some cultures to speak about the assault with members of the opposite sex. • Understand that victims may not report or discuss the assault because the stigma associated with it is so overwhelmingly negative. In some cultures, for example, the loss of virginity prior to marriage is devastating and may render victims unacceptable for an honorable marriage. Even discussing an assault or sexual terms may be linked with intense embarrassment and shame in some cultures. • Be aware that beliefs about women, men, sexuality, sexual orientation, gender identity or expression, race, ethnicity, and religion may vary greatly among victims of different cultural backgrounds. Also, understand that what helps one victim deal with a traumatic situation like sexual assault may not be the same for another victim. • Help victims obtain culturally specific assistance and/or provide referrals where they exist.43 ―Victims with limited English proficiency44 41 This section was adapted partially from Connecticut’s Technical Guidelines for Health Care Response to Victims of Sexual Assault, 1998, pp. 12–14, and from Iowa’s Sexual Assault: A Protocol for Forensic and Medical Examination, 1998, pp. 1–4. 42 Bullet drawn from A. Blue, The Provision of Culturally Competent Health Care, from the Web site of the Medical University of South Carolina College of Medicine (http://academicdepartments.musc.edu/fm_ruralclerkship/curriculum/culture.htm) . 43 For example, to raise their level of hope and comfort during the exam, some patients may benefit from talking about culturally specific models of healing (where they exist) and their application to recovery from sexual assault. To facilitate such a discussion, they may wish to speak with a religious or spiritual healer from their culture. 44 The Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) New & Revised Standards & EPs for PatientCentered Communication, Accreditation Program: Hospital, HR.01.02.01, PC.02.01.21, RC.02.01.01, RI.01.01.01, RI.01.01.03, effective January 1, 2011, http://medicine.osu.edu/orgs/ahec/Documents/Post_PatientCenteredCareStandardsEPs_20100609.pdf (PDF); Joint 33 • Be patient and understanding toward victims’ language skills and barriers, which may worsen with the crisis of sexual assault. 45 • Develop policies and train responders to be able to identify a victim’s limited English proficiency and primary language spoken and written. • Make every attempt to provide same language service through the use of demonstrably bilingual examiners or by providing monolingual examiners with support from professional interpretation services and translated materials for victims who are not proficient in English, 46 are LEP or who may prefer to communicate in a non-English language. Use qualified interpreters when possible and not victims’ families or friends. 47 Take the victim’s country of origin, acculturation level, and dialect into account when responding or arranging interpretation.48 Remember to speak directly to victims when interpreters are used. Consider the victim’s need for modesty and privacy when determining where interpreters should be located in the exam room. • Train interpreters about issues related to sexual assault and the exam process49 whenever they are needed to facilitate communication in these cases. Ensure that the examiners are trained in the proper utilization and ethical requirements of using an interpreter. • Make sure that interpreters understand that they may need to testify.50 • Understand that immigrant victims may fear that assisting law enforcement may identify them to immigration authorities for deportation. • All sexual assault victims should be provided information regarding U-Visa relief, in the event that this information would be helpful. Even if this information is not helpful to them directly, the information is often passed on to others by word of mouth and can benefit others in the future. • Work with law enforcement partners to develop and publicize protocols precluding detention or other immigration enforcement against victims who come forward to report a sexual assault. • Work with law enforcement to develop and publicize U-Visa certification protocols. • While it is not appropriate to ask a victim’s immigration status, anticipate that an immigrant victim will not self-identify as undocumented for fear of deportation. Such information about their rights should be offered in a non-judgmental manner to all victims and in coordination with a referral to an immigration service provider expert in working with immigrant victim populations. ―Victims with disabilities • Understand that victims with disabilities may have physical, sensory, cognitive, developmental, or mental health disabilities, or a combination of disabilities. Make every effort to recognize issues that arise for victims with disabilities (both in general and in relation to their specific disability) and provide reasonable accommodations when working with them. • Be aware that the risk of criminal victimization (including sexual assault) for people with disabilities is much higher than for people without disabilities. People with disabilities are often victimized Commission, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered