About this course:
This module aims to outline the trauma-informed care of victims of sexual violence, including assessment, forensic evidence collection procedures, documentation, and a brief overview of providing testimony. This course also satisfies the requirements for nurses practicing in the state of Texas for sexual assault and forensic medicine continuing education.
This module aims to outline the trauma-informed care of victims of sexual violence, including assessment, forensic evidence collection, documentation, and a brief overview of providing testimony. This course also satisfies the continuing education requirement for nurses in the state of Texas for sexual assault and forensic training. Any nurse employed in an emergency department in Texas must take a one-time 2 contact hour course on forensic evidence collection, including information relevant to forensic evidence and age-appropriate care. The state of Illinois offers its own free 2-contact hour SANE training course for staff working within emergency departments through their attorney general's office, www.illinoisattorneygeneral.gov. Nurses in KY and elsewhere should refer to our other Forensic Evidence courses.
By the completion of this module, the nurse should be able to:
- identify critical points in evidence collection for sexual assault
- discuss age-appropriate patient care elements for victims of sexual assault in the emergency room or urgent care setting
- describe the sexual assault evidence kit
- explain how to best document and photograph evidence
In the 1970s, prior to the development of forensic nursing organizations or certifications, nurses began to recognize the need for better care of patients seeking treatment for sexual assault. Since then, forensic nursing has evolved as a specialty certification. The International Association of Forensic Nurses (IAFN) was formed and developed the scope and standards of the forensic nursing practice. Victims who are cared for by Sexual Assault Nurse Examiners (SANEs) have improved outcomes, and the use of trained SANEs is now considered a standard of care in many hospitals (US Department of Justice [DOJ], n.d.). The role of the forensic nurse, or SANE, is a fluid one. Forensic nurses work with victims of violent crime and provide forensic medical care, collect evidence, and give testimony when needed. This highly specialized care is important because victims of violent crimes require health professionals trained in the delivery of trauma-informed care related to an assault in order to achieve optimal outcomes. President Joe Biden once said, "Forensic nurses play an integral role in bridging the gap between law and medicine. They should be in each and every emergency room" (IAFN, 2021a).
According to the Centers for Disease Control and Prevention (CDC, 2020), sexual violence affects millions of people in the United States each year. Sexual violence affects people of all ages, genders, and sexual orientations, but the victims are most often female. More than one in three women has experienced sexual violence in their lifetime. Nearly one in five women has experienced an attempted or completed rape. One in three female rape victims experienced her first assault between the ages of 11 and 17. One in eight female victims of rape state that the first attack occurred before the age of 10. One in four men in the United States has experienced sexual violence, with one in 38 men has experienced attempted or completed rape. One in four male rape victims experienced their first attack between the ages of 11 and 17, and about one in four reported his first attack occurred before the age of 10 (CDC, 2020)
Forensic nurse- a registered or advanced practice nurse who has received special education and training and provides care for patients who have experienced acute and chronic health consequences due to violent crime. Forensic nurses also offer consultation and testify for civil and criminal proceedings (IAFN, 2021a).
Examiner- the healthcare provider who is conducting the sexual assault medical forensic examination. This includes forensic nurses or SANEs, physicians, or physician assistants trained in forensics (IAFN, 2021b).
Sexual assault advocate- a trained professional whose role is to provide counseling and support services to victims of sexual assault or violent crimes (DOJ, 2013).
Adolescent- children under 18 years of age who have reached the age of puberty. These patients have physical development and characteristics similar to an adult (IAFN, 2021b).
Adult- a person over the age of 18 who is not a child (IAFN, 2021b).
Pediatric child- children under 18 who have not reached puberty and do not have secondary sexual characteristics. Females who have not reached the age of menarche are included in this definition for physical examination; however, the patient's mental and emotional development should be considered when treating the patient (IAFN, 2021b).
Elderly- persons over the age of 65 (IAFN, 2021b).
Abrasion- a scraping type injury that is superficial (Texas A&M College of Nursing [TCON], 2019).
Bruise or contusion- bleeding beneath the surface of the skin (TCON, 2019).
Cut- an opening in the skin caused by forceful contact with a sharp object (TCON, 2019).
Laceration or tear- an injury caused by the blunt force, tearing, ripping, stretching, crushing, pulling apart, over-bending, or shearing of the skin (TCON, 2019).
Petechiae- multiple small pinpoint hemorrhagic spots (TCON, 2019).
Scar- fibrous tissue after healing of a wound (TCON, 2019).
Acute sexual assault- a sexual assault occurring within 7 days prior to the medical examination. For children or other vulnerable patients, assaults that occur during the last contact with the suspect (TCON, 2019).
Non-acute sexual assault- any sexual assault that occurred more than 7 days ago (TCON, 2019).
Drug-facilitated sexual assault (DFSA)- any sexual assault during which drugs, alcohol, or intoxicants are given to the victim deliberately by the perpetrator (TCON, 2019).
Standards of Forensic Nursing Practice
Forensic nursing uses the Quality-Caring Model as its theoretical framework. The IAFN developed standards of practice based on this model. The standards of forensic nursing practice are below:
- coordination of care
- health teaching and health promotion
- evaluation (Narcavage-Bradley et al., 2021)
As the first standard of forensic nursing, assessment includes collecting data such as patient demographics, physical, emotional, psychosocial, cognitive, sexual, and developmental. The assessment is designed to help the nurse understand the patient's needs, preferences, and comprehension of the situation (Narcavage-Bradley et al., 2021).
The nurse will analyze the data obtained to determine an actual or potential diagnosis. The nurse will use clinical findings to prioritize problems with the patient. Diagnoses will be used to determine appropriate testing and follow-up (Narcavage-Bradley et al., 2021).
The nurse will work with the patient and multidisciplinary team to identify expected outcomes. Each situation will have unique outcomes determined by the patient's status and his or her response to the s
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The nurse will work with the patient and multidisciplinary team to develop a plan of care to preserve and restore the patient's health. The plan will be based on the patient's needs and consider the potential short- and long-term effects of violent assault. An example of an appropriate plan is scheduling counseling for the patient and referring the patient to a crime victim's fund for financial assistance (Narcavage-Bradley et al., 2021).
Implementation of the plan is performed in collaboration with a multidisciplinary team and will be documented appropriately. Health teaching and promotion should also be incorporated. The SANE must be able to identify what is needed for a healthy and safe environment for the patient while identifying any appropriate disease prevention interventions needed. The patient's developmental level, readiness to learn, culture, and socioeconomic status will be considered when individualizing the implementation. The SANE will anticipate the patient's needs to prevent the risk of negative health outcomes (Narcavage-Bradley et al., 2021).
The final standard of practice is evaluation. The SANE will assess the plan of care throughout the process, revising goals and outcomes as needed. The SANE will consider whether their plan is patient-centered, effective, efficient, safe, and timely (Narcavage-Bradley et al., 2021).
Evidence Collection and Preservation
The Texas government code chapter 420, also known as the Texas Sexual Assault Prevention and Crisis Services Act, puts forth procedures that a nurse must follow to collect evidence during a forensic examination of a sexual assault or abuse victim. After a patient has sustained an assault, the personal nature of the exam requires specialized professional learning and expertise. To ensure compliance with Texas law, the Texas Board of Nursing requires nurses practicing in the emergency room and those who may perform a forensic examination on a sexual assault victim to receive specific forensic evidence collection training (TCON, 2019).
The purpose of the Texas Evidence Collection Protocol (TECP) is to offer guidance for healthcare professionals in Texas who provide forensic assessments on patients presenting with sexual victimization or suspected of committing sexual offenses. The goal is to provide timely, comprehensive care while minimizing additional trauma to the patient. While the entire TECP can be accessed on the Texas Attorney General website, the key points of the protocol are (TCON, 2019):
- Sexual assault is traumatic whether or not physical injuries are present.
- Emergent medical conditions should be treated before or concurrently with forensic issues (i.e., evidence collection).
- Non-fatal strangulation is a life-threatening medical event requiring specialized assessment and patient monitoring.
- Patients guide the assessment and have the right to decline the examination or evidence collection.
The protocol offers basic information for examiners and minimum requirements for forensic care. Other points mentioned in the care of the forensic patient include (TCON, 2019):
- Examiners should use open-ended questions.
- All care providers should be mindful of maintaining confidentiality.
- Access to a sexual assault advocate during the forensic medical assessment is mandated by Texas law. The advocate is a distinct and separate entity from the healthcare providers and law enforcement personnel.
- The reporting of abuse is mandatory if the victim is a child or a person with a disability. These incidents must be reported regardless of the wishes of the patient, family, or friends within the state of Texas.
- Pediatric patients and suspected perpetrators should be seen by a forensic expert (this includes SANEs and forensic nurse examiners).
- While examining the patient and collecting evidence, contamination of potential evidence should be avoided.
- Nurses should stay within their professional practice guidelines. This can be difficult when caring for suspected abusers or survivors of trauma.
- For military-affiliated survivors, reporting options must be given to them by a person knowledgeable about the Department of Defense policies.
- Institutional policies should exist regarding the process for obtaining photographs, identifying patients in photographs, and documenting the existence of such photographs in the patient's medical records.
- A sexual assault examination can occur without using a sexual assault evidence kit (SAEK). These kits should only be used when necessary.
Adult survivors of sexual assault can choose to report or not report the offense to law enforcement. When a patient chooses to report the incident, the assault should be reported to law enforcement in the jurisdiction the incident occurred. The patient should be given access to all support services, including healthcare treatment, evidence collection, and advocacy. If a patient chooses not to report the incident to law enforcement immediately, sexual assault evidence can be collected and processed up to 5 years later if the patient chooses to report the crime at a later date. Nonreporting sexual assault evidence can be submitted to the Texas DPS Crime Laboratory Service for storage. The evidence should be packaged in a box sealed with heavy tape. The examiner should initial the box where part of the initials is on the tape and part on the box. The box should be appropriate for standard shipping. No liquid (e.g., blood or urine) samples should be included. These patients should be given access to all the same support services (TCON, 2019).
Patient-Centered and Trauma-Informed Care
Sexual assault is a traumatic event that is often accompanied by negative consequences on overall health and well-being. Nurses should care for these patients using trauma-informed care, which starts with acquiring an understanding of the source of the trauma endured. Sources of trauma include a recent assault, previous experiences of abuse, and historical trauma. Trauma-informed care also recognizes the effect that the trauma may have on the family and friends of the victim, including their ability to care for the victim (Office for Victims of Crime, n.d.). A trauma-informed approach requires attending to the victim's emotional safety as diligently as their physical safety. The goal of care is to reduce the risk of further injury (i.e., re-traumatization) while recognizing the patient's recent neurobiological trauma. Nurses should provide culturally sensitive care and use self-identifying gender preference and trauma-informed practices when discussing assigned sex at birth. Human behavior is affected by the neurobiological changes that occur during trauma. There is no expected or "normal" behavior after a sexual assault. Some behaviors that may be observed in a patient following a sexual assault are:
- blunt or flat affect
- fidgeting or poor eye contact
- difficulty remembering details
- difficulty with why questions
- emotional lability (Narcavage-Bradley et al., 2021)
Patients can experience decreased cognitive function following a sexual assault. It is best to inform patients about each step of the process before it happens during the exam. When possible, offer choices. Patients should be allowed ample time to answer questions, stopping for a break if the patient appears to be overwhelmed. When in doubt, ask the patient what they need to feel safe. Difficult questions must be asked to properly treat the patient and prevent further injury. However, this questioning should be performed in a humane, respectful, and sensitive manner. It is best practice to start an interview with less stressful questions about general health information. Explain the rationale for all questions asked. Once the interview focuses on the incident in question, the interviewer should explain to the patient that it is necessary to review exactly what occurred so that they can provide the best treatment available. Questions should be open-ended, and the interviewer should avoid questions that begin with "why." Patients may have more difficulty with memory when seen immediately following the sexual assault if they have not slept. Since neurobiological changes seen with assault can lead to long term conditions, patients' mental and physical needs should be addressed. Sexual assault advocates should be provided whenever available to enhance the patient's comfort level. A sexual assault advocate's role is to provide counseling and support services to victims of sexual assault or violent crimes. Non-English-speaking patients or patients with vision or hearing impairments should be offered interpreters (DOJ, 2013).
Chain of Custody
Evidence should be collected with care so that it will be admissible as evidence in legal proceedings. Chain of custody must be maintained and documented throughout the assessment and collection process. This includes documentation of the dates and times of each transfer and every individual who handles any piece of evidence. Evidence should be labeled with the patient's name, date of birth, medical identification number, examiner's initials, date, and time. Facility policy should dictate how the evidence inside the sexual assault evidence kit (SAEK) is labeled. With each transfer, the chain of custody documentation should include:
- receipt of evidence
- storage of evidence
- transfer of evidence
- date and time of transfer
- printed name and signature of each person transferring, receiving, or possessing evidence (DOJ, n.d.)
Physical Examination and Interview of the Forensic Patient
Prior to beginning an examination, verbal and written consent will be obtained. A forensic examination should occur in a quiet, safe environment that offers the patient privacy. The forensic examination can take anywhere from 2 to 6 hours (Illinois Attorney General [IAG], 2019). The patient assessment should not be interrupted by the outside environment. Recommended equipment and space include the following:
- an image capturing system, such as a digital camera (personal photography equipment or phones should not be used as the chain of custody cannot be maintained on personal devices)
- a colposcope or other magnification system
- a sexual assault evidence kit and associated forensic medical documentation forms
- a DFSA or toxicology testing kit (DFSA urine should be frozen or refrigerated to maintain the chain of custody)
- paper bags
- evidence tape
- marking pens
- indicated personal protective equipment (PPE)
- a drying area for evidence
- locked and secured temporary storage space for any evidence awaiting release to law enforcement (DOJ, n.d.)
Adult and elderly patients will have similar protocols regarding evidence collection and physical examination. Adolescent patients require examination by a certified forensic professional, such as a SANE (DOJ, n.d.).
Adult and adolescent patients who present with reports of an assault have the right to receive a forensic medical assessment. These patients should be triaged as a medical emergency and given a 3 or above level on the 5-tier emergency room triage system (Subramanian & Green, 2015). In Texas, it is recommended that sexual assault patients are triaged at a level 2 (TCON, 2019). The patients should be seen as soon as possible by standard healthcare providers. Once the patient is stable, a forensic medical assessment should be offered. The patient should be escorted to a private waiting area, ensuring the patient is safe and the suspect is not present. It may be necessary to speak to the patient alone to obtain this information. The examiner should first assess the patient's pain level and ask about any bleeding. The patient should avoid using the restroom, washing, changing clothes, smoking, eating, or drinking until the exam is completed. If the patient must use the restroom, the urine should be collected (if DFSA is suspected), and the patient should avoid wiping until after the evidence has been collected. The chain of custody on all specimens must be maintained. If not present, the forensic examiner and a sexual assault advocate should be notified of the patient's arrival (DOJ, n.d.).
The forensic examiner should obtain informed consent after introducing themself to the patient and explaining what to expect with the forensic exam. The examiner should determine if the patient wishes to report the incident to law enforcement. For elderly patients over the age of 65, reporting is mandatory. The medical assessment may occur before or during the forensic sexual assault assessment and varies depending on facility policy. The examiner should obtain a detailed description of the incident. Along with a verbatim description of the assault, the examiner should document the following:
- all persons present during patient history and assessment
- the time, date, and location of the assault
- any physical contact and penetrative acts by the perpetrator
- any possible injuries to the suspect
- the use of lubricant, including saliva
- any patient actions between the assault and arriving at the facility (e.g., oral care, changing clothes, vomiting, smoking, swimming, douching, or bathing)
- the presence or absence of menstruation and the use of a menstrual cup or tampon during the assault or forensic assessment
- the use of a condom or other barrier
- the occurrence of ejaculation by the patient or suspect
- any weapon or physical force used (DOJ, n.d.)
The steps for evidence collection and packaging include (DOJ, n.d.):
- Obtain written consent/authorization.
- Apply powder-free gloves when handling any kit contents, changing gloves between each swab.
- The examiner should open the sealed SAEK after first inspecting the kit's integrity.
- The examiner should not cough or sneeze over the evidence.
- Each item of clothing should be individually sealed in a paper bag. The patient's underwear should go in the SAEK.
- A prepackaged DFSA specimen kit should be utilized to collect urine. Indications for this include unexplained memory loss, loss of consciousness, nausea, vomiting, and dizziness.
- Place blood or urine DFSA samples in a sealed and labeled biohazard bag that is then placed into a sealed and labeled cardboard box. Urine should not be placed in the SAEK to maintain the chain of custody.
- When a prepackaged DFSA kit is not available, the examiner may use one gray top tube of blood and a dirty urine specimen.
- Swabs should be placed directly into swab boxes. All other wet evidence should be air-dried before packaging, if possible. When air drying is not possible, wet evidence should be refrigerated. Law enforcement can take specimens for drying.
- Envelopes that contain evidence should be sealed with self-adhesive labels or tape, not saliva.
- All evidence should be sealed and labeled with the date and time of collection and the examiner's initials.
If a child is brought in for possible sexual assault, the child should have an assessment regardless of when the assault occurred or what the child states occurred. Children should be evaluated by a trained forensic professional. Forensic experts are trained to ask the most appropriate questions to obtain a history. Forensic medical assessments completed by a trained expert can obtain additional medical findings, new information, information regarding sexually transmitted infections, and the presence of other victims. When a forensic professional is not available, the forensic medical history, assessment, and acute evidence collection can be completed by an available healthcare provider. The patient should then be referred to a forensic expert for additional assessment when possible (DOJ, 2016).
Pediatric patients reporting sexual assault should also be triaged at a level 2 (DOJ, 2016). As with an adult or adolescent patient, the patient should be seen as soon as possible, stabilized, and a forensic medical exam offered. The care leading up to the forensic medical exam will be the same as for an adult or adolescent patient (DOJ, 2016).
The forensic examiner will obtain informed consent after introducing himself or herself to the patient and explaining what to expect next. Even pediatric patients can refuse all or part of the exam. The examiner should try to discern what is preventing the patient's assent and change their process if necessary. If the patient continues to decline after changing the process, the patient should be given the opportunity to return at another time for assessment. If the patient returns within 120 hours of the assault, a SAEK can still be obtained. All cases of suspected sexual assault of a child under 18 must be reported to law enforcement. As above, the medical assessment may occur before or during the forensic sexual assault assessment and varies depending on facility policy. The examiner should obtain a detailed description of the incident and document the same information as with an adult exam. Evidence is also collected following the same procedure as with adult patients (DOJ, 2016).
Sexual Assault Evidence Kit
Sexual assault evidence kits should meet or exceed minimum national guidelines. It is recommended to standardize kits within a jurisdiction and across a state or territory. In Texas, the Texas Customized Sexual Assault Evidence Collection Kit by Tri-Tech, Inc. should be used (TCON, 2019; DOJ, 2013). Regardless of how kit contents vary, every kit should meet the following minimum guidelines:
- a kit container with a blank label for identifying information and documenting the chain of custody (most items will be placed in the container after being dried, packaged, labeled, and sealed, although bags should be provided for bulky items that will not fit in the container);
- an instruction sheet or checklist that guides the examiner in collecting evidence and maintaining the chain of custody;
- a set of forms that facilitate evidence collection and analysis, including patient authorization to collect and release evidence, the medical forensic history, and anatomical diagrams;
- any materials necessary for collecting and preserving the following evidence:
- clothing, underwear, and foreign material dislodged from clothing
- foreign material on the patient's body, including debris and dried secretions
- fibers, loose hairs, fingernail cuttings or scrapings, various types of swabs
- plucked or pulled hair
- vaginal and cervical swabs
- penile swabs
- anal/perianal swabs
- oral swabs
- body swabs
- known blood, saliva, or buccal swab for DNA analysis and comparison (DOJ, 2013)
Swabbing and Evidence Collection
Forensic evidence deteriorates with time, so it is important that evidence be collected as soon as possible. Evidence should be collected whether the patient is seen directly after the assault or days later, even if the patient has showered, douched, swam, etc. Sexual assault samples can be taken for 5 days or longer post-assault. As technology advances, that time period expands, and in some instances, can be up to 9 days. When swabbing a patient, it is best practice to collect evidence using two swabs from each site (DOJ, 2016). Before swabbing each site, the process and reason for swabbing should be explained. Photographs can be taken at this time per facility protocol. Taking photographs during the process of evidence collection prevents the patient from having injured areas exposed multiple times. It also allows for photographs of the evidence and injuries to be taken before being disturbed or altered (DOJ, n.d.). The procedure for collecting swabs and evidence includes the following steps:
- Moisten swabs with sterile water when necessary or directed prior to evidence collection. Swabs can be placed in the swab box without being dried.
- Prevent cross-contamination with strict practices such as changing gloves between sites, not coughing over swabs, etc.
- Seal swabs from left and right body parts in the same envelope but in different boxes. For example, swabs from the left and right breasts are placed in different boxes, and then both boxes are sealed inside the same envelope.
- Some examiners wear gloves and masks during evidence collection. The use of a mask by the examiner may cause stress to a patient who recently experienced a sexual assault. The examiner will need to use judgment on a case-by-case basis regarding whether wearing a mask is the best option (DOJ, n.d.). The Texas Evidence Collection Advisory Board (TXECAB) is not aware of empirical evidence indicating the use of masks will prevent evidence contamination (TCON, 2019).
- The oral swab's purpose is to recover foreign DNA. Foreign DNA degrades quickly in the oral cavity. If an oral assault is suspected, oral swabs should be collected as soon as possible. Oral swabs should be collected when oral penetration is suspected or if the patient is unconscious.
- The oral swab collection process includes putting on new gloves and using two swabs to swab the inside of the patient's mouth around the gum lines. The two swabs should be sealed in a labeled swab box and then into the oral swab envelope.
- The known DNA buccal swabs/Whatman Flinders Technology [FTA] card is used to determine the patient's DNA for comparison to other samples. The swabs for foreign DNA should be obtained first. The examiner should then wait 15-20 minutes, have the patient swish their mouth with water, and then wait another 15-20 minutes. The patient's known DNA should then be collected, sealed, labeled, and placed within the SAEK as directed.
- Any matted head hair should be clipped or swabbed with lightly moistened swabs. Reference samples should be collected by cutting or pulling/plucking hair, depending on facility policy and kit instructions. As with previous samples, these should be sealed, labeled, and placed in the SAEK as directed (DOJ, n.d.). The TXECAB indicates that hair should not be pulled out due to undue trauma and stress (TCON, 2019).
- To collect head hair combings, the patient's hair should be combed over a piece of paper after putting on new gloves. When appropriate, the patient can comb their own hair over the paper. The comb should be bound to the paper, placed in the provided envelope, sealed, labeled, and placed in the SAEK as directed (DOJ, 2013).
- Clothing should be collected to recover possible foreign matter or DNA. Any existing damage to clothing should be documented and photographed. The collection protocol and process for different articles of clothing are as follows:
- Always collect the patient's underwear when allowed, even if the patient has changed since the assault. This applies to underwear in contact with genitals, not bras. If the patient is not wearing underwear, collect the articles of clothing touching the patient's anal and genital areas. Do not cut through any holes or rips in the underwear.
- Any clothing that was worn during the assault or immediately afterward may have foreign DNA, including bras, pants, and shirts. Coats, socks, and shoes do not always need to be collected. The articles chosen for collection should be based on the patient's description of the assault and the examiner's judgment. Only the patient's underwear should be placed into the SAEK.
- After putting on new gloves, the examiner should place a clean sheet on the floor, followed by the large changing paper in the SAEK on top of the clean sheet. A gown can be held up to provide the patient privacy while removing clothing. The patient should be instructed to stand in the middle of the changing paper and place individual clothing items separately on the paper. The changing paper should be labeled, and each article of clothing should be inspected, documenting item, color, and any damage. Damaged or stained clothing may be photographed. Each item of clothing should then be placed in a separate paper bag to prevent cross-contamination. Any wet clothing should be dried when possible. If unable to dry wet clothing, it should be arranged for release to law enforcement, notifying them that the clothing is wet (DOJ, 2013).
- Any dried secretions and debris found on the patient should be collected. After changing gloves, the patient should be inspected from head to toe, and any suspected foreign material should be collected in the dried/secretions/debris envelope.
- Any debris should be placed in the paper provided in the SAEK, sealed in an envelope, and labeled with the site.
- Any dried secretions should be flaked onto a paper bindle from the SAEK. The site should be swabbed twice with two swabs moistened with sterile water.
- Touch DNA is collected to assess for foreign DNA on the patient. The collection of touch DNA should be based on the patient's description of the assault and assessment findings. Any sites the patient states may have foreign DNA should be swabbed. If the patient lives with the suspect, touch DNA may not be as valuable forensically. Each area should be swabbed using two lightly moistened swabs. Each swab's site and source should be documented using the patient's own words (DOJ, 2013).
- Fingernail swabs are collected to obtain foreign DNA. If the patient describes scratching the suspect, clippings may be more appropriate. New gloves should be worn, and two sets of two moistened swabs should be run under each of the patient's fingernails, one set for each hand. Using wooden sticks to scrape under the nails is not recommended, as this may injure the patient. The four swabs should then be sealed, labeled, and placed in SAEK as directed (DOJ, 2013).
- Any matted pubic hair can be clipped or swabbed with moistened swabs. If reference samples are taken, they should be collected by cutting or pulling per policy or kit instructions. Placed in the provided envelope, sealed, labeled, and placed in the SAEK as directed (DOJ, 2013). As above, TXECAB does not recommend pulling out hair strands, as this causes undue stress for the patient (TCON, 2019).
- Pubic hair combings (and comb) are collected to obtain trace evidence, which can include foreign hairs. This is most useful in the case of unknown or acquaintance sexual assault. The process to obtain this sample is similar to combing head hair. The paper should be placed under the buttock, and the pubic hair combed over the paper. The paper should be sealed in the provided envelope, labeled, and placed in SAEK as directed.
- Vulva swabs are collected to recover foreign DNA. New gloves should be worn to swab the vulva with two swabs simultaneously. The inner labia majora, labia minora, and the hymen should be included, avoiding the urinary meatus. The swabs can be premoistened with sterile water if instructions on the kit allow. Swabs should be sealed, labeled, and placed in SAEK as directed.
- Vaginal or cervical swabs are collected to recover foreign DNA. Vaginal and cervical swabs should only be collected on adolescents or adults unless the pediatric patient is under sedation with physician direction or supervision. Vaginal washings are not recommended, as they can dilute the sample obtained. New gloves should be worn to insert a vaginal speculum after photographs of any genital injuries have been obtained. Two dry swabs should be gently placed into the cervical os and held in place for 5-10 seconds; they should then be used to swab the surface of the cervix and the posterior fornix of the vagina. Swabs should be sealed, labeled, and placed in SAEK as directed.
- Penile swabs are collected to recover foreign DNA. A male patient may be allowed to swab his own penis at the discretion of the examiner. New gloves should be worn to swab the head of the penis with two premoistened swabs, avoiding the urethral meatus. The same two swabs should be used to swab under the foreskin and the shaft of the penis. Swabs should be sealed, labeled, and placed in SAEK as directed.
- Scrotal swabs are used to recover foreign DNA. Male patients may also swab their own scrotums when appropriate. New gloves should be worn to swab the scrotum using two premoistened swabs. Swabs should be sealed, labeled, and placed in SAEK as directed.
- Anal swabs are collected to recover foreign DNA. New gloves should be worn to swab around the external anus using two premoistened swabs. Swabs should be sealed, labeled, and placed in SAEK as directed.
- Retained objects in the vagina or rectum are collected to recover foreign DNA or evidence. This includes collecting tampons, menstrual cups, or retained objects. Any retained objects in prepubertal females should be collected under sedation by a physician or a supervised SANE. The object(s) should be allowed to air dry, if possible, and placed in a dried secretion/debris envelope, labeled and sealed (DOJ, 2013).
The SAEK should be sealed with new gloves after removing the red evidence labels and orange biohazard labels from the kit. Once all evidence is labeled and sealed, the SAEK can be sealed with the red tape provided in the kit. The biohazard label should be affixed to the front of the SAEK. All documentation on the front of the kit should be completed. The examiner must sign their name and write the date and time over the evidence tape so that the signature goes from the kit across the label back to the kit to demonstrate a lack of tampering during legal proceedings (TCON, 2019).
Once the evidence is collected, it should be documented and photographed. All evidence should be labeled and sealed in a corresponding envelope or paper bag. Each evidence sample should be labeled with the patient's identifying information, including their legal name, date of birth, and medical record number. The date, time, and examiner's signature or initials should be on each specimen package. All collection bags or envelopes should be put into the primary SAEK container. The container should be closed, sealed, or taped, and the examiner should initial, date, and time across the seal to demonstrate a lack of tampering. The kit should also be labeled with the patient's identifying information (Kleypas & Badiye, 2020).
The summary of collecting evidence in adult and pediatric patients are outlined in Table 2, while Table 3 reviews samples that are not routinely recommended for collection.
Summary of Evidence Collection Recommendations
Facilities should develop and approve forensic medical assessment documentation forms for use within their institution. The term alleged should be replaced with reported or stated when documenting the patient's history. If an interpreter is used, this should be documented. The patient's pertinent medical and surgical history should be documented, as well as the last menstrual period, obstetric history, and current medications. Once the forensic medical assessment is documented, one copy should be placed in the SAEK and a second copy made available to law enforcement. All originals should stay at the healthcare facility (DOJ, n.d.).
When documenting the attack, the adolescent or adult patient should be asked to start from just before the assault to when they arrived at the facility. The examiner should document exactly what the patient says and place quotation marks at the beginning and end of their history, as direct quotes are best practice. The patient should be allowed to proceed at a pace that is comfortable for them. For prepubertal children, extensive interviewing should be avoided if the examiner is not forensically trained. If the patient is uncomfortable repeating their trauma aloud, the patient should be offered the option of writing their story down. Patients should be asked to clarify any unclear statements that may be relevant to the medical forensic exam (DOJ, n.d.).
Injuries should be documented using body diagrams and photographs, or "no visible trauma noted" if no injuries can be observed. For adults, only acute injuries should be documented unless the patient reports a pattern of abuse. All pertinent injuries should be documented in the case of a pediatric patient. Measurements, descriptions, and locations of each injury should be included on the body diagram in mm or cm. The type of injury should be documented using the definitions provided above. Anal and genital injuries should be documented using clock positions when the patient is supine. For example, an injury to the urethral meatus would be placed at 12 o'clock (DOJ, n.d.).
Informed consent must be obtained prior to taking photographs. Assent from a pediatric patient is also recommended, but informed consent must be obtained from an adult parent or guardian. Patients should be notified of how the photographs will be stored and used. Patients should be reassured that the photographs will only be used for medical forensic purposes and are protected in medical facilities. Photographs can be sealed by a court order at the conclusion of the legal proceedings. The institutional policy should outline the process for taking photographs, how the patient is identified in the photograph, and how the photographs are linked to the permanent medical record. Photographs may allow for additional expert opinions without requiring patients to undergo additional assessments. Photographs are typically used during legal proceedings to show physical findings, and quality photos may be used to evaluate recurrent sexual abuse in children. Anal and genital photographs should not be released to law enforcement unless a subpoena or written patient consent is obtained. Tips for clear and accurate photographs include:
- use adequate lighting (avoid using a flash in the exam room as this can change the color of evidence and include a color bar in the photograph to ensure accurate colors)
- maintain focus, keep the camera steady, and keep the perspective undistorted
- use a forensic scale or ruler for size reference
- take at least two photographs of each area, one with and one without scale
- photograph evidence in place before removing it or collecting it
- minimize background distractions
- take at least two shots at three orientations: a medium-range photograph of each injury, regional shots with injuries in context that show orientation on body parts, and close-up images of particular injuries with scale
- shield uninvolved breasts or genitals when possible (highly graphic photos are sometimes deemed inadmissible in court, leaving the case less credible)
- close-up photos of hands and fingernails should include damaged or missing nails
- photograph any restraint marks or signs of bondage on wrists, ankles, or neck
- photograph any transfer evidence present, such as dirt, gravel, or plants
- photograph any bite marks (DOJ, 2013)
It is recommended that jurisdictions notify examiners promptly if there will be a need for testimony in court. Pretrial preparation of examiners is recommended. Examiners should be prepared to testify as factual or expert witnesses if needed. Every examination should be documented with the expectation of a trial and the need to testify. Broad education on testifying in court is encouraged for examiners. The examiner should familiarize themself with typical courtroom proceedings, expectations, and the types of testimony, and what can be said during each type. Testifying in court can be difficult, and cross-examination will likely occur. Examiners can perceive questions from defense counsel to be hostile or intimidating and should be prepared to handle these situations effectively. Speaking to defense attorneys to help with pretrial preparations can educate examiners on defense perspectives and tactics. It helps for examiners to be up to date on new practices and related case law (DOJ, 2013).
Treatment Plan and Testing
Laboratory testing should include nucleic acid amplification tests (NAATs) for chlamydia and gonorrhea of any suspected penetration or contact sites, wet prep or urine/vaginal NAAT for trichomoniasis, wet prep or vaginal pH and potassium hydroxide for bacterial vaginosis and candidiasis, and serum samples for HIV, hepatitis B, and syphilis. Trichomonas, bacterial vaginosis, gonorrhea, and chlamydial infections are the most frequently diagnosed STIs among victims of sexual assault. The presence of STIs does not necessarily indicate the infection was transmitted during the attack, so the forensic exam presents an opportunity to identify preexisting infections. Informed consent is required for testing. The CDC's (2015) treatment guidelines for sexual assault include:
- An empiric antimicrobial regimen for the prophylaxis of chlamydia, gonorrhea, and trichomoniasis is recommended for adult patients:
- a single dose of ceftriaxone (Rocephin) 250 mg IM
- a single dose of azithromycin (Zithromax) 1 g PO
- a single dose of metronidazole (Flagyl) 2 g PO or tinidazole (Tindamax) 2 g PO (contraindicated if recent alcohol consumption, may need a printed prescription to take at home)
- No prophylactic antimicrobial treatment is recommended in children due to the very low rates of STIs in children after assault or abuse.
- Postexposure hepatitis B vaccination should be offered if the patient does not have evidence of hepatitis B immunity. If the suspect is known to have hepatitis, unvaccinated patients should receive the hepatitis B vaccine and immunoglobulin (HBIG) therapy. The vaccine and HBIG should be administered at the time of examination if indicated. Patients who were previously vaccinated but have not had postvaccination testing of immunity should receive a single vaccine booster dose.
- Human papillomavirus (HPV) vaccination is recommended in females aged 9-26 years and males aged 9-21 years. For men who have sex with men who have not received the entire HPV vaccination course in the past, the HPV vaccine is recommended until 26 years of age.
- Recommendations for HIV prophylaxis should be based on individual patient risk factors according to the CDC post-exposure HIV risk assessment (CDC, 2015).
- Emergency contraception should be offered or considered for any female patients of reproductive age. This can be taken within 5 days after sexual assault to decrease pregnancy risk. Emergency contraception works by preventing ovulation, fertilization, or implantation. All females need informed consent for pregnancy prophylaxis. Catholic patients have the right to protect themselves from unwanted pregnancies related to sexual assault. Emergency contraception should not be confused with taking medications to induce abortions; it is a method of birth control to be used occasionally in specific situations and not as a primary form of birth control. Emergency contraception will not interfere with an existing pregnancy. Most women with contraindications to estrogen-containing birth control can use emergency contraception, as it is only taken for one day. The standard prophylaxis is a single dose of levonorgestrel (Plan B One-Step) 1.5 mg PO or a two-dose regimen of 0.75 mg PO. It is most effective if taken within 72 hours of exposure, but it can be taken up to 5 days after exposure (DOJ, 2013).
The TCON's (2019) treatment guidelines for sexual assault vary slightly from the CDC's.
For example, the standard prophylactic treatment for patients over 45kg does not specify for the option of administering tinidazole (Tindamax) 2 g PO. TCON encourages providers to consider post-exposure hepatitis B vaccination, HIV prophylaxis, and HPV vaccination (for sexual assault patients over 9 years of age and under 27 who have not previously been vaccinated). For patients under 45kg, TCON recommends:
- a single dose of ceftriaxone (Rocephin) 25-50 mg/kg IM (not to exceed 125 mg)
- erythromycin (Erythrocin) 50 mg/kg/day PO for 14 days, divided QID (TCON, 2019)
Discharge Planning and Follow-up Care
Discharge instructions should include a summary of the sexual assault exam, with information such as evidence collected, tests that were conducted, medications prescribed or administered, and any other treatments received. The patients should be made aware of any follow-up appointments that were scheduled or that need to be scheduled. The discharge paperwork should also contain information on local sexual assault advocacy programs with contact information and business hours. Instructions for follow-up for re-evaluation should be given clearly. Also, the patient should be educated on what to expect following the assault with respect to the healing of injuries, expected time frames for healing, and any other expected findings or changes. A patient should be scheduled for follow-up at least 2-4 weeks after the assault for STI care, HIV testing, and administration of Hepatitis B vaccine. Screening should be done for domestic violence, dating violence, or other forms of abuse. The patient's physical safety and emotional well-being should be addressed. According to the Department of Justice (n.d.), it is not obtrusive to ask these patients questions such as:
- "Where are you going after discharge?"
- "Who will you be leaving and staying with?"
- "Will these people be able to provide you with adequate support?"
- "If you feel unsafe, what will you do to get help?"
Verify that the patient does not need an emergency shelter or alternative housing option. Some patients will be eligible for protection orders. The nurse must make sure the patient feels safe upon discharge and should assist the patient in the development of a plan to feel safe. Any planning must take into account personal and specific concerns (e.g., a patient with a physical disability will necessitate placement in a shelter that is able to meet the needs of a patient who requires assistance with activities of daily living; Subramanian & Green, 2015).
Centers for Disease Control and Prevention. (2015). 2015 sexually transmitted diseases treatment guidelines: Sexual assault and abuse and STDs. https://www.cdc.gov/std/tg2015/sexual-assault.htm
Centers for Disease Control and Prevention. (2020). Injury prevention and control: Sexual violence is preventable. https://www.cdc.gov/injury/features/sexual-violence/index.html
Illinois Attorney General. (2019). Your rights and choices for a medical forensic exam. https://illinoisattorneygeneral.gov/victims/saimplementationtaskforce/Medical_Foresnic_Services_Fact_Sheet_for_Hospitals_and_APHCFs.pdf
International Association of Forensic Nurses. (2021a). What is forensic nursing? https://www.forensicnurses.org/page/WhatisFN
International Association of Forensic Nurses. (2021b). Use of terms. https://www.safeta.org/page/ProtocolUseofTerms#:~:text=Sexual%20assault%20medical%20forensic%20examination%3A,and%20treatment%20of%20these%20patients.
Kleypas, D. & Badiye, A. (2020). Evidence collection. StatPearls Publishing, LLC. https://www.ncbi.nlm.nih.gov/books/NBK441852/
Narcavage-Bradley, C., Pozar, T., & Pierce-Weeks, J. (2021). IAFN sexual assault nurse examiner certification: A review for the SANE-A® and SANE-P® exams. (J. Robinson, Ed.). Springer Publishing.
Office for Victims of Crime. (n.d.). Trauma-informed care. SANE program development and operation guide. retrieved February 1, 2021 from https://www.ovcttac.gov/saneguide/building-a-patient-centered-trauma-informed-sane-program/trauma-informed-care
Subramanian, S. & Green, J. (2015). The general approach and management of the patient who discloses a sexual assault. Journal of the Missouri State Medical Association, 112(3), 211-217. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170132
Texas A&M College of Nursing. (2019). Texas evidence collection protocol. Texas Attorney General Sexual Assault Prevention and Crisis Services Program. https://www.texasattorneygeneral.gov/sites/default/files/files/divisions/crime-victims/TECP.pdf
US Department of Justice. (n.d.). National best practices for sexual assault kits: A multidisciplinary approach. retrieved February 1, 2021 from https://www.ncjrs.gov/pdffiles1/nij/250384.pdf
US Department of Justice. (2013). A national protocol for sexual assault medical forensic examinations: Adults/adolescents. 2nd edition. https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf
US Department of Justice. (2016). A national protocol for sexual abuse medical forensic examinations: Pediatric. https://www.justice.gov/ovw/file/846856/download