Standard Operating Procedures

Clinical Indicators of Sexual Violence in Custody

Attachment 8.

Standard Operating Procedures

Goal

This pilot study is being conducted to determine the feasibility of conducting surveillance for sexual violence in correctional settings using medical indicators.

Background

As part of the 2003 Prison Rape Elimination Act, the Bureau of Justice Statistics (BJS) at the U.S. Department of Justice initiated studies to determine the incidence of sexual violence in correctional facilities. To complement these studies, BJS has requested assistance from the CDC National Center for HIV/AIDS, Viral Hepatitis, STD, TB Prevention (NCHHSTP) and National Center for Injury Prevention and Control (NCIPC) to establish a passive surveillance system for medical indicators of sexual violence.

BJS conducted inmate interviews to determine prevalence of sexual violence in correctional facilities ^1. Of the 23,398 inmates interviewed, 4.5% self-reported sexual victimization, 0.5% of inmates reported being injured in an inmate-on-inmate assault and 0.3% of inmates reported being injured in a staff-on-inmate assault. BJS also reviewed administrative records for allegations of sexual violence in 2004 – 2006 ^2-4. Most allegations of sexual violence were unsubstantiated or unfounded (<20%) and the proportion of incidents that resulted in a victim injury was low. For example, among substantiated inmate-on-inmate sexual violence, 20% of incidents resulted in a victim injury in 2006. Community studies of male sexual assault in the United States have also shown low rates of injury ^5-8. Extra-genital trauma (abrasions, contusions, superficial lacerations) was identified approximately 33% of patients. Although anal penetration occurred in approximately 85% of assaults, rectal trauma was identified in only 5%-15% of patients.

As one method to validate the two types of BJS surveys (administrative records and inmate surveys), CDC will establish a pilot surveillance system in up to five jails and four state prisons to prospectively report medical conditions that may be associated with sexual violence beginning in 2009.

Method

The pilot surveillance will be conducted prospectively for 12 months. Prison systems will identify up to five facilities to conduct surveillance. If possible, prison systems should consider including facilities that participated in the 2007 BJS Sexual Victimization Survey ^1. Large jails may consider restricting the inmate population to reduce the burden of the data collection (e.g., restricting the population to certain units, inmates serving sentences greater than one month, or limiting the number of clinic days).

The surveillance form (see below) will be completed only for inmates who either make an allegation of sexual violence to a health care provider or are diagnosed with one of the five listed conditions described in Part A. The surveillance will be conducted among adult (>18 years old) male inmates. If an inmate is treated outside of the correctional facility, the correctional health care provider will obtain the information from the treating clinician. Inmates who are identified either during rounding or “sick call” visits to units, walk-in visits, urgent care, and emergency visits will be eligible. The form will be completed by a clinician (physician, physician assistant, nurse practitioner, or nurse) following the inmate examination.

Phase 1: Training and implementation: CDC will provide orientation and training to health staff at the facility. The facility will identify a point of contact for the 12 month data collection period.

Phase 2: Observation: CDC investigators will conduct one-day site visits to a limited number of facilities to observe the implementation of the pilot activities. CDC will regularly contact the facility point of contact for updates.

Phase 3: Validation and summary: CDC investigators will conduct a final site visit to review medical records for inmates identified through surveillance. A summary report will be provided to the Bureau of Justice Statistics and the National Institute of Justice.

CDC Points of Contact

Drew Voetsch, PhD Project Officer (404) 639-8088 [email protected]

Kristina Bowles, MPH Project Coordinator (404) 639-1815 [email protected]

Instructions to Complete the Surveillance Form

The date is the month/day/year (MM/DD/YYYY) of the first encounter that the inmate either made an allegation or was diagnosed with one of the conditions in Part A.

The inmate identification number is the number used by the facility to track the inmate. This number will be used to link the form to the medical record for the validation phase. The identification number will be physically removed before being collected by CDC investigators and removed from the facility.

Part A-Indicators of Sexual Violence

Fill out the surveillance form only if:

• An inmate either makes an allegation of sexual violence, or

• An inmate has any of the following conditions diagnosed as part of the clinical examination:

1. Rectal bleeding

2. Rectal or anal tears or fissures

3. Bruises, scratches, or abrasions on buttocks

4. Genital bruising

5. Nipple injuries.

Notes:

• Record instances of these conditions even if there is no allegation of sexual violence or if the patient‘s symptom can be explained by something other than sexual assault.

• We are not asking that all inmates are examined for these injuries as part of the surveillance.

If any indicator in Part A is identified, complete Parts B – Part E

Part B-Demographics

1. Current age in years

2. Height and weight if measured or most recent height and weight documented

3. Race/ethnicity documented in the medical record, by inmate self-report, or clinician identification

Part C. General injury assessment

Record if any of these injuries are identified as part of the clinical examination:

1. Bruises or scratches to the wrists, ankles, shoulders, or central on body

2. Defensive injuries to the arms, hands or finger nails

3. Broken bone

4. Bite wound

5. Teeth chipped or knocked out recently (i.e., during the current incarceration)

6. Bruises or cuts in or near the mouth

Part D. Mental health assessment

This information is based on information obtained during the medical examination and not part of a separate examination by a mental health professional:

1. High levels of anxiety - Does the inmate appear agitated or unusually upset during the examination?

2. Post traumatic stress disorder - Does the inmate report experiencing symptoms consistent with PTSD following exposure to a traumatic event, including: persistent re-experience of the event; persistent avoidance of stimuli associated with the trauma; significant impairment in social, occupational, or other important areas of functioning; self-blame; uncontrollable emotions, such as fear, anger, guilt, shame, anxiety; mood swings; nightmares and sleeping disorders; eating disorders; suicidal thoughts or suicide attempts?

3. Extreme emotional reactions at suggestion of sexual assault – If the inmate does not make an allegation of sexual violence but has one of the six diagnoses in part A, does the inmate react with extreme anger, sadness, etc? Note that the provider should not change his or her routine practice regarding discussions of sexual assault with inmates (i.e., Do not ask all inmates about sexual assault if they meet the criteria in part A).

4. Story/report not matching the physical signs - If the inmate does not make an allegation of sexual violence but has one of the six diagnoses in part A, does the inmate explanation seem plausible?

Part E. Follow-up

1. HIV/STD testing - Was the inmate tested for HIV, syphilis, gonorrhea, Chlamydia, hepatitis B, or other sexually transmitted diseases?

2. Mental health referral - Was the inmate referred for a mental health examination?

3. Segregation, protective custody, or transfer recommended - Did the clinician recommend to the security staff that the inmate’s housing status change?

4. Incident report initiated - Was an incident report initiated?

C Survey identification number: ____________________________ linical Indicators of Sexual Violence in Custody Surveillance Form							Date: _____/_____/ 20____
Part A. Indicators of sexual violence
Did the inmate make an allegation of sexual violence?  Yes  No	-OR-		Did the inmate have any of the following?
			 Rectal bleeding  Rectal or anal tears or fissures  Bruises, scratches, or abrasions on buttocks					 Genital bruising  Nipple injuries
If inmate made an allegation of sexual violence or any condition in Part A is identified, complete Parts B-E
Part B. Demographics
Age: _________(years) Height: _______(inches) Weight:_______(pounds)		Race (check all that apply):  White  Black or African American  Hispanic or Latino  Asian				 American Indian or Alaska Native  Native Hawaiian or Other Pacific Islander  No information available
Part C. General injury assessment
Did the inmate have any of the following injuries? (check all that apply)
 Bruises or scratches to the throat  Bruises or scratches to the wrists  Bruises or scratches to the ankles  Bruises or scratches to the shoulders  Bruises or scratches central on body				 Defensive injuries to the arms, hands or finger nails  Broken bone  Bite wound  Teeth chipped or knocked out recently  Bruises or cuts in or near the mouth
Part D. Mental health assessment
Check all that apply  High levels of anxiety  Post traumatic stress disorder				 Extreme emotional reactions at suggestion of sexual assault  Story/report not matching the physical signs
Part E. Follow-up
Check all that apply  HIV/STD testing  Mental health referral				 Segregation, protective custody, or transfer recommended  Incident report initiated
NOTICE: Public reporting for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 1121-XXXX.

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Draft 2/26/2009