In the mid-1970s many hospitals were still turning rape victims away and sending them elsewhere. It was not uncommon for the county general hospital to be the second stop for a rape victim who had first gone to a private hospital seeking care. Many hospitals did not have a rape protocol. Some hospital personnel were afraid of the forensic component of evidence collection; others were concerned about the time commitment should the case go to court and they be called to testify.
When these referring hospitals were surveyed in Minneapolis, it was found that less than one out of three rape victims referred to the county hospital from their emergency departments actually arrived (Ledray, 1986a). The other rape victims were lost to follow-up. How were the victims to know they would not be turned away yet again?
The first sexual assault nurse clinician/ examiner programs were developed in the late 1 97Os by nurses concerned about this lack of adequate care following such a crisis. The first programs were developed simultaneously yet independently in Memphis (1976), Minneapolis (1977), and Amarillo, Texas (1978). It was not, however, until many years later that collaboration between programs began (P. Speck, J. Ferrell, personal communication, August 1992).
In August of 1992, the first national meeting bringing these pioneering nurses together was held in Minneapolis. Seventy-two nurses from 26 programs in the United States and Canada participated. This working meeting allowed these nurses to meet colleagues with common interests and goals. For the first time they were able to come together to share ideas, discuss concerns, and develop strategies to further devefop this emerging area of nursing expertise. This meeting set the stage for shared program growth and development; from this meeting the International Association of Forensic Nurses was formed.
What Is a Sexual Assault Nurse Clinician/Examiner?
A sexual assault nurse clinician or examiner (the title is a matter of program preference) is a registered nurse who has been specially trained to provide comprehensive care to sexual assault survivors. She usually is certified by her local institution after completing a training program of approximately 40 hours. Demonstrated competence in conducting a comprehensive evidential examination also is required.
Although one program requires applicants to be nurse practitioners, and other programs prefer nurses with a bachelor's degree, most institutions will train any competent registered nurse and do not believe advanced training or degrees are necessary for application.
Although sexual assault nurse examiners work cooperatively with medical facilities, most are from independent nursing programs that contract with the hospital to provide these specific services on an on-call basis. Some hospitals that see large numbers of rape victims have their own program.
Whenever a sexual assault survivor comes to the emergency department of a participating hospital, the staff pages the sexual assault nurse examiner on call. Although the staff treats urgent physical injuries immediately and makes the woman feel safe and comfortable, all additional service is provided by the nurse examiner when she arrives.
Because most rape survivors are women, female nurses are employed as sexual assault nurse clinicians. When these nurses began to see clients in 1977, a male nurse also was employed to be available to male victims. The offer, however, was consistently declined. Like female survivors, male victims too had been raped by men and often experienced the same generalized fear and mistrust of men and felt more comfortable being seen by a female nurse (Ledray, 1978).
Advantages of the Nurse Examiner Program
For Emergency Departments. Few emergency departments do enough sexual assault examinations to maintain the proficiency of all their staff in that area. Expertise is important not only to ensure proper evidence collection and chain of evidence, but also to establish credibility when testifying in a court of law.
In a busy trauma center that has a nurse examiner on call, it is not necessary to take the staff away from other duties to complete the evidential examination. Without this service, the survivor may have to wait hours while lifethreatening trauma takes priority for staff time. A nurse examiner can typically complete an evidential examination in half the time it might otherwise take staff members who are unfamiliar with the protocol.
For the Police. The nurse examiner often plays an important role in helping the survivor sort through her concerns and questions about reporting. Many women come to the hospital uncertain if they want to report the rape to the police. The nurse examiner, who is familiar with the legal system, can give the survivor accurate information about what reporting is, what her options within the legal system are, and what support services will be available if she chooses to report. Experience has shown most women's fears about reporting are based on unrealistic and unsubstantiated fears.
Having a small number of nurses with whom the police can work consistently has many advantages for the police. In addition to obtaining evidence useful in proving a case, the nurse ensures that the police receive reports quickly. She also is able to forward and interpret laboratory findings.
Because of fear for their safety and the need for extra social support, many survivors will spend some time with a friend rather than returning home after a rape. The nurse often maintains contact with the survivor and can therefore be helpful when police need to contact her to make a formal statement, such as when a suspect is apprehended. The nurse also may be available to accompany the survivor when she makes the statement.
Suspect Examinations. The nurse examiner also plays an important role in ensuring that evidence is collected properly from a suspect. This is most often an abbreviated examination, which includes pulled pubic and head hairs, saliva specimens, and blood for type and DNA. Proper chain of evidence also must be maintained.
For the County Attorney. A typical concern in many states when a nurse examiner program is proposed is the fear that the nurse will not be as credible a witness in court as the emergency department physician. Experience has shown the opposite to be true. Most emergency department physicians have much less experience collecting evidence than the trained, certified sexual assault nurse examiner. The nurse examiner is an experienced witness who is easier to contact than a physician, and is cooperative and willing to be available on short notice. The Santa Cruz, California, county attorney believes that since nurse examiners began collecting evidence, more assailants have pled guilty (Arndt, 1988).
In most areas, the close working relationship among nurses collecting evidence and attorneys prosecuting cases has resulted in a re-evaluation of the type of evidence helpful for prosecution. This has resulted in changes in the protocol, many of which are discussed later in this article.
For the Survivor. The survivor who is examined by a sexual assault nurse examiner is ensured to be working with an individual with up-to-date information on all aspects of care as she progresses through the criminal justice system. Having a nurse available on-call averts long delays a survivor might otherwise encounter in a busy trauma center. The nurse will work with the survivor and provide her with information, so she can make more educated choices about her options in the emergency department and as her case progresses through the criminal justice system. The nurse can help her anticipate potential problems and avoid them when possible. Most importantly, the survivor has someone available who understands what she is going through and is there to help.
State of the Art Sexual Assault Examination
Because hospitals and sexual assault nurse examiner programs have each developed their own sexual assault protocols, there are variations in the collection procedure and treatment components. California and 16 other states have developed statewide protocols. Rjurteen additional states have adopted a protocol developed by the US Department of Justice.
More states, however, have developed rape examination kits that are available free of charge or at a low cost. The use of these kits allows for more consistency in the type of evidence collected and helps ensure that the proper chain of evidence is maintained. Step-bystep instructions are included so that the kits can be used to collect evidence in a systematic fashion in any clinic or emergency department.
Although some variation is likely to continue, all forensic examinations of the sexual assault survivor in the emergency department should include the following five essential components:
* Treatment and documentation of injuries;
* Treatment and evaluation of sexually transmitted diseases;
* Pregnancy risk evaluation and prevention;
* Crisis intervention and arrangements for follow-up counseling; and
* Collection of medicolegal evidence while maintaining the proper chain of evidence.
Essential Examination Components
Physical Injuries. Although care and treatment of injuries are certainly an important concern to the emergency department staff, unless the injuries are life threatening, proper forensic documentation should occur first. This documentation involves photographs, a written description of the injuries, and documentation on body drawings included as a part of the sexual assault examination report. It also is important to document areas of pain or soreness indicated by the survivor, especially if there is no visible injury.
Documentation of physical injuries that show that force was used is important to demonstrate that the sexual contact was against the woman's will. The absence of physical trauma, however, does not indicate that no force or coercion was used and that the woman consented. This is, however, the defense typically used when no physical trauma is documented. Defense attorneys suggest that "most" rape victims are injured, so absence of injury shows consent.
Although many individuals expect genital and/or nongenital trauma - such as cuts, scratches, and bruises - to be common in a sexual assault, they are much less common than one might expect. Studies have shown that only 27% of sexuai assault victims have even minor nongenital injuries and only 3% have major injuries requiring treatment; fewer still, less than 1%, required hospital admission (Tucker, 1990).
Hicks (1980) found even fewer injuries: 8%, with only 1% requiring treatment. Other studies indicated that as few as 16% to as many as 87% of the examinations reveal genital trauma in an average of 2.3 sites, the most common being the posterior fourchette (Cartwright, 1987; Slaughter, 1992). These later results were obtained using a colposcope (a binocular microscope to which a 35 mm camera can be attached). This instrument allows the nurse conducting the evidential examination to magnify the vaginal area and better identify any tears in the mucosa. Pictures taken through the colposcope lens are used in court to document force.
A common tactic of the defense attorney in cases in which vaginal trauma is found is to attempt to indicate that vaginal trauma could occur from "vigorous consenting sexual contact." In order to provide expert testimony that vaginal trauma findings are consistent with nonconsensual sexual contact and inconsistent with consenting sexual contact, nurse examiners from several counties in California are currently gathering colposcopy data following consensual sexual contact. Volunteer female subjects are examined within 24 hours of consenting peni le -vaginal intercourse following a specific examination protocol. Each subject then fills out a questionnaire about the types of sexual contact. This questionnaire and photographic slides taken through the colposcope are then evaluated. The examiner does not see the subject's questionnaire at the time of the examination. Initial findings indicate the subjects are dramatically lacking in signs of trauma (Slaughter, 1992).
Sexually Transmitted Diseases. In 1988, the state of California completed its first major revision of the protocol for a medicolegal examination of the sexual assault victim in over 20 years. At that time, the protocol included baseline testing for sexually transmitted diseases (STD) during the initial examination. The initial theory was that if a rape survivor tested negative for a STD at the time of the initial examination, then positive on follow-up, the assailant could be tested. If the assailant was found positive, that would be further evidence that he had raped her.
Unfortunately, many programs have found this baseline data has not been useful in court and has even been used against the victim. If she is positive initialiy, defense attorneys use this information in an attempt to demonstrate that she is sexually promiscuous, and therefore is likely to have consented. Even if she is initially negative, then positive on follow-up, it is too easy for the suspect to be treated anonymously and be negative by the time a court order can be obtained to test him (Ledray, 1992).
Baseline data collection also can be confusing to the survivor. Too often rape survivors believe that negative test results from the baseline data means they have not "gotten anything from the assault," rather than understanding that it means only that they did not have an STD prior to the assault. Another problem is the often relatively low return rate for follow-up testing.
Many programs have more recently adopted a protocol of administration of prophylactic antibiotics only, omitting the baseline STD data collection. Following this protocol, treatment is provided to prevent syphilis, chlamydiosis, and gonorrhea, according to guidelines from the Centers for Disease Control. Less invasive oral medications are probably a better choice than intramuscular injections. (Many teenagers may choose not to take the antibiotic if the only option is an injection, because they fear needles. Teenagers also are unlikely to return for follow-up care. Consequently, we want to provide a form of treatment acceptable to them when possible.) Not completing expensive STD testing during the initial examination and again at follow-up also is more cost-effective.
Because it is not possible to treat for all STD infections, it is still important to provide the survivor with information on STD symptoms. When prophylactic antibiotics have been provided, this information also should include information on treating yeast infections, which are common in women following the use of antibiotics. Minnesota was the first state to develop an STD information pamphlet that all medical facilities providing treatment to sexual assault survivors are required to provide their clients.
Human Immunodeficiency Virus Exposure. Human immunodeficiency virus (HIV) exposure is an evergrowing concern of sexual assault victims today. Although heterosexual transmission accounts for only 6% of adult HIV infections in the United Stales, it now accounts for 75% of the adult infections worldwide (Danis, 1993). In response to this growing concern, some programs are testing all sexual assault survivors for HIV infection in the emergency department and 3 or 6 months after the assault. The risk of exposure varies with the type of assault and the rate of infection in the area. In high risk areas, such as California, New Jersey and Florida, and high risk anal assaults, testing is especially important.
In a 3-year study of rape survivors completed in Minneapolis, a relatively low risk area, no HIV-positive conversions were found in 412 rape survivors tested (Ledray, 1991). As a result, routine HIV testing is not now conducted in Minneapolis. Instead, the concern is addressed and the rape survivor is given the information she needs to evaluate her likely risk. With this information she and her sexual partner(s) can make educated choices about HIV testing and safe sex practices until she can be tested in 6 months and assured that she is not HIV-infected.
Risk of Pregnancy. In a study conducted in Minneapolis, it was found that one of the main three concerns that brings sexual assault survivors to the emergency department after a rape is the fear that they may become pregnant (Ledray, 1991). Sexual assault survivors seen within 72 hours of the assault should be evaluated to determine their risk for becoming pregnant. Those at high risk must be informed about the use of ethinyl estradiol and norgestrel (Ovral) to prevent a pregnancy from occurring or proceeding. If they choose, they can be given two tablets of regular strength Ovral at the time and two more to take in 12 hours. Trimethobenzamide (TiganX or another antiemetic, also should be provided to prevent the survivor from regurgitating the Ovral.
Forensic Evidence Collection. The sexual assault evidential examination conducted in the emergency department provides evidence related to three major areas of investigation necessary for the successful prosecution of a case. It provides evidence to demonstrate proof of force, identify the assailant, and demonstrate that recent sexual contact did indeed occur. It is important for the nurse to be aware of the types of evidence she is attempting to recover as she conducts the examination.
Proof of Force. Documentation of genital and nongenital injury is likely the best proof of force. Quotes from the victim that indicate fear for her safety or her life also are important; however, such statements often are overlooked and not recorded by a busy emergency department staff focused on physical findings. Clothing with tears or stains or that is saturated with alcohol also should be retained. It is not necessary to keep all the clothing if there is not any evidence present, however. Only the underpants, which are likely to contain seminal fluid, should be routinely kept for evidence.
Identification of the Assailant. Evidence used to identify the assailant includes pubic hair combings, which may identify hair that came from the assailant and any of the assailant's blood found on the victim. Blood can be used not only to identify his blood group, but also to identify his genetic make-up (ie, his DNA). DNA also can be identified from sperm and seminal fluid.
First used in 1987, many states now have DNA banks (Lewis, 1988). Once convicted, sex offenders in these states are required to give a blood specimen that is put into a computerized DNA bank. In the fall of 1993, Minnesota became the first state to identify a sex offender solely on DNA evidence. This case is scheduled for trial in the winter of 1994.
Proof of Recent Sexual Contact. A variety of markers are used to establish recent coitus. They include the presence of motile sperm, sperm heads, and the level of acid phosphatase. Even with consensual coitus in which the man ejaculated, studies have recovered sperm in as few as 25% of the cases evaluated (Randall, 1986).
Acid phosphatase and prostatic acid phosphatase (PAP) - enzymes usually not found in the vagina, but found in high concentration in seminal fluid - are another measure useful in documenting recent coitus. One study found this to be a better marker than sperm (Tucker, 1990): In 1007 cases, researchers found sperm present in only 1 % of the cases with oral involvement, 2% of the anal rapes, 19% of the skin specimens (using Wood's rays), and 37% of the cases involving vaginal rapes. Acid phosphatase, however, was identified in 1 1 % of the cases involving an oral assault, 12% of the anal assaults, 4.3% of the skin specimens, and 62% of the vaginal assaults.
Another important finding in this study was that although positive results were obtained up to 36 hours after the rape, 68% of the positive specimens were collected within 5 hours of the rape, and 88% of the positive specimens were collected within 12 hours of the rape (Tucker, 1990).
It is therefore important to take the time between the rape and the collection of evidence into consideration when evaluating the results. A lack of positive findings does not indicate that no sexual contact occurred. It may show only a deterioration of evidence with the passage of time and a hostile environment. It also may indicate that the assailant did not ejaculate in the orifice. A finding negative for sperm and positive for acid phosphatase may indicate that the assailant has had a vasectomy.
Chain of Evidence. Medical personnel usually are not familiar with what is necessary to maintain the proper chain of evidence. As a result, improper documentation and handling of evidence of sexual assault is typically the greatest problem that occurs in institutions without nurse examiners. Unfortunately, if the proper chain of evidence is not maintained, the evidence is useless to the prosecuting attorney and, if an assailant has been apprehended, charges most likely will be dropped in these cases. Although we have made major strides in providing compassionate care for the victim of a sexual assault, this is an area where much improvement is still required.
In order to maintain the proper chain of evidence, it is essential that each individual who has possession of the collected specimens sign for the evidence. The evidence must remain in their possession, in eye contact, or in a locked area with limited key access. The security provided for narcotics in most medical facilities is the closest parallel.
Crisis Intervention. Once the rape is over and the woman knows she has survived, her second struggle begins: the struggle to recover. Research conducted in Minneapolis indicated that simply having a caring individual in the examination room with the survivor was later identified by the survivor as extremely helpful to her. This was true even when all the individual did was to introduce themselves and sit by her side (Ledray, 1984).
Rape is a serious life crisis that disrupts the survivor's normal pattern of adapting and coping. During this initial crisis phase the survivor may experience a wide range of emotions and behavioral responses. She may appear disorganized and unable to make even small decisions. She may be in shock and experiencing considerable anxiety and agitation. She may be crying and hysterical, or calm and withdrawn. She may experience anger, shame, guilt, humiliation, and vulnerability. She often will be overly sensitive to the attitudes and behavior of others and may experience abrupt mood swings in response to minor external clues.
As a result of the perceived loss of personal power and control that occurred during the rape, many women report feeling extremely helpless and vulnerable after the assault. They may become dependent and seek direction and support from others. They may struggle with attempting to regain control, although making even a minor decision is now difficult. Helping them to regain this sense of control - by allowing them to make decisions between two choices - can be an effective method of enhancing recovery.
During this time of crisis the survivor is more open and accessible to outside intervention that will promote effective coping and prevent the development of ineffective or maladaptive coping strategies. She needs an empathetic, supportive listener who will allow her to talk about the assault - without pressure - as she is ready to do so. It is especially important to help the survivor and her significant others separate issues of vulnerability from blame. Although she may have made choices that made her more vulnerable, she is not to blame for the rape - no matter what she did. She may, however, decide to avoid some of these choices in the future, such as excessive use of alcohol or walking alone late at night.
Feelings of guilt often can be mitigated by reassuring the victim that whatever she did was the best decision she could make at the time. It is not important whether she choose to fight back or was too afraid to fight back; the point is that she survived. What is important now is to give the survivor unconditional positive acceptance and to validate her decision, whatever it was, rather than to judge her.
The survivor also needs to know that the fears and anxiety she has, or will soon be feeling, are normal. With support and counseling she will recover. She will be able to go out alone again without fear. She will eventually be able to trust other people again. She will move beyond the nightmares and the inability to concentrate. She will not have to live forever with these and other symptoms of post-traumatic stress disorder (PTSD), so common following a sexual assault (Ledray, 1986b). (Research has demonstrated that the higher the level of threatening events, such as physical injury and the use of weapons, the more likely the survivor will be to develop PTSD [Houskamp, 1991]).
Most important, however, is the survivor's need to know that she does not have to suffer alone. Most communities now have sexual assault centers available to provide her with the support she needs and deserves. Before she leaves the emergency department, she should have the information necessary to make an appointment for follow-up counseling. If possible, permission should be gotten from her to have a counselor call her for an appointment; all too often rape survivors will not call for help. They do not call because they do not want to relive the horrors of the assault; they are feeling too ashamed and humiliated; or they blame themselves and feel they do not deserve the help and support of others. They also all too often incorrectly believe that if they do not think about "it," "it" will go away and not bother them.
Sexual Assault Response Team. In some areas the nurse examiner collects the evidence and does the crisis intervention. In other areas the nurse works in conjunction with a rape crisis counselor, usually a volunteer from a local crisis center; this situation is often referred to as the sexual assault response team (SART), In some areas this team may include a hospital social worker, chaplain, or police officer. In all areas, all organizations must work cooperatively for the successful completion of each case; the closeness of this working relationship often determines the terminology used to describe it.
The role of the nurse examiner goes far beyond collecting forensic evidence that will be useful should the case go to court. Her role involves providing comprehensive care for the survivor and working cooperatively with other individuals in the legal system. The forensic nurse working in this role is uniquely qualified to provide the comprehensive care necessary to the sexual assault survivor. Treating injuries, preventing pregnancy from occurring or proceeding, and preventing the contraction of a sexually transmitted disease from the rape helps reduce secondary injury. Crisis intervention and supportive counseling help the victim move toward recovery and survivor status.
The forensic nurse often functions as a case manager, working with the survivor as she moves through the system, coordinating the various components and ensuring no piece is left missing. Because of this unique position, the forensic nurse also has a responsibility to ensure continual program evaluation and ongoing nursing research.
Especially because this is still a new, emerging area of specialization, we must do all we can to ensure thai we provide sexual assault survivors of the future with the best possible services available.
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