Best Practice for SANE The SANE examination of the victim of sexual assault may assist with the investigation and prosecution of the case but is foremost intended to assist the survivor of sexual assault in her/his recovery. The guideline that is included at the end of this chapter was developed by the Wisconsin Chapter of the International Association of Forensic Nurses and is recommended for the care of the adolescent and adult when there is a history or concern of sexual abuse or assault. The guideline is not intended to include all the triage issues, medical evaluations, tests, and follow-up that may be necessary for appropriate care for an individual patient. Not all the steps outlined in this guideline will be appropriate for every patient. The purpose of this guideline is to provide direction for the SANE in the care of the adolescent or adult sexual assault patient. Prioritizing Victim Well-Being The physical and psychological well-being of the sexual assault patient should always be given precedence over forensic needs. In some cases, the investigation may have to be delayed if law enforcement identifies that strangulation or a loss of consciousness occurred during the assault or if the victim complains of active bleeding or is pregnant or has abdominal pain. The victim of sexual assault needs prophylaxis to prevent sexually transmitted infection and pregnancy. The victim should always be referred to SANE for assessment and care. Ensuring Competency in Forensic Evaluation Assessment, examination and evidence collection should only be done by those healthcare providers trained as SANE. The examination and evidence collection of the victim which follows a sexual assault is complicated and time consuming. If done by healthcare providers who are poorly trained in the evaluation and/or who have a limited understanding of the many needs and concerns of sexual assault victims, it can be as intrusive, invasive and as traumatizing as the assault. The collection of evidence and the documentation of injury cannot be done in retrospect. If the evidence collection is done improperly or the chain of custody not properly maintained, the result may be a thwarted investigation and unsatisfactory prosecution. Expertise is also important to establish credibility when testifying in a court of law. Patient Consent Best practice guidelines inform us that the patient must consent to a SANE examination and evidence collection. Consent can be given or withdrawn for any portion of the exam at any time. Victim Reporting of Sexual Assaults Best practice guidelines indicate that an adult victim of sexual assault should be offered the following reporting options: . Report the assault to law enforcement and having evidence collected. . Choose NOT to report and NOT having evidence collected. . Choose to have evidence collected even though the victim is undecided or choose to remain anonymous about reporting. In these cases, collaboration between law enforcement and the SANE is essential. A protocol that includes how this process will take place and what information is to be given to the patient must be developed. Confidentiality of the victim is important as well as the maintenance of the chain of custody (evidence). The advantage of collecting evidence without a report is to facilitate reporting and allow for early evidence collection without putting pressure on the victim to make a decision about reporting before she/he is able to do so. Whatever decision is made by the victim should be supported by the SANE. The victim who decides not to report or who is undecided should be assessed and treated in the same manner as the victim who is reporting. Community Based Advocacy Advocacy is included in the healthcare response. SANE must be objective in order to provide the best treatment and collect the most accurate information. The emotional needs of victims are best cared for by the rape crisis advocate. The SANE should contact advocacy when a victim presents for evaluation, and the SANE and advocate together should respond as a team. Community based advocates can provide support to a victim from the beginning, throughout the investigative and prosecution process. Many cases will not be prosecuted and the victim will need assistance from advocacy if the case is not taken to court. Timeliness of Evidence Collection Evidence can be compromised or lost if not collected within a timely manner. Evidence collection is usually done within 96 hours of an assault but may be done beyond that time. The documentation of injury can be compelling evidence and injury can persist beyond 96 hours. However, injury may not be visible for hours or days. Patients/victims seen within hours of a sexual assault may have injury that cannot be seen and documented during an initial examination and should be instructed to return if injury becomes apparent later. Release of Medical Information Medical information, including evidence collected during a medical forensic examination, is protected under the Health Insurance Portability & Accountability Act (HIPPA). It can only be released to law enforcement or accessed for legal proceedings with the adult victim’s written consent or when ordered by a court with jurisdiction in the matter. At the time of the adult victim examination, discussion of the need for the completion of a release of medical records form to facilitate the legal investigation and subsequent action should be done. Prophylaxis Treatment Prophylaxis for the prevention of sexually transmitted infection and emergency contraception should be offered and provided to all patients following current standards. The Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease Treatment Guidelines are an excellent resource for appropriate treatment. Wisconsin Statute 50.375 mandates that a hospital that provides emergency services must provide emergency contraception to victims of sexual assault. Mandatory Reporting There is mandatory reporting of suspected child victims of physical and sexual assault and neglect. There is no mandatory reporting for adult victims (18 years and older) unless the adult victim cannot make their own healthcare decisions i.e., those patients who have a legal guardian who makes decisions for them. The other exception to this law is in the case of injuries caused by a weapon or incidents involving life-threatening assault. These incidents must be reported to law enforcement agencies regardless of reporting the sexual assault. Financial Responsibility Best practice guidelines are very clear in their position on treating uninsured and underinsured sexual assault victims: ability to pay should never be an obstacle to obtaining a medical forensic examination! It is the responsibility of the SANE to provide the victim with accurate information about Crime Victim’s Compensation (CVC) and Sexual Assault Forensic Exam (SAFE) funds—including how and where to apply for these funds. Crime Victim Compensation (CVC) Program If a victim is reporting the crime to the police, she/he may be eligible for Crime Victim Compensation (CVC) Funds. These funds can be used to pay for the medical costs of sexual assault exams (if the patient does not have insurance or medical assistance), clothing taken for evidence, et cetera. The requirements that applicants need to meet, in order to receive these funds are included in the brochure “A Measure of Justice – Financial Help for Victims of Crime” produced by the CVC Program and available by calling 1-800-446-6564. Sexual Assault Forensic Exam (SAFE) Funds The SAFE funds assist victims who have had a sexual assault forensic exam without requiring them to: . Report to law enforcement . Participate in the criminal justice process . Have their own insurance company billed for the exam It should be noted that the funds available through the SAFE fund are only intended to cover the cost of forensic exams. Examination of the Suspect of Sexual Assault The SANE may be asked to conduct a suspect exam as a part of the criminal investigation. Examination and evidence collection from the suspect of sexual assault is as important as the examination and evidence collection from the victim. Important biological or trace evidence and/or physical findings may be found which will link the suspect to the crime or provide useful corroborative information to the investigation of the crime and to its successful prosecution. Neutrality, objectivity and patient confidentiality is critical for both the victim and suspect exams. Although the possibility of cross contamination is virtually impossible if proper procedures are followed, it is prudent to meticulously document the measures taken to prevent any cross contamination such as the changing of gloves and clothes, the washing of hands and/or the cleaning of the room between the exams. SANE Training The Wisconsin Coalition Against Sexual Assault (WCASA) SANE Faculty provide training to healthcare providers in the evaluation and treatment of the adult and child victims of sexual assault. For additional information about this training, contact WCASA at 608-257-1516. The content of these trainings adheres to the standards of such established by the International Association of Forensic Nurses. Certification as a SANE-A and as a SANE-P is obtained through the International Association of Forensic Nurses. Certification as a SANE-A demonstrates expertise in the evaluation of the adult victim of sexual assault and certification as a SANE-P is considered competency in the evaluation of the child victim of sexual abuse. Wisconsin Chapter of the International Association of Forensic Nurses The professional organization that represents forensic nursing is the International Association of Forensic Nurses (IAFN). SANE is the largest subspecialty of forensic nursing. Information about the Wisconsin chapter of the IAFN and its members can be obtained at the website www.wi-iafn.org. Wisconsin Adult Sexual Assault Response Team Protocol (pp. 31-34) by Wisconsin Coalition Against Sexual Assault, 2011. Retrieved from https://www.wcasa.org/file_open.php?id=203 Reprinted with permission.