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The following course content

Introduction

We will be reviewing the defining characteristics of forensic nursing and sexual assault. We will discuss the multi-disciplinary approach to caring for pediatric patients. Specifics of the forensic health assessment, specimen collection, and forensic photography will be described.

The all-important documentation requirements will be reviewed. Sexually transmitted disease and pregnancy implications will be discussed. This is a lot of information; I will try to make it as painless as possible. Let’s dive in.

Overview of Forensic Nursing

Forensic nursing is an important field that cares for victims at an incredibly vulnerable time. This leads to a high level of responsibility for Sexual Assault Nurse Examiners (SANE) and many requirements to help protect victims. We will navigate these requirements in as straight-forward a way as possible.

Forensic nursing is a multi-disciplinary approach involving not just different medical providers, but also law enforcement and community health. Forensic nurses must understand each professional’s role in caring for sexual assault victims.

In general, it is best to have one trusted person (that would be you, the SANE nurse) perform most care, especially care that would jeopardize privacy or comfort. Care of these patients requires knowledge and skills very different from standard nursing. You have already proven you have these knowledge and skills; we will simply hone them a little bit.

Sexual Violence Against Pediatrics

In this course we will be discussing sexual assault and care of pediatrics. The International Association of Forensic Nurses (IAFN) defines pediatrics as pre-puberty – generally accepted as before age 13 – and adolescence as post-puberty but before the age of 18 (14). Sexual assault is non-consensual sexual contact that is often accompanied by physical assault.

Sexual assault may be perpetrated by a stranger, or someone known to the victim, including a parent or caregiver. Forms of physical assault include physical blows, grabbing or restraints, involuntary ingestion of drugs, biting and strangulation (8). 

Sexual assault against children is different and more complicated than assault against an adult. Children depend upon caregivers and adults, and abusers may use this fact to silence victims. In many cases sexual abuse of children is not a single event, but a long-standing progression of abuse (8). 

Prevalence and Statistics 

Sexual assault is a serious issue, affecting one in nine girls and one in 20 boys under the age of 18 (9). Females, age 16-19, are four times more likely to be victims of sexual assault than the general population (10). In most cases the abuser is known to the victim; 59% of child sexual assault cases are perpetrated by an acquaintance and 34% by a family member (9).

Native Americans, people with disabilities, transgender individuals, and people identifying as gay, lesbian, or bisexual are more likely to suffer sexual assault (8,10,14). Specific to intimate partner violence, risk is increased with young age, lower socioeconomic status, mental health disorders, substance misuse, history of abuse and poor community support system (14).

Many victims either present late, or later withdraw their allegation of sexual assault because of the associated shame. Be aware of these risk factors when assessing patients with injuries concerning for sexual assault.  

Long-Term Effects 

Sexual assault is a crime with long-lasting effects on victims, both mentally and physically. Sexually transmitted diseases (STDs), such as Human Immunodeficiency Virus (HIV) and Herpes Simplex Virus (HSV) are not curable and will last the duration of the victim’s life.

Other STDs can have serious health impacts if not recognized and treated appropriately. If pregnancy occurs, this presents long-term psychological and financial problems for the victim and their family on top of the physical consequences.  

Mental health is another major concern following sexual assault. Children that have been victims of sexual abuse are four times more likely to abuse drugs (11). This has a number of health, social and legal implications. Victims of child sexual assault are also three times more likely to suffer from major depression and suicidal ideation, and four times more likely to experience PTSD (11).

These are serious mental health concerns that can greatly impact the victim’s life. It is important to monitor for, assess and treat these concerns.

The Sexual Assault Response Team 

It may be helpful to institute a Sexual Assault Response Team (SART) to coordinate a response among the different professionals involved. Members of a typical SART include advocates, law enforcement, prosecutors, and of course, health care providers.  

Advocates are victim support resources, such as the National Sexual Assault Hotline, that provide emotional support, language assistance services, and referrals. The level of involvement depends on the advocacy group and whether or not they have an in-person component.  

Law enforcement ensure victim safety, collect evidence, interview the suspect, and prepare the criminal case against the assailant. Law enforcement will likely be involved in most sexual assault cases, especially considering many jurisdictions have requirements for investigation of pediatric sexual assault.  

Health care providers include you and the other providers you collaborate with to assess and treat health concerns. Common examples are emergency medical technicians (EMTs) from initial contact, and physicians, nurse practitioners, or physician assistants for prescribing treatment.  

Prosecutors determine if there is sufficient evidence to charge the suspect with a crime, and if so, prosecute the case against them. Prosecutors will typically deal more directly with the victim or their parent/guardian; however, you should be aware of the prosecutor’s role in educating the patient.  

Child protective services (CPS) may also be involved. CPS assesses the child’s immediate safety and coordinates healthcare and law enforcement (8). 

Whether or not your workplace uses a formal SART, you will interact with most, if not all, of these different professions/groups in your care of a sexual assault victim. It is important to understand and respect the role of each member of the care team.

This of course includes your role as the Sexual Assault Nurse Examiner (SANE). As we will discuss, many aspects of caring for sexual assault survivors falls on you. Make use of these other professions but don’t forget how valuable you are. 

Key Aspects of Sexual Assault Care 

It is important to always keep forensic nursing victims centered. Sexual assault victims presenting for care should be treated as a priority when triaging patients. Ensuring privacy and comfort is crucial to providing care for victims.

It is best not to leave sexual assault victims in the common waiting area. Guide them to a more private location whenever possible. When assessing the patient, be extra vigilant in maintaining privacy by closing doors or curtains and draping the patient when appropriate.  

Victims will – rightly so – fear for their safety. It is important to ensure their safety and the safety of staff if the assailant pursues the victim. Collaborate with your facility’s resources and law enforcement to ensure security. Be sure to record the names of any visitors the victim wants to see in case someone comes looking for them at the facility.

Formulate a plan for if the assailant or a stranger comes looking for the patient.  Ensure confidentiality so that the patient cannot be easily identified from outside of the room, in case the aggressor gains access to the care area.  

It is vital to get informed consent from the victim and/or their guardian before performing any procedure, including specimen collection, forensic photography, sexually transmitted infection (STI) testing, and pregnancy testing. Informed consent should be given both verbally and written in a language the patient understands. Be mindful of the child’s reading level.

Victim support advocates can help arrange translation if needed. When informing the child, be sure to assess their developmental level and use words that they can understand. For children under the age for consent, identify the parent/guardian who will consent for them. If the parent/guardian is not available or is suspected in the abuse, contact child protective services to arrange for legal consent to the exam (8). 

Always maintain confidentiality and assure the victim that assessments are kept confidential. Sexual assault survivors have had their privacy violated in a serious way. To properly care for the patient and build trust, it is important to respect their right to confidentiality. Remember, consent and confidentiality are legal requirements. Educating the patient on their rights may help ease their concerns. 

When it comes to involving law enforcement, nurses are often required to report suspected child abuse. Note that it is suspected abuse, so you do not need to confirm abuse before reporting. The Rape, Abuse and Incest National Network (RAINN) is a good resource for finding laws related to sexual assault in each state (15).

Failure to report abuse when it is mandated often comes with a criminal penalty, so know the rules where you work (8).  If criminal reporting is being pursued, contact local law enforcement and CPS early in the process. If you are reporting the assault because it is mandated, be sure to inform the patient of your mandated reporting, and what they can expect from law enforcement.  

Health History, Observation and Assessment 

Sexual assault victims have had their privacy and autonomy violated by the assault, so as caregivers we must promote privacy and autonomy as much as possible. Provide privacy during all parts of the exam. It is important to accommodate patients’ requests to have a parent or chaperone present to promote feelings of security and comfort.

Also accommodate patient requests for caregivers of a specific gender when feasible. Carefully explain and obtain consent for each part of the exam. We do not want victims to feel further violated by the exam, which may already feel very invasive. Allow the patients as much autonomy and control as possible in the examination process to minimize the potential for this feeling. If transfer to another facility is necessary to care for the patient, do so while minimizing time delays and loss of evidence.  

Signs and Symptoms of Abuse 

You should be aware of the signs and symptoms of abuse, as patients and parents may be hesitant to report the abuse. A sexually transmitted disease (STD), pains, sores, bleeding, injury, or discharge from the genitalia are red flags for abuse.

Behavioral signs include anxiety, depression, PTSD, behavioral regression, distrust, learning problems, and inappropriate sexual behavior (8). 

Initial Response 

The initial response to reported or suspected abuse should follow these steps: 

1. Make the child with confirmed/suspected abuse a priority 
2. Perform a focused/brief assessment of presenting issues, timing, and nature of the abuse 
3. Make the mandatory report of abuse 
4. Report any immediate safety concerns to law enforcement and CPS 
5. Provide a screening exam for vital signs and injuries 
6. Determine whether an acute or nonacute exam is necessary based on timing of abuse, and arrange for the appropriate exam 
7. Alert exam facility (if necessary) and victim advocates 

Physical Assessment 

Remember, health and safety needs always come first. Assessment should be thorough and methodical. This helps uncover all injuries and potential sources of evidence. Assess for any major trauma and treat any findings before completing a history.

Any airway compromise, bleeding, and severe pain should be treated urgently. Control bleeding and replace volume loss with IV fluid or blood products as appropriate. Treatment of these physical conditions is no different than for any other patient, aside from the emphasis on privacy and obtaining consent.  

Strangulation as part of the sexual assault can have dire consequences. For strangulation victims, assess for lost consciousness, if they were shaken, if they hit their head, if they are having difficulty breathing, and if they are experiencing any neurologic or vision changes (13).

These assessments can reveal serious concerns of airway trauma, traumatic brain injury, cervical spine injury, and stroke. Imaging of the head, neck and/or brain may be necessary (13). 

Equipment 

There is specific equipment that can help in proper assessment of a sexual assault victim. A copy of the most current exam protocol for your jurisdiction should be available. A sexual assault evidence collection kit should be available (more to come on this later on).

A device or method for drying evidence should be available to properly prepare evidence. A camera and related supplies should be on hand for forensic photography. Finally, standard exam and testing supplies should be readily available.

A speculum exam is not indicated in per-pubescent females unless there are concerns of bleeding or a foreign body (8). A colposcope or anoscope may be necessary to visualize internal injuries.

Medical Forensic Health History  

When it is feasible, the investigative and medical forensic history should be done together. The exam should include the examiner (you), the child and possibly their chaperone; law enforcement and CPS should not be part of the exam. The forensic health history should contain the following specific elements (8). 

Date and time of the sexual assault: timing can influence evidence collection, testing, and treatment of the patient. Many aspects of evidence collection and testing are time sensitive, so accurate timing of the assault is important.  

Pertinent medical history, especially those that may affect assessment or treatment of injuries: this should be limited to patient history that may affect care of the assault injuries. Examples include previous injuries, bleeding disorders, or health conditions affecting the area of the assault. 

What the patient did after the assault (if presenting acutely): including things such as showering or bathing, urinating or defecating, brushing teeth, eating or drinking, changing clothes, or similar activities that may affect what evidence is left on the patient.  

Assault-related history: location of injured body parts and any associated pain, bleeding, or trauma.  

If the suspect is known to the victim or there is any known information about the suspect: including a physical description, name or any other identifiable characteristics.  

Nature of the physical assault: such as the location, if the assault included strangling, blows, biting, or restraints, and whether the suspect was injured. 

Any alcohol or drug use: as this may affect memory of the event. If a drug was used, a toxicology sample within 120 hours (5 days) is recommended. 

Description of the sexual assault: this should be accurate but brief. Include if the anus, genitals or mouth were penetrated, any objects used and whether contraception or lubricants were used.  

When working with children, it may be helpful to have them name body parts and use their language when asking about the sexual assault. It may also be necessary to speak to the child privately without the parent or guardian present, especially if the parent/guardian is suspected in the abuse. Use good clinical judgement here. 

Toxicology 

Routine toxicology is not recommended, however if alcohol or drugs were a factor in the sexual assault, toxicology should be performed (8). This requires explaining and obtaining consent from the patient’s parent/guardian. A blood sample should be used if the drug was ingested within 24 hours, or a urine sample may be used if the drug was ingested within 120 hours (5 days) (8). Toxicology can be useful both for treating the patient appropriately and prosecuting the assailant.  

Voluntary drug use should not discredit a patient’s claim of sexual assault. If law enforcement presses charges of illegal drug use, it may make the victim less likely to follow through with investigation of the assault (8). Some jurisdictions even protect sexual assault victims from such charges. If voluntary drug use is reported, the patient should be referred to addiction counseling.  

Special Populations 

When caring for a patient with a disability, respect their wishes to allow or deny a personal caregiver to be present. Provide culturally sensitive care when treating victims of another culture. Cultural norms can affect a victim’s view of sexual assault and the type of care they want to receive. When feasible, accommodate patient requests for caregivers of a specific gender. It is also important to be sure to communicate clearly in a language the patient understands.  

When caring for a transgender individual, treat their physical condition based on the sex organs present and treat their total person in a way appropriate for their identity. If the patient has female sex organs that were involved in the sexual assault, treat them as you would a biological female with the same presentation.

One exception is if pregnancy has occurred in transgender males, even when taking hormone therapy (more to come on this) (4). In this case, the patient would need to be informed of the risk of pregnancy and cared for accordingly.  

Make use of victim support services. Victim support services can help with translation for patients not proficient in English or any language. Support services can also help arrange shelter and legal representation for victims. Contact support services early in the process, as some services may accompany the patient through the examination process, if the patient so wishes.  

Mental Health Assessment 

Mental health assessment is another important part of the exam. Individuals react to major stressors differently, so it is important to not make judgments on an individual’s mental state based on their behavior. Always ask patients about their mental state to get a proper assessment.

Suicide risk assessment using a validated tool, such as the Suicidal Behaviors Questionnaire-Revised (SBQ-R), can help with diagnosing major mental health concerns (7).  The SBQ-R includes four questions that assess a person’s risk for suicide. It is important to be empathetic but ask direct questions when assessing suicidality. Direct questioning helps illicit honest answers about suicidal thoughts.  

Specimen Collection 

Specimen collection kits must contain: a container, an instruction sheet or checklist, forms for consent and evidence collection, and collection materials. These collection materials include material for collecting clothing/foreign materials for evidence, vaginal/cervical swabs, penile swabs, perianal swabs, oral swabs, and body swabs. Materials specific to pre-pubescent children should be included.  

Assess patients for presence of evidence with initial assessment. Take measures to prevent loss of evidence and collect it early in the process whenever possible. When collecting samples, always wear proper personal protective equipment (PPE) to protect yourself and use non-powdered gloves to prevent contamination of the sample (8).

For children, samples should be taken from the external genitalia only (8). Store dry evidence in paper containers, and dry wet evidence in a drying box if available. Minimize the amount of time between collection of evidence and transfer to the storage collection kit to best preserve evidence. Specimens should only be transported away from the facility by law enforcement.

DNA Analysis 

Most modern systems utilize DNA analysis. When collecting evidence for DNA analysis it is important to also collect a sample of the patient’s DNA to distinguish between victim and aggressor. A DNA sample of any recent consensual sexual partners should also be collected to narrow down DNA evidence to the suspect.

This is usually done with a blood sample or a simple buccal swab inside the person’s mouth (8). Patient DNA samples should be used for comparison purposes only. Samples should not be given to law enforcement for any other purposes.  

DNA samples are processed in a forensic laboratory by separating the DNA from the specimen, then using polymerase chain reaction (PCR) to replicate the DNA. Different DNA strands can then be identified and separated for interpretation (5). 

Clothing Evidence 

Many times, evidence can exist on clothing that may have been washed off the body. To properly collect evidence from clothing, place a clean hospital bed sheet on the floor and collection paper on top of the sheet. Have the patient disrobe over the collection paper to catch any falling potential evidence.

Be thoughtful in how much clothing to collect as evidence, and only collect clothing with patient’s consent. If the patient needs replacement clothes, advocate groups may be able to provide clothes to the patient. Most samples should be collected within 72 hours of the abuse, but unwashed clothes worn during the abuse can be collected beyond 72 hours (8). 

Swab Collection 

Use swabs to collect blood or other body fluid samples from the patient’s body, hair, and anogenital area. If fluids are dried, first moisten them with a moist swab, then collect as a wet sample (8). This can be done using two wet swabs, or a wet swab followed by a dry swab (5).

Properly collected DNA samples can be used to identify suspects even from touch contact (5). Vaginal or cervical swabs are often wet mounted to detect sperm (8). Label all samples properly and store appropriately after drying. If the sample cannot be dried in the facility, store it according to jurisdictional policy. This may sound like a lot of policies to remember, but that is why having the policies included in the collection kit is so important.

Medical Forensic Photography 

Forensic photography is a standard of care in the assessment and treatment of sexual assault of children. In either case, always be sure to explain the photograph procedure and get consent before taking any photographs. If the child does not consent to all or part of the photograph, you must honor that decision. 

Photography Technique 

Photographs should include injured areas only. Be sure that photographs are in focus and include all borders of the wound. It is recommended that photographs include three different orientations with three shots at each orientation. At least one shot should include a forensic measurement device by the wound for clear documentation of size, and at least one without the measurement device to prove no features are covered by the measurement tool.  

• First, take three full scale shots that show the injured area in context to the entire body.  
• Next, take three medium scale shots that show the affected body part.  
• Finally, take three close-up shots of the injury to give clear details.   

These photographs should be taken only by you, the examiner. Patients may feel very vulnerable during this process, so it is important that photographs are taken by someone they trust, and that privacy and dignity are maintained throughout the process.

Once taken, photographs must be clearly labeled and follow the chain of custody if being used as evidence for criminal prosecution. Photographs are considered part of the patient’s medical forensic record and are not automatically turned over to law enforcement. Law enforcement must subpoena photographs that are required for their investigation. 

Photography Equipment 

SANE nurses should be familiar with the equipment used for forensic photography. You should be able to adjust shutter speed and lens aperture to control exposure of the photographs. A quality macro lens with ring strobe flash produces the best forensic photographs (8).

Include a color bar in photographs to account for any distortion of color. If you are unsure of how to use certain features of your equipment, refer to the manufacturer instructions and owner’s manual. 

STD Testing and Prophylaxis 

Sexually transmitted disease (STD) testing and prophylaxis is an important part of the sexual assault treatment process.  The most common STDs in sexual assault victims are trichomoniasis, gonorrhea and chlamydia (8).  The following from the Centers for Disease Control (CDC) summarizes when STD testing should be performed for children (4).

• Child had experienced penetration or there is evidence of recently healed penetrative injury to genitals, anus, or oropharynx. 
• Child has been abused by a stranger. 
• Child has been abused by a perpetrator known to be infected with a STD or at high risk for STDs. 
• Child has a sibling or other relative or person in the household with a STD 
• Child lives in an area with a high rate of STDs in the community. 
• Child has signs or symptoms of STDs.
• Child has already been diagnosed with one STD. 
• Child or caregiver requests STD testing. 

Symptoms 

The following are symptoms of common STDs and infections: (16):  

Chlamydia: 

• Painful urination, lower abdominal pain, vaginal or penile discharge, and pain or bleeding with intercourse.  

Gonorrhea:  

• Thick, cloudy or bloody discharge, painful urination or bowel movements, painful testicles in males and vaginal bleeding in females (16). 

Trichomoniasis: 

• Greenish or yellowish vaginal discharge, penile discharge, genital burning or itching, strong vaginal odor and painful urination.  

HIV (early signs): 

• Fever, headache, sore throat, swollen lymph nodes and rash.  

Herpes simplex virus: 

• Small red bumps or sores in the genital and anal area accompanied by pain or itching.  

Hepatitis:  

• Abdominal pain, nausea, vomiting, fever, dark urine, muscle pain and jaundice.  

Syphilis: 

• A reddish-brown rash with penny-sized sores, fever, enlarged lymph nodes and aches.  

Testing 

For HIV, testing should be repeated at 4-6 weeks and 3 months. Victims not vaccinated against hepatitis B should be vaccinated. The first dose should be given on exam, second dose at 1-2 months and third dose at 4-6 months. Follow up syphilis testing at 4-6 weeks is recommended. People with high risk for developing hepatitis (because of immunosuppression or known exposure) should be retested at 6 months.  

Treatment 

Suspected or confirmed HIV positive patients should be treated with a 28-day course of triple antiretroviral therapy. There is no standard therapy for children, so seek expert opinion for antiretroviral therapy (4).

Patients receiving triple antiretroviral therapy should have serum creatinine, alanine transaminase (ALT), and aspartate aminotransferase (AST) checked at baseline and end of therapy.  

Prophylactic treatment is not recommended for pre-pubescent children, as their incidence of STDs is low (8). CDC treatment recommendations for confirmed cases of common STDs are summarized below. 

Recommended Regimens for Chlamydial Infection Among Infants and Children: 

• For infants and children who weigh <45kg: Erythromycin base or ethyl succinate 50 mg/kg body weight/day orally divided into 4 doses daily for 14 days. 
• Data is limited regarding the effectiveness and optimal dose of azithromycin for treating chlamydial infection among infants and children weighing <45kg. 
• For children weighing >45 kg but aged <8 years: Azithromycin 1gm orally in a single dose. 
• For children aged >8 years: Azithromycin 1gm orally in a single dose or Doxycycline 100mg orally 2 times/day for 7 days. 

Recommended Regimen for Syphilis among infants and children: 

• Benzathine penicillin G 50,000 units/kg body weight IM, up to the adult dose of 2.4 million units in a single dose. 

Recommended regimen for uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis among infants and children weighing <45 kg: 

• Ceftriaxone 25-50mg/kg body weight IV or IM in a single dose, not to exceed 250mg IM. 

Common side effects of these medications include nausea, vomiting, diarrhea, and fatigue. More serious side effects to be aware of are kidney stones, hepatitis, and hepatotoxicity. This information can be used to educate patients and parents/guardians.

Pregnancy Risk Evaluation and Care 

In pre-pubescent girls there is no risk of pregnancy. If the patient has achieved menarche, follow the adult-adolescent guidelines for pregnancy evaluation and treatment.

Documentation 

Documentation should be factual and use standard language. Any statements made by the child during the exam should be documented verbatim (8). This table from the Department of Justice outlines what descriptors to use when describing wounds (8). 

Documentation of an evidence collection kit report is required. This report should contain only medical issues relating to the assault. Patient consent forms, forensic photography and history of assault should also be included. A diagram depicting the location of injuries on the patient should also be included in the forensic medical record.  

As discussed in the assessment section, required documentation on the medical forensic history includes date and time of the assault, pertinent medical history, recent consensual sexual activity, post-assault activities, assault-related history, suspect information, nature of the assault, alcohol or drug involvement, and description of the assault. The Department of Justice recommends a review process of documentation to ensure accurate, objective data is reported (8). 

A medical forensic report should be kept separate from the patient’s primary medical record. This ensures privacy and confidentiality. Information in this report should be related to the assault only and be limited to objective information.

Documentation is required each time a collection kit is transferred from one person to the next, including transferring to another healthcare facility or transferring over to law enforcement.

Discharge and Follow-Up 

It is important to provide thorough patient education at discharge. Education should be both written and oral, and include medical concerns, advocacy, counseling services available, and the investigative process. Education materials should be individualized to the patient’s developmental and reading level.

Factors that affect patient compliance with recommended treatment include education level, employment status, and lack of health insurance – with lack of health insurance being the biggest factor (3). If the patient’s parent/guardian does not have health insurance, collaborating with social workers for resources may help improve compliance.  

The Violence Against Women Act (VAWA) and STOP Violence Against Women Formula Grant Program will cover payment for the medical forensic exam, but not other forms of treatment provided during the visit (8). VAWA does not cover children under 11 years old, but many states cover the cost of the exam (8). 

Collaborate with community resources and law enforcement to give clear education on these areas and obtain patient resources. Any follow-up for STD testing or other health concerns should be arranged prior to discharge. Ensure that all medical and mental health needs of the patient are addressed prior to discharge.

It is also important to address patient safety concerns prior to discharge. Many cases of sexual assault involve someone the victims know. Collaborate with law enforcement and CPS to find a safe place for the patient to discharge to if not going home with the parent.  

Conclusion

In conclusion, we have discussed the key aspects and statistics of sexual assault. The impact this crime has on victims was described. More importantly, the way we can assess and treat victims was outlined.

Techniques for maintaining patient dignity and privacy during the examination process were presented. The specifics of specimen collection and forensic photography were reviewed.

Hopefully there are some take-home points from this information you can carry with you in your care of this vulnerable population. Remember to collaborate with the other members of the sexual assault response team to provide the best care for the patient. Continue treating these patients with care and dignity, and thank you for the work you do.

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