Please note: This course only provides 2 of the required 5 hours of training to renew a Kentucky SANE certification.
- Describe the general prevalence of sexual assault violence
- Identify key principles of trauma informed approaches
- Describe patient-centered care to minimize the physical and psychological trauma to the patient of a sexual assault crime.
- Recognize the definition of professional roles of forensic evidence
- Describe the types of examination and reporting associated with sexual assault patients.
- Recognizing the essential steps collection and preservation of forensic evidence
- Describe chain of custody and the importance of the process
- Describe wound identification
- Describe the forensic nursing examination process using a focused, thorough and systemic approach
- Describe the risk factors, preventative factors and preventative implications
Forensic nursing is essential to adequately identifying and assessing patients who suffered abuse, or in the event of an unexpected or traumatic death. The process of forensic nursing science is to safely and legally collect and document the evidence in a methodical manner; adherence to the forensic evidence collection process will protect the integrity of the evidence and the victim (Drake, Langford, & Young, 2016).
In May of 2016, the 69th World Health Assembly adopted a global plan of action to strengthen the role of the health system’s response to address interpersonal violence against women and girls and against children (International Association of Forensic Nurses, 2015).
The World Health Organization (WHO) in 2010 defined “sexual violence” as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances or acts to traffic, or otherwise directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting including but not limited to home and work” (11).
Worldwide sexual violence takes many forms and may include but is not limited to rape, sexual harassment, sexual assault/abuse, forced or coerced marriage or cohabitation, genital mutilation and forced prostitution or trafficking for the intent of sexual exploitation (WHO, 2002). Sexual violence may include intimate partner violence. The WHO (2010) defined “intimate partner violence” as “behavior within an intimate relationship that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors” (p. 11).
In a multicounty study conducted by the WHO, the prevalence of sexual violence by a partner ranged from 6% to 59% and by a non-partner from 0.3% to 11.5% in subjects up to 49 years of age. In the same study, 3% to 24% of the subjects reported that their first sexual experience was forced and occurred during adolescence. Among women, prevalence rates for sexual and/or physical violence involving an intimate partner across the lifespan range from 15% to 71% of women (WHO, 2010).
In a systematic review of 75 studies, the prevalence rate of sexual violence across the lifespan for lesbian or bisexual women ranged from 15.6% to 85% and for gay or bisexual men from 11.8% to 54% (Rothman, Exner, & Baughman, 2011). Limited studies address the prevalence rates of intimate partner and sexual violence in adult males; those that exist are problematic given that most experts believe available statistics drastically under-represent the number of male rape victims.
In studies from developed countries, 5% to 10% of men report a history of male child sexual abuse (WHO, 2002). Numerous consequences are associated with sexual violence. Sexual violence in childhood and adolescence is significantly associated with higher rates of health risks and health-risk behaviors in both males and females. In adulthood, intimate partner and sexual violence is associated with higher prevalence rates of unintended pregnancies, abortions and pregnancy complications, sexually transmitted infections, mental health disorders, and suicide. Children of women who experience intimate partner or sexual violence are more likely to have poorer overall health and educational outcomes and behavioral and emotional disturbances associated with perpetrating or experiencing violence themselves later in life (WHO, 2010).
Law to Protect Sexual Assault Victims
Kentucky as SAFE Exams (also called rape exams) have historically only been available to victims if the crime was reported to law enforcement. However, federal law was enacted in 2005 to encourage more victims to get medical treatment and have samples collected for potential use in prosecution. Now, states must provide SAFE Exams without requiring the patient/victim to cooperate with law enforcement, which includes reporting required for payment of services or agreeing to press charges. To comply with federal law, Kentucky eliminated the ‘reporting for payment’ requirement in 2009. The 2010 Kentucky General Assembly enacted House Bill 500, which became effective July 15, 2010, to govern performance of such exams throughout the Commonwealth. These changes serve two primary purposes: (1) to improve victims’ access to necessary medical treatment and (2) to increase the availability of samples in delayed reporting cases (Kentucky Association of Sexual Assault Programs, n.d.).
Forensic Clinical Nurse Specialist. The registered nurse who is “prepared to provide expert forensic patient care while also serving colleagues as consultants, educators and researchers.”
Risk Manager. An individual “with a strong background in forensic science, nurses with advanced degrees in forensics are well prepared to serve as forensic investigators and as experts in risk management.”
Forensic Assessment and Consultation Team.Team members from sexual assault and domestic violence teams who come together to provide examinations and assessment for both victims and/or suspects that are referred to the team.
Clinical forensic nurse. The registered nurse who “provides care for the survivors of crime related injury and deaths.”
Forensic nurse investigator.The registered nurse who works within a medical examiner or coroner’s role “representing the decedent’s right to social justice through a scientific investigation of the scene and circumstances of death.”
Forensic nurse examiner. The registered nurse who can provide analysis of “physical and psychological trauma, questionable deaths and or psychopathology evaluations related to forensic cases and interpersonal violence” and “is cross-trained in several subspecialties serving a wider range of forensic patients.”
Sexual assault nurse examiner (SANE). Registered nurses who have specialized education and skills that support the provision of a comprehensive forensic-medical examination and evaluation as well as “maximizing the collection of biological, trace and physical evidence and minimizing the patient’s emotional trauma.”
Forensic psychiatric nurse. The registered nurse who “specializes in the assessment and intervention of criminal defendants, patients in legal custody who have been accused of a crime, or have been court mandated for psychiatric evaluation.”
Forensic correctional, institutional or custodial nurse. The registered nurse who “specializes in the care, treatment, and rehabilitation of persons who have been sentenced to prisons or jails for violation of criminal statutes and require medical assessment and intervention.”
Legal nurse consultant. The American Association of Legal Nurse Consultants (AALNC) lists legal nurse consulting as “the analysis and evaluation of facts and testimony and the rendering of informed opinions related to the delivery of nursing and other healthcare services and outcomes, and the nature and cause of injuries. The legal nurse consultant is a licensed registered nurse who performs a critical analysis of clinically related issues in a variety of settings in the legal arena. The nurse is a clinical expert with a strong educational and experiential foundation and is qualified to assess adherence to standards and guidelines of practice as applied to nursing practice.”
Nurse attorney. A registered nurse who also has a valid “Juris Doctorate” degree who practices as an attorney-at-law generally specializing in civil or criminal cases involving healthcare-related issues.”
Nurse coroner.A registered nurse who may be either elected into this position or hired into the role. The role provides specific jurisdictional powers to provide “investigation and certification of questioned deaths, to determine the cause and manner of death as well as the circumstances pertaining to the decedent’s identification and notification of next of kin.”
Emergency Nurse. There are additional roles in nursing that encompass forensic nursing principles and practice. The Emergency Nurse routinely cares for individuals related to trauma, violence, intentional/unintentional injury, workplace injuries, vehicular events, medical emergencies that may have legal implications, are deceased or dying, human trafficking, stabbings, gunshot wounds, or interpersonal violence of all kinds. ED nurses may also care for persons who are convicted of crimes, sexual assault, suffer from mental illness, addiction, and intentional/unintentional drug ingestions (Early, 2016).
Types of Examinations:
Acute Examination. A medical forensic sexual assault examination that occurs within five days of the sexual assault in the adolescent/adult patient population, and within 72 hours of the assault in the prepubertal patient population.
Medical Forensic Examination. A medical evaluation of the sexually assaulted patient that includes a history, physical examination, injury identification, documentation, risk assessment and treatment as well as resources and referrals. This examination may occur with or without evidence collection.
Non-Acute Examination. A medical/forensic sexual assault examination that occurs more than five days after the assault in the adolescent/adult patient population, and after 72 hours in the prepubescent patient population.
Adolescent/Adult Population. Female patients who have reached the onset of menses or higher in sexual development; male patients who have reached Tanner Stage 3 of Sexual Maturity or higher.
Types of Reporting:
Prepubescent Population. Female patients who have not yet reached the onset of menses and male patients who have not yet reached Tanner Stage 3 of Sexual Maturation.
Anonymous Report. The type of report a sexual assault victim makes while obtaining a medical forensic exam and chooses not to participate in the criminal justice system and/or provide any personally identifying information to law enforcement. Evidence and information is released to law enforcement, but without victim identifying information. An anonymous reporting victim consents only to evidence storage.
Law Enforcement Report.The type of report a sexual assault victim makes who chooses to participate in the criminal justice system.
Medical Report.The type of report a sexual assault victim makes while obtaining a medical forensic exam and choosing not to participate in the criminal justice system, but does provide personally identifying information to law enforcement. Evidence and information is released to law enforcement with victim identifying information. A medical reporting victim can choose to have evidence tested.
Health care providers who are the first to encounter the sexually assaulted victims and they should delicately balance to support the patient’s emotional trauma while proficiently and efficiently interview and collect forensic evidence. The first step to a patient-centered approach is to respond to patients and family in a nonjudgmental and supportive manner. The goal is to reduce any further trauma that may be inflicted through the forensic process; therefore, communicating to the patient each step of the evidence collection process is important. Sexual assault is a traumatic event, and therefore trauma-informed care must be the top priority.
The Substance Abuse and Mental Health Services Administration (SAMHSA) developed six key principles of a trauma-informed approach (SAMHSA, 2018). A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific:
- Trustworthiness and Transparency
- Peer Support
- Collaboration and Mutuality
- Empowerment, Voice and Choice
- Cultural, Historical, and Gender Issues
In all cases, providers should minimize any traumatic aspects of the evaluation. Below are some suggestions for responding appropriately to the needs of sexual assault victims in a hospital setting (New Hampshire Department of Justice Office of the Attorney General, 2012).
(1) Be aware that some patients may have had previous negative experiences with medical personnel, and may be wary of how they will be treated now.
(2) Do not make assumptions. To prevent making incorrect assumptions, nothing about the patient’s life or the nature of the assault should be assumed. This is especially true for assuming the sexual orientation of either the patient or the offender.
(3) Experiencing a sexual assault is the ultimate loss of control for patients therefore it is imperative that the patient be informed about the medical process, and every effort should be made to give a sense of control back to the patient. Explain each step of the medical process, and the patient should be allowed to ask questions and make decisions about the care they are receiving. The provider should respect patient choices.
(4) It is important to note that offenders can often be family members or caretaker/service providers, especially in child abuse and elderly/incapacitated adult abuse cases. There may also be times where the offender presents as the “secondary victim” or “helping friend.” Professionals need to be aware of this so the patient does not experience re-victimization, or have their decisions unduly influenced by the unwanted presence of this individual. Always ask the victim (without anyone else present) who he or she would like to have in the exam room and be sure to respect their decision.
(5) Every effort should be made by the medical personnel to assist and facilitate communication with the victim. Victims may have difficulty communicating, some reasons including: (a) shock from having experienced trauma, (b) having been drugged, (c) not speaking English, (d) being hearing impaired, (e) having a cognitive defect or impaired or reduced mental capacity. This makes it difficult to comprehend questions, or they may not possess the language and communication skills necessary to explain what has happened to them.
(6) Health professionals are expected to make every possible effort to clearly and effectively communicate at a level that is appropriate and commensurate with the victim’s ability.
(7) Feelings of guilt and shame, and that the victim somehow ‘caused’ the assault are common victim responses. These feelings can be especially strong in cases where alcohol was involved, or when a male is the victim of an assault. Victims may feel ashamed that they were unable to protect themselves from the assault and/or confused if they experienced an involuntary physiological response to the assault. It is important that the patients be reassured that the assault was not their fault and whatever they did to survive the assault was the right thing to do.
(8) It is important to recognize that sexual assault affects everyone involved with the primary victim of the crime. The family and friends of the sexual assault patient are also, in many ways, secondary victims of the sexual assault and may experience feelings like those of the actual victim. It is important to recognize that this population may need assistance as well, and to help them access the resources available at the local crisis center. These secondary victims are usually able to better support and respond to the needs of the primary victim when they themselves are receiving information, support and services.
(9) Certain patients may be hesitant to receive care; out of fear they will get in trouble due to their conduct before or after the assault. This may be a concern for victims who fear deportation and/or the adolescent population where underage drinking, drug consumption and “sneaking out” or lying to their parents/caregivers may have occurred. It is important to reassure patients that any decision or choice they made does not mean they deserved to be sexually assaulted.
(10) In hospitals that provide Sexual Assault Nurse/Forensic Examiner (SANE/SAFE) services, the examiner should be notified as soon as the patient presents at the emergency room, and whether the patient is opting for evidence collection.
(11) Regardless of who will complete the medical forensic evaluation, all the available options should be reviewed with the patient. Whenever possible, the patient’s decision should be carried out by health care providers.
Sexual Assault Evidence Collection (SAECK) Kits
The Kentucky State Police Crime Laboratory provides Sexual Assault Evidence Collection Kits (SAECK) for examinations of victims at no cost to examination facilities or law enforcement agencies. [NOTE: KSP Crime Laboratory does not provide the entire toolkit caddy and supplies; only the SAECK within the toolkit.] In the past, kits were typically brought to hospitals by law enforcement officials as needed, usually when responding to reports. Fortunately, kits may be stocked in advance, therefore, it is not necessary to wait until a victim is present. Any hospital or other sexual assault examination facility may request kits from the Kentucky State Police Crime Laboratory. Kits are provided at no cost to the facility. However, the facility is responsible for paying for delivery or arranging pick up. Kits may be requested from either the Central Laboratory or the nearest Branch Laboratory (Kentucky Association of Sexual Assault Programs, n.d.).
Additional supplies are to be added to the kits:
- Butterfly needles (2)
- 3 cc syringe 18 g needle
- Purple top tube
- Several 2 x 2s
- Role of tape Sterile water or saline (to moisten swabs and control with)
- Pre-filled saline flush or vial of saline
- 10 cc syringe, and 18 g needle
- Speculum KY jelly 16 additional swabs (hospital stock - if there are two in a package then you only need 8 packages)
- Blank envelopes (4)
- Urine specimen cup Black ink pen or sharpie to label envelopes
- Chux pad (1)
- Paper bags (4) – medium
- Consent Forms (reporting and non-reporting) (must be issued by hospital)
Principles of Evidence Collection
There are two very important principles to follow when collectingforensic evidence: (1) is the prevention of contaminating the samples collected and (2) preserving the integrity of the sample. This can be achieved by following the steps outlined below (TXDPS, 2017).
(1) To preserve the identity and chain-of-custody of each item of evidence, each sample or exhibit must be labeled.
(2) Evidence should be labeled with exhibit numbers on the outside of all containers being submitted.
(3) The evidence should correspond to labeling and item descriptions of a crime scene log. Labeling should not occur on the item itself; rather it should be on a tag attached to the item in an area not to be tested or on its individual container.
(4) It is recommended that at a minimum, items be labeled with an item number, location of collection, date collected (to include time; as required by some agencies), and initials of individual who collected the item. Other pertinent information may also be included, depending on local agency policy.
(5) It is highly recommended that an item numbering system be used when referring to item numbers on the submission form for evidence that will be submitted to the Crime Lab. The Crime Laboratory Service is using a Laboratory Information Management System that will assign your evidence a laboratory item number. The Laboratory will correlate your item number to the laboratory item number to ensure that the evidence is properly reported. Small items should be placed in appropriate containers.
(6) ALL EVIDENCE MUST BE LABELED AND PROPERLY SEALED. For a seal to be considered proper, the tape must have the initials of the person performing the seal and the date on which the seal was created with some part of the labeling extending over the edge of the seal. Tape should completely cover all openings to the evidence container. Please do not use staples as they do not constitute a proper seal and may present a safety hazard. These steps are taken to ensure that if a seal has been tampered with, it will be evident.
(7) The container of items suspected of containing blood or other body fluids must be either labeled with a biohazard symbol or in a red container, except as it pertains to the shipping container.
(8) The shipping container for Biological Substances Category B must have a UN3373 symbol and the inside container must be either red or labelled with a biohazard symbol. (Please see guidelines from US Postal Service available online for specific instructions)
(9) Containers of glass and/or sharp objects should be identified as such on the container (TXDPS, 2017).
Chain of Custody
While medical information and forensic evidence may be collected together, forensic evidence must be collected, preserved and documented in a manner that ensures its admissibility later as evidence in court. The custody of the evidence in the collection kit, as well as any clothing or other collected items, must be accounted for from the time it is initially collected until it is admitted into evidence at trial. This is accomplished by establishing a “chain of custody.” Chain of custody chronologically documents everyone who handles a piece of evidence from the time it is collected. The unbroken chain of custody establishes the integrity of the evidence and any subsequent analysis of the evidence and is a prerequisite to admitting the evidence in court.
Sealing the kit with the evidence tape provided, and initialing that seal, establishes that the medical forensic evidence has not been tampered with and ensures the integrity of the evidence. This also applies to any collected clothing or other items which are not sealed in the kit.
The chain of custody for a piece of evidence is established by documenting the name and date that the item is received and/or transferred to another individual, beginning at the date and time the evidence is initially collected. The evidence must also be labeled with the name of the unique patient information identifier, the sexual assault examiner, and the source of the specimen. Additionally, the evidence must be kept in a manner that precludes tampering. This is accomplished by sealing the evidence kit with the evidence tape provided, initialing the seal, and keeping the evidence in a secure place. It is important to emphasize the documentation of the chain of custody includes the receipt, storage, and transfer of evidence.
Storage of Samples
Report to Law Enforcement (Victim Choice). Samples should be transferred to the appropriate law enforcement officials as soon as possible. Chain of custody documentation must be maintained on samples and a copy must accompany samples all the time (Kentucky Association of Sexual Assault Programs, n.d.).
No Report to Law Enforcement (Victim Choice). Under the new law, the hospital or other examination facility at which the exam is performed has the duty to either store the samples or arrange for their storage. Samples must be stored for at least 90 days to give the victim time to consider filing a delayed report. The hospital, in which samples were collected, must either provide for secure storage of the samples or transfer samples to a designated storage facility. Samples should be secured inside of a locked container that is sealed so that tampering would be evident. Each person who breaks the seal should be required to document the purpose and circumstances related to the access (Kentucky Association of Sexual Assault Programs, n.d.).
Payment Protection for Safe Exams. The Sexual Assault Examination Program operated by the Crime Victims Compensation Board pays for services included in the SAFE Exam. To comply with federal and state law, policies have been changed to allow for payment in cases where a victim chooses not to report. Revised payment forms and processes may be found at http://cvcb. ky.gov/. For payment rates, see 107 KAR 2:010. Kentucky law states that “no charge shall be made to the victim for these examinations.” See KRS 216B.400. Not all victims are eligible for Crime Victims Compensation Fund reimbursement. For more information, contact the Crime Victims Compensation Board at 800-469-2120, or visit their website at http://cvcb.ky.gov/
ENSURING (Kentucky Association of Sexual Assault Programs, n.d.).
STEP 1: Clothing
(1) Clothing frequently contains the most important evidence in a case of sexual assault. The reasons for this are two-fold:
a. Clothing provides a surface upon which traces of foreign matter may be found, such as the offender's semen, saliva, blood, hairs, and fibers, as well as debris from the crime scene. While foreign matter can be washed off or worn off the body of the patient, the same substances often may be found intact on clothing for a considerable length of time following the assault.
b. Damaged or torn clothing may be significant. It may be evidence of force and can also provide laboratory standards for comparing trace evidence from the clothing of the patient with trace evidence collected from the suspect and/or the crime scene.
(2) The most common items of clothing collected from patients and submitted to crime laboratories for analysis are underwear, hosiery, blouses, shirts, and slacks. There are also instances when coats and even shoes must be collected. These items should only be taken if the patient wore them at the time of the assault and they likely contain evidence in the case. A patient’s wallet, cash and credit cards should not be taken. A patient’s jewelry should not be taken. If the examiner believes material has been transferred from the offender onto the victim’s jewelry, the jewelry should be swabbed using sterile water/saline and swabs, and packaged appropriately as part of the evidence collection kit.
(3) In the process of criminal activity, different garments may have contacted different surfaces and debris from both the crime scene and the offender. Keeping garments separate from one another permits the forensic scientist to reach certain pertinent conclusions regarding reconstruction of criminal actions. Therefore, each garment should be placed separately in its own paper bag to prevent cross-contamination.
(4) When the determination has been made that the victim’s clothing contains possible evidence related to the assault, with patient consent, those items should be collected. The patient has the right to refuse to turn over any article of clothing. Underpants of female victims of sexual assault where penile-vaginal penetration has occurred should always be collected if the patient is seen within 120 hours of the examination, even if the patient has changed underpants since the assault.
(5) If it is determined that the patient is not wearing the same clothing, the examiner should inquire as to the location of the original clothing. This information should be given to the investigating officer so that he or she can plan to retrieve the clothing before any potential evidence is destroyed.
(6) It is important that the treating facility have access to clothing the patient can wear home if her/his clothing is collected for evidence. Disposable paper hospital clothing is not acceptable. If there is no clothing available, many retail stores will make donations, or contact your local crisis center and ask them if they can be of assistance.
Clothing Collection Procedure. The clothing should be collected and packaged in accordance with the following procedures:
(1) Each facility should obtain large paper evidence bags from local law enforcement authority or evidence supply stores as these are not included in the evidence collection kits.
(2) Utilize the two paper drapes that come in the kit. Place the first drape down on the floor – this will later be discarded as it may pick up trace from your facility floor. Place the second paper drape on top of the first drape and this is where your patient will stand and disrobe. If trace falls off while disrobing, the top drape will collect the trace. The drape the patient stands on should be collected whether you see visible trace or not. To collect the drape, utilize a pharmacy fold and include it in its own paper bag. Discard the bottom drape.
(3) After air-drying items when necessary, appropriate articles of clothing (i.e. underpants, hosiery, slips, or bras) should be put into individual small paper bags. Whenever possible, any wet stains, should be allowed to air dry before being placed into paper bags. It is preferable that each piece of clothing be folded inward, placing a piece of paper against any stain, so that the stains are not in contact with the bag or other parts of the clothing.
(4) If, after air drying as much as possible, moisture is still present on the clothing and might leak through the paper bag, the labeled and sealed clothing bags should be placed inside a larger plastic bag with the top of the plastic bag left open. In these instances, a label should be affixed to the outside of the plastic bag, which will alert law enforcement that wet evidence is present inside the plastic bag. This will enable law enforcement to remove the clothing and avoid loss of evidence due to putrefaction.
(5) It is important to remember that sanitary napkins, tampons, and infant diapers may also be valuable as evidence because they may contain semen or pubic hairs from the perpetrator. Items such as slacks, dresses, blouses, or shirts should be put into larger paper bags.
STEP 2: Trace Evidence
When caring for a sexual assault patient there may be material or fibers that are found related to the assault. This is identified as trace evidence. These materials can help to corroborate circumstances and provide evidence beyond DNA. As with all steps, be sure to wear gloves in the collection of trace evidence, changing between samples.
Place any hairs, fibers, or other materials, if found on the victim or examination table, in the bindle provided. Fold bindle to contain the trace evidence and return bindle to envelope. Seal and fill out all information requested on envelope.
STEP 3: Oral Swabs and Smears
In cases where the patient was orally penetrated, the oral swabs and smear can be as important as the vaginal or anal samples. The purpose of this procedure is to recover seminal fluid from recesses in the oral cavity where traces of semen could survive.
Holding four swabs together swab the oral cavity including the gum line and inside the cheeks. Attention should be paid to those areas of the mouth, such as between the upper and lower lip and gum, where semen might remain for the longest amount of time. Prepare the oral smear by wiping all four swabs across the middle surface of the labeled glass slide. The smear should not be fixed or stained. Allow oral swabs and smear to air dry. Close and seal slide holder and return to kit. Return dried swabs to the Oral Swabs and Smear envelope. Seal and fill out all information requested on envelope.
Once oral swabs have been collected, have the patient rinse their mouth and wait 30 minutes before collecting buccal swab samples (step 13).
STEP 4: Foreign Strains on Body Swabs
Semen is the most common fluid deposited on the patient by the offender. There are also other fluids, such as saliva, which can be analyzed by laboratories to aid in the identification of the perpetrator. It is important that the provider ask the patient about any possible foreign material left behind and examine the patient's body for evidence of foreign matter.
If fluids, such as saliva, seminal fluid and dried blood, are observed on other parts of the patient's body during the examination, the material should be collected using a set of swabs. A different set of swabs should be used for every fluid collected from each location on the body.
Oral contact with the victim’s breast or genitalia is common. It is important to ask the patient directly if and where the offender put his/her mouth, or where the suspect ejaculated. If the patient has not bathed or showered and contact has occurred, or the patient is uncertain, collect the specimens.
Dried fluids are collected by dampening the swab with sterile water/saline and swabbing the indicated area. After allowing the swab to air dry, it should be returned to the envelope provided. In the event multiple sites require collection, the examiner should obtain additional swabs and envelopes from the hospital supply and label accordingly. Seal and fill out all information requested on envelope.
Bite Mark Procedure. Bite marks may be found on patients that occurred during a sexual assault, and should not be overlooked as important evidence. Saliva, like semen, may demonstrate the DNA profile of the individual from whom it originated. Bite mark impressions can be compared with the teeth of a suspect and can sometimes become as important for identification purposes, as fingerprint evidence. The collection of saliva and the taking of a photograph of the affected area are the minimum procedures that should be followed in cases where a bite mark is present, or believed to be present.
The collection of saliva from the bite mark should be made prior to the cleansing or dressing of any wound. If the skin is broken, swabbing of the actual punctures should be avoided when collecting dried saliva.
It is important that photographs of bite marks be taken properly. An individual, deemed appropriate for the situation and who has sufficient photography skills, should be contacted immediately to take photographs of bite mark evidence utilizing an American Board of Forensic Odontology #2 standard found on their website (http://www.crimescene.com/store/index.php?main_page=product_info&products_id=342).
Saliva is collected from the bite mark area by moistening two sterile swabs with a minimum of sterile water/saline and gently swabbing the affected area, following the same procedures as instructed for other dried fluids described in Step 4.
STEP 5: External Genital Swabs
If the circumstances of the assault suggest there has been contact between the victim’s genitalia and the offender’s mouth or penis WITHIN 5 DAYS of the examination, there exists the possibility that saliva or seminal fluid may be found on the patient’s external genitalia. In this instance, the two cotton tipped swabs in the envelope should be moistened slightly with sterile water/saline and the entire pubic area should be swabbed, the swabs dried and packaged appropriately. Seal and fill out all information requested on envelope.
When the patient is prepubescent, external genital swabs should be collected instead of vaginal and cervical swabs.
STEP 6: Pubic Hair Combings
Pubic hair can retain trace evidence from a sexual assault. For this reason, collection of pubic hair combings may be beneficial. If the patient is prepubescent or has shaved her/his pubic hair, external genital swabs would be more appropriate.
Place the bindle under the patient’s pubic area/buttocks and run the provided comb through the pubic hair collecting any foreign material that falls out into the bindle. The comb and bindle should be packaged and sent even if there is not visible debris or material. Seal and fill out all information requested on envelope.
Where there is evidence of semen or other matted material on pubic hair, it may be collected in the same manner as other dried fluids. The swab should be placed in a small paper envelope and labeled "possible fluid sample from pubic hair." Although this specimen may also be collected by cutting off the matted material, it is important to obtain the patient's permission before cutting any amount of hair.
STEP 7: Pubic Hair Standards
Pubic hair standards are a pulled sample of the patient's pubic hair (a minimum of 30 hairs). This sample IS NOT TYPICALLY COLLECTED except for the following circumstances:
(1) There is an unknown offender where a scene investigation by law enforcement is expected; or
(2) There is a scene investigation where evidence collection reveals a hair sample in need of the victim's hair for comparison purposes.
In these circumstances, and with the victim’s consent, pull a minimum of 30 pubic hair samples from multiple locations using only gloved hands. Do not use tweezers as they may damage the hair shaft. Do not cut hair for the sample. Place collected hairs in the bindle and envelope provided. Seal and fill out all information requested on envelope.
STEP 8: Head Hair Standards
Head hair standards are a pulled sample of the patient's head hair (a minimum of 30 hairs). This sample IS NOT TYPICALLY COLLECTED except for the following circumstances:
(1) There is an unknown offender where a scene investigation by law enforcement is expected; or
(2) There is a scene investigation where evidence collection reveals a hair sample in need of the victim's hair for comparison purposes.
In these circumstances, and with the victim’s consent, pull a minimum of 30 head hair samples from multiple locations using only gloved hands. Do not use tweezers as they may damage the hair shaft. Do not cut hair for the sample. Place collected hairs in the bindle and envelope provided. Seal and fill out all information requested on envelope.
STEP 9: Anal Swab and Smear
After fully explaining the procedure to the patient, put the patient in either supine or prone knee-chest position, and apply gentle bilateral pressure with the examiner’s hands to the patient’s buttocks. Allow approximately 2 minutes for anal dilation to occur. Swab the anal cavity using the four swabs provided. To minimize patient discomfort, these swabs may be moistened slightly with sterile water/saline. Prepare the smear by wiping swabs across the top, labeled surface of the microscope slide. The smear should not be fixed or stained. Allow all swabs and smear to air dry. Close and seal slide holder and return to kit. Dry and return swabs to envelope. Seal and fill out all information requested on envelope. Any additional examinations or tests (such as STI testing, cultures, anoscopy, etc.) involving the rectum should be conducted.
STEP 10: Vaginal and Penile Swabs and Smears
Vaginal Swabs.Vaginal swabs should only be obtained in the adolescent (pubertal) and adult population of female patients. Prepubescent patients would have external genital swabbing only. When collecting the vaginal specimens, it is important not to aspirate the vaginal orifice or to dilute the fluids in any way.
Utilizing a speculum in the patient who has reached the onset of menses, swab the vaginal vault using the four swabs provided. Prepare the vaginal smear by wiping the four swabs across the middle surface of the labeled glass slide. The smear should not be fixed or stained. Allow all swabs and smear to dry. Close and seal slide holder and return to kit. Dry and return swabs to envelope. Seal and fill out all information requested on envelope. The remainder of the pelvic examination should be performed and any additional examinations or tests (such as STI culturing, etc.) should be conducted.
Collection of Tampons as Evidence.The sexual assault examiner may find that the patient has inserted a tampon in response to menstruation or bleeding post assault, or the patient may have a tampon in from the time of the assault. The tampon may have absorbed residual semen from the offender. It will therefore be necessary to collect the tampon as evidence. Obtain a sterile urine specimen collection container from hospital supply. Label the container with the name of the patient, date, time and collector's initials. Punch three or four small (18-gauge needle) air holes through the cover of the container. Carefully remove the tampon from the patient's vaginal cavity, or ask the patient to remove the tampon, and place it in the urine specimen container. Cover the specimen container and place it into a paper bag. Label the bag with the name of the patient, date, time and collector's initials. Seal the paper bag with tape and keep it separate from the Evidence Collection Kit. Do not attempt to secure the tampon and packaging in the Evidence Collection Kit. Refrigerate the specimen if transport to the laboratory is not immediate. Be sure to circle or highlight "refrigerate" on the front of the kit and notify law enforcement to ensure that the evidence will be properly preserved.
Penile Swabs. For the male patient, both adult and child: the presence of saliva on the penis could indicate that oral-genital contact was made; the presence of vaginal fluids could help corroborate that the penis was introduced into a vaginal orifice; and feces or lubricants might be found if rectal penetration occurred.
The proper method of swabbing the penis is to slightly moisten the two swabs provided, with sterile water/saline, and thoroughly swab the external surfaces of the penile shaft and glans. All outer areas of the penis and scrotum where contact is suspected should be swabbed. Allow all swabs to air dry. Place both swabs in the envelope, seal and return kit. Care should be taken to avoid the urethral meatus as this could result in obtaining a DNA sample of the victim instead of the perpetrator. Any other applicable hospital testing (such as RPR, VDRL, HIV, etc.) should be done at the same time.
STEP 11: Cervical Swab and Smear
As with vaginal samples, cervical samples are only collected in patients who are past onset of menses. The cervix provides an excellent source for sperm and DNA collection. The cervix serves as a reservoir for sperm as the flow of cervical mucus creates strands that direct the sperm upward. Cervical swabs should be collected across the face of the cervix and in the cervical os.
This area is first visualized with a speculum. Then the area is swabbed by holding four dry swabs together across the face of the cervix. Prepare the smear by wiping the four swabs across the middle surface of the labeled glass slide. The smear should not be fixed or stained. Allow all swabs and smear to air dry. Close and seal the slide holder and return to kit. Air dry and return swabs to envelope. Seal and fill out all information requested on envelope.
STEP 12: Fingernail Clippings and Swabbing
Fingernail clippings are commonly collected on patients which may have been in a physical altercation during an assault. They may contain skin cells of the suspect and are simple to collect.
Use clippers from kit and the nurse or patient may cut the fingernails onto the enclosed bindle. Nails from both hands should be included. When finished, close the clippers and include them in the bindle. Close the bindle and place in the envelope, filling out all requested information.
If a patient has very short nails, declines having nails cut, or in the case of a child where cuttings could be difficult, a swab collection may be used. This is accomplished by moistening one swab with sterile water/saline and then swabbing underneath each of the 10 fingernails. Only one swab is used. The swab is then air-dried and placed in envelope. Seal and fill out all information requested on envelope.
STEP 13: Buccal Swabs
In some instances of sexual assault, dried deposits of blood, semen, or saliva may be found at the crime scene or on the body or clothing of either the patient or suspect. The purpose of collecting DNA Sample/Buccal Swabs is to determine the patient's DNA profile for comparison with such deposits.
Prior to collection of the buccal swabs, have the patient rinse their mouth and wait 30 minutes before collecting the samples.
Swab the inner aspects of both cheeks with all four swabs until moistened. Allow both swabs to dry. Place swabs in the appropriate envelope. Seal and fill out all information requested on envelope.
Buccal swabs should be taken in ALL acute sexual assault patients, including children.
STEP 14: Additional Evidence
One additional envelope is included in the Colorado kit. Use clinical discretion as to whether it is a needed evidence collection component or not. This will vary based on the patient, history and circumstances of the assault. For example, it may be appropriate to swab a female's abdomen when she says the suspect ejaculated on her. Other circumstances may exist where the additional envelope will be helpful and the sexual assault examiner should use their best clinical judgment in determining appropriateness of inclusion.
Each additional sample should be packaged in its own separate envelope seal and fill out all information as requested on the additional envelope. When more envelopes are needed than are provided in the kit, hospital envelopes or saved envelopes from other evidence (Colorado Sexual Assault Evidence Collection Protocol, 2015).
(1) When packaging evidence, the goal is to preserve the original integrity of the sample. For this reason, samples should be properly segregated so that contamination does not occur and all instruments, bottles, test tubes, envelopes and other containers used to package evidentiary items must be clean and not previously used. It is necessary that evidence samples and standards be packaged separately. The collection of these items must be separated by space and if possible by time as well.
(2) Liquid evidence must be mailed in a conveyance container separate from non-liquid evidence. All packaging must be labeled and a chain of custody maintained (in the manner deemed appropriate by your agency) so that all items can be readily identified by all who have been a part of the chain of custody.
(3) Samples may be transported by either personal delivery or use of a trackable delivery service (such as Federal Express or UPS). Any carrier used to transport evidence shall have the ability to track the package. A printed copy of the package tracking documentation should be
Pediatric Sexual Assault
Reports showed that 12% - 25% of girls and 8% - 10% of boys were sexually abused by age 18, most often by a male family member or trusted acquaintance (Orr, 2016). The sexual assault nurse examiner-pediatrics (SANE-P) credentialing started in 2007. Each state has laws governing sexual assault to minors. SANE-P has an incredible opportunity to educate the differences between physical injury and non-physical injury such as fondling, oral-genital, genital or anal contact without penetration), and how each contributes to the emotional trauma of pediatric sexual abuse patients (Orr, 2016).
Risk factors associated with intimate partner or sexual violence victimization include but are not limited to young age, lower socioeconomic status, exposure to maltreatment as a child, mental health disorders, alcohol and/or illicit drug use, weak or absentsupport systems within the community, and societal support of violence (WHO, 2010).
Risk and Protective Factors
(intimate partner and sexual violence)
(1) Women and men with lower levels of education are at increased risk of experiencing and perpetrating, respectively, intimate partner violence.
(2) Exposure to child maltreatment is strongly associated with: a) the perpetration by men of intimate partner and sexual violence; and b) the experiencing by women of intimate partner and sexual violence.
(3) An antisocial personality disorder is a strong risk factor for the perpetration of both intimate partner and sexual violence.
(4) Harmful use of alcohol is frequently found to be associated with the perpetration of both intimate partner and sexual violence.
(5) Males who have multiple partners or are suspected by their partners of infidelity are more likely to perpetrate both intimate partner and sexual violence.
(6) Attitudes that are accepting of violence are strongly associated with both the perpetration and experiencing of intimate partner and sexual violence. Risk factors specific to intimate partner violence n
(7) History of violence as a perpetrator or victim is a strong risk factor for future intimate partner violence.
(8) Marital discord and dissatisfaction are strongly associated with both the perpetrating and experiencing of intimate partner violence (WHO, 2010).
(specific to sexual violence)
(1) Beliefs in family honor and sexual purity are associated with a lack of social pressure to persuade young men that coercive sex is wrong.
(2) Sexual violence committed by men is to a large extent rooted in ideologies of male sexual entitlement. These belief systems grant women extremely few legitimate options to refuse sexual advances.
(3) Weak legal sanctions for sexual violence send the message that such violence is condoned, and may even exclude certain forms of sexual violence from the legal definition (WHO, 2010).
(1) Different risk and protective factors may operate in different countries and settings. Hence, it is important to identify and then address those risk factors most strongly associated with intimate partner violence and sexual violence in each setting.
(2) Primary prevention efforts should focus on younger age groups.
(3) Preventing all forms of violence and abuse, especially child maltreatment, will help to reduce the levels of intimate partner and sexual violence.
(4) Reducing overall alcohol consumption in a population may help to reduce the harmful use of alcohol and with it the perpetration and experiencing of intimate partner and sexual violence.
(5) There are several modifiable factors associated with intimate partner violence that can be targeted by primary prevention measures such as reducing acceptance of violence, increasing women’s access to education, changing laws that discriminate against women and implementing more gender equitable policies. Although targeting these factors will likely also reduce sexual violence, the required evidence is currently lacking (WHO, 2010).
Cataruozolo, P. E. (2015). Forensic Nursing: Focus on SANE. Journal of Legal Nurse Consulting, 26(1), 33-37.
Colorado Sexual Assault Evidence Collection Protocol (2015).
Drake, S. A., Langford, R., & Young, A. (2016). The development of quantitative instruments to evaluate cognition and competency of forensic nursing science.Nursing Education Perspectives, 37(6), 313. doi:http://dx.doi.org.ezproxy.shu.edu/10.1097/01.NEP.0000000000000044
Early, S. (2016). North America's Evolving Nursing Specialty. Journal of Legal Nurse Consulting, 27(4), 10-15.
Geller, L. (2015). NURSE TO KNOW. Forensic nursing's game changer. Canadian Nurse, 111(4), 26-29.
International Association of Forensic Nurses (2015). Retrieved from ForensicNurses.org
Kentucky Association of Sexual Assault Programs (n.d.). Retrieved from file:///U:/Forensic%20Evidence%20Collection%20Component%20in%20Continuing%20Education/Kentucky/SAFEtoolkitguideFINAL.pdf
Orr, J. L. (2016). The Role of the Forensic SANE Nurse in Pediatric Sexual Assault. Journal of Legal Nurse Consulting, 27(4), 16-20.
Rothman, E. F., Exner, D., & Baughman, A. L. (2011). The Prevalence of Sexual Assault against People Who Identify as Gay, Lesbian, or Bisexual in the United States: A Systematic Review. Trauma, Violence and Abuse, 12, 55-66.
Substance Abuse and Mental Health Services Administration (2018). Retrieved from https://www.samhsa.gov/nctic/trauma-interventions
Texas Department of Public Safety (TXDPS). (2017). Texas physical evidence handbook (version 10).
Report of the Attorney General’s National Task Force on Children Exposed to Violence (2012) https://www.justice.gov/defendingchildhood/cev-rpt-full.pdf
World Health Organization/London School of Hygiene and Tropical Medicine (2010). Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva, World Health Organization (WHO).
World Report on Violence and health (2002). Geneva, World Health Organization (WHO).