There are several ways for sexual assault patients to enter the healthcare system. One way is via the emergency department. Others may be initially encountered in clinics, physicians’ offices, or school health systems. Occasionally, law enforcement officers transport suspects or victims to a location staffed with a qualified SANE. Because all medical facilities do not have expert in-house personnel to perform the required examinations, many communities prefer the latter model. Most current sexual assault programs are aware of the Emergency Medical Treatment and Active Labor Act (EMTALA) guidance, which outlines criteria if the sexual assault patient is to bypass the medical screening examination (MSE) and only have evidence collection in the emergency department.

“If an individual presents to a dedicated emergency department and requests services that are not for a medical condition, such as preventive care services (immunizations, allergy shots, flu shots) or the gathering of evidence for criminal law cases (e.g., sexual assault, blood alcohol test), the hospital is not obligated to provide a MSE under EMTALA to this individual.” (www.medlaw.com/searchpro/index.php?q=sexual+assault).

However, many facilities require an MSE because of the assaultive mechanism, the patient and clinician being unaware of any injuries until after the assessment is complete, and risk evaluation of pregnancy, STI and HIV exposure. Nevertheless, in the rare case that an individual has incurred obvious serious injuries and is in need of immediate medical attention, this takes priority over the sexual assault examination. Most patients, however, are physically stable and able to complete this voluntary examination process and to discuss the reported event.

Sexual assault patients exhibit diverse and complex needs based on age, gender, and acuity of the circumstance. Physical, psychological, financial, and legal issues are all priorities that must be considered in the plan of care for the patient. It is important to note that the lack of physical injury is not uncommon in the patient who reports a sexual assault. The role of the examiner is that of objectively providing exemplary nursing care and expert, competent evidence collection, and documentation for each patient. Documentation should include the history of the event from the patient, observations, findings, and the samples collected. It should not include opinion-based comments in the summary such as “no injuries consistent with sexual assault are noted”.

A stable patient should be placed in a private room as soon as possible, preferably away from the emergency department. Privacy, safety, and confidentiality must be ensured. The Health Insurance Portability and Accountability Act (HIPAA) and other state medical privacy laws permit sharing of information in certain circumstances when the patient provides consent for dissemination or when law enforcement is involved. Covered entities and law enforcement agencies must collaborate to develop concise protocols for protected health information disclosure. State law will dictate whether information must be disclosed and to whom.

It is essential for nurses to have current knowledge of reporting mandates within their jurisdiction and to understand legalities regarding patient rights, consents for evidentiary examinations, and the guidelines for documentation and dissemination of information associated with the event. In most states, the sexually assaulted adult patient is not required to report the assault to law enforcement to be provided a medical/forensic examination. However, in all 50 states the sexual abuse of children is a mandated report to police or the child protection agency (Child Abuse Prevention and Treatment Act [CAPTA], 1996).

Early in the study of sexual assault, many believed that the examiner could assess the patient and determine whether the intercourse was consensual or nonconsensual. The absence of injury was commonly misinterpreted as a consenting adult. This belief was largely influenced by the 1966 study by Masters and Johnson, which described the body’s physiological response to consenting partner’s sexual stimulation. The study was used as an attempt to use the body’s response to consensual foreplay and stimulation to explain why lack of such stimulation may cause injury in nonconsensual intercourse. The theory was that that the reaction of the body would protect the woman from injury. There is no scientific basis to support the theory in relation to sexual assault cases. Stephen Johnston v. the Commonwealth of Virginia (2000) and Velasquez v. the Commonwealth of Virginia (2002) challenged the use of this theory for consent cases in court. Recent literature shows that there is little difference in the findings in consensual and nonconsensual intercourse (Anderson, McClain, & Riviello, 2006).

Severe physical injuries or genital trauma associated with sexual assault in an adult are considered to be atypical. However, if sadistic or masochistic tendencies are involved in the sexual act, injuries may be profound. If force has been inflicted, there will usually be evidence of such force on the body or clothes of the victim. Physical injury most commonly includes lacerations, contusions, bite marks, and broken fingernails. It should be noted that the presence of injuries does not necessarily equate to nonconsensual sexual activity or that the absence of injury negates the patient’s assertion of rape.

Professionals must also be alert to the prevalence of sexual assaults involving the use of drugs and alcohol. It is imperative that immediate action be taken to preserve evidence because of the rapid speed of the body’s metabolism. The most common substance used is alcohol (LeBeau, 1999). Drugs and alcohol can result in a loss of consciousness and an inability to resist. Some drugs cause memory loss and incapacitation even with the use of very unlikely drugs such as in the case of an adult male repeatedly using tetrahydrozoline (Visine) to induce a comatose state in an adult female and four female children for the purposes of sexual assault (Spiller, 2007). The effects of many drugs are enhanced when taken with alcohol. Patients who are impaired from the effects of drugs and alcohol often do not remember the assault. They may be found in public areas partially clothed. There are known cases where the individual is arrested for public intoxication without consideration that a sexual assault may have occurred, initiating the chain of events. Information that this might be a drug/alcohol sexual assault must be given to the forensic laboratory to ensure that the appropriate toxicological analyses are completed (see Chapter 10).

Unique challenges must be considered when bleeding injuries complicate evidence recovery. Collecting the best specimen remains the objective. In clinical practice, cleaning and preparing a wound for a dressing is not evidence recovery, and if the patient is stable, evidence should be collected first. For example, a bite mark causing bleeding should be swabbed where the lips of the suspect made contact with the skin above, below, and in the middle of the injury before performing other wound care. This will provide for the best sample to distinguish deposited DNA from the patient’s blood. When extreme genital injuries are present, evidence recovery is complicated. If a severe vaginal tear exists in certain anatomical locations, the optimum ejaculate specimen may have been washed out of the vaginal vault with the flushing of the blood. In this type of scenario, one might consider collecting the entire blood trail beginning from the end of the trail and proceeding upward with a 4-by-4-inch gauze moistened with sterile water. This can be repeated for each anatomical structure such as foot, lower leg, or thigh until collection is complete to the vaginal vault. These gauze wipes will need to air-dry and be packaged individually, sealed, and labeled as noted in later sections. Unusual circumstances affecting evidence collection and preservation will occur. It is sensible in these situations to consult a law enforcement evidence technician or a crime laboratory analyst for suggestions.

If patients are menstruating, collect tampons and sanitary napkins. Air-dry them as much as possible and then place them in a separate paper collection bag. Wet evidence that cannot be dried thoroughly at the exam site should then be packaged in leak-proof containers and separated from other evidence. This must be communicated when being signed over to law enforcement.

Tangible evidence has a collective significance in the criminal and civil investigation of sexual violence. The nature of trace or “transfer” evidence is highly variable and can be found at almost every crime scene. Trace evidence can include hair, fiber, glass, soil, and other particulate matter. The media has highly influenced the public’s perception about crime scene investigations and the role of evidence in legal proceedings. This immersion in crime scene investigations through television programs such as CSI has also raised expectations of those who identify, collect, and process evidence. Most states have patterned their policies and procedures for consistency with the laboratory standards of the Federal Bureau of Investigation (FBI). However, the SANE must be aware of variations within the state or local jurisdiction.

Sources of potential biological or genetic evidence are continually expanding with advances in scientific analysis and testing of materials that might be suitable for DNA typing. DNA is contained in all body tissue fluid and cells, with the exception of white blood cells (McClintock, 2008). FNEs are not mandated to collect DNA evidence but rather obtain body fluids or tissues that might contain DNA. Among these are blood and blood stains, semen, saliva, hair roots, bone, teeth, and tissue. Similar to perspiration or sebaceous secretions, urine also contains enough epithelial material to generate a DNA profile (McClintock, 2008). Swabbings of the oral or vaginal cavity as well as bite marks (see Chapter 26) can be used to recover DNA. Certain items of physical evidence collected at the scene of the crime may also contain DNA. Examples are cigarettes, toothpicks, bottles or cans, bullets, condoms, ligatures, clothing, knives, and other weapons.

Biological evidence possesses its greatest value in investigations where DNA types can be compared to known profiles obtained from either the victim or the suspect. The investigation efforts may occur over several years, so precise documentation, record keeping, and specimen management are imperatives. It is important, therefore, to collect the samples on a medium that can stabilize the genetic material. The use of an FTA collection card permits both short- and long-term storage of biological specimens at room temperature (FTA is a registered trademark of Flinders Technologies, Pty. Ltd.). This card is made from an absorbent cellulose-based paper that contains chemical substances to inhibit bacterial growth and to protect the DNA from enzymatic degradation. Samples such as blood and saliva can be “spotted” onto this collection card for storage up to 17 years (McClintock, 2008). These cards are preferred for collecting offender DNA samples for inclusion into forensic databases.

Certain biological materials such as semen and urine require refrigeration or freezing. The local crime laboratory will provide guidance for these and other specimens such as hair, bone, teeth, and body tissue. To avoid cross-contamination of evidence that may contain DNA, the forensic examiner must take precautions to wear a mask and to do frequent handwashing and glove changes throughout the examination.

A vital part of evidence collection is the patient’s clothing. Clothing worn by the victim at the time of the sexual assault is often found to have physical or biological evidence that needs to be preserved. If clothes have been changed, collect the clothing items that remain next to the body areas affected. This is most commonly the underwear and in many cases the bra or undershirt. Case studies are demonstrating significant value with DNA results from the bra because of saliva on the breasts. Look briefly at the clothing and describe the presence of any stains or tears. A more detailed inspection will be done in the forensic laboratory. Clothing preservation can be facilitated by first placing a clean sheet or piece of table paper on the floor to act as a barrier. Then place a second sheet or layer of table paper on top of the barrier and have the patient disrobe over it. Carefully drop each item of clothing at a separate location on the sheet/paper, making sure to not to commingle clothing items in a single pile (Ferrell, 2007).