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Testimony

Statement by
Rose Weahkee, PhD
Director
Division of Behavioral Health
Indian Health Service
U.S. Department of Health and Human Services (HHS)

on
Native Women: Protecting, Shielding, and Safeguarding Our Sisters, Mothers, and Daughters 

before
Committee on Indian Affairs
United States Senate


Thursday July 14, 2011

Mr. Chairman and Members of the Committee:

Good afternoon, I am Dr. Rose Weahkee, Indian Health Service (IHS) Director for the Division of Behavioral Health. I am pleased to have this opportunity to testify on the Indian health system’s response to protecting, shielding, and safeguarding American Indian and Alaska Native women and girls. 

The IHS plays a unique role in the U.S. Department of Health and Human Services to meet the Federal trust responsibility to provide health care to American Indians and Alaska Natives (AI/AN).  The IHS provides comprehensive health service delivery to 1.9 million Federally-recognized American Indians and Alaska Natives through a system of IHS, Tribal, and Urban operated facilities and programs based on treaties, judicial determinations, and Acts of Congress. The mission of the agency is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level, in partnership with the population we serve. The agency aims to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to the service population. Our foundation is to promote healthy American Indian and Alaska Native people, communities, and cultures, and to honor the inherent sovereign rights of Tribes.

The IHS works in partnership with the communities it serves as such, IHS hospital administration frequently includes Tribal representatives who closely participate, as key stakeholders, in the health care delivery system. Additionally, under the Indian Self-Determination and Education Assistance Act (ISDEAA), many Tribes across the country have assumed full authority for all health care delivery within their communities, including hospital operations. Currently, 84% of Alcohol and Substance Abuse programs and 54% of Mental Health programs are Tribally operated. Traditionally, behavioral health and medical programs, both IHS and Tribally operated, have been separately managed; however, it is now a major focus of the IHS to reintegrate these programs to provide more efficient and effective patient care.

Introduction

AI/AN women are central to family and community life, yet domestic violence, and intimate partner violence, continues to be a serious and pervasive problem. Domestic violence often begins with intimate partner rape and can end in homicide. The statistics on domestic violence and sexual assault against AI/AN women are alarming. According to the Centers for Disease Control and Prevention, 39% of AI/AN women have experienced intimate partner violence – the highest percentage in the U.S.[1] In addition, one out of every three AI/AN women will be sexually assaulted in her lifetime,[2] and AI/AN women are more than five times as likely to die from domestic violence-related injuries than women of any other race.[3]

It is important to acknowledge the role that historical and intergenerational trauma has played in the high levels of domestic violence and sexual assault against AI/AN women. Colonization brought significant changes for AI/AN people – changes that have been attributed to the high levels of violent crime in Indian Country, particularly violence against women.[4][5][6][7]

What the numbers do not tell us, however, is the tremendous physical and psychological toll that sexual assault and domestic violence take on individuals and society. Besides the obvious costs of medical care and evidence collection, there is increasing evidence that interpersonal violence is associated with many common health problems, including obesity, hypertension, chronic pain, headaches, gastrointestinal problems, complications of pregnancy, post traumatic stress disorder (PTSD), alcohol use disorders, depression, and anxiety.[8]  All of these health problems can impact an individual’s family life and ability to work. The economic impact of the loss of work and productivity is enormous.

Tribal Law and Order Act

The President signed the Tribal Law and Order Act (TLOA) on July 29, 2010. The Act was an important step toward helping the Federal government better address the unique public safety challenges that confront Tribal communities. The Act emphasizes decreasing violence against women, and is one of many steps needed to address the challenges faced by AI/AN women and girls. The various provisions of the TLOA offer important policy support for health, wellness, and public safety in AI/AN communities and a recognition of the multiple factors that influence domestic violence and sexual assault issues. The TLOA also has several health specific provisions which will be addressed in further detail below. Taken together, these provisions should increase the rate of domestic violence and sexual assault convictions. Increased convictions may increase the reporting of domestic violence and sexual assault incidents by changing the climate and norms surrounding violence against women in AI/AN communities.

Testimony and Production of Documents by Federal Employees

Section 263 of the TLOA requires the IHS Director to provide written approval or disapproval of subpoenas or other requests from Tribal or State courts for the testimony of IHS employees or for the production of documents by IHS employees under the Director’s supervision.  The IHS Division of Regulatory Affairs, on advice from the HHS Office of the General Counsel, is the lead representative on implementation of Section 263. The IHS has drafted a revised delegation of authority to permit IHS Area Directors to authorize testimony by Federal employees in criminal and civil cases at the local level. The draft delegation of authority notes that: 1) subpoenas and requests may be approved if the request is consistent with HHS’ policy to remain impartial; and 2) subpoenas or requests for documents or testimony in violent crime cases which would include sexual assault and domestic violence must be approved or disapproved within 30 days after receipt or the subpoenas and requests will be deemed approved. The draft delegation of authority pertains to factual information obtained by Federal employees in carrying out their official duties. It does not apply to requests for expert testimony from Federal employees.

IHS Sexual Assault Policy

Section 265 of the TLOA adds a new section to the Indian Law Enforcement Act requiring the IHS Director to develop sexual assault policies and protocols based on similar protocols established by the DOJ.  In response, IHS established a national sexual assault policy, which is the foundation for local policies at hospitals managed by the IHS as they develop their own standard operating procedures and protocols on sexual assault medical forensic examinations. The policy establishes a uniform standard of care for sexual assault victims seeking clinical services. The policy ensures that the needs of the victim are addressed, care is culturally sensitive, patient-centered, and community response is coordinated. The policy also includes evidence collection guidance which aligns with criminal justice system response and subpoena regulations. The IHS consulted with Tribal leaders and Urban Indian health directors and is reviewing comments for incorporation in future revisions of this policy.

Study of IHS Sexual Assault and Domestic Violence Response Capabilities

Section 266 of the TLOA authorizes the Comptroller General to study the capability of IHS facilities and Tribal programs to collect, maintain, and secure evidence of sexual assaults and domestic violence incidents required for criminal prosecution and to develop recommendations for improving those capabilities. This section also requires a report to Congress to assess current readiness and propose recommendations for improving response capabilities. IHS has cooperated with the GAO in the development of this study, which is due to Congress no later than one year after July 29, 2010.

IHS Domestic Violence Prevention Initiative

In 2009, Congress appropriated $7.5 million to the IHS in the Omnibus Appropriations Act, P.L. 111-8, to implement a nationally-coordinated Domestic Violence Prevention Initiative (DVPI). In 2010, Congress appropriated an additional $2.5 million for a total of $10 million. Prior to developing specific domestic violence and sexual assault prevention and treatment programs and initiatives, IHS engaged in Tribal consultation sessions with the National Tribal Advisory Committee on Behavioral Health (NTAC). The NTAC is composed of elected Tribal leaders across all twelve IHS Service Areas. Using the NTAC recommendations as a guide, the IHS established the DVPI.

The DVPI promotes the development of evidence-based and practice-based models that represent culturally-appropriate prevention and treatment approaches to domestic violence and sexual assault from a community-driven context. The DVPI expands outreach and increases awareness by funding programs that provide outreach, victim advocacy, intervention, policy development, community response teams, and community and school education programs. The funding is also being used for the purchase of forensic equipment and includes case coordination of Sexual Assault Nurse Examiner (SANE), Sexual Assault Forensic Examiner (SAFE), and Sexual Assault Response Team (SART) programs to help victims of sexual assault by training medical personnel on how to properly conduct sexual assault medical forensic exams.

DVPI has awarded a total of 65 projects that include IHS, Tribally, and Urban operated programs. These include 49 domestic violence and sexual assault community developed models, 8 domestic violence and sexual assault Urban Indian health program grants, and 8 SANE/SAFE/SART programs. Projects have recently begun reporting on practice- and evidence-based outcome measures to assess program effectiveness. 

From August 2010 through January 2011, 56 of the 65 funded programs reported data. From these programs, DVPI funding resulted in over 220 project-affiliated full-time equivalent positions and the development of 21 interdisciplinary SARTs. Over 2,100 victims of domestic violence or sexual assault were served and over 3,300 referrals were made for mostly domestic violence services, culturally-based services, and clinical behavioral health services. Over 140 individuals received shelter services. Forty-eight adult and 18 child SAFE kits were completed and submitted to Federal, State, and Tribal law enforcement. Over 9,100 patients were screened for domestic violence and nearly 9,500 community members were reached through community and educational events.  There were 37 training events held, including training on domestic violence, mandated reporting for abuse, child maltreatment, dating violence, and bullying, with 442 participants attending. Although the DVPI is in the early stages of implementation, these preliminary data strongly suggest very effective programming is taking place in Indian Country across a wide range of communities and areas of focus.    

In addition to the direct services above, the national DVPI conference was conducted last week, July 6 – 8, in Albuquerque, New Mexico. At the conference, DVPI funded recipients were able to participate in training, effective dialogue, network, and share their program experience and expertise involving the prevention and treatment of domestic violence and sexual assault in Indian Country. Over 140 DVPI program and IHS staff attended the conference which specifically covered community awareness planning, advocacy, safety planning, agency collaborations (specifically with the Federal Bureau of Investigation), impact of battery violence on children, provider self care, working with Tribal advocacy programs, engaging men, incorporating traditional healing, teen dating awareness, and conducting effective community assessments. Specific to the SANE/SAFE/SART programs, the conference covered the important role staff play in evidence collection, identifying abuse, and understanding local sexual assault laws.

IHS Partnerships

IHS has devoted considerable effort to develop and share effective programs throughout the Indian health system. Strategies to address domestic violence and sexual assault include collaborations and partnerships with consumers and their families, Tribes and Tribal organizations, Urban Indian health programs, Federal, State, and local agencies, as well as public and private organizations. We believe the development of programs that are collaborative, community driven, and nationally supported offers the most promising potential for long term success and sustainment. Our partnership and consultation with Tribes ensure that we are working together in improving the health of AI/AN communities.

Through a partnership with the Administration for Children and Families (ACF) dating to 2002, IHS and ACF collaborated to fund over 35 sites to identify strategies and develop interventions to address domestic violence in AI/AN communities. These domestic violence pilot programs trained medical and nursing staff to screen for domestic violence and to provide safety planning for all female patients, forged community partnerships, and developed policies and procedures on domestic violence. In addition, sites developed culturally sensitive screening tools, policies and procedures, and informational brochures.  These programs also educated community members and adolescents on healthy relationships, dating violence, and domestic violence. This partnership and the work of the domestic violence pilot programs provided the foundation for future IHS efforts in domestic violence prevention, and led to IHS wide screening for domestic violence, routine domestic violence education, and the development of safety planning for women. The joint release of a 2010 report by the IHS, ACF, and Futures Without Violence offers a series of recommendations to ensure that domestic violence victims receive appropriate medical care at clinics and hospitals.

The IHS and the DOJ Office on Victims of Crime (OVC) entered into a partnership involving the Federal Bureau of Investigation and the Department of the Interior. This partnership is the SANE-SART AI/AN Initiative, and is funded through the OVC. The goal of the SANE/SART Initiative is to address the needs of sexual assault victims in Indian Country that restores the dignity, respect, and mental and physical health of victims of sexual assault and ensures more effective and victim-centered investigations and prosecutions. Using evidence-based practices involving SANEs, SARTs, and victim-centered law enforcement practices, the initiative will support victim recovery, satisfaction, and cooperation with the Federal criminal justice system, as well as supporting victims’ of sexual assault and Tribal communities’ need for justice. To address this overall goal, the project will identify, assess, and support existing SANE and SART efforts by providing training and technical assistance resources for all of the IHS and OVC funded SANE/SART programs, and through the development of comprehensive SANE/SART demonstration projects.

Summary

To adequately address the problem of violence against AI/AN women, IHS focuses on both prevention and treatment services.  HIS treats individuals with associated behavioral health problems, and engages and empowers communities to change accepted norms of violence. Prevention of domestic violence and sexual assault begins with strong community prevention programs.

Our prevention and treatment efforts must also focus on children and adults who have already witnessed or experienced domestic violence and sexual assault. Our youth, who have witnessed domestic violence or who have experienced child abuse/sexual abuse including incest are at great risk of becoming victims or perpetrators of violence and sexual assault as adults. Girls who witness the domestic abuse of their mothers, or who are victims of childhood sexual abuse are at special risk of developing PTSD, depression, and alcohol use disorders including binge drinking and alcohol dependence. Because alcohol and/or drugs are involved in the overwhelming majority of assaults, the IHS is proactively focusing on behavioral health treatment and rehabilitation through partnerships and initiatives directed at minimizing the causes of such abuse. 

In summary, the safety of AI/AN women and girls is a serious problem with multiple personal, familial, and community factors.  The programs IHS supports significantly improve the lives of AI/AN women and girls. The IHS and its Tribal and Federal partners are committed to maximizing available resources to provide appropriate prevention and treatment services, as well as safe environments for AI/AN women and girls in all our communities.

This concludes my remarks and I will be happy to answer any questions that you may have.  Thank you.



[1] Centers for Disease Control and Prevention (2008). Adverse health conditions and health risk behaviors associated with intimate partner violence-United States, 2005. MMWR, 57(05), 113-117. Retrieved March 2, 2010, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm
[2] Sacred Circle and the National Congress of American Indians Task Force on Violence Against Women in Indian Country (2006, September). Restoration of Safety for Native Women. Restoration of Native Sovereignty,5.
[3] Department of Justice, Bureau of Justice Statistics National Crime Database.
[4] BigFoot, D. S. (2000). History of Victimization in Native Communities. University of Oklahoma Health Sciences Center, Center on Child Abuse and Neglect, grant number 97-VI-GX-0002 (NCJ 213165).
[5] Bubar, R., & Thurman, P.J. (2004). Violence against Native women. Social Justice, 31(4), 70-86.
[6] Poupart, L.M. (2002). Crime and justice in American Indian communities. Social Justice, 29(1-2), 144-159.
[7] Smith, A. (2003). Not an Indian tradition: The sexual colonization of Native Peoples [Electronic version]. Hypatia, 18, 70-85. Retrieved June 16, 2007.
[8] Centers for Disease Control and Prevention (2008). Adverse health conditions and health risk behaviors associated with intimate partner violence-United States, 2005. MMWR, 57(05), 113-117. Retrieved March 2, 2010, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm

Last revised: June 18, 2013