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Sexual Assault and the Sexual Assault Nurse Examiner In West Virginia.

Introduction

Sexual assault is felt to be under reported. Statistics from the Rape, Abuse & Incest National Network (RAINN) estimate that 68% of sexual assaults are not reported. (1) In addition, it is believed that 1 out of every 6 American women will have been the victim of an attempted or completed rape in her lifetime. (2) Ninety percent of rapists never spend a day in jail or prison. (1) According to a study of high school students who reported they were forced to have sexual intercourse at some time in their lives, disparities based upon race was evidenced by 13.5 % of multiple-race students reporting forced sexual intercourse compared to 7.4% of white students. (3)

In West Virginia, sexual assault is defined at the sexual contact of one person with another without the appropriate legal consent. (4) Lack of legal consent can result from forcible compulsion or the incapacity to consent. According to West Virginia article 61-8B-2 a person is deemed incapable of consent if their age is less than 16 years, if they are considered mentally incapacitated or physically helpless or they are considered mentally defective. The notable difference between assault and abuse is penetration. (4)

The Sexual Assault Response/Resource Team (SART) consists of community professionals from hospital(s) (medical professionals), law enforcement, rape crisis center, and prosecuting attorney's office. The group works to coordinate immediate, multidisciplinary, victim-centered, high quality response to sexual assault cases. Other community members who are invested in the process of assisting victims of sexual assault may also participate, such as public health department, churches, college/university representatives, and others. (4) SARTs have also "enhanced public safety by increasing public awareness, increasing reporting, and facilitating investigation." (5)

In 2014, the West Virginia state legislature established the Sexual Assault Forensic Examination (SAFE) Commission. (6) The Commission was charged with establishing mechanisms to authorize minimum training requirements, approve local/regional plans, and develop data. They were also asked to work with local Sexual Assault Forensic Examinations Boards to identify a facility "appropriate and qualified for receipt and treatment" of a sexual assault victim and evaluate needs of an area and develop alternate plans. (6)

Sexual Assault Nurse Examiners (SANEs)

Sexual Assault Nurse Examiners (SANEs) are registered nurses who have been specially trained to provide comprehensive care to the sexual assault patient and have demonstrated competency in conducting a forensic medical examination. A SANE is also able to provide expert witness testimony. (4) The first SANE program was established in Memphis, TN in 1976. (5) It was not until 1991 that the first list of 20 SANE programs was published in the Journal of Emergency Nursing. (7)

SANEs provide more timely exams, compassionate and effective care, improved evidence collection, stronger cases for prosecution and decreased costs. (8,9) SANEs allow the victim to have more control over the pace of the exam and treatment. The victim is in a supportive environment where they have the undivided attention of the SANE. (10) The goal of the SANE is to remain unbiased, reveal the assailant if the patient discloses that information and coordinates with the investigator/law enforcement. The forensic examination is based upon the history obtained and health care needs are similarly determined. The SANE provides patient centered care, so that patient is not put through any unnecessary procedures. This type of process allows the patient to decline any part of the exam or collection.

A SANE is a nurse first, and as such, do not make medical diagnoses. They identify deviation from normal or changes in status. They provide treatments that may be prescribed by other disciplines and monitor the response to treatment. SANEs coordinate the big picture.

SANE Programs & Training

Where SANE programs exist, they have made a difference in the quality of care provided to the victim, improved evidence collection, and stronger cases for prosecution. (8,9) A forensic exam can take 2 - 3 hours, a SANE nurse can work solely with the sexual assault patient allowing for an evaluation paced by the patient, while the activities of a busy emergency department can proceed as usual.

The SANE receives training for adult evaluation through a 40-hour didactic course. The first 24 hours is provided through a free, online program. (11) The course work is completed with 16 hours of classroom training. Following the didactic course, there is a 25-hour clinical requirement. During the clinical requirement they perform speculum exams and assist with adult and adolescent cases. They complete 3 adult/adolescent exams with a preceptor and once the preceptor "signs-off", this affirms the SANE is competent to perform exams. The Pediatric SANE has an additional 40 hours of training and a 40-hour clinical requirement. The onset of menses is used as a guide to determine whether an adult versus pediatric SANE is appropriate.

Evaluation Process

Initial Patient Presentation

When a patient presents with concern for sexual assault, they should be roomed as quickly as possible. A prolonged time in the waiting room can add to the anxiety associated with an already stressful situation. The patient should be evaluated for injury by the ED provider. (12) Non-genital injury resulting from sexual assault has been reported in a range from 23-85% of patients. (5) Of those injuries most, are self-limited and require only basic wound care and moderate injuries represent 2-17%. One--two percent are severe injuries requiring hospitalization. (5) Strangulation has recently been identified as one of the most lethal forms of domestic violence and should be assessed in all victims of sexual assault. (13)

Documentation of the history should be recorded as much as possible in the patient's own words. Limit documentation regarding the details of the assault, since those will be obtained by the SANE. Avoid using value words such as normal, satisfactory, positive or negative.

Forensic Evidence Considerations

The time limit for collection of forensic evidence is < 96 hours. Whether adult or pediatric the SANE should be contacted as soon as possible to minimize loss of evidence. If the assault occurred greater than 96 hours prior to presentation, a "non-acute' examination is conducted. The patient needs to provide consent to the forensic examination. The SANE is often on call from home, so prior to calling the SANE to perform the exam, the examination process including duration, evidence collection and purpose should be explained to the patient. Wear gloves when examining the patient, so there is no contamination of the forensic evidence. The forensic evidence should be collected first, so if the patient needs to urinate, the SANE would like the first voided specimen and it should not be a clean catch. A clean catch urine would potentially remove evidence. The patient should not eat or drink until the SANE has performed their examination and collected the evidence. Any clothing items which might be brought in from home as evidence should be stored in a paper bag, a plastic bag promotes growth of mold and degrades the evidence. Table 1 lists the items for which the patient needs to consent.

Patient Advocates

If the patient consents to presence of an advocate, the community representative should be contacted as soon as possible. The advocate is felt to be crucial to the recovery and support process for the patient. The services offered by the advocate include advocacy and support during forensic medical exam, law enforcement investigation and court proceedings; offering crisis intervention and/or emotional support to their families; assisting with referrals and coordinating services with other agencies; and explaining the criminal justice system and supporting victims through the process. There are nine rape crisis centers in West Virginia and they can be found on the FRIS web site. (14)

Non-Reporting Situations

In a "non-report" the individual receives a forensic examination, the sex crime evidence kit is sent to Marshall University Forensic Science Center. If no investigation initiated within 24 months, the kit is categorized as "non-active" and samples may be used for training once de-identified. The forensic evidence is submitted to the law-enforcement in a "report", but sent via courier service if a "non-report." The life span of blood and urine submitted is limited and variable. The life span of swabs, smears and similar evidence if properly collected and dried is unlimited.

Financial Expenses

The WV Forensic Medical Examination fund will pay for the cost of the forensic medical examination regardless of whether law enforcement is involved or not involved. The WV Crime Victims Compensation Fund provides for compensation to" innocent victims who had suffered personal injury and who have out-of-pocket" expenses "as a result of criminally injurious conduct." (15) To be eligible the victim needs to file a claim within 72 hours of the event.

Post Exposure Prophylaxis

The management of the patient presenting for sexual assault evaluation includes discussion of emergency contraception, post exposure prophylaxis (PEP) for hepatitis B, sexually transmitted infections, and HIV. The risk of pregnancy after sexual assault is 5%. The upper limit for prophylaxis is 5 days. Levonorgestrel is most effective if given within 72 hours. (16) Risk of pregnancy is three times higher with BMI >25. Ulipristal acetate is an alternative and is effective up to 5 days from intercourse. (16) It requires a prescription, levonorgestrel is available over the counter. Prophylaxis for gonorrhea, chlamydia, and trichomonas can be found on the CDC web site, looking for the most up to date recommendation. If the patient has had hepatitis vaccination the patient should be evaluated response to the vaccine with a hepatitis B surface antibody and if not, the first hepatitis vaccine administered with plan to repeat in 1-2 months and 4 - 6 months.

Regarding HIV risk, the CDC cites a risk of 0.1-0.2% with receptive vaginal intercourse with an HIV positive source. The risk with receptive anal intercourse is 0.1-0.3% and with oral intercourse it is undetermined and approximates 0.05%. (17) Risk varies with the number of assailants and condom use. If HIV PEP considered it should be initiated within 72 hours. If the source is known to be HIV positive prophylaxis is recommended. When the source is unknown risk assessment is more difficult. Assistance with non-occupational Post Exposure Prophylaxis (nPEP) related decisions can be obtained by calling the National Clinician's Post Exposure Prophylaxis Hotline (PEP Line) (telephone: 888-448-4911) or the CDC website or http://www. nccc.ucsf.edu. If HIV PEP provided, 3-7 days should be provided to assess tolerance and close follow up before the provided medication/prescription runs out. Baseline pregnancy test, complete blood cell count and serum chemistry should be performed. The patient should also be made aware of the cost of HIV-PEP, which typically exceeds one thousand dollars.

Post-Evaluation Procedures

Following the ED evaluation, the patient may wish to wash up and may need some clothing to wear home. Try not to send the patient home in hospital gown. Make sure that they have a copy of the kit number from the SANE for their reference. The patient will need follow up for re-evaluation for sexually transmitted infection, repeat hepatitis B vaccine if needed. If the patient is given HIV PEP they will need follow up in 3--7 days to recheck lab and tolerance to medication and prescription for continued medication. This is a very stressful life event for the patient, they will need follow up for emotional assessment. The patient advocate can help with counselling. The advocate can also help to coordinate with law enforcement and prosecuting attorney. The patient may also need a ride home.

Pediatric Patient Evaluations

For pediatric patients, follow up at a local Child Advocacy Center should be scheduled. They have a child and family friendly atmosphere where the staff provides a multidisciplinary response. Forensic interviews are conducted in these facilities. The Child Advocacy Centers provide victim support and advocacy. To find a center that responds to your local area and a further list of services please look at their web site. www. wvcan.org The event should also be reported to Child Protective Services, they too can help to assure appropriate follow up for the child.

Conclusions

SANEs are a wonderful resource for the clinician, the patient, and law enforcement. They perform an invaluable service. The medical provider's role is to facilitate the patient evaluation. The involvement of SANE does not excuse the provider from providing care. The medical provider will need to discuss PEP for pregnancy, Sexually Transmitted Infections, HIV and Hepatitis B. Appropriate follow up using the resources available such as primary care provider, rape advocacy centers, and child advocacy centers should be arranged and discussed with the patient. Keep in mind, for the patient this event is life-changing and they will likely need some counselling to assist them in managing their emotions.

Thank you SANEs!

References

(1.) Rape, Abuse, and Incest National Network Statistics Page. 2017. Retrieved from Rape, Abuse, and Incest National Network: https://www.rainn.org/statistics

(2.) Rape, Abuse, and Incest National Network Statistics. 2017. Retrieved from: https://www.rainn.org/statistics/scope-problem

(3.) Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual non-minority individuals. Am J Public Health. 2011 Aug;101(8):1481-1494.

(4.) West Virginia Foundation for Rape and Information Services. Sexual Assault in West Virginia: An informational handout. West Virginia Foundation for Rape and Information Services.

(5.) Riviello RJ et al. Evaluation and management of the sexually assaulted or sexually abused patient, 2nd edition. ACEP. 2013.

(6.) Legislature, WV. West Virginia State Legislature. 2016. Retrieved from West Virginia State Code: http://www.legis.state.wv.us/WVCODE/Code.cfm?chap=15&art=9B

(7.) Lenehan G. Sexual assault nurse examiners: A SANE way to care for rape victims. Journal of Emergency Nursing. 1991. 1-2.

(8.) Kagan-Krieger. The sexual assault nurse examiner. The Canadian Nurse. 20-24.

(9.) Nugent-Borakove. Testing the efficacy of SANE/SART programs: Do they make a difference in sexual assault arrest and prosecution outcomes? American Prosecutors Research Institute. 2006.

(10.) Fehler-Cabral. Adult sexual assault survivor's experience with sexual assault nurse examiners (SANES). Journal of Interpersonal Violence. 2011. 2618-3639.

(11.) West Virginia Foundation for Rape Information & Services. West Virginia Sexual Assault Nurse Examiner (SANE) online training for adults and adolescents. 2017. Retrieved from: http://www.fris.org/OnlineTraining/SANE.html

(12.) Linen. Care of the adult patient after sexual assault. NEJM. 2011, 834-841.

(13.) Crane. Interpretation of non-genital injuries in sexual assault. Best Practice & Research Clinical Obstetrics and Gynecology. 2013. 103-111.

(14.) West Virginia Foundation for Rape Information Services. West Virginia Rape Crisis Centers. 2017. Retrieved from: http://www.fris.org/CrisisCenters/WVCrisisCenters.html

(15.) West Virginia State Legislature. West Virginia Legislature. 2014. Retrieved from: http://www.legis.state.wv.us/Joint/victims.cfm

(16.) Glasier. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and lovonorgestrel. Contraception. 2011. 363-367.

(17.) Centers for Disease Control. HIV/AIDS. 2017. Retrieved from: https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html

Debra J. Paulson, MD, Margaret Denny, RN, Melinda Sharon, MPH

Department of Emergency Medicine, West Virginia University School of Medicine
Table 1. List of SANE-related procedures that require patient consent.

Informed consent and/or refusal is needed for each of the following:
* Medical evaluation and treatment
* Reporting the crime
* Performing a physical examination
* Photo-documentation
* Evidence collection: The patient has the right to decline the
  collection of any & all specimens
* Transfer of evidence to law enforcement personnel
* Presence of advocate
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Title Annotation:Special Article
Author:Paulson, Debra J.; Denny, Margaret; Sharon, Melinda
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Nov 1, 2017
Words:2575
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