A look at an Alaskan
response to interpersonal violence across the lifespan
Written by Angelia Trujillo & L. Diane Casto
ALASKA IS UNIQUE and shares
similarities with other Arctic regions across the globe. The state is the
largest in the union and is one-fifth the size of the entire lower 48 states. It
is often referred to as the “Last Frontier”. The population of the entire state
is approximately 735,0001 and only 14% of communities are connected
by road to other places. In fact, Alaska’s communities are considered “the most
remote and rural in the nation, scattered across vast tracts of undeveloped
land and separated by challenging topographical features.”2
Alaska has consistently ranked in the top five
states for per capita domestic violence rates over the past two decades.
Alaskan women are sexually assaulted at 2.6 times the national average and
killed by intimate partners at 1.5 times the national average3,4. In
2018, Alaska Natives comprised approximately 15% of the population; however,
84% of Alaska Native women have experienced violence in their lifetime5,6.
Curtis, Kvernmo, and Bjerregaard (2005) noted a high rate of violence and
sexual abuse amongst Arctic populations, with the abuse often being associated
with chronic illness and mental health problems. Healy and Meadows (2007) noted
that women’s health is “a crucial part of the health of their communities” and
called for research to identify the actual rates of IPV and its effects on
women’s health in the Arctic.
Interpersonal violence (IPV) comprises a spectrum
of sexual and physical violence against individuals that are often
interconnected and share similar root causes throughout life stages9.
Specifically, IPV includes intimate partner violence along with domestic
violence, sexual assault, child physical and sexual abuse, or elder abuse. The
various categories of IPV are not limited to any one country or culture but are
endemic around the world9,10,11, although they are frequently
associated with cultural differences12,13.
IPV, in all its forms, has been associated with sequelae including
death, physical trauma, short and long term disability, poor health, chronic
pain, unexplained pelvic pain, post-traumatic stress disorder, depression,
substance abuse disorders, and an increased rate of health care utilization
over the general population14,15,16,17,18,19,20. An additional
concern is that the “hidden trauma” from IPV during childhood translates to IPV
in later life, including the potential for the childhood victim of IPV to
become an adult IPV perpetrator21,22. Economically, IPV is
responsible for $900 million in lost productivity. Healthcare costs for abused
women are reportedly 50% higher than for non-abused women15.
Care for victims of IPV is further complicated by the fact
that healthcare providers have reported a lack of training regarding the issues
of IPV at rates ranging from 33%23 to 61%24. Barriers
toward screening attitudes and practice have been identified in both
quantitative and qualitative research regarding lack of time, lack of education
and HCP estimate of the prevalence of abuse17,25,26,27,28,29,30.
Waalen, Goodwin, Spitz, Petersen, and Saltzman (2000) noted that barriers to
screening for violence are similar to barriers to screening for other
conditions (i.e. smoking, weight loss, substance abuse) — all complex and
sensitive issues that can be difficult to discuss.
This is in contrast to the fact that nurses and healthcare
providers are in a unique position to recognize, report, and intervene
proactively in IPV10. It is also in contrast to the fact that
patients typically have a positive view towards HCP screening. Morse, Lafleur,
Fogarty, Mittal, and Cerulli (2012) found that 66% of women (n=142) said they
would admit IPV if asked, emphasizing the positive role that HCP can play in
the assessment and response to IPV. Ramachandran et al. (2013) notes that not
only do many of the major healthcare provider associations support screening,
but that the U.S. Department of Health & Human Services recommends that all
women be screened for IPV as part of preventive services. Boursnell (2010)
noted that HCP are a gateway to health services, and training and awareness of
IPV screening would result in practice improvements and patient outcomes.
Historically, Alaska has relied on the Sexual Assault Nurse
Examiner (SANE) model to meet the needs of sexual assault victims. However,
there are a number of issues associated with this model: 1) there is
intermittent and limited training availability in Alaska; 2) this model focuses
on nurse response only; 3) the response is limited to victims of sexual assault;
and 4) there is often difficulty in recruiting and retaining nurses for this
limited role, especially in rural locations.
Of importance, the skills typically associated with SANEs
are the same skills that are also utilized for the care of victims of domestic
violence, strangulation, child abuse, and other interpersonal violence related
issues. However, in many areas of the state of Alaska, nurses and providers
find themselves in situations in which they need to identify forensic evidence,
collect and preserve that evidence, and accurately document a patient’s words
and condition. Nurses and providers may be requested to function as fact or
expert witnesses in medical legal investigations. This requires that they hold
the necessary knowledge, skills, and abilities to do so from the onset of care
of the patient.
Interpersonal violence in any form is emotional and
trauma-inducing for victims, families of victims, perpetrators, and
communities. Alaskans who are working to stop violent behaviors need more tools
and resources, as well as better training, in order to provide healing to
victims and accountability for perpetrators. In order to meet Alaskan needs, the
University of Alaska Anchorage’s College of Health, the Council on Domestic
Violence and Sexual Assault (CDVSA, part of the Alaska Department of Public
Safety), and the Alaska Nurses Association collaborated in March 2019 to launch
the Alaska Comprehensive Forensic Training Academy (ACFTA), a training for
comprehensive forensic documentation that is the first of its kind in the
nation. The ACFTA is a pilot program designed to promote and develop forensic
training for nurses, physicians, nurse practitioners, and physician assistants
in order to build a community’s capacity to respond to violence. The academy
does not replace specialized sexual assault trainings. Rather, it gives
participants important tools to assist victims of all forms of interpersonal
violence, whether sexual assault, intimate partner abuse, child abuse, elder
abuse, strangulation, or other forms of assault. Participants develop the
skills needed to collect and preserve evidence from victims, and they learn to
work in partnership with local law enforcement, advocates, service providers,
and others to consistently assess and document victimization.
Because Alaska has the highest rates of interpersonal
violence in the country, it is important to focus on broad, comprehensive
assessments and care for all victims of violent crime. The ACFTA is designed to
provide an evidence-based and trauma-informed care approach: Instead of simply
treating and releasing a victim, a healthcare provider who is trained at the
academy can more comprehensively evaluate a patient, document evidence with an
awareness of forensic principles, and connect the patient to community
resources. Additionally, the academy will increase community awareness of
occurrences of violence that are not reported, investigated and, when
Building community capacity to respond to violence is
especially important for small communities with limited human and fiscal
resources. In rural Alaska, many communities cannot sustain a specialized
sexual assault nurse examiner or a sexual assault forensic examiner, but have
established health care, law enforcement, and advocacy roles. If the one health
provider in a community is trained broadly to respond to many forms of violence
and understands how to work with law enforcement and advocates, theoretically
there is a better chance that victims of violence will be appropriately
treated, and that forensic evidence will be collected to assist in the pursuit
The academy is a two-part program that includes
approximately 25 hours of online training and 24 hours of in-person, hands-on
training. The online training, offered on an ongoing basis, includes modules
developed by national and Alaska educators and researchers in the fields of
sexual assault, domestic violence, strangulation, sex trafficking, elder abuse,
and pediatric sexual and physical abuse. The in-person training takes place at
the University of Alaska Anchorage campus and is being offered every four
The hands-on portion of the curriculum focuses on
experiential training to develop the ability to complete forensic exams that
will help the victim and improve outcomes in the justice system. Participants
work with actors and live models, using case studies designed to simulate cases
that might present in the hospital, clinic, or outpatient setting. Attendees
have the opportunity to practice trauma-informed screening and patient
communication, evidence collection and preservation, medical photodocumentation,
narrative and graphic forensic documentation, as well as network with other
members of the multidisciplinary teams from around the state. CDVSA is also
currently offering travel scholarships for nurses and providers in
geographically remote locations of the state who would otherwise be unable to
travel to Anchorage for a three-day training program due to costs of travel.
At the time of this writing, ACFTA has completed three
in-person training sessions. Participants represented rural and urban
communities from throughout the state and have diverse roles including nursing,
community health, advocacy, legal, and advanced practice. Future cohorts have
registrants that include physicians, physician assistants, emergency medical
services, juvenile justice, and social workers. Participant evaluations have
been overwhelmingly positive. Evaluation comments included: “These
skills/knowledge will be helpful to me in my role,” “This should be a basic
skill for nurses [providers],” and “I think all providers, ER, and clinical
staff should receive this training.”
Participants reported that the most valuable portion of the
training was the use of live models and also competency stations where they
were required to demonstrate proficiency at tasks including evidence collection
and processing, medical photodocumentation, and pelvic examinations. One
participant summed up the general consensus of the attendees: “I've
never done a pelvic exam or handled a situation where I can talk with or interview
a victim. Being able to go through the process in detail definitely helped
piece together everything that needs to be involved.”
The goal for this training is to develop a sustainable model
of care for victims of violence, regardless of age, gender, or location. It is
expected that this comprehensive forensic training will meet medical-forensic
needs for victims, hospitals, law enforcement, and prosecution. The
availability of this generalist training may also be more palatable to
individuals who are not interested in solely being a SANE or for those
individuals who reside in locations without ability to support dedicated SANEs.
In communities who do not have dedicated SANEs or response programs, these
forensically trained nurses and providers would then also be able to respond to
local Sexual Assault Response Teams.
Having providers with forensic training strengthens
documentation and evidence collection practices, improves future law
enforcement investigation and prosecution, provides needed data for research to
support response and prevention of violence, and improves ability of providers
to adequately respond in difficult situations.
Reprinted in part from Alaska Justice Forum: A
publication of the Justice Center, University of Alaska Anchorage, Volume
36(1), Fall 2019. Available here.
Angelia Trujillo is associate professor with the
University of Alaska Anchorage School of Nursing.
L. Diane Casto is executive director of the Alaska
Council on Domestic Violence and Sexual Assault.
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