Emergency physicians frequently treat patients who have been assaulted: fight bites, stabbings, gunshot wounds, sexual violence. These are our day-to-day.
I took care of Mr. A recently after a reported trip and fall. His pattern of injuries, however, were not quite consistent with such a benign event. While I was suturing a laceration, Mr. A revealed that he had been attacked on the way home from work. His assailants screamed a litany of racial epithets, and demanded that he “go home,” saying that he didn't belong “here.” He was visibly shaken. He was not only afraid for himself but also for his children.
This encounter underscored the fact that I often do not fully know or understand the motivations behind an injury. I am trained to stabilize and treat. But what is the risk of further violence beyond the emergency department visit? What will be the enduring psychological toll? How do I account for these factors in my discharge plan?
These questions are becoming more pertinent to care as the number of hate crimes is on the rise. Some 867 hate crimes were reported in the 10 days following the 2016 presidential election. (Southern Poverty Law Center. Nov. 29, 2016; bit.ly/2jKkH2i.) Broken windows, swastika etchings, and racist graffiti scrawled on the walls of churches, mosques, and cars echoed centuries of hate-based violence. Many of my patients started expressing concerns about their personal safety and shared incidents of verbal harassment that they feared would escalate, just as it had for Mr. A. I could not, in good conscience, reassure them.
The Federal Bureau of Investigation's latest statistics show a six percent increase in hate crimes and a 67 percent increase in incidents targeting Muslim Americans from 2014 to 2015. (Jan. 23, 2017; bit.ly/2jK79nF.) One-third of these involved physical violence. (Uniform Crime Report Hate Crime Statistics, 2015. Nov. 14, 2016; bit.ly/2jKh3W8.) And the Bureau of Justice Statistics estimates that two-thirds of hate crimes go unreported to the police. (Hate Crime Victimization, 2003-2011. March 21, 2013; http://bit.ly/2j8PUiQ.)
All victims of violence experience subsequent fear and anxiety, but the psychological sequelae of hate crimes are unique. Being attacked because of who you are — your race, religion, gender, or sexual orientation — produces slow healing wounds and feelings of increased vulnerability, even worthlessness. The enduring trauma can last years, if not a lifetime. (Am J Public Health 2010;100:2433; J Interpers Violence 2016;Oct 13:1.)
Safety in the ED
Like any outbreak, we must first understand the natural course of the disease: how to identify it, how it thrives, how it is transmitted, and how to treat, prevent, and respond to it. Unfortunately, we do not know how to best assess or care for patients after a hate crime. We don't even track it; there is no ICD-10 code for hate crime.
But emergency providers have an opportunity and a responsibility to nurture and maintain an emergency department environment where everyone, especially survivors of hate crimes, can feel safe while receiving care. How can we make the emergency department a place where those most marginalized can find sanctuary? How can we provide support and care to survivors of hate crimes during and beyond their ED visit?
Fostering a welcoming emergency department begins with examining our personal and institutional biases and addressing how they affect our delivery of patient care. We need to develop methods to identify, document, and track hate crimes, and create standards of care to ensure patient safety and well-being during and beyond the emergency department visit, just as we have started to do with intimate partner violence and sex trafficking.
One simple way we can begin on the individual level is by asking patients presenting after an assault if they believe they were targeted because of their identity. Just like an incident of intimate partner violence, individuals under imminent threat of subsequent violence need to be given a chance to make a safety plan, whether it is finding safe housing or community resources.
The emergency department certainly does not function in a vacuum. We alone will not solve systemic problems of inequality or hate-based violence, but we have an important part to play. Through hospital-community partnerships, we can begin to better understand and meet our patients' needs during the ED visit and beyond.
There is a clear need to develop systems to provide survivors of hate crimes with community-based support, follow up, and safety plans beyond the clinical encounter. As health care providers on the frontline of public health, we are the ones who will be taking care of these patients. We have an opportunity to develop the mechanisms to provide patients like Mr. A with the care they deserve.