NT OF ME J T US U.S. Department of Justice R T A I P C E E D
B
O J C S F A V Office of Justice Programs F M O I N A C I J S R E BJ G O OJJ DP O F PR Office for Victims of Crime JUSTICE Sexual Assault Nurse Examiner SANE
Development & Operation Guide
Sexual Assault Resource Service Minneapolis, Minnesota
Office for Victims of Crime
NCJ 170609 Advocating for the Fair Treatment of Crime Victims U.S. Department of Justice Office of Justice Programs 810 Seventh Street NW. Washington, DC 20531
Janet Reno Attorney General
Raymond C. Fisher Associate Attorney General
Laurie Robinson Assistant Attorney General
Noël Brennan Deputy Assistant Attorney General
Kathryn M. Turman Acting Director, Office for Victims of Crime
Office of Justice Programs World Wide Web Homepage http://www.ojp.usdoj.gov/
Office for Victims of Crime World Wide Web Homepage: http://www.ojp.usdoj.gov/ovc/
For grant and funding information contact U.S. Department of Justice Response Center 1–800–421–6770
This document was prepared by the Sexual Assault Resource Service, under grant number 96–VF–GX–K012, awarded by the Office for Victims of Crime, Office of Justice Programs, U. S. Department of Justice. The opinions, findings, and conclusion or recommendations expressed in this document are those of the authors and do not necessarily represent the official position or policies of the U. S. Department of Justice.
The Office for Victims of Crime is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance, the Bureau of Justice Statistics, the National Institute of Justice, and the Office of Juvenile Justice and Delinquency Prevention. NT OF ME J T US U.S. Department of Justice R T A I P C E E D
B
O J C S F A V Office of Justice Programs F M O I N A C I J S R E BJ G O OJJ DP O F PR Office for Victims of Crime JUSTICE Sexual Assault Nurse Examiner SANE
Development & Operation Guide
Linda E. Ledray, PhD, RN, FAAN Sexual Assault Resource Service Minneapolis, Minnesota
Office for Victims of Crime
Advocating for the Fair Treatment of Crime Victims SANE Development and Operation Guide
CONTENTS
Chapter 1: Introduction...... 1
■ Project Goals and Objectives ...... 1 ■ Scientific Basis of This Guide ...... 2 ■ Terminology...... 2 • She or He ...... 2 • Rape, Sexual Assault, or Abuse? ...... 2 • Victim or Survivor? ...... 2 ■ SANE Guide Evaluation ...... 2
Chapter 2: History and Development of SANE Programs ...... 3
■ Rape in the United States ...... 3 ■ Demonstrating the Need for SANE Programs ...... 5 ■ History of SANE Program Development ...... 5
Chapter 3: SANE Program Model ...... 7
■ What Is a SANE? SANC? SAFE? FNE? ...... 7 ■ SANE Program Values, Mission, and Goals...... 7 • Values Statement ...... 8 • Mission Statement ...... 8 • Program Goals ...... 8 ■ SANE Scope of Practice ...... 9 • Medical Care ...... 9 • Reporting and Victim Support ...... 9 ■ Education, Training, Research, and Program Evaluation ...... 9 ■ SANE Standards of Practice ...... 9 ■ How a Model SANE Program Operates ...... 10 • Hospital-Based SANE Programs ...... 10 • Community-Based SANE Programs...... 10 • Community Response and Responsibilities ...... 11 • SANE Responsibilities ...... 11 ■ Community Impact and Benefit ...... 12
iii Contents
Chapter 4: SART: A Community Approach ...... 13
■ Who Is on a SART? ...... 13 ■ The Sexual Assault RESPONSE Team Model ...... 13 • How a Sexual Assault RESPONSE Team Operates ...... 13 • Sexual Assault RESPONSE Team Model Limitations ...... 14 ■ The Sexual Assault RESOURCE Team Model ...... 14 ■ Summary ...... 15
Chapter 5: Assessing the Feasibility of a SANE Program ...... 17
■ Needs Assessment ...... 17 • Identifying Allies ...... 17 • Determining the Extent of the Community Problem of Rape ...... 17 ■ Assessing Community Services and Developing Community Support...... 18 • Law Enforcement ...... 18 • Rape Crisis Center ...... 18 • Medical Facility ...... 18 • Prosecuting Attorney ...... 19 • Other Agencies...... 19 ■ Identifying and Overcoming Obstacles: ...... 19 • Concerns About Costs...... 19 • Fear of Interference ...... 20 • Concern the SANE Will Not Do the Exam as well as the Physician ...... 20 • Concern the SANE Will Not Be a Credible Witness ...... 21 ■ Deciding to Proceed ...... 22 ■ Starting a Formal Task Force ...... 22 ■ Developing a SART ...... 23
Chapter 6: A Look at Funding ...... 25
■ Program Development and Operation Costs ...... 26 • Needs Assessment ...... 26 • Facilities and Utilities ...... 27 • Supplies and Equipment ...... 27 • Staff Advertising and Selection ...... 29 • Staff Training ...... 29 • Program Media Promotion ...... 29 • Staff Salaries ...... 29 ■ Current SANE Program Funding ...... 29
iv SANE Development and Operation Guide
■ SANE Program Funding Options ...... 30 • Where to Look for SANE Program Funding ...... 30 • Fundraising Process ...... 33 ■ Looking to the Future as You Begin ...... 34 ■ Summary ...... 34
Chapter 7: Starting Your SANE Program ...... 35
■ How Long Can It Really Take?...... 35 ■ Hours of Operation ...... 35 ■ Population Served ...... 35 ■ Deciding on Program Location ...... 35 ■ One Location or Multiple Exam Sites ...... 36 • Advantages of a Single Exam Site ...... 36 • Disadvantages of a Single Exam Site ...... 36 • Adapting the SANE Program to Multiple Exam Sites ...... 37 • Disadvantages of Multiple Exam Sites ...... 37 ■ Regional SANE Programs ...... 37 ■ Community-Based Program Exam Sites ...... 37 ■ Hospital ED-Based Exam Sites...... 38 • Advantages of the ED Exam Site ...... 38 • Overcoming Disadvantages of the ED Exam Site ...... 39 ■ Hospital Clinic-Based Exam Sites ...... 39 ■ Summary of SANE Location Trends ...... 39
Chapter 8: SANE Program Staff ...... 41
■ SANE Program Directors ...... 41 • Reporting Structure...... 41 • Job Duties ...... 41 • On Call ...... 42 ■ The Role of the Physician ...... 42 ■ Staff Selection ...... 43 ■ Staffing Patterns ...... 44 ■ Staff Meetings ...... 44 ■ SANE Salaries ...... 45 ■ SANE Staffing Recommendations...... 46 • Program Director ...... 46 • Medical Director ...... 46 • SANE Staff ...... 47 ■ Summary ...... 47
v Contents
Chapter 9: SANE Training ...... 49
■ Certification ...... 49 • National Certification ...... 49 • State Level Certification ...... 49 • Local Certification ...... 50 ■ SANE Training Options ...... 50 ■ SANE Training Today ...... 50 ■ Utilizing an Existing Training Program ...... 51 ■ Importing a SANE Training Program ...... 51 ■ Organizing Local SANE Training...... 52 • Identifying Local Experts ...... 52 • Selecting a SANE Trainer ...... 53 ■ SANE/SART Training Resources ...... 53 • Color Atlas ...... 53 • Evidentiary Exam Videotape ...... 53 ■ SANE Training Components ...... 54 • Programmatic ...... 54 • Medical ...... 54 • Legal ...... 54 • Forensic Practices and Procedures...... 54 • Psychological ...... 55 ■ Continuing SANE Education ...... 55 ■ Future SANE Training Trends ...... 55 ■ Summary ...... 55
Chapter 10: Establishing and Maintaining Program Coverage ...... 57
■ Using Staff Positions ...... 57 ■ Using On-Call Positions ...... 57 • Length of On-Call Shifts ...... 57 • Assigning Your On-Call Shifts ...... 57 • Changes in the On-Call Schedule ...... 58 • Paid and Unpaid On-Call Service ...... 58 ■ Response Time ...... 59 ■ When Should the SANE Be Paged and by Whom? ...... 59 ■ Delayed Response ...... 60 ■ Selecting a Paging System ...... 60 ■ On-Call Backup ...... 61 ■ Using an Answering Service ...... 61 ■ Summary ...... 61 vi SANE Development and Operation Guide
Chapter 11: SANE Program Operation ...... 63
■ Medical Evaluation and Care of Injuries...... 63 ■ The SANE Evidentiary Exam...... 63 • Forensic Evidence Collection...... 63 • Followup Forensic Exams ...... 72 • Helpful Tips for Evidence Collection ...... 73 ■ Additional Components of the SANE Exam ...... 73 • STD Evaluation and Preventive Care ...... 73 • HIV ...... 73 • HIV Post-Exposure Prophylaxis ...... 74 • Pregnancy Risk Evaluation and Prevention ...... 75 • Crisis Intervention and Counseling ...... 76 ■ Maintaining Chain-of-Evidence ...... 76 ■ Maintaining Evidence Integrity ...... 76 ■ Documentation ...... 77 ■ After the Exam ...... 78 ■ Testifying in Court ...... 78 ■ Working with Special Populations ...... 79 • Male Victims ...... 79 • Same Gender Sexual Assault ...... 80 • Gay and Lesbian Victims...... 80 • People with Developmental Disabilities...... 81 • People with Physical Disabilities ...... 83 • The Elderly ...... 85 • Self-Injury Victims ...... 86 • Refugees and Immigrants ...... 86 • Working with Interpreters ...... 88 ■ Providing Culturally Congruent Care ...... 89 ■ Additional Program Components...... 91 ■ Summary ...... 91
Chapter 12: Pediatric SANE Exam ...... 93
■ Setting ...... 93 ■ Special Training...... 93 ■ Sexual Assault Response/Resource Team (SART)...... 94 ■ Interview ...... 94 • Who Conducts the Interview ...... 94 • Victim Interview ...... 94 • Caretaker Interview ...... 97
vii Contents
■ Consent, Confidentiality, and Reporting: ...... 97 • Minor Consent ...... 97 • Confidentiality ...... 97 • Adolescents ...... 98 • Mandated Reporting ...... 98 ■ Collection of Physical Evidence ...... 99 • Goal ...... 99 • Components ...... 99 • When to Do an Evidentiary Exam ...... 99 • Preparing the Child for the Exam ...... 99 • Exam Positions ...... 100 • Recommended Equipment ...... 101 • Evidence Collection Sites ...... 102 • STD Testing...... 102 • Hair Specimens ...... 102 ■ Interpretation of Findings ...... 103 • Class 1-Normal Appearing Genitalia ...... 103 • Class 2-Nonspecific Findings ...... 103 • Class 3-Specific Findings ...... 103 • Class 4-Definitive Findings ...... 103 ■ Antibiotics for Prevention and Treatment of STDs ...... 103 ■ Pregnancy Risk Evaluation and Treatment...... 104 ■ Psychological Considerations ...... 104 ■ Discharge Planning ...... 105 • Child Protective Services ...... 105 • Medical Care ...... 106 • Other ...... 106 ■ Summary ...... 106
Chapter 13: Policies and Procedures ...... 107
■ Consent ...... 107 ■ Court Testimony ...... 107 ■ Drug and Alcohol Screening ...... 108 ■ Evaluation of Nongenital Injuries (When to Refer to a Physician) ...... 109 ■ Evidentiary Exam Timing (Rape Kit Completion; STD Treatment; Pregnancy Prevention) ...... 109 ■ Examination Sites for Evidence Collection ...... 110 ■ HIV ...... 111 ■ Holiday and Weekend Work ...... 112 ■ Interpreters ...... 112
viii SANE Development and Operation Guide
■ Malpractice Insurance ...... 113 ■ Mandatory Institutional Inservices ...... 113 ■ Mandatory Reporting of Sexual Assaults of Vulnerable Adults and Minors...... 114 ■ Medication Administration ...... 114 ■ Noncompliant Victims...... 115 ■ Nonreporting Victims ...... 115 ■ On-Call Schedule (Primary) ...... 116 ■ On-Call Schedule (Backup) ...... 117 ■ Photographs ...... 117 ■ Pregnancy Risk Evaluation and Emergency Interception ...... 118 ■ Program Evaluation and Research ...... 118 ■ Psychiatric Inpatient/Extended Care Unit Sexual Assault Evaluation ...... 119 ■ Rape Drug Screening ...... 120 ■ Records ...... 122 ■ STD Evaluation and Prevention (Other than HIV) ...... 122 ■ Statutory Rape/Teen Consenting Sex ...... 123 ■ Suicide Potential Evaluation ...... 124 ■ Time Cards/Time Sheets ...... 125 ■ Unavailability/Vacation ...... 125 ■ Unconscious Victim ...... 125
Chapter 14: Maintaining a Healthy Ongoing Program ...... 127
■ SANE Vicarious Traumatization and Burnout ...... 127 • Identifying Symptoms ...... 127 • Symptoms of Vicarious Traumatization or Burnout ...... 128 • Reducing Impact on Staff ...... 128 ■ Program Evaluation ...... 130 • Formal and Informal Evaluation Strategies ...... 130 • Process Evaluation ...... 131 • Output Evaluation ...... 131 • Outcome Evaluation ...... 131 • Data Collection and Analysis ...... 132 • Evaluation Utilization ...... 132 • Steps of Program Evaluation Planning ...... 132 • Evolution of SANE Program Evaluation...... 133 ■ Maintaining a Healthy Ongoing Relationship with Other Agencies and Organizations...... 133 ■ Summary ...... 133
ix Contents
Appendixes ...... 135
A: Project Staff and Advisory Committee ...... 137 B: Participating SANE Programs ...... 139 C: Rape Kit Supply Resources ...... 149 D: SANE Training Programs ...... 151 E: SANE Trainers ...... 153 F: Funding Resources ...... 155 G: Startup Checklist ...... 167 H: Clinical Skills Competency Checklist ...... 175 I: SANE Protocols ...... 195 J: SANE Forms ...... 201 K: SANE Evaluation Tools...... 233 Glossary ...... 285
Bibliography ...... 287
SANE Guide Evaluation ...... 297
x SANE Development and Operation Guide
SUGGESTIONS FOR USING THIS GUIDE
A multidisciplinary response is needed to serve This guide was designed to be read in its entirety, victims of sexual assault, and OVC anticipates that with each chapter building on information pre- individuals from many disciplines, not just forensic sented in the previous chapter. Treating each nursing, will use this guide to aid their efforts in chapter independently would have required much establishing and operating a SANE program. duplication of basic information, greatly increasing Indeed, the impetus driving the development of the length of the guide. Constant duplication of several SANE programs has come from law en- the same information in each chapter would also forcement, sexual assault victim advocates, and be annoying and distracting to most readers. In a others. Therefore, this guide was written from the few instances, information is repeated for clarity perspective that not everyone who reads it will and to preclude frequent referral back to previous have a forensic nursing or even a clinical back- chapters. Readers who are unable to read the ground. At the same time, there are a few clinical manual in its entirety are advised that: issues addressed in this guide that cannot ad- equately be addressed in “layman’s terms.” We ■ The use of female pronouns for victims was hope that this guide strikes a reasoned balance. As a deliberate choice and the rationale is ex- the effort to develop a SANE program should be a plained in Chapter 1, page 2, in the section multidisciplinary one, we suggest that nonclini- “Terminology.” cians refer to the nursing and medical members of ■ Female pronouns were also used to refer to the organizing team for clarification or further SANE practitioners, as the overwhelming discussion of clinical topics. To aid the nonmedical majority of them are female. reader, a glossary of acronyms used throughout the ■ Throughout the guide, references are made guide is located after the appendixes. to “the survey.” This refers to a survey conducted of existing SANE programs at the An important issue is the rapid development of beginning of the project and is described in State policies and procedures governing the pro- Chapter 1, page 2, in the section “Scientific cesses and protocols of SANE programs that Basis of This Guide.” occurred during the writing and review of this guide. Users of this guide should understand that State statutes and policies always take prece- A MESSAGE FROM A dence over the recommendations described in this manual.
xi SANE Development and Operation Guide
A MESSAGE FROM THE OVC ACTING DIRECTOR
OVC believes that an informed, effective response to violence in America transcends the criminal justice system, and builds on many disciplines, including the health care sector. We know that victims of sexual assault suffer psychological trauma and, all too frequently, long-term health consequences as a result of their victimization. Therefore, providing sensitive health care to victims is critically important in the aftermath of a sexual assault. Unfortunately, the traditional model for sexual assault medical evidentiary exams frequently compounds the traumatization of victims. Medical personnel in the emergency room setting often regard the needs of most sexual assault victims as less urgent than other patients in the emergency room. As a result, rape victims may endure long hours of waiting in the public areas of busy emergency rooms. They are not allowed to eat, drink, or even urinate while they wait for a physician to conduct the medical evidentiary exam. Frequently, the physicians or nurses who perform the exams have not been trained in medical evidence collection procedures or do not perform these procedures frequently enough to maintain their proficiency. Some physicians are reluctant even to perform the medical eviden- tiary exam, knowing that they might be called away to spend a day or more in court testifying or that their qualifications to testify might be questioned due to their lack of training and experience. In re- sponse to these issues, the first Sexual Assault Nurse Examiner (SANE) program was developed in 1976, offering a multidisciplinary, victim-centered way of responding to sexual assault victims. There are now more than 100 SANE programs throughout the U.S., but these programs are not enough to serve the hundreds of thousands of children and adults who are victims of sexual assault every year.
The services of trained, experienced SANE practitioners help to preserve the victim’s dignity, enhance medical evidence collection for better prosecution, and promote community involvement and concern with crime victims and their families. OVC has a strong interest in promoting the replication of pro- grams such as SANE. This SANE Development and Operation Guide is the result of that interest and we anticipate that it will serve as a blueprint for nurses and other community leaders who wish to establish a similar program in their own community. OVC commends Dr. Linda Ledray and her colleagues in forensic nursing across the nation for their strong, visible leadership in developing and supporting programs that help sexual assault victims take the first steps toward healing.
Kathryn M. Turman Acting Director Office for Victims of Crime
xiii SANE Development and Operation Guide
ACKNOWLEDGMENT
When Dr. Linda Ledray started the Sexual Assault The Office for Victims of Crime at the Department Resource Service (SARS) at Hennepin County of Justice also recognized the need for this SANE Medical Center in Minneapolis in 1977, she did Development and Operation Guide in order to so with the intent of developing a nursing focused provide others the ability to efficiently and knowl- service delivery model that could one day be im- edgeably start SANE programs using the wisdom plemented in rural Minnesota. At that time, of those who have been operating SANE programs. according to Dr. Ledray, she did not understand With this Guide, others can learn from the trials the impact that this model, now known as SANE, and errors of those who went before, and they can would have across the country, and that 20 years move ahead more rapidly to improve services for later it would be considered a “new,” innovative sexual assault victims in their communities. treatment model for sexual assault victims. This Guide has taken the combined effort and Dr. Ledray was excited to discover in the mid expertise of many individuals. Kathy Simmelink, 1980’s that nurses in Amarillo, Texas; Memphis, MA, RN and Maggie Dexheimer Pharris, MPH, Tennessee; and Tampa, Florida were also focusing MS, RN together wrote the chapter on the pediat- on responsive treatment for sexual assault victims. ric examination pulling together information These nursing pioneers realized that by pooling provided by SANEs across the country with a their resources of creativity, energy, and enthusi- significant contribution from Pat Speck, MSN, asm, progress in developing a treatment model RN, CS, FNP and Colleen O’Brien, MS, RN, who for this victim population would happen more are both advisory committee members of this quickly. With the publication of this SANE Guide, project. Based on the sage advice of Judge Isobel Dr. Ledray has now identified 116 functioning Gomez, also an advisory committee member, SANE programs, and her organization has con- Maggie Dexheimer Pharris, MPH, MS, RN, tacted many more SANE programs nearing opera- rewrote the section on special populations to better tion in behalf of rape victims. focus on meeting the unique needs of individuals rather than perpetuating stereotypes. Patricia The magnitude of effort required to develop the Moen, JD; Thomas Kiresuk, Ph.D.; Lee Barry, JD; SANE program cannot be accomplished in a Carolyn Levitt, MD; and Kit Mauer, BSN, RN, vacuum. It takes the combined efforts of many also on the advisory committee, contributed by individuals with vision, commitment, and tenacity. reviewing the manuscript and making suggestions It takes the efforts of those who know what they for additions and revisions. Pat Speck and Colleen want to do is right and who are persistent in O’Brien were gracious enough to carefully reread overcoming the roadblocks that might prevent the the revised manuscript numerous times without implementation of this vision for their community. complaint and edit extensively as they did so. As Dr. Ledray helped others to initiate SANE Susan Valentine from SARS offered sound advice, programs in their communities over the past 20 careful manuscript reviews, and good judgment to years, she noticed the same struggles that she had keep the project on track. This project also ben- initially encountered in Minneapolis were occur- efited greatly from the contributions of Joye ring in these communities. The need for a SANE Whatley, the project monitor at OVC, Olga Guide became apparent. Trujillo, Legal Counsel, OVC; Timothy Johnson,
xv Acknowledgment
Program Specialist, OVC; Kristen Gremmell, This Guide is the result of the efforts of these Program Manager, Violence Against Women individuals and the many SANEs across the Grants Office, U.S. Department of Justice; and country who shared their materials and experience Ronald C. Laney, Director, Missing Children’s with Dr. Ledray and SARS. OVC hopes that it Program, Office of Juvenile Justice and Delin- will assist others in developing and operating a quency Prevention, U. S. Department of Justice. SANE program so that communities across the Thanks also goes to Grace Coleman, the OVC nation can better meet the needs of sexual assault editor, who spent many hours ensuring that the victims. If we cannot stop rape, at least we can final product was one of quality and Chris Naylor, work together to reduce the suffering of its victims the SARS secretary, as always, also pitched in and and improve the system that responds to it. stayed late when necessary to ensure that the project was completed.
xvi SANE Development and Operation Guide
CHAPTER 1 INTRODUCTION
In 1991, when the Journal of Emergency Nursing eager to explore the possibility of starting a SANE published the first list of SANE programs, there program in their area. were only 20 programs listed (ENA: 91). In a 1996 update, 86 SANE programs were identified As a result, existing SANE programs have been (Ledray: 96a). This updated list was used as the inundated with requests for information about the basis of a survey of SANE programs conducted by development and operation of the SANE model. the Sexual Assault Resource Service (SARS) at While those experienced in this field have been Hennepin County Medical Center in Minneapolis willing to do whatever possible to assist individuals in order to obtain information about current and groups in developing new programs, this help SANE program structure and practice. Fifty-nine has primarily been verbal assistance in answering (68%) of the 86 programs surveyed responded. Of questions and offering advice to help individuals these 59 programs responding, 3 were established anticipate and overcome obstacles. With each between 1976 and 1979; 10 between 1980 and phone call from a new area, the process was 1989; and 46 between 1990 and 1996. Although repeated once again. The caller, while highly the initial SANE development was slow with only motivated, was often unsure where to start or three programs in existence at the end of the even what questions to ask. The advice given was 1970’s, program development today is progressing typically based on personal experience in one rapidly. During the progress of writing this program and did not necessarily meet the needs manual, 117 SANE programs were identified and of other communities. are listed in Appendix B. It is anticipated that their number has already changed significantly. This list Project Goals and Objectives of existing SANE programs will be updated on a SANE Web site
1 Chapter 1: Introduction
forms, policies, procedures, protocols, training guide to refer to the victim population. This options, and program evaluation tools. Standards decision reflects the fact that the majority of of Practice are provided when there is a recognized victims within this victim population are female. standard. When program options are a choice, No intent was made to exclude application to advantages and disadvantages for each option are male victims. When it is established that there discussed. are different needs based on the sex of the victim, these are distinguished. The distinguished project staff and advisory committee working on this project recognize that Rape, Sexual Assault, or Abuse? different communities have different needs and resources. Whenever possible, these differences are Since the legal definitions of rape, sexual assault, addressed and options provided with rationale for and abuse vary from State to State, in this guide inclusion and selection. the terms will be used interchangeably to refer to any unwanted contact of one person’s sexual organs by another, regardless of sex, with or without Scientific Basis of This Guide penetration, and with or without resulting physical Work on this guide includes a complete review of injury. the SANE literature. The information available is included in this guide, with references, for your Victim or Survivor? use. In addition, this guide is based on information The decision was made to refer to the victim of from the 59 (68%) programs who responded to rape in this guide rather than the survivor. This the survey of the 86 programs identified in the decision was made because of the request of many 1996 JEN survey (Ledray: 96b). Followup phone victims to recognize the fact that they were victim- calls were made to several programs to obtain ized, and in the emergency department (ED) they additional information for clarification. Since not feel like a victim, not a survivor. In the ED or every question was answered on every survey, the SANE clinic during the initial period of crisis, few information and numbers included are based on victims have moved to survivor status. the answered questions only and do not always add up to 59. SANE Guide Evaluation Since national certification or standardization of SANE programs and training has not yet been A questionnaire is included at the back of this implemented, this manual reflects the experience guide to assist in evaluating its completeness and and judgment of the project staff, advisory com- utility. The questionnaire consists of two pages mittee, and the programs who responded to our which are designed to be pulled from the manual, request for information (See Appendix A: Project folded in half with the address visible, stapled, and Staff and Advisory Committee; and Appendix B: mailed. List of Participating SANE Programs), as well as Your comments and suggestions will help to the current SANE literature. update and improve this guide in the future so that it will be even more useful. We truly want and Terminology need your assistance. Please complete the evaluation questionnaire and return it once you She or He? have reviewed the information in this guide. While SANE programs deal with both male and female sexual assault and abuse victims, for the most part female pronouns will be used in this
2 SANE Development and Operation Guide
HISTORY AND CHAPTER 2 DEVELOPMENT OF SANE PROGRAMS
Even though rape has likely occurred for as long as metropolitan areas, the rate actually increased 70 humankind has existed (Brownmiller: 75), there percent in smaller suburban cities and 40 percent only has been a concerted effort to better under- in rural areas. The Northeastern and Midwestern stand the issue and better meet the needs of States experienced a 6-percent decline, the South- survivors has developed only since the early 1970’s. ern States a 5-percent decline, and the Western One of the first researchers to systematically study States a 2-percent decline in reported forcible the impact on and needs of this population was rapes. In 1995, the highest reporting rate occurred Ann Burgess who holds both a nursing degree and in August, and the lowest reported rate was in an Ed.D. (Burgess & Holmstrom: 74a). Burgess December (Uniform Crime Report: 96). identified a pattern of psychological response which she referred to as Rape Trauma Syndrome Despite these reported statistics, the actual rate of (Burgess & Holmstrom: 74b), and she continues rape remains unknown. We can only speculate that to be actively involved in furthering the scientific this increased reporting rate outside of metropoli- understanding of rape. tan areas represents an actual increase in crime. An increase in reported rapes may also be the result of better community education, increased service Rape in the United States availability, and improved reporting of crime. The 1996 Uniform Crime Report indicates that Estimates of the number of women who are 97,464 women were forcibly raped in the United actually raped range from an additional four to an States in 1995. This represents a 5-percent decrease additional nine victims for every one woman who in reported rapes from 1994, and a 9-percent reports. In one SANE program, while approxi- decrease from 1991. Even though the numbers mately 20 percent of victims are uncertain about reported in the survey are declining, this figure still reporting when they first came to the ED, working indicates that in 1995, 72 of every 100,000 women through their fears and concerns with a knowledge- in the United States were the victims of a forcible able SANE has empowered 95 percent of these rape and reported the crime to the police. More survivors to report (Ledray: 92a). rapes occurred in large metropolitan areas, where As with all Crime Index offenses, reports of the rate was 76 victims per 100,000 population, forcible rape are sometimes considered “un- compared with 49 per 100,000 in rural communi- founded” by law enforcement, and they are then ties (Uniform Crime Report: 96). excluded from the crime count. The rate of “un- Geographically, 39 percent of the 1995 forcible founded” cases is notably higher for rape than for rapes occurred in the most heavily populated any other index crime. In 1995, 8 percent of Southern States, 25 percent in the Midwestern forcible rapes were determined by law enforcement States, 23 percent in the Western States, and 13 to be “unfounded,” compared with 2 percent of all percent in the Northeastern States. The 2-year other index crimes (Uniform Crime Report: 96). trend indicates there was a decline in all regions of Some individuals in the criminal justice system the country, especially in large metropolitan areas. may assume that all “unfounded” cases are false During the 10-year period that the rate of reported reports, deceitfully reported and baseless. However, forcible rapes declined 10 percent in large this is not necessarily the case. Reported rape cases
3 Chapter 2: History and Developement of SANE Programs
are actually classified by police as “unfounded” for Violence has a significant impact on the physical a variety of reasons. These reasons for classifying a and psychosocial health of millions of Americans rape case as “unfounded” vary greatly from one every year. Since women are so often the victims of community to another, but the following are the violence, it is essential that women who present to most common reasons: emergency departments for even minor trauma be thoroughly evaluated. ED staff must be aware of ■ The police are unable to locate the victim. the types of injuries most likely resulting from ■ The victim decides not to follow through violence, and the victim must be asked about the with prosecution. cause of the trauma to determine if it is the result ■ The victim repeatedly changes the account of violence and further evaluation is required of the rape. (Sheridan: 93). When violence such as rape is ■ The victim recants. identified, trained staff need to be available to provide services. Only in 1992 did the guidelines ■ No assailant can be identified. of the Joint Commission on the Accreditation of ■ The police believe no rape occurred. Healthcare Organizations (JCAHO) first require emergency and ambulatory care facilities to have There are also a variety of other situations that protocols on rape, sexual molestation, and domes- impede or prevent completion of the investigation tic abuse (Bobak: 92). and in which the case may be classified as “un- founded” (Aiken: 93). Unfortunately, not everyone Fortunately, women’s groups have been working to distinguishes between “changing the story” and provide services to victims of violence, such as rape recalling additional data, or telling different aspects and domestic abuse, before large sums of money of the same story, or distinguishing between an were available to support these grassroots pro- untrue allegation and a victim who is so fearful of grams. Rape centers began to be established across the assailant that she recants her story out of fear the country in the early 1970’s, primarily utilizing for her life or the life of her family. The number volunteer staff. While the sexual assault recovery one reason victims give for not wanting to report movement and most rape centers continue to is fear of the assailant, whose parting words in depend upon volunteer labor, more money is 76 percent of the cases were, “If you tell anyone... becoming available to pay staff. Goodyear (1989) (or report to the police), I’ll come back and suggests that staff must be paid for their work with kill you...rape you again...rape your child” rape victims. Women working as volunteer workers (Ledray: 96a). help perpetuate the tradition of women as unpaid caregivers and allows society to avoid responsibility. Unfortunately, only 4 percent of rapists go to jail either as the result of guilty pleas or guilty verdicts The landmark Violence Against Women Act (Minneapolis Police Chief’s Report: 89). This is (VAWA) of 1994 was introduced by Senator Biden true even though 51 percent of reported forcible and signed into law on September 13, 1994, as rapes in metropolitan areas are cleared by arrest Title IV of the Violent Crime Control and Law and 52 percent in rural and suburban areas. The Enforcement Act of 1994. In addition to doubling arrest rate for forcible rapes declined in 1995 by the Federal penalties for repeat offenders and 4 percent in metropolitan areas, 6 percent in requiring date rape to be treated the same as suburban areas, and 14 percent in rural areas stranger rape, this Act made $800 million available (Uniform Crime Report: 96). The results were for training and program development over a 6- slightly better in an earlier Detroit report which year period. This was an important recognition of indicated out of 372 reported rapes, convictions the need for specialized services for female crime resulted in 13 percent of these cases (Tintinalli & victims of violent crime. Hoelzer: 85).
4 SANE Development and Operation Guide
Demonstrating the Need for There are also many anecdotal and published reports of physicians being reluctant to do the SANE Programs exam. This was due to many factors including their The impetus to develop SANE programs began lack of experience and training in forensic evidence with nurses, other medical professionals, counse- collection (Bell: 95; Lynch: 93; Speck & Aiken: lors, and advocates working with rape victims in 95), the time-consuming nature of the evidentiary hospitals, clinics, and other settings. These indi- exam in a busy ED with many other medically viduals recognized that services to sexual assault urgent patients (DiNitto et al.: 86; Frank: 96), and victims were inadequate and not at the same high the potential that if they completed the exam they standard of care as for other ED clients (Holloway were then vulnerable to being subpoenaed and & Swan: 93; O’Brien: 96). When rape victims taken away from their work in the ED to testify in came to the ED for care, they often had to wait as court and be questioned by a sometimes hostile long as 4 to 12 hours in a busy, public area; their defense attorney (Thomas & Zachritz: 93; DiNitto wounds were seen as less serious than the other et al.: 86; Speck & Aiken: 95; Frank: 96). This trauma victims; and rape victims competed unsuc- often resulted in documentation of evidence that cessfully for staff time alongside the critically ill was rushed, inadequate, or incomplete (Frank: 96). (Holloway & Swan: 93; Sandrick: 96; Speck & Many physicians even refused to do the exam Aiken: 95). They were often not allowed to eat, (DiNitto et al.: 86). In one case, it was reported drink, or urinate while they waited, for fear of that a rape victim was sent home from a hospital destroying evidence (Thomas & Zachritz: 93). without having an evidentiary exam completed Doctors and nurses were often not sufficiently because no physician could be found to do the trained to do medical-legal exams, and many were exam (Kettelson: 95). also lacking in their ability to provide expert As research became more readily available on the witness testimony (Lynch: 93). Even when they complex needs and appropriate followup of rape had been trained, staff often did not complete a victims, nurses and other professionals realized the sufficient number of exams to maintain their level importance of providing the best ED care possible of proficiency (Lenehan: 91; Yorker; 96; Tobias: (Lenehan: 91). For 75 percent of these victims the 90). Even when the victim’s medical needs were initial ED contact was the only known contact met, their emotional needs all too often were they had with medical or professional support staff overlooked (Speck & Aiken: 95), or even worse, (Ledray: 92a). Nurses also were very aware that the victim was blamed for the rape by the ED staff while they were credited with only “assisting the (Kiffe: 96). physician with the exam,” in reality they were Typically, the rape victim faced a time-consuming, already doing everything except the pelvic exam cumbersome succession of examiners for one exam, (DiNitto et al.: 86; Ledray: 92a). It was clear to some with only a few hours of orientation and these nurses that it was time to re-evaluate the little experience. ED services were inconsistent and system and consider a new approach that would problematic. Often the only physician available to better meet the needs of sexual assault victims. do the vaginal exam after the rape was male (Lenehan: 91). While approximately half of rape History of SANE Program victims in one study were unconcerned with the gender of the examiner, for the other half this was Development extremely problematic. Even male victims often To better meet the needs of this underserved prefer to be examined by a woman, as they too are population, the first SANE programs were estab- most often raped by a man and experience the lished in Memphis, TN in 1976 (Speck & Aiken: same generalized fear and anger towards men that 95); Minneapolis, MN in 1977 (Ledray & female victims experience (Ledray: 96a). Chaignot: 80; Ledray: 93b); and Amarillo, TX in
5 Chapter 2: History and Developement of SANE Programs
1979 (Antognoli-Toland: 85). Unfortunately, these 1989, and 73 additional SANE programs estab- nurses worked in isolation until the late 1980’s. In lished between 1990 and 1996. Eighty-six SANE 1991, Gail Lenehan, editor of the Journal of programs were identified and included in the Emergency Nursing (JEN), recognized the impor- October 1996, listing of SANE programs pub- tance of this new role for nurses and published the lished in JEN (Ledray: 96b). This number is likely first list of 20 SANE programs (ENA: 91). to grow much more rapidly in the years to come.
In 1992, 72 individuals from 31 programs across After years of effort on the part of SANEs and the United States and Canada came together at a other forensic nurses, the American Nurses Asso- meeting hosted by the Sexual Assault Resource ciation (ANA) officially recognized Forensic Service and the University of Minnesota School of Nursing as a new specialty of nursing in 1995 Nursing in Minneapolis. At that meeting, the (Lynch: 96). SANE is the largest subspecialty of International Association of Forensic Nurses forensic nursing. At the 1996 IAFN meeting in (IAFN) was formed (Ledray & Simmelink: 97). Kansas City, Geri Marullo, Executive Director of The IAFN is an international professional organi- ANA, predicted that within 10 years the Joint zation of registered nurses formed to develop, Commission on the Accreditation of Healthcare promote, and disseminate information about the Organizations (JCAHO) would require every science of forensic nursing nationally and interna- hospital to have a forensic nurse available tionally. Membership in IAFN surpassed the 1,000 (Marullo: 96). mark in 1996 and continues to grow (Lynch: 96). Statewide networks of SANE programs have While the initial SANE development was slow, recognized the need to develop State policies, with only three programs operating by the end of procedures, and guidelines to direct SANE pro- the 1970’s, development today is progressing much gram operations in their area. State guidelines and more rapidly. We are now aware of 10 new pro- procedures always take precedence over the recom- grams that were established between 1980 and mendations in this guide.
6 SANE Development and Operation Guide
SANE PROGRAM CHAPTER 3 MODEL
Before deciding to start a SANE program, it is examination of only sexual assault victims to the important to understand what a SANE program completion of evidentiary exams on domestic does and does not do, the scope of nursing prac- abuse victims, accident victims, and other popula- tice, and how a typical SANE program operates. tions where forensic evidence collection may be This chapter defines the terms typically used in useful. Forensic evidence is all too often overlooked relation to SANE programs. An example of SANE in busy medical facilities where the focus is on program values statement, mission statement, clinical treatment. goals, and scope of practice are presented. The chapter concludes with a discussion of the opera- At the October 1996 IAFN annual meeting held tion of a model SANE program and its impact on in Kansas City, the SANE Council voted on the the community. terminology it wanted to use in the standards to define this new position. While there were some dissenting votes, the overwhelming decision was to What Is a SANE? SANC? use the title SANE, Sexual Assault Nurse Examiner. SAFE? FNE? A Sexual Assault Nurse Examiner (SANE) is a Since forensic nurse examiner programs began registered nurse, R.N., who has advanced educa- independently and functioned independently until tion in forensic examination of sexual assault the first meeting held in Minneapolis in 1992, victims. In some areas, the SANE is still referred to different terminology has been used across the by other names, including Sexual Assault Nurse country to define the new role. The Minneapolis Clinician (SANC), and Sexual Assault Forensic program used the term Sexual Assault Nurse Examiner (SAFE). While the preference for Clinician (SANC) to denote a clinical nursing role particular terminology may vary, for the purpose that went beyond examination of the sexual assault of this manual the term SANE is used. victim. The SANC role in Minneapolis broadened the continuum of services provided to sexual assault victims, emphasizing crisis intervention and SANE Program Values, supportive counseling in the ER setting, and Mission, and Goals continuing with followup counseling by specially According to Peter Drucker there are five questions trained nurse counselors. To avoid a conflict in that must be answered to effectively assess the roles, the nurse counselor who provides followup values, mission, and goals of a nonprofit organiza- services is a separate clinician from the SANC who tion (Rossum: 93). A mission statement should provides services to the victim in the ER. The clearly and succinctly describe an organization’s Memphis program, like many others, preferred the reason for being. To develop a mission statement acronym SANE—Sexual Assault Nurse Examiner. begin by asking the following: Some newer programs have chosen to use the more 1. What is our business (mission)? What are we generic term of Sexual Assault/ Forensic Examiner trying to achieve? What specific results are we (SAFE) or Forensic Nurse Examiner (FNE). A seeking? What are our major strengths? What are program in Minnesota has chosen the SAFE our major weaknesses? terminology because they hope to move beyond
7 Chapter 3: SANE Program Model
After addressing the above question, focus on the Those who do report also have a right to sensitive following questions: and knowledgeable support without bias during this often difficult process through the criminal 2. Who is our customer or client? Who is the justice system. Those who do not report still have primary customer (service users)? Who are our a right to expert health care. supporting customers (Board, volunteers, staff, law enforcement, prosecutor, other agencies)? Will our In addition, a SANE program is based on the belief customers change? that providing a higher standard of evidence collection and care can speed the victim’s recovery 3. What does the customer or client value? What to a higher level of functioning, prevent secondary do our primary customers value? What do our injury or illness, and ultimately increase the supporting customers value? How are we providing prosecution of sex offenders and reduce the inci- what our customers or clients value? dence of rape. 4. What have been our results? How do we define results? To what extent have we achieved these Mission Statement results? How are we using our resources? The primary mission of a SANE program is to meet the needs of the sexual assault victim by 5. What is our plan? What have we learned and providing immediate, compassionate, culturally what do we recommend? Where should we focus sensitive, and comprehensive forensic evaluation our efforts? What, if anything, should we do and treatment by trained, professional nurse differently? What is our plan to achieve results? experts within the parameters of the individual’s State Nurse Practice Act, the SANE standards of Answering these questions is a critical step in the IAFN, and the individual agency policies. ensuring that an organization focuses on the activities that will achieve the desired results. The following are examples of SANE program values, Program Goals mission statement, and goals. This next step involves the development of specific goals and objectives. The following are examples of Values Statement SANE program goals: The basis of a SANE program operation is the ■ To protect the sexual assault victim from belief that sexual assault victims have the right to further harm. immediate, compassionate, and comprehensive ■ To provide crisis intervention. medical-legal evaluation and treatment by a ■ specially trained professional who has the experi- To provide timely, thorough, and profes- ence to anticipate their needs during this time of sional forensic evidence collection, docu- crisis. As health care providers, the SANE has an mentation, and preservation of evidence. ethical responsibility to provide victims with ■ To evaluate and treat prophylactically for complete information about choices so victims can sexually transmitted diseases (STDs). make informed decisions about the care they want ■ To evaluate pregnancy risk and offer to receive. prevention. ■ To assess, document, and seek care for A SANE program is also based on a belief that all injuries. sexual assault victims have a right (and responsibil- ■ ity) to report the crime of rape. While every victim To appropriately refer victims for immediate may not choose to report to law enforcement, she and followup medical care and followup has a right to know what her options are and what counseling. to expect if she does or does not decide to report.
8 SANE Development and Operation Guide
■ To enhance the ability of law enforcement to tell and to ensure that she gets the support she agencies to obtain evidence and successfully will need after she leaves the SANE facility. This prosecute sexual assault cases. usually includes a discussion between the victim and the SANE about reporting to law enforce- Based on the above values, mission statements, and ment. If the victim has made a choice not to program goals, each SANE program should report, she needs to discuss why she may be develop a community-specific strategic plan or hesitant to report. In most cases, the SANE developmental plan of action. This process involves encourages the victim to report the crime and translating the values and mission statements into makes referrals to legal advocacy agencies that can action. Where are we now? What do we have to do provide the support necessary to help the victim to get to where we want to be? This plan of action through the criminal justice process. is the blueprint for obtaining financial support (See Chapter 6: A Look at Funding). The SANE also provides emotional support and crisis intervention. The SANE makes an initial SANE Scope of Practice assessment of the victim’s psychological function- ing sufficient to determine if she is suicidal, A SANE program provides 24-hour on call services oriented to person, place, and time; or if she is in for all male and female victims of sexual assault or need of referral for followup support, evaluation, abuse. counseling, or treatment.
Medical Care Education, Training, The purpose of the SANE examination of the Research, and Program sexual assault victim is specifically to assess, docu- ment, and collect forensic evidence. In addition, Evaluation prophylactic treatment of STDs and prevention of In addition, the SANE is active in training person- pregnancy are provided by the SANE following a nel from other health care and community agencies pre-established medical protocol or with the who provide services to sexual assault victims. Each approval of a consulting physician. While the SANE program also conducts ongoing program SANE may treat minor injuries, such as washing evaluation and periodic research studies to evaluate and bandaging minor cuts or abrasions, further the impact, treatment needs, client outcomes and evaluation and care of any major physical trauma is services provided to sexual assault victims. This referred to the ED or a designated medical facility. should include a variety of program output, process, and outcome evaluation research activities. The SANE conducts a limited medical examina- tion, not a routine physical examination, and clearly explaining this difference to the client is SANE Standards of Practice important. Obvious pathology or suspicious At the 1996 annual meeting of IAFN, the SANE findings that may be observed are reported to the Council voted and adopted the first SANE Stan- client with a suggestion for followup care and dards of Practice. The standards incorporate the referral. Evaluation and diagnosis of pathology is following: beyond the scope of the SANE examination. ■ Goals of Sexual Assault Nurse Examiners. Reporting and Victim Support ■ Definition of the practice area. While the SANE is not a legal advocate, she does ■ Conceptual framework of SANE practice. provide the rape victim with information to assist ■ Components of evaluation and her in anticipating what may happen next in documentation. making choices about reporting and deciding who 9 Chapter 3: SANE Program Model
■ Forensic evaluation components. During the time it takes for the SANE to respond ■ SANE minimum qualifications. (usually no more than 1 hour), the ED or clinic staff will evaluate and treat any urgent or life- For a nominal fee, a copy of the SANE Standards of threatening injuries. If treatment is medically Practice may be obtained by telephoning IAFN at necessary, the ED staff will treat the client, always 609–848–8356 or writing to IAFN 6900 Grove considering and documenting thoroughly the Road Thorofare, NJ 08086-9447. forensic ramifications of the lifesaving and stabiliz- ing medical procedures. If clothes or objects are While this guide was being developed, many State removed from the victim by the ED staff, care policies, protocols, or regulations have emerged. For should be taken utilizing forensic principles for example, based on the IAFN SANE Standards of handling and storage of the physical evidence. If Practice, the Virginia State Council of Forensic medical necessity dictates treatment prior to the Nurses published their own Standards of Practice for arrival of the SANE, ED staff will take photo- Sexual Assault Nurse Examiners (1997). Always graphs following established forensic procedures. determine if there are State policies and standards However, it is preferable that the SANE take all relevant to the operation of SANE programs within forensic photographs. your own State before implementing a SANE program in you area. You may request a copy of the When the ED staff determines that the victim Virginia Standards by contacting Kim Wieczorek, does not require immediate medical care, the RN, BSN, FNE at telephone number 804-281- victim is made comfortable in a private room 8574 or writing to: St. Mary’s Hospital Emergency near the ED. This area should enhance the Department, Forensic Nurse Examiners, 5801 victim’s sense of safety and security and provide Bremo Road, Richmond, VA 23226. comfort and quiet in a sound-proof room with comfortable furniture, preferably a sofa that she How a Model SANE Program can lie down on while she waits, a telephone, and a locked door. Family members who accompany Operates the victim, with the victim’s permission, should A SANE is usually available on call, off premises, be allowed to stay with the victim while she 24 hours a day, 7 days a week. The on call SANE is waits. If there was no oral sex, she is offered paged immediately whenever a sexual assault or something to eat or drink while she waits. abuse victim enters the community’s response If she has not yet filed a police report and she system. If the protocol indicates a rape advocate knows she wants to do so, the triage nurse will call should be called, the staff or SANE also will page the police to take the initial report at the hospital. the advocate on call. If the victim is upset, and a hospital chaplain or social worker is available on site, with her permis- Hospital-Based SANE Programs sion, they will be called to wait with her until the If the SANE program is hospital-based, victims SANE, advocate, or counselor arrives. may enter the system in the following ways: Community-Based SANE Programs ■ Calling local law enforcement who will transport them to the hospital emergency If the SANE program is community-based, victims department or SANE exam clinic. may enter the system in the following ways: ■ Going directly to the hospital emergency ■ Calling the local law enforcement where department or hospital clinic they will be triaged for injuries and, if ■ Calling the designated crisis line for only minor injuries or no injuries are assistance. present, they will be transported to the
10 SANE Development and Operation Guide
community-based SANE facility by law When the ED staff determines that the patient enforcement. does not require urgent or lifesaving medical care, ■ Going to the ED of a local hospital on their the victim is not admitted to the hospital. She is own, where they will be triaged for injuries, instead transported by law enforcement to the and if there are only minor injuries or no community-based SANE program facility. injury present, they will be transported to the community-based SANE program. SANE Responsibilities ■ Going directly to the community-based Once the SANE arrives, she is responsible for SANE program during office hours. completing the entire sexual assault evidentiary ■ Calling the designated crisis line for assis- exam including crisis intervention, STD preven- tance and receiving a referral to the tion, pregnancy risk evaluation and interception, community-based SANE program. collection of forensic evidence, and referrals for additional support and care. Community Response and Responsibilities When the victim is uncertain about reporting. If the victim has not yet decided if she wants to In response to a sexual assault victim in the commu- report, the SANE will discuss the victim’s fears and nity, law enforcement is charged with initiating the concerns with her and provide her with the infor- investigation of the crime and determining if the mation necessary to make an informed decision. client has serious injuries necessitating ED evalua- tion or care. If moderate to severe injury is detected, If the victim does not want to report at this time, the victim is evaluated by paramedics and referred but is unsure if she will report at a future date, the to the hospital ED. This occurs with less than 4 SANE will make sure the victim is aware of her percent of rape victims, as rape seldom involves options and the limitations of reporting at a later serious injury (Tucker, Ledray & Werner: 90). date. The SANE will also offer to complete an evidentiary exam kit that can be held in a locked Life-threatening injuries indicate whether the refrigerator for a specified time (usually 1 month client needs to go to the hospital ED first rather or an appropriate period of time as mandated by than to a SANE facility. When no injuries are State statutes if any exist) in case she chooses to suspected, the client is transported from the crime report later. scene to the community SANE facility where she is met by the SANE within 1 hour. If the victim goes Mandatory reporting. In States with mandatory directly to a hospital ED, the staff will evaluate the reporting laws for felony crimes or child abuse, the victim for life-threatening injuries requiring SANE will follow established protocol for report- immediate treatment. When these are present, the ing after explaining the process and her responsi- ED staff will admit the victim to the ED and bilities to the victim or the victim’s family when a notify the on call SANE to come to the hospital child is involved and a parent is present. (NOTE: ED. The ED staff will evaluate and treat the This is different from statutory rape laws which are injuries, always considering the forensic implica- discussed in Chapter 13: Policies and Procedures.) tions of the lifesaving and stabilizing medical procedures. Clothing or objects removed from the When the victim does not want to report. If the client are handled and labeled to maintain the victim decides not to report and an evidentiary proper chain-of-evidence. Photographs are taken of exam is not completed, the SANE can still offer the injuries for forensic purposes by the ED staff. her medications to prevent STDs, evaluate her risk After the patient is stabilized medically, the SANE of pregnancy, and offer pregnancy prevention for will collect the forensic evidence in the designated up to 72 hours post-rape. The SANE also will ED area.
11 Chapter 3: SANE Program Model
make referrals for followup medical care and necessary, a community referral can be made to counseling and provide the victim with written better meet her long-term housing needs. followup information.
When a report is made. When a report is made or Community Impact and the victim is certain she will be reporting, a com- Benefit plete evidentiary exam is conducted following the SANE agency protocol. In most agencies, the A SANE program cannot operate in isolation and complete exam is conducted within 36 hours of be effective. Developing good community relation- the sexual assault, and an abbreviated exam is ships must begin with the decision to consider completed between 36 and 72 hours post-rape (up developing a SANE program. When cooperating to 96 hours in some States). (NOTE: Please see the agencies are informed about the SANE model of Section on seminal fluid evidence in Chapter 11: care, they are more likely to see the benefits of SANE Program Operation, which describes the collaborating with the SANE program to help rationale for use of the complete versus the abbre- victims. Working closely with community re- viated exam.) sources from the very beginning will encourage collaboration in the future. As a collaborative After obtaining a signed consent, the SANE will effort, the community can decide the type of conduct a complete exam including the collection SANE program which best meets the community of evidence in a rape kit, further assessment and needs. documentation of injuries, prophylactic care for STDs, evaluation of pregnancy risk and preventive Change is often threatening because the results are care, crisis intervention, and referral for followup unknown. It is common to have some resistance to medical and psychological care. any change including the implementation of a SANE program. Just because one may encounter Discharge. If the victim is alone, the SANE will resistance, even strong resistance, it does not follow talk with her about whom she would like to call that the idea is a bad one, or that it won’t succeed. and where she will go from the hospital. Every Chapter Five: Assessing the Feasibility of a SANE effort will be made to find a place for her to go Program addresses the types of resistance others where she will feel safe and will not be alone. When have encountered, along with information on how necessary, arrangements may be made for shelter they were able to resolve these obstacles. placement. If she is intoxicated or does not want to leave until morning, arrangements may be made for The next chapter on developing a sexual assault her to sleep in a specified area of the hospital when response or resource team concentrates on develop- this type of space is available. In many facilities, this ing and maintaining strong working community will be an ED holding room or crisis center. If relationships.
12 SANE Development and Operation Guide
SART: A COMMUNITY CHAPTER 4 APPROACH
No SANE program can operate in isolation. To depending on the needs of the clients and the goals be optimally effective and provide the best service of the SART team. possible to victims of sexual assault, the SANE must function as a part of a team of individuals The Sexual Assault from community organizations. They can be either formally organized as a Sexual Assault Response/ RESPONSE Team Model Resource Team or as informal collaborators. The original SART model, developed in Califor- Communities that have chosen to organize for- nia, involves a coordinated response. This SART mally into a team have developed different con- concept is based on the belief that a team response cepts of a Sexual Assault Response/Resource Team helps prevent the victim from reporting the (SART). One way is to work as a team of individu- account of the assault repeatedly. It also helps als who respond together to jointly interview the prevent confusion among professionals trying to victim at the time of the sexual assault exam. meet the needs of the rape victim as she progresses Another way is to work independently on a day- through the health care and criminal justice to-day basis but communicate with each other systems. regularly (possibly daily, and meet weekly or In communities using the California SART model monthly) to discuss mutual cases and solve mutual where multiple members of the SART respond to problems thus making the system function more the emergency department together to conduct the smoothly. sexual assault exam, the team usually includes law enforcement, the SANE, and a rape advocate. They Who Is on a SART? are all present when the victim makes her initial statement so she only needs to tell the account once. SART team members typically include the SANE, police or sheriff, detective, prosecutor, rape crisis How a Sexual Assault RESPONSE Team center advocate or counselor, and emergency department medical personnel. The makeup of the Operates SART team will vary from area to area, depending When law enforcement is called to the scene of a upon the community needs and resources. Ideally sexual assault, they will protect the client from the team will include representatives from the further harm, protect the crime scene evidence, community who can best help the victims. In and take a limited statement from the victim to some areas, it may include the SANE and the determine if a sex crime was committed. They will police. The SART team may also include an then call the hospital ED triage who will page the expanded range of professionals who work with SANE on call and the rape advocate on call. When specific victims populations: a school counselor, a the police and victim arrive at the hospital, the battered women’s advocate, a counselor who works SANE will decide if the victim should be directed with prostitutes, and any combination of represen- to the ED for medical evaluation by a physician, or tatives of programs in the community who are directed immediately to the SANE area for forensic concerned about the problem of sexual assault. examination. The SANE will stay with the victim The team membership may change over time during any necessary medical evaluation and until
13 Chapter 4: SART: A Community Approach
she is cleared medically and transferred to the Sexual Assault RESPONSE Team Model SANE examination area. Limitations If a client presents to the ED initially, law enforce- While the coordinated effort of a SART certainly ment is called immediately to determine if a crime has some advantage, there are also some limitations has been committed. The SANE and advocate may to this approach. If the victim is uncertain about also be called to help facilitate the victim’s admis- reporting, she may feel pressured to report when sion to the SART system. In a limited number of protocol requires law enforcement personnel to communities, a prosecuting attorney also responds interview the victim before the SANE becomes to the hospital as a member of the SART. The involved. The advocate will support the victim in police are called initially in many areas to certify that whatever decision she makes, even if the decision a crime has been committed, because in these locales, is not to prosecute. If the victim decides not to the hospital is compensated for the medical eviden- report, this also may result in a victim who cannot tiary exam only if there is an accompanying police access health care for STD and pregnancy risk statement certifying that there was a crime. For a evaluation and prevention. more comprehensive discussion of issues related to compensation, please refer to the section on SANE If the victim decides not to report, the hospital care Program Funding Options in Chapter Six of this is then typically not paid by the crime victims manual. compensation fund. When the police authorize reimbursement, they are more likely to require that With the advocate present to provide support, the a police report be made. In areas where payment is SANE and police conduct an indepth interview of authorized through another agency, reporting is the victim after briefly conferring to coordinate not necessarily a requirement for payment. De- questioning and reduce repetition. In California, tailed information on compensation issues is the penal code gives the victim a right to have any provided in Chapter Six: A Look at Funding. two individuals of her choice present for support during police questioning. The advocate may be In addition, while repetition of the account of the one of these two. Once the interview is completed, sexual assault is certainly an unpleasant experience the police officer will wait outside the exam room that most victims want to avoid, the assumption while the SANE collects the evidence which is then that they will be better off if they do not have to turned over to law enforcement or locked in a do so is only a presumption. Research of treatment secured area for law enforcement to pick up at a efficacy has in fact shown that repetition of the later time. With the victim’s permission, the account of the assault in detail has a beneficial, advocate will remain in the exam room to provide desensitizing, healing effect (Foa: 97). support during the exam as well. The Sexual Assault When the exam is completed, the SANE will make any necessary arrangements for followup medical RESOURCE Team Model care, and the advocate will make arrangements to Other parts of the country have modified the contact the victim for followup supportive counsel- initial SART model to better meet the needs of ing and legal advocacy. their community while trying to maintain the team Members of the SART may also meet regularly to concept that the SART model fosters. In many of discuss cases, or they may communicate informally these other areas, while the team members meet after the initial ED experience. regularly and communicate routinely about cases,
14 SANE Development and Operation Guide they do not actually respond at the same time. informally about specific cases. The goal of this They function cooperatively, not conjointly, which type of meeting is to gather the primary decision- is why some choose to refer to themselves as a makers, such as the directors or managers of the resource team, rather than a response team. involved agencies, and resolve problems that affect the group as a whole. At this meeting, the nature of In these areas, the police respond to the crime the SART’s work is usually broader policy issues, scene and take the initial report and then transport rather than specific case issues. the rape victim to the hospital or SANE clinic. The SANE assumes responsibility for the care of the The Sexual Assault Resource Team needs to be rape victim at the hospital or SANE clinic and aware of how the victim’s testimony can jeopardize completes the evidentiary exam. The police officer her case should she want to prosecute. For ex- is not present during the exam and may not even ample, when the victim tells her account of the wait at the hospital. Rather, the SANE will call the assault to the police, the SANE, the prosecutor, police when the exam is completed, and they will and the advocate at different times, her memory return for the victim. After discussing the exam and the completeness of each account may vary findings with the SANE, the police may also take somewhat. When present, these discrepancies must possession of the evidence and provide the victim be addressed if the case goes to court. Therefore, all with a safe ride home. team members need to meet or communicate over the phone to discuss cases, issues, and concerns. If the victim comes to the hospital before contact- While in many States, sexual assault advocates who ing the police, with the victim’s permission, the have completed the required training cannot be SANE may call the police to come to the hospital subpoenaed to testify in court, both the SANE and to take the initial report. The police may complete law enforcement personnel will be called, and they the report at the hospital, and the SANE may then need to have consistent facts about each case. be present during the interview.
The rape center advocate may bring a victim to the Summary hospital or be paged at the same time the SANE is For a SANE program to be successful, all involved paged. The advocate may also be contacted at a agencies must work together. It takes a coordinated later point in time to provide followup advocacy community approach to deal with the multiple and counseling. The advocate will likely go with needs of the rape victim and to prosecute the the sexual assault victim when meeting with the sex offender. However the SART model operates, crimes detective and prosecutor at a later point in whomever is included on the team, whatever name time. is used to describe the team, the important concern Most areas also have a standing SART meeting to is ensuring a coordinated community response discuss broader concerns and to communicate with the needs of the victim as the primary focus.
15 SANE Development and Operation Guide
ASSESSING THE CHAPTER 5 FEASIBILITY OF A SANE PROGRAM
The first step in determining the feasibility of organizations. Explain the SANE/SART concept to developing a SANE program is to determine a them and look for potential allies in program community’s need. If the need is there, then development and membership on a community obstacles to SANE program development must be resource team. identified, and adequate support or resources to overcome these obstacles must be obtained. Determining the Extent of the Community Problem of Rape Needs Assessment While meeting with community players, determine A community needs assessment must be com- the number of rapes that occur in the community pleted before making the decision that a SANE/ each year. Getting a count of the actual number of SART program is appropriate for the community. rapes may be more difficult to determine than anti- Potential funders will ask for this information cipated. At a minimum, talk with people from the before they consider financially supporting the local police department, rape crisis center, medical concept. Keeping an open mind during this initial facility, and prosecuting attorney’s office. Ask these assessment phase is important because a simpler people about who else should be contacted. change may be sufficient to provide adequate Provide information about the SANE/SART community services for sexual assault victims. On concept to individuals who are interested in the other hand, it may be that, while there is need improving services to victims of rape. Use this for implementing a SANE/SART program, information to identify one individual in each sufficient community support may not exist. agency who is involved in providing care to sexual Perhaps all that can be accomplished initially is to assault victims, who is knowledgeable about the plant the first seed of the idea that may take several current system, and who may be willing to work to years to germinate. try to improve those services. Offer to send them Many communities have agencies who conduct some information describing the SANE/SART needs assessments. If possible, identify such a local concept and how it works, prior to the initial visit. resource to work with because a properly done The articles “Sexual Assault Nurse Clinician: A needs assessment can be very time-consuming and fifteen-year experience in Minneapolis” and “The expensive. Even though a needs assessment may be Sexual Assault Examination: Overview and lessons a source of additional work, it is extremely benefi- learned in one program,” in the Journal of Emer- cial, adding credibility to pleas to establish a gency Nursing, June 1992 (Ledray: 92a & 92b), are SANE program. good choices because they are concise and easy to read and because they contain discussions about Identifying Allies and demonstrate the advantages of the SANE concept for other agencies. They also summarize Begin by talking to people in the community who the most common obstacles and resistance to the work with rape victims or who are concerned development of a SANE program and provide about the problem of rape, such as personnel in accurate information to counter these concerns. law enforcement, hospitals, teen medical clinics, Follow up these contacts with a personal visit to district attorneys’ offices, and victim assistance each agency.
17 Chapter 5: Assessing the Feasibility of a SANE Program
Assessing Community Rape Crisis Center Services and Developing The local rape crisis center should be asked the Community Support following: ■ How many rape victims do staff see each Law Enforcement year? Start by contacting the local police department. ■ How many crisis calls does the center receive? Ask if they have a special unit that investigates ■ What are the victims saying about medical rape cases. If one exists, get the name and phone services? number of the police officer in charge of this unit. ■ Call that person and obtain the following What percentage of the victims have reported information: the rape to law enforcement? ■ What is the staff’s assessment of the effective- ■ What are the number of reported sexual ness of the current medical response? assaults the unit receives each year? Ask for ■ What does staff believe are the strengths detailed clarification of the numbers. For and weaknesses of the current health care example, some police departments include response? the number of indecent exposures in their ■ What percentage of rape victims, do staff sex crimes statistics; others may just include believe, have rape exams completed? stranger rapes or only rapes that involve ■ vaginal/penile penetration. Ask about the Are staff familiar with the SANE/SART numbers of adult, adolescent, and child concept, and if so, how do they think it sexual assault victims. Remember, the litera- could improve community victim services? ture suggests that the actual rate for sexual assaults is 5 to 10 times the number of rapes Medical Facility reported. The next step is to identify which medical facilities ■ What percentage of rape reports do the police in the community see most of the rape victims. consider unfounded and how do they deter- Begin by calling the ED nurse managers and mine that a rape report is unfounded? asking how many rape victims their facility sees ■ How efficient and effective do the police each month and year. Try to identify a staff person, consider the current medical response? probably a doctor or nurse in the ED or women’s ■ Do officers have long waits after they clinic who works with the rape victims at each take a rape victim to the hospital? facility and who is particularly concerned about their care, and ask that person for the following ■ Where do they usually take the rape victims information: they see, and why do they go to that particu- lar medical facility? ■ How many rape exams does the clinic (or ED) ■ Is the medical evidence collected complete do each year? An estimate may be all that is and is the proper chain-of-evidence available as hospitals often do not record the maintained? sexual assault as a primary diagnosis and if ■ Is the medical staff cooperative in sharing they do, they may include both victim and information with them and helping them perpetrator exams. Consequently, the num- gain access to the medical records and ber of sexual assault victims seen may not be maintaining contact with the victims? retrievable, and when cases are identified, the numbers may not be accurate. ■ Are the police familiar with the SANE/SART concept, and if so, do they think it could ■ How are exams done, and by whom? Ask for a improve victim services in the community? copy of their protocol and ask if the doctors 18 SANE Development and Operation Guide
or nurses currently doing the rape exams are exists, and the resistance or obstacles to imple- satisfied with the system. menting a SANE/SART program that might be ■ Are they familiar with the SANE/SART encountered. concept, and if so, do they think it could improve services for victims at their facility? Identifying and Overcoming Prosecuting Attorney Obstacles Talk to the prosecuting attorney who is most active Obstacles identified in the literature that SANE prosecuting sexual assault cases. Larger jurisdic- programs have had to overcome include the tions often have a special sex crimes prosecuting following: unit. When available, the lead attorney in that unit will be the best person to provide the following ■ The fear of physicians that the SANE would information: miss injuries in the initial exam (Ledray: 96a; O’Brien: 96a). ■ What are the number of rapes the ■ The concern of physicians that they will still prosecutor’s office reviews each year? be called to testify in court even though they ■ What number do they charge, plea bargain, did not complete the exam (Ledray & and take to trial? Simmelink: 97). ■ What is their experience with the rape kit ■ The belief of prosecutors that a physician evidence? must conduct the exam in order for the ■ Is the kind of evidence they need from the physical evidence to stand up in the court local medical facilities provided? room (DiNitto et al.: 86). ■ Do they work together with the medical staff ■ The belief of prosecutors that the SANE to improve the evidence collection process? will not be as credible a witness in court as ■ Do they encounter problems in getting the physician (Ledray: 92a; Antognoli- medical staff to testify? Toland: 85). ■ What are the advantages of working together ■ Inadequate funding (O’Brien: 96a). with the medical staff? ■ Narrow interpretation of old laws requiring a ■ Are they familiar with the SANE/SART physician to collect the evidence for it to be concept, and if so, how could it improve used in court and for the cost of the exam to evidence collection? be reimbursable (Speck & Aiken: 95). Unfortunately, little hard data is available about the Other Agencies efficacy of the SANE model. Most of what is Ask the above contacts to identify additional available is testimonial or anecdotal. On the other agencies or individuals who they believe are key hand, no published data even suggests that the community players working with sexual assault SANE model is ineffective or not preferable to the victims. This could be a program in the school former model which involves a nurse and physician system, a pediatric clinic, a domestic violence jointly completing the evidentiary exam. program, a local women’s group, or a church group. Be sure to include them in the assessment Concerns About Cost phase. Starting and operating a SANE program costs Meeting with these agencies should provide a more money. Chapter 6: A Look at Funding deals with accurate idea of the services available for rape cost and funding issues more specifically. The victims in the area, the problems with the local amount of additional costs can vary greatly, system, the support for change that currently 19 Chapter 5: Assessing the Feasibility of a SANE Program
depending upon how the program is structured. consequence, victims may decide it is not worth The treatment of rape victims by hospitals today is the effort to report. However, with a SANE’s not free, but the costs are usually hidden. support, more victims make a police report and follow through with prosecution (Arndt: 88). By Having a SANE available on call may actually be providing the rape victim with additional assis- more cost effective to the facility because it frees tance, resources, and support, SANEs facilitate the both the ED physician and nurse, saving an victim’s followthrough with the legal process estimated 20 minutes of physician time and 3.5 (Frank: 96; Ledray: 92a). This support results in hours of ED nursing time (Rambow et al.: 92). more victims filing police reports (Arndt: 88). The costs for SANE programs are more modest One program had an additional 15 percent of rape than the costs in facilities with physicians complet- victims who reported after talking with a SANE ing even a portion of the exam (DiNitto: 86). even though the victims were initially hesitant to Actual costs for the physician fee, use of the ED, make a police report. The SANE is aware of the laboratory fees, and medication costs often exceed usual fears that keep victims from reporting and is the amounts reimbursed by the State. If there are thus able to give victims the needed information to no legal restrictions on billing the victim, or no make more informed decisions (Ledray: 92a). special arrangements are made with the hospital, victims may be charged these additional expenses SANEs provide continuity of care from reporting (DiNitto et al.: 86). Please see Chapter 6, under to conviction (Ledray & Arndt: 94). SANEs also the section “VOCA Funding” for an expanded shorten the time a victim must spend in the ED discussion of the reimbursement and billing of (DiNitto et al.: 86). Unlike the ED physician who expenses. Having the nurses work on call has may be called away during the rape exam to see a greatly reduced program costs, as has the ability more urgent ED case, the SANE is able to stay to successfully train and utilize nurses without with the victim until the entire exam is completed advanced degrees (Ledray: 96a). (Frank: 96). In a client satisfaction questionnaire mailed to 201 victims 2 weeks after they were seen Fear of Interference by a SANE for an exam, 93 percent of those returning the questionnaire were satisfied with the There are numerous ways in which the SANE care they received. Unfortunately, only 33 (16%) assists the police and the prosecutor. SANEs can returned the questionnaire (Speck & Aiken: 95). ensure that the police get records of exams in a In most communities, having a SANE respond more timely fashion. They can interpret the guarantees the availability of a female examiner findings for the police and prosecutor when which is important to many victims (Arndt: 88). necessary. Some SANEs routinely ask for the name, address, and phone number of friends or relatives Concern the SANE Will Not Do the Exam with whom the victim might decide to stay, and through whom they may later be contacted. This as well as the Physician information is often very helpful to the police The reliability of the evidence collected from a rape (Ledray: 92a). Police generally prefer to work with victim has been a prime concern in determining a few forensically trained nurses, as opposed to who would conduct the sexual assault exam. Until dozens of different nurses and physicians in a busy recently in England, only police surgeons, usually ED because these nurses know what evidence to men, were allowed to collect evidence from rape collect and how to maintain the proper chain- victims. When a group of female general practice of-evidence, which makes the police officer’s job physicians decided they wanted to make their easier (Yorker: 96). services available, their ability to develop the necessary forensic skills to collect evidence was In EDs without a SANE program, victims some- challenged by the police surgeons. They have, times encounter busy, insensitive staff, and as a
20 SANE Development and Operation Guide however, proven their abilities and are now ac- that the lack of injuries or the absence of sperm cepted (Wright, Duke, Fraser & Sviland: 89). does not mean that the woman was not raped This was a necessary first step before the police (Ledray: 92a). were willing to train nurses for this role in England (Holloway & Swan: 93). In a study comparing 24 sexual assault evidence kits collected by SANEs to 73 collected by non- The real issue is one of training and experience, SANEs, the SANE kits were overall better docu- not professional background. Just as with any other mented and more complete, and the SANEs always specialized clinical skill, competency in the collec- maintained proper chain-of-evidence, whereas the tion of forensic evidence and the completion of a others did not. Thirteen (18%) of the kits com- sexual assault evidentiary exam entails training and pleted by non-SANEs either had no indication of experience. It does not necessarily require an who had collected the evidence or the records were advanced medical degree. Unfortunately, most illegible thus making the available evidence useless. medical and nursing schools do not teach forensic Overall, 48 percent of the non-SANE kits had principles. Few physicians or nurses have the some break in the chain-of-evidence compared to opportunity to complete a sufficient number of none of the rape kits collected by SANEs (Ledray rape exams to develop or maintain proficiency, & Simmelink: 97). even if they have completed the training. A pri- mary advantage of the SANE program is that a Concern the SANE Will Not Be a Credible dedicated, limited number of nurses complete all Witness in Court of the evidentiary exams in a given hospital or clinic, which enables them to complete an ad- Concerns about SANE credibility are unfounded. equate number of exams to develop and maintain In fact, there are several reports of prosecutors, proficiency (DiNitto et al.: 86). who were initially concerned, later finding that the SANE is an extremely credible witness in court as a The SANE evidence collection process has evolved result of her extensive experience and expertise in over the years because SANEs have historically met conducting the sexual assault exam (Ledray & periodically with the prosecuting attorneys about Barry: in press). SANEs are also more accessible the use of evidence in the courtroom. As a result of and more willing to adjust their schedules to testify this history, today the evidence that is collected is because it is an expected part of their chosen more complete and useful in obtaining a convic- position (Ledray: 92a; Antognoli-Toland: 85). tion. For example, one program now routinely Prosecuting attorneys who have worked with collects an extra tube of blood that can be held and SANEs know they can rely upon the competence run for drug or alcohol analysis if the assailant of the SANE as a witness if the case goes to trial claims the victim was so drunk she doesn’t remem- (Yorker: 96). The testimony of the SANE is backed ber giving consent or if he claims the sex was up by solid credentials and impressive numbers of consensual because she exchanged sex for drugs victims seen (Lenehan: 91). As a result of this solid (Ledray: 92a). SANE education, training, and experience, Tennes- see more broadly interpreted its State laws to allow Because SANE programs follow a case from the the SANE to testify in court (Speck & Aiken: 95). initial evidence collection through to prosecution, they have collected valuable data on the results of A common concern of physicians is that the the evidence collected. These data have included physician will still be called to testify in court. In information such as the likelihood of finding one community where thousands of rape cases sperm at a specific site, at a specific point in time, have been completed by SANEs, not one case in and the likelihood of a rape victim being injured which the testimony was given by the SANE alone during the assault. This information has also been ever required the prosecutor to subpoena the ED helpful to county attorneys who need to explain physician to testify about the evidence collected
21 Chapter 5: Assessing the Feasibility of a SANE Program
(Ledray & Simmelink: 97). When the physician is of implementing a SANE program. Be prepared to called to testify, it has always been about injuries present the following: that were treated. ■ A summary of the findings collected, includ- The Santa Cruz County Attorney believes that ing the best estimates available of the number having the SANE collect evidence and be available of reported rapes and actual rapes in the to testify in court has resulted in more guilty pleas community each year. (Arndt: 88). In other communities, the SANE ■ The positive and negative aspects of the model is credited with an increase in conviction current response to rape. rates (Solola & Severs: 83). To date, two programs ■ A brief description of how a SANE program in operation for more than 10 years continue to operates. have an impressive 96-percent conviction rate in ■ cases in which the SANE did the exam (O’Brien: The benefits of a SANE program for rape 96a; Smith: 96). In other communities, at the very victims and each agency involved. If possible, least, there has not been the feared decline in list and respond to each concern presented by convictions (DiNitto et al.: 86). community agencies and solicit additional issues and concerns.
Deciding to Proceed To establish a SANE program, two primary task force goals must be achieved. The first primary Based on the initial assessment, one of the follow- goal is to establish an initial meeting with commu- ing conclusions is likely: nity leaders for an open discussion of the SANE ■ The community system may be efficient and concept and identification of additional concerns effective, and it may not need a major change and information that will be needed. to a SANE/SART system. An additional goal is to get a commitment from ■ The problems in the system won’t be fixed each agency to meet again to explore further the with the implementation of a SANE/SART possibility of starting a SANE/ SART program in program, but some other approach may the community or region. Getting community be more helpful. leaders to this first meeting is a big step. Getting ■ While the system is in drastic need of the them to come back again is even bigger. Respect type of restructuring a SANE/SART program their time by starting when scheduled and stop- could provide, there is currently too little ping on time. Have an agenda and stick to it. support and too many obstacles to make the commitment to take on the project. When meeting with the community, provide comprehensive information about the SANE ■ The community could indeed benefit from program. When you do not have information, the implementation of a SANE/SART make a sincere effort to obtain it but do not program, and there is at least enough support promise information for the next meeting that is to take the next step toward overcoming any likely not available. Be honest about what is not existing obstacles in the community in the known and not available. When unsuccessful in hope of implementing a SANE program. obtaining requested information, explain what efforts were made to obtain it and ask for sugges- Starting a Formal Task Force tions or help getting the additional facts. The next step is bringing together a group of interested individuals from the previously men- tioned agencies to meet and discuss the possibility
22 SANE Development and Operation Guide
To get community leaders to commit to meetings, Developing a SART be accommodating. For example, be flexible and creative in finding a convenient meeting time and Once a working committee is established, discuss place. If possible, get your agency to provide coffee becoming a SART even if developing a SANE and bagels or cookies. If individuals miss a meet- program at the present time may not be possible. ing, send them a summary of what was discussed In all likelihood, the group of individuals brought with the time and location for the next meeting. It together to discuss starting a SANE program are at is also important to call individuals who are unable least a major portion of a SART team membership to attend to let them know that they were missed (See Chapter 4: SART: A Community Approach). and that you really hope they will be able to attend If the group decides to continue meeting as a the next meeting. If possible, tell them what type SART, ask who else should be invited to the of input would be helpful from them. If they don’t meetings. Continued communication among attend, keep sending them minutes of the meetings interested agencies may result in the development so they are at least informed about the progress. of a SANE program in the future or it may at least Periodically reassess who should be included on the result in the improvement of victim services in initial task force. other ways.
23 SANE Development and Operation Guide
CHAPTER 6 A LOOK AT FUNDING
Funding is a vital issue often overlooked in the staff cannot leave until the exam is completed. The early stages of SANE program development. The ED must supply both a physician and a nurse to inability to obtain needed funding for program conduct the sexual assault exam so consequently startup costs has thwarted the past efforts of both may be required to testify in court. If there numerous nurses who wanted to develop a local is a delay in court cases, scheduling problems will SANE program. Many of these nurses were arise in the ED. When promoting the establish- employed at medical centers and expected their ment of a SANE program with hospital ad- medical center to incur the initial costs of SANE ministrators, provide a cost-benefit analysis to program development. While some were successful administrators, demonstrating how a SANE in making their case, many others were not. More program can provide some services in a more cost- often, these nurses were good clinicians who effective manner. wanted to start SANE programs because they realized they were not providing victims of sexual Less tangible, but equally important benefits assault with state-of-the-art clinical care in their should also be included in the discussion. Even institution. They were aware that there was a though cost considerations drive many decisions in better way, the SANE way. Unfortunately, because health care, intensifying competition in the ambu- their focus was on the clinical aspects of care, latory health care sector also focuses on the provi- funding was an afterthought. To a great extent, sion of quality, patient-centered care. Point out the ability to obtain program funding is the test that the provision of SANE services would enhance of program feasibility. If the necessary funding the medical facility’s reputation with the commu- cannot be obtained, it will not be possible to nity, allowing the hospital to stand out among its develop a SANE program. competitors. Finally, hospitals and medical centers are increasingly interested in and involved with The reality of the health care climate today is that community wellness efforts. Explain how a SANE it has become cost driven, and to a great extent, program, with its cadre of educated, experienced limited by cost. Most hospitals already provide forensic nurse specialists, provides an invaluable services which do not produce revenues sufficient resource for a hospital’s community outreach and to cover costs. Understandably, hospital adminis- education initiatives. For example, the SANE can trators are reluctant to develop an additional educate law enforcement and county attorneys program that they perceive will increase costs and about evidence collection and use of evidence. decrease profits. Hospital administrators may not For the community, the SANE can raise the understand that hospitals already assume many community’s awareness about how secondary indirect and overhead costs associated with exam- trauma is caused by sexual assault. ining and treating sexual assault victims, such as physician and nursing time, supplies, and staff However, even with the most favorable cost-benefit training. Furthermore, because the ED staff does analysis, one cannot assume that a hospital will fund not conduct these exams routinely, it takes these all the costs associated with an ideal SANE program. clinicians longer than a SANE. In addition, while This is why SANE program costs and funding ED staff is involved with a sexual assault exam, the options must be an initial consideration, starting ED may need additional staff to cover other cases with the goal of developing a realistic and fundable in the ED and overtime may be required because program, not necessarily the ideal program.
25 Chapter 6: A Look at Funding
This chapter addresses both the cost of program Needs Assessment development and program operation, including In most cases, the cost of the community and options when minimal funds are available as well as institutional needs assessment involves the time of ideal options when funds are more readily avail- a committed individual. In the early days, this was able. (Many SANE programs start with minimal most often institutional employees who were aware funds and are able to improve staff pay and ben- of the inadequate services to sexual assault victims. efits as well as extend program services after they The employees were typically nurses working in have established themselves in the community and the ED or a clinic that saw rape victims, and they demonstrated the service need and benefit. It is wanted to improve services for these victims. With essential to realistically anticipate all initial costs the increased awareness of the SANE model, the in order to obtain adequate startup and program needs assessment is now often provided by some- operational funding.) This chapter also reviews the one working with rape victims outside the hospital, funding of SANE programs currently in operation. such as the police, an advocate from the local rape Lastly, it considers potential funding sources for crisis center, or staff at the prosecutor’s office. program development and operation. Many State attorneys general and governors are now even taking leadership roles in promoting the Program Development and SANE concept on a statewide level. Operation Costs While an interested institution may be willing to Program development and operation costs vary donate staff time, the hundreds of hours of needed greatly. Surveyed programs indicated that initial time may have to be spread out over a full year or startup costs ranged from $6,000 to over $50,000, more. If there is an intense amount of interest, it is and averaged $30,000 to $40,000. Much can be more likely that an agency or organization will done to control and lower these costs when neces- provide a substantial amount of paid, experienced, sary (See Chapter 7: Starting Your SANE Pro- professional staff time to determine program gram). Depending on the resources available, this feasibility and startup activities. section provides cost-saving options for consider- ation. It provides information on the minimum, If an individual, rather than an institution, is the unavoidable costs for those working with strict interested party, then a time commitment must be limitations, as well as options when more financial negotiated. While this person may be able to resources are available. The costs of program perform some of the tasks involved with the initial development are not all monetary; in fact, many of needs assessment and feasibility studies on institu- the costs are time commitments from personnel. tional time, most efforts will be uncompensated, off-duty hours. If the interested individual’s supervi- Important Startup Costs of Developing a sor does not support compensated work hours for SANE Program: the development of a SANE program, the alterna- ■ Community and institutional needs tive is to find someone in the institution who does assessment. support the SANE project. Another possibility is to find support outside the institution, but this is not ■ Facilities and utilities. an optimal solution if the institution’s support is ■ Supplies and equipment. vital to the SANE project. At this point, the feasibil- ■ Staff advertising and selection. ity of developing a SANE program needs to be ■ Staff training (See Chapter 9: SANE Training). carefully reconsidered. Another strategy may need to be developed, including postponing the develop- ■ Program media promotion. ment of the SANE program until more support can ■ Staff salaries for the first year (See Chapter 8: be generated. SANE Program Staff).
26 SANE Development and Operation Guide
Facilities and Utilities company or a community agency, before adding it to the budget. Even $10 per month adds up when Office space for the program director, secretary, it is multiplied by 10 nurses and 12 months. and staff meetings are almost always located in space donated to the program. The only exceptions Exam equipment. The hospital ED or clinic to this across the country are programs operated where the exams are being completed is often independently for profit. When the program is willing to donate exam supplies. In many States, hospital-based, the hospital donates the space. the rape exam kits are provided by law enforce- Community-based programs are usually housed ment at no charge. Standardized kits can also be administratively with the sponsoring community purchased when they are not available free from agency. Office space should be negotiated either law enforcement. Consult with the local State with the hospital where the services will be pro- crime laboratory that will be analyzing the evi- vided or with the sponsoring community agency. dence collected before purchasing the kits. Since A SANE program provides the hospital or commu- the price and contents of “standardized” kits vary nity agency with a valuable resource and a lot of greatly from manufacturer to manufacturer, ask to community goodwill. Take advantage of the have a sample sent for review before making a negotiating power this provides to avoid expensive decision to purchase a particular kit. The crime office overhead. laboratory may know where to purchase standard- ized kits. They are available from a number of Supplies and Equipment sources. (See Appendix C: Rape Kit Supply Re- Both office and exam supplies and equipment need sources). Law enforcement agencies often pay for to be included in the initial budget. Much like this cost because use of standardized kits benefits office space, however, it is often possible to get the law enforcement by promoting better evidence sponsoring institution to donate supplies, at least collection. Emphasize this benefit to the law for the first year of operation. It will be especially enforcement agency when negotiating with them important during this first year to keep an accurate to provide these kits. account of the actual supply costs. These cost A Polaroid camera and/or a 35mm camera will also records will be useful to negotiate for continued be needed. Before making the purchase, check to donation by the institution or to know the actual see if the ED or clinic where the exams will be expenses if the program needs to assume them. completed already has one available that SANE Office equipment. In addition to the usual office staff could access. Small 35mm cameras with equipment, a SANE program needs a computer automatic focus that are easy to operate and will with access to the Internet and facsimile (FAX) take adequate pictures of injuries are available for capabilities. The FAX capabilities can be part of as little as $100. A camera with a macro lens the computer or a separate piece of equipment. attachment will produce higher quality, closeup The FAX equipment should have the capability of photos. Later, when the budget allows, the camera displaying the name and phone number of the equipment can be upgraded. Don’t be tempted to receiving agency prior to pushing the send key. get camera equipment that is so sophisticated that This allows staff the chance to double check that the staff will have trouble using it effectively. Also, sensitive or confidential data are sent to the correct ensure that the cost of film and film development agency. To ensure data security, store client data in is covered in the budget if these costs, which can be a computer separate from the computer linked to considerable, are not reimbursed by law enforce- the Internet. ment or the prosecutor’s office.
Each SANE needs a long-range pager. Always try If the budget allows, consider purchasing a digital to get this cost donated, possibly by a paging camera that can transmit photo evidence directly to the police department, if it is utilizing this
27 Chapter 6: A Look at Funding
technology. The police department may even be budget is tight, arrange to have access to the willing to provide the SANE program this equip- equipment rather than to purchase it. ment. One Minnesota police department offered to do so, recognizing the value to the investigative If the SANE program is located in a separate clinic, efforts of its department. Another consideration is a pelvic examination table also must be acquired. photographic equipment which captures ultraviolet A microscope may be necessary to observe wet images. While more sophisticated, it is very mounts for motile sperm. effective in identifying and highlighting bruising, Additional equipment that will soon become a especially in women of color. While this technol- standard, but which is still not available to many ogy was once controversial and its accuracy chal- SANE programs because of the cost, are the lenged in the courtroom, its scientific value is now colposcope ($10,000 to $15,000 for the colpo- widely accepted. The use of a digital camera, scope alone); light staining microscope ($1,000 to however, must be discussed with the local prosecut- $1,500); digital camera systems with direct com- ing attorney’s office because digital imagery can be puter links; and video equipment with print altered easily and, consequently, it may not be capabilities. Because of the excessive cost of the accepted by that office. colposcope, some programs, especially those working with children, have chosen instead to Common Examination Supplies purchase MedScope ($3,500; $11,500 including ■ Rape kits. ■ Slides. camera, internal lens, camera holder, monitor, printer, foot switch, VCR, and cart). It is currently ■ ■ Clean-catch urine specimen Paper bags. being evaluated in a trial study funded by OVC. containers. ■ Labels. ■ Wet preparation tubes. ■ Fingernail Exam paperwork. At a minimum, the SANE staff ■ Roll of white paper clippers. will need the following exam forms: (e.g., butcher paper) ■ Envelopes. ■ Sexual Assault Exam Report (with chain-of- ■ Fingernail file or Q-tip ■ Swabs. custody). (to scrape under the nail. ■ ■ Gauze. Evidentiary Exam Consent which includes ■ Tourniquets. consent to release evidence to and communi- ■ Needles. ■ Syringes. cate with law enforcement. ■ Plastic combs. ■ Pregnancy Prevention Consent. ■ Blood tubes for bloodtype, ■ pregnancy, alcohol, and Gloves. ■ Laboratory forms including a specimen chain- drugs. ■ Gowns. of-custody. ■ ■ Disposable towels. ■ Normal saline. Program brochures. ■ Followup materials. ■ Barrier drapes. ■ Pencils and pens. ■ Speculums of various sizes. ■ Film. Additional forms may include the following: ■ Lubricant (for bi-manual ■ Biological and ■ Medical and other referral forms. exam). sharps waste ■ Nursing Care Plan. ■ Fixative (depending on receptacles. ■ Medical History Forms. lab protocol). To avoid expensive printing of these forms, includ- ing the brochure, all can be produced on a com- An alternate light source will also be needed. Much puter. Several low cost computer printing programs like the camera, these light sources are typically are available from which to choose. available in the ED or clinic for eye exams. If the
28 SANE Development and Operation Guide
Staff Advertising and Selection responses, both negative and positive, that might follow public disclosure. Advertising costs to recruit nurses for a SANE position can be reduced by posting the new SANE Once the new SANE program is in operation, positions in local hospital EDs and clinics such as media attention can also be helpful in alerting the obstetrics and gynecology clinic. Advertising potential clients to the availability of the service in the local newspaper may also be necessary. This and how it can be accessed. The focus of this can cost hundreds of dollars. Ask the sponsoring media coverage would include magazine articles, institution if it will assume this cost; if not, adver- newspaper editorials, and television spots about tising must be included in the budget. Media general services and awards given to the program publicity associated with the development of the or a particular staff member. A testimonial from a SANE program will not only alert the community rape victim would also be appropriate in this of the program but may provide free advertising for message. interested nursing personnel. Sending flyers to the local nurses’ associations, schools of nursing, and Staff Salaries other local institutions is another less expensive mechanism for locating interested and talented Many variables influence the determination of staff nurses. Recruitment strategies should include salaries. Some variables are location of the SANE recruiting for nurses who are sensitive and knowl- program not only geographically but also whether edgeable of diverse community populations and hospital-based or community-based. The number the issues involving sexual assault. of sexual assault cases and the jurisdiction—urban or rural—affect the pay schedule. Please refer to Staff Training Chapter 8: SANE Program Staff for a detailed discussion of SANE salaries. If the new SANE staff is sent to an established SANE training program the cost will run approxi- mately $250 to $500 per person, plus travel Current SANE Program expenses (See Appendix D: SANE Training Pro- Funding grams). If a trainer is brought in to provide train- ing, the cost will be $1,000 to $1,200 per day, per The survey of existing SANE programs found the trainer, for 5 or 6 days of training, plus travel following. Thirty programs were public nonprofit expenses (See Appendix E: SANE Trainers). agencies, either associated with a nonprofit hospi- tal, a nonprofit community program, or a govern- Program Media Promotion ment agency. Six were private, for profit, and one program characterized itself as a coalition. The Media attention spotlighting the plight of rape yearly budgets ranged from $6,000 to $825,000 victims can generate considerable public response. with an average of $122,000. It is rare to have all Use this community interest and support to elicit program funding from one source. Most programs improvement of services to rape victims. Media rely on a variety of funding sources. attention is particularly effective if an individual victim is highlighted. Many victims are willing and Many SANE programs (N=20) are directly reim- even anxious to tell their story to the media when bursed for services by Federal money that is admin- they do not believe their needs were properly istered by a State or county agency. The rationale is addressed at the time of the rape. This can offer an that, since the exam is being completed to collect opportunity to constructively focus their desire to evidence, the State, not the victim or her insurance, effect a change in the system for future victims. should pay for the cost of the evidence collection. Before a rape victim goes public, however, staff This money may be provided directly from a State should discuss with the victim the potential agency, however, it is usually disbursed to the
29 Chapter 6: A Look at Funding
county and reimbursed on a per-case basis. Bills for SANE Program Funding each case are submitted by the SANE program for payment to a designated office, usually the law Options enforcement agency or the prosecutor’s office. This The literature indicates SANE programs have been reimbursement may be limited to a set maximum started using Federal research grant funding (Ledray dollar amount that will be paid for each exam & Chaignot: 80), local community foundation completed, ranging from as little as $75 per exam grants, community fund-raising (Frank: 96; to $500 per exam. The reimbursement may also be O’Brien: 96a), and fee-for-service reimbursement payment of the actual charges for the evidentiary from the hospitals served, police, and/or the county exam, without a set dollar limit. This reimburse- attorney’s office (O’Brien: 96a). Some hospitals ment was found to cover a continuum of program have an in-house SANE programs because they costs ranging from 33 percent to as much as 80 serve large numbers of sexual assault victims. Other percent of ongoing SANE program operating costs. SANE programs are independent nursing programs or agencies that contract with the hospital to Additional funding is provided through govern- provide services on an on-call basis and bill the ment agencies, at the State level (N=18), at the hospital on a per case basis for the exam (Burgess & county level (N=5), or at the city level (N=2). State Fawcett: 96; O’Brien: 96a). money is often received as a grant through the State Department of Corrections or through a Where to Look for SANE Program State Crime Victims Assistance or Crime Victims Compensation Fund. An additional 11 SANE Funding programs receive Federal grant money. The best funding strategy includes approaching a variety of resources including local private founda- SANE programs (N=44) also rely on donations tions, State agencies, and Federal resources. The from a variety of sources, including local founda- U.S. Department of Justice Response Center will tions, corporations, businesses, churches, hospital place interested fund-seekers on a mailing list to foundations, women’s groups, the United Way, receive updated information on funding resources universities, and individuals. Donations may for violence against women programs. Call 800– support a specific clinical service, for equipment 421–6770 to be added to the list. such as a colposcope or light staining microscope, or for ongoing operating expenses. VOCA funding. The Victims of Crime Act (VOCA) of 1984 established the Crime Victims Most hospital-based programs (N=47), or 94 Fund, which is derived from fines and special percent of the total of 50 hospital-based programs, assessments collected from Federal criminal offend- are fortunate to have the hospital assume responsi- ers—not from tax dollars. The Crime Victims Fund bility for the remainder of their costs not covered is administered by the Office for Victims of Crime by grants, donations, or reimbursement for ser- (OVC). Each year, OVC distributes approximately vices. Two additional SANE programs have a 90 percent of the Fund by formula to States to consortium of agencies that share the additional, support victim assistance and compensation pro- nonreimbursed expenses. Two of the 9 nonhospital grams that provide services to Federal and State SANE programs, have similar relationships with crime victims. All States and territories receive their sponsoring agencies, the YWCA and a annual VOCA funding and, in turn, the States Violence Against Women’s program. award VOCA Victim Assistance grant funds to local community-based organizations to provide services directly to victims of crime.
30 SANE Development and Operation Guide
A limited amount of VOCA funds is also awarded the completion of a medical evidentiary examina- directly by OVC each year in the form of discre- tion such as a report, x-rays, medical photographs, tionary grants to improve and enhance the avail- and other clinical assessments as evidence of ability of victim services. These discretionary grant cooperation with law enforcement in cases involv- funds support a variety of nationwide initiatives, ing sexual assault or abuse” (Final Program Guide- such as developing training curricula, training lines, Victims of Crime Act FFY 1997 Victim victim service providers and criminal justice profes- Compensation Program, The Federal Register, 14 sionals, and identifying and disseminating informa- February 1997). tion about promising practices in victims services. OVC discretionary funds do not provide opera- To determine which agency is responsible for tional funding for victim services organizations. billing locally, contact an area hospital and ask whom they bill for the sexual assault evidentiary Community programs interested in obtaining a exam. Since the specific amount reimbursed and VOCA grant for operational funding should apply the services for which the SANE can be reimbursed to the State agency designated by the Governor of typically vary from county to county, the SANE their State to administer the State VOCA victim will need to contact the appropriate agency in her assistance grant monies. Appendix F contains a list county and ask for a copy of the policy. If rape of the State agencies that administer the VOCA victims are examined from more than one county, Victim Assistance Funding. Each State has discre- a copy of the evidentiary exam reimbursement tion to determine which organizations will receive policy will be needed for each county. Reimburse- funding based upon the VOCA victim assistance ment generally comes from the county in which guidelines and the needs of crime victims within the rape occurred, which will not necessarily be the each State. Most States make awards on a competi- county where the exam is completed. tive basis. Although many programs compete for this money, this is an excellent source of funding More information on VOCA formula and discre- for sexual assault programs. tionary grant funding, as well as OVC, can be obtained via the OVC Homepage on the World States also receive VOCA funding for their victim Wide Web at the following address: http:// compensation programs that may be used to pay www.ojp.usdoj.gov/ovc/. for evidentiary exams given to victims of sexual assault. States may disburse funds to a variety of Reimbursement of costs associated with the State or county agencies that conduct the exams— forensic exam is a complex issue. According to a very often a police or sheriff’s department. Law 1997 report by The Urban Institute prepared for enforcement agencies are more likely to mandate the National Institute of Justice, “Medical costs that crime victims report their victimization and and cumbersome restitution mechanisms in sexual cooperate with the prosecution in order for the assault cases continue to be a barrier for victims examination expenses to be reimbursed. Victim and discourage many women from seeking needed advocates should understand that States have some medical care and undergoing examinations to discretion in defining the nature and extent of collect evidence needed for prosecution” (The “victims’ cooperation with law enforcement.” Urban Institute: 97). In 1996, The Urban Institute OVC’s most recent VOCA Victim Compensation conducted site visits to 12 States as part Final Program Guidelines recognize that there may of its study of the S-T-O-P (Services, Training, be cultural or psychological factors that undermine Officers, and Prosecutors) grant implementation a victim’s willingness to report sexual assault or to process. Most of the 12 States visited had long- report the crime in a timely fashion. Thus, the standing State legislation that covered the waiver of VOCA Guidelines allow States to “accept proof of charges for forensic examinations of sexual assault
31 Chapter 6: A Look at Funding
victims; others passed similar legislation during Another reimbursement issue is that only part of final congressional consideration of the Violence the procedure is forensic; the rest is medical. Many Against Women Act (VAWA), which was spon- women, according to The Urban Institute Report, sored by Senator Joseph Biden and passed by seek medical care in emergency rooms after a Congress in 1994. sexual assault with no intention of reporting the crime to police. In at least two States, States paid The Urban Institute reported that hospitals incur for “evidence collection” but not “followup ser- substantial costs in conducting forensic examina- vices.” Hospitals then either covered the cost or tions. Costs are around $800 if a physician con- attempted to bill the victim for these “additional ducts the exam; and substantially lower (between services.” $200 and $300) if a trained nurse such as a SANE conducts the exam. The report continues as VAWA funding. VAWA authorized a 6-year follows: funding cycle for formula grants similar to the OVC victims assistance formula grants to the State laws vary in the mechanism they specify States. The VAWA funds are available to States to for reimbursing hospitals and relieving victims distribute to victim service agencies as well as of the burden of payment. Most of the 12 States prosecution, law enforcement, and the courts. Like visited by the State Institute had no State the VOCA programs, most of the VAWA funding appropriation for covering these costs, and those is distributed directly to the States through formula that did usually did not appropriate enough grants. The Violence Against Women Grants funds to cover the need. One State had a Office (VAWGO) is the Federal agency that backup fund that could pay for examination administers the S-T-O-P Violence Against Women costs if other mechanisms failed. The various Formula Grant Program. Each State must allocate payment mechanisms, or lack of them, still a minimum of 25 percent of S-T-O-P funds to leave victims with a financial burden in quite nonprofit, nongovernmental victim services a number of States.... Most of the payment agencies. The State agency that administers the mechanisms established by the site visit States S-T-O-P grant determines the process for awarding still leave some victims with either primary or subgrants. State are not required to competitively secondary responsibility for payment because select recipient organizations. To be eligible for either they or the hospital have to apply for S-T-O-P funds, States must certify that they incur compensation to cover the cost of the exam. If the full out-of-pocket cost of forensic medical the victim must apply, she must pay the hospital examinations for sexual assault victims either by first and then seek reimbursement. Situations providing or arranging for free examinations, or where hospitals may, and do, seek payment by reimbursing the victim for the full cost of the from victims include the following: examination. As discussed previously in this ■ Low levels of reimbursement by counties do chapter in the section regarding VOCA funding, not cover most of the hospital’s cost. States utilize differing interpretations of what ■ The victim has medical insurance that will actions constitute victim cooperation with law cover the cost of emergency care. enforcement to establish reimbursement eligibility. ■ Crime Victim Compensation Boards take years to pay claims, although they send an award Twenty-five percent of each State’s S-T-O-P falls letter relatively quickly. into a discretionary category, and the purpose of this funding need not be strictly law enforcement, ■ Crime Victim Compensation Boards or county prosecution, or victim services, but must conform agencies reject victim claims for reimburse- to the broad guidelines of VAWA. Discretionary ment because police reports indicate that a case is “unfounded” or because the victim “fails to funded projects must still fulfill at least 1 of the 7 cooperate with prosecution.” purpose areas of this program. More information
32 SANE Development and Operation Guide on VAWGO funding can be obtained via the Cooperating Collection, and many States have VAWGO Homepage on the World Wide Web at collections in more than one city” (“A Message to the following address: http://www.ojp.usdoj.gov/ Grant-seekers” 1997, http://fdncenter.org/2onlib/ VAWGO. The telephone number for VAWGO is 2ufgall.html). 202–307–6026. Appendix F also contains a list of the State agencies that administer the S-T-O-P The Foundation Center also publishes many useful grant funds. reference directories. One of the most useful is The Foundation Directory (Renz, Baker & Read: 96). It Byrne funding. The Edward Byrne Formula Grant is frequently updated and lists all of the private Program, administered by the Bureau of Justice foundations by State. It provides information on Assistance of the U.S. Department of Justice, trends in foundation giving, how much grant awards funds to States for use by States and units money each foundation has available, to what of local government to improve the functioning geographical area, and for what purposes. This is a of the criminal justice system. As one of the 26 valuable resource when applying for private legislatively authorized purpose areas, government foundation funding. units may make awards to subgrantees to provide assistance to jurors and witnesses and assistance, Many Cooperating Collections of the Foundation other than compensation, to victims of crime. The Center also make available for public use a search- Edward Byrne Formula Grant Program may be able database of funding resources called FC a potential source of funding for some services Search: The Foundation Center’s Database on CD- designed to assist sexual assault victims. Appendix ROM. The Foundation Center’s main libraries and F contains a listing of the State agencies that Cooperating Collections offer grant-seekers a administer the Edward Byrne Formula Grant myriad of services on site and on line, including Program. access to publications, periodicals, training work- shops, online tutorials on grant-funding research Other Federal and private funding. There are and proposal writing, online responses via e-mail other potential resources for SANE program to reference questions, and computerized data- funding beyond the U.S. Department of Justice. bases. The Foundation Center is one of many These include other Federal agencies such as the resources available online and has links to other U.S. Department of Health and Human Services, resources for grant-seekers on its Web site at: private foundations, community foundations, http://fdncenter.org/. A tremendous number of grant making public charities, individual donors, grant funding organizations now maintain their and fundraising campaigns. The Foundation own site or homepage on the Internet including Center is an excellent source of information on the most agencies of the Federal Government. many grant funding resources. The Foundation Center does not make grants, rather, it provides Fundraising Process information on those entities that do. In addition The following processes are suggested for effective to maintaining libraries in Atlanta, Cleveland, New and efficient fundraising: York City, San Francisco, and Washington, D.C., the Foundation Center has a nationwide network ■ Make sure the type of funds needed is an of affiliated libraries and nonprofit resource centers integral part of the developmental plan: called Cooperating Collections. According to startup funds, capital expenditures, general information provided by the Foundation Center operating expenses, special project funds, on its Internet site, “These collections provide a funds to increase organizational capabilities. core group of Center publications for public ■ Gather information about potential program reference and some level of instruction on how to funding sources and support, including do funding research.... Every State has at least one government, foundation, and local private
33 Chapter 6: A Look at Funding
donors; fundraising activities; professional soring institution in 88 percent of the programs organizations with grant opportunities; and in- which are hospital-based, compared to only 22 kind gifts and services. percent of the programs that are nonhospital-based. ■ Analyze and synthesize the above information. This is probably due to more limited resources and ■ Decide which prospects are most promising. budgets in community programs as compared to Match the organization’s interests with those hospital organizations. It appears that the decision of potential funders. to affiliate a SANE program with a large institu- ■ Develop a time-line of proposal writing based tion, such as a hospital, may be an effective choice on application deadlines, funding cycles, and in ensuring ongoing program funding. program needs. Providing effective crisis intervention and preven- ■ Cultivate potential donors in the private sector: tive care for sexual assault victims is an important rely heavily on professional contacts and component in promoting health maintenance personal networking, relationships of the and preventing secondary injuries. Although the Advisory Board, community stakeholders, etc. provision of these services may initially increase ■ Keep track of initial contacts made and costs of the health care facility, research and careful potential donors’ interests; invite potential accounting of direct and indirect costs can con- donors to any and all events such as open vincingly demonstrate that in the long term, houses, press conferences, exhibits, educa- overall costs can be reduced. tional initiatives, public interest events. ■ Keep donors and potential donors informed of program progress through letters, memos, a Summary newsletter, telephone contacts, or one-on-one It is imperative to develop a funding strategy meetings and informal lunches. before establishing a program to ensure long-term ■ Focus on a distinctive characteristic of your financial solvency and continuation of the pro- project that sets it apart from other similar gram. It may be possible to negotiate with the local projects and that will appeal to and motivate hospital or a government or community agency to a funding entity to support your program. The assume financial responsibility for the ongoing appeal might vary from one donor to the next. SANE program costs. Initial startup costs typically For government funding, a program might serve as a model; for a local business or organiza- represent a large portion of the non-reimbursable tion, it could generate good will and promote costs of a SANE program. A local hospital may the donor’s community visibility, or provide an be willing to assume the future costs that exceed opportunity for unique collaboration. reimbursement, especially if the hospital adminis- tration understands that it is already assuming ■ Follow up with donors who provide support with thank you letters. Always respond to many hidden costs associated with treating sexual requests for information and don’t forget to assault victims in a less cost efficient manner. ask for additional support. Obtaining ongoing grants and donations is a full- time job. A SANE program manager cannot do Looking to the Future as You full-time fundraising and manage the day-to-day Begin clinical program responsibilities. It is essential to plan ahead when establishing a new SANE pro- Clearly SANE program affiliations have a signifi- gram in order to reduce the amount of time and cant impact on program funding. Fifty of the 59 attention that the SANE program manager must programs surveyed are hospital-based. Survey place on ensuring the financial viability of the respondents indicated that program costs that program. exceed the program income are paid by the spon-
34 SANE Development and Operation Guide
STARTING YOUR CHAPTER 7 SANE PROGRAM
Once the decision has been made to develop a unavoidable reasons such as severe weather warn- SANE program, the SART team will need to work ings with travel restrictions, it is important to plan together to create a vision of how the SANE to provide complete coverage 24 hours a day, 7 program will be implemented. The strategic plan days a week. will be based on the SANE vision and mission statements. Developing a strategic plan not only Population Served involves a basic startup plan of operation but also anticipates obstacles encountered later on during All programs that report client gender in the the operation of the SANE program. Conse- literature see both females and males. Some quently, this chapter provides information about programs see adults, adolescents, and children how existing SANE programs have approached (O’Brien: 96a; Speck & Aiken: 95); others see only many of the organizational decisions that need to adults and adolescents (Arndt: 88; Ledray: 96a). be made (see Appendix G: Startup Checklist). Some programs started with a more limited patient population and then expanded the age bracket How Long Can It Really Take? served (Ledray: 96a; O’Brien: 96a). While every community is different, the average Several SANE programs plan to add forensic SANE program startup time is 1 to 2 years. It can examination of battered women, children who are take longer. This includes the time from the initial physically abused, and other crime victims, as well concept to actual service delivery. It will, of course, as the possible addition of automobile accident take longer in areas where there is more resistance victims to their existing services. Several programs and where fewer resources exist. Even in an area complete nonliving victim forensic examinations, where the SANE concept is well understood and and others are considering doing so as well. accepted and where there are ample resources, it Even if the intent is to eventually see all ages of will take at least 6 months for the necessary team rape victims and populations other than sexual building, strategizing, staff selection, and training. assault, it would be wise to start with a small well- defined population and expand services to addi- Hours of Operation tional populations as staffing, funding, and other resources allow. This is especially important when The majority of existing SANE programs provide there is not a firm figure available of the expected services 24 hours per day, 7 days a week, including caseload. holidays and weekends (Antognoli-Toland: 85; Ledray: 92a). One program indicated that in the initial stage, the SANEs completed exams during Deciding on Program evenings, nights, holidays, and weekends with the Location ob-gyn residents completing the exams during the day Monday through Friday (Thomas & Zachritz: When establishing a new program, one of the most 93). After a few years of operation, this SANE basic decisions is the location of the SANE exami- program proved to be so effective that the SANEs nation site. Since SANE programs provide service assumed the caseload 24 hours a day. While there 24 hours a day, 7 days a week, safety and security may be times when the SANE is not available for for staff and victims is an important consideration. 35 Chapter 7: Starting Your SANE Program
Other considerations include the following: Nine programs surveyed routinely go to more than one site to complete exams. Five of these go to two ■ Physical and psychological comfort of the hospital EDs, one goes to two different hospital client. clinic locations, and one goes to seven different ■ Access to medical support services to provide hospital ED locations. The later program will soon for care of injuries. be adding an additional location, a university ■ Pharmacy or medication access. medical clinic. One free-standing program rou- ■ Access to psychological support services. tinely goes to nine different community locations, including EDs and clinics to complete exams. ■ Access to laboratory services. Another goes to four sites including a jail, two ■ Access to the necessary supplies and equip- different EDs, and a clinic. ment to complete an exam. One Location or Multiple Advantages of a Single Exam Site Exam Sites The primary advantage of a single location is that all necessary exam supplies and equipment can be Fifty of the SANE programs responding to the centrally located in a setting familiar to the SANE survey routinely complete exams at only one and only one set of equipment is necessary. Dupli- location. Ten of these specified that they will go to cating the equipment at more than one site can be other locations such as the jail (for suspect exams), very costly, especially when a colposcope is used. morgue, health department, women’s clinic, or Colposcopic examination is quickly becoming other hospitals to perform evidentiary exams, if state-of-the-art. necessary. Examples where an evidentiary exam might be completed in a location other than the Disadvantages of a Single Exam Site primary exam sites are when a SANE program that Hospital administrators understandably do not usually sees clients at a community clinic transfers like to be in a position of sending their clients to a client with injuries to the ED for emergency care. another facility for care, especially to another Another example is when a victim first goes to a hospital ED. It is inconvenient for the victim; it referring hospital with injuries that make it diffi- makes the hospital staff appear less capable; and cult to move her to the primary SANE exam site. hospital administrators perceive it as bad for In both cases, the SANE goes to the ED to com- business. Because of these facts, many hospital plete the exam. administrators would prefer that the SANE come to their facility. SANE Locations 50 When initially deciding if nurses should go to 50 other hospitals, or if all victims could be sent to one hospital site, the Sexual Assault Resource 40 Service (SARS) in Minneapolis kept track of the number of rape victims sent from a nearby hospital 30 to their one exam site at a different hospital, over a
20 3-month period. Only one out of three clients 9 reporting a rape at the referring hospital made it to 10 the second hospital where the SANE program was located, even when many were given a cab voucher 0 for transfer (Ledray, Linda E. Unpublished One Site Multiple Sites data. Sexual Assault Resource Service, Minneapo- Program Exam Location lis, MN, 1984.) Based on these results, the
36 SANE Development and Operation Guide
Minneapolis SANE program decided that addi- These sites will likely span a large area with several tional hospital sites would be added. Approxi- community hospitals or clinics involved, and the mately one hospital ED site was added each year SANE may travel 2 hours or more to reach some until SARS was providing services to all seven examination sites. hospital EDs in Hennepin County, with a 1-hour maximum response time. Regional SANE programs are also an important alternative from a staff training and competency Adapting the SANE Program to Multiple perspective. By serving a larger, regional area, the SANE staff will see more clients collectively and Exam Sites each will be able to complete a sufficient number To deal most effectively with multiple exam sites, of exams to develop and maintain their clinical SARS has a space identified for SANE supplies at competence. each hospital and has, in addition, provided each SANE with a portable exam kit (a large tackle box) Regional SANE programs may be sponsored by a where routine supplies and paperwork are kept for single agency and provide services to other agencies easy transport. Hospitals wanting the SANE to in the region on a fee-for-service basis, or the come to their facility are responsible for obtaining program costs may be shared by a consortium of the necessary pieces of large equipment that cannot agencies. be transported. Every effort should be made to keep the policies and procedures as consistent as possible Community-Based Program at all seven hospitals to avoid confusion, especially with new hospital or SANE program staff. Exam Sites Of the nine programs that are administratively Another program with multiple hospital sites community-based programs, five also do the exams decided to compromise by locating their equip- in a community-based facility: two of these have ment, including a colposcope, at one hospital exam sites in a free-standing clinic; two at rape where the SANE does the majority of their exams. crisis centers; and one in a YWCA. The other four The SANEs remain available to go to other speci- are community-based administratively, but they fied sites when necessary if injuries preclude actually do the exams in a hospital: one of these transport to the primary site. In these cases, the programs completes exams in two hospital EDs SANE will carry routine supplies and paperwork and three complete the exams in hospital-based in a portable exam kit. clinics specifically set up for their use.
Disadvantages of Multiple Exam Sites The community-based programs typically refer to A disadvantage of multiple sites for the SANE staff an ED for treatment of injuries, and all but two is that even when every effort is made to maintain have a medical director. The two programs without consistency, equipment, policies, and procedures an identified medical director both have a physi- vary somewhat from site to site. Dealing with these cian who reviews their protocols on a consulting variances can be confusing, especially for new staff. basis. Programs with community-based exam sites, such Regional SANE Programs as the Memphis program and the program operat- ing at the YWCA, Grand Rapids, Michigan have a Especially in rural areas where no one medical very specific protocol for the evaluation of injuries facility sees large numbers of sexual assault cases, and for medication standing orders. They also have multiple sites covering a regional area but using a medical director who is readily available by pager. the same SANE staff may be the only cost-effective In Grand Rapids, when a rape victim comes to a method of providing SANE program services.
37 Chapter 7: Starting Your SANE Program
referring hospital, hospital staff page the on call Advantages of the ED Exam Site rape crisis volunteer advocate and the police. The There are numerous advantages to completing the advocate calls the SANE and then directs the evidentiary exam in the ED. The ED operates 24 victim to the YWCA. If necessary, the advocate hours a day, 7 days a week and is a secure facility may go to the hospital and escort the victim to the with a wide array of support services available on YWCA, where the SANE and the police meet site. Physicians are available for easy consultation them. Since the YWCA building is not open 24 about medications and injuries. Any medications hours a day, the police officer also provides security ordered can be dispensed to the victim prior to her after normal operating hours. The SANE performs discharge, ensuring she gets the necessary medica- the urine pregnancy test (UPT) using a simple 4- tions. Laboratory facilities are readily available to minute urine test similar to the home pregnancy complete tests such as UPT’s, and if necessary, to test and prepares and examines a wet mount for assist with a blood draw. motile sperm. All the medications are located on site and are given to the victim prior to her depar- Often rape victims come to an ED seeking care for ture (Dunnuck, Chris. Personal communication. minor injuries or wanting treatment for STDs or 25 November 1996). because they are concerned about being pregnant. If the SANE program is located in the ED, the Although programs completing exams outside a SANE comes to the ED to complete the eviden- hospital setting are few in number, they do offer tiary exam. Furthermore, the victims do not have some advantages to the hospital-based program. to be sent elsewhere because all the necessary In States where hospitals are mandated to report medical expertise is readily available to evaluate felony crimes, the State statutes for mandated and care for any sustained injuries. reporting do not apply to these community-based programs. In these cases, the SANE will encourage The medical expertise available in the ED does not reporting but will ultimately respect the decision come without a price, however. If the cost of the of the client. There is also more privacy in a ED overhead and ED physician fee is charged to community-based exam site. Especially in a small the victim, to her insurance, to the SANE pro- community, it is likely that the victim or her family gram, or to the State reparations board, it can will encounter other people they know. All neces- represent a sizable sum. It is important to decide sary supplies and equipment are usually located at if the cost is justified. We now know that only a the community-based exam site for easy access. In small percentage of victims, 22 percent to 27 addition, there is no additional billing for medical percent, have even minor injuries such as bruising care or services. or a cut, which require no treatment. Even fewer, 3 percent to 4 percent, have injuries requiring Hospital ED-Based treatment, and less than 1 percent are so severely Exam Sites injured they require hospital admission (Solola & Severs: 83; Tucker, Ledray & Werner: 90). Two of the initial three programs developed in the 1970’s were based in a hospital ED, and one was To better determine how often the SANE was located at a community clinic. This trend has concerned about potential injury even after the continued today with the vast majority of identi- victim had been cleared by the ED staff, one study fied programs indicating that they are hospital ED- reviewed 164 SANE cases completed between June based. Fifty of the 59 programs responding to the and November of 1996. In 44 (27%) cases, the survey are hospital based. Thirty-nine of these SANE requested additional medical evaluation programs primarily complete exams in one or more of injuries (Ledray, Linda E., Unpublished data. EDs, eight in a hospital clinic, and three in both a Sexual Assault Resource Service, Minneapolis, hospital clinic and the ED. MN, 1996). It is possible that the ED staff would
38 SANE Development and Operation Guide triage for injuries even more thoroughly if they One clinic-based program initially completed knew the client was being moved to a nonmedical exams only in the ED, but recently moved all of setting. It appears this extensive medical coverage is its exams to a clinic located close to the ED. Two utilized with a very small number of victims, and it other programs, currently ED-based, are consider- is not necessary in most cases. ing a similar move in the near future. In many ways, this appears to represent the best of both Overcoming Disadvantages of the ED worlds. The clinic locations are away from the Exam Site hustle and bustle of the ED, and the high overhead costs. The patient doesn’t need to go to a second To keep the costs down and retain service in the location when she reports her rape to the ED; she ED, one solution may be to negotiate a more is simply walked down the hall to the clinic when reasonable fee for the use of the ED and ED staff the SANE arrives. Family and friends can use time. One program has negotiated a $50 fee for the hospital facilities, such as the coffee shop, while use of the ED, which also includes the physician’s waiting, and they can still contact the triage nurse time and all medications given the victim (Kathy with questions while the exam is being completed. Bell. Personal communication, 26 November 1996). Community-based programs may actually charge If the SANE is concerned about injuries she feels the hospital a fee for coming to the ED to complete require further evaluation, or if she wants to the exam for their clients (Colleen O’Brien. Personal consult with a physician about medications, that communications. 25 November 1996). is easily accomplished in a hospital clinic-based program. Laboratory facilities and support are also EDs can be busy, inhospitable locations, where the readily available, and prescriptions can be filled at victim’s privacy may be compromised. Care must the hospital pharmacy and sent home with the be taken to shield the victim from distractions and victim. In addition, hospital social workers, crisis loss of privacy. Often a specific exam room away psychiatric nurse consultants, or a chaplain is likely from the center of the ED can be fitted with a to be available on site to sit with a distraught pelvic table and designated for the use of the victim or family member until the SANE arrives. SANE. Simple additions such as wallpaper, a more comfortable chair, a shower for use after the exam, and a telephone can significantly increase the Summary of SANE Location comfort level of the victim. Trends The majority of SANE programs continue to be Hospital Clinic-Based hospital based, with most located in the ED. Exam Sites However, there seems to be a new trend to locate SANE programs outside of an ED. Fourteen of the Eight of the hospital-based programs and three 59 programs responding now complete exams in a additional programs that are administratively based hospital clinic, 11 of these only complete exams in in the community conduct their exams in hospital a clinic, and 2 also complete exams in the ED. It is clinics. These clinic settings include urgent care, expected that others will soon follow this trend by a women’s assessment center, and clinics speci- adding clinic exam sites. fically designated for sexual assault victims. The community-based programs that use hospital clinic Now that the credibility of the SANE model has space are usually in donated space, and the victim been established, it is no longer necessary for the does not become a hospital patient unless she has close medical supervision of the ED setting. sustained injuries and is transferred to the ED Research demonstrates that few victims sustain for treatment. injuries requiring ED care. While communities
39 Chapter 7: Starting Your SANE Program
certainly have different resources and different crimes, but these State statutes do not apply to the needs, a hospital-based clinic setting, especially community-based programs. While the SANE will one in close proximity to the ED for referrals and encourage reporting, she will respect the decision security at night, appears to have more advantages of the client. Also, the victim’s privacy is more than disadvantages. The community-based pro- protected in a community-based exam site. Finally, gram site, however, also offers some advantages the victim does not receive additional billing for over the hospital-based program. For example, medical care or services. some States mandate hospitals to report felony
40 SANE Development and Operation Guide
CHAPTER 8 SANE Program Staff
Who typically directs a SANE program and who is administrator (N=3); hospital CEO (N=2); ambu- best qualified to do so? To whom does the director latory services (N=2); ED administrator (N=1); report and what role does she play? What qualifi- human resources (N=1); and a specialized women’s cations do existing SANE programs look for when health clinic director (N=1). hiring staff? How large of a staff is needed? How are SANEs typically paid, and what are the op- Twelve SANE program directors report to agencies tions? Selecting the right staff is a critical step outside of a hospital administrative structure. toward establishing a successful SANE program. These include a rape crisis center director (N=2), This chapter provides information on how existing YWCA administrator (N=2), district attorney SANE programs have responded to these staffing (N=2), police detective (N=1), family violence questions and which options to consider when coordinator (N=1), and advisory boards or coordi- starting a SANE program. nating boards (N=4). Five programs are indepen- dent and indicate no reporting structure outside their organization. Two programs did not respond SANE Program Directors to this question. Fifty-three (93%) of the SANE programs respond- ing to the survey have nurses as the SANE pro- gram director. Of the six remaining programs, one Reporting Structure is run by a physician’s assistant (PA); one by a For SANE Program Directors social worker (M.S.W.); one by a nonnurse health Number of SANE Programs (N=57) 20 administrator; one by a nonnurse educator (M.S. Hospital Adminstration Ed.); and two by physicians. Followup phone calls 16 Non-Hosp. Admin. to the nonnurse directed programs revealed that 15 14 four of these programs have a nurse identified as 12 the program coordinator who functions in much 10 the same way as a nurse program director. The two 10 exceptions include the program run by an M.S. 5 Ed. that is operated jointly with a rape crisis center 5 and a unique program operated by a PA and primarily staffed by PAs. 0 Nurse Medical Other Outside Independent Reporting Structure Manager Director Hospital Agencies Admin. Forty of these SANE program directors report Reporting to... directly to hospital administration. Of these 40, 16 report to a nurse manager (of these 16, 9 are the emergency department nurse manager); 10 Job Duties report to a medical director (of these 10, 8 are the In most SANE programs, the director is respon- director of emergency medicine). An additional sible for the overall program operation and vision, 14 of the 40 report to a hospital administrator as well as managing the day-to-day operation of including the VP of patient care (N=4); assistant
41 Chapter 8: SANE Program Staff
the SANE program. The director may also be The survey results indicate that the majority of the responsible for the budget, including the procure- directors, 76 percent (N=38), take call routinely. ment of the necessary funding for ongoing pro- Many of these are smaller programs where the gram operation. The director is responsible for director takes call during weekday office hours. If staff recruitment, hiring, training, and continuing the director is on salary during this time, she is not professional development. Another important job paid additional on call pay. A director who takes call function includes avoiding or reducing staff when she is not salaried is usually paid or receives burnout by keeping the job environment as compensatory time. One director, who owns a healthy as possible for the staff and for herself (an private, for profit, SANE program, is not specifically important topic, that is discussed in greater detail compensated for on call time. In three programs, in Chapter 14, Maintaining a Healthy Ongoing 6 percent, the directors only take call during an Program). Providing staff with a safe, supportive emergency. They may fill in during off hours that work environment ensures that the staff feels cannot be covered by the other staff, or they work comfortable bringing its questions, concerns, and “backup” call taking the cases that come in when the issues to be discussed and resolved. In addition, the primary nurse on call is already busy conducting an SANE program director must ensure that adequate exam. Nine directors, 18 percent, never take call, staff is available and that backup emergency even those who are qualified to do so. options are in place for providing continuous program coverage. SANE Program Directors On Call The SANE program director serves a valuable role Percentage of Directors (N=50) as the liaison with other community agencies. She 80 76% must be an active member of the SART team and may be a key player in ensuring that the team 70 membership remains active and involved. Many 60 SANE directors are actively involved in commu- 50
nity education about sexual assault issues and the 40
role of the SANE. This may include both informal Percentage community presentations and formal classroom 30 18% instruction at the local university. 20 10 6% It is also the director’s responsibility to oversee 0 ongoing program evaluation and research activities Routinely Takes Calls Never Takes and ensure that the results of these efforts are Takes Calls in Emergencies Call incorporated into modifying and improving the program. The Role of the Physician On Call Of the 33 ED-based programs responding, ap- proximately one-third (N=10), have no medical Most SANE directors are RNs who are actively director but rely upon the physician available in involved in the clinical component of the SANE the ED to staff SANE cases and sign off prescribed program and take call. Sometimes this is done to medications and charts in the ED. Ten others have meet the needs of the program, but it is usually a specified physician who approves their protocols seen as an important way for them to maintain and routinely reviews their cases. The remaining 13 their professional expertise and credibility as well consider themselves a part of the ED, and the ED as enhancing job satisfaction.
42 SANE Development and Operation Guide
One program director indicated that while she Role Of The Physician would never exclude a nurse solely on the basis of Number Of Programs (N=42) past victimization, she is aware that it is essential ED based programs for nurses who are rape victims themselves to 15 Clinic based programs resolve their own issues through formal counseling 13 prior to employment as a SANE. The director 12 believes extensive counseling enhances the SANE’s 10 10 ability to maintain personal and professional 9 boundaries. Even many years later after extensive 7 counseling, difficult periods may occur, such as the 6 anniversary of the SANE’s rape or a particular case that is too close to her own experience, which may 3 2 prevent her from being effective. Even though a past rape experience may give the nurse more 0 empathy, a SANE cannot help someone else resolve Available Specified ED medical Specified No specified ED physician physician director medical physician issues if she has not yet effectively resolved them director for herself (Ledray: 92a). Physician Used While many SANEs have advanced nursing degrees, the majority do not. It has been clearly medical director is their medical director as well. demonstrated that an advanced nursing degree is Seven of the nine clinic-based programs have a not necessary to successfully function in this role specified medical director, two do not. (Ledray: 96a). Moreover, since large pools of nurses with advanced degrees are not readily available in Staff Selection many metropolitan areas, they certainly would not be available in rural communities. The minimum Most SANEs are female nurses. In the survey of requirement is that the individual is a registered SANE programs, only one program indicated that nurse (RN). While one forensic program is run it has a male nurse who takes call. Studies show and staffed by physician assistants (PA), and two that approximately 50 percent of victims, even programs have physicians taking call, by definition male victims, prefer to have the exam completed they cannot be SANEs. It is not recommended that by a woman and sometimes insist on being seen by they be hired in this capacity. While physicians and a woman (Wright, Duke, Fraser & Sviland: 89; PAs certainly can complete an evidentiary exam, Ledray: 96a; Lewington: 88). they may require a higher salary compensation, and this may become an issue in the clinical Good clinical skills along with good written and practice of the group. In addition, PAs cannot oral communication skills are identified as impor- function independently as the RN can. PAs can tant qualifications for a SANE (Antognoli-Toland: legally only practice under the direction of a 85). A background in obstetrics-gynecology and physician. psychiatry, as well as experience in positions that require independence, such as public health The 35 programs reporting the educational level of nursing, school nursing, and ED nursing is pre- SANE staff, indicated that they had a nearly equal ferred by one program (Ledray: 92a). Good percentage of nursing diploma (28%), associate assessment skills, including the ability to evaluate degree (33%), and bachelor degree (28%) prepared a situation and know when to ask for help, are nurses working as SANEs. A relatively large essential staff requirements (Ledray: 93b). number of SANEs were with advanced degrees (11%).
43 Chapter 8: SANE Program Staff
SANE Staff Educational Degree Levels SANE Staffing Levels Percentage Of Staff (N=35 Programs) Percentage Of Programs (N=50)
35% 33% 80% 70% 64% 30% 28% 28% 60% 25% 50% 20% 40% 32% 15% 11% 30% 10% 20%
5% 10% 4%
0% 0% Nursing Associate Bachelor Advanced 10 or Less 11 to 20 21 or More Diploma Degree Degree Degree Number Of Staff
Staffing Patterns The majority of programs, (84%), reported a Determining the SANE staffing level depends on manageable SANE to exam ratio of 40 exams or the number of cases expected monthly, coupled less per year, per SANE: 12 programs, (39%), with the consideration that regardless of the reported a SANE to exam ratio of 10 or less per number of cases, SANEs must be available 24 year, per SANE; 10 programs, (32%), reported a hours a day, 7 days a week. Only one program SANE to exam ratio of 11 to 20 cases per year, per surveyed indicated it was not able to provide SANE; 4 programs, (13%), reported a SANE to continuous coverage due to a shortage of staff. Two exam ratio of 21 to 40 exams per year, per SANE. programs with continuous coverage were, however, Five programs, (16%), reported a very high ratio able to do so with just ONE SANE! One of these of 75 to 225 exams per SANE, per year. nurses saw 80 cases per year and worked another The program with the highest SANE to exam ratio job as well. She did occasionally take a vacation, of 1:225 employed only four SANEs in a program at which time the ED staff completed the sexual that averaged 900 exams per year. The next highest assault exams. The general consensus from SANEs ratio was 1:120. In this program 10 SANEs see an is that, while possible, it is extremely difficult to average of 1,200 cases per year. Unlike any other complete more than two sexual assault exams program, SANEs in this program are paid a salary without time off between cases. for 8 hours Monday through Friday when most of Of the programs surveyed, 32 (64%) had 10 or their cases, child sexual abuse cases, are seen by fewer staff taking call, 16 (32%) had 11 to 20 staff, appointment. They also work on call during the and only 2 programs (4%), had more than 20 staff. evenings, nights, and weekends. They are paid $30 One of these had 30 staff and completed 1,600 per hour, and their nursing coordinator reports exams a year; the other had 36 staff and completed these SANEs want more hours rather than fewer 200 exams per year. hours (Pat Speck. Personal communication. 16 January 1997). Only 31 programs reported both the SANE staff number and the number of exams completed each Staff Meetings year. Of these, the reported staff to exam ratio varied from a low of one staff to three exams, to an Because SANEs work in isolation, it is essential extreme high of one staff to 225 exams per year. that they have the opportunity to meet regularly to
44 SANE Development and Operation Guide discuss cases, policies, and procedures; to receive SANE Salaries additional training and support; and to “debrief.” The literature indicates that most SANE programs Of the programs responding to the survey, the pay the nurses per case for the exam. The range majority, 64 percent (N=32), meet on a monthly documented is from $100 per exam (Bell: 95; basis. Another 10 percent (N=5) of the programs Massachusetts Nurse: 95; Thomas & Zachritz: 93) meet biweekly, 10 percent meet bimonthly, and 10 to $150 per exam (Frank: 96). One program percent meet quarterly. Only 4 percent (N=2) meet indicates that they pay the SANE a 3-hour mini- semiannually, and 2 percent (N=1) meet as fre- mum at the local staff nurse salary level, more if quently as weekly. the exam takes longer than 3 hours (Ledray: 92a). The programs paying more for each exam indicate Frequency Of Staff Meetings that they do not pay for costly on call time Percentage Of Programs (N=50) (O’Brien: 96; Thomas & Zachritz: 93). One 80% program reported that they pay the SANE $50 per
70% 64% hour for courtroom testimony (O’Brien: 96) and
60% another pays $100 per appearance (Thomas & Zachritz: 93). 50% 40% The survey results were somewhat different than 30% the literature. Two-thirds of the responding pro- 20% 10% 10% 10% grams indicated that they paid for on call time and 10% 2% 4% one-third did not. 0% Weekly Biweekly Monthly Bimonthly Quarterly Semi- annually On Call Payment N=57 80% Sixty-five percent (N=19) of staff meetings last 2 67% hours, while 10 percent (N=3) last 1.5 hours, and 70% 14 percent (N=4) last 1 hour. Three programs 60% responding (10%) indicated their staff meetings 50% can last 3 to 4 hours. One of these programs meets 40% 33% only quarterly and two programs meet monthly. 30% 20% Length Of Staff Meetings 10% Number Of Programs (N=29) 0% Pay for Call No On Call Pay 80%
70% 65%
60% On call pay ranged from $1 per hour to $7.50 per
50% hour, with an average pay of $2.89 per hour for on
40% call time. The programs not paying for on call time
30% did not necessarily pay more for exams. The lowest paying program pays no on call time and paid the 20% 14% 10% 10% SANE $18.00 per hour for the exam. The highest 10% paying program was the program with the 1:225 0% 1 Hr 1.5 Hrs 2 Hrs 3-4 Hrs staff to exam ratio that hired only nurses with an advanced degree. In addition to paying $30.00 per
45 Chapter 8: SANE Program Staff
hour for day shift work during the week, they pay survey results indicating the frequent need for $5 per hour for on call time, and $200 per case SANE program directors to take primary and when called in for an exam. emergency backup call. This provides an important depth of coverage not otherwise available. It also SANE programs with a small number of cases, gives the director considerably more credibility often in rural areas, simply cannot cover the high with her staff and the community. cost of on call pay. In some areas, the hospital nursing union contract may require the hospital In some States, the SANE director can also be to pay nurses on call pay. In these instances, the called to court as the “keeper of the records” to SANE program may need to negotiate with the testify to the facts contained in the records col- union to make an exception for the SANE pro- lected by SANEs on her staff. As a SANE, the gram. If this is not possible, the SANE program director can also testify as an expert witness if she may need to be administratively based outside the maintains her clinical competence. hospital to avoid cost prohibitive on call pay requirements. It is also important that the program director have management skills, including budget and program One-third of the responding programs pay the evaluation skills so that she is able to effectively SANE a per case rate for the exams with a range of represent the program in the community. A $50 to $200 per exam. The other two-thirds of the knowledge of community resources is useful. The programs pay an hourly rate from $18 to $50 per ability to conduct staff training, to provide com- hour for the actual time spent completing the munity and professional education, and to make evidentiary exam. The average rate paid is $25 per conference presentations is an equally important hour for the exam. Some programs indicate they qualification for an effective SANE program pay a rate equal to the community staff nurse director to possess. hourly salary, others pay 1.5 times the community staff nurse salary. Some have established a minimum The program director does not need to occupy a number of hours the SANE is paid when she full-time position; in fact, in most smaller SANE responds to a case. This minimum ranged from 2 to programs, the position is not full-time. To have 4 hours. The time estimated to complete an exam some paid administrative time available for the ranged from 2.5 to 5 hours with an average of 3.2 director is always necessary, but the amount of hours. More than half, 30 programs, also pay the time will vary greatly with the size and budget same hourly rate for attending staff meetings. of the program. Having the director function on call regularly is also an effective means for her to augment her income while maintaining her clinical SANE Staffing expertise. Recommendations Medical Director The following SANE staffing recommendations are based on the results of the survey indicating While a relationship with a physician is essential current practices, the literature reviewed, and the for prescription and injury protocols, and general experience of the advisory committee. medical consultation, it is not necessary to have a medical director. SANE programs are nursing Program Director programs, and the primary activities are nursing activities not requiring medical authority. Because The individual best qualified to act as a program of this, a reporting authority through nursing is director is a SANE qualified to complete the sufficient. evidentiary exam and who maintains her competence. This recommendation is based on
46 SANE Development and Operation Guide
If the decision is made that medical authority is All but one SANE identified is female, and only 11 preferred, identify a consulting physician who is percent have advanced degrees, reinforcing the familiar with the program needs and who will be recommendation in the literature that an advanced available for consultation and to help establish degree is not necessary and should not be a require- protocols. Programs based at a medical facility ment when developing a SANE program. While can utilize physicians on duty, to sign prescriptions most programs employ 10 or fewer SANEs, staffing at the time of the exam. patterns vary greatly and are not directly a function of the number of exams completed per year. SANE Staff Salaries vary greatly and range from a low of $18 Any interested and qualified registered nurse who per hour with no on call pay and no additional per completes the training is qualified to be a SANE. exam pay to a high of $30 per hour for scheduled An advanced degree is not a requirement. The hours with a $5 per hour on call pay, and $200 training must be conducted by an experienced per exam when not on salary. Two-thirds of the SANE, preferably with at least 2 years of SANE programs pay for on call time at an average rate experience. Continuing education and SANE exam of $2.89, and two-thirds pay an hourly rate for experience requirements should be met yearly for the exam time averaging $25 per hour. continued active SANE status. While the number of SANEs hired and the num- Summary ber of victims requiring services vary greatly from program to program, sufficient staff should be Although national standards have not yet been available so that a SANE does not routinely established, the survey of existing SANE programs complete more than two exams during one on has identified many similarities. By far, the majority call shift. Establishing and maintaining an on call of SANE programs are directed by nurses who schedule is addressed in the next chapter. report to a nurse manager or hospital administrator.
47 SANE Development and Operation Guide
CHAPTER 9 SANE TRAINING
The registered nurses (RNs) who are selected for State-Level Certification SANE duties must receive the proper training to State-level certification is an option being consid- ensure that they perform effectively in the SANE ered by several States, since at this time, there is role. No matter how motivated an RN may be or no standardized national certification or training how well she functioned in her former positions, requirements for SANEs. Massachusetts has the SANE program will not be successful unless recently developed a statewide sexual assault each employee has the proper training for her training program under the auspices of the Public particular role. What training is needed? How are Health Department for both nurse and physician programs today training their staff? What are the certification. Massachusetts requires recertification current training options? Where can staff go for every 2 years based on competency (Massachusetts training? Who is qualified to do SANE training? Nurse: 95). Texas has established a multidisciplin- Choices must be made between the ideal situation ary group working out of the Attorney General’s and the realistic training needs of the program. Office and criteria for State level certification (J. The goal must always be to provide the best Ferrell. Personal communication. 3 October 1998). possible training for the SANE staff that is possible Other States may follow with similar requirements. with the resources available and without putting The desire to develop State certification or licen- unrealistic demands on either the staff or the sure in the absence of national certification is budget. largely driven by the desire to establish credibility when the SANE is required to testify in court. Certification However, since IAFN is actively seeking to develop national standards and certification, State agencies National Certification may better meet their needs by concentrating on There is currently no national SANE certification. providing solid basic SANE training for their However, the IAFN recognizes the importance of local SANE programs to ensure their credibility establishing national-level certification for SANEs in the courtroom rather than focusing on the to ensure both consistency in practice and credibil- credentialing process. ity in the courtroom. As a first step toward this A problem inherent with State credentialing is that end, a committee chaired by Patricia Crane, MSN, there will likely be considerable variation in NP, RNC and cochaired by Diana Schunn, RN, expectations of the practicing SANE and a lack of BSN, has developed goals for SANE training consistency in the training requirements from State programs and is working on recommendations for to State. Implementation of State certification will SANE training curricula. These were approved and probably create a new level of government regula- adopted by vote of the SANE council at the tion of SANE practice that may be impossible to October 1998 IAFN conference. They will be dismantle when national certification is imple- available through IAFN. mented. Each State will then need to decide if the national certification will be required instead of the
49 Chapter 9: SANE Training
State requirements, or justify why the State re- training. Existing basic SANE training programs quirements will be required in addition to the typically consist of approximately 40 hours of national requirements. classroom instruction.
Local Certification SANE Training Topics It is important to note that even when a specific ■ Definition of the SANE role. trainer provides “certification” after completing a ■ Collection of evidence (including forensic SANE training course, it is important to ask who procedures such as maintaining the chain-of- or what institution is “certifying” the training, evidence). since there is no nationally recognized certification. ■ In most cases it is a local hospital or SANE pro- Testing and/or treatment of STDs. gram. Continuing Education Units (CEU) should ■ Evaluation and prevention of pregnancy. always be provided with training. ■ Typical victim responses and crisis intervention. ■ Assessment of injuries. SANE Training Options ■ Documentation. A common question from someone wanting to ■ Courtroom testimony (Mock Trial). start a SANE program is “Can I send one person to ■ Corroborating with related community a training program, then have her come back and agencies. train the remainder of the staff?” The overwhelm- ing advice from experienced SANEs is “NO!” ■ Competently completing an exam. While the question is usually asked in an attempt ■ Forensic photography. to reduce initial startup costs, which is an under- standable concern, the training will not be ad- Some programs also specify a designated number equate, and the quality of the SANE program will of clinical hours after completing the classroom be jeopardized. Cut costs somewhere else. training. The range, when required, is from 40 There are three primary options for SANE train- hours (Kettleson: 95) to as many as 96 hours of ing. The first option is to send the entire staff to additional clinical experience (Antognoli-Toland: an established basic SANE training program. A 85). Additional clinical hours usually include second option is to hire a qualified SANE trainer experience in the following areas: to come to the community to conduct a complete ■ Normal vaginal speculum and bi-manual training program for all SANE/SART staff. The examination experience. third option is to organize part of the training ■ locally, utilizing local expertise, and hire a qualified Normal well-child examinations (for SANE trainer to come to the community to programs seeing children). conduct the portion of the training specifically ■ Courtroom observation. related to SANE evidence collection and documen- ■ Specified number of adult or child eviden- tation. This person may or may not also act as a tiary exam observations. consultant to the program. Most programs do not have a set number of re- quired clinical hours but rather train until the new SANE Training Today SANE indicates that she feels comfortable with the In the survey of existing SANE programs, approxi- procedures and demonstrates competency. Some mately one-third of the programs surveyed provide programs require the trainee to return a signed their own SANE training and two-thirds utilize an certificate of completion for the clinical component established SANE training program for the initial prior to receiving their course completion
50 SANE Development and Operation Guide certification. Other programs require the trainee to to develop professional networks and mentoring demonstrate competence utilizing a competency relationships with experienced SANEs. checklist for each clinical skill (Gaffney: 97). (See Appendix H: Clinical Skills Competency Check- There are a couple of disadvantages to utilizing the list). Still other programs have the SANE complete existing programs. First, if the SANE staff is large, an exam, either simulated or real, while being it can be expensive. The cost for the basic SANE observed, to demonstrate competency. training ranges from $250 to $500 per person, plus travel expenses. The cost for an advanced clinical Once trained, all but eight programs surveyed training course can run $1,200 per week, plus indicated they require specific criteria for maintain- travel expenses. If the staff is small or if there is ing certification. While no two programs are the a training program nearby, attending a SANE same, the most common requirements include the training course may be a more realistic option. following: Another possibility might be to provide the initial SANE training locally but later send a representa- ■ Completion of a specific number of exams tive to one of the existing basic or advanced per year. training programs to develop additional expertise ■ Attendance at staff meetings. to bring back and share with the other program ■ CEUs such as SANE relevant literature staff. If an individual SANE is being added to the reviews. staff, it can be more financially feasible to send one ■ Conference attendance. person to an established training program. ■ Externships with physicians and nurse A second problem may be timing. These programs practitioners. are usually run only once a year. Program startup ■ Continuing to take call and remain actively timing might not coincide with the dates of the involved in the SANE program. preferred training program. If existing training programs and training dates are identified in the Any interested and qualified registered nurse who early strategic planning phase, this problem might completes the training can become a SANE. An be avoided. If the SANE staff is sufficiently large, a advanced degree is not a requirement. The training special training program may be negotiated specifi- must be conducted by an experienced SANE, cally for that community. preferably with at least 2 years of SANE experi- ence. Continuing education and SANE exam A common misconception is that the training experience requirements should be met yearly for responsibilities have ended once the initial SANE continued active SANE status. training through an established SANE course is completed. A big piece of the initial training job is Utilizing an Existing Training completed, however, issues such as the role of the local police, rape center, prosecutor’s office, and the Program appropriate interactions among these agencies and the SANE program must be addressed. Local If financial resources permit, the entire staff may policies, procedures, and protocols must also be attend one of several SANE training programs addressed. available. (See Appendix D: SANE Training Programs). This option provides assurance that the training will be competent and the trainer experi- Importing a SANE Training enced. Some programs have chosen to send some Program staff to one training program and other staff to a different program so that they can share their If a large SANE staff is involved, it may be more varied experiences. This also provides opportunities cost effective to hire a qualified trainer to come
51 Chapter 9: SANE Training
to the local area and provide a complete SANE to date and doing these exams according to the training program. The cost as of 1997 is approxi- current SANE state-of-the-art evidentiary exam mately $1,000 to $1,200 per day for the trainer, standards. plus travel expenses (See Appendix E: SANE Trainers). Hiring a trainer affords more control If there is a school of nursing in the area, explore over the training dates, and if one trainer is not the option of developing a SANE training program available during the preferred dates, another trainer for credit, or for no credit, but associated with the may be able to better accommodate program school of nursing. needs. Importing a trainer also allows for more Look to experts from the local rape crisis center to flexibility in the training format. Instead of a one- teach about the crisis response of rape victims and week program, for instance, the training can be crisis intervention needs. divided into 2- or 3-day segments to better meet the SANE staff schedules. Training can occur 2 Local police can best talk about State rape laws and days, 1 week, and 3 days another, for instance. The the investigation process. They can also address the training agenda can also be negotiated, to better evidence they find most helpful to them in investi- meet the SANE staff needs. CEU’s should always gating a sexual assault case. They can discuss how be provided for the training. Once again, it is still they would like to interact with the SANE in the important to recognize the need to include training ED or clinic. A local police photographer will be a specific to the local SANE program and commu- good source of information about photographing nity needs. injuries. Organizing Local SANE Staff from the prosecuting attorney’s office can provide valuable information about the type of Training evidence needed and the State laws regarding Another option, which may be time-consuming, reporting and confidentiality. That office can also but more cost effective, is the organization of help prepare the SANE staff for courtroom testi- training that maximizes the use of local experts. A mony, and may even provide mock courtroom big advantage of this option is the involvement of experience. Often used in legal training programs, other programs in the area. If other organizations mock trial experience can significantly reduce the are involved in the training, they are more likely to anxiety often associated with the initial courtroom be committed to the success of the program. They appearance. also will be more familiar with the SANE staff and A nurse practitioner or physician from a local an important step will be taken towards building obstetrics department or planned parenthood local support and fostering open communication center will be able to provide comprehensive among agencies. Taking the opportunity to recog- training about normal pelvic examination, preg- nize and utilize agencies’ expertise will increase the nancy risk evaluation, treating for STDs, and the SANE’s opportunity to share experiences with the use of the colposcope. If there is a local STD clinic, agencies and ensure that the SANE staff knows it may be another good resource. Make arrange- the information these local community agencies ments with whoever provides this initial training to indicate is “the most important.” have the SANE staff go to this clinic to practice normal pelvic exams and colposcopic examination. Identifying Local Experts The local hospital clinical laboratory will be a good Local experts must be carefully screened. Just resource to review blood drawing technique and because a local facility is now completing rape also to provide additional practice. A physician exams does not mean that its staff is necessarily up from a local ED or clinic may welcome the oppor- tunity to meet with the SANE staff and talk about
52 SANE Development and Operation Guide assessing physical trauma. If the ED does the clinically with a SANE program. A trainer should training, the ED staff will likely feel more com- have a minimum of a B.S.N. and preferably an fortable with the trauma assessment skills of the advanced nursing degree. Education training and SANEs. Clinical skills competency checklists can experience is essential. University faculty experi- be provided to these outside organizations and ence is extremely helpful, but at a minimum, look clinicians in order to standardize the skills training for someone with experience conducting SANE (See Appendix H: Clinical Skills Competency training. Ask to see her Curriculum Vitae and ask Checklist). for names and phone numbers of others for whom she has provided training. Call her references to see It can be helpful to have the SANE staff go to other how satisfied they were with the training they community sites for training such as the police received and the assistance she provided. department or the county attorney’s office. This will allow SANE staff to meet other members of these When hiring a trainer to come to the community, agencies. Include a tour of the local crime lab so the she should be flexible and willing to meet the SANEs can learn more about how the evidence SANE staff training needs. Be sure to establish they will collect is processed and analyzed. ahead of time if she will also be willing to consult with the SANE staff or director about the SANE Selecting a SANE Trainer program development before the training and to answer questions after the training. Ask if there will It will still be necessary to select a qualified SANE be an increased cost for this additional assistance. trainer to come and teach other portions of the training. This should include at least the following information: SANE/SART Training Resources ■ Collection of evidence, what to look for and where, and what to collect and how. Color Atlas ■ Maintaining chain-of-evidence. An excellent training resource for information on ■ Presenting credentials as a SANE in court. the evidentiary exam is the Color Atlas of Sexual ■ Patterns of injuries in sexual assault cases. Assault (Girardin, Faugno, Seneski, Slaughter, & ■ Data collection and recording. Whelan: 97) Written specifically for the SANE by ■ Consent specific to sexual assault forensic SANEs, it contains 221 color illustrations prima- exam (How SANE consent differs from rily of genital anatomy and trauma. It includes routine medical coniínt for treatment). normal and abnormal findings with complete explanations for the SANE. It distinguishes assault ■ Patient confidentiality. from nonassault injuries and includes a section on ■ Reporting. emotional care of the assault victim as well. Pub- ■ Working with the noncompliant rape victim. lished by Mosby, it is available through local ■ Adolescent rape issues. bookstores. ■ Child-victim specific issues, if the program will be seeing child victims (See the section Evidentiary Exam Videotape in Chapter 12 on Preparing the Child for Two videotapes are currently available, both pro- the Exam). duced by SANEs, for use as an adjunct to eviden- tiary exam training. One was produced by Ameri- When looking for a trainer, in addition to the cost, can Forensic Nurses and the other by Manfred look for someone who has a minimum of 2 years Hochmeister, MD and Jamie Ferrell, RN, BSN. experience, preferably 5, as a SANE doing eviden- tiary exams and who is still actively involved
53 Chapter 9: SANE Training
American Forensic Nurses, a California-based Programmatic SANE/SART program, has developed a 45-minute ■ Role of the SANE and forensic nursing videotape “The Sexual Assualt Examination: history. Essential Forensic Techniques” with a supplemental training manual about the SANE exam (Phone: ■ Program goals, objectives, vision, and 760–324–1124; Fax: 760–321–2750). If you mission. indicate that you heard about this training aid in ■ Review of program policies and procedures. this manual, Western Nurse Specialists (WNS) has ■ Working with the media. offered to donate $25 from each videotape sale to ■ Facilities familiarization. this project to provide additional technical assis- ■ tance toward developing SANE programs. A SANE program evaluation research. comprehensive and uptodate SANE/SART specific ■ Training program evaluation. training tool, it includes the following information: Medical ■ SART members roles. ■ STD review of statistics, symptoms, and ■ Interview process. treatment options. ■ Medical-legal examination. ■ Pregnancy risk evaluation, prevention, testing ■ Forensic photography. options, termination options. ■ ■ Genital trauma and examination. The normal genitalia (pelvic and anal) and normal growth and development in adults, ■ Chain-of-custody. adolescents, and children (when applicable). ■ Victim followup care. ■ Techniques for blood drawing. The videotape by Manfred Hochmeister, MD and ■ Physical assessment, identifying injuries and Jamie Ferrel, RN, VSN, “Sexual Assault: The criteria for medical referral to physicians. Health Care Response” is a comprehensive guide to ■ Using the colposcope and obtaining 35mm the forensic examination and evidence collection of and/or video pictures (if available). the adult sexual assault client. A version is available ■ Followup resources and needs of the rape for medical personnel and another version for victim. nonmedical personnel. Newly released in 1999, this step-by-step videotape documents the latest Legal techniques in forensic examination and evidence ■ Local State rape laws and the police report collection. This videotape can be ordered for $95 and investigation process. from the Institute of Legal Medicine, University of ■ Role of local law enforcement (street police Bern, Buehlstrasse 20, CH-3012, Switzerland; or and police investigator). (from the US and Canada) by Fax (0041) 011 31 ■ 31 631 84 15. Obtaining consent. ■ Maintaining confidentiality. SANE Training Components ■ Role of the local prosecuting attorney. ■ The local court process. Whether evaluating an existing SANE training program or developing a new local training pro- Forensic Practices and Procedures gram, ensure that, at a minimum, the following ■ Noting the types of evidence collected in rape components are included: cases and the utilization of evidence. ■ Determining the source of specimens.
54 SANE Development and Operation Guide
■ Maintaining chain-of-evidence. Additional recommendations include the ■ Utilizing evidentiary exam timing and following: protocol. ■ Membership in IAFN. ■ Noting extragenital pattern injuries in sexual ■ Membership in the American Nurses assault. Association (ANA). ■ Noting genital injuries in sexual assault. ■ Membership in the local State nurses ■ Photographing injuries. association. ■ Collecting, labeling, storing, and processing laboratory specimens. Future SANE Training Trends ■ Medical-legal interviewing. Offering forensic nursing courses and SANE ■ Documenting and recording with a jury in training at the university level, utilizing an experi- mind. enced nursing faculty appears to be the current ■ Testifying in court as an expert witness and trend. There are already several forensic nursing factual witness. courses offered at the university level which qualify for university credit and that offer advanced Psychological degrees. These include Fitchberg University in ■ The emotional needs of the rape victim and Worchester, Massachusetts and Beth-El College how to meet them. of Nursing, Colorado Springs, Colorado. Other ■ Crisis intervention with the rape victim. institutions, such as Columbia University, School of Nursing in New York, New York, offer SANE ■ Suicide risk evaluation. training programs that do not qualify for university ■ Role of the local rape crisis center. credit. Mount Royal College in Calgary, British ■ Victim’s fears about reporting and what it Columbia offers forensic nursing courses via the means to report in the local community. Internet that can, of course, be accessed from any ■ Discharge and followup resources and needs computer, anywhere in the world, for credit of the rape victim (including safety assess- through their institution. ment and planning). ■ Diversity and cultural issues. Summary Continuing SANE Education SANE training is currently not standardized nationally and both the quality and components Once the SANE staff is trained, it is important to vary greatly from one program to the next. Most establish criteria for continuing education. Recom- existing SANE programs utilize an established mendations for continued education include, at a SANE training program, and once trained, have minimum, the following on a yearly basis: specified criteria for continued local certification. ■ Maintaining RN licensure. It is anticipated that within the next 2 years there ■ Completion of at least one SANE exam. will be standardized minimum training require- ■ Ongoing SANE training such as attending or ments recognized by IAFN. These minimum presenting one SANE inservice, providing training requirements will be required for the CEU credit, peer chart review, or attending national certification that will follow. or presenting a SANE case presentation, attending or presenting at a Forensic Nursing or Forensic Science conference.
55 SANE Development and Operation Guide
ESTABLISHING AND CHAPTER 10 MAINTAINING PROGRAM COVERAGE
It is essential to develop and maintain a reputation the SANE on-call schedule, decisions must be for reliability in the community, especially when made about the length of on-call shifts, how they the service is new. The referring community will be assigned, what changes in the on-call programs must know that if they call the SANE, schedule are allowable, and how these changes will or refer a rape victim to the SANE facility, a SANE be made. Decisions must also be made about how will arrive in a reasonable period of time to see the the SANE will be paid for on-call time, the allow- victim and follow appropriate protocols. able maximum response time, when the SANE should be paged and by whom, and what type of Using Staff Positions pager system will be used. In addition, a formal or informal backup call system should be considered. The only way to eliminate response time is to have SANEs available on site. It takes a very high volume Length of On-Call Shift of cases or the ability to schedule exams to make Smaller programs with fewer cases usually have this model cost effective. There are no identified longer on-call shifts. These may be 24- or 48-hour SANE programs with paid SANE staff available on shifts. As the caseload increases, the on-call shifts site 24 hours a day. One SANE program with a typically decrease in length to 12 hours and even to very high volume, 1,200 to 1,500 cases per year, has 8-hour shifts. Eight-hour shifts that coincide with found it cost effective to have SANEs available on area hospital nursing schedules make it easier for site Monday through Friday during office hours. the SANE to work her call around other scheduled Although they see injured victims in the ED, the work. The standard practice is to have the shifts SANEs otherwise work at only one clinic where all short enough that the SANE will be unlikely to noncritical victims are brought in by law enforce- complete more than two exams during any one ment or children’s services. While they do see adults shift. Shorter shifts, however, mean more shifts to who walk in, more than three-fifths of their cases cover, which usually means hiring and training are children and adolescents. Programs that work more staff. with children and do exams on a nonurgent, scheduled basis are more likely to have salaried positions with regular hours. Assigning On-Call Shifts Most often each SANE is hired to take a predeter- Smaller programs may also have the SANE direc- mined number of on-call shifts each month. The tor see cases during her office hours. Assuming number of shifts will usually vary from SANE to her office is near the exam site, this cuts costs, SANE and is a function of her availability and the reduces the need for additional staff, shortens the needs of the program. Each SANE may initially be response time, and helps her to maintain clinical assigned an equal number of day, evening, and competence. night shifts, or an individual SANE may routinely be responsible for a particular shift. The shifts Using On-Call Positions assigned may also vary greatly week to week and month to month, depending on the availability of When exams cannot be scheduled, which is the the SANE staff. Except under unusual circum- situation in most sexual assault cases, utilizing on- stances, no SANE should be assigned to take more call positions is cost effective. When establishing
57 Chapter 10: Establishing and Maintaining Program Coverage
than two nights in a row when she is working given the option of trading shifts or giving away another job. When SANE shifts vary month to shifts. A record is kept by the program director. month, the call schedule should be made at least Shifts can also be traded informally each month 2 weeks prior to the end of the month. before the call schedule is developed.
Staff may prefer to work the same shift all month, The director, or her representative, reads through perhaps the same day of the week if there are 24- the list of available shifts for the month one by hour call shifts. This consistency allows staff to one. As she does so, much like in a card game, the plan their other jobs around their call schedule. first SANE to speak up gets the shift. The SANE While this process makes scheduling very predict- puts the appropriate chip in the center of the table able, it can result in a more rigid call schedule and for each shift she takes, until all shifts are gone and requested changes in the call schedule must be everyone has used all their chips. If there are holes worked out with other staff in advance. Emergen- in the schedule after the first time through, the cies, vacation requests, and special needs of the director reads through the list of remaining shifts SANE staff need to be accommodated whenever again until all are filled. Nurses who have partici- possible. pated in a self-scheduling process of this nature have ensured that all shifts are covered. Work shifts often assigned on a nursing unit are another option for scheduling on-call shifts. With Changes in the On-Call Schedule this option, the program director tries to accom- modate the SANE’s specific requests when making While it is understandable that changes in the on- out the schedule. This method, however, is labor call schedule will need to be made, it is important intensive for the nursing director, and the results that nonemergency on-call schedule changes be rarely please staff. kept to a minimum. Whenever a change is made, the likelihood of paging errors increases. This is There is another method that provides for consid- especially true if each SANE has a different pager erable flexibility, gives the responsibility to the staff number assigned. In these cases, whenever possible, to select the shifts they want, while maintaining both the nurse initially assigned and the nurse some external “fairness” about who takes which taking call for her need to keep their pagers turned shifts, thus resulting in a happier staff. This on. For nonemergency on-call changes, the SANE method is referred to as the “poker chip method.” is usually responsible for finding her own replace- In this method, each SANE has a predetermined ment and to call all agencies that might page her number of day, evening, and night shifts she has with the changes, including law enforcement, rape agreed to take as well as an agreed-upon number of crisis advocate, the SANE office, the answering weekend shifts. The schedule is completed at a service, and each participating hospital. In emer- staff meeting, and it is important that everyone gency situations, the SANE should call the office is present or has arranged for another SANE to or director at her home, and she will arrange for represent her desires. coverage and notification of the change.
Each SANE is given a red poker chip for each Paid and Unpaid On-Call Service evening shift for which she is responsible, a blue chip for each day shift, and a white chip for each Our survey of existing SANE programs indicated night shift. She is also given a white square for that two-thirds of the responding programs pay for every weekend shift which she is expected to cover. on-call time and one-third do not. The programs (Weekend shifts are considered Friday evening not paying for on-call time did not necessarily pay through Sunday night.) While everyone is initially more for exams, even though the literature sug- assigned a specified number of weekend, day, gested they did, and they probably should do so. evening, and night shifts, periodically they are
58 SANE Development and Operation Guide
Paying for on-call coverage is cost prohibitive for cannot be met. If the SANE arrives earlier than an small SANE programs that see fewer than 100 expected 1-hour response limit, the staff and the cases each year. If the SANE program is not victim will be happy to see her early, and she will covered by a union contract, the director may have feel good about her response. If she arrives later the option to pay more per exam, rather than than a 30-minute expected response time, however, paying for on-call time. An equitable solution is the opposite will be true. The maximum response payment of per-case amount that is equal to a time is not the usual or average amount of time for 3-hour minimum salary at the prevailing nursing a response, but the maximum expected response wage in the community (or time and one-half, if time. The SANE should always respond as soon as financial resources allow), plus what the nurse possible. would make if she were paid at the local nursing community on-call rate for the entire length of her Each SANE director needs to decide if she wants shift. to routinely track response time, rather than wait for a problem to arise. Whenever the SANE’s response takes longer than the established limit, Response Time the program director needs to be advised of the The agreement with cooperating facilities served reasons why. It is easy to have the SANE note the should always include a maximum acceptable time the victim arrived in the ED or clinic, the response time from the moment the SANE is time she was first paged, and the time she arrived. paged until she arrives at the door. This is impor- She should also note the reason for any delays as tant so that everyone involved (the victim, the well. Some law enforcement and medical facilities medical staff, the police, and the SANE) knows will record this information routinely. (See Appen- what to expect. A realistic response time needs to dix J: SANE Forms.) be established. While minimizing waiting time for a victim is important, this consideration must be When Should the SANE Be balanced with a realistic view of the program’s capabilities and resources. Paged and by Whom? To shorten the victim’s wait, the director must Most existing SANE programs have set 1 hour as analyze all factors that may contribute to a delay. the maximum acceptable response time for the First, look at when and by whom the SANE is SANE; from the time she is paged until she arrives paged. In most existing SANE programs, the SANE at the ED or clinic. The SANE response time, is paged by the triage nurse or by the clinic recep- from the point when she is paged to that of tionist when the victim arrives at the ED, unless the arriving for the exam, is 30 minutes in some SANE program is operating in a jurisdiction that programs (Speck & Aiken: 95; Holloway & Swan: requires the police to be notified first to determine 93) and generally no more than 60 minutes in if a crime has been committed (See Chapter 4: others (Ledray: 92a). The time limit set should be SART: A Community Approach under the section primarily determined by the geographical area “How a Sexual Assault RESPONSE Team Oper- served by the SANE program. Even 1.5 hours may ates” and also Chapter 6: A Look at Funding under not be realistic for a regional center that serves a the section Where to Look for SANE Program large area. In this case, it may be necessary to set a Funding”). It is important to know how long 2-hour maximum response time. response time takes after the victim has arrived. If Establishing too short of a maximum response the facility staff is waiting until the victim is seen by time is not good for the program. It is better to a physician and examined before they page the have a longer response time that can consistently SANE, the system must be changed. This can be met than to have a shorter response time that significantly increase the SANE’s response time.
59 Chapter 10: Establishing and Maintaining Program Coverage
It is important to set up a system that ensures the Delayed Response victim moves quickly through the initial triage process. While it is certainly important that urgent Program policy should identify when the SANE or life-threatening injuries to the victim take prece- may delay her arrival at the ED or clinic. These dence over a rape exam, past experience has shown may include cases when the victim is so intoxicated that a very small percentage of rape cases involve she is unable to consent to an exam or cooperate serious injuries. (See Chapter 11: SANE Program with an exam and when it is uncertain if she was Operation, “Nongenital injury evidence” for a sexually assaulted. It may also include urgent cases detailed discussion of the literature on this issue.) in which the victim must be evaluated immediately to determine the extent of her physical injuries. Even in cases where immediate treatment is Extensive injury alone is not necessarily a criterion required, the SANE should be paged as soon as the for delaying the SANE’s response. SANE exams rape victim arrives at the ED or clinic or as soon as can be completed in the stabilization room, the the staff determine that a rape, or attempted rape ICU, or the operating room and may result in was involved. The SANE and staff can then decide capturing valuable forensic evidence that would if the SANE should respond immediately, or if otherwise be lost. This is a decision the SANE other urgent care will delay her rape exam. If they should make in conjunction with the physician decide the SANE should not respond immediately, and possibly with input from the police as well. In the SANE can at least get ready to come in and one case, police request for a SANE exam resulted remain in contact with the ED or clinic so she can in identifying superficial vaginal injuries while the respond when needed. patient was being prepped for lifesaving surgery. This evidence was the primary foundation for a Some protocols direct the police to page the SANE conviction (Speck & Aiken: 95). as they leave the crime scene with the victim on their way to the facility. This is an effective method to reduce the response time. It is essential that the Selecting a Paging System police wait to page until they are on their way. If Each SANE should have her own pager. Paging the police do page earlier, they must be sure to systems are less expensive now than even a few page back to the SANE if the victim changes her years ago, and the cost savings of sharing a pager mind and refuses to go in for an exam. do not justify the inconvenience to the SANEs. Long-range pagers afford the SANE more flexibil- Other programs have tried sending the SANE to ity and are highly recommended. It is also recom- the hospital when the local rape crisis center or mended that the pagers have a function that allows teen pregnancy clinic, for instance, calls her to say each pager two paging numbers that can be turned they just saw a rape victim who they are sending on and off independently. One number can then over immediately. Many times these programs be assigned to every pager. This is the number that change their policy when victims do not show up referring programs will page when they want the at the hospital where the SANE is waiting. It can on-call SANE. The on-call SANE ensures that this be less confusing, be less expensive to the SANE number is functioning on her pager. program, and saves a lot of time if the SANE is paged after the victim has arrived at an exam site. Each pager is then also assigned an individual The exception to this might be having the police number for each SANE. SANEs are not required page the SANE when they are en route with a rape to keep their pager on when they are not on call, victim. but this allows each SANE the option of doing so, and it allows the program additional depth of coverage. If the on-call SANE has a question or needs assistance, she can page another SANE and
60 SANE Development and Operation Guide request her help. While the other SANE might not When primary on-call service is paid, backup on- always be able to help, sometimes she can. This is call service is usually paid as well. Since the backup especially useful for newer, less experienced on-call SANE is much less likely to be called in, SANEs. When everyone is willing to help in this the pay is usually half the primary on-call rate, way, being on call is a much less stressful experi- however. Usually, everyone is expected to perform ence. It is important for everyone to know help is the same amount of backup call as they take of available when needed. primary call.
While not as convenient for referring agencies, if If the primary on-call SANE cannot get to the a paging system allows for only one number per exam site within the specified maximum response pager, use individual numbers for each SANE, and time once a month or more because there is more provide the referring programs with an on call than one case to be seen, it may be necessary to schedule. Otherwise SANEs not officially on call implement a backup on-call system. would be forced to turn off their pagers or be constantly interrupted. It is very helpful to have Using an Answering Service SANEs not officially on call available to each other. Since a SANE office staff is not available 24 hours On-Call Backup a day, an answering service can be helpful to take office after hour and weekend calls. This will The best way to ensure that a SANE is always significantly reduce the pressure of routine calls available is to implement a formal backup on-call going to the on-call nurse, yet it will ensure that system. A formal backup system is more likely to emergency calls are properly directed. The cost is be necessary if the SANE program does exams at relatively low, especially when it is weighed against more than one location and if a large number of the quality of service and security of knowing that exams are completed. emergency calls from clients, EDs, clinics, or the community will be screened and properly routed. The backup on-call SANE is usually utilized at the discretion of the primary on-call SANE. It is If the decision is to use an answering machine expected that backup will be called when there are instead of an answering service, emergency calls requests for service from two different exam sites at will need to be directed to another number where the same time. Many programs recognize that it is the victim in crisis can be evaluated and the proper very stressful to complete more than two exams in staff paged. If the local rape crisis center has a 24- a single on-call period, and three exams are usually hour crisis phone line, with its permission, it may the upper limit that an individual SANE can be be possible to direct emergency calls to that expected to perform. Because of this, in some number after SANE program office hours. programs, it is acceptable for the SANE to utilize a backup on-call system after she has completed two Summary or three cases. A balance must be reached between meeting the If the SANE is comfortable with her ability to needs of the SANE staff and meeting the needs of complete the work in a timely manner, she is not the program. The better both needs are successfully required to call the backup. However, whenever integrated, the more effective the SANE program she is unable to do a case, she can choose to call for will be. Staff satisfaction increases, performance backup. If the primary on-call SANE is unable to and productivity are maximized, while staff turn- take call at the last minute due to a family emer- over is reduced, thereby decreasing program costs. gency or illness, and no one else can take the shift, Be creative in looking for ways to develop the on- the backup SANE will be expected to move up to call schedule and don’t be afraid to change. If one primary on-call status. system doesn’t work, try something else. 61 SANE Development and Operation Guide
SANE PROGRAM CHAPTER 11 OPERATION
When the on call SANE arrives at the ED or clinic even with serious injuries if the victim is stable, she will complete all components of the eviden- the surgery can be delayed until after the forensic tiary exam according to the established protocol. exam. (Speck & Aiken: 95). Forensic evidence can This protocol must be clear to the SANE, other also be collected in the operating room while the SART members, and the staff at participating victim is being prepped for surgery, if necessary. medical facilities. The SANE’s awareness of the unique needs of special populations within her The SANE Evidentiary Exam community is also important. In 1987, California became the first State to Medical Evaluation and standardize statewide protocol (Arndt: 88). Since few States have standardized protocols, there is a Care of Injuries significant variation in what evidence is collected When a sexual assault victim comes to the ED and how it is collected in different SANE pro- or clinic because she has been raped, a routine grams. However, the evidentiary exam always physical exam is not necessary, and it is not involves other components in addition to the recommended. The victim must understand that collection of forensic evidence. the evidentiary exam is not routine medical care. The SANE will not be performing a routine PAP Essential Exam Components smear when she completes the pelvic exam. This ■ Forensic evidence collection. should be communicated to the victim verbally ■ and in the written consent (Ledray: 96a). STD evaluation and preventive care. ■ Pregnancy risk evaluation and prevention. The ED or clinic staff is typically responsible for ■ Crisis intervention. medically triaging the sexual assault victim for serious injury, including taking vital signs prior to ■ Care of injuries (completed by the medical staff). the arrival of the SANE (Ledray: 92a). Unstable vital signs, altered consciousness, and peritoneal There are a number of articles explaining the pain or bleeding will alert the physician or nurse specific components of the evidentiary exam, some to injury (Hampton: 95). If the injuries are life step-by-step (Blair & Warner: 92; Bobak: 92; threatening or require immediate medical treat- Girardin, Faugna, Seneski, Slaughter & Whelan: ment prior to the arrival of the SANE, the ED or 97; Hampton: 95; Ledray: 92b; Ledray: 95; clinic staff should maintain forensic principles Ledray: 96a; Osborn & Neff: 89). All include the when documenting the injuries in the medical following specific evidentiary exam components. record. This may also involve taking pictures prior to treatment. Forensic Evidence Collection If possible, the SANE should collect the forensic Time frame. While a complete exam including all evidence before treating injuries, as medical of the above components is usually only done treatment can result in the loss of potentially during the first 36 hours after a sexual assault, an valuable trace or biological evidence. Sometimes abbreviated exam is completed for up to 72 hours
63 Chapter 11: SANE Program Operation
after a sexual assault and, for some jurisdictions, up (Frank: 96), however, it will more likely take only to 96 hours (Frank: 96). An uncomplicated exam, 2 to 4 hours (Lenehan: 91; Sandrick: 96; Holloway without injuries, can take 1 to 5 hours to complete & Swan: 93).
Use of evidence collected. There are four primary Specific Evidentiary Exam Components uses of the evidence collected by the SANE: ■ Written consent. 1. To confirm recent sexual contact. ■ Assault history, including orifices where violence was used or penetration occurred and by what, 2. To show that force or coercion was used. and forms of violence used and where. 3. To identify the assailant. ■ Pertinent medical information including 4. To corroborate the victim’s story. allergies, current pregnancy status, and menstrual cycle. DNA Evidence. The use of deoxyribonucleic acid (DNA) evidence is a recent technology used ■ General physical assessment for trauma. primarily in the criminal justice process to identify ■ Assessment of involved orifices for trauma. an assailant. To do this, blood must also be drawn ■ Sperm and seminal fluid specimens from from the victim to distinguish her DNA from any involved orifices. foreign DNA found on or in her body. ■ Foreign biological matter collection. In 1987, the first assailant was convicted of sexual ■ Fingernail scrapings or clippings. assault with the help of DNA evidence. The case was upheld on appeal the following year (Lewis: ■ Pubic hair combing for foreign hairs and other materials. 88). In 1991, the Minnesota Bureau of Criminal Apprehension (BCA) Laboratory became the first ■ Blood for typing and DNA screening. State crime lab to identify a suspect on the basis of ■ Saliva for victim secretor status (In many areas, DNA alone. As a result of this valuable investiga- this is no longer used and is now replaced by tive procedure, an otherwise unidentified rapist DNA). was found and convicted (Ledray & Netzel: 97). ■ Urine specimen (when rape drug use is The recognition of DNA as a valuable investigative suspected). tool, and the knowledge that many rapists are ■ Collection of torn or stained clothing. repeat offenders, led to the development of the FBI Primary Areas of Variation Combined DNA Index System (CODIS) (Miller: 96). The DNA Identification Act, included in the ■ Amount of documentation. 1994 Crime Bill, allocated $40 million to expand ■ Prophylactic treatment for STDs vs. culturing. DNA testing capabilities. As a result, today 57 ■ Collection of additional blood or urine laboratories in 27 States participate in the CODIS specimens for drug and alcohol analysis. system (Miller: 96). These databases are used for “DNA fingerprinting” in much the same way as ■ Clothing collected as evidence. conventional fingerprint databases are used. ■ Required number of head and pubic hairs if Genetic profiles found in semen and blood evi- collected routinely. dence are now used to link serial rapists, identify ■ Utilization of colposcope or MedScope and light offenders of multiple assaults and exonerate falsely staining microscope. accused suspects (Ledray & Netzel: 97). Examples of sexual assault evidentiary exam proto- DNA evidence can be obtained by collecting any cols are included in Appendix I: SANE Protocols. available blood evidence that could have come from the assailant and remained on the skin or
64 SANE Development and Operation Guide clothing of the victim. If the victim reports that 84), it is important to remember that the absence she scratched the assailant, fingernail scrapings of sperm or seminal fluid findings does not dis- should also be collected to find a match with the prove recent sexual intercourse. Even when sexual suspected assailant’s blood or skin. Whenever intercourse has occurred, sperm may not be found possible, with the victim’s permission, fingernail if the assailant has had a vasectomy, is sexually clippings are preferable to scrapings. An explana- dysfunctional, or the sperm deteriorated due to the tion should be given to the victim about how, with time between the exam and the forced penetration clippings, the crime laboratory can gently separate (Tucker, Ledray & Werner: 90). any material that is possibly from the assailant without contaminating his DNA which might be Vaginal secretions can be screened for the presence found with cells (and her DNA) from her nails. of sperm with a wet mount during evidence If the SANE scrapes the nails, she should scrape collection. While any microscope can be used, a gently, not vigorously, to try to avoid sample con- light staining microscope developed specifically for tamination. DNA from semen can also be obtained use by the SANE aids significantly in simplifying by swabbing the involved orifices with a standard this procedure. The light staining microscope size cotton tip swab. Any dried or liquid foreign enhances and makes the color of the sperm more matter on the body or clothing should also be distinct without staining the slide or altering it in collected for DNA evidence (Ledray & Netzel: 97). any way. The image viewed through the light staining microscope is optically enhanced to make In addition, when the SANE completes the the sperm appear bright yellow against a blue evidentiary exam, blood evidence or buccal cell background. It also eliminates the need for the user scrapings from the side of the mouth is collected to find the optimal magnification. This enhanced from the victim for DNA analysis to distinguish image can also be photographed through an her DNA from that of the assailant (Frank: 96). attachable camera for evidence (Peele & Matranga: 97; O’Brien: 96a). It can even be attached to the Hair evidence. The primary use of hair evidence is same monitor as the colposcope (Peele & to identify the assailant. The collection of hair Matranga: 97). evidence from the victim is controversial. While accurate data is not available, obtaining foreign Seminal fluid evidence is analyzed for sperm, hair samples is rare. When foreign hair is collected, motile or nonmotile, and for acid phosphatase hair must also be available from the victim for (ACP). ACP is actually an array of related isoen- comparison with any foreign hair that is found in zymes which is found in much greater concentra- or on her body. Some examiners always pluck 15 tion in semen than in any other body fluid to 20 head hairs and pubic hairs as a part of the (Davies: 78). Vaginal secretions have been found to evidentiary exam (Osborn & Neff: 89). Others cut contain very low levels of endogenous ACP. The hairs rather than pluck, since many laboratories do exact tissue source of the vaginal ACP is uncertain, not analyze the root (Osborn & Neff: 89). Other but is believed to be endometrium. The two examiners do not collect hair evidence as a routine specific ACPs most often analyzed in the evalua- part of the evidentiary exam because collection is tion of sexual assault, are prostatic acid phos- painful, and if hair evidence is needed from the phatase (PAP) and prostatic specific antigen (PSA). victim, it is retrievable at a later date (Ledray: 92b). Since vaginal ACP and prostatic ACP cannot be distinguished biochemically, the only reliable Seminal fluid evidence. Seminal fluid evidence is differentiation is the quantitative level. Since used for two purposes: to show that recent sexual prostatic ACP found in semen is in much higher intercourse occurred and to identify the assailant. concentration than vaginal ACP, a high level would Since 34 percent or more of rapists are sexually indicate that there has been recent sexual contact dysfunctional (Groth & Burgess: 77) and others with seminal fluid being left in the vagina (Green: wear condoms (Norvell, Benrubi & Thompson:
65 Chapter 11: SANE Program Operation
88). The interpretation of actual numeric results of (N=15) in one study (Soules, et al: 78), 65 percent analysis will be different depending on the specific (N=980) in another study (Silverman et al.: 78), substrate used by the laboratory as there is no and in as little as 25 percent (N=542) in yet standard. The laboratory must indicate how the another study (Randall: 86). analysis was done in order to determine how to interpret the findings as positive or negative for In a study of 1,007 rape victims examined, sperm prostatic ACP. was found in only 1 percent (N=3) of the 369 cases involving oral rape. All of the positive oral speci- Cases negative for sperm and positive for acid mens were collected within 3 hours of the rape. phosphatase typically involve an assailant who has Of the 210 cases with rectal involvement, only 2 had a vasectomy, but this result is also possible in percent (N=4) were positive for sperm. These cases involving an assailant who is a chronic exams were all completed within 4 hours of the alcoholic (Enos & Beyer: 80). rape. In the 111 skin specimens collected, 19 percent (N=12) were positive. All but two of the In a sexually functional, nonrape population, positive specimens were collected within 4 hours of sperm has been found on exam within 24 hours the rape (Tucker, Ledray & Werner: 90). after consenting sexual intercourse with known ejaculation, as often as 100 percent of the time Of the 919 vaginal specimens, 37 percent (N=317) were positive. Of these, the majority, 83
Specimens Positive For Sperm
6 6
5
4
3 3
2 2
1111 1 1 1 1 1
Number of Positive Cases Number of Positive 00 0 00 000 000 00 000 000 0 1 2 3 4 56789 10 Hours Between Sexual Assault and Exam
Skin N=111 Specimens Collected; 10% (N=11) Positive Anal N=210 Specimens Collected; 2% (N=4) Positive Oral N=369 Specimens Collected; 1% (N=4) Positive
66 SANE Development and Operation Guide percent (N=263) were examined within 5 hours, cited above, of the oral specimens, 11 percent and 307 were examined within 12 hours of the (N=40) were positive for PAP; of the rectal speci- rape. Only 7 of the positive specimens were mens, 12 percent (N=32) were positive for PAP; collected more than 20 hours after the rape of the skin specimens, 43 percent (N=72) were (Tucker, Ledray & Werner: 90). positive for PAP; and of the cases involving vaginal assault, 62 percent (N=566), were positive for PAP These data clearly indicate that the vaginal site is (Tucker, Ledray & Werner: 90). the most likely site to obtain specimens positive for sperm. It also indicates that by far the majority of In another study of 212 women who had consent- positive results will be collected within the first 5 ing sex within 4 days, comparing PAP (prostatic hours after the assault, and that even then, it is acid phosphatase) to PSA (prostatic specific rare that specimens positive for sperm will be antigen), researchers got better results with PAP obtained in any site other than the vaginal site. than PSA analyses. While both were positive in 59 It is imperative that the SANE is aware that this percent of the cases, PAP was positive 84 percent does not, however, mean sexual contact did not of the time and PSA was positive 60 percent of the occur (Tucker, Ledray & Werner: 90). time. PAP was negative only 2 percent of the time when PSA was positive, and PSA was negative 25 Because of the small percentage of positive sperm percent of the time when PAP was positive (Roach specimens, the literature indicates that it can be & Vladutiu: 93). Most programs collect vaginal very helpful to also analyze the specimens collected sperm and acid phosphatase specimens using for prostatic acid phosphatase (PAP). While it is cotton tip swabs. A few programs use a vaginal still more likely that specimens will be negative normal saline aspirate or vaginal washings for this than positive, the results are more likely to be purpose (Osborn & Neff: 89). positive for PAP than for sperm. In the same study
Vaginal Specimens Positive for Sperm
80 N=919 Specimens Collected; 37% (N=344) Positive 70 70 68
60 52 50 44 40 31 30
20 12
Number of Positive Cases Number of Positive 10 5 4 5 5 2 3 2 2 2 2 3 2 1 1 0 1 111 0 00 0 1 2 3 45678 9 10 11 12 13 14 15 16 17 18 19 20 2122 23 24 25 30 36 39 Hours Between Exam & Sexual Assault
67 Chapter 11: SANE Program Operation
victim’s clothing (Frank: 96), most now specify Percent of Total Specimen by Orifice that clothing should only be collected as evidence
80% if it has tears or stains. While this may have been helpful when less well-trained ED personnel were 70% 62% 60% collecting the clothing, a well-trained SANE can better decide what clothing will be useful evidence. 50% 43% 40% For many victims, their winter coat or shoes may
30% be valuable property that cannot be replaced. If some clothing does not hold important evidence, Positive for A.P. for Positive 20% 12% 11% there is no reason for it to be turned over to law Percent of Specimens Percent 10%
0% enforcement. When kept for evidence, clothing Oral Rectal Vaginal Skin should be allowed to air dry prior to placing each Orifice Examined article into a separate paper bag, labeled with the client’s name, identifying number, date, time, SANE’s name, and the type of article (Ledray: Specimens Positive for PAP/PSA 92b). N=212 100% Nongenital injury evidence. Physical injuries are 84% the best proof of force and should always be 80% photographed, described on drawings, and docu- 59% 60% 60% mented in writing on the SANE Exam Report as evidence of force (Ledray: 92b). Photographs are 40% not meant to take the place of good charting (Pasqualone: 96). It is also important to note that 20% the absence of injuries does not mean no force or 0% coercion was used. Absence of injury does not Both PSA & PAP Positive PSA Positive PAP Positive prove consent (Tucker, Ledray & Werner: 90). Specific consent to photograph is necessary but Vaginal washes. Vaginal washes to collect sperm may be included as a standard part of the exam evidence and DNA to identify the assailant are consent. In a facility which maintains medical recommended by two clinicians (Sandrick: 96). records, two sets of pictures should always be One of these clinicians specifies that the vagina be taken. One set always remains with the medical washed with 10 ml of saline, which is then aspi- record. The second set should be given to the rated and saved for analysis (Roach & Vladutiu: police (although some programs give it to the 93). The crime laboratory in each State will have victim) and will usually be the pictures used in a preference as to which method to use. court. Whenever pictures are taken, the first picture should always be of the victim’s face, and Clothing evidence. Clothing is primarily useful as others should follow in a systematic order, such as evidence to prove force was used. It can also be head to toe, or front to back. They should be taken helpful to corroborate the victim’s story. For first without a scale to show nothing is being instance, if the victim claims she struggled on the hidden, then with a scale to document size. While grass, grass stains on her clothing will corroborate a coin such as a quarter is sufficient, a gray photo- this and the absence of grass stains can be used graphic scale will also assist with color determina- against her, as happened in the widely publicized tion. Each picture should include a label with the State of Florida vs. Smith (Kennedy) trial. While victim’s name in the picture. If a Polaroid camera is some programs recommend collecting all of the used, the SANE should print her name and title,
68 SANE Development and Operation Guide the date, the time, and the client’s name and record injuries” are injuries where one can easily identify number on the back of every Polaroid. Some the object used to inflict the injury by the pattern programs may choose to use the medical record left on the victim, such as a coat hanger, iron, number instead of the victim’s name. extension cord, belt, or the imprint of a ring worn by the assailant. Bite marks are important pat- Photographic documentation of injuries should be terned injuries that can be linked to a suspect’s completed using a 35mm camera with a standard dental pattern. Since most assailants choke using 50mm lens, or a 35-110 zoom lens, and 100-200 their dominant hand, the finger-tip pattern can speed (ASA) color film. A disadvantage of 35mm identify the assailant’s handedness. A right-handed pictures is that they must be sent out for develop- assailant will usually grab the victim’s anterior neck ing and are often not available to the police when so as to leave a single thumb bruise at the right they investigate or to prosecutors when they are lateral neck and several finger-tip bruises to the left deciding if they will charge the case. Polaroid film lateral neck (Sheridan: 93). has the advantage of allowing the victim to take one set of pictures with her when the exam is The literature cautions the forensic nurse against completed, and of being available to the police trying to closely date the age of a bruise by its during their initial investigation. It has the disad- color. While we know that recent bruising is red vantage of poorer quality, especially for closeups. or dark blue in color, and older bruising may be Polaroid film is also very expensive (Sheridan: 93). green-blue or yellow-blue, and older still bruising Injuries not properly documented with pictures may be barely visible, people vary greatly in their may result in liability for failure to document rates of healing. Medications may affect bleeding (Pasqualone: 96). Therefore, staff must take and healing response as well. Sheridan suggests that pictures of all areas that have sustained injury, deep blue-purple bruising is best documented as a even of breasts and genitalia. “relatively recent bruise” or as “consistent with Mary Jane’s report of being punched by Jim Smith The nurse must be knowledgeable about patterns 24 hours prior” (Sheridan: 93). of injuries resulting from violence so she knows the appropriate questions to ask and where to look for Physicians need to feel certain that any injuries or injuries on the basis of the history (Sheridan: 93). concerns about further evaluation of possible injury Intentional injuries tend to be located more central will be referred to them. Physicians need not be on the body and accidental injuries more distal concerned that injuries will be missed by the SANE toward the extremities when domestic violence is if they understand that she will err on the side of involved. Injuries are most often inflicted where caution when evaluating and referring sexual assault the victim can easily hide them. The most com- victims to them (Ledray: 96a). Some programs have mon injuries are broken ear drums from severe developed specific criteria for the nurse to use in slapping, neck bruising from choking, punch determining when to consult with a physician. One bruising to the upper arm, and “defensive postur- program suggests that the nurse consult with a ing” injuries to the outer mid-ulnar areas of the physician when there is extensive genital trauma, arms. Also common are whip or cord like injuries asymmetric joint swelling, head or chest trauma, to the back; punch or bite injuries to the breasts neurological deficits, respiratory distress, need for and nipples; punch injuries to the abdomen, medications, suspicion or need to confirm an especially in pregnant women; punch and kick existing pregnancy (Antognoli-Toland: 85). injuries to the lateral thighs; and facial bruising, abrasions, and lacerations (Sheridan: 93). The literature indicates injuries resulting from sexual assault are relatively rare. In a review of 372 “Patterned injury” is different from the similar ED rape cases, 68 percent of the victims seen had term, “pattern of injury” discussed above. Both no injury, 26 percent had mild injuries, 5 percent are, however, important forensic terms. “Patterned moderate injuries and less than 1 percent, 0.2
69 Chapter 11: SANE Program Operation
percent, were severely injured. Victims 50 years old complaints of vaginal pain, discomfort, or bleeding and over were twice as likely to be injured, 63 (Tintinalli & Hoelzer: 85). Another study found percent, compared with 32 percent of the victims that 22 of 83 (27%) victims had genital injuries under 50 years old (Tintinalli & Hoelzer: 85). following a rape ( Bowyer & Dalton: 97). Still another study found only 1 percent of rape victims had genital injuries so severe that they required Non-Genital Injuries Suffered During Rape surgical repair, 75 percent of which were upper ED Rape Cases (N=372) vaginal lacerations (Geist: 88). They also found 80% 68% that upper vaginal lacerations usually presented 70% with profuse bleeding and pain, and lower vaginal 60% lacerations were more common in virgins. 50% 40% The pattern of genital injury in female sexual 26% 30% assault victims has been a more recent area of 20% study. Since the posterior fourchette is the point of 10% 5% greatest stress when forceful stretching occurs, and 0.2% it is the point of first contact of the penis with the Percentage Of Rape Victims Of Rape Percentage 0% None Mild Moderate Severe vagina, the resulting injury is characterized as an Degree Of Injury “acute mounting injury” (Slaughter & Brown: 92; Slaughter, Brown, Crowley & Peck: 97). Because no posterior fourchette injuries were found in a control group of sexually active adolescents, and Another study found 5 percent of victims had injuries were found in 33 percent of the abused major nongenital injuries, and women over 35 population, the researchers concluded that poste- years of age were nearly twice as likely to be injured rior fourchette injuries are indicative of sexual (Marchbanks, Lui & Mercy: 90). In another study assault (McCauley, Gorman & Guzinski: 86). of 440 rape victims, 46 percent had some nongenital trauma, however, only 1 percent In a study that compared the physical vaginal required hospitalization (Cartwright, Moore, examination findings of 311 rape victims to a Anderson & Brown: 86). In a study of 98 rape group of 75 women after consenting sexual inter- victims, only 27 percent had even minor course, researchers found that 213 (68%) of the nongenital injuries not requiring treatment, 3 rape victims had genital trauma and only 8 (11%) percent had injuries requiring treatment, and less of the consenting women had genital trauma. than 1 percent required hospitalization (Tucker, Furthermore, none of the women who were Ledray & Werner: 90). examined after consenting sex had injury in more than one site (Slaughter et al.: 97). Of the 213 Genital trauma evidence. Genital trauma is useful victims with trauma, however, they found that 200 to show both recent sexual contact and force. Just (94%) had trauma at one or more of four sites as with nongenital trauma, the absence of genital including posterior fourchette, Labia minora, trauma does not indicate consent (Cartwright, hymen, or fossa navicularis; 162 (76%) had 3.1 Moore, Anderson & Brown: 86). While the sites of injury, making injury at more than one site examiner will usually not find genital injuries, this indicative of rape. Trauma varied by site: tears should not influence their testimony regarding the appeared most often on the posterior fourchette validity of the rape since most rape victims do not and fossa navicularis; abrasions appeared on the experience genital injury as a result of the rape labia; and ecchymosis was seen on the hymen. (Bowyer & Dalton: 97). In one study, vaginal They also found that all women with tears re- injuries represented only 19 percent of the total ported vaginal bleeding. Five victims mistakenly injuries and were always accompanied by
70 SANE Development and Operation Guide reported their menstrual period had begun. elderly clients. The colposcopic exam is especially Researchers also concluded that timing of the exam important as a part of the pediatric protocol was crucial because beyond 24 hours, the likeli- (Soderstrom: 94). hood of identifying injury was significantly re- duced. At followup examination, which occurred With gross visualization alone, positive genital beyond 4 days (average of 25 days), all injury was findings occur in only 10 percent to 30 percent resolved and there was no scarring and no evidence of the cases (Cartwright et al.: 86; Tintinalli & of the previous trauma. They also found that with Hoelzer: 85). With colposcopic examination, the exception of hymenal tears, which were nearly genital trauma has been identified in 87 percent four times more common in adolescent victims, (N= 114) of sexual assault cases (Slaughter & injury was not related to age. Brown: 92). When a colposcope is used, the magnification must always be documented, the The literature also suggests that colposcopic pictures or video must be well focused and clear, examination to magnify genital tissue is an impor- standard positions for examination should be used tant asset to the identification of genital trauma and documented, and a method of measurement (Frank: 96; Slaughter & Brown: 92; Slaughter et should be used (Soderstrom: 94). al.: 97; Peele & Matranga: 97). With the use of a colposcope, the number of cases increased by 8 In a study of genital trauma in a consenting percent because three or more genital injuries were population using the colposcope, 11 (61%) of 18 identified as compared to identification with the volunteers, who had consenting sex within 6 hours, naked eye (O’Brien: 97). Photographic equipment, had positive findings of micro trauma. This trauma both still and video, can be easily attached for was not visualized with gross visualization but forensic documentation. In one study, 28 percent required the use of the colposcope (Norvell, of 440 rape victims had genital trauma, however, Benrubi & Thompson: 84). only 16 percent were identifiable without staining Other studies indicate Toluidine blue and Gentian or colposcopic exam (Cartwright, Moore, Ander- violet can significantly enhance the visualization of son & Brown: 86). In the legal arena, the use of genital injuries compared with gross visualization the colposcope is well documented as an accepted alone. Toluidine blue is a nuclear stain commonly practice in the examination of adults and children used to detect vulvar cancer (Norvell, Benrubi & (IAFN: 96). The fact that it is noninvasive makes it Thompson: 84). It has also been found useful in particularly valuable for examination of young or sexual assault examinations to detect perineal lacerations and abrasions. Since it is spermicidal, Genital Trauma Evidence the literature consistently suggests it should only be used after all specimens are collected. One study 28% 30% examined 22 women after being sexually assaulted 25% within the previous 48 hours. Forty percent were found to have vaginal lacerations when examined 20% 16% using Toluidine blue. Of these, 70 percent (N=7) 15% of the positives were nulliparas (Laufer & Souma:
10% 82). Another study found that 14 of 24 (58%) cases were positive for genital trauma using Tolui- 5% dine blue ( McCauley et al.: 86).
0%
Percentage Of Rape Survivors Percentage Trauma w/Naked Eye Trauma w/Naked Eye & Other clinicians indicate that while lacerations Colposcope seen using Toluidine blue were also seen with Identification of Genital Trauma colposcopic examination by an experienced exam- iner, the dye does make the injuries easier for the
71 Chapter 11: SANE Program Operation
lay audience, such as juries, to visualize. The prison for anyone who uses a controlled substance colposcope is however, the preferred method for to commit a crime of violence, including sexual better genital trauma documentation (O’Brien: 97; assault (U.S. House of Representatives: 96). Slaughter & Brown: 92; Norvell, Benrubi & Thompson: 84). In a review of 17 SANE pro- There has been such an intense community opposi- grams, only 4 indicated they used Toluidine blue tion to Rohypnol that in October 1997, the and 11 used a colposcope for the sexual assault manufacturer Hoffmann La Roche Laboratories evidentiary exam (Kathy Bell. Personal Communi- announced at the National Coalition Against cation. 26 November 1996). Sexual Assault (NCASA) annual conference in Cleveland that it plans to add a color-releasing Blood evidence. The SANE should always draw agent to Rohypnol making it easier to detect if the victim’s blood for type and DNA (Frank: 96). covertly slipped into someone’s beverage. Once In addition, it is recommended that an additional approved by the regulatory agencies, the new tube of blood routinely be drawn for blood and Rohypnol tablets dissolve more slowly and they alcohol analysis should this become an issue later release a bright blue color as they dissolve. When if the case is charged (Ledray: 92a). dissolved in darker liquids, the drink appears cloudy. In all drinks, particles also float to the top Urine evidence. Recently it has come to the of the beverage, signaling that something has been attention of the medical community that a long- added (NCASA: 97). acting benzodiadepine, flunitrazepam (Rohypnol) and a powerful sedative, gamma hydroxy butyrate Whenever the victim’s story is consistent with a (GHB) are being used as date rape drugs. Victims drug-facilitated rape, and if she is seen within 72 may report a history of having only a couple of hours of the assault, a urine specimen should be alcoholic beverages but quickly becoming ex- collected for drug analysis. By calling 800–608– tremely intoxicated. When the victim awakens, 6540, the necessary paperwork with an authoriza- usually more than 12 hours later, she may find tion code will be Faxed to the SANE. She should herself undressed, or partially dressed, with vaginal complete the form and return it with a urine or rectal soreness making her believe she has been specimen by Fedex to the independent laboratory raped. The victim can often remember very little of with whom Hoffmann LaRoche Laboratories have the incident prior to awakening, other than flashes. contracted to analyze the urine. The form will Even though there is little memory and perhaps no contain complete information on the process, and certainty of a sexual assault, the SANE should Hoffmann LaRoche Laboratories will cover all adhere to the standard sexual assault protocol and testing and shipping costs. It will take approxi- collect the first voided urine for a drug screen. If mately 2 weeks for the complete drug analysis of the victim calls prior to coming to the hospital or the urine to be Faxed back (Ledray: 96c). clinic, she should be told to collect her first voided urine and bring it with her (Ledray: 96b; Anglin, Followup Forensic Exams Spears & Hutson: 97). In those cases where genital trauma was identified, Flunitrazepam has been used for sleep disorders in a followup exam may strengthen the evidence of Europe, Mexico, and Asia since its initial release in genital trauma. Photographs should be taken at 1975. It is used legally in 80 countries and is the time of the followup exam to document the widely and easily available, but it has not been healing of the genital injuries for comparison approved for use in the United States. In October purposes in court. Most SANE programs, however, 1996, the United States passed a Federal law, The do not routinely perform a followup forensic exam Drug-Induced Rape Prevention and Punishment on every victim, and these exams may not be Act of 1996, which provides for up to 20 years in reimbursable in every State.
72 SANE Development and Operation Guide
Helpful Tips for Evidence Collection Some programs still culture and treat prophylacti- cally for STDs although they give no rationale for ■ When a speculum is used, it should be lubric- the cultures (Osborn & Neff: 89), other than to ated with water, not gel lubricant, so evidence establish a baseline (Hampton: 95), which has no is not contaminated (Hampton: 95). demonstrated forensic utility. There is also evi- ■ Swabs used to collect skin specimens should dence that STD cultures for gonorrhea obtained at be barely moistened with normal saline the initial exam immediately after the assault may (Hampton: 95). Others specify the use of not only indicate a pre-existing infection, but also water for this purpose (Ledray: 92b). that gonococcus may be deposited in the vagina ■ Tetanus prophylaxis, if not already current, with the seminal fluid of the assailant (Hayman & should be given when the evidentiary exam Lanza: 71; Ledray: 91). identifies any break in the skin or mucosa (Blair & Warner: 92). STD cultures are very expensive and time- consuming for the victim who must return mul- ■ An alternate light source should be used on tiple times for testing and unfortunately most clothing before the victim disrobes (Hamp- victims do not return (Blair & Warner: 92). In one ton: 95), as well as on the body after disrob- study, only 25 percent of the victims seen in the ing to look for body fluids and foreign ED returned for the initial STD followup visit objects, such as sand, to corroborate the (Ledray: 91), and in another study, only 15 percent victim’s story as well as to identify the assail- returned. The researchers were able to contact 47 ant (Frank: 96). percent of those who had not returned for Additional Components of followup, and they found an additional 11 percent of these went elsewhere for medical followup, the SANE Exam however, only 14 percent told the physician about the rape (Tintinalli & Hoelzer: 85). If cultures are STD Evaluation and Preventive Care taken, they do not have to be handled as evidence Since there is no evidence of cultures being useful because they are not useful in court (Blair & in court, and there is data showing that they have Warner: 92). Most clinicians recommend prophy- been used against the victim to suggest sexual lactic treatment following CDC guidelines (Frank: promiscuity, it is not recommended to culture for 96; Arndt: 88; Antognoli-Toland: 85; Tintinalli & STDs as a part of the evidentiary exam (Ledray: Hoelzer: 85). For more information call the 92a). Contracting an STD from the assailant is National STD Hotline: 800–227–8922. of significant concern to victims, however, and because it is of great concern, the issue must be HIV addressed as a part of the initial exam. One study Since the early 1980’s, HIV has been a grave found that 36 percent of the rape victims coming concern for rape victims even though the actual to the ED stated their primary reason for coming risk still appears to be very low. In an attempt to was concern about having contracted an STD better evaluate this risk, 412 Midwest rape victims (Ledray: 91), however, the actual risk is rather low. with vaginal or rectal penetration were tested for The National Center for Disease Control estimates HIV in the ED, then again at 3 months post- the risk of rape victims getting gonorrhea is 6 rape, and again at 6 months post-rape. Not one percent to 12 percent, Chlamydia is 4 percent to seroconverted. This study also found, however, that 17 percent, the syphilis risk is 0.5 percent to 3 even if the victim did not ask about HIV in the percent, and the risk of HIV is less than 1 percent ED, within 2 weeks, she expressed a concern for (CDC: 93). herself or her sexual partner. While the researchers
73 Chapter 11: SANE Program Operation
did not recommend routine HIV testing, based on (Foster & Bartlett: 89). When it is recommended the recommendations of the study population, in high-risk cases, the health status of the victim they recommend that even if victims do not raise and her ability to withstand the potential side the issue of HIV or AIDS in the ED, the SANE effects must be taken into consideration along with should, in a matter-of-fact manner, provide them the severity of risk (Gostin et al.: 94). information about their risk, testing, and safe sex options. This will allow them to make decisions As a result of various State laws and the Federal based on facts, not fear, and reduce the psychologi- Sexual Assault Prevention Act of 1993 and The cal trauma of the fear of HIV (Ledray: 93b). It is Violent Crime Control and Law Enforcement Act important to note that this study was conducted in of 1994, involuntary testing of the offender is now a community with a relatively low overall HIV required. While the testing point varies according rate. Communities with high HIV rates will have a to State law, in most States testing cannot be done greater risk that an assailant is HIV positive. While until after the assailant is convicted of the rape and testing can begin as early as 6 weeks after exposure, a court order is obtained for testing. This usually 3 months or even 6 months is more often recom- takes more than the 6 months necessary for the mended to avoid multiple testing (Gostin, victim to seroconvert if she is going to do so, and Lazzarini, Alexander, Brandt, Mayer & Silverman: in some cases it may take a full year or more to 94). obtain the testing results from the assailant. Testing may not occur until the time of pretrial release The risk of HIV exposure after sexual contact, when it is used to determine his risk of HIV while it varies, overall is reported to be less than transmission. While victims still want this informa- other routes of exposure such as needle sticks, tion for their own peace of mind, the time delay needle sharing, mother to infant, or transfusions. does not preclude the need for the victim to be While the actual risk varies from study to study, if tested as well. the sexual partner is known to be HIV positive, the risk of HIV from sexual contact may be similar to Initial post-exposure treatment must be started the risk with a needle stick (Royce, Sena, Cates & within 72 hours or it is not recommended. When Cohen: 97). given following a rape, post-exposure prophylaxis is the same as for occupational exposure to HIV. This HIV Post-Exposure Prophylaxis involves giving zidovudine 200 mg three times a day and lamivudine 150 mg twice a day for 4 As a result of a recent case-control study which weeks. The costs for the medication and monitor- concluded that treatment with zidovudine after ing run approximately $800, and until the treat- needle stick exposure decreased the odds of HIV ment is proven to be effective, insurers may refuse infection by 79 percent, antiretroviral treatment is to cover the cost (Katz & Gerberding: 97). Since now considered the standard of care in parenteral most SANE programs cannot assume this addi- (e.g., needle stick) occupational exposure to HIV. tional expense, and since the treatment must be Unfortunately, data on the long-term toxicity of started within 72 hours, if this option is discussed, zidovudine and the safety of combined anti- it is important to have a treatment or referral retroviral treatment are not available (Carpenter, policy in place so the victim can make an informed Fischl, Hammer, et al.: 96). Since there have been decision. For more information, call the National several cases of possible HIV seroconversion after a AIDS Information Hotline: 800–342–AIDS. rape, post-exposure prophylaxis is being selectively (For Spanish speakers call 800–344–SIDA; For recommended for high-risk exposures in high-risk hearing impaired persons call TTY/TDD Hotline areas. Antiretroviral treatment is not advocated 800–AIDS–TTY). when the HIV status of the assailant is unknown due to the cost and potential toxicity of zidovudine
74 SANE Development and Operation Guide
Pregnancy Risk Evaluation and One program suggests that the consent form for Prevention the use of pregnancy interception drugs include all three options available to the victim, and that one Rape victims of reproductive age also fear becoming option is always checked and signed by the victim. pregnant as a result of a rape. Pregnancy resulting This will provide clear documentation of why the from rape is indeed the cause of great concern and medication (Ovral) is or is not given. The first significant additional trauma to the victim. Most would be the typical informed consent of possible programs offer pregnancy prevention or intercep- complications with agreement to take the medica- tion for the woman at risk of becoming pregnant, tion. The second would be “I understand that if they are seen within 72 hours of the rape and because (I am already taking a contraceptive/had a have a negative pregnancy test in the ED. Some- tubal ligation) pregnancy prevention is not recom- times referred to as “the morning-after pill,” oral mended for me.” The third option would be “even contraceptives such as Ovral are used for emergency though pregnancy prevention was recommended contraception (ACOG: 96). Two tablets of a by the SANE, I (the victim) chose not to take the contraceptive containing ethinyl estradiol, 0.05 mg, medication” (Speck: 96). and norgestrel, 0.5 mg, (Ovral) are taken at the time of the evidentiary exam and two more in 12 Testing for pregnancy is always necessary prior to hours is the usual form of pregnancy prevention. giving any medications, as 2 percent of rape Each dose should be given after an antiemetic agent victims have been found to be pregnant when the to prevent nausea (Osborn & Neff: 89; Ledray: evidentiary exam was completed in the ED and not 92b; Hampton: 95; ACOG: 96). This will reduce all were aware of the pregnancy (Tucker, Ledray & the risk of pregnancy by 60 percent to 90 percent. Werner: 90; Warner: 87). Fortunately, at least one If a low dosage ethinyl estradiol contraceptive, study found pregnant women were less likely to be such as Lo-Ovral, Nordene, Levlen, Triphasil, or physically injured during a rape, and the rape had Trilevlen, is used, a dose equivalent to 100ug of little immediate effect on the pregnancy. No estrogen, 4 tablets, should be provided for each spontaneous abortions or deliveries occurred dose (Yuzpe, Smith & Rademaker: 82). Two within 4 weeks of the rape. A low birth rate (24%) programs operating at a Catholic hospital went as and preterm deliveries (16%) were common, far as to get special permission from the diocese to however (Satin, Hemsell, Stone, Theriot, & administer Ovral (Frank: 96; O’Brien: 97). Wendel: 91).
The risk of pregnancy from a rape is the same as If the victim chooses to take medication for the risk of pregnancy from a one time sexual pregnancy interception, it is also important to encounter. This is estimated to be 2 percent to 5 inform her about the effect on her next period. Up percent (Yuzpe, Smith & Rademaker: 82; Holmes, to 98 percent of patients will menstruate within 21 Resnick, Kilpatrick & Best: 96). Holmes et al. days after the treatment. In 90 percent of the cases, found that the majority of these pregnancies menses will be of normal duration for that patient. occurred among adolescents and resulted from a If the medication is given prior to ovulation, the known and often related perpetrator. Unfortu- onset of menstrual bleeding may be 3 to 7 days nately, only 11 percent of these victims received earlier than expected. If the treatment is given after immediate medical attention for the rape. Fifty ovulation, the onset of bleeding may be on time or percent decided to terminate the pregnancy later. delayed. An additional 11.8 percent had a spontaneous abortion, and 5.9 percent placed the infant up for Unfortunately, this treatment is not 100 percent adoption. With better preventive care after the effective in preventing pregnancy. A review of 10 rape, it is possible that more of these pregnancies studies found an overall effectiveness rate of at least and abortions could have been prevented. 75 percent. That does not mean that 25 percent
75 Chapter 11: SANE Program Operation
will become pregnant. It means that if 100 women Maintaining have intercourse in the middle 2 weeks of their cycle, approximately 8 (8%) would become Chain-of-Evidence pregnant without postcoital interception. With Maintaining proper chain-of-evidence is as impor- interception only 2 (2%), representing a 75 tant as collecting the proper evidence. Completed percent reduction, of the 100 would become documentation, or chain-of-evidence, is essential pregnant (ACOG: 96). If the victim has not had and must include the signature of everyone who a period within 21 days she should be advised to had possession of the evidence from the individual have a pregnancy test. who collected the evidence to the individual bringing the evidence into the courtroom. If this Crisis Intervention and Counseling proper chain-of-evidence is not maintained, the Another basic component of the evidentiary exam evidence will be inadmissible (Ledray: 93b). If the is crisis intervention, mental health assessment, SANE must leave the room for any reason during and referral for followup counseling. Many SANEs the exam, the evidence must go with her (Frank: do their own crisis intervention and followup 96). She must be able to say in court that the counseling (Speck & Aiken: 95; Ledray: 92b); evidence was in her possession from the time it was others have rape advocates present in the ED or collected until the time it was secured in the locked clinic or refer to a local rape center, social service, refrigerator or given to law enforcement. Maintain- or to the hospital chaplain for followup counseling ing chain-of-evidence is critical to prevent any (Antognoli-Toland: 85). possibility of evidence tampering and to prevent the defense counsel from raising the issue of While many victims may want to “go home and reasonable doubt of evidence integrity. forget it,” experience tells the SANE that victims are seldom able to effectively do so. Continued It is not necessary, nor is it appropriate, for the fear and anxiety resulting from the rape can police officer to be in the exam room when the significantly affect the victim’s life, including her evidence is collected to maintain proper chain-of- work, school, and relationships with others far into evidence. The police can leave the area, and the the future (Ledray: 96a). The psychological impact nurse can call them when the exam is completed, and treatment needs of the victim has been ad- in 2 to 3 hours, to return and pick up the evidence. dressed extensively in the psychological literature. Both signatures on the chain-of-evidence A review of these crisis needs is beyond the bounds document are all that is necessary. When the police of this summary. Dr. Burgess summarized and cannot immediately return, the SANE can place labeled the psychological impact Rape Trauma the evidence in a locked storage area, preferably a Syndrome (Burgess and Holmstrom: 74). Self-help refrigerator with limited access, and when the books, such as Recovering From Rape (Ledray: 94), police do return, any available nurse can sign that are available for the large majority of rape victims she removed the evidence from the refrigerator and who do not return for counseling and are some- gave it to the police officer (Ledray: 93b). times recommended to victims in the ED by SANEs (Ledray: 96a). The Assistance League, a Maintaining Evidence national organization that for several years has Integrity provided clothing for rape victims after the eviden- tiary exam, began providing in October 1997 the While it is suggested that the specimen be refriger- book Recovering From Rape to sexual assault victims ated for long-term storage to prevent deterioration at the time of the evidentiary exam throughout the of the specimens, it is essential that the evidence be State of Minnesota and in parts of California kept in an area of less than 75 degrees Fahrenheit (Maggie Trenkmann. Personal communication, and the blood not be frozen. This means that October 24, 1997).
76 SANE Development and Operation Guide storage in an air-conditioned room is sufficient for Basic Documentation short-term storage (Ledray: 93b). ■ Location, date, and time of assault. Documentation ■ Nature of physical contacts. ■ Race, identity (if known), and number of The amount of documentation varies from pro- assailants. gram to program. Some SANEs ask specific investigative details including what the walls ■ Weapons and restraints used. looked like in the area where the victim was raped ■ Actual and attempted penetration of which (Frank: 96). Detailed information is included in orifice by penis, objects, or fingers. the Comprehensive Sexual Assault Assessment Tool ■ Sites of ejaculation, if known. (CSAAT). This tool was developed to provide a systematic guide for collecting information about ■ If a condom was used. the rape victim and offender. It includes detailed ■ Activities of the victim that may have destroyed investigative information about the victim and evidence, such as bathing, douching, bowel offender as well as victim forensic data and data movement, use of tampon. about the victim’s post-rape functioning. If this ■ If there was consenting sex within the last tool is widely employed by SANEs across the 72 hours and with whom. country, then it can be used as a research tool to compile statistics across programs (Burgess & ■ If the victim has changed clothes. Fawcett: 96). ■ Contraceptive use. ■ Current pregnancy. Other authors caution against collecting this detailed investigative information and suggest that ■ Allergies. the SANE should only ask for information neces- ■ Victim’s general appearance and response sary to deal with the immediate physical and during exam. psychological needs of the victim as well as to ■ Physical injuries. appropriately collect and interpret the physical and laboratory findings. Details reported by the nurse Sources: (Osborn & Neff: 89; Antognoli-Toland: 85; that differ from the police report may be used by Ledray: 92b; Slaughter & Brown: 92). the defense attorney to show discrepancies in the victim’s story. The only documentation required is It is important not to be afraid to include the name information necessary to guide the exam and treat of the assailant, just be sure to use qualifying the victim (Smith: 87). statements such as “patient states” or “patient reports” If the exam findings match the history It is important to remember that in addition to the given by the victim, the nurse should also docu- SANE assault exam report, the entire chart is a part ment that “there is congruence between the victim’s of the legal record and can be submitted as evi- story and her injuries” or “the injuries are consis- dence if the case goes to court. All statements, tent with the victim’s account of the assault” procedures, and actions must be accurately, com- (Sheridan: 93). pletely, and legibly recorded (Blair & Warner: 92). It is important to accurately and completely assess There is disagreement over the use of the term and document the emotional state of the victim “alleged” in medical documentation of a sexual and quote important statements made by the assault. Non-SANE medical personnel were taught victim, such as threats made by the assailant to use the term “alleged” because it was up to the (Antognoli-Toland: 85; Sheridan: 93).
77 Chapter 11: SANE Program Operation
court to decide if the rape occurred (Bobak: 92). Testifying in Court Several prosecuting attorneys state medical profes- sionals should never use the term “alleged” in Only a small percentage of cases will actually go to medical documentation as the term has negative trial, and the SANE will be called to testify. In a connotations and may be interpreted by judges and review of 372 cases seen in a Detroit ED in 1980, juries as meaning the victim exaggerated or lied only three went to trial and required medical (Sheridan: 93). testimony. Testimony about the injuries was a significant issue in only one of these cases. Ninety- seven percent of the guilty pleas resulted from plea After the Exam bargains (Tintinalli & Hoelzer: 85). It is impor- Many SANE programs have a place for the victim tant, however, to treat every case as if it will go to to shower, brush her teeth, and change clothes after court. Charting clearly and completely at the time the exam. They often provide her with a change of of the initial exam is the best preparation. clothes as well (Holloway & Swan: 93; Thomas & The SANE should always meet with the prosecutor Zachritz: 93; Frank: 96; Sandrick: 96). The Assis- prior to testimony to be better informed about the tance League, a national charitable organization, significant issues involved and the defense that will provides these services to rape victims in many likely be used to properly prepare her testimony in States throughout the country. If a chapter exists in the particular case. For instance, if it is significant an area that does not currently provide this service, that no physical injuries were found, the SANE it may be willing to do so after being made aware should review the data on the likelihood of injury of the need. during rape; if it was a delayed report, she should It is not unusual for the victim to be afraid to review the data on the typical time between rape return home alone, so it is important to offer to and reporting. If the prosecutor does not initiate call a friend or relative to be with the victim during this meeting, the SANE should do so. Because of the exam and to take her home (Ledray: 96a). her training and experience, the SANE will likely More than 50 percent of rape victims move or be qualified to testify as an expert, rather than just change their phone number as a result of the rape a factual witness, in sexual assault cases (Ledray & (Tintinalli & Hoelzer: 85). Anticipating this Barry, 1998). potential move, while in the ED, the SANE may want to get the phone number of a close friend The SANE needs to conduct herself professionally who will always know how to contact the victim. and confidently in the courtroom. She should dress appropriately for the occasion. When sure of the Since the victim may be in a state of emotional facts, she should communicate that certainty. shock at the time of the initial examination, it is When she is uncertain or if she does not know the important to provide her with written discharge answer to a question, the SANE should also information to take home with her (Osborn & communicate this. If she does not understand a Neff: 89; Speck & Aiken: 95). Followup phone question, she should ask for the question to be calls within 24 to 48 hours to check on her emo- repeated and should never attempt to guess the tional and physical status, medical concerns, and meaning of the question. She should never demon- compliance with medications provided and to strate anger, even if the defense attorney asks the assist with additional referrals are also recom- same question repeatedly. It is important for the mended (Osborn & Neff: 89; Ledray: 96a; SANE to define her area of expertise and not Tintinalli & Hoelzer: 85). testify about other matters such as the accuracy of DNA evidence. Watching a criminal trial or participating in a mock trial is excellent prepara- tion and increases confidence.
78 SANE Development and Operation Guide
Working with Special revealing the sexual assault. Five of the men did not initially report their sexual assault. It is impor- Populations tant to teach emergency personnel to ask men who Male Victims present for treatment of physical injuries if they have been sexually assaulted in a way that preserves As with the rape of women, the rape of men is often dignity for the victim and demonstrates a not sexually motivated, but rather is a crime of nonjudgmental or neutral attitude on the part of aggression (Groth: 90). Sexual assault treatment the caregiver. centers report that males comprise approximately 6 percent to 10 percent of their clientele (Koss & Male victims of sexual assault experience post Harvey: 91; Libscomb, Muram, Speck & Mercer: traumatic stress reactions similar to those observed 1992). Male rape is generally thought to be more among female victims with fear being most com- underreported than female rape. Male rape victims monly reported, followed by depression, suicidal are even less likely to report than women because behavior or ideation, anger, somatic problems, of the extreme embarrassment that they typically sexual dysfunctions, and disturbances in peer experience and because many men fear being relationships (Koss & Harvey: 91). Men will need misunderstood as homosexual. Most male rape the same level of crisis intervention and followup victims have not considered the fact that men are care as women. However, males may be less likely also raped, and this contributes to the devastation than females to seek and receive support from and stigmatization that they experience. This family and friends. Their ability to seek support trauma is similar to that experienced by a female will vary according to the level of stigmatization victim who, while aware that rape does occur, never they feel, the circumstances of the rape, and the considered that she could become a victim of rape. sensitivity of care they receive in the ED or SANE community clinic. Donnelly and Kenyon (1996) Lipscomb, Muram, Speck, and Mercer (1992) point out that when a man is rectally raped, reviewed 99 male rape cases seen at their center. pressure on the prostate can produce erection and Of these, 80 were incarcerated and 19 were from even orgasm, which may be confusing to male the community. The men represented 5.7 percent victims. Heterosexual men may struggle with issues of their clientele. They found that all of the men surrounding sexual orientation. Some men may were raped by other men, except for one who was feel that their body has betrayed them. The SANE raped by two women during a robbery and extor- can allay fears and confusion by explaining that tion attempt. None of the victims was injured to this is a physiological reaction to pressure on the the point of needing medical attention. As with prostate. women, threat of physical force alone was sufficient to subdue them. Only two men, both Victim gender is not an indicator of the offender’s inmates, sustained even minor injuries. The sexual orientation or preference. In a study of community victims were older and more likely to convicted male sex offenders who raped men, A. have had weapons used against them. Nicholas Groth (1990) found that at the time of their offense, all of the men were actively engaged Another study conducted by Kaufman et al. in consenting sexual encounters or relationships, (1979) comparing 14 male victims with 100 with 9 percent reporting that those encounters female victims, found that the males were more were almost exclusively with other men and 32 often injured. Nine males (64%) were beaten, five percent reporting sexual activity with both men severely, compared with 23 percent of the women. and women. In Groth’s study, 27 percent of the The men were also more likely the victims of convicted sex offenders reported that they confined multiple assaults by multiple assailants and were their consenting sexual activity to women and half more likely to be held captive. The men were more of them were married. likely to seek treatment for injuries without 79 Chapter 11: SANE Program Operation
The SANE serves male victims well by taking the population, about 30 percent (Abbott: 97). It is time to listen to what their experience was, what important for the SANE to sort through her they were feeling as it happened, and what their feelings about same gender relationships so that immediate concerns are. It is helpful to describe she can treat all victims with dignity, respect, and common reactions men have after being sexually compassion. All people who have been abused by assaulted and to stress that men do get raped their partners report the same range of feelings of regardless of who they are, what they were doing, fear, anger, guilt, depression, and anxiety over their or how they look. Men may worry that they appear living situation. too effeminate, and this caused the assault. Gay men may wonder if the offender assaulted them The majority of stranger assaults on people of the because of their sexual orientation and struggle same gender involve men, usually heterosexual with resultant self-blame. All men, just as with all men. When the victim is gay or perceived to be women, need to be reassured that their appearance, gay, and the perpetrator attempts to humiliate or sexual orientation, and sexual preference had demean him, the assault can be considered in some nothing to do with them being raped. Men are States as part of a hate or bias crime involving susceptible to the same techniques by which rapists power and control over the victim. Not all States gain control over female victims, the use of weap- consider same gender sexual assault as a bias crime. ons, entrapment, intimidation, threats, and Alabama, for example, states that a bias crime is coercion. one based on the offender’s bias towards a victim’s race, color, ethnicity, religion, physical, or mental Men who have been raped by women suffer the disability. Both gay and heterosexual victims who same feelings of helplessness, fear, and anxiety as have been sexually assaulted are at high risk for do women who have been raped by men. They depression and suicidal behavior. After being will, however, need more anticipatory guidance in sexually assaulted by a man, gay men frequently considering how friends and family members may feel more stigmatized and vulnerable, and hetero- react. Many men will react to a man who tells sexual men usually go through a process of ques- them he was raped by one or more women by tioning their sexuality (Abbott: 97). laughing and saying, “Why doesn’t that ever happen to me?” The victim is left with his intense While female same gender assault is very rare, it fear and anxiety invalidated which can lead to does happen. Women who are forced to have sex feelings of self-doubt, isolation, stigmatization, and with other women experience the same emotional depression. reactions as women who are forced to have sex with men. They may also go through a process of Same Gender Sexual Assault questioning their sexuality if they are heterosexual or have an increased sense of vulnerability if they While little quantitative or qualitative research is are lesbian or bisexual. The SANE needs to sort available on same gender sexual assaults, it is through what kind of contact took place and important for the SANE to understand the dynam- collect evidence wherever there may be hair, saliva, ics involved in same gender assaults. The term or vaginal secretions from the assailant. “homosexual assault,” which is often used in the literature, is not accurate in that many of the Gay and Lesbian Victims perpetrators of same gender sexual assaults are not “homosexual.” As with all people who have been sexually as- saulted, the degree to which persons who are gay The majority of same gender acquaintance assaults or lesbian will be able to recover from a sexual occur as part of a pattern of domestic abuse in assault depends on the amount of support they same gender relationships. The rate of same gender have. Their recovery will also be affected by the domestic abuse reflects that of the heterosexual amount of discrimination they experience from the
80 SANE Development and Operation Guide community around them including the health care Lesbian victims of sexual assault by men experience and legal professionals charged with their care after a unique constellation of concerns. Lesbians the assault. Fear of disclosure is frequently a major constitute the lowest risk group for sexually issue, even for people who are very publicly open transmitted diseases of all sexually active adults and about their sexual orientation because of the may not be well aware of current STD risks from further loss of control it represents. Even if the heterosexual exposure. They also have not had to assault was not a crime of bias or hate, often it feels worry about pregnancy risks and will need careful as though it is and results in increased anxiety, deep counseling about pregnancy risk and prophylaxis. personal doubt, negative self image, and depression For women who have not had sex with a man, (Miller: 97). vaginal penetration may be painful both physically and emotionally. Lesbian women often report People who are well integrated into the gay and sexual dysfunction after a rape which can be lesbian community may, however, have additional confusing as they ponder why the experience of strengths with which to deal with the sexual violence with a man has carried over to their assault, gained from the coming out process and nurturing sexual relationship with another woman. the constant consideration of hate and bias crimes Lesbians, like others, often wonder if the rape was and how to heal from them (Miller: 97). their fault, but it may also bring up a deep-seated sexual confusion as the victim questions if she At particular risk are adolescents who live in really wanted the assault to happen and whether it families or communities where homosexuality is occurred because she looks straight. Many lesbians not accepted and who are just beginning to explore feel intense shame at having been violated by a issues of same gender sexual orientation but do not man and forced to have sex with someone other have supportive connections in the gay and lesbian than her gender or sexual preference—which community. Being raped by someone of the same represents an extra dimension beyond the experi- gender and considering the ramifications of ence of straight female or gay male rape victims. reporting can produce extreme anxiety. The SANE Common emotional reactions include a sense of needs to understand that the adolescent’s sexual isolation, vulnerability, punishment, and paranoia identity is in the process of unfolding and using (i.e.,“Did he pick me because I look gay?”). Many labels like “gay” or “lesbian” may be premature and lesbians report a deep sense of shame at having threatening. It is less threatening to talk about been violated by a man, which damages their sense attractions and interests. Confidentiality is of of self in that they had previously prided them- utmost importance for these youth as premature selves on their independence and self-sufficiency disclosure of sexual orientation can be extremely but now feel extremely vulnerable. It is important dangerous when the adolescent does not have the that SANEs have accurate information about strength or support in place to deal with ho- lesbianism and anti-lesbian crime so that they can mophobic reactions of people in their family and provide sensitive, appropriate care to lesbians who community. Psychological autopsies have shown have been sexually assaulted (Tallmer: 96). that roughly one-third of all adolescents be- tween the ages of 15 to 19 who have committed People with Developmental Disabilities suicide were struggling with issues of sexual identity (Dexheimer Pharris: 95). SANEs must A review of assault rates indicates that from 68 pay special attention to helping adolescents, who percent to 83 percent of people with developmen- have experienced same gender sexual assaults, sort tal disabilities will be sexually assaulted in their through all of the ramifications of reporting. These lifetime, which represents a 50 percent higher rate youth will need referral for supportive services as than the rest of the population (Pease & Frantz: they sort through their reactions to the assault and 94). Of the sexual assaults of people with develop- continue to explore issues surrounding sexual mental disabilities, 30 percent are by family identity. 81 Chapter 11: SANE Program Operation
members, 30 percent by friends or acquaintances, In caring for people with developmental disabili- and 27 percent by service providers, with the ties, it is important for the SANE to do a brief likelihood of abuse by service providers increasing assessment of the victim’s cognitive capacity so that as the severity of disability increases. People with appropriate care can be given. Specifically, the developmental disabilities are more likely to be re- SANE needs to determine if the victim has the victimized by the same person and more than half ability to provide informed consent, which entails never seek assistance from legal or treatment the cognitive capacity to weigh the risks and services (Pease & Frantz: 94). Reporting may benefits of different treatment options and the involve a loss of independence, for example, if a ramifications of reporting or not reporting an person is enjoying a new sense of independence in assault. The ability to provide informed consent is a group home. Reporting an ongoing assault by a affected not only by cognitive capacity but also by staff member or other resident may pose the threat the level of emotional stress a person is experienc- of reinstitutionalization. ing. People who are otherwise very high function- ing may lack the ability to make even simple When someone is sexually assaulted by a person decisions after experiencing the trauma of an from a professional helping agency licensed by the assault. The SANE must continually assess whether State, a criminal report may be filed by the victim, the victim understands what she is saying and however, the SANE as a mandated reporter will doing. need to assure that the State licensing agency receives a report of the abuse to investigate miscon- In determining decisionmaking competence, the duct. Some States have vulnerable adult protection SANE is balancing two very important ethical agencies that serve as contact points for such values: protecting and promoting the individual’s reports. well-being and respecting the individual’s self- determination (Buchanan & Brock: 89). A first One of the factors that keeps people with develop- consideration is whether or not the person is her or mental disabilities at a greater risk for sexual assault his own guardian and whether she or he functions is the lack of good educational curricula to instruct independently in the community. In cases where people with developmental disabilities about the person has been deemed legally unable to the nature of sexual assault and how to assert provide informed consent, it may be necessary to themselves in establishing and maintaining self- contact a legal guardian to obtain consent to do an protective sexual boundaries. Even though 99 evidentiary exam. If a legal guardian is not avail- percent of assaults on people with disabilities able, the SANE proceeds with evidence collection, involve offenders who are known to the victim, acting in what she perceives to be the victim’s best the majority of self-protection curricula is geared interest and informs the legal guardian as soon as towards stranger rape (Seattle Rape Relief: 97). he or she is available. Exams are never done against Readers are referred to a manual written by Terri a person’s will. The reason for the exam should be Pease, Ph.D. and Beverly Frantz, M.S. entitled explained in terms that victims can understand and Your Safety...Your Rights & Personal Safety and their consent/assent should be obtained regardless Abuse Prevention Education Program to Empower of legal ability to provide informed consent. In Adults with Disabilities and Train Service Providers situations where the victim is not able to verbally published in 1994 by the Network of Victim express his or her wishes, the SANE must be Assistance, 16 N. Franklin Street, Suite 105, sensitive to grimaces and body movements so as to Doylestown, PA 18901, 215–348–5664. A video never retraumatize a person who has been sexually by the same name is available through Fanlight assaulted. As with any person who has been Productions, 47 Halifax Street, Boston, MA sexually assaulted, throughout the exam, the SANE 02130, 617–524–8838. explains what she is doing and why, in terms that the victim can understand.
82 SANE Development and Operation Guide
The SANE must also determine the sexual assault People with Physical Disabilities victim’s capacity for processing information. The People with physical disabilities may also be at use of concrete examples and language is recom- greater risk for sexual assault, especially if they are mended for all victims. Even though a person may dependent on others for personal care. Ninety-nine be living on her own or driving a car, she may not percent of offenders who sexually assault people be able to read or to process complex abstract with disabilities are known to their victims (Seattle concepts. People who have developmental or Rape Relief: 97). When the offender is someone learning disabilities may be reluctant to admit that who is supposed to be in a helping relationship, they cannot read well or at all. It is best to say, concerns about loss of services and independence “There are some important things I would like to arise. The victim is left with fear and anxiety over teach you. How do you learn best? By having the potential harm from people whom they should someone tell you? Through pictures? Through be able to trust and rely on for assistance and reading?” The SANE will need to assess retention support. This can lead to overwhelming feelings of of new information. A social worker or public vulnerability, stigmatization, and depression. If the health nurse may need to be involved in planning assailant works for a helping agency, a report to the post-assault care. State licensing board is mandated. People with limited abstract reasoning skills will After having been sexually assaulted, people who need help in trying to determine who to tell about are differently abled respond emotionally in all the the assault and who they do not want to know same ways that people who are currently able- about the assault. Often when they return home bodied respond. They may, however, need to talk or to school or work, people with developmental through how they perceived the role their disability disabilities freely disclose details of the assault and might have played in making them more vulner- become revictimized by the attention of those able to the assault. The SANE can listen to their around them. The SANE can greatly assist the concerns and what the experience was like for victim by talking through how different people will them. They will benefit from reviewing the roles react, who needs to know, how much to share with force, threats, and coercion play in rape and from whom, and what the possible ramifications are of being reminded that even strong able-bodied men sharing information. For people who are unable to and women are sometimes raped. imagine people’s possible reactions and who are very verbal, it may be best to encourage a few days People who are differently abled are only “disabled” off of school or work so that they can process their to the extent that their differences are not accom- strong feelings and reactions with staff or counse- modated for by society. It is imperative that SANE lors rather than with people on the bus or at work programs provide services that are equally acces- or school. sible to all people.
In considering whether to share information about Because so much of the post-assault care involves the assault with other professionals in the victim’s an exchange of information (telling the story of the life, the SANE is weighing the person’s well-being assault, discussing feelings, explaining the eviden- with the right to confidential care and need to be tiary exam, teaching about common symptoms of in control of who is told. When staff from group rape related post traumatic stress disorder and homes or other social service agencies are present, means of coping, etc.), people who are deaf or hard it is important to honor the victim’s right to of hearing will need sensitive and appropriate care. confidentiality and discuss with her or him what Deaf is defined as a hearing loss of such severity information can be shared. Confidentiality should that the individual must depend primarily upon not be broken except when there is a clear need to visual communication such as writing, lip reading, involve another caring person to protect the victim manual communication and gestures. Hard of from additional harm. 83 Chapter 11: SANE Program Operation
hearing is defined as a hearing loss resulting in a seems to be having trouble understanding. functional loss, but not to the extent that the Be sensitive to the fact that she will be individual must depend primarily upon visual observing closely your body language and communications (Schumacher & Hung Lee: 97). will pick up on visual signs of frustration. While deafness is not a handicap in and of itself, Try to relax and to help her relax. deaf and hard of hearing people are handicapped ■ Look directly at the person while speaking. by the lack of services that provide sign language Even a slight turn of the head can obscure interpreters. SANE programs must have a system the Deaf [or] Hard of Hearing person’s in place to communicate with people whose vision. Do not talk to her if your back is primary means of communication is signing. The turned or when you are in the dark or in program should also provide access to a TTY/ another room. Do not turn away in the TDD (teletypewriter/telecommunications device) middle of a sentence. Other distracting for deaf and hard of hearing people to call. factors affecting communication include mustaches which obscure lips, smoking, The following guidelines for caring for people who pencil chewing, and putting your hands in are deaf or hard of hearing were compiled by Kathy front of your face. Schumacher, edited by May Hung Lee and pub- ■ lished in the Minnesota Coalition Against Sexual Do not speak to a Deaf [or] Hard of Hearing Assault Training Manual (1997, pp. 2-49–2-51): person with your back to a light, window or mirror. Have the light in YOUR face, not ■ When Deaf [or] Hard of Hearing victims hers. seek services, they will have the same basic ■ Every Deaf [or] Hard of Hearing person will needs and fears that hearing victims have. communicate in a different way. Some will They need to feel welcome. Motion the use speech only; some will use American person to follow you to a quiet office. Tell Sign Language only; some will use a combi- the individual your name. Write it down on nation of sign language, finger spelling, and paper if the victim does not seem to under- speech; some will use body language and stand. Ask the victim if he or she wants an facial expressions to supplement their interpreter—there are sign language inter- interactions. Deaf [or] Hard of Hearing preters as well as oral interpreters. Also, let people use many ways to convey an idea to the victim know (on paper, if necessary) that another person. Sign language is an inclusive you will be calling for an interpreter. term that refers to any method of communi- ■ It is important to have the Deaf [or] Hard of cation: American Sign Language, signing Hearing person’s attention before speaking. exact English, finger spelling, and any Since she cannot hear the usual call for combination of these. attention, she may need a tap on the shoul- ■ Just as each individual has her own style of der, a wave of the hand, or other visual speaking, grammar usage, vocabulary, and signals to gain her attention. Do not speak favorite idioms and clichés, Deaf [or] Hard before she is ready to listen. of Hearing people also have their own ■ If the victim is wearing a hearing aid, do not individualized manner of speaking in sign assume she will or should have good hearing. language. People who use exact English are She will still have some difficulty and will probably more able to converse through benefit from your consideration. written means. Often, hiring a sign language ■ Whether she indicates she can read lips or interpreter will be your only effective com- not, body language and gestures will help munication method with someone whose communication. Write down any words she native language is American Sign Language. Understand that American Sign Language
84 SANE Development and Operation Guide
(ASL) is not the same as English. The ■ People with some hearing loss find it is hard interpreter is trained to recognize and utilize to hear in the presence of background noise, similar signs as the Deaf [or] Hard of Hear- so be sure to move away from such noise. ing person. Examples of American Sign ■ Ask her to let you know what to do to better Language, as written may be: Movie last enable her to understand you—her hearing night. Wow good. Should see you. Laugh ability will vary with rooms, background roll (“The movie I saw last night was very noise, fatigue, and many other factors. good. You should see it. I laughed so hard I was almost falling on the floor.”), or Home People who have impaired vision usually do not many problems. Not good my house. Want need assistance in familiar surroundings but will out finish trouble. (“There are a lot of need accommodations when they are in the problems at home. My house is not a pleas- hospital or clinic for a sexual assault exam. They ant place right now. If my husband/boy will need to be oriented to their surroundings. It friend/partner leaves, the trouble may stop.”) will be especially important to talk about every- To someone familiar to sign language, thing you are doing. Before you touch them, this manner of expression is quite clear. explain that you will be touching them and how Interpreting word for word is not always and why. When moving from one room to the understandable. next, they can be offered your arm to grasp above ■ Try to maintain eye contact with the deaf the elbow for guidance. Verbally point out obstruc- person. Eye contact helps convey the feeling tions, like chairs, exam tables, etc. Always tell the of direct communication. If the interpreter is person when you are leaving the room. If the present, continue to talk directly to the deaf victim has a guide dog, do not be diverted by [it] person. Do not use phrases such as “Tell her or ask about the dog’s reaction—this distracts that.” Speak directly to her. blame from where it belongs—with the rapist (Erb: 96). ■ Be flexible in the use of language. English may not be a Deaf [or] Hard of Hearing person’s primary language, and therefore you The Elderly may need to simplify your sentences. Many people do not recognize that the elderly are ■ Pantomime, body language, and facial at risk for sexual assault. Older women with expressions are important factors in commu- impaired mental functioning are especially vulner- nication. Experiment with different tech- able. Rape may go undetected when health care niques. Be sure you use all of them. professionals overlook the signs. Community ■ Do not shout or use exaggerated lip or facial health care facilities with large populations of movements. Use an almost normal rate of elderly women need to be educated by the SANE speaking—not too fast, but not so slowly that regarding symptoms of a potential sexual assault the natural rhythm is lost. The thought and how the health care facility staff should should come as a whole. Take care to “round respond when an assault is suspected. Whenever an off words.” Enunciate clearly and distinctly, assault occurs in a health care facility, the appropri- keeping the voice as vibrant as possible. ate governmental adult protection agency must be notified, and they in turn are responsible for ■ Do not assume the victim can read lips. reporting the incident to the State health care ■ Use words with the most lip movement, facility regulating agency. such as “25 cents” instead of “a quarter.” ■ If she does not understand, change the Decreased hormonal levels following menopause wording. Use other expressions that get the result in a reduction in vaginal lubrication and same point across. Do not repeat the same cause the vaginal wall to become thinner and more phrase over and over. 85 Chapter 11: SANE Program Operation
friable. Therefore, elderly women are at an in- sexual assault in the past, or an incest experience creased risk for vaginal tears and injury when they and withdrew and dissociated from the partner. have been vaginally raped. Because of these physi- The victim may also have re-experienced the ological changes, a pedersen speculum, which is traumatic experience while alone. This usually longer and thinner than the graves speculum, occurs during times of stress for the woman, such should be used during the pelvic exam for evidence as following the first disclosure of incest or the collection, and special care should be taken to recent loss of a loved one who has been supportive, assess for intravaginal injury. In some elderly or following an intense therapy session in which women, the SANE will need to simply insert the the precipitating trauma was discussed. swabs and avoid the trauma of inserting a specu- lum. Just as with premenarchal young women and Clues for the SANE to look for in suspected false- children, if there are external tears in the introitus, reporting cases include a vague description of the internal injuries must also be considered. assailant, too vague for the described circumstances of the assault, often not even including his race; Declining physical strength and agility heightens stalking, including leaving notes telling the victim the elderly’s fear of not being able to resist or how beautiful or terrible she or he is; superficial escape an assault. For the elderly, loss of hearing cuts or scratches of the inner thigh or inner arm, increases the fear that an intruder will not be consistent with the victim’s handedness; an unusual heard. Loss of visual acuity causes shadows to take event reported as part of the rape, such as dirt and on an ominous quality heightening fear. Frail leaves in the vagina; unusual patterned injuries elderly are at greater risk for injury. After an such as superficial straight patterned cuts intersect- assault, well-meaning relatives may wish to place ing the nipples described as occurring during a an elderly family member who has been raped in a struggle; and multiple rape reports. The victim nursing care facility, which serves to further limit may also report a history of incest that resembles their independence and poses the threat of never the current trauma she or he is reporting. returning to independent living (Simmelink: 96). The SANE can assist elderly victims and their Fortunately, it is not the SANE’s job to determine family members to make plans that maximize the if the person was raped, so evidence collection with person’s independence yet assure her safety. The these cases should proceed as usual. The SANE SANE is able to refer the family to individuals and should not, however, be afraid to indicate “injuries agencies that can work with them in assuring an inconsistent with reported history” if that is the appropriate placement, if needed. Any placement case. Since the role of the SANE is to provide the should protect the elderly rape victims without care required for every victim, in these cases further limiting her enjoyment in life and sense of especially, mental health assessment and referral autonomy. are essential (Ledray: 94).
Self-Injury Victims Refugees and Immigrants Self-injury victims are a special subcategory of Refugees are people who had to leave their native victims who may make false reports. It is particu- country and are seeking asylum in the United larly important that the SANE be aware of clues to States because it was too politically or physically false reports from this victim group. It is not dangerous to stay in their homeland. Immigrants uncommon for victims who have not resolved are people who have chosen to come to the United some past trauma to injure themselves and report States. In the past few decades, many men and having been raped. The victim may have actually women came to the United States from Southeast had sex with someone who thought the sex was Asia, South America, Central America, Northern consensual, but during the sexual contact, the Africa, and Bosnia as a result of war. Refugees and victim had a traumatic re-experiencing of a painful new immigrants are especially vulnerable to
86 SANE Development and Operation Guide victimization. They may be particularly vulnerable admits to being raped. Both male and female if they immigrated illegally and are afraid to report victims may admit to a physical assault, especially violent incidents or if they are uneducated and if there are injuries to explain, however, even when unaware of their rights, or how to access services. asked directly, they may deny any sexual contact. Assailants assume that people who are undocu- This will be problematic to the SANE, the police, mented will not report an assault to the legal and the prosecutor if the evidence of the rape is authorities for fear of being deported. Sexual identified later. Valuable evidence will have been predators capitalize on the vulnerability of recent lost and credibility as a witness will be in jeopardy. immigrants and refugees. To facilitate a truthful disclosure early, it is essential that the SANE interview the victim in privacy and While accurate numbers are not available, the work at building a trusting relationship. If the literature indicates that in refugees seeking counsel- victim does not speak English, a professional ing, 52 percent of the men and 80 percent of the interpreter must be provided. women were sexually tortured during the war or political conflict in their home country (Agger: Because the consequences of rape within their 87). When people who have been sexually tortured cultural context are so grave, women from some are raped, they not only experience the trauma of non-Western cultures may not seek treatment the rape, but also are vulnerable to a traumatic re- immediately following a rape. They may wait until experiencing of the sexual torture. For refugees an injury, pregnancy, or a sexually transmitted who were subjected to torture in their native disease forces them to seek medical care. They may countries, a doctor or nurse was often present at also be in extreme emotional crisis and suicidal. the time of torture. For this reason, the mere Understanding the meaning of rape in their culture presence of medical personnel after a rape may be and knowing appropriate, culturally sensitive anxiety producing. SANEs should be aware of this referral sources is crucial. Strict confidentiality, possible history and realize that due to the devas- even from other family members and staff from the tating nature of the experience and its emotional victim’s culture must be maintained (Mollica & sequelae, most torture victims will not readily Son: 89). While bicultural staff are most often an disclose a history of torture. Extra care must be advantage and facilitate understanding and cred- taken to assure refugee or immigrant rape victims ibility, with some victims, they can be a threat to that they do not have to do anything they do not confidentiality for the victim and should not be want to do and that if something hurts, they present. The social stigma of people from the should let the SANE know, and the SANE will community knowing about the assault can be so stop. The SANE should explain what she is doing powerful that it prevents the victim from telling and why. The victim should be encouraged to keep what happened and getting needed care. The her eyes open during the pelvic exam—this will victim needs to have control over whether a reduce the likelihood of flashbacks to the torture specific professional interpreter will be utilized, experience. Torture victims who have been raped especially if the interpreter is from his or her need to hear that they have not sustained any community. Although it is always essential to permanent physical damage and be reassured that explain the person’s legal right to confidential care, their body will heal, if this is the case. Just as with many people who come from war torn countries incest victims, they will need additional support in will not be able to trust promises of confidentiality, the rape recovery process. no matter how strong, because of the extensive use of informants in their home country. Under If a female victim comes from a culture that blames conditions of war, people are reluctant to confide the victim for rape or does not consider her in and trust even close friends. Therefore, a tension marriageable once raped, she may deny that she develops between the need to have a culturally was raped. If married, she may reasonably fear that specific interpreter skilled in the victim’s dialect her husband will blame her and/or reject her if she 87 Chapter 11: SANE Program Operation
present and the need to maintain complete confi- The following guidelines adapted from the Center dentiality. Generally, both male and female victims for Cross-Cultural Health’s handbook, Caring of sexual assault will feel more comfortable with a Across Cultures: The Provider’s Guide to Cross- female interpreter and staff. Cultural Health Care (1997) outline important principles in working with interpreters: Working with Interpreters ■ Meet with the interpreter briefly before the Providing interpreter services is not optional, it is interview to explain the situation and what legally mandated. The U.S. Department of Health kind of questioning and teaching you will and Human Services considers lack of interpreta- need to be doing. Attend to any personal tion to be a form of discrimination. Title VI of the issues the interpreter may have regarding Civil Rights Act of 1964 [601 78 Stat 252 942 sexual assault. Discuss how the interaction USC 2000d)] states that “no person in the United will proceed and where the interpreter States shall, on the ground of race, color, or should sit. If the interpreter needs to be in national origin, be excluded from participation in, the room during the exam, she can be on the be denied benefits of, or be subjected to discrimi- other side of a curtain to assure maximal nation under any program or activity receiving privacy for the victim. [Note: Ask the Federal financial assistance” (Center for Cross- interpreter about any areas requiring cultural Cultural Health: 97). sensitivity prior to the interview.] ■ The legal aspect of the SANE exam demands that When speaking, address yourself to the the environment be one in which the assault victim victim, not the interpreter. Maintain eye is comfortable enough to honestly describe what contact, as appropriate, with the victim, not happened to her. Due to possible cultural sensitivi- the interpreter. Speak directly to the victim, ties and the potential of breach of confidentiality, addressing him or her as “you,” not the family members or friends should never be used as interpreter. interpreters in providing care and collecting ■ Don’t say anything you don’t want the victim evidence. Many SANE programs utilize the to hear. Expect everything to be translated. interpreter services of local medical and legal Realize that what may be said in a few words agencies. Professional interpreters not only speak in one language, may require a lengthy both languages but are also trained in how to make paraphrase in another. a person’s message clear. The professional inter- ■ Speak clearly, in a normal voice and not too preter is also held accountable for confidentiality, fast. Stop at comfortable intervals for the accuracy, and unbiased interpretation of what has interpreter so that she can translate what you been said. Consequently, it is also not sufficient to are saying accurately and completely [— use a bilingual staff person to interpret. Employing generally] one long sentence or three or four highly skilled, professional interpreters is an short ones. Stop at a natural place for the essential component of providing comprehensive interpreter to pass your message along. services to non-English speaking victims of sexual Always stop at the end of a sentence. Short assault. Interpreter services need to be planned in simple sentences are easier to translate. advance for the immigrant groups residing in the ■ Expect the interpreter to interrupt when SANE’s area of service. (The reader is referred to necessary for clarification or to take notes if this chapter’s section on “People With Physical things become complicated. Disabilities,” which covers issues surrounding the ■ Avoid jargon and technical terms. You may need for interpreters for people who are deaf or need to repeat what you have said in differ- hard of hearing.) ent words if your message is not understood.
88 SANE Development and Operation Guide
■ Meet with the interpreter afterward to assess Providing Culturally how things went and to see if she is satisfied with the accuracy of the information passed Congruent Care along. Also attend to any vicarious traumati- The way people react to and recover from sexual zation she may be experiencing from having assault is largely determined by the culture(s) passed along the story of the assault. within which they live. An essential part of SANE ■ Have the interpreter sign a statement that training involves assuring competency in providing she interpreted for you and the victim culturally congruent care. Culture does not simply including the date, time, and agency for refer to ethnic origin or race, but rather implies all which she works. of the groups and subgroups that surround and support individuals. Transcultural nurse theorist In situations where an interpreter is not available Madeleine Leininger (1995) defines culture as the for the language of the victim, or when the avail- learned, shared, and transmitted knowledge of able interpreter is a member of the victim’s com- values, beliefs, norms, and lifeways of a particular munity and she or he prefers a stranger, there are group that guides an individual or group in their phone medical interpreter services that can be thinking, decisions, and actions in patterned ways. accessed. The drawbacks of phone interpreter Subculture is closely related to culture and refers to services are the expense and the inability to pick up a group that deviates in certain areas from the on nonverbal cues. The following services can be dominant culture in values, beliefs, norms, moral accessed for interpreter services (Center for Cross- codes, and ways of living with some distinctive Cultural Health: 1997): features of its own. Leininger (1995) defines culturally congruent care as those cognitively based AT&T Language Line Service, 1 Lower Ragsdale assistive, supportive, facilitative, or enabling acts or Drive, Monterey, CA 93940, 800–874–9426 or decisions that are mostly tailormade to fit with an 800–752–0093 (call to set up an account or hear individual’s, group’s, or institution’s cultural values, a recorded demonstration of the Language Line beliefs, and lifeways in order to provide meaning- service). The service have up to 140 languages and ful, beneficial, satisfying care that leads to health is available 24 hours a day, 7 days a week. They can and well-being. usually connect you with an interpreter within 60 seconds. For frequent users who subscribe to the An individual’s culture(s) will shape the way she service on a monthly basis, the rates are $2.20 to experiences a sexual assault and how she will $4.50 per minute depending on the language and recover from it. To provide culturally congruent the volume discounts available. For users who care and to be of maximal assistance to her clients, cannot predict their need on a monthly basis or each SANE needs two essential skills: 1) the ability justify a monthly minimum, the rates are $3.50 to to acquire essential knowledge about the cultures $4.50 per minute depending on the language. For and subcultures in her service area and 2) the occasional users, the rates are $4.15 to $7.25 per ability to do a culturalogical assessment to deter- minute, depending on the language. mine the degree to which each individual ascribes to cultural values and mores governing sexual Pacific Interpreters, Inc., 1020 SW Taylor, Suite assault and recovery from trauma. 280, Portland, OR 97205. 800–870–1069 or information@pacinterp (e-mail). They have more There is a temptation to use a cookbook approach than 65 languages and specialize in interpreting in to caring for people from various cultural back- the health care and social service areas and charge grounds, listing how each individual culture sees $1.95 per minute with volume discounts available.
89 Chapter 11: SANE Program Operation
sexual assault. While broadly informative, this young woman feels, what she thinks might hap- approach carries the danger of stereotyping indi- pen, and what she wants to do. Victims may be viduals and of not responding in a way that is reluctant to further stigmatize people of their race. comfortable or helpful to them. The SANE does, Many women who have been raped by men from however, need to know the potential differences their own minority racial group are faced with and similarities between her culture and the intense conflicting feelings of wanting to hold the culture(s) of the people she serves. The following assailant accountable, yet not wanting to send process is recommended: another man of her race to jail. If victims perceive the legal system as being racist and not trustwor- 1. Analyze your own cultural beliefs and values. thy, they may fear sending an innocent man to jail Formal cultural assessment guides are available to for their assailant’s crime (White: 94; Wilson: 94). assist nurses in this process such as that provided The SANE needs to be aware of and sensitive to by the Center for Cross-Cultural Health (1997). these dynamics in her community.
2. Get to know the cultures in your service area. 4. Be aware of culturally appropriate referral General cultural guidebooks such as those written sources for followup care and develop partnerships by Lipson, Dibble, and Minarik (1996) and Geissler with them. Culture shapes the way we frame (1993) provide an overview of different cultures, traumatic experiences and how we best heal from but it is best to meet with people from the cultures them. They may thus reach for a larger lesson to represented in your community who are knowledge- be learned from the experience and not be so able about health care practices. Listen to them extremely overwhelmed by feelings of guilt and about their experiences and beliefs surrounding shame, but rather deal with the painful situation sexual assault, reporting, and recovery. Optimally a by using tolerance, denial, or stoicism (Kanuha: partnership will be formed to best serve people 97). Other cultures may have a specific ritual for from that community. Each SANE program needs healing post traumatic stress, such as the Navajo to be proactive in establishing these partnerships Enemy Way ceremony. This is a ritual in which with all communities in the service area. the family and tribe accept responsibility for the impact of trauma on young returning warriors 3. Become proficient in conducting culturalogical through the use of a healing ceremony which assessments. This involves assessing where each facilitates processing war trauma and reintegration individual is at in terms of their own unique set of into the peacetime community (Marsella, Fried- values, beliefs, and lifestyle. It also involves being man, Gerrity & Scurfield: 1996). Juris Draguns aware that clients may belong to subcultures or (1996) points out that cultures vary in their groups such as gay, lesbian, transgender, and components of intervention to post traumatic bisexual communities; a subculture of homeless stress disorder in the following ways: people; the deaf community, etc. The SANE can get a good sense of the person’s cultural influences ■ Use of interpretations and their rationale by asking, “How will the people who are important and basis. to you react to this assault?”, and exploring the ■ Extent and nature of verbal interaction meaning of the rape and people’s reactions to the between client and therapist. victim. The SANE needs to listen to how the ■ victim perceives the ramifications of reporting, not Role of verbal communication. reporting, telling others, etc. For example, in some ■ Role differentiation between client and communities an adolescent girl who is vaginally therapist. raped may be ostracized from the community or ■ Respective weights of physical and somatic no longer considered marriageable. The SANE and psychological distress. needs to thoroughly explain the limits of confiden- tiality within the legal system and listen to how the
90 SANE Development and Operation Guide
■ Role of ritual in psychotherapy. counseling (Speck & Aiken: 95; Ledray: 92b); and ■ Use of metaphor, imagery, myth, and consultation services with other SANE programs storytelling in psychotherapy. (Speck & Aiken: 95; Ledray: 92a). ■ Nature of relationship between therapist As SANE programs mature, these program compo- and client. nents grow as well. New SANE programs will likely concentrate their efforts on providing clinical SANE programs need to be aware of the cultural services and obtaining training for their own staff. differences in the above areas for the cultures As SANEs become more experienced, they may represented in the area they serve in order to begin to provide training for other professionals provide culturally congruent crisis intervention and nonprofessionals in the community. With even services. Updated information on how specific more experience and depth of knowledge, they cultures provide crisis intervention can be one may be able to provide consultation services to function of the partnerships alluded to earlier newer SANE programs. between SANE and cultural communities within the service area. Cultures are not stagnant and do change so updates on how cultures view and Summary respond to rape are essential. Collecting evidence for the evidentiary examina- tion of the rape victim is the central focus of the Additional Program SANE program operation. While guidelines can Components certainly be provided concerning what evidence should generally be collected, it is important to Additional components of SANE programs recognize that every case will likely be just a little referred to in the literature include education and different from another. Additionally, each SANE training for the medical and nursing community needs to have a thorough understanding of the (Speck & Aiken: 95); 24 hour hotline (Speck & forensic principles involved and an understanding Aiken: 95); court advocacy services (Speck & of special populations that may be encountered so Aiken: 95); scientific research and program evalua- that each rape victim can receive the best possible tion (Speck & Aiken: 95; Burgess & Fawcett: 96; care available. Holloway & Swan: 93; Ledray: 93); followup
91 SANE Development and Operation Guide
PEDIATRIC SANE CHAPTER 12 EXAM
Nursing care of children who have been sexually parental neglect. In other States, a police report is abused or sexually assaulted involves all of the mandated for all sexual assaults of children. It is skills utilized by SANEs in caring for adults, with important that each SANE knows the mandatory the added knowledge of pediatric growth and reporting guidelines for the jurisdiction in which development. SANEs who work with children she works. need to be able to give care that is appropriate to each child’s age and developmental stage. This The sexual assault exam will be affected by the chapter will address special considerations of a relationship of the child to the offender; the child’s pediatric SANE exam and is to be read in conjunc- physical, emotional, and mental development; the tion with the entire manual. Only the differences child’s ability to communicate and understand; and between a pediatric and adult SANE exam and the child’s ability to trust another person (i.e., the sexual assault examination will be discussed. SANE). Attention must be given to recognizing and responding to these factors. Child sexual abuse is defined as the involvement of developmentally immature children or adolescents The goal of a pediatric SANE exam is to provide in sexual activities that they do not fully compre- comprehensive sexual abuse evaluation and nursing hend, to which they are unable to give informed care to a child and her family in an environment consent, or that violate taboos or family relation- that is comfortable for the child. Consideration is ships (Emans, Laufer & Goldstein: 98). It can given to the physical and emotional needs of the range from exhibitionism, to fondling, to inter- child, collection of evidence, screening for and course. Approximately two-thirds of child victims prevention of STDs and pregnancy, providing for are abused by a family member (Reghr: 90). When the safety of the child, and referral for followup a child has been sexually abused by a relative or medical care and counseling. someone who is responsible for his or her care, or when the abuse is the result of parental neglect, Setting the SANE must deal with issues pertaining to the child’s protection and involve the appropriate A busy hospital emergency room can be frighten- governmental protection agencies. ing to a young child, therefore it is recommended that pediatric exams be completed in an alternative The term sexual assault refers to any sexual act setting when possible (Stovall, Muram & Wilder: performed by one person on another without that 88). A quiet setting away from traffic and deco- person’s consent. The assault may involve the rated to appeal to children will help the child feel threat of force or the person may not be able to relaxed and welcomed give consent because of age, mental or physical capacity, or cognitive impairment due to drugs or Special Training alcohol (Emans, Laufer & Goldstein: 98). Sexual assault of a child is usually an acute traumatic Pediatric SANEs need to be knowledgeable about event. Child protection and police notification the physical, intellectual, and emotional develop- laws for sexual assault vary from State to State with ment of children and adolescents. Ideally, the some States mandating a report to police and child SANE will have pediatric training and possess protection only if the assault occurred as a result of highly developed skills in communication with
93 Chapter 12: Pediatric SANE Exam
children. The SANE must be comfortable with child’s statements are the primary evidence used in children and enjoy working with them. Thorough successful conviction. Successful prosecution may knowledge of the developmental stages of child- depend on the child’s ability to tell what happened, hood is essential, as is an understanding of pediat- and the skill of the person eliciting, documenting, ric anatomy and the ability to interpret normal and and testifying to the child’s story. The purpose of abnormal findings. Skills and experience in con- the initial interview is to create an opportunity for ducting interviews with children, collecting and the child to tell what happened in a way that will documenting forensic evidence, and testifying in both benefit the child and obtain objective verbal court are also important. Pediatric or family evidence for prosecution. In a good interview, the practice nurse practitioners or nurses with experi- child will feel listened to, understood, valued, and ence working with children are good candidates for affirmed, and thus begin the road to recovery. At SANE training where children are part of the client the same time, subjective verbal evidence from the population. child will be documented by the licensed profes- sional or SANE for use by the courts. Sexual Assault Response/ Who Conducts the Interview Resource Team (SART) Careful consideration must be given to who will Chronic sexual abuse of children is generally conduct the interview. Interviewers need to be inflicted by someone who is known to, or part of, trained by experts in forensic interviewing tech- the child’s family. Often the abuse has occurred for niques. They must have a thorough understanding some time before it is discovered, and it may have of child development and abuse dynamics. It takes a profound and long-lasting impact on the child experience and training to know how to frame and family. To respond to the complex needs of questions that elicit information from the child children and their families, most pediatric SANE that will be admissible in court. Some SANE programs utilize a team approach to effectively programs may choose to provide the advanced gather needed information and evidence. In training necessary to prepare the SANE to conduct addition to the SANE, the team may include other pediatric forensic interviews. Other SANE models health care staff, workers from child protection, may use a team approach, having the SANE collect and representatives from law enforcement (i.e., the physical evidence, with a social worker, psy- police, district or county attorney). chologist, child protection worker, or law enforce- ment officer completing the bulk of the forensic Interview interview. A skilled interview and documentation as to what Victim Interview the child says during the exam are essential compo- nents of the evidence collection process. Past An initial interview with the child should take studies support the fact that the majority of place as soon as possible after the suspicion of children with legally confirmed sexual abuse have abuse has been disclosed so that the child’s state- normal or nonspecific genital findings (Adams, ments are not affected by memory loss or influ- Harper, Knudson & Revilla: 94; DeJong & Rose: enced by talking to others. Consideration is given 91; Muram: 89). In a study of 236 children where to the child’s readiness and ability to talk, the the perpetrators were convicted for sexual abuse, child’s physical and emotional needs, time of last normal genital examination findings were reported suspected incident, and the availability of a trained in 28 percent of cases. Nonspecific findings were person to conduct the interview. If the last incident reported in 49 percent, suspicious in 9 percent, of abuse occurred within 72 hours, a physical exam and abnormal in 14 percent (Adams et al.: 94). and evidence collection should be done as soon as In cases with normal or nonspecific findings, the possible to preserve evidence. If a child becomes
94 SANE Development and Operation Guide reluctant to discuss the abuse later, initial state- presence is often distracting. The parent’s nonver- ments will be important evidence. It is important bal reaction to disclosed information or possible to be aware of and sensitive to the child’s eating coaching may influence what the child discloses. and sleep schedules. In cases where the abuse Also, anyone who observes the interview may occurred more than 72 hours ago and the child is become a witness and thus may be excluded from tired, hungry, or unwilling to talk, or if an experi- the courtroom at a later date when their supportive enced interviewer is not available, delaying the presence is needed by the child (Sorenson, Bottoms interview would be a wise decision. & Perona: 97).
The interview should take place in a quiet room The interviewer’s first task is to create a safe and with a minimum of distractions. A two-way trusting environment in which rapport can be mirror, if available, allows medical and legal established with the child. The interviewer should professionals who also need the information to introduce him or herself to the child, explain the observe the interview without making the child purpose of the interview, sit at eye level, and feel uncomfortable. A few simple toys to establish maintain eye contact. The child needs to be told rapport as well as paper and crayons to illustrate that she is not in any trouble. Beginning the what happened may be helpful. Too many toys and interview with several neutral questions will give equipment in the area may prove distracting for the child time to relax and become familiar with the child. the interviewer. The child can be asked about favorite toys, pets, school, friends, who they live Although all team members may need the informa- with, the names of the people in their families, tion obtained from the interview, it is recom- what they like best about the people they live with, mended that one person alone conduct the inter- what they like to do when they are alone, what view and that repeat or multiple interviews be makes them happy, sad, mad, scared, etc. (Kolilis, avoided whenever possible. Repeated questions run 1996). This will also allow the interviewer time to the risk of implying to a child that he or she is not assess the child’s linguistic, cognitive, behavioral, believed or that the answers provided earlier may and social development (Levitt: 93; Sorenson, not have been correct answers. Children’s answers Bottoms & Perona: 97). to repeated questions may acquire a rote quality that detracts from their credibility. Children Next, general open-ended questions, such as “Why questioned repeatedly may also become bored or are you here today?” or “What were you told about uncomfortable and deny the abuse occurred in an coming here?”, can be asked to elicit a narrative effort to end the interview (Paradise: 90). To allow response as the interview moves into a discussion other team members access to the information of the abuse. The child is asked to tell what hap- obtained in the interview, the use of two-way pened and then allowed to tell the story in his or mirrors, videotaping, and concise, detailed written her own words with as few interruptions as pos- documentation are recommended (Jezierski: 92; sible. Neutral statements such as “Can you tell me Levitt: 93; Pope & Brucker: 91; Sacks: 89; Stovall, more about that?” or “What happened next?” or Muram & Wilder: 88; Wright, Duke, Fraser & “What else?” will support children and encourage Sviland: 89). them to continue. Open-ended, nonleading, neutral questions are recommended. Direct or A parent, guardian, or advocate may request to be “yes” and “no” questions should be used only to present during the interview. While in some States verify or clarify what has been shared (Levitt: 93; this may be the victim’s right, their presence is Sorenson, Bottoms & Perona: 97). “Why” ques- generally not recommended when interviewing tions are avoided as they imply blame. The child children who have been sexually abused (Kivlahan, should be told that it is okay to respond “I don’t Kruse & Furnell: 92). A parent or guardian’s know” or “I don’t remember.”
95 Chapter 12: Pediatric SANE Exam
Young children are concrete thinkers and may not If anatomical dolls are used, it is essential that know that a pronoun refers to the subject of a the interviewer be trained in their use. previous sentence, therefore the interviewer needs to be careful with words like “he,” “she,” “there,” Anatomical dolls or diagrams are used by some and “that” as they may hold a different meaning or programs to determine what words the child uses be confusing to the child. Children under 9 or 10 to label body parts. It is important to know what years are not always able to give accurate estimates children call their own body parts. The interviewer of time, distance, weight, color, or relational ties. goes through the identification from head to toe “Why” and “when” questions should be avoided and shows no surprise as the child names the body in this age group. “When” can be answered by parts. Questions like “What do you call this part?” “Where were you, and where was mommy or other “What is it for?” and “Is it for anything else?” can family when it happened?” As concrete, literal be asked as the interviewer points to sexual and thinkers, young children may, for example, answer nonsexual body parts. “no” to the question, “Did you have your clothes If anatomical diagrams are used, they should be on?” when they were wearing their pajamas (Gra- age, gender, and race appropriate. After identifying ham Walker: 97). Clarifying questions will need to and labeling all body parts, the child is instructed be asked. For example, “So, you were naked?” “No, to use a crayon to draw a circle around the parts of I had my pajamas on.” SANEs need to be knowl- his or her body that the person touched. The child edgeable on the developmental stages of childhood, is then asked to draw a circle on the perpetrator which are included in most pediatric nursing texts diagram around the parts of his or her body that (Rollins: 95; Sieving: 95). were used to touch the child. The drawings are Some programs use anatomical dolls or anatomical placed side by side, and the child is asked to draw a diagrams as interview aids, while others rely on the line between the parts of the adult body that were use of children’s drawings. The use of anatomical marked and the parts of the child’s body that were dolls has raised controversy, and guidelines for marked and is asked to tell what parts are being their use has been established (APSAC: 95). Some connected. The diagrams must be labeled and courts have disallowed the evidence related to their made a part of the permanent record.The child use. Decisions to use anatomical dolls or not signs the sheets, they are dated and signed by the should be made in conjunction with the local interviewer, and a notation is made that states, prosecuting attorney’s office. Ceci and Bruck “words describing body parts are the words used by (1993) reviewed the literature in the area of the child” (Poyer: 97). children’s memory and suggestibility and found Objectivity and a neutral response to the content children age 4 years and younger to be more of disclosure should be maintained throughout the suggestible than older children. Other studies done interview. The SANE should be comfortable on the use of anatomical dolls as interview aids discussing sexual abuse with the child and never with children ages 3–7 have found that the dolls respond with shock or disbelief. The child’s expres- increase recall accuracy with little or no increase in sion of feelings, both physical and emotional, can false reports of genital touching (Katz et al.: 95). be elicited and supported throughout the interview Anatomical dolls allow the child to “show” rather by asking, “How did that make you feel?” than “tell” what happened when verbalization is difficult. The child is told that the dolls are used to In concluding the interview, the child is asked if help talk about and show things that really hap- he or she has any questions. Questions should be pened. Dolls have been found by some to be useful answered honestly. Promises which cannot be kept in confirming the interviewer’s understanding of should not be made. The child should be thanked the child’s description of the abuse and reduce the for participating in the interview. likelihood of misunderstanding (APSAC: 95).
96 SANE Development and Operation Guide
Written documentation of the interview process and information in a child abuse investigation. should include the specific questions that were Exceptions to parental consent exist when the asked as well as verbatim answers from the child. parent or legal guardian is also the suspected The child’s nonverbal behavior, such as changes in offender or when a parent cannot be found and facial expression, and emotional responses are also time-sensitive evidence must be collected. In these documented. The child’s drawings are labeled. The situations, a police officer, a representative from name and title of all people present during the the State children’s services or the court may interview must be recorded (Muram: 87; Paradise: authorize an exam. 90; Tipton: 89). When the interview is taped, the date, time, location, name of child, and name and On occasion, minors present on their own, with- title of the interviewer and anyone else present out a parent or guardian, requesting confidential must be included in the recording. care for sexual abuse or assault. Adolescent minors may be able to consent for themselves. It is impera- Caretaker Interview tive that the SANE be aware of the specific laws in her legal jurisdiction governing minor consent for The child’s caretaker is interviewed individually medical and forensic care, specifically STD and and separately from the child by the SANE. The pregnancy assessment and treatment. caretaker is requested to provide information about events leading up to the assault and what is known Even in situations where the law mandates that the about the incident (what, where, when, who). consent of a parent, guardian, or legal authority is Complete name and address of suspected offender, necessary to conduct a sexual abuse/assault eviden- if known, relationship of the suspected offender to tiary exam, the minor’s consent is also always the child, the child’s medical history, and observed necessary to proceed with the exam. An exam is changes in the child’s behavior or physical condi- never done against the patient’s will, no matter tion should be taken as an initial assessment. When what age. known, the suspected offender is never present during the interview or evaluation process. The Confidentiality interviewer gathers information about the circum- Medical records including photographs are pro- stances under which the caretaker first learned of tected by confidentiality laws. In most States, the allegations and assesses the family’s reactions parents have the right to access their child’s medical and support systems (Davies et al.: 96). The SANE records, but not records related to police investiga- must also determine whether protective issues exist tion. Challenges to confidentiality often arise when so that a safe disposition can be planned for the the parent is the suspected offender or the noncus- child. todial parent demands to see the medical record and the custodial parent refuses. Some States and Consent, Confidentiality, and SANE programs have solved this problem by Reporting separating medical records (which includes medical history, diagnosis or impressions, medical treat- Minor Consent ments, and medical referrals) from the forensic investigative record (which includes anatomical In some States, a parent or legal guardian must sign descriptions of genitals and pattern injuries, investi- a consent giving authorization to complete the gative interviews, and verbal history of the assault/ exam, photograph injuries, collect evidence, abuse). Other States have created laws which provide medical treatment, and release information protect the confidentiality of the medical record by to the proper authorities. In other places, indi- forcing the medical provider to lock up the forensic vidual State law dictates who can consent for a record and to release it only to a team member or child to be examined and who can access evidence
97 Chapter 12: Pediatric SANE Exam
by protective court order. By separating the medical some SANE programs have chosen to provide and forensic records, the critical evidence of the primary and secondary care to the raped adolescent investigation remains confidential and belongs to who seeks screening and prophylaxis for STDs, the investigating law enforcement jurisdiction care of injuries, and contraceptive and pregnancy (Aiken & Speck: 91). When the SANE’s forensic related care under the laws that govern these record is considered part of an investigative record, categories of medical care of adolescents. Laws it is usually protected under laws that govern police governing minor consent and confidentiality vary investigations and is protected until it becomes from State to State, and SANEs need to know the public in a legal proceeding such as discovery. If laws governing minor consent in the jurisdictions maintained as part of the patient chart, forensic they serve. investigative records and child maltreatment forms can be clearly marked, “denial to access” to alert Adolescents consenting to their own care need to medical records personnel not to release them be informed by the SANE of the limits of confi- without a court order or request from the investiga- dentiality. When a police report is being filed, the tive team. However, keep in mind when you are adolescent should be told which information designing your record system around confidentiality becomes part of the public record, who will have issues, any record that has relevance to the court access to it, and under what circumstances. The can be subpoenaed unless protected by the court SANE must also be aware of billing policies, so (Nass: 91). that adolescents can be informed if their parents might receive an itemized bill or statement of A team consisting of representatives from law services provided. Whether or not the SANE enforcement, child protection, the county or involves a parent or legal guardian will depend on district attorney’s office, medical institution, and the adolescent’s ability to provide informed con- the SANE program should develop a written sent, the State’s laws allowing adolescents to give protocol addressing confidentiality and consent consent for their own care, the adolescent’s ex- issues that adheres to individual State laws. pressed desire regarding parental involvement, and the existence of adequate post-assault support for Adolescents the adolescent (Dexheimer Pharris & Ledray: 97). Since the 1970’s, an increasing body of Federal and Mandated Reporting State legislation allows minors to consent to their own medical care in the areas of sexual and repro- All States have designated mandated reporting of ductive health and chemical dependency, or in suspected child abuse. In most States, health care cases where they have some degree of emancipation professionals are mandated to report when their from their parents (i.e., if they are married, have professional service brings them into contact with a given birth, are in the military, are living apart minor child whom they suspect may be a victim of from their parents, or are legally emancipated). abuse by a person who is responsible for their care, When this legislation is called upon to enable an in a position of authority, or has a significant adolescent to consent for his or her own care, the relationship (i.e., family member or someone living adolescent alone has the right to access or release in the same home). A report may also be mandated the medical records related to that care. As of in situations where a sexual assault occurred as a 1995, most States did not have statutes specifically result of parental neglect. In some States, any enabling or prohibiting minors’ consent for sexual criminal sexual conduct mandates a report to the assault evidentiary exams (English, Matthews, police. It is essential that all team members have Extavour, Palamountain and Yang: 95; Dexheimer a thorough understanding of the laws governing Pharris & Ledray: 96). Given that citizens of any mandatory reporting of child abuse and sexual age may report crime without parental consent, assault in the legal jurisdictions they serve.
98 SANE Development and Operation Guide
Specifically, they must know what, when, how, and have elapsed since the last suspected incident of where to report. abuse, an exam will be arranged as soon as conve- nient for the child, family, and examiner. The Collection of Physical nature of the exam will depend on the history of suspected abuse and includes assessment for genital Evidence abnormalities and cultures for STDs when indi- This section highlights the ways in which a pediat- cated (American Academy of Pediatrics, Committee ric exam differs from an adult exam. Please remem- on Adolescence, 94; American Academy of Pediat- ber that the information here should be used in rics, Committee on Child Abuse and Neglect: 91; conjunction with the information regarding adult Kaufhold: 93; Kivlahan, Kruse & Furnell: 92; exams contained throughout the manual. The Levitt: 93; Stovall, Muram, Wilder: 88). pediatric protocols and sexual assault exam forms In addition to a positive history of sexual contact, for two successful SANE programs that care for other factors considered in the decision to collect children are included in Appendix I. evidence may include 1) nonspecific or specific genital findings upon examination, 2) access to Goal the victim by suspected offender, 3) inconsistent The goal of the pediatric sexual assault exam is to history from child and or parents, or 4) evidence 1) identify the child’s emotional and physical needs of acute injury. In one program, when these factors related to the assault, 2) collect and document were considered, this group was four times more evidence following a suspected sexual contact, and likely to have definitive laboratory evidence of 3) provide appropriate followup health care and assault than the group with a negative history and counseling referrals. normal findings (Speck: 1999).
Components The age of the suspected offender also needs to be considered. If the reported offender is younger The components of the exam include a general than the age of spermarche, sperm evidence will physical examination, thorough examination of the not be found. For most boys, sperm is first pro- oral and anogenital area, collection of forensic duced at age 13, but may occur as young as age evidence, screening for evidence of sexual contact 11 (Neinstein: 96). such as STD and pregnancy, prophylactic treat- ment to prevent STDs and pregnancy when Preparing the Child for the Exam needed, crisis intervention and emotional support for the child and family, and referral for followup The child should be prepared for the evidentiary care (Kaufhold: 93; Kivlahan, Kruse & Furnel: 92; exam by explaining what will happen in terms that O’Brien: 92; Sacks: 89). the child can understand. In preparation, the child should be shown equipment such as the colpo- When to Do an Evidentiary Exam scope, gloves, and swabs and allowed to try them out on a stuffed animal or doll. An animal or doll A child who presents within 72 hours of a sus- can be used to demonstrate procedures and posi- pected incident of sexual abuse will immediately tions that the child will experience. This brief receive a complete evidentiary exam. The exam will playtime has been shown to reduce the child’s include visual inspection and collection of speci- anxiety while allowing the examiner an opportu- mens to detect semen and cultures for STDs as nity to assess the child’s developmental, behavioral, deemed appropriate per the child’s reported history. and emotional status. Many examiners believe that, Specimens are only collected in the orifices and if possible, the exam should be completed apart body surfaces reported to have had contact with the from the child’s parents or guardians. Others think assailant’s body fluids. When greater than 72 hours a parent, guardian, or support person who has been
99 Chapter 12: Pediatric SANE Exam
chosen by the child to be present during the exam genitalia include the lateral recumbent with knees may reduce the child’s anxiety. Most children are flexed. This position might be used when the content to be examined apart from their parents, history dictates that the assault occurred in the and additional historical information can then be prone knee chest position. Abnormalities seen in elicited during the exam to further clarify the the supine frog leg or lateral recumbent positions details of the sexual assault. may disappear when the patient is inspected in the prone knee chest position. With adequate preparation, most children will be able to relax and participate in the evidentiary When the child is ready, the SANE will carefully exam. Under no circumstance should a frightened, examine all orifices where sexual contact is sus- resistant child be restrained to complete the exam. pected. In an anogenital exam in girls, the exam Restraint and force, often a part of the sexual abuse includes careful inspection of the perineum, the experience, will only heighten the child’s fear and clitoris, the hymen, and the anus. Careful inspec- anxiety and intensify the psychological impact of tion of the perineum includes inspection of the the abuse. The SANE may experience a rare mons, the clitoris, the labia majora, the labia occasion where a child’s fears cannot be calmed minora, the vestibule, the urethra, the hymen, the and he or she cannot be distracted, and yet it is visible vaginal structures, the fossa navicularis, the felt that an immediate exam is necessary. In these posterior fourchette, the perineal body, and the rare situations, the use of sedation such as Versed anal structures including the verge (anocutaneous (HCMC Pediatric Sexual Abuse Exam Protocol: line), the pecten, the pectinate line and anal crypts, 97), Diazepam, Chloral hydrate or Fentanyl anal papilla and rectal columns, and rectal ampul- (O’Brien: 92) has been recommended. lae when visible. Visualization of the hymen can be done by applying gentle traction on the labia After preparation of the child for the exam, it is re- majora by grasping them between the thumb and commended that the examiner begin with a routine, forefinger on each side and gently pulling in an complete pediatric physical examination. This will outward and downward direction. This method allow the SANE to gain the child’s trust and under- should open the vulvar structures for full visualiza- standing that the anogenital exam is part of that tion by the examiner. The hymen is examined for routine exam. Sexual development should be in- recent or past trauma, and the diameter of both the dicated according to the Tanner scale (Sieving: 95). hymenal opening and hymenal rim is noted (Levitt: 93). The physical examination of male Exam Positions children includes careful inspection of the inner The two most popular examination positions for thighs, penis, glans, scrotum, and anus. The anus children during inspection of the genitalia are the in male and female children can be evaluated by supine frog leg position and the prone knee-chest gently separating the buttocks and waiting for the position. In the frog leg position, the child is child to relax. supine on the exam table with head elevated, hips Documentation should include tanner staging and flexed, soles of feet together and drawn up towards anogenital findings. All anogenital findings must the buttocks. Frightened or younger patients may be documented completely and accurately on be examined in the frog leg position while sitting genital or anal diagrams or by magnified photogra- on a trusted person’s lap (Soderstrom: 94). The phy. Any fresh or healed injuries or signs of STDs knee chest position places the child’s head, chest, are clearly described, noting color, size, and loca- and knees on the examining table while the tion of any discoloration, tears, abrasions, ecchy- buttocks are elevated for visualization of the mosis, or swelling. genitalia. Other positions for evaluation of the
100 SANE Development and Operation Guide
Recommended Equipment minora, and 4) cervix. With the colposcope, that order changed to 1) hymen, 2) cervix, 3) posterior Use of a colposcope or medscope for examination fourchette, and 4) labia minora (O’Brien: 97). of the genitalia in pediatric cases is strongly en- couraged. This equipment provides the examiner The medscope, which is an adapted dental camera, with excellent illumination and magnification, provides photographic documentation that has a making clarification of detected injuries easier. greater depth of field than the colposcope, is less Camera and video attachment allows for the expensive, and can be used to document injuries documentation of findings (Kaufhold: 93; Levitt: elsewhere on the body (McDonald: 97). 93; Soderstrom: 94). Conventional (non- colposcopic) protocols have historically yielded In the absence of the colposcope, videocolposcope, positive genital findings in only 10 percent to 30 or medscope, the standard fluorescent ring lamp percent of cases. In reporting 4 years’ experience with magnifying capacity of 5X is helpful in with the colposcope in the exam of children for assessing vaginal trauma (Tipton: 89). Another possible sexual abuse, Woodling and Heger (1986) alternative is the use of a 35 mm camera with a identified lesions which would have been missed 105 mm macro 1:1 telephoto lens with an attached without the aid of the colposcope in 10 percent of flash ring (Kaufhold: 93). Hand held magnifying the cases. Myers et al. (1989) studied the use of lenses (5X) have also been used. colposcopy in 500 females, 91 percent of whom were under age 19. They found that colposcopy McCauley, Gorman, and Guzinski (1986) found provided additional information about physical the use of 1 percent toluidine blue dye to increase findings not seen during visual examination of the detection rate of posterior fourchette lacera- genitalia in 11.8 percent of cases (Myers, Bays, tions from 16.5 percent to 33 percent in a pediat- Becker, Berliner & Saywitz: 89). Teixeira (1981) ric sexually abused population and from 4 percent had similar findings in the colposcopic evaluation to 28 percent in an adolescent population. Al- of 102 children under 14 years of age, with the though these findings support the use of toluidine colposcope proving useful in clarifying the diagno- blue dye in detecting injuries, it is important to sis. Teixeira found colposcopic examination helpful consider that toluidine blue dye has been found to in assessing fimbriated hymens in children under be spermicidal (Laufer & Souma: 82). If applied the age of 10. In a retrospective chart review prior to the collection of vaginal specimens, the comparing genital findings prior to program dye may alter the evidence of motile sperm found acquisition of colposcope with findings after on a wet mount. The effect of the dye on ven- colposcopic examination was initiated, one SANE ereal disease detection is unknown. However, program found the colposcope to not only increase Hochmeister et al. (1997) found that neither the detection of microtrauma by 11 percent in chil- dye nor the various dilutants (1 percent acetic acid dren and adolescents, but it also changed the or lubricants) had a negative effect on the ability to location where most frequent injuries were de- obtain DNA profiles using either RFLP or PCR tected. In girls from birth to 12 years of age, prior methods of detection. Any program considering to colposcopic exam initiation, the order of most the use of 1 percent solution of toluidine blue dye frequent areas of injury detected was 1) hymen, should ensure that use of the dye does not interfere 2) labia minora, 3) posterior fourchette, and with laboratory procedures used in the detection of 4) rectum. With the colposcope, the order biological samples (semen, sperm, saliva, blood). If of most frequent site of injury in this age group collecting specimens prior to applying the dye, the was 1) hymen, 2) rectum, 3) labia minora, and SANE must keep in mind that this may leave room 4) posterior fourchette. In girls ages 13 to 17, the for the argument in court that the findings were order of most frequent site of injury precolposcopy made with the insertion of speculum or swabs. was 1) hymen, 2) posterior fourchette, 3) labia
101 Chapter 12: Pediatric SANE Exam
Additional recommended equipment may include STDs, multiple partners, or past history of STD; Foley catheters for better visualization of the 2) the child has symptoms or signs of an STD; or hymen of menstruating adolescents. In rare in- 3) there is a high STD prevalence in the commu- stances, pediatric anoscopes or speculums may be nity (CDC: 93). Other decisions to test for STDs needed, however, because of the pain involved with should be made on an individual basis by the their insertion, they are generally used only under SANE and may include meeting the needs of a general anesthesia and not in the outpatient parent who wants to be sure no STD was transmit- setting. The reader is referred to the SANE litera- ted. For adolescents who have been sexually abused ture for guidance on the use of these tools. over time, baseline testing should follow the above guidelines, keeping in mind that adolescents can Evidence Collection Sites have gonorrhea and chlamydia and be asymptom- atic. Adolescents who present for an evidentiary Current common practice dictates that specimens exam for a one-time assault that occurred within for semen be collected only from orifice and skin the past 3 days are not tested for STDs but rather locations that the child indicates were involved in treated prophylactically for gonorrhea, chlamydia, any assault that occurred within the past 72 hours and syphilis and referred for followup testing in 2 or according to jurisdictional protocol. The only weeks. When testing is to be done, it may include difference in the collection of skin, oral, rectal, or culturing for gonorrhea and chlamydia from the vaginal specimens between adult and pediatric introitus in prepubertal girls or endocervix in exams will be in the case of vaginal specimens in adolescent girls, and rectum and throat in both the prepubertal girl. A speculum examination in boys and girls. A syphilis serology should also be the prepubertal girl may be extremely painful and obtained, and HIV serology offered (Kaufhold: is not necessary or recommended for the collection 93). A wet prep can be done for trichomonas. of vaginal specimens or cultures. Speculum inser- Testing for gonorrhea and chlamydia should be tion is recommended when there is suspected repeated in 2 weeks, syphilis serology in 6 to 8 penetrating vaginal injury and bleeding from an weeks, and the HIV serology in 3 months and internal source. In this case, speculum examina- again in 6 months. tions in the prepubertal child can be done under general anesthesia (Paradise, 90). In the prepuber- The practice of routine testing for STDs in asymp- tal girl, vaginal specimens can be collected with a tomatic prepubertal girls following disclosure of dry cotton sterile swab. Some authors suggest a sexual abuse has recently been challenged with new small urethral size swab be used to collect vaginal information. In a study conducted at the Memphis specimens when the vaginal site is involved Sexual Assault Resource Center, only 1.4 percent (Kaufhold: 93; Levitt: 93; Muchlinski, Boonstra & of 865 prepubertal girls seen within 72 hours of Johnson: 89; Sacks: 89), however, Ledray and assault were found to test positive for N. gonor- Netzel (1997) have found that evidence will not rhea. All subjects who tested positive were symp- be obtained as often using a small diameter swab, tomatic. There were no asymptomatic positive especially if the fiber is not cotton. In prepubertal results. Based on this information, it has been girls, gonorrhea and chlamydia cultures can be suggested that routine screening for gonorrhea in obtained from the introitus because in prepubertal asymptomatic prepubertal girls is not indicated. girls these bacteria grow in the vaginal epithelium. Re-evaluation in 2 weeks following the assault is recommended (Muram, Speck & Dockter: 96). STD Testing Baseline testing for asymptomatic prepubertal Hair Specimens children is not recommended except in the follow- The pulling of head and pubic hair is generally no ing circumstances: 1) the suspected offender is longer done in pediatric exams. However, it is known to have an STD or to be at high risk for important that deleting this practice be confirmed
102 SANE Development and Operation Guide with the local county or district attorney and the following findings: recent or healed lacerations of State forensic laboratory. the hymen and vaginal mucosa, hymenal opening of one or more centimeters, procto-episiotomy (a Interpretation of Findings laceration of the vaginal mucosa extending to involve the rectal mucosa), and indentations on the Sexual assault examiners can expect to be called vulvar skin indicating teeth marks (bite marks). The upon to testify in court whether or not their category also includes patients with laboratory findings are consistent with sexual assault. Much confirmation of a venereal disease (e.g., gonorrhea). debate has arisen over what is normal and what is abnormal in pediatric genital findings. It is Class 4: Definitive Findings essential that a beginning Sexual Assault Nurse Any presence of sperm (Muram: 89, p. 212). Examiner train and consult with an experienced examiner. Interpretation of findings takes both In order to communicate the meaning of their experience and knowledge. Serious consequences findings, SANEs should familiarize themselves can result if an inexperienced examiner assigns with the literature on the frequency of findings in more or less meaning than is appropriate to genital confirmed cases of sexual abuse for each category findings. Numerous references and guides exist to of the classification system they use. For example, assist SANEs in determining how to interpret and when testing the above classification system, classify findings (Adams: 97; Adams & Knudson: Muram (1989) found that of 31 girls who were 96; Aiken: 90; Chadwick et al.: 89; Girardin, confirmed victims of sexual abuse, no abnormali- Faugno, Seneski, Slaughter & Whelan: 97; Heger ties were detected in 29 percent and nonspecific & Emans: 92; Muram: 89). A classification system abnormalities were detected in 26 percent. Abnor- is only a guideline to facilitate communication mal findings suggesting sexual abuse (class 3) were with nonmedical personnel. The following exem- seen in only 45 percent of the girls. Another study plar is a classification system developed by David reports that of 205 prepubertal girls who were Muram (1989) and used by many SANE programs victims of sexual abuse, 32 percent had no abnor- for prepubertal girls: malities (class 1), 22 percent had nonspecific findings (class 2), and 46 percent had abnormal Class 1: Normal Appearing Genitalia findings (class 3) that strongly suggested sexual abuse (Aiken: 90). These studies suggest that Class 2: Nonspecific Findings physical findings alone are insufficient documenta- Abnormalities of the genitalia that could have been tion and must be accompanied by information caused by sexual abuse but are also often seen in gleaned from a thorough history, a skilled inter- girls who are not victims of sexual abuse, e.g., view, and observation of the child’s behavior inflammation and scratching. These findings may (Aiken: 90). be the sequelae of poor perineal hygiene or nonspe- cific infection. Included in this category are redness Antibiotics for Prevention and of the external genitalia, increased vascular pattern of the vestibular and labial mucosa, presence of Treatment of STDs purulent discharge from the vagina, small skin In general, routine prophylactic antibiotic treat- fissures or lacerations in the area of the posterior ment to prevent STD in children following the fourchette, and agglutination of the labia minora. disclosure of sexual abuse is not recommended (Giardino, Finkel, Giardino, Seidl & Ludwig: 92; Class 3: Specific Findings Muram: 87; Paradise: 90). Prophylactic antibiotics The presence of one or more abnormalities that are not recommended in the prepubertal strongly suggest sexual abuse can include the population because 1) the risk of acquiring STDs
103 Chapter 12: Pediatric SANE Exam
is low, 2) no single antimicrobial agent is effective in the family that disclosure may bring. Emotions against all infections, and 3) often abuse has been that children feel at this time include shame, guilt, ongoing over a long period of time necessitating anger, confusion, fear, betrayal, isolation, sadness, higher antibiotic doses than those prescribed for and fear of abandonment. At disclosure, during the prophylaxis. Treatment with antibiotics may be interview process and during the evidentiary exam, considered when the offender is known to have an the SANE and other team members can begin to STD, the child is unlikely to return for followup, address the child’s emotional needs and initiate the it is a one-time assault by a stranger, or multiple healing process. assailants have been involved. After the SANE exam, the child should be thanked The American Academy of Pediatrics, Committee for reporting the crime and participating in the on Adolescence (1994) recommends that prophy- interview and exam. Children should be told that lactic antibiotics be offered to adolescents to what happened was not their fault and that their prevent syphilis, gonorrhea, and chlamydia. The body is normal. One way to do this is to explain SANE must remember that all three of these the process of healing. If the child is acutely bacterial infections can be present in an asymp- injured, the injury should be explained, and the tomatic adolescent and that prophylactic doses do SANE should explain that the child’s injuries can not equal treatment doses. If adolescent females be expected to heal because the body is normal. have been infected and are not treated, these Signs and symptoms of infection can be taught infections pose the risk of PID with long-term also. If the injury has healed, the child may be told consequences, including sterility. Guidelines for that the injury has already healed. If the child has prophylactic treatment for STDs including hepati- no evidence of injury, the child should be told tis B, and treatment of known infection are con- there is no evidence of injury. Either way the child tained in the Sexual Transmitted Diseases Treatment should be told their body is normal. Implementing Guidelines, Center for Disease Control (1997). the nursing process by encouraging the child to make choices during the examination, facilitating Pregnancy Risk Evaluation the development of a safety plan, and teaching personal safety techniques will give the child a and Treatment sense of power and control.
Females who have begun menstruation will need to Addressing the emotional issues will necessitate an be evaluated for pregnancy risk and offered postco- understanding of the child or adolescent’s develop- ital contraception as described elsewhere in this mental tasks affected by the abuse or assault, manual. For the prepubertal physically mature previous traumatic experiences and recovery, female who is not yet menstruating, postcoital sources of support, and other concurrent stressors. interception should be evaluated as an option in Older adolescents may need more individual care consultation with the parent and supervising in addition to support given to the entire family. physician. Family members will also be significantly affected Psychological by the disclosure of sexual abuse. The impact of the abuse on the child and the family will depend on Considerations the nature and duration of the abuse, the relation- The disclosure of sexual abuse will create intense ship of the assailant to the family, the amount of conflicting emotions and psychological needs for support the family has, the coping skills and the child and the family. At disclosure, the child stability of the family, and any recent crises the may experience both tremendous relief and fear. family may have experienced. Emotions that The child may feel responsible for the disruption parents and guardians may feel include guilt for
104 SANE Development and Operation Guide not protecting the child, anger, sadness, confusion, school work is an additional assault on a trauma- and helplessness. While parents will need to have tized student’s fragile self esteem. While sexual their feelings validated at the time of disclosure, abuse or assault can be very traumatizing for youth, they also need a great deal of information. They it doesn’t have to be. Children whose families take need to know what behaviors may be exhibited by action to keep them safe and show them love and their child and how to meet her emotional needs. understanding usually do not experience long-term effects from the abuse. Turman and Dinsmore (1997) report the following common reactions for children following traumatic Families need to know what steps to take next for events. Children from birth to age 2 may react to legal, medical, and psychological followup, and trauma by increased clinging, crying, biting, they need to know which community resources to throwing things, and becoming agitated. Children turn to for help in the days ahead. Assessment of ages 2 to 6 may re-enact the trauma over and over, the family’s needs is complex, therefore it is recom- develop separation anxiety, become more with- mended that all families be referred for counseling drawn, regress in previously mastered skills, eat following disclosure of sexual abuse. A list of less, have nightmares, or act out. Children ages 6 resources available in the community should be to 10 typically react to trauma with difficulty provided for the family at the time of the eviden- concentrating, and often report headaches, stom- tiary exam. If possible, an initial appointment for achaches, dizziness, loss of appetite, and sleep followup counseling should be made before the disturbances. They may have trouble controlling family leaves the clinic or emergency room. It is their behavior and their imaginative skills may lead also recommended that a member of the sexual to embellishment of the event. They also will often abuse team call the parent or guardian a few days show signs of regressed behavior. From ages 10 to following the exam to offer additional resources or 14, trauma may be manifested by regression, shows information. of anger, mood swings, theatrical portrayal of the traumatic event, self-judging and stigmatizing, Discharge Planning withdrawal from family and school, psychosomatic illnesses, and minimization of the traumatic event Child Protective Services in an attempt to deny it. Adolescents often respond to trauma by becoming very critical of parental or In all States, Child Protective Services (CPS) are authority figures, turning to their parents only State legislated and mandated investigators who are when severely troubled. Teens often try to deny the responsible for devising a safety plan for children at assault happened and spend time behind locked imminent risk for harm. The SANE must consider doors or withdraw into music. They also often the potential for harm to the child prior to their become self-judging and suffer self-esteem issues. release/discharge from the SANE program. Open Common reactions to unresolved trauma in the communication between the SANE and the CPS adolescent population include risky sexual behav- caseworker facilitates consultation and encourages ior, chemical (ab)use, running away, depression, involvement of the CPS caseworker prior to eating disorders, sleep disturbances, suicidality, releasing the child to the parents or guardian. regressed behavior, and psychosomatic illnesses. When there is doubt about the child’s safety, she School can be very difficult because of the im- should not be released to the parents, and the CPS paired ability to concentrate and alterations in peer caseworker or law enforcement should be con- relationships, and students who have been sexually sulted in developing a safe discharge plan. The abused or assaulted may need special accommoda- SANE must follow the mandatory reporting tions for a period of time. Slipping behind in protocol of the jurisdiction in which she practices and assure safe disposition of the child.
105 Chapter 12: Pediatric SANE Exam
Medical Care related to the assault, 2) collect evidence following a suspected sexual contact, and 3) provide appro- The child’s care giver will need to be instructed priate followup health care and counseling refer- on the care of any injuries and given medication rals. SANEs must know local laws governing the instructions, if applicable. Followup appointments care of minors so that they can determine in which with the primary health care provider should be situations law enforcement and child protection made for repeat STD testing, if necessary, and for agency involvement is mandatory and when re-assessment of injuries. These appointments minors can consent for their own care. No matter should be scheduled for the patient’s followup what age, the patient’s consent is always necessary medical needs and will generally follow a schedule to proceed with an exam; patients are never forced of evaluation in 2 to 3 weeks, 3 months, and 6 to undergo an exam. In child abuse exams, the months (CDC: 1993). interview is an essential part of the forensic evi- dence collection. Studies have shown that the Other majority of children with legally confirmed sexual In hospital centers, the care giver should be given abuse have normal or nonspecific genital findings. telephone numbers for the rape crisis center, victim/ It is therefore recommended that interviews be witness (advocacy) programs, law enforcement, conducted by an expertly trained professional. county or district attorney’s office, CPS, as well as information on crime victim compensation Components of the evidentiary exam include a programs. In integrated interdisciplinary commu- general physical examination, thorough examina- nity programs where SANEs, law enforcement, tion of the oral and anogenital area, collection of advocacy, and counseling work together sharing forensic evidence, and screening for evidence of information, these professionals pick up the case sexual contact such as STD and pregnancy when immediately and contact the family with informa- indicated. Specimens are only collected from the tion. orifices and body surfaces reported to have had contact with the assailant’s body fluids. A speculum is not used in examining prepubertal girls, unless Summary penetrating injury is suspected and then it is This chapter addresses special considerations for usually done under general anesthesia. For adoles- SANE programs serving pediatric populations. cents, prophylactic treatment to prevent STDs and SANEs who care for children must be comfortable pregnancy is recommended. Additional supplies interacting with children and knowledgeable of needed to care for a pediatric population include pediatric growth and development. Pediatric child-friendly pictures and furniture, a few simple SANE programs operate out of a quiet, child- toys, crayons, drawing paper, and equipment for friendly environment and are designed to meet the magnified photography (colposcope). An ample unique needs of children and their families. The supply of teddy bears who may be looking for goal of the pediatric SANE program is to 1) adoption is also helpful. identify the child’s emotional and physical needs
106 SANE Development and Operation Guide
POLICIES CHAPTER 13 AND PROCEDURES
The purpose of this chapter is to provide examples Procedure of SANE program policies and procedures for Prior to any of the above activities, the SANE consideration or adaptation by a new SANE explains the SANE role to the victim, what is to program. It is anticipated that every community be done, and why. She asks the victim to read and program will have unique needs, and so and sign the appropriate consent form(s). On the program policies and procedures will need to pregnancy interception form, the three options adapt. The following policies and procedures available to the victim reflect the risks associated reflect the Minnesota hospital-based model and with both informed consent and informed refusal have common components of an integrated to take medication to prevent a pregnancy. One community-based model. When appropriate, the option on the pregnancy interception form should policy or procedure provided is followed by a always be checked and signed by the victim.The “rationale” describing which factors were taken original copy of all consent form(s) remains with into consideration when developing the policy. the agency record (hospital or clinic). These examples of hospital-based SANE policies and procedures are meant as a starting point and as a guide. Rationale The victim should always check one option on the Consent pregnancy interception form. This provides clear documentation of why the pregnancy interception Policy is or is not given. The first option would be the typical informed consent of possible complications The SANE must obtain written consent to per- with agreement to take medication for pregnancy form the following activities: interception, such as Ovral. The second option would be “I understand [that because I am already ■ Complete an evidentiary exam. taking a contraceptive/had a tubal ligation] preg- ■ Release the exam report and evidence. nancy prevention is not recommended for me.” ■ Communicate with law enforcement The third option would be “even though preg- (except in mandated reporting cases). nancy prevention was recommended by the SANE, ■ Photograph (35mm, Polaroid, or video). I (the victim) chose not to take the medication” ■ Provide medication for pregnancy (Speck: 96). (See Appendix J: SANE Forms). interception. ■ Release oral or written information to other Court Testimony agencies. Policy One program suggests that it is important that the It is understood that the SANE will respond to any consent form for the use of pregnancy intercep- subpoena regarding an exam she has completed. tion, such as Ovral, include all three options She will cooperate to whatever extent possible to available to the victim.
107 Chapter 13: Policies and Procedures
make herself available to testify in court when Procedure needed. The SANE program will pay the agreed If the SANE is concerned that the victim is under rate of pay for a variety of activities associated with the influence of mood-altering substances that may court testimony, which may include pretrial impair her judgment to the point of making it conferences, preparing for testimony, traveling, unsafe to discharge her from the ED, she will waiting to testify, and testifying. consult with a physician and draw blood for drug Even when the nurse is no longer employed by the or alcohol testing. This specimen will be run by the SANE program, she will remain obligated to the ED or hospital laboratory prior to discharging the court of jurisdiction to testify and will be paid to client. do so. In all other cases, the blood will be placed in the Procedure rape kit for later analysis by the crime laboratory, if necessary. In these cases where the client does not Subpoenas will be sent to the SANE office. As appear intoxicated, the SANE will explain to the soon as a subpoena arrives the SANE office secre- client that she is drawing blood so that if the tary will contact the appropriate SANE, who will assailant attempts to say she consented to exchange then contact the subpoenaing attorney, usually the sex for drugs, or she was so intoxicated that she prosecutor’s office. does not remember consenting, there will be evidence to dispel his defense. Drug and Alcohol Screening Rationale (Other than for Rape Drugs) Drug and alcohol screening of sexual assault Policy victims has historically been controversial because this information has the potential to be used Drug and alcohol screening may be obtained for against the victim to blame or shame her or to two purposes. These are for medical-legal liability attempt to impugn her testimony in court. Unfor- and as crime evidence. tunately, drugs and alcohol are today being inten- Crime evidence. The SANE will ALWAYS draw tionally used more frequently by assailants as a two extra tubes of blood for potential use as crime weapon to overcome the resistance of a potential evidence. These are placed in the rape kit and victim. As we better understand this behavior, we labeled “hold for alcohol/drug screen.” also better understand the necessity of obtaining blood for drug and alcohol evidence. Medical-legal concern. An alcohol or drug screen will ONLY be run Stat in the ED when there is a When intoxication is suspected by medical person- medical-legal concern that the victim is intoxicated nel, the victim must be tested prior to discharge and cannot be discharged without liability. from the ED to avoid medical-legal liability for releasing an individual who is legally intoxicated The SANE will always document on the SANE and may be a harm to themselves or others. Exam Report the presence of other indicators of intoxication such as steady or unsteady gait; Blood is used instead of urine because of the coherent or incoherent speech; orientation or preference of the crime lab for analysis and storage. disorientation to person, place, or time; any odor Be sure to check with the local crime laboratory of alcohol on the breath; intact memory or lack of personnel. Drug and alcohol screens are not run memory for recent or past events; and any state- routinely as they are very expensive tests and can ments concerning drug or alcohol use before, be run at a later time by the crime lab if the level of during, or after the sexual assault. victim intoxication becomes a question when the case goes to court. 108 SANE Development and Operation Guide
Unfortunately, in many cases, the offender will Rationale claim the victim consented to exchange sex for Nongenital injuries inflicted during rape are drugs. A negative drug screen can be helpful to generally superficial and do not need medical disprove this defense. The offender may also claim intervention. In the 1 percent to 3 percent of the victim was so intoxicated that she does not victims who do have emergency injuries, delay remember consenting. Even if she did use drugs could mean the difference between health and or alcohol, an accurate blood level can be used to disability, even death. corroborate her statement. It is important for the SANE to develop good Evaluation of Nongenital nursing assessment and evaluation skills to allow Injuries her to accurately triage the victim for physical injury. If physicians feel confident the SANE will Policy do a thorough physical assessment for medical sequelae and refer back to them, they will have When the rape victim first arrives at the ED or confidence in the SANE’s role as a collaborator clinic, the ED or clinic staff will triage for injuries. in providing comprehensive care for the victim. Any injuries requiring immediate treatment will be stabilized and treated at that time. If immediate treatment is not required, the SANE will collect Evidentiary Examination evidence and document injuries prior to referring Timing the victim back to the ED or clinic MD for any necessary treatment. Policy A complete evidentiary exam will be completed on The SANE will consult with or refer to a physician all sexual assault survivors seen at a participating whenever she is concerned about the victim’s facility up to 36 hours (often up to 72 hours for medical well-being and when any of the following pediatric cases) after a sexual assault. This policy are identified: may vary from State to State and may extend to ■ Extensive genital trauma. 96 hours after a sexual assault in some States. ■ Pregnancy. A complete exam includes the following five components: ■ Asymmetric joint swelling. ■ Head or chest trauma. 1. Collection of medical-legal evidence utilizing a ■ Neurological deficits. rape kit and following the SANE program protocol. ■ Respiratory distress. 2. STD risk evaluation and prophylactic treatment.
Procedure 3. Pregnancy risk evaluation and emergency interception. After the SANE completes the evidentiary exam in the ED or clinic, she will discuss the treatment and 4. Care and documentation of injuries. care with the staff physician. She will, at that time, express her concerns about any physical issues and 5. Crisis intervention and followup referrals. ask the physician to further evaluate the victim prior to discharge, if necessary. If the physician is Post-36 hour exam. A post-36 hour exam will be unable to see the victim immediately, the SANE completed between 36 and 72 hours (96 hours in will transfer the victim back to the ED or clinic some jurisdictions) after a sexual assault. It does nursing staff for supervision until she is cleared NOT include the collection of evidence in the rape medically.
109 Chapter 13: Policies and Procedures
kit, but may include the collection of other physi- fluid evidence. As DNA collection and analysis cal or verbal evidence of the crime. It also includes becomes more sophisticated, this policy may the following: change significantly and exams may be completed for a much longer time period. Historically rape ■ STD risk evaluation and prophylactic kits were collected up to 48 hours after the assault treatment. (Green: 88). This was based on fertility studies ■ Pregnancy risk evaluation and emergency which defined sperm viability and presence in the interception. vaginal and cervical areas for up to 48 hours after ■ Care and documentation of injuries. intercourse. More recent studies focusing on sexual ■ Crisis intervention and followup referrals. assault evidence collection have challenged this 48- hour rule (Speck: in press). In a sample of 1,007 Post-72 hour exam. A post 72-hour exam is rape exams, most of the positive specimens were completed in some cases including those with collected within 12 hours of the rape. The only injuries that can be documented. The police positive sperm specimens collected beyond 36 should be encouraged to bring these cases to the hours of the rape were N=6 vaginal specimens SANE for documentation. If the ED or clinic staff collected in young adolescents, 16 years of age or is uncertain what the client wants or needs, they younger (Tucker, Ledray & Werner: 90). will page the SANE who will go into the facility and make her own determination about the needs Once semen has dried on clothing, it will no of the victim. If there are no injuries and the ED or longer deteriorate, but may provide positive results clinic staff feel comfortable assessing the needs of for weeks and even months or years after the the victim, the SANE may not be paged. Hospital assault. Antibiotics can be given to prevent the and clinic staff should always call the SANE if transmission of syphilis, gonorrhea, and chlamydia, there is any torn or soiled clothing for the SANE and pregnancy interception can prevent a preg- to collect as evidence or if there is physical evi- nancy if given within 72 hours after sexual inter- dence, such as injuries, for the SANE to document course. However, the sooner it is given the more on the Sexual Assault Exam Report Form (For reliable the results. Since prophylactic care to form see Ledray: 93b). prevent an STD is not recommended after 72 hours, the victim should be referred for testing Any clothing, especially underpants worn directly and treatment based on the results of these tests. after the assault, towels, or bedding that may have dried semen, will be bagged for evidence even Examination Sites for beyond the 72-hour limit. In addition, injuries can be documented beyond the 72-hour limit. Evidence Collection Policy Procedure The history from the client is critical in directing When the ED or clinic staff page the SANE to the SANE’s investigation and evidence collection. report that a client has arrived, the SANE will ask Specimens are only collected from the orifices or them when the assault occurred and if there are any sites the adult or adolescent victim indicates were injuries. Based on this information, the SANE will involved in the sexual assault. decide if she needs to go in, and she will let the ED or clinic staff know what she will be doing and why. Procedure Rationale After obtaining informed consent to conduct an examination, the SANE will ask the victim to tell These exam timing recommendations are based on her what happened and will specifically ask what the likelihood of collecting sperm and seminal
110 SANE Development and Operation Guide orifices (oral, anal, or vaginal) were involved and Prophylactic treatment for HIV is not routinely where there might have been ejaculation. An recommended or offered due to the potential alternate light source will also be used to identify toxicidity of the medications used (e.g., where skin specimens might be collected. The zidovudine), its high cost, and current low com- SANE will then collect specimens only from the munity HIV risk. If the case is a high-risk case, reported orifices. the victim should be given information about postexposure prophylaxis and referral information. Rationale Postexposure prophylaxis must be decided on a case-by-case basis. If it is known, or there is good Collection of evidence in the adult or adolescent reason to expect that the assailant was HIV posi- victim is based on and driven by the victim’s tive, the victim should be referred to the ED consent and willingness to participate in the physician for evaluation for postexposure prophy- investigative process (IAFN SANE Standards of laxis. When utilized, it must be started as soon as Practice: 96). It is disrespectful to assume the possible and within 72 hours. victim is lying and collect specimens from orifices where she denies any contact occurred. There are High-risk factors include the following: also no data to show that useful evidence has been collected from an orifice not reported to be in- ■ Anal rape. volved. It is very expensive and time-consuming to ■ Vaginal rape when other STDs are present collect and analyze unnecessary specimens. Collec- that would threaten the integrity of the tion of a positive specimen from an additional site vaginal mucosa. might even undermine the victim’s credibility. ■ Vaginal rape with traumatic tearing injury. An exception to this policy would be cases in ■ Known or suspected HIV positive offender. which the victim is unconscious or has little ■ Known or suspected IV-drug use by the memory of the assault possibly as a result of drug offender. use, voluntary or involuntary, or because the victim ■ Known or suspected bisexual activity of the is incoherent or developmentally disabled. When offender. the victim cannot provide information on the sites involved, the SANE should collect evidence from Procedure all orifices. By going ahead and collecting the The SANE will determine if the rape is high risk biological evidence so it is not lost, the SANE is for HIV exposure. She will inform the victim of acting on what she believes is in the victim’s best current community HIV transmission rates and interest. The other exception would be in States discuss her level of risk. She will also provide the where collection from all orifices is required. victim with the appropriate written literature and followup information on HIV testing sites and safe HIV sex practices for the victim and her sexual partner to consider until she can be tested for HIV. When Policy appropriate, information on HIV postexposure prophylaxis will also be provided. The SANE will not routinely do baseline testing for HIV at the time of the evidentiary exam. She will talk with the victim about her risk, fears, and Rationale concerns regarding the possibility of contracting As discussed in Chapter 11, how to best deal with HIV. If the rape is considered a high risk for HIV the issue of HIV is complicated and controversial exposure, she will recommend that the victim be (Blair & Warner: 92). Because the rates of infection tested for HIV after 3 months and again 6 months vary from State to State, so does the actual risk of after the rape.
111 Chapter 13: Policies and Procedures
infection. It is important to evaluate the actual Interpreters community prevalence of HIV before determining the local HIV policy. Zidovudine is the current Policy drug of choice for health care workers exposed to the HIV virus in a needle stick incident. However, Whenever a client does not speak English or is due to its potential toxicidity, its use is not recom- deaf, with her permission, an interpreter should be mended when the HIV status of the assailant is called, even if a family member or friend is avail- unknown in a sexual assault (Foster & Bartlett: 89). able to interpret. If an interpreter is not available on site, a telephone interpreter service should be employed. The hospital where the exam is being Holiday and Weekend Work completed is responsible for payment of the professional interpreter’s fees. Policy Each SANE will be expected to be available to take Procedure call every third weekend and every third holiday As soon as the SANE determines that the client and its associated weekend. This includes the cannot speak fluent English, she attempts to following holidays. explain to the client that she wants to call for an interpreter. If the client agrees, an interpreter is Procedure then called. She should not begin the exam until Staff are given one white square of paper for each the interpreter has arrived. The SANE will first shift of weekend call that they are responsible for a have the interpreter explain to the victim that all month. Before the scheduling begins, they have the information is confidential and that she cannot disclose anything said to anyone outside of the room at any time without the victim’s written Holidays* permission or she will lose her job. New Year’s Day Veterans Day Martin Luther King, Jr. Day Thanksgiving Day The interpreter should be used for all aspects of care including the following: President’s Day Friday after Thanksgiving Easter Christmas Eve Day ■ Explanation of patient’s rights. Memorial Day Christmas Day ■ Explanation of confidentiality. Independence Day New Year’s Eve ■ Obtaining informed consent. ■ Labor Day Explanation of exam procedures and purpose. * Weekends begin Friday evening and run through Sunday ■ night. Followup instructions and discharge. The interpreter should be “debriefed” by the opportunity of accepting additional weekend shift SANE after the victim has left. This should include squares from others, or giving away their squares. a reminder about maintaining complete confiden- Each time they take a weekend shift, they place tiality. Resources for telephonic interpreter services one square in the center of the table until all of are listed in Chapter 11: SANE Program Opera- their squares are gone and all shifts are covered. tion, in the section entitled “Working with Interpreters.”
112 SANE Development and Operation Guide
Rationale even if she has left the employment when the suit is brought. The plan does not cover actions that are It is important to get the client’s permission be- outside the scope of her employment or which fore calling an interpreter, especially when the constitute criminal or unauthorized conduct. community of her nationality is small, and it might be possible that her confidentiality could be broken Rationale by calling a local interpreter whom she may know. It is also important, however, not to assume that If the SANE is employed by a hospital or another the victim will be completely honest about what institution, that facility will usually provide mal- happened when a family member is present. This is practice insurance for all employees and should especially true in cultures where victim blaming is also provide liability defense and indemnification predominant. It is imperative to be aware of the coverage for the SANEs. In this case, it is not cultural beliefs and biases. necessary for the SANE to carry her own malprac- tice insurance, and some institutional attorneys If the services of a particular language are used may recommend that the SANE not carry addi- frequently, it may be helpful to do special training tional insurance as that will just encourage claims with interpreters to ensure that they are aware of naming her personally in a law suit, and her the special needs of this population and to encour- personal insurance will be used first to pay any age them to find ways of dealing with the impact claim for damages that may occur. If she is named, the information may have on themselves. When the hospital that employs her will represent her. the victim is seen more than once for followup, Other attorneys may recommend the SANE always utilizing the services of the same interpreter for carry her own professional liability insurance. The each visit is advised to facilitate establishing SANE should check with her institutional attorney rapport. Debriefing to deal with the impact of and her personal attorney before deciding if she the information on the interpreter is essential. wants or needs to carry additional malpractice insurance. Ask to see a copy of the institution Malpractice Insurance indemnification plan. If the SANE is not covered by an institution, the hospital where she provides Policy service will most certainly require proof of profes- sional liability insurance with specified required As long as the SANE is practicing within the scope limits before she is allowed to practice at their of her employment, including work in other facility. community hospitals to which the county has agreed to provide services, she is covered for profes- sional malpractice under the provisions of the Mandatory Institutional county hospital by which she is employed. She is Inservices not required to carry her own malpractice insur- ance, and it is not recommended that she do so. Policy The indemnification plan protects the SANE The SANE will be expected to attend all manda- against liability claims resulting from her work for tory training for the institutions with which the the county. If she should be sued, the county will SANE program is associated. She will be paid for defend her in court, settle the claim, and pay the her time at the training by the SANE program. amount of any judgment rendered. Regardless if These include the following issues: CPR Training, the allegations against her are true or false, the plan Patient Confidentiality, Fire and Safety, and will protect her. The indemnification plan applies Patient’s Rights. to any of her actions or omissions that occur while she is an employee performing her SANE duties,
113 Chapter 13: Policies and Procedures
Procedure Medication Administration The SANE director will provide the SANE with a list of times and dates for the inservices. The Policy SANE will make the necessary arrangements to Medications to prevent a pregnancy, prevent a attend and will inform her Director when each sexually transmitted disease, treat minor injuries, program is completed. or prevent nausea may be administered to the victim in the ED or clinic following the established Mandatory Reporting of medical protocol. In hospital-based programs, the SANE will confer with the physician on duty. Sexual Assaults of Vulnerable When prescribed, medications should be provided Adults and Minors to the victim prior to her departure from the facility as a part of the evidentiary examination and Policy at no additional charge. The SANE is mandated to report the sexual assault of a vulnerable adult to adult protection services or Procedure the police. The SANE is also mandated to report The SANE will meet with the client to decide what to the police or child protection services the sexual her needs and desires are concerning pregnancy assault of a minor by a family member, caretaker, and STD prevention. The SANE will also assess or a person in a position of authority over the the victim’s allergies and obtain a UPT. Based on minor, or a sexual assault that was a result of the results and following the medical protocol, the parental neglect. In some cases, this report may SANE will recommend a course of action to the already have been made prior to the SANE’s staff MD on duty and get the physician’s signature arrival. In the State of Minnesota, the SANE is on the chart and on the prescription blank. The NOT mandated to report statutory rape. SANE will get the necessary consent forms signed (e.g., Ovral Consent/Pregnancy Interception). She Procedure will then obtain the medications for the client and provide her both oral and written instructions When the SANE determines that a minor or prior to her discharge. Programs that utilize nurse vulnerable adult meet the reporting guidelines, practitioners with prescriptive authority may she will ask for evidence that a report has already choose to write their own prescriptions. been made. If a report has not been made, she will immediately report the assault to the proper authority. Rationale While the SANE program has an established Rationale medical protocol, pre-approved by each participat- ing facility or supervising physician, SANEs do not It is important to confer with the institution have prescriptive authority and the MD on duty is attorney and be aware of the State laws as well as ultimately responsible for medical care provided, the Federal laws. States have different laws regulat- including the administration of medications. A ing mandatory reporting for child sexual abuse, close working relationship and case review is vulnerable adults, felony sexual assault of adults, essential. and statutory rape. (See statutory rape policy and procedure this chapter.)
114 SANE Development and Operation Guide
In most programs, the medication expense is Nonreporting Victims included in the total evidentiary exam charge. It is not billed separately, as some agencies do not (Adolescent and Adult) reimburse for medications. Programs that function Policy as an extension of a public health clinic may administer the medication directly and at no If the client is uncertain that she wants to report additional charge through the clinic. while in the ED or clinic, the SANE will discuss her fears and concerns to help her make an in- Noncompliant Victims formed decision about reporting. If she is still uncertain and the rape occurred within 36 hours, Policy she will be encouraged to let the SANE collect evidence so that it is not lost if she decides to If for any reason, the victim refuses to sign the report later. If she is certain she does not want to consent for treatment, or after signing the consent report, she will be offered STD prevention and form states she does not want an exam, or any pregnancy risk evaluation and preventive care. portion of the exam, the SANE will respect the While the SANE will strongly encourage the client’s wishes. victim to exercise her right and responsibility to report a sexual assault, the victim always has the Procedure right to make her own decision, and that decision The SANE will explain the purpose of the exam will be respected and honored by the SANE. No and process to the client, discuss her concerns, and third party report will be made except where inform her of the use and release of the evidence. required by State law. She will then ask her to read and sign the consent form. If she refuses to do so, the SANE will ask Procedure what her specific objection is and talk with her When the SANE first arrives, she will ask the about this. If she still refuses to sign, the SANE victim if she has reported. If she has not, she will will inform her of the consequences of her refusal ask her if she would like to do so. If she is uncer- (the loss of evidence and the possibility that she tain, reporting will be discussed and a decision will be responsible for the ED or clinic exam made before any further action is taken. charges). If she consents to parts of the exam, but not the complete exam, the SANE will comply Rationale with her desires. While it is believed that reporting a sexual assault Rationale or attempted assault is the right and responsibility of every victim and the only way to stop rape, only Informed consent is always necessary for examina- the victim can ultimately make that decision. It is tion and treatment. The adult or even an adoles- important that the SANE understand why the cent has the right to refuse treatment, depending victim might be reluctant to report so that she can on the State law, regardless of the desires of any provide her with accurate information about parent or guardian. However, the age limit for the reporting and better enable the victim to make an adolescent varies from State to State. For some informed decision. It is always important that the States, the age limit is 12 years of age and up, for SANE be thoroughly familiar with the laws of her others 16 and up, or 18. It is essential to consult State, including any mandatory reporting statute with the institution attorney and know the State for felony sexual assault. The resulting responsibili- laws. (See Appendix J: SANE Forms.) ties must be appropriately included in the policies and procedures.
115 Chapter 13: Policies and Procedures
On-Call Schedule (Primary) SANEs will be paid the local nursing contract hourly call rate for primary on-call time. Policy Procedure A SANE is on call, off premises, for an 8-hour period starting at 8:00 a.m. each day. Each nurse The “poker chip” call schedule development will be assigned her own pager. Each SANE is method. Each SANE is given a red poker chip for hired to take a predetermined number of shifts of each evening shift for which she is responsible, a call each month. The number of shifts each nurse blue chip for each day shift, and a white chip for is assigned varies from SANE to SANE and is a each night shift. While everyone is initially as- function of her availability and the needs of the signed equal numbers of day, evening, and night program. Each SANE is initially assigned an equal shifts, periodically they are given the option of number of day, evening, and night shifts. Except trading shifts or giving away shifts. A record is kept under unusual circumstances, no SANE will be by the program director. Shifts can also be traded assigned to take more than 2 nights in a row and informally each month when the call schedule is no more than 20 eight-hour shifts of primary call developed. per month. The call schedule is completed 2 weeks prior to the end of the month at a staff meeting for As the call schedule is developed, the SANE puts the following month. the appropriate chip in the center of the table for each shift she takes until all shifts are gone and The SANE is responsible for making sure her pager everyone has used all their chips. is functional and that she remains within the pager range. Under normal circumstances, the SANE is Whenever the SANE goes into the ED or clinic, expected to respond to the ED or clinic as soon as she will record on the Exam Data Form the time possible or within a maximum of 1 hour from the the client arrived at the ED or clinic, the time she time she is paged. Exceptions when a delayed was paged, and the time she arrived at the ED or response may be necessary or acceptable are clinic. The reasons for any planned or unplanned outlined under “delayed responses.” delay exceeding the expected maximum response time of 1 hour will also be recorded. If the delay The next working day after taking call, the SANE was significant, disruptive, or if the ED or clinic is responsible to report any new cases to the office staff appeared upset by the delay, the SANE will secretary including information for followup and also call the SANE director the next morning to any additional pertinent information. The secre- explain the situation to her. Every 2 weeks, the tary will give her the case number at that time. SANE will turn in her patient records including the Sexual Assault Data Sheet to the SANE office. While it is acknowledged that changes in the on- call schedule will need to be made, it is important Delayed responses. Under the following circum- that nonemergency on-call schedule changes be stances, a delayed response may be necessary or kept to a minimum due to the increased likelihood acceptable: of errors occurring when changes are made. Whenever possible, both the nurse initially as- ■ When the victim is too intoxicated to signed and the nurse taking call for her will keep consent to an exam, cooperate with an exam, their pagers turned on. For nonemergency on-call or give an accurate account of the circum- changes, the SANE is responsible to find her own stances under which it is suspected she was coverage and to call the office, answering service, raped. The SANE, in consultation with the and each participating hospital with the changes. medical staff, will determine if the victim In emergency situations, the SANE should call the should be allowed to sleep in the ED until office or the SANE director at home, and they will she is more responsive, and the evidentiary arrange for coverage. exam can be completed. 116 SANE Development and Operation Guide
■ When the medical staff decide it is in the to two different hospitals at close to the same time, best interest of the victim to have x-rays or and after the SANE has completed two or more other lifesaving medical treatment com- exams on one shift. If the SANE feels comfortable pleted prior to the exam. If possible, and in with her ability to complete the work in a timely concurrence with the physician, the SANE manner, she does not have to call the backup. will come in and collect the necessary Whenever she feels unable to do a case, she can evidence in the stabilization room, the choose to utilize backup. operating room, or the ICU. If the primary on call SANE is unable to take call ■ When the primary on-call SANE is busy at the last minute due to a family emergency or completing a case and must call the backup illness, and no one else can take the shift, the on-call SANE. The SANE should also SANE on backup call will be expected to move up explain this to the staff, in case it necessitates to primary. a delay in response time. ■ If the primary and backup on-call SANEs are both busy conducting examinations when Photographs there is another case. The primary SANE should inform the referring staff of the Policy situation and give them an estimate of the Whenever there are injuries, the SANE will take time a SANE can arrive. Supportive staff two sets of Polaroid pictures and one set of 35mm such as a hospital chaplain, mental health pictures of all injuries. Pictures of vaginal injuries worker, social worker, or an advocate should will be taken with the colposcope. All pictures will be contacted to wait with the victim. She include a label in the picture with the victim’s should also update the referring staff of her name, date, time, and SANE’s signature, and a situation if there is a change in her expected standardized measurement instrument to indicate response time. the size of the injury. Some hospitals use the patient’s medical record number in place of the Whenever there is a delay in responding, the patient’s name. SANE should remain in contact with the ED or clinic periodically. She should also contact the Procedure referring agency prior to going off call to check on the victim’s situation and report the status of the One set of Polaroid pictures is placed in a sealed case to the oncoming SANE. envelope and kept with the client record. The second set of Polaroid pictures is placed in a sealed On-Call Schedule (Backup) envelope, which is also labeled with the client’s name, date, time, and SANE’s signature, and Policy attached to the outside of the rape kit with a rubber band. The undeveloped roll of 35mm film To ensure a SANE is available should the primary is secured and labeled in the same way and at- SANE on call need assistance, a second person is tached to the rape kit. always on backup call. SANEs are paid half the primary on-call rate for backup call. Everyone is Rationale expected to take the same amount of backup call as they take of primary call. Polaroid pictures are taken so the police and prosecuting attorney have a visual presentation of The backup on-call SANE is utilized at the discre- the injuries when they are deciding if they can or tion of the primary on-call SANE. It is expected should charge the case. A roll of 35mm film is also that backup will be called when two cases come in taken because there may be deterioration on the
117 Chapter 13: Policies and Procedures
Polaroid pictures if there is a significant delay Tigan 250 mg to take in 12 hours. The SANE before the case goes to court. instructs the victim to call if she becomes nause- ated and vomits within 1 hour of taking the Ovral. Pregnancy Risk Evaluation Rationale and Emergency Interception Deciding to prevent a pregnancy is a moral deci- Policy sion which can be made only by the victim. In order to make an informed decision, she must The SANE will evaluate the risk of pregnancy know her risk of becoming pregnant and the for every victim seen in the ED or clinic. If she options to prevent a pregnancy. The SANE has an determines that the victim is at risk of becoming ethical responsibility to provide the rape victim pregnant as a result of the rape, the SANE informs with this information. Two programs operating at the victim and explains to her options to prevent a Catholic hospitals went as far as to get special pregnancy. permission from the diocese to administer Ovral (Frank: 96; O’Brien: 97). Procedure To determine if the victim is at risk of becom- The risk of pregnancy from a rape is the same as ing pregnant, the SANE should determine the the risk of pregnancy from a one-time sexual following: encounter. This is estimated to be 2 percent to 4 percent (Yuzpe, Smith & Rademaker: 82). It is ■ Was there vaginal-penile contact? important to always test for pregnancy first, as 2 ■ Is the victim mid-cycle or are her menstrual percent of rape victims are pregnant in the ED and cycles irregular? not all are aware of the pregnancy (Tucker, Ledray & Werner: 90; Warner: 87). ■ Is she using contraceptives or has she had a tubal ligation or hysterectomy? The above recommendation is the standard form ■ Is she currently menopausal? of prevention (Osborn & Neff: 89; Ledray: 92b; ■ Is she pregnant based on the results of a Hampton: 95), and it is currently offered at most UPT (urine pregnancy test) completed in existing SANE programs. This reduces the risk of the ED or clinic? pregnancy by 60 percent to 90 percent. Programs using a low dosage ethinyl estradiol contraceptive, ■ Does she understand how the medication give a dose equivalent to 100 mg of estrogen, 4 being offered will prevent a pregnancy? tablets, for each dose (Yuzpe, Smith & Rademaker: If it is determined that the victim is at risk, her 82). (For additional information see Chapter 11: UPT results are negative, it is within 72 hours of SANE Program Operation.) the rape, and she wants to take medication to prevent a pregnancy from occurring, the SANE Program Evaluation and will consult with the staff MD. With the MD’s concurrence, the SANE explains the risks and has Research the victim read and sign the Ovral consent form. Policy The SANE then gives the victim two 50 mg Ovral tablets to take immediately with Tigan 250 mg to Every SANE should spend a portion of her time prevent nausea (it is best to give the Tigan about collecting data that will be used in program 30 minutes prior to the Ovral and to have her eat evaluation or research activities. This is an integral a couple of crackers or a piece of bread). She also part of the SANE role, and it is an ongoing job gives her two additional Ovral tablets and another expectation. In addition, the SANE will bring
118 SANE Development and Operation Guide potential program evaluation or research questions Psychiatric Inpatient/ to the attention of the SANE program director for consideration of future systematic evaluation Extended Care Unit Sexual research. The SANE will be paid at her normal rate Assault Evaluation of pay for her time spent on any aspect of program evaluation or research with funds from the SANE Policy program or another source, such as a special grant. Whenever the staff of an inpatient psychiatric unit The SANE program director is responsible for the at a hospital served by the SANE program deter- development, funding, and operation of all pro- mines or suspects that a psychiatric patient was gram evaluation and research projects. She should involved in sexual contact with another patient or delegate data collection and other evaluation with any other person while on the unit, they will research activities to interested SANEs. While all immediately page the on-call SANE. The SANE SANEs are expected to participate in data collection will determine, in conjunction with the inpatient as a part of their routine client interaction, addi- staff, if the SANE examination will be conducted tional evaluation research activities are optional. in the psychiatric unit or if the patient will be transported to the usual SANE examination area. The SANE program director is responsible for If the same situation occurs on an extended care deciding how the results of program evaluation unit, the patient will be transported to a contract- research should be utilized by the SANE program. ing facility for the SANE examination. However, all SANEs are expected to provide suggestions and input into this process. SANEs The SANE will assess the situation when she who are interested are also encouraged to submit arrives to determine the following: the results of these special projects for publication ■ Was the sexual contact consensual? with the director’s concurrence. ■ Does the patient have the ability of giving Procedure informed consent? ■ Was there a possible violation of the facility’s The SANE program director should explain all duty to protect the patient? evaluation research activities to the SANEs and provide them with the necessary forms and instruc- If the patient is a vulnerable adult, a report must tions for completion. She should also work with be made to the police or adult protection services. them to develop, obtain funding, and implement If the incident is the result of a clear case of neglect new projects. or failure to protect on the part of the health care facility, or if the perpetrator was an employee of Rationale the facility, the State’s health care facility regulating agency also must be informed so a proper investi- The role of the SANE and the treatment of sexual gation can be conducted. assault victims is a relatively new field. To ensure that the best possible services and treatment options are provided, SANEs have a responsibility Procedure to do continual program process and outcome The SANE will verify legal authorization to research. SANEs cannot afford to assume that the consent by checking the signature on the patient’s current practice and methodology is necessarily the admission consent form and by checking the chart “best” way to provide services or the best services for documentation of a designated legal guardian. to provide victims. Only by continually evaluating If the patient is not able to give consent, the SANE service delivery process and outcome can programs will attempt to get the proper consent. The SANE continue to develop and grow professionally and will then assess the patient’s cognitive capacity. provide even better services to victims. 119 Chapter 13: Policies and Procedures
If the SANE determines that the patient is coher- Indicators the SANE would use in making the ent, she will explain her reason for being there and determination of possible rape drug use include the inform the patient of her rights. The SANE will following: then assess if the patient is aware of what happened and, if so, if the patient considers the sexual ■ A history of being out drinking with friends, contact consensual. With the consent of the having just one or two drinks (too few to patient, she will complete a sexual assault eviden- account for the high level of “intoxication”), tiary exam. A police or adult protection report will a moment where she recognizes feeling also be made with the patient’s permission or as strange, then feeling suddenly “very drunk.” mandated by law. Unfortunately, she may still look normal and while a little unsteady on her feet, she may Rationale be able to walk out of the bar with her assailant. A client who is not capable of giving consent for ■ Becoming very “intoxicated,” very rapidly, medical care is likely not capable of giving consent within a matter of 5 to 15 minutes, for sexual contact and is thus a vulnerable adult. especially after accepting a drink from some- Also, by virtue of her status as an inpatient, the one, or drinking a drink she left unattended. patient is likely vulnerable (Dexheimer Pharris & ■ Ledray: 97). Waking up 8 or more hours later, uncertain if she has been raped, but believing she may have been raped because she is experiencing Rape Drug Screening vaginal soreness, or because she has no Rohypnol, GHB, and Others clothes on, or waking up with a strange man, with no memory, or a very spotty Policy memory of what happened. ■ Whenever the SANE suspects that the rape victim Being told she was given “Roaches,” was drugged by flunitrazepam (trade name “Roofies, “Mexican Valium,”or “R-2.” Rohypnol), GHB (gamma hydroxybutyrate), or ■ History of feeling or being told she suddenly any other “Date Rape Drug” used to incapacitate appeared drunk, drowsy, dizzy, confused, the woman, within the previous 72 hours or less, with impaired motor skills, impaired judg- with the victim’s informed consent, the SANE will ment, and amnesia. save the first voided urine and send it to the ■ History of “cameo appearances” in which the independent laboratory hired by Hoffman-La victim remembers waking up, possibly seeing Roche for free confidential drug testing. In some the assailant with her, but being unable to jurisdictions, urine collection may occur up to 96 move, and passing out once again. hours post-ingestion since some drugs, such as ■ High school or college age, as GHB and valium, may be detected for a longer period of Rohypnol abuse is more common, but not time. limited to these populations, especially in Florida, Texas, and Mexico. Unfortunately, The SANE will inform the victim that the testing its presence is quickly spreading across the will be done confidentially, identifying her only by country and may be seen in any State. a number, and will test for flunitrazepam, other benzodiazepines (the family of compounds to which flunitrazepam belongs), marijuana (cannab- Procedure inoids), GHB, cocaine, amphetamines, some When the victim reports within 72 hours (96 opiates, barbiturates, and alcohol. hours in some jurisdictions) of likely drug inges- tion, the SANE will obtain the first voided, clean
120 SANE Development and Operation Guide catch specimen, maintaining chain-of-custody In 1996, Congress passed the Drug-Induced Rape using the Sexual Assault Laboratory Results form Prevention and Punishment Act, imposing up to (See Appendix J: SANE Forms). She will docu- a 20-year prison term for anyone giving an illicit ment the time of likely drug ingestion, the number drug to another person without their consent with of times the victim has voided since ingestion, and the intent of committing rape. Congress increased any prescription medication she is currently taking. the penalties for both trafficking in Rohypnol and the use of Rohypnol and other controlled sub- Obtain an authorization from Hoffman-La Roche stances by sexual predators. Despite the Federal laboratories for free testing by calling 800–608– law, prosecution for rape and for the use of 6540. When this number is answered the SANE will Rohypnol and other rape drugs continues to be be asked to provide an identifying case number. handled primarily at the State level. This law also (This may be the SANE case number or medical required the Drug Enforcement Agency (DEA) to record number, or a number determined using a study reclassifying Rohypnol from a Schedule IV system of choice). sedative/hypnotic to a Schedule I of the Federal Controlled Substances Act. This reclassification is Hoffman-La Roche will fax a form with an authori- a method for providing closer control of more zation number. Complete the form and sign it, call dangerous drugs. The producers of Rohypnol, FedEx to pick up the specimen. If FedEx does not Hoffman-La Roche, oppose this reclassification. arrive prior to the SANE’s leaving the ED, the specimen should be locked in the ED specimen The drug screen, completed by ElSohly Laborato- refrigerator with the other evidence and a chain-of- ries, is currently the most economical testing evidence form should be attached. The ED nurse available to identify flunitrazepam and other drugs. will sign that she gave the specimen to FedEx. It will While some individuals recommend testing by a be taken to the independent laboratory, ElSohly laboratory with no association to Hoffman-La Laboratories, with whom Hoffman-La Roche has Roche Laboratories, most hospital laboratories contracted to perform the drug screen. cannot test for flunitrazepam, and the screen can cost in excess of $850. Most programs do not have the funding to allow for this additional cost. Rationale Hoffman-La Roche is paying the fees, but an According to the Drug Enforcement Agency and independent contracted lab, ElSohly Laboratory, rape crisis centers, the use of drugs to make a is performing the tests, and ElSohly Laboratory’s woman more vulnerable to rape has been increas- work is respected in the field. Therefore, ElSohly’s ing dramatically across the United States since test results should not be considered unreliable. 1995. In addition to alcohol, two drugs known to However, there are a number of laboratories across be used for this purpose are Rohypnol and GHB. the country, including some crime labs, capable of Rohypnol trafficking and possession cases have identifying flunitrazepam, and many large agencies been identified in 36 States. Rohypnol is widely have chosen not to use ElSohly laboratories for used across Europe and Latin America where it their testing site. is prescribed as a preoperative sedative and for treating insomnia. GHB is a behavioral central Urine is used instead of blood because both nervous system depressant that actually excites the Rohypnol and GHB are out of the blood stream brain into an epileptic seizure and shuts down within 4 hours. While it is not known for certain other CNS functions. It is used illegally by body how long these substances can be detected in the builders and RAVE party goers. Both drugs are urine, it is believed GHB can be identified for only powerful, fast-acting sedatives that share similar up to 12 hours after ingestion. Rohypnol can be side effects including resulting memory loss for detected for 36 to 60 hours, however, identifica- large periods of time. tion is more likely when the sample is collected
121 Chapter 13: Policies and Procedures
office (See Appendix K: SANE Evaluation Tools). Drug Test Results of Urine Samples From Reported Rape Cases 410 Samples These include the following: Morphine/Opiates 1.6%
Other Drugs 1.7% Flunitrazepam .9% ■ SANE Data Form. Barbiturates .5% Codeine 1.7% ■ SANE Clinical Data Sheet. Amphetamines 5.2% None Found 29.1% Cocaine 5.7% A copy of the consent for release of information and a copy of the Sexual Assault Exam Report GHB 7.3% should be attached to the evidence provided the police.
Marijuana 11.1%
Alcohol 25.1% Procedure Other Benzodiazepines 12.0% The SANE completes all paperwork while in the ED or clinic, makes the necessary copies, and within 36 hours after ingestion. Specimens can be attaches them to the rape kit for the police. collected up to 72 hours (96 hours in some juris- dictions) because other drugs that may have been Rationale used can be detected for a longer time period. It is essential that all original paperwork is com- The above chart reflects the 1997 statistics. As of pleted immediately. Some programs maintain the February 1998, 578 samples have been tested by records in their clinic, separate from hospital ElSohly Laboratories as a part of this program, and medical records, to ensure additional confidentiality. only five specimens have been found positive for Flunitrazepam (Rohypnol) and 30 for GHB. STD Evaluation and Prevention (Other than HIV) Records Policy Policy The SANE should not culture for any STD in the The SANE is responsible for completing all SANE ED or clinic. If the victim is being seen within 72 records before leaving the ED or clinic. The hours (96 hours in some jurisdictions) of the rape original copies of all hospital records are left as a and is at risk, the SANE will offer prophylactic part of the hospital chart (See Appendix J: SANE treatment for gonorrhea, syphilis, and chlamydia Forms). These include the following: according to the medication protocol. Adolescents 12 years of age and older do not need parental ■ Sexual Assault Exam Report. consent to be treated for STDs. ■ Waiver of Medical Privilege and Authoriza- tion for Release of Medical and Legal Procedure Information. If the victim is at risk and wants treatment to ■ Ovral Consent Form (when appropriate). prevent STDs, the SANE determines her preg- ■ Laboratory Request Forms (when nancy status by getting a UPT, and she asks her appropriate). about allergies to medications. She then discusses ■ Critical Item Suicide Potential Assessment the case with the ED or clinic physician. She (when appropriate). reminds them of the medication protocol and obtains a prescription signed for the medication Forms used for internal data collection and pro- that is given to the victim. The medication is gram evaluation purposes are returned to the SARS
122 SANE Development and Operation Guide obtained according to ED or clinic procedure and clinic pages the SANE on call, and she goes into given to the victim with instructions prior to the facility to assess the situation. discharge. (See Chapter 12: The Pediatric SANE Exam, for exceptions.) After talking to the parents, the SANE talks with the teenager alone. She informs the teenager of Rationale the statutory rape laws, the purpose for these laws, and of her right to refuse to have an exam. The There is no evidence that initial baseline cultures SANE then assesses if sex occurred and, if so, or cultures taken on followup are useful in court, when; if the sex was consenting; the age of the and there is data showing they are sometimes used partner; and if she wants to have a rape exam. If against the victim to suggest sexual promiscuity. the teenager claims there was no sex, or if she As a result, these initial ED cultures are not claims the sex was consenting and she does not recommended (Ledray: 92b). Culturing is also very want an exam, the SANE does not perform an expensive and time-consuming for the victim who exam. If the age difference meets the terms of the must return for testing, and unfortunately most statutory rape laws, but after talking to the SANE, victims do not return (Blair & Warner: 92). In one the daughter still refuses the exam, no exam will study, 25 percent of the victims seen in the ED be completed. returned for the initial STD followup visit (Ledray: 91), and in another study, only 15 percent re- The SANE does, however, offer treatment for turned. In this second study, they were able to STDs and pregnancy prevention. The SANE is contact 47 percent of those who had not returned NOT mandated to report statutory rape in the for followup, and they found an additional 11 State of Minnesota unless the adult perpetrator is percent of these went elsewhere for medical a caretaker or an adult in a position of authority followup, however, only 14 percent told the over the minor. If the sexual contact was with a physician they saw for followup about the rape teacher, relative, counselor, teen group leader, or (Tintinalli & Hoelzer: 85). Most clinicians recom- other person in a caretaker position, it may fall mend prophylactic treatment following CDC under mandatory reporting statutes. If so, the guidelines (Frank: 96; Arndt: 88; Antognoli- SANE must explain this to the adolescent and her Toland: 85; Tintinalli & Hoelzer: 85). If cultures parents and, when appropriate, make the neces- are taken, they need not be handled as evidence sary report. The adolescent still will not be forced because they are not used in court (Blair & to undergo examination against her will. Warner: 92). Procedure As of 1995, all States have statutes allowing adolescents to consent for diagnosis and treatment The SANE first talks with the parent(s) and for STDs although there is variation in the age daughter together, then she talks with the daugh- limit from State to State ( Dexheimer Pharris & ter alone. If uncertain how to proceed, the SANE Ledray: 97). should call the SANE on backup call or the SANE program director to discuss the case. After talking to the daughter and deciding on her preferred Statutory Rape/Teen course of action, the SANE staffs the case with Consenting Sex the ED or clinic staff, explaining her decision and rationale to them, in case the parents decide Policy to talk to someone else. She then explains her If parents bring their teenaged daughter to the ED decision and rationale to the parent(s). She should or clinic insisting on having a rape exam completed acknowledge their concerns about their daughter’s to ascertain if she is sexually active, the hospital or sexuality and talk about their other options for
123 Chapter 13: Policies and Procedures
dealing with their daughter’s sexual activity other included the hiring of additional dedicated staff. than a rape exam or rape charges. The SANE This resulted in a significant increase in the always offers referrals for family counseling. number of statutory rape cases they charged and convicted (Donovan: 97). Rationale The SANE must be thoroughly familiar with the It is important to acknowledge and plan a strategy pertinent Federal and State statutes and the ahead of time to deal with the two issues involved: institutional policies and expectations (Dexheimer Pharris & Ledray: 97). It is important to talk with 1. State and Federal statutory rape laws and the the institutional attorney, prosecuting attorney, and local enforcement policy. police about enforcement of the statutory rape laws 2. Parental concern over the sexuality of an and the rights of an adolescent to refuse an exam. adolescent. For instance, the SANE may make a greater effort to get consent for an exam from a 15 year old who Statutory rape laws have been on the books of is “dating” and is sexually active with a 25 year old, most States for decades but have generally not been than she would from a 15 year old who is sexually enforced. In an attempt to reduce the number of active with her 18 year old boyfriend, even though teenage pregnancies and lower the costs of welfare, both technically meet the statutory rape guidelines. a growing number of policymakers are encouraging A police report will be made by the SANE only aggressive enforcement of statutory rape laws. This when mandated by law. move is based on the widespread belief that many of the young mothers became pregnant as a result It is important to acknowledge the parents’ con- of coercive sex by older men, and increased en- cern for their daughter and their desire to keep her forcement of statutory rape laws is necessary to safe. It is equally important not to make a moral protect them from abuse and exploitation judgment but rather to provide them with addi- (Donovan: 97). Enforcement is also based on the tional information about other options. It may be yet unsubstantiated belief that if these men fear necessary to also inform them of birth control they will be prosecuted for statutory rape, they will options to prevent pregnancy and of STD preven- not become sexually involved with these minors, tion. Parents struggling with their adolescent and the number of teenage pregnancies will thus daughter’s sexual activity may benefit from a be reduced. As Donovan (1997) points out, referral for family counseling with a professional however, health care providers fear that if they are skilled in adolescent health and sexuality issues. forced to report these cases as statutory rape, the teenagers will either not seek care or not be truth- Suicide Potential Evaluation ful with the providers. Policy This has prompted considerable public debate, and changes in the laws of several States have already The SANE will complete a Critical Item Suicide occurred. In 1996, Florida voted to make the Potential Assessment (CISPA) form whenever the impregnation of a girl 16 years of age or younger following is true: by a male 21 years of age or older a reportable form ■ The victim expresses suicidal thoughts. of child abuse. Recognizing the potentially negative ■ impact on health care, they excluded health care The SANE is concerned that the victim may workers and counselors who provide services to attempt to hurt herself. pregnant teenagers from the mandated reporting ■ When asked, the victim confirms that she has requirements. California implemented a statutory thought of harming herself. rape vertical prosecution program in 1995, which
124 SANE Development and Operation Guide
■ The victim has a history of suicidal thoughts the date, hours worked, location, type of work or attempts. (e.g., ED visit, staff meeting, court testimony, meeting with director, community presentation, If the CISPA score indicates that the victim is at office work, etc.) and the client number when risk, the SANE will request an evaluation by the appropriate. Crisis Intervention staff prior to discharge. If the client refuses this referral, the identified consulting Procedure physician should be notified and the refusal noted in the chart. The SANE will then consult with the The completed time card and time sheet will be medical staff to determine if the victim meets the signed by the SANE and delivered to the office by criteria for a medical protective hold as dangerous the end of the work day (5:00 p.m.) to guarantee to herself or others. If so, the SANE will complete payment on time. her exam and turn the care of the victim over to the ED or clinic staff. The consulting physician Unavailability/Vacation will place a medical protective hold on the victim. If the victim attempts to leave the facility, security Policy must be called to detain her. Under normal circumstances, no more than two Procedure SANEs should be on vacation or unavailable for call at the same time. A planned absence or The SANE will ask the victim if she has thought unavailablitiy for 1 week or more must be ap- of harming herself. When there is any concern of proved in advance by the SANE director. immediate or potential suicide risk, the SANE will complete the CISPA and communicate her con- Procedure cerns and the results of the CISPA to the physician when she discusses the victim’s case with the After speaking with the SANE director, the SANE physician. The original CISPA will be kept with must enter the dates of her unavailability in the the patient’s medical record. vacation book.
Rationale Unconscious Victim Suicide attempts are a real concern following a Policy sexual assault and in most cases can be prevented through appropriate recognition of risk and If the client is unconscious and unable to sign a prevention. Any expressed suicide thoughts must consent, the SANE will attempt to contact a be taken seriously and carefully evaluated. (See parent, guardian, or relative for consent to conduct Appendix J: SANE Forms.) Be sure to check with an evidentiary exam. When no appropriate parent an institutional attorney and know the local State or guardian is available, the exam will be com- laws concerning when a medical protective hold pleted after documenting the situation and at- can be applied and by whom. tempts made to obtain consent.
Time Cards/Time Sheets Procedure The SANE will document on the patient’s record Policy the reasons for not being able to obtain consent Each SANE is responsible for completing a time and the reasons for conducting an evidentiary sheet and a time card and for submitting them to exam after conferring with the ED or ICU staff the SANE office secretary. Each entry will include and/or police involved. She will then proceed to
125 Chapter 13: Policies and Procedures
complete an evidentiary exam and secure the evidence collected maintaining proper chain-of- custody. When in doubt, she will collect evidence from all orifices. When the victim regains con- sciousness or an appropriate parent or guardian is located, consent will be obtained to release the evidence to the police.
Rationale If biological evidence is not collected as soon as possible, it will be lost. By going ahead and collect- ing the evidence, the SANE is acting on what she believes is in the victim’s best interest. The eviden- tiary exam is not invasive, and it does not expose the victim to any undue risk or harm. (While State law usually recognizes the doctrine of implied consent, it is important to confer with the hospital or State’s attorney when developing a protocol to ensure that the SANE protocol is based on local State law.)
126 SANE Development and Operation Guide
MAINTAINING A CHAPTER 14 HEALTHY ONGOING PROGRAM
Maintaining a healthy work environment involves Little empirical research has specifically evaluated developing and fostering a healthy effective the impact of work with sexual assault victims on program model and a healthy productive staff. the caregiver. Recognizing that the SANE role, While SANEs report that working with sexual with long hours on call and working with multiple assault clients is a privilege and that they are victims of severe trauma, can be stressful to the fortunate to work with this population (Ledray: SANE is important. No matter what measures are 93b), they also recognize that this service is very taken to reduce the impact, some staff will leave emotionally draining (Arndt: 88; Ledray: 92a). as a result of this burnout (O’Brien: 96a). Some As a result of this work, SANEs may fear for their SANEs may need to leave the position either own safety, fear the assailant may go after them, temporarily or permanently to reduce the stress in experience vicarious traumatization with sexual, their lives and maintain a healthy balance. How- cognitive, and emotional impairment, or just be ever, better understanding of the potential negative physically exhausted after seeing numerous clients impact and the corresponding development of and serving long hours on call (Frank: 96). strategies to address the consequences can reduce this costly distress and turnover.
SANE Vicarious In a study of both sexual assault counselors and Traumatization and Burnout counselors who work with a wide variety of popu- lations, Schauben and Frazier (1995) found that Working with victims of trauma is stressful to the the percentage of sexual assault victims in an caregiver and has been recognized as a source of individual’s caseload was associated with a disrup- burnout and vicarious traumatization. Vicarious tion in his or her belief about the safety of the trauma is the enduring psychological consequence world and the goodness of other people, symptoms of a caregiver’s exposure to the traumatic experi- of PTSD, and self-reported vicarious trauma. ences of the victims for whom they care (Schauben However, the study also indicated that work with and Frazier: 95). Responses include a change in the a higher percentage of rape victims was not corre- caregiver’s belief that the world is safe and that lated with job burnout or the negative effect people can generally be trusted. As a result of their associated with depression. In fact, the researchers work, SANEs can experience symptoms of post- indicated that many of the caregivers in their study traumatic stress disorder (PTSD), such as sleep reported many positive aspects of the work that disturbance, nightmares, intrusive thoughts, easily they found rewarding in spite of the heavy irritated feelings, exaggerated startle response, caseload. Counselors reported that their ability to withdrawal from others, feelings of increased help people in crisis move toward recovery was a vulnerability, and emotional reactions such as fear positive aspect of their work. and anxiety (McCann & Pearlman: 90).
The impact of continuous work with sexual assault Identifying Symptoms victims goes beyond what is typically referred to as The SANE must be aware of the typical symptoms “staff burnout.” In particular, sexual assault work of vicarious traumatization in order to reduce the affects the caregiver’s sexuality and increases her negative impact of work with sexual assault vic- awareness of the potential for violence in her own tims. The SANE director should assist SANEs in life (Pearlman & Saakvitne: 95). 127 Chapter 14: Maintaining a Healthy Ongoing Program
recognizing symptoms to ensure that they remain Symptoms of Vicarious Traumatization or effective in their work with victims. A SANE Burnout suffering from burnout or vicarious traumatization will be less effective in helping the victims she sees, The following boxed information lists symptoms and without timely intervention, she ultimately of vicarious traumatization or staff burnout that may have to take a leave of absence or leave the should be considered and evaluated. This is not an position. exhaustive list. One incident of a symptom is less significant than a newly developed pattern of The SANE director may choose to provide all symptoms. For example, a particular SANE may SANEs with copies of the PTSD Checklist and always be late to meetings or be somewhat sloppy Burnout Self-Evaluation Tool included in the in completing her paperwork. While that may be appendix. She may want to encourage each SANE a problem, the SANE director would be more to complete these evaluations annually to assist the concerned that these behaviors were indicative of SANE in recognizing and measuring her current vicarious traumatization if an otherwise very neat level of distress (See Appendix K: SANE Evalua- SANE, who is typically on time, changes her tion Tools). behavior. It would be of special concern if the change followed a particularly difficult case or a SANEs should recognize that stress is also associ- particularly busy period. ated with other areas of the SANE’s life, such as raising children, other relationships, and money Reducing Impact on Staff problems, not just from her work with victims. Regardless of the origin, stress always has the Reducing the potential impact of working with potential to affect the SANE’s ability to work this victim population begins with careful screen- effectively with victims. Recognizing the stress, ing of potential SANEs to identify and hire those identifying the cause, and taking steps to resolve or individuals with healthy boundaries and good reduce the stress are critical measures in maintain- personal support systems. Maintaining a healthy ing balance and ensuring effectiveness in both the sense of humor about the work is also important. personal and work lives of the SANE. While individuals who do not work with victim
Cognitive Impact: Emotional Impact: ■ Forgetfulness. ■ Anger. ■ Trouble concentrating. ■ Depression. ■ Cynicism. ■ Hyper vigilance. ■ Perfectionism. ■ Anxiety. ■ Apathy. ■ Irritability. ■ Reduced productivity. ■ Emotional liability. ■ Rigidity. ■ Crying excessively. ■ Negative attitude. ■ Fears. ■ Preoccupation with trauma. ■ Isolation. ■ Minimization. ■ Suspiciousness. ■ Inability to accept limitations. ■ Numbness. ■ Thoughts of harm to self or others. ■ Suicidal thoughts.
128 SANE Development and Operation Guide
Behavioral Impact: Sexual Impact: ■ Alcohol or drug abuse. ■ Intrusive deviant sexual images. ■ Not being available for call when scheduled. ■ Deviant sexual urges. ■ Excessive physical illness. ■ Trouble becoming aroused. ■ Easily irritated. ■ Vaginismus. ■ Sleep disturbance. ■ Disturbed body image. ■ Eating disturbance. ■ Inability to reach orgasm. ■ Weight loss or gain when not trying to lose ■ Seeing deviant sexual activity as “normal.” or gain weight. ■ Identifying all sexual activity as rape. ■ Inability to complete tasks on time. ■ “Sloppy” completion of paperwork. Schauben and Frazier (1995) also asked counselors ■ Tardiness for meetings and taking an exces- working with sexual assault victims about the sive time to get into the ED. strategies they used to deal with work-related stress. The strategies used most often included seeking populations may not understand the humor, the emotional support from friends and family, getting SANE director needs to allow and even encourage advice about what to do from a colleague, and humor that is not disrespectful of the victim. humor. The researchers found that respondents who used these coping strategies were less likely To expect the work environment to meet all the to use alcohol or drugs, denial, or disengagement. SANE’s support needs is unrealistic. Encouraging Thirty-five percent of the respondents also re- staff to have outside interests, to take adequate ported that they engaged in activities that pro- time off, and to go on vacations to renew them- moted physical health, such as exercise and eating selves is essential. It may even be necessary for a healthy food. Meditation, being outdoors in a SANE to take an extended leave of absence. natural environment, and keeping a journal were the next most frequently reported strategies for The SANE director should exemplify the need stress reduction. Leisure activities such as going to to take care of oneself and to prevent vicarious the movies, reading, gardening, and listening to traumatization. She should encourage SANEs to music also were frequently reported as helpful ways nurture outside interests, especially activities that to reduce work-related stress. Getting adequate provide a physical release and a healthy balance in sleep and proper nutrition are also good preventive life. Hobbies are important stress reducing activi- measures. ties, especially hobbies that allow for a sense of completion of a task or goal and that allow for Other measures found helpful to prevent or complete disengagement from work. SANEs need combat vicarious traumatization and burnout to set personal limits and maintain strong bound- include monthly staff meetings which incorporate aries, such as not giving their home phone num- case reviews and provide debriefing and mutual bers to victims and seeing clients only during support, especially for the more distressing cases official duty hours. The on-call SANE should (Tobias: 90; Arndt: 88; Holloway & Swan: 93). handle all emergencies. While she may consult Sometimes it may be necessary to refer staff to a with the SANE who initially saw the victim in the counselor or psychologist for additional emotional ED, it is not recommended to expect the same support (Holloway & Swan: 93). SANE to be available to answer questions 24 hours a day, 7 days a week.
129 Chapter 14: Maintaining a Healthy Ongoing Program
Providing adequate professional development and may include information such as the average ongoing advanced training is another important number of exams completed each month or year method of avoiding burnout. SANEs that are by SANEs that can then be used to decide if it is continuing to grow and develop professionally time to consider hiring new staff. express more job satisfaction and are more likely to remain with the program. Ongoing program evaluation must be an integral part of every SANE program. Evaluation is not Maintaining adequate SANE staffing is critical to effective as a one-time activity completed for ensuring that the stress associated with call duty “outside” purposes, such as those that might be does not become excessive. Determining the imposed by a funder. Evaluation is much more number of SANEs to hire is not an easy decision, effective as an ongoing process to answer “internal” however. If the staff is too large, then SANEs do questions posed by program staff. Evaluation is not see enough cases to maintain their proficiency usually problem-focused. Its goal is often to or income. Costs associated with payment for time provide information to help solve a specific prob- spent in staff meetings and training also rise lem. When the issues and problems evaluated tremendously. come from the SANE staff, it is more likely that the results will be utilized to improve the services As discussed in chapter eight, when SANEs are delivered. Program evaluation is a tool to help consistently completing two cases in a single on- staff learn what they do well, what goals they are call period, it may be time to reduce the on-call accomplishing, and where they could improve in hours in a shift (e.g., from 12 hours to 8 hours) order to achieve unrealized goals. and hire more SANEs. This is more likely to occur during the first few years of program operation Formal and Informal Evaluation when the caseload grows the most rapidly. When Strategies signs of stress such as increased illness or dissatis- faction begin to appear, or when a larger than usual Program evaluation may take the form of formal number of unfilled shifts remain in a new on-call evaluation using experimental research designs, or schedule, it may be time to re-evaluate the number it may involve informal data collection strategies. of shifts assigned to each SANE. This should be While using formal and informal evaluation done at a minimum every year, and every 6 strategies may accomplish many of the same months may be necessary during the first few years functions, formal evaluation projects tend to utilize when the number of victims seen is more likely to more rigorous methods, with larger groups and be increasing rapidly. over longer periods of time. Formal evaluations also tend to utilize standardized tools with estab- Program Evaluation lished reliability and validity, or they establish the reliability and validity of measures developed prior Program evaluation allows for a systematic assess- to the implementation of the formal evaluation. ment of program strengths and limitations in order to improve the program service delivery process There are three general types of program evalua- and outcomes. The linking of program process or tion: process evaluation, output evaluation, and performance with participant outcomes helps outcome evaluation. Each may be accomplished program staff evaluate their progress and modify formally or informally. Appendix K includes the program as appropriate. Information obtained sample program evaluation tools that can be through program evaluation can be used by implemented and utilized for effective SANE administrators or funders to make decisions about program evaluation at all levels. future program goals, strategies, and options. This
130 SANE Development and Operation Guide
Process Evaluation ■ The number of community training programs completed. This type of evaluation focuses on how program ■ services are delivered. Examples of process evalua- The number and content of phone calls tion include the following: from rape victims. ■ The number of followup visits by rape ■ Sexual assault victims are surveyed and asked victims or the percentage of victims seen if it is helpful to have the rape advocate come in the ED that return for counseling. into the ED automatically or paged first. ■ The number of program brochures ■ Sexual assault victims are asked if the issue distributed. of HIV should be brought up in the ED or at ■ The number of public service announce- a later point in time. ments (PSAs) in the media. ■ Followup telephone surveys are conducted ■ Peer chart reviews for completeness and 2 months after the assault to see if sexual accuracy of documentation. assault victims took advantage of referral information provided to them in the ED. Outcome Evaluation ■ Rape victims who did not come in for Outcome evaluation focuses on the results of the counseling are called 2 months after the service delivered to the targeted individuals or assault. They are assessed for symptoms of groups. When designing an outcome evaluation, PTSD and asked if they are interested in it is important to identify the target individuals coming in for counseling at this point in or groups. Then it is important to explicitly state time. The follow through rate with counsel- what will change in the target group. Knowledge, ing visits scheduled is compiled at this time. attitude, behavior, belief, or symptoms may be ■ Victims are surveyed 2 weeks after the ED expected to change as a result of the intervention. visit and asked about their satisfaction with With sexual assault, it may be the reduction of care provided by the police, hospital medical symptoms of PTSD. staff, SANE, and the rape advocate. The results evaluated may be immediate, short- ■ SANEs complete data sheets in the ED on term, or long-term. every client seen which provides the follow- ing information: Immediate Outcome. The immediate outcomes • The time between the victim’s arrival at of service may include the following: the ED and the SANE’s arrival. ■ Victims who did not initially want to report • If no police report was made prior to the the rape decide to do so after talking with SANE’s arrival, whether the SANE tried the SANE. to resolve the client’s fears and counsel the ■ victim about the importance of filing a Victims decide to take STD and pregnancy police report. prevention medication. ■ Independent assessment of the rape kits Output Evaluation completed by SANEs and nonSANEs are Output or performance evaluation assesses the done to see if the correct evidence was amount and type of work accomplished by the collected, properly documented, and the SANE program. This may include information chain-of-evidence maintained. such as the following: ■ Peer review of the impact of SANE testi- mony on courtroom testimony is gathered. ■ The number of evidentiary exams completed each month.
131 Chapter 14: Maintaining a Healthy Ongoing Program
Short-Term Outcome. Short-term outcome may average or percentage of cases, or it may involve include the first few weeks or months after the sophisticated statistical analysis. Often, graphical assault and include evaluations of the following: representations of group or individual values is extremely helpful in understanding results. ■ The percentage of victims who become pregnant even though they are provided Appendix K includes a sample of process, output, preventive care in the ED. and outcome tools that may be useful in evaluating ■ Case presentations and peer reviews. the SANE program impact on the individual victim and the community. Also included are Long-Term Outcome. Evaluations of client evaluators’ comments on the use of the tools (See outcomes 1 year after the rape and beyond are Appendix K: SANE Evaluation Tools). generally considered long-term evaluations. The longer the time period between the initial contact Evaluation Utilization and the evaluation followup, the more difficult it In addition to answering questions raised by SANE will be to locate former victims. A smaller sample staff and ultimately improving SANE services, can be expected. This smaller sample may or may evaluation findings may be useful to the SANE not be representative of rape victims, since those program in other ways. Findings may be used to who cannot be located may be better or worse off. convince funders to fund new program compo- Examples would include the following evaluations: nents or continue funding for effective programs. ■ One year anniversary telephone calls or Community leaders who support the SANE mailed questionnaires assessing symptoms program may want access to the results to justify of PTSD in clients seen for counseling and their ongoing support and to obtain the additional in those not seen. support of their colleagues. The media may be ■ Courtroom outcomes of SANE and interested in the results. Other SANE programs nonSANE cases in the area, that would will likely be interested in the evaluation findings assess, for example, the proportion of guilty as they implement programs in their community. verdicts in the SANE cases as compared to Providing the results of the SANE program evalua- the nonSANE cases. tion data to community organizations is useful for ■ Client satisfaction questionnaires completed building the credibility and trust of the community 1 year after the rape that provide feedback and of potential clients even if the results are from clients having gone through the judicial negative or show how the program can be im- or legal system. proved. Ongoing program evaluation is a charac- ■ Yearly meetings with other community teristic of effective organizations. When commu- agencies to evaluate their satisfaction with nity organizations decide what programs they are the SANE program. going to support, they will want to see documenta- ■ Community sexual assault felony charge tion of program effectiveness. rates and prosecution rates of SANE and non-SANE cases. Steps of Program Evaluation Planning 1. List the SANE program’s primary goals and Data Collection and Analysis activities. Evaluation data may be collected using standard- 2. Identify problem areas, questions, or ized tests with established reliability and validity. It concerns. also may be collected using informal questionnaires 3. Identify the outcome(s) of those individuals developed specifically for a SANE program evalua- or groups who make use of SANE services. tion. The data provided may be a simple count, an 4. Formulate evaluation question(s).
132 SANE Development and Operation Guide
5. Identify the type of information needed to More effort may be required to establish this answer the question(s). communication with agencies that are not a part 6. Identify how to obtain the information. of the SART, but it is no less important. Inviting a representative to a SANE meeting where a topic 7. Decide who will obtain the information and of mutual interest is discussed is one way of over what time frame. accomplishing this objective. Informal meetings 8. Decide how the information obtained will or lunches are another way to do the same. Making be used. a point to talk informally at statewide training programs and conferences is also useful. Evolution of SANE Program Evaluation It is essential that the SANE program maintains The type and intensity of the evaluation that will membership in community, county, State, and be the most helpful will evolve as the SANE national organizations that promote ongoing program evolves. Programs and staff that are new collaboration. Not only is communication facili- can benefit most from effective process evaluation. tated, but these memberships greatly enhance the Informal, simple, process evaluation of immediate ability of the SANE program to effect change and or short-term impact will be useful to staff in advance the services to victims both locally and evaluating their program policies and procedures nationally. In addition to the local SART, target and in making early decisions about possible organizations might include the following: changes in service delivery. Programs that are more established may decide to implement a more ■ State and national sexual assault coalitions. elaborate victim and system outcome evaluation ■ International Association of Forensic Nurses component which includes both short-term and (IAFN) and State chapters of IAFN when long-term components. The SANE program can available. often make use of evaluation or resource expertise at nearby universities. Sometimes a graduate ■ National Organization for Victim Assistance student in evaluation studies or a related field may (NOVA). be able to integrate their thesis with the evaluation ■ State Nurses Association and American of the SANE program. Local evaluation consult- Nurses Association. ants may also be solicited to help the program; ■ American Professional Society on the Abuse sometimes they will be willing to do so pro bono. of Children (APSAC). Even if external consultants are used, the SANE director and staff should play the primary role in creating the evaluation questions and deciding Summary upon the outcomes that are appropriate for their Maintaining a healthy staff, working cooperatively own program. with other agencies, and conducting ongoing program evaluation are important and necessary Maintaining a Healthy components of SANE program operation. Unfor- tunately, all too often, program directors who have Ongoing Relationship good intentions become overwhelmed with the with Other Agencies expectation that they “must” do elaborate program and Organizations evaluation and as a result do none. Limitations in staff time, equipment, and resources are real. Open communication is the most important Sometimes the decision is made to eliminate component of maintaining a healthy relationship program evaluation and measures to better train with the other community agencies with which the and support staff in an attempt to save these SANE program works. Regular formal meetings resources. However, when staff are not adequately with the SANE/SART is an effective method of maintaining open communication. 133 Chapter 14: Maintaining a Healthy Ongoing Program
supported and evaluation is not incorporated as an provides to the community-at-large (Arndt: 88). integral part of the SANE process, the real result Probably the best testimony of the efficacy of the may be the waste of valuable resources. SANE model is that communities that now have SANE programs wonder what they did without Many of the SANE programs in existence today are them (Lenehan: 91). Good evaluation will ensure operating because nurses or physicians who visited that these programs continue to strengthen, grow, or previously worked in hospitals with a SANE and better meet the needs of the people they serve. program saw the advantages a SANE program
134 SANE Development and Operation Guide
APPENDIXES
Appendix A: Project Staff and Advisory Committee ...... 137
Appendix B: Participating SANE Programs ...... 139
Appendix C: Rape Kit Supply Resources ...... 149
Appendix D: SANE Training Programs ...... 151
Appendix E: SANE Trainers...... 153
Appendix F: Funding Resources ...... 155
Appendix G: Startup Checklist...... 167
Appendix H: Clinical Skills Competency Checklist...... 175
Appendix I: SANE Protocols...... 195
Appendix J: SANE Forms ...... 201
Appendix K: SANE Evaluation Tools...... 233
135 SANE Development and Operation Guide
PROJECT STAFF APPENDIX A AND ADVISORY COMMITTEE
Project Staff Thomas Kiresuk, Ph.D. Director Linda E. Ledray, Ph.D., RN, FAAN Program Evaluation Resource Center Principal Investigator Minneapolis, MN Project Director and Principal Author Director, Sexual Assault Resource Service Kit Mauer, BSN, RN (SARS) SANE Minneapolis, MN Midwest Childrens Resource Center St. Paul, MN Kathy Simmelink, MA, RN Project Assistant Carolyn Levitt, MD SANE Medical Director Sexual Assault Resource Service Midwest Childrens Resource Center Minneapolis, MN St. Paul, MN
Maggie Dexheimer Pharris, MPH, MS, RN Patricia Moen, JD Project Assistant Director of Criminal Justice and Law SANE Enforcement Services Sexual Assault Resource Service State of Minnesota Minneapolis, MN St. Paul, MN
Susan Valentine Colleen O’Brien, RN, MSN Project Office Manager Program Director Minneapolis Medical Research Foundation SANE/YWCA Program Minneapolis, MN Ridgeway, WI
Patricia Speck, MSN, RN, CS, FNP Advisory Committee Coordinator of Nursing Services Lee Barry, JD Memphis Sexual Assault Resource Center Assistant Hennepin County Attorney Memphis, TN Minneapolis, MN
Judge Isobel Gomez, JD Hennepin County Judge Minneapolis, MN
137 SANE Development and Operation Guide
PARTICIPATING SANE APPENDIX B PROGRAMS
List of Operating SANE CALIFORNIA Programs American Forensic Nurses 255 North El Cielo Road, Suite 195 ALABAMA Palm Springs, CA 92262 SANE program Contact: Faye Battiste-Otto c/o Rape Crisis Center Phone: (909) 796-6300 501 N. Bishop Lane Fax: (909) 796-3007 Mobile, AL 36608 Contact: Teresa Lynn, RN, BSN Center for Forensic Excellence (334) 450-2244 Contact: Darlene Bradley 11234 Anderson Street ALASKA Loma-Linda, CA 92354 Alaska CARES Phone: (909) 478-8077 Contact: Diana Weber Fax: (909) 824-4641 4001 Dale Street, Suite 112 Anchorage, AK 99508 Dominican Hospital SART/SANE Program Phone: (907) 561-8301 1555 Soquel Drive Fax: (907) 561-8170 Santa Cruz, CA 95065 Contact: Peggy Lopez, RN SART/SANE Program of Matanuska Valley Phone: (408) 462-7744 c/o Valley Hospital Fax: (408) 462-7816 Coordinator: Rita Bennett P.O. Box 1687 County Sexual Assault Response Team Palmer, AK 99645 1411 E. 31st Street Phone: (907) 746-8503 Oakland, CA 94602 Contact: Hillary Larkin, RA South Peninsula Hospital SANE Program Phone: (510) 437-8396 4300 Bartlett Street Homer, AK 99603 Napa-Soland SART Program Contact: Colleen James, RN, BSN 1100 Trancas Street, Suite 202 (907) 235-0287 Napa, CA 34558 Contact: Elizabeth Cassinos ARIZONA Phone: (707) 226-9145 SARS Tucson Rape Crisis Center San Francisco Rape Treatment Center 1632 North Country Club 2801 A 25th St. Tuscon, AZ 85716 San Francisco, CA 94110 Contact: Nora Gilray, RN, SANE Contact: Carmen Henesy, RN (520) 529-0634 Phone: (415) 821-3222
139 Appendix B
SANE Ukiah Valley Medical Center Sexual Assault Response Team (SART) 275 Hospital Drive Marshall Hospital Ukiah, CA 95482 Marshall Way Contact: Karen Paoli, RN Placerville, CA 95667 Phone: (707) 463-7400, ext. 1342 Contact: Nancy Housel, RN, SANE Phone: (916) 622-1441, ext. 772 SART/SANE California Hospital Medical Center Sexual Assault Response Team (SART) 1401 South Grand Santa Barbara County Health Care Services Los Angeles, CA 90015 300 San Antonio Road Contact: Jeannie Stephenson, RN Santa Barbara, CA 93110 Phone: (213) 742-5519 Contact: Therese McKenna, RN, SANE Phone: (805) 681-5468 SART Hanford Community Medical Center Sexual Assault Response Team 450 Greenfield Avenue Santa Clara Valley Health and Hospital System Hanford, CA 93230 751 S. Bascom Avenue, Bldg H-12 Contact: Georgeanne Greene, Coordinator San Jose, CA 95128 Phone: (209) 585-5258 Contact: Sandra McKinnon, Rn, NP Fax: (209) 585-5325 Phone: (408) 885-6460
SART Palomar Pomerdo Health System Suspected Abuse Response Team Contact: (Ages 0-13): Diana Fuagno, RN, BSN 2180 Johnson Avenue CPN San Luis Obispo, CA 93401 555 East Valley Parkway Contact: Maggie Nally, RN, SANE Escondido, CA 92025 Phone: (805) 781-4878 Phone: (619) 739-3444 Ages 14-Adult: Margaret Whelan, RN Tulare District Hospital SART 15615 Pomerado Road 821 Cherry Street Poway, CA 92064 Tulare, CA 93274 Phone: (619) 739-3444 Contact: Angie Zakula, RN Phone: (209) 688-0821 Sexual Assault Response Service Antelope Valley Hospital University of California Davis Medical Center 1600 West Avenue J Forensic Evaluation Team Annex Suite B 2315 Stockton Blvd. Lancaster, CA 93534 Sacramento, CA 96817 Contact: Sandy Darrington Contact: Bill Green, MD Phone: (805) 723-7273 ext. 5566 Phone: (916) 734-2011 Fax: (805) 949-5566 Violence Intervention Program Sexual Assault Response Team (SART) LAC-USC Medical Center Kern Medical Center 1240 North Mission Road 1830 Flower Street Los Angeles, CA 90033 Bakersfield, CA 93305 Contact: Deborah Kilgore, Director Contact: Kris Petty, RN, SANE, or Thum, RN, Phone: (213) 226-3961 SANE Fax: (213) 226-2573 Phone: (805) 326-2679
140 SANE Development and Operation Guide
Western Nurse Specialists Inc. Sexual Assault Treatment Program 25809 Business Center Dr., Suite A c/o Sudbury General Hospital Redlands, CA 92373 700 Paris Street Contact: Faye Battiste-Otto, RN, SANE, or Sudbury, Ontario, Canada P3E3B5 Mary Rudolph, RN, SANE Contact: Mary Carter, Coordinator Phone: (909) 796-6300 Phone: (705) 675-4743 Fax: (705) 675-4781 CANADA Health Sciences Center Adult Emergency Surrey Memorial Hospital SANE Program 820 Sherbrook Avenue 13750 96th Avenue Winnipeg, Manitoba, Canada R3A1R9 Surrey, B.C. Canada V3V1Z2 Contact: Beth Ariss, RN Contact: Sheila Early Phone: (204) 633-0886 Phone: (604) 581-2211 ext. 2513
Ontario Network of Sexual Assault Care and Victoria Sexual Assault Service Treatment Centres Royal Jubilee Hospital Victoria c/o Women’s College Hospital 2101 Richmond Avenue 76 Grenville Street Victoria, BC Canada V8R4R7 Toronto, Ontario, Canada M5S1B2 Contact: Sue Dean Contact: Sheilia McDonald Phone: (604) 727-4354 Phone: (416) 323-6400, ext. 4472 COLORADO SANE Program Boulder County Rape Crisis Team Grant-MacEvan Community College 2885 East Aurora #13 City Center Campus Boulder, CO 80303 Health & Community Studies Division Contact: Judy Houchins 10700 - 104 Avenue Alberta, Canada P5J2P2 Memorial Hospital SANE Program Coordinator: Elaine DeGrandpre 1400 E. Boulder Phone: (403) 497-5709 Colorado Springs, CO 80909 Fax: (403) 497-5720 Contact: Sharon Stinson, RN, SANE Phone: (719) 575-2422 or (719) 475-6820 Sexual Assault Services British Columbia Womens Center Poudre Valley Hospital 4500 Oak Street 1024 Soth Lemay Avenue Vancouver, BC Canada V6H3N1 Fort Collins, CO 80524-3998 Contact: Carolyn Dudley Contact: Susan Webster, RN Phone: (604) 875-3284 Phone: (970) 495-7000 Fax: (604) 875-3136 Pueblo Suicide Prevention & Rape Crisis Center Sexual Treatment Center 1925 East Orman Avenue, Suite G-25 339 Crawford Avenue Pueblo, CO 81004 Windsor, Canada N9A5C6 Contact: Shannon Richter Coordinator: Kathy McIntosh Phone: (519) 255-2234 Fax: (519) 255-2255
141 Appendix B
SANE of Larimer County SANE of N.E. Georgia McKee Medical Center 3019 Lexington Road 2000 Eoise Avenue Athens, GA 30605 Loveland, CO 80538 Contact: Hillary Ruston, RN Contact: Linda Beede, FNP Phone: (706) 353-1912 Phone: (970) 203-2513 Southeast Georgia Forensic Nursing Service Sexual Assault Survivor, Inc. 3100 Kemble Avenue P.O. Box 5135 Brunswick, GA 31520 Greeley, CO 80631-0135 Contact: Lisa Esposito Contact: Nancy Raben Phone: (912) 262-3892
DELAWARE Southeast Georgia Regional Medical Center Medical Center of Delaware SANE Program 161 Belle Point Parkway 4755 Ogletown-Stanton Road Brunswick, GA 31525 Newark, DE 19718 Contact: Casey Harper, RN Contact: Kathy Rainey, RN, or Peggy Humphrey, Phone: (912) 264-5505 RN Fax: (912) 262-3988 Phone: (302) 733-1700 HAWAII FLORIDA Hawaii Island SANE Project NEP/Forensics 145 Uluani Street 2214 East Henry Avenue Hilo, HI 96720 Tampa, FL 33610 Contact: Nancy Moser, RN Contact: Shirley Engleman, ARNP, Program Phone: (808) 935-7141 Director Phone: (813) 253-6000 INDIANA Center of Hope SANE Inc. St. Vincent Hospital C/O Florida Hospital Kissimmee 2001 West 86th Street 200 Hilda Street Indianapolis, IN 46240 Kissimmee, FL 34742 Contact: Joann Wilson, Coordinator Contact: Pam Steioff, RN, SANE Phone: (317) 338-2121 Phone: (407) 993-6640 Fax: (317) 338-3523
GEORGIA Fort Wayne Sexual Assault Treatment Center Gwinnett Sexual Assault Resource Center 800 Broadway - Suite 301 PO Box 186 Fort Wayne, IN 4680 Duluth, GA 30136 Contact: Dawn Rice, RN, SANE Contact: Ann Burdges, Legal Advocacy Phone: (219) 425-3333 Coordinator Fax: (219) 425-3334 Phone: (770) 497-9122 KANSAS Northeast Georgia Medical Center SANE/SART 743 Spring Street N.E. Via Christi, St. Joseph Campus Gainesville, GA 30501 3600 East Harry Contact: Cinda Anderson, RN, SANE Wichita, KS 67218 Phone: (770) 535-3595 Contact: Diane Schunn, RN, BSN, SANE Phone: (316) 689-5252 142 SANE Development and Operation Guide
MARYLAND MINNESOTA SANE Mankato Sexual Assault Access Team Physicians Memorial Hospital 15J Hospital Box 1070 Mankato, MN 56002-8673 701 East Charles Street Contact: Kathy Smith La Plata, MD 20646 Phone: (507) 389-4630 Contact: Mary Lou Hiordahl, RN, SANE Fax: (507) 345-2926 Phone: (301) 609-4160 Midwest Children’s Resource Center SANE Program 360 Sherman Street, Suite 200 Calvert Memorial Hospital St. Paul, MN 55102 100 Hospital Road Contact: Dianne McCormick, CPNP Prince Fredrick, MD 20678 Phone: (800) 422-0879 Contact: Anita Efremov, RN, Clinical Coordinator S.A.F.E. Program Phone: (410) 535-8362 Regina Medical Center 1175 Nininger Road Sexual Assault Forensic Examiner Program Hastings, MN 55033 Mercy Medical Center Contact: Sheri Arnett Contact: Carol Kimmel, Program Coordinator 301 St. Paul Place Sexual Assault Resource Service Baltimore, MD 21202 525 Portland Ave. South Phone: (410) 332-9477 Minneapolis, MN 55415 Contact: Linda Ledray, RN, PhD MICHIGAN Phone: (612) 347-5832 SANE Program Fax: (612) 347-8751 C/O Emergency Munson Medical Center MISSOURI 1105 6th Street Kansas City SANE Traverse City, MI 49684 2301 Home Street Contact: Paula Meyer, Director Kansas City, MO 64108 Phone: (616) 935-6333 Contact: Micky Cowdrey Phone: (816) 454-5364 Sexual Assault Nurse Examiners Fax: (816) 454-0431 Sparrow Hospital Emergency Department 1215 East Michigan Avenue SART Sexual Assault Response Team PO Box 30480 PO Box N Lansing, MI 48909-7980 600 East Broadway Contact: Della Hughes, RN Columbia Health Department Phone: (517) 483-3887 Columbia, MO 65205 Contact: Mary Martin, RN, NP Sexual Assault Program Phone: (601) 736-2676 YMCA 24 Sheldon S.E. The Children’s Mercy Hospital Grand Rapids, MI 49503 2401 Gillham Road Contact: Sherry Arndt, RN, MP, Chief Nurse Kansas City, MO 64108 Examiner Contact: Bev Arnold-Biagioli, CNS, Child Phone: (616) 459-4652 Protection (816) 234-3000 143 Appendix B
St. Louis Children’s Hospital Rensselaer County SANE Program 400 S. Kingshighway Blvd. Samaritan Hospital St. Louis, MO 63110 2215 Burdett Avenue Contact: Nancy Duncan, RN, CPNP Troy, NY 12180 (314) 454-6294 Contact: Ann Coonrad, Coordinator Phone: (518) 271-3638 NEBRASKA Fax: (518) 271-3434 SANE/SART Program Bryan Memorial Hospital Ulster County SANE Program 1600 South 48th Street c/o Office of District Attorney Lincoln, NE 68506-1299 275 Wall Street Contact: Cindy Selig, RNC, NSN\ Kingston, NY 14201 Phone: (402) 483-3316 Contact: Laurel Herdman, Executive Director Phone: (914) 339-7080 NEVADA Fax: (914) 340-3185 Sexual Assault Response Program PO Box 669 Westchester SANE Dayton, NV 89403 Victims Assistance Service Contact: Robin Sparks, RN 2269 Sawmill River Road (702) 885-4161 Elmsford, NY 10523 Contact: Karen Coleman, SANE Coordinator NEW HAMPSHIRE Phone: (614) 345-3113 New Hampshire/Vermont SANE Program RR 1 Box 384 NORTH CAROLINA Cornish, New Hampshire 03475 North Carolina Coalition Against Sexual Assault Contact: Jennifer Pierce Contact: SAFE/SART Project Coordinator Phone: (603) 675-5809 174 Mine Lake Court - Suite 100 Fax: Same as above. Raleigh, NC 27615 Phone: (919) 676-7611 NEW MEXICO Fax: (919) 676-1355 Albuquerque SANE Collaborative PO Box 37139 OHIO Albuquerque, NM 87176-7137 SANE Program Contact: Pat Schindler, RN, SANE Blanchard Valley Regional Health Center Phone: (505) 266-7711 145 West Wallace Street Findlay, OH 45840 NEW YORK Contact: Barb Cramer Forensic Sexual Assault Examiners Inc. Phone: (419) 423-5206 PO Box 556 Fax: (419) 423-5402 Lindenhurst, NY 11757 Contact: Patricia Kelly, RN, SANE SANE/SART Project Phone: (516) 957-1409 Union County 500 Landon Avenue Marysville, OH Contact: Rebecca Dillon, RN, CEN Phone: (937) 644-3833
144 SANE Development and Operation Guide
Summit County SANE Program Tulsa Sexual Assault Nurse Examiners Program Summa Health System c/o Tulsa Police Department 525 East Market Street 600 Civic Center ADM, Building Room 417 Tulsa, OK 74113 Akron, OH 44309-2090 Contact: Kathy Bell, RN Contact: Renee Collette, RN, BSN, BA, CEN, Phone: (918) 596-7608 SANE Fax: (918) 596-9330
OKLAHOMA PENNSYLVANIA Broken Arrow Oklahoma SANE Program Evangelical Community Hospital SANE Program 3000 South Elm Place 1 Hospital Drive Broken Arrow, OK 74012 Lewisburg, PA 17837 Contact: Judy Dyke, RN NREMT-P Contact: Darlene Rowe, RN, SANE Phone: (918) 343-7641 Phone: (717) 522-2657
Central Oklahoma Clinical Forensic Consultants Child Forensic Nurse Examiners Inc. Lenok Health Center PO Box 60216 21 Slocum Avenue Oklahoma City, OK 73146 Tunkhannock, PA 18657 Contact: Robert Williamson, RN Contact: Sue Perdew, PhD, RN Phone: (405) 272-0316 Phone: (717) 836-7668
Forensic SANE Program SAFE Program Claremore Regional Hospital Harrisburg Hospital 1202 North Muskogee Place P.O. Box 8700 Claremore, OK 74017 Harrisburg, PA 17105 Contact: Karen Smith, BSN Contact: Edie Baldwin, Coordinator Phone: (918) 266-2632 Phone: (717) 782-5713
Oklahoma City Sexual Assault Examiner Program SANE Doylestown Hospital P.O. Box 26307 595 West State Street Room EB 319 Doylestown, PA 18901 Oklahoma City, OK 73126 Contact: Patricia Vida, RN Coordinator: Linda Cummins Phone: (215) 345-2828 Phone: (405) 271-5135 Fax: (405) 271-7007 TENNESSEE Chattanooga Sexual Assault Crisis and Resource Shawnee Regional Sexual Assault Nurse Examiners Center 1102 West MacArthur Street 300 East 8th Street Shawnee, OK 74801 Chattanooga, TN 37403 Contact: Charlotte Howard, RN Contact: Cheryl Matthews, MSED Phone: (405) 878-8140 Phone: (423) 755-2720
Memphis Sexual Assault Resource Center 1331 Union Avenue, Suite 1150 Memphis, TN 38112 Contact: Pat Speck, RNC, MSN, FNP Phone: (901) 528-2161
145 Appendix B
“Our Kids” - Nashville SANE Program 1900 Hayes Street Emergency Services Nashville, TN 37203 Harris Methodist Hospital Contact: Sue Ross, PNP, or Julie Rosof, ENP 1600 Hospital Parkway Phone: (615) 862-4390 Bedford, TX 76002-6913 Contact: Karen McCurdy, RN TEXAS Phone: (817) 685-4259 CARE Team Dr. Leah Lamb Sexual Assault Nurse Examiners Program Child Abuse and Evaluation Northwest Texas Hospital Health Care System 801 7th Avenue PO Box 1110 Fort Worth, TX 76104 Amarillo, TX 79175 Phone: (817) 885-3953 Contact: Jamie Ferrell, RN, SANE Fax: (817) 870-7445 Phone: (806) 354-1155 Day Harris, Resource Coordinator for ER Services Hendrick Medical Center Emergency Department Phone: (806) 354-1165 1242 North 19th Abilene, TX 79601-2316 SANE Program of Ben Taub Contact: Connie Bowlin, RN, CEN 1504 Taub Loop Phone: (915) 670-2151 Houston, TX 77030 Contact: DeDe McClamrock, RN Herman Hospital SANE Program Phone: (713) 793-2625 6411 Fannin Houston, TX 77030 UTAH Contact: Sherry Bryan, RN, SANE, EMT-P Cache Valley SART Phone: (713) 704-5355 l1145 North Main Fax: (713) 704-5189 Logan, UT 84321 Contacts: Dianne Crockett and Beth Booten SANE Program Phone: (435) 787-0000 Arlington Memorial Hospital 800 West Randol Hill Road VIRGINIA Arlington, TX 76102 Forensic Nurse Examiners Contact: Sandra Harris St. Mary’s Hospital Phone: (817) 546-6100 5801 Bremo Road Richmond, VA 23226 SANE Program Contact: Bonnie Price, Coordinator Department of Emergency Medicine Phone: (281) 857-4804 John Peter Smith Hospital Fax: (281) 285-9305 1500 South Main Street Richmond VA SART Fort Worth, TX 76104 Contact: Stacey Lasseter Contact: Dr. Audrey Jones Phone: (804) 281-8574 Phone: (817) 927-3598
146 SANE Development and Operation Guide
Carilion Roanoke Community Hospital SANE WISCONSIN Program Berlin Hospital SANE Program 101 Elm Avenue SE 225 Memorial Drive Roanoke, VA 24013 Berlin, WI 54923 Contact: Melissa G. Ratcliff, RN, CEN, Contact: Bonnie Manthei, RN Coordinator Phone: (414) 498-4563 Phone: (540) 985-9887 Meriter Emergency Services Inova Fairfax Hospital c/o SANE Program 3300 Gallows Road 207 South Park Street Falls Church, VA 22042 Madison, WI 57315 Contact: Sue Brown Contact: Colleen O’Brien Phone: (703) 698-3505 Phone: (608) 267-6206 Fax: (703) 280-3821 SANE Program Rockingham Memorial Hospital St. Elizabeth ER Department 235 Cantrell Avenue 1506 South Oneida Street Harrisonburg, VA 22801 Appleton, WI 54915 Contact: Linda Heatwoke, RN Contact: Rosemary Dvorachek, Coordinator Phone: (540) 433-4393 Phone: (920) 738-2100 Fax: (920) 730-5912 SANE Program Chesapeake General Hospital SANE Program PO Box 2038 St. Lukes Hospital Chesapeake, VA 23320 St. Mary’s Medical Center Contact: Jeannie Leonard, RN 3801 Spring Street Phone: (804) 482-6128 Racine, WI 53406 Contact: Barbara Campbell, RN SANE Southside Regional Medical Center Phone: (414) 636-4201 801 South Adams Petersburg, VA 23803 SANE St. Mary’s Medical Center Contact: Dawn Sarper, RN, SANE 1726 Shawans Avenue Phone: (804) 862-5680 Green Bay, WI 54303 Contact: Marlene Scheffen WASHINGTON Phone: (414) 498-4563 Ione Annette Arden Blue Mountain Medical Group SANE 111 South 2nd Avenue St. Mary’s Hospital Walla Walla, WA 99362 1044 Kabel Avenue Phone: (509) 522-0100 Rhinelander, WI 54501 Contact: Mary Hageny, RN St. Peter Hospital SA Clinic Phone: (715) 369-6600 413 Lilly Road NE Olympia, WA 98506 St. Vincent Hospital SANE Program Contact: Nancy Diaz PO Box 13508 Phone: (360) 493-4071 Green Bay, WI 54307-3508 Fax: (509) 527-1080 Contact: Paula Hafeman, RN, MSN, CEN Phone: (414) 433-8391
147 Appendix B
Sexual Assault Treatment Center PO Box 0342 Milwaukee, WI 53201-0342 Contact: Marlene Putz, RN Phone: (414) 937-5209
148 SANE Development and Operation Guide
RAPE KIT SUPPLY APPENDIX C RESOURCES
Sexual Assault Evidence Sirchie Finger Print Laboratories 100 Hunter Place Kit Suppliers Youngsville, North Carolina 27596 When seeking bids for sexual assault evidence kits, 1-919-554-2244 it’s important to ask if the supplier is an FDA Lynn Peavey approved packing facility. The following FDA 14865 W. 105th St. approved companies supply the vast majority of Lenexa, Kansas 66219 programs in the United States: 1-913-888-0600 Tri Tech 4019 Executive Park Blvd. S.E. South Port, North Carolina 28461 1-800-438-7884
149 SANE Development and Operation Guide
SANE TRAINING APPENDIX D PROGRAMS
The following is the list of SANE training pro- Mercy Safe Program grams which accept applications from nurses Mercy Medical Center interested in attending training at their location: St. Paul Place Baltimore, MD 21202 South Peninsula Hospital Carole Kimmell, RN 4300 Bartlett Street 410-332-9499 Homer, Alaska 99603 Once a Year: September Colleen James, RN 907-235-0287 University of North Carolina Hospitals Once a Year: October Department of Emergency Medicine CB 7594 American Forensic Nurses Chapel Hill, North Carolina 27599 255 North El Cielo Road Susan Hohenhaus, RN, CEN Suite 195 919-966-1088 Palm Springs, CA 92262 Twice a Year: January and July Faye Battiste-Otto, RN 760-779-2280 (pager) Tulsa Sexual Assault Nurse Examiner 909-796-6300 Program Twice a Year: Spring and Fall Tulsa Police Department 600 Civic Center Palomar Pomerado Health System Tulsa, OK 74103 15615 Pomerado Road Kathy Bell, RN Poway, CA 92064 918-596-7608 Diana Faugno, RN, BCFE Two or Three Times per Year 760-739-3444 Once a Year: Winter Memphis Sexual Assault Resource Center Mock Trial Training: May 2675 Union Avenue Extended Memphis, TN 38112 Forensic Nursing Specialists Pat Speck, MS, RN P.O. Box 2512 901-272-2020 Santa Cruz, CA 95063 Advanced Training Only Sandra Goldstein, MS, RN 408-465-9826 Texas Office of the A.G. Sexual Assault Prevention & Crisis SANE/SART Program Services Division Via Christi Medical Center P.O. Box 12548 3600 East Harry Austin, TX 78711 Wichita, KS 67218 Jamie Ferrell, SANE Program Director Diana Schunn, RN 512-936-1661 316-689-5252 Scheduled based on community Once a Year readiness/needs
151 Appendix D
INOVA SANE Program YWCA/SANE Program INOVA Fairfax Hospital c/o Meriter Emergency Services 3300 Gallows Road 202 Park Street Falls Church, VA 22042-3300 Madison, WI 53715 Sue Brown, RN, BSN Colleen O’Brien, RN, MS 703-698-3505 608-267-6000 Ext. 7063 Once a Year: End of March Once a Year: First Week in May
152 SANE Development and Operation Guide
APPENDIX E SANE TRAINERS
Following is the list of SANE Trainers who are Jamie Ferrell, RN, BSN, CEN, SANE available to provide training at the time and 1306 Buena Vista location of your choice: Amarillo, TX 79106 512-936-1661 Sherry Arndt, RN, MPA Forensic Nursing Services Sandra Goldstein, MS, RN Prairie Division Forensic Nursing Services RR 1 - Box 171 P.O. Box 2512 Comfrey, MN 56019-9713 Santa Cruz, CA 95063 507-877-3663 408-465-9826
Faye Battiste-Otto, RN Susan Hohenhaus, RN, CEN American Forensic Nurses University of North Carolina Hospitals 255 North El Cielo Road Department of Emergency Medicine Suite 195 CB 7594 Palm Springs, CA 92262 Chapel Hill, NC 27599 760-779-2280 (pager) 919-966-1088 909-796-6300 Colleen James, RN Kathy Bell, RN South Peninsula Hospital Tulsa Sexual Assault Nurse Examiner 4300 Bartlett Street Program Homer, Alaska 99603 Tulsa Police Department 907-235-0287 600 Civic Center Tulsa, OK 74103 Linda E. Ledray, PhD, RN, FAAN 918-596-7608 Professional Resource Service Foshay Tower Sue Brown, RN, BSN Suite 1108 INOVA SANE Program 821 Marquette Avenue South INOVA Fairfax Hospital Minneapolis, MN 55402 3300 Gallows Road 612-889-0889 Falls Church, VA 22042-3300 703-698-3505 Diana Schunn, RN SANE/SART Program Diana Faugno, RN, BCFE Via Christi Medical Center Palomar Pomerado Health System 3600 East Harry 15615 Pomerado Road Wichita, KS 67218 Poway, CA 92064 316-689-5252 760-739-3444
153 SANE Development and Operation Guide
APPENDIX F FUNDING RESOURCES
STATE AGENCIES ADMINISTERING THE DEPARTMENT OF JUSTICE/OFFICE OF JUSTICE PROGRAMS FORMULA GRANT PROGRAMS 9/11/97
155 SANE Development and Operation Guide A GRANT PROGRAM Community Affairs BJA Contact: A GRANT Economic & Community Economic (202) 305-2404 [011] (684) 633-5221: Agency[011] (684) 633-5221 Contact:OVC Contact: VAWGO Agency (202) 305-1764 [011] (684) 633-4163 (202) 616-3565 (202) 305-1792 (202) 616-3210(202) 616-3565 (202) 305-2404 (202) 305-2381 d Assault & Sexual Assault & Sexual Violence (907) 269-5082 VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE STOP AGAINST Alabama Crime Victims Alabama Crime Compensation of Alabama Department of Alabama Department & Community Affairs Economic & of Economic Alabama Department (334)-242-4007 Contact:OVC (202) 616-3579 (334) 242-5843 Contact: OVC (202) 616-3579 Affairs (334) 242-5803 Contact: VAWGO (202) 305-2358 BJA Contact: (334) 242-5891 (907) 465-3040 Contact:OVC (907) 465-4356 Contact: OVC (907) 465-4356 Contact: VAWGO BJA Contact: (202) 616-3456 Violent CrimesViolent Compensation Boar Violence Council on Domestic Council on DomesticTroopers Alaska State (202) 616-3565 Compensation ProgramNo Planning Criminal Justice (202) 616-3565 Planning Justice Criminal General Office of the Attorney (202) 305-2379 Arizona Criminal JusticeArizona Criminal Commission(602) 542-1928 Arizona Department of Contact:OVC Women Office for Governor’s Commission Justice Arizona Criminal (602) 233-2480 Safety Public Contact: OVC Contact: VAWGO (602) 542-1755 (202) 305-2379 BJA Contact: (602) 542-1928 (202) 305-2148 (202) 616-3579 ReparationsVictims Crime Board Office of Intergovernmental(501) 682-3660 Contact:OVC (202) 616-3579 (202) 616-3210 Office of Intergovernmental Services Office of Intergovernmental & Administration (501) 682-5206 Contact: OVC Services of Finance Department Services Department of & Administration Finance & Administration Department of Finance (501) 682-1074 (501) 682-5206 Contact: VAWGO (202) 514-8874 BJA Contact: State Board of Control Board State (916) 324-6629 Contact:OVC (202) 616-3565 Office of Criminal Governor’s Office of Criminal Governor’s Planning Office of Criminal Justice Governor’s Planning Justice (916) 327-3687 Contact: OVC Planning Justice (916) 324-9216 Contact: VAWGO (916) 324-9166 (202) 616-3294 BJA Contact: STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Alabama Alaska American Samoa Arizona Arkansas California
157 Appendix F A GRANT PROGRAM [011] (671) 472-8931 A GRANT (202) 307-3180 (202) 305-1762 [011] (671) 475-9162 Contact:VAWGO (202) 305-2381 BJA Contact: (202) 305-2356 Bureau of AdvocacyBureau Violence & Sexual Domestic (904) 488-8016 Government of GuamGovernment [011] (671) 475-3324 ext. 285 Contact: (202) 616-3565 OVC of the Governor Office of the Governor Office rogram Department of Law AffairsWomen’s of Bureau of Planning Bureau d Council Justice Council Justice (302) 577-3466 Division of Criminal Justice of Criminal Division (303) 239-4402 Contact:OVC Justice of Criminal Division of Criminal Justice Division (303) 239-5703 of Criminal Justice Division Contact: OVC (303) 239-5728 Contact: VAWGO (303) 239-4442 BJA Contact: (202) 616-3579 ServicesVictim of Office (860) 529-3089 Contact:OVC (202) 616-2032 ServicesVictim of Office (202) 616-3579 (860) 529-3089 of Policy Office Contact: OVC (202) 616-2032 (202) 305-1792 of Policy Office & Management (860) 418-6403 Contact: VAWGO (202) 616-3456 & Management BJA Contact: (860) 566-3500 Delaware Violent CrimesViolent Delaware Compensation Boar (302) 995-8383 Contact:OVC Criminal Delaware (302) 577-3697 Contact: OVC Criminal Delaware Council Criminal Justice Delaware (302) 577-3430 Contact: VAWGO BJA Contact: (202) 305-2925 (202) 616-3581VictimsCrime Compensation Program(202) 879-4216 Contact:OVC (202) 616-3581 & Development Management of Grants Office (202) 727-6537 Contact: OVC Management of Grants Office Management & Development of Grants Office (202) 307-3180 & Development (202) 727-6554 Contact: VAWGO (202) 727-6537 BJA Contact: (202) 307-6068 (202) 616-3581 of the AttorneyOffice Compensation General Bureau(904) 414-3301 Contact:OVC (202) 616-3581 of the Attorney General Office on Force Task Governor’s (904) 414-3300 of Community Assistance Bureau Contact: OVC Management & Grants (202) 305-2404 (904) 921-2168 Contact: VAWGO (202) 307-3180 (202) 616-3295 BJA Contact: (202) 616-3581 CoordinatingCriminal Justice Council Coordinating Criminal Justice (404) 559-4949 Contact:OVC (202) 616-3581 Coordinating Criminal Justice Council Coordinating Criminal Justice (404) 559-4949 Contact: OVC Council (404) 559-4949 Contact: VAWGO Council BJA Contact: (202) 616-3295 (404) 559-4949 (202) 616-3581 Compensation P No (202) 616-3581 (202) 305-2404 VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Colorado Connecticut Delaware District of District Columbia Florida Georgia Guam
158 SANE Development and Operation Guide Council A GRANT PROGRAM Institute A GRANT (202) 616-3210 (202) 305-2649 Kentucky Justice Cabinet Justice Kentucky Cabinet Justice Kentucky Cabinet Justice Kentucky Department of theDepartment of the(808) 586-1282 Contact:OVC Department of the Department of the (808) 586-1282 Contact: OVC Department of the General Attorney (808) 586-1096 Contact: General Department of the Attorney VAWGO (808) 586-1151 BJA Contact: BJA Contact: (202) 616-3294 (202) 616-3565Victims Crime Idaho Compensation Program(208) 334-6070 Contact:OVC (202) 616-3565 Department of Health Idaho Welfare & Department of Idaho (208) 334-5580 Contact: OVC Department of Law Enforcement Idaho Law Enforcement (208) 884-7042 Contact: VAWGO (208) 884-7040 BJA Contact: (202) 305-1764 (202) 616-3565Illinois Court of Claims(217) 782-7101 Contact:OVC (202) 616-3210 Justice Illinois Criminal (202) 616-3565 Information Authority (312) 793-8550 Justice Illinois Criminal Contact: OVC (202) 305-1792 Authority Information Justice Illinois Criminal Information Authority (312) 793-8550 (312) 793-8550 Contact: VAWGO (202) 616-8958 BJA Contact: Indiana Criminal Justice Institute Justice Indiana Criminal Institute Justice Indiana Criminal Institute Justice Indiana Criminal Justice Indiana Criminal (317) 233-3383 Contact:OVC (317) 233-3341 Contact: OVC (317) 232-7610 Contact: VAWGO (317) 232-2561 BJA Contact: (202) 616-3210 of the Attorney GeneralOffice Assistance DivisionVictim Crime Assistance DivisionVictim Crime of the Attorney General Office (515) 281-5044 Contact:OVC Abuse Substance (202) 616-3210 (202) 616-3210 Alliance on Governor’s Abuse (515) 281-5044 Alliance on Substance Governor’s (515) 242-6379 Contact: OVC (202) 616-3210 (202) 305-2977 (515) 242-6379 Contact: VAWGO (202) 305-2977 (202) 305-2354 BJA Contact: (202) 305-2903 (913) 296-2359 Contact:OVC (913) 296-2215 Contact: OVC (913) 296-2215 Contact: VAWGO (913) 296-0926 BJA Contact: Office of the Attorney GeneralOffice of the Attorney General Office of the Attorney General Office Coordinating Kansas Criminal Justice (202) 616-3579 Crime Victims Compensation Board(502) 564-7986 Contact:OVC (202) 616-3210 (202) 616-3579 Contact: OVC (202) 616-3210 (502) 564-7554 (202) 305-2977 Contact: VAWGO (202) 305-2404 (202) 305-2903 (502) 564-7554 BJA Contact: (202) 305-2358 (502) 564-7554 VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky
159 Appendix F nforcement A GRANT PROGRAM Louisiana Commission on Law E BJA Contact: (617) 727-6300 A GRANT Louisiana Commission (601) 359-7880(202) 305-2404 BJA Contact: (202) 305-1767 Louisiana Commission for Victims AssistanceVictims for (617) 727-6300 extension 305 (202) 616-2032 rogram Services of Human Safety of Public (207) 877-8016 on Law Enforcement(504) 925-4437 Contact:OVC on Law Enforcement (504) 925-1757 Contact: OVC on Law Enforcement (504) 925-4443 (504) 925-3513 Contact: VAWGO BJA Contact: (202) 514-8874 Louisiana Commission (202) 616-3579 of Department Maine Compensation P Victims (202) 616-3579 Department Maine Department Maine (202) 307-3180 Safety Department of Public Maine (207) 626-8800 Contact:OVC (207) 287-5060 Contact: OVC (207) 624-8758 Contact: VAWGO BJA Contact: (202) 307-6068 (202) 616-2032 SafetyDepartment of Public Services& Correctional (410) 764-4094 Maryland Department (202) 616-2032 Resources of Human of Crime Office Governor’s (410) 767-7477 & Alcohol Abuse Commission Drug Governor’s & Prevention Control (202) 307-3180 (410) 321-3521 (410) 321-3521 ext. 330 OVC Contact:OVC Contact: OVC Contact: VAWGO (202) 305-1762 (202) 616-2032 of the Attorney GeneralOffice (617) 727-2200 ext. 2251 Office Massachusetts (202) 616-2032 Safety Office of Public Executive Safety Office of Public Executive (202) 307-3180 OVC Contact:OVC (202) 616-2032 (617) 727-5200 Contact: OVC Contact: VAWGO (202) 305-2404 BJA Contact: (202) 307-6068 Crime Victim ServicesVictim Crime Commission(517) 373-0979 Contact:OVC (202) 616-3210 Services CommissionVictim Crime Department Michigan Contact: OVC (517) 373-1826 Policy Control of Drug Office (202) 616-3210 Services of Social (517) 335-3931 Contact: VAWGO (517) 373-2952 (202) 307-6061 BJA Contact: (202) 305-2977 Crime Victims ReparationsVictims Crime Board(612) 282-6267 Department of Corrections Contact:OVC Department of Corrections Contact: OVC Safety Department of Public (202) 616-3210 (612) 642-0221 Contact: VAWGO (202) 305-2649 (612) 643-3593 BJA Contact: (202) 307-0710 (612) 296-0922 (202) 616-3210 Victim Crime Mississippi Compensation Program(601) 359-6766 Contact:OVC Safety Department of Public Planning Safety of Public Division of Public Division Safety Department of Public (601) 359-7880 Safety Department of Public Contact: (202) 616-3579 OVC Planning Safety of Public Division Planning Safety (601) 359-7880 (202) 616-3579 Contact: VAWGO VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi
160 SANE Development and Operation Guide ublic Safety A GRANT PROGRAM Nebraska Commission on Law Nebraska (505) 827-9099 A GRANT VAWGO Contact:VAWGO (202) 307-6061 (202) 305-2649 ContactVAWGO (202) 305-2356 (202) 305-1792 Commission on Law Nebraska VAWGO Contact: VAWGO (202) 305-2592 Reparation Commission Reparation OVC Contact: (202) 616-3210 OVC OVC Contact: (202) 616-2032 OVC Nebraska Commission on Law Nebraska (609) 984-7347 (609) 984-3880 BJA Contact: OVC Contact: (202) 616-3579 OVC Reparation Commission d Safety of Law & Public Safety of Law & Public (609) 292-5939 Division of Workers’ of Division Compensation(573) 526-3511 Contact: (202) 616-3210 OVC Department Missouri Safety of Public (573) 751-4905 Department Missouri Safety Department of Public Missouri Safety of Public (314) 751-4905 (314) 751-4905 BJA Contact: Montana BoardMontana of Crime Control(406) 444-3653 Contact: (202) 616-2032 OVC Board Montana of Crime Control (406) 444-3604 of Crime Control Board Montana (406) 444-3604 (406) 444-3604 Control of Crime Board Montana BJA Contact: Enforcement & Criminal JusticeEnforcement & Criminal Justice Enforcement (402) 471-2194 Contact:OVC & Criminal Justice Enforcement & Criminal Justice Enforcement (402) 471-2194 Contact: OVC (402) 471-2194 Contact: VAWGO (402) 471-2194 BJA Contact: (202) 616-8958 Nebraska Commission on Law Nebraska (202) 616-2032 DepartmentNevada of Administration(702) 486-2740 Contact:OVC (202) 616-2032 Resources Department of Human & Development of the Attorney General Office Safety & Public Vehicles Department of Motor (702) 688-1628 Contact: OVC (202) 305-2977 (702) 486-3095 Contact: VAWGO (202) 305-2592 (702) 687-5282 BJA Contact: (202) 616-3294 (202) 616-3565 HampshireNew Department of Justice(603) 271-1284 Contact:OVC (202) 616-3565 Department of Justice Hampshire New (603) 271-1297 Contact: OVC Department of Justice Hampshire New (603) 271-1297 (603) 271-1234 Contact: VAWGO Department of Justice Hampshire New BJA Contact: (202) 307-1232 Compensation Boar (201) 648-2107 ext. 7716 Contact:OVC Contact: OVC Contact: VAWGO (202) 307-0283 (202) 616-2032 of CrimeVictims (202) 616-2032 Department Jersey New Department Jersey New (202) 307-3180 Department of Law & P Jersey New (505) 841-9432 Contact: (202) 616-3579 OVC (505) 841-9432 (505) 841-9432 BJA Contact: (202) 616-3456 (202) 616-3581Victims Crime Mexico New Reparation Commission Victims Crime Mexico New (202) 616-3581Victims Crime Mexico New Safety Department of Public (202) 307-3180 VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Missouri Montana Nebraska Nevada New Hampshire New Jersey New New Mexico New
161 Appendix F A GRANT PROGRAM [011] (670) 664-4550 A GRANT (202) 305-2404 (202) 307-1232 [011] (670) 664-4550 VAWGO Contact: VAWGO (202) 305-1792 (919) 571-4736 (919) 571-4736 (919) 571-4736 (202) 616-3581 (202) 307-3180 (202) 616-3295 OVC Contact:OVC (202) 616-3565 Contact: VAWGO (202) 305-2379 BJA Contact: (202) 305-2356 [011] (670) 664-4550 Ohio Attorney General’s Office General’s Attorney Ohio Justice of Criminal Office Services of Criminal Justice Office (405) 557-6704 (405) 557-6707 (405) 557-6707 OVC Contact: (202) 616-3565 OVC rogram Agency Planning Criminal Justice Agency Planning Criminal Justice Agency Planning Criminal Justice New York Crime Victims BoardVictims Crime York New BoardVictims Crime York New (518) 457-8063 Contact:OVC (202) 616-3581 Division State York New of Criminal Division State York New (518) 457-1779 Contact: OVC (202) 616-3581 Services of Criminal Justice (518) 485-7913 Contact: VAWGO Services Justice BJA Contact: (518) 457-8462 North Carolina Victims Carolina North Compensation Commission (919) 733-7974 Crime Commission Governor’s Crime Commission Governor’s Crime Commission Governor’s Contact: OVC Contact: VAWGO BJA Contact: OVC Contact: (202) 616-3581 OVC Dakota DepartmentNorth Divisionof Corrections & Probationof Parole Dakota Department North (701) 328-6195 Contact:OVC Division of Corrections & Probation of Parole Dakota Department North of Criminal Investigation (701) 328-6195 Dakota Bureau North of Maternal Division of Health Contact: OVC Office General’s Attorney & Child Health (701) 328-3340 (701) 328-5500 Contact: VAWGO BJA Contact: (202) 305-2354 (202) 616-3210 Compensation P No (202) 616-3210 (202) 305-2649 Victims of Crime Compensation of Crime Victims Court of ClaimsProgram of Ohio(614) 466-7764 Contact:OVC (614) 466-5610 (202) 616-2032 Contact: OVC Services Contact: VAWGO (614) 728-8738 (614) 466-7782 (202) 307-1232 (202) 307-3180 BJA Contact: (202) 616-2032 Council Attorney District Crime Victims Compensation Board(405) 557-6704 Council Attorney District Attorney Council District (202) 616-3579 Attorney Council District Contact: OVC (202) 305-2649 Contact: VAWGO (202) 307-0710 BJA Contact: OVC Contact: (202) 616-3579 OVC CrimeDepartment of Justice Compensation ProgramVictims’ Assistance SectionVictims’ Crime Department of Justice(503) 378-5348 Contact: (202) 616-3565 OVC Division Services Criminal Justice (503) 378-5348 Services Division Criminal Justice (503) 378-3725 (503) 378-3725 BJA Contact: (202) 616-3294 VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD New York New Carolina North North Dakota Islands Mariana Northern Ohio Oklahoma Oregon
162 SANE Development and Operation Guide rime & Delinquency A GRANT PROGRAM Pennsylvania Commission on C Pennsylvania BJA Contact: Department of Justice Governor’s Justice Commission Justice Governor’s A GRANT VAWGO Contact:VAWGO (202) 307-6068 Pennsylvania Commission on Pennsylvania (717) 787-8559 ext. 3031 (202) 307-3180 (202) 307-3180 Program Women Governor’s Justice Commission Justice Governor’s (615) 741-8277 Contact:VAWGO (202) 305-2404 (202) 305-1767 BJA Contact: OVC Contact: (202) 616-3581 OVC (717) 787-8559 ext. 3031 Pennsylvania Commission on Pennsylvania (809) 723-4949 Contact:OVC (202) 616-3581 Affairs Women’s (809) 721-7676 Contact VAWGO (809) 725-0335 (202) 616-3295 BJA Contact: [011] (680) 488-1002 OVC Contact: (202) 616-3565 OVC rogram Ministry of Health AgainstViolence STOP No Program Byrne Edward No OVC Contact: (202) 616-3581 OVC Crime & Delinquency(717) 783-0551 ext. 3093 Crime & Delinquency Crime & Delinquency (717) 787-2040 ext. 8559 Pennsylvania Commission on Pennsylvania No Compensation ProgramNo Office General’s Attorney The Commission for No Compensation P No General Treasurer’s OfficeTreasurer’s General (401) 277-2287 Contact:OVC Commission Justice Governor’s (401) 277-2620 Contact: OVC (401) 277-4497 Contact: VAWGO (401) 277-2620 BJA Contact: (202) 616-2032 of the GovernorOffice AssistanceVictim of Division (803) 734-1930 (803) 896-8712 Contact:OVC & Grants of Safety Office (202) 616-2032 Contact: OVC & Grants of Safety Office (202) 616-3581 (803) 896-8712 & Grants of Safety Office (202) 307-3180 Contact: VAWGO (803) 896-8708 (202) 305-2404 (202) 307-0283 BJA Contact: (202) 305-1767 (202) 616-3581 Department Dakota South Servicesof Social (605) 773-6317 Department Dakota South Contact:OVC Department Dakota South Services of Social (605) 773-4330 of Operations Office Governor’s Contact: OVC Services of Social (605) 773-4330 Contact: VAWGO (605) 773-6313 BJA Contact: (202) 307-6061 (202) 616-3210 of ClaimsDivision Administration(615) 741-2734 (202) 616-3210 Services Department of Human (615) 313-4767 of Criminal Office Contact: (202) 616-3579 OVC (202) 305-2977 Programs Justice of Criminal Office Programs Justice (615) 741-8277 OVC Contact: (202) 616-3579 OVC VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Pennsylvania Puerto Rico Puerto Republic of Republic Palau Rhode Island South Carolina South Dakota Tennessee
163 Appendix F A GRANT PROGRAM , Trade & , Trade , Department of Community A GRANT VAWGO Contact:VAWGO BJA Contact: (202) 305-2649 (202) 616-8958 Commission (809) 774-6400 Criminal Justice DivisionCriminal Justice Division Criminal Justice Division Criminal Justice Planning Commission Department of Social Department of Community Crime Victims Crime Victims Compensation of the Office Division GeneralAttorney (512) 936-1200 of the Governor Office (512) 463-1919 Contact: (202) 616-3579 OVC of the Governor Office of the Governor Office (512) 463-1919 (512) 463-1952 OVC Contact: (202) 616-3579 OVC Office of CrimeOffice ReparationsVictim (801) 533-4000 Contact:OVC (801) 533-4000 ReparationsVictim of Crime Office of Crime Office Contact: OVC (202) 616-3579 Justice Commission on Criminal & Juvenile Reparations Victim (801) 533-4000 Contact VAWGO (801) 538-1060 BJA Contact: (202) 305-1764 (202) 616-3579Victims Center for Crime Services(802) 241-1250 Contact:OVC ServicesVictims Center for Crime Center for Crime Contact: OVC (202) 616-2032 (802) 241-1250 Safety Department of Public Vermont (802) 828-5456 (202) 305-2381 Contact: VAWGO Services Victims (202) 307-1232 BJA Contact: (802) 244-8781 (202) 616-2032 of CrimeDivision CompensationVictims’ (804) 367-8686 Contact:OVC Services Justice Department of Criminal (804) 786-3923 Contact: OVC Department of Criminal Services Justice Services Justice Department of Criminal (804) 225-3900 (202) 305-2404 Contact: VAWGO (804) 786-1577 BJA Contact: (202) 305-2358 (202) 616-2032VictimsCriminal Compensation Commission (809) 774-1166 Contact:OVC (202) 616-2032 Law Enforcement (809) 774-6400 Contact: OVC (202) 307-3180 Planning Law Enforcement Commission Planning Law Enforcement (809) 774-6400 Contact: VAWGO BJA Contact: (202) 616-3295 Program(360) 902-5340 Contact:OVC (360) 902-7994 Contact: OVC Services & Health (360) 753-9684 Development & Economic Trade Development Economic Contact: VAWGO (360) 586-0665 BJA Contact: (202) 616-3581 Crime Victim Compensation (202) 616-3581 (202) 305-2404 (202) 616-3565VictimsCrime Compensation Fund(304) 347-4850 Contact:OVC (202) 616-2032 (202) 616-3565 Division Safety Highway & Criminal Justice (304) 558-8814 Contact: OVC (202) 616-2032 Division Safety Highway (202) 305-2381 & Justice Criminal (304) 558-8814 (304) 558-8814 Contact: VAWGO (202) 305-2404 (202) 616-3456 Division Safety & Highway Justice Criminal BJA Contact: (202) 514-8874 VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Texas Utah Vermont Virginia Virgin Islands Washington West Virginia
164 SANE Development and Operation Guide A GRANT PROGRAM A GRANT (307) 777-7841 (307) 777-7181 Bureau of Justice Assistance of Justice Bureau Violence Against Women Grants Office Grants Women Against Violence BJA VAWGO Crime Victims Crime Victims Compensation (202) 616-3210 of the Attorney GeneralOffice Crime Victims Compensation of the Attorney General Office (202) 616-3210 of the Attorney General Office of Criminal Investigation Division (202) 305-2649 (202) 307-0710 Commission(307) 635-4050 Contact:OVC (202) 616-2032 (307) 635-4050 Commission Contact: OVC (202) 616-2032 (202) 305-1792 Contact: VAWGO (202) 305-2148 BJA Contact: Office of Crime Victims ServicesVictims of Crime Office ServicesVictims of Crime Office (608) 266-6470 Contact:OVC Assistance of Justice Office Assistance of Justice Office (608) 267-2251 Contact: OVC (608) 266-7185 Contact: VAWGO (608) 266-7282 BJA Contact: VOCA VICTIMVOCA FORMULACOMPENSATION VICTIM ASSISTANCE VOCA FORMUL WOMEN VIOLENCE AGAINST STOP Office for Victims of Crime Victims Office for Victims of Crime Act Victims STATE GRANT PROGRAM FORMULA GRANT PROGRAM PROGRAM BYRNE FORMUL EDWARD Wyoming Wisconsin OVC VOCA
165 SANE Development and Operation Guide
APPENDIX G STARTUP CHECKLIST
167 SANE Development and Operation Guide
169 Appendix G
170 SANE Development and Operation Guide
171 Appendix G
172 SANE Development and Operation Guide
173 Appendix G
174 SANE Development and Operation Guide
CLINICAL SKILLS APPENDIX H COMPETENCY CHECKLIST
175 SANE Development and Operation Guide
177 Appendix H
COLUMBIA UNIVERSITY SCHOOL OF NURSING FORENSIC NURSING SPECIALTY
Donna A. Gaffney, DNSC, RN, FAAN
SEXUAL ASSAULT EXAMINER
New York City, New York
178 SANE Development and Operation Guide
179 Appendix H
180 SANE Development and Operation Guide
181 Appendix H
182 SANE Development and Operation Guide
183 Appendix H
184 SANE Development and Operation Guide
185 Appendix H
186 SANE Development and Operation Guide
187 Appendix H
188 SANE Development and Operation Guide
189 Appendix H
190 SANE Development and Operation Guide
191 Appendix H
192 SANE Development and Operation Guide
193 Appendix H
194 SANE Development and Operation Guide
APPENDIX I SANE PROTOCOLS
195 SANE Development and Operation Guide
197 Appendix I
198 SANE Development and Operation Guide
199 Appendix I
200 SANE Development and Operation Guide
APPENDIX J SANE FORMS
201 SANE Development and Operation Guide
203 Appendix J
204 SANE Development and Operation Guide
205 Appendix J
206 SANE Development and Operation Guide
207 Appendix J
208 SANE Development and Operation Guide
209 Appendix J
210 SANE Development and Operation Guide
211 Appendix J
212 SANE Development and Operation Guide
213 Appendix J
214 SANE Development and Operation Guide
215 Appendix J
216 SANE Development and Operation Guide
217 Appendix J
218 SANE Development and Operation Guide
219 Appendix J
220 SANE Development and Operation Guide
221 Appendix J
222 SANE Development and Operation Guide
223 Appendix J
224 SANE Development and Operation Guide
225 Appendix J
226 SANE Development and Operation Guide
227 Appendix J
228 SANE Development and Operation Guide
229 Appendix J
230 SANE Development and Operation Guide
231 Appendix J
232 SANE Development and Operation Guide
APPENDIX K SANE EVALUATION TOOLS
233 SANE Development and Operation Guide
235 Appendix K
236 SANE Development and Operation Guide
237 Appendix K
238 SANE Development and Operation Guide
239 Appendix K
240 SANE Development and Operation Guide
241 Appendix K
242 SANE Development and Operation Guide
243 Appendix K
244 SANE Development and Operation Guide
245 Appendix K
246 SANE Development and Operation Guide
247 Appendix K
248 SANE Development and Operation Guide
249 Appendix K
250 SANE Development and Operation Guide
251 Appendix K
252 SANE Development and Operation Guide
253 Appendix K
254 SANE Development and Operation Guide
255 Appendix K
256 SANE Development and Operation Guide
257 Appendix K
258 SANE Development and Operation Guide
259 Appendix K
260 SANE Development and Operation Guide
261 Appendix K
262 SANE Development and Operation Guide
263 Appendix K
264 SANE Development and Operation Guide
265 Appendix K
266 SANE Development and Operation Guide
267 Appendix K
268 SANE Development and Operation Guide
269 Appendix K
270 SANE Development and Operation Guide
271 Appendix K
272 SANE Development and Operation Guide
273 Appendix K
274 SANE Development and Operation Guide
275 Appendix K
276 SANE Development and Operation Guide
277 Appendix K
278 SANE Development and Operation Guide
279 Appendix K
280 SANE Development and Operation Guide
281 Appendix K
282 SANE Development and Operation Guide
283 Appendix K
284 SANE Development and Operation Guide
GLOSSARY OF GLOSSARY ACRONYMS
ACP - Acid Phosphatase MSW - Master of Social Work ACOG - American College of Gynecologists NCASA - National Coalition Against Sexual Assault ANA - American Nurses’ Association NOVA - National Organization of Victim APSAC - American Professional Society on the Assistance Abuse of Children OVC - Office for Victims of Crime BCA - Bureau of Criminal Apprehension PA - Physician’s Assistant BSN - Bachelor of Science in Nursing PAP - Prostatic Acid Phosphatase CEU - Continuing Education Units PSA - Prostatic Specific Antigen or Public Service CISPA - Critical Item Suicide Potential Assessment Announcements CODIS - Combined DNA Index System PTSD - Post-Traumatic Stress Disorder CNS - Central Nervous System RN - Registered Nurse CPS - Child Protective Services SAFE - Sexual Assault Forensic Examiner CSAAT - Comprehensive Sexual Assault SANC - Sexual Assault Nurse Clinician Assessment Tool SANE - Sexual Assault Nurse Examiner DEA - Drug Enforcement Agency SARS - Sexual Assault Resource Service DNA - deoxyribonucleic acid SART - Sexual Assault RESPONSE/RESOURCE ED - Emergency Department Team FNE - Forensics Nurse Examiner S-T-O-P - Services, Training, Officers, and GHB - gamma hydroxy butyrate Prosecutors HCMC - Hennepin County Medical Center UPT - Urine Pregnancy Test IAFN - International Association of Forensic VAWA - Violence Against Women Act Nurses VAWGO - Violence Against Women Grants JCAHO - Joint Commission on the Accreditation Offices of Healthcare Organizations VOCA - Victims of Crime Act JEN - Journal of Emergency Nursing WNS - Western Nurse Specialists
285 SANE Development and Operation Guide
BIBLIOGRAPHY
Abbott, P. 1997. Same sex assault. Minnesota . November 1994. Sexual assault and Coalition Against Sexual Assault Training Manual. the adolescent. Pediatrics 94. Minneapolis, MN: Minnesota Coalition Against Sexual Assault. American Professional Society on the Abuse of Children (APSAC). 1995. Practice Guidelines: American College of Gynecologists (ACOG). Use of Anatomical Dolls in Child Sexual Abuse 1996. Evidence-based guidelines for clinical issues Assessment. Chicago, Ill: APSAC. in obstetrics and gynecology. Practice Patterns. A message to grantseekers. 1997. http:// Adams, J. A. 1997. Sexual abuse and adolescents. fdncenter.org/2onlib/2ufgall.html. Pediatric Annals 26:5, 299-305. Anglin, Deirdre, Spears, Kelvin, and Hutson, H. Adams, J. A. and Knudson, S. 1996. Genital Range. April 1997. Flunitrazepam and its involve- findings in adolescent girls referred for suspected ment in date or acquaintance rape. Academy of sexual abuse. Archives of Pediatric Adolescent Emergency Medicine 4:4. Medicine 150: 850-857. Antognoli-Toland, Paula. May/June 1985. Com- Adams, J. A., Harper, K., Knudson, S., and prehensive program for examination of sexual Revilla, J. 1994. Examination findings in legally assault victims by nurses: A hospital-based project confirmed child sexual abuse. It’s normal to be in Texas. Journal of Emergency Nursing. 11:3. normal. Pediatrics 949:3:310-317. Arndt, Sherry. October 1988. Nurses help Santa Agger, I. 14-20 June 1987. The female political Cruz sexual assault survivors. California Nurse. prisoner: A victim of sexual torture. Presented at the Eighth World Congress for Sexology, Heidel- Bell, Kathy. July, August, September 1995. Tulsa berg/FRG. Sexual Assault Nurse Examiners program. The Oklahoma Nurse. Aiken, Margaret M. 1990. Documenting sexual abuse in prepubertal girls. MCN 15:176-177. . 26 November 1996. Personal com- munication. . 1993. False allegation: A concept in the context of rape. Journal of Psychosocial Nursing Blair, Tina M.H. and Warner, Carmen Germaine. 31:11. 1992. Sexual assault. Topics in Emergency Medicine 14:4. Aiken, Margaret M. and Speck, Patricia. 1991. Confidentiality in cases of rape: A concept recon- Bobak, Irene M. 1992. Violence against women. sidered. Journal of Clinical Ethics 2:1. Maternity and Gynecologic Care. Chapter 43.
American Academy of Pediatrics. Committee on Bowyer, Lucy and Dalton, Maureen E. May 1997. Child Abuse and Neglect. 1991. Guidelines for Female victims of rape and their genital injuries. the evaluation of sexual abuse of children. Pediat- British Journal of Obstetrics and Gynaecology 104, rics 86:2. 617-620.
287 Bibliography
Brownmiller, Susan. 1975 Against Our Will: Men, Davies, Anne. 1978. A preliminary investigation Women, and Rape. New York: Simon and Schuster. using p-Nitrophenyl Phosphate to Quantitate Acid Phosphatase on swabs examined in cases of sexual Buchanan, A. E. and Brock, D. W. 1989. Deciding assault. Medical Science Law 18:3. for Others: The Ethics of Surrogate Decision Making. New York: Cambridge University Press. Davies, D., Cole, J., Albertella, G., McCulloch, L., Allen, K., and Kekevian, H. 1996. A model Burgess, Ann W. and Fawcett, Jacqueline. April for conducting forensic interviews with child 1996. The comprehensive sexual assault assessment victims of abuse. Child Maltreatment 1:3, 189-199. tool. Nurse Practitioner 21:4. DeJong, A. R. and Rose, M. 1991. Legal proof of Burgess, Ann W. and Holmstrom, Linda L. May- child sexual abuse in the absence of physical June 1974 (A). Crisis and counseling requests of evidence. Pediatrics 88:3. rape victims. Nursing Research 23:3. Dexheimer Pharris, Margaret. 1995. Adolescent . September 1974 (B). Rape trauma suicide, Chapter 21, Nursing Care of Infants and syndrome. American Journal of Psychiatry 131:9. Children, 5th ed., eds. Whaley and Wong. St. Louis, MO: Mosby. Carpenter, C. C., Fischl, M.A., and Hammer, S. M. et al. 1996. Antiretroviral therapy for HIV Dexheimer Pharris, Margaret and Ledray, Linda E. infection in 1996: Recommendations of an inter- 1997. Consent and confidentiality in the care of national panel. Journal of the American Medical the sexually assaulted adolescent. Journal of Association 276:146-154. Emergency Nursing 23:3.
Cartwright, Peter S., Moore, Royanne A., Ander- DiNitto, Diana, Martin, Patricia Yancey, Norton, son, Jean R., and Brown, Douglas, H. 1986. Diane Blum, and Maxwell, Sharon M. May Genital injury and implied consent to alleged rape. 1986. Who should examine rape survivors. Ameri- The Journal of Reproductive Medicine. can Journal of Nursing 86:5.
Ceci, S. J. and Bruck, M. 1993. Suggestibility Donnelly, D. A. and Kenyon, S. 1996. Honey, of the child witness: A historical review and we don’t do men. Gender stereotypes and the synthesis. Psychological Bulletin 113:403-439. provision of services to sexually assaulted males. Journal of Interpersonal Violence 11:3. Center for Cross-Cultural Health. 1997. Caring Across Cultures: The Provider’s Guide to Cross- Donovan, Patricia. January/February 1997. Can Cultural Health Care. Minneapolis, MN: The statutory rape laws be effective in preventing Center for Cross-Cultural Health. adolescent pregnancy? Family Planning Perspectives 29:1. Centers for Disease Control and Prevention. 1993. Sexual transmitted diseases treatment guidelines. Draguns, Juris G. 1996. Ethnocultural consider- MMWR 42:1-102. ations in treatment of PSTD: Therapy and service delivery, Ethnocultural Aspects of Posttraumatic Stress . 1997. SexuallyTransmitted Diseases Disorder, eds. Marsella, Friedman, Gerrity & Treatment Guidelines. Atlanta, Ga.: CDC. Scurfield. Washington, D.C.: American Psycho- Chadwick, D. L., Berkowitz, C. C., Kerns, D. logical Association. et al. 1989. The Color Atlas of Child Abuse. St. Dunnuck, Chris. 25 November 1996. Personal Louis: CV Mosby. communication.
288 SANE Development and Operation Guide
Emans, S. J., Laufer, M.R., and Goldstein, O. P., Geist, Richard F. August 1988. Sexually related Eds. 1998. Chapter 20: Sexual abuse. Pediatric trauma. Emergency Medicine Clinics of North and Adolescent Gynecology. 4th Ed. Philadelphia: America 6:3. Lippincott-Raven, 751-794. Giardino, A. P., Finkel, M. A., Giardino, E. R., ENA. 1991. Sexual assault nurse examiner resource Seidl, T., and Ludwig, S. 1992. A Practical list. Journal of Emergency Nursing 17:31-35A. Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. St. Louis, MO: Sage Publica- English, A., Matthews, M., Extavour, K., tions. Palamountain, C., and Yang, J. 1995. State Minor Consent Statutes: A Summary. Cincinnati: Center Girardin, Barbara W., Faugno, Diana K., Seneski, for Continuing Education in Adolescent Health. Patty C., Slaughter, Laura, and Whelan, Margaret. 1997. Color Atlas of Sexual Assault. St. Louis, MO: Enos, W. F. and Beyer, J. C. April 1980. Prostatic Mosby-YearBook. acid phosphatase, aspermia, and alcoholism in rape cases. Journal of Forensic Sciences 25:2. Goodyear-Smith, F. A. 1989. Medical evaluation of sexual assault findings in the Auckland region. Erb, S. 1996. Disabled women and rape. Rape New Zealand Medical Journal 102:493-495. Crisis Advocate Training Manual. Houston, TX: Houston Drug Action Council Rape Crisis Gostin, Lawrence O., Lazzarini, Zita, Alexander, Program. Diane, Brandt, Allan M., Mayer, Kenneth H., and Silverman, Daniel C. 11 May 1994. HIV Federal Register, The. 14 February 1997. Final testing, counseling, and prophylaxis after program guidelines, Victims of Crime Act FFY sexual assault. Journal of the American Medical 1997 Victim Compensation Program. Association 271:18.
Ferrell, J. 25 September 1997. Personal communi- Graham Walker, A. 1997. A few abbreviated cation. suggestions for questioning children, Child Victims and Witnesses Interviewing and Investigating, ed. K. Foa, Edna B. 1997. Trauma and women: Course, L. Poyer. Washington, D.C.: U. S. Attorney’s predictors, and treatment. Journal of Clinical Office. Psychiatry 58:9. Green, William. 1988. Rape: The Evidential Foster, I. and Bartlett, John G. 18 November Examination and Management of the Adult Female 1989. Rape and subsequent seroconversion to Victim. Massachusetts: Lexington Books. HIV. British Medical Journal 299. Groth, A. Nicholas. 1990 Men who Rape: The Frank, Christina. December 1996. The new way Psychology of the Offender. New York: Plenum to catch rapists. Redbook. Press. Gaffney, D. 5, 6, 13, and 14 June 1997. Sharing Groth, A. Nicholas and Burgess, Ann W. 6 Octo- our caring: Development of a sexual assault ber 1977. Sexual dysfunction during rape. The nurse examiner team. Columbia University School New England Journal of Medicine. of Nursing—Forensic Nursing Specialty. Hampton, Harriette L. 26 January 1995. Care Geissler, E. M. 1993. Pocket Guide to Cultural of the woman who has been raped. The New Assessment. St. Louis, MO: Mosby. England Journal of Medicine.
289 Bibliography
Hayman, C. R. and Lanza, D. February 1971. Katz, S., Schonfeld, D. J., Carter, A. S., Leventhal, Sexual assault on women and girls. American J. M., and Cicchetti, D. V. 1995. The accuracy of Journal of Obstetrics and Gynecology 109. children’s reports with anatomically correct dolls. Developmental and Behavioral Pediatrics 16:2, Heger, A. and Emans, S. J. 1992. Evaluation of 71-76. the Sexually Abused Child: A Medical Textbook and Photographic Atlas. New York: Oxford Univer- Kaufhold, M. 1993. Medical assessment of chil- sity Press. dren who have been recently raped. Journal of Child Sexual Abuse 2:1. Hennepin County Medical Center. 1997. Pediatric Sexual Abuse Exam Protocol. Minneapolis, Kaufman, A., Divasto, P., Jackson, R., Voorhees, MN. H., and Christy, J. 1980. Male rape victims: Noninstitutionalized assault. American Journal of Hochmeister, M. N., Whelan, M., Borer, U. V., Psychiatry 137, 221-223. Gehrig, C., Binda, S., Berzlanovich, A., Rauch, E., and Dirnhofer, R. 1997. Effects of toluidine Kettelson, Debby. 1995. Rape: Nurses trained to blue and de-staining reagents used in sexual assault take evidence. Unit News/District News, District of examinations on the ability to obtain DNA profiles East Hawaii. from postcoital vaginal swabs. Journal of Forensic Sciences 42:2, 316-319. Kiffe, Barbara J. August 1996. Study evaluating nurses’ reactions toward rape victims. (Ph.D. Holloway, Mavis and Swan, Amanda. 28 July diss., Augsburg College, Minneapolis, MN). 1993. A & E management of sexual assault. Nursing Standard 7:45. Kivlahan, C., Kruse, R., and Furnell, D. 1992. Sexual assault examinations in children: The role Holmes, Melisa M., Resnick, Heidi S., Kilpatrick, of a statewide network of health care providers. Dean G., and Best, Connie L. 1996. Rape-related AJDC 146. pregnancy: Estimates and descriptive characteristics from a national sample of women. Kolilis, G. H. 1996. The role of law enforcement in the investigation of child maltreatment, Recogni- IAFN Statement. November 1996. Presentation. tion of Child Abuse for the Mandated Reporter, ed. “Utility of the colposcope in the sexual assault J. A. Monteleone. St. Louis, MO: G.W. Medical examination.” Fourth Annual Scientific Assembly Publishing. of Forensic Nurses, Kansas City. Kosse, M. P. and Harvey, M. R. 1991. The Rape Jezierski, M. 1992. Sexual assault nurse examiner: Victim: Clinical and Community Interventions. A role with lifetime. Journal of Emergency Nursing 2nd ed. New York: McGraw Hill. 18:2. Laufer, Alison, A. and Souma, Micki L. November Kanuha, V. 1997. Minnesota Coalition Against 1982. Use of toluidine blue for documentation of Sexual Assault Training Manual. Minneapolis, traumatic intercourse. Obstetrics and Gynecology MN: Minnesota Coalition Against Sexual Assault. 60:5.
Katz, Mitchell H. and Gerberding, Julie Louise. Ledray, Linda E. 1984. Sexual assault resource 1997. Postexposure treatment of people exposed to service. Unpublished data. the human immunodeficiency virus through sexual contact or injection-drug use. The New England . 1991. Sexual assault and sexually Journal of Medicine 336:15. transmitted disease: The issues and concerns. Rape and Sexual Assault III: A Research Handbook. New York & London: Garland Publishing. 290 SANE Development and Operation Guide
. 1992(A). The sexual assault nurse Ledray, Linda E. and Simmelink, K. February clinician: A fifteen-year experience in Minneapolis. 1997. Sexual assault: Clinical issues: Efficacy of Journal of Emergency Nursing 18:3. SANE evidence collection. A Minnesota study. Journal of Emergency Nursing 23:1. .1992(B). The sexual assault exam: Overview and lessons learned in one program. Leininger, Madeleine. 1995. Transcultural Nursing: Journal of Emergency Nursing 18:3. Concepts, Theories, Research & Practice, 2nd Ed. New York: McGraw Hill. . 1993 (A). Sexual assault nurse clinician: An emerging area of nursing expertise. Lenehan, Gail P. February 1991. Sexual assault Clinical Issues in Perinatal and Women’s Health nurse examiners: A SANE way to care for rape Nursing, ed. Linda C. Andrist. Philadelphia: J. B. victims. Journal of Emergency Nursing 17:1. Lippincott. Levitt, C. J. 1993. Medical evaluation of the . 1993 (B). Evidence collection: An sexually abused child. Primary Care 20:2. update. Journal of Child Sexual Abuse 2:1. Lewington, F. R. 1988. New initiatives in the . 1994. Rape or self-injury. Journal of investigation of rape. Medico-Legal Journal 56:3. Emergency Nursing. 20:4. Lewis, Ricki. June 1988. DNA fingerprints: . 1995. Sexual assault: clinical issues. Witness for the prosecution. Discover. Sexual assault evidentiary exam and treatment protocol. Journal of Emergency Nursing 21:4. Lipscomb, Gary H., Muram, David, Speck, Patricia M., and Mercer, Brian M. 10 June 1992. . March 1996 (A). The sexual assault Male victims of sexual assault. Journal of the resource service: A model of care. Minnesota American Medical Association 267:22. Medicine 79. Lipson, J. G., Dibble, S. L. and Minarik, P. A. . October 1996 (B). Sexual assault: 1996. Culture & Nursing Care: A Pocket Guide. Clinical issues: Sexual assault nurse examiner San Francisco: San Francisco Nursing Press. (SANE) programs. Journal of Emergency Nursing 22:5. Lynch, Virginia A. 1993. Forensic nursing: Diver- sity in education and practice. Journal of Psychoso- Ledray, Linda E. and Arndt, Sherry. 1994. Exam- cial Nursing 31:11. ining the sexual assault victim: A new model for nursing care. Journal of Psychosocial Nursing 32:2. . November 1996. Presentation. “President’s report: Goals of the IAFN.” Fourth Ledray, Linda E. and Barry, Lee. June 1998. SANE Annual Scientific Assembly of Forensic Nurses expert and factual testimony. Journal of Emergency Conference, Kansas City. Nursing 24:3. Marchbanks, Polly A., Lui, Kung-Jong, and Mercy, Ledray, Linda E. and Chaignot, Mary Jane. 1980. James A. 1990. Risk of injury from resisting Services to sexual assault victims in Hennepin rape. American Journal of Epidemiology 132:3. County. Evaluation and Change (special issue). Marsella, A. J., Friedman, J. M., Gerrity, E. T., and Ledray, Linda E. and Netzel, L. April 1997. Scurfield, R. M. 1996. Ethnocultural Aspects of Forensic nursing: DNA evidence collection. Posttraumatic Stress Disorder. Washington, D.C.: Journal of Emergency Nursing 23:2. American Psychological Association.
291 Bibliography
Marullo, Geri. November 1996. Presentation. Muchlinski, E., Boonstra, C., and Johnson, J. “The future and the forensic nurse: New 1989. Planning and implementing a pediatric dimensions for the 21st century.” Fourth Annual sexual assault evidentiary examination program. Scientific Assembly of Forensic Nurses Conference, Journal of Emergency Nursing 15:3. Kansas City. Muram, D. 1987. Rape, incest, trauma: The Massachusetts Nurses Association. December molested child. Clinical Obstetrics and Gynecology 1995. MNA collaborates with DPH to train sexual 30. assault nurse examiners. Massachusetts Nurse. . 1989. Child sexual abuse: Relation- McCann, I. L. and Pearlman, L. A. 1990. Vicari- ship between sexual acts and genital findings. ous traumatization: A framework for understand- Child Abuse & Neglect 13: 211-216. ing the psychological effects of working with victims. Journal of Traumatic Stress 3: 131-149. Muram, D., Speck, P. M., and Dockter, M. 1996. Child sexual abuse examination: Is there a need McCauley, Jeanne, Gorman, Richard L., and for routine screening for N. Gonorrhoeae? Journal Guzinski, Gay. December 1986. Toluidine blue in of Pediatric Adolescent Gynecology 9. the detection of perineal lacerations in pediatric and adolescent sexual abuse victims. Pediatrics Myers, J., Bays, J., Becker, J., Berliner, C., and 78:6. Saywitz, K. J. 1989. Expert testimony in child sexual abuse litigation. Nebraska Law Review 68:1 McDonald, D. 5 September 1997. Personal & 2. communication regarding medscope. Fairfax Hospital, VA. Nass, D. 1991. Confidentiality and the rape victim: Ethical intent vs. political reality. Journal McNeese, V. and Monteleone, J. A. 1996. Sexual of Clinical Ethics 2:1. abuse in children, Recognition of Child Abuse for the Mandated Reporter, ed. J. A. Monteleone. St. Louis, National Coalition Against Sexual Assault MO: G.W. Medical Publishing. (NCASA). October 1997. Hoffman La Roche announcement to add color-releasing agent to Miller, Jay V. Letter. Virginia A. Lynch. October Rohypnol. NCASA Annual Conference.Cleveland, 11, 1996. Fourth Annual Scientific Assembly of OH. Forensic Nurses Kansas City Conference. Novem- ber 1996. Neinstein, L. S. 1996. Adolescent Health Care: A Practical Guide, 3rd Ed. Baltimore: Williams Miller, P. 1997. Sexual violence and the gay and and Wilkins. lesbian communities. Minnesota Coalition Against Sexual Assault Training Manual. Minneapolis, Norvell, Mark K., Benrubi, Guy I., and Thomp- MN: Minnesota Coalition Against Sexual Assault. son, Robert J. April 1984. Investigation of microtrauma after sexual intercourse. The Journal Minneapolis Police Department. Crime Analysis of Reproductive Medicine 29:4. Unit. 1989. Police Chief’s report. O’Brien, Colleen. 1992. Medical and forensic Mollica, Richard F. and Son, Linda. June 1989. examination by a sexual assault nurse examiner Cultural dimensions in the evaluation and treat- of a 7 year-old victim of sexual assault. Journal ment of sexual trauma. Psychiatric Clinics of North of Emergency Nursing 18:3. America 12:2.
292 SANE Development and Operation Guide
. 1996 (A). Sexual assault nurse Poyer, K. L. 1997. Child Victims and Witnesses examiner (SANE) program coordinator. Journal Interviewing and Investigating. Washington, of Emergency Nursing 23:5. D.C.: U. S. Attorney’s Office.
. 25 November 1996 (B). Personal Randall, B. 1986. Persistence of vaginal communication. spermatazoa as assessed by routine cervicovaginal (pap) smears. Journal of Forensic Science 32. . October 1997. Forensic nursing: Improved forensic documentation of genital Rambow, B., Atkinson, C. Frost, T. H., and injuries with colposcopy. Journal of Emergency Peterson, G. F. 1992. Female sexual assault: Nursing 23:5. Medical and legal implications. Annals of Emer- gency Medicine 21:727-731. Osborn, M. and Neff, J. May/June 1989. Patient care guidelines: Evidentiary examination in Reghr, C. 1990. Parental responses to extra-familial sexual assault. Journal of Emergency Nursing 15:3. child sexual assault. Child Abuse & Neglect 14.
Paradise, J. E. 1990. The medical evaluation of the Renz, L., Baker, K., and Read, P. 1996. The sexually abused child. Pediatric Clinics of North Foundation Directory. 9th edition. Chapter 6. New America 37. York: The Foundation Center.
Pasqualone, Georgia A. 1996. Forensic RNs as Roach, Barbara A. and Vladutiu, Adrian O. 1993. photographers: Documentation in the ED. Journal Letter to the Editor: Prostatic specific antigen of Psychosocial Nursing 34:10. and prostatic acid phosphatase measured by radioimmunoassay in vaginal washings from Pearlman, L. A. and Saakvitne, K. W. 1995. cases of suspected sexual assault. Clinica Chimica Treating Therapists with Vicarious Traumatization Acta 216:199-201. and Secondary Stress Disorder. Compassion Fatigue: Secondary Traumatic Stress Disorders from Treating Rollins, J. H. 1995. Growth and development of the Traumatized, ed. C. Figley. New York: Brunner/ children, Nursing Care of Infants and Children, Mazel. ed. Wong. St. Louis, MO: Mosby.
Pease, T. and Frantz, B. 1994. Your Safety . . . Your Rossum, C. 1993. How to Assess Your Nonprofit Rights & Personal Safety and Abuse Prevention Organization with Peter Drucker’s Five Most Education Program to Empower Adults with Dis- Important Questions. San Francisco: Jossey-Bass. abilities and Train Service Providers. Doylestown, PA: Network of Victim Assistance. Royce, Rachel A., Sena, Arlene, Cates, Jr., Willard, and Cohen, Myron S. 10 April 1997. Sexual Peele, Kathleen and Matranga, Myrna. April 1997. transmission of HIV. The New England Journal of Use of a microscope and video colposcope in Medicine 336:15. sexual assault investigations. The Nurse Practitioner 22:4. Sacks, D. 1989. Canadian guidelines for health care providers for the examination of children Pope, C. and Brucker, M. 1991. Adolescents as suspected to have been sexually abused. Canada victims: An overview of the special impact of Diseases Weekly Report 15:3. sexual abuse. NAACOGS Clinical Issues in Prenatal and Women’s Health Nursing 2:2. Sandrick, Karen M. 5 June 1996. Tightening the chain of evidence. Hospitals and Health Networks.
293 Bibliography
Satin, Andrew J., Hemsell, David L., Stone, Jr., Smith, Helen Guthrie. 5 June 1996. SART: Special Irving C., Theriot, Sheri, and Wendel, Jr., George team helps net convictions. Press-Telegram. D. May 1991. Sexual assault in pregnancy. Obstet- rics and Gynecology 77:5. Smith, Linda S. March/April 1987. Sexual as- sault—The nurse’s role. AD Nurse. Schauben, Laura J. and Frazier, Patricia A. 1995. Vicarious trauma: The effects on female counselors Soderstrom, Richard M. January 1994. of working with sexual violence survivors. Psychol- Colposcopic documentation: An objective ap- ogy of Women Quarterly 19: 49-64. proach to assessing sexual abuse of girls. Journal of Reproductive Medicine 39:1. Schumacher, K. and Hung Lee, M. 1997. Persons who are deaf and hard of hearing. Minnesota Solola, A., Scott, C., and Severs, H. 1983. Rape: Coalition Against Sexual Assault Training Manual. Management in a non-institutional setting. Obstet- Minneapolis, MN: Minnesota Coalition Against rics and Gynecology 61. Sexual Assault. Sorenson, Bottoms, and Perona. 22 February1997. Seattle Rape Relief. 1997. Sexual assault on people Intake and Forensic Interviewing in the Children’s with disabilities. Minnesota Coalition Against Sexual Advocacy Center Setting: A Handbook. Washington, Assault Training Manual. Minneapolis, MN: D.C.: National Network of Children’s Advocacy Minnesota Coalition Against Sexual Assault. Centers.
Sheridan, Daniel J. 1993. The role of the battered Soules, M. R., Pollard A. A., Brown, K. et al. 1978. woman’s specialist. Journal of Psychosocial Nursing The forensic laboratory evaluation of evidence in 31:11. alleged rape. American Journal of Obstetrics and Gynecology 130: 142-147. Sieving, R. E. 1995. Health promotion of the adolescent and family. Nursing Care of Infants Speck, Patricia M. June 1996. Sexual assault: and Children, ed. Wong. St. Louis, MO: Mosby. Clinical issues: Memphis sexual assault resource center: Consent for pregnancy prevention. Journal Silverman, E. M. and Silverman, A. G. 1978. of Emergency Nursing 22:3. Persistence of spermatozoa in the lower genital tracts of women. Journal of the American Medical . 16 January 1997. Personal communi- Association 240. cation.
Simmelink, Kathy. December 1996. Sexual assault: . 1999. Chapter 31: Sexual assault. Clinical issues: Lessons learned from three elderly Manual of Emergency Care, 5th Ed., eds. Susan sexual assault survivors. Journal of Emergency Sheehy and Gail Lenehan. St. Louis, MO: Mosby. Nursing 22:6. Speck, Patricia M. and Aiken, Margaret M. April Slaughter, Laura and Brown, Carl, R.V. January 1995. 20 years of community nursing service: 1992. Colposcopy to establish physical findings in Memphis sexual assault resource center. Tennessee rape victims. American Journal of Obstetrics and Nurse. Gynecology 166:1. Stovall, T. G., Muram, D., and Wilder, M. 1988. Slaughter, Laura, Brown, Carl, R. V., Crowley, Sexual abuse and assault: Comprehensive program Sharon, and Peck, Roxy. March 1997. Patterns of utilizing a centralized system. Adolescent and genital injury in female sexual assault victims. Pediatric Gynecology 1. American Journal of Obstetrics and Gynecology 176:3.
294 SANE Development and Operation Guide
Tallmer, A. 1996. Lesbian victims. Rape Crisis U.S. House of Representatives. 1996. Drug- Advocate Training Manual. Houston, TX: Houston Induced Rape Prevention and Punishment Act of Drug Action Council Rape Crisis Program. 1996, H.R. 4137.
Texeira, R. G. 1981. Hymenal colposcopic exami- Virginia State Council of Sexual Assault Nurse nation in sexual offenses. American Journal of Examiners: State Standards Task Force. 13 Forensic and Medical Pathology 2:209-214. March 1997. Standards of Practice for Sexual Assault Nurse Examiners. Thomas, Mark and Zachritz, Helenmarie. June 1993. Tulsa sexual assault nurse examiners Warner, C. G. 1987. Rape and sexual assault, (SANE) program. Journal of Oklahoma State Emergency Care: A Comprehensive Review, eds. T. Medical Association 86. Kravis and C. G. Warner. Gaithersburg, MD: Aspen Publishers. Tintinalli, Judith E. and Hoelzer, Marion. May 1985. Clinical findings and legal resolution in White, E. C. 1994. Chain, Chain Change: For sexual assault. Annals of Emergency Medicine 14:5. Black Women in Abusive Relationships. Seattle, WA: Seal Press. Tipton, A. C. 1989. Child sexual abuse: Physical examination techniques and interpretation of Wilson, M. 1994. Crossing the Boundary: Black findings. Adolescent and Pediatric Gynecology 2. Women Survive Incest. Seattle, WA: Seal Press.
Tobias, Gabriella. October 1990. Rape examina- Woodling, B. A. and Heger, A. 1986. The use of tions by GPs. The Practitioner 234. the colposcope in the diagnosis of sexual abuse in the pediatric age group. Child Abuse and Neglect Trenkman, Maggie. 24 October 1997. Personal 111:114. communication. Wright, C. M., Duke, L., Fraser, E., and Sviland, Tucker, Sharon, Ledray, Linda E., and Werner, L. 1989. Northumbria women’s police doctor Joan Stehle. July 1990. Sexual assault evidence scheme: A new approach to examining victims of collection. Wisconsin Medical Journal. sexual assault. British Medical Journal 298.
Turman, K. M. and Dinsmore, J. 1997. Child Yorker, Beatrice Crofts. January 1996. Nurses in Victims and Witnesses: A Handbook for Criminal Georgia care for survivors of sexual assault. Georgia Justice Professionals. Washington, D.C.: U. S. Nursing. Department of Justice, Office of the United States Attorney. Yuzpe, A. Albert, Smith, R. Percival, and Rademaker, Alfred W. April 1982. A multicenter The Urban Institute. 1997. Evaluation of the S-T- clinical investigation employing ethinyl estradiol O-P Formula Grants to Combat Violence Against combined with dl-norgestrel as a postcoital contra- Women. Washington, D.C.: National Institute of ceptive agent. Fertility and Sterility 37:4. Justice, U.S. Department of Justice.
Uniform Crime Reports. October 13, 1996. Crime in the United States. U.S. Department of Justice. Washington, DC: Federal Bureau of Investigation.
295 SANE Development and Operation Guide
SANE GUIDE EVALUATION EVALUATION
Your feedback is an important and essential part of making this guide an effective tool. We ask that you please take the time to complete the following questionnaire at this time. OVC is interested in learning what information in this guide was useful and what additional information you would like included in revisions. Your honest response will help us improve this guide. Once completed, tear the questionnaire from the manual, fold it in half and staple it with the return address to the Sexual Assault Resource Service (SARS) on the outside and put it in the mail.
1. What kind of agency do you work for? (Check all that apply)
■ 1. Police
■ 2. Hospital
■ 3. Prosecutor’s office
■ 4. Rape center
■ 5. Existing SANE program
■ 6. Other______(specify)
2. What is your academic background? Please list degrees, certifications, areas of study: ______
3. a. Do you currently have an operating SANE program in your area? ■ 1. Yes
■ 2. No
■ 3. Uncertain
b. Do you have a SART program in your area? ■ 1. Yes
■ 2. No
■ 3. Uncertain
4. a. Is there interest in starting a SANE program in your area? ■ 1. Yes
■ 2. No
■ 3. Uncertain
297 Evaluation
b. Is there interest in starting a SART program in your area? ■ 1. Yes
■ 2. No
■ 3. Uncertain
5. a. Are you currently working to develop a SANE program? ■ 1. Yes
■ 2. No
■ 3. Uncertain
b. Are you currently working to develop a SART program? ■ 1. Yes
■ 2. No
■ 3. Uncertain
If you are working to develop a new SANE or SART program, please answer the items in the following section. If not, please go to Question 9.
6. What development work have you done prior to receiving this guide?
______
______
______
7. How helpful do you believe this guide will be? ■ 1. Very helpful
■ 2. Moderately helpful
■ 3. Not very helpful
■ 4. Not at all helpful
8. How do you plan to use this guide? ■ 1. Start a SANE program
■ 2. Improve a program
■ 3. Influence legislation
■ 4. Reference Guide
■ 5. Interagency collaboration
■ 6. Other______298 SANE Development and Operation Guide
9. Is there anything you would have done differently if you had this guide before you started working to develop your SANE/SART program?
■ 1. No
■ 2. Yes, please explain: ______
______
10. Do you want to work in a SANE program?
■ 1. Yes
■ 2. No, because______
■ 3. Uncertain, because______
11. Did you share this information with anyone else?
■ 1. No
■ 2. Yes, the information was shared with ______
12. Do you believe you could start a SANE program with the information in this guide alone?
■ Yes
■ No... I would also need: ______
______
______
13. If the following technical assistance was available, would you utilize it?
a. SANE program development WEB page ■ Yes ■ No ■ don’t have computer
b. e-mail assistance ■ Yes ■ No ■ don’t have e-mail
c. Telephone assistance ■ Yes ■ No ■ Unsure
d. Regional workshop/SANE development conference ■ Yes ■ No ■ Unsure
299 Evaluation
At what location would you prefer to attend______
e. Other, please specify______
______
14. If there was a possibility to share SANE/SART information with other programs (e.g., providing local program statistics such as the number of cases seen, convictions, etc. to a central national center and getting other area and compiled national statistics in return) would you be willing to participate?
■ 1. Yes
■ 2. No
■ 3. Uncertain, I would need more information about: ______
______
For each item below, please circle the number that represents your opinion about that section.
123 4 Very Moderately Minimally Not Useful Useful Useful Useful
1. SANE History and description of current program operation 1234
2. SANE program model information 1234
3. SART information 1234
4. Needs assessment 1234
5. Overcoming obstacles 1234
6. Program costs and funding 1234
300 SANE Development and Operation Guide
7. Starting a SANE program 1234
8. Program staff 1234
9. SANE Training 1234
10. Establishing and maintaining coverage 1234
11. Program operation 1234
12. The pediatric SANE exam 1234
13. Policies and procedures 1234
14. Maintaining a healthy program 1234
15. Which of the above items was the LEAST helpful? ______
16. Which of these items was the MOST helpful? ______
17. What would make this guide more useful?______
______
18. Would you recommend this guide to a colleague? ■ 1. Yes
■ 2. No
■ 3. Uncertain
301 Evaluation
For updated information and to be on our mailing list:
Agency Name______
Address______
Phone______FAX______e-mail______
302 SANE Development and Operation Guide
Place Stamp Here
Dr. Linda E. Ledray, RN, Ph.D., FAAN Sexual Assault Resource Service 525 Portland Avenue South Minneapolis, MN 55415
303