 in 2021.
• In 2019, about 50% of calls to Maine's sexual assault crisis and support line involved child sexual abuse.
• 35-37% of Maine youth who experience forced sexual contact or sex consider suicide, versus 9-10% of peers without such experiences.

Helping a Victim of Sexual Assault

• Safe people to talk to for victims of sexual assault could be
• Sexual assault advocacy center
• MECASA (Maine Coalition Against Sexual Assault)
• Local centers of help
• SAFE nurse
• Police
• Church
• Family and Friends
• Therapists

What Happens at the Hospital Following Sexual Assault?

• SAFE/SANE evaluation
• Advocacy
• History of the assault
• Head-to-toe exam
• Documenting injuries
• Treatment for injuries
• STI prophylaxis
• Pregnancy prophylaxis
• Evidence collection including the kit
• Forensic photography
• Follow-up care planning
• Reassurance/emotional security
• Safety planning
• Reporting to Law Enforcement
• Expert testimony
• Confidentiality

Maine State Sex Crimes Kit

• A survivor of sexual assault has four options when using the Maine State Sex Crimes kit:
• No evidence collection, No report.
• No evidence collection, Yes report.
• Evidence collection, No report.
• Anonymous kit sent to local Law Enforcement.
• Evidence collection, Yes report.
• Kit sent to Law Enforcement covering location of Sexual Assault.
• The amount of evidence collected is determined by the victims.

Domestic Violence

• Domestic violence is a pattern of abusive behavior used by one partner to gain or maintain power and control over another intimate partner.
• Includes physical, sexual, emotional, economic, or psychological actions or threats that influence another person, including behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt injure or wound someone (USDOJ Office on Violence Against Women, 2014.
• Forms of domestic violence include control, physical abuse, sexual abuse, emotional abuse & intimidation, isolation, verbal abuse with coercion, threats & blame, using male privilege and economic abuse.

Domestic Violence Nationally

• About 1 in 5 women and 1 in 7 men report experiencing severe physical violence from an intimate partner in their lifetime.
• About 1 in 5 women and 1 in 12 men have experienced contact sexual violence by an intimate partner.
• 10% of women and 2% of men report having been stalked by an intimate partner.
• IPV starts early and continues throughout people's lives.

Domestic Violence in Maine

• From 2020-2022, 49% of Maine's homicides were domestic abuse homicides.
• Nationally, in 2020, 89% of women were killed by a male they knew.
• Domestic Violence can lead to Suicidality, Stalking, Non-Fatal Strangulation, Sexual Abuse, and Serial Battering.
• Negative health problems from Domestic Violence can include cardiac problems, Digestive trouble, Reproductive challenge, Muscle and bone issues, nervous system difficulties, mental health challenges like depression, anxiety, PTSD, and suicidal ideation.
• Domestic violence victims are at higher risk for engaging in unhealthy, high-risk behaviors such as smoking and substance use.
• The lifetime economic cost associated with medical services for IPV-related injuries, lost productivity from paid work, criminal justice and other costs, was $3.6 trillion.
• The cost of IPV over a victim's lifetime was $103,767 for women and $23,414 for men.

Tree of Power and Control

• Includes: physical violence, sexual violence, using coercion and threats, using intimidation, using emotional abuse, using isolation, minimizing, denying, blaming, using children, using male privilege, and using economic abuse.

Forms of Abuse Within Domestic Violence

• Domestic violence includes abuse of the older adult, LGBTQ+ abuse, teen dating violence, reproductive coercion and child abuse & abuse of children who witness abuse.
• Abuse can be classified as Financial, Neglect, or Physical of the SA kind.
• Emotional, Mental, Physical, and SA is another type.
• SA = sexual assault
• Sabotaging birth control and stealthing are also types of abuse.
• 1 in 3 children in home with IPV will be physical abused.

Helping in a Domestic Violence Situation

• Safe people to talk to for victims of domestic violence are the same as victims of sexual harassment with some exceptions, such as:
• MCEDV (Maine Coalition to End Domestic Violence)
• Partners for Peace

What Happens at the Hospital

• SAFE/SANE
• Advocate
• History of The Assault
• Head-To-Toe Exam
• Document Injuries
• Treatment For Injuries
• STI Prophylaxis
• Pregnancy Prophylaxis
• Evidence Collection
• Forensic Photography
• Follow-Up Care And Planning
• Reassurance/ Emotional Security
• Safety Planning
• Report To LEO
• Expert Testimony
• Confidentiality

Human Trafficking

• Compelled into labor/commercial sex work through force, fraud, or coercion for economic gain of a trafficker or any minor in commercial sex work is a victim/survivor of human trafficking.
• ACT (recruiting, harboring, transporting, providing, obtaining, or otherwise acquiring).
• Includes any scheme, plan, or pattern to make a person fear for themselves or others; through the use of addiction, withholding documents, threatening family or individual, etc.
• for economic gain of the trafficker or third party through exploitation, servitude, debt bondage, and slavery.

Sex Trafficking in Maine

• Sex Trafficking occurs in every county and town in Maine, and there is a difference between Rural versus Urban.
• There is an estimated 300-400 cases annually in Maine, and in 2021, the Consortium served >150 survivors of Human Trafficking in Greater Bangor area.
• A profile Sex Trafficking Victim in Maine: female, male, trans-gender, non-binary, gender fluid, white, BIPOC, Native American between 14-30 years old *Seeing all ages substance use.
• Entry into the life through family member, caregiver, or significant other.
  • Exploitation and abuse often begins in childhood.

Labor Trafficking in Maine

• Relates to industries such as tourism, hospitality, and seasonal work.
• Involves employers who provide housing, transportation, and meals, along with their employment and paid a regular wage but work beyond normal hours or very long hours.
• Shift during the start of the pandemic from sex trafficking to having people run drugs and weapons.

Vulnerabilities

• In order from basic to least basic needs one can have vulnerabilities in:
  • Physiological needs like food, water, shelter, clothes, warmth and drugs and love.
  • Safety needs, Security ,Safety, Order, Predictability, Control
  • Belongings and love needs like Intimacy, Friends, Love, Acceptance, Trust, Relationships.
  • Esteem needs: prestige recognition and feeling accomplished: respect from others.
  • Self-Actualization: Achieving one's full potential- Creative activities

Risk Factors For Exploitation

• Unoused, Unmet health needs, Unmet health needs, Lack of resources or financial, Social media, intellectual and/or physical disabilities, low self-esteem, fosters care/and or with DHHS/CPS.
• Truancy, history of trauma like childhood trauma, generational trauma, LGBT, BIPOC, Immigrants.
• desire to be loved or cared for and have a basic sense of belonging.

Indicators of Human Trafficking

• Referral from law enforcement or community partner.
• Frequenting hotels.
• No access to personal identification.
• Untreated health issues.
• Homeless (youth)
• Evidence of a controlling, abusive employer, partner or older adult.
• Inabilty to identify the location of residence.
• Works excessively long hours or unusual hours.
• Mentions of quota or debt.
• Travel without means.
• Disconnection from loved ones and support.
• Not Allowed to Speak.
• Trauma Related Symptoms.
• Fear or Hypervigilance.
• Substance use.
• Unexplained expensive items.
• Unusual brandings/tattoos.

How To Respond In A Trauma/ Exploitation Event

• Survival: In the life to find a way to get out.
• Safety: Transition to a better life style.
• Stability: This comes from recovery.
• Educate Yourself
• Be Non-Judgmental
• Know and Verbalize Resources if you help the people involved.
• Develop Rappor
• Trust Survivors Knowing Themselves and Their Own Time
• Keep Communication Open
• Be A Safe Haven