Sexual Assault and Examinations (Kentucky)

Adolescent: For forensics, the term adolescent is used to differentiate the age at which a victim would be subject to a pediatric examination. This could vary by state, as age and maturity level should be considered (OVW, 2013).

Disability: Someone with mental or physical impairments that may limit their ability to perform specific life activities or tasks (OVW, 2013).

Domestic Violence: A broad term to describe any violent, coercive, or abusive behavior that may be used to harm or intimidate a partner. Examples may include threats, physical violence, emotional or sexual abuse, isolation, manipulation, etc. (OVW, 2013).

Sexual assault: Any unwanted sexual contact without providing consent. It may also be called rape, sexual misconduct, sexual harassment, etc. (OVW, 2013).

Sexual assault examiner: A healthcare provider who has been trained in performing forensic medical examinations. The provider could be a nurse, nurse practitioner, physician, physician assistant, etc. (OVW, 2013).

Sexual assault response team (SART): A team of specially trained individuals who respond to sexual assault victims. Team members may include healthcare providers, law enforcement, and victim advocates. SARTs may vary from state to state, as not all states have a well-developed response team (OVW, 2013).

Suspected sex offender: This person has been accused and suspected of committing a sexual assault against someone (OVW, 2013).

Victim: Someone reporting being sexually assaulted (OVW, 2013).

Victim advocate: Often working for or with a local rape crisis center, victim advocates are called at each report of sexual assault. These individuals will offer their supportive resources and services and often remain with the victim throughout the forensic examination at the victim's request (OVW, 2013).

Vulnerable adults: Individuals with decreased mental capacity or impairments that prohibit them from being fully functioning, consenting adults (OVW, 2013).

According to the World Health Organization (WHO), sexual violence includes any form of sexual act, attempted sexual act, unwanted acts, or advances by any person, regardless of relationship status (WHO, 2013). Sexual violence is a worldwide problem and can include any of the following (International Association of Forensic Nurses [IAFN], 2018):

• Sexual harassment
• Rape
• Sexual abuse/assault
• Forced/coerced marriage
• Genital mutilation
• Forced prostitution
• Trafficking

Sexual violence is a worldwide public health concern. Here are some statistics to ponder to shed some light on the magnitude of a known problem.

Kentucky statistics include the following (Kentucky Association of Sexual Assault Programs [KASAP], n.d.-a):

• 39% of Kentucky women will be victims of sexual violence at some point in their life.
• 18% of Kentucky men will be victims of sexual violence at some point in their life.
• 23% of women will experience attempted (or completed) rape.
• Almost 50% of Kentucky females were raped before the age of 18.

National statistics include the following (Centers for Disease Control and Prevention [CDC], 2022):

• More than 50% of women will be a victim of sexual violence.
• 1 in 3 men will be a victim of sexual violence.
• 1 in 3 women experience sexual harassment in a public place.
• 1 in 9 men will experience sexual harassment.
• 4 out of 5 women report being raped before the age of 25.
• Almost 50% report being raped before the age of 18.
• 8 out of 10 males report being forced to penetrate before the age of 25.
• Approximately 50% of non-Hispanic American Indian or Alaska Native and multiracial women report being raped in their lifetime.
• A sexual assault occurs every 68 seconds.
• ONLY 25 out of every 1,000 rapists end up in prison.

Any form of sexual assault or violence is known to cause trauma to the survivor. When sexual violence occurs during childhood or adolescence, survivors have much higher risks to their health and mental well-being. Adults who experience sexual violence are said to have higher chances of sexually transmitted infections (STIs), unintended pregnancies, abortions, complications during pregnancy, mental health conditions, and suicide (IAFN, 2018).

Unfortunately, the risk factors do not end with the survivors; the children of survivors are also at risk. Research has shown that children of women who have experienced traumatic events as a result of sexual violence are at risk of having poor health and educational outcomes as they grow older. Emotional, behavioral, and mental health disturbances may also occur at higher rates (IAFN, 2018).

Forensic nursing strives to bridge the gap between the science of nursing and the criminal justice system. Both nurses and nurse practitioners can specialize in forensics, as they are specially trained to manage the care of victims of sexual assault, neglect, physical assault, and intimate partner violence.

Forensic nurses can be found in any of the following (Foudoulian, 2023):

• Emergency departments (ED)
• Child advocacy centers
• Coroner's offices
• Police departments
• Correctional facilities
• Community-based clinics

Forensic nursing encompasses a wide range of specialized care for individuals who have experienced any or all of the following:

• Sexual assault
• Intimate partner violence (IPV)
• Child abuse or neglect
• Elder abuse
• Incarceration

SANEs are registered nurses who have gained additional specialized training to care for victims of sexual assault. The primary roles of a SANE include (Maynard, 2023):

• Determining whether a victim can provide informed consent for a forensic examination.
• Perform a thorough physical assessment, including obtaining a complete medical history.
• Providing education to victims regarding the risk of contracting STIs, the need for testing, and the available prophylaxis measures.
• Providing education regarding the risk of pregnancy as a result of the assault, as well as options and resources available.
• Collect deoxyribonucleic acid (DNA) samples and take photos during the forensic examination, if indicated.
• Document all details of the event history, medical history, injuries, samples taken, etc.
• Be prepared to provide expert testimony with the assistance of the documentation should the case move forward to trial.

Annually, more than 400,000 individuals over 12 are sexually assaulted. The standard of care after a sexual assault is to present to a medical facility for assessment and treatment for those requiring immediate medical attention, followed by a forensic examination. Included in a forensic examination is the provision of an advocate, mental health services, prophylaxis for STIs, and other resources. SANE coverage is limited in many locations nationwide, leaving sexual assault survivors at risk for inadequate or zero sexual assault care (Thiede & Miyamoto, 2021).

Kentucky has 104 hospitals, and only 15 are designated SANE-ready, meaning they employ a SANE for 24/7 coverage (Michas, 2023).

Multiple studies have proven that patient outcomes improve for sexual assault survivors when a SANE coordinates their care. Since SANEs have specialized training, there are less likely to be gaps in evidence collection, the evidence collection kits will be handled appropriately and sealed, the chain of command is less likely to be broken, and trauma-informed care will be provided.

The IAFN provides SANEs with the opportunity to become board-certified in both pediatric and adolescent/adult populations. Board certification may not be required, as all states can develop their credentialing process. Be sure to educate yourself on the specific requirements of the state you live and work in to remain compliant (OVW, 2018).

Should a nurse be interested in becoming certified in forensic nursing, the IAFN has developed a certification process with specific requirements that must be met. To sit for the forensic certification exam, nurses must (Maynard, 2023):

• Carry a full, unrestricted nursing license in the state where they live (or compact license).
• Have practiced as a registered nurse for at least two years (three years if sitting for the pediatric exam).
• Have successfully completed the required 40-hour SANE course (must meet state-mandated educational requirements).
• Participated in a forensic preceptorship.
• Have at least 300 hours of sexual assault-related nursing practice in the past three years. Two hundred hours must have been performed in the population the nurse is seeking certification. For example, nurses cannot sit for the pediatric certification exam without experience caring for the pediatric population. 

Educational requirements and course offerings may vary by state, as some may encompass in-person, didactic training for sexual assault forensic providers.

As the leader in forensic nursing, the IAFN offers online forensic courses specializing in adult/adolescent and pediatric populations. The online IAFN training courses provide the didactic component that allows nurses and advanced practice nurses to become forensically trained. Specifically designed to meet all educational requirements, nurses receive 41 contact hours at completion (40 hours for the pediatric course). In addition to the didactic component, clinical components may also be required, depending on your state's regulations for certification.

For those who prefer in-person courses, consider contacting your state board of nursing for leads on your state's offerings. The IAFN also provides a list of their approved courses.

With the hustle and bustle of most EDs, it can be challenging to remember the concept of trauma-informed care in sexual assault patients who come through the ED. Combine this with hospitals that do not employ trained SANEs, which can increase the survivor's trauma experience.

SANEs are trained to maintain a trauma-informed approach, leaving the survivor at the center. The survivor has a hand in their care throughout the forensic interview and examination process. The overall goal is to prevent the survivor from being re-traumatized. The six identified principles of trauma-informed care are (Brown et al., 2022):

1. Safety
2. Transparency & trust
3. Collaboration
4. Support
5. Cultural and gender issues
6. Empowerment

Developing rapport and providing individualized care helps create an environment built on trust and safety.

Sexual assault survivors may be scared to report their assault to law enforcement or may be afraid to go through with a forensic examination. From a trauma-informed approach, it is crucial to educate survivors on their rights to refuse an examination or to report their assault. Explaining what could happen if they proceed with reporting and an examination is also acceptable.

Collecting evidence during a forensic examination increases the likelihood of a perpetrator being caught and charged. Once a perpetrator gets convicted, then it is one step in the right direction of preventing future sexual assaults from occurring (RAINN, n.d.a).

Consent is key before beginning any part of the forensic examination. The examination may be delayed if a victim cannot consent (due to substance use, intoxication, etc.). Nurses and providers must remain culturally aware of any issues that may arise for specific populations and accommodate any request by the victim to allow a friend or family member to remain with them.

Before beginning any part of the exam, providers will need to be sure that they thoroughly explain each part of the examination process. It is also essential to educate the victim on their right to refuse any portion of the forensic examination.

Each facility may have its policies regarding consent, but in general, consent is needed for all of the following (OVW, 2013):

• Medical care
• Pregnancy testing and treatment
• STI testing and treatment/prophylaxis (including human immunodeficiency virus [HIV])
• Evidence collection using photography
• Need for medical records release
• The notification of law enforcement (if they are not already present)
• Any form of evidence collection
• Evidence release
• Any necessary toxicology screening

Unless the victim falls in the mandatory reporting category (minor, vulnerable adult, etc.), they can choose whether or not they want to report their assault. In this case, the examiner can explain to the victim what could happen if they do and do not report. It is crucial to remain unbiased and to provide a victim-centered response (OVW, 2018).

The Violence Against Women Act (VAWA) developed a grant program that provides funds to all states to ensure no victim will have to pay for sexual assault services (OVW, 2013).

As with any form of medical examination, specific equipment may be necessary. Facilities should have up-to-date forensic examination protocols specific to the state, standard forensic exam equipment, supplies for the victim (change of clothes, etc.), a sexual assault evidence collection kit, swabs and drying station, and more (OVW, 2018).

Forensic Exam Equipment

Victims should be evaluated and medically treated upon arrival at a designated exam facility or local ED. Once the victim is medically cleared (or even before), healthcare providers should notify local law enforcement and victim advocates so they can offer their services. Every person who is a victim of sexual assault has the right to a victim advocate; it will be up to the victim to choose to accept offers for services and resources, as well as if they want the advocate to stay with them during the forensic exam (OVW, 2013).

Often, advocates can be helpful during the exam process by providing emotional support. Sexual assault examiners are responsible for remaining unbiased and focused on collecting evidence.

The proper protocol starts with the SAE introducing themselves to the victim and gaining consent before proceeding with an exam. Once consent is obtained, the examiner will start collecting a medical history from the victim. Necessary information to collect may include the following (IAFN, 2018):

• Allergies
• Past medical history
• Past surgical history
• Current medications
• Recreational drug use
• Immunization history
• Last menstrual cycle
• Pregnancy history
• Contraception use
• Last consensual sexual encounter

Once a health history foundation is obtained, the examiner will shift the interview toward the traumatic events surrounding the sexual assault. The information given during this time will help the SAE determine key areas to pay attention to when collecting evidence at the next examination stage. Information to discuss may include (IAFN, 2018):

• Alleged sexual acts during the event
• Time and date of the event
• Event location
• Any information about the assailant
• Any use of threats, weapons, or restraints
• Any use of electronic devices used during the event for recording purposes
• Potential for drug-facilitated assault
• Any contraception that may have been used
• Ejaculation information (if it occurred, where, etc.)
• Physical injuries associated with the assault
• Pain or bleeding
• Evidence destruction

It is important to note that the SAFE will identify critical pieces of the history and forensic interview to help guide their physical examination and evidence collection (IAFN, 2018).

During an approved forensic course, examiners will learn about normal anatomical variants and specific injuries commonly acquired during a sexual assault. Please note that having no apparent signs of injury does not mean an assault did not occur. Forensic courses will also go over specific methods used to identify and confirm physical findings during an examination, such as (IAFN, 2018):

• Position
• Labial examination and separation
• Irrigation
• Use of a colposcope for better visualization of internal structures
• Anoscopic examinations may occur in some states if within a nurse's scope of practice
• Hymen visualization
• Toluidine blue dye use
• Expert consultation

The goal of evidence collection is to gather as much evidence as possible. The SAE examiner will utilize the information provided during the health history, physical findings, and with the help of sexual assault kit instructions. DNA specimens and photography will most likely be utilized at this stage after first gaining consent. The examiner must pay close attention to exam findings, as each injury and potential evidence must be documented.

It is essential to continue to explain each step of the exam to the victim and collect consent before progressing. Take the survivor's lead, if necessary. For example, if the survivor is not ok with a vaginal examination, listen. It is acceptable to explain the potential for not gathering key evidence should they decide to report their assault to law enforcement. This is part of gaining consent; the victim gets to decide which parts of the exam they are comfortable with and which they are not (IAFN, 2018).

Types of evidence to collect may include any of the following:

• DNA
• Physical findings
• Event History
• Toxicology studies
• Forensic photography
• Foreign bodies, conception tools, tampons, etc. 

Adjunct methods and tools may be used during the evidence-collection phase to assist in visualization and collection. Alternate light sources can help with better visualization. Various swab collection techniques may be necessary depending on the type and location. A speculum is often used for vaginal examinations, and colposcopes can assist with magnification for photographic purposes (IAFN, 2018).

Trace evidence may be collected in dirt, sand, leaves, grass, glass, etc. The evidence must be documented and photographed if any of these aspects are identified, then secured safely in envelopes or a paper bag (not plastic). Evidence collection bags and envelopes must all be sealed, initialed, dated, and timed (Kleypas & Badiye, 2023).

Swabs located within a forensic examination kit are often used to collect evidence in blood, saliva, semen, and urine. Biological evidence such as these may be collected with swabs (often moistened with a sterile solution) on the skin, under fingernails, on bitemarks, oral or buccal region, and in the perineal, vaginal, cervical, and rectal areas (Kleypas & Badiye, 2023).

Clothing worn at the time of the assault is considered evidence. Those who may come in contact with a survivor first (such as law enforcement and ED staff) should be aware of national protocols and instruct survivors not to change clothes, bathe, use the bathroom, or shower. If a survivor has changed their clothes, there may still be evidence on the clothes they were wearing at the time of the assault, so it is appropriate to request those items to be adequately secured in a paper bag as evidence (Kleypas & Badiye, 2023).

As with each process, consent for photography is required at each step of the examination process. Not each examination will require photography, as not each survivor will present a visual injury to be considered as evidence. As a general rule, only utilize photography as an evidence-collection method if it is relevant to the specific event and can be used as supporting evidence. It is important to note that examiners must familiarize themselves with legal considerations concerning their state. Personal cell phones are generally discouraged. Forensic organizations often have access to designated photography equipment (IAFN, 2018).

Also known as a "rape kit," sexual assault evidence collection kit contents may vary by state. Kits may include swabs for evidence collection, blood sample supplies, comb, bags, and paper sheets for clothing and other evidence collection, envelopes, document forms, and instructions. Unfortunately, many hospitals are not deemed "SANE-ready," necessitating the examinations be performed by someone not forensically trained (Rape, Abuse & Incest National Network [RAINN], n.d., b).

Whenever possible, it is essential to request that the survivor refrain from doing any of the following before their sexual assault examination:

• Using the bathroom
• Showering/bathing
• Changing their clothes
• Cleaning/freshening up
• Brushing their hair

Naturally, individuals will want to do any of these, so if they happen to be performed, it does not eliminate the ability to have a forensic exam. Typically, DNA evidence will need to be collected within 72 hours of the assault occurring. If an examination is performed after 72 hours, there is a slight chance that some evidence may still be present (RAINN, n.d., b).

Documentation is vital in the forensic examination process, as it brings to the surface all components of the history, reported event findings, physical evidence, and more. Not to mention, there is always the potential that a SANE may be called to testify as an expert witness in cases that go to trial. Given that this could occur years after an examination, nurse examiners may only have their documentation to go by during that process. Adequate documentation is crucial (IAFN, 2018).

In addition to the history, each component of the physical examination, evidence collection, injury assessment, and verbal reports must be documented. When obtaining the survivor's recollection of the event, nurse examiners should document direct quotes as much as possible. Nurse examiners must utilize the recommended terminology when documenting each area of injury (IAFN, 2018).

It is ultimately the survivor's decision whether they wish to report the assault to local law enforcement. The examiner must explain the options available, though this will vary depending on age, cognitive ability, and circumstances surrounding the assault. For example, an adult can decide not to report, but if the examination is being done due to a report of sexual assault on a small child, reporting to law enforcement is necessary (IAFN, 2018).

SANEs must educate themselves and adhere to the rules surrounding the chain of custody for sexual assault evidence collection kits. The chain of custody documentation must include the patient's identifying information, date and time of collection, and law enforcement case number. It must remain safe until it is released to law enforcement. Each individual with access to evidence or evidence collection kit must also be documented on the chain of custody form (Kleypas & Badiye, 2023).

The length of time evidence will be stored may vary by state. In Kentucky, there is no statute of limitation for rape and sodomy offenses. There is a one-year statute of limitation for sexual abuse if the victim is over the age of eighteen. If under eighteen, the statute is five years (RAINN, 2023).

Sexual assaults that occur when the perpetrator uses alcohol or drugs to alter someone's ability to give proper consent are termed drug or alcohol-facilitated sexual assaults; this can happen to anyone, with alcohol being the most common route perpetrators utilize. The use of drugs or alcohol does not make the assault any less real for anyone affected by it. A potential downside is that victims may be unable to consent to a forensic exam until they are no longer under the influence (Drug Enforcement Administration [DEA], 2017).

There is always a risk of STIs during sexual assaults. Healthcare providers are thoroughly trained to explain necessary information in a way that the survivor will understand. Providers are expected to educate on specific risk factors (this can vary based on assault details) and offer STI testing and treatment. STI testing and treatment follow-up education are also key (OVW, 2013).

Survivors have the right to accept or deny treatment offerings once they have been educated on the most common STIs, symptoms to watch for, and the STIs that may not demonstrate symptoms immediately or mimic other things (IAFN, 2018).

Pregnancy is a common fear as a result of sexual assault. Based on information gathered during the examination, healthcare providers can provide the victim with information regarding their risk of becoming pregnant due to their assault. Victims can be offered a pregnancy test (they must also provide consent for this) and potential treatment options. Victims of sexual assault have the right to be offered pregnancy prevention as it is consistent with state protocols and regulations. Contraception methods and follow-up options should also be discussed (OVW, 2018).

After sexual assaults occur, victims are often concerned about unintended pregnancies. The risk of a pregnancy arising from a sexual assault can vary for many reasons, such as the last menstrual cycle, ovulation period, contraception used, and more. Emergency contraception is an option to offer victims following a sexual assault. These are often called the "morning-after pill." Levonelle is a pill that must be taken within 72 hours of the assault, and ellaOne can be taken up to five days following an assault (National Health Services [NHS] Inform, 2022). It is important to note that a victim's weight can affect the efficacy of these medications. It is also essential to educate victims that these do not protect against STIs, so that additional treatment options may be necessary.

As there are often multiple components in a sexual assault case, each individual may have specific tasks to complete before discharge. For example, suppose the victim reports their assault to law enforcement. In that case, it may be beneficial for the nurse examiner and law enforcement to be present during the history interview. In an already traumatic situation, making someone disclose details of their assault multiple times is not in their best interests (OVW, 2013).