HCOVID-19: The Pandemic’s Impact on Access to Care for Philadelphia’s Sexual Assault Survivors

FOR SURVIVORS OF SEXUAL ASSAULT, THE ISOLATION AND FINANCIAL IMPACT OF THE PANDEMIC HAS BEEN OVERWHELMING. IN PHILADELPHIA, THERE ARE RESOURCES AND ORGANIZATIONS WHOSE DOORS HAVE REMAINED OPEN AND ARE READY TO HELP.

By Darci Moon Gold

For survivors of sexual assault, recovering from their trauma can be financially costly.

From counseling costs, to medical bills, to subsequent trauma, the money that survivors have to spend can all add to the burden of healing. In the United States, the average lifetime cost for survivors of sexual assault is $122,461, according to a June 2017 study from the American Journal of Preventive Medicine (AJPM).

For Madi, the pandemic has made her recovery even more costly and difficult. Madi*, who was sexually assaulted in February 2020, faced an altogether new obstacle for survivors of sexual assault: how to navigate the healing process through the financial uncertainty of COVID and isolation is has caused. Resources, already limited, have become even more difficult to access.

“For a really long time in quarantine, I tried my best not to think about it,” Madi said. “But in quarantine you have a lot of time to think.”

Throughout all of these implications of the pandemic, there are groups of individuals who are suffering invisibly, beneath the surface and without much aid.

Survivors often feel it is unfair they bear the sole responsibility to seek care after an assault. This becomes even further compounded when coupled with the difficulties created by COVID. It can cause survivors to not get the care they may need.

“I have never even thought about where to start for any sexual trauma counseling,” Madi said. “I didn’t even know what was available.”

The number of ways an assault creates trauma are exponential, beginning with whether or not to seek help.

“I felt so much shame, it felt like I had bigger fish to fry,” Madi said, about her after being assaulted. Seeking counseling or care for her assault felt overwhelming, almost impossible.

The question becomes, what resources exist in Philadelphia to help survivors and what do they cost? Furthermore, are they accessible for those in financial distress or without insurance, and for residents who require discretion and immediate care?

Due to the economic disadvantages the pandemic has created and the isolation it has caused, vital care has become inaccessible for many. Additionally, the effect isolation has on the process of healing and coping with trauma has delayed and hindered that process for many.

When it comes to care after an assault, Philadelphians may come into contact with nonprofit organizations such as Philadelphia Sexual Assault Response Center (PSARC) and WOAR Philadelphia Center Against Sexual Violence (WOAR). PSARC offers free, immediate medical and forensic care following an assault and may also connect survivors to Philadelphia Police Department’s Special Victims Unit (SVU) should they wish to a sexual assault. That decision is up to the individual and PSARC treats survivors regardless of if they report. WOAR focuses on providing free trauma counseling to survivors.

PSARC works closely with WOAR, a relationship affected by the current need for social distancing as a result of the pandemic.

“We love WOAR,” Jordana Popovitch, PSARC sexual assault nurse examiner, said. “They are incredibly helpful. We call them when we find out that we have a patient we need to see.”

The available resources of care for survivors of sexual assault in Philadelphia is clear: survivors can go to PSARC for immediate medical care, are connected to the Philadelphia Police Department’s Special Victims Unit should they wish to report the crime, and are directed to WOAR for trauma counseling. In effect, the three organizations work closely together, effectively.

The available resources of care for survivors of sexual assault in Philadelphia is clear: survivors can go to PSARC for immediate medical care, are connected to the Philadelphia Police Department’s Special Victims Unit should they wish to report the crime, and are directed to WOAR for trauma counseling. In effect, the three organizations work closely together, effectively.

Despite resources in place to assist survivors, accessing care can be difficult. Especially during a pandemic.

INSURANCE

“We’re seeing people that need a lot of support throughout the city,” Rachel Copen, director of counseling services for WOAR, said.

WOAR, the preeminent trauma counseling service for survivors of sexual assault in the Philadelphia area, provides treatment at no cost to these survivors. Those services are more crucial than ever in times of financial insecurity. The issue lies in the fact that most survivors are initially unaware of the free nature of WOAR’s services, according to Copen.

“I would say most people don’t realize we don’t take insurance,” Copen said. “Most agencies in Philly are insurance-based, so I think there’s an assumption that we’re insurance-based.”

Getting help after an assault can be complicated by assumptions about access, particularly around payment for services. Many likely believe without insurance they can’t afford help, a misconception that becomes more complicated by widespread unemployment during the pandemic.

Since the pandemic began stripping Philadelphians of their employment, by June 2020 the unemployment rate in Philadelphia county was a record high 17.7%, according to a report from the U.S. Bureau of Labor Statistics. Because the majority of Philadelphians are employed in industries directly affected by COVID-19, unemployment in Philadelphia was expected to skyrocket, according to a June 2020 report from the City Controller. In the report, Philadelphia was listed as the county with the second-highest job COVID-19 impact rate in the country behind Kings, New York.

According to a January 2020 report from the United States Bureau of Labor Statistics, the Philadelphia metropolitan area alone saw a decrease in 204,100 jobs from November 2019 to November 2020, a 6.8% decrease.

Because the majority of Philadelphians rely on employer insurance, experiencing job loss and little opportunity to find employment with comparable benefits has implications, real or perceived, in accessing care.

Even before the pandemic began in March 2020, Philadelphia had the second highest uninsured persons rate in Pennsylvania, 9.7%, according to a 2017 report from Pennsylvania State Data Center. In 2019, 46.2% of Philadelphians relied on their employers for insurance, according to a report from the United States Census Bureau. Insurance accessibility has become an increasingly polarizing issue in the United States as of late, even more so since the onslaught of the pandemic.

Insurance-free services for Philadelphia survivors of sexual assault are crucial, based on the city’s history of a high uninsured persons rate.

However, organizations such as WOAR which do not require any form of insurance are not only a necessity for uninsured individuals. There are occasions where even those who have access to insurance to assist with covering counseling costs may want an alternative route, one with no paper trail associating them to an assault. Survivors such as Madi who are under their parents insurance may also require insurance-free care.

“It’s a hard topic to discuss,” Madi, who hasn’t shared what happened with her parents, said. “It took me a really long time to come out about this. To this day, only my really close friends know.”

For survivors still on their parent’s or a partner’s insurance, seeking care at an insurance-based organization would require them to disclose information they may not be prepared to. For survivors from all backgrounds, an insurance-free organization may be the only option for privacy or financial reasons.

“We continue to try to get the word out that we’re free,” Copen said about the services WOAR offers.

Before COVID-19 and the pandemic hit, causing many Philadelphians to lose their jobs and employer insurance, WOAR had experience serving uninsured individuals. Copen stressed that the organization has always been a “safe-space” for individuals, regardless of citizenship status or income.

“We do tend to be a good space for people who are undocumented that can’t get insurance but need specialized service,” she said.

A sudden lack of insurance as a result of COVID-19 can become an issue for a significant number of people as one in five women and one in 71 men are raped during their lifetime, according to the National Sexual Violence Resource Center. Though counseling is often a necessity for survivors of sexual assault, the cost of counseling may seem like an insurmountable financial burden.

According to a 2014 report from JAMA Psychiatry, 55% of psychiatrists do not accept insurance. Oftentimes survivors of sexual assault need the help of both a psychologist and psychiatrist in order to receive the necessary prescriptions, according to the AJPM report. Furthermore, access to counseling is only half the battle; survivors without insurance must also pay out of pocket for any prescriptions related to their counseling and potential inpatient programs, another way that dealing with the trauma can multiply the cost for survivors.

“There’s a lot of agencies in the city that are covered under Medicaid,” she said. “So it kind of feels free because there’s no copay.”

While Medicaid can make services feel free to patients who participate in the program, those who utilize WOAR don’t even need to be enrolled in Medicaid to receive services at no cost.

Although WOAR’s sexual trauma counseling services are free, Copen does not cite that as a reason most individuals make initial contact, mostly because they are unaware of the fact.

Insurance-free trauma counseling is hard to come by in Philadelphia and the United States, generally. Without financial assistance the costs can add up, especially over time. Average counseling costs in the United States often range between $100 to $200 per session without insurance, according to Psychology Today. Should survivors be without a job due to the pandemic, they would be responsible for 100% of counseling costs without access to the limited free services available. For Philadelphians without insurance seeking sexual trauma therapy, WOAR’s ability to offer free services is unique for the city, Copen said.

COVID COMPLICATIONS

Centers like WOAR exist to provide sexual trauma counseling, specifically. Victims of sexual assault are more likely to experience symptoms of anxiety, PTSD, depression, and eating disorders, according to a 2017 report from AJPM. Those results of assault are only heightened by the pandemic, Madi said.

“The obsessions are terrible,” she said, regarding her thoughts about the assault. “Sometimes when the thought would pop up, it would be so intrusive.”

According to a 2021 report from Mental Health America, more than eight in 10 Americans exhibited symptoms of “moderate to severe” anxiety in September 2020, likely due in part to the pandemic.

These heightened rates of anxiety and related disorders in survivors of assault have been noted by WOAR’s counseling center.

“Trauma therapy is not always the safest option for every survivor, depending on their current mental health stability,” Copen said.

With mental health generally worsening during the isolation of the pandemic, survivors of sexual assault are likely to experience heightened symptoms, something beyond the scope of care offered by a trauma counseling center that works with survivors of a sexual assault

“We’re seeing a lot more people that might be better served by an agency that can work with severe mental illness,” Copen said.

According to Popovitch, the isolation caused by the enduring pandemic has been understandably difficult for survivors of sexual assault. Because of mandated quarantines, some survivors have even been forced to isolate with their abusers.

“If their assailant is always there, how is that going to impact their ability to even seek care over the telephone?” Popovitch wondered.

Although many victim centers have pivoted to telehealth and some may offer free services or take insurance, accessibility remains a severe problem for those who live with their abusers.

The financial burden is staggering and inaccessible for many survivors. A fact only complicated by the fallout from COVID. While there is an increased demand for counseling services because of the effects of the pandemic’s isolation, there are less means of accessing the support.

Madi largely relies on her parents for financial assistance. Her father owns his own business and as the pandemic hit, Madi could feel the impact when the family’s livelihood was not necessarily secure or stable.

“There was a little bit of time where it was like, ‘Oh, wow. My dad’s business just took a hit,’” Madi said. “Try to be a little bit careful with spending.”

Business has evened out for the family now, but the fear of a financial crisis coupled with processing her assault was difficult for Madi. Although her access to care was not permanently stalled financially, the possibility and likelihood is frightening for someone processing such a recent assault.

HELP FROM GOVERNMENT

Government assistance for counseling costs is crucial, especially during and because of the financial and mental health difficulties brought on by the pandemic.

Accessibility has always been an issue regarding adequate counseling, long before COVID-19. The Commonwealth of Pennsylvania provides a state fund for survivors’ counseling services. The Pennsylvania Victims Compensation Assistance Program (VCAP), under the Pennsylvania Commission on Crime and Delinquency (PCCD), provides $5,000 for adults and $10,000 for minors for counseling services for survivors of several types of crime.

There are two claim types available for survivors of sexual assault. The standard claim has specific stipulations, most notably that the crime was reported to police and any claim must be filed within two years after an assault. The second claim type called the Sexual Assault Counseling Claim (SACC), which was created in November 2019, does not require reporting to the police.

“One claim is filed per incident and that amount, that $5,000 or $10,000, that is the amount for life for that particular claim,” Rita Brim, a claims processing supervisor for VCAP, said in a phone interview.

Should survivors receive any financial compensation as a result of the crime, they are required to reimburse VCAP for any monetary assistance provided for counseling services. There is no option for claimants to receive more funds beyond the cap.

“All those amounts are set forward by the law,” Brim said. “So unfortunately sometimes we get questions of, ‘Can you extend the payments?’ And unfortunately, as much as we’d like to at times, we can’t.”

Although the total average financial burden for survivors of rape well exceeds $120,000, Brim considers the $5,000 cap for adults adequate.

“Because we’re the payer of last resort, usually, so people should be using their insurance if they have it,” Brim said. “And then we pay the copays and deductibles. So usually, not always, but that is an ample amount for individuals.”

Due to the pandemic, there are many more uninsured persons in Philadelphia than before. The $5,000 cap would only cover just under a year of weekly counseling for uninsured persons at a private practice in the United States, not including any additional psychiatric care or prescriptions.

The criteria for a SACC does not take the claimant’s financial situation into account. This becomes an issue in a time of financial crisis when there’s an increased need for services but a decreased means of accessing.

The legislation regarding this new sexual assault claim type was announced via a press release from Gov. Tom Wolf in February 2020. VCAP has an annual budget of $5 million to distribute specifically to the new sexual assault counseling claims.

“Because it’s a newer thing, people are not aware of it,” she said. “We got 143 of those sexual assault claims in the entire year of 2020,” Brim said, speaking to the total number of these claim types in Pennsylvania.

There were 558 standard claims paid throughout Pennsylvania in 2020, according to the director of VCAP’s Office of Victim’s Services, Kathleen Buckley.

“So, it’s very small in comparison to the regular claim types we get,” Brim said.

In 2020, VCAP paid out a total of nine SACC and standard claims for adult survivors of sexual assault residing in Philadelphia.

According to a 2019 report from the U.S. Department of Justice, only 33% of rapes are reported to the police. Since just under seven in 10 sexual assault survivors do not report, it has only been since November 2019 that the vast majority of sexual assault survivors are now eligible for VCAP’s new sexual assault counseling claim.

However, it is important to note that if someone doesn’t report a sexual assault to the police, there are less opportunities to inform survivors about various victim services.

“I think that the majority of the survivors that are reaching out for services have filed a police report,” Brim said, regarding the small number of sexual assault counseling claims last year.

Madi referenced her lack of confidence in the police as her reasoning for not reporting the assault.

“As a girl, you feel kind of scared to [go to the police],” Madi said. “Are the police even going to do anything?”

Instead of relying on police intervention for any resolution, she has had to look elsewhere.

“For my own coping mechanism, I kind of just wanted to forget about it,” Madi said. “I feel like I wouldn’t be able to heal if the situation kept getting brought up, if the police were involved.”

Even with the new claim type, there was a still a slight decrease in the total number of sexual assault claims filed from 2019 to 2020. According to Brim, that may be due to the pandemic and possibly because Phildelphians and Pennsylvanians are largely unaware of the reimbursements VCAP offers.

“When the legislation first passed and we were made aware of that, we actually did a lot of outreach to victim services agencies and a lot of counseling providers that we’ve paid out to before,” she said. “We sent them, you know, a letter, letting them know that this is an option for any clients they may have.”

Despite these efforts, the small number of claims may be surprising considering the new funding stream available for survivors who elect to not file a sexual assault report with the police.

“We do contribute some of that to a lot of the different victim services providers,” Brim said, regarding communication to and from providers throughout Pennsylvania about the new claim type. “Many of them are closed during COVID so there maybe wasn’t as much outreach to survivors or assistance for survivors in that way, I think, across the board.”

So few claims where survivors are not required to have reported to the police could be attributed to the fallout from COVID or difficulties getting the message about the new claim type out during the pandemic. Regardless of the number of claims filed, the issue of sexual assault and navigating the repercussions are still a pervasive issue.

“I think, at least in my opinion, I thought we’d be getting a lot more of them than we have,” Brim said. “We haven’t seen a huge increase in those types of claims.”

LOCAL IMPACT

As the parent organization for VCAP, which manages and distributes counseling reimbursement for survivors in Pennsylvania, PCCD also delegates some of its funds to survivors services centers throughout the state. In Philadelphia, the local recipient is primarily WOAR.

Because WOAR is a leading sexual trauma counseling service in Philadelphia, it treats a steady influx of survivors. Due to the high volume, there is a one to three month waiting period for WOAR’s specialized individual counseling program.

“We have a very high number of people that reach out for our therapy services,” Copen said. “Currently we have, I think, about 300 people that we’re servicing right now for therapy.”

Because of WOAR’s funding structure, it has a fixed number of staff each year and cannot adjust staffing levels to meet fluctuating or increased demand. The ability to receive services is based on the available care, and only a small number of clinicians are employed by WOAR each year.

“A lot of other agencies in the city, because they function off of insurance, they have the ability to just hire and then bill,” Copen said.

WOAR functions based on donations from both the government and private sector, the latter of which initially decreased at the beginning of the pandemic, according to Copen. WOAR’s largest fundraising efforts usually occur in April, sexual assault awareness month. Those in-person events were canceled in 2020 due to the pandemic.

Ironically, almost immediately prior to the pandemic, WOAR ran a yearlong study with patients and telehealth. Copen said there was little to no interest.

“They were more interested in coming in person,” Copen said. “They felt it really important to come in person.”

So despite complications wrought by the pandemic, because it had previous experience with administering telehealth services, Copen feels WOAR has seamlessly continued to deliver services during COVID-19.

“We were able to really quickly, without even missing a day, provide telehealth phone sessions,” she said.

With the option of in-person counseling services unavailable at this time, WOAR is still seeing a steady use of resources compared to other years, according to Copen.

“The number of calls to our hotline is lower, but the amount of time we’re spending on the hotline and the services we’re providing to people are taking longer than usual,” she said.

Lower numbers seem to be a common theme for survivor services in Philadelphia. PSARC, the nonprofit also funded by VCAP that provides immediate medical and forensic care to sexual assault survivors and one of the three main agencies that provide care in response to sexual assaults, is seeing similar trends.

“We’ve seen a decrease in numbers,” Barbara Osborne, the center’s director, said. She attributed this to the possibility of survivors’ fear seeking care in a medical environment due to the pandemic.

Popovitch, the PSARC nurse practitioner, wonders if the medical nature of its services may deter survivors.

“Imagine the thought of going into an emergency department during a global pandemic,” she said.

However, PSARC is not an emergency room, Osborne and Popovitch noted. When patients arrive at PSARC, they are always taken to a private room within the facility to be treated.

An advocate from WOAR then arrives to support patients through the exam process. Patients can decide whether they would like the support of an advocate but, as Popoivtch said, PSARC goes into “nurse-mode” when a victim arrives. Having someone from an organization like WOAR in the room is often helpful for patients when being examined and treated.

“We’re performing a medical exam, trying to make sure we’re taking care of them physically and forensically,” Popovitch said. “So when an advocate is there, that person is one thousand percent focused on the patient, which obviously is much, much better for the patient.”

Advocates being present during an exam means an extra person in the room, which has become difficult due to pandemic social distancing guidelines.

Despite PSARCs close working relationship with the Philadelphia Police Department, utilizing PSARC services is not contingent on patients reporting a sexual assault to the police or even receiving a forensic exam.

“Patients can refuse any part of care in the exam,” Osborne said. “The services they want from us, they can decide. They’re in charge.”

Despite a mix of public and nonprofit agencies working in unison to offer triage, support, and services during what is most likely the darkest days of a survivor’s life, it is a frail and fragile dance between these organizations and the survivor.

Individuals seeking trauma counseling from WOAR are often unaware that its services are free and not insurance-based. Numbers are down at PSARC where patients receive specialized, individualized, COVID-safe care even outside of the pandemic. While VCAP does offer some funding to assist in the cost of counseling services, the amount is far below the average cost for a victim of assault. Many feel that the best course for survivors seeking aid is in the private not-for-profit organizations, like WOAR and PSARC.

WOAR’s donors, made up of private citizens and foundations, have continued to donate throughout the pandemic. PSARC remains staffed and prepared for patients. The message from both is the same: we have resources and we are open.

“We are definitely here and willing to help,” Copen said.

While resources exist in Philadelphia, even searching for them can feel like a burden for survivors of sexual assault.

It’s been over a year since the pandemic began, causing the isolation and job loss of millions of Americans. Philadelphians have suffered greatly, and for survivors of sexual assault it has been even more challenging. For Madi, navigating a gauntlet of barriers to access care and overcome the trauma of a sexual assault been hard, but she remains strong and hopeful.

“I know this is kind of cliché, but don’t blame yourself,” Madi said. “You don’t even realize you’re doing it. I did it for a really long time. But don’t blame yourself.”

*Madi asked to remain anonymous. Philadelphia Neighborhoods’ policy is to not use unnamed sources except on occasions that could jeopardize someone’s personal safety.

Contact WOAR for trauma counseling services and PSARC for immediate medical and forensic care.

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