Texas Nursing Forensics

About

Introduction 

In the United States, sexual assault was historically considered a judicial problem; however, it is now considered a major public health concern because of the health and psychological effects on individuals. The problem most notably emerged in the public eye in the 1960s with the women's liberation movement. In recent times the #METOO movement has increased awareness of the problem, and many organizations have surfaced to assist the assaulted. This course will focus on the problem in rural areas in the state of Texas and how nurses working in these facilities can best assist patients who have been sexually assaulted. 

Statistical Evidence 

National Statistics 

According to the Rape Abuse and Incest National Network (RAINN) (1), every 68 seconds someone is sexually assaulted in the United States, and every nine minutes, that victim is a child (1). Only 25 out of every 1,000 perpetrators will end up in prison (1).in less than every 80 seconds, a person is sexually assaulted. In 2015 the Texas Statewide Sexual Assault Prevalence Study found that 33.2% of adult Texans or 413,000 individuals reported having been sexually assaulted at some point during their lives (2).  

Each year in the United States (1):  

• 80,600 inmates are sexually assaulted or raped 
• 60,000 children were victims of “substantiated or indicated” sexual abuse 
• 433,648 people 12 and older were sexually assaulted or raped 
• 18,900 military personnel experienced unwanted sexual contact 
• 1 out of every 6 women have been the victim of attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted) 
• 1 in 3 men have experienced an attempted or completed rape in their lifetime 
• More women and children are sexually assaulted than men, and that girls under 18 years of age are at the highest risk. According to RAINN (1), men and boys, especially college-aged, are also at risk with transgender students at the highest risk of this group. 

Most common locations where sexual assault occurs in the U.S. (1): 

• 55% at or near the victim’s home 
• 15% in an open public space 
• 12% at or near a relative’s home 
• 10% in an enclosed but public area (i.e. parking garage or lot) 
• 8% on school property 

Activities the victims were doing when they were assaulted (1): 

• 48% were sleeping or performing another activity at home 
• 29% were traveling to and from work or school, or traveling to shop or run errands 
• 12% were working 
• 7% were attending school 
• 5% were doing an unknown or other activity 

Sexual Assault on Children (1): 

• 1 in 9 girls and 1 in 20 boys under the age of 18 experience sexual abuse or assault 
• 2 out of 3 victims of sexual assault or rape (under the age of 18) are age 12 – 17 
• Victims of sexual assault or rape under the age of 18 are about 4 times more likely to develop symptoms of drug abuse and PTSD as adults, and about 3 times more likely to experience a major depressive episode as adults 

Texas Statistics 

The latest statistics on sexual assault in the state of Texas were from 2018 and is as follows (2): 

• Total number of reported sexual assault incidents was 19,816, a 9.4% increase from the prior year 
• Of victim-to-offender relationships, 11% were romantic, 14% parental/child, 19% other family, and 55% other. 
• Victims were 88% were female and 12% male 
• Victims who were aged 10 – 14 were the group with highest number of cases 
• Of all victims, 82% were white, 17% black, and 1% American Indian/Alaskan Native, Asian, or Native Hawaiian/Pacific Islander 

Location of sexual assault incidents in Texas in 2018 (2): 

• 16,015 in residents/homes 
• 2,041 in unknown or other areas 
• 657 in a hotel/motel 
• 718 in school/college 
• 710 in a highway/road/alley 
• 506 in a parking lot/garage 
• 268 in fields/woods 
• 185 in commercial/office buildings 
• 176 in drug stores, doctor’s offices, or hospitals 

The Basics: Sexual Assault 

What is Sexual Assault? 

Sexual assault, also termed sexual violence, is described as “any type of unwanted sexual contact, including words and actions of a sexual nature against a person’s will and without their consent; a person may use force, threats, manipulation, or coercion to commit sexual violence” (3). Sexual assault is often defined separate from rape. Rape consists of penetration, whether vaginally, anally, or orally. Sexual assault is any type of unwanted sexual content and is not limited to rape.  Sexual abuse, as described by the American Psychological Association (APA) "is unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent" (3). Assault can be the product of domestic abuse, gang violence, date rape, and incest. Assault can be inflicted on any age or gender and often occurs by someone who is related to or knows the victim.  

What is SANE? 

In many parts of the United States, Sexual Assault Nurse Examiners (SANE), nurses who are expertly trained in performing forensic examinations and collection of evidence, are utilized (5). SANEs are nurses who specialize in forensic nursing. In forensic nursing, the health and legal system intersect (10). SANE programs began as early as the 1970s. At that time, nurses noticed that victims of sexual assault were not provided high quality care like other patients were in the emergency department. Nurses also noticed that the victims were very concerned about STDs and pregnancy and needed special treatment.  Over the next 20 years, the forensic specialty grew, and the First SANE programs were started in Tennesse, Minnesota, and Texas. Today, Texas registered nurses working in the emergency departments must learn the SANE process to perform the forensics exams and evidence collection by completing a 2-hour educational program.  

Nursing's Role 

Sexual assault is an extremely traumatic experience. Those affected can have a wide range of issues, emotionally, spiritually, physically, and psychologically. Nurses working in the emergency department are often first responders. Compassion, empathy, and privacy are a hallmark of excellent practice when caring for patients who have been sexually assaulted.  

Many patients will experience shock and disbelief. "Why me? Will I be okay?" or "It's no big deal, I'm fine" (6). There may be "fear of responses from friends, family, the public, and criminal justice providers" (7). Victims of rape may also have concerns about pregnancy, STIs, and HIV/AIDS. These patients may feel their world has turned upside down. They may be scorned, told it was deserved, and fear their names could be made public (7).  

In order to provide excellent care, all gender identities must be taken into consideration, as well as age and sexual orientation. No bias or judgment should be displayed to the patient. Customs, beliefs, religious, and spiritual needs should also be considered during the visit 

Team Collaboration 

Working with all personnel in the emergency department is essential. From paramedics, law enforcement officers, family, or anyone accompanying the patient to physicians, social workers, and forensic medical examiners, each professional has a specific skill set and role in the patient's care. Teamwork among these groups of individuals will provide the best possible outcomes for the patient. Team members involved in a victim’s care may include (8): 

• “Community-based advocates 
• Law enforcement officers 
• SANEs, physicians or nurses trained in sexual assault medical forensic evidence collection 
• Law enforcement victim service advocates 
• District Attorney’s Office personnel, legal victim advocates and attorneys” 

Interview 

The interviewing nurse should actively listen, believe what the patient discloses, validate the patient’s feelings, maintain confidentiality, and honor the patient’s decisions on what to do about the assault. When caring for patients who have sexually assaulted, treating the whole person rather than the "problem" alone is vital. Repeating information back to the patient can help to elicit more precise information. Repeating information can also help to validate what the patient is saying, creating an atmosphere of trust. Consider that patients may not want to talk about the assault, as reliving it could bring out unwanted emotions. 

If the patient arrives alone, the nurse should inquire if the patient wants a companion or an advocate to be present. An advocate could be a family member, friend, member of the clergy, or social worker. The patient can choose if they want someone present. Care must be taken to ensure the patient feels comfortable, as the presence of someone emotionally involved (or even the assaulter themselves) may deter the patient from being open and honest. An interpreter should also be arranged if needed, with the patient's consent.  

If the patient has not alerted the local police, the nurse should inquire if they wish to report the assault and if so, the police should then be called. If available, a sexual assault response team (SART) should be immediately contacted. It is of the utmost importance to remember that the patient always makes the primary decision of what to do surrounding the case. Also, the patient must give consent first before any decisions are made. Admitting the patient to a private room in a quiet area of the emergency department lessens interruptions from outside sources.  

Assessment 

After obtaining consent to perform the assessment, the patient should be advised of every step before each part of the exam. The patient should be informed they have total control of what is happening. It is important for the nurse to help the patient understand they always have the right to refuse any and all steps in the examination.  

When performing the initial assessment and gathering information, documentation must include a very detailed and complete history, including any physical trauma to the patient’s body. The history should include any bruises, lacerations, or other visual injuries and how and when they occurred. The nurse should perform the interview slowly, giving the patient time to process and answer each question. The patient may or may not want to identify the person who assaulted them and should not be coerced into doing so. 

A complete medical, surgical, and gynecologic history, in the case of a female patient, and any new symptoms occurring after the assault should be asked. Drug allergies, medications, and any alcohol or illegal drugs used at the time of the event are also documented. A compassionate and empathic tone should always be used to allow the patient to feel safe. The patient should not feel any judgment from any emergency department personnel. Patients should be given the opportunity and encouraged to grieve and react during this time. They should feel comfortable enough to ask and answer questions throughout the interview.  

According to Texas law, nurses must obtain written consent from the patient. During the complete physical exam, the nurse will be charged with ensuring physical evidence of the assault from clothing or body fluids is not disturbed. Also, during this time, suicidality and emotional support should be assessed. Providing expert treatment for patients who have been sexually assaulted is of utmost importance. When available, a SANE nurse will perform the forensic examination. This examination is vital to collect and preserve physical evidence from the patient while also assessing life and limb injuries. If a SANE nurse is unavailable, as may be the case in Texas's rural areas, a "medical forensic examiner" will perform the examination. 

Documentation 

When documenting the case, the nurse should use open-ended questions to elicit the patient's best and clearest responses. Documentation must be complete and exact, including every stage of the assault with times, dates, and descriptions, with consideration for the patient's emotional state and ability to recall. Using motivational interviewing can be helpful as well. Documenting in the patient’s own words is best practice. Nurses should try their best to document all of the following about the case (8): 

• “All those present during the patient’s history and examination 
• Time, date, and location of assault(s) 
• Contact and/or penetrative acts by suspect(s) 
• Was the suspect injured in any way, if known? 
• Use of lubricant, including saliva 
• Patient’s actions between the sexual assault and arrival at the facility (brushing teeth, using mouthwash, smoking, vaping, changing clothes, vomiting, swimming, showering, or bathing) 
• Was a condom used? 
• Did ejaculation occur? Where?  
• Any weapon use or physical force, or threat of weapon use or physical force? 
• Description of condition of clothing (and was clothing torn or stained prior to assault?)”  

In the case of a minor, a parent will give consent, and if no parent is available or is the assaulter, the child will be turned over to the appropriate child and family services in the state. If the assaulted patient has dementia or is an elder with cognitive issues and is therefore unable to consent, adult protective services should be contacted (8). There are also rules governing military sexual offenses. Remember when documenting these cases, whether using handwritten or electronic medical records, any and all information is subject to HIPAA.  

Texas Forensic Law 

The Texas government code 420.031 (9) describes the protocol that must be taken to develop and protect evidence collection in a sexual assault case. Since a major part of Texas is rural, the code was enacted to protect and care for patients and the collected evidence in areas where a SANE nurse is not available. In these cases, a medical forensic examiner may perform the exam and evidence collection.  

A medical forensic examiner is described as any practitioner Medical Doctor, Registered Nurse, Nurse Practitioner, or Physician's Assistant who has undergone a minimum of 2 hours of training in forensic evidence collection. The law outlines requirements in the collection and preservation of evidence. In 2019, the code was amended to require written informed consent from the patient or guardian for release of the evidence and must be gained prior to the history and physical. Obtaining consent also carries important psychological implications after a sexual assault since the patient's right to consent was violated by the assaulter. Sexual assault examination teams should always be involved as early as possible.  

Texas Forensic Law: Statute of Limitations 

The statute of limitations for sexual assault cases can be defined as a deadline in which a person can report a sexual assault. The statute of limitations vary per state and the length of time for reporting can depend on whether the case is criminal or civil. Criminal cases are committed against the state and prosecuted by the state; civil cases occur between individuals/groups and are prosecuted by a civil court (i.e. family court or personal injury cases) (12). In Texas, the statute of limitations varies by age and whether the case is criminal or civil. The following are general statute of limitations regarding sexual assault in Texas (13)(14). The legal age of sexual consent in Texas is 17. 

For adults, the statute of limitation is 10 years from the victim’s 18th birthday. As of 2019, victims of sexual assault can file a personal injury claim for injuries arising from childhood sexual abuse up to 30 years from the incident. 

There is no statute of limitations if: 

• During the investigation of the offense, biological matter (evidence) is collected, and the matter has not yet been subjected to forensic DNA testing 
• Forensic DNA testing results show that the matter does not match the victim or any other person whose identity is readily ascertained 
• Probable cause exists to believe that the defendant has committed the same or a similar sex offense against five more victims  
• Continuous sexual abuse of young child or disabled individual occurs 
• Indecency with a child occurs 

Texas Forensic Law: Evidence 

Sexual assault evidence can be found in several areas, including the crime scene, the patient's body, skin, hair, nails and clothing, and other items belonging to the patient (11). There is a specific kit used to collect this evidence. As described by RAINN, the kit is best known as a RAPE or Sexual Assault Evidence Kit (SAEK) and is inclusive of the items listed below (11): 

• Bags and paper sheets to put on the floor and collect clothing or other evidence that may fall off the patient while undressing, 
• A comb to collect evidence from hair 
• Forms for documentation  
• Envelopes and containers for the evidence 
• Instructions on use of the kit 
• Sampling materials and swabs 

Types of evidence collected are usually skin samples, scrapings from fingernails, and oral, genital, and anal swabbing internal and external. Directions on how to collect this evidence are included in the kit. The forensic examiner can also use special types of photography to document internal injurie. (11). Personal cameras should never be used. Remember, it is the law that the patient consents to each part of the exam. 

As described by RAINN, prior to the forensic exam, it is best if the patient has not changed clothes, combed their hair, brushed their teeth, tried to clean the area, showered, or bathed, or used a restroom. If needing to use the restroom, a urine sample should be collected, educating the patient not to cleanse the perianal area. If they have already showered or bathed and have not arrived at the emergency room yet, emergency personnel need to educate the patient to keep the clothes they were wearing and any other belongings they had with them at the time of the assault in a paper bag in order to preserve the evidence (11).  If the patient comes to the emergency department up to 7 days after being sexually assaulted, the exam can still be performed. After the 7 days, it is at the forensic examiner's discretion whether the exam should be performed. Collecting and protecting forensic evidence is a legal, moral, and professional responsibility (12). 

Any medical witness who testifies in court is held in the highest regard and as experts in sexual assault cases (5). Courts will closely scrutinize the chain of custody, and if broken, it can cause a conflict in the case and question of validity. Cases may be heard in criminal, civil, juvenile, military courts, or grand juries. If a forensics examiner is called to be a "fact" witness, no opinions on the case will be heard. Only the procedures that were performed on the patient will be admitted, and if the testifier is not the professional who performed the examination, they may be questioned regarding SANE protocols.  

If called upon to be an expert witness, the SANE nurse not only has knowledge of protocols but can educate and give opinions to the court. In either case, the necessity for excellent knowledge of SANE protocols is important. Nurses must be comfortable testifying in court as it is a rigorous and stress-provoking experience. Working with your organization's lawyers and prosecutors, as well as reviewing the case extensively, will prepare the nurse to testify in a case (5). 

Texas Law: Chain of Custody 

In order to protect the patient and evidence for the courts, a chain of custody of the evidence must be followed precisely. Failure to comply does not mean the evidence is not admissible in the courts; however, the more complete the evidence, the better chance of conviction of the assaulter. Texas A&M's nursing program offers a chain of evidence handbook outlining each step in the collection of evidence. The information below highlights the collection process from that handbook (8). 

Collection of Evidence and Packing 

• “Collect evidence so that it will be admissible as evidence in legal proceedings later. Therefore, chain of custody must be maintained and documented throughout the entire patient assessment and evidence collection processes.
• Chain of custody documents the dates and times of everyone who handles every piece of evidence, from the time it is collected through to legal proceedings."  
• Evidence should be labeled with patient’s name, date of birth, unique identifier number, examiner’s initials, date, and time. 
• If adult patient chooses non-reporting method, the external SAEK is labeled only with the unique identifier number (often the medical record number or the Track-Kit barcode). The Track-Kit identifier can be utilized. 
• Consider also labeling additional evidence not included in the kit (i.e., clothing collected when patient is reporting to law enforcement) with Track-Kit labels without the barcode. 
• Evidence inside the SAEK is labeled according to standard facility procedure. Follow facility protocols on non-reporting evidence collection. 
• Consider providing a card with the unique identifier for the patient if the Track-Kit identifier is not utilized.” 

Chain of Custody Documentation 

Documentation must include:  

• Receipt of evidence 
• Storage of the evidence  
• Transfer of the evidence 
• Date and time of each transfer 
• The printed name and signature of each person in possession of or transferring the evidence  
• Signatures of all persons transferring or receiving the evidence 

Swab and Evidence Collection 

Explain the reason and process for collection prior to collecting from each site. Nurses can use this time to take digital photos (depending on facility protocol). There should be two swabs used from each site." (8). 

Evidence must be kept in sight of the person collecting it at all times. After collected, the evidence must be dried and contained in the SAEK kit and sealed per kit instructions until it can be handed over to the appropriate law enforcement official and opened only by crime lab personnel. Each emergency department should have a locked storage space to provide temporary custody of collected evidence until it can be transferred to the appropriate persons or lab. If a patient is transferred to another facility, the chain of custody again must be documented according to the law. 

The law in Texas allows an adult to choose whether to report the assault to law enforcement. If the person chooses not to report, evidence will still be collected and preserved for up to 5 years post-assault. In the case of child sexual assault, elder abuse (over 65), or disabled persons, all medical personnel must report the case to law enforcement as mandatory reporters. Texas caregivers are also required to give patients an information sheet describing where to find appropriate services for the sexually assaulted. This document can be found on the Texas consumer protection website or here: Information for Survivors of Sexual Assault (texas.gov) 

Physical and Emotional Effects 

After a sexual assault, patients can experience anxiety and depression, post-traumatic stress disorder (PTSD) and turn to alcohol and/or substance abuse. There may be feelings of fear, denial, guilt, shame, loss of self, loss of control, and anger (8). They may feel like their world has been turned upside down, life has stopped, or they cannot move forward. They may feel ashamed and wonder if, in some way, they were responsible. They may not feel safe in their own space and may lack trust.  

In domestic cases, the patient may be concerned about their attacker. They may worry that their attacker will be prosecuted and sent away. Daily life can be disrupted to the point of self-isolation and loss of the patient's job, family, and social life. A patient may become disabled to the point of homelessness and poverty. Many may feel the attack is transparent and that others can tell they have been assaulted just by looking at them. Flashbacks can occur at any time, and they may experience nightmares of being chased or attacked. They may also have constant thoughts of the abuse, causing insomnia and intense anxiety.  

Support for Victims 

Patients who have been sexually assaulted may contemplate and attempt suicide (8). These issues can extend into long periods of time, with unknown triggers bringing flashbacks or repeated negative feelings. Patients should be informed that their feelings are normal, and each person heals in different ways and in different timeframes. Ongoing support and therapy can assist the patient in recovery as well as self-help and group programs. There are many online, telephone, and in-person programs for victims as well as organizations to assist with ongoing issues. For example, the Rape, Abuse & Incest National Network (RAINN) program can be helpful in advocating for patients and guiding them on their journey to recovery. The National Sexual Violence Resource Center is also a helpful resource. 

Many psychologists and therapists work explicitly with victims of sexual assault. The attorney general of the state of Texas website has information and resources for all crime victims. Having a trained sexual assault counselor at the emergency visit time can be of great assistance with the initial contact and subsequent referrals to professionals. Compassionate, empathic, and supportive care by emergency nurses at the initial contact can positively impact the patient's road to a safe and healthy recovery.  

Physical injuries must also be considered using clinical assessment, radiology, MRIs, and CT scans when necessary. Laboratory collection for STDs (sexually transmitted diseases), pregnancy in females, possible HIV, and other illness exposures are also a consideration during the physical exam and history taking. Follow-up care for these injuries with subsequent laboratory tests and appointments made with appropriate specialists should be made.  

Follow up 

Ideally, the nurse could schedule a telephone call with the patient in 2-3 days to assess how they are doing and for continued support and referrals. At that time, the patient may have more questions or concerns that the nurse can help with and provide for follow-up care and resources. A list of educational programs and therapists who specialize in sexual assault and support groups should be supplied to the patient at the time of the visit and subsequent phone calls. There is no handbook on how to recover from trauma; it is an individual journey that is experienced solely by each person. However, there are many resources to assist a patient who has been sexually assaulted at the time of the event and long after.  

Conclusion 

Sexual assault has become a major health problem in the United States. The state of Texas has implemented a code of laws to identify, protect, and collect evidence from patients who have experienced this crisis. The utilization of SANE nurses is common in major metropolitan area hospitals, but many rural areas in that state are not equipped with the program. To properly care for these patients and collect and protect evidence appropriately, Texas has mandated education for emergency department nurses not served by SANE personnel.  

It is imperative that emergency department nurses become educated on the use of SAEK kits for evidence collection and chain of custody protocols. The utilization of the SANE method allows for standardized care that is safe, and protective of the patient and their rights. 

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