Forensic Sexual Assault Examinations in Emergency Departments

sexual violence is prevalent throughout all of our communities

sexual violence is prevalent throughout all of our communities

a victim can be of any age, gender, ethnicity, or economic class

each victim's experience in assault is extremely individualized

but what is universal is their need to be treated with dignity and respect

all while voluntarily participating in a forensic sexual assault medical


the medical profession has made great strides when it comes to providing

victims of sexual assault

with the best possible care with the development and training of sexual

assault nurse examiners also known as "s.a.n.e.s" the use of these highly skilled and

specialized group of nurses has become the gold standard when it comes to

performing these types of exams.

unfortunately, many communities are without access to sexual assault nurse

examiners until then adult victims of rape will receive their forensic


at local emergency departments

having a basic understanding of how to perform a proper forensic sexual assault

medical examinations is crucial

for any medical professional working in an emergency department

acute victims of sexual violence

individuals assaulted within the previous seventy two hours

may present at the emergency department in several different ways

they may come by themselves with friends or family members they may be escorted

by a sexual assault advocate from a local rape crisis center. A victim may

also present accompanied by local law enforcement officer

no matter what path leads the victim to your emergency department

treating them with compassion understanding and professionalism is a

crucial component for each forensic medical examination

when a victim of sexual violence presents to an emergency department for

an exam

it is best practice to move them to a private waiting room or exam room as soon

as possible

most victims feel extremely exposed and vulnerable after an assault

having the victim avoid waiting for an examination in a community space

will help to cultivate a sense of report with the medical staff

and the feeling of safety and security for the victim

especially if they're being escorted by a law enforcement officer

this is very important since the victim will be asked to share details regarding

their assault with the medical staff

and they will undergo a physical examination that has the potential to

mirror the trauma that they just experienced. Sexual assault forensic

examination kids are provided at no cost to to emergency departments by the

Arkansas state crime lab out of Little Rock.

these basic kits provide the medical professional with essential steps to

collecting forensic evidence after a sexual assault

the manner in which this exam is performed will create a lasting impact

on the victim.

At any point during the examination the victim has the right to refuse any parts

of the exam

and or evidence collection as well as the right to stop the examination


This exam is completely voluntary and under no circumstances should the victim

be made to feel otherwise.

It is recommended to advise the victim before and throughout the examination of

their right to stop at any time.

It is important to communicate the sense of control to the victim

since so many circumstances leading them up to this point

have been out of their control.

Let the victim know that you will explain every step of the examination before you

complete it so they will not be startled.

It is also best practice to offer to contact a local sexual assault advocate

for the victim if that resource is available in the community

and if they are not already involved

an advocate will play an essential role in the long term care of a victim of

sexual violence

as well as providing emotional care and support during the immediate medical


It is highly recommended that a sexual assault advocate be present during

the exam

but this decision is ultimately left to the victim.

The advocate's role is to provide emotional support,

professional advocacy, and follow-up resources to the victim as desired.

The advocate does not participate in any part of the investigation or the

collection of forensic evidence.

It is the medical professionals role to carefully collect evidence and provide

medical care for the victims in a supportive, compassionate environment.

Included in the forensic examination kits as a guide for obtaining

an appropriate history from the sexual assault victim prior to the examination

this will allow the medical professional to assess where on the victim's body

evidence may be collected.

The victim's body is a crime scene.

Preserving the evidence is an important part of solving the investigation

follow the instructions on the sheet

while maintaining a judgment free demeanor in providing a safe and

compassionate environment for them.

It is very important that the only information documented comes directly

from the victim.

When gathering evidence for the forensic examination,

keep in mind the idea of least invasive

to most invasive

the next step is not specifically included in the forensic examination kit

this step involves collecting the victim's clothing

if the clothing worn by the victim was what he or she was wearing during the

time of the assault

place a disposable drop off on the floor of the exam room

have the victim step onto the drop cloth to disrobe

if you have an advocate present or another nurse

please use another cloth to provide a sense of privacy for the victim during

this part of the exam

have the victim hand each article of clothing to you individually with gloved


place each item in a separate paper bag.

Once the victim's clothing has been collected,

have them put on a gown and sit on the exam bed.

Carefully perform a head to toe assessment

providing them with as much privacy as possible by sectioning off exposed areas

any injuries noted should be photo documented

with each injury a set of three pictures should be taken one for

anatomical identification

one with a ruler

and another closeup of the injury.

During this assessment, like all others,

talk the victim through what is being done and remember to ask their permission

throughout the process.

Once the head to toe assessment is completed

the victim should then be placed in the lithotomy position.

You will then perform a pubic hair coming by first placing the provided paper

underneath the victims buttocks.

Remember that explaining this process beforehand will reduce the anxiety of

the victim. It is never acceptable or needed to pluck a victims pubic hair.

If the victim does not have pubic hair

simply visualize the area for any possible hairs from the offender or

other foreign d_n_a_ as well as any obvious signs of body fluids.

The final two parts of the examination are the vaginal or penile swaps

and the rectal swabs.

if you are not a s.a.n.e.

these two steps will need to be performed by a physician

There are four vaginal or penile swabs

on a female victim

use two swabs for the outside of the vagina

moving the labial folds to swab for evidence


always talk to your victim and prepare them before touching them.

Use the second set of slots for internal vaginal collection. A speculum may be

inserted at this point for more effective swab collection but it is not


if there is vaginal injury do not attempt the speculum insertion

this will only cause severe pain and possibly result in further injury to

the victim

lubrication may not be used on the speculum because it has the potential to

contaminate the evidence.

Visually look for any abrasions,

tearing, or bruising externally

and internally

when doing the penile swabs on a male victim

use the swabs one-by-one and cover the shaft and head of the penis making

sure the entire area has been swamped.

Do not insert the swamp inside of the penis.

This portion of the exam has the potential to be extremely emotional for

the victim.

It is imperative that the medical professional walks the victim through

the process and is aware of their emotional state.

Allowing them to stop,

or take a break

may be needed.

The final step of the collection process is the rectal swabs.

This is a a very important part of the examination even if the victim does not

disclose that any rectal penetration had occurred.

Have the victim continue to lie on their back

and if physically able,

have them gently pull their own leads up to their chest with their knees bent.

Take the rectal swabs and roll them on the inside of the anus and then

slightly insert the tip of the swap on the inside of the rectum.

Once the exam is completed,

allow the swabs to dry completely.

you may use a swab dryer if available or simply flip a disposable cup over to act

as a drying station for your swabs.

Remember to label everything and do not mix up the swabs or allow the swabs to


The victim may now get dressed in new clothing

that they have brought themselves

or ones that have been provided to them by the advocate or the hospital.

At this point

prophylactic antibiotics to prevent sexually transmitted infections and

emergency contraceptives

should be discussed with the victim.

The victim has the right to choose to refuse or accept the medication.

Once all the evidence is dry, place in the corresponding envelope.

Once the envelopes are correctly filled out in sealed, place them back in the

forensic evidence collection kit.

fill out the front of the kit and sign,

date, and time record only when you are handing it to the investigating officer

who is now taking the evidence into custody.

Many times, the sexual assault examination is the only potential piece

of evidence from an assault.

The need for professional,


and compassionate personnel to perform these examinations is an unavoidable


for many emergency departments.

Providing these examinations are not only about collecting the evidence

they are also about preserving the last amount of dignity

a sexual assault survivor may have after an assault.

Please invest in organizational and or individual education

on providing proper and effective

forensic sexual assault examinations.

Well the forensic examination itself is important because you're looking for any

evidence that you can find

at all

to determine if there is anything out there that can coaberate with what the

victim said.

It can be just as important when you have a trained

nurse who has training, experience, education

if they're isn't anything that shows up

because as long as that person, that nurse is doing her job

correctly, she can explain to the jury

the procedure that she follows, why it's the correct procedure and in the absence of

any physical evidence or forensic evidence that

can be found

why that doesn't necessarily mean that nothing happened

and that

victims story can still be accurate.

if the collection and the procedure that the nurse is following is

done incorrectly or done poorly

uh... certainly that will be exploited at trial

the defense attorney can cross-examine the nurse and

bring out all the reasons that it was a

good procedure was not followed

uh... and that can always hurt the credibility

which is why

any education any training

is very valuable when you want a nurse that's on the stand and it goes

to credibility

if a nurse can

when shes being introduced to the jury and she can explain to the jury

all of the training that she's had all the education she's had

she's basically testifying as an expert anyway because this is a specialized


Very few people know about it certainly very few people do it rape


So it's vital that the jury gets to hear that nurse that witness has a


that gives her credibility to show the jury that she knows what she's

talking about and that she's doing it correctly because there are other people

out there that will be able to inform the defense of this is really the proper

procedure and here's the procedure they followed

um which can exploit the weakness, damage the credibility and hurt the case even

if something was found. I think it is really important for any nurses going to do

sexual assault examinations using rape kits and doing that type of work

it's important that they don't wait on the education and training to come to



they need to search it out and

the Arkansas coalition against sexual assault, their their website

has links to a lot of education material also training material

on that website as well as they're are a great place to go to to find where

training may be coming up.

You've got to be trained when you're doing a job as important as this you

have to have good training.


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