Lifting Barriers to Care for Sexual 
Assault: The Medical Forensic 
Exam for Survivors with Disabilities 

March 17, 2020 
Kim Day, RN, SANE-A, SANE-P 
Angelita Olowu, BSN, RN, SANE


A, SANE-P 



Speakers 


Kim Day 
RN, SANE-A, SANE-P 
Grants Project Director 
International Association 

of Forensic Nurses 


Speakers (2) 

Angelita Olowu 

BSN, RN, SANE-A, 
SANE-P 

Forensic Nursing 
Specialist 

International Association 
of Forensic Nurses 



Acknowledgement and Disclosure 

This webinar was made possible in part by funding provided by an award 
from the Office on Violence Against Women, U.S. Department of Justice, 
Grant No. 2016-TA-AX-K008. 

The opinions, findings, conclusions, and recommendations expressed in this 
presentation are those of the authors and do not necessarily reflect the views 
of the Department of Justice, Office on Violence Against Women or the 
International Association of Forensic Nurses. 

The International Association of Forensic Nurses is accredited as a provider 
of nursing continuing professional development by the American Nurses 
Credentialing Center’s Commission on Accreditation. 

The planners, presenters and content reviewers of this presentation disclose 
no conflicts of interest. 

Upon attending the course in it’s entirety and completing the course 
evaluation, IAFN members will receive a certificate that documents 1.5 hours 
of nursing continuing education. 



Objectives 

• 
Have an increased understanding of sexual 
violence against individuals with disabilities; 
• 
Recognize some of the specific needs and 
barriers that survivors with disabilities face 
when accessing support and services, 
particularly forensic exams; and 
• 
Strategize ways to create an accessible and 
welcoming experience for survivors with 
disabilities. 

Disability and Sexual Assault: What 
We Know 



Caveat: Lack of Research 

• 
There is limited research in the area of people 
with disabilities and sexual assault 
• 
There is limited professional training in this 
area 

What are Some of the Facts? 

• 
Current and ex-intimate partners are most 
common perpetrators (48%) 
• 
Women with disabilities had more than 4 
times the odds of experiencing sexual 
assault in the past year compared to 
women without disabilities (Martin, Ray, 
Alvarez et al, 2006) 

The Facts (continued) 

• 
People with intellectual/developmental 
disabilities are 7x more likely to experience 
sexual violence 
• 
Women with I/DD are 12x more likely to 
experience sexual violence 
• 
14% of men with disabilities reported 
experiencing sexual violence at some point 
in their lifetime compared to 4% of men 
without disabilities 
Source: Bureau of Justice Statistics, National Crime Victimization Survey, Special Tabulation 
Credit: Katie Park/NPR 



Sexual Violence per BJS 



Sexual Assault and Adolescent Girls 

Girls’ Experiences at Age 16 by physical disability status 

Physical 
Disability Status 
Never had sexual 
intercourse 
All consensual Forced sexual 
intercourse 
No disability 66.3 27.7 6.0 

Minimal disability 48.2 40.9 10.9 

Mild disability 63.7 23.4 12.9 

Severe disability 57.9 31.0 11.1 

1994-1995 Wave 1 Data from the National Longitudinal Study of Adolescent 
Health Probability sample of adolescents in grades 7-12 in US Schools. N = 24,105 
Disability severity index is set on a functional, self and parent defined scale at the 
time of the survey Source: Cheng and Udry, 2002 



Unique Dynamics – Increased Risk 

• 
People with disabilities are more likely to 
need assistance with personal, private tasks 
that can lead to victimization 
• 
People with disabilities are targeted for 
perceived vulnerabilities 
• 
People with disabilities are often denied 
sexual education 

Barriers for Survivors with Disabilities 



Barriers 

Recognizing the 
different types of 
disabilities, what are 
some of the barriers the 
patient may face when 
seeking SA exam 
services? 



Barriers (2) 



Types of Barriers 

• 
Three types of barriers for survivors with all 
types of disabilities: 
• 
Physical barriers 
• 
Communication barriers 
• 
Attitudinal barriers 

Physical Barriers 

• 
Lack of physical access 
to spaces 

• 
Inaccessible exam 
procedures 

Communication Barriers 

• 
Lack of ASL interpreters 
• 
Lack of privacy for Deaf survivors 
• 
Need for materials in alternative formats 
• 
Need for materials in plain language by 
providers to explain the process in plain 
language 
• 
Patient education materials need to be 
written in plain language 

Attitudinal Barriers 

• 
Lack of familiarity with how to conduct 
accessible exams amongst service providers 
• 
Lack of familiarity in interacting with people 
with disabilities and talking about 
accommodations 
• 
Agencies and medical facilities do not 
prioritize developing an accessible 
procedure for people with disabilities 

Solutions for Forensic Examiners to 
Ensure Accessible Exams for Survivors 
with Disabilities 



Addressing Physical Barriers 

• 
Ensure accessible spaces (exam rooms) 
• 
Develop procedures for physically adaptive 
exams as needed 

Accessible Exam Rooms 



Accessible Exam Rooms (2) 

• 
Accessible route INTO and THROUGH the 
room 
• 
An entry door with clear width, maneuvering 
clearance, and accessible hardware 
• 
Accessible exam table and equipment 
• 
Adequate clear floor space for side transfers 
and lift equipment 
• 
Ensure access before a patient comes in with 
these needs 

Positioning and the Exam Table 

Things for the provider to think about 



A Note for Female Survivors with 
Spinal Cord Injuries 

• 
50% incidence of autonomic dysreflexia 
(ADR) women with spinal cord lesions 
• 
Be aware that this can occur in women with 
spinal cord injury at or above T6 

Hospital Settlement re: Physical 
Access 

In November 2005, a settlement was reached 
with the largest private hospital in the nation's 
capital, Washington Hospital Center (WHC). 
This settlement is one of the first of its kind to 
address access to hospital facilities and 
equipment for patients with mobility 

disabilities and other disabilities. 



Under the Settlement the Hospital 
Will: 

• 
Remove barriers throughout the hospital; 
• 
Procure accessible exam tables for every 
department that uses exam tables (after the 
date of the agreement, all new exam tables 
and chairs purchased by WHC will be 
accessible) ; 
• 
Survey all equipment and purchase 
accessible equipment where needed; 

WHC Settlement (2) 

• 
Review and revise its polices, implement 
special procedures for patients with spinal 
cord injuries; and 
• 
Provide training to its staff to ensure 
implementation and use of its new policies 
and equipment. 

Addressing Communication Barriers 

• 
Can impact Deaf survivors, survivors who are 
blind or low vision, and people with 
cognitive disabilities 
• 
Solutions may look different 

Deaf Communication 



Deaf Communication Suggestions 

• 
Ask the Deaf/ Hard of hearing person their 
preference for communication 
• 
ASL interpreter 
• 
In-person interpreter should be the 
preference, allows for the greatest level of 
communication 
• 
Other options (in a pinch) include Video 
Relay Services and Video Remote 
Interpreting –require video chat technology 

Deaf Communication (2) 

• 
Communicate directly with the person, not 
the interpreter 
• 
Do not rely on note passing or lip reading 
unless it is the expressed preference of the 
person 

Vision Disabilities Suggestions 



Vision Disability Suggestions (2) 

• 
Never make assumptions 
• 
Don’t touch or move mobility aids or service 
animals 
• 
Describe procedures before performing them 
• 
All forms and documents should: 
• 
Be available in large font (24 pt+) and 
• 
Be available in Braille and 
• 
Be available electronically via screen reader 
• 
Be read aloud by staff 

Cognitive/Developmental Disability 
Suggestions 



Cognitive/Developmental Disability 
Suggestions (2) 

• 
Assess ability to consent – what does 
medical consent look like for people with 
I/DD? 
• 
Education and instructions should be given 
so that the person understands, ensure 
comfort 
• 
Resources: pictorial guides, videos 
• 
Address the patient directly, not a support 
person or guardian 

I/DD Suggestions (3) 

• 
Conduct the exam without parent/caregiver/ 
guardian present 
• 
Encourage expression of concerns 
• 
Assess for coercion 
• 
Identify if the patient has a history of GYN 
exams 
• 
Describe each step prior to doing it 

Addressing Attitudinal Barriers 

• 
Conduct regular disability training 
• 
Partner with disability agencies and self-
advocacy organizations 

General Disability Etiquette 

Address the 
person directly 
Treat adults as 
adults 

Place yourself at 
eye level when 
conversing 

Identify yourselfand your role 

Do not lean on 
wheelchair-
respect 
boundaries 

Speak in plain 
language 
Offer assistance, 
wait for 
acceptance of helpand instructions 
Listen attentivelyto those with 
speech difficulties 
If you are unsure-
ASK! 

Adapted from: CIDNY, the Center for Independence of the Disabled in New York, Inc. 



Other General Tips 

• 
Do not assume a person has or does not 
have a disability, focus on what they need to 
have a positive experience 
• 
Someone might not want to disclose their 
disability or the nature of that disability, but 
may disclose that they need additional 
supports 

Overcoming Barriers Chat 

• 
What are your resources for working with 
patients with disabilities within your medical 
facilities? 
• 
What are your options when you are in need of 
an accessible space? 
• 
Do you have access to additional staff to assist 
in making need adjustments to accommodate 
your patients with the exam if necessary? 
• 
What are your community resources for 
patients that you may see with disabilities? 

Case Studies 



Case Study: Angie 


• 
Angie, age 40 with 
cerebral palsy 
• 
Caregiver accompanies 
patient, and answers 
questions posed to the 
patient 
• 
Angie looks unkempt, 
has bruising noted on 
her thighs and buttocks 
• 
She appears fearful of 
reporting to police 

Case Study: Leon 

• 
Leon, 18-year-old Deaf 
male 
• 
Writes out, with pen 
and paper provided by 
providers at the 
healthcare facility that 
he was sexually 
assaulted 
• 
Concerned that 
perpetrator is well 
known in his community 

Case Study: Rhonda 

• 
Rhonda, 32-year-old quadriplegic 
female with a history of traumatic 
brain injury 
• 
Arrived to medical facility alone 
via private ambulance 
• 
Resides at home with her mom 
who is her caregiver and an uncle 
• 
States recalling her uncle 
administering her meds then 
mom administering meds again 

Questions 



Resources 

Picture Guide to Sexual Assault Exam from Hennepin County: 

https://www.endabusepwd.org/publications/accessing-safetyhennepin-
county-implementation-documents/ 

Talk About Sexual Violence Resources: https://thearc.org/findresources/?
search_resource=sexual+violence&audience=searchA 
udience&type=searchtype&topic=searchTopic 

Tour of Nurse Examiner Program for Patients with Disabilities 
Video from Michigan: https://www.ywcawcmi.org/ourservices/
weave/tour-nurse-examiner-program-patients-dd/ 



Contact Information 

For more information about 
Sexual Assault Forensic 
Exam Technical Assistance 
(SAFEta) 
Visit: www.safeta.org 
For questions contact us at: 
info@safeta.org 
Helpline: 877-819-7278 
Kim Day RN, SANE-A, 
SANE-P 
Grants Project Director 

kimday@forensicnurses.org 

Angelita Olowu, BSN, RN, 
SANE-A, SANE-P 
Forensic Nursing Specialist 

aolowu@forensicnurses.org 


Thank you! 

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