Competency Evaluation in Sexual Assault

Competency Evaluation in Sexual Assault Nursing

The report of the U.S. Department of Justice Office of Violence Against Women entitled: "A National Protocol for Sexual Assault Medical Forensic Examinations: Adults and Adolescents" relates that: "Sexual assault can result in physical trauma and significant mental anguish and suffering for victims. Victims may be reluctant, however, to report the assault to law enforcement and to seek medical attention for a variety of reasons." (2004) This is because victims fear their assailants and worry that they may not be believed and they also feel embarrassed and lack easily accessible services. The U.S. Department of Justice Office of Violence Against Women reports the development of a protocol based on national, local and tribal experts input throughout the United States, which included representative of law enforcement, prosecutors, advocates, medical personnel, forensic experts as well as others.

Protocol Goals

The protocol is stated to have the goals as follows: (1) to supplement the many excellent protocols that have been developed by individual states, tribes and local jurisdictions and those at the national level. This protocol is considered to be a guideline rather than a list of requirements; (2) to provide guidance to jurisdictions on responding to victims that are adults or adolescents; (3) to support the use of coordinated community responses to sexual violence; (4) Address the needs of victims while promoting the response of the criminal justice system. This includes stabilization, treatment and engagement of victims as "essential partners in the criminal investigation"; and (5) to promote high-quality, sensitive, and supportive exams for all victims, with no regards to their jurisdiction or geographical location of the provision of service. (the U.S. Department of Justice, 2004)

II. Operational Issues

Under the section entitled 'Operational Issues' specifically addressed is the role of 'Sexual Assault Forensic Examiners' which are the health care professionals who conduct the examination stating that "It is critical that all examiners, regardless of their discipline, are committed to providing compassionate and quality care for patients disclosing sexual assault, collecting evidence competently, and testifying in court as needed." (the U.S. Department of Justice, 2004) Recommendations for building the capacity of examiners performing these exams in jurisdictions include: (1) Encourage the development of specific examiner knowledge, skills and attitudes; and (2) Encourage advanced education and supervised clinical practice of examiners, as well as certification for nurses who are examiners." (the U.S. Department of Justice, 2004) There are specifications that facilities are obligated to meet and recommendations for jurisdictions in terms of the building of capacity of the health care facilities for responding to sexual assault cases however, the information most important to the nurse includes aspects of proper methods and procedures in terms of evidence documentation. Generally, the jurisdictions will have standardized sexual assault collection kits or will purchase kits that are premade through vendors. Despite the variations, critical components of the kits include: (1) a kit container; (2) Instruction sheet or checklist; (3) Forms; and (4) Materials for collection and preservation of evidence required by the crime forensics laboratory. (the U.S. Department of Justice, 2004)

III. Type of Evidence Collected

Evidence that may be collected however, this is not an exhaustive list includes: (1) Clothing; (2) Foreign materials on the body; (3) Hair (including head and pubic hair samples and combings); (4) Oral and anogenital swabs and smears; (5) Body swabs; and (6) a blood or saliva sample for DNA analysis and comparison. (U.S. Department of Justice, 2004) Other necessary knowledge for the nurse according to the U.S. Department of Justice includes considerations of timing when collecting evidence. The rule-of-thumb is that data should be collected within 72 hours after the assault because evidence collected "...beyond that point is conceivable." (the U.S. Department of Justice, 2004) Because this is so, the cutoff or limitation has been lengthened to between five days and one week in some jurisdictions. As the technologies of DNA advance the time limits are being noted by the U.S. Department of Justice to be extended even further and as well this is attributed to the stability of DNA as evidence. The U.S. Department of Justice notes that there are cases being solved presently that when the evidence was collected over two years ago the evidence was considered in too small of samples to be usable in forensic testing.

III. Evidence Integrity & Chain of Custody Requirements in Forensic Science

Evidence integrity is addressed in the U.S. Department of Justice report which states that proper collection, preservation and maintenance of the 'chain of custody' of the evidence is critically important to subsequent use of the evidence to prosecute offenders in criminal proceedings. Chain of custody is the process of documentation of the evidence at every step, and accounting for every minute of the evidence's location from the time of collection until the evidence is submitted in the courtroom during the trial prosecuting the offender. A break in the 'chain of custody' results in the evidence being inadmissible which means that the evidence has lost its integrity and the court will not consider the evidence after integrity is lost. Recommendations provided by the U.S. Department of Justice include the following for health care providers and other responders in maintaining the integrity of the evidence collected in connection to a sexual assault case: (1) Follow jurisdictional policies for drying, packaging, labeling, and sealing the evidence; (2) Follow jurisdictional policies for documenting exam findings, the medical forensic history, and the patient's demeanor/statements, and packaging, labeling, and sealing such documentation; (3) Follow jurisdictional policies for consistent evidence management and distribution. A duly authorized agent should transfer evidence from the exam site to the appropriate crime lab or other designated storage site (e.g., a law enforcement property facility); (4) Make sure storage procedures maximize evidence preservation. Ensure that storage areas are kept secure and at the proper temperature for the evidence. Also, make sure jurisdictional policies are in place to address the secure storage of evidence in cases in which patients are undecided about reporting; and (5) Maintain the chain of custody of evidence. All those involved in handling, documenting, transferring, and storing evidence should be educated regarding the specifics of their roles in properly preserving evidence and maintaining the chain of custody. (the U.S. Department of Justice, 2004)

V. Examination Process

The examination process is also addressed in the U.S. Department of Justice report which states in relation to initial contact with the patient that many patients initially present "at a designated exam facility, but most who receive immediate medical care initially contact a law enforcement or advocacy agency for help." (2004) in cases where 911 is called the initially assistance to victims is often in the form of emergency medical services (EMS) or police officer personnel. Recommendations of the U.S. Department of Justice for initial contact with victims includes: (1) Build consensus among involved agencies regarding procedures for a coordinated initial response when a recent sexual assault is disclosed or reported, and educate responders on procedures. Encourage victims to interact with advocates as soon after disclosure as possible; (2) Recognize essential elements of initial response. In particular, encourage victims to seek medical care and have evidence collected. In the case of life-threatening or serious injuries, obtain emergency medical assistance according to jurisdictional policy. Any life-threatening wounds should be treated and victims' immediate safety needs should be addressed before evidence is collected; and (3) if victims decide to seek medical care and/or have evidence collected, follow jurisdictional policies for preserving evidence, collecting a urine sample if needed, and transporting victims to the exam site. (the U.S. Department of Justice, 2004) the U.S. Department of Justice makes recommendations for 'triage and intake' which include the following for facilitation of triage and intake that addresses the needs of patients: (1) Consider sexual assault patients a priority. Use private locations in the exam facility for the primary patient consultation and initial law enforcement interviews, offer a waiting area for family members and friends, and provide childcare if possible; (2) Respond to acute injury, trauma care, and safety needs of patients before collecting evidence. Patients should not wash, change clothes, urinate, defecate, smoke, drink, or eat until initially evaluated by examiners, unless necessary for treating acute medical needs; (3) Alert examiners to the need for their services at the exam site; (4) Contact victim advocates so they can offer services to the patient, if not already done; (5) Assess and respond to safety concerns, such as threats to the patient or staff, upon arrival of patients at the exam site; and (6) Assess patients' needs for immediate medical or mental health intervention. Seek informed consent from patients before providing treatment, according to facility policy.

VI. Documentation of Sexual Assault

Documentation of sexual assault by health care personnel makes a requirement of separate documentation of the medical record by examiners and all other involved clinicians. Recommendations for documentation by health care providers are stated by the U.S. Department of Justice to include: (1) Ensuring that all appropriate documentation is completed. The forensic details of the exam are documented in the medical forensic report, according to jurisdictional policy. The only medical issues documented in this report are acute findings that potentially relate to the assault or preexisting medical factors that could influence interpretation of findings. Separate medical documentation by examiners and other involved clinicians follows a standard approach -- address acute complaints, gather pertinent historical data, describe findings, and document treatment and follow-up care; and (2) Ensuring the accuracy and objectivity of medical forensic reports by seeking education on proper report writing. (the U.S. Department of Justice, 2004) Photographic evidence of the injuries sustained by the patient may be used to supplement the medical forensic history and to document findings of a physical nature. The U.S. Department of Justice states that following recommendations in the area of photographic documentation: (1) Come to a consensus about the extent of forensic photography necessary. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, while others limit photography to detected injuries; (2) Consider who will take photographs and what equipment will be used. Photographers should be familiar with equipment operation as well as educated in forensic photography and in ways to maintain the patient's privacy and dignity while taking photographs. Consult with jurisdictional criminal justice agencies and examiners regarding the type of equipment that should be used; (3) Obtain informed consent from patients before taking photographs. Patients should understand the purpose of the photographs, what will be photographed and any related procedures, the potential uses of photographs during investigation and prosecution, and the possible need for follow-up photographs; (4) Consider the patient's comfort and need for modesty. • Identify who will be present when photographs are taken; and (5) Take initial and follow-up photographs as appropriate, according to jurisdictional policy.

VII. Evidence Collection Procedures

In relation to exam and evidence collection procedures, the U.S. Department of Justice states that jurisdictional policy is the guidelines that examiners look to in collecting evidence. Recommendations made for exam and evidence collection procedures include the following: (1) Strive to collect as much evidence from patients as possible, considering the scope of informed consent, the medical forensic history, the examination, and evidence collection kit instructions; (2) Be aware of evidence that may be pertinent to the issue of whether the patient consented to sexual contact with the suspect. Understand how biological evidence is tested; (3) Prevent exposure (of both patients and staff) to infectious materials and contamination of evidence; (4) Understand the implication of the presence or lack of semen (in cases involving male suspects); (5) Seek informed consent from patients for each portion of the exam and evidence collection; (6) Modify the exam and evidence collection to address the specific needs and concerns of patients; (7) Conduct the general physical and anogenital examination, guided by the scope of informed consent and the medical forensic history. Document findings on body diagram forms. With the patient's consent, use an alternate light source, colposcope, and anoscope, as appropriate and if available, to increase the likelihood of detecting evidence; (8) Collect evidence to submit to the crime lab for analysis, according to jurisdictional policy; (9) Collect blood and/or urine for toxicology screening, if applicable; and (10) Keep medical specimens separate from forensic specimens collected during the exam. (U.S. Department of Justice, 2004)

VIII. Sexual Assault Facilitated Through Drug

The health care provider, whether it be a nurse or a medical doctor must give consideration to the possibility that the individual may have been drugged in order for the perpetrator to facilitate the assault. Recommendations stated by the U.S. Department of Justice includes education of all responders in this area as well as obtaining informed consent from patients when testing their urine. When the patient provides permission, urine samples should be immediately collected if ingestion of drugs for facilitation of the assault is suspected. If the ingestion of drugs for facilitation of sexual assault was within 24 hours of the exam a blood sample should be collected as well.

IX. STIS and STDS

Sexually transmitted disease or infection evaluation and care is addressed as well by the U.S. Department of Justice which include the following: (1) Offer patients information about the risks of STIs (including HIV), the symptoms and what to do if symptoms occur, testing and treatment options, follow-up care, and referrals. Referrals should include free and low-cost testing, counseling, and treatment available in various sections of the community. For HIV testing, confidential and anonymous testing is recommended; (2) Consider testing patients for STIs during the initial exam on a case-by-case basis. If testing is done, follow the guidelines of the Centers for Disease Control and Prevention (CDC); (3) • Encourage patients to accept prophylaxis against STIs during the initial exam. (Note, however, that treatment may not be appropriate for some individuals -- for example, if they have a condition that may be adversely affected by taking prophylaxis.) the CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and bacterial vaginosis (BV), as well as the hepatitis B virus. If accepted, provide care that meets or exceeds CDC guidelines. If declined, it is medically prudent to obtain cultures and arrange for a follow-up exam and testing. Seek informed consent from patients for treatment, according to facility policy; (4) Encourage and facilitate follow-up STI examinations, testing, immunizations, and treatment as directed; and (5) Offer postexposure prophylaxis for HIV to patients at high risk for exposure, particularly when it is known that suspects have HIV / AIDS. Meet or exceed CDC recommendations. Discuss risks and benefits of the prophylaxis with patients prior to their decisions to accept or decline treatment. Careful monitoring and follow-up by a health care provider or agency experienced in HIV issues is required.

X. Informed Consent & Confidentiality Issues

Informed consent is necessary for the following: (1) general medical care; (2) pregnancy testing and care; (3) testing and prophylaxis for STIs; (4) HIV prophylaxis; (5) permission to recontact the patient for medical purposes; and (6) release of medical information. (U.S. Department of Justice, 2004) it is necessary as well to gain consent of the patient for the purpose of forensic exam and evidence collection. Informed consent for forensic examination in clued the following: (1) notification to law enforcement or other authority; (2) photographs including colposcopic images; (3) the examination itself and evidence collection; (5) toxicology screening; (5) release of information and evidence to law enforcement; (6) permission to recontact patients for reasons related to their criminal sexual assault case; and (7) Patient notification in case of DNA match or additional victims. (U.S. Department of Justice, 2004)

Another issue that must be addressed by health care personnel as well as nursing staff is the 'confidentiality' of patients. Recommendations of the U.S. Department of Justice in the area of patient confidentiality include: (1) make sure jurisdiction policies address confidentiality issues related to the exam process; (2) increase the understanding of responders and patients in relevant confidentiality issues; (3) consider the impact of the Federal privacy laws regarding health information on victims of sexual assault; and (5) strive to resolve intrajurisdicitonal conflicts. (U.S. Department of Justice, 2004)

The 'Sexual Assault Forensic Examiner' is many times a nurse. These nurses/examiners must be properly education and trained in this area and are required to be committed to providing health care of high quality and of compassion while conducted evidence collection in a manner that is thorough and appropriate. The 'Sexual Assault Nurse Examiner' (SANE) is a registered nurse who has received specialized education as well as fulfilling clinical requirements prior to conducting these examinations. Certification for SANEs are common for this endeavor in health care. The U.S. Department of Justice states that it is highly beneficial for the SANE to know: (1) the dynamics and impact of sexual victimization; (2) Jurisdictional laws related to sexual offenses; (3) Coordinated multidisciplinary response, roles of each responding agency, (4) procedures for communicating with each agency during immediate response; (5) the importance of examiner neutrality and objectivity during the examination; (6) the broad spectrum of potential evidence and physical findings in these cases; and (7) the importance of the medical forensic history and other documentation. (2004) it is important that the nurse understand the forensic significance of the examination procedure and evidence collection in sexual assault cases. The examination is a methodical documentation of physical findings and facilitation of evidence from patients' bodies and clothing. The evidence collected during the exam is used to reconstruct the details of the assault on the victim and enables this to be accomplished in a scientific and objective manner. The biological evidence which is gathered during the examination, specifically, semen, blood, vaginal secretions, saliva, vagina epithelial cells, and other biological evidence can be identified as well as genetically typed in the forensic crime lab. The information gathered provides evidence concerning the determination of sexual contact, the circumstances of the incident and may be compared to reference samples that are collected from the patient and suspects of the sexual assault.

XI. Forensic Medicine History

The forensic medical history which must be included in the report following a sexual assault includes the following information:

1) the date and time of the sexual assault;

2) the pertinent patient medical history;

3) Recent consensual sexual activity;

4) Post-assault activities of patients;

5) Assault related patient history;

6) Suspect information (if known); and 7) Nature of the physical assault(s).

Further needed in the collection of information is an accurate however, brief description of any: (1) penetration of genitalia - however slight; (2) penetration of the anal opening; however slight; (3) oral contact with genitals; (4) other contact with genitals; (5) oral contact with the anus; (6) nongenital acts; other acts (including use of objects; (7) if know, whether ejaculation occurred and location of ejaculation; and (8) use of contraception or lubricants.

XII. Pregnancy Risks and Alternatives Following Sexual Assault

Another consideration is pregnancy risks in which case the U.S. Department of Justice offers the following recommendations:

Discuss the probability of pregnancy with patients.

Administer a baseline pregnancy test for all patients with reproductive capability.

Discuss treatment options with patients, including reproductive health services. (U.S. Department of Justice, 2004)

XIII. Discharge & Follow-up Care

The U.S. Department of Justice report states in relation to discharge and follow-up recommendations that the following should be inclusive:

It is important to ensure that patients are fully informed about post-exam care. Information may include referrals to other professionals to make sure that patients' medical and/or mental health needs related to the assault have been addressed, discharge instructions, follow-up appointments with the examiner or other health care providers, and contact procedures for medical follow-up. In addition to medical follow-up, follow-up may be indicated to document developing or healing injuries and complete resolution of healing.

Advocates and law enforcement representatives, if involved, should coordinate with examiners to discuss other issues with patients, including planning for their safety and well-being, physical comfort needs, information needs, the investigative process, advocacy and counseling options, and law enforcement and advocacy follow-up contact procedures. (U.S. Department of Justice, 2004)

It is important that the nurse understand that sexual assault affects different individuals in different ways depend upon factors such as:

Age;

Gender and/or gender identity;

Physical health history and current status;

Mental health history and current status;

Disability;

Language needs and communication modalities;

Ethnic and cultural beliefs and practices;

Religious and spiritual beliefs and practices;

Economic status, including homelessness;

Immigration and refugee status;

Sexual orientation;

Military status;

History of previous victimization;

Past experience with the criminal justice system;

Whether the assault involved drugs and/or alcohol;

Prior relationship with the suspect, if any;

Whether they were assaulted by an assailant who was in an authority position over them;

Whether the assault was part of a broader continuum of violence and/or oppression (e.g., intimate partner and family violence, gang violence, hate crimes, war crimes, and trafficking);