Well, hello, everyone. I think we can go ahead and get started. My name is Sarah Jimenez Valdez. I am a project manager with the International Association of Forensic Nurses. We are excited that you've joined us today for this webinar panel on medical advocacy. We are grateful to be joined by several advocates that are across the United States who just have a variety of experience. Today's webinar was possible, or I'm sorry, made possible with grant funds awarded by the Office of Victims of Crime for the SANE Program TTA project. I do have a few housekeeping things that we need to cover before we get started. I do first want to start with a brief disclaimer. Let me go ahead and actually show that to you. There we go. The opinions, findings, and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. That said, this is an interactive webinar, so we do encourage you to use the Q&A feature to submit any questions you might have for the panelists and or facilitators. If you need any technical assistance, the chat is also available, so I will be able to monitor that and help you with any needs you might have that come up. And then lastly, the IAFN is an accredited provider of continuing education, or I'm sorry, continuing nursing education, and so there will be 1.5 CE available for this presentation once we're done. The planners and presenters of this course have, or I'm sorry, presentation have no relevant financial relationships with ineligible companies to disclose. With that, I would like to welcome our facilitators for this panel discussion. We do have Chantelle Hammond with the International Association of Forensic Nurses and Karla Vierteller with the National Sexual Assault Resource Violence Center. Sorry about that. Chantelle, if you'd like to go ahead and do an introduction. Hi, everyone. Thank you for that introduction, Sarah. I'm Chantelle Hammond. I'm one of the forensic nurse specialists here at the IAFN. I'll be facilitating this panel along with Karla. I'm representing IAFN on this panel and also forensic nurses, because I know we have many, many questions on how we can work along with advocates. Karla, would you like to do a short introduction? Sure. Hello, everyone. My name is Karla Vierteller, and I'm the Advocacy and Resources Director at the National Sexual Violence Resource Center. We are a part of Respect Together and also house the Pennsylvania Coalition Against Rape. And I'm very excited to be here today. Chantelle, do you want to share a little bit about our learning outcomes? Yes. So, like you mentioned, this medical advocacy panel is really about what advocacy looks like when a patient comes in for a medical forensic exam. So, in this panel, we hope that you all have an increased understanding of the value of advocacy accompaniment for a sexual assault patient during a medical exam and also increase your knowledge of the importance of collaboration with a multidisciplinary team so that you can provide resources to a diverse population. And so, we know that each patient has their own unique needs, and a lot of that is worked along with advocates and how we can work together to provide those needs for our patients. All right. There you go. Thanks, everyone. I am going to start by talking a little bit about advocates and different types of advocates because we want to be very clear that while we use this generalized term, there are different kinds of advocates with different roles and different levels of confidentiality or privileged communication. So, first, we're going to talk about community-based advocates. And those are advocates based in a generally sexual violence, domestic violence, or other type of violent support systems. They are funded generally through VAWA and other community services. Violence Against Women Act, excuse me for using an acronym. So those are the rape crisis advocates that will generally go to the hospital. So these folks, community-based advocates, champion victims' rights, focus on the survivor. So through their funding, they are able to, their goal and their job is to work with survivors and to work with the survivor through every part after victimization, every step. Community-based advocates inform survivors of their options and rights before, during, and after the forensic exam and also hold high levels of confidentiality, similar to a therapist, although that varies from state to state. And I will put in the chat after we're done, Rain, who provides a national hotline for sexual assault services, has a wonderful chart to determine levels of confidentiality in your state. And generally, an advocate, a community-based advocate can be a volunteer or a staff member. And generally, the requirement is receiving a certain number of hours of training that is, the training is selected and verified through the funder of the community-based program. And then that advocate, volunteer or paid, would be under the supervision of someone at the rape crisis center, generally someone called a direct services supervisor or something similar. And then another type of advocate is a system-based, systems-based advocates, who you may come in contact with at the hospital when giving a forensic rape exam. So these advocates will work within a system, whether the hospital, the DA's office, could be a police advocate, a campus advocate, or another social service agency. And those advocates are employed by the system. And so the goal of that advocate is, at the end of the day, to fulfill the role of the system. So for example, if you, if there is someone working with the police, an advocate that works with the police, the goal of that advocate would be to help the police build the case and create a good relationship with the survivor. And then also systems-based advocates support survivors, but they also do provide information and support. But systems-based advocates typically do not hold the same confidentiality as community-based advocates. Some may be mandated reporters. We've worked with some on campuses who are Title IX reporters, et cetera. So we wanted to sort of share that with you all, just to differentiate between the two types of advocates, and also to share that it is important for the survivor at the hospital, survivor patient at the hospital, to have access to full confidentiality. So an ideal situation would be for a community-based advocate to be present with the survivor through all phases of the forensic rape exam, even in the initial intake portion, and for that advocate to be able to talk through all of the options with the survivor. Systems-based advocates can also be very helpful, but it's important for the survivor to know upfront what their level of confidentiality is and sort of who they work for, what their role is. So hopefully that is helpful to you all, and we can get started with the panel. Thank you for listening to me. Thank you, Carla, for providing us some background about confidentiality advocates. So we have a great panel, group of panelists today from all various backgrounds who serve pediatrics, adult adolescents, and even patients from different diverse communities. So first I want to introduce Sarah Walters. She's a project coordinator with the National Sexual Violence Resource Center. We have Laurel Shepard, who is a program director, and she's with the Victim Witness Services for Northern Arizona. We have Gina Scarmella, which is, she is an independent consultant, and she has a background with working with the Boston Area Rape Crisis Center. And then we also have Lori Jenkins, who is a sexual assault service director, and she works with the Refuge in Utah. So thank you all for joining us today, and we're going to kind of jump into the panel discussion. And again, also as a reminder for our participants that we do have the Q&A function if you all have any questions as we go along. So similar to what Carla said, that advocates can look different depending on where they practice. We know that you can be paid staff, you know that you can be a volunteer, we know that you can have a background in an academic degree where you have a background in social work, criminal justice, also psychology or education, or you can get some on-the-job training during and before you actually start working. And so with that being said, we kind of want to just learn about your role. So what was your role either now or when you were working, and what did that look like when you worked along with the medical team and accompanied patients during the medical forensic exam? Gina, we can start with you. Great. So, again, my name is Gina Scaramella, and as folks shared, I had a long career at the Boston Area Rape Crisis Center. And I still do work around medical advocacy, but now I do it as a consultant, more doing technical assistance. But early in my career, I actually was a volunteer at the Boston Area Rape Crisis Center on the hotline, and that's when, like many people who end up in this work, I learned about some of the roles that exist in rape crisis centers and about social work and all of those things and ended up going to social work school and was hired when I came out to develop the medical advocacy program there. And at the time, we really weren't getting many cases at all, maybe going to the hospital in a dense urban area maybe 12, 15 times a year. And in addition to that, what we were also seeing was just a huge amount of trauma coming from people who had been to the hospital. So my role really was about building up that program and understanding what was going on that was causing such distress to people who had gone to the hospital and changing that. And SANE was a big, big part of what made that difference and has made me a huge champion of the program. And so over the years, as my role changed and developed, so as an executive director, I supported the SANE program and worked with them on the first national tele-nursing initiative and now work with IAFN on their TeleSafe initiative. So it really has been a thread through my career to be focused on this intervention as one that really can make a huge difference in the lives of survivors. So I don't know if I even answered your question, but hopefully somewhere in there I did. Yeah, you did. I just really want like a background about you and then once we kind of get a background about everyone, we can go back to medical advocacy and like what that looks like when accompanying a patient. Sarah, would you like to go next? Yeah, my name is Sarah. I currently now work for NSVRC, which Carla mentioned, we are a national technical assistance provider and I work on a handful of projects there at NSVRC. But prior to coming to NSVRC, I did work as a direct service advocate in a community-based organization in New York, Pennsylvania. So it's sort of a unique county in that it has a very dense urban center and a lot of rural parts of the community. So we worked on outreach, but one of my primary roles was as a medical advocate. I was on call all the time to respond to our hospital. We had two hospital systems, but also teams of forensic nurses who kind of moved around a little bit and they would call us if they were responding to a call within the county. And so this was a 24-hour a day, seven day a week. Somebody was always available in our county. So I worked as a medical advocate and did hospital accompaniments and healthcare-based setting accompaniment in general. We would also go to doctor's offices if we were called there. And I also worked on our local college campus as sort of a campus advocate. And sometimes that would involve escorting folks to campus services, health services, or helping them off campus with those, meeting those needs. So that's how I ended up where I am now. Thank you. Laurel, would you like to go next? Sure. Thank you, Yati. I'm coming to you guys from the Navajo Nation. My experience comes from a kind of a mishmash of a few different things. And I had the unique opportunity to serve with law enforcement for about 12 to 15 years prior to coming into the work of advocacy. But advocacy has been with me since day one. As a federal law enforcement officer in Indian country, we were more often than not the advocates, the CPS workers, the just about everything, if you can imagine what that work looks like out there in various reservations throughout the United States. And then moving forward, I went into some of the direct services. And then over the past couple of years, our program was tasked to, the Navajo Nation came to our program. And we are a nonprofit and community-based organization. It started out as a voluntary program originally. And a couple of years ago, the Navajo Nation came to us and asked us, what does advocacy look like? What do you guys mean? And so we have, we actually serve all victims of crime. So we get a lot of different kinds of cases. And when it comes to Indian country, sometimes a lot of those, you think it's a intox because some areas are still in prohibition era. And it actually turns out to be more something bigger, like a sexual assault very often. So over the past couple of years, I've worked to establish advocacy programs in various communities throughout the Navajo Nation. So since in the past couple of years, I think we've opened six offices on the nation and have provided over in this last quarter, I think about 15,000 different services to the people and our visitors on the nation. And it's all dependent on, it's a mix of what, a lot of mixture of the type of crimes that we see, but sometimes they're very much related and intertwined. So thank you for having me. Thank you. And thank you for all the work that you do, especially in highlighting how things can be different when working with tribal communities within Navajo Nation and in other tribal communities and how sometimes you might have to play multiple roles and how that intertwines in providing services for patients. Lori, can you give us a little background about your role? My name is Lori Jenkins and I work for The Refuge Utah. We are a community-based crisis center. And we are located in Utah County, which has two of our state's largest universities. So we're kind of in the middle of that, which gives us some unique challenges where it's the education. It's difficult to educate a whole new thousands of people coming on campus and they might not be there for a really long time. And then, you know, in three months, four months, we have a whole new set of individuals. And we know with college students, that's a higher demographic for sexual assault to happen. So we have some unique challenges. We do, our center has both domestic violence and sexual assault components of helping individuals. We have a special pediatric area that we serve and do the accompaniment to our pediatric cases, but also our adult cases. We have eight hospitals. We've got rural areas and the city. So we kind of run the gamut. We do send two advocates out to each call, which has been a little bit different than we've seen, because as you know, there's more than one victim. You have your primary victim, but there's family members and friends that are also trying to grapple with what happened and to know the best next steps. So we try and think outside the box to really help and support the individuals in our community and are just proceeding from there. Great. Thanks, everyone. What a great, what a great panel. So the next question is for everyone. How are you trained and how do you maintain confidentiality? And actually, I will pick someone. Sarah, if you want to start, and then you can pass it on to someone else. Thanks. Sure. Yeah. So when it comes to, and I'm sure folks on this panel can speak to this as well, when it comes to what awards an advocate, their level of confidentiality, it is different from state to state, both what that confidentiality level is, but also what that training requires. I can speak to here in Pennsylvania, where I worked as an advocate, sexual assault advocates complete a 40-hour training that is approved by our state funders and state coalition, who are the funders. And that curriculum is updated and maintained by the coalition and then delivered by those centers, like the one I worked at. So part of my job was actually to then deliver that training to other folks and be a part of that advocate training. And I think that was having advocates who do the work also be a part of providing the training was such an important part of what our organization did. And I also worked at a dual center as well. I worked at a center that was funded to provide support services for sexual assault survivors, as well as domestic violence and human trafficking. So in Pennsylvania, in addition to the 40-hour sexual assault training, there was also a 31-hour domestic violence training. So in total 71 hours here in Pennsylvania. So it's an in-depth training. And I can probably say very generally that that is the case for a lot of advocates across the country. It's a very involved and very important training that covers a lot of topics, including, I wrote some down so that I wouldn't forget, things like trauma-informed care, cultural competency, working with marginalized and oppressed communities, understanding the rights and options, both legally and medically in your state and your area, so that you can then communicate that to victims and survivors. And usually that training will also have some kind of skill development element that will include like a role play or going through scenarios so that people can feel especially prepared prior to going into the actual work. And that was sort of how I was trained. And then the other thing that came from that was that our team was in the unique position to both be providing direct service, so using our training practically, but then turning around and providing more training to the community because we provided community education. So I'm a very much like learn by doing, but also learn by teaching kind of person. So I think that that was also a great tool that we had in our organization. but you have to have that training in order to be awarded that confidentiality. In order to maintain that confidentiality, you have to be working under the supervision of that agency. So, that was my experience, personally, but I'll pass it over to Gina to add anything else. Sure. Massachusetts works very similarly. So, with almost the exact same structure that you just described, I'll add one thing to what you were sharing, which is that our advocates and programming also got involved with helping to train in the hospitals, for example, residency programs and other things, and SANEs. So, there was a lot of cross-train where they would come into parts of our training, and we would go into parts of their training, as well as other medical provider trainings, which was, I think, a really rich exchange. Laurel? Yeah. So, a lot of the same things in our area, as well, with the 40-hour core, whether it's DV with advocacy or sexual violence, but in addition to that, we came upon a unique situation with an Indian country, of course, in talking about privileges. Before, we didn't, our privilege, our communication wasn't privileged within, on the tribe, tribal nations. So, we're dealing with a lot, like a giant jurisdictional nightmare. We have the state, we have federal, and we have county and tribal on top of everything else. So, some of our tribal laws did not protect our work with victims. But that, through years of work, that actually just got mentioned. We had some amendments made to our victim rights bill, which was before only four sentences, and has been very much updated as of recently. So, our area is really working to catch up on how we're going to move forward with that. But part of that comes, some of that confidentiality and that privilege, as well. And then, when it comes to training, of course, the basic, we do the state stuff. And when it comes to the tribe and working and trying to properly and effectively train advocates who are working on tribal communities, it became really hard. Because when I went through, and just my experience, adding volunteer advocacy or coming from a law enforcement perspective, a lot of the training that I went to was not applicable. A lot of it was not applicable. And it really, it was something we could dream of having on the nation. And so, just this past July, we put together a specific training for advocates working on the nation. Definitely not accredited. It's just something we put together really quick, because we know we needed some type of training for all the advocates out there. And so, we made it specific to what you might actually experience on the nation and how our laws, reflecting our current laws and practices out there. So, it is, in our work, of course, the state mandates, of course. And then, we get a lot of federal support. But sometimes, again, we really have to train new advocates and new individuals on what it actually looks like out here. And so, sometimes it's on-the-fly training, sometimes. Oh, I was supposed to, let's go to Lori. Sorry. I guess I will concur with everything that has been said. We also do the 40-hour training. And then, we have monthly two-hour in-service training to make sure that people are kept current. As we know, each legislative session, there's something new that's coming down and that we need to ebb and flow and adjust. And I love that it's not static, because hopefully, through that, we are making improvements and learning and growing. We have unique situations that happen in areas. So, it's great to get that additional training. And it's great to get the team together, because people go out in twos. They're not seeing the greater team altogether, like they had in training. And it kind of just unifies and gets people back together. We like to do a lot of our community leaders and experts in their field, so that they're learning from the person that they're working with, with our forensic nurses. And they're learning from those specific people that they might bump into in the hospital. So, it's great to have that ongoing training and to keep people up-to-date with things. Thank you. Yes, training is... It sounds like there's a very, like, you know, from a baseline 40-hour training, but then it's going to look different depending on where you come from and depending on who you serve. And one thing I love about our group of panelists is that you talk about serving campus communities, talking about serving pediatrics, or even rural, or even urban communities. And obviously, those different communities are going to have different needs. So, could you all touch based on, like, what are the priorities when you all are coming in for a medical forensic exam with a patient? And what are some of your priorities when serving those patients, survivors? And anyone can jump in. I'll jump in. So, in an urban environment like Boston, where there's, you know, many hospitals, I think there was, in our catchment area, maybe 16 hospitals, seven of which were hospitals where there was a SANE program, where both SANE and our center would respond through the same page, meaning beep-beep kind of page. And so, those were the ones that were the big teaching hospitals where they were very busy. I think, you know, before the pandemic, we were at about 525 a year in terms of cases, and that's just adults. We actually didn't serve pediatric patients from our site. I think that probably would have been the next horizon. But so, because it's such a diverse community and you're needing to be ready to be, I think in some ways the training is similar to hotline where you really need to ready yourself to be ready for whoever is there. And so, the background training you're getting in cultural humility and in understanding where communities are coming from and understanding, you know, your area, your city, the neighborhoods in your city, and the different cultural groups within that is really important. And I think rape crisis centers and probably other advocacy organizations tend to be pretty good at emphasizing that learning. So, I think that serves you well. And just having a listening, active listening frame as you're greeting someone and sort of understanding what they need is probably two of the things. You know, coming in with a humility in your, from your training and being ready to listen and learn from that person what they need. Along with what Gina said, we really try and train our advocates to not enter the hospital room as here I am, but there you are. And seeing from a victim's perspective what their major concern or needs are. One of the last cases I went on, this girl was pretty beat up and had a lot of injury. And her main concern was she was going to one of the universities. Her main concern was the test she had in the morning. That certainly wouldn't have been my main concern, but we have to take victims where they're at and where their power and control has been taken away, make sure that we back that bus up and go from their perspective and help them adjust with what their major needs are and just be, have it be victim-centered and victim-led. So when we're dealing with a medical advocacy, one of our first priorities is safety. Just in our area, that tends to be one of our biggest concerns. And then usually after, of course, it's medical care. Unfortunately, on the reservations, cases tend to be more severe. And so aside from the sexual assault, usually comes a lot of medical issues, medical attention that is needed before we can even get to that forensic exam. But after that, one of the things is the communication with the client. It's really a lot of that medical jargon, medical lingo is really thrown out there pretty quickly. So making sure the client understands what is going on and what is happening and really giving them the power to choose again and make informed decisions after that. So those are some of the main priorities that come up initially when dealing with cases. And then the other thing, it sounds like you mentioned the test being one of the priorities of the victim at the time. The other thing that comes into play in a lot of areas out here, because we're on a reservation, everyone's related to each other, everyone knows each other. So sometimes the victim's priority becomes confidentiality. So those are some of the things that we really try to address right away in order to get them comfortable and have a say in making some good choices for themselves. Thank you. And Laurel, I also, we had a question about specifically Indian country and what advocacy training looks like for the needs of tribal communities. And you spoke about some new training that you developed. Can you share a little bit about that? Yeah, so we, just based off of the experiences and knowing my community, my nation, we took the laws and brought them forth with what we've seen on the nation and really created a unique advocacy program to respond to how the nation is currently. For example, on reservations, we have the Major Crimes Act. So some places, some reservations police their own. So they're 638, similar to IHS, where you have an IHS facility or you have one that is a 638 contract. So my community, we police our own, but we have that big brother oversight from our federal partners where they oversee all our major crimes through the Major Crimes Act. And so an example of how we do, one thing we created through it is understanding that our tribe, our laws only have a three-year statute of limitation. And so when it comes to fine tuning what that training looks like, because sometimes off the reservation, sometimes I think there's no statute of limitations more often there. So it's not necessarily the case and federal cases are taking about a year and a half to plus. Year and a half is a good timing for an investigation to be complete. And then from there, it is sent on to the U.S. Attorney's Office. From there, it takes more time. And by the time they decide they're going to prosecute or they're going to send declination letters back to the nation, that tribal statute of limitations has expired. And so we really went through in having community-based or anybody from a home tribe working with federal partners to start advocacy right away for a number of reasons. And so that's kind of how we looked at fine tuning what advocacy looked like in our area, because it looks very, very different. And some of the things that we've incorporated also include working with traditional healing in lieu of counseling and making those available to everyone. And also another thing is hiring from communities, because maybe from one community looking at another, it still looks very different. And how advocacy is completed for that community varies even. We're dealing with a giant landmass out here on the Navajo Nation, too. So there's all those different considerations that were made when we created this training for our advocates working on the nation. So it's also a lot of fine tuning, because we're also working towards adjusting some of those. So as advocates sometimes on the nation, we're also working with advocating for our laws and some policy change on a higher level, too. So we've got a lot of different layers of what advocacy looks like on tribal lands. And Lori, something that I thought was unique about your program is that you have two volunteers come in for the or two advocates come in for the exam. And so you do deal with a lot of volunteers, a lot of like especially like from the college campuses. Can you speak a little bit about if there is any different training expectations for volunteers versus if somebody was a paid staff? Yeah, we found that this system works really well in our community. Being by two universities, we do get a lot of volunteers that are willing to give their time. That's one great thing I can say about our Utah community is they're willing to volunteer. But we have a primary advocate and a secondary advocate. And so with the two of them going out, the primary advocate would usually have more experience. And to become a primary advocate, you have to have gone on four different calls where you're in the room. Then you get kind of a basis of different people's approach and you get to see a lot of different cases. And so a secondary who would be a newer advocate is always able to learn from the primary. And then as so they're able to help them, they're able to kind of guide them. And usually they'll see four different versions before they become a primary. And it's great to sometimes they're both in the room and other times we've got mom and dad who are in the waiting room. And they're just grappling with how do I help my son or daughter or my niece or their loved one. And it's great that an advocate with training of resources and things can sit down with them. And we have a packet of information. Go through that. Explain community resources. Explain how the system works. Explain victims' rights and then help them to educate on some of the rape myths. Like not asking, well, why were you there at this time at night or what were you wearing or different things like that. But just even educating them phrases like, I sure love you. I'm so sorry that this happened. What does support look like to you? And to have them be able to articulate, like, I don't want to talk about this all the time unless I'm ready to talk about it. Or can you not hug me a lot unless I reach out. Just different things. And as we know, it looks different to everyone. So with ours, we do have a part. We have a grant that does matching. And so the hours that are volunteered, they help with that matching grant. And then we do have a paid grant that can pay certainly not what they're worth, but some stipend to have them go out, pay mileage. We have 12 different facilities that we're covering from one end of our county to the other. So it can pay mileage and it can pay time when they're there. But it seems to work out really well for us because we do understand there's more than one victim during a case. So that's our two system. There's a question received from Caprice who is sharing that she would like some information. She's starting a medical advocacy program in her community and she's curious about best practices. So if maybe you could each share one best practice of providing medical advocacy, that would be great. And let's start with Laurel. Thank you for the question. That's always exciting getting to start a new program and getting to develop it the way you want or what the area is. But one of the key things, especially when starting this advocacy program out here on the nation, was really getting a good overview of what was already in place. And getting an idea of who the partners are, who is already providing some of the services that you might need within a medical facility is huge. And building those partnerships, building those relationships, and understanding who's on your team in this work that we're doing. And then from there, building upon that within, and that way you're not start recreating any wheels or recreating anything. You already have a good foundation to move forward on. So I think that was one of the biggest things that I could recommend when starting a new program. I feel like for this one, something that came to mind is something that we have been working with in some of our grantee sites. And that is finding ways to secure buy-in from the people who make policy in the places where you'll be providing these services. And what does that look like? And I think, at least when we were trying to do this, when I was providing direct service, particularly on a college campus. And we were trying to sort of make the case as why we needed to have advocates on campus and have this space for advocacy. Is we sort of had to appeal and move away from numbers and statistics. They know all of those. They've heard all of them. And have real tangible stories to share and real things that show that this type of help and assistance makes a difference to the people that that organization might be serving. So whether that's a hospital-based program, wanting to support their patients in the best way possible. And also a campus wanting to support their students in the best way possible. Having opportunities to have those conversations and show the impact and the change, I think, is not only a great way to establish a program, but also to sustain it. So having that in place and having sort of that, here's not an elevator speech, but kind of an elevator speech of this is why it's important and this is why it matters. That you can sort of deliver at will to whoever it is that needs to hear it. So I think that that is a great place to start, especially with a program that you're trying to get off the ground. Let's see. I think I would go with, well, two things. One would be thinking about how formalized you could get in creating an intentional, like an MOU with any sites that you're going to be responding to so that the expectations are really clear. Because if it's new, you do want to make sure that you're delivering what is expected and providing what's expected and what you can provide. And then I guess the second part of that, the second piece would be about how, just where are you and having a good assessment of what your capacity is. People doing that work will, it's a lot to be even on call for some people. Some people seem to have an unbelievable capacity to just be on call, and it doesn't seem to phase them a lot. I think it's a genetic thing. Other people do not have that gene, and it's very exhausting for them to just be on call and then somewhere in the middle for others. And so I think figuring out the staffing, how you're going to do it and how much duplication of service you need in terms of the staffing at any one time. So really just how you're going to take care of people and how many people you need and how much you can really do with the capacity you have. Yeah, I would also say that in some areas sometimes having community-based and system-based can get a little interesting. In Utah County, it's very much so viewed as like, oh my gosh, the system-based advocates are like, oh my gosh, thank you so much for coming and doing this three-hour exam where I have more time that I can help them through the legal process instead of sitting there during that time. And it's very much so like a relay race where one person passes the baton, and I don't need to go through their whole court case because they're doing that and doing that really well, and they don't need to come sit during the exam. But in some areas, it can be viewed as when people are touching down at the same spot like, oh, are you interfering with my grant and my numbers that this won't go well? And so sometimes that takes a real mind shift, and it takes a lot of creativity and a lot of being tenacious to stick with it to say, like, we can touch at the same spot, but why wouldn't we want more services for the victims in this area and in this location? So it seems weird that having additional services isn't always viewed as the great benefit that it can be. Sometimes that takes, I'm going to call it, creativity to get that over and sought after that we can all be there at the same time and just work more as a relay race. Yeah, Lori, something that you're really touching on is a victim-centered approach, or for clinicians, that's a patient-centered approach, and it's actually highlighted in the national protocol for medical forensic exams for adult, adolescent, and pediatrics, and it talks about how, you know, victims deserve timely, compassionate, respectful, and appropriate care, you know, that promotes healing as well as promotes informed decision-making, and so that really ties into offering more resources than just maybe one, and if that means collaborating with community-based advocates and system-based advocates to, you know, provide that centered care, then that's what, you know, is important and best practice for that area or for that patient. Exactly, because a lot of system-based, they don't have, our center has free individual therapy, and we have groups, and we have classes, and we have things that they don't provide, which I don't think they need to provide because we have that, and they have things, and just like we heard earlier, there's different confidentiality, and I don't think all the time that's expressed enough to victims. They feel that a victim's advocate is a victim's advocate, and whatever goes to them, you know, stays with them, and same with our forensic nurses. Our forensic nurses in our area are great to say, you know, I'm here, I'm here to help you, but just so you know, anything that you say to me could be sent up line, you know, in both directions, and so I need you to know that. If at any time you would like me to step out so that you can talk to your community-based advocates, I would be happy to do that, but I don't know that always system-based advocates are expressing that to give them an option, and I think conversations would be a little bit different because as we know, sometimes there's been underage drinking or drug use or whatnot, and they need to know that what they say could be used against them possibly. Yeah, and that sounds very familiar. When I worked in a community-based clinic, we worked very closely alongside advocates, and it's so important to have both parties there, present in the beginning of that medical forensic exam, the forensic nurse and the advocate, because I would say, like, you know, I'm your nurse, I'm here to take care of you, your needs come first. Everything that you say, though, could potentially go on this medical document, right, and although everything you say is used for, you know, helps guide my exam, helps me take care of you, however, we do have advocates that you can talk to that has that different level of confidentiality, right, and so having that advocate there in the beginning kind of helps with that and really helps, like, the teams communicate. In speaking about, like, the medical forensic exam and providing medical advocacy, are there any barriers or challenges that you all face in that? Because, you know, we say all the time, like, you know, we want an advocate there in the beginning, during the exam, and to be there to support that patient at the end, however, especially highlighted during COVID, that didn't always happen, so have you all experienced any barriers or challenges in being able to be there throughout the whole exam for that patient? Yeah, I can start. Something that happened kind of consistently, I started providing direct service smack in the middle of, like, the peak of COVID in 2020, so when we first began doing hospital accompaniments, it was entirely over the phone because we were actually not allowed to come into the hospital facilities at that time, so that created a barrier in that I think offering a patient or survivor a phone in the middle of sort of an exam that can be really traumatizing and they might be having the worst day of their life, and you hand them a phone and say, talk to someone, it doesn't always translate very well, and that was something we struggled with a lot, is connecting between that phone and them being able and feeling empowered to say, hey, I'm going to call you, I'm going to talk to you, and then feeling empowered to seek our services upon discharge, too, and find that follow-up care that they might need. But something that, outside of that, that I experienced a lot as a direct service advocate was, and this kind of relates back to starting up a program and making those relationships and making sure people know what advocates do and why they're there and what their purpose is and why they're important, was we struggled a lot with law enforcement in our community not respecting the confidentiality needs and rights of having an advocate there in the room and providing that confidential space. And a lot of that was more on the domestic violence side of things. So if somebody presented in the ER as a DV victim, a lot of times, by the time I got there as an advocate, there would already be police in the room. And a part of the problem there was that I didn't have a chance then to go in and say, before you say anything to anybody, here is what your rights are. And here is what all those different folks who may cycle into this room, how each one differs in what they're gonna have to talk to other people about. And I think that was always a struggle that we had. And sometimes it was just as simple as that law enforcement officer didn't know that an advocate was coming, didn't understand that that was even taking place. But there were times when they were very aware, but there would be friction upon entering that space. And there's not a lot in training, I think a lot about how to navigate those conversations and how to assert yourself as an advocate and say, these are the rights that this person has, and I need you to respect that as a law enforcement officer and give us this space and yield this space to us until this person asks you to come back in. And I think that that was something that was remedied a lot by our relationships that we formed with law enforcement locally, who would know like, oh, they're from the YWCA, let me just back out of the, and I think, so it was just an ongoing thing, but I think that was at least for my community that I serve, because we also served human trafficking survivors as well. So if somebody disclosed when they came in that they'd been trafficked, we would also be called. And that was oftentimes an instance where law enforcement might already be in the space. And so I think finding ways to navigate that and supporting advocates in learning how to navigate those spaces, because of complicated relationships that already exist between our communities sometimes and law enforcement was a really important and definitely an ongoing challenge that we had. Also along with that, we had the case that sometimes medical professionals are a hiccup in that we've had victims go into the hospital and they're like, this is what happened to me. We've had nurses, regular emergency room nurses that have said, if you want the medical forensic exam, you have to be willing to press charges. Which is totally incorrect for our state. And the exam is free of charge, but then you find out about a victim that dropped out of school to pay a two, $3,000 emergency department bill, and then stayed out of school for another couple months to be able to afford the therapy that they felt they needed. And then to find out later that all those services were provided free of charge and that were ready and just waiting for them to want access for those was pretty traumatizing for a victim that I spoke with the other day. So sometimes it's getting the word out. I would say that's our biggest roadblock is getting the word out to people in our community that these services are available and to have law enforcement and medical care providers to know that. And to say, here, go this direction. They have everything, you're in charge of the exam. You can just go in and say, I'd like the medication or I'd like the head to toe exam and the medication, or I'd like to restrict my kid because I haven't decided what I'd like to go with. So there are a lot of different possibilities that way that they can utilize. Got a comment? Yeah, did you say me? Yeah, I was thinking about some challenges we had over the years when the problem was actually someone in the emergency room where there was a provider in the emergency room, maybe a nurse manager who just was not on the same page about the protocol of how we had set up for survivors to be treated, because there was a protocol in all these hospitals. Things like, there was a protocol, if a SANE nurse wasn't available after a certain number of tries, they were to start initiating doing the exam themselves using their own internal staff and they wouldn't do that. So somebody could be waiting eight hours. Different issues like that that came up, I think were difficult to handle because was it us as the advocacy program that tended to have less credibility with those players, providers than SANE, but SANE also has a lot of relationship with the hospital and the hospital teams. So I think some of those dynamics are really complicated to figure out. So I guess I would just say, some sort of formalized feedback loops between the different groups of folks involved can be really helpful. So there are identified people to go to. So I can probably echo all those challenges, but in addition to some of the things, especially like during COVID, advocacy wasn't an essential employee or anything. So we had some major restrictions on our nation. So it was really hard to get help out there, but we kind of, we navigated through it. But when it comes to having a medical accompaniment through the hospitals, we really struggle with finding the staff sometimes because right now in our area, I think on the nation in general, so we work with all victims. So we're not in a medical setting, but we have heavily supported our local healthcare center who were fortunate to have a pediatric examiner as well. And unfortunately more often than not, she's a one man show. So that with her SANE program, we've been able to come in and be welcome and create some of these processes. But it's also a big challenge within that medical facility because it's IHS. So we get a lot of turnover. There's people cycling through the ER. And so not everyone is up to speed on who's who and what is going on. So it's really hard to maintain that education with everyone moving through. In addition is buy-in from all the various players in that are responding to these cases. So we struggle with our law enforcement. We struggle with probably about every aspect of an exam. So there's not an exam that is completed where we don't have a challenge or we don't have something come up. I know that our area has really been struggling with tracking and if these cases are even being processed. So there's in our area, unfortunately, we do see a lot of challenges and between a few MITEI, we've been able to really help and navigate through those processes, but we're really ongoing in identifying what those best practices look like. And a lot of best practices, we talk about barriers. It almost kind of coincides and something that you all touched on is communication. So communication with the same team and the advocacy team and how important it is that that's an ongoing communication to figure out who's gonna solve that problem. We have an issue with the ER where patients aren't being served the way that they should. Is it the advocacy? Is it the same? And really having that ongoing communication with those community partners. Can you all talk about the importance of SARTs or multidisciplinary teams? If we all communicate and know about each other's role, would that kind of help overcome some of those barriers? I think those are some of the best practices out there that we'd love to see. And it's just the level of education and buy-in from different areas. I mean, there's so many contributing factors to why some of these are not working. I know that we do have, like during COVID, everything shut down. There was no court. They let out people from jail. There was nothing going on. And so that made it really hard. But as we start, literally, I think probably in January was when, late January, early February was when we finally lifted the mask mandates in our area. And just as of maybe a month ago, our courts finally opened back up. So we've advocated for a long time for MDTs. And we know they would work beautifully if we could get everyone to participate. But there's only a few participants. And so that's really hard. I think where it has worked for what we are doing for those who are participating in certain things is really figuring out a communication plan and establishing what each other's roles are and really prepping through the process. And on my end, it's a lot of training on advocates and really introducing those new individuals to different areas where they'll be practicing and having them build relationships there. Because even relationships between providers and advocates are huge in getting to know who they are. So the trust. And then trust is another thing. It was really hard to establish a program out on the nation, for one, because programs we've had, you would think that tribes get a lot of grants and things like that. And they do. But it's sometimes these grants, a lot of the time, historically, we've had an advocacy program come in one year and be gone the next. And that cycle just happened for a number of years. So when our program came through, it was really building that trust piece and the relationship and saying, hey, we're going to be here. And so we're finally moving into that stage. And we know that these MDTs and SART teams could be really beneficial. It's just a matter of putting in the work and finding the people, too. So yeah. In Utah County, we have both a Special Victims Task Force, which is a multidisciplinary team where we've been able to actually help each other with huge cases and have it be very supportive. And that's where you can get people to do your training and to help be your community resources. And that's gone really well. Starting this last year, we've been invited to a multidisciplinary team that screens all of the sexual assault cases. And it's been a different experience. They have the forensic nurse team. They also have the detective that's doing the case, the attorneys that are hearing the case. But I think it's a real much-needed component to have the community-based there because not every case, as we know, goes to trial or is moved forward. But that doesn't mean that the healing and the services aren't needed. So even as, well, especially even if a case is two years old, but then that word comes down that it's not moving forward, that's a time when they're going to need more supportive services and have things brought back up that these are an option for group therapy, classes, individual therapy, and other things. We know that we can't have justice be equal to healing, because then a lot of times that won't happen. But the more you just interface with different people, then you're able to kind of get your foot in the door to be able to make a difference in different areas. Sarah, is that something? Yeah, I was just going to speak to, and I think, Lori, you could probably say the same about the importance in terms of campuses and communities. So having those teams that include folks from those campuses as well was really integral for us in order to establish our presence on the campus, because we then had folks on our SART community team that were from the school, were from the college's police force, were from even the Title IX office, people who were working on campus in various capacities, were a part of the community-based SART team. So we would have even the local hospital nurses were a part of it. So it was a very well-integrated group of people. I will say one of the challenges with it is, I think this was mentioned already, is turning over positions when you have this group of people in a lot of these roles. And you meet, if you're lucky, once a month, I think, having that turnover sometimes. And maybe the person who is new in that role, the district attorney's office, doesn't even know the SART exists because nobody told them about it. So there's a lot of that, too, of how hard it can be to maintain and whose plate that falls on, really. Who on the team is meant to uphold all of those things. But I do know that having that team was incredibly important for us as community advocates to stay involved and talking to all these different components of folks who worked and served our community. And maybe working to help minimize or work around those barriers that we were facing in providing medical advocacy. Thank you, Sarah. One question we wanted to ask, and this was for you, Laurie, but I think all of you could probably share something. How is medical advocacy different when the patient is considered pediatric? That's a really good question. It does end up needing some creativity. Definitely, as forensic nurses, everyone knows you would never force an exam on someone. But you can get really creative. And I've seen some awesome nurses that pull tricks out of their bag of getting a minor or a young child distracted. As we know, the exam looks different between a pediatric individual as to an adult. And again, we have multiple victims. You have never seen distress than as a parent with a minor child that has been sexually assaulted or abused. And so definitely, that's been a benefit for us sending to advocates. Because sometimes, you need to be playing with the siblings or playing with that minor individual while mom gets an interview. And vice versa, just being a distraction and helping to calm mom or dad down. Another challenge is a lot of times we know that with minor victims, they usually know the perpetrator, which can cause a lot of trauma all the way around, whether that's a brother or a father or an uncle or an aunt. There's also that violation of trust in the family. And sometimes, it is a person that lives in their home. So there's that added stress of if they are forthright or say, are they going to get their brother in trouble? Or are they going to get somebody that they love and care about? Because we know most times previous to that, there's a lot of grooming involved. And like, we're going to keep this secret. Or you don't want me to have to leave the house. Or this is going to be our special secret type thing. Our minor patients, you would think they would be in more trauma in that moment. But a lot of times, it doesn't look that way in the moment. It's kind of like onions. There are definite layers. We are very lucky in our community to have a Children's Justice Center where that exam can take place in maybe not a hospital environment, a home-like environment, and where their interview can take place where they get to pick the person. And it's recorded so that they don't have to be interviewed over and over. We do have some extra training that is on top of the 40-hour. We have an additional 10-hour pediatric training where we go through ages and stages and best practices so that we're trauma-informed. And so that we don't ask questions that would lead them to answer. Because we, of course, just like everywhere else, we're mandatory reporters. And we know that at that point, they're already linked into the system. But we don't want to do that interview. That's not our place. That's not our position. So with that additional training and working hands-in-hand with the Children's Justice Center, I think we have a really good flow at how to make that work in our community. And Laura, you're talking about the horrific interview that you can provide at a CAC. Yeah. As we talk about the needs for different survivors, we know that there are gaps in being able to access resources for after sexual assault for survivors from different communities, such as survivors of color, LGBTQ-plus survivors, survivors who may have disabilities. We talk about tribal survivors and survivors from rural areas, and even survivors who may have different immigration status. So can you all touch on what providing resources to diverse communities may look like and how there may be a different approach for how you might need to tailor the resources to different unique communities? I can speak a little bit to this. We had a very small team of advocates in the community that I served. And so me being a part of maybe four other people who were doing this on the team, I sort of became the in-house expert about serving LGBTQ-plus survivors as someone who identifies within the community myself, but also who was in charge of developing the training around the issue. Developing the training around those topics for community members and organizations. So I can speak specifically to that. I think in terms of tailoring resources, something that I found, and this obviously isn't possible for every organization, but sending folks into that space who do have some sort of understanding of that person's lived experience and being able to have a sensitivity to that and also be willing to learn and understand in the moment. And I know that probably sounds very self-explanatory, but it isn't, at least from my experience and practice. Sometimes I will come into a space where maybe I'm serving or working with a trans survivor. And up until I walked into that room, they have been misgendered because of what's the marker on their paperwork and folks coming in and out of the space. And so they're adding on these layers of trauma that whether it is intended or not by the staff helping them, they may not feel empowered to speak up and may not have the strength in that moment to educate the people in the room. So I can then become that voice for them if they need me to speak up to the nurses and staff about what they prefer to be called, if they need me to speak to whoever might be in that space on their behalf. And then also when it comes to connecting with resources, understanding what your community has and what it can offer is really important, like knowing what the queer coalition was in our county and knowing the person who ran it. So I knew personally that I could vouch for that. I think the vouching is just as important. So understanding if I'm going to refer somebody to this place that I know and trust that it's a safe place for that person of whatever life experience they're coming from. But then also understanding the climate of your own community, understanding what that person who lives in your community and is of that lived experience is going through in that space. And so just maintaining an understanding of your own community and also just being willing to learn even in the moment and maybe be the voice for that person in the space is just as important as connecting them with relevant resources upon leaving. I would echo what Sarah said, but also add that as we're leaving, we give our victims and our secondary victims a packet that kind of talks about next steps, community resources and whatnot. And so during the exam, if they mention that they're from the LGBTQ+, or if they're from a certain university or part of the military or whatnot, we add into that packet pages that are specific to that university, all of the systems and programs that they can use there, centers and other groups and classes that could help with LGBTQ+, individuals that would make them feel more comfortable. So that the packet isn't so overwhelming to include everything for everyone. It ends up being customizable because we know that in that moment, they might not be retaining everything, but then when they have something, most people could lose a packet of information, but they don't lose their email or their computer as often. So they can pull that up when maybe three months down the road, they thought that they could kind of push things down and things would go away. And when they realize that they're not, they can pull that up and it's kind of customized resources for them. We found that that's really helpful for victims moving forward. I could share a couple of groups that come to mind. I mean, one is male survivors, which are not as uncommon as it used to be, but I still think that there's some additional training that can be provided to advocates accompanying male survivors to just understand that experience a little bit more. So we definitely provided that. And so I think that's an important group too. That's a pretty significant percentage, I think usually about 10 to 15% of accompaniments, at least in urban areas. And then in some areas in Boston was one, we also were accompanying folks who were coming in from correctional facilities. So that was another group of folks who you just had to have a little bit of a different training and mindset in terms of, they're not going to go make a cup of tea later. In the same way, like some of the frameworks you might have in your head for self-care and other things have to really change. So that was another group of folks. So just tuning people into what some helpful ways of providing ideas around self-care and being with that person might be. I also can recall a case I was on a million years ago where the survivor ended up disclosing that she was a Jehovah's Witness and was very uncomfortable with the conversation around prophylactic abortion care. And so I think that experience just really helped me remember not to make any assumptions based on people's age or anything. So I think even if somebody appears to be part of a group that you might think you've got in your frame or you're part of it and feel like you know it, that people can come from different spaces because of intersectionality. And so just being ready to listen and hear that. Yeah, and even like you said, going back to tying back in the nurse and that when you talk about prophylactic medication, because so many people don't understand that medication isn't like an abortive pill and that if you're already pregnant, then it's not going to change the fact that you're pregnant and it's more so preventative. So I think we get that a lot, especially with religious communities. Yeah, so Raul, you had a comment? Yeah, sure. So one of the things that we have done is a language. In our area, we still have a lot of Navajo-only speakers. So and then also, like for example, Navajo was my first language and I think I have the English language down a little bit. So I still have a preference when, and just as an example, I still have a preference to speak Navajo and I feel like I can get more across when speaking that language instead. So that's one thing. And then also, we are, like I mentioned, we're community-based. So we have one of the privileges of being able to create programs based off of the needs of the communities. And again, just where we're at, a lot of the time, we are the resource. Sometimes we are the only resource. There are times that we really utilize warm handoffs with partners who can provide better services or more services geared to their needs. But usually always that's done with somebody we know. So we have really good partnerships for those things. But one of the things that we created in terms of groups, because like DV support groups, victim support groups was not working in my community. And we needed a more practical approach. And one of the things that, as a result of figuring that out, we created the Healing Through Weaving support group for victims. And what that is, is weaving, traditional Navajo weaving is something that's ingrained all the way back down through from our creation. And so it's a means of support through the teachings of the loom and the meaning of weaving and the prayers and songs that come with it. But also in the long run, provides a practical approach where they are learning something and reconnecting or reconnecting, then also using it as if they stick with it as an income source at some point too. So that's kind of how we've tailored what resources look like in terms of support for our area specifically. As we begin to wrap up this panel discussion, which has been fabulous. I thank you all for joining us today. I just wanna briefly go around and have everyone in one word, describe the feeling or something about why you joined this work. So when I think about why I joined doing this work, one word that comes to mind is passion. Like I was very passionate about the work that I do. So anyone can jump in, just pick one word to describe what that I went to serving as an advocate for patients of sexual violence. I can go first and I'm gonna write my, I put mine in the chat too, just because it's not, our language is, I'll define it. And the word is K'eh. And what that means is, is my relation, my traditional role and responsibility to my people to be healthy and happy and to be safe. And so through K'eh, that is the work and the reason why that I continue to advocate and work on behalf of our people for a better future. And I think that attainment to that balance of something we strive for is called H'zhon. And that's where we're balanced with all things around us, including the earth elements and the people around us. So that traditional responsibilities to my people and community. Thank you, I love that. I would say purpose. Yeah, that gives me a real feeling of making a difference. And as people have said that it's on so many layers, being with somebody individually can really translate to creating system change. And that's really incredible. Thank you. I would say mine is community. For me, I think being a part of the queer community, also being a part of a community of women and fems and women identifying folks, a community of survivors, I myself am a survivor of sexual violence. I think that element of community comes up in doing advocacy in so many different ways. And I think that community is also such a tenet of healing and restoration. So I think that would probably be sort of a driving factor behind wanting to do this work and be present. I would echo all of those. All of those are great. I would fall back on advocacy, but making sure that it's passionate advocacy, that it's advocacy that involves the community, that people have choices, and that we help them in that darkest hour. So I would say advocacy. And Carla, you want to close us out? Sure. Yeah, I just wanted to say thank you all to for being here. All of our participants were wonderful and your various expertise was just great to hear. Yeah, thank you all for being here. And I just wanted to share again that both IFN and NSVRC are here to provide technical assistance, training, whatever you may need as you move through this journey. So thank you all and have a great rest of your day. And we're actually going to pass it back over to Sarah who is the project manager within this grant. She has some additional closeout information for you all. I just want to echo what Carla said. I want to thank each of our panelists, Gina, Laurel, Lori, and Sarah for your time and all that you shared to help inform us and really highlighting all the work that advocates do and those differences that barriers exist that sometimes aren't visible to all of us. I think I can speak for many in thanking you all for all that you do and all that you give in the well-being or caring for the well-being of victims of crime in your everyday work, whether you're gifted with those natural oncogenetics or not. And then lastly, I would like to thank our facilitators, Chantal and Carla, for helping us navigate this important conversation.

medical advocacy program

establishing partnerships

available resources

securing buy-in

real-life stories

comprehensive training

trauma-informed care

cultural competency

collaboration with multidisciplinary teams

needs and priorities of survivors

effective communication

confidentiality concerns