Care, Appendix B, August 2010, http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf. 45 Carolyn Ham, Reducing Language Barriers to Combating Domestic Violence: The Requirements of Title VI, Battered Women’s Justice Project, October 2004, http://new.vawnet.org/summary.php?doc_id=1621&find_type=web_desc_GC. 46 Health care providers generally are covered by language access requirements under Title VI which requires them to take reasonable steps to provide language-appropriate health care, including the use of qualified bilingual staff, interpreters, and translators. 47 Use of such informal and biased interpreters may result in unreliable communication, violate the patient’s privacy, undermine the patient’s claim of privilege, and jeopardize the use of the victim’s statements in court. In cases of intimate partner sexual assault, it is particularly important not to use family members who are not likely to adopt a neutral stance or maintain the confidentiality necessary. 48 For example, a Cuban interpreter may encounter language and trust obstacles when trying to communicate with a victim from rural Mexico. (L. Zarate, Suggestions for Upgrading the Cultural Competency Skills of SARTs, Arte Sana Web site, http://www.arte-sana.com, 2003.) 49 Professional interpreters are expected to be familiar with confidentiality requirements and cultural issues. 50 Interpreters would not be expected to act as witnesses as to what was said in the examination room if they are present solely to facilitate direct communication between the patient and examiner. 34 repeatedly by the same offender.51 Caretakers, family members, or friends may be responsible for the sexual assault. In such cases, offenders may bring victims to the exam site, and jurisdictional and facility policies should be in place to provide guidance on how staff should screen for and handle situations that are threatening to patients or facility personnel. • Respect victims’ wishes to have or not to have caretakers, family members, or friends present during the exam. Although these individuals may be accustomed to speaking on behalf of persons with disabilities, it is critical that they not influence the statements of victims during the exam process. If aid is required (e.g., from a language interpreter or mental health professional), those providing assistance should not be associated with victims. • Follow exam facility and jurisdictional policy for assessing vulnerable adults’ ability to consent to the exam and evidence collection and involving protective services. Again, note that guardians could be offenders. (For a more detailed discussion on seeking informed consent of patients, including consent by victims from specific populations, see A.3. Informed Consent.) • Speak directly to victims with disabilities, even when interpreters, intermediaries, or guardians are present. • Assess a victim’s level of ability and need for assistance during the exam process. Explain exam procedures to victims and ask what help they require, if any (e.g., people with physical disabilities may need assistance to get on and off the exam table or to assume positions necessary for the exam, or may need an alternative to the standard table). But, do not assume they will need special aid. Ask for permission before proceeding to help them (or touch them, handle a mobility or communication device, or touch a service animal).52 • Note that not all individuals who are Deaf or hard-of-hearing understand sign language or can read lips. Not all blind persons can read Braille. Communication equipment that may be beneficial to victims with sensory disabilities include TTY machines, word boards, speech synthesizers, anatomically correct dolls, materials in alternative formats, and access to interpreter services. Responders should familiarize themselves with the basics of communicating with an individual using such devices.53 Let the individual specify the preferred method of communication. Be aware that victims with sensory disabilities may prefer communicating through an intermediary who is familiar with their patterns of speech. • Recognize that individuals may have some degree of cognitive disability: mental retardation, traumatic brain injury, neurodegenerative conditions such as Alzheimer’s disease, or stroke. Speak to victims in a clear and calm voice and ask very specific and concrete questions. Be exact when explaining what will happen during the exam process and why. Be aware that victims with cognitive disabilities may be easily distracted and have difficulty focusing. To reduce distractions, conduct the exam in an area that is void of bright lights and loud noises. It may also be helpful if examiners and others present in the exam room refrain from wearing uniforms with ornamental designs and jewelry. • Keep in mind that victims with disabilities may be reluctant to report the crime or consent to the exam for a variety of reasons, including fear of not being believed, fear of getting in trouble, and fear of losing their independence. For example, they may have to enter a long-term care facility if their caretakers assaulted them or may need extended hospitalization to treat and allow injuries to heal. The perpetrator may also be their caregiver and the only person they rely on for daily living assistance. • Recognize that it may be the first time victims with disabilities have