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Determine Communication Standards

The way SART team members communicate with each other and with victims plays a large part in providing effective victim services. While other sections in this toolkit have briefly described communication issues, this section reviews those issues in more detail, covering—

• Shared language.
• Ethics.
• Confidentiality.

Shared Language

If language creates reality, and words define real life experiences, then how we choose words and use language has great influence.¹

Individuals who have been sexually assaulted are often defined by service providers according to their professional relationship. For example, for medical and nursing personnel, the person is a patient. For a social worker or counselor, he or she is a client. The police and prosecuting attorney's office interact with victims and witnesses. Rape crisis staff provide services to victims and survivors.²

This section reviews how to—

• Consider the impact of your words.
• Develop common definitions.

Consider the Impact of Your Words

You need to be especially attentive about language used in the health care and justice systems. Victims turn to these places for help, healing, and fairness. Every single word and phrase has vital consequences for restoring victims' trust and well-being. For this reason, it is not only important both to know and understand the language of each other's disciplines, but to create a shared SART language accepted by all participating agencies.

For example, one forensic nurse has stated, "The choice of words can make a big difference in the forensic medical exam report, especially in court." The nurse stated that she learned about the importance of language the hard way—the first time she testified in court. The defense attorney tried to discredit the victim because the nurse had documented "patient refused" for a procedure that many other jurisdictions no longer consider important. The nurse learned that in the future it would be better to document "patient declined" on the forensic medical exam form.³

Develop Common Definitions

You can facilitate better interagency communication by establishing common definitions for technical words. One way to create a shared language is for SART members to discuss their roles and responsibilities, giving them an opportunity to ask questions and clarify procedures. Another way to shape a common language is by developing SART protocols or guidelines, in which terms are defined and easily understood. Documenting a shared language may also mean developing a list of frequently used acronyms to ensure that all SART members understand abbreviated language used in interagency work.

Each SART is governed by statutory definitions, protocol terms, and agency-specific terminology. The following list should help you institutionalize frequently used words to ensure the words and definitions are understood and used consistently across disciplines as they refer to the response to sexual assault. The list, adapted from one developed by the Centers for Disease Control and Prevention,⁴ is simply a guide, a starting place, as you develop a multidisciplinary, shared language specific to your jurisdiction.

Ethics

According to A Program Manual for Child Death Review, which contains a chapter on ethical dilemmas faced by teams, "ethics is commonly defined as a set of moral principles or a system of moral values that govern an individual or group."⁵ Ethical codes also provide boundaries that keep relationships between victims and responders appropriate (e.g., SART members should not give victims their home phone numbers or personal histories or invite them out for purely social engagements).

Multidisciplinary ethics affect all SART members because decisions made by one discipline affect other disciplines. For example, a bilingual advocate who is supporting a victim during a detective's interview may conclude that an interpreter's translation is incorrect; yet the advocate's role is not to participate in the interview or translate for the victim. This situation could cause a dilemma for the advocate (to speak or not to speak) and could affect criminal justice proceedings. Discussing possible ethical situations beforehand (e.g., during team meetings) can help ensure that interagency roles are understood, even in exceptional situations.

This section reviews—

• SART code of ethics.
• Ethics and the law.
• Ethical communication.

SART Code of Ethics

The dignity and healing of victims depends on the respect and assistance extended to them by professionals. To establish a victim-centered response, you should understand the codes of ethics governing advocates and medical and legal responders and work to develop a standard of ethical principles for the team itself. Use the following list as a catalyst for customizing SART standards when responding to victims or working with team members and allied professionals:⁶

• SART Ethical Principles for Responding to Victims
  • Maintain proficiency in the delivery of services through continuing education.
  • Provide accessible services to victims, including services that are culturally sensitive.
  • Report any conflict of interest that prevents delivering competent services to victims.
  • Respect and protect victims' rights.
  • Respect privacy and confidentiality.
• SART Ethical Principles for Working With Colleagues, Other Professionals, and the Public
  • Respect others.
  • Seek appropriate methods for addressing conflict with colleagues that will model constructive conflict resolution.
  • Help those who are new to the field to promote consistent quality in the response to sexual violence.
  • Promote crime and violence prevention.

Ethics and the Law

Sometimes the relationship between ethics and what the law requires may not be the same or may not be clearly distinguished. While closely related, ethical responsibilities usually exceed legal duties and too often we may observe that what may be legal, may not necessarily be ethical.⁷

Consider the following ethical dilemmas to determine the best responses for your jurisdiction. What if—

• In a spousal rape case, the victim meets with the detective and recants her original report of the rape. Case evidence supports the victim's initial version of events, not the recantation. What should the prosecutor do? What is the role of the victim advocate in this situation?
• A landlord hired a convicted sex offender who raped a tenant. During a case review, it becomes clear that the landlord had a duty to warn the victim about a foreseeable risk. Should SART members notify the victim of a tort liability when the civil case could have an impact on the criminal case?
• A victim declines the forensic exam after being transported to the hospital for fear his or her recreational drug use will be detected. Should primary responders assure the victim that he or she has nothing to worry about? The victim is also terrified that the attacker will harm him or her if the sexual assault is reported. Law enforcement knows the suspect is dangerous and wants to apprehend him. Should team members pressure the victim to report by emphasizing the dire public safety issues at stake?

Ethical Communication

Many times, dilemmas arise because SART members think the best action is immediate action. However, immediate action may not always be the best solution. Consider, for example, that during a case review, an advocate realizes the victim had a crucial piece of evidence and it is clear that law enforcement is unaware of the evidence. The advocate could reason that because the victim is cooperating with the police, the information could be shared without a confidentiality waiver. However, instead of making an either/or decision (to speak or not to speak), the advocate might consider contacting the victim to obtain a waiver or encourage the victim to contact police.

Or, what if—

• Following law enforcement's press release of an arrest involving sexual assault in a suburban hospital facility, additional victims have come forward, presenting new allegations of sexual assault against a hospital employee. The community is beginning to panic and members of the press are approaching various SART representatives for interviews and information. How does the team determine who will speak to the media and what information will be released in a way that preserves victim confidentiality but also provides the community with information?
• While informally discussing a case that has been referred for prosecution, two SART members discover that a conflicting piece of information exists. How should the team proceed?
• A sexual assault forensic examiner is called out of the exam room, leaving the advocate and victim alone together with the evidence. This circumstance breaks the chain of custody, but the evidence was not tampered with. Should an advocate ignore the issue on the grounds that nobody would ever know?

Working through potential dilemmas proactively can minimize cross-disciplinary misunderstandings or ethical breaches. It is crucial for core SART members to understand ethical codes that govern each discipline and to work together as a team to create a shared ethical standard (e.g., how different disciplines, with different job responsibilities and varying degrees of confidentiality/privileged communications, can resolve issues).

Ethical situations that cause dilemmas generally have warning signs. When applying ethics to a crisis-related situation, take proactive measures whenever possible. For example, the following phrases signal a potential for a compromised ethical response that could ultimately affect criminal justice outcomes:⁸

• "Well, maybe just this once . . ."
• "No one will ever know . . ."
• "Everyone does it . . ."
• "Shred that document."
• "We didn't have this conversation."
• "No one will get hurt."

Confidentiality

Protecting victims of sexual violence requires understanding relevant privacy rules and regulations, evidentiary privileges and waivers, the unique status of individuals with disabilities or other protected classes of victims, and state and federal constitutional rights—including crime victims' rights amendments and statutes (see Victims' Rights in this toolkit).

Establish SART guidelines to protect victims' privacy. Inform victims of their privacy rights and the ways in which privacy may be compromised or privileged communication waived during civil or criminal litigation. In addition, let victims know the types of information that may be exposed and the roles of the advocate and attorney in protecting their privacy.

Whether your SART is just starting or has been established for years, you'll need to develop and regularly review your confidentiality policy. At a minimum, it should include⁹—

• A policy section on the philosophy and rationale of confidentiality.
• Policies on responding to subpoenas.
• Clear policies on what information must be held confidential.
• Policies that outline how and when victims' confidentiality is protected (including in support groups).
• Policies that ensure victims give informed consent when privilege is waived.

This section reviews—

• Confidential and privileged communications.
• Informed choice and consent.
• SART recordkeeping.
• Unintentional confidentiality waivers.
• Intentional confidentiality waivers.
• Open records.
• Other confidentiality issues (e.g., HIPAA, use of interpreters, mandated reporting, advocates onsite, and confidentiality as it relates to different types of victims).

Confidential and Privileged Communications

Although the concepts of confidentiality and privileged communications overlap, they are not necessarily the same. For example, victims are entitled to confidentiality regardless of statutes governing privileged communications. Information that is confidential and kept out of public record, however, could be disclosed by court order, as there are no legal protections for confidential communications. On the other hand, information that is privileged may never be disclosed, unless the privilege has been waived or certain exceptions have been met.¹⁰

Read on for more information about—

• Confidential communication.
• Privileged communication.

Confidential Communications

A confidential communication is one made with the expectation of privacy. Information that is confidential is private information that is not accessible to the general public. However, if confidential information is subpoenaed, it must generally be released unless it is privileged information. An example of a confidential communication might be when a victim tells a trusted coworker about a sexual assault that took place. This communication is made with the expectation of privacy. However, there is nothing to prevent the coworker from telling other people about the sexual assault. And, if the coworker were to be subpoenaed, he or she would have to answer questions.

Privileged Communications

Privileged communication is defined as statements made by people within protected relationships (e.g., husband and wife, attorney and client) that the law shelters from forced disclosure on the witness stand. Three general categories of privileges exist:¹¹

• Absolute—protects any communication or record of communication between a victim and a qualifying service provider made in furtherance of psychological and emotional healing from examination by defendant or the court.
• Absolute diluted—a privilege that was absolute by its promulgation, but later qualified by a court by allowing for an in camera (in chambers) review of the oral communication or the records. Generally, a court's reason for diluting an absolute privilege is a fear of depriving a defendant of due process rights.
• Qualified—the privilege as written gives discretion to a judge or administrator to hold an in camera review to determine whether the information contained in the confidential communication will be used as evidence in the proceeding.

Absolute privileges allow for complete confidentiality and privacy (e.g., the information holder may never or almost never be required to testify or produce documents). More commonly, states have limited (absolute diluted) or qualified privileges, such that community-based service providers may be required to produce records and testimony for judicial inspection. The judge then decides what may or may not be publicly disclosed. Additionally, more than one privilege may apply (e.g., if the advocate is a social worker and rape crisis counselor, there may be statutory protections governing both roles). Hence, whether a confidential communication is privileged depends on the relationship between the parties and the circumstances under which the communication is made.

Informed Choice and Consent

Victims may feel that they have nothing to hide and that confidential information can only help them or their court case. However, informed consent requires you to explain to victims the potential uses and misuses of confidential information once it is released to judges, defendants, the police, or public agencies. Also, court records may become public records that anyone can access; you need to consider ways to protect victims' privacy (e.g., sealing court files, prohibiting distribution of documents).¹² In other words, informed consent depends on informed choice:

• Informed choice is a voluntary, well-considered decision that an individual makes on the basis of options, information, and understanding. The decisionmaking process should result in a free and informed decision by the individual about whether he or she wants to proceed.
• Informed consent is the communication between victim and provider that confirms that the victim has made an informed and voluntary choice to proceed. Informed consent can only be obtained after the victim has been informed about the process and other alternatives. Voluntary consent cannot be obtained by means of duress, coercion, or misrepresentation. Regardless of the presence or absence of written documentation, informed consent requires providers to ensure that a victim has knowingly and voluntarily agreed to the process. Whether informed consent is written or verbal, however, it cannot replace the informed-choice process, which depends on the exchange of information between providers and victims.

Informed consent also requires that victims understand the implications of their choices, without feeling threatened. For example, if a victim declines a sexual assault medical forensic exam, the lack of physical evidence could negatively affect the prosecution of the case. Victims need to fully understand the benefits and disadvantages of their decisions so that they do not regret their decisions later.

SART Recordkeeping

Nonprofit organizations and government agencies may embrace technology without thoroughly understanding the unintended consequences that may arise from it. As data systems become increasingly interconnected, it is vital that SART organizations anticipate and minimize the potential for harm to victims. Essentially, you need to secure the confidentiality of all communications and minimize any data about victims that are collected, stored, and shared. In addition, because some victims will request assistance or advocacy online, it is critical to think proactively through all safety, confidentiality, and monitoring possibilities in connection with electronic communications.

Carefully balance the benefits of recording information against the possible harm that the information could cause the victim or the criminal case if the information were released. Consider written policies on recordkeeping based on guiding principles. In other words, you should always know why information is being kept (e.g., for funders, for the victim's benefit, for reference).

There are benefits and burdens to recordkeeping. Making decisions about what to record and what not to record is easier if you have some underlying principles to guide the process.¹³ You'll need to decide—

• Who will have access to SART files.
• Who will be the designated custodian of SART records.
• What records will be kept following case reviews.
• What process will be used to maintain and destroy files.

In addition, you'll need to develop policies for electronically stored records, such as the following:¹⁴

• Choose passwords that are difficult or impossible to guess. Make the password at least eight characters long and use uppercase and lowercase characters, numbers, and punctuation.
• Regularly back up critical data.
• Use virus protection software.
• Use a firewall as a gatekeeper between SART computers and the Internet.
• Log off of the Internet after you're finished using it.
• Use screensavers with password protection.
• Physically secure computers (e.g., laptops should be secured, desktop PCs should not be publicly accessible).
• Position screens to prevent inadvertent viewing.
• Place servers in closed, properly ventilated rooms.
• Encrypt data.
• Do not e-mail victim-related information to anyone.

Unintentional Confidentiality Waivers

Some of the greatest threats to victims' confidentiality and privacy are subpoenas, the demand that crisis counseling records be produced in civil or criminal proceedings, mere slips of the tongue, media reports, victims' lack of informed consent when waiving confidentiality rights, and public records laws. Here are a few examples of how confidentiality breaches can happen:

• A court subpoenas the records of a crisis center and requires testimony of the counselor without the victim's consent. The center believes it has no legal recourse to fight a subpoena.
• In a hospital parking lot, an advocate and a sexual assault forensic nurse debrief about an exam they had been involved in, disclosing case details and using the victim's name within hearing distance of others.
• Staff at a rape crisis center are meeting in the center's conference room and do not hear the landlord enter the building. They are discussing support services available for a victim. The landlord, attempting to be courteous, stands outside the conference room and hears every word spoken because he did not want to interrupt the meeting.

According to Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions¹⁵—

If there is a confidentiality waiver, is it a complete waiver as a matter of law or does the state, territory, campus, military, or tribal code and statute recognize partial or limited waivers? Are time limits specified on the waiver? May victims authorize professionals, each of whom has a privileged relationship with the victim, to communicate with one another without compromising the privilege?

Intentional Confidentiality Waivers

Victims can voluntarily waive their privileges, but you should alert them to the benefits and drawbacks of doing so. For example, a benefit could be that sharing information with others on the SART team could improve services and help pending investigations. On the other hand, victims may not be able to control the type or amount of information released or to whom it is released.¹⁶ For example—

• Some or all of the records may be given to the defendant.
• Some or all of the information may get introduced in court, depending on judges' rulings.
• Advocates may be called to testify at trial.
• Advocates' personal observations, beliefs, and opinions may be disclosed.
• Trial testimony may be available to the public through the court clerk's office.
• Information discussed during counseling sessions held after the waiver is signed may not be confidential.

In addition, although the victim can dictate what the center may voluntarily release, once the center does so, confidentiality is waived and, if a subpoena is served, all victim records and communications may be subject to release.¹⁷

In general, releases of information should be clear, concise, and limited to a specific purpose to be achieved; individually tailored to the needs of specific victims; and thoroughly reviewed with the victim.¹⁸ Consider including the following information:

• Name of the agency or person permitted to share information.
• Names of agencies or organizations to which disclosures will be made.
• Name of the victim.
• Purpose of the disclosure.
• How much and what kind of information is to be disclosed.
• The victim's signature.
• The date the waiver was signed.
• A statement that the confidentiality waiver can be revoked at any time except to the extent that your SART has already reviewed the case.
• The date, event, or condition upon which the consent will expire if not previously revoked.

The most common situations in which victims intentionally waive privilege are when they¹⁹—

• Report a crime: Let victims know that if they want their attackers arrested and prosecuted, the medical forensic information will be released to law enforcement and prosecution. (Counseling and other private records are not, however, automatically subject to disclosure.)
• File a civil lawsuit: Let victims know that it will be very difficult to control their privacy. If they file civil suits based on physical and emotional damages, their psychotherapist/counselor records may be made public.

When drafting confidentiality policies, carefully consider not allowing emergency verbal releases of information. Only in the rarest of circumstances should a victim be able to authorize a release of information by phone or by any means of communication that does not allow the victim to read and sign the release. If you do decide to allow verbal releases, stipulate the following safeguards in your policy:²⁰

• Clearly document which emergency circumstances apply.
• Make sure that other SART members witness and sign the release.
• Make the scope of information to be released as narrow as possible.
• Follow up the verbal release with a written one as soon as possible.

Open Records

Nearly every state has its own version of the Freedom of Information Act, some of which are referred to as open records, open meetings, open government, or sunshine laws. The laws may contain exemptions to disclosure that a victim may want to protect (e.g., exemptions specific to certain classes of victims, such as victims of sexual violence or minors).²¹ For example, Florida law requires that certain sex offense information remain confidential as long as the following conditions are met:²²

• The victim is not already known in the community.
• The victim has not voluntarily called public attention to the offense.
• The victim's identity has not otherwise become a reasonable subject of public concern.
• Disclosure would endanger the victim, cause mental or emotional harm, make the victim reluctant to testify, or otherwise be inappropriate.

Other Confidentiality Issues

Many other issues affect confidentiality. Here is a sampling of issues, with links for more information:

• HIPAA.
• Interpreters.
• Mandated reporting.
• Advocates onsite.
• Types of victims.

HIPAA

The Health Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the privacy and security of an individual's health data, particularly regarding the acquisition, use, and exchange of patient information. The rule poses some challenges for SARTs, however, when individuals are not clear on HIPAA exemptions and permissible disclosures.

Interpreters

Before using an interpreter to translate for victims, be aware of any confidentiality issues that may arise. Also be aware that finding an interpreter unknown to the victim may be a challenge, depending on the size of your jurisdiction. Review any local and state laws, rules, and procedures regarding the use of interpreters in your jurisdiction.

Mandated Reporting

In many states, medical personnel must report to law enforcement and/or social services if they have treated children, elderly persons, or vulnerable adults who have been sexually assaulted.²³ On the other hand, laws requiring health care providers to report cases of competent, adult rape victims vary greatly throughout the Nation. Some states specifically require health care providers to report treatment of sexual assault victims to law enforcement, others require health care providers to report nonaccidental or intentional injuries that can include rape, and still others have laws mandating reporting for injuries caused by criminal conduct or violence.

Keep in mind that members in your SART could interpret state reporting statutes differently, depending on their discipline. Resolve any questions about reporting requirements up front by developing reporting protocols or guidelines and by institutionalizing the guidelines with memorandums of understanding or agreement.

Advocates Onsite

In some jurisdictions, SARTs place advocates at district attorney's offices, law enforcement agencies, or probation and parole departments in addition to community-based advocacy organizations. Where such arrangements exist, it is essential that the government-based agencies have a clear understanding of the different confidentiality and privilege responsibilities that apply to community-based advocates.

Types of Victims

Unique confidentiality issues may arise when serving specific victims. For example—

• Victims in educational settings. Maintaining confidentiality on campus can be problematic. Students often live in such close proximity to each other that privacy is short lived. Jurisdictional issues also come into play (federal laws, state laws, school policies), as do several other factors (e.g., age of victim and attacker, relationship between victim and attacker). For more information, read—
  • Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions.
  • Family Educational Right to Privacy Act, 20 U.S.C. § 1232g.
  • The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, 20 U.S.C. § 1092(f).
  • Campus Sex Crimes Prevention Act, Public Law 106-386, § 160.
  • Foley Amendment (to the Campus Sex Crimes Prevention Act).
  • Rutgers University Confidentiality Guidelines.
• Military victims. The Department of Defense offers unrestricted and restricted reporting options to military victims of sexual assault. Victims go through the unrestricted reporting channel when they want medical treatment, counseling, and an official investigation of the case. If a victim wants medical treatment and counseling but does not want the case to be officially investigated (and therefore retains confidentiality), he or she would be able to use the restricted reporting channel. For more information, read—
  • Sexual Assault Prevention and Response (SAPR) Program, Directive Number 6495.01.
  • Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions.
• Rural victims. To maintain the privacy of rural victims, consider creating protocols for victims needing services regionally to protect their privacy or activation protocols providing guidance on the response to sexual assault when suspects are well known or in trusted positions (e.g., teachers, coaches, clergy, law enforcement officers, doctors). You also could conduct a community needs assessment survey or hold a town meeting, which might bring to light other issues that need to be addressed when developing guidelines to help ensure victim anonymity. For more information, read—
  • In This Toolkit: Serving Rural Victims.
  • In This Toolkit: Protocols.
• American Indian victims. For American Indian victims of sexual assault to be afforded protected communications on tribal land, it is helpful to identify elders or native healers who can work confidentially with these victims. Oral history and traditions can still be used to develop and apply concepts of tribal justice. Disclosure itself, especially to multiple professionals, is not always culturally congruent with American Indian values of privacy, the emphasis on spiritual recovery, and the protection of native cultures from further outside intrusion.

  American Indian communities that have confidentiality policies within their tribal codes can help ensure that victims are afforded both state statutory and tribal code rights for privileged communications to ensure privacy whether victims receive tribal or non-tribal services.

  For more information, read—

  • In This Toolkit: American Indian Victims.

Resources

Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions
Includes chapters on state and federal privileged communications statutes, rape shield laws, sources of privacy for victims, confidentiality waivers, discovery issues and confidentiality, public records, mandatory reporting, anonymous victims, and privacy considerations for specific populations.

Confidentiality and Information-Sharing Within a Coordinated Community Response
Outlines privileged communications for advocates, confidentiality and databases, recordkeeping, and confidentiality differences between government-based and community-based advocates.

Data Security Checklist to Increase Victim Safety & Privacy
Describes the importance of maintaining victims' safety and privacy when using data collection technology, and includes a checklist of guidelines and recommendations to enhance database security.

Discovery Versus Production: There is a Difference
Discusses the basic differences between discovery and production when a defendant seeks access to a victim's records, and the importance of that difference to the victim.

Final Privacy Rule Preamble, U.S. Department of Health and Human Services
Includes standards for protecting the privacy of individually identifiable health information. It applies to health care providers who must provide enhanced protections for individually identifiable health information.

Parameters of Privilege and Confidentiality when Collaborating with Community Partners—A Guide for Sexual Assault Counselors and Advocates
Provides members of multidisciplinary teams with information about the scope of privileged communications that sexual assault counselors/advocates must honor. Search for this publication on the National Sexual Violence Resource Center's Library Web site.

Privacy of Victims' Counseling Communications
Reviews state laws and issues related to the privacy of communications between victims and their counselors.

Victim Rights Law Center
Provides information and answers to frequently asked questions on victims' rights including privacy, immigration, physical safety, education, employment, housing, financial compensation, and criminal justice.

The Victim's Right to Confidentiality
Provides a historical background on confidentiality and its implications for services received at rape crisis centers in Illinois.

Notes

1 Susan Faupel, 2001, Concern for Language Justified, Springfield, IL: Illinois Coalition Against Sexual Assault, 12.

2 See, for example, Ohio Department of Health, 2004, Ohio Protocol For Sexual Assault Forensic And Medical Examination, Columbus, OH: Ohio Department of Health.

3 National SART Listserv, December 2006.

4 K.C. Basile and L.E. Saltzman, 2002, Sexual Violence Surveillance: Uniform Definitions and Recommended Data Elements, Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 9–11.

5 Theresa Covington, Valodi Foster, and Sara Rich, 2002, A Program Manual for Child Death Review, Okemos, MI: The National Center for Child Death Review, 79.

6 Florida Network of Victim Witness Services, Code Of Professional Ethics for Florida Victim Witness Service Providers. Accessed June 18, 2010.

7 Covington, Foster, and Rich, A Program Manual for Child Death Review, 80.

8 Len Marrella, 2001, In Search of Ethics: Conversations with Men and Women of Character, Sandord, FL: DC Press, 248.

9 Jessica Mindlin, Liani Jean Heh Reeves, and the National Crime Victim Law Institute at Lewis & Clark Law School, 2005, Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions, Portland, OR: National Crime Victim Law Institute.

10 Ibid.

11 Ibid, 13–14.

12 Ibid.

13 Leslie Hagen, Kathleen Hagenian, Gail Keieger, and Kim Rattet, 2001, Confidentiality Policy Considerations and Recommendations: A Resource Manual for Michigan Domestic Violence and Sexual Assault Programs, Okemos, MI: Michigan Coalition Against Domestic and Sexual Violence.

14 Connecticut Sexual Assault Crisis Services, Inc., 2003, Confidentiality—The Foundation of Healing: A Manual for Sexual Assault Crisis Centers, East Hartford, CT: Connecticut Sexual Assault Crisis Services, Inc.

15 Mindlin, Reeves, and the National Crime Victim Law Institute at Lewis & Clark Law School, Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions, 24.

16 Connecticut Sexual Assault Crisis Services, Inc., 2003, Confidentiality—The Foundation of Healing: A Manual for Sexual Assault Crisis Centers, East Hartford, CT: Connecticut Sexual Assault Crisis Services, Inc., 6-19–6-20.

17 Mindlin, Reeves, and the National Crime Victim Law Institute at Lewis & Clark Law School, Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions, 25.

18 Hagen, Hagenian, Keieger, and Rattet, Confidentiality Policy Considerations and Recommendations: A Resource Manual for Michigan Domestic Violence and Sexual Assault Programs, 23.

19 Mindlin, Reeves, and the National Crime Victim Law Institute at Lewis & Clark Law School, Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions, 24–25.

20 Hagen, Hagenian, Keieger, and Rattet, Confidentiality Policy Considerations and Recommendations: A Resource Manual for Michigan Domestic Violence and Sexual Assault Programs, 29–30.

21 Mindlin, Reeves, and the National Crime Victim Law Institute at Lewis & Clark Law School, Confidentiality and Sexual Violence Survivors: A Toolkit for State Coalitions, 35.

22 Ibid.

23 Teresa Scalzo, 2006, "Rape and Sexual Assault Reporting Laws," The Voice 1(3).

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