Sexual Assault Nurse Examiner programs in the United States

Multidisciplinary Perspectives on the Implementation of a Comprehensive Sexual Assault Telehealth Program in Rural Communities: A Qualitative Study

Access to quality sexual assault (SA) care in rural communities is limited by challenges surrounding building and sustaining a skilled SA nurse examiner workforce. Telehealth can facilitate access to expert care while cultivating a local sexual assault response. The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center aims to decrease disparities in SA care by providing expert, live, interactive mentoring, quality assurance, and evidence-based training via telehealth. This study examines multidisciplinary perceptions of pre-implementation barriers and SAFE-T program impact using qualitative methods. Implications for the implementation of telehealth programs to support access to quality SA care are considered.

Emergency Department Nurses' Perceptions of Patient Substance Use, Impact on Sexual Assault Care, and Access to Follow-up Behavioral Health Resources

INTRODUCTION

Patients may present to the emergency department for sexual assault care under the influence of drugs or alcohol. However, many emergency nurses are not prepared to meet their unique needs or aware of follow-up behavioral health resources. The purpose of this study was to (1) summarize current resources provided to patients and processes for referral to behavioral health services after sexual assault care, (2) explore emergency nurses' attitudes and behaviors toward patient substance use, and (3) explore nurses' perceptions of adjunct mobile health interventions for follow-up behavioral health care and describe anticipated barriers to use.

METHODS

Fifteen emergency nurses participated in semi-structured qualitative interviews.

RESULTS

Participants had mixed perceptions of patient intoxication during sexual assault care. They felt that conversations about substance use may be more appropriate after the ED visit. Participants recognized the opportunity to connect ED patients with substance use treatment or prevention resources but perceived that there are few local service providers. Most participants were not referring patients with substance use issues to behavioral health services after sexual assault care and said that their emergency departments did not have processes for referral to these services. Acceptability of mobile health for follow-up behavioral health care was high, but participants had concerns for patient privacy and internet access. Participants gave recommendations to improve referral practices and patient engagement with mobile health interventions.

DISCUSSION

This study highlights the need for emergency nurses to consider patient intoxication during sexual assault care and opportunities to connect patients with resources post-assault.

Emergency Contraception Administration, Toxicology Kit Use, and Postassault Reporting: A Comparison of Sexual Assault Nurse Examiner (SANE) and Non-SANE Medical Providers

Sexual assault nurse examiners (SANEs) are specially trained to meet the postassault medical forensic needs of sexual assault patients. However, there remains a dearth of literature comparing directly postassault service provision and action in cases treated by SANEs as compared to non-SANE medical providers. In this study, we compare rates of emergency contraception administration, toxicology kit use, reports to police at the time of examination, and mandatory child abuse reports among n = 3,969 sexual assault cases treated by SANEs and non-SANE medical providers. Compared to cases treated by non-SANE medical providers, cases treated by SANEs were significantly more likely to have emergency contraception administered, less likely to have a toxicology kit collected, less likely to have a police report filed at the time of examination, and more likely to have a mandatory child abuse report filed. Observed patterns suggest that non-SANE medical providers may find it difficult to balance the needs of the criminal justice system with those of their patients, whereas SANEs provide a tailored, comprehensive first response. We discuss the importance of consistent, accurate documentation and clearly defined protocols in the medical forensic response to sexual assault patients.

Rural Availability of Sexual Assault Nurse Examiners (SANEs)

PURPOSE

Sexual assault care provided by sexual assault nurse examiners (SANEs) is associated with improved health and prosecutorial outcomes. Upon completion of SANE training, nurses can demonstrate their experience and expertise by obtaining SANE certification. Availability of nurses with SANE training or certification is often limited in rural areas, and no studies of rural certified SANEs exist. The purpose of this study is to describe rural SANE availability.

METHODS

We analyze both county-level and hospital-level data to comprehensively examine SANE availability. We first describe the geographic distribution of certified SANEs across rural and nonrural (ie, urban or suburban) Pennsylvania counties. We then analyze hospital-level data from semistructured interviews with rural hospital emergency department administrators using qualitative content analysis.

FINDINGS

We identified 49 certified SANEs across Pennsylvania, with 24.5% (n = 12) located in 8 (16.7%) of Pennsylvania's 48 rural counties. The remaining 37 certified SANEs (75.5%) were located in 13 (68.4%) of Pennsylvania's 19 nonrural counties. Interview data were collected from 63.9% of all eligible rural Pennsylvania hospitals (n = 63) and show that 72.5% (n = 29) have SANEs. Of these, 20.7% (n = 6) have any certified SANE availability. A minority of hospitals (42.5%; n = 17) have continuous SANE coverage.

CONCLUSIONS

Very few SANEs in rural Pennsylvania have certification, suggesting barriers to certification may exist for rural SANEs. Though a majority of hospitals have SANEs, availability of SANEs was limited by inconsistent coverage. A lack of certified SANEs and inconsistent SANE coverage may place rural sexual assault victims at risk of receiving lower quality sexual assault care.

The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review

BACKGROUND

Specialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice.

METHODS

A systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted.

RESULTS

We included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services.

CONCLUSIONS

This review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

Sexually Transmitted Infections

The diagnosis and treatment of sexually transmitted infections is a crucial component of providing evidence-based care in the emergency department. Understanding how to make the diagnosis and implement effective treatment is essential to maintaining and improving public health. Providers should also be adept at giving care to sexual assault survivors and seeking out the expertise of specially trained professionals within networks known as SANE, SAFE, or SART. These networks are critical to providing standardized care to sexual assault patients. Prophylaxis remains a key element for the prevention of sexually transmitted infections in all patients who are considered high risk.

Veterinary Forensic Pathology of Animal Sexual Abuse

Animal sexual abuse (ASA) involves harm inflicted on animals for the purposes of human sexual gratification and includes such terms as bestiality, zoophilia, zoosadism, animal sexual assault, and others. The prevalence of ASA is not known, although it may be more common than is currently perceived. Veterinarians have the skills required to identify and document cases of ASA. This article reviews the terminology, legal definitions and forms of ASA, and its social and psychological context. An investigative approach is outlined, including an alternate light source examination; collection of swabs for DNA analysis; sampling vaginal washes, rectal washes, and toenails for trace evidence and biologic analyses; radiographic studies; and a complete forensic necropsy, including histopathology. Gross lesions identified in ASA victims include injuries to the anus, rectum, penis, scrotum, nipples, and vagina; the presence of foreign bodies; and abrasions, bruising, and other evidence of nonaccidental injury. Specialized procedures, including examination using alternate light sources and screening tests to identify human seminal fluid within samples from ASA victims, are of potential value but have not been validated for use in animals.

Evaluating the legal impact of Sexual Assault Nurse Examiner programs: an empirically validated toolkit for practitioners

There has been sustained interest in the academic literature and in policy circles regarding how Sexual Assault Nurse Examiner (SANE) programs may bolster sexual assault prosecution rates in their communities, in addition to the health care they provide to their patients. To build evaluation capacity among forensic nurses so that they can evaluate their own programs, a practitioner-oriented, step-by-step evaluation toolkit (the SANE Practitioner Evaluation Toolkit) that can be used by SANE-A and SANE-P programs, and their community partners, to examine sexual assault prosecution rates in their local jurisdictions was created and validated. This article describes the process of creating and empirically validating the toolkit and presents the toolkit itself and accompanying resources that are available to practitioners. This article also provides recommendations regarding program readiness to engage in evaluation activities, without compromising program sustainability and patient care.

The Impact of Sexual Assault Nurse Examiner Programs on Criminal Justice Case Outcomes: A Multisite Replication Study

To address the underreporting and underprosecution of adult sexual assaults, communities throughout the United States have implemented multidisciplinary interventions to improve postassault care for victims and the criminal justice system response. One such model is the Sexual Assault Nurse Examiner (SANE) Program, whereby specially trained nurses provide comprehensive psychological, medical, and forensic services for sexual assault. In this study, we conducted a multisite evaluation of six SANE programs (two rural programs, two serving midsized communities, two urban) to assess how implementation of SANE programs affects adult sexual assault prosecution rates. At each site, most sexual assaults reported to law enforcement were never referred by police to prosecutors or were not charged by the prosecutor's office (80%-89%). Individually, none of the sites had a statistically significant increase in prosecution rates pre-SANE to post-SANE. However, when the data were aggregated across sites, thereby increasing statistical power, there was a significant effect such that cases were more likely to be prosecuted post-SANE as compared with pre-SANE. These findings suggest that the SANE intervention model does have a positive impact on sexual assault case progression in the criminal justice system. Nevertheless, there is still a pressing need for improvement as the vast majority of both pre-SANE and post-SANE resulted in nonreferral/no charges filed.

A review of the health effects of sexual assault on African American women and adolescents

OBJECTIVE

To review the research findings for mental and physical health outcomes and health behaviors of African American women and adolescents after sexual assault.

DATA SOURCES

Searches of the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, PsycINFO, and PubMed from January 2001 through May 2012 using the terms Blacks, African Americans, sexual abuse, sexual offenses, and rape.

STUDY SELECTION

Criteria for inclusion included (a) results of primary research conducted in the United States and published in English, (b) African American females age 13 and older, (c) sexual assault or sexual abuse reported as distinct from other types of abuse, and (d) health status as an outcome variable. Twenty-one publications met inclusion criteria.

DATA EXTRACTION

Articles were reviewed for the mental and physical health and health behavior outcomes associated with sexual assault of African American women and adolescents.

DATA SYNTHESIS

Sexual assault was associated with increased risk of poor mental and physical health outcomes in the general population of women and adolescents. There was an increased risk of unhealthy behaviors (e.g., drinking, drug use, risky sexual behaviors) for all women and adolescents, with the highest risk reported for African American women and adolescents. Help seeking from family and friends demonstrated conflicting results. Cumulative effects of repeated assaults appear to worsen health outcomes.

CONCLUSION

Sexual assault has significant effects on the physical and mental health and health behaviors of women and adolescents in the general population. Less evidence is available for differences among African American women and adolescents. More research is needed to understand the influence of race on women's and adolescents' responses to assault.

Nonoccupational postexposure HIV prophylaxis in sexual assault programs: a survey of SANE and FNE program coordinators

This cross-sectional study describes sexual assault nurse examiner (SANE)/forensic nurse examiner (FNE) program practices related to HIV testing, nonoccupational postexposure prophylaxis (nPEP), and common barriers to offering HIV testing and nPEP. A convenience sample of 174 SANE/FNE programs in the United States and Canada was drawn from the International Association of Forensic Nurses database, and program coordinators completed Web-based surveys. Three fourths of programs had nPEP policies, 31% provided HIV testing, and 63% offered nPEP routinely or upon request. Using χ(2) and Fisher's exact tests, a greater proportion of Canadian programs had an nPEP protocol (p = .010), provided HIV testing (p = .004), and offered nPEP (p = .0001) than U.S.-based programs. Program coordinators rated providing pre- and/or posttest counseling and follow-up as the most important barrier to HIV testing, and medication costs as the most important barrier to providing nPEP. Our results indicate HIV-related services are offered inconsistently across SANE/FNE programs.

Sexual assault training in emergency medicine residencies: a survey of program directors

INTRODUCTION

There is currently no standard forensic medicine training program for emergency medicine residents. In the advent of sexual assault nurse examiner (SANE) programs aimed at improving the quality of care for sexual assault victims, it is also unclear how these programs impact emergency medicine (EM) resident forensic medicine training. The purpose of this study was to gather information on EM residency programs' training in the care of sexual assault patients and determine what impact SANE programs may have on the experience of EM resident training from the perspective of residency program directors (PDs).

METHODS

This was a cross-sectional survey. The study cohort was all residency PDs from approved EM residency training programs who completed a closed-response self-administered survey electronically.

RESULTS

We sent surveys to 152 PDs, and 71 responded for an overall response rate of 47%. Twenty-two PDs (31%) reported that their residency does not require procedural competency for the sexual assault exam, and 29 (41%) reported their residents are required only to observe sexual assault exam completion to demonstrate competency. Residency PDs were asked how their programs established resident requirements for sexual assault exams. Thirty-seven PDs (52%) did not know how their sexual assault exam requirement was established.

CONCLUSION

More than half of residency PDs did not know how their sexual assault guidelines were established, and few were based upon recommendations from the literature. There is no clear consensus as to how PDs view the effect of SANE programs on resident competency with the sexual assault exam. This study highlights both a need for increased awareness of EM resident sexual assault education nationally and also a possible need for a training curriculum defining guidelines for EM residents performing sexual assault exams.

Substance use among women receiving post-rape medical care, associated post-assault concerns and current substance abuse: results from a national telephone household probability sample

OBJECTIVE

To examine post-rape substance use, associated post rape medical and social concern variables, and past year substance abuse among women reporting having received medical care following a most recent or only lifetime incident of rape.

METHOD

Using a subsample of women who received post-rape medical care following a most recent or only rape incident (n=104) drawn from a national household probability sample of U.S. women, the current study described the extent of peritraumatic substance use, past year substance misuse behaviors, post-rape HIV and pregnancy concerns, and lifetime mental health service utilization as a function of substance use at time of incident.

RESULTS

One-third (33%) of women seeking post-rape medical attention reported consuming alcohol or drugs at the time of their rape incident. Nearly one in four (24.7%) and one in seven (15%) women seeking medical attention following their most recent rape incident endorsed drug (marijuana, illicit, non-medical use of prescription drugs, or club drug) use or met substance abuse criteria, respectively, in the past year. One in twelve (8.4%) women reported at least monthly binge drinking in the past year. Approximately two-thirds of women reported seeking services for mental health needs in their lifetime. Post-rape concerns among women reporting peritraumatic substance use were not significantly different from those of women not reporting such use.

CONCLUSIONS

Substance use was reported by approximately one-third of women and past year substance abuse was common among those seeking post-rape medical care. Implications for service delivery, intervention implementation, and future research are discussed.

Prosecution of adult sexual assault cases: a longitudinal analysis of the impact of a sexual assault nurse examiner program

Most sexual assaults are never reported to law enforcement, and even among reported cases, most will never be successfully prosecuted. This reality has been a long-standing source of frustration for survivors, victim advocates, as well as members of the criminal justice system. To address this problem, communities throughout the United States have implemented multidisciplinary response interventions to improve post-assault care for victims and increase reporting and prosecution rates. One such model is the Sexual Assault Nurse Examiner (SANE) program, whereby specially trained nurses (rather than hospital emergency department [ED] physicians) provide comprehensive psychological, medical, and forensic services for sexual assault victims. The purpose of this study was to examine whether adult sexual assault cases were more likely to be investigated and prosecuted after the implementation of a SANE program within a large Midwestern county. A quasi-experimental design was used to compare criminal justice system case progression pre-SANE to post-SANE. Results from longitudinal multilevel ordinal regression modeling revealed that case progression through the criminal justice system significantly increased pre- to post-SANE: more cases reached the "final" stages of prosecution (i.e., conviction at trial and/or guilty plea bargains) post-SANE. These findings are robust after accounting for changes in operation at the focal county prosecutors' office and seasonal variation in rape reporting. Implications for policy and practice are discussed.

Sexual assault nurse examiners' perceptions of their relationship with doctors, rape victim advocates, police, and prosecutors

In response to the negative and inefficient treatment of rape victims by emergency room personnel, the first Sexual Assault Nurse Examiner (SANE) programs began in the late 1970s. While SANEs, doctors, rape victim advocates, police officers and prosecutors work together to ensure the most comprehensive and sensitive care of rape victims, they all have very different roles and objectives. This research explores SANEs' perceptions of their relationships with other professionals who treat or interact with rape victims. Data from interviews with 39 Sexual Assault Nurse Examiners from four East Coast states indicate positive relationships are marked by open communication, respect shown towards SANEs as well as rape victims, and a sense of appreciation among SANEs. On the contrary, negative relationships result when SANEs believe police treat victims poorly, when advocates overstep boundaries and question SANEs about evidence collection or the exam, and when prosecutors fail to properly prepare them to testify during a trial.

Sexual assault nurse examiners' perceptions of the revictimization of rape victims

While Sexual Assault Nurse Examiner programs have improved the treatment of rape victims by offering more compassionate and thorough treatment, SANEs believe victims continue to face revictimization by the medical, criminal justice and legal systems. The purpose of this research is to explore SANEs' perceptions of the revictimization of rape victims by the police, legal system and medical system. Data from interviews with 39 Sexual Assault Nurse Examiners from four East Coast states reveal that most SANEs believe that the medical, criminal justice, and legal systems wield the power to revictimize rape victims. SANEs were more likely to cite the criminal justice system as a source of revictimization, followed by the medical system and legal system. According to SANEs, police contribute to victims' distress through failure to ask questions in a sensitive manner, failure to proceed with investigations, and by asking victim-blaming questions. Revictimization by the legal system results when charges are never filed, cases are postponed or dropped, plea bargains are unsatisfactory, and victims' character and credibility are questioned. Revictimization by the medical system is marked by long waits for medical attention.

The forensic nursing in sexual assaults: the immunochemical diagnosis and prevention of its adverse effects

Sexual assault was a ubiquitous and serious problem in our society. The world's care centers and forensic associations, which were at the forefront of scientific research in sexual assaults, discussed the role of the Forensic Nursing in their early diagnosis and their prevention, but little has been written in literature regarding their appropriate management. This article focuses on the immunochemical laboratory investigation in diagnosis and prevention of its adverse effects in sexual assaults and the role of the Forensic Nursing played in this task. After a careful reading of all the material received from many of the care centers and the associations contacted, a Forensic Nursing Examination Program, with specific immunochemical address, is identified.

Emergency contraception services for adolescents: a National Survey of Children's Hospital Emergency Department Directors

STUDY OBJECTIVE

To assess emergency contraception (EC) counseling and prescribing practices of children's hospital emergency department (ED) directors and the use of EC protocols in these settings.

DESIGN

Cross-sectional study of children's hospital ED directors responding to a 15-minute 44-item semi-structured survey during telephone interviews.

PARTICIPANTS

50 of 96 eligible directors of children's hospital EDs in the United States.

MAIN OUTCOME MEASURES

EC protocols, EC counseling processes, EC prescribing practices.

RESULTS

Most (80%) ED directors reported always offering EC as part of sexual assault care; 66% were more likely to provide onsite EC in these situations. Only 52% identified the progestin-only regimen as the EC dispensed in their ED, and most (96%) limited provision to fewer than 120 hours after sex. Although 58% of ED directors reported ever prescribing ongoing contraception when providing EC, none had prescribed EC for future use. Written ED protocols for providing EC were more common for sexual assault care (76%) than for non-sexual assault care (14%). Directors who worked at hospitals with a sexual assault program were less likely to discuss all the recommended topics for EC counseling.

CONCLUSIONS

The recommended standard of care for providing EC to adolescents in children's hospital EDs is not being met. Although risk of pregnancy following sexual assault and consensual unprotected sex is identical, discrepant practices emerged from this survey of pediatric ED directors. Increased education and policy initiatives within children's hospital EDs are needed to standardize EC services for adolescents in this setting.

Organizational correlates of secondary traumatic stress and burnout among sexual assault nurse examiners

This study explores correlates of secondary traumatic stress (STS) and burnout among SANE nurses. Cross-sectional interviews were conducted with nurses from a random sample of SANE programs. The interview measured organizational and demographic variables and current levels of STS and burnout. STS and burnout were found to be related but not identical processes. Organizational variables played a significant role in predicting both outcomes. The results have implications for increasing organizational support as a way of lessening the impact of STS and burnout.

Impact of sexual assault nurse examiners on the evaluation of sexual assault in a pediatric emergency department

BACKGROUND

Nearly 44% of sexual assault victims in the United States are younger than 18 years. These victims often present to emergency departments for care after the assault. To date, the effectiveness of sexual assault nurse examiners (SANEs) on the evaluation and management of pediatric and adolescent sexual assault victims in a pediatric emergency department (PED) has not been evaluated.

OBJECTIVE

To evaluate whether the use of SANEs in a PED improves the medical care of pediatric and adolescent sexual assault victims.

DESIGN/METHODS

Medical records of patients who presented to an urban PED with a history of sexual assault and required forensic evaluation (rape kit) from December 2004 to December 2006 were reviewed in a retrospective, blinded fashion for the following documentation: (1) the genitourinary (GU) examination and if a GU injury was present; (2) evaluation for sexually transmitted infections (STIs) (Neisseria gonorrhoeae and Chlamydia trachomatis), and serologies for hepatitis B and C, HIV, and VDRL; (3) prescription of prophylaxis for STIs, HIV, and pregnancy; (4) evaluation by a PED social worker; and (5) referral to sexual assault crisis services. Patients were grouped as to whether a SANE had been involved in their care. The assignment of a patient to a SANE was random, as SANEs in the PED of this institution do not take call from home and are present in the PED as part of their routine nursing shift. To examine the differences between groups, chi analysis or Fisher exact test was used.

RESULTS

Of the 114 patients whose medical records were reviewed, 60 had been evaluated by a SANE (SANE), and 54 patients had not (SANE); 98% of patients were girls. There were no differences between the 2 patient groups with respect to time of day when they presented to the PED, time after assault to presentation to the PED, sex, age, or race. All medical records had the history of the sexual assault documented in the medical record. Patients evaluated by a SANE were more likely to have the GU examination documented (71% vs 41%; P < 0.001) and to have GU injury documented (21% vs 0%; P = 0.024). Eligible patients were more likely to have testing for N. gonorrhoeae and C. trachomatis (98% vs 76%; P < or = 0. 001), and serologies for hepatitis B and C (95% vs 80%%; P = 0.03) and HIV (93% vs 72%; P = 0.03) when a SANE had been involved in their care. There were no significant differences between groups with respect to obtaining serology for VDRL. There were no significant differences between groups with respect to provision of prophylaxis for N. gonorrhoeae, C. trachomatis, or HIV. Significantly more patients were prescribed prophylaxis for pregnancy by a SANE (85% vs 64%; P = 0.025). Although there were no significant differences between groups with respect to an evaluation by a PED social worker, significantly more patients in the SANE group were referred to the Rape Crisis Center for support and counseling (98% vs 30%; P < 0.001).

CONCLUSIONS

Many more patients who had been sexually assaulted received STI testing, pregnancy prophylaxis, and referrals to the Rape Crisis Center when a SANE was present for the evaluation in the PED. Even with a SANE providing medical care, not all eligible patients had medical record documentation of the GU examination or that they received appropriate STI testing or STI and HIV prophylaxis. Ongoing quality assurance in programs that use SANEs is needed to ensure optimal medical evaluation of children and adolescents with sexual assault.

Comprehensive medical care for victims of sexual assault: a survey of Illinois hospital emergency departments

BACKGROUND

Sexual assault is a major public health problem affecting 17 million women in the United States. Hospital emergency departments (EDs) are often the primary point of care for these women. We propose the concept of "comprehensive medical care management" (CMCM) at the primary point of care for victims of sexual assault. The objectives of this study were (a) to describe medical care services provided to sexual assault victims presenting at the EDs in Illinois hospitals, and (b) to identify the percentage of hospitals that always provide all 10 elements of CMCM.

STUDY DESIGN

This is a cross-sectional prevalence study. A 14-item phone survey was administered to 187 eligible EDs in Illinois from July to September 2004. Outcome measures were the percentages of EDs that provide the elements of CMCM: (a) acute medical care; (b) history and physical exam; (c and d) acute and long-term rape crisis counseling; (e and f) prophylactic and therapeutic sexually transmitted infection (STI) management; (g and h) prophylactic and therapeutic HIV management; and (i and j) counseling and provision of emergency contraception.

RESULTS

An 83% response rate of eligible emergency rooms provided the following data: while 100% of emergency rooms provide acute medical care upon presentation, two thirds provide rape crises counseling, two thirds provide STI management, 4 of 10 report counseling and provision of emergency contraceptives, and only 28.2% provide HIV management. About 1 in 10 (9.6%) provides all elements of CMCM.

CONCLUSION

Although there are recommendations from various medical organizations for all 10 elements of CMCM for victims of sexual assault, very few hospitals provide CMCM. Improvements must be made to provide quality comprehensive care for victims of sexual assault.

Negotiating the challenges of multidisciplinary responses to sexual assault victims: sexual assault nurse examiner and victim advocacy programs

The purpose of this study was to examine Sexual Assault Nurse Examiner (SANE) programs' relationships with victim advocacy organizations. A national telephone survey was conducted of randomly selected SANE programs, all of which served adults, and some of which also served adolescents and children. Nearly one-third of 231 participants reported that SANEs in their program had experienced conflicts related to roles and boundaries with victim advocacy organizations at some point during the program's history. The most frequently mentioned conflicts involved professional autonomy, control, or turf issues. Future researchers should address personnel, organizational, and structural factors that facilitate collaborative relationships between SANE and victim advocacy organizations.

Assault history and follow-up contact of women survivors of recent sexual assault

The purpose of this comparative descriptive study is to describe and examine differences in assault characteristics and the issues surrounding follow-up contact of women survivors of a recent sexual assault. This study identified assault characteristics: half of the assaults were by strangers; approximately one-third of the assaults occurred in the victim's home; 29% of the victims were abducted; weapons and physical force were used in over half of the cases; 63% were vaginal assaults; and 86% involved penile penetration. Three months after the assault and the initial examination, only 23% (n = 18) of the study participants could be contacted by telephone for follow-up. The study's findings provide not only data regarding the characteristics of sexual assault, but also the difficulties in contacting adult female survivors for follow-up services. Recommendations outline the importance of thorough, individualized examinations and the need for improved, timely, follow-up services for sexual assault victims.

Sexual assault nurse examiner program characteristics, barriers, and lessons learned

Sexual Assault Nurse Examiner (SANE) programs have been developed throughout the United States to better meet the needs of sexual assault survivors. This study builds upon three previously published national surveys of SANE programs, with a random sample of 243 SANE programs surveyed. Results are discussed along with implications Jbr SANE program practice.

Sexual assault nurse examiners' experiences providing expert witness court testimony

Nurses from a national random sample of SANE programs were interviewed about their most recent experience providing expert witness court testimony (N = 110). Forty-three percent of the SANEs characterized this experience "fine" with no difficulties, but 58% mentioned that they had encountered problems. Challenges they faced while testifying are explored in depth and implications for forensic nursing practice are discussed.

Health care-based interventions for women who have experienced sexual violence: a review of the literature

Thirty publications that evaluated health care-based interventions for women who experienced sexual violence were reviewed. The findings highlight that clinicians often need training in the provision sexual assault care, and that not all emergency departments have sexual assault care protocols. Studies examining effectiveness found that Sexual Assault Nurse Examiner programs are very helpful, that health care-based sexual assault treatment settings attract more women than do forensic-based settings, that sexual assault survivors often prefer a combination of medication and counseling treatment, and that preexam administration of a video explaining the collection of forensic evidence may reduce women's stress during the procedure. Studies on postexposure HIV prophylaxis found that many women did not complete the treatment regimen, often because of side effects. Emergency contraception to prevent postrape pregnancy is not consistently offered to women. Only one study reported on abortion as part of the range of sexual assault services.

Responding to sexual assault victims' medical and emotional needs: a national study of the services provided by SANE programs

We measured the consistency with which a national random sample of 110 Sexual Assault Nurse Examiner (SANE) programs provided 17 services to sexual assault victims. SANE programs consistently offered forensic evidence collection, sexually transmitted infection (STI) prophylaxis, information on HIV, information on pregnancy risk, and referrals to community resources. Reasons programs did not routinely offer particular services (e.g., STI cultures, HIV testing/prophylaxis, emergency contraception (EC)) included financial constraints, difficulties balancing medical care with legal prosecution, and affiliations with Catholic hospitals.

Sexual Assault Nurse Examiner (SANE) Program Goals and Patient Care Practices

PURPOSE

To examine Sexual Assault Nurse Examiners (SANE) programs' goals and guiding philosophies and how they influence patient care practices for sexual assault victims.

DESIGN

Data were collected from a national random sample of SANE to examine whether programs differed significantly in their goals and patient care practices.

METHODS

Iterative cluster analysis was used to identify types of programs distinct in their stated goals.

FINDINGS

Three types of emphasis in SANE programs were identified: (a) prosecution of cases as a primary goal; (b) attending to patients' emotional needs, supporting feminist values, empowering patients, and changing the community response to rape; and (c) least importance on prosecution of cases and average importance on the other goals. Programs that were more focused on prosecution goals provided less comprehensive patient services.

CONCLUSIONS

Programs focused on prosecution as a primary goal were less likely to provide comprehensive services, especially those involving patient education. Such information is important for patients because their health concerns (e.g., pregnancy, STIs) have long-term implications for their well-being. Historical and structural differences among SANE programs might explain these different patient care practices. Researchers should examine the underlying processes in SANE programs that shape both their goals and patient care approaches.

Program and sexual assault survivor characteristics for one SANE program

Sexual Assault Nurse Examiner (SANE) programs address the unique and specific needs of sexual assault survivors. However, relatively little is known about the actual characteristics of existing programs and the characteristics of rape survivors who seek treatment in emergency rooms with SANE programs. This article presents information about one program's development, operation, and clients.

The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes

In sexual assault nurse examiner (SANE) programs, specially trained forensic nurses provide 24-hour-a-day, first-response medical care and crisis intervention to rape survivors in either hospitals or clinic settings. This article reviews the empirical literature regarding the effectiveness of SANE programs in five domains:(a) promoting the psychological recovery of survivors, (b) providing comprehensive and consistent post-rape medical care (e.g., emergency contraception, sexually transmitted disease [STD] prophylaxis), (c) documenting the forensic evidence of the crime completely and accurately, (d) improving the prosecution of sexual assault cases by providing better forensics and expert testimony, and (e) creating community change by bringing multiple service providers together to provide comprehensive care to rape survivors. Preliminary evidence suggests that SANE programs are effective in all domains, but such conclusions are tentative because most published studies have not included adequate methodological controls to rigorously test the effectiveness of SANE programs. Implications for practice and future research are discussed.

Organizational characteristics of Sexual Assault Nurse Examiner programs: results from the national survey project

A random sample of representatives from Sexual Assault Nurse Examiner (SANE) programs throughout the United States were contacted to participate in in-depth telephone interviews about program operations and services for sexual assault patients. Programs that had been in operation 5 years or less at the time of this study are compared to older programs to examine trends.

Sexual assault services delivered by SANEs

Sexual Assult Nurse Examiner (SANE) programs have become the standard of care for sexual assault victims in many urgent care settings. This study examines SANE clinical nursing practices at one Canadian sexual assault urgent care centre.

Sexual assault evidence collection more accurate when completed by sexual assault nurse examiners: Colorado's experience

INTRODUCTION

The purpose of this study was to determine if sexual assault nurse examiners (SANEs) provide more effective evidence collection compared with non-SANE-trained nurse and physician colleagues.

METHODS

Five hundred fifteen audits were completed by crime laboratory analysts on sexual assault evidence kits submitted to the Colorado Bureau of Investigation from October 1999 to April 2002.

RESULTS

Of 515 evidence kits audited, 279 were completed by SANEs. Non-SANE physicians and nurses completed 236 kits. Evidence kits collected by SANEs were more likely to have a completed chain of custody (92%) compared with 81% of non-SANE-collected kits. SANEs also were more likely to have properly sealed individual specimen envelopes (91% vs 75%), to have labeled the individual specimen envelopes (95% vs 88%), and to have collected the appropriate amount of pubic hair (88% vs 74%) and head hair (95% vs 80%). SANEs more frequently included the appropriate number of blood tubes (95% vs 80%), collected the appropriate amount of swabs (88% vs 71%), and included a vaginal fluid slide for sperm motility (87% vs 72%). Both groups prepared slides at a high rate for each penetrated orifice (87% vs 90%) and both had a high rate of including the crime laboratory report in the completed kit (97% vs 93%).

DISCUSSION

Studies such as this provide documentation that evidence collection kits prepared by SANEs are more accurate and complete when compared with evidence collection kits prepared by non-SANE nurses and physicians. Additional studies are needed to further validate the efficacy of SANE-completed evidentiary examinations.

Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault

BACKGROUND

The medical response to adult sexual assault should comprise: the collection of forensic evidence, the treatment of injuries, and follow-up counselling. In the past, victims of sexual assault reporting directly to the police may not have received this total medical care. The Copenhagen Center for Victims of Sexual Assault at Rigshospitalet, Denmark offers a 24-h service. Medical treatment and psychosocial follow up is offered independent of police reporting. The aim of this study was to assess whether adult sexual assault victims who reported to the police differed from those who did not report to the police.

METHODS

Using clinical records, sociodemographics, characteristics of the assault, and type of preventive medical treatment received were obtained for 156 consecutive women consulting the Copenhagen Center (March 1st to December 31st 2000). Comparisons between characteristics of victims who reported to the police or not were determined.

RESULTS

Ninety-four (60.2%) of the women reported to the police. Women who sought services within 24 h of the assault, had experienced use of force, were subjected to assault outdoors, and among whom nongenital injuries were observed were more likely to report to the police (p < 0.05). However, in the multivariate model these associations fell below significance, and only the type of perpetrator remained significantly related to police reporting. The adjusted odds ratio for police reporting when the perpetrator was a friend was 0.4 (95% CI 0.17-0.94). There was no statistical difference between the victims who did or did not report to the police to request prophylactic antibiotics or emergency contraception.

CONCLUSION

Observed injuries and requests for prophylactic antibiotics or emergency contraception were not influenced by whether the woman did or did not report directly to the police. Hence the need for medical treatment appears to be similar in the two groups, and available specialized care for victims of sexual assault should not be restricted to those who immediately report to the police.

Forensic nursing in the context of sexual assault: comparing the opinions and practices of nurse examiners and nurses

This population-based study compared nurses who had participated in a sexual assault nurse examiner training program (SANEs) to nurses who had not participated in the program (nonSANEs) on their opinions and practices in relation to the collection of forensic evidence. Self-administered surveys were distributed to all SANEs and non-SANEs employed in sexual assault care centres in Ontario (N = 317). We found that SANEs were more likely to indicate that certain samples, items, or questions should not be taken and/or asked as a regular part of the forensic examination. They were less likely to perceive the presence of physical injuries and semen and/or sperm as being "extremely important" to a positive legal outcome. Finally, more SANEs reported experiencing dilemmas with respect to their dual roles as caregivers and evidence collectors. These findings are discussed in relation to the more expansive and comprehensive experience and education of SANEs versus nonSANEs. Implications for care offered to victims of sexual assault are discussed.

Establishing a sexual assault nurse examiner (SANE) program in the emergency department

Sexual assault cases present complex medical, psychological, social, and legal challenges to emergency practitioners. Sexual Assault Nurse Examiner (SANE) programs were designed to improve and expedite this patient care. The following review describes unique requirements, objectives, and resources when developing a program based in the Emergency Department.

A community-based approach to sexual assault

The community-based Athens-Clarke County Sexual Assault Nurse Examiners (ACC-SANE) program was developed to respond to the needs of sexual assault victims. Although this type of SANE model allows for a strong nurse-managed program, there are frustrations and pitfalls that differ from most hospital-based programs. At this time, the majority (71%) of SANE programs are based in hospitals, and few (15%) function in outpatient/community facilities. In the ACC-SANE program, many community agencies interact to provide a seamless approach to postassault health care, counseling, and criminal prosecution. SANE nurses are well equipped to provide forensic examinations in a caring, out-of-hospital environment. The program is housed in a remodeled cottage that rests on property owned by the Athens-Clarke County government and that is adjacent to the local police department. ACC-SANE is governed by a nonprofit board of directors. This management model has allowed the original organizing groups to remain active in the development of the program. As these agencies continue in the governance of the program, they remain committed to the success of ACC-SANE. The impact of program growth and published program guidelines is examined.