Continuing Education Activity

Medical management should be the first and top priority in caring for sexual assault victims. After the patient is clinically stable, proper assault protocol can commence. Once the initial examiner explains the options to the patient, an appropriate examiner who may be a physician or a nurse who, with training in evidence collection, obtains consent and evidence via the Sexual Assault Examination Kit (SAEK). This activity outlines the proper collection, handling, and documentation of specimens such as clothing, bodily fluids, and fingernail scrapings, and highlights the role of the healthcare team in managing patients who undergo sexual assault.

Objectives:

• Outline the general recommendations and guidelines on clothing collection and documentation.
• Outline the function of sexual assault nurse examiner.
• Summarise the implications of sexual assault on physical and mental health.
• Review the caring for a victim of sexual assault.

Introduction

Defining sexual assault is challenging as some sources interpret it as rape or general assault, while others conclude that it should serve as a separate classification. According to the National Crime Victimization Survey (NCVS), sexual assault is a crime of unwanted sexual contact occurring between victim and offender, which may or may not involve force. The NCVS definition includes verbal threats but excludes rape or attempted rape.[1] Sexual assault does not discriminate, as victims range from the young to the elderly, regardless of race, gender, or socioeconomic status. However, one study noted that more than half of the sexual assault cases reviewed involved patients 24 years old and younger, with nearly 92% being female.[2] The offender is often known to the victim before the assault.

Medical management should be the first and top priority in caring for sexual assault victims. Ensuring the patient’s safety and investigating any acute trauma (e.g., lacerations, head trauma, inebriation) should be completed before evidence collection. After the patient is clinically stable, proper assault protocol can commence. Once the initial examiner explains the options to the patient, an appropriate examiner who may be a physician or a nurse who, with training in evidence collection, obtains consent and evidence via the Sexual Assault Examination Kit (SAEK).[3] The SAEK contains step-by-step procedures for the proper collection, handling, and documentation of specimens such as clothing, bodily fluids, and fingernail scrapings. Ideally, forensic evidence collection should occur within 72 hours of the assault, but many jurisdictions allow collection up to 5 days post-assault. A thorough examination should still take place in the event the patient does not want to complete a SAEK or is outside the window of evidence collection.[4]

A proper investigation includes determining if the patient has bathed/showered, urinated, defecated, douched, or changed clothing since the incident. Although the SAEK can is still possible, this information requires adequate documentation as it may alter the forensic analysis.[4] Even so, clothing can offer immense forensic insight as nearly two-thirds of forensic evidence can be discovered on clothing or linens.[5] The following includes general recommendations and guidelines on clothing collection and documentation: 

• In the event the patient was transferred via EMS, the sheets should be collected from the mode of transportation to preserve any critical evidence.[6]
• Once ready for collection, the provider sets two layers of examination table paper down on the floor. Linens will suffice if table paper is not available. The patient then removes each item of clothing one at a time and places each item in a separate paper bag. If the patient requires assistance in removing clothing, the examiner should don gloves and replace these gloves with each article of clothing. The examiner should fold the top layer of paper and include it in a separate paper bag as well.[7]
• Ideally, the patient’s clothes should remain intact. However, if the clothes need to be cut, the examiner should preserve any stains, holes, or tears that may be present.[6]
• If the patient presents with any ligatures or ties, the integrity of the knot needs to be maintained, as this may indicate the offender’s criminal signature.[6]
• Following collection, every paper bag should have a label that includes family name, date of birth, date of sample, type of sample, and examiner.[8]
• Bags should be sealed and should never be left unattended.[3]
• Law enforcement will then need to sign for the evidence once the SAEK is complete.[3]

Function

What is the function of SANE?

SANE is an acronym for sexual assault nurse examiner.  These individuals have specific training in victim and evidence handling.  Many communities across the United States have this service.  They work closely with law enforcement and follow a chain of custody to ensure that evidence collected is admissible in court.

What if a SANE is not readily available?

SANE availability varies by jurisdiction, and thus may not be present at every healthcare location. Some nurse examiners are contracted through community-based approaches and can respond to calls of sexual assault within a certain radius. Others operate by hospital-centered care in which sexual assault cases transfer to those facilities with the proper training in place. Police officials and EMS should be aware of these procedures and should transport the patient to the facility with SANE availability. Providers should be cognizant of the established procedures within their practice in case the patient presents on their own, and a SANE is not available. A SAEK is typically accessible through the Emergency Department or local health department and can be completed by providers with proper training. However, an evidence collection kit completed by a SANE demonstrates superiority in terms of accuracy and completeness when compared to those performed by non-SANE nurses and physicians.[9]

What can examiners do to limit contamination and aid preservation?

Two ways to limit contamination include wearing disposable gloves and changing those gloves after collecting each article of clothing. Providers should limit the number of people that go into the exam room to ensure both a lack of disruption and patient privacy during evidence collection.

Examiners should not place the patient’s clothes in a plastic bag as this can contribute to bacterial and fungal growth.[10] If the clothes are damp or wet, they must be air-dried before inserting them into the paper bag.[4]

What if a patient does not want to report or does not want to complete a SAEK?

All sexual assault cases must be reported for patients who are 17 years old and younger as well as for elderly or disabled patients.[6] Other laws concerning mandatory reporting differ by state; therefore, providers should be knowledgeable of the local regulations in their practicing state. For those patients in which reporting is not a requirement, a SAEK may be completed in case the patient later decides to report the assault. It is imperative to explain all elements of both the medical and forensic examinations to patients. Ultimately, the patient can refuse the SAEK and should be fully supported nonetheless. A comprehensive medical evaluation and proper referral to sexual assault victim resources, including crisis centers and psychiatric facilities, should still occur.

Issues of Concern

Due to its diverse definitions, sexual assault statistical analysis varies widely by source. However, there is documentation that the lifetime prevalence of assault is roughly 3% in men and ranges from 13 to 39% in women. These longitudinal studies may neglect under-represented and often high-risk populations such as incarcerated, pediatric, elderly, or disabled patients.[6] One survey discovered higher rates of sexual assault in those 17-years and younger, with 26.6% females and 5.1% of males so afflicted.[11] Additionally, the LBGTQ population experiences higher rates of sexual assault than their heterosexual counterparts, with the prevalence of lifetime sexual assault estimated to be 15.6 to 85% for lesbian or bisexual women and 11.8 to 54.0% for gay or bisexual men.[12]

Physical Trauma

Roughly 66% of sexual assault victims report physical trauma, with physical findings due to force manifesting more often than genital trauma. Injuries range from defensive marks to penetrating trauma and can be hidden by hair or clothing.[4] Furthermore, victims may be subject to unwanted pregnancy, adverse outcomes of an established pregnancy, and sexually transmitted infections. Discussion concerning different outcomes, potential diagnoses, treatments, and preventative measures should occur to ensure patient safety. Providers need to assess and treat these ailments during the patient’s examination, specifically managing life-threatening injuries prior to completing the SAEK. 

Emotional Trauma

There are significant implications of sexual assault on mental health. Nearly 46% of women that experienced sexual assault during their adulthood qualified for a diagnosis of Post-Traumatic Stress Disorder, which manifests as recurring thoughts or emotions concerning the event, hyperarousal state, and chronic substance abuse.[13][4] The majority, however, recovered from assault-related PTSD within a few months.[13] Providers can aid in the management of mental health by recognizing and recording the patient’s behavioral self-blame as this predicts early symptom severity of PTSD and may warrant a more comprehensive mental health evaluation.[13]

Even without the initial self-blame, a referral to a therapist or other trained personnel is often necessary. Depression, anxiety, shame, guilt, intimacy-related complaints can all be concerns of victims following sexual assault. Some victims may struggle with processing the event; thus, they may require written documentation to serve as a reminder about the completed assessment and resources available for survivors of sexual assault.

Clinical Significance

Caring for a victim of sexual assault is a complex process that requires a multifaceted approach. There should be a restricted number of patient interactions during the examination. Limiting the number of providers and visitors strengthens the patient’s trust with the sole examiner, ensures patient privacy, and lessens the risk of evidence contamination. However, once the patient is stable and their story and exam documented, many additional services may be provided to the patient.

Law enforcement is typically involved in the patient’s care from the start. They, along with EMS, might be the ones to bring the patient to a care center. Law enforcement is also the entity that may retrieve clothing from the victim’s house if they have left behind the clothing worn during the incident. Contact information for local law enforcement should be given to the patient upon discharge for follow up on their case or to make a report at a later time.[10]

The patient should follow up with a primary care provider in a week or two, especially if they experienced physical trauma or developed an STI. Referral to an OB/GYN is crucial if the patient is pregnant or begins to have gynecological complaints such as pain with sex or irregular or missed menses.

Due to the psychological distress experienced by victims of sexual abuse, follow up with a therapist or other trained professional should be advised. Survivors of sexual assault benefit from referral to local advocacy or crisis centers, which provide support to the patient for the successful return to their life after this trauma. Patients should receive instruction to seek a higher level of care through the Emergency Department if suicidal or homicidal ideation occurs at any time.[10] To ensure patients have adequate support, providers need to remain abreast of local resources available to survivors of sexual assault.

Enhancing Healthcare Team Outcomes

Caring for a sexual assault victim is a complex process and requires an interprofessional team of healthcare professionals that includes a sexual assault nurse examiner, and a number of physicians in different specialties, for example, psychiatry, OB/GYN, and orthopedics. The moment the triage nurse has admitted the patient, the emergency department clinician, and the assigned nurse are responsible for coordinating the care that involves ensuring the patient's safety, medical management, and commencing the proper assault protocol. On account of the serious implications of sexual assault on the mental health of the patient, complete mental health evaluation, and follow-up with a therapist/trained professional are absolutely necessary to improve patient outcomes.