last updated February 1, 2006
Examination by a forensic or other medical provider trained in both evidence collection and sexual assault issues can be critical in ensuring the victims are provided with necessary medical services and that physical evidence that will be necessary for a prosecution is collected. The World Health Organization, for example, notes that a study in Canada found that documentation by trained forensic or other medical providers can increase the likelihood that a perpetrator will be arrested, charged and convicted. From World Health Organization, First World Report on Violence and Health 166 (2002). Particularly when the survivor's physical injuries are not serious (and thus when a victim's non-consent is likely to be contested in a prosecution), it is very important that other relevant evidence—such as bumps, bruises, contusions, and abrasions—be documented.
In the United States, nurses who are trained in the proper collection of medical evidence and on issues concerning sexual assault are called Sexual Assault Nurse Examiners (SANE). These SANEs are on-call in emergency rooms, agencies, clinics, or independent SANE centers. SANEs must follow specific protocols concerning evidence collection and treatment and care of the victim. Although most SANE programs are located in health care facilities or hospital emergency departments, some can be found in sexual assault or rape crisis centers or even in private health care facilities or departments. From Donna A. Gaffney, Community-Based Sexual Assault Nurse Examiners: A New Role for the Visiting Nurses Association, Violence Against Women 27-3 (Joan Zorza ed., 2002).
Generally, there are five goals of an examination by a SANE. These include "(a) documentation and care of injuries; (b) collection of medical-legal evidence, (c) evaluation of risk and prophylactic treatment of sexually transmitted diseases (STDs), (d) evaluation of risk and emergency pregnancy interception, and (e) crisis intervention." From Linda E. Ledray, Sexual Assault Nurse Examiner (SANE) Program, Sourcebook on Violence Against Women 243, 243-44 (Claire M. Renzetti et al. eds. 2001). The examination may take from 30 minutes to an hour depending on the extent of injuries and assault.
It is important to note that while a SANE is not an advocate, she can provide a sexual assault victim with information not only about what to expect during the exam, but also "with information to assist her in anticipating what may happen next in making choices about reporting and deciding who to tell and gets the support that she will need after she leaves the SANE facility." SANEs can also provide emotional support and assistance. From Linda E. Ledray, Sexual Assault Nurse Examiner (SANE), Office for Victims of Crime (July 1999), available in PDF and HTML formats.
When a victim arrives in the emergency room, emergency room personnel will treat any serious injuries. When possible, however, they will wait to treat injuries until the SANE has had a chance to document the injuries and collect evidence. SANE examinations may be conducted only with the victim's written consent.
It is essential that the survivor be assessed for sexual assault in a quiet environment where his or her privacy and confidentiality are respected. The clinician must be supportive and must ask the survivor if she would like to have someone present during the subsequent interview and examination.
First, the SANE identifies and treats acute injuries; treatment of other injuries will be delayed to ensure that evidence is preserved. If the victim consents, the SANE will photograph the victim's injuries.
Next, the SANE will conduct both a medical and an assault history interview the victim. The medical interview aims to obtain information necessary to complete the subsequent physical examination, such as information about allergies, substance use, history of illnesses, current medications, pregnancy status, and menstrual cycle.
The assault history will serve as a guide for the physical examination. The assault history interview will focus on information about the assault, such as information about the day and time of the assault, characteristics of the attacker(s), and characteristics of the assault such as penetration of any orifice, weapon used if any, forms of violence used and where, clothing worn during the incident, and the survivor's level of consciousness. It is imperative to determine if the survivor had douched, bathed, showered, defecated or urinated since the assault, as evidence of the incident may not remain on the body after these activities.
Although a complete assault history is necessary, the assault history is intended to serve only as a guide for the physical examination; the SANE should not attempt to gather investigative information, such as information about the weight or height of the perpetrator. As Ledray explains:
Many authors caution against the forensic examiner collecting detailed investigative information and suggest that the SANE should ask only for the information necessary to collect the proper medical evidence, deal with the immediate physical and psychological needs of the survivor, and collect and interpret the physical and laboratory findings. . . . Details reported by the nurse, which differ from the police report, may be used by the defense attorney to show discrepancies in the survivor's story. The only documentation that is necessary is that needed to guide the exam and treat the survivor.
From Linda E. Ledray, Evidence Collection and Care of the Sexual Assault Survivor: The SANE-SART Response (August 2001).
Next, the SANE will conduct the physical examination. A thorough physical examination is an invasive, long, and uncomfortable process for a sexual assault survivor. Therefore, it is essential that the clinician is supportive, calm, and objective at all times. The World Health Organization recommends showing the victim a video that discusses what will happen during the examination and why these steps are necessary. Such a video can significantly reduce the trauma that can be associated with the examination. From World Health Organization, First World Report on Violence and Health 166 (2002).
The purpose of the physical examination is to assess the patient's injuries and collect evidence that can be used in any later legal proceeding against the attacker. Physical evidence collection protocols are necessary to ensure that all relevant evidence is collected, that the evidence collected will be admissible in a legal proceeding, and that the evidence is not contaminated or diluted during the collection process. Because different jurisdictions may have different legal requirements concerning the admissibility of evidence, the procedures for collecting and storing physical evidence will depend on the particular legal context in question. Some countries provide medical professionals with kits that can help accelerate and standardize evidence collection. In the United States, such standardized evidence-collection kits are called "Rape Kits" and include items (envelopes, slides, etc.) for collecting, storing and labeling physical evidence, as well as history and physical examination forms necessary to document the survivor's medical and assault history, the collection of evidence, and any treatment and follow-up instructions.
Photographic evidence can be used if the facilities are available and only if the patient consents to being photographed. However, if this is not possible, then all abrasions, bites, burns, contusions, lacerations, and bruises are to be located, measured, and described adequately in the examination forms. This helps in providing adequate treatment for all injuries and in assessing the patient's recovery on follow-up visits.
After the exam is complete, many hospitals provide survivors with clean clothes and a place to shower. The assistance of a victim advocate can be critical at this point; the victim may not want to return home, or may need alternative safe housing. Ledray explains that victims should be provided with written information about resources and support services, since she may be in a state of shock; in addition, Ledray recommends follow-up calls one or two days after the exam.
Finally, any hospital protocol for responding to sexual assault victims, whether it includes a SANE or not, should require the health care provider to conduct a pregnancy assessment, test for sexually transmitted diseases, provide emergency contraception, and offer referrals to other support services.
Adapted from Linda E. Ledray, Evidence Collection and Care of the Sexual Assault Survivor: The SANE-SART Response (August 2001); World Health Organization, First World Report on Violence and Health166 (2002).
A detailed description of the physical examination is available on pages 257-260 of the Compendium: Model Strategies and Practical Measures on the Elimination of Violence Against Women in the Field of Crime Prevention and Criminal Justice, International Centre for Criminal Law Reform and Criminal Justice Policy (March 1999).
For a collection of research and reports on Sexual Assault Nurse Examiner programs, click here.
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