Title: Sexual Assault Nurse Examiner (SANE)
Series: Development & Operation Guide
Author: Linda E. Ledray
Published: Office for Victims of Crime, July 1999
Subject: Victims of crime, child sexual abuse, rape and sexual assault,
victim services
220 pages
520,000 bytes

-------------------------------

Figures, charts, forms, and tables are not included in this ASCII plain-text
file. To view this document in its entirety, download the Adobe Acrobat
graphic file available from this Web site.

-------------------------------

U.S. Department of Justice
Office of Justice Programs
Office for Victims of Crime

Sexual Assault Nurse Examiner
Development & Operation Guide

Sexual Assault Resource Service
Minneapolis, Minnesota

SANE
NCJ 170609

This document was prepared by the Sexual Assault Resource Service,
under grant number 96-VF-GX-K012, awarded by the Office for Victims
of Crime, Office of Justice Programs, U. S. Department of Justice. The
opinions, findings, and conclusion or recommendations expressed in this
document are those of the authors and do not necessarily represent the
official position or policies of the U. S. Department of Justice.

U.S. Department of Justice
Office of Justice Programs
810 Seventh Street NW.
Washington, DC 20531

Janet Reno
Attorney General

Raymond C. Fisher
Associate Attorney General

Laurie Robinson
Assistant Attorney General

Noel Brennan
Deputy Assistant Attorney General

Kathryn M. Turman
Acting Director, Office for Victims of Crime

Office of Justice Programs
World Wide Web Homepage
http://www.ojp.usdoj.gov/

Office for Victims of Crime
World Wide Web Homepage:
http://www.ovc.gov

For grant and funding information contact
U.S. Department of Justice Response Center 1-800-421-6770

-------------------------------

The Office for Victims of Crime is a component of the Office of Justice
Programs, which also includes the Bureau of Justice Assistance, the
Bureau of Justice Statistics, the National Institute of Justice, and the
Office of Juvenile Justice and Delinquency Prevention.

-------------------------------

U.S. Department of Justice
Office of Justice Programs
Office for Victims of Crime

Sexual Assault Nurse Examiner
Development & Operation Guide

Linda E. Ledray, PhD, RN, FAAN
Sexual Assault Resource Service
Minneapolis, Minnesota

SANE Development and Operation Guide

CONTENTS

Chapter 1: Introduction

--Project Goals and Objectives
--Scientific Basis of This Guide
--Terminology

o She or He
o Rape, Sexual Assault, or Abuse?
o Victim or Survivor?

--SANE Guide Evaluation

Chapter 2: History and Development of SANE Programs

--Rape in the United States
--Demonstrating the Need for SANE Programs
--History of SANE Program Development

Chapter 3: SANE Program Model

--What Is a SANE? SANC? SAFE? FNE?
--SANE Program Values, Mission, and Goals

o Values Statement
o Mission Statement
o Program Goals

--SANE Scope of Practice

o Medical Care
o Reporting and Victim Support

--Education, Training, Research, and Program Evaluation
--SANE Standards of Practice
--How a Model SANE Program Operates

o Hospital-Based SANE Programs
o Community-Based SANE Programs
o Community Response and Responsibilities
o SANE Responsibilities

--Community Impact and Benefit

Chapter 4: SART: A Community Approach

--Who Is on a SART?
--The Sexual Assault RESPONSE Team Model

o How a Sexual Assault RESPONSE Team Operates
o Sexual Assault RESPONSE Team Model Limitations

--The Sexual Assault RESOURCE Team Model
--Summary

Chapter 5: Assessing the Feasibility of a SANE Program

--Needs Assessment

o Identifying Allies
o Determining the Extent of the Community Problem of Rape

--Assessing Community Services and Developing Community Support 

o Law Enforcement
o Rape Crisis Center
o Medical Facility
o Prosecuting Attorney
o Other Agencies

--Identifying and Overcoming Obstacles:

o Concerns About Costs
o Fear of Interference
o Concern the SANE Will Not Do the Exam as well as the Physician
o Concern the SANE Will Not Be a Credible Witness

--Deciding to Proceed
--Starting a Formal Task Force
--Developing a SART

Chapter 6: A Look at Funding

--Program Development and Operation Costs

o Needs Assessment
o Facilities and Utilities
o Supplies and Equipment
o Staff Advertising and Selection
o Staff Training
o Program Media Promotion
o Staff Salaries

--Current SANE Program Funding
--SANE Program Funding Options

o Where to Look for SANE Program Funding
o Fundraising Process

--Looking to the Future as You Begin
--Summary

Chapter 7: Starting Your SANE Program

--How Long Can It Really Take?
--Hours of Operation
--Population Served
--Deciding on Program Location
--One Location or Multiple Exam Sites

o Advantages of a Single Exam Site
o Disadvantages of a Single Exam Site
o Adapting the SANE Program to Multiple Exam Sites
o Disadvantages of Multiple Exam Sites

--Regional SANE Programs
--Community-Based Program Exam Sites
--Hospital ED-Based Exam Sites

o Advantages of the ED Exam Site
o Overcoming Disadvantages of the ED Exam Site

--Hospital Clinic-Based Exam Sites
--Summary of SANE Location Trends

Chapter 8: SANE Program Staff

--SANE Program Directors

o Reporting Structure
o Job Duties
o On Call

--The Role of the Physician
--Staff Selection
--Staffing Patterns
--Staff Meetings
--SANE Salaries
--SANE Staffing Recommendations

o Program Director
o Medical Director
o SANE Staff

--Summary

Chapter 9: SANE Training

--Certification

o National Certification
o State Level Certification
o Local Certification

--SANE Training Options
--SANE Training Today
--Utilizing an Existing Training Program
--Importing a SANE Training Program
--Organizing Local SANE Training

o Identifying Local Experts
o Selecting a SANE Trainer

--SANE/SART Training Resources

o Color Atlas
o Evidentiary Exam Videotape

--SANE Training Components

o Programmatic
o Medical
o Legal
o Forensic Practices and Procedures
o Psychological

--Continuing SANE Education
--Future SANE Training Trends
--Summary

Chapter 10: Establishing and Maintaining Program Coverage

--Using Staff Positions
--Using On-Call Positions

o Length of On-Call Shifts
o Assigning Your On-Call Shifts
o Changes in the On-Call Schedule
o Paid and Unpaid On-Call Service

--Response Time
--When Should the SANE Be Paged and by Whom?
--Delayed Response
--Selecting a Paging System
--On-Call Backup
--Using an Answering Service
--Summary

Chapter 11: SANE Program Operation

--Medical Evaluation and Care of Injuries
--The SANE Evidentiary Exam

o Forensic Evidence Collection
o Followup Forensic Exams
o Helpful Tips for Evidence Collection

--Additional Components of the SANE Exam

o STD Evaluation and Preventive Care
o HIV
o HIV Post-Exposure Prophylaxis
o Pregnancy Risk Evaluation and Prevention
o Crisis Intervention and Counseling

--Maintaining Chain-of-Evidence
--Maintaining Evidence Integrity
--Documentation
--After the Exam
--Testifying in Court
--Working with Special Populations

o Male Victims
o Same Gender Sexual Assault
o Gay and Lesbian Victims
o People with Developmental Disabilities
o People with Physical Disabilities
o The Elderly
o Self-Injury Victims
o Refugees and Immigrants
o Working with Interpreters

--Providing Culturally Congruent Care
--Additional Program Components
--Summary

Chapter 12: Pediatric SANE Exam

--Setting
--Special Training
--Sexual Assault Response/Resource Team (SART)
--Interview

o Who Conducts the Interview
o Victim Interview
o Caretaker Interview

--Consent, Confidentiality, and Reporting:

o Minor Consent
o Confidentiality
o Adolescents
o Mandated Reporting

--Collection of Physical Evidence

o Goal
o Components
o When to Do an Evidentiary Exam
o Preparing the Child for the Exam
o Exam Positions
o Recommended Equipment
o Evidence Collection Sites
o STD Testing
o Hair Specimens

--Interpretation of Findings

o Class 1-Normal Appearing Genitalia

o Class 2-Nonspecific Findings
o Class 3-Specific Findings
o Class 4-Definitive Findings

--Antibiotics for Prevention and Treatment of STDs
--Pregnancy Risk Evaluation and Treatment
--Psychological Considerations
--Discharge Planning

o Child Protective Services
o Medical Care
o Other

--Summary

Chapter 13: Policies and Procedures

--Consent
--Court Testimony
--Drug and Alcohol Screening
--Evaluation of Nongenital Injuries (When to Refer to a Physician)
--Evidentiary Exam Timing (Rape Kit Completion; STD Treatment;
Pregnancy Prevention)
--Examination Sites for Evidence Collection
--HIV
--Holiday and Weekend Work
--Interpreters
--Malpractice Insurance
--Mandatory Institutional Inservices
--Mandatory Reporting of Sexual Assaults of Vulnerable Adults and
Minors
--Medication Administration
--Noncompliant Victims
--Nonreporting Victims
--On-Call Schedule (Primary)
--On-Call Schedule (Backup)
--Photographs
--Pregnancy Risk Evaluation and Emergency Interception
--Program Evaluation and Research
--Psychiatric Inpatient/Extended Care Unit Sexual Assault Evaluation
--Rape Drug Screening
--Records
--STD Evaluation and Prevention (Other than HIV)
--Statutory Rape/Teen Consenting Sex
--Suicide Potential Evaluation
--Time Cards/Time Sheets
--Unavailability/Vacation
--Unconscious Victim

Chapter 14: Maintaining a Healthy Ongoing Program

--SANE Vicarious Traumatization and Burnout

o Identifying Symptoms
o Symptoms of Vicarious Traumatization or Burnout
o Reducing Impact on Staff

--Program Evaluation

o Formal and Informal Evaluation Strategies
o Process Evaluation
o Output Evaluation
o Outcome Evaluation
o Data Collection and Analysis
o Evaluation Utilization
o Steps of Program Evaluation Planning
o Evolution of SANE Program Evaluation

--Maintaining a Healthy Ongoing Relationship with Other Agencies and
Organizations
--Summary

Appendixes 

A: Project Staff and Advisory Committee
B: Participating SANE Programs
C: Rape Kit Supply Resources
D: SANE Training Programs
E: SANE Trainers
F: Funding Resources (Please see PDF file)
G: Startup Checklist (Please see PDF file)
H: Clinical Skills Competency Checklist (Please see PDF file)
I: SANE Protocols (Please see PDF file)
J: SANE Forms (Please see PDF file)
K: SANE Evaluation Tools (Please see PDF file)

Glossary (Please see PDF File)

Bibliography

SANE Guide Evaluation (Please see PDF file)

-------------------------------

SUGGESTIONS FOR USING THIS GUIDE

A multidisciplinary response is needed to serve victims of sexual assault,
and OVC anticipates that individuals from many disciplines, not just
forensic nursing, will use this guide to aid their efforts in establishing and
operating a SANE program. Indeed, the impetus driving the development
of several SANE programs has come from law enforcement, sexual assault victim advocates, and others. Therefore, this guide was written from the perspective that not everyone who reads it will have a forensic nursing or even a clinical background. At the same time, there are a few clinical issues addressed in this guide that cannot adequately be addressed in "layman's terms." We hope that this guide strikes a reasoned balance.

As the effort to develop a SANE program should be a multidisciplinary one, we suggest that nonclinicians refer to the nursing and medical members of the organizing team for clarification or further discussion of clinical topics. To aid the nonmedical reader, a glossary of acronyms used
throughout the guide is located after the appendixes. 

An important issue is the rapid development of State policies and procedures governing the processes and protocols of SANE programs that occurred during the writing and review of this guide. Users of this guide should understand that State statutes and policies always take precedence over the recommendations described in this manual. 

This guide was designed to be read in its entirety, with each chapter building on information presented in the previous chapter. Treating each chapter independently would have required much duplication of basic information, greatly increasing the length of the guide. Constant duplication of the same information in each chapter would also be annoying and distracting to most readers. In a few instances, information is repeated for clarity and to preclude frequent referral back to previous chapters. Readers who are unable to read the manual in its entirety are advised that:

--The use of female pronouns for victims was a deliberate choice and the
rationale is explained in Chapter 1, page 2, in the section "Terminology."

--Female pronouns were also used to refer to SANE practitioners, as
the overwhelming majority of them are female.

--Throughout the guide, references are made to "the survey." This
refers to a survey conducted of existing SANE programs at the beginning
of the project and is described in Chapter 1, page 2, in the section
"Scientific Basis of This Guide."

A MESSAGE FROM THE OVC ACTING DIRECTOR

OVC believes that an informed, effective response to violence in America
transcends the criminal justice system, and builds on many disciplines,
including the health care sector. We know that victims of sexual assault
suffer psychological trauma and, all too frequently, long-term health
consequences as a result of their victimization. Therefore, providing
sensitive health care to victims is critically important in the aftermath of a
sexual assault. Unfortunately, the traditional model for sexual assault
medical evidentiary exams frequently compounds the traumatization of
victims. Medical personnel in the emergency room setting often regard the
needs of most sexual assault victims as less urgent than other patients in
the emergency room. As a result, rape victims may endure long hours of
waiting in the public areas of busy emergency rooms. They are not
allowed to eat, drink, or even urinate while they wait for a physician to
conduct the medical evidentiary exam. Frequently, the physicians or
nurses who perform the exams have not been trained in medical evidence
collection procedures or do not perform these procedures frequently
enough to maintain their proficiency. Some physicians are reluctant even
to perform the medical evidentiary exam, knowing that they might be
called away to spend a day or more in court testifying or that their
qualifications to testify might be questioned due to their lack of training
and experience. In response to these issues, the first Sexual Assault Nurse
Examiner (SANE) program was developed in 1976, offering a
multidisciplinary, victim-centered way of responding to sexual assault
victims. There are now more than 100 SANE programs throughout the
U.S., but these programs are not enough to serve the hundreds of
thousands of children and adults who are victims of sexual assault every
year. 

The services of trained, experienced SANE practitioners help to preserve
the victim's dignity, enhance medical evidence collection for better
prosecution, and promote community involvement and concern with crime
victims and their families. OVC has a strong interest in promoting the
replication of programs such as SANE. This SANE Development and
Operation Guide is the result of that interest and we anticipate that it will
serve as a blueprint for nurses and other community leaders who wish to
establish a similar program in their own community. OVC commends Dr.
Linda Ledray and her colleagues in forensic nursing across the nation for
their strong, visible leadership in developing and supporting programs that
help sexual assault victims take the first steps toward healing.

Kathryn M. Turman
Acting Director
Office for Victims of Crime

ACKNOWLEDGMENT

When Dr. Linda Ledray started the Sexual Assault Resource Service
(SARS) at Hennepin County Medical Center in Minneapolis in 1977, she
did so with the intent of developing a nursing focused service delivery
model that could one day be implemented in rural Minnesota. At that time,
according to Dr. Ledray, she did not understand the impact that this
model, now known as SANE, would have across the country, and that 20
years later it would be considered a "new," innovative treatment model for
sexual assault victims.

Dr. Ledray was excited to discover in the mid 1980's that nurses in
Amarillo, Texas; Memphis, Tennessee; and Tampa, Florida were also
focusing on responsive treatment for sexual assault victims. These nursing
pioneers realized that by pooling their resources of creativity, energy, and
enthusiasm, progress in developing a treatment model for this victim
population would happen more quickly. With the publication of this
SANE Guide, Dr. Ledray has now identified 116 functioning SANE
programs, and her organization has contacted many more SANE programs
nearing operation in behalf of rape victims.

The magnitude of effort required to develop the SANE program cannot be
accomplished in a vacuum. It takes the combined efforts of many
individuals with vision, commitment, and tenacity. It takes the efforts of
those who know what they want to do is right and who are persistent in
overcoming the roadblocks that might prevent the implementation of this
vision for their community. As Dr. Ledray helped others to initiate SANE
programs in their communities over the past 20 years, she noticed the
same struggles that she had initially encountered in Minneapolis were
occurring in these communities. The need for a SANE Guide became
apparent.

The Office for Victims of Crime at the Department of Justice also
recognized the need for this SANE Development and Operation Guide in
order to provide others the ability to efficiently and knowledgeably start
SANE programs using the wisdom of those who have been operating
SANE programs. With this Guide, others can learn from the trials and
errors of those who went before, and they can move ahead more rapidly to
improve services for sexual assault victims in their communities.

This Guide has taken the combined effort and expertise of many
individuals. Kathy Simmelink, MA, RN and Maggie Dexheimer Pharris,
MPH, MS, RN together wrote the chapter on the pediatric examination
pulling together information provided by SANEs across the country with a
significant contribution from Pat Speck, MSN, RN, CS, FNP and Colleen
O'Brien, MS, RN, who are both advisory committee members of this
project. Based on the sage advice of Judge Isobel Gomez, also an advisory
committee member, Maggie Dexheimer Pharris, MPH, MS, RN, rewrote
the section on special populations to better focus on meeting the unique
needs of individuals rather than perpetuating stereotypes. Patricia Moen,
JD; Thomas Kiresuk, Ph.D.; Lee Barry, JD; Carolyn Levitt, MD; and Kit
Mauer, BSN, RN, also on the advisory committee, contributed by
reviewing the manuscript and making suggestions for additions and
revisions. Pat Speck and Colleen O'Brien were gracious enough to
carefully reread the revised manuscript numerous times without complaint
and edit extensively as they did so. Susan Valentine from SARS offered
sound advice, careful manuscript reviews, and good judgment to keep the
project on track. This project also benefited greatly from the contributions
of Joye Whatley, the project monitor at OVC, Olga Trujillo, Legal
Counsel, OVC; Timothy Johnson, Program Specialist, OVC; Kristen
Gremmell, Program Manager, Violence Against Women Grants Office,
U.S. Department of Justice; and Ronald C. Laney, Director, Missing
Children's Program, Office of Juvenile Justice and Delinquency
Prevention, U. S. Department of Justice. Thanks also goes to Grace
Coleman, the OVC editor, who spent many hours ensuring that the final
product was one of quality and Chris Naylor, the SARS secretary, as
always, also pitched in and stayed late when necessary to ensure that the
project was completed.

This Guide is the result of the efforts of these individuals and the many
SANEs across the country who shared their materials and experience with
Dr. Ledray and SARS. OVC hopes that it will assist others in developing
and operating a SANE program so that communities across the nation can
better meet the needs of sexual assault victims. If we cannot stop rape, at
least we can work together to reduce the suffering of its victims and
improve the system that responds to it.

SANE Development and Operation Guide

CHAPTER 1  

INTRODUCTION

In 1991, when the Journal of Emergency Nursing published the first list of
SANE programs, there were only 20 programs listed (ENA: 91). In a 1996
update, 86 SANE programs were identified (Ledray: 96a). This updated
list was used as the basis of a survey of SANE programs conducted by the
Sexual Assault Resource Service (SARS) at Hennepin County Medical
Center in Minneapolis in order to obtain information about current SANE
program structure and practice. Fifty-nine (68%) of the 86 programs
surveyed responded. Of these 59 programs responding, 3 were established
between 1976 and 1979; 10 between 1980 and 1989; and 46 between 1990
and 1996. Although the initial SANE development was slow with only
three programs in existence at the end of the 1970's, program development
today is progressing rapidly. During the progress of writing this manual,
117 SANE programs were identified and are listed in Appendix B. It is
anticipated that their number has already changed significantly. This list of
existing SANE programs will be updated on a SANE Web site
<www.sane-sart.com> that has been funded by the Office for Victims of
Crime, Office of Justice Programs, Department of Justice, which began
functioning in January 1999.

This current flurry of interest in SANE is to a great extent a result of the
media attention created by the 1994 recognition of the Tulsa SANE
program when it received the Innovations in State and Local Government
Award from the Ford Foundation and John F. Kennedy School of
Government at Harvard University (Yorker: 96). While Tulsa was
certainly not the first community to develop a SANE program, the Tulsa
program has taken an active role in promoting the concept. As a result,
individuals and private and public institutions across the country became
aware of the potential benefits of the SANE model for their own
community, and they became eager to explore the possibility of starting a
SANE program in their area. 

As a result, existing SANE programs have been inundated with requests
for information about the development and operation of the SANE model.
While those experienced in this field have been willing to do whatever
possible to assist individuals and groups in developing new programs, this
help has primarily been verbal assistance in answering questions and
offering advice to help individuals anticipate and overcome obstacles.
With each phone call from a new area, the process was repeated once
again. The caller, while highly motivated, was often unsure where to start
or even what questions to ask. The advice given was typically based on
personal experience in one program and did not necessarily meet the
needs of other communities.

Project Goals and Objectives

The Office for Victims of Crime (OVC), Office of Justice Programs
(OJP), U. S. Department of Justice (DOJ), recognized the need for
additional information and technical assistance when they funded this
project. OVC's goal, and the goal of this project, is to facilitate SANE
program development by providing information about existing SANE
program operation and development in a systematic and comprehensive
format. This manual is intended for those who want to develop a SANE
program and for those already operating a SANE program who want to
ensure that they are utilizing the most current information and standards.

The goal of this manual is to provide the necessary information to develop
and operate a SANE program in an easily understood format. It includes
references for or samples of many essential forms, policies, procedures,
protocols, training options, and program evaluation tools. Standards of
Practice are provided when there is a recognized standard. When program
options are a choice, advantages and disadvantages for each option are
discussed. 

The distinguished project staff and advisory committee working on this
project recognize that different communities have different needs and
resources. Whenever possible, these differences are addressed and options
provided with rationale for inclusion and selection. 

Scientific Basis of This Guide 

Work on this guide includes a complete review of the SANE literature.
The information available is included in this guide, with references, for
your use. In addition, this guide is based on information from the 59
(68%) programs who responded to the survey of the 86 programs
identified in the 1996 JEN survey (Ledray: 96b). Followup phone calls
were made to several programs to obtain additional information for
clarification. Since not every question was answered on every survey, the
information and numbers included are based on the answered questions
only and do not always add up to 59.

Since national certification or standardization of SANE programs and
training has not yet been implemented, this manual reflects the experience
and judgment of the project staff, advisory committee, and the programs
who responded to our request for information (See Appendix A: Project
Staff and Advisory Committee; and Appendix B: List of Participating
SANE Programs), as well as the current SANE literature. 

Terminology

She or He? 

While SANE programs deal with both male and female sexual assault and
abuse victims, for the most part female pronouns will be used in this guide
to refer to the victim population. This decision reflects the fact that the
majority of victims within this victim population are female. No intent
was made to exclude application to male victims. When it is established
that there are different needs based on the sex of the victim, these are
distinguished.

Rape, Sexual Assault, or Abuse? 

Since the legal definitions of rape, sexual assault, and abuse vary from
State to State, in this guide the terms will be used interchangeably to refer
to any unwanted contact of one person's sexual organs by another,
regardless of sex, with or without penetration, and with or without
resulting physical injury.

Victim or Survivor? 

The decision was made to refer to the victim of rape in this guide rather
than the survivor. This decision was made because of the request of many
victims to recognize the fact that they were victimized, and in the
emergency department (ED) they feel like a victim, not a survivor. In the
ED or SANE clinic during the initial period of crisis, few victims have
moved to survivor status. 

SANE Guide Evaluation 

A questionnaire is included at the back of this guide to assist in evaluating
its completeness and utility. The questionnaire consists of two pages
which are designed to be pulled from the manual, folded in half with the
address visible, stapled, and mailed. 

Your comments and suggestions will help to update and improve this
guide in the future so that it will be even more useful. We truly want and
need your assistance. Please complete the evaluation questionnaire and
return it once you have reviewed the information in this guide. 

CHAPTER 2  

HISTORY AND DEVELOPMENT OF SANE PROGRAMS

Even though rape has likely occurred for as long as humankind has
existed (Brownmiller: 75), there only has been a concerted effort to better
understand the issue and better meet the needs of survivors has developed
only since the early 1970's. One of the first researchers to systematically
study the impact on and needs of this population was Ann Burgess who
holds both a nursing degree and an Ed.D. (Burgess & Holmstrom: 74a).
Burgess identified a pattern of psychological response which she referred
to as Rape Trauma Syndrome (Burgess & Holmstrom: 74b), and she
continues to be actively involved in furthering the scientific understanding
of rape. 

Rape in the United States

The 1996 Uniform Crime Report indicates that 97,464 women were
forcibly raped in the United States in 1995. This represents a 5-percent
decrease in reported rapes from 1994, and a 9-percent decrease from
1991. Even though the numbers reported in the survey are declining, this
figure still indicates that in 1995, 72 of every 100,000 women in the
United States were the victims of a forcible rape and reported the crime to
the police. More rapes occurred in large metropolitan areas, where the rate
was 76 victims per 100,000 population, compared with 49 per 100,000 in
rural communities (Uniform Crime Report: 96).

Geographically, 39 percent of the 1995 forcible rapes occurred in the most
heavily populated Southern States, 25 percent in the Midwestern States,
23 percent in the Western States, and 13 percent in the Northeastern
States. The 2-year trend indicates there was a decline in all regions of the
country, especially in large metropolitan areas. During the 10-year period
that the rate of reported forcible rapes declined 10 percent in large
metropolitan areas, the rate actually increased 70 percent in smaller
suburban cities and 40 percent in rural areas. The Northeastern and
Midwestern States experienced a 6-percent decline, the Southern States a
5-percent decline, and the Western States a 2-percent decline in reported
forcible rapes. In 1995, the highest reporting rate occurred in August, and
the lowest reported rate was in December (Uniform Crime Report: 96). 

Despite these reported statistics, the actual rate of rape remains unknown.
We can only speculate that this increased reporting rate outside of
metropolitan areas represents an actual increase in crime. An increase in
reported rapes may also be the result of better community education,
increased service availability, and improved reporting of crime. Estimates
of the number of women who are actually raped range from an additional
four to an additional nine victims for every one woman who reports. In
one SANE program, while approximately 20 percent of victims are
uncertain about reporting when they first came to the ED, working
through their fears and concerns with a knowledgeable SANE has
empowered 95 percent of these survivors to report (Ledray: 92a).

As with all Crime Index offenses, reports of forcible rape are sometimes
considered "unfounded" by law enforcement, and they are then excluded
from the crime count. The rate of "unfounded" cases is notably higher for
rape than for any other index crime. In 1995, 8 percent of forcible rapes
were determined by law enforcement to be "unfounded," compared with 2
percent of all other index crimes (Uniform Crime Report: 96). Some
individuals in the criminal justice system may assume that all "unfounded"
cases are false reports, deceitfully reported and baseless. However, this is
not necessarily the case. Reported rape cases are actually classified by
police as "unfounded" for a variety of reasons. These reasons for
classifying a rape case as "unfounded" vary greatly from one community
to another, but the following are the most common reasons: 

--The police are unable to locate the victim.
--The victim decides not to follow through with prosecution.
--The victim repeatedly changes the account of the rape.
--The victim recants.
--No assailant can be identified.
--The police believe no rape occurred.

There are also a variety of other situations that impede or prevent
completion of the investigation and in which the case may be classified as
"unfounded" (Aiken: 93). Unfortunately, not everyone distinguishes
between "changing the story" and recalling additional data, or telling
different aspects of the same story, or distinguishing between an untrue
allegation and a victim who is so fearful of the assailant that she recants
her story out of fear for her life or the life of her family. The number one
reason victims give for not wanting to report is fear of the assailant, whose
parting words in 76 percent of the cases were, "If you tell anyone... (or
report to the police), I'll come back and kill you...rape you again...rape
your child" (Ledray: 96a).

Unfortunately, only 4 percent of rapists go to jail either as the result of
guilty pleas or guilty verdicts (Minneapolis Police Chief's Report: 89).
This is true even though 51 percent of reported forcible rapes in
metropolitan areas are cleared by arrest and 52 percent in rural and
suburban areas. The arrest rate for forcible rapes declined in 1995 by 
4 percent in metropolitan areas, 6 percent in suburban areas, and 14
percent in rural areas (Uniform Crime Report: 96). The results were
slightly better in an earlier Detroit report which indicated out of 372
reported rapes, convictions resulted in 13 percent of these cases (Tintinalli
& Hoelzer: 85).

Violence has a significant impact on the physical and psychosocial health
of millions of Americans every year. Since women are so often the
victims of violence, it is essential that women who present to emergency
departments for even minor trauma be thoroughly evaluated. ED staff
must be aware of the types of injuries most likely resulting from violence,
and the victim must be asked about the cause of the trauma to determine if
it is the result of violence and further evaluation is required (Sheridan:
93). When violence such as rape is identified, trained staff need to be
available to provide services. Only in 1992 did the guidelines of the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO)
first require emergency and ambulatory care facilities to have protocols on
rape, sexual molestation, and domestic abuse (Bobak: 92).

Fortunately, women's groups have been working to provide services to
victims of violence, such as rape and domestic abuse, before large sums of
money were available to support these grassroots programs. Rape centers
began to be established across the country in the early 1970's, primarily
utilizing volunteer staff. While the sexual assault recovery movement and
most rape centers continue to depend upon volunteer labor, more money is
becoming available to pay staff. Goodyear (1989) suggests that staff must
be paid for their work with rape victims. Women working as volunteer
workers help perpetuate the tradition of women as unpaid caregivers and
allows society to avoid responsibility.

The landmark Violence Against Women Act (VAWA) of 1994 was
introduced by Senator Biden and signed into law on September 13, 1994,
as Title IV of the Violent Crime Control and Law Enforcement Act of
1994. In addition to doubling the Federal penalties for repeat offenders
and requiring date rape to be treated the same as stranger rape, this Act
made $800 million available for training and program development over a
6-year period. This was an important recognition of the need for
specialized services for female crime victims of violent crime. 

Demonstrating the Need for SANE Programs

The impetus to develop SANE programs began with nurses, other medical
professionals, counselors, and advocates working with rape victims in
hospitals, clinics, and other settings. These individuals recognized that
services to sexual assault victims were inadequate and not at the same
high standard of care as for other ED clients (Holloway & Swan: 93;
O'Brien: 96). When rape victims came to the ED for care, they often had
to wait as long as 4 to 12 hours in a busy, public area; their wounds were
seen as less serious than the other trauma victims; and rape victims
competed unsuccessfully for staff time alongside the critically ill
(Holloway & Swan: 93; Sandrick: 96; Speck & Aiken: 95). They were
often not allowed to eat, drink, or urinate while they waited, for fear of
destroying evidence (Thomas & Zachritz: 93). Doctors and nurses were
often not sufficiently trained to do medical-legal exams, and many were
also lacking in their ability to provide expert witness testimony (Lynch:
93). Even when they had been trained, staff often did not complete a
sufficient number of exams to maintain their level of proficiency
(Lenehan: 91; Yorker; 96; Tobias: 90). Even when the victim's medical
needs were met, their emotional needs all too often were overlooked
(Speck & Aiken: 95), or even worse, the victim was blamed for the rape
by the ED staff (Kiffe: 96).

Typically, the rape victim faced a time-consuming, cumbersome
succession of examiners for one exam, some with only a few hours of
orientation and little experience. ED services were inconsistent and
problematic. Often the only physician available to do the vaginal exam
after the rape was male (Lenehan: 91). While approximately half of rape
victims in one study were unconcerned with the gender of the examiner,
for the other half this was extremely problematic. Even male victims often
prefer to be examined by a woman, as they too are most often raped by a
man and experience the same generalized fear and anger towards men that
female victims experience (Ledray: 96a).

There are also many anecdotal and published reports of physicians being
reluctant to do the exam. This was due to many factors including their
lack of experience and training in forensic evidence collection (Bell: 95;
Lynch: 93; Speck & Aiken: 95), the time-consuming nature of the
evidentiary exam in a busy ED with many other medically urgent patients
(DiNitto et al.: 86; Frank: 96), and the potential that if they completed the
exam they were then vulnerable to being subpoenaed and taken away from
their work in the ED to testify in court and be questioned by a sometimes
hostile defense attorney (Thomas & Zachritz: 93; DiNitto et al.: 86; Speck
& Aiken: 95; Frank: 96). This often resulted in documentation of evidence
that was rushed, inadequate, or incomplete (Frank: 96). Many physicians
even refused to do the exam (DiNitto et al.: 86). In one case, it was
reported that a rape victim was sent home from a hospital without having
an evidentiary exam completed because no physician could be found to do
the exam (Kettelson: 95). 

As research became more readily available on the complex needs and
appropriate followup of rape victims, nurses and other professionals
realized the importance of providing the best ED care possible (Lenehan:
91). For 75 percent of these victims the initial ED contact was the only
known contact they had with medical or professional support staff
(Ledray: 92a). Nurses also were very aware that while they were credited
with only "assisting the physician with the exam," in reality they were
already doing everything except the pelvic exam (DiNitto et al.: 86;
Ledray: 92a). It was clear to these nurses that it was time to re-evaluate
the system and consider a new approach that would better meet the needs
of sexual assault victims.

History of SANE Program Development

To better meet the needs of this underserved population, the first SANE
programs were established in Memphis, TN in 1976 (Speck & Aiken: 95);
Minneapolis, MN in 1977 (Ledray & Chaignot: 80; Ledray: 93b); and
Amarillo, TX in 1979 (Antognoli-Toland: 85). Unfortunately, these nurses
worked in isolation until the late 1980's. In 1991, Gail Lenehan, editor of
the Journal of Emergency Nursing (JEN), recognized the importance of
this new role for nurses and published the first list of 20 SANE programs
(ENA: 91).

In 1992, 72 individuals from 31 programs across the United States and
Canada came together at a meeting hosted by the Sexual Assault Resource
Service and the University of Minnesota School of Nursing in
Minneapolis. At that meeting, the International Association of Forensic
Nurses (IAFN) was formed (Ledray & Simmelink: 97). The IAFN is an
international professional organization of registered nurses formed to
develop, promote, and disseminate information about the science of
forensic nursing nationally and internationally. Membership in IAFN
surpassed the 1,000 mark in 1996 and continues to grow (Lynch: 96).

While the initial SANE development was slow, with only three programs
operating by the end of the 1970's, development today is progressing
much more rapidly. We are now aware of 10 new programs that were
established between 1980 and 1989, and 73 additional SANE programs
established between 1990 and 1996. Eighty-six SANE programs were
identified and included in the October 1996, listing of SANE programs
published in JEN (Ledray: 96b). This number is likely to grow much more
rapidly in the years to come. 

After years of effort on the part of SANEs and other forensic nurses, the
American Nurses Association (ANA) officially recognized Forensic
Nursing as a new specialty of nursing in 1995 (Lynch: 96). SANE is the
largest subspecialty of forensic nursing. At the 1996 IAFN meeting in
Kansas City, Geri Marullo, Executive Director of ANA, predicted that
within 10 years the Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO) would require every hospital to have a forensic
nurse available (Marullo: 96). 

Statewide networks of SANE programs have recognized the need to
develop State policies, procedures, and guidelines to direct SANE
program operations in their area. State guidelines and procedures always
take precedence over the recommendations in this guide. 

CHAPTER 3  

SANE PROGRAM MODEL 

Before deciding to start a SANE program, it is important to understand
what a SANE program does and does not do, the scope of nursing
practice, and how a typical SANE program operates. This chapter defines
the terms typically used in relation to SANE programs. An example of
SANE program values statement, mission statement, goals, and scope of
practice are presented. The chapter concludes with a discussion of the
operation of a model SANE program and its impact on the community.

What Is a SANE? SANC? SAFE? FNE?

Since forensic nurse examiner programs began independently and
functioned independently until the first meeting held in Minneapolis in
1992, different terminology has been used across the country to define the
new role. The Minneapolis program used the term Sexual Assault Nurse
Clinician (SANC) to denote a clinical nursing role that went beyond
examination of the sexual assault victim. The SANC role in Minneapolis
broadened the continuum of services provided to sexual assault victims,
emphasizing crisis intervention and supportive counseling in the ER
setting, and continuing with followup counseling by specially trained
nurse counselors. To avoid a conflict in roles, the nurse counselor who
provides followup services is a separate clinician from the SANC who
provides services to the victim in the ER. The Memphis program, like
many others, preferred the acronym SANE--Sexual Assault Nurse
Examiner. 

Some newer programs have chosen to use the more generic term of Sexual
Assault/ Forensic Examiner (SAFE) or Forensic Nurse Examiner (FNE).
A program in Minnesota has chosen the SAFE terminology because they
hope to move beyond examination of only sexual assault victims to the
completion of evidentiary exams on domestic abuse victims, accident
victims, and other populations where forensic evidence collection may be
useful. Forensic evidence is all too often overlooked in busy medical
facilities where the focus is on clinical treatment. 

At the October 1996 IAFN annual meeting held in Kansas City, the SANE
Council voted on the terminology it wanted to use in the standards to
define this new position. While there were some dissenting votes, the
overwhelming decision was to use the title SANE, Sexual Assault Nurse
Examiner. 

A Sexual Assault Nurse Examiner (SANE) is a registered nurse, R.N.,
who has advanced education in forensic examination of sexual assault
victims. In some areas, the SANE is still referred to by other names,
including Sexual Assault Nurse Clinician (SANC), and Sexual Assault
Forensic Examiner (SAFE). While the preference for particular
terminology may vary, for the purpose of this manual the term SANE is
used.

SANE Program Values, Mission, and Goals 

According to Peter Drucker there are five questions that must be answered
to effectively assess the values, mission, and goals of a nonprofit
organization (Rossum: 93). A mission statement should clearly and
succinctly describe an organization's reason for being. To develop a
mission statement begin by asking the following:

1. What is our business (mission)? What are we trying to achieve? What
specific results are we seeking? What are our major strengths? What are
our major weaknesses? 

After addressing the above question, focus on the following questions:

2. Who is our customer or client? Who is the primary customer (service
users)? Who are our supporting customers (Board, volunteers, staff, law
enforcement, prosecutor, other agencies)? Will our customers change? 

3. What does the customer or client value? What do our primary
customers value? What do our supporting customers value? How are we
providing what our customers or clients value?

4. What have been our results? How do we define results? To what extent
have we achieved these results? How are we using our resources?

5. What is our plan? What have we learned and what do we recommend?
Where should we focus our efforts? What, if anything, should we do
differently? What is our plan to achieve results?

Answering these questions is a critical step in ensuring that an
organization focuses on the activities that will achieve the desired results.
The following are examples of SANE program values, mission statement,
and goals.

Values Statement

The basis of a SANE program operation is the belief that sexual assault
victims have the right to immediate, compassionate, and comprehensive
medical-legal evaluation and treatment by a specially trained professional
who has the experience to anticipate their needs during this time of crisis.
As health care providers, the SANE has an ethical responsibility to
provide victims with complete information about choices so victims can
make informed decisions about the care they want to receive.

A SANE program is also based on a belief that all sexual assault victims
have a right (and responsibility) to report the crime of rape. While every
victim may not choose to report to law enforcement, she has a right to
know what her options are and what to expect if she does or does not
decide to report. Those who do report also have a right to sensitive and
knowledgeable support without bias during this often difficult process
through the criminal justice system. Those who do not report still have 
a right to expert health care.

In addition, a SANE program is based on the belief that providing a
higher standard of evidence collection and care can speed the victim's
recovery to a higher level of functioning, prevent secondary injury or
illness, and ultimately increase the prosecution of sex offenders and
reduce the incidence of rape.

Mission Statement

The primary mission of a SANE program is to meet the needs of the
sexual assault victim by providing immediate, compassionate, culturally
sensitive, and comprehensive forensic evaluation and treatment by trained,
professional nurse experts within the parameters of the individual's State
Nurse Practice Act, the SANE standards of the IAFN, and the individual
agency policies.

Program Goals

This next step involves the development of specific goals and objectives.
The following are examples of SANE program goals:

--To protect the sexual assault victim from further harm. 

--To provide crisis intervention. 

--To provide timely, thorough, and professional forensic evidence
collection, documentation, and preservation of evidence.

--To evaluate and treat prophylactically for sexually transmitted
diseases (STDs).

--To evaluate pregnancy risk and offer prevention. 

--To assess, document, and seek care for injuries. 

--To appropriately refer victims for immediate and followup medical
care and followup counseling.

--To enhance the ability of law enforcement agencies to obtain
evidence and successfully prosecute sexual assault cases.

Based on the above values, mission statements, and program goals, each
SANE program should develop a community-specific strategic plan or
developmental plan of action. This process involves translating the values
and mission statements into action. Where are we now? What do we have
to do to get to where we want to be? This plan of action is the blueprint
for obtaining financial support (See Chapter 6: A Look at Funding). 

SANE Scope of Practice

A SANE program provides 24-hour on call services for all male and
female victims of sexual assault or abuse.

Medical Care

The purpose of the SANE examination of the sexual assault victim is
specifically to assess, document, and collect forensic evidence. In
addition, prophylactic treatment of STDs and prevention of pregnancy are
provided by the SANE following a pre-established medical protocol or
with the approval of a consulting physician. While the SANE may treat
minor injuries, such as washing and bandaging minor cuts or abrasions,
further evaluation and care of any major physical trauma is referred to the
ED or a designated medical facility. 

The SANE conducts a limited medical examination, not a routine physical
examination, and clearly explaining this difference to the client is
important. Obvious pathology or suspicious findings that may be observed
are reported to the client with a suggestion for followup care and referral.
Evaluation and diagnosis of pathology is beyond the scope of the SANE
examination.

Reporting and Victim Support

While the SANE is not a legal advocate, she does provide the rape victim
with information to assist her in anticipating what may happen next in
making choices about reporting and deciding who to tell and to ensure that
she gets the support she will need after she leaves the SANE facility. This
usually includes a discussion between the victim and the SANE about
reporting to law enforcement. If the victim has made a choice not to
report, she needs to discuss why she may be hesitant to report. In most
cases, the SANE encourages the victim to report the crime and makes
referrals to legal advocacy agencies that can provide the support necessary
to help the victim through the criminal justice process. 

The SANE also provides emotional support and crisis intervention. The
SANE makes an initial assessment of the victim's psychological
functioning sufficient to determine if she is suicidal, oriented to person,
place, and time; or if she is in need of referral for followup support,
evaluation, counseling, or treatment. 

Education, Training, Research, and Program Evaluation

In addition, the SANE is active in training personnel from other health
care and community agencies who provide services to sexual assault
victims. Each SANE program also conducts ongoing program evaluation
and periodic research studies to evaluate the impact, treatment needs,
client outcomes and services provided to sexual assault victims. This
should include a variety of program output, process, and outcome
evaluation research activities.

SANE Standards of Practice

At the 1996 annual meeting of IAFN, the SANE Council voted and
adopted the first SANE Standards of Practice. The standards incorporate
the following: 

--Goals of Sexual Assault Nurse Examiners.

--Definition of the practice area.

--Conceptual framework of SANE practice.

--Components of evaluation and documentation.

--Forensic evaluation components.

--SANE minimum qualifications. 

For a nominal fee, a copy of the SANE Standards of Practice may be
obtained by telephoning IAFN at 609-848-8356 or writing to IAFN 6900
Grove Road Thorofare, NJ 08086-9447. 

While this guide was being developed, many State policies, protocols, or
regulations have emerged. For example, based on the IAFN SANE
Standards of Practice, the Virginia State Council of Forensic Nurses
published their own Standards of Practice for Sexual Assault Nurse
Examiners (1997). Always determine if there are State policies and
standards relevant to the operation of SANE programs within your own
State before implementing a SANE program in you area. You may request
a copy of the Virginia Standards by contacting Kim Wieczorek, RN, BSN,
FNE at telephone number 804-281-8574 or writing to: St. Mary's Hospital
Emergency Department, Forensic Nurse Examiners, 5801 Bremo Road,
Richmond, VA 23226.

How a Model SANE Program Operates

A SANE is usually available on call, off premises, 24 hours a day, 7 days
a week. The on call SANE is paged immediately whenever a sexual
assault or abuse victim enters the community's response system. If the
protocol indicates a rape advocate should be called, the staff or SANE also
will page the advocate on call. 

Hospital-Based SANE Programs

If the SANE program is hospital-based, victims may enter the system in
the following ways: 

--Calling local law enforcement who will transport them to the
hospital emergency department or SANE exam clinic.

--Going directly to the hospital emergency department or hospital
clinic.

--Calling the designated crisis line for assistance. 

During the time it takes for the SANE to respond (usually no more than 1
hour), the ED or clinic staff will evaluate and treat any urgent or life-
threatening injuries. If treatment is medically necessary, the ED staff will
treat the client, always considering and documenting thoroughly the
forensic ramifications of the lifesaving and stabilizing medical procedures.
If clothes or objects are removed from the victim by the ED staff, care
should be taken utilizing forensic principles for handling and storage of
the physical evidence. If medical necessity dictates treatment prior to the
arrival of the SANE, ED staff will take photographs following established
forensic procedures. However, it is preferable that the SANE take all
forensic photographs. 

When the ED staff determines that the victim does not require immediate
medical care, the victim is made comfortable in a private room near the
ED. This area should enhance the victim's sense of safety and security
and provide comfort and quiet in a sound-proof room with comfortable
furniture, preferably a sofa that she can lie down on while she waits, a
telephone, and a locked door. Family members who accompany the
victim, with the victim's permission, should be allowed to stay with the
victim while she waits. If there was no oral sex, she is offered something
to eat or drink while she waits. 

If she has not yet filed a police report and she knows she wants to do so,
the triage nurse will call the police to take the initial report at the 
hospital.
If the victim is upset, and a hospital chaplain or social worker is available
on site, with her permission, they will be called to wait with her until the
SANE, advocate, or counselor arrives.

Community-Based SANE Programs

If the SANE program is community-based, victims may enter the system
in the following ways: 

--Calling the local law enforcement where they will be triaged for
injuries and, if only minor injuries or no injuries are present, they will be
transported to the community-based SANE facility by law enforcement.

--Going to the ED of a local hospital on their own, where they will be
triaged for injuries, and if there are only minor injuries or no injury
present, they will be transported to the community-based
SANE program.

--Going directly to the community-based SANE program during office
hours.

--Calling the designated crisis line for assistance and receiving a referral to
the community-based SANE program.

Community Response and Responsibilities 

In response to a sexual assault victim in the community, law enforcement
is charged with initiating the investigation of the crime and determining if
the client has serious injuries necessitating ED evaluation or care. If
moderate to severe injury is detected, the victim is evaluated by
paramedics and referred to the hospital ED. This occurs with less than 4
percent of rape victims, as rape seldom involves serious injury (Tucker,
Ledray & Werner: 90). 

Life-threatening injuries indicate whether the client needs to go to the
hospital ED first rather than to a SANE facility. When no injuries are
suspected, the client is transported from the crime scene to the community
SANE facility where she is met by the SANE within 1 hour. If the victim
goes directly to a hospital ED, the staff will evaluate the victim for
life-threatening injuries requiring immediate treatment. When these are
present, the ED staff will admit the victim to the ED and notify the on call
SANE to come to the hospital ED. The ED staff will evaluate and treat the
injuries, always considering the forensic implications of the lifesaving and
stabilizing medical procedures. Clothing or objects removed from the
client are handled and labeled to maintain the proper chain-of-evidence.
Photographs are taken of the injuries for forensic purposes by the ED
staff. After the patient is stabilized medically, the SANE will collect the
forensic evidence in the designated ED area.

When the ED staff determines that the patient does not require urgent or
lifesaving medical care, the victim is not admitted to the hospital. She is
instead transported by law enforcement to the community-based SANE
program facility.

SANE Responsibilities

Once the SANE arrives, she is responsible for completing the entire sexual
assault evidentiary exam including crisis intervention, STD prevention,
pregnancy risk evaluation and interception, collection of forensic
evidence, and referrals for additional support and care.

When the victim is uncertain about reporting. If the victim has not yet
decided if she wants to report, the SANE will discuss the victim's fears
and concerns with her and provide her with the information necessary to
make an informed decision.

If the victim does not want to report at this time, but is unsure if she will
report at a future date, the SANE will make sure the victim is aware of her
options and the limitations of reporting at a later date. The SANE will also
offer to complete an evidentiary exam kit that can be held in a locked
refrigerator for a specified time (usually 1 month or an appropriate period
of time as mandated by State statutes if any exist) in case she chooses to
report later. 

Mandatory reporting. In States with mandatory reporting laws for felony
crimes or child abuse, the SANE will follow established protocol for
reporting after explaining the process and her responsibilities to the victim
or the victim's family when a child is involved and a parent is present.
(NOTE: This is different from statutory rape laws which are discussed in
Chapter 13: Policies and Procedures.)

When the victim does not want to report. If the victim decides not to
report and an evidentiary exam is not completed, the SANE can still offer
her medications to prevent STDs, evaluate her risk of pregnancy, and
offer pregnancy prevention for up to 72 hours post-rape. The SANE also
will make referrals for followup medical care and counseling and provide
the victim with written followup information.

When a report is made. When a report is made or the victim is certain she
will be reporting, a complete evidentiary exam is conducted following the
SANE agency protocol. In most agencies, the complete exam is conducted
within 36 hours of the sexual assault, and an abbreviated exam is
completed between 36 and 72 hours post-rape (up to 96 hours in some
States). (NOTE: Please see the Section on seminal fluid evidence in
Chapter 11: SANE Program Operation, which describes the rationale for
use of the complete versus the abbreviated exam.)

After obtaining a signed consent, the SANE will conduct a complete exam
including the collection of evidence in a rape kit, further assessment and
documentation of injuries, prophylactic care for STDs, evaluation of
pregnancy risk and preventive care, crisis intervention, and referral for
followup medical and psychological care. 

Discharge. If the victim is alone, the SANE will talk with her about whom
she would like to call and where she will go from the hospital. Every
effort will be made to find a place for her to go where she will feel safe
and will not be alone. When necessary, arrangements may be made for
shelter placement. If she is intoxicated or does not want to leave until
morning, arrangements may be made for her to sleep in a specified area of
the hospital when this type of space is available. In many facilities, this
will be an ED holding room or crisis center. If necessary, a community
referral can be made to better meet her long-term housing needs.

Community Impact and Benefit

A SANE program cannot operate in isolation and be effective. Developing
good community relationships must begin with the decision to consider
developing a SANE program. When cooperating agencies are informed
about the SANE model of care, they are more likely to see the benefits of
collaborating with the SANE program to help victims. Working closely
with community resources from the very beginning will encourage
collaboration in the future. As a collaborative effort, the community can
decide the type of SANE program which best meets the community needs.

Change is often threatening because the results are unknown. It is
common to have some resistance to any change including the
implementation of a SANE program. Just because one may encounter
resistance, even strong resistance, it does not follow that the idea is a bad
one, or that it won't succeed. Chapter Five: Assessing the Feasibility of a
SANE Program addresses the types of resistance others have encountered,
along with information on how they were able to resolve these obstacles. 

The next chapter on developing a sexual assault response or resource team
concentrates on developing and maintaining strong working community
relationships.

CHAPTER 4  

SART: A COMMUNITY APPROACH

No SANE program can operate in isolation. To be optimally effective and
provide the best service possible to victims of sexual assault, the SANE
must function as a part of a team of individuals from community
organizations. They can be either formally organized as a Sexual Assault
Response/Resource Team or as informal collaborators.

Communities that have chosen to organize formally into a team have
developed different concepts of a Sexual Assault Response/Resource
Team (SART). One way is to work as a team of individuals who respond
together to jointly interview the victim at the time of the sexual assault
exam. Another way is to work independently on a day-to-day basis but
communicate with each other regularly (possibly daily, and meet weekly
or monthly) to discuss mutual cases and solve mutual problems thus
making the system function more smoothly. 

Who Is on a SART?

SART team members typically include the SANE, police or sheriff,
detective, prosecutor, rape crisis center advocate or counselor, and
emergency department medical personnel. The makeup of the SART team
will vary from area to area, depending upon the community needs and
resources. Ideally the team will include representatives from the
community who can best help the victims. In some areas, it may include
the SANE and the police. The SART team may also include an expanded
range of professionals who work with specific victims populations: a
school counselor, a battered women's advocate, a counselor who works
with prostitutes, and any combination of representatives of programs in
the community who are concerned about the problem of sexual assault.
The team membership may change over time depending on the needs of
the clients and the goals of the SART team. 

The Sexual Assault RESPONSE Team Model

The original SART model, developed in California, involves a coordinated
response. This SART concept is based on the belief that a team response
helps prevent the victim from reporting the account of the assault
repeatedly. It also helps prevent confusion among professionals trying to
meet the needs of the rape victim as she progresses through the health care
and criminal justice systems.

In communities using the California SART model where multiple
members of the SART respond to the emergency department together to
conduct the sexual assault exam, the team usually includes law
enforcement, the SANE, and a rape advocate. They are all present when
the victim makes her initial statement so she only needs to tell the account
once. 

How a Sexual Assault RESPONSE Team Operates

When law enforcement is called to the scene of a sexual assault, they will
protect the client from further harm, protect the crime scene evidence, and
take a limited statement from the victim to determine if a sex crime was
committed. They will then call the hospital ED triage who will page the
SANE on call and the rape advocate on call. When the police and victim
arrive at the hospital, the SANE will decide if the victim should be
directed to the ED for medical evaluation by a physician, or directed
immediately to the SANE area for forensic examination. The SANE will
stay with the victim during any necessary medical evaluation and until she
is cleared medically and transferred to the SANE examination area.

If a client presents to the ED initially, law enforcement is called
immediately to determine if a crime has been committed. The SANE and
advocate may also be called to help facilitate the victim's admission to the
SART system. In a limited number of communities, a prosecuting attorney
also responds to the hospital as a member of the SART. The police are
called initially in many areas to certify that a crime has been committed,
because in these locales, the hospital is compensated for the medical
evidentiary exam only if there is an accompanying police statement
certifying that there was a crime. For a more comprehensive discussion of
issues related to compensation, please refer to the section on SANE
Program Funding Options in Chapter Six of this manual.

With the advocate present to provide support, the SANE and police
conduct an indepth interview of the victim after briefly conferring to
coordinate questioning and reduce repetition. In California, the penal code
gives the victim a right to have any two individuals of her choice present
for support during police questioning. The advocate may be one of these
two. Once the interview is completed, the police officer will wait outside
the exam room while the SANE collects the evidence which is then turned
over to law enforcement or locked in a secured area for law enforcement
to pick up at a later time. With the victim's permission, the advocate will
remain in the exam room to provide support during the exam as well.

When the exam is completed, the SANE will make any necessary
arrangements for followup medical care, and the advocate will make
arrangements to contact the victim for followup supportive counseling and
legal advocacy.

Members of the SART may also meet regularly to discuss cases, or they
may communicate informally after the initial ED experience.

Sexual Assault RESPONSE Team Model Limitations

While the coordinated effort of a SART certainly has some advantage,
there are also some limitations to this approach. If the victim is uncertain
about reporting, she may feel pressured to report when protocol requires
law enforcement personnel to interview the victim before the SANE
becomes involved. The advocate will support the victim in whatever
decision she makes, even if the decision is not to prosecute. If the victim
decides not to report, this also may result in a victim who cannot access
health care for STD and pregnancy risk evaluation and prevention.

If the victim decides not to report, the hospital care is then typically not
paid by the crime victims compensation fund. When the police authorize
reimbursement, they are more likely to require that a police report be
made. In areas where payment is authorized through another agency,
reporting is not necessarily a requirement for payment. Detailed
information on compensation issues is provided in Chapter Six: A Look at
Funding. 

In addition, while repetition of the account of the sexual assault is
certainly an unpleasant experience that most victims want to avoid, the
assumption that they will be better off if they do not have to do so is only
a presumption. Research of treatment efficacy has in fact shown that
repetition of the account of the assault in detail has a beneficial,
desensitizing, healing effect (Foa: 97).

The Sexual Assault RESOURCE Team Model 

Other parts of the country have modified the initial SART model to better
meet the needs of their community while trying to maintain the team
concept that the SART model fosters. In many of these other areas, while
the team members meet regularly and communicate routinely about cases,
they do not actually respond at the same time. They function
cooperatively, not conjointly, which is why some choose to refer to
themselves as a resource team, rather than a response team. 

In these areas, the police respond to the crime scene and take the initial
report and then transport the rape victim to the hospital or SANE clinic.
The SANE assumes responsibility for the care of the rape victim at the
hospital or SANE clinic and completes the evidentiary exam. The police
officer is not present during the exam and may not even wait at the
hospital. Rather, the SANE will call the police when the exam is
completed, and they will return for the victim. After discussing the exam
findings with the SANE, the police may also take possession of the
evidence and provide the victim with a safe ride home. 

If the victim comes to the hospital before contacting the police, with the
victim's permission, the SANE may call the police to come to the hospital
to take the initial report. The police may complete the report at the
hospital, and the SANE may then be present during the interview. 

The rape center advocate may bring a victim to the hospital or be paged at
the same time the SANE is paged. The advocate may also be contacted at
a later point in time to provide followup advocacy and counseling. The
advocate will likely go with the sexual assault victim when meeting with
the sex crimes detective and prosecutor at a later point in time.

Most areas also have a standing SART meeting to discuss broader
concerns and to communicate informally about specific cases. The goal of
this type of meeting is to gather the primary decision-makers, such as the
directors or managers of the involved agencies, and resolve problems that
affect the group as a whole. At this meeting, the nature of the SART's
work is usually broader policy issues, rather than specific case issues.

The Sexual Assault Resource Team needs to be aware of how the victim's
testimony can jeopardize her case should she want to prosecute. For
example, when the victim tells her account of the assault to the police, the
SANE, the prosecutor, and the advocate at different times, her memory
and the completeness of each account may vary somewhat. When present,
these discrepancies must be addressed if the case goes to court. Therefore,
all team members need to meet or communicate over the phone to discuss
cases, issues, and concerns. While in many States, sexual assault
advocates who have completed the required training cannot be subpoenaed
to testify in court, both the SANE and law enforcement personnel will be
called, and they need to have consistent facts about each case. 

Summary

For a SANE program to be successful, all involved agencies must work
together. It takes a coordinated community approach to deal with the
multiple needs of the rape victim and to prosecute the offender. However
the SART model operates, whomever is included on the team, whatever
name is used to describe the team, the important concern is ensuring a
coordinated community response with the needs of the victim as the
primary focus.

CHAPTER 5  

ASSESSING THE FEASIBILITY OF A SANE PROGRAM

The first step in determining the feasibility of developing a SANE
program is to determine a community's need. If the need is there, then
obstacles to SANE program development must be identified, and adequate
support or resources to overcome these obstacles must be obtained. 

Needs Assessment

A community needs assessment must be completed before making the
decision that a SANE/SART program is appropriate for the community.
Potential funders will ask for this information before they consider
financially supporting the concept. Keeping an open mind during this
initial assessment phase is important because a simpler change may be
sufficient to provide adequate community services for sexual assault
victims. On the other hand, it may be that, while there is need for
implementing a SANE/SART program, sufficient community support may
not exist. Perhaps all that can be accomplished initially is to plant the first
seed of the idea that may take several years to germinate. 

Many communities have agencies who conduct needs assessments. If
possible, identify such a local resource to work with because a properly
done needs assessment can be very time-consuming and expensive. Even
though a needs assessment may be a source of additional work, it is
extremely beneficial, adding credibility to pleas to establish a SANE
program. 

Identifying Allies

Begin by talking to people in the community who work with rape victims
or who are concerned about the problem of rape, such as personnel in law
enforcement, hospitals, teen medical clinics, district attorneys' offices,
and victim assistance organizations. Explain the SANE/SART concept to
them and look for potential allies in program development and
membership on a community resource team.

Determining the Extent of the Community Problem of Rape 

While meeting with community players, determine the number of rapes
that occur in the community each year. Getting a count of the actual
number of rapes may be more difficult to determine than anticipated. At
a minimum, talk with people from the local police department, rape crisis
center, medical facility, and prosecuting attorney's office. Ask these
people about who else should be contacted.

Provide information about the SANE/SART concept to individuals who
are interested in improving services to victims of rape. Use this
information to identify one individual in each agency who is involved in
providing care to sexual assault victims, who is knowledgeable about the
current system, and who may be willing to work to try to improve those
services. Offer to send them some information describing the
SANE/SART concept and how it works, prior to the initial visit. The
articles "Sexual Assault Nurse Clinician: A fifteen-year experience in
Minneapolis" and "The Sexual Assault Examination: Overview and
lessons learned in one program," in the Journal of Emergency Nursing,
June 1992 (Ledray: 92a & 92b), are good choices because they are concise
and easy to read and because they contain discussions about and
demonstrate the advantages of the SANE concept for other agencies. They
also summarize the most common obstacles and resistance to the
development of a SANE program and provide accurate information to
counter these concerns. Follow up these contacts with a personal visit to
each agency.

Assessing Community Services and Developing Community Support

Law Enforcement

Start by contacting the local police department. Ask if they have a special
unit that investigates rape cases. If one exists, get the name and phone
number of the police officer in charge of this unit. Call that person and
obtain the following information:

--What are the number of reported sexual assaults the unit receives each
year? Ask for detailed clarification of the numbers. For example, some
police departments include the number of indecent exposures in their 
sex crimes statistics; others may just include stranger rapes or only rapes
that involve vaginal/penile penetration. Ask about the numbers of adult,
adolescent, and child sexual assault victims. Remember, the literature
suggests that the actual rate for sexual assaults is 5 to 10 times the number
of rapes reported. 

--What percentage of rape reports do the police consider unfounded and
how do they determine that a rape report is unfounded? 

--How efficient and effective do the police consider the current medical
response? 

--Do officers have long waits after they take a rape victim to the hospital? 

--Where do they usually take the rape victims they see, and why do they
go to that particular medical facility? 

--Is the medical evidence collected complete and is the proper
chain-of-evidence maintained? 

--Is the medical staff cooperative in sharing information with them and
helping them gain access to the medical records and maintaining contact
with the victims? 

--Are the police familiar with the SANE/SART concept, and if so, do
they think it could improve victim services in the community?

Rape Crisis Center

The local rape crisis center should be asked the following: 

--How many rape victims do staff see each year? 

--How many crisis calls does the center receive?

--What are the victims saying about medical services?

--What percentage of the victims have reported the rape to law
enforcement? 

--What is the staff's assessment of the effectiveness of the current medical
response?

--What does staff believe are the strengths and weaknesses of the current
health care response?

--What percentage of rape victims, do staff believe, have rape exams
completed? 

--Are staff familiar with the SANE/SART concept, and if so, how do they
think it could improve community victim services? 

Medical Facility

The next step is to identify which medical facilities in the community see
most of the rape victims. Begin by calling the ED nurse managers and
asking how many rape victims their facility sees each month and year. Try
to identify a staff person, probably a doctor or nurse in the ED or women's
clinic who works with the rape victims at each facility and who is
particularly concerned about their care, and ask that person for the
following information:

--How many rape exams does the clinic (or ED) do each year? An estimate
may be all that is available as hospitals often do not record the sexual
assault as a primary diagnosis and if they do, they may include both victim
and perpetrator exams. Consequently, the number of sexual assault victims
seen may not be retrievable, and when cases are identified, the numbers
may not be accurate.

--How are exams done, and by whom? Ask for a copy of their protocol
and ask if the doctors or nurses currently doing the rape exams are
satisfied with the system. 

--Are they familiar with the SANE/SART concept, and if so, do they think
it could improve services for victims at their facility?

Prosecuting Attorney

Talk to the prosecuting attorney who is most active prosecuting sexual
assault cases. Larger jurisdictions often have a special sex crimes
prosecuting unit. When available, the lead attorney in that unit will be the
best person to provide the following information: 

--What are the number of rapes the prosecutor's office reviews each year?

--What number do they charge, plea bargain, and take to trial? 

--What is their experience with the rape kit evidence? 

--Is the kind of evidence they need from the local medical facilities
provided? 

--Do they work together with the medical staff to improve the evidence
collection process? 

--Do they encounter problems in getting medical staff to testify? 

--What are the advantages of working together with the medical staff?

--Are they familiar with the SANE/SART concept, and if so, how could it
improve evidence collection? 

Other Agencies

Ask the above contacts to identify additional agencies or individuals who
they believe are key community players working with sexual assault
victims. This could be a program in the school system, a pediatric clinic, a
domestic violence program, a local women's group, or a church group. Be
sure to include them in the assessment phase.

Meeting with these agencies should provide a more accurate idea of the
services available for rape victims in the area, the problems with the local
system, the support for change that currently exists, and the resistance or
obstacles to implementing a SANE/SART program that might be
encountered.

Identifying and Overcoming Obstacles 

Obstacles identified in the literature that SANE programs have had to
overcome include the following: 

--The fear of physicians that the SANE would miss injuries in the initial
exam (Ledray: 96a; O'Brien: 96a).

--The concern of physicians that they will still be called to testify in court
even though they did not complete the exam (Ledray & Simmelink: 97). 

--The belief of prosecutors that a physician must conduct the exam in
order for the physical evidence to stand up in the court room (DiNitto et
al.: 86).

--The belief of prosecutors that the SANE will not be as credible a witness
in court as the physician (Ledray:92a; AntognoliToland: 85). 

--Inadequate funding (O'Brien: 96a).

--Narrow interpretation of old laws requiring a physician to collect the
evidence for it to be used in court and for the cost of the exam to be
reimbursable (Speck & Aiken: 95).

Unfortunately, little hard data is available about the efficacy of the SANE
model. Most of what is available is testimonial or anecdotal. On the other
hand, no published data even suggests that the SANE model is ineffective
or not preferable to the former model which involves a nurse and
physician jointly completing the evidentiary exam.

Concerns About Cost 

Starting and operating a SANE program costs money. Chapter 6: A Look
at Funding deals with cost and funding issues more specifically. The
amount of additional costs can vary greatly, depending upon how the
program is structured. The treatment of rape victims by hospitals today is
not free, but the costs are usually hidden. 

Having a SANE available on call may actually be more cost effective to
the facility because it frees both the ED physician and nurse, saving an
estimated 20 minutes of physician time and 3.5 hours of ED nursing time
(Rambow et al.: 92). The costs for SANE programs are more modest than
the costs in facilities with physicians completing even a portion of the
exam (DiNitto: 86). Actual costs for the physician fee, use of the ED,
laboratory fees, and medication costs often exceed the amounts reimbursed
by the State. If there are no legal restrictions on billing the victim, or no
special arrangements are made with the hospital, victims may be charged
these additional expenses (DiNitto et al.: 86). Please see Chapter 6, under
the section "VOCA Funding" for an expanded discussion of the
reimbursement and billing of expenses. Having the nurses work on call
has greatly reduced program costs, as has the ability to successfully train
and utilize nurses without advanced degrees (Ledray: 96a). 

Fear of Interference

There are numerous ways in which the SANE assists the police and the
prosecutor. SANEs can ensure that the police get records of exams in a
more timely fashion. They can interpret the findings for the police and
prosecutor when necessary. Some SANEs routinely ask for the name,
address, and phone number of friends or relatives with whom the victim
might decide to stay, and through whom they may later be contacted. This
information is often very helpful to the police (Ledray: 92a). Police
generally prefer to work with a few forensically trained nurses, as opposed
to dozens of different nurses and physicians in a busy ED because these
nurses know what evidence to collect and how to maintain the proper
chain-of-evidence, which makes the police officer's job easier (Yorker:
96). 

In EDs without a SANE program, victims sometimes encounter busy,
insensitive staff, and as a consequence, victims may decide it is not worth
the effort to report. However, with a SANE's support, more victims make
a police report and follow through with prosecution (Arndt: 88). By
providing the rape victim with additional assistance, resources, and
support, SANEs facilitate the victim's followthrough with the legal process
(Frank: 96; Ledray: 92a). This support results in more victims filing police
reports (Arndt: 88). One program had an additional 15 percent of rape
victims who reported after talking with a SANE even though the victims
were initially hesitant to make a police report. The SANE is aware of the
usual fears that keep victims from reporting and is thus able to give
victims the needed information to make more informed decisions (Ledray:
92a).

SANEs provide continuity of care from reporting to conviction (Ledray &
Arndt: 94). SANEs also shorten the time a victim must spend in the ED
(DiNitto et al.: 86). Unlike the ED physician who may be called away
during the rape exam to see a more urgent ED case, the SANE is able to
stay with the victim until the entire exam is completed (Frank: 96). In a
client satisfaction questionnaire mailed to 201 victims 2 weeks after they
were seen by a SANE for an exam, 93 percent of those returning the
questionnaire were satisfied with the care they received. Unfortunately,
only 33 (16%) returned the questionnaire (Speck & Aiken: 95). In most
communities, having a SANE respond guarantees the availability of a
female examiner which is important to many victims (Arndt: 88).

Concern the SANE Will Not Do the Exam as well as the Physician

The reliability of the evidence collected from a rape victim has been a
prime concern in determining who would conduct the sexual assault exam.
Until recently in England, only police surgeons, usually men, were
allowed to collect evidence from rape victims. When a group of female
general practice physicians decided they wanted to make their services
available, their ability to develop the necessary forensic skills to collect
evidence was challenged by the police surgeons. They have, however,
proven their abilities and are now accepted (Wright, Duke, Fraser &
Sviland: 89). This was a necessary first step before the police were willing
to train nurses for this role in England (Holloway & Swan: 93). 

The real issue is one of training and experience, not professional
background. Just as with any other specialized clinical skill, competency
in the collection of forensic evidence and the completion of a sexual
assault evidentiary exam entails training and experience. It does not
necessarily require an advanced medical degree. Unfortunately, most
medical and nursing schools do not teach forensic principles. Few
physicians or nurses have the opportunity to complete a sufficient number
of rape exams to develop or maintain proficiency, even if they have
completed the training. A primary advantage of the SANE program is that
a dedicated, limited number of nurses complete all of the evidentiary
exams in a given hospital or clinic, which enables them to complete an
adequate number of exams to develop and maintain proficiency (DiNitto
et al.: 86). 

The SANE evidence collection process has evolved over the years because
SANEs have historically met periodically with the prosecuting attorneys
about the use of evidence in the courtroom. As a result of this history,
today the evidence that is collected is more complete and useful in
obtaining a conviction. For example, one program now routinely collects
an extra tube of blood that can be held and run for drug or alcohol analysis
if the assailant claims the victim was so drunk she doesn't remember
giving consent or if he claims the sex was consensual because she
exchanged sex for drugs (Ledray: 92a). 

Because SANE programs follow a case from the initial evidence collection
through to prosecution, they have collected valuable data on the results of
the evidence collected. These data have included information such as the
likelihood of finding sperm at a specific site, at a specific point in time,
and the likelihood of a rape victim being injured during the assault. This
information has also been helpful to county attorneys who need to explain
that the lack of injuries or the absence of sperm does not mean that the
woman was not raped (Ledray: 92a).

In a study comparing 24 sexual assault evidence kits collected by SANEs
to 73 collected by non-SANEs, the SANE kits were overall better
documented and more complete, and the SANEs always maintained
proper chain-of-evidence, whereas the others did not. Thirteen (18%) of
the kits completed by non-SANEs either had no indication of who had
collected the evidence or the records were illegible thus making the
available evidence useless. Overall, 48 percent of the non-SANE kits had
some break in the chain-of-evidence compared to none of the rape kits
collected by SANEs (Ledray & Simmelink: 97).

Concern the SANE Will Not Be a Credible Witness in Court

Concerns about SANE credibility are unfounded. In fact, there are several
reports of prosecutors, who were initially concerned, later finding that the
SANE is an extremely credible witness in court as a result of her extensive
experience and expertise in conducting the sexual assault exam (Ledray &
Barry: in press). SANEs are also more accessible and more willing to
adjust their schedules to testify because it is an expected part of their
chosen position (Ledray: 92a; Antognoli-Toland: 85). Prosecuting
attorneys who have worked with SANEs know they can rely upon the
competence of the SANE as a witness if the case goes to trial (Yorker:
96). The testimony of the SANE is backed up by solid credentials and
impressive numbers of victims seen (Lenehan: 91). As a result of this
solid SANE education, training, and experience, Tennessee more broadly
interpreted its State laws to allow the SANE to testify in court (Speck &
Aiken: 95). 

A common concern of physicians is that the physician will still be called
to testify in court. In one community where thousands of rape cases have
been completed by SANEs, not one case in which the testimony was given
by the SANE alone ever required the prosecutor to subpoena the ED
physician to testify about the evidence collected (Ledray & Simmelink:
97). When the physician is called to testify, it has always been about
injuries that were treated. 

The Santa Cruz County Attorney believes that having the SANE collect
evidence and be available to testify in court has resulted in more guilty
pleas (Arndt: 88). In other communities, the SANE model is credited with
an increase in conviction rates (Solola & Severs: 83). To date, two
programs in operation for more than 10 years continue to have an
impressive 96-percent conviction rate in cases in which the SANE did the
exam (O'Brien: 96a; Smith: 96). In other communities, at the very least,
there has not been the feared decline in convictions (DiNitto et al.: 86).

Deciding to Proceed 

Based on the initial assessment, one of the following conclusions is likely: 

--The community system may be efficient and effective, and it may not
need a major change to a SANE/SART system. 

--The problems in the system won't be fixed with the implementation of a
SANE/SART program, but some other approach may be more helpful. 

--While the system is in drastic need of the type of restructuring a
SANE/SART program could provide, there is currently too little support
and too many obstacles to make the commitment to take on the project. 

--The community could indeed benefit from the implementation of a
SANE/SART program, and there is at least enough support to take the
next step toward overcoming any existing obstacles in the community in
the hope of implementing a SANE program.

Starting a Formal Task Force 

The next step is bringing together a group of interested individuals from
the previously mentioned agencies to meet and discuss the possibility of
implementing a SANE program. Be prepared to present the following: 

--A summary of the findings collected, including the best estimates
available of the number of reported rapes and actual rapes in the
community each year. 

--The positive and negative aspects of the current response to rape. 

--A brief description of how a SANE program operates.

--The benefits of a SANE program for rape victims and each agency
involved. If possible, list and respond to each concern presented by
community agencies and solicit additional issues and concerns.

To establish a SANE program, two primary task force goals must be
achieved. The first primary goal is to establish an initial meeting with
community leaders for an open discussion of the SANE concept and
identification of additional concerns and information that will be needed. 

An additional goal is to get a commitment from each agency to meet again
to explore further the possibility of starting a SANE/ SART program in
the community or region. Getting community leaders to this first meeting
is a big step. Getting them to come back again is even bigger. Respect
their time by starting when scheduled and stopping on time. Have an
agenda and stick to it.

When meeting with the community, provide comprehensive information
about the SANE program. When you do not have information, make a
sincere effort to obtain it but do not promise information for the next
meeting that is likely not available. Be honest about what is not known
and not available. When unsuccessful in obtaining requested information,
explain what efforts were made to obtain it and ask for suggestions or help
getting the additional facts. 

To get community leaders to commit to meetings, be accommodating. For
example, be flexible and creative in finding a convenient meeting time and
place. If possible, get your agency to provide coffee and bagels or cookies.
If individuals miss a meeting, send them a summary of what was discussed
with the time and location for the next meeting. It is also important to call
individuals who are unable to attend to let them know that they were
missed and that you really hope they will be able to attend the next
meeting. If possible, tell them what type of input would be helpful from
them. If they don't attend, keep sending them minutes of the meetings so
they are at least informed about the progress. Periodically reassess who
should be included on the initial task force.

Developing a SART

Once a working committee is established, discuss becoming a SART even
if developing a SANE program at the present time may not be possible. In
all likelihood, the group of individuals brought together to discuss starting
a SANE program are at least a major portion of a SART team membership
(See Chapter 4: SART: A Community Approach). If the group decides to
continue meeting as a SART, ask who else should be invited to the
meetings. Continued communication among interested agencies may
result in the development of a SANE program in the future or it may at
least result in the improvement of victim services in other ways.

CHAPTER 6  

A LOOK AT FUNDING

Funding is a vital issue often overlooked in the early stages of SANE
program development. The inability to obtain needed funding for program
startup costs has thwarted the past efforts of numerous nurses who wanted
to develop a local SANE program. Many of these nurses were employed
at medical centers and expected their medical center to incur the initial
costs of SANE program development. While some were successful in
making their case, many others were not. More often, these nurses were
good clinicians who wanted to start SANE programs because they realized
they were not providing victims of sexual assault with state-of-the-art
clinical care in their institution. They were aware that there was a better
way, the SANE way. Unfortunately, because their focus was on the
clinical aspects of care, funding was an afterthought. To a great extent, 
the ability to obtain program funding is the test of program feasibility. If
the necessary funding cannot be obtained, it will not be possible to
develop a SANE program.

The reality of the health care climate today is that it has become cost
driven, and to a great extent, limited by cost. Most hospitals already
provide services which do not produce revenues sufficient to cover costs.
Understandably, hospital administrators are reluctant to develop an
additional program that they perceive will increase costs and decrease
profits. Hospital administrators may not understand that hospitals already
assume many indirect and overhead costs associated with examining and
treating sexual assault victims, such as physician and nursing time,
supplies, and staff training. Furthermore, because the ED staff does not
conduct these exams routinely, it takes these clinicians longer than a
SANE. In addition, while ED staff is involved with a sexual assault exam,
the ED may need additional staff to cover other cases in the ED and
overtime may be required because staff cannot leave until the exam is
completed. The ED must supply both a physician and a nurse to conduct
the sexual assault exam so consequently both may be required to testify in
court. If there is a delay in court cases, scheduling problems will arise in
the ED. When promoting the establishment of a SANE program with
hospital administrators, provide a cost-benefit analysis to administrators,
demonstrating how a SANE program can provide some services in a more
cost-effective manner. 

Less tangible, but equally important benefits should also be included in the
discussion. Even though cost considerations drive many decisions in
health care, intensifying competition in the ambulatory health care sector
also focuses on the provision of quality, patient-centered care. Point out
that the provision of SANE services would enhance the medical facility's
reputation with the community, allowing the hospital to stand out among
its competitors. Finally, hospitals and medical centers are increasingly
interested in and involved with community wellness efforts. Explain how
a SANE program, with its cadre of educated, experienced forensic nurse
specialists, provides an invaluable resource for a hospital's community
outreach and education initiatives. For example, the SANE can educate
law enforcement and county attorneys about evidence collection and use
of evidence. For the community, the SANE can raise the community's
awareness about how secondary trauma is caused by sexual assault. 

However, even with the most favorable cost-benefit analysis, one cannot
assume that a hospital will fund all the costs associated with an ideal
SANE program. This is why SANE program costs and funding options
must be an initial consideration, starting with the goal of developing a
realistic and fundable program, not necessarily the ideal program.

This chapter addresses both the cost of program development and program
operation, including options when minimal funds are available as well as
ideal options when funds are more readily available. (Many SANE
programs start with minimal funds and are able to improve staff pay and
benefits as well as extend program services after they have established
themselves in the community and demonstrated the service need and
benefit. It is essential to realistically anticipate all initial costs in order 
to
obtain adequate startup and program operational funding.) This chapter
also reviews the funding of SANE programs currently in operation. Lastly,
it considers potential funding sources for program development and
operation.

Program Development and Operation Costs

Program development and operation costs vary greatly. Surveyed
programs indicated that initial startup costs ranged from $6,000 to over
$50,000, and averaged $30,000 to $40,000. Much can be done to control
and lower these costs when necessary (See Chapter 7: Starting Your
SANE Program). Depending on the resources available, this section
provides cost-saving options for consideration. It provides information on
the minimum, unavoidable costs for those working with strict limitations,
as well as options when more financial resources are available. The costs
of program development are not all monetary; in fact, many of the costs
are time commitments from personnel. 

Needs Assessment

In most cases, the cost of the community and institutional needs
assessment involves the time of a committed individual. In the early days,
this was most often institutional employees who were aware of the
inadequate services to sexual assault victims. The employees were
typically nurses working in the ED or a clinic that saw rape victims, and
they wanted to improve services for these victims. With the increased
awareness of the SANE model, the needs assessment is now often
provided by someone working with rape victims outside the hospital, such
as the police, an advocate from the local rape crisis center, or staff at the
prosecutor's office. Many State attorneys general and governors are now
even taking leadership roles in promoting the SANE concept on a
statewide level. 

While an interested institution may be willing to donate staff time, the
hundreds of hours of needed time may have to be spread out over a full
year or more. If there is an intense amount of interest, it is more likely that
an agency or organization will provide a substantial amount of paid,
experienced, professional staff time to determine program feasibility and
startup activities.

If an individual, rather than an institution, is the interested party, then a
time commitment must be negotiated. While this person may be able to
perform some of the tasks involved with the initial needs assessment and
feasibility studies on institutional time, most efforts will be
uncompensated, off-duty hours. If the interested individual's supervisor
does not support compensated work hours for the development of a SANE
program, the alternative is to find someone in the institution who does
support the SANE project. Another possibility is to find support outside
the institution, but this is not an optimal solution if the institution's 
support
is vital to the SANE project. At this point, the feasibility of developing a
SANE program needs to be carefully reconsidered. Another strategy may
need to be developed, including postponing the development of the SANE
program until more support can be generated. 

Facilities and Utilities 

Office space for the program director, secretary, and staff meetings are
almost always located in space donated to the program. The only
exceptions to this across the country are programs operated independently
for profit. When the program is hospital-based, the hospital donates the
space. Community-based programs are usually housed administratively
with the sponsoring community agency. Office space should be negotiated
either with the hospital where the services will be provided or with the
sponsoring community agency. A SANE program provides the hospital or
community agency with a valuable resource and a lot of community
goodwill. Take advantage of the negotiating power this provides to avoid
expensive office overhead.

Supplies and Equipment

Both office and exam supplies and equipment need to be included in the
initial budget. Much like office space, however, it is often possible to get
the sponsoring institution to donate supplies, at least for the first year of
operation. It will be especially important during this first year to keep an
accurate account of the actual supply costs. These cost records will be
useful to negotiate for continued donation by the institution or to know the
actual expenses if the program needs to assume them. 

Office equipment. In addition to the usual office equipment, a SANE
program needs a computer with access to the Internet and facsimile (FAX)
capabilities. The FAX capabilities can be part of the computer or a
separate piece of equipment. The FAX equipment should have the
capability of displaying the name and phone number of the receiving
agency prior to pushing the send key. This allows staff the chance to
double check that sensitive or confidential data are sent to the correct
agency. To ensure data security, store client data in a computer separate
from the computer linked to the Internet. 

Each SANE needs a long-range pager. Always try to get this cost donated,
possibly by a paging company or a community agency, before adding it to
the budget. Even $10 per month adds up when it is multiplied by 10 nurses
and 12 months.  

Exam equipment. The hospital ED or clinic where the exams are being
completed is often willing to donate exam supplies. In many States, the
rape exam kits are provided by law enforcement at no charge.
Standardized kits can also be purchased when they are not available free
from law enforcement. Consult with the local State crime laboratory that
will be analyzing the evidence collected before purchasing the kits. Since
the price and contents of "standardized" kits vary greatly from
manufacturer to manufacturer, ask to have a sample sent for review before
making a decision to purchase a particular kit. The crime laboratory may
know where to purchase standardized kits. They are available from a
number of sources. (See Appendix C: Rape Kit Supply Resources). Law
enforcement agencies often pay for this cost because use of standardized
kits benefits law enforcement by promoting better evidence collection.
Emphasize this benefit to the law enforcement agency when negotiating
with them to provide these kits. 

A Polaroid camera and/or a 35mm camera will also be needed. Before
making the purchase, check to see if the ED or clinic where the exams
will be completed already has one available that SANE staff could access.
Small 35mm cameras with automatic focus that are easy to operate and
will take adequate pictures of injuries are available for as little as $100. A
camera with a macro lens attachment will produce higher quality, closeup
photos. Later, when the budget allows, the camera equipment can be
upgraded. Don't be tempted to get camera equipment that is so
sophisticated that the staff will have trouble using it effectively. Also,
ensure that the cost of film and film development is covered in the budget
if these costs, which can be considerable, are not reimbursed by law
enforcement or the prosecutor's office. 

If the budget allows, consider purchasing a digital camera that can
transmit photo evidence directly to the police department, if it is utilizing
this technology. The police department may even be willing to provide the
SANE program this equipment. One Minnesota police department offered
to do so, recognizing the value to the investigative efforts of its
department. Another consideration is photographic equipment which
captures ultraviolet images. While more sophisticated, it is very effective
in identifying and highlighting bruising, especially in women of color.
While this technology was once controversial and its accuracy challenged
in the courtroom, its scientific value is now widely accepted. The use of a
digital camera, however, must be discussed with the local prosecuting
attorney's office because digital imagery can be altered easily and,
consequently, it may not be accepted by that office.

An alternate light source will also be needed. Much like the camera, these
light sources are typically available in the ED or clinic for eye exams. If
the budget is tight, arrange to have access to the equipment rather than to
purchase it.

If the SANE program is located in a separate clinic, a pelvic examination
table also must be acquired. A microscope may be necessary to observe
wet mounts for motile sperm.

Additional equipment that will soon become a standard, but which is still
not available to many SANE programs because of the cost, are the
colposcope ($10,000 to $15,000 for the colposcope alone); light staining
microscope ($1,000 to $1,500); digital camera systems with direct
computer links; and video equipment with print capabilities. Because of
the excessive cost of the colposcope, some programs, especially those
working with children, have chosen instead to purchase MedScope
($3,500; $11,500 including camera, internal lens, camera holder, monitor,
printer, foot switch, VCR, and cart). It is currently being evaluated in a
trial study funded by OVC.

Exam paperwork. At a minimum, the SANE staff will need the following
exam forms: 

--Sexual Assault Exam Report (with chain-of-custody).

--Evidentiary Exam Consent which includes consent to release evidence to
and communicate with law enforcement.

--Pregnancy Prevention Consent.

--Laboratory forms including a specimen chain-of-custody.

--Program brochures.

--Followup materials.

Additional forms may include the following: 

--Medical and other referral forms.

--Nursing Care Plan.

--Medical History Forms. 

To avoid expensive printing of these forms, including the brochure, all
can be produced on a computer. Several low cost computer printing
programs are available from which to choose. 

Staff Advertising and Selection

Advertising costs to recruit nurses for a SANE position can be reduced by
posting the new SANE positions in local hospital EDs and clinics such as
the obstetrics and gynecology clinic. Advertising in the local newspaper
may also be necessary. This can cost hundreds of dollars. Ask the
sponsoring institution if it will assume this cost; if not, advertising must be
included in the budget. Media publicity associated with the development
of the SANE program will not only alert the community of the program
but may provide free advertising for interested nursing personnel. Sending
flyers to the local nurses' associations, schools of nursing, and other local
institutions is another less expensive mechanism for locating interested
and talented nurses. Recruitment strategies should include recruiting for
nurses who are sensitive and knowledgeable of diverse community
populations and the issues involving sexual assault.

Staff Training 

If the new SANE staff is sent to an established SANE training program
the cost will run approximately $250 to $500 per person, plus travel
expenses (See Appendix D: SANE Training Programs). If a trainer is
brought in to provide training, the cost will be $1,000 to $1,200 per day,
per trainer, for 5 or 6 days of training, plus travel expenses (See Appendix
E: SANE Trainers). 

Program Media Promotion

Media attention spotlighting the plight of rape victims can generate
considerable public response. Use this community interest and support to
elicit improvement of services to rape victims. Media attention is
particularly effective if an individual victim is highlighted. Many victims
are willing and even anxious to tell their story to the media when they do
not believe their needs were properly addressed at the time of the rape.
This can offer an opportunity to constructively focus their desire to effect
a change in the system for future victims. Before a rape victim goes
public, however, staff should discuss with the victim the potential
responses, both negative and positive, that might follow public disclosure.

Once the new SANE program is in operation, media attention can also be
helpful in alerting potential clients to the availability of the service and
how it can be accessed. The focus of this media coverage would include
magazine articles, newspaper editorials, and television spots about general
services and awards given to the program or a particular staff member. A
testimonial from a rape victim would also be appropriate in this message.

Staff Salaries

Many variables influence the determination of staff salaries. Some
variables are location of the SANE program not only geographically but
also whether hospital-based or community-based. The number of sexual
assault cases and the jurisdiction--urban or rural--affect the pay schedule.
Please refer to Chapter 8: SANE Program Staff for a detailed discussion of
SANE salaries.

Current SANE Program Funding

The survey of existing SANE programs found the following. Thirty
programs were public nonprofit agencies, either associated with a
nonprofit hospital, a nonprofit community program, or a government
agency. Six were private, for profit, and one program characterized itself
as a coalition. The yearly budgets ranged from $6,000 to $825,000 with an
average of $122,000. It is rare to have all program funding from one
source. Most programs rely on a variety of funding sources.

Many SANE programs (N=20) are directly reimbursed for services by
Federal money that is administered by a State or county agency. The
rationale is that, since the exam is being completed to collect evidence, the
State, not the victim or her insurance, should pay for the cost of the
evidence collection. This money may be provided directly from a State
agency, however, it is usually disbursed to the county and reimbursed on a
per-case basis. Bills for each case are submitted by the SANE program for
payment to a designated office, usually the law enforcement agency or the
prosecutor's office. This reimbursement may be limited to a set maximum
dollar amount that will be paid for each exam completed, ranging from as
little as $75 per exam to $500 per exam. The reimbursement may also be
payment of the actual charges for the evidentiary exam, without a set
dollar limit. This reimbursement was found to cover a continuum of
program costs ranging from 33 percent to as much as 80 percent of
ongoing SANE program operating costs.

Additional funding is provided through government agencies, at the State
level (N=18), at the county level (N=5), or at the city level (N=2). State
money is often received as a grant through the State Department of
Corrections or through a State Crime Victims Assistance or Crime Victims
Compensation Fund. An additional 11 SANE programs receive Federal
grant money.

SANE programs (N=44) also rely on donations from a variety of sources,
including local foundations, corporations, businesses, churches, hospital
foundations, women's groups, the United Way, universities, and
individuals. Donations may support a specific clinical service, for
equipment such as a colposcope or light staining microscope, or for
ongoing operating expenses. 

Most hospital-based programs (N=47), or 94 percent of the total of 50
hospital-based programs, are fortunate to have the hospital assume
responsibility for the remainder of their costs not covered by grants,
donations, or reimbursement for services. Two additional SANE programs
have a consortium of agencies that share the additional, nonreimbursed
expenses. Two of the 9 nonhospital SANE programs, have similar
relationships with their sponsoring agencies, the YWCA and a Violence
Against Women's program.

SANE Program Funding Options

The literature indicates SANE programs have been started using Federal
research grant funding (Ledray & Chaignot: 80), local community
foundation grants, community fund-raising (Frank: 96; O'Brien: 96a), and
fee-for-service reimbursement from the hospitals served, police, and/or
the county attorney's office (O'Brien: 96a). Some hospitals have an
in-house SANE programs because they serve large numbers of sexual
assault victims. Other SANE programs are independent nursing programs
or agencies that contract with the hospital to provide services on an
on-call basis and bill the hospital on a per case basis for the exam
(Burgess & Fawcett: 96; O'Brien: 96a).

Where to Look for SANE Program Funding

The best funding strategy includes approaching a variety of resources
including local private foundations, State agencies, and Federal resources.
The U.S. Department of Justice Response Center will place interested
fund-seekers on a mailing list to receive updated information on funding
resources for violence against women programs. Call 800-421-6770 to be
added to the list. 

VOCA funding. The Victims of Crime Act (VOCA) of 1984 established
the Crime Victims Fund, which is derived from fines and special
assessments collected from Federal criminal offenders--not from tax
dollars. The Crime Victims Fund is administered by the Office for Victims
of Crime (OVC). Each year, OVC distributes approximately 90 percent of
the Fund by formula to States to support victim assistance and
compensation programs that provide services to Federal and State crime
victims. All States and territories receive annual VOCA funding and, in
turn, the States award VOCA Victim Assistance grant funds to local
community-based organizations to provide services directly to victims of
crime. 

A limited amount of VOCA funds is also awarded directly by OVC each
year in the form of discretionary grants to improve and enhance the
availability of victim services. These discretionary grant funds support a
variety of nationwide initiatives, such as developing training curricula,
training victim service providers and criminal justice professionals, and
identifying and disseminating information about promising practices in
victims services. OVC discretionary funds do not provide operational
funding for victim services organizations.

Community programs interested in obtaining a VOCA grant for
operational funding should apply to the State agency designated by the
Governor of their State to administer the State VOCA victim assistance
grant monies. Appendix F contains a list of the State agencies that
administer the VOCA Victim Assistance Funding. Each State has
discretion to determine which organizations will receive funding based
upon the VOCA victim assistance guidelines and the needs of crime
victims within each State. Most States make awards on a competitive
basis. Although many programs compete for this money, this is an
excellent source of funding for sexual assault programs. 

States also receive VOCA funding for their victim compensation
programs that may be used to pay for evidentiary exams given to victims
of sexual assault. States may disburse funds to a variety of State or county
agencies that conduct the exams--very often a police or sheriff's
department. Law enforcement agencies are more likely to mandate that
crime victims report their victimization and cooperate with the prosecution
in order for the examination expenses to be reimbursed. Victim advocates
should understand that States have some discretion in defining the nature
and extent of "victims' cooperation with law enforcement." OVC's most
recent VOCA Victim Compensation Final Program Guidelines recognize
that there may be cultural or psychological factors that undermine a
victim's willingness to report sexual assault or to report the crime in a
timely fashion. Thus, the VOCA Guidelines allow States to "accept proof
of the completion of a medical evidentiary examination such as a report,
x-rays, medical photographs, and other clinical assessments as evidence of
cooperation with law enforcement in cases involving sexual assault or
abuse" (Final Program Guidelines, Victims of Crime Act FFY 1997
Victim Compensation Program, The Federal Register, 14 February 1997).

To determine which agency is responsible for billing locally, contact an
area hospital and ask whom they bill for the sexual assault evidentiary
exam. Since the specific amount reimbursed and the services for which
the SANE can be reimbursed typically vary from county to county, the
SANE will need to contact the appropriate agency in her county and ask
for a copy of the policy. If rape victims are examined from more than one
county, a copy of the evidentiary exam reimbursement policy will be
needed for each county. Reimbursement generally comes from the county
in which the rape occurred, which will not necessarily be the county
where the exam is completed.

More information on VOCA formula and discretionary grant funding, as
well as OVC, can be obtained via the OVC Homepage on the World Wide
Web at the following address: http://www.ojp.usdoj.gov/ovc/.

Reimbursement of costs associated with the forensic exam is a complex
issue. According to a 1997 report by The Urban Institute prepared for the
National Institute of Justice, "Medical costs and cumbersome restitution
mechanisms in sexual assault cases continue to be a barrier for victims and
discourage many women from seeking needed medical care and
undergoing examinations to collect evidence needed for prosecution" (The
Urban Institute: 97). In 1996, The Urban Institute conducted site visits to
12 States as part of its study of the S-T-O-P (Services, Training, Officers,
and Prosecutors) grant implementation process. Most of the 12 States
visited had long-standing State legislation that covered the waiver of
charges for forensic examinations of sexual assault victims; others passed
similar legislation during final congressional consideration of the Violence
Against Women Act (VAWA), which was sponsored by Senator Joseph
Biden and passed by Congress in 1994.

The Urban Institute reported that hospitals incur substantial costs in
conducting forensic examinations. Costs are around $800 if a physician
conducts the exam; and substantially lower (between $200 and $300) if a
trained nurse such as a SANE conducts the exam. The report continues as
follows:

State laws vary in the mechanism they specify for reimbursing hospitals
and relieving victims of the burden of payment. Most of the 12 States
visited by the State Institute had no State appropriation for covering these
costs, and those that did usually did not appropriate enough funds to cover
the need. One State had a backup fund that could pay for examination
costs if other mechanisms failed. The various payment mechanisms, or
lack of them, still leave victims with a financial burden in quite a number
of States.... Most of the payment mechanisms established by the site visit
States still leave some victims with either primary or secondary
responsibility for payment because either they or the hospital have to
apply for compensation to cover the cost of the exam. If the victim must
apply, she must pay the hospital first and then seek reimbursement.
Situations where hospitals may, and do, seek payment from victims
include the following:

--Low levels of reimbursement by counties do not cover most of the
hospital's cost.

--The victim has medical insurance that will cover the cost of emergency
care.

--Crime Victim Compensation Boards take years to pay claims, although
they send an award letter relatively quickly.

--Crime Victim Compensation Boards or county agencies reject victim
claims for reimbursement because police reports indicate that a case is
"unfounded" or because the victim "fails to cooperate with prosecution."

Another reimbursement issue is that only part of the procedure is forensic;
the rest is medical. Many women, according to The Urban Institute
Report, seek medical care in emergency rooms after a sexual assault with
no intention of reporting the crime to police. In at least two States, States
paid for "evidence collection" but not "followup services." Hospitals then
either covered the cost or attempted to bill the victim for these "additional
services."

VAWA funding. VAWA authorized a 6-year funding cycle for formula
grants similar to the OVC victims assistance formula grants to the States.
The VAWA funds are available to States to distribute to victim service
agencies as well as prosecution, law enforcement, and the courts. Like the
VOCA programs, most of the VAWA funding is distributed directly to the
States through formula grants. The Violence Against Women Grants
Office (VAWGO) is the Federal agency that administers the S-T-O-P
Violence Against Women Formula Grant Program. Each State must
allocate a minimum of 25 percent of S-T-O-P funds to nonprofit,
nongovernmental victim services agencies. The State agency that
administers the S-T-O-P grant determines the process for awarding
subgrants. State are not required to competitively select recipient
organizations. To be eligible for S-T-O-P funds, States must certify that
they incur the full out-of-pocket cost of forensic medical examinations for
sexual assault victims either by providing or arranging for free
examinations, or by reimbursing the victim for the full cost of the
examination. As discussed previously in this chapter in the section
regarding VOCA funding, States utilize differing interpretations of what
actions constitute victim cooperation with law enforcement to establish
reimbursement eligibility.

Twenty-five percent of each State's S-T-O-P falls into a discretionary
category, and the purpose of this funding need not be strictly law
enforcement, prosecution, or victim services, but must conform to the
broad guidelines of VAWA. Discretionary funded projects must still
fulfill at least 1 of the 7 purpose areas of this program. More information
on VAWGO funding can be obtained via the VAWGO Homepage on the
World Wide Web at the following address:
http://www.ojp.usdoj.gov/VAWGO. The telephone number for VAWGO
is 202-307-6026. Appendix F also contains a list of the State agencies that
administer the S-T-O-P grant funds. 

Byrne funding. The Edward Byrne Formula Grant Program, administered
by the Bureau of Justice Assistance of the U.S. Department of Justice,
awards funds to States for use by States and units of local government to
improve the functioning of the criminal justice system. As one of the 26
legislatively authorized purpose areas, government units may make awards
to subgrantees to provide assistance to jurors and witnesses and assistance,
other than compensation, to victims of crime. The Edward Byrne Formula
Grant Program may be a potential source of funding for some services
designed to assist sexual assault victims. Appendix F contains a listing of
the State agencies that administer the Edward Byrne Formula Grant
Program.

Other Federal and private funding. There are other potential resources for
SANE program funding beyond the U.S. Department of Justice. These
include other Federal agencies such as the U.S. Department of Health and
Human Services, private foundations, community foundations, grant
making public charities, individual donors, and fundraising campaigns.
The Foundation Center is an excellent source of information on the many
grant funding resources. The Foundation Center does not make grants,
rather, it provides information on those entities that do. In addition to
maintaining libraries in Atlanta, Cleveland, New York City, San
Francisco, and Washington, D.C., the Foundation Center has a nationwide
network of affiliated libraries and nonprofit resource centers called
Cooperating Collections. According to information provided by the
Foundation Center on its Internet site, "These collections provide a core
group of Center publications for public reference and some level of
instruction on how to do funding research.... Every State has at least one
Cooperating Collection, and many States have collections in more than
one city" ("A Message to Grant-seekers" 1997,
http://fdncenter.org/2onlib/2ufgall.html).

The Foundation Center also publishes many useful reference directories.
One of the most useful is The Foundation Directory (Renz, Baker & Read:
96). It is frequently updated and lists all of the private foundations by
State. It provides information on trends in foundation giving, how much
grant money each foundation has available, to what geographical area, and
for what purposes. This is a valuable resource when applying for private
foundation funding.

Many Cooperating Collections of the Foundation Center also make
available for public use a searchable database of funding resources called
FC Search: The Foundation Center's Database on CD-ROM. The
Foundation Center's main libraries and Cooperating Collections offer
grant-seekers a myriad of services on site and on line, including access to
publications, periodicals, training workshops, online tutorials on
grant-funding research and proposal writing, online responses via e-mail
to reference questions, and computerized databases. The Foundation
Center is one of many resources available online and has links to other
resources for grant-seekers on its Web site at: 
http://fdncenter.org/. A tremendous number of grant funding organizations
now maintain their own site or homepage on the Internet including most
agencies of the Federal Government.

Fundraising Process 

The following processes are suggested for effective and efficient
fundraising: 

--Make sure the type of funds needed is an integral part of the
developmental plan: startup funds, capital expenditures, general operating
expenses, special project funds, funds to increase organizational
capabilities.

--Gather information about potential program funding sources and support,
including government, foundation, and local private donors; fundraising
activities; professional organizations with grant opportunities; and in-kind
gifts and services.

--Analyze and synthesize the above information.

--Decide which prospects are most promising. Match the organization's
interests with those of potential funders.

--Develop a time-line of proposal writing based on application deadlines,
funding cycles, and program needs.

--Cultivate potential donors in the private sector: rely heavily on
professional contacts and personal networking, relationships of the
Advisory Board, community stakeholders, etc.

--Keep track of initial contacts made and potential donors' interests; invite
potential donors to any and all events such as open houses, press
conferences, exhibits, educational initiatives, public interest events.

--Keep donors and potential donors informed of program progress through
letters, memos, a newsletter, telephone contacts, or one-on-one meetings
and informal lunches.

--Focus on a distinctive characteristic of your project that sets it apart from
other similar projects and that will appeal to and motivate a funding entity
to support your program. The appeal might vary from one donor to the
next. For government funding, a program might serve as a model; for a
local business or organization, it could generate good will and promote the
donor's community visibility, or provide an opportunity for unique
collaboration. 

--Follow up with donors who provide support with thank you letters.
Always respond to requests for information and don't forget to ask for
additional support.

Looking to the Future as You Begin

Clearly SANE program affiliations have a significant impact on program
funding. Fifty of the 59 programs surveyed are hospital-based. Survey
respondents indicated that program costs that exceed the program income
are paid by the sponsoring institution in 88 percent of the programs which
are hospital-based, compared to only 22 percent of the programs that are
nonhospital-based. This is probably due to more limited resources and
budgets in community programs as compared to hospital organizations. It
appears that the decision to affiliate a SANE program with a large
institution, such as a hospital, may be an effective choice in ensuring
ongoing program funding. 

Providing effective crisis intervention and preventive care for sexual
assault victims is an important component in promoting health
maintenance and preventing secondary injuries. Although the provision of
these services may initially increase costs of the health care facility,
research and careful accounting of direct and indirect costs can
convincingly demonstrate that in the long term, overall costs can be
reduced.

Summary

It is imperative to develop a funding strategy before establishing a
program to ensure long-term financial solvency and continuation of the
program. It may be possible to negotiate with the local hospital or a
government or community agency to assume financial responsibility for
the ongoing SANE program costs. Initial startup costs typically represent
a large portion of the non-reimbursable costs of a SANE program. A local
hospital may be willing to assume the future costs that exceed
reimbursement, especially if the hospital administration understands that it
is already assuming many hidden costs associated with treating sexual
assault victims in a less cost efficient manner.

Obtaining ongoing grants and donations is a full-time job. A SANE
program manager cannot do full-time fundraising and manage the
day-to-day clinical program responsibilities. It is essential to plan ahead
when establishing a new SANE program in order to reduce the amount of
time and attention that the SANE program manager must place on
ensuring the financial viability of the program. 

-------------------------------

Important Startup Costs of Developing a SANE Program:

--Community and institutional needs assessment.

--Facilities and utilities.

--Supplies and equipment.

--Staff advertising and selection.

--Staff training (See Chapter 9: SANE Training).

--Program media promotion.

--Staff salaries for the first year (See Chapter 8: SANE Program Staff).

-------------------------------

Common Examination Supplies 

--Rape kits.

--Clean-catch urine specimen containers.

--Wet preparation tubes.

--Roll of white paper (e.g., butcher paper)

--Fingernail file or Q-tip (to scrape under the nail).

--Tourniquets.

--Syringes.

--Blood tubes for bloodtype, pregnancy, alcohol, and drugs.
    
--Disposable towels.    

--Barrier drapes.  

--Speculums of various sizes.  

--Lubricant (for bi-manual exam).        

--Fixative (depending on lab protocol).

--Slides.

--Paper bags.

--Labels.

--Fingernail clippers.

--Envelopes.

--Swabs. 

--Gauze.

--Needles. 

--Plastic combs. 

--Gloves. 

--Gowns.

--Normal saline.

--Pencils and pens.

--Film.

--Biological and sharps waste receptacles.

-------------------------------

CHAPTER 7   

STARTING YOUR SANE PROGRAM

Once the decision has been made to develop a SANE program, the SART
team will need to work together to create a vision of how the SANE
program will be implemented. The strategic plan will be based on the
SANE vision and mission statements. Developing a strategic plan not only
involves a basic startup plan of operation but also anticipates obstacles
encountered later on during the operation of the SANE program.
Consequently, this chapter provides information about how existing
SANE programs have approached many of the organizational decisions
that need to be made (see Appendix G: Startup Checklist).

How Long Can It Really Take?

While every community is different, the average SANE program startup
time is 1 to 2 years. It can take longer. This includes the time from the
initial concept to actual service delivery. It will, of course, take longer in
areas where there is more resistance and where fewer resources exist. Even
in an area where the SANE concept is well understood and accepted and
where there are ample resources, it will take at least 6 months for the
necessary team building, strategizing, staff selection, and training.

Hours of Operation

The majority of existing SANE programs provide services 24 hours per
day, 7 days a week, including holidays and weekends (Antognoli-Toland:
85; Ledray: 92a). One program indicated that in the initial stage, the
SANEs completed exams during evenings, nights, holidays, and weekends
with the ob-gyn residents completing the exams during the day Monday
through Friday (Thomas & Zachritz: 93). After a few years of operation,
this SANE program proved to be so effective that the SANEs assumed the
caseload 24 hours a day. While there may be times when the SANE is not
available for unavoidable reasons such as severe weather warnings with
travel restrictions, it is important to plan to provide complete coverage 24
hours a day, 7 days a week.

Population Served

All programs that report client gender in the literature see both females
and males. Some programs see adults, adolescents, and children (O'Brien:
96a; Speck & Aiken: 95); others see only adults and adolescents (Arndt:
88; Ledray: 96a). Some programs started with a more limited patient
population and then expanded the age bracket served (Ledray: 96a;
O'Brien: 96a). 

Several SANE programs plan to add forensic examination of battered
women, children who are physically abused, and other crime victims, as
well as the possible addition of automobile accident victims to their
existing services. Several programs complete nonliving victim forensic
examinations, and others are considering doing so as well.

Even if the intent is to eventually see all ages of rape victims and
populations other than sexual assault, it would be wise to start with a small
well-defined population and expand services to additional populations as
staffing, funding, and other resources allow. This is especially important
when there is not a firm figure available of the expected caseload.

Deciding on Program Location

When establishing a new program, one of the most basic decisions is the
location of the SANE examination site. Since SANE programs provide
service 24 hours a day, 7 days a week, safety and security for staff and
victims is an important consideration. Other considerations include the
following: 

--Physical and psychological comfort of the client. 

--Access to medical support services to provide for care of injuries. 

--Pharmacy or medication access. 

--Access to psychological support services.

--Access to laboratory services.

--Access to the necessary supplies and equipment to complete an exam.

One Location or Multiple Exam Sites 

Fifty of the SANE programs responding to the survey routinely complete
exams at only one location. Ten of these specified that they will go to
other locations such as the jail (for suspect exams), morgue, health
department, women's clinic, or other hospitals to perform evidentiary
exams, if necessary. Examples where an evidentiary exam might be
completed in a location other than the primary exam sites are when a
SANE program that usually sees clients at a community clinic transfers a
client with injuries to the ED for emergency care. Another example is
when a victim first goes to a referring hospital with injuries that make it
difficult to move her to the primary SANE exam site. In both cases, the
SANE goes to the ED to complete the exam.

Nine programs surveyed routinely go to more than one site to complete
exams. Five of these go to two hospital EDs, one goes to two different
hospital clinic locations, and one goes to seven different hospital ED
locations. The later program will soon be adding an additional location, a
university medical clinic. One free-standing program routinely goes to
nine different community locations, including EDs and clinics to complete
exams. Another goes to four sites including a jail, two different EDs, and a
clinic.

Advantages of a Single Exam Site

The primary advantage of a single location is that all necessary exam
supplies and equipment can be centrally located in a setting familiar to the
SANE and only one set of equipment is necessary. Duplicating the
equipment at more than one site can be very costly, especially when a
colposcope is used. Colposcopic examination is quickly becoming
state-of-the-art.

Disadvantages of a Single Exam Site

Hospital administrators understandably do not like to be in a position of
sending their clients to another facility for care, especially to another
hospital ED. It is inconvenient for the victim; it makes the hospital staff
appear less capable; and hospital administrators perceive it as bad for
business. Because of these facts, many hospital administrators would
prefer that the SANE come to their facility. 

When initially deciding if nurses should go to other hospitals, or if all
victims could be sent to one hospital site, the Sexual Assault Resource
Service (SARS) in Minneapolis kept track of the number of rape victims
sent from a nearby hospital to their one exam site at a different hospital,
over a 3-month period. Only one out of three clients reporting a rape at the
referring hospital made it to the second hospital where the SANE program
was located, even when many were given a cab voucher for transfer
(Ledray, Linda E. Unpublished data. Sexual Assault Resource Service,
Minneapolis, MN, 1984.) Based on these results, the Minneapolis SANE
program decided that additional hospital sites would be added.
Approximately one hospital ED site was added each year until SARS was
providing services to all seven hospital EDs in Hennepin County, with a
1-hour maximum response time. 

Adapting the SANE Program to Multiple Exam Sites

To deal most effectively with multiple exam sites, SARS has a space
identified for SANE supplies at each hospital and has, in addition,
provided each SANE with a portable exam kit (a large tackle box) where
routine supplies and paperwork are kept for easy transport. Hospitals
wanting the SANE to come to their facility are responsible for obtaining
the necessary pieces of large equipment that cannot be transported. Every
effort should be made to keep the policies and procedures as consistent as
possible at all seven hospitals to avoid confusion, especially with new
hospital or SANE program staff.

Another program with multiple hospital sites decided to compromise by
locating their equipment, including a colposcope, at one hospital where the
SANE does the majority of their exams. The SANEs remain available to
go to other specified sites when necessary if injuries preclude transport to
the primary site. In these cases, the SANE will carry routine supplies and
paperwork in a portable exam kit. 

Disadvantages of Multiple Exam Sites

A disadvantage of multiple sites for the SANE staff is that even when
every effort is made to maintain consistency, equipment, policies, and
procedures vary somewhat from site to site. Dealing with these variances
can be confusing, especially for new staff. 

Regional SANE Programs

Especially in rural areas where no one medical facility sees large numbers
of sexual assault cases, multiple sites covering a regional area but using 
the same SANE staff may be the only cost-effective method of providing 
SANE program services. These sites will likely span a large area with
several community hospitals or clinics involved, and the SANE may travel
2 hours or more to reach some examination sites. 

Regional SANE programs are also an important alternative from a staff
training and competency perspective. By serving a larger, regional area,
the SANE staff will see more clients collectively and each will be able to
complete a sufficient number of exams to develop and maintain their
clinical competence.

Regional SANE programs may be sponsored by a single agency and
provide services to other agencies in the region on a fee-for-service basis,
or the program costs may be shared by a consortium of agencies.

Community-Based Program Exam Sites 

Of the nine programs that are administratively community-based
programs, five also do the exams in a community-based facility: two of
these have exam sites in a free-standing clinic; two at rape crisis centers;
and one in a YWCA. The other four are community-based
administratively, but they actually do the exams in a hospital: one of these
programs completes exams in two hospital EDs and three complete the
exams in hospital-based clinics specifically set up for their use.

The community-based programs typically refer to an ED for treatment of
injuries, and all but two have a medical director. The two programs
without an identified medical director both have a physician who reviews
their protocols on a consulting basis. 

Programs with community-based exam sites, such as the Memphis
program and the program operating at the YWCA, Grand Rapids,
Michigan have a very specific protocol for the evaluation of injuries and
for medication standing orders. They also have a medical director who is
readily available by pager. In Grand Rapids, when a rape victim comes to
a referring hospital, hospital staff page the on call rape crisis volunteer
advocate and the police. The advocate calls the SANE and then directs the
victim to the YWCA. If necessary, the advocate may go to the hospital and
escort the victim to the YWCA, where the SANE and the police meet
them. Since the YWCA building is not open 24 hours a day, the police
officer also provides security after normal operating hours. The SANE
performs the urine pregnancy test (UPT) using a simple 4-minute urine
test similar to the home pregnancy test and prepares and examines a wet
mount for motile sperm. All the medications are located on site and are
given to the victim prior to her departure (Dunnuck, Chris. Personal
communication. 25 November 1996).

Although programs completing exams outside a hospital setting are few in
number, they do offer some advantages to the hospital-based program. 
In States where hospitals are mandated to report felony crimes, the State
statutes for mandated reporting do not apply to these community-based
programs. In these cases, the SANE will encourage reporting but will
ultimately respect the decision of the client. There is also more privacy in
a community-based exam site. Especially in a small community, it is
likely that the victim or her family will encounter other people they know.
All necessary supplies and equipment are usually located at the
community-based exam site for easy access. In addition, there is no
additional billing for medical care or services.

Hospital ED-Based Exam Sites

Two of the initial three programs developed in the 1970's were based in a
hospital ED, and one was located at a community clinic. This trend has
continued today with the vast majority of identified programs indicating
that they are hospital ED-based. Fifty of the 59 programs responding to the
survey are hospital based. Thirty-nine of these programs primarily
complete exams in one or more EDs, eight in a hospital clinic, and three in
both a hospital clinic and the ED. 

Advantages of the ED Exam Site

There are numerous advantages to completing the evidentiary exam in the
ED. The ED operates 24 hours a day, 7 days a week and is a secure facility
with a wide array of support services available on site. Physicians are
available for easy consultation about medications and injuries. Any
medications ordered can be dispensed to the victim prior to her discharge,
ensuring she gets the necessary medications. Laboratory facilities are
readily available to complete tests such as UPT's, and if necessary, to
assist with a blood draw. 

Often rape victims come to an ED seeking care for minor injuries or
wanting treatment for STDs or because they are concerned about being
pregnant. If the SANE program is located in the ED, the SANE comes to
the ED to complete the evidentiary exam. Furthermore, the victims do not
have to be sent elsewhere because all the necessary medical expertise is
readily available to evaluate and care for any sustained injuries.

The medical expertise available in the ED does not come without a price,
however. If the cost of the ED overhead and ED physician fee is charged
to the victim, to her insurance, to the SANE program, or to the State
reparations board, it can represent a sizable sum. It is important to decide 
if the cost is justified. We now know that only a small percentage of
victims, 22 percent to 27 percent, have even minor injuries such as
bruising or a cut, which require no treatment. Even fewer, 3 percent to 4
percent, have injuries requiring treatment, and less than 1 percent are so
severely injured they require hospital admission (Solola & Severs: 83;
Tucker, Ledray & Werner: 90). 

To better determine how often the SANE was concerned about potential
injury even after the victim had been cleared by the ED staff, one study
reviewed 164 SANE cases completed between June and November of
1996. In 44 (27%) cases, the SANE requested additional medical
evaluation of injuries (Ledray, Linda E., Unpublished data. Sexual Assault
Resource Service, Minneapolis, MN, 1996). It is possible that the ED staff
would triage for injuries even more thoroughly if they knew the client was
being moved to a nonmedical setting. It appears this extensive medical
coverage is utilized with a very small number of victims, and it is not
necessary in most cases.

Overcoming Disadvantages of the ED Exam Site

To keep the costs down and retain service in the ED, one solution may be
to negotiate a more reasonable fee for the use of the ED and ED staff time.
One program has negotiated a $50 fee for the use of the ED, which also
includes the physician's time and all medications given the victim (Kathy
Bell. Personal communication, 26 November 1996). Community-based
programs may actually charge the hospital a fee for coming to the ED to
complete the exam for their clients (Colleen O'Brien. Personal
communications. 25 November 1996).

EDs can be busy, inhospitable locations, where the victim's privacy may
be compromised. Care must be taken to shield the victim from distractions
and loss of privacy. Often a specific exam room away from the center of
the ED can be fitted with a pelvic table and designated for the use of the
SANE. Simple additions such as wallpaper, a more comfortable chair, a
shower for use after the exam, and a telephone can significantly increase
the comfort level of the victim.

Hospital Clinic-Based Exam Sites  

Eight of the hospital-based programs and three additional programs that
are administratively based in the community conduct their exams in
hospital clinics. These clinic settings include urgent care, a women's
assessment center, and clinics specifically designated for sexual assault
victims. The community-based programs that use hospital clinic space are
usually in donated space, and the victim does not become a hospital
patient unless she has sustained injuries and is transferred to the ED for
treatment.

One clinic-based program initially completed exams only in the ED, but
recently moved all of its exams to a clinic located close to the ED. Two
other programs, currently ED-based, are considering a similar move in the
near future. In many ways, this appears to represent the best of both
worlds. The clinic locations are away from the hustle and bustle of the ED,
and the high overhead costs. The patient doesn't need to go to a second
location when she reports her rape to the ED; she is simply walked down
the hall to the clinic when the SANE arrives. Family and friends can use
hospital facilities, such as the coffee shop, while waiting, and they can still
contact the triage nurse with questions while the exam is being completed. 

If the SANE is concerned about injuries she feels require further
evaluation, or if she wants to consult with a physician about medications,
that is easily accomplished in a hospital clinic-based program. Laboratory
facilities and support are also readily available, and prescriptions can be
filled at the hospital pharmacy and sent home with the victim. In addition,
hospital social workers, crisis psychiatric nurse consultants, or a chaplain
is likely to be available on site to sit with a distraught victim or family
member until the SANE arrives.

Summary of SANE Location Trends

The majority of SANE programs continue to be hospital based, with most
located in the ED. However, there seems to be a new trend to locate SANE
programs outside of an ED. Fourteen of the 59 programs responding now
complete exams in a hospital clinic, 11 of these only complete exams in a
clinic, and 2 also complete exams in the ED. It is expected that others will
soon follow this trend by adding clinic exam sites. 

Now that the credibility of the SANE model has been established, it is no
longer necessary for the close medical supervision of the ED setting.
Research demonstrates that few victims sustain injuries requiring ED care.
While communities certainly have different resources and different needs,
a hospital-based clinic setting, especially one in close proximity to the ED
for referrals and security at night, appears to have more advantages than
disadvantages. The community-based program site, however, also offers
some advantages over the hospital-based program. For example, some
States mandate hospitals to report felony crimes, but these State statutes
do not apply to the community-based programs. While the SANE will
encourage reporting, she will respect the decision of the client. Also, the
victim's privacy is more protected in a community-based exam site.
Finally, the victim does not receive additional billing for medical care or
services. 

CHAPTER 8  

SANE Program Staff

Who typically directs a SANE program and who is best qualified to do so?
To whom does the director report and what role does she play? What
qualifications do existing SANE programs look for when hiring staff?
How large of a staff is needed? How are SANEs typically paid, and what
are the options? Selecting the right staff is a critical step toward
establishing a successful SANE program. This chapter provides
information on how existing SANE programs have responded to these
staffing questions and which options to consider when starting a SANE
program.

SANE Program Directors

Fifty-three (93%) of the SANE programs responding to the survey have
nurses as the SANE program director. Of the six remaining programs, one
is run by a physician's assistant (PA); one by a social worker (M.S.W.);
one by a nonnurse health administrator; one by a nonnurse educator (M.S.
Ed.); and two by physicians. Followup phone calls to the nonnurse
directed programs revealed that four of these programs have a nurse
identified as the program coordinator who functions in much the same
way as a nurse program director. The two exceptions include the program
run by an M.S. Ed. that is operated jointly with a rape crisis center and a
unique program operated by a PA and primarily staffed by PAs.

Reporting Structure 

Forty of these SANE program directors report directly to hospital
administration. Of these 40, 16 report to a nurse manager (of these 16, 9
are the emergency department nurse manager); 10 report to a medical
director (of these 10, 8 are the director of emergency medicine). An
additional 14 of the 40 report to a hospital administrator including the VP
of patient care (N=4); assistant administrator (N=3); hospital CEO (N=2);
ambulatory services (N=2); ED administrator (N=1); human resources
(N=1); and a specialized women's health clinic director (N=1). 

Twelve SANE program directors report to agencies outside of a hospital
administrative structure. These include a rape crisis center director (N=2),
YWCA administrator (N=2), district attorney (N=2), police detective
(N=1), family violence coordinator (N=1), and advisory boards or
coordinating boards (N=4). Five programs are independent and indicate
no reporting structure outside their organization. Two programs did not
respond to this question.

Job Duties

In most SANE programs, the director is responsible for the overall
program operation and vision, as well as managing the day-to-day
operation of the SANE program. The director may also be responsible for
the budget, including the procurement of the necessary funding for
ongoing program operation. The director is responsible for staff
recruitment, hiring, training, and continuing professional development.
Another important job function includes avoiding or reducing staff
burnout by keeping the job environment as healthy as possible for the staff
and for herself (an important topic, that is discussed in greater detail in
Chapter 14, Maintaining a Healthy Ongoing Program). Providing staff
with a safe, supportive work environment ensures that the staff feels
comfortable bringing its questions, concerns, and issues to be discussed
and resolved. In addition, the SANE program director must ensure that
adequate staff is available and that backup emergency options are in place
for providing continuous program coverage.

The SANE program director serves a valuable role as the liaison with
other community agencies. She must be an active member of the SART
team and may be a key player in ensuring that the team membership
remains active and involved. Many SANE directors are actively involved
in community education about sexual assault issues and the role of the
SANE. This may include both informal community presentations and
formal classroom instruction at the local university. 

It is also the director's responsibility to oversee ongoing program
evaluation and research activities and ensure that the results of these
efforts are incorporated into modifying and improving the program.

On Call 

Most SANE directors are RNs who are actively involved in the clinical
component of the SANE program and take call. Sometimes this is done to
meet the needs of the program, but it is usually seen as an important way
for them to maintain their professional expertise and credibility as well 
as enhancing job satisfaction.

The survey results indicate that the majority of the directors, 76 percent
(N=38), take call routinely. Many of these are smaller programs where the
director takes call during weekday office hours. If the director is on salary
during this time, she is not paid additional on call pay. A director who
takes call when she is not salaried is usually paid or receives compensatory
time. One director, who owns a private, for profit, SANE program, is not
specifically compensated for on call time. In three programs, 6 percent, the
directors only take call during an emergency. They may fill in during off
hours that cannot be covered by the other staff, or they work "backup" call
taking the cases that come in when the primary nurse on call is already
busy conducting an exam. Nine directors, 18 percent, never take call, even
those who are qualified to do so.

The Role of the Physician

Of the 33 ED-based programs responding, approximately one-third
(N=10), have no medical director but rely upon the physician available in
the ED to staff SANE cases and sign off prescribed medications and
charts in the ED. Ten others have a specified physician who approves their
protocols and routinely reviews their cases. The remaining 13 consider
themselves a part of the ED, and the ED medical director is their medical
director as well. Seven of the nine clinic-based programs have a specified
medical director, two do not. 

Staff Selection 

Most SANEs are female nurses. In the survey of SANE programs, only
one program indicated that it has a male nurse who takes call. Studies
show that approximately 50 percent of victims, even male victims, prefer
to have the exam completed by a woman and sometimes insist on being
seen by a woman (Wright, Duke, Fraser & Sviland: 89; Ledray: 96a;
Lewington: 88). 

Good clinical skills along with good written and oral communication
skills are identified as important qualifications for a SANE
(Antognoli-Toland: 85). A background in obstetrics-gynecology and
psychiatry, as well as experience in positions that require independence,
such as public health nursing, school nursing, and ED nursing is preferred
by one program (Ledray: 92a). Good assessment skills, including the
ability to evaluate a situation and know when to ask for help, are essential
staff requirements (Ledray: 93b). 

One program director indicated that while she would never exclude a
nurse solely on the basis of past victimization, she is aware that it is
essential for nurses who are rape victims themselves to resolve their own
issues through formal counseling prior to employment as a SANE. The
director believes extensive counseling enhances the SANE's ability to
maintain personal and professional boundaries. Even many years later
after extensive counseling, difficult periods may occur, such as the
anniversary of the SANE's rape or a particular case that is too close to her
own experience, which may prevent her from being effective. Even
though a past rape experience may give the nurse more empathy, a SANE
cannot help someone else resolve issues if she has not yet effectively
resolved them for herself (Ledray: 92a). 

While many SANEs have advanced nursing degrees, the majority do not.
It has been clearly demonstrated that an advanced nursing degree is not
necessary to successfully function in this role (Ledray: 96a). Moreover,
since large pools of nurses with advanced degrees are not readily available
in many metropolitan areas, they certainly would not be available in rural
communities. The minimum requirement is that the individual is a
registered nurse (RN). While one forensic program is run and staffed by
physician assistants (PA), and two programs have physicians taking call,
by definition they cannot be SANEs. It is not recommended that they be
hired in this capacity. While physicians and PAs certainly can complete an
evidentiary exam, they may require a higher salary compensation, and this
may become an issue in the clinical practice of the group. In addition, PAs
cannot function independently as the RN can. PAs can legally only
practice under the direction of a physician.

The 35 programs reporting the educational level of SANE staff, indicated
that they had a nearly equal percentage of nursing diploma (28%),
associate degree (33%), and bachelor degree (28%) prepared nurses
working as SANEs. A relatively large number of SANEs were with
advanced degrees (11%). 

Staffing Patterns

Determining the SANE staffing level depends on the number of cases
expected monthly, coupled with the consideration that regardless of the
number of cases, SANEs must be available 24 hours a day, 7 days a week.
Only one program surveyed indicated it was not able to provide
continuous coverage due to a shortage of staff. Two programs with
continuous coverage were, however, able to do so with just ONE SANE!
One of these nurses saw 80 cases per year and worked another job as well.
She did occasionally take a vacation, at which time the ED staff completed
the sexual assault exams. The general consensus from SANEs is that,
while possible, it is extremely difficult to complete more than two sexual
assault exams without time off between cases.

Of the programs surveyed, 32 (64%) had 10 or fewer staff taking call, 16
(32%) had 11 to 20 staff, and only 2 programs (4%), had more than 20
staff. One of these had 30 staff and completed 1,600 exams a year; the
other had 36 staff and completed 200 exams per year.

Only 31 programs reported both the SANE staff number and the number
of exams completed each year. Of these, the reported staff to exam ratio
varied from a low of one staff to three exams, to an extreme high of one
staff to 225 exams per year. The majority of programs, (84%), reported a
manageable SANE to exam ratio of 40 exams or less per year, per SANE:
12 programs, (39%), reported a SANE to exam ratio of 10 or less per
year, per SANE; 10 programs, (32%), reported a SANE to exam ratio of
11 to 20 cases per year, per SANE; 4 programs, (13%), reported a SANE
to exam ratio of 21 to 40 exams per year, per SANE. Five programs,
(16%), reported a very high ratio of 75 to 225 exams per SANE, per year. 

The program with the highest SANE to exam ratio of 1:225 employed
only four SANEs in a program that averaged 900 exams per year. The
next highest ratio was 1:120. In this program 10 SANEs see an average of
1,200 cases per year. Unlike any other program, SANEs in this program
are paid a salary for 8 hours Monday through Friday when most of their
cases, child sexual abuse cases, are seen by appointment. They also work
on call during the evenings, nights, and weekends. They are paid $30 per
hour, and their nursing coordinator reports these SANEs want more hours
rather than fewer hours (Pat Speck. Personal communication. 16 January
1997).

Staff Meetings

Because SANEs work in isolation, it is essential that they have the
opportunity to meet regularly to discuss cases, policies, and procedures; to
receive additional training and support; and to "debrief." 

Of the programs responding to the survey, the majority, 64 percent
(N=32), meet on a monthly basis. Another 10 percent (N=5) of the
programs meet biweekly, 10 percent meet bimonthly, and 10 percent meet
quarterly. Only 4 percent (N=2) meet semiannually, and 2 percent (N=1)
meet as frequently as weekly. 

Sixty-five percent (N=19) of staff meetings last 2 hours, while 10 percent
(N=3) last 1.5 hours, and 14 percent (N=4) last 1 hour. Three programs
responding (10%) indicated their staff meetings can last 3 to 4 hours. One
of these programs meets only quarterly and two programs meet monthly.

SANE Salaries

The literature indicates that most SANE programs pay the nurses per case
for the exam. The range documented is from $100 per exam (Bell: 95;
Massachusetts Nurse: 95; Thomas & Zachritz: 93) to $150 per exam
(Frank: 96). One program indicates that they pay the SANE a 3-hour
minimum at the local staff nurse salary level, more if the exam takes
longer than 3 hours (Ledray: 92a). The programs paying more for each
exam indicate that they do not pay for costly on call time (O'Brien: 96;
Thomas & Zachritz: 93). One program reported that they pay the SANE
$50 per hour for courtroom testimony (O'Brien: 96) and another pays
$100 per appearance (Thomas & Zachritz: 93).

The survey results were somewhat different than the literature. Two-thirds
of the responding programs indicated that they paid for on call time and
one-third did not.

On call pay ranged from $1 per hour to $7.50 per hour, with an average
pay of $2.89 per hour for on call time. The programs not paying for on
call time did not necessarily pay more for exams. The lowest paying
program pays no on call time and paid the SANE $18.00 per hour for the
exam. The highest paying program was the program with the 1:225 staff
to exam ratio that hired only nurses with an advanced degree. In addition
to paying $30.00 per hour for day shift work during the week, they pay $5
per hour for on call time, and $200 per case when called in for an exam. 

SANE programs with a small number of cases, often in rural areas, simply
cannot cover the high cost of on call pay. In some areas, the hospital
nursing union contract may require the hospital to pay nurses on call pay.
In these instances, the SANE program may need to negotiate with the
union to make an exception for the SANE program. If this is not possible,
the SANE program may need to be administratively based outside the
hospital to avoid cost prohibitive on call pay requirements.

One-third of the responding programs pay the SANE a per case rate for
the exams with a range of $50 to $200 per exam. The other two-thirds of
the programs pay an hourly rate from $18 to $50 per hour for the actual
time spent completing the evidentiary exam. The average rate paid is $25
per hour for the exam. Some programs indicate they pay a rate equal to
the community staff nurse hourly salary, others pay 1.5 times the
community staff nurse salary. Some have established a minimum number
of hours the SANE is paid when she responds to a case. This minimum
ranged from 2 to 4 hours. The time estimated to complete an exam ranged
from 2.5 to 5 hours with an average of 3.2 hours. More than half, 30
programs, also pay the same hourly rate for attending staff meetings.

SANE Staffing Recommendations

The following SANE staffing recommendations are based on the results of
the survey indicating current practices, the literature reviewed, and the
experience of the advisory committee.

Program Director

The individual best qualified to act as a program director is a SANE
qualified to complete the evidentiary exam and who maintains her
competence. This recommendation is based on survey results indicating
the frequent need for SANE program directors to take primary and
emergency backup call. This provides an important depth of coverage not
otherwise available. It also gives the director considerably more credibility
with her staff and the community. 

In some States, the SANE director can also be called to court as the
"keeper of the records" to testify to the facts contained in the records
collected by SANEs on her staff. As a SANE, the director can also testify
as an expert witness if she maintains her clinical competence.

It is also important that the program director have management skills,
including budget and program evaluation skills so that she is able to
effectively represent the program in the community. A knowledge of
community resources is useful. The ability to conduct staff training, to
provide community and professional education, and to make conference
presentations is an equally important qualification for an effective SANE
program director to possess.

The program director does not need to occupy a full-time position; in fact,
in most smaller SANE programs, the position is not full-time. To have
some paid administrative time available for the director is always
necessary, but the amount of time will vary greatly with the size and
budget of the program. Having the director function on call regularly is
also an effective means for her to augment her income while maintaining
her clinical expertise.

Medical Director

While a relationship with a physician is essential for prescription and
injury protocols, and general medical consultation, it is not necessary to
have a medical director. SANE programs are nursing programs, and the
primary activities are nursing activities not requiring medical authority.
Because of this, a reporting authority through nursing is sufficient. 

If the decision is made that medical authority is preferred, identify a
consulting physician who is familiar with the program needs and who will
be available for consultation and to help establish protocols. Programs
based at a medical facility can utilize physicians on duty, to sign
prescriptions at the time of the exam.

SANE Staff

Any interested and qualified registered nurse who completes the training
is qualified to be a SANE. An advanced degree is not a requirement. The
training must be conducted by an experienced SANE, preferably with at
least 2 years of SANE experience. Continuing education and SANE exam
experience requirements should be met yearly for continued active SANE
status.

Summary

Although national standards have not yet been established, the survey of
existing SANE programs has identified many similarities. By far, the
majority of SANE programs are directed by nurses who report to a nurse
manager or hospital administrator. All but one SANE identified is female,
and only 11 percent have advanced degrees, reinforcing the 
recommendation in the literature that an advanced degree is not necessary
and should not be a requirement when developing a SANE program.
While most programs employ 10 or fewer SANEs, staffing patterns vary
greatly and are not directly a function of the number of exams completed
per year.

Salaries vary greatly and range from a low of $18 per hour with no on call
pay and no additional per exam pay to a high of $30 per hour for
scheduled hours with a $5 per hour on call pay, and $200 per exam when
not on salary. Two-thirds of the programs pay for on call time at an
average rate of $2.89, and two-thirds pay an hourly rate for the exam time
averaging $25 per hour. 

While the number of SANEs hired and the number of victims requiring
services vary greatly from program to program, sufficient staff should be
available so that a SANE does not routinely complete more than two
exams during one on call shift. Establishing and maintaining an on call
schedule is addressed in the next chapter.

CHAPTER 9  

SANE TRAINING

The registered nurses (RNs) who are selected for SANE duties must
receive the proper training to ensure that they perform effectively in the
SANE role. No matter how motivated an RN may be or how well she
functioned in her former positions, the SANE program will not be
successful unless each employee has the proper training for her particular
role. What training is needed? How are programs today training their
staff? What are the current training options? Where can staff go for
training? Who is qualified to do SANE training? 

Choices must be made between the ideal situation and the realistic training
needs of the program. The goal must always be to provide the best
possible training for the SANE staff that is possible with the resources
available and without putting unrealistic demands on either the staff or the
budget.

Certification

National Certification

There is currently no national SANE certification. However, the IAFN
recognizes the importance of establishing national-level certification for
SANEs to ensure both consistency in practice and credibility in the
courtroom. As a first step toward this end, a committee chaired by Patricia
Crane, MSN, NP, RNC and cochaired by Diana Schunn, RN, BSN, has
developed goals for SANE training programs and is working on
recommendations for SANE training curricula. These were approved and
adopted by vote of the SANE council at the October 1998 IAFN
conference. They will be available through IAFN.

State-Level Certification

State-level certification is an option being considered by several States,
since at this time, there is no standardized national certification or training
requirements for SANEs. Massachusetts has recently developed a
statewide sexual assault training program under the auspices of the Public
Health Department for both nurse and physician certification.
Massachusetts requires recertification every 2 years based on competency
(Massachusetts Nurse: 95). Texas has established a multidisciplinary
group working out of the Attorney General's Office and criteria for State
level certification (J. Ferrell. Personal communication. 3 October 1998).
Other States may follow with similar requirements.

The desire to develop State certification or licensure in the absence of
national certification is largely driven by the desire to establish credibility
when the SANE is required to testify in court. However, since IAFN is
actively seeking to develop national standards and certification, State
agencies may better meet their needs by concentrating on providing solid
basic SANE training for their local SANE programs to ensure their
credibility in the courtroom rather than focusing on the credentialing
process.

A problem inherent with State credentialing is that there will likely be
considerable variation in expectations of the practicing SANE and a lack
of consistency in the training requirements from State to State.
Implementation of State certification will probably create a new level of
government regulation of SANE practice that may be impossible to
dismantle when national certification is implemented. Each State will then
need to decide if the national certification will be required instead of the
State requirements, or justify why the State requirements will be required
in addition to the national requirements. 

Local Certification

It is important to note that even when a specific trainer provides
"certification" after completing a SANE training course, it is important to
ask who or what institution is "certifying" the training, since there is no
nationally recognized certification. In most cases it is a local hospital or
SANE program. Continuing Education Units (CEU) should always be
provided with training.

SANE Training Options

A common question from someone wanting to start a SANE program is
"Can I send one person to a training program, then have her come back
and train the remainder of the staff?" The overwhelming advice from
experienced SANEs is "NO!" While the question is usually asked in an
attempt to reduce initial startup costs, which is an understandable concern,
the training will not be adequate, and the quality of the SANE program
will be jeopardized. Cut costs somewhere else. 

There are three primary options for SANE training. The first option is to
send the entire staff to an established basic SANE training program. A
second option is to hire a qualified SANE trainer to come to the
community to conduct a complete training program for all SANE/SART
staff. The third option is to organize part of the training locally, utilizing
local expertise, and hire a qualified SANE trainer to come to the
community to conduct the portion of the training specifically related to
SANE evidence collection and documentation. This person may or may
not also act as a consultant to the program. 

SANE Training Today

In the survey of existing SANE programs, approximately one-third of the
programs surveyed provide their own SANE training and two-thirds
utilize an established SANE training program for the initial training.
Existing basic SANE training programs typically consist of approximately
40 hours of classroom instruction.

Some programs also specify a designated number of clinical hours after
completing the classroom training. The range, when required, is from 40
hours (Kettleson: 95) to as many as 96 hours of additional clinical
experience (Antognoli-Toland: 85). Additional clinical hours usually
include experience in the following areas: 

--Normal vaginal speculum and bi-manual examination experience.

--Normal well-child examinations (for programs seeing children).

--Courtroom observation.

--Specified number of adult or child evidentiary exam observations. 

Most programs do not have a set number of required clinical hours but
rather train until the new SANE indicates that she feels comfortable with
the procedures and demonstrates competency. Some programs require the
trainee to return a signed certificate of completion for the clinical
component prior to receiving their course completion certification. Other
programs require the trainee to demonstrate competence utilizing a
competency checklist for each clinical skill (Gaffney: 97). (See Appendix
H: Clinical Skills Competency Checklist). Still other programs have the
SANE complete an exam, either simulated or real, while being observed,
to demonstrate competency.

Once trained, all but eight programs surveyed indicated they require
specific criteria for maintaining certification. While no two programs are
the same, the most common requirements include the following: 

--Completion of a specific number of exams per year.

--Attendance at staff meetings.

--CEUs such as SANE relevant literature reviews.

--Conference attendance.

--Externships with physicians and nurse practitioners.

--Continuing to take call and remain actively involved in the SANE
program. 

Any interested and qualified registered nurse who completes the training
can become a SANE. An advanced degree is not a requirement. The
training must be conducted by an experienced SANE, preferably with at
least 2 years of SANE experience. Continuing education and SANE exam
experience requirements should be met yearly for continued active SANE
status.

Utilizing an Existing Training Program

If financial resources permit, the entire staff may attend one of several
SANE training programs available. (See Appendix D: SANE Training
Programs). This option provides assurance that the training will be
competent and the trainer experienced. Some programs have chosen to
send some staff to one training program and other staff to a different
program so that they can share their varied experiences. This also provides
opportunities to develop professional networks and mentoring
relationships with experienced SANEs.

There are a couple of disadvantages to utilizing the existing programs.
First, if the SANE staff is large, it can be expensive. The cost for the basic
SANE training ranges from $250 to $500 per person, plus travel expenses.
The cost for an advanced clinical training course can run $1,200 per week,
plus travel expenses. If the staff is small or if there is a training program
nearby, attending a SANE training course may be a more realistic option.
Another possibility might be to provide the initial SANE training locally
but later send a representative to one of the existing basic or advanced
training programs to develop additional expertise to bring back and share
with the other program staff. If an individual SANE is being added to the
staff, it can be more financially feasible to send one person to an
established training program. 

A second problem may be timing. These programs are usually run only
once a year. Program startup timing might not coincide with the dates of
the preferred training program. If existing training programs and training
dates are identified in the early strategic planning phase, this problem
might be avoided. If the SANE staff is sufficiently large, a special training
program may be negotiated specifically for that community. 

A common misconception is that the training responsibilities have ended
once the initial SANE training through an established SANE course is
completed. A big piece of the initial training job is completed, however,
issues such as the role of the local police, rape center, prosecutor's office,
and the appropriate interactions among these agencies and the SANE
program must be addressed. Local policies, procedures, and protocols
must also be addressed.

Importing a SANE Training Program

If a large SANE staff is involved, it may be more cost effective to hire a
qualified trainer to come to the local area and provide a complete SANE
training program. The cost as of 1997 is approximately $1,000 to $1,200
per day for the trainer, plus travel expenses (See Appendix E: SANE
Trainers). Hiring a trainer affords more control over the training dates, and
if one trainer is not available during the preferred dates, another trainer
may be able to better accommodate program needs. Importing a trainer
also allows for more flexibility in the training format. Instead of a one-
week program, for instance, the training can be divided into 2- or 3-day
segments to better meet the SANE staff schedules. Training can occur 2
days, 1 week, and 3 days another, for instance. The training agenda can
also be negotiated, to better meet the SANE staff needs. CEU's should
always be provided for the training. Once again, it is still important to
recognize the need to include training specific to the local SANE program
and community needs. 

Organizing Local SANE Training

Another option, which may be time-consuming, but more cost effective, is
the organization of training that maximizes the use of local experts. A big
advantage of this option is the involvement of other programs in the area.
If other organizations are involved in the training, they are more likely to
be committed to the success of the program. They also will be more
familiar with the SANE staff and an important step will be taken towards
building local support and fostering open communication among agencies.
Taking the opportunity to recognize and utilize agencies' expertise will
increase the SANE's opportunity to share experiences with the agencies
and ensure that the SANE staff knows the information these local
community agencies indicate is "the most important." 

Identifying Local Experts

Local experts must be carefully screened. Just because a local facility is
now completing rape exams does not mean that its staff is necessarily up
to date and doing these exams according to the current SANE
state-of-the-art evidentiary exam standards. 

If there is a school of nursing in the area, explore the option of developing
a SANE training program for credit, or for no credit, but associated with
the school of nursing.

Look to experts from the local rape crisis center to teach about the crisis
response of rape victims and crisis intervention needs.

Local police can best talk about State rape laws and the investigation
process. They can also address the evidence they find most helpful to
them in investigating a sexual assault case. They can discuss how they
would like to interact with the SANE in the ED or clinic. A local police
photographer will be a good source of information about photographing
injuries. 

Staff from the prosecuting attorney's office can provide valuable
information about the type of evidence needed and the State laws
regarding reporting and confidentiality. That office can also help prepare
the SANE staff for courtroom testimony, and may even provide mock
courtroom experience. Often used in legal training programs, mock trial
experience can significantly reduce the anxiety often associated with the
initial courtroom appearance. 

A nurse practitioner or physician from a local obstetrics department or
planned parenthood center will be able to provide comprehensive training
about normal pelvic examination, pregnancy risk evaluation, treating for
STDs, and the use of the colposcope. If there is a local STD clinic, it may
be another good resource. Make arrangements with whoever provides this
initial training to have the SANE staff go to this clinic to practice normal
pelvic exams and colposcopic examination. The local hospital clinical
laboratory will be a good resource to review blood drawing technique and
also to provide additional practice. A physician from a local ED or clinic
may welcome the opportunity to meet with the SANE staff and talk about
assessing physical trauma. If the ED does the training, the ED staff will
likely feel more comfortable with the trauma assessment skills of the
SANEs. Clinical skills competency checklists can be provided to these
outside organizations and clinicians in order to standardize the skills
training (See Appendix H: Clinical Skills Competency Checklist). 

It can be helpful to have the SANE staff go to other community sites for
training such as the police department or the county attorney's office. This
will allow SANE staff to meet other members of these agencies. Include a
tour of the local crime lab so the SANEs can learn more about how the
evidence they will collect is processed and analyzed.

Selecting a SANE Trainer

It will still be necessary to select a qualified SANE trainer to come and
teach other portions of the training. This should include at least the
following information:

--Collection of evidence, what to look for and where, and what to collect
and how.

--Maintaining chain-of-evidence.

--Presenting credentials as a SANE in court.

--Patterns of injuries in sexual assault cases.

--Data collection and recording.

--Consent specific to sexual assault forensic exam (How SANE consent
differs from routine medical consent for treatment). 

--Patient confidentiality.

--Reporting.

--Working with the noncompliant rape victim.

--Adolescent rape issues.

--Child-victim specific issues, if the program will be seeing child victims
(See the section in Chapter 12 on Preparing the Child for the Exam).

When looking for a trainer, in addition to the cost, look for someone who
has a minimum of 2 years experience, preferably 5, as a SANE doing
evidentiary exams and who is still actively involved clinically with a
SANE program. A trainer should have a minimum of a B.S.N. and
preferably an advanced nursing degree. Education training and experience
is essential. University faculty experience is extremely helpful, but at a
minimum, look for someone with experience conducting SANE training.
Ask to see her Curriculum Vitae and ask for names and phone numbers of
others for whom she has provided training. Call her references to see how
satisfied they were with the training they received and the assistance she
provided. 

When hiring a trainer to come to the community, she should be flexible
and willing to meet the SANE staff training needs. Be sure to establish
ahead of time if she will also be willing to consult with the SANE staff or
director about the SANE program development before the training and to
answer questions after the training. Ask if there will be an increased cost
for this additional assistance.

SANE/SART Training Resources

Color Atlas

An excellent training resource for information on the evidentiary exam is
the Color Atlas of Sexual Assault (Girardin, Faugno, Seneski, Slaughter,
& Whelan: 97) Written specifically for the SANE by SANEs, it contains
221 color illustrations primarily of genital anatomy and trauma. It includes
normal and abnormal findings with complete explanations for the SANE.
It distinguishes assault from nonassault injuries and includes a section on
emotional care of the assault victim as well. Published by Mosby, it is
available through local bookstores. 

Evidentiary Exam Videotape

Two videotapes are currently available, both produced by SANEs, for use
as an adjunct to evidentiary exam training. One was produced by
American Forensic Nurses and the other by Manfred Hochmeister, MD
and Jamie Ferrell, RN, BSN. American Forensic Nurses, a
California-based SANE/SART program, has developed a 45-minute
videotape "The Sexual Assualt Examination: Essential Forensic
Techniques" with a supplemental training manual about the SANE exam
(Phone: 760-324-1124; Fax: 760-321-2750). If you indicate that you heard
about this training aid in this manual, Western Nurse Specialists (WNS)
has offered to donate $25 from each videotape sale to this project to
provide additional technical assistance toward developing SANE
programs. A comprehensive and uptodate SANE/SART specific training
tool, it includes the following information:

--SART members roles.

--Interview process.

--Medical-legal examination.

--Forensic photography.

--Genital trauma and examination.

--Chain-of-custody.

--Victim followup care.

The videotape by Manfred Hochmeister, MD and Jamie Ferrel, RN, VSN,
"Sexual Assault: The Health Care Response" is a comprehensive guide to
the forensic examination and evidence collection of the adult sexual
assault client. A version is available for medical personnel and another
version for nonmedical personnel. Newly released in 1999, this
step-by-step videotape documents the latest techniques in forensic
examination and evidence collection. This videotape can be ordered for
$95 from the Institute of Legal Medicine, University of Bern, Buehlstrasse
20, CH-3012, Switzerland; or (from the US and Canada) by Fax (0041)
011 31 31 631 84 15.

SANE Training Components

Whether evaluating an existing SANE training program or developing a
new local training program, ensure that, at a minimum, the following
components are included:

Programmatic

--Role of the SANE and forensic nursing history.

--Program goals, objectives, vision, and mission.

--Review of program policies and procedures.

--Working with the media.

--Facilities familiarization.

--SANE program evaluation research. 

--Training program evaluation.

Medical

--STD review of statistics, symptoms, and treatment options.

--Pregnancy risk evaluation, prevention, testing options, termination
options.

--The normal genitalia (pelvic and anal) and normal growth and
development in adults, adolescents, and children (when applicable).

--Techniques for blood drawing. 

--Physical assessment, identifying injuries and criteria for medical referral
to physicians.

--Using the colposcope and obtaining 35mm and/or video pictures (if
available).

--Followup resources and needs of the rape victim.

Legal

--Local State rape laws and the police report and investigation process.

--Role of local law enforcement (street police and police investigator).

--Obtaining consent. 

--Maintaining confidentiality.

--Role of the local prosecuting attorney.

--The local court process.

Forensic Practices and Procedures

--Noting the types of evidence collected in rape cases and the utilization of
evidence.

--Determining the source of specimens.

--Maintaining chain-of-evidence.

--Utilizing evidentiary exam timing and protocol.

--Noting extragenital pattern injuries in sexual assault.

--Noting genital injuries in sexual assault.

--Photographing injuries.

--Collecting, labeling, storing, and processing laboratory specimens.

--Medical-legal interviewing.

--Documenting and recording with a jury in mind.

--Testifying in court as an expert witness and factual witness.

Psychological

--The emotional needs of the rape victim and how to meet them.

--Crisis intervention with the rape victim.

--Suicide risk evaluation. 

--Role of the local rape crisis center.

--Victim's fears about reporting and what it means to report in the local
community.

--Discharge and followup resources and needs of the rape victim 
(including safety assessment and planning).

--Diversity and cultural issues.

Continuing SANE Education

Once the SANE staff is trained, it is important to establish criteria for
continuing education. Recommendations for continued education include,
at a minimum, the following on a yearly basis:

--Maintaining RN licensure.

--Completion of at least one SANE exam. 

--Ongoing SANE training such as attending or presenting one SANE
inservice, providing CEU credit, peer chart review, or attending or
presenting a SANE case presentation, attending or presenting at a Forensic
Nursing or Forensic Science conference. 

Additional recommendations include the following: 

--Membership in IAFN.

--Membership in the American Nurses Association (ANA). 

--Membership in the local State nurses association.

Future SANE Training Trends

Offering forensic nursing courses and SANE training at the university
level, utilizing an experienced nursing faculty appears to be the current
trend. There are already several forensic nursing courses offered at the
university level which qualify for university credit and that offer advanced
degrees. These include Fitchberg University in Worchester, Massachusetts
and Beth-El College of Nursing, Colorado Springs, Colorado. Other
institutions, such as Columbia University, School of Nursing in New
York, New York, offer SANE training programs that do not qualify for
university credit. Mount Royal College in Calgary, British Columbia
offers forensic nursing courses via the Internet that can, of course, be
accessed from any computer, anywhere in the world, for credit through
their institution.

Summary

SANE training is currently not standardized nationally and both the
quality and components vary greatly from one program to the next. Most
existing SANE programs utilize an established SANE training program,
and once trained, have specified criteria for continued local certification. 

It is anticipated that within the next 2 years there will be standardized
minimum training requirements recognized by IAFN. These minimum
training requirements will be required for the national certification that
will follow. 

-------------------------------

SANE Training Topics

--Definition of the SANE role.

--Collection of evidence (including forensic procedures such as
maintaining the chain-of-evidence).

--Testing and/or treatment of STDs.

--Evaluation and prevention of pregnancy.

--Typical victim responses and crisis intervention.

--Assessment of injuries.

--Documentation.

--Courtroom testimony (Mock Trial).

--Corroborating with related community agencies.

--Competently completing an exam.

--Forensic photography. 

-------------------------------

CHAPTER 10  

ESTABLISHING AND MAINTAINING PROGRAM COVERAGE

It is essential to develop and maintain a reputation for reliability in the
community, especially when the service is new. The referring community
programs must know that if they call the SANE, or refer a rape victim to
the SANE facility, a SANE will arrive in a reasonable period of time to
see the victim and follow appropriate protocols. 

Using Staff Positions

The only way to eliminate response time is to have SANEs available on
site. It takes a very high volume of cases or the ability to schedule exams
to make this model cost effective. There are no identified SANE programs
with paid SANE staff available on site 24 hours a day. One SANE
program with a very high volume, 1,200 to 1,500 cases per year, has
found it cost effective to have SANEs available on site Monday through
Friday during office hours. Although they see injured victims in the ED,
the SANEs otherwise work at only one clinic where all noncritical victims
are brought in by law enforcement or children's services. While they do
see adults who walk in, more than three-fifths of their cases are children
and adolescents. Programs that work with children and do exams on a
nonurgent, scheduled basis are more likely to have salaried positions with
regular hours. 

Smaller programs may also have the SANE director see cases during her
office hours. Assuming her office is near the exam site, this cuts costs,
reduces the need for additional staff, shortens the response time, and helps
her to maintain clinical competence.

Using On-Call Positions 

When exams cannot be scheduled, which is the situation in most sexual
assault cases, utilizing on- call positions is cost effective. When
establishing the SANE on-call schedule, decisions must be made about the
length of on-call shifts, how they will be assigned, what changes in the
on-call schedule are allowable, and how these changes will be made.
Decisions must also be made about how the SANE will be paid for on-call
time, the allowable maximum response time, when the SANE should be
paged and by whom, and what type of pager system will be used. In
addition, a formal or informal backup call system should be considered.

Length of On-Call Shift 

Smaller programs with fewer cases usually have longer on-call shifts.
These may be 24- or 48-hour shifts. As the caseload increases, the on-call
shifts typically decrease in length to 12 hours and even to 8-hour shifts.
Eight-hour shifts that coincide with area hospital nursing schedules make
it easier for the SANE to work her call around other scheduled work. The
standard practice is to have the shifts short enough that the SANE will be
unlikely to complete more than two exams during any one shift. Shorter
shifts, however, mean more shifts to cover, which usually means hiring
and training more staff. 

Assigning On-Call Shifts 

Most often each SANE is hired to take a predetermined number of on-call
shifts each month. The number of shifts will usually vary from SANE to
SANE and is a function of her availability and the needs of the program.
Each SANE may initially be assigned an equal number of day, evening,
and night shifts, or an individual SANE may routinely be responsible for a
particular shift. The shifts assigned may also vary greatly week to week
and month to month, depending on the availability of the SANE staff.
Except under unusual circumstances, no SANE should be assigned to take
more than two nights in a row when she is working another job. When
SANE shifts vary month to month, the call schedule should be made at
least 2 weeks prior to the end of the month.

Staff may prefer to work the same shift all month, perhaps the same day
of the week if there are 24-hour call shifts. This consistency allows staff to
plan their other jobs around their call schedule. While this process makes
scheduling very predictable, it can result in a more rigid call schedule and
requested changes in the call schedule must be worked out with other staff
in advance. Emergencies, vacation requests, and special needs of the
SANE staff need to be accommodated whenever possible.

Work shifts often assigned on a nursing unit are another option for
scheduling on-call shifts. With this option, the program director tries to
accommodate the SANE's specific requests when making out the schedule.
This method, however, is labor intensive for the nursing director, and the
results rarely please staff.

There is another method that provides for considerable flexibility, gives
the responsibility to the staff to select the shifts they want, while
maintaining some external "fairness" about who takes which shifts, thus
resulting in a happier staff. This method is referred to as the "poker chip
method." In this method, each SANE has a predetermined number of day,
evening, and night shifts she has agreed to take as well as an agreed-upon
number of weekend shifts. The schedule is completed at a staff meeting,
and it is important that everyone is present or has arranged for another
SANE to represent her desires. 

Each SANE is given a red poker chip for each evening shift for which she
is responsible, a blue chip for each day shift, and a white chip for each
night shift. She is also given a white square for every weekend shift which
she is expected to cover. (Weekend shifts are considered Friday evening
through Sunday night.) While everyone is initially assigned a specified
number of weekend, day, evening, and night shifts, periodically they are
given the option of trading shifts or giving away shifts. A record is kept
by the program director. Shifts can also be traded informally each month
before the call schedule is developed. 

The director, or her representative, reads through the list of available shifts
for the month one by one. As she does so, much like in a card game, the
first SANE to speak up gets the shift. The SANE puts the appropriate chip
in the center of the table for each shift she takes, until all shifts are gone
and everyone has used all their chips. If there are holes in the schedule
after the first time through, the director reads through the list of remaining
shifts again until all are filled. Nurses who have participated in a
self-scheduling process of this nature have ensured that all shifts are
covered.

Changes in the On-Call Schedule

While it is understandable that changes in the on- call schedule will need
to be made, it is important that nonemergency on-call schedule changes be
kept to a minimum. Whenever a change is made, the likelihood of paging
errors increases. This is especially true if each SANE has a different pager
number assigned. In these cases, whenever possible, both the nurse
initially assigned and the nurse taking call for her need to keep their pagers
turned on. For nonemergency on-call changes, the SANE is usually
responsible for finding her own replacement and to call all agencies that
might page her with the changes, including law enforcement, rape crisis
advocate, the SANE office, the answering service, and each participating
hospital. In emergency situations, the SANE should call the office or
director at her home, and she will arrange for coverage and notification of
the change.

Paid and Unpaid On-Call Service 

Our survey of existing SANE programs indicated that two-thirds of the
responding programs pay for on-call time and one-third do not. The
programs not paying for on-call time did not necessarily pay more for
exams, even though the literature suggested they did, and they probably
should do so. 

Paying for on-call coverage is cost prohibitive for small SANE programs
that see fewer than 100 cases each year. If the SANE program is not
covered by a union contract, the director may have the option to pay more
per exam, rather than paying for on-call time. An equitable solution is
payment of per-case amount that is equal to a 3-hour minimum salary at
the prevailing nursing wage in the community (or time and one-half, if
financial resources allow), plus what the nurse would make if she were
paid at the local nursing community on-call rate for the entire length of her
shift.

Response Time 

The agreement with cooperating facilities served should always include a
maximum acceptable response time from the moment the SANE is paged
until she arrives at the door. This is important so that everyone involved
(the victim, the medical staff, the police, and the SANE) knows what to
expect. A realistic response time needs to be established. While
minimizing waiting time for a victim is important, this consideration must
be balanced with a realistic view of the program's capabilities and
resources.

Most existing SANE programs have set 1 hour as the maximum acceptable
response time for the SANE; from the time she is paged until she arrives at
the ED or clinic. The SANE response time, from the point when she is
paged to that of arriving for the exam, is 30 minutes in some programs
(Speck & Aiken: 95; Holloway & Swan: 93) and generally no more than
60 minutes in others (Ledray: 92a). The time limit set should be primarily
determined by the geographical area served by the SANE program. Even
1.5 hours may not be realistic for a regional center that serves a large area.
In this case, it may be necessary to set a 2-hour maximum response time.

Establishing too short of a maximum response time is not good for the
program. It is better to have a longer response time that can consistently
be met than to have a shorter response time that cannot be met. If the
SANE arrives earlier than an expected 1-hour response limit, the staff and
the victim will be happy to see her early, and she will feel good about her
response. If she arrives later than a 30-minute expected response time,
however, the opposite will be true. The maximum response time is not the
usual or average amount of time for a response, but the maximum
expected response time. The SANE should always respond as soon as
possible.

Each SANE director needs to decide if she wants to routinely track
response time, rather than wait for a problem to arise. Whenever the
SANE's response takes longer than the established limit, the program
director needs to be advised of the reasons why. It is easy to have the
SANE note the time the victim arrived in the ED or clinic, the time she
was first paged, and the time she arrived. She should also note the reason
for any delays as well. Some law enforcement and medical facilities will
record this information routinely. (See Appendix J: SANE Forms.)

When Should the SANE Be Paged and by Whom? 

To shorten the victim's wait, the director must analyze all factors that may
contribute to a delay. First, look at when and by whom the SANE is paged.
In most existing SANE programs, the SANE is paged by the triage nurse
or by the clinic receptionist when the victim arrives at the ED, unless the
SANE program is operating in a jurisdiction that requires the police to be
notified first to determine if a crime has been committed (See Chapter 4:
SART: A Community Approach under the section "How a Sexual Assault
RESPONSE Team Operates" and also Chapter 6: A Look at Funding
under the section Where to Look for SANE Program Funding"). It is
important to know how long response time takes after the victim has
arrived. If the facility staff is waiting until the victim is seen by a
physician and examined before they page the SANE, the system must be
changed. This can significantly increase the SANE's response time. 

It is important to set up a system that ensures the victim moves quickly
through the initial triage process. While it is certainly important that
urgent or life-threatening injuries to the victim take precedence over a
rape exam, past experience has shown that a very small percentage of rape
cases involve serious injuries. (See Chapter 11: SANE Program Operation,
"Nongenital injury evidence" for a detailed discussion of the literature on
this issue.)

Even in cases where immediate treatment is required, the SANE should be
paged as soon as the rape victim arrives at the ED or clinic or as soon as
the staff determine that a rape, or attempted rape was involved. The SANE
and staff can then decide if the SANE should respond immediately, or if
other urgent care will delay her rape exam. If they decide the SANE
should not respond immediately, the SANE can at least get ready to come
in and remain in contact with the ED or clinic so she can respond when
needed.

Some protocols direct the police to page the SANE as they leave the crime
scene with the victim on their way to the facility. This is an effective
method to reduce the response time. It is essential that the police wait to
page until they are on their way. If the police do page earlier, they must be
sure to page back to the SANE if the victim changes her mind and refuses
to go in for an exam. 

Other programs have tried sending the SANE to the hospital when the
local rape crisis center or teen pregnancy clinic, for instance, calls her to
say they just saw a rape victim who they are sending over immediately.
Many times these programs change their policy when victims do not show
up at the hospital where the SANE is waiting. It can be less confusing, be
less expensive to the SANE program, and saves a lot of time if the SANE
is paged after the victim has arrived at an exam site. The exception to this
might be having the police page the SANE when they are en route with a
rape victim.

Delayed Response 

Program policy should identify when the SANE may delay her arrival at
the ED or clinic. These may include cases when the victim is so
intoxicated she is unable to consent to an exam or cooperate with an exam
and when it is uncertain if she was sexually assaulted. It may also include
urgent cases in which the victim must be evaluated immediately to
determine the extent of her physical injuries. Extensive injury alone is not
necessarily a criterion for delaying the SANE's response. SANE exams
can be completed in the stabilization room, the ICU, or the operating room
and may result in capturing valuable forensic evidence that would
otherwise be lost. This is a decision the SANE should make in conjunction
with the physician and possibly with input from the police as well. In one
case, police request for a SANE exam resulted in identifying superficial
vaginal injuries while the patient was being prepped for lifesaving surgery.
This evidence was the primary foundation for a conviction (Speck &
Aiken: 95).

Selecting a Paging System 

Each SANE should have her own pager. Paging systems are less expensive
now than even a few years ago, and the cost savings of sharing a pager do
not justify the inconvenience to the SANEs. Long-range pagers afford the
SANE more flexibility and are highly recommended. It is also
recommended that the pagers have a function that allows each pager two
paging numbers that can be turned on and off independently. One number
can then be assigned to every pager. This is the number that referring
programs will page when they want the on-call SANE. The on-call SANE
ensures that this number is functioning on her pager. 

Each pager is then also assigned an individual number for each SANE.
SANEs are not required to keep their pager on when they are not on call,
but this allows each SANE the option of doing so, and it allows the
program additional depth of coverage. If the on-call SANE has a question
or needs assistance, she can page another SANE and request her help.
While the other SANE might not always be able to help, sometimes she
can. This is especially useful for newer, less experienced SANEs. When
everyone is willing to help in this way, being on call is a much less
stressful experience. It is important for everyone to know help is available
when needed.

While not as convenient for referring agencies, if a paging system allows
for only one number per pager, use individual numbers for each SANE,
and provide the referring programs with an on call schedule. Otherwise
SANEs not officially on call would be forced to turn off their pagers or be
constantly interrupted. It is very helpful to have SANEs not officially on
call available to each other.

On-Call Backup 

The best way to ensure that a SANE is always available is to implement a
formal backup on-call system. A formal backup system is more likely to
be necessary if the SANE program does exams at more than one location
and if a large number of exams are completed.

The backup on-call SANE is usually utilized at the discretion of the
primary on-call SANE. It is expected that backup will be called when
there are requests for service from two different exam sites at the same
time. Many programs recognize that it is very stressful to complete more
than two exams in a single on-call period, and three exams are usually the
upper limit that an individual SANE can be expected to perform. Because
of this, in some programs, it is acceptable for the SANE to utilize a backup
on-call system after she has completed two or three cases.

If the SANE is comfortable with her ability to complete the work in a
timely manner, she is not required to call the backup. However, whenever
she is unable to do a case, she can choose to call for backup. If the primary
on-call SANE is unable to take call at the last minute due to a family
emergency or illness, and no one else can take the shift, the backup SANE
will be expected to move up to primary on-call status. 

When primary on-call service is paid, backup on-call service is usually
paid as well. Since the backup on-call SANE is much less likely to be
called in, the pay is usually half the primary on-call rate, however.
Usually, everyone is expected to perform the same amount of backup call
as they take of primary call. 

If the primary on-call SANE cannot get to the exam site within the
specified maximum response time once a month or more because there is
more than one case to be seen, it may be necessary to implement a backup
on-call system. 

Using an Answering Service 

Since a SANE office staff is not available 24 hours a day, an answering
service can be helpful to take office after hour and weekend calls. This
will significantly reduce the pressure of routine calls going to the on-call
nurse, yet it will ensure that emergency calls are properly directed. The
cost is relatively low, especially when it is weighed against the quality of
service and security of knowing that emergency calls from clients, EDs,
clinics, or the community will be screened and properly routed.

If the decision is to use an answering machine instead of an answering
service, emergency calls will need to be directed to another number where
the victim in crisis can be evaluated and the proper staff paged. If the local
rape crisis center has a 24-hour crisis phone line, with its permission, it
may be possible to direct emergency calls to that number after SANE
program office hours.

Summary

A balance must be reached between meeting the needs of the SANE staff
and meeting the needs of the program. The better both needs are
successfully integrated, the more effective the SANE program will be.
Staff satisfaction increases, performance and productivity are maximized,
while staff turnover is reduced, thereby decreasing program costs. Be
creative in looking for ways to develop the on-call schedule and don't be
afraid to change. If one system doesn't work, try something else.

Title: Sexual Assault Nurse Examiner (SANE)
Series: Development & Operation Guide
Author: Linda E. Ledray
Published: Office for Victims of Crime, July 1999
Subject: Victims of crime, child sexual abuse, rape
and sexual assault,
victim services
148 pages
305,000 bytes

-------------------------------

Figures, charts, forms, and tables are not included in
this ASCII plain-text
file. To view this document in its entirety, download
the Adobe Acrobat
graphic file available from this Web site or order a
print copy from 
NCJRS at 800-851-3420 (877-712-9279 for TTY
users). Office for
Victims of Crime Resource Center at 800-627-6872.

-------------------------------

CHAPTER 11  

SANE PROGRAM OPERATION

When the on call SANE arrives at the ED or clinic
she will complete all
components of the evidentiary exam according to the
established protocol.
This protocol must be clear to the SANE, other SART
members, and the
staff at participating medical facilities. The SANE's
awareness of the
unique needs of special populations within her
community is also
important.

Medical Evaluation and Care of Injuries

When a sexual assault victim comes to the ED or
clinic because she has
been raped, a routine physical exam is not necessary,
and it is not
recommended. The victim must understand that the
evidentiary exam is
not routine medical care. The SANE will not be
performing a routine PAP
smear when she completes the pelvic exam. This
should be communicated
to the victim verbally and in the written consent
(Ledray: 96a). 

The ED or clinic staff is typically responsible for
medically triaging the
sexual assault victim for serious injury, including
taking vital signs prior
to the arrival of the SANE (Ledray: 92a). Unstable
vital signs, altered
consciousness, and peritoneal pain or bleeding will
alert the physician or
nurse to injury (Hampton: 95). If the injuries are life
threatening or require
immediate medical treatment prior to the arrival of
the SANE, the ED or
clinic staff should maintain forensic principles when
documenting the
injuries in the medical record. This may also involve
taking pictures prior
to treatment. 

If possible, the SANE should collect the forensic
evidence before treating
injuries, as medical treatment can result in the loss of
potentially valuable
trace or biological evidence. Sometimes even with
serious injuries if the
victim is stable, the surgery can be delayed until after
the forensic exam.
(Speck & Aiken: 95). Forensic evidence can also be
collected in the
operating room while the victim is being prepped for
surgery, if necessary. 

The SANE Evidentiary Exam

In 1987, California became the first State to
standardize statewide
protocol (Arndt: 88). Since few States have
standardized protocols, there
is a significant variation in what evidence is collected
and how it is
collected in different SANE programs. However, the
evidentiary exam
always involves other components in addition to the
collection of forensic
evidence.

There are a number of articles explaining the specific
components of the
evidentiary exam, some step-by-step (Blair &
Warner: 92; Bobak: 92;
Girardin, Faugna, Seneski, Slaughter & Whelan: 97;
Hampton: 95;
Ledray: 92b; Ledray: 95; Ledray: 96a; Osborn &
Neff: 89). All include
the following specific evidentiary exam components. 

Forensic Evidence Collection

Time frame. While a complete exam including all of
the above
components is usually only done during the first 36
hours after a sexual
assault, an abbreviated exam is completed for up to
72 hours after a sexual
assault and, for some jurisdictions, up to 96 hours
(Frank: 96). An
uncomplicated exam, without injuries, can take 1 to 5
hours to complete
(Frank: 96), however, it will more likely take only 2
to 4 hours (Lenehan:
91; Sandrick: 96; Holloway & Swan: 93).

Use of evidence collected. There are four primary
uses of the evidence
collected by the SANE: 

1. To confirm recent sexual contact.

2. To show that force or coercion was used.

3. To identify the assailant.

4. To corroborate the victim's story. 

DNA Evidence. The use of deoxyribonucleic acid
(DNA) evidence is a
recent technology used primarily in the criminal
justice process to identify
an assailant. To do this, blood must also be drawn
from the victim to
distinguish her DNA from any foreign DNA found on
or in her body. 

In 1987, the first assailant was convicted of sexual
assault with the help of
DNA evidence. The case was upheld on appeal the
following year (Lewis:
88). In 1991, the Minnesota Bureau of Criminal
Apprehension (BCA)
Laboratory became the first State crime lab to
identify a suspect on the
basis of DNA alone. As a result of this valuable
investigative procedure,
an otherwise unidentified rapist was found and
convicted (Ledray &
Netzel: 97). 

The recognition of DNA as a valuable investigative
tool, and the
knowledge that many rapists are repeat offenders, led
to the development
of the FBI Combined DNA Index System (CODIS)
(Miller: 96). The
DNA Identification Act, included in the 1994 Crime
Bill, allocated $40
million to expand DNA testing capabilities. As a
result, today 57
laboratories in 27 States participate in the CODIS
system (Miller: 96).
These databases are used for "DNA fingerprinting" in
much the same way
as conventional fingerprint databases are used.
Genetic profiles found in
semen and blood evidence are now used to link serial
rapists, identify
offenders of multiple assaults and exonerate falsely
accused suspects
(Ledray & Netzel: 97). 

DNA evidence can be obtained by collecting any
available blood evidence
that could have come from the assailant and remained
on the skin or
clothing of the victim. If the victim reports that she
scratched the assailant,
fingernail scrapings should also be collected to find a
match with the
suspected assailant's blood or skin. Whenever
possible, with the victim's
permission, fingernail clippings are preferable to
scrapings. An
explanation should be given to the victim about how,
with clippings, the
crime laboratory can gently separate any material that
is possibly from the
assailant without contaminating his DNA which
might be found with cells
(and her DNA) from her nails. If the SANE scrapes
the nails, she should
scrape gently, not vigorously, to try to avoid sample
contamination.
DNA from semen can also be obtained by swabbing
the involved orifices
with a standard size cotton tip swab. Any dried or
liquid foreign matter on
the body or clothing should also be collected for
DNA evidence (Ledray &
Netzel: 97).

In addition, when the SANE completes the
evidentiary exam, blood
evidence or buccal cell scrapings from the side of the
mouth is collected
from the victim for DNA analysis to distinguish her
DNA from that of the
assailant (Frank: 96).

Hair evidence. The primary use of hair evidence is to
identify the
assailant. The collection of hair evidence from the
victim is controversial.
While accurate data is not available, obtaining foreign
hair samples is rare.
When foreign hair is collected, hair must also be
available from the victim
for comparison with any foreign hair that is found in
or on her body.
Some examiners always pluck 15 to 20 head hairs and
pubic hairs as a
part of the evidentiary exam (Osborn & Neff: 89).
Others cut hairs rather
than pluck, since many laboratories do not analyze the
root (Osborn &
Neff: 89). Other examiners do not collect hair
evidence as a routine part
of the evidentiary exam because collection is painful,
and if hair evidence
is needed from the victim, it is retrievable at a later
date (Ledray: 92b). 

Seminal fluid evidence. Seminal fluid evidence is
used for two purposes:
to show that recent sexual intercourse occurred and to
identify the
assailant. Since 34 percent or more of rapists are
sexually dysfunctional
(Groth & Burgess: 77) and others wear condoms
(Norvell, Benrubi &
Thompson: 84), it is important to remember that the
absence of sperm or
seminal fluid findings does not disprove recent sexual
intercourse. Even
when sexual intercourse has occurred, sperm may not
be found if the
assailant has had a vasectomy, is sexually
dysfunctional, or the sperm
deteriorated due to the time between the exam and the
forced penetration
(Tucker, Ledray & Werner: 90). 

Vaginal secretions can be screened for the presence of
sperm with a wet
mount during evidence collection. While any
microscope can be used, a
light staining microscope developed specifically for
use by the SANE aids
significantly in simplifying this procedure. The light
staining microscope
enhances and makes the color of the sperm more
distinct without staining
the slide or altering it in any way. The image viewed
through the light
staining microscope is optically enhanced to make the
sperm appear bright
yellow against a blue background. It also eliminates
the need for the user
to find the optimal magnification. This enhanced
image can also be
photographed through an attachable camera for
evidence (Peele &
Matranga: 97; O'Brien: 96a). It can even be attached
to the same monitor
as the colposcope (Peele & Matranga: 97).

Seminal fluid evidence is analyzed for sperm, motile
or nonmotile, and for
acid phosphatase (ACP). ACP is actually an array of
related isoenzymes
which is found in much greater concentration in
semen than in any other
body fluid (Davies: 78). Vaginal secretions have been
found to contain
very low levels of endogenous ACP. The exact tissue
source of the
vaginal ACP is uncertain, but is believed to be
endometrium. The two
specific ACPs most often analyzed in the evaluation
of sexual assault, are
prostatic acid phosphatase (PAP) and prostatic
specific antigen (PSA).
Since vaginal ACP and prostatic ACP cannot be
distinguished
biochemically, the only reliable differentiation is the
quantitative level.
Since prostatic ACP found in semen is in much
higher concentration than
vaginal ACP, a high level would indicate that there
has been recent sexual
contact with seminal fluid being left in the vagina
(Green: 88). The
interpretation of actual numeric results of analysis
will be different
depending on the specific substrate used by the
laboratory as there is no
standard. The laboratory must indicate how the
analysis was done in order
to determine how to interpret the findings as positive
or negative for
prostatic ACP. 

Cases negative for sperm and positive for acid
phosphatase typically
involve an assailant who has had a vasectomy, but
this result is also
possible in cases involving an assailant who is a
chronic alcoholic (Enos
& Beyer: 80).

In a sexually functional, nonrape population, sperm
has been found on
exam within 24 hours after consenting sexual
intercourse with known
ejaculation, as often as 100 percent of the time
(N=15) in one study
(Soules, et al: 78), 65 percent (N=980) in another
study (Silverman et al.:
78), and in as little as 25 percent (N=542) in yet
another study (Randall:
86).

In a study of 1,007 rape victims examined, sperm was
found in only 1
percent (N=3) of the 369 cases involving oral rape.
All of the positive oral
specimens were collected within 3 hours of the rape.
Of the 210 cases with
rectal involvement, only 2 percent (N=4) were
positive for sperm. These
exams were all completed within 4 hours of the rape.
In the 111 skin
specimens collected, 19 percent (N=12) were
positive. All but two of the
positive specimens were collected within 4 hours of
the rape (Tucker,
Ledray & Werner: 90).

Of the 919 vaginal specimens, 37 percent (N=317)
were positive. Of
these, the majority, 83 percent (N=263) were
examined within 5 hours,
and 307 were examined within 12 hours of the rape.
Only 7 of the positive
specimens were collected more than 20 hours after
the rape (Tucker,
Ledray & Werner: 90).

These data clearly indicate that the vaginal site is the
most likely site to
obtain specimens positive for sperm. It also indicates
that by far the
majority of positive results will be collected within
the first 5 hours after
the assault, and that even then, it is rare that
specimens positive for sperm
will be obtained in any site other than the vaginal site.
It is imperative that
the SANE is aware that this does not, however, mean
sexual contact did
not occur (Tucker, Ledray & Werner: 90).

Because of the small percentage of positive sperm
specimens, the
literature indicates that it can be very helpful to also
analyze the
specimens collected for prostatic acid phosphatase
(PAP). While it is still
more likely that specimens will be negative than
positive, the results are
more likely to be positive for PAP than for sperm. In
the same study cited
above, of the oral specimens, 11 percent (N=40) were
positive for PAP; of
the rectal specimens, 12 percent (N=32) were positive
for PAP; of the skin
specimens, 43 percent (N=72) were positive for PAP;
and of the cases
involving vaginal assault, 62 percent (N=566), were
positive for PAP
(Tucker, Ledray & Werner: 90).

In another study of 212 women who had consenting
sex within 4 days,
comparing PAP (prostatic acid phosphatase) to PSA
(prostatic specific
antigen), researchers got better results with PAP than
PSA analyses.
While both were positive in 59 percent of the cases,
PAP was positive 84
percent of the time and PSA was positive 60 percent
of the time. PAP was
negative only 2 percent of the time when PSA was
positive, and PSA was
negative 25 percent of the time when PAP was
positive (Roach &
Vladutiu: 93). Most programs collect vaginal sperm
and acid phosphatase
specimens using cotton tip swabs. A few programs
use a vaginal normal
saline aspirate or vaginal washings for this purpose
(Osborn & Neff: 89).

Vaginal washes. Vaginal washes to collect sperm
evidence and DNA to
identify the assailant are recommended by two
clinicians (Sandrick: 96).
One of these clinicians specifies that the vagina be
washed with 10 ml of
saline, which is then aspirated and saved for analysis
(Roach & Vladutiu:
93). The crime laboratory in each State will have a
preference as to which
method to use.

Clothing evidence. Clothing is primarily useful as
evidence to prove force
was used. It can also be helpful to corroborate the
victim's story. For
instance, if the victim claims she struggled on the
grass, grass stains on
her clothing will corroborate this and the absence of
grass stains can be
used against her, as happened in the widely publicized
State of Florida vs.
Smith (Kennedy) trial. While some programs
recommend collecting all of
the victim's clothing (Frank: 96), most now specify
that clothing should
only be collected as evidence if it has tears or stains.
While this may have
been helpful when less well-trained ED personnel
were collecting the
clothing, a well-trained SANE can better decide what
clothing will be
useful evidence. For many victims, their winter coat
or shoes may be
valuable property that cannot be replaced. If some
clothing does not hold
important evidence, there is no reason for it to be
turned over to law
enforcement. When kept for evidence, clothing
should be allowed to air
dry prior to placing each article into a separate paper
bag, labeled with the
client's name, identifying number, date, time, SANE's
name, and the type
of article (Ledray: 92b). 

Nongenital injury evidence. Physical injuries are the
best proof of force
and should always be photographed, described on
drawings, and
documented in writing on the SANE Exam Report as
evidence of force
(Ledray: 92b). Photographs are not meant to take the
place of good
charting (Pasqualone: 96). It is also important to note
that the absence of
injuries does not mean no force or coercion was used.
Absence of injury
does not prove consent (Tucker, Ledray & Werner:
90). 

Specific consent to photograph is necessary but may
be included as a
standard part of the exam consent. In a facility which
maintains medical
records, two sets of pictures should always be taken.
One set always
remains with the medical record. The second set
should be given to the
police (although some programs give it to the victim)
and will usually be
the pictures used in court. Whenever pictures are
taken, the first picture
should always be of the victim's face, and others
should follow in a
systematic order, such as head to toe, or front to back.
They should be
taken first without a scale to show nothing is being
hidden, then with a
scale to document size. While a coin such as a quarter
is sufficient, a gray
photographic scale will also assist with color
determination. Each picture
should include a label with the victim's name in the
picture. If a Polaroid
camera is used, the SANE should print her name and
title, the date, the
time, and the client's name and record number on the
back of every
Polaroid. Some programs may choose to use the
medical record number
instead of the victim's name.

Photographic documentation of injuries should be
completed using a
35mm camera with a standard 50mm lens, or a
35-110 zoom lens, and
100-200 speed (ASA) color film. A disadvantage of
35mm pictures is that
they must be sent out for developing and are often not
available to the
police when they investigate or to prosecutors when
they are deciding if
they will charge the case. Polaroid film has the
advantage of allowing the
victim to take one set of pictures with her when the
exam is completed,
and of being available to the police during their initial
investigation. It has
the disadvantage of poorer quality, especially for
closeups. Polaroid film
is also very expensive (Sheridan: 93). Injuries not
properly documented
with pictures may result in liability for failure to
document (Pasqualone:
96). Therefore, staff must take pictures of all areas
that have sustained
injury, even of breasts and genitalia.

The nurse must be knowledgeable about patterns of
injuries resulting from
violence so she knows the appropriate questions to
ask and where to look
for injuries on the basis of the history (Sheridan: 93).
Intentional injuries
tend to be located more central on the body and
accidental injuries more
distal toward the extremities when domestic violence
is involved. Injuries
are most often inflicted where the victim can easily
hide them. The most
common injuries are broken ear drums from severe
slapping, neck
bruising from choking, punch bruising to the upper
arm, and "defensive
posturing" injuries to the outer mid-ulnar areas of the
arms. Also common
are whip or cord like injuries to the back; punch or
bite injuries to the
breasts and nipples; punch injuries to the abdomen,
especially in pregnant
women; punch and kick injuries to the lateral thighs;
and facial bruising,
abrasions, and lacerations (Sheridan: 93).

"Patterned injury" is different from the similar term,
"pattern of injury"
discussed above. Both are, however, important
forensic terms. "Patterned
injuries" are injuries where one can easily identify the
object used to inflict
the injury by the pattern left on the victim, such as a
coat hanger, iron,
extension cord, belt, or the imprint of a ring worn by
the assailant. Bite
marks are important patterned injuries that can be
linked to a suspect's
dental pattern. Since most assailants choke using their
dominant hand, the
finger-tip pattern can identify the assailant's
handedness. A right-handed
assailant will usually grab the victim's anterior neck
so as to leave a single
thumb bruise at the right lateral neck and several
finger-tip bruises to the
left lateral neck (Sheridan: 93).

The literature cautions the forensic nurse against
trying to closely date the
age of a bruise by its color. While we know that
recent bruising is red or
dark blue in color, and older bruising may be
green-blue or yellow-blue,
and older still bruising may be barely visible, people
vary greatly in their
rates of healing. Medications may affect bleeding and
healing response as
well. Sheridan suggests that deep blue-purple bruising
is best documented
as a "relatively recent bruise" or as "consistent with
Mary Jane's report of
being punched by Jim Smith 24 hours prior"
(Sheridan: 93). 

Physicians need to feel certain that any injuries or
concerns about further
evaluation of possible injury will be referred to them.
Physicians need not
be concerned that injuries will be missed by the
SANE if they understand
that she will err on the side of caution when
evaluating and referring
sexual assault victims to them (Ledray: 96a). Some
programs have
developed specific criteria for the nurse to use in
determining when to
consult with a physician. One program suggests that
the nurse consult with
a physician when there is extensive genital trauma,
asymmetric joint
swelling, head or chest trauma, neurological deficits,
respiratory distress,
need for medications, suspicion or need to confirm an
existing pregnancy
(Antognoli-Toland: 85). 

The literature indicates injuries resulting from sexual
assault are relatively
rare. In a review of 372 ED rape cases, 68 percent of
the victims seen had
no injury, 26 percent had mild injuries, 5 percent
moderate injuries and
less than 1 percent, 0.2 percent, were severely injured.
Victims 50 years
old and over were twice as likely to be injured, 63
percent, compared with
32 percent of the victims under 50 years old
(Tintinalli & Hoelzer: 85).

Another study found 5 percent of victims had major
nongenital injuries,
and women over 35 years of age were nearly twice as
likely to be injured
(Marchbanks, Lui & Mercy: 90). In another study of
440 rape victims, 46
percent had some nongenital trauma, however, only 1
percent required
hospitalization (Cartwright, Moore, Anderson &
Brown: 86). In a study of
98 rape victims, only 27 percent had even minor
nongenital injuries not
requiring treatment, 3 percent had injuries requiring
treatment, and less
than 1 percent required hospitalization (Tucker,
Ledray & Werner: 90).

Genital trauma evidence. Genital trauma is useful to
show both recent
sexual contact and force. Just as with nongenital
trauma, the absence of
genital trauma does not indicate consent (Cartwright,
Moore, Anderson &
Brown: 86). While the examiner will usually not find
genital injuries, this
should not influence their testimony regarding the
validity of the rape
since most rape victims do not experience genital
injury as a result of the
rape (Bowyer & Dalton: 97). In one study, vaginal
injuries represented
only 19 percent of the total injuries and were always
accompanied by 
complaints of vaginal pain, discomfort, or bleeding
(Tintinalli & Hoelzer:
85). Another study found that 22 of 83 (27%) victims
had genital injuries
following a rape ( Bowyer & Dalton: 97). Still
another study found only 1
percent of rape victims had genital injuries so severe
that they required
surgical repair, 75 percent of which were upper
vaginal lacerations (Geist:
88). They also found that upper vaginal lacerations
usually presented with
profuse bleeding and pain, and lower vaginal
lacerations were more
common in virgins. 

The pattern of genital injury in female sexual assault
victims has been a
more recent area of study. Since the posterior
fourchette is the point of
greatest stress when forceful stretching occurs, and it
is the point of first
contact of the penis with the vagina, the resulting
injury is characterized as
an "acute mounting injury" (Slaughter & Brown: 92;
Slaughter, Brown,
Crowley & Peck: 97). Because no posterior fourchette
injuries were found
in a control group of sexually active adolescents, and
injuries were found
in 33 percent of the abused population, the
researchers concluded that
posterior fourchette injuries are indicative of sexual
assault (McCauley,
Gorman & Guzinski: 86). 

In a study that compared the physical vaginal
examination findings of 311
rape victims to a group of 75 women after consenting
sexual intercourse,
researchers found that 213 (68%) of the rape victims
had genital trauma
and only 8 (11%) of the consenting women had
genital trauma.
Furthermore, none of the women who were examined
after consenting sex
had injury in more than one site (Slaughter et al.: 97).
Of the 213 victims
with trauma, however, they found that 200 (94%) had
trauma at one or
more of four sites including posterior fourchette,
Labia minora, hymen, or
fossa navicularis; 162 (76%) had 3.1 sites of injury,
making injury at more
than one site indicative of rape. Trauma varied by
site: tears appeared
most often on the posterior fourchette and fossa
navicularis; abrasions
appeared on the labia; and ecchymosis was seen on
the hymen. They also
found that all women with tears reported vaginal
bleeding. Five victims
mistakenly reported their menstrual period had begun.
Researchers also
concluded that timing of the exam was crucial
because beyond 24 hours,
the likelihood of identifying injury was significantly
reduced. At followup
examination, which occurred beyond 4 days (average
of 25 days), all
injury was resolved and there was no scarring and no
evidence of the
previous trauma. They also found that with the
exception of hymenal
tears, which were nearly four times more common in
adolescent victims,
injury was not related to age.

The literature also suggests that colposcopic
examination to magnify
genital tissue is an important asset to the
identification of genital trauma
(Frank: 96; Slaughter & Brown: 92; Slaughter et al.:
97; Peele &
Matranga: 97). With the use of a colposcope, the
number of cases
increased by 8 percent because three or more genital
injuries were
identified as compared to identification with the
naked eye (O'Brien: 97).
Photographic equipment, both still and video, can be
easily attached for
forensic documentation. In one study, 28 percent of
440 rape victims had
genital trauma, however, only 16 percent were
identifiable without
staining or colposcopic exam (Cartwright, Moore,
Anderson & Brown:
86). In the legal arena, the use of the colposcope is
well documented as an
accepted practice in the examination of adults and
children (IAFN: 96).
The fact that it is noninvasive makes it particularly
valuable for
examination of young or elderly clients. The
colposcopic exam is
especially important as a part of the pediatric protocol
(Soderstrom: 94).

With gross visualization alone, positive genital
findings occur in only 10
percent to 30 percent of the cases (Cartwright et al.:
86; Tintinalli &
Hoelzer: 85). With colposcopic examination, genital
trauma has been
identified in 87 percent (N= 114) of sexual assault
cases (Slaughter &
Brown: 92). When a colposcope is used, the
magnification must always be
documented, the pictures or video must be well
focused and clear,
standard positions for examination should be used and
documented, and a
method of measurement should be used (Soderstrom:
94).

In a study of genital trauma in a consenting
population using the
colposcope, 11 (61%) of 18 volunteers, who had
consenting sex within 6
hours, had positive findings of micro trauma. This
trauma was not
visualized with gross visualization but required the
use of the colposcope
(Norvell, Benrubi & Thompson: 84).

Other studies indicate Toluidine blue and Gentian
violet can significantly
enhance the visualization of genital injuries compared
with gross
visualization alone. Toluidine blue is a nuclear stain
commonly used to
detect vulvar cancer (Norvell, Benrubi & Thompson:
84). It has also been
found useful in sexual assault examinations to detect
perineal lacerations
and abrasions. Since it is spermicidal, the literature
consistently suggests it
should only be used after all specimens are collected.
One study examined
22 women after being sexually assaulted within the
previous 48 hours.
Forty percent were found to have vaginal lacerations
when examined
using Toluidine blue. Of these, 70 percent (N=7) of
the positives were
nulliparas (Laufer & Souma: 82). Another study
found that 14 of 24
(58%) cases were positive for genital trauma using
Toluidine blue (
McCauley et al.: 86). 

Other clinicians indicate that while lacerations seen
using Toluidine blue
were also seen with colposcopic examination by an
experienced examiner,
the dye does make the injuries easier for the lay
audience, such as juries, to
visualize. The colposcope is however, the preferred
method for better
genital trauma documentation (O'Brien: 97; Slaughter
& Brown: 92;
Norvell, Benrubi & Thompson: 84). In a review of 17
SANE programs,
only 4 indicated they used Toluidine blue and 11 used
a colposcope for the
sexual assault evidentiary exam (Kathy Bell. Personal
Communication. 26
November 1996).

Blood evidence. The SANE should always draw the
victim's blood for
type and DNA (Frank: 96). In addition, it is
recommended that an
additional tube of blood routinely be drawn for blood
and alcohol analysis
should this become an issue later if the case is
charged (Ledray: 92a).

Urine evidence. Recently it has come to the attention
of the medical
community that a long-acting benzodiadepine,
flunitrazepam (Rohypnol)
and a powerful sedative, gamma hydroxy butyrate
(GHB) are being used
as date rape drugs. Victims may report a history of
having only a couple
of alcoholic beverages but quickly becoming
extremely intoxicated. When
the victim awakens, usually more than 12 hours later,
she may find herself
undressed, or partially dressed, with vaginal or rectal
soreness making her
believe she has been raped. The victim can often
remember very little of
the incident prior to awakening, other than flashes.
Even though there is
little memory and perhaps no certainty of a sexual
assault, the SANE
should adhere to the standard sexual assault protocol
and collect the first
voided urine for a drug screen. If the victim calls
prior to coming to the
hospital or clinic, she should be told to collect her
first voided urine and
bring it with her (Ledray: 96b; Anglin, Spears &
Hutson: 97).

Flunitrazepam has been used for sleep disorders in
Europe, Mexico, and
Asia since its initial release in 1975. It is used legally
in 80 countries and
is widely and easily available, but it has not been
approved for use in the
United States. In October 1996, the United States
passed a Federal law,
The Drug-Induced Rape Prevention and Punishment
Act of 1996, which
provides for up to 20 years in prison for anyone who
uses a controlled
substance to commit a crime of violence, including
sexual assault (U.S.
House of Representatives: 96). 

There has been such an intense community opposition
to Rohypnol that in
October 1997, the manufacturer Hoffmann La Roche
Laboratories
announced at the National Coalition Against Sexual
Assault (NCASA)
annual conference in Cleveland that it plans to add a
color-releasing agent
to Rohypnol making it easier to detect if covertly
slipped into someone's
beverage. Once approved by the regulatory agencies,
the new Rohypnol
tablets dissolve more slowly and they release a bright
blue color as they
dissolve. When dissolved in darker liquids, the drink
appears cloudy. In
all drinks, particles also float to the top of the
beverage, signaling that
something has been added (NCASA: 97).

Whenever the victim's story is consistent with a
drug-facilitated rape, and
if she is seen within 72 hours of the assault, a urine
specimen should be
collected for drug analysis. By calling 800-608-6540,
the necessary
paperwork with an authorization code will be Faxed
to the SANE. She
should complete the form and return it with a urine
specimen by Fedex to
the independent laboratory with whom Hoffmann
LaRoche Laboratories
have contracted to analyze the urine. The form will
contain complete
information on the process, and Hoffmann LaRoche
Laboratories will
cover all testing and shipping costs. It will take
approximately 2 weeks for
the complete drug analysis of the urine to be Faxed
back (Ledray: 96c).

Followup Forensic Exams

In those cases where genital trauma was identified, a
followup exam may
strengthen the evidence of genital trauma.
Photographs should be taken at 
the time of the followup exam to document the
healing of the genital
injuries for comparison purposes in court. Most
SANE programs,
however, do not routinely perform a followup
forensic exam on every
victim, and these exams may not be reimbursable in
every State.

Helpful Tips for Evidence Collection

--When a speculum is used, it should be lubricated
with water, not gel
lubricant, so evidence is not contaminated (Hampton:
95).

--Swabs used to collect skin specimens should be
barely moistened
with normal saline (Hampton: 95). Others specify the
use of water for this
purpose (Ledray: 92b). 

--Tetanus prophylaxis, if not already current, should
be given when
the evidentiary exam identifies any break in the skin
or mucosa (Blair &
Warner: 92).

--An alternate light source should be used on clothing
before the victim
disrobes (Hampton: 95), as well as on the body after
disrobing to look for
body fluids and foreign objects, such as sand, to
corroborate the victim's
story as well as to identify the assailant (Frank: 96).

Additional Components of the SANE Exam

STD Evaluation and Preventive Care 

Since there is no evidence of cultures being useful in
court, and there is
data showing that they have been used against the
victim to suggest sexual
promiscuity, it is not recommended to culture for
STDs as a part of the
evidentiary exam (Ledray: 92a). Contracting an STD
from the assailant is 
of significant concern to victims, however, and
because it is of great
concern, the issue must be addressed as a part of the
initial exam. One
study found that 36 percent of the rape victims
coming to the ED stated
their primary reason for coming was concern about
having contracted an
STD (Ledray: 91), however, the actual risk is rather
low. The National
Center for Disease Control estimates the risk of rape
victims getting
gonorrhea is 6 percent to 12 percent, Chlamydia is 4
percent to 17 percent,
the syphilis risk is 0.5 percent to 3 percent, and the
risk of HIV is less than
1 percent (CDC: 93).

Some programs still culture and treat prophylactically
for STDs although
they give no rationale for the cultures (Osborn &
Neff: 89), other than to
establish a baseline (Hampton: 95), which has no
demonstrated forensic
utility. There is also evidence that STD cultures for
gonorrhea obtained at
the initial exam immediately after the assault may not
only indicate a
pre-existing infection, but also that gonococcus may
be deposited in the
vagina with the seminal fluid of the assailant
(Hayman & Lanza: 71;
Ledray: 91).

STD cultures are very expensive and time-consuming
for the victim who
must return multiple times for testing and
unfortunately most victims do
not return (Blair & Warner: 92). In one study, only 25
percent of the
victims seen in the ED returned for the initial STD
followup visit (Ledray:
91), and in another study, only 15 percent returned.
The researchers were
able to contact 47 percent of those who had not
returned for followup, and
they found an additional 11 percent of these went
elsewhere for medical
followup, however, only 14 percent told the physician
about the rape
(Tintinalli & Hoelzer: 85). If cultures are taken, they
do not have to be
handled as evidence because they are not useful in
court (Blair & Warner:
92). Most clinicians recommend prophylactic
treatment following CDC
guidelines (Frank: 96; Arndt: 88; Antognoli-Toland:
85; Tintinalli &
Hoelzer: 85). For more information call the National
STD Hotline:
800-227-8922.

HIV 

Since the early 1980's, HIV has been a grave concern
for rape victims
even though the actual risk still appears to be very
low. In an attempt to
better evaluate this risk, 412 Midwest rape victims
with vaginal or rectal
penetration were tested for HIV in the ED, then again
at 3 months post-
rape, and again at 6 months post-rape. Not one
seroconverted. This study
also found, however, that even if the victim did not
ask about HIV in the
ED, within 2 weeks, she expressed a concern for
herself or her sexual
partner. While the researchers did not recommend
routine HIV testing,
based on the recommendations of the study
population, they recommend
that even if victims do not raise the issue of HIV or
AIDS in the ED, the
SANE should, in a matter-of-fact manner, provide
them information about
their risk, testing, and safe sex options. This will
allow them to make
decisions based on facts, not fear, and reduce the
psychological trauma of
the fear of HIV (Ledray: 93b). It is important to note
that this study was
conducted in a community with a relatively low
overall HIV rate.
Communities with high HIV rates will have a greater
risk that an assailant
is HIV positive. While testing can begin as early as 6
weeks after
exposure, 3 months or even 6 months is more often
recommended to
avoid multiple testing (Gostin, Lazzarini, Alexander,
Brandt, Mayer &
Silverman: 94). 

The risk of HIV exposure after sexual contact, while
it varies, overall is
reported to be less than other routes of exposure such
as needle sticks,
needle sharing, mother to infant, or transfusions.
While the actual risk
varies from study to study, if the sexual partner is
known to be HIV
positive, the risk of HIV from sexual contact may be
similar to the risk
with a needle stick (Royce, Sena, Cates & Cohen:
97). 

HIV Post-Exposure Prophylaxis

As a result of a recent case-control study which
concluded that treatment
with zidovudine after needle stick exposure decreased
the odds of HIV
infection by 79 percent, antiretroviral treatment is
now considered the
standard of care in parenteral (e.g., needle stick)
occupational exposure to
HIV. Unfortunately, data on the long-term toxicity of
zidovudine and the
safety of combined anti-retroviral treatment are not
available (Carpenter,
Fischl, Hammer, et al.: 96). Since there have been
several cases of
possible HIV seroconversion after a rape,
post-exposure prophylaxis is
being selectively recommended for high-risk
exposures in high-risk areas.
Antiretroviral treatment is not advocated when the
HIV status of the
assailant is unknown due to the cost and potential
toxicity of zidovudine
(Foster & Bartlett: 89). When it is recommended in
high-risk cases, the
health status of the victim and her ability to withstand
the potential side
effects must be taken into consideration along with
the severity of risk
(Gostin et al.: 94).

As a result of various State laws and the Federal
Sexual Assault
Prevention Act of 1993 and The Violent Crime
Control and Law
Enforcement Act of 1994, involuntary testing of the
offender is now
required. While the testing point varies according to
State law, in most
States testing cannot be done until after the assailant
is convicted of the
rape and a court order is obtained for testing. This
usually takes more than
the 6 months necessary for the victim to seroconvert
if she is going to do
so, and in some cases it may take a full year or more
to obtain the testing
results from the assailant. Testing may not occur until
the time of pretrial
release when it is used to determine his risk of HIV
transmission. While
victims still want this information for their own peace
of mind, the time
delay does not preclude the need for the victim to be
tested as well.

Initial post-exposure treatment must be started within
72 hours or it is not
recommended. When given following a rape,
post-exposure prophylaxis is
the same as for occupational exposure to HIV. This
involves giving
zidovudine 200 mg three times a day and lamivudine
150 mg twice a day
for 4 weeks. The costs for the medication and
monitoring run
approximately $800, and until the treatment is proven
to be effective,
insurers may refuse to cover the cost (Katz &
Gerberding: 97). Since most
SANE programs cannot assume this additional
expense, and since the
treatment must be started within 72 hours, if this
option is discussed, it is
important to have a treatment or referral policy in
place so the victim can
make an informed decision. For more information,
call the National AIDS
Information Hotline: 800-342-AIDS. (For Spanish
speakers call 800-344-
SIDA; For hearing impaired persons call TTY/TDD
Hotline 800-AIDS-
TTY).

Pregnancy Risk Evaluation and Prevention

Rape victims of reproductive age also fear becoming
pregnant as a result
of a rape. Pregnancy resulting from rape is indeed the
cause of great
concern and significant additional trauma to the
victim. Most programs
offer pregnancy prevention or interception for the
woman at risk of
becoming pregnant, if they are seen within 72 hours
of the rape and have a
negative pregnancy test in the ED. Sometimes
referred to as "the
morning-after pill," oral contraceptives such as Ovral
are used for
emergency contraception (ACOG: 96). Two tablets of
a contraceptive
containing ethinyl estradiol, 0.05 mg, and norgestrel,
0.5 mg, (Ovral) are
taken at the time of the evidentiary exam and two
more in 12 hours is the
usual form of pregnancy prevention. Each dose
should be given after an
antiemetic agent to prevent nausea (Osborn & Neff:
89; Ledray: 92b;
Hampton: 95; ACOG: 96). This will reduce the risk
of pregnancy by 60
percent to 90 percent. If a low dosage ethinyl
estradiol contraceptive, such
as Lo-Ovral, Nordene, Levlen, Triphasil, or Trilevlen,
is used, a dose
equivalent to 100ug of estrogen, 4 tablets, should be
provided for each
dose (Yuzpe, Smith & Rademaker: 82). Two
programs operating at a
Catholic hospital went as far as to get special
permission from the diocese
to administer Ovral (Frank: 96; O'Brien: 97).

The risk of pregnancy from a rape is the same as the
risk of pregnancy
from a one time sexual encounter. This is estimated to
be 2 percent to 5
percent (Yuzpe, Smith & Rademaker: 82; Holmes,
Resnick, Kilpatrick &
Best: 96). Holmes et al. found that the majority of
these pregnancies
occurred among adolescents and resulted from a
known and often related
perpetrator. Unfortunately, only 11 percent of these
victims received
immediate medical attention for the rape. Fifty
percent decided to
terminate the pregnancy later. An additional 11.8
percent had a
spontaneous abortion, and 5.9 percent placed the
infant up for adoption.
With better preventive care after the rape, it is
possible that more of these
pregnancies and abortions could have been prevented.

One program suggests that the consent form for the
use of pregnancy
interception drugs include all three options available
to the victim, and
that one option is always checked and signed by the
victim. This will
provide clear documentation of why the medication
(Ovral) is or is not
given. The first would be the typical informed
consent of possible
complications with agreement to take the medication.
The second would
be "I understand that because (I am already taking a
contraceptive/had a
tubal ligation) pregnancy prevention is not
recommended for me." The
third option would be "even though pregnancy
prevention was
recommended by the SANE, I (the victim) chose not
to take the
medication" (Speck: 96).

Testing for pregnancy is always necessary prior to
giving any
medications, as 2 percent of rape victims have been
found to be pregnant
when the evidentiary exam was completed in the ED
and not all were
aware of the pregnancy (Tucker, Ledray & Werner:
90; Warner: 87).
Fortunately, at least one study found pregnant women
were less likely to
be physically injured during a rape, and the rape had
little immediate
effect on the pregnancy. No spontaneous abortions or
deliveries occurred
within 4 weeks of the rape. A low birth rate (24%)
and preterm deliveries
(16%) were common, however (Satin, Hemsell,
Stone, Theriot, &
Wendel: 91). 

If the victim chooses to take medication for
pregnancy interception, it is
also important to inform her about the effect on her
next period. Up to 98
percent of patients will menstruate within 21 days
after the treatment. In
90 percent of the cases, menses will be of normal
duration for that patient.
If the medication is given prior to ovulation, the onset
of menstrual
bleeding may be 3 to 7 days earlier than expected. If
the treatment is given
after ovulation, the onset of bleeding may be on time
or delayed.

Unfortunately, this treatment is not 100 percent
effective in preventing
pregnancy. A review of 10 studies found an overall
effectiveness rate of at
least 75 percent. That does not mean that 25 percent
will become
pregnant. It means that if 100 women have
intercourse in the middle 2
weeks of their cycle, approximately 8 (8%) would
become pregnant
without postcoital interception. With interception
only 2 (2%),
representing a 75 percent reduction, of the 100 would
become pregnant
(ACOG: 96). If the victim has not had a period within
21 days she should
be advised to have a pregnancy test. 

Crisis Intervention and Counseling

Another basic component of the evidentiary exam is
crisis intervention,
mental health assessment, and referral for followup
counseling. Many
SANEs do their own crisis intervention and followup
counseling (Speck &
Aiken: 95; Ledray: 92b); others have rape advocates
present in the ED or
clinic or refer to a local rape center, social service, or
to the hospital
chaplain for followup counseling (Antognoli-Toland:
85). 

While many victims may want to "go home and
forget it," experience tells
the SANE that victims are seldom able to effectively
do so. Continued fear
and anxiety resulting from the rape can significantly
affect the victim's
life, including her work, school, and relationships
with others far into the
future (Ledray: 96a). The psychological impact and
treatment needs of the
victim has been addressed extensively in the
psychological literature. A
review of these crisis needs is beyond the bounds of
this summary. Dr.
Burgess summarized and labeled the psychological
impact Rape Trauma
Syndrome (Burgess and Holmstrom: 74). Self-help
books, such as
Recovering From Rape (Ledray: 94), are available for
the large majority of
rape victims who do not return for counseling and are
sometimes
recommended to victims in the ED by SANEs
(Ledray: 96a). The
Assistance League, a national organization that for
several years has
provided clothing for rape victims after the
evidentiary exam, began
providing in October 1997 the book Recovering From
Rape to sexual
assault victims at the time of the evidentiary exam
throughout the State of
Minnesota and in parts of California (Maggie
Trenkmann. Personal
communication, October 24, 1997).

Maintaining Chain-of-Evidence 

Maintaining proper chain-of-evidence is as important
as collecting the
proper evidence. Completed documentation, or
chain-of-evidence, is
essential and must include the signature of everyone
who had possession
of the evidence from the individual who collected the
evidence to the
individual bringing the evidence into the courtroom.
If this proper
chain-of-evidence is not maintained, the evidence will
be inadmissible
(Ledray: 93b). If the SANE must leave the room for
any reason during the
exam, the evidence must go with her (Frank: 96). She
must be able to say
in court that the evidence was in her possession from
the time it was
collected until the time it was secured in the locked
refrigerator or given
to law enforcement. Maintaining chain-of-evidence is
critical to prevent
any possibility of evidence tampering and to prevent
the defense counsel
from raising the issue of reasonable doubt of evidence
integrity. 

It is not necessary, nor is it appropriate, for the police
officer to be in the
exam room when the evidence is collected to
maintain proper
chain-of-evidence. The police can leave the area, and
the nurse can call
them when the exam is completed, in 2 to 3 hours, to
return and pick up
the evidence. Both signatures on the
chain-of-evidence document are all
that is necessary. When the police cannot immediately
return, the SANE
can place the evidence in a locked storage area,
preferably a refrigerator
with limited access, and when the police do return,
any available nurse can
sign that she removed the evidence from the
refrigerator and gave it to the
police officer (Ledray: 93b).

Maintaining Evidence Integrity 

While it is suggested that the specimen be refrigerated
for long-term
storage to prevent deterioration of the specimens, it is
essential that the
evidence be kept in an area of less than 75 degrees
Fahrenheit and the
blood not be frozen. This means that storage in an
air-conditioned room is
sufficient for short-term storage (Ledray: 93b). 

Documentation

The amount of documentation varies from program to
program. Some
SANEs ask specific investigative details including
what the walls looked
like in the area where the victim was raped (Frank:
96). Detailed
information is included in the Comprehensive Sexual
Assault Assessment
Tool (CSAAT). This tool was developed to provide a
systematic guide for
collecting information about the rape victim and
offender. It includes
detailed investigative information about the victim
and offender as well as
victim forensic data and data about the victim's
post-rape functioning. If
this tool is widely employed by SANEs across the
country, then it can be
used as a research tool to compile statistics across
programs (Burgess &
Fawcett: 96).

Other authors caution against collecting this detailed
investigative
information and suggest that the SANE should only
ask for information
necessary to deal with the immediate physical and
psychological needs of
the victim as well as to appropriately collect and
interpret the physical and
laboratory findings. Details reported by the nurse that
differ from the
police report may be used by the defense attorney to
show discrepancies in
the victim's story. The only documentation required is
information
necessary to guide the exam and treat the victim
(Smith: 87).

It is important to remember that in addition to the
SANE assault exam
report, the entire chart is a part of the legal record and
can be submitted as
evidence if the case goes to court. All statements,
procedures, and actions
must be accurately, completely, and legibly recorded
(Blair & Warner:
92). It is important to accurately and completely
assess and document the
emotional state of the victim and quote important
statements made by the
victim, such as threats made by the assailant
(Antognoli-Toland: 85;
Sheridan: 93). 

It is important not to be afraid to include the name of
the assailant, just be
sure to use qualifying statements such as "patient
states" or "patient
reports" If the exam findings match the history given
by the victim, the
nurse should also document that "there is congruence
between the victim's
story and her injuries" or "the injuries are consistent
with the victim's
account of the assault" (Sheridan: 93).

There is disagreement over the use of the term
"alleged" in medical
documentation of a sexual assault. Non-SANE
medical personnel were
taught to use the term "alleged" because it was up to
the court to decide if
the rape occurred (Bobak: 92). Several prosecuting
attorneys state medical
professionals should never use the term "alleged" in
medical
documentation as the term has negative connotations
and may be
interpreted by judges and juries as meaning the victim
exaggerated or lied
(Sheridan: 93).

After the Exam

Many SANE programs have a place for the victim to
shower, brush her
teeth, and change clothes after the exam. They often
provide her with a
change of clothes as well (Holloway & Swan: 93;
Thomas & Zachritz: 93;
Frank: 96; Sandrick: 96). The Assistance League, a
national charitable
organization, provides these services to rape victims
in many States
throughout the country. If a chapter exists in an area
that does not
currently provide this service, it may be willing to do
so after being made
aware of the need.

It is not unusual for the victim to be afraid to return
home alone, so it is
important to offer to call a friend or relative to be
with the victim during
the exam and to take her home (Ledray: 96a). More
than 50 percent of
rape victims move or change their phone number as a
result of the rape
(Tintinalli & Hoelzer: 85). Anticipating this potential
move, while in the
ED, the SANE may want to get the phone number of
a close friend who
will always know how to contact the victim.

Since the victim may be in a state of emotional shock
at the time of the
initial examination, it is important to provide her with
written discharge
information to take home with her (Osborn & Neff:
89; Speck & Aiken:
95). Followup phone calls within 24 to 48 hours to
check on her
emotional and physical status, medical concerns, and
compliance with
medications provided and to assist with additional
referrals are also
recommended (Osborn & Neff: 89; Ledray: 96a;
Tintinalli & Hoelzer:
85). 

Testifying in Court

Only a small percentage of cases will actually go to
trial, and the SANE
will be called to testify. In a review of 372 cases seen
in a Detroit ED in
1980, only three went to trial and required medical
testimony. Testimony
about the injuries was a significant issue in only one
of these cases.
Ninety-seven percent of the guilty pleas resulted from
plea bargains
(Tintinalli & Hoelzer: 85). It is important, however,
to treat every case as
if it will go to court. Charting clearly and completely
at the time of the
initial exam is the best preparation. 

The SANE should always meet with the prosecutor
prior to testimony to
be better informed about the significant issues
involved and the defense
that will likely be used to properly prepare her
testimony in the particular
case. For instance, if it is significant that no physical
injuries were found,
the SANE should review the data on the likelihood of
injury during rape;
if it was a delayed report, she should review the data
on the typical time
between rape and reporting. If the prosecutor does not
initiate this
meeting, the SANE should do so. Because of her
training and experience,
the SANE will likely be qualified to testify as an
expert, rather than just a
factual witness, in sexual assault cases (Ledray &
Barry, 1998). 

The SANE needs to conduct herself professionally
and confidently in the 
courtroom. She should dress appropriately for the
occasion. When sure of
the facts, she should communicate that certainty.
When she is uncertain or
if she does not know the answer to a question, the
SANE should also
communicate this. If she does not understand a
question, she should ask
for the question to be repeated and should never
attempt to guess the
meaning of the question. She should never
demonstrate anger, even if the
defense attorney asks the same question repeatedly. It
is important for the
SANE to define her area of expertise and not testify
about other matters
such as the accuracy of DNA evidence. Watching a
criminal trial or
participating in a mock trial is excellent preparation
and increases
confidence.

Working with Special Populations

Male Victims

As with the rape of women, the rape of men is often
not sexually
motivated, but rather is a crime of aggression (Groth:
90). Sexual assault
treatment centers report that males comprise
approximately 6 percent to 10
percent of their clientele (Koss & Harvey: 91;
Libscomb, Muram, Speck &
Mercer: 1992). Male rape is generally thought to be
more underreported
than female rape. Male rape victims are even less
likely to report than
women because of the extreme embarrassment that
they typically
experience and because many men fear being
misunderstood as
homosexual. Most male rape victims have not
considered the fact that men
are also raped, and this contributes to the devastation
and stigmatization
that they experience. This trauma is similar to that
experienced by a
female victim who, while aware that rape does occur,
never considered
that she could become a victim of rape. 

Lipscomb, Muram, Speck, and Mercer (1992)
reviewed 99 male rape
cases seen at their center. Of these, 80 were
incarcerated and 19 were from
the community. The men represented 5.7 percent of
their clientele. They
found that all of the men were raped by other men,
except for one who was
raped by two women during a robbery and extortion
attempt. None of the
victims was injured to the point of needing medical
attention. As with
women, threat of physical force alone was sufficient
to subdue them. Only
two men, both inmates, sustained even minor injuries.
The community
victims were older and more likely to have had
weapons used against
them. 

Another study conducted by Kaufman et al. (1979)
comparing 14 male
victims with 100 female victims, found that the males
were more often
injured. Nine males (64%) were beaten, five severely,
compared with 23
percent of the women. The men were also more likely
the victims of
multiple assaults by multiple assailants and were
more likely to be held
captive. The men were more likely to seek treatment
for injuries without
revealing the sexual assault. Five of the men did not
initially report their
sexual assault. It is important to teach emergency
personnel to ask men
who present for treatment of physical injuries if they
have been sexually
assaulted in a way that preserves dignity for the
victim and demonstrates a
nonjudgmental or neutral attitude on the part of the
caregiver.

Male victims of sexual assault experience post
traumatic stress reactions
similar to those observed among female victims with
fear being most
commonly reported, followed by depression, suicidal
behavior or ideation,
anger, somatic problems, sexual dysfunctions, and
disturbances in peer
relationships (Koss & Harvey: 91). Men will need the
same level of crisis
intervention and followup care as women. However,
males may be less
likely than females to seek and receive support from
family and friends.
Their ability to seek support will vary according to
the level of
stigmatization they feel, the circumstances of the
rape, and the sensitivity
of care they receive in the ED or SANE community
clinic. Donnelly and
Kenyon (1996) point out that when a man is rectally
raped, pressure on
the prostate can produce erection and even orgasm,
which may be
confusing to male victims. Heterosexual men may
struggle with issues
surrounding sexual orientation. Some men may feel
that their body has
betrayed them. The SANE can allay fears and
confusion by explaining
that this is a physiological reaction to pressure on the
prostate.

Victim gender is not an indicator of the offender's
sexual orientation or
preference. In a study of convicted male sex offenders
who raped men, A.
Nicholas Groth (1990) found that at the time of their
offense, all of the
men were actively engaged in consenting sexual
encounters or
relationships, with 9 percent reporting that those
encounters were almost
exclusively with other men and 32 percent reporting
sexual activity with
both men and women. In Groth's study, 27 percent of
the convicted sex
offenders reported that they confined their consenting
sexual activity to
women and half of them were married. 

The SANE serves male victims well by taking the
time to listen to what
their experience was, what they were feeling as it
happened, and what
their immediate concerns are. It is helpful to describe
common reactions
men have after being sexually assaulted and to stress
that men do get
raped regardless of who they are, what they were
doing, or how they look.
Men may worry that they appear too effeminate, and
this caused the
assault. Gay men may wonder if the offender
assaulted them because of
their sexual orientation and struggle with resultant
self-blame. All men,
just as with all women, need to be reassured that their
appearance, sexual
orientation, and sexual preference had nothing to do
with them being
raped. Men are susceptible to the same techniques by
which rapists gain
control over female victims, the use of weapons,
entrapment, intimidation,
threats, and coercion.

Men who have been raped by women suffer the same
feelings of
helplessness, fear, and anxiety as do women who have
been raped by men.
They will, however, need more anticipatory guidance
in considering how
friends and family members may react. Many men
will react to a man who
tells them he was raped by one or more women by
laughing and saying,
"Why doesn't that ever happen to me?" The victim is
left with his intense
fear and anxiety invalidated which can lead to
feelings of self-doubt,
isolation, stigmatization, and depression. 

Same Gender Sexual Assault

While little quantitative or qualitative research is
available on same gender
sexual assaults, it is important for the SANE to
understand the dynamics
involved in same gender assaults. The term
"homosexual assault," which
is often used in the literature, is not accurate in that
many of the
perpetrators of same gender sexual assaults are not
"homosexual." 

The majority of same gender acquaintance assaults
occur as part of a
pattern of domestic abuse in same gender
relationships. The rate of same
gender domestic abuse reflects that of the
heterosexual population, about
30 percent (Abbott: 97). It is important for the SANE
to sort through her
feelings about same gender relationships so that she
can treat all victims
with dignity, respect, and compassion. All people
who have been abused
by their partners report the same range of feelings of
fear, anger, guilt,
depression, and anxiety over their living situation. 

The majority of stranger assaults on people of the
same gender involve
men, usually heterosexual men. When the victim is
gay or perceived to be
gay, and the perpetrator attempts to humiliate or
demean him, the assault
can be considered in some States as part of a hate or
bias crime involving
power and control over the victim. Not all States
consider same gender
sexual assault as a bias crime. Alabama, for example,
states that a bias
crime is one based on the offender's bias towards a
victim's race, color,
ethnicity, religion, physical, or mental disability. Both
gay and
heterosexual victims who have been sexually
assaulted are at high risk for
depression and suicidal behavior. After being sexually
assaulted by a man,
gay men frequently feel more stigmatized and
vulnerable, and
heterosexual men usually go through a process of
questioning their
sexuality (Abbott: 97). 

While female same gender assault is very rare, it does
happen. Women
who are forced to have sex with other women
experience the same
emotional reactions as women who are forced to have
sex with men. They
may also go through a process of questioning their
sexuality if they are
heterosexual or have an increased sense of
vulnerability if they are lesbian
or bisexual. The SANE needs to sort through what
kind of contact took
place and collect evidence wherever there may be
hair, saliva, or vaginal
secretions from the assailant. 

Gay and Lesbian Victims 

As with all people who have been sexually assaulted,
the degree to which
persons who are gay or lesbian will be able to recover
from a sexual
assault depends on the amount of support they have.
Their recovery will
also be affected by the amount of discrimination they
experience from the
community around them including the health care and
legal professionals
charged with their care after the assault. Fear of
disclosure is frequently a
major issue, even for people who are very publicly
open about their sexual
orientation because of the further loss of control it
represents. Even if the
assault was not a crime of bias or hate, often it feels
as though it is and
results in increased anxiety, deep personal doubt,
negative self image, and
depression (Miller: 97).

People who are well integrated into the gay and
lesbian community may,
however, have additional strengths with which to deal
with the sexual
assault, gained from the coming out process and the
constant
consideration of hate and bias crimes and how to heal
from them (Miller:
97).

At particular risk are adolescents who live in families
or communities
where homosexuality is not accepted and who are just
beginning to
explore issues of same gender sexual orientation but
do not have
supportive connections in the gay and lesbian
community. Being raped by
someone of the same gender and considering the
ramifications of
reporting can produce extreme anxiety. The SANE
needs to understand
that the adolescent's sexual identity is in the process
of unfolding and
using labels like "gay" or "lesbian" may be premature
and threatening. It is
less threatening to talk about attractions and interests.
Confidentiality is of
utmost importance for these youth as premature
disclosure of sexual
orientation can be extremely dangerous when the
adolescent does not have
the strength or support in place to deal with
homophobic reactions of
people in their family and community. Psychological
autopsies have
shown that roughly one-third of all adolescents
between the ages of 15 to
19 who have committed suicide were struggling with
issues of sexual
identity (Dexheimer Pharris: 95). SANEs must pay
special attention to
helping adolescents, who have experienced same
gender sexual assaults,
sort through all of the ramifications of reporting.
These youth will need
referral for supportive services as they sort through
their reactions to the
assault and continue to explore issues surrounding
sexual identity.

Lesbian victims of sexual assault by men experience a
unique
constellation of concerns. Lesbians constitute the
lowest risk group for
sexually transmitted diseases of all sexually active
adults and may not be
well aware of current STD risks from heterosexual
exposure. They also
have not had to worry about pregnancy risks and will
need careful
counseling about pregnancy risk and prophylaxis. For
women who have
not had sex with a man, vaginal penetration may be
painful both
physically and emotionally. Lesbian women often
report sexual
dysfunction after a rape which can be confusing as
they ponder why the
experience of violence with a man has carried over to
their nurturing
sexual relationship with another woman. Lesbians,
like others, often
wonder if the rape was their fault, but it may also
bring up a deep-seated
sexual confusion as the victim questions if she really
wanted the assault to
happen and whether it occurred because she looks
straight. Many lesbians
feel intense shame at having been violated by a man
and forced to have
sex with someone other than her gender or sexual
preference--which
represents an extra dimension beyond the experience
of straight female or
gay male rape victims. Common emotional reactions
include a sense of
isolation, vulnerability, punishment, and paranoia
(i.e.,"Did he pick me
because I look gay?"). Many lesbians report a deep
sense of shame at
having been violated by a man, which damages their
sense of self in that
they had previously prided themselves on their
independence and
self-sufficiency but now feel extremely vulnerable. It
is important that
SANEs have accurate information about lesbianism
and anti-lesbian crime
so that they can provide sensitive, appropriate care to
lesbians who have
been sexually assaulted (Tallmer: 96).

People with Developmental Disabilities

A review of assault rates indicates that from 68
percent to 83 percent of
people with developmental disabilities will be
sexually assaulted in their
lifetime, which represents a 50 percent higher rate
than the rest of the
population (Pease & Frantz: 94). Of the sexual
assaults of people with
developmental disabilities, 30 percent are by family
members, 30 percent
by friends or acquaintances, and 27 percent by service
providers, with the
likelihood of abuse by service providers increasing as
the severity of
disability increases. People with developmental
disabilities are more likely
to be re-victimized by the same person and more than
half never seek
assistance from legal or treatment services (Pease &
Frantz: 94).
Reporting may involve a loss of independence, for
example, if a person is
enjoying a new sense of independence in a group
home. Reporting an
ongoing assault by a staff member or other resident
may pose the threat of
reinstitutionalization. 

When someone is sexually assaulted by a person from
a professional
helping agency licensed by the State, a criminal
report may be filed by the
victim, however, the SANE as a mandated reporter
will need to assure that
the State licensing agency receives a report of the
abuse to investigate
misconduct. Some States have vulnerable adult
protection agencies that
serve as contact points for such reports.

One of the factors that keeps people with
developmental disabilities at a
greater risk for sexual assault is the lack of good
educational curricula to
instruct people with developmental disabilities about
the nature of sexual
assault and how to assert themselves in establishing
and maintaining
self-protective sexual boundaries. Even though 99
percent of assaults on
people with disabilities involve offenders who are
known to the victim, 
the majority of self-protection curricula is geared
towards stranger rape
(Seattle Rape Relief: 97). Readers are referred to a
manual written by
Terri Pease, Ph.D. and Beverly Frantz, M.S. entitled
Your Safety...Your
Rights & Personal Safety and Abuse Prevention
Education Program to
Empower Adults with Disabilities and Train Service
Providers published
in 1994 by the Network of Victim Assistance, 16 N.
Franklin Street, Suite
105, Doylestown, PA 18901, 215-348-5664. A video
by the same name is
available through Fanlight Productions, 47 Halifax
Street, Boston, MA
02130, 617-524-8838.

In caring for people with developmental disabilities, it
is important for the
SANE to do a brief assessment of the victim's
cognitive capacity so that
appropriate care can be given. Specifically, the SANE
needs to determine
if the victim has the ability to provide informed
consent, which entails the
cognitive capacity to weigh the risks and benefits of
different treatment
options and the ramifications of reporting or not
reporting an assault. The
ability to provide informed consent is affected not
only by cognitive
capacity but also by the level of emotional stress a
person is experiencing.
People who are otherwise very high functioning may
lack the ability to
make even simple decisions after experiencing the
trauma of an assault.
The SANE must continually assess whether the
victim understands what
she is saying and doing. 

In determining decisionmaking competence, the
SANE is balancing two
very important ethical values: protecting and
promoting the individual's
well-being and respecting the individual's
self-determination (Buchanan
& Brock: 89). A first consideration is whether or not
the person is her or
his own guardian and whether she or he functions
independently in the
community. In cases where the person has been
deemed legally unable to
provide informed consent, it may be necessary to
contact a legal guardian
to obtain consent to do an evidentiary exam. If a legal
guardian is not
available, the SANE proceeds with evidence
collection, acting in what she
perceives to be the victim's best interest and informs
the legal guardian as
soon as he or she is available. Exams are never done
against a person's
will. The reason for the exam should be explained in
terms that victims
can understand and their consent/assent should be
obtained regardless of
legal ability to provide informed consent. In situations
where the victim is
not able to verbally express his or her wishes, the
SANE must be sensitive
to grimaces and body movements so as to never
retraumatize a person
who has been sexually assaulted. As with any person
who has been
sexually assaulted, throughout the exam, the SANE
explains what she is
doing and why, in terms that the victim can
understand.

The SANE must also determine the sexual assault
victim's capacity for
processing information. The use of concrete examples
and language is
recommended for all victims. Even though a person
may be living on her
own or driving a car, she may not be able to read or to
process complex
abstract concepts. People who have developmental or
learning disabilities
may be reluctant to admit that they cannot read well
or at all. It is best to
say, "There are some important things I would like to
teach you. How do
you learn best? By having someone tell you? Through
pictures? Through
reading?" The SANE will need to assess retention of
new information. A
social worker or public health nurse may need to be
involved in planning
post-assault care.

People with limited abstract reasoning skills will need
help in trying to
determine who to tell about the assault and who they
do not want to know
about the assault. Often when they return home or to
school or work,
people with developmental disabilities freely disclose
details of the assault
and become revictimized by the attention of those
around them. The
SANE can greatly assist the victim by talking through
how different
people will react, who needs to know, how much to
share with whom, and
what the possible ramifications are of sharing
information. For people who
are unable to imagine people's possible reactions and
who are very verbal,
it may be best to encourage a few days off of school
or work so that they
can process their strong feelings and reactions with
staff or counselors
rather than with people on the bus or at work or
school.

In considering whether to share information about the
assault with other
professionals in the victim's life, the SANE is
weighing the person's
well-being with the right to confidential care and need
to be in control of
who is told. When staff from group homes or other
social service agencies
are present, it is important to honor the victim's right
to confidentiality
and discuss with her or him what information can be
shared.
Confidentiality should not be broken except when
there is a clear need to
involve another caring person to protect the victim
from additional harm.

People with Physical Disabilities

People with physical disabilities may also be at
greater risk for sexual
assault, especially if they are dependent on others for
personal care.
Ninety-nine percent of offenders who sexually assault
people with
disabilities are known to their victims (Seattle Rape
Relief: 97). When the
offender is someone who is supposed to be in a
helping relationship,
concerns about loss of services and independence
arise. The victim is left
with fear and anxiety over the potential harm from
people whom they
should be able to trust and rely on for assistance and
support. This can
lead to overwhelming feelings of vulnerability,
stigmatization, and
depression. If the assailant works for a helping
agency, a report to the
State licensing board is mandated.

After having been sexually assaulted, people who are
differently abled
respond emotionally in all the same ways that people
who are currently
able-bodied respond. They may, however, need to
talk through how they
perceived the role their disability might have played
in making them more
vulnerable to the assault. The SANE can listen to
their concerns and what
the experience was like for them. They will benefit
from reviewing the
roles force, threats, and coercion play in rape and
from being reminded
that even strong able-bodied men and women are
sometimes raped.

People who are differently abled are only "disabled"
to the extent that
their differences are not accommodated for by
society. It is imperative that
SANE programs provide services that are equally
accessible to all people. 

Because so much of the post-assault care involves an
exchange of
information (telling the story of the assault,
discussing feelings, explaining
the evidentiary exam, teaching about common
symptoms of rape related
post traumatic stress disorder and means of coping,
etc.), people who are
deaf or hard of hearing will need sensitive and
appropriate care. Deaf is
defined as a hearing loss of such severity that the
individual must depend
primarily upon visual communication such as writing,
lip reading, manual
communication and gestures. Hard of hearing is
defined as a hearing loss
resulting in a functional loss, but not to the extent that
the individual must
depend primarily upon visual communications
(Schumacher & Hung Lee:
97). While deafness is not a handicap in and of itself,
deaf and hard of
hearing people are handicapped by the lack of
services that provide sign
language interpreters. SANE programs must have a
system in place to
communicate with people whose primary means of
communication is
signing. The program should also provide access to a
TTY/TDD
(teletypewriter/telecommunications device) for deaf
and hard of hearing
people to call.

The following guidelines for caring for people who
are deaf or hard of
hearing were compiled by Kathy Schumacher, edited
by May Hung Lee
and published in the Minnesota Coalition Against
Sexual Assault Training
Manual (1997, pp. 2-49-2-51):

--When Deaf [or] Hard of Hearing victims seek
services, they will have
the same basic needs and fears that hearing victims
have. They need to feel
welcome. Motion the person to follow you to a quiet
office. Tell the
individual your name. Write it down on paper if the
victim does not seem
to understand. Ask the victim if he or she wants an
interpreter--there are
sign language interpreters as well as oral interpreters.
Also, let the victim
know (on paper, if necessary) that you will be calling
for an interpreter.

--It is important to have the Deaf [or] Hard of
Hearing person's attention
before speaking. Since she cannot hear the usual call
for attention, she may
need a tap on the shoulder, a wave of the hand, or
other visual signals to
gain her attention. Do not speak before she is ready to
listen.

--If the victim is wearing a hearing aid, do not assume
she will or should
have good hearing. She will still have some difficulty
and will benefit 
from your consideration.

--Whether she indicates she can read lips or not, body
language and
gestures will help communication. Write down any
words she seems to be
having trouble understanding. Be sensitive to the fact
that she will be
observing closely your body language and will pick
up on visual signs of
frustration. Try to relax and to help her relax.

--Look directly at the person while speaking. Even a
slight turn of the head
can obscure the Deaf [or] Hard of Hearing person's
vision. Do not talk to
her if your back is turned or when you are in the dark
or in another room.
Do not turn away in the middle of a sentence. Other
distracting factors
affecting communication include mustaches which
obscure lips, smoking,
pencil chewing, and putting your hands in front of
your face.

--Do not speak to a Deaf [or] Hard of Hearing person
with your back
to a light, window or mirror. Have the light in YOUR
face, not hers.

--Every Deaf [or] Hard of Hearing person will
communicate in a
different way. Some will use speech only; some will
use American Sign
Language only; some will use a combination of sign
language, finger
spelling, and speech; some will use body language
and facial expressions
to supplement their interactions. Deaf [or] Hard of
Hearing people use
many ways to convey an idea to another person. Sign
language is an
inclusive term that refers to any method of
communication: American
Sign Language, signing exact English, finger spelling,
and any
combination of these.

--Just as each individual has her own style of
speaking, grammar
usage, vocabulary, and favorite idioms and cliches,
Deaf [or] Hard of
Hearing people also have their own individualized
manner of
speaking in sign language. People who use exact
English are probably
more able to converse through written means. Often,
hiring a sign
language interpreter will be your only effective
communication method
with someone whose native language is American
Sign Language.
Understand that American Sign Language (ASL) is
not the same as
English. The interpreter is trained to recognize and
utilize similar signs as
the Deaf [or] Hard of Hearing person. Examples of
American Sign
Language, as written may be: Movie last night. Wow
good. Should see
you. Laugh roll ("The movie I saw last night was very
good. You should
see it. I laughed so hard I was almost falling on the
floor."), or Home
many problems. Not good my house. Want out finish
trouble. ("There are
a lot of problems at home. My house is not a pleasant
place right now. If
my husband/boyfriend/partner leaves, the trouble may
stop.") To someone
familiar to sign language, this manner of expression is
quite clear.
Interpreting word for word is not always
understandable.

--Try to maintain eye contact with the deaf person.
Eye contact helps
convey the feeling of direct communication. If the
interpreter is present,
continue to talk directly to the deaf person. Do not
use phrases such as
"Tell her that." Speak directly to her.

--Be flexible in the use of language. English may not
be a Deaf [or]
Hard of Hearing person's primary language, and
therefore you may need to
simplify your sentences.

--Pantomime, body language, and facial expressions
are important
factors in communication. Experiment with different
techniques. Be sure
you use all of them.

--Do not shout or use exaggerated lip or facial
movements. Use an almost
normal rate of speaking--not too fast, but not so
slowly that the natural
rhythm is lost. The thought should come as a whole.
Take care to "round
off words." Enunciate clearly and distinctly, keeping
the voice as vibrant
as possible. 

--Do not assume the victim can read lips.

--Use words with the most lip movement, such as "25
cents" instead of "a
quarter." 

--If she does not understand, change the wording. Use
other expressions
that get the same point across. Do not repeat the same
phrase over and
over.

--People with some hearing loss find it is hard to hear
in the presence
of background noise, so be sure to move away from
such noise.

--Ask her to let you know what to do to better enable
her to understand
you--her hearing ability will vary with rooms,
background noise, fatigue,
and many other factors. 

People who have impaired vision usually do not need
assistance in
familiar surroundings but will need accommodations
when they are in the
hospital or clinic for a sexual assault exam. They will
need to be oriented
to their surroundings. It will be especially important
to talk about
everything you are doing. Before you touch them,
explain that you will be
touching them and how and why. When moving from
one room to the
next, they can be offered your arm to grasp above the
elbow for guidance.
Verbally point out obstructions, like chairs, exam
tables, etc. Always tell
the person when you are leaving the room. If the
victim has a guide dog,
do not be diverted by [it] or ask about the dog's
reaction--this distracts
blame from where it belongs--with the rapist (Erb:
96).

The Elderly

Many people do not recognize that the elderly are at
risk for sexual
assault. Older women with impaired mental
functioning are especially
vulnerable. Rape may go undetected when health care
professionals
overlook the signs. Community health care facilities
with large
populations of elderly women need to be educated by
the SANE regarding
symptoms of a potential sexual assault and how the
health care facility
staff should respond when an assault is suspected.
Whenever an assault
occurs in a health care facility, the appropriate
governmental adult
protection agency must be notified, and they in turn
are responsible for
reporting the incident to the State health care facility
regulating agency. 

Decreased hormonal levels following menopause
result in a reduction in
vaginal lubrication and cause the vaginal wall to
become thinner and more
friable. Therefore, elderly women are at an increased
risk for vaginal tears
and injury when they have been vaginally raped.
Because of these
physiological changes, a pedersen speculum, which is
longer and thinner
than the graves speculum, should be used during the
pelvic exam for
evidence collection, and special care should be taken
to assess for
intravaginal injury. In some elderly women, the
SANE will need to simply
insert the swabs and avoid the trauma of inserting a
speculum. Just as with
premenarchal young women and children, if there are
external tears in the
introitus, internal injuries must also be considered.

Declining physical strength and agility heightens the
elderly's fear of not
being able to resist or escape an assault. For the
elderly, loss of hearing
increases the fear that an intruder will not be heard.
Loss of visual acuity
causes shadows to take on an ominous quality
heightening fear. Frail
elderly are at greater risk for injury. After an assault,
well-meaning
relatives may wish to place an elderly family member
who has been raped
in a nursing care facility, which serves to further limit
their independence
and poses the threat of never returning to independent
living (Simmelink:
96). The SANE can assist elderly victims and their
family members to
make plans that maximize the person's independence
yet assure her
safety. The SANE is able to refer the family to
individuals and agencies
that can work with them in assuring an appropriate
placement, if needed.
Any placement should protect the elderly rape victims
without further
limiting her enjoyment in life and sense of autonomy.

Self-Injury Victims

Self-injury victims are a special subcategory of
victims who may make
false reports. It is particularly important that the
SANE be aware of clues
to false reports from this victim group. It is not
uncommon for victims
who have not resolved some past trauma to injure
themselves and report
having been raped. The victim may have actually had
sex with someone
who thought the sex was consensual, but during the
sexual contact, the
victim had a traumatic re-experiencing of a painful
sexual assault in the
past, or an incest experience and withdrew and
dissociated from the
partner. The victim may also have re-experienced the
traumatic
experience while alone. This usually occurs during
times of stress for the
woman, such as following the first disclosure of
incest or the recent loss
of a loved one who has been supportive, or following
an intense therapy
session in which the precipitating trauma was
discussed.

Clues for the SANE to look for in suspected
false-reporting cases include
a vague description of the assailant, too vague for the
described
circumstances of the assault, often not even including
his race; stalking,
including leaving notes telling the victim how
beautiful or terrible she or
he is; superficial cuts or scratches of the inner thigh or
inner arm,
consistent with the victim's handedness; an unusual
event reported as part
of the rape, such as dirt and leaves in the vagina;
unusual patterned
injuries such as superficial straight patterned cuts
intersecting the nipples
described as occurring during a struggle; and multiple
rape reports. The
victim may also report a history of incest that
resembles the current
trauma she or he is reporting. 

Fortunately, it is not the SANE's job to determine if
the person was raped,
so evidence collection with these cases should
proceed as usual. The
SANE should not, however, be afraid to indicate
"injuries inconsistent
with reported history" if that is the case. Since the
role of the SANE is to
provide the care required for every victim, in these
cases especially,
mental health assessment and referral are essential
(Ledray: 94).

Refugees and Immigrants

Refugees are people who had to leave their native
country and are seeking
asylum in the United States because it was too
politically or physically
dangerous to stay in their homeland. Immigrants are
people who have
chosen to come to the United States. In the past few
decades, many men
and women came to the United States from Southeast
Asia, South
America, Central America, Northern Africa, and
Bosnia as a result of war.
Refugees and new immigrants are especially
vulnerable to victimization.
They may be particularly vulnerable if they
immigrated illegally and are
afraid to report violent incidents or if they are
uneducated and unaware of
their rights, or how to access services. Assailants
assume that people who
are undocumented will not report an assault to the
legal authorities for fear
of being deported. Sexual predators capitalize on the
vulnerability of
recent immigrants and refugees. 

While accurate numbers are not available, the
literature indicates that in
refugees seeking counseling, 52 percent of the men
and 80 percent of the
women were sexually tortured during the war or
political conflict in their
home country (Agger: 87). When people who have
been sexually tortured
are raped, they not only experience the trauma of the
rape, but also are
vulnerable to a traumatic re-experiencing of the
sexual torture. For
refugees who were subjected to torture in their native
countries, a doctor
or nurse was often present at the time of torture. For
this reason, the mere
presence of medical personnel after a rape may be
anxiety producing.
SANEs should be aware of this possible history and
realize that due to the
devastating nature of the experience and its emotional
sequelae, most
torture victims will not readily disclose a history of
torture. Extra care
must be taken to assure refugee or immigrant rape
victims that they do not
have to do anything they do not want to do and that if
something hurts,
they should let the SANE know, and the SANE will
stop. The SANE
should explain what she is doing and why. The victim
should be
encouraged to keep her eyes open during the pelvic
exam--this will reduce
the likelihood of flashbacks to the torture experience.
Torture victims who
have been raped need to hear that they have not
sustained any permanent
physical damage and be reassured that their body will
heal, if this is the
case. Just as with incest victims, they will need
additional support in the
rape recovery process.

If a female victim comes from a culture that blames
the victim for rape or
does not consider her marriageable once raped, she
may deny that she was
raped. If married, she may reasonably fear that her
husband will blame her
and/or reject her if she admits to being raped. Both
male and female
victims may admit to a physical assault, especially if
there are injuries to
explain, however, even when asked directly, they may
deny any sexual
contact. This will be problematic to the SANE, the
police, and the
prosecutor if the evidence of the rape is identified
later. Valuable evidence
will have been lost and credibility as a witness will be
in jeopardy. To
facilitate a truthful disclosure early, it is essential that
the SANE interview
the victim in privacy and work at building a trusting
relationship. If the
victim does not speak English, a professional
interpreter must be
provided.

Because the consequences of rape within their
cultural context are so
grave, women from some non-Western cultures may
not seek treatment
immediately following a rape. They may wait until an
injury, pregnancy,
or a sexually transmitted disease forces them to seek
medical care. They
may also be in extreme emotional crisis and suicidal.
Understanding the
meaning of rape in their culture and knowing
appropriate, culturally
sensitive referral sources is crucial. Strict
confidentiality, even from other
family members and staff from the victim's culture
must be maintained
(Mollica & Son: 89). While bicultural staff are most
often an advantage
and facilitate understanding and credibility, with
some victims, they can
be a threat to confidentiality for the victim and should
not be present. The
social stigma of people from the community knowing
about the assault
can be so powerful that it prevents the victim from
telling what happened
and getting needed care. The victim needs to have
control over whether a
specific professional interpreter will be utilized,
especially if the
interpreter is from his or her community. Although it
is always essential to
explain the person's legal right to confidential care,
many people who
come from war torn countries will not be able to trust
promises of
confidentiality, no matter how strong, because of the
extensive use of
informants in their home country. Under conditions
of war, people are
reluctant to confide in and trust even close friends.
Therefore, a tension
develops between the need to have a culturally
specific interpreter skilled
in the victim's dialect present and the need to
maintain complete
confidentiality. Generally, both male and female
victims of sexual assault
will feel more comfortable with a female interpreter
and staff.

Working with Interpreters

Providing interpreter services is not optional, it is
legally mandated. The
U.S. Department of Health and Human Services
considers lack of
interpretation to be a form of discrimination. Title VI
of the Civil Rights
Act of 1964 [601 78 Stat 252 942 USC 2000d)] states
that "no person in
the United States shall, on the ground of race, color,
or national origin, be
excluded from participation in, be denied benefits of,
or be subjected to
discrimination under any program or activity
receiving Federal financial
assistance" (Center for Cross-Cultural Health: 97).

The legal aspect of the SANE exam demands that the
environment be one
in which the assault victim is comfortable enough to
honestly describe
what happened to her. Due to possible cultural
sensitivities and the
potential of breach of confidentiality, family members
or friends should
never be used as interpreters in providing care and
collecting evidence.
Many SANE programs utilize the interpreter services
of local medical and
legal agencies. Professional interpreters not only
speak both languages but
are also trained in how to make a person's message
clear. The
professional interpreter is also held accountable for
confidentiality,
accuracy, and unbiased interpretation of what has
been said.
Consequently, it is also not sufficient to use a
bilingual staff person to
interpret. Employing highly skilled, professional
interpreters is an
essential component of providing comprehensive
services to non-English
speaking victims of sexual assault. Interpreter
services need to be planned
in advance for the immigrant groups residing in the
SANE's area of
service. (The reader is referred to this chapter's
section on "People With
Physical Disabilities," which covers issues
surrounding the need for
interpreters for people who are deaf or hard of
hearing.) 

The following guidelines adapted from the Center for
Cross-Cultural
Health's handbook, Caring Across Cultures: The
Provider's Guide to
Cross-Cultural Health Care (1997) outline important
principles in working
with interpreters:

--Meet with the interpreter briefly before the
interview to explain
the situation and what kind of questioning and
teaching you will need to
be doing. Attend to any personal issues the interpreter
may have regarding
sexual assault. Discuss how the interaction will
proceed and where the
interpreter should sit. If the interpreter needs to be in
the room during the
exam, she can be on the other side of a curtain to
assure maximal privacy
for the victim. [Note: Ask the interpreter about any
areas requiring cultural
sensitivity prior to the interview.]

--When speaking, address yourself to the victim, not
the interpreter.
Maintain eye contact, as appropriate, with the victim,
not the interpreter.
Speak directly to the victim, addressing him or her as
"you," not the
interpreter. 

--Don't say anything you don't want the victim to
hear. Expect everything
to be translated. Realize that what may be said in a
few words in one
language, may require a lengthy paraphrase in
another. 

--Speak clearly, in a normal voice and not too fast.
Stop at comfortable
intervals for the interpreter so that she can translate
what you are saying
accurately and completely [--generally] one long
sentence or three or four
short ones. Stop at a natural place for the interpreter
to pass your message
along. Always stop at the end of a sentence. Short
simple sentences are
easier to translate.

--Expect the interpreter to interrupt when necessary
for clarification
or to take notes if things become complicated. 

--Avoid jargon and technical terms. You may need to
repeat what you
have said in different words if your message is not
understood. 

--Meet with the interpreter afterward to assess how
things went and to see
if she is satisfied with the accuracy of the information
passed along. Also
attend to any vicarious traumatization she may be
experiencing from
having passed along the story of the assault. 

--Have the interpreter sign a statement that she
interpreted for you and the
victim including the date, time, and agency for which
she works. 

In situations where an interpreter is not available for
the language of the
victim, or when the available interpreter is a member
of the victim's
community and she or he prefers a stranger, there are
phone medical
interpreter services that can be accessed. The
drawbacks of phone
interpreter services are the expense and the inability
to pick up on
nonverbal cues. The following services can be
accessed for interpreter
services (Center for Cross-Cultural Health: 1997):

AT&T Language Line Service, 1 Lower Ragsdale
Drive, Monterey, CA
93940, 800-874-9426 or 800-752-0093 (call to set up
an account or hear a
recorded demonstration of the Language Line
service). The service have
up to 140 languages and is available 24 hours a day, 7
days a week. They
can usually connect you with an interpreter within 60
seconds. For
frequent users who subscribe to the service on a
monthly basis, the rates
are $2.20 to $4.50 per minute depending on the
language and the volume
discounts available. For users who cannot predict
their need on a monthly
basis or justify a monthly minimum, the rates are
$3.50 to $4.50 per
minute depending on the language. For occasional
users, the rates are
$4.15 to $7.25 per minute, depending on the
language.

Pacific Interpreters, Inc., 1020 SW Taylor, Suite 280,
Portland, OR
97205. 800-870-1069 or information@pacinterp
(e-mail). They have more
than 65 languages and specialize in interpreting in the
health care and
social service areas and charge $1.95 per minute with
volume discounts
available.

Providing Culturally Congruent Care

The way people react to and recover from sexual
assault is largely
determined by the culture(s) within which they live.
An essential part of
SANE training involves assuring competency in
providing culturally
congruent care. Culture does not simply refer to
ethnic origin or race, but
rather implies all of the groups and subgroups that
surround and support
individuals. Transcultural nurse theorist Madeleine
Leininger (1995)
defines culture as the learned, shared, and transmitted
knowledge of
values, beliefs, norms, and lifeways of a particular
group that guides an
individual or group in their thinking, decisions, and
actions in patterned
ways. Subculture is closely related to culture and
refers to a group that
deviates in certain areas from the dominant culture in
values, beliefs,
norms, moral codes, and ways of living with some
distinctive features of
its own. Leininger (1995) defines culturally congruent
care as those
cognitively based assistive, supportive, facilitative, or
enabling acts or
decisions that are mostly tailormade to fit with an
individual's, group's, or
institution's cultural values, beliefs, and lifeways in
order to provide
meaningful, beneficial, satisfying care that leads to
health and well-being. 

An individual's culture(s) will shape the way she
experiences a sexual
assault and how she will recover from it. To provide
culturally congruent
care and to be of maximal assistance to her clients,
each SANE needs two
essential skills: 1) the ability to acquire essential
knowledge about the
cultures and subcultures in her service area and 2) the
ability to do a
culturalogical assessment to determine the degree to
which each individual
ascribes to cultural values and mores governing
sexual assault and
recovery from trauma. 

There is a temptation to use a cookbook approach to
caring for people
from various cultural backgrounds, listing how each
individual culture
sees sexual assault. While broadly informative, this
approach carries the
danger of stereotyping individuals and of not
responding in a way that is
comfortable or helpful to them. The SANE does,
however, need to know
the potential differences and similarities between her
culture and the
culture(s) of the people she serves. The following
process is
recommended:

1. Analyze your own cultural beliefs and values.
Formal cultural
assessment guides are available to assist nurses in this
process such as that
provided by the Center for Cross-Cultural Health
(1997). 

2. Get to know the cultures in your service area.
General cultural
guidebooks such as those written by Lipson, Dibble,
and Minarik (1996)
and Geissler (1993) provide an overview of different
cultures, but it is
best to meet with people from the cultures represented
in your community
who are knowledgeable about health care practices.
Listen to them about
their experiences and beliefs surrounding sexual
assault, reporting, and
recovery. Optimally a partnership will be formed to
best serve people
from that community. Each SANE program needs to
be proactive in
establishing these partnerships with all communities
in the service area.

3. Become proficient in conducting culturalogical
assessments. This
involves assessing where each individual is at in
terms of their own unique
set of values, beliefs, and lifestyle. It also involves
being aware that clients
may belong to subcultures or groups such as gay,
lesbian, transgender, and
bisexual communities; a subculture of homeless
people; the deaf
community, etc. The SANE can get a good sense of
the person's cultural
influences by asking, "How will the people who are
important to you react
to this assault?", and exploring the meaning of the
rape and people's
reactions to the victim. The SANE needs to listen to
how the victim
perceives the ramifications of reporting, not
reporting, telling others, etc.
For example, in some communities an adolescent girl
who is vaginally
raped may be ostracized from the community or no
longer considered
marriageable. The SANE needs to thoroughly explain
the limits of
confidentiality within the legal system and listen to
how the young woman
feels, what she thinks might happen, and what she
wants to do. Victims
may be reluctant to further stigmatize people of their
race. Many women
who have been raped by men from their own minority
racial group are
faced with intense conflicting feelings of wanting to
hold the assailant
accountable, yet not wanting to send another man of
her race to jail. If
victims perceive the legal system as being racist and
not trustworthy, they
may fear sending an innocent man to jail for their
assailant's crime
(White: 94; Wilson: 94). The SANE needs to be
aware of and sensitive to
these dynamics in her community.

4. Be aware of culturally appropriate referral sources
for followup care
and develop partnerships with them. Culture shapes
the way we frame
traumatic experiences and how we best heal from
them. They may thus
reach for a larger lesson to be learned from the
experience and not be so
extremely overwhelmed by feelings of guilt and
shame, but rather deal
with the painful situation by using tolerance, denial,
or stoicism (Kanuha:
97). Other cultures may have a specific ritual for
healing post traumatic
stress, such as the Navajo Enemy Way ceremony.
This is a ritual in which 
the family and tribe accept responsibility for the
impact of trauma on
young returning warriors through the use of a healing
ceremony which
facilitates processing war trauma and reintegration
into the peacetime
community (Marsella, Friedman, Gerrity & Scurfield:
1996). Juris
Draguns (1996) points out that cultures vary in their
components of
intervention to post traumatic stress disorder in the
following ways:

--Use of interpretations and their rationale and basis.

--Extent and nature of verbal interaction between
client and therapist.

--Role of verbal communication.

--Role differentiation between client and therapist.

--Respective weights of physical and somatic and
psychological distress.

--Role of ritual in psychotherapy.

--Use of metaphor, imagery, myth, and storytelling in
psychotherapy.

--Nature of relationship between therapist and client.

SANE programs need to be aware of the cultural
differences in the above
areas for the cultures represented in the area they
serve in order to provide
culturally congruent crisis intervention services.
Updated information on
how specific cultures provide crisis intervention can
be one function of the
partnerships alluded to earlier between SANE and
cultural communities
within the service area. Cultures are not stagnant and
do change so
updates on how cultures view and respond to rape are
essential.

Additional Program Components

Additional components of SANE programs referred
to in the literature
include education and training for the medical and
nursing community
(Speck & Aiken: 95); 24 hour hotline (Speck &
Aiken: 95); court
advocacy services (Speck & Aiken: 95); scientific
research and program
evaluation (Speck & Aiken: 95; Burgess & Fawcett:
96; Holloway &
Swan: 93; Ledray: 93); followup counseling (Speck
& Aiken: 95; Ledray:
92b); and consultation services with other SANE
programs (Speck &
Aiken: 95; Ledray: 92a). 

As SANE programs mature, these program
components grow as well.
New SANE programs will likely concentrate their
efforts on providing
clinical services and obtaining training for their own
staff. As SANEs
become more experienced, they may begin to provide
training for other
professionals and nonprofessionals in the community.
With even more
experience and depth of knowledge, they may be able
to provide
consultation services to newer SANE programs.

Summary

Collecting evidence for the evidentiary examination
of the rape victim is
the central focus of the SANE program operation.
While guidelines can
certainly be provided concerning what evidence
should generally be
collected, it is important to recognize that every case
will likely be just a
little different from another. Additionally, each
SANE needs to have a
thorough understanding of the forensic principles
involved and an
understanding of special populations that may be
encountered so that each
rape victim can receive the best possible care
available. 

-------------------------------

Essential Exam Components

--Forensic evidence collection.

--STD evaluation and preventive care.

--Pregnancy risk evaluation and prevention.

--Crisis intervention.

--Care of injuries (completed by the medical staff).

-------------------------------

Specific Evidentiary Exam Components

--Written consent.

--Assault history, including orifices where violence
was used or
penetration occurred and by what, and forms of
violence used and where.

--Pertinent medical information including allergies,
current pregnancy
status, and menstrual cycle.

--General physical assessment for trauma. 

--Assessment of involved orifices for trauma.

--Sperm and seminal fluid specimens from involved
orifices.

--Foreign biological matter collection.

--Fingernail scrapings or clippings.

--Pubic hair combing for foreign hairs and other
materials.

--Blood for typing and DNA screening.

--Saliva for victim secretor status (In many areas, this
is no longer used
and is now replaced by DNA).

--Urine specimen (when rape drug use is suspected).

--Collection of torn or stained clothing.

Primary Areas of Variation

--Amount of documentation.

--Prophylactic treatment for STDs vs. culturing.

--Collection of additional blood or urine specimens
for drug and alcohol
analysis.

--Clothing collected as evidence.

--Required number of head and pubic hairs if
collected routinely.

--Utilization of colposcope or MedScope and light
staining microscope.

Examples of sexual assault evidentiary exam
protocols are included in
Appendix I: SANE Protocols.

-------------------------------

Basic Documentation

--Location, date, and time of assault.

--Nature of physical contacts.

--Race, identity (if known), and number of assailants.

--Weapons and restraints used.

--Actual and attempted penetration of which orifice
by penis, objects, or
fingers. 

--Sites of ejaculation, if known.

--If a condom was used. 

--Activities of the victim that may have destroyed
evidence, such as
bathing, douching, bowel movement, use of tampon. 

--If there was consenting sex within the last 72 hours
and with whom.

--If the victim has changed clothes.

--Contraceptive use.

--Current pregnancy.

--Allergies.

--Victim's general appearance and response during
exam.

--Physical injuries. 

Sources: (Osborn & Neff: 89; Antognoli-Toland: 85;
Ledray: 92b;
Slaughter & Brown: 92). 

CHAPTER 12  

PEDIATRIC SANE EXAM

Nursing care of children who have been sexually abused or sexually
assaulted involves all of the skills utilized by SANEs in caring for adults,
with the added knowledge of pediatric growth and development. SANEs
who work with children need to be able to give care that is appropriate to
each child's age and developmental stage. This chapter will address
special considerations of a pediatric SANE exam and is to be read in
conjunction with the entire manual. Only the differences between a
pediatric and adult SANE exam and sexual assault examination will be
discussed. 

Child sexual abuse is defined as the involvement of developmentally
immature children or adolescents in sexual activities that they do not fully
comprehend, to which they are unable to give informed consent, or that
violate taboos or family relationships (Emans, Laufer & Goldstein: 98). It
can range from exhibitionism, to fondling, to intercourse. Approximately
two-thirds of child victims are abused by a family member (Reghr: 90).
When a child has been sexually abused by a relative or someone who is
responsible for his or her care, or when the abuse is the result of parental
neglect, the SANE must deal with issues pertaining to the child's
protection and involve the appropriate governmental protection agencies. 

The term sexual assault refers to any sexual act performed by one person
on another without that person's consent. The assault may involve the
threat of force or the person may not be able to give consent because of
age, mental or physical capacity, or cognitive impairment due to drugs or
alcohol (Emans, Laufer & Goldstein: 98). Sexual assault of a child is
usually an acute traumatic event. Child protection and police notification
laws for sexual assault vary from State to State with some States
mandating a report to police and child protection only if the assault
occurred as a result of parental neglect. In other States, a police report is
mandated for all sexual assaults of children. It is important that each
SANE knows the mandatory reporting guidelines for the jurisdiction in
which she works. 

The sexual assault exam will be affected by the relationship of the child to
the offender; the child's physical, emotional, and mental development; the
child's ability to communicate and understand; and the child's ability to
trust another person (i.e., the SANE). Attention must be given to
recognizing and responding to these factors.

The goal of a pediatric SANE exam is to provide comprehensive sexual
abuse evaluation and nursing care to a child and her family in an
environment that is comfortable for the child. Consideration is given to
the physical and emotional needs of the child, collection of evidence,
screening for and prevention of STDs and pregnancy, providing for the
safety of the child, and referral for followup medical care and counseling. 

Setting 

A busy hospital emergency room can be frightening to a young child,
therefore it is recommended that pediatric exams be completed in an
alternative setting when possible (Stovall, Muram & Wilder: 88). A quiet
setting away from traffic and decorated to appeal to children will help the
child feel relaxed and welcomed.

Special Training 

Pediatric SANEs need to be knowledgeable about the physical,
intellectual, and emotional development of children and adolescents.
Ideally, the SANE will have pediatric training and possess highly
developed skills in communication with children. The SANE must be
comfortable with children and enjoy working with them. Thorough
knowledge of the developmental stages of childhood is essential, as is an
understanding of pediatric anatomy and the ability to interpret normal and
abnormal findings. Skills and experience in conducting interviews with
children, collecting and documenting forensic evidence, and testifying in
court are also important. Pediatric or family practice nurse practitioners or
nurses with experience working with children are good candidates for
SANE training where children are part of the client population. 

Sexual Assault Response/Resource Team (SART)

Chronic sexual abuse of children is generally inflicted by someone who is
known to, or part of, the child's family. Often the abuse has occurred for
some time before it is discovered, and it may have a profound and
long-lasting impact on the child and family. To respond to the complex
needs of children and their families, most pediatric SANE programs utilize
a team approach to effectively gather needed information and evidence. In
addition to the SANE, the team may include other health care staff,
workers from child protection, and representatives from law enforcement
(i.e., police, district or county attorney).

Interview

A skilled interview and documentation as to what the child says during the
exam are essential components of the evidence collection process. Past
studies support the fact that the majority of children with legally
confirmed sexual abuse have normal or nonspecific genital findings
(Adams, Harper, Knudson & Revilla: 94; DeJong & Rose: 91; Muram:
89). In a study of 236 children where the perpetrators were convicted for
sexual abuse, normal genital examination findings were reported in 28
percent of cases. Nonspecific findings were reported in 49 percent,
suspicious in 9 percent, and abnormal in 14 percent (Adams et al.: 94). In
cases with normal or nonspecific findings, the child's statements are the
primary evidence used in successful conviction. Successful prosecution
may depend on the child's ability to tell what happened, and the skill of the
person eliciting, documenting, and testifying to the child's story. The
purpose of the initial interview is to create an opportunity for the child to
tell what happened in a way that will both benefit the child and obtain
objective verbal evidence for prosecution. In a good interview, the child
will feel listened to, understood, valued, and affirmed, and thus begin the
road to recovery. At the same time, subjective verbal evidence from the
child will be documented by the licensed professional or SANE for use by
the courts. 

Who Conducts the Interview

Careful consideration must be given to who will conduct the interview.
Interviewers need to be trained by experts in forensic interviewing
techniques. They must have a thorough understanding of child
development and abuse dynamics. It takes experience and training to
know how to frame questions that elicit information from the child that
will be admissible in court. Some SANE programs may choose to provide
the advanced training necessary to prepare the SANE to conduct pediatric
forensic interviews. Other SANE models may use a team approach,
having the SANE collect the physical evidence, with a social worker,
psychologist, child protection worker, or law enforcement officer
completing the bulk of the forensic interview. 

Victim Interview

An initial interview with the child should take place as soon as possible
after the suspicion of abuse has been disclosed so that the child's
statements are not affected by memory loss or influenced by talking to
others. Consideration is given to the child's readiness and ability to talk,
the child's physical and emotional needs, time of last suspected incident,
and the availability of a trained person to conduct the interview. If the last
incident of abuse occurred within 72 hours, a physical exam and evidence
collection should be done as soon as possible to preserve evidence. If a
child becomes reluctant to discuss the abuse later, initial statements will
be important evidence. It is important to be aware of and sensitive to the
child's eating and sleep schedules. In cases where the abuse occurred
more than 72 hours ago and the child is tired, hungry, or unwilling to talk,
or if an experienced interviewer is not available, delaying the interview
would be a wise decision.

The interview should take place in a quiet room with a minimum of
distractions. A two-way mirror, if available, allows medical and legal
professionals who also need the information to observe the interview
without making the child feel uncomfortable. A few simple toys to
establish rapport as well as paper and crayons to illustrate what happened
may be helpful. Too many toys and equipment in the area may prove
distracting for the child. 

Although all team members may need the information obtained from the
interview, it is recommended that one person alone conduct the interview
and that repeat or multiple interviews be avoided whenever possible.
Repeated questions run the risk of implying to a child that he or she is not
believed or that the answers provided earlier may not have been correct
answers. Children's answers to repeated questions may acquire a rote
quality that detracts from their credibility. Children questioned repeatedly
may also become bored or uncomfortable and deny the abuse occurred in
an effort to end the interview (Paradise: 90). To allow other team
members access to the information obtained in the interview, the use of
two-way mirrors, videotaping, and concise, detailed written
documentation are recommended (Jezierski: 92; Levitt: 93; Pope &
Brucker: 91; Sacks: 89; Stovall, Muram & Wilder: 88; Wright, Duke,
Fraser & Sviland: 89). 

A parent, guardian, or advocate may request to be present during the
interview. While in some States this may be the victim's right, their
presence is generally not recommended when interviewing children who
have been sexually abused (Kivlahan, Kruse & Furnell: 92). A parent or
guardian's presence is often distracting. The parent's nonverbal reaction
to disclosed information or possible coaching may influence what the
child discloses. Also, anyone who observes the interview may become a
witness and thus may be excluded from the courtroom at a later date when
their supportive presence is needed by the child (Sorenson, Bottoms &
Perona: 97). 

The interviewer's first task is to create a safe and trusting environment in
which rapport can be established with the child. The interviewer should
introduce him or herself to the child, explain the purpose of the interview,
sit at eye level, and maintain eye contact. The child needs to be told that
she is not in any trouble. Beginning the interview with several neutral
questions will give the child time to relax and become familiar with the
interviewer. The child can be asked about favorite toys, pets, school,
friends, who they live with, the names of the people in their families, what
they like best about the people they live with, what they like to do when
they are alone, what makes them happy, sad, mad, scared, etc. (Kolilis,
1996). This will also allow the interviewer time to assess the child's
linguistic, cognitive, behavioral, and social development (Levitt: 93;
Sorenson, Bottoms & Perona: 97). 

Next, general open-ended questions, such as "Why are you here today?" or
"What were you told about coming here?", can be asked to elicit a
narrative response as the interview moves into a discussion of the abuse.
The child is asked to tell what happened and then allowed to tell the story
in his or her own words with as few interruptions as possible. Neutral
statements such as "Can you tell me more about that?" or "What happened
next?" or "What else?" will support children and encourage them to
continue. Open-ended, nonleading, neutral questions are recommended.
Direct or "yes" and "no" questions should be used only to verify or clarify
what has been shared (Levitt: 93; Sorenson, Bottoms & Perona: 97).
"Why" questions are avoided as they imply blame. The child should be
told that it is okay to respond "I don't know" or "I don't remember." 

Young children are concrete thinkers and may not know that a pronoun
refers to the subject of a previous sentence, therefore the interviewer
needs to be careful with words like "he," "she," "there," and "that" as they
may hold a different meaning or be confusing to the child. Children under
9 or 10 years are not always able to give accurate estimates of time,
distance, weight, color, or relational ties. "Why" and "when" questions
should be avoided in this age group. "When" can be answered by "Where
were you, and where was mommy or other family when it happened?" As
concrete, literal thinkers, young children may, for example, answer "no" to
the question, "Did you have your clothes on?" when they were wearing
their pajamas (Graham Walker: 97). Clarifying questions will need to be
asked For example, "So, you were naked?" "No, I had my pajamas on."
SANEs need to be knowledgeable on the developmental stages of
childhood, which are included in most pediatric nursing texts (Rollins: 95;
Sieving: 95).

Some programs use anatomical dolls or anatomical diagrams as interview
aids, while others rely on the use of children's drawings. The use of
anatomical dolls has raised controversy, and guidelines for their use has
been established (APSAC: 95). Some courts have disallowed the evidence
related to their use. Decisions to use anatomical dolls or not should be
made in conjunction with the local prosecuting attorney's office. Ceci and
Bruck (1993) reviewed the literature in the area of children's memory and
suggestibility and found children age 4 years and younger to be more
suggestible than older children. Other studies done on the use of
anatomical dolls as interview aids with children ages 3-7 have found that
the dolls increase recall accuracy with little or no increase in false reports
of genital touching (Katz et al.: 95). Anatomical dolls allow the child to
"show" rather than "tell" what happened when verbalization is difficult.
The child is told that the dolls are used to help talk about and show things
that really happened. Dolls have been found by some to be useful in
confirming the interviewer's understanding of the child's description of
the abuse and reduce the likelihood of misunderstanding (APSAC: 95). 

If anatomical dolls are used, it is essential that the interviewer be trained
in their use.

Anatomical dolls or diagrams are used by some programs to determine
what words the child uses to label body parts. It is important to know what
children call their own body parts. The interviewer goes through the
identification from head to toe and shows no surprise as the child names
the body parts. Questions like "What do you call this part?" "What is it
for?" and "Is it for anything else?" can be asked as the interviewer points
to sexual and nonsexual body parts.

If anatomical diagrams are used, they should be age, gender, and race
appropriate. After identifying and labeling all body parts, the child is
instructed to use a crayon to draw a circle around the parts of his or her
body that the person touched. The child is then asked to draw a circle on
the perpetrator diagram around the parts of his or her body that were used
to touch the child. The drawings are placed side by side, and the child is
asked to draw a line between the parts of the adult body that were marked
and the parts of the child's body that were marked and is asked to tell
what parts are being connected. The diagrams must be labeled and made a
part of the permanent record. The child signs the sheets, they are dated and
signed by the interviewer, and a notation is made that states, "words
describing body parts are the words used by the child" (Poyer: 97). 

Objectivity and a neutral response to the content of disclosure should be
maintained throughout the interview. The SANE should be comfortable
discussing sexual abuse with the child and never respond with shock or
disbelief. The child's expression of feelings, both physical and emotional,
can be elicited and supported throughout the interview by asking, "How
did that make you feel?"

In concluding the interview, the child is asked if he or she has any
questions. Questions should be answered honestly. Promises which cannot
be kept should not be made. The child should be thanked for participating
in the interview.

Written documentation of the interview process should include the
specific questions that were asked as well as verbatim answers from the
child. The child's nonverbal behavior, such as changes in facial
expression, and emotional responses are also documented. The child's
drawings are labeled. The name and title of all people present during the
interview must be recorded (Muram: 87; Paradise: 90; Tipton: 89). When
the interview is taped, the date, time, location, name of child, and name
and title of the interviewer and anyone else present must be included in
the recording. 

Caretaker Interview

The child's caretaker is interviewed individually and separately from the
child by the SANE. The caretaker is requested to provide information
about events leading up to the assault and what is known about the
incident (what, where, when, who). Complete name and address of
suspected offender, if known, relationship of the suspected offender to the
child, the child's medical history, and observed changes in the child's
behavior or physical condition should be taken as an initial assessment.
When known, the suspected offender is never present during the interview
or evaluation process. The interviewer gathers information about the
circumstances under which the caretaker first learned of the allegations
and assesses the family's reactions and support systems (Davies et al.: 96).
The SANE must also determine whether protective issues exist so that a
safe disposition can be planned for the child.

Consent, Confidentiality, and Reporting

Minor Consent

In some States, a parent or legal guardian must sign a consent giving
authorization to complete the exam, photograph injuries, collect evidence,
provide medical treatment, and release information to the proper
authorities. In other places, individual State law dictates who can consent
for a child to be examined and who can access evidence and information
in a child abuse investigation. Exceptions to parental consent exist when
the parent or legal guardian is also the suspected offender or when a
parent cannot be found and time-sensitive evidence must be collected. In
these situations, a police officer, a representative from the State children's
services or the court may authorize an exam. 

On occasion, minors present on their own, without a parent or guardian,
requesting confidential care for sexual abuse or assault. Adolescent minors
may be able to consent for themselves. It is imperative that the SANE be
aware of the specific laws in her legal jurisdiction governing minor
consent for medical and forensic care, specifically STD and pregnancy
assessment and treatment.

Even in situations where the law mandates that the consent of a parent,
guardian, or legal authority is necessary to conduct a sexual abuse/assault
evidentiary exam, the minor's consent is also always necessary to proceed
with the exam. An exam is never done against the patient's will, no matter
what age. 

Confidentiality

Medical records including photographs are protected by confidentiality
laws. In most States, parents have the right to access their child's medical
records, but not records related to police investigation. Challenges to
confidentiality often arise when the parent is the suspected offender or the
noncustodial parent demands to see the medical record and the custodial
parent refuses. Some States and SANE programs have solved this problem
by separating medical records (which includes medical history, diagnosis
or impressions, medical treatments, and medical referrals) from the
forensic investigative record (which includes anatomical descriptions of
genitals and pattern injuries, investigative interviews, and verbal history of
the assault/abuse). Other States have created laws which protect the
confidentiality of the medical record by forcing the medical provider to
lock up the forensic record and to release it only to a team member or by
protective court order. By separating the medical and forensic records, the
critical evidence of the investigation remains confidential and belongs to
the investigating law enforcement jurisdiction (Aiken & Speck: 91). When
the SANE's forensic record is considered part of an investigative record,
it is usually protected under laws that govern police investigations and is
protected until it becomes public in a legal proceeding such as discovery.
If maintained as part of the patient chart, forensic investigative records
and child maltreatment forms can be clearly marked, "denial to access" to
alert medical records personnel not to release them without a court order
or request from the investigative team. However, keep in mind when you
are designing your record system around confidentiality issues, any record
that has relevance to the court can be subpoenaed unless protected by the
court (Nass: 91). 

A team consisting of representatives from law enforcement, child
protection, the county or district attorney's office, medical institution, and
the SANE program should develop a written protocol addressing
confidentiality and consent issues that adheres to individual State laws. 

Adolescents

Since the 1970's, an increasing body of Federal and State legislation
allows minors to consent to their own medical care in the areas of sexual
and reproductive health and chemical dependency, or in cases where they
have some degree of emancipation from their parents (i.e., if they are
married, have given birth, are in the military, are living apart from their
parents, or are legally emancipated). When this legislation is called upon
to enable an adolescent to consent for his or her own care, the adolescent
alone has the right to access or release the medical records related to that
care. As of 1995, most States did not have statutes specifically enabling or
prohibiting minors' consent for sexual assault evidentiary exams (English,
Matthews, Extavour, Palamountain and Yang: 95; Dexheimer Pharris &
Ledray: 96). Given that citizens of any age may report crime without
parental consent, some SANE programs have chosen to provide primary
and secondary care to the raped adolescent who seeks screening and
prophylaxis for STDs, care of injuries, and contraceptive and pregnancy
related care under the laws that govern these categories of medical care of
adolescents. Laws governing minor consent and confidentiality vary from
State to State, and SANEs need to know the laws governing minor
consent in the jurisdictions they serve.

Adolescents consenting to their own care need to be informed by the
SANE of the limits of confidentiality. When a police report is being filed,
the adolescent should be told which information becomes part of the
public record, who will have access to it, and under what circumstances.
The SANE must also be aware of billing policies, so that adolescents can
be informed if their parents might receive an itemized bill or statement of
services provided. Whether or not the SANE involves a parent or legal
guardian will depend on the adolescent's ability to provide informed
consent, the State's laws allowing adolescents to give consent for their
own care, the adolescent's expressed desire regarding parental
involvement, and the existence of adequate post-assault support for the
adolescent (Dexheimer Pharris & Ledray: 97). 

Mandated Reporting

All States have designated mandated reporting of suspected child abuse.
In most States, health care professionals are mandated to report when their
professional service brings them into contact with a minor child whom
they suspect may be a victim of abuse by a person who is responsible for
their care, in a position of authority, or has a significant relationship (i.e.,
family member or someone living in the same home). A report may also
be mandated in situations where a sexual assault occurred as a result of
parental neglect. In some States, any criminal sexual conduct mandates a
report to the police. It is essential that all team members have a thorough
understanding of the laws governing mandatory reporting of child abuse 
and sexual assault in the legal jurisdictions they serve. Specifically, they
must know what, when, how, and where to report.

Collection of Physical Evidence

This section highlights the ways in which a pediatric exam differs from an
adult exam. Please remember that the information here should be used in
conjunction with the information regarding adult exams contained
throughout the manual. The pediatric protocols and sexual assault exam
forms for two successful SANE programs that care for children are
included in Appendix I.

Goal

The goal of the pediatric sexual assault exam is to 1) identify the child's
emotional and physical needs related to the assault, 2) collect and
document evidence following a suspected sexual contact, and 3) provide
appropriate followup health care and counseling referrals.

Components

The components of the exam include a general physical examination,
thorough examination of the oral and anogenital area, collection of
forensic evidence, screening for evidence of sexual contact such as STD
and pregnancy, prophylactic treatment to prevent STDs and pregnancy
when needed, crisis intervention and emotional support for the child and
family, and referral for followup care (Kaufhold: 93; Kivlahan, Kruse &
Furnel: 92; O'Brien: 92; Sacks: 89). 

When to Do an Evidentiary Exam

A child who presents within 72 hours of a suspected incident of sexual
abuse will immediately receive a complete evidentiary exam. The exam
will include visual inspection and collection of specimens to detect semen
and cultures for STDs as deemed appropriate per the child's reported
history. Specimens are only collected in the orifices and body surfaces
reported to have had contact with the assailant's body fluids. When
greater than 72 hours have elapsed since the last suspected incident of
abuse, an exam will be arranged as soon as convenient for the child,
family, and examiner. The nature of the exam will depend on the history
of suspected abuse and includes assessment for genital abnormalities and
cultures for STDs when indicated (American Academy of Pediatrics,
Committee on Adolescence, 94; American Academy of Pediatrics,
Committee on Child Abuse and Neglect: 91; Kaufhold: 93; Kivlahan,
Kruse & Furnell: 92; Levitt: 93; Stovall, Muram, Wilder: 88). 

In addition to a positive history of sexual contact, other factors considered
in the decision to collect evidence may include 1) nonspecific or specific
genital findings upon examination, 2) access to the victim by suspected
offender, 3) inconsistent history from child and or parents, or 4) evidence 
of acute injury. In one program, when these factors were considered, this
group was four times more likely to have definitive laboratory evidence of
assault than the group with a negative history and normal findings (Speck:
1999). 

The age of the suspected offender also needs to be considered. If the
reported offender is younger than the age of spermarche, sperm evidence
will not be found. For most boys, sperm is first produced at age 13, but
may occur as young as age 11 (Neinstein: 96).

Preparing the Child for the Exam

The child should be prepared for the evidentiary exam by explaining what
will happen in terms that the child can understand. In preparation, the
child should be shown equipment such as the colposcope, gloves, and
swabs and allowed to try them out on a stuffed animal or doll. An animal
or doll can be used to demonstrate procedures and positions that the child
will experience. This brief playtime has been shown to reduce the child's
anxiety while allowing the examiner an opportunity to assess the child's
developmental, behavioral, and emotional status. Many examiners believe
that, if possible, the exam should be completed apart from the child's
parents or guardians. Others think a parent, guardian, or support person
who has been chosen by the child to be present during the exam may
reduce the child's anxiety. Most children are content to be examined apart
from their parents, and additional historical information can then be
elicited during the exam to further clarify the details of the sexual assault.

With adequate preparation, most children will be able to relax and
participate in the evidentiary exam. Under no circumstance should a
frightened, resistant child be restrained to complete the exam. Restraint
and force, often a part of the sexual abuse experience, will only heighten
the child's fear and anxiety and intensify the psychological impact of the
abuse. The SANE may experience a rare occasion where a child's fears
cannot be calmed and he or she cannot be distracted, and yet it is felt that
an immediate exam is necessary. In these rare situations, the use of
sedation such as Versed (HCMC Pediatric Sexual Abuse Exam Protocol:
97), Diazepam, Chloral hydrate or Fentanyl (O'Brien: 92) has been
recommended.

After preparation of the child for the exam, it is re- commended that the
examiner begin with a routine, complete pediatric physical examination.
This will allow the SANE to gain the child's trust and understanding that
the anogenital exam is part of that routine exam. Sexual development
should be indicated according to the Tanner scale (Sieving: 95).

Exam Positions

The two most popular examination positions for children during
inspection of the genitalia are the supine frog leg position and the prone
knee-chest position. In the frog leg position, the child is supine on the
exam table with head elevated, hips flexed, soles of feet together and
drawn up towards the buttocks. Frightened or younger patients may be
examined in the frog leg position while sitting on a trusted person's lap
(Soderstrom: 94). The knee chest position places the child's head, chest,
and knees on the examining table while the buttocks are elevated for
visualization of the genitalia. Other positions for evaluation of the
genitalia include the lateral recumbent with knees flexed. This position
might be used when the history dictates that the assault occurred in the
prone knee chest position. Abnormalities seen in the supine frog leg or
lateral recumbent positions may disappear when the patient is inspected in
the prone knee chest position. 

When the child is ready, the SANE will carefully examine all orifices
where sexual contact is suspected. In an anogenital exam in girls, the
exam includes careful inspection of the perineum, the clitoris, the hymen,
and the anus. Careful inspection of the perineum includes inspection of
the mons, the clitoris, the labia majora, the labia minora, the vestibule, the
urethra, the hymen, the visible vaginal structures, the fossa navicularis, the
posterior fourchette, the perineal body, and the anal structures including
the verge (anocutaneous line), the pecten, the pectinate line and anal
crypts, anal papilla and rectal columns, and rectal ampullae when visible.
Visualization of the hymen can be done by applying gentle traction on the
labia majora by grasping them between the thumb and forefinger on each
side and gently pulling in an outward and downward direction. This
method should open the vulvar structures for full visualization by the
examiner. The hymen is examined for recent or past trauma, and the
diameter of both the hymenal opening and hymenal rim is noted (Levitt:
93). The physical examination of male children includes careful
inspection of the inner thighs, penis, glans, scrotum, and anus. The anus in
male and female children can be evaluated by gently separating the
buttocks and waiting for the child to relax. 

Documentation should include tanner staging and anogenital findings. All
anogenital findings must be documented completely and accurately on
genital or anal diagrams or by magnified photography. Any fresh or
healed injuries or signs of STDs are clearly described, noting color, size,
and location of any discoloration, tears, abrasions, ecchymosis, or
swelling.

Recommended Equipment

Use of a colposcope or medscope for examination of the genitalia in
pediatric cases is strongly encouraged. This equipment provides the
examiner with excellent illumination and magnification, making
clarification of detected injuries easier. Camera and video attachment
allows for the documentation of findings (Kaufhold: 93; Levitt: 93;
Soderstrom: 94). Conventional (non-colposcopic) protocols have
historically yielded positive genital findings in only 10 percent to 30
percent of cases. In reporting 4 years' experience with the colposcope in
the exam of children for possible sexual abuse, Woodling and Heger
(1986) identified lesions which would have been missed without the aid of
the colposcope in 10 percent of the cases. Myers et al. (1989) studied the
use of colposcopy in 500 females, 91 percent of whom were under age 19.
They found that colposcopy provided additional information about
physical findings not seen during visual examination of genitalia in 11.8
percent of cases (Myers, Bays, Becker, Berliner & Saywitz: 89). Teixeira
(1981) had similar findings in the colposcopic evaluation of 102 children
under 14 years of age, with the colposcope proving useful in clarifying the
diagnosis. Teixeira found colposcopic examination helpful in assessing
fimbriated hymens in children under the age of 10. In a retrospective chart
review comparing genital findings prior to program acquisition of
colposcope with findings after colposcopic examination was initiated, one
SANE program found the colposcope to not only increase detection of
microtrauma by 11 percent in children and adolescents, but it also
changed the location where most frequent injuries were detected. In girls
from birth to 12 years of age, prior to colposcopic exam initiation, the
order of most frequent areas of injury detected was 1) hymen, 2) labia
minora, 3) posterior fourchette, and 4) rectum. With the colposcope, the
order of most frequent site of injury in this age group was 1) hymen, 2)
rectum, 3) labia minora, and 4) posterior fourchette. In girls ages 13 to 17,
the order of most frequent site of injury precolposcopy was 1) hymen, 2)
posterior fourchette, 3) labia minora, and 4) cervix. With the colposcope,
that order changed to 1) hymen, 2) cervix, 3) posterior fourchette, and 4)
labia minora (O'Brien: 97).

The medscope, which is an adapted dental camera, provides photographic
documentation that has a greater depth of field than the colposcope, is less
expensive, and can be used to document injuries elsewhere on the body
(McDonald: 97). 

In the absence of the colposcope, videocolposcope, or medscope, the
standard fluorescent ring lamp with magnifying capacity of 5X is helpful
in assessing vaginal trauma (Tipton: 89). Another alternative is the use of
a 35 mm camera with a 105 mm macro 1:1 telephoto lens with an attached
flash ring (Kaufhold: 93). Hand held magnifying lenses (5X) have also
been used.

McCauley, Gorman, and Guzinski (1986) found the use of 1 percent
toluidine blue dye to increase the detection rate of posterior fourchette
lacerations from 16.5 percent to 33 percent in a pediatric sexually abused
population and from 4 percent to 28 percent in an adolescent population.
Although these findings support the use of toluidine blue dye in detecting
injuries, it is important to consider that toluidine blue dye has been found
to be spermicidal (Laufer & Souma: 82). If applied prior to the collection
of vaginal specimens, the dye may alter the evidence of motile sperm
found on a wet mount. The effect of the dye on venereal disease detection
is unknown. However, Hochmeister et al. (1997) found that neither the dye
nor the various dilutants (1 percent acetic acid or lubricants) had a
negative effect on the ability to obtain DNA profiles using either RFLP or
PCR methods of detection. Any program considering the use of 1 percent
solution of toluidine blue dye should ensure that use of the dye does not
interfere with laboratory procedures used in the detection of biological
samples (semen, sperm, saliva, blood). If collecting specimens prior to
applying the dye, the SANE must keep in mind that this may leave room
for the argument in court that the findings were made with the insertion of
speculum or swabs.

Additional recommended equipment may include Foley catheters for
better visualization of the hymen of menstruating adolescents. In rare
instances, pediatric anoscopes or speculums may be needed, however,
because of the pain involved with their insertion, they are generally used
only under general anesthesia and not in the outpatient setting. The reader
is referred to the SANE literature for guidance on the use of these tools. 

Evidence Collection Sites

Current common practice dictates that specimens for semen be collected
only from orifice and skin locations that the child indicates were involved
in any assault that occurred within the past 72 hours or according to
jurisdictional protocol. The only difference in the collection of skin, oral,
rectal, or vaginal specimens between adult and pediatric exams will be in
the case of vaginal specimens in the prepubertal girl. A speculum
examination in the prepubertal girl may be extremely painful and is not
necessary or recommended for the collection of vaginal specimens or
cultures. Speculum insertion is recommended when there is suspected
penetrating vaginal injury and bleeding from an internal source. In this
case, speculum examinations in the prepubertal child can be done under
general anesthesia (Paradise, 90). In the prepubertal girl, vaginal
specimens can be collected with a dry cotton sterile swab. Some authors
suggest a small urethral size swab be used to collect vaginal specimens
when the vaginal site is involved (Kaufhold: 93; Levitt: 93; Muchlinski,
Boonstra & Johnson: 89; Sacks: 89), however, Ledray and Netzel (1997)
have found that evidence will not be obtained as often using a small
diameter swab, especially if the fiber is not cotton. In prepubertal girls,
gonorrhea and chlamydia cultures can be obtained from the introitus
because in prepubertal girls these bacteria grow in the vaginal epithelium.

STD Testing

Baseline testing for asymptomatic prepubertal children is not
recommended except in the following circumstances: 1) the suspected
offender is known to have an STD or to be at high risk for STDs, multiple
partners, or past history of STD; 2) the child has symptoms or signs of an
STD; or 3) there is a high STD prevalence in the community (CDC: 93).
Other decisions to test for STDs should be made on an individual basis by
the SANE and may include meeting the needs of a parent who wants to be
sure no STD was transmitted. For adolescents who have been sexually
abused over time, baseline testing should follow the above guidelines,
keeping in mind that adolescents can have gonorrhea and chlamydia and
be asymptomatic. Adolescents who present for an evidentiary exam for a
one-time assault that occurred within the past 3 days are not tested for
STDs but rather treated prophylactically for gonorrhea, chlamydia, and
syphilis and referred for followup testing in 2 weeks. When testing is to be
done, it may include culturing for gonorrhea and chlamydia from the
introitus in prepubertal girls or endocervix in adolescent girls, and rectum
and throat in both boys and girls. A syphilis serology should also be
obtained, and HIV serology offered (Kaufhold: 93). A wet prep can be
done for trichomonas. Testing for gonorrhea and chlamydia should be
repeated in 2 weeks, syphilis serology in 6 to 8 weeks, and the HIV
serology in 3 months and again in 6 months. 

The practice of routine testing for STDs in asymptomatic prepubertal girls
following disclosure of sexual abuse has recently been challenged with
new information. In a study conducted at the Memphis Sexual Assault
Resource Center, only 1.4 percent of 865 prepubertal girls seen within 72
hours of assault were found to test positive for N. gonorrhea. All subjects
who tested positive were symptomatic. There were no asymptomatic
positive results. Based on this information, it has been suggested that
routine screening for gonorrhea in asymptomatic prepubertal girls is not
indicated. Re-evaluation in 2 weeks following the assault is recommended
(Muram, Speck & Dockter: 96). 

Hair Specimens

The pulling of head and pubic hair is generally no longer done in pediatric
exams. However, it is important that deleting this practice be confirmed
with the local county or district attorney and the State forensic laboratory.

Interpretation of Findings

Sexual assault examiners can expect to be called upon to testify in court
whether or not their findings are consistent with sexual assault. Much
debate has arisen over what is normal and what is abnormal in pediatric
genital findings. It is essential that a beginning Sexual Assault Nurse
Examiner train and consult with an experienced examiner. Interpretation
of findings takes both experience and knowledge. Serious consequences
can result if an inexperienced examiner assigns more or less meaning than
is appropriate to genital findings. Numerous references and guides exist to
assist SANEs in determining how to interpret and classify findings
(Adams: 97; Adams & Knudson: 96; Aiken: 90; Chadwick et al.: 89;
Girardin, Faugno, Seneski, Slaughter & Whelan: 97; Heger & Emans: 92;
Muram: 89). A classification system is only a guideline to facilitate
communication with nonmedical personnel. The following exemplar is a
classification system developed by David Muram (1989) and used by
many SANE programs for prepubertal girls:

Class 1: Normal Appearing Genitalia

Class 2: Nonspecific Findings

Abnormalities of the genitalia that could have been caused by sexual
abuse but are also often seen in girls who are not victims of sexual abuse,
e.g., inflammation and scratching. These findings may be the sequelae of
poor perineal hygiene or nonspecific infection. Included in this category
are redness of the external genitalia, increased vascular pattern of the
vestibular and labial mucosa, presence of purulent discharge from the
vagina, small skin fissures or lacerations in the area of the posterior
fourchette, and agglutination of the labia minora.

Class 3: Specific Findings 

The presence of one or more abnormalities that strongly suggest sexual
abuse can include the following findings: recent or healed lacerations of
the hymen and vaginal mucosa, hymenal opening of one or more
centimeters, procto-episiotomy (a laceration of the vaginal mucosa
extending to involve the rectal mucosa), and indentations on the vulvar
skin indicating teeth marks (bite marks). The category also includes
patients with laboratory confirmation of a venereal disease (e.g.,
gonorrhea). 

Class 4: Definitive Findings 

Any presence of sperm (Muram: 89, p. 212).

In order to communicate the meaning of their findings, SANEs should
familiarize themselves with the literature on the frequency of findings in
confirmed cases of sexual abuse for each category of the classification
system they use. For example, when testing the above classification
system, Muram (1989) found that of 31 girls who were confirmed victims
of sexual abuse, no abnormalities were detected in 29 percent and
nonspecific abnormalities were detected in 26 percent. Abnormal findings
suggesting sexual abuse (class 3) were seen in only 45 percent of the girls.
Another study reports that of 205 prepubertal girls who were victims of
sexual abuse, 32 percent had no abnormalities (class 1), 22 percent had
nonspecific findings (class 2), and 46 percent had abnormal findings (class
3) that strongly suggested sexual abuse (Aiken: 90). These studies suggest
that physical findings alone are insufficient documentation and must be
accompanied by information gleaned from a thorough history, a skilled
interview, and observation of the child's behavior (Aiken: 90). 

Antibiotics for Prevention and Treatment of STDs

In general, routine prophylactic antibiotic treatment to prevent STD in
children following the disclosure of sexual abuse is not recommended
(Giardino, Finkel, Giardino, Seidl & Ludwig: 92; Muram: 87; Paradise:
90). Prophylactic antibiotics are not recommended in the prepubertal 
population because 1) the risk of acquiring STDs is low, 2) no single
antimicrobial agent is effective against all infections, and 3) often abuse
has been ongoing over a long period of time necessitating higher antibiotic
doses than those prescribed for prophylaxis. Treatment with antibiotics
may be considered when the offender is known to have an STD, the child
is unlikely to return for followup, it is a one-time assault by a stranger, or
multiple assailants have been involved. 

The American Academy of Pediatrics, Committee on Adolescence (1994)
recommends that prophylactic antibiotics be offered to adolescents to
prevent syphilis, gonorrhea, and chlamydia. The SANE must remember
that all three of these bacterial infections can be present in an
asymptomatic adolescent and that prophylactic doses do not equal
treatment doses. If adolescent females have been infected and are not
treated, these infections pose the risk of PID with long-term consequences,
including sterility. Guidelines for prophylactic treatment for STDs
including hepatitis B, and treatment of known infection are contained in
the Sexual Transmitted Diseases Treatment Guidelines, Center for Disease
Control (1997). 

Pregnancy Risk Evaluation and Treatment 

Females who have begun menstruation will need to be evaluated for
pregnancy risk and offered postcoital contraception as described
elsewhere in this manual. For the prepubertal physically mature female
who is not yet menstruating, postcoital interception should be evaluated as
an option in consultation with the parent and supervising physician.

Psychological Considerations 

The disclosure of sexual abuse will create intense conflicting emotions
and psychological needs for the child and the family. At disclosure, the
child may experience both tremendous relief and fear. The child may feel
responsible for the disruption in the family that disclosure may bring.
Emotions that children feel at this time include shame, guilt, anger,
confusion, fear, betrayal, isolation, sadness, and fear of abandonment. At
disclosure, during the interview process and during the evidentiary exam,
the SANE and other team members can begin to address the child's
emotional needs and initiate the healing process. 

After the SANE exam, the child should be thanked for reporting the crime
and participating in the interview and exam. Children should be told that
what happened was not their fault and that their body is normal. One way
to do this is to explain the process of healing. If the child is acutely
injured, the injury should be explained, and the SANE should explain that
the child's injuries can be expected to heal because the body is normal.
Signs and symptoms of infection can be taught also. If the injury has
healed, the child may be told that the injury has already healed. If the
child has no evidence of injury, the child should be told there is no
evidence of injury. Either way the child should be told their body is
normal. Implementing the nursing process by encouraging the child to
make choices during the examination, facilitating the development of a
safety plan, and teaching personal safety techniques will give the child a
sense of power and control. 

Addressing the emotional issues will necessitate an understanding of the
child or adolescent's developmental tasks affected by the abuse or assault,
previous traumatic experiences and recovery, sources of support, and
other concurrent stressors. Older adolescents may need more individual
care in addition to support given to the entire family.

Family members will also be significantly affected by the disclosure of
sexual abuse. The impact of the abuse on the child and the family will
depend on the nature and duration of the abuse, the relationship of the
assailant to the family, the amount of support the family has, the coping
skills and stability of the family, and any recent crises the family may
have experienced. Emotions that parents and guardians may feel include
guilt for not protecting the child, anger, sadness, confusion, and
helplessness. While parents will need to have their feelings validated at
the time of disclosure, they also need a great deal of information. They
need to know what behaviors may be exhibited by their child and how to
meet her emotional needs. 

Turman and Dinsmore (1997) report the following common reactions for
children following traumatic events. Children from birth to age 2 may
react to trauma by increased clinging, crying, biting, throwing things, and
becoming agitated. Children ages 2 to 6 may re-enact the trauma over and
over, develop separation anxiety, become more withdrawn, regress in
previously mastered skills, eat less, have nightmares, or act out. Children
ages 6 to 10 typically react to trauma with difficulty concentrating, and
often report headaches, stomachaches, dizziness, loss of appetite, and
sleep disturbances. They may have trouble controlling their behavior and
their imaginative skills may lead to embellishment of the event. They also
will often show signs of regressed behavior. From ages 10 to 14, trauma
may be manifested by regression, shows of anger, mood swings, theatrical
portrayal of the traumatic event, self-judging and stigmatizing, withdrawal
from family and school, psychosomatic illnesses, and minimization of the
traumatic event in an attempt to deny it. Adolescents often respond to
trauma by becoming very critical of parental or authority figures, turning
to their parents only when severely troubled. Teens often try to deny the
assault happened and spend time behind locked doors or withdraw into
music. They also often become self-judging and suffer self-esteem issues.
Common reactions to unresolved trauma in the adolescent population
include risky sexual behavior, chemical (ab)use, running away,
depression, eating disorders, sleep disturbances, suicidality, regressed
behavior, and psychosomatic illnesses. School can be very difficult
because of the impaired ability to concentrate and alterations in peer
relationships, and students who have been sexually abused or assaulted
may need special accommodations for a period of time. Slipping behind in
school work is an additional assault on a traumatized student's fragile self
esteem. While sexual abuse or assault can be very traumatizing for youth,
it doesn't have to be. Children whose families take action to keep them
safe and show them love and understanding usually do not experience
long-term effects from the abuse.

Families need to know what steps to take next for legal, medical, and
psychological followup, and they need to know which community
resources to turn to for help in the days ahead. Assessment of the family's
needs is complex, therefore it is recommended that all families be referred
for counseling following disclosure of sexual abuse. A list of resources
available in the community should be provided for the family at the time
of the evidentiary exam. If possible, an initial appointment for followup
counseling should be made before the family leaves the clinic or
emergency room. It is also recommended that a member of the sexual
abuse team call the parent or guardian a few days following the exam to
offer additional resources or information. 

Discharge Planning

Child Protective Services

In all States, Child Protective Services (CPS) are State legislated and
mandated investigators who are responsible for devising a safety plan for
children at imminent risk for harm. The SANE must consider the potential
for harm to the child prior to their release/discharge from the SANE
program. Open communication between the SANE and the CPS
caseworker facilitates consultation and encourages involvement of the
CPS caseworker prior to releasing the child to the parents or guardian.
When there is doubt about the child's safety, she should not be released to
the parents, and the CPS caseworker or law enforcement should be
consulted in developing a safe discharge plan. The SANE must follow the
mandatory reporting protocol of the jurisdiction in which she practices
and assure safe disposition of the child. 

Medical Care

The child's care giver will need to be instructed on the care of any injuries
and given medication instructions, if applicable. Followup appointments
with the primary health care provider should be made for repeat STD
testing, if necessary, and for re-assessment of injuries. These appointments
should be scheduled for the patient's followup medical needs and will
generally follow a schedule of evaluation in 2 to 3 weeks, 3 months, and 6
months (CDC: 1993).

Other

In hospital centers, the care giver should be given telephone numbers for
the rape crisis center, victim/witness (advocacy) programs, law
enforcement, county or district attorney's office, CPS, as well as
information on crime victim compensation programs. In integrated
interdisciplinary community programs where SANEs, law enforcement,
advocacy, and counseling work together sharing information, these
professionals pick up the case immediately and contact the family with
information. 

Summary

This chapter addresses special considerations for SANE programs serving
pediatric populations. SANEs who care for children must be comfortable
interacting with children and knowledgeable of pediatric growth and
development. Pediatric SANE programs operate out of a quiet,
child-friendly environment and are designed to meet the unique needs of
children and their families. The goal of the pediatric SANE program is to
1) identify the child's emotional and physical needs related to the assault,
2) collect evidence following a suspected sexual contact, and 3) provide
appropriate followup health care and counseling referrals. SANEs must
know local laws governing the care of minors so that they can determine
in which situations law enforcement and child protection agency
involvement is mandatory and when minors can consent for their own
care. No matter what age, the patient's consent is always necessary to
proceed with an exam; patients are never forced to undergo an exam. In
child abuse exams, the interview is an essential part of the forensic
evidence collection. Studies have shown that the majority of children with
legally confirmed sexual abuse have normal or nonspecific genital
findings. It is therefore recommended that interviews be conducted by an
expertly trained professional. 

Components of the evidentiary exam include a general physical
examination, thorough examination of the oral and anogenital area,
collection of forensic evidence, and screening for evidence of sexual
contact such as STD and pregnancy when indicated. Specimens are only
collected from the orifices and body surfaces reported to have had contact
with the assailant's body fluids. A speculum is not used in examining
prepubertal girls, unless penetrating injury is suspected and then it is
usually done under general anesthesia. For adolescents, prophylactic
treatment to prevent STDs and pregnancy is recommended. Additional
supplies needed to care for a pediatric population include child-friendly
pictures and furniture, a few simple toys, crayons, drawing paper, and
equipment for magnified photography (colposcope). An ample supply of
teddy bears who may be looking for adoption is also helpful. 

CHAPTER 13  

POLICIES AND PROCEDURES

The purpose of this chapter is to provide examples of SANE program
policies and procedures for consideration or adaptation by a new SANE
program. It is anticipated that every community and program will have
unique needs, and so program policies and procedures will need to adapt.
The following policies and procedures reflect the Minnesota
hospital-based model and have common components of an integrated
community-based model. When appropriate, the policy or procedure
provided is followed by a "rationale" describing which factors were taken
into consideration when developing the policy. These examples of
hospital-based SANE policies and procedures are meant as a starting point
and as a guide. 

Consent

Policy

The SANE must obtain written consent to perform the following
activities:

--Complete an evidentiary exam. 

--Release the exam report and evidence. 

--Communicate with law enforcement (except in mandated reporting
cases). 

--Photograph (35mm, Polaroid, or video).

--Provide medication for pregnancy interception. 

--Release oral or written information to other agencies.

One program suggests that it is important that the consent form for the use
of pregnancy interception, such as Ovral, include all three options
available to the victim.

Procedure

Prior to any of the above activities, the SANE explains the SANE role to
the victim, what is to be done, and why. She asks the victim to read and
sign the appropriate consent form(s). On the pregnancy interception form,
the three options available to the victim reflect the risks associated with
both informed consent and informed refusal to take medication to prevent
a pregnancy. One option on the pregnancy interception form should
always be checked and signed by the victim. The original copy of all
consent form(s) remains with the agency record (hospital or clinic).

Rationale

The victim should always check one option on the pregnancy interception
form. This provides clear documentation of why the pregnancy
interception is or is not given. The first option would be the typical
informed consent of possible complications with agreement to take
medication for pregnancy interception, such as Ovral. The second option
would be "I understand [that because I am already taking a
contraceptive/had a tubal ligation] pregnancy prevention is not
recommended for me." The third option would be "even though pregnancy
prevention was recommended by the SANE, I (the victim) chose not to
take the medication" (Speck: 96). (See Appendix J: SANE Forms).

Court Testimony

Policy

It is understood that the SANE will respond to any subpoena regarding an
exam she has completed. She will cooperate to whatever extent possible to
make herself available to testify in court when needed. The SANE
program will pay the agreed rate of pay for a variety of activities
associated with court testimony, which may include pretrial conferences,
preparing for testimony, traveling, waiting to testify, and testifying.

Even when the nurse is no longer employed by the SANE program, she
will remain obligated to the court of jurisdiction to testify and will be paid
to do so.

Procedure

Subpoenas will be sent to the SANE office. As soon as a subpoena arrives
the SANE office secretary will contact the appropriate SANE, who will
then contact the subpoenaing attorney, usually the prosecutor's office.

Drug and Alcohol Screening (Other than for Rape Drugs)

Policy

Drug and alcohol screening may be obtained for two purposes. These are
for medical-legal liability and as crime evidence. 

Crime evidence. The SANE will ALWAYS draw two extra tubes of blood
for potential use as crime evidence. These are placed in the rape kit and
labeled "hold for alcohol/drug screen." 

Medical-legal concern. An alcohol or drug screen will ONLY be run Stat
in the ED when there is a medical-legal concern that the victim is
intoxicated and cannot be discharged without liability. 

The SANE will always document on the SANE Exam Report the presence
of other indicators of intoxication such as steady or unsteady gait;
coherent or incoherent speech; orientation or disorientation to person,
place, or time; any odor of alcohol on the breath; intact memory or lack of
memory for recent or past events; and any statements concerning drug or
alcohol use before, during, or after the sexual assault. 

Procedure

If the SANE is concerned that the victim is under the influence of
mood-altering substances that may impair her judgment to the point of
making it unsafe to discharge her from the ED, she will consult with a
physician and draw blood for drug or alcohol testing. This specimen will
be run by the ED or hospital laboratory prior to discharging the client. 

In all other cases, the blood will be placed in the rape kit for later analysis
by the crime laboratory, if necessary. In these cases where the client does
not appear intoxicated, the SANE will explain to the client that she is
drawing blood so that if the assailant attempts to say she consented to
exchange sex for drugs, or she was so intoxicated that she does not
remember consenting, there will be evidence to dispel his defense. 

Rationale

Drug and alcohol screening of sexual assault victims has historically been
controversial because this information has the potential to be used against
the victim to blame or shame her or to attempt to impugn her testimony in
court. Unfortunately, drugs and alcohol are today being intentionally used
more frequently by assailants as a weapon to overcome the resistance of a
potential victim. As we better understand this behavior, we also better
understand the necessity of obtaining blood for drug and alcohol evidence. 

When intoxication is suspected by medical personnel, the victim must be
tested prior to discharge from the ED to avoid medical-legal liability for
releasing an individual who is legally intoxicated and may be a harm to
themselves or others.

Blood is used instead of urine because of the preference of the crime lab
for analysis and storage. Be sure to check with the local crime laboratory
personnel. Drug and alcohol screens are not run routinely as they are very
expensive tests and can be run at a later time by the crime lab if the level
of victim intoxication becomes a question when the case goes to court. 

Unfortunately, in many cases, the offender will claim the victim consented
to exchange sex for drugs. A negative drug screen can be helpful to
disprove this defense. The offender may also claim the victim was so
intoxicated that she does not remember consenting. Even if she did use
drugs or alcohol, an accurate blood level can be used to corroborate her
statement. 

Evaluation of Nongenital Injuries 

Policy

When the rape victim first arrives at the ED or clinic, the ED or clinic
staff will triage for injuries. Any injuries requiring immediate treatment
will be stabilized and treated at that time. If immediate treatment is not
required, the SANE will collect evidence and document injuries prior to
referring the victim back to the ED or clinic MD for any necessary
treatment.

The SANE will consult with or refer to a physician whenever she is
concerned about the victim's medical well-being and when any of the
following are identified:

--Extensive genital trauma.

--Pregnancy. 

--Asymmetric joint swelling. 

--Head or chest trauma.

--Neurological deficits.

--Respiratory distress.

Procedure

After the SANE completes the evidentiary exam in the ED or clinic, she
will discuss the treatment and care with the staff physician. She will, at
that time, express her concerns about any physical issues and ask the
physician to further evaluate the victim prior to discharge, if necessary. If
the physician is unable to see the victim immediately, the SANE will
transfer the victim back to the ED or clinic nursing staff for supervision
until she is cleared medically. 

Rationale

Nongenital injuries inflicted during rape are generally superficial and do
not need medical intervention. In the 1 percent to 3 percent of victims
who do have emergency injuries, delay could mean the difference between
health and disability, even death. 

It is important for the SANE to develop good nursing assessment and
evaluation skills to allow her to accurately triage the victim for physical
injury. If physicians feel confident the SANE will do a thorough physical
assessment for medical sequelae and refer back to them, they will have
confidence in the SANE's role as a collaborator in providing
comprehensive care for the victim.

Evidentiary Examination Timing

Policy

A complete evidentiary exam will be completed on all sexual assault
survivors seen at a participating facility up to 36 hours (often up to 72
hours for pediatric cases) after a sexual assault. This policy may vary from
State to State and may extend to 96 hours after a sexual assault in some
States. A complete exam includes the following five components: 

1. Collection of medical-legal evidence utilizing a rape kit and following
the SANE program protocol. 

2. STD risk evaluation and prophylactic treatment.

3. Pregnancy risk evaluation and emergency interception.

4. Care and documentation of injuries.

5. Crisis intervention and followup referrals.

Post-36 hour exam. A post-36 hour exam will be completed between 36
and 72 hours (96 hours in some jurisdictions) after a sexual assault. It does
NOT include the collection of evidence in the rape kit, but may include
the collection of other physical or verbal evidence of the crime. It also
includes the following: 

--STD risk evaluation and prophylactic treatment.

--Pregnancy risk evaluation and emergency interception.

--Care and documentation of injuries.

--Crisis intervention and followup referrals. 

Post-72 hour exam. A post 72-hour exam is completed in some cases
including those with injuries that can be documented. The police should
be encouraged to bring these cases to the SANE for documentation. If the
ED or clinic staff is uncertain what the client wants or needs, they will
page the SANE who will go into the facility and make her own
determination about the needs of the victim. If there are no injuries and
the ED or clinic staff feel comfortable assessing the needs of the victim,
the SANE may not be paged. Hospital and clinic staff should always call
the SANE if there is any torn or soiled clothing for the SANE to collect as
evidence or if there is physical evidence, such as injuries, for the SANE to
document on the Sexual Assault Exam Report Form (For form see Ledray:
93b).

Any clothing, especially underpants worn directly after the assault, towels,
or bedding that may have dried semen, will be bagged for evidence even
beyond the 72-hour limit. In addition, injuries can be documented beyond
the 72-hour limit.

Procedure

When the ED or clinic staff page the SANE to report that a client has
arrived, the SANE will ask them when the assault occurred and if there
are any injuries. Based on this information, the SANE will decide if she
needs to go in, and she will let the ED or clinic staff know what she will
be doing and why.

Rationale

These exam timing recommendations are based on the likelihood of
collecting sperm and seminal fluid evidence. As DNA collection and
analysis becomes more sophisticated, this policy may change significantly
and exams may be completed for a much longer time period. Historically
rape kits were collected up to 48 hours after the assault (Green: 88). This
was based on fertility studies which defined sperm viability and presence
in the vaginal and cervical areas for up to 48 hours after intercourse. More
recent studies focusing on sexual assault evidence collection have
challenged this 48-hour rule (Speck: in press). In a sample of 1,007 rape
exams, most of the positive specimens were collected within 12 hours of
the rape. The only positive sperm specimens collected beyond 36 hours of
the rape were N=6 vaginal specimens collected in young adolescents, 16
years of age or younger (Tucker, Ledray & Werner: 90). 

Once semen has dried on clothing, it will no longer deteriorate, but may
provide positive results for weeks and even months or years after the
assault. Antibiotics can be given to prevent the transmission of syphilis,
gonorrhea, and chlamydia, and pregnancy interception can prevent a
pregnancy if given within 72 hours after sexual intercourse. However, the
sooner it is given the more reliable the results. Since prophylactic care to
prevent an STD is not recommended after 72 hours, the victim should be
referred for testing and treatment based on the results of these tests. 

Examination Sites for Evidence Collection

Policy

The history from the client is critical in directing the SANE's investigation
and evidence collection. Specimens are only collected from the orifices or
sites the adult or adolescent victim indicates were involved in the sexual
assault.

Procedure

After obtaining informed consent to conduct an examination, the SANE
will ask the victim to tell her what happened and will specifically ask what
orifices (oral, anal, or vaginal) were involved and where there might have
been ejaculation. An alternate light source will also be used to identify
where skin specimens might be collected. The SANE will then collect
specimens only from the reported orifices.

Rationale

Collection of evidence in the adult or adolescent victim is based on and
driven by the victim's consent and willingness to participate in the
investigative process (IAFN SANE Standards of Practice: 96). It is
disrespectful to assume the victim is lying and collect specimens from
orifices where she denies any contact occurred. There are also no data to
show that useful evidence has been collected from an orifice not reported
to be involved. It is very expensive and time-consuming to collect and
analyze unnecessary specimens. Collection of a positive specimen from an
additional site might even undermine the victim's credibility.

An exception to this policy would be cases in which the victim is
unconscious or has little memory of the assault possibly as a result of drug
use, voluntary or involuntary, or because the victim is incoherent or
developmentally disabled. When the victim cannot provide information on
the sites involved, the SANE should collect evidence from all orifices. By
going ahead and collecting the biological evidence so it is not lost, the
SANE is acting on what she believes is in the victim's best interest. The
other exception would be in States where collection from all orifices is
required.

HIV

Policy

The SANE will not routinely do baseline testing for HIV at the time of the
evidentiary exam. She will talk with the victim about her risk, fears, and
concerns regarding the possibility of contracting HIV. If the rape is
considered a high risk for HIV exposure, she will recommend that the
victim be tested for HIV after 3 months and again 6 months after the rape.

Prophylactic treatment for HIV is not routinely recommended or offered
due to the potential toxicidity of the medications used (e.g., zidovudine),
its high cost, and current low community HIV risk. If the case is a
high-risk case, the victim should be given information about postexposure
prophylaxis and referral information. Postexposure prophylaxis must be
decided on a case-by-case basis. If it is known, or there is good reason to
expect that the assailant was HIV positive, the victim should be referred to
the ED physician for evaluation for postexposure prophylaxis. When
utilized, it must be started as soon as possible and within 72 hours.

High-risk factors include the following: 

--Anal rape.

--Vaginal rape when other STDs are present that would threaten the
integrity of the vaginal mucosa.

--Vaginal rape with traumatic tearing injury.

--Known or suspected HIV positive offender.

--Known or suspected IV-drug use by the offender.

--Known or suspected bisexual activity of the offender.

Procedure

The SANE will determine if the rape is high risk for HIV exposure. She
will inform the victim of current community HIV transmission rates and
discuss her level of risk. She will also provide the victim with the
appropriate written literature and followup information on HIV testing
sites and safe sex practices for the victim and her sexual partner to
consider until she can be tested for HIV. When appropriate, information
on HIV postexposure prophylaxis will also be provided.

Rationale

As discussed in Chapter 11, how to best deal with the issue of HIV is
complicated and controversial (Blair & Warner: 92). Because the rates of
infection vary from State to State, so does the actual risk of infection. It is
important to evaluate the actual community prevalence of HIV before
determining the local HIV policy. Zidovudine is the current drug of choice
for health care workers exposed to the HIV virus in a needle stick incident.
However, due to its potential toxicidity, its use is not recommended when
the HIV status of the assailant is unknown in a sexual assault (Foster &
Bartlett: 89).

Holiday and Weekend Work

Policy

Each SANE will be expected to be available to take call every third
weekend and every third holiday and its associated weekend. This
includes the following holidays.

Procedure

Staff are given one white square of paper for each shift of weekend call
that they are responsible for a month. Before the scheduling begins, they
have the opportunity of accepting additional weekend shift squares from
others, or giving away their squares. Each time they take a weekend shift,
they place one square in the center of the table until all of their squares are
gone and all shifts are covered.

Interpreters

Policy

Whenever a client does not speak English or is deaf, with her permission,
an interpreter should be called, even if a family member or friend is
available to interpret. If an interpreter is not available on site, a telephone
interpreter service should be employed. The hospital where the exam is
being completed is responsible for payment of the professional
interpreter's fees. 

Procedure

As soon as the SANE determines that the client cannot speak fluent
English, she attempts to explain to the client that she wants to call for an
interpreter. If the client agrees, an interpreter is then called. She should
not begin the exam until the interpreter has arrived. The SANE will first
have the interpreter explain to the victim that all information is
confidential and that she cannot disclose anything said to anyone outside
of the room at any time without the victim's written permission or she
will lose her job. 

The interpreter should be used for all aspects of care including the
following:

--Explanation of patient's rights.

--Explanation of confidentiality.

--Obtaining informed consent.

--Explanation of exam procedures and purpose.

--Followup instructions and discharge.

The interpreter should be "debriefed" by the SANE after the victim has
left. This should include a reminder about maintaining complete
confidentiality. Resources for telephonic interpreter services are listed in
Chapter 11: SANE Program Operation, in the section entitled "Working
with Interpreters." 

Rationale

It is important to get the client's permission before calling an interpreter,
especially when the community of her nationality is small, and it might be
possible that her confidentiality could be broken by calling a local
interpreter whom she may know. It is also important, however, not to
assume that the victim will be completely honest about what happened
when a family member is present. This is especially true in cultures where
victim blaming is predominant. It is imperative to be aware of the cultural
beliefs and biases.

If the services of a particular language are used frequently, it may be
helpful to do special training with interpreters to ensure that they are
aware of the special needs of this population and to encourage them to
find ways of dealing with the impact the information may have on
themselves. When the victim is seen more than once for followup,
utilizing the services of the same interpreter for each visit is advised to
facilitate establishing rapport. Debriefing to deal with the impact of the
information on the interpreter is essential. 

Malpractice Insurance

Policy

As long as the SANE is practicing within the scope of her employment,
including work in other community hospitals to which the county has
agreed to provide services, she is covered for professional malpractice
under the provisions of the county hospital by which she is employed. She
is not required to carry her own malpractice insurance, and it is not
recommended that she do so. 

The indemnification plan protects the SANE against liability claims
resulting from her work for the county. If she should be sued, the county
will defend her in court, settle the claim, and pay the amount of any
judgment rendered. Regardless if the allegations against her are true or
false, the plan will protect her. The indemnification plan applies to any of
her actions or omissions that occur while she is an employee performing
her SANE duties, even if she has left the employment when the suit is
brought. The plan does not cover actions that are outside the scope of her
employment or which constitute criminal or unauthorized conduct.

Rationale

If the SANE is employed by a hospital or another institution, that facility
will usually provide malpractice insurance for all employees and should
also provide liability defense and indemnification coverage for the
SANEs. In this case, it is not necessary for the SANE to carry her own
malpractice insurance, and some institutional attorneys may recommend
that the SANE not carry additional insurance as that will just encourage
claims naming her personally in a law suit, and her personal insurance will
be used first to pay any claim for damages that may occur. If she is
named, the hospital that employs her will represent her. Other attorneys
may recommend the SANE always carry her own professional liability
insurance. The SANE should check with her institutional attorney and her
personal attorney before deciding if she wants or needs to carry additional
malpractice insurance. Ask to see a copy of the institution indemnification
plan. If the SANE is not covered by an institution, the hospital where she
provides service will most certainly require proof of professional liability
insurance with specified required limits before she is allowed to practice
at their facility. 

Mandatory Institutional Inservices

Policy

The SANE will be expected to attend all mandatory training for the
institutions with which the SANE program is associated. She will be paid
for her time at the training by the SANE program. These include the
following issues: CPR Training, Patient Confidentiality, Fire and Safety,
and Patient's Rights.

Procedure

The SANE director will provide the SANE with a list of times and dates
for the inservices. The SANE will make the necessary arrangements to
attend and will inform her Director when each program is completed.

Mandatory Reporting of Sexual Assaults of Vulnerable Adults and Minors

Policy

The SANE is mandated to report the sexual assault of a vulnerable adult
to adult protection services or the police. The SANE is also mandated to
report to the police or child protection services the sexual assault of a
minor by a family member, caretaker, or a person in a position of
authority over the minor, or a sexual assault that was a result of parental
neglect. In some cases, this report may already have been made prior to
the SANE's arrival. In the State of Minnesota, the SANE is NOT
mandated to report statutory rape.

Procedure

When the SANE determines that a minor or vulnerable adult meet the
reporting guidelines, she will ask for evidence that a report has already
been made. If a report has not been made, she will immediately report the
assault to the proper authority.

Rationale

It is important to confer with the institution attorney and be aware of the
State laws as well as the Federal laws. States have different laws
regulating mandatory reporting for child sexual abuse, vulnerable adults,
felony sexual assault of adults, and statutory rape. (See statutory rape
policy and procedure this chapter.)

Medication Administration

Policy

Medications to prevent a pregnancy, prevent a sexually transmitted
disease, treat minor injuries, or prevent nausea may be administered to the
victim in the ED or clinic following the established medical protocol. In
hospital-based programs, the SANE will confer with the physician on
duty. When prescribed, medications should be provided to the victim prior
to her departure from the facility as a part of the evidentiary examination
and at no additional charge.

Procedure

The SANE will meet with the client to decide what her needs and desires
are concerning pregnancy and STD prevention. The SANE will also
assess the victim's allergies and obtain a UPT. Based on the results and
following the medical protocol, the SANE will recommend a course of
action to the staff MD on duty and get the physician's signature on the
chart and on the prescription blank. The SANE will get the necessary
consent forms signed (e.g., Ovral Consent/Pregnancy Interception). She
will then obtain the medications for the client and provide her both oral
and written instructions prior to her discharge. Programs that utilize nurse
practitioners with prescriptive authority may choose to write their own
prescriptions.

Rationale

While the SANE program has an established medical protocol,
pre-approved by each participating facility or supervising physician,
SANEs do not have prescriptive authority and the MD on duty is
ultimately responsible for medical care provided, including the
administration of medications. A close working relationship and case
review is essential.

In most programs, the medication expense is included in the total
evidentiary exam charge. It is not billed separately, as some agencies do
not reimburse for medications. Programs that function as an extension of a
public health clinic may administer the medication directly and at no
additional charge through the clinic.

Noncompliant Victims

Policy

If for any reason, the victim refuses to sign the consent for treatment, or
after signing the consent form states she does not want an exam, or any
portion of the exam, the SANE will respect the client's wishes.

Procedure

The SANE will explain the purpose of the exam and process to the client,
discuss her concerns, and inform her of the use and release of the
evidence. She will then ask her to read and sign the consent form. If she
refuses to do so, the SANE will ask what her specific objection is and talk
with her about this. If she still refuses to sign, the SANE will inform her
of the consequences of her refusal (the loss of evidence and the possibility
that she will be responsible for the ED or clinic exam charges). If she
consents to parts of the exam, but not the complete exam, the SANE will
comply with her desires. 

Rationale

Informed consent is always necessary for examination and treatment. The
adult or even an adolescent has the right to refuse treatment, depending on
the State law, regardless of the desires of any parent or guardian.
However, the age limit for the adolescent varies from State to State. For
some States, the age limit is 12 years of age and up, for others 16 and up,
or 18. It is essential to consult with the institution attorney and know the
State laws. (See Appendix J: SANE Forms.)

Nonreporting Victims (Adolescent and Adult)

Policy

If the client is uncertain that she wants to report while in the ED or clinic,
the SANE will discuss her fears and concerns to help her make an
informed decision about reporting. If she is still uncertain and the rape
occurred within 36 hours, she will be encouraged to let the SANE collect
evidence so that it is not lost if she decides to report later. If she is 
certain
she does not want to report, she will be offered STD prevention and
pregnancy risk evaluation and preventive care. While the SANE will
strongly encourage the victim to exercise her right and responsibility to
report a sexual assault, the victim always has the right to make her own
decision, and that decision will be respected and honored by the SANE.
No third party report will be made except where required by State law.

Procedure

When the SANE first arrives, she will ask the victim if she has reported. If
she has not, she will ask her if she would like to do so. If she is uncertain,
reporting will be discussed and a decision made before any further action
is taken.

Rationale

While it is believed that reporting a sexual assault or attempted assault is
the right and responsibility of every victim and the only way to stop rape,
only the victim can ultimately make that decision. It is important that the
SANE understand why the victim might be reluctant to report so that she
can provide her with accurate information about reporting and better
enable the victim to make an informed decision. It is always important
that the SANE be thoroughly familiar with the laws of her State, including
any mandatory reporting statute for felony sexual assault. The resulting
responsibilities must be appropriately included in the policies and
procedures.

On-Call Schedule (Primary)

Policy

A SANE is on call, off premises, for an 8-hour period starting at 8:00 a.m.
each day. Each nurse will be assigned her own pager. Each SANE is hired
to take a predetermined number of shifts of call each month. The number
of shifts each nurse is assigned varies from SANE to SANE and is a
function of her availability and the needs of the program. Each SANE is
initially assigned an equal number of day, evening, and night shifts.
Except under unusual circumstances, no SANE will be assigned to take
more than 2 nights in a row and no more than 20 eight-hour shifts of
primary call per month. The call schedule is completed 2 weeks prior to
the end of the month at a staff meeting for the following month.

The SANE is responsible for making sure her pager is functional and that
she remains within the pager range. Under normal circumstances, the
SANE is expected to respond to the ED or clinic as soon as possible or
within a maximum of 1 hour from the time she is paged. Exceptions when
a delayed response may be necessary or acceptable are outlined under
"delayed responses."

The next working day after taking call, the SANE is responsible to report
any new cases to the office secretary including information for followup
and any additional pertinent information. The secretary will give her the
case number at that time.

While it is acknowledged that changes in the on- call schedule will need to
be made, it is important that nonemergency on-call schedule changes be
kept to a minimum due to the increased likelihood of errors occurring
when changes are made. Whenever possible, both the nurse initially
assigned and the nurse taking call for her will keep their pagers turned on.
For nonemergency on-call changes, the SANE is responsible to find her
own coverage and to call the office, answering service, and each
participating hospital with the changes. In emergency situations, the
SANE should call the office or the SANE director at home, and they will
arrange for coverage. SANEs will be paid the local nursing contract hourly
call rate for primary on-call time.

Procedure

The "poker chip" call schedule development method. Each SANE is given
a red poker chip for each evening shift for which she is responsible, a blue
chip for each day shift, and a white chip for each night shift. While
everyone is initially assigned equal numbers of day, evening, and night
shifts, periodically they are given the option of trading shifts or giving
away shifts. A record is kept by the program director. Shifts can also be
traded informally each month when the call schedule is developed.

As the call schedule is developed, the SANE puts the appropriate chip in
the center of the table for each shift she takes until all shifts are gone and
everyone has used all their chips.

Whenever the SANE goes into the ED or clinic, she will record on the
Exam Data Form the time the client arrived at the ED or clinic, the time
she was paged, and the time she arrived at the ED or clinic. The reasons
for any planned or unplanned delay exceeding the expected maximum
response time of 1 hour will also be recorded. If the delay was significant,
disruptive, or if the ED or clinic staff appeared upset by the delay, the
SANE will also call the SANE director the next morning to explain the
situation to her. Every 2 weeks, the SANE will turn in her patient records
including the Sexual Assault Data Sheet to the SANE office.

Delayed responses. Under the following circumstances, a delayed
response may be necessary or acceptable:

--When the victim is too intoxicated to consent to an exam, cooperate with
an exam, or give an accurate account of the circumstances under which it
is suspected she was raped. The SANE, in consultation with the medical
staff, will determine if the victim should be allowed to sleep in the ED
until she is more responsive, and the evidentiary exam can be completed. 

--When the medical staff decide it is in the best interest of the victim to
have x-rays or other lifesaving medical treatment completed prior to the
exam. If possible, and in concurrence with the physician, the SANE will
come in and collect the necessary evidence in the stabilization room, the
operating room, or the ICU.

--When the primary on-call SANE is busy completing a case and
must call the backup on-call SANE. The SANE should also explain this to
the staff, in case it necessitates a delay in response time.

--If the primary and backup on-call SANEs are both busy conducting
examinations when there is another case. The primary SANE should
inform the referring staff of the situation and give them an estimate of the
time a SANE can arrive. Supportive staff such as a hospital chaplain,
mental health worker, social worker, or an advocate should be contacted to
wait with the victim. She should also update the referring staff of her
situation if there is a change in her expected response time.

Whenever there is a delay in responding, the SANE should remain in
contact with the ED or clinic periodically. She should also contact the
referring agency prior to going off call to check on the victim's situation
and report the status of the case to the oncoming SANE.

On-Call Schedule (Backup)

Policy

To ensure a SANE is available should the primary SANE on call need
assistance, a second person is always on backup call. SANEs are paid half
the primary on-call rate for backup call. Everyone is expected to take the
same amount of backup call as they take of primary call. 

The backup on-call SANE is utilized at the discretion of the primary
on-call SANE. It is expected that backup will be called when two cases
come in to two different hospitals at close to the same time, and after the
SANE has completed two or more exams on one shift. If the SANE feels
comfortable with her ability to complete the work in a timely manner, she
does not have to call the backup. Whenever she feels unable to do a case,
she can choose to utilize backup.

If the primary on call SANE is unable to take call at the last minute due to
a family emergency or illness, and no one else can take the shift, the
SANE on backup call will be expected to move up to primary.

Photographs

Policy

Whenever there are injuries, the SANE will take two sets of Polaroid
pictures and one set of 35mm pictures of all injuries. Pictures of vaginal
injuries will be taken with the colposcope. All pictures will include a label
in the picture with the victim's name, date, time, and SANE's signature,
and a standardized measurement instrument to indicate the size of the
injury. Some hospitals use the patient's medical record number in place of
the patient's name. 

Procedure

One set of Polaroid pictures is placed in a sealed envelope and kept with
the client record. The second set of Polaroid pictures is placed in a sealed
envelope, which is also labeled with the client's name, date, time, and
SANE's signature, and attached to the outside of the rape kit with a
rubber band. The undeveloped roll of 35mm film is secured and labeled in
the same way and attached to the rape kit.

Rationale

Polaroid pictures are taken so the police and prosecuting attorney have a
visual presentation of the injuries when they are deciding if they can or
should charge the case. A roll of 35mm film is also taken because there
may be deterioration on the Polaroid pictures if there is a significant delay
before the case goes to court. 

Pregnancy Risk Evaluation and Emergency Interception

Policy

The SANE will evaluate the risk of pregnancy for every victim seen in the
ED or clinic. If she determines that the victim is at risk of becoming
pregnant as a result of the rape, the SANE informs the victim and explains
to her options to prevent a pregnancy.

Procedure

To determine if the victim is at risk of becoming pregnant, the SANE
should determine the following: 

--Was there vaginal-penile contact?

--Is the victim mid-cycle or are her menstrual cycles irregular?

--Is she using contraceptives or has she had a tubal ligation or
hysterectomy?

--Is she currently menopausal? 

--Is she pregnant based on the results of a UPT (urine pregnancy test)
completed in the ED or clinic?

--Does she understand how the medication being offered will prevent a
pregnancy?

If it is determined that the victim is at risk, her UPT results are negative, it
is within 72 hours of the rape, and she wants to take medication to prevent
a pregnancy from occurring, the SANE will consult with the staff MD.
With the MD's concurrence, the SANE explains the risks and has the
victim read and sign the Ovral consent form. The SANE then gives the
victim two 50 mg Ovral tablets to take immediately with Tigan 250 mg to
prevent nausea (it is best to give the Tigan about 30 minutes prior to the
Ovral and to have her eat a couple of crackers or a piece of bread). She
also gives her two additional Ovral tablets and another Tigan 250 mg to
take in 12 hours. The SANE instructs the victim to call if she becomes
nauseated and vomits within 1 hour of taking the Ovral.

Rationale

Deciding to prevent a pregnancy is a moral decision which can be made
only by the victim. In order to make an informed decision, she must know
her risk of becoming pregnant and the options to prevent a pregnancy. The
SANE has an ethical responsibility to provide the rape victim with this
information. Two programs operating at Catholic hospitals went as far as
to get special permission from the diocese to administer Ovral (Frank: 96;
O'Brien: 97).

The risk of pregnancy from a rape is the same as the risk of pregnancy
from a one-time sexual encounter. This is estimated to be 2 percent to 4
percent (Yuzpe, Smith & Rademaker: 82). It is important to always test
for pregnancy first, as 2 percent of rape victims are pregnant in the ED
and not all are aware of the pregnancy (Tucker, Ledray & Werner: 90;
Warner: 87). 

The above recommendation is the standard form of prevention (Osborn &
Neff: 89; Ledray: 92b; Hampton: 95), and it is currently offered at most
existing SANE programs. This reduces the risk of pregnancy by 60
percent to 90 percent. Programs using a low dosage ethinyl estradiol
contraceptive, give a dose equivalent to 100 mg of estrogen, 4 tablets, for
each dose (Yuzpe, Smith & Rademaker: 82). (For additional information
see Chapter 11: SANE Program Operation.)

Program Evaluation and Research

Policy

Every SANE should spend a portion of her time collecting data that will
be used in program evaluation or research activities. This is an integral
part of the SANE role, and it is an ongoing job expectation. In addition,
the SANE will bring potential program evaluation or research questions to
the attention of the SANE program director for consideration of future
systematic evaluation research. The SANE will be paid at her normal rate
of pay for her time spent on any aspect of program evaluation or research
with funds from the SANE program or another source, such as a special
grant.

The SANE program director is responsible for the development, funding,
and operation of all program evaluation and research projects. She should
delegate data collection and other evaluation research activities to
interested SANEs. While all SANEs are expected to participate in data
collection as a part of their routine client interaction, additional evaluation
research activities are optional.

The SANE program director is responsible for deciding how the results of
program evaluation research should be utilized by the SANE program.
However, all SANEs are expected to provide suggestions and input into
this process. SANEs who are interested are also encouraged to submit the
results of these special projects for publication with the director's
concurrence.

Procedure

The SANE program director should explain all evaluation research
activities to the SANEs and provide them with the necessary forms and
instructions for completion. She should also work with them to develop,
obtain funding, and implement new projects.

Rationale

The role of the SANE and the treatment of sexual assault victims is a
relatively new field. To ensure that the best possible services and
treatment options are provided, SANEs have a responsibility to do
continual program process and outcome research. SANEs cannot afford to
assume that the current practice and methodology is necessarily the "best"
way to provide services or the best services to provide victims. Only by
continually evaluating service delivery process and outcome can programs
continue to develop and grow professionally and provide even better
services to victims.

Psychiatric Inpatient/Extended Care Unit Sexual Assault Evaluation 

Policy

Whenever the staff of an inpatient psychiatric unit at a hospital served by
the SANE program determines or suspects that a psychiatric patient was
involved in sexual contact with another patient or with any other person
while on the unit, they will immediately page the on-call SANE. The
SANE will determine, in conjunction with the inpatient staff, if the SANE
examination will be conducted in the psychiatric unit or if the patient will
be transported to the usual SANE examination area. If the same situation
occurs on an extended care unit, the patient will be transported to a
contracting facility for the SANE examination.

The SANE will assess the situation when she arrives to determine the
following: 

--Was the sexual contact consensual?

--Does the patient have the ability of giving informed consent?

--Was there a possible violation of the facility's duty to protect the patient?

If the patient is a vulnerable adult, a report must be made to the police or
adult protection services. If the incident is the result of a clear case of
neglect or failure to protect on the part of the health care facility, or if the
perpetrator was an employee of the facility, the State's health care facility
regulating agency also must be informed so a proper investigation can be
conducted.

Procedure

The SANE will verify legal authorization to consent by checking the
signature on the patient's admission consent form and by checking the
chart for documentation of a designated legal guardian. If the patient is
not able to give consent, the SANE will attempt to get the proper consent.
The SANE will then assess the patient's cognitive capacity. 

If the SANE determines that the patient is coherent, she will explain her
reason for being there and inform the patient of her rights. The SANE will
then assess if the patient is aware of what happened and, if so, if the
patient considers the sexual contact consensual. With the consent of the
patient, she will complete a sexual assault evidentiary exam. A police or
adult protection report will also be made with the patient's permission or
as mandated by law. 

Rationale

A client who is not capable of giving consent for medical care is likely not
capable of giving consent for sexual contact and is thus a vulnerable adult.
Also, by virtue of her status as an inpatient, the patient is likely vulnerable
(Dexheimer Pharris & Ledray: 97).

Rape Drug Screening Rohypnol, GHB, and Others

Policy

Whenever the SANE suspects that the rape victim was drugged by
flunitrazepam (trade name Rohypnol), GHB (gamma hydroxybutyrate), or
any other "Date Rape Drug" used to incapacitate the woman, within the
previous 72 hours or less, with the victim's informed consent, the SANE
will save the first voided urine and send it to the independent laboratory
hired by Hoffman-La Roche for free confidential drug testing. In some
jurisdictions, urine collection may occur up to 96 hours post-ingestion
since some drugs, such as valium, may be detected for a longer period of
time. 

The SANE will inform the victim that the testing will be done
confidentially, identifying her only by a number, and will test for
flunitrazepam, other benzodiazepines (the family of compounds to which
flunitrazepam belongs), marijuana (cannabinoids), GHB, cocaine,
amphetamines, some opiates, barbiturates, and alcohol.

Indicators the SANE would use in making the determination of possible
rape drug use include the following: 

--A history of being out drinking with friends, having just one or two
drinks (too few to account for the high level of "intoxication"), a moment
where she recognizes feeling strange, then feeling suddenly "very drunk."
Unfortunately, she may still look normal and while a little unsteady on her
feet, she may be able to walk out of the bar with her assailant.

--Becoming very "intoxicated," very rapidly, within a matter of 5 to 15
minutes, especially after accepting a drink from someone, or drinking a
drink she left unattended.

--Waking up 8 or more hours later, uncertain if she has been raped, but
believing she may have been raped because she is experiencing vaginal
soreness, or because she has no clothes on, or waking up with a strange
man, with no memory, or a very spotty memory of what happened.

--Being told she was given "Roaches," "Roofies," "Mexican
Valium,"or "R-2."

--History of feeling or being told she suddenly appeared drunk, drowsy,
dizzy, confused, with impaired motor skills, impaired judgment, and
amnesia.

--History of "cameo appearances" in which the victim remembers
waking up, possibly seeing the assailant with her, but being unable to
move, and passing out once again.

--High school or college age, as GHB and Rohypnol abuse is more
common, but not limited to these populations, especially in Florida, Texas,
and Mexico. Unfortunately, its presence is quickly spreading across the
country and may be seen in any State.

Procedure

When the victim reports within 72 hours (96 hours in some jurisdictions)
of likely drug ingestion, the SANE will obtain the first voided, clean catch
specimen, maintaining chain-of-custody using the Sexual Assault
Laboratory Results form (See Appendix J: SANE Forms). She will
document the time of likely drug ingestion, the number of times the victim
has voided since ingestion, and any prescription medication she is
currently taking.

Rationale

According to the Drug Enforcement Agency and rape crisis centers, the
use of drugs to make a woman more vulnerable to rape has been
increasing dramatically across the United States since 1995. In addition to
alcohol, two drugs known to be used for this purpose are Rohypnol and
GHB. Rohypnol trafficking and possession cases have been identified in
36 States. Rohypnol is widely used across Europe and Latin America
where it is prescribed as a preoperative sedative and for treating insomnia.
GHB is a behavioral central nervous system depressant that actually
excites the brain into an epileptic seizure and shuts down other CNS
functions. It is used illegally by body builders and RAVE party goers.
Both drugs are powerful, fast-acting sedatives that share similar side 
effects including resulting memory loss for large periods of time. 

In 1996, Congress passed the Drug-Induced Rape Prevention and
Punishment Act, imposing up to a 20-year prison term for anyone giving
an illicit drug to another person without their consent with the intent of
committing rape. Congress increased the penalties for both trafficking in
Rohypnol and the use of Rohypnol and other controlled substances by
sexual predators. Despite the Federal law, prosecution for rape and for the
use of Rohypnol and other rape drugs continues to be handled primarily at
the State level. This law also required the Drug Enforcement Agency
(DEA) to study reclassifying Rohypnol from a Schedule IV
sedative/hypnotic to a Schedule I of the Federal Controlled Substances
Act. This reclassification is a method for providing closer control of more
dangerous drugs. The producers of Rohypnol, Hoffman-La Roche, oppose
this reclassification.  

The drug screen, completed by ElSohly Laboratories, is currently the most
economical testing available to identify flunitrazepam and other drugs.
While some individuals recommend testing by a laboratory with no
association to Hoffman-La Roche Laboratories, most hospital laboratories
cannot test for flunitrazepam, and the screen can cost in excess of $850.
Most programs do not have the funding to allow for this additional cost.
Hoffman-La Roche is paying the fees, but an independent contracted lab,
ElSohly Laboratory, is performing the tests, and ElSohly Laboratory's
work is respected in the field. Therefore, ElSohly's test results should not
be considered unreliable. However, there are a number of laboratories
across the country, including some crime labs, capable of identifying
flunitrazepam, and many large agencies have chosen not to use ElSohly
laboratories for their testing site.

Urine is used instead of blood because both Rohypnol and GHB are out of
the blood stream within 4 hours. While it is not known for certain how
long these substances can be detected in the urine, it is believed GHB can
be identified for only up to 12 hours after ingestion. Rohypnol can be
detected for 36 to 60 hours, however, identification is more likely when
the sample is collected within 36 hours after ingestion. Specimens can be
collected up to 72 hours (96 hours in some jurisdictions) because other
drugs that may have been used can be detected for a longer time period.

The above chart reflects the 1997 statistics. As of February 1998, 578
samples have been tested by ElSohly Laboratories as a part of this
program, and only five specimens have been found positive for
Flunitrazepam (Rohypnol) and 30 for GHB. 

Records

Policy

The SANE is responsible for completing all SANE records before leaving
the ED or clinic. The original copies of all hospital records are left as a
part of the hospital chart (See Appendix J: SANE Forms). These include
the following: 

--Sexual Assault Exam Report.

--Waiver of Medical Privilege and Authorization for Release of Medical
and Legal Information.

--Ovral Consent Form (when appropriate).

--Laboratory Request Forms (when appropriate).

--Critical Item Suicide Potential Assessment (when appropriate).

Forms used for internal data collection and program evaluation purposes
are returned to the SARS office (See Appendix K: SANE Evaluation
Tools). These include the following:

--SANE Data Form.

--SANE Clinical Data Sheet.

A copy of the consent for release of information and a copy of the Sexual
Assault Exam Report should be attached to the evidence provided the
police.

Procedure

The SANE completes all paperwork while in the ED or clinic, makes the
necessary copies, and attaches them to the rape kit for the police.

Rationale

It is essential that all original paperwork is completed immediately. Some
programs maintain the records in their clinic, separate from hospital
medical records, to ensure additional confidentiality.

STD Evaluation and Prevention (Other than HIV)

Policy

The SANE should not culture for any STD in the ED or clinic. If the
victim is being seen within 72 hours (96 hours in some jurisdictions) of
the rape and is at risk, the SANE will offer prophylactic treatment for
gonorrhea, syphilis, and chlamydia according to the medication protocol.
Adolescents 12 years of age and older do not need parental consent to be
treated for STDs.

Procedure

If the victim is at risk and wants treatment to prevent STDs, the SANE
determines her pregnancy status by getting a UPT, and she asks her about
allergies to medications. She then discusses the case with the ED or clinic
physician. She reminds them of the medication protocol and obtains a
prescription signed for the medication that is given to the victim. The
medication is obtained according to ED or clinic procedure and given to
the victim with instructions prior to discharge. (See Chapter 12: The
Pediatric SANE Exam, for exceptions.)

Rationale

There is no evidence that initial baseline cultures or cultures taken on
followup are useful in court, and there is data showing they are sometimes
used against the victim to suggest sexual promiscuity. As a result, these
initial ED cultures are not recommended (Ledray: 92b). Culturing is also
very expensive and time-consuming for the victim who must return for
testing, and unfortunately most victims do not return (Blair & Warner: 92).
In one study, 25 percent of the victims seen in the ED returned for the
initial STD followup visit (Ledray: 91), and in another study, only 15
percent returned. In this second study, they were able to contact 47 percent
of those who had not returned for followup, and they found an additional
11 percent of these went elsewhere for medical followup, however, only
14 percent told the physician they saw for followup about the rape
(Tintinalli & Hoelzer: 85). Most clinicians recommend prophylactic
treatment following CDC guidelines (Frank: 96; Arndt: 88;
Antognoli-Toland: 85; Tintinalli & Hoelzer: 85). If cultures are taken, they
need not be handled as evidence because they are not used in court (Blair
& Warner: 92). 

As of 1995, all States have statutes allowing adolescents to consent for
diagnosis and treatment for STDs although there is variation in the age
limit from State to State ( Dexheimer Pharris & Ledray: 97).

Statutory Rape/Teen Consenting Sex

Policy

If parents bring their teenaged daughter to the ED or clinic insisting on
having a rape exam completed to ascertain if she is sexually active, the
hospital or clinic pages the SANE on call, and she goes into the facility to
assess the situation.

After talking to the parents, the SANE talks with the teenager alone. She
informs the teenager of the statutory rape laws, the purpose for these laws,
and of her right to refuse to have an exam. The SANE then assesses if sex
occurred and, if so, when; if the sex was consenting; the age of the
partner; and if she wants to have a rape exam. If the teenager claims there
was no sex, or if she claims the sex was consenting and she does not want
an exam, the SANE does not perform an exam. If the age difference meets
the terms of the statutory rape laws, but after talking to the SANE, the
daughter still refuses the exam, no exam will be completed. 

The SANE does, however, offer treatment for STDs and pregnancy
prevention. The SANE is NOT mandated to report statutory rape in the
State of Minnesota unless the adult perpetrator is a caretaker or an adult in
a position of authority over the minor. If the sexual contact was with a
teacher, relative, counselor, teen group leader, or other person in a
caretaker position, it may fall under mandatory reporting statutes. If so,
the SANE must explain this to the adolescent and her parents and, when
appropriate, make the necessary report. The adolescent still will not be
forced to undergo examination against her will.

Procedure

The SANE first talks with the parent(s) and daughter together, then she
talks with the daughter alone. If uncertain how to proceed, the SANE
should call the SANE on backup call or the SANE program director to
discuss the case. After talking to the daughter and deciding on her
preferred course of action, the SANE staffs the case with the ED or clinic
staff, explaining her decision and rationale to them, in case the parents
decide to talk to someone else. She then explains her decision and
rationale to the parent(s). She should acknowledge their concerns about
their daughter's sexuality and talk about their other options for dealing
with their daughter's sexual activity other than a rape exam or rape
charges. The SANE always offers referrals for family counseling.

Rationale

It is important to acknowledge and plan a strategy ahead of time to deal
with the two issues involved: 

1. State and Federal statutory rape laws and the local enforcement policy.

2. Parental concern over the sexuality of an adolescent. 

Statutory rape laws have been on the books of most States for decades but
have generally not been enforced. In an attempt to reduce the number of
teenage pregnancies and lower the costs of welfare, a growing number of
policymakers are encouraging aggressive enforcement of statutory rape
laws. This move is based on the widespread belief that many of the young
mothers became pregnant as a result of coercive sex by older men, and
increased enforcement of statutory rape laws is necessary to protect them
from abuse and exploitation (Donovan: 97). Enforcement is also based on
the yet unsubstantiated belief that if these men fear they will be
prosecuted for statutory rape, they will not become sexually involved with
these minors, and the number of teenage pregnancies will thus be reduced.
As Donovan (1997) points out, however, health care providers fear that if
they are forced to report these cases as statutory rape, the teenagers will
either not seek care or not be truthful with the providers. 

This has prompted considerable public debate, and changes in the laws of
several States have already occurred. In 1996, Florida voted to make the
impregnation of a girl 16 years of age or younger by a male 21 years of
age or older a reportable form of child abuse. Recognizing the potentially
negative impact on health care, they excluded health care workers and
counselors who provide services to pregnant teenagers from the mandated
reporting requirements. California implemented a statutory rape vertical
prosecution program in 1995, which included the hiring of additional
dedicated staff. This resulted in a significant increase in the number of
statutory rape cases they charged and convicted (Donovan: 97).

The SANE must be thoroughly familiar with the pertinent Federal and
State statutes and the institutional policies and expectations (Dexheimer
Pharris & Ledray: 97). It is important to talk with the institutional
attorney, prosecuting attorney, and police about enforcement of the
statutory rape laws and the rights of an adolescent to refuse an exam. For
instance, the SANE may make a greater effort to get consent for an exam
from a 15 year old who is "dating" and is sexually active with a 25 year
old, than she would from a 15 year old who is sexually active with her 18
year old boyfriend, even though both technically meet the statutory rape
guidelines. A police report will be made by the SANE only when
mandated by law. 

It is important to acknowledge the parents' concern for their daughter and
their desire to keep her safe. It is equally important not to make a moral
judgment but rather to provide them with additional information about
other options. It may be necessary to also inform them of birth control
options to prevent pregnancy and of STD prevention. Parents struggling
with their adolescent daughter's sexual activity may benefit from a
referral for family counseling with a professional skilled in adolescent
health and sexuality issues.

Suicide Potential Evaluation

Policy

The SANE will complete a Critical Item Suicide Potential Assessment
(CISPA) form whenever the following is true:

--The victim expresses suicidal thoughts.

--The SANE is concerned that the victim may attempt to hurt herself.

--When asked, the victim confirms that she has thought of harming
herself.

--The victim has a history of suicidal thoughts or attempts.

If the CISPA score indicates that the victim is at risk, the SANE will
request an evaluation by the Crisis Intervention staff prior to discharge. If
the client refuses this referral, the identified consulting physician should
be notified and the refusal noted in the chart. The SANE will then consult
with the medical staff to determine if the victim meets the criteria for a
medical protective hold as dangerous to herself or others. If so, the SANE
will complete her exam and turn the care of the victim over to the ED or
clinic staff. The consulting physician will place a medical protective hold
on the victim. If the victim attempts to leave the facility, security must be
called to detain her.

Procedure

The SANE will ask the victim if she has thought of harming herself. When
there is any concern of immediate or potential suicide risk, the SANE will
complete the CISPA and communicate her concerns and the results of the
CISPA to the physician when she discusses the victim's case with the
physician. The original CISPA will be kept with the patient's medical
record.

Rationale

Suicide attempts are a real concern following a sexual assault and in most
cases can be prevented through appropriate recognition of risk and
prevention. Any expressed suicide thoughts must be taken seriously and
carefully evaluated. (See Appendix J: SANE Forms.) Be sure to check
with an institutional attorney and know the local State laws concerning
when a medical protective hold can be applied and by whom.

Time Cards/Time Sheets

Policy

Each SANE is responsible for completing a time sheet and a time card and
for submitting them to the SANE office secretary. Each entry will include
the date, hours worked, location, type of work (e.g., ED visit, staff
meeting, court testimony, meeting with director, community presentation,
office work, etc.) and the client number when appropriate. 

Procedure

The completed time card and time sheet will be signed by the SANE and
delivered to the office by the end of the work day (5:00 p.m.) to guarantee
payment on time.

Unavailability/Vacation

Policy

Under normal circumstances, no more than two SANEs should be on
vacation or unavailable for call at the same time. A planned absence or
unavailablitiy for 1 week or more must be approved in advance by the
SANE director.

Procedure

After speaking with the SANE director, the SANE must enter the dates of
her unavailability in the vacation book.

Unconscious Victim

Policy

If the client is unconscious and unable to sign a consent, the SANE will
attempt to contact a parent, guardian, or relative for consent to conduct an
evidentiary exam. When no appropriate parent or guardian is available,
the exam will be completed after documenting the situation and attempts
made to obtain consent. 

Procedure

The SANE will document on the patient's record the reasons for not being
able to obtain consent and the reasons for conducting an evidentiary exam
after conferring with the ED or ICU staff and/or police involved. She will
then proceed to complete an evidentiary exam and secure the evidence
collected maintaining proper chain-of-custody. When in doubt, she will
collect evidence from all orifices. When the victim regains consciousness
or an appropriate parent or guardian is located, consent will be obtained to
release the evidence to the police.

Rationale 

If biological evidence is not collected as soon as possible, it will be lost.
By going ahead and collecting the evidence, the SANE is acting on what
she believes is in the victim's best interest. The evidentiary exam is not
invasive, and it does not expose the victim to any undue risk or harm.
(While State law usually recognizes the doctrine of implied consent, it is
important to confer with the hospital or State's attorney when developing
a protocol to ensure that the SANE protocol is based on local State law.)

-------------------------------

Holidays*

New Year's Day           
Martin Luther King, Jr. Day
President's Day
Easter
Memorial Day
Independence Day
Labor Day
Veterans Day
Thanksgiving Day
Friday after Thanksgiving
Christmas Eve Day
Christmas Day
New Year's Eve

* Weekends begin Friday evening and run through Sunday night.

-------------------------------

Obtain an authorization from Hoffman-La Roche laboratories for free
testing by calling 800-608-6540. When this number is answered the
SANE will be asked to provide an identifying case number. (This may be
the SANE case number or medical record number, or a number
determined using a system of choice).

Hoffman-La Roche will fax a form with an authorization number.
Complete the form and sign it, call FedEx to pick up the specimen. If
FedEx does not arrive prior to the SANE's leaving the ED, the specimen
should be locked in the ED specimen refrigerator with the other evidence
and a chain-of-evidence form should be attached. The ED nurse will sign
that she gave the specimen to FedEx. It will be taken to the independent
laboratory, ElSohly Laboratories, with whom Hoffman-La Roche has
contracted to perform the drug screen.

-------------------------------

CHAPTER 14 

MAINTAINING A HEALTHY ONGOING PROGRAM

Maintaining a healthy work environment involves developing and
fostering a healthy effective program model and a healthy productive
staff. While SANEs report that working with sexual assault clients is a
privilege and that they are fortunate to work with this population (Ledray:
93b), they also recognize that this service is very emotionally draining
(Arndt: 88; Ledray: 92a). As a result of this work, SANEs may fear for
their own safety, fear the assailant may go after them, experience vicarious
traumatization with sexual, cognitive, and emotional impairment, or just
be physically exhausted after seeing numerous clients and serving long
hours on call (Frank: 96).

SANE Vicarious Traumatization and Burnout 

Working with victims of trauma is stressful to the caregiver and has been
recognized as a source of burnout and vicarious traumatization. Vicarious
trauma is the enduring psychological consequence of a caregiver's
exposure to the traumatic experiences of the victims for whom they care
(Schauben and Frazier: 95). Responses include a change in the caregiver's
belief that the world is safe and that people can generally be trusted. As a
result of their work, SANEs can experience symptoms of post-traumatic
stress disorder (PTSD), such as sleep disturbance, nightmares, intrusive
thoughts, easily irritated feelings, exaggerated startle response, withdrawal
from others, feelings of increased vulnerability, and emotional reactions
such as fear and anxiety (McCann & Pearlman: 90). 

The impact of continuous work with sexual assault victims goes beyond
what is typically referred to as "staff burnout." In particular, sexual assault
work affects the caregiver's sexuality and increases her awareness of the
potential for violence in her own life (Pearlman & Saakvitne: 95).

Little empirical research has specifically evaluated the impact of work
with sexual assault victims on the caregiver. Recognizing that the SANE
role, with long hours on call and working with multiple victims of severe
trauma, can be stressful to the SANE is important. No matter what
measures are taken to reduce the impact, some staff will leave as a result
of this burnout (O'Brien: 96a). Some SANEs may need to leave the
position either temporarily or permanently to reduce the stress in their
lives and maintain a healthy balance. However, better understanding
of the potential negative impact and the corresponding development of
strategies to address the consequences can reduce this costly distress and
turnover. 

In a study of both sexual assault counselors and counselors who work with
a wide variety of populations, Schauben and Frazier (1995) found that the
percentage of sexual assault victims in an individual's caseload was
associated with a disruption in his or her belief about the safety of the
world and the goodness of other people, symptoms of PTSD, and
self-reported vicarious trauma. However, the study also indicated that
work with a higher percentage of rape victims was not correlated with job
burnout or the negative effect associated with depression. In fact, the
researchers indicated that many of the caregivers in their study reported
many positive aspects of the work that they found rewarding in spite of the
heavy caseload. Counselors reported that their ability to help people in
crisis move toward recovery was a positive aspect of their work. 

Identifying Symptoms

The SANE must be aware of the typical symptoms of vicarious
traumatization in order to reduce the negative impact of work with sexual
assault victims. The SANE director should assist SANEs in recognizing
symptoms to ensure that they remain effective in their work with victims.
A SANE suffering from burnout or vicarious traumatization will be less
effective in helping the victims she sees, and without timely intervention,
she ultimately may have to take a leave of absence or leave the position.

The SANE director may choose to provide all SANEs with copies of the
PTSD Checklist and Burnout Self-Evaluation Tool included in the
appendix. She may want to encourage each SANE to complete these
evaluations annually to assist the SANE in recognizing and measuring her
current level of distress (See Appendix K: SANE Evaluation Tools). 

SANEs should recognize that stress is also associated with other areas of
the SANE's life, such as raising children, other relationships, and money
problems, not just from her work with victims. Regardless of the origin,
stress always has the potential to affect the SANE's ability to work
effectively with victims. Recognizing the stress, identifying the cause, and
taking steps to resolve or reduce the stress are critical measures in
maintaining balance and ensuring effectiveness in both the personal and
work lives of the SANE. 

Symptoms of Vicarious Traumatization or Burnout

The following boxed information lists symptoms of vicarious
traumatization or staff burnout that should be considered and evaluated.
This is not an exhaustive list. One incident of a symptom is less
significant than a newly developed pattern of symptoms. For example, a
particular SANE may always be late to meetings or be somewhat sloppy
in completing her paperwork. While that may be a problem, the SANE
director would be more concerned that these behaviors were indicative of
vicarious traumatization if an otherwise very neat SANE, who is typically
on time, changes her behavior. It would be of special concern if the change
followed a particularly difficult case or a particularly busy period.

Reducing Impact on Staff

Reducing the potential impact of working with this victim population
begins with careful screening of potential SANEs to identify and hire
those individuals with healthy boundaries and good personal support
systems. Maintaining a healthy sense of humor about the work is also
important. While individuals who do not work with victim populations
may not understand the humor, the SANE director needs to allow and
even encourage humor that is not disrespectful of the victim. 

To expect the work environment to meet all the SANE's support needs is
unrealistic. Encouraging staff to have outside interests, to take adequate
time off, and to go on vacations to renew themselves is essential. It may
even be necessary for a SANE to take an extended leave of absence. 

The SANE director should exemplify the need to take care of oneself and
to prevent vicarious traumatization. She should encourage SANEs to
nurture outside interests, especially activities that provide a physical
release and a healthy balance in life. Hobbies are important stress reducing
activities, especially hobbies that allow for a sense of completion of a task
or goal and that allow for complete disengagement from work. SANEs
need to set personal limits and maintain strong boundaries, such as not
giving their home phone numbers to victims and seeing clients only during
official duty hours. The on-call SANE should handle all emergencies.
While she may consult with the SANE who initially saw the victim in the
ED, it is not recommended to expect the same SANE to be available to
answer questions 24 hours a day, 7 days a week.

Schauben and Frazier (1995) also asked counselors working with sexual
assault victims about the strategies they used to deal with work-related
stress. The strategies used most often included seeking emotional support
from friends and family, getting advice about what to do from a colleague,
and humor. The researchers found that respondents who used these coping
strategies were less likely to use alcohol or drugs, denial, or
disengagement. Thirty-five percent of the respondents also reported that
they engaged in activities that promoted physical health, such as exercise
and eating healthy food. Meditation, being outdoors in a natural
environment, and keeping a journal were the next most frequently reported
strategies for stress reduction. Leisure activities such as going to the
movies, reading, gardening, and listening to music also were frequently
reported as helpful ways to reduce work-related stress. Getting adequate
sleep and proper nutrition are also good preventive measures.

Other measures found helpful to prevent or combat vicarious
traumatization and burnout include monthly staff meetings which
incorporate case reviews and provide debriefing and mutual support,
especially for the more distressing cases (Tobias: 90; Arndt: 88; Holloway
& Swan: 93). Sometimes it may be necessary to refer staff to a counselor
or psychologist for additional emotional support (Holloway & Swan: 93).

Providing adequate professional development and ongoing advanced
training is another important method of avoiding burnout. SANEs that are
continuing to grow and develop professionally express more job
satisfaction and are more likely to remain with the program.

Maintaining adequate SANE staffing is critical to ensuring that the stress
associated with call duty does not become excessive. Determining the
number of SANEs to hire is not an easy decision, however. If the staff is
too large, then SANEs do not see enough cases to maintain their
proficiency or income. Costs associated with payment for time spent in
staff meetings and training also rise tremendously. 

As discussed in chapter eight, when SANEs are consistently completing
two cases in a single on- call period, it may be time to reduce the on-call
hours in a shift (e.g., from 12 hours to 8 hours) and hire more SANEs.
This is more likely to occur during the first few years of program
operation when the caseload grows the most rapidly. When signs of stress
such as increased illness or dissatisfaction begin to appear, or when a
larger than usual number of unfilled shifts remain in a new on-call
schedule, it may be time to re-evaluate the number of shifts assigned to
each SANE. This should be done at a minimum every year, and every 6
months may be necessary during the first few years when the number of
victims seen is more likely to be increasing rapidly.

Program Evaluation

Program evaluation allows for a systematic assessment of program
strengths and limitations in order to improve the program service delivery
process and outcomes. The linking of program process or performance
with participant outcomes helps program staff evaluate their progress and
modify the program as appropriate. Information obtained through program
evaluation can be used by administrators or funders to make decisions
about future program goals, strategies, and options. This may include
information such as the average number of exams completed each month
or year by SANEs that can then be used to decide if it is time to consider
hiring new staff.

Ongoing program evaluation must be an integral part of every SANE
program. Evaluation is not effective as a one-time activity completed for
"outside" purposes, such as those that might be imposed by a funder.
Evaluation is much more effective as an ongoing process to answer
"internal" questions posed by program staff. Evaluation is usually
problem-focused. Its goal is often to provide information to help solve a
specific problem. When the issues and problems evaluated come from the
SANE staff, it is more likely that the results will be utilized to improve
the services delivered. Program evaluation is a tool to help staff learn what
they do well, what goals they are accomplishing, and where they could
improve in order to achieve unrealized goals. 

Formal and Informal Evaluation Strategies

Program evaluation may take the form of formal evaluation using
experimental research designs, or it may involve informal data collection
strategies. While using formal and informal evaluation strategies may
accomplish many of the same functions, formal evaluation projects tend to
utilize more rigorous methods, with larger groups and over longer periods
of time. Formal evaluations also tend to utilize standardized tools with
established reliability and validity, or they establish the reliability and
validity of measures developed prior to the implementation of the formal
evaluation.

There are three general types of program evaluation: process evaluation,
output evaluation, and outcome evaluation. Each may be accomplished
formally or informally. Appendix K includes sample program evaluation
tools that can be implemented and utilized for effective SANE program
evaluation at all levels.

Process Evaluation

This type of evaluation focuses on how program services are delivered.
Examples of process evaluation include the following:

--Sexual assault victims are surveyed and asked if it is helpful to have
the rape advocate come into the ED automatically or paged first. 

--Sexual assault victims are asked if the issue of HIV should be brought up
in the ED or at a later point in time.

--Followup telephone surveys are conducted 2 months after the assault to
see if sexual assault victims took advantage of referral information
provided to them in the ED.

--Rape victims who did not come in for counseling are called 2 months
after the assault. They are assessed for symptoms of PTSD and asked if
they are interested in coming in for counseling at this point in time. The
follow through rate with counseling visits scheduled is compiled at this
time.

--Victims are surveyed 2 weeks after the ED visit and asked about their
satisfaction with care provided by the police, hospital medical staff,
SANE, and the rape advocate.

--SANEs complete data sheets in the ED on every client seen which
provides the following information:

o The time between the victim's arrival at the ED and the SANE's arrival.

o If no police report was made prior to the SANE's arrival, whether the
SANE tried to resolve the client's fears and counsel the victim about the
importance of filing a police report. 

Output Evaluation

Output or performance evaluation assesses the amount and type of work
accomplished by the SANE program. This may include information such
as the following:

--The number of evidentiary exams completed each month.

--The number of community training programs completed.

--The number and content of phone calls from rape victims.

--The number of followup visits by rape victims or the percentage of
victims seen in the ED that return for counseling.

--The number of program brochures distributed.

--The number of public service announcements (PSAs) in the
media.

--Peer chart reviews for completeness and accuracy of documentation.

Outcome Evaluation

Outcome evaluation focuses on the results of the service delivered to the
targeted individuals or groups. When designing an outcome evaluation, it
is important to identify the target individuals or groups. Then it is
important to explicitly state what will change in the target group.
Knowledge, attitude, behavior, belief, or symptoms may be expected to
change as a result of the intervention. With sexual assault, it may be the
reduction of symptoms of PTSD. 

The results evaluated may be immediate, short-term, or long-term.

Immediate Outcome. The immediate outcomes of service may include the
following: 

--Victims who did not initially want to report the rape decide to do so after
talking with the SANE.

--Victims decide to take STD and pregnancy prevention medication.

--Independent assessment of the rape kits completed by SANEs and
nonSANEs are done to see if the correct evidence was collected, properly
documented, and the chain-of-evidence maintained.

--Peer review of the impact of SANE testimony on courtroom testimony is
gathered.

Short-Term Outcome. Short-term outcome may include the first few
weeks or months after the assault and include evaluations of the
following:

--The percentage of victims who become pregnant even though they are
provided preventive care in the ED.

--Case presentations and peer reviews.

Long-Term Outcome. Evaluations of client outcomes 1 year after the rape
and beyond are generally considered long-term evaluations. The longer
the time period between the initial contact and the evaluation followup,
the more difficult it will be to locate former victims. A smaller sample can
be expected. This smaller sample may or may not be representative of
rape victims, since those who cannot be located may be better or worse
off. Examples would include the following evaluations:

--One year anniversary telephone calls or mailed questionnaires assessing
symptoms of PTSD in clients seen for counseling and in those not seen.

--Courtroom outcomes of SANE and nonSANE cases in the area, that
would assess, for example, the proportion of guilty verdicts in the SANE
cases as compared to the nonSANE cases.

--Client satisfaction questionnaires completed 1 year after the rape that
provide feedback from clients having gone through the judicial or legal
system.

--Yearly meetings with other community agencies to evaluate their
satisfaction with the SANE program. 

--Community sexual assault felony charge rates and prosecution rates of
SANE and non-SANE cases.

Data Collection and Analysis

Evaluation data may be collected using standardized tests with established
reliability and validity. It also may be collected using informal
questionnaires developed specifically for a SANE program evaluation.
The data provided may be a simple count, an average or percentage of
cases, or it may involve sophisticated statistical analysis. Often, graphical
representations of group or individual values is extremely helpful in
understanding results.

Appendix K includes a sample of process, output, and outcome tools that
may be useful in evaluating the SANE program impact on the individual
victim and the community. Also included are evaluators' comments on the
use of the tools (See Appendix K: SANE Evaluation Tools).

Evaluation Utilization

In addition to answering questions raised by SANE staff and ultimately
improving SANE services, evaluation findings may be useful to the
SANE program in other ways. Findings may be used to convince funders
to fund new program components or continue funding for effective
programs. Community leaders who support the SANE program may want
access to the results to justify their ongoing support and to obtain the
additional support of their colleagues. The media may be interested in the
results. Other SANE programs will likely be interested in the evaluation
findings as they implement programs in their community. 

Providing the results of the SANE program evaluation data to community
organizations is useful for building the credibility and trust of the
community and of potential clients even if the results are negative or show
how the program can be improved. Ongoing program evaluation is a
characteristic of effective organizations. When community organizations
decide what programs they are going to support, they will want to see
documentation of program effectiveness.

Steps of Program Evaluation Planning

1. List the SANE program's primary goals and activities.

2. Identify problem areas, questions, or concerns.

3. Identify the outcome(s) of those individuals or groups who make use of
SANE services.

4. Formulate evaluation question(s).

5. Identify the type of information needed to answer the question(s).

6. Identify how to obtain the information.

7. Decide who will obtain the information and over what time frame.

8. Decide how the information obtained will be used.

Evolution of SANE Program Evaluation

The type and intensity of the evaluation that will be the most helpful will
evolve as the SANE program evolves. Programs and staff that are new can
benefit most from effective process evaluation. Informal, simple, process
evaluation of immediate or short-term impact will be useful to staff in
evaluating their program policies and procedures and in making early
decisions about possible changes in service delivery. Programs that are
more established may decide to implement a more elaborate victim and
system outcome evaluation component which includes both short-term
and long-term components. The SANE program can often make use of
evaluation or resource expertise at nearby universities. Sometimes a
graduate student in evaluation studies or a related field may be able to
integrate their thesis with the evaluation of the SANE program. Local
evaluation consultants may also be solicited to help the program;
sometimes they will be willing to do so pro bono. Even if external
consultants are used, the SANE director and staff should play the primary
role in creating the evaluation questions and deciding upon the outcomes
that are appropriate for their own program.

Maintaining a Healthy Ongoing Relationship with Other Agencies and
Organizations

Open communication is the most important component of maintaining a
healthy relationship with the other community agencies with which the
SANE program works. Regular formal meetings with the SANE/SART is
an effective method of maintaining open communication. 

More effort may be required to establish this communication with
agencies that are not a part of the SART, but it is no less important.
Inviting a representative to a SANE meeting where a topic of mutual
interest is discussed is one way of accomplishing this objective. Informal
meetings or lunches are another way to do the same. Making a point to
talk informally at statewide training programs and conferences is also
useful. 

It is essential that the SANE program maintains membership in
community, county, State, and national organizations that promote
ongoing collaboration. Not only is communication facilitated, but these
memberships greatly enhance the ability of the SANE program to effect
change and advance the services to victims both locally and nationally. In
addition to the local SART, target organizations might include the
following:

--State and national sexual assault coalitions.

--International Association of Forensic Nurses (IAFN) and State
chapters of IAFN when available. 

--National Organization for Victim Assistance (NOVA).

--State Nurses Association and American Nurses Association. 

--American Professional Society on the Abuse of Children (APSAC).

Summary

Maintaining a healthy staff, working cooperatively with other agencies,
and conducting ongoing program evaluation are important and necessary
components of SANE program operation. Unfortunately, all too often,
program directors who have good intentions become overwhelmed with
the expectation that they "must" do elaborate program evaluation and as a
result do none. Limitations in staff time, equipment, and resources are
real. Sometimes the decision is made to eliminate program evaluation and
measures to better train and support staff in an attempt to save these
resources. However, when staff are not adequately supported and
evaluation is not incorporated as an integral part of the SANE process, the
real result may be the waste of valuable resources.

Many of the SANE programs in existence today are operating because
nurses or physicians who visited or previously worked in hospitals with a
SANE program saw the advantages a SANE program provides to the
community-at-large (Arndt: 88). Probably the best testimony of the
efficacy of the SANE model is that communities that now have SANE
programs wonder what they did without them (Lenehan: 91). Good
evaluation will ensure that these programs continue to strengthen, grow,
and better meet the needs of the people they serve.

-------------------------------

Cognitive Impact:

--Forgetfulness.

--Trouble concentrating.

--Cynicism.

--Perfectionism.

--Apathy.

--Reduced productivity.

--Rigidity.

--Negative attitude.

--Preoccupation with trauma.

--Minimization.

--Inability to accept limitations.

--Thoughts of harm to self or others.

-------------------------------

Emotional Impact:

--Anger.

--Depression.

--Hyper vigilance.

--Anxiety.

--Irritability.

--Emotional liability.

--Crying excessively.

--Fears.

--Isolation.

--Suspiciousness.

--Numbness.

--Suicidal thoughts.

-------------------------------

Behavioral Impact:

--Alcohol or drug abuse.

--Not being available for call when scheduled.

--Excessive physical illness.

--Easily irritated.

--Sleep disturbance.

--Eating disturbance.

--Weight loss or gain when not trying to lose or gain weight.

--Inability to complete tasks on time.

--"Sloppy" completion of paperwork.

--Tardiness for meetings and taking an excessive time to get into the ED.

-------------------------------

Sexual Impact:

--Intrusive deviant sexual images.

--Deviant sexual urges.

--Trouble becoming aroused.

--Vaginismus.

--Disturbed body image.

--Inability to reach orgasm.

--Seeing deviant sexual activity as "normal."

--Identifying all sexual activity as rape.

-------------------------------

APPENDIXES

Appendix A: Project Staff and Advisory Committee

Appendix B: Participating SANE Programs     

Appendix C: Rape Kit Supply Resources

Appendix D: SANE Training Programs

Appendix E: SANE Trainers

Appendix F: Funding Resources     

Appendix G: Startup Checklist

Appendix H: Clinical Skills Competency Checklist     

Appendix I: SANE Protocols     

Appendix J: SANE Forms     

Appendix K: SANE Evaluation Tools     

[NOTE: Appendixes F--K are not included in this plain-text file.]
-------------------------------     

APPENDIX A

Project Staff and Advisory Committee

Project Staff

Linda E. Ledray, Ph.D., RN, FAAN
Principal Investigator 
Project Director and Principal Author
Director, Sexual Assault Resource Service (SARS)
Minneapolis, MN 

Kathy Simmelink, MA, RN
Project Assistant
SANE
Sexual Assault Resource Service 
Minneapolis, MN

Maggie Dexheimer Pharris, MPH, MS, RN
Project Assistant
SANE
Sexual Assault Resource Service
Minneapolis, MN

Susan Valentine
Project Office Manager 
Minneapolis Medical Research Foundation
Minneapolis, MN

Advisory Committee 

Lee Barry, JD
Assistant Hennepin County Attorney
Minneapolis, MN

Judge Isobel Gomez, JD
Hennepin County Judge
Minneapolis, MN

Thomas Kiresuk, Ph.D.
Director 
Program Evaluation Resource Center
Minneapolis, MN

Kit Mauer, BSN, RN
SANE
Midwest Childrens Resource Center
St. Paul, MN

Carolyn Levitt, MD
Medical Director
Midwest Childrens Resource Center
St. Paul, MN

Patricia Moen, JD
Director of Criminal Justice and Law  Enforcement Services 
State of Minnesota
St. Paul, MN

Colleen O'Brien, RN, MSN
Program Director
SANE/YWCA Program 
Ridgeway, WI

Patricia Speck, MSN, RN, CS, FNP
Coordinator of Nursing Services 
Memphis Sexual Assault Resource Center 
Memphis, TN

-------------------------------      

APPENDIX B

Participating SANE Programs

List of Operating SANE Programs

ALABAMA

SANE program 
c/o Rape Crisis Center 
501 N. Bishop Lane 
Mobile, AL 36608
Contact: Teresa Lynn, RN, BSN
(334) 450-2244

ALASKA

Alaska CARES
Contact: Diana Weber
4001 Dale Street, Suite 112
Anchorage, AK 99508
Phone: (907) 561-8301
Fax: (907) 561-8170

SART/SANE Program of Matanuska Valley 
c/o Valley Hospital 
Coordinator: Rita Bennett
P.O. Box 1687
Palmer, AK 99645
Phone: (907) 746-8503

South Peninsula Hospital SANE Program 
4300 Bartlett Street
Homer, AK 99603
Contact: Colleen James, RN, BSN
(907) 235-0287

ARIZONA

SARS
Tucson Rape Crisis Center 
1632 North Country Club
Tuscon, AZ 85716
Contact: Nora Gilray, RN, SANE
(520) 529-0634

CALIFORNIA

American Forensic Nurses 
255 North El Cielo Road, Suite 195 
Palm Springs, CA 92262
Contact: Faye Battiste-Otto 
Phone: (909) 796-6300
Fax: (909) 796-3007

Center for Forensic Excellence 
Contact: Darlene Bradley 
11234 Anderson Street 
Loma-Linda, CA 92354
Phone: (909) 478-8077
Fax: (909) 824-4641

Dominican Hospital SART/SANE Program 
1555 Soquel Drive 
Santa Cruz, CA 95065
Contact: Peggy Lopez, RN
Phone: (408) 462-7744     
Fax: (408) 462-7816        

County Sexual Assault Response Team 
1411 E. 31st Street 
Oakland, CA 94602
Contact: Hillary Larkin, RA 
Phone: (510) 437-8396

Napa-Soland SART Program 
1100 Trancas Street, Suite 202   
Napa, CA 34558 
Contact: Elizabeth Cassinos
Phone: (707) 226-9145

San Francisco Rape Treatment Center 
2801 A 25th St. 
San Francisco, CA 94110
Contact: Carmen Henesy, RN 
Phone: (415) 821-3222

SANE Ukiah Valley Medical Center 
275 Hospital Drive 
Ukiah, CA 95482
Contact: Karen Paoli, RN 
Phone: (707) 463-7400, ext. 1342 

SART/SANE
California Hospital Medical Center 
1401 South Grand
Los Angeles, CA 90015
Contact: Jeannie Stephenson, RN
Phone: (213) 742-5519

SART
Hanford Community Medical Center 
450 Greenfield Avenue 
Hanford, CA 93230
Contact: Georgeanne Greene, Coordinator
Phone: (209) 585-5258
Fax: (209) 585-5325

SART Palomar Pomerdo Health System 
Contact: (Ages 0-13): Diana Fuagno, RN, BSN CPN
555 East Valley Parkway 
Escondido, CA 92025
Phone: (619) 739-3444
Ages 14-Adult: Margaret Whelan, RN
15615 Pomerado Road 
Poway, CA 92064
Phone: (619) 739-3444

Sexual Assault Response Service 
Antelope Valley Hospital 
1600 West Avenue J
Annex Suite B
Lancaster, CA 93534
Contact: Sandy Darrington
Phone: (805) 723-7273 ext. 5566
Fax: (805) 949-5566

Sexual Assault Response Team (SART)
Kern Medical Center 
1830 Flower Street 
Bakersfield, CA 93305
Contact: Kris Petty, RN, SANE, or Thum, RN, SANE
Phone: (805) 326-2679

Sexual Assault Response Team (SART)
Marshall Hospital 
Marshall Way 
Placerville, CA 95667
Contact: Nancy Housel, RN, SANE
Phone: (916) 622-1441, ext. 772

Sexual Assault Response Team (SART)
Santa Barbara County Health Care Services 
300 San Antonio Road 
Santa Barbara, CA 93110
Contact: Therese McKenna, RN, SANE 
Phone: (805) 681-5468

Sexual Assault Response Team 
Santa Clara Valley Health and Hospital System 
751 S. Bascom Avenue, Bldg H-12
San Jose, CA 95128
Contact: Sandra McKinnon, Rn, NP 
Phone: (408) 885-6460

Suspected Abuse Response Team 
2180 Johnson Avenue 
San Luis Obispo, CA 93401
Contact: Maggie Nally, RN, SANE 
Phone: (805) 781-4878

Tulare District Hospital SART
821 Cherry Street
Tulare, CA 93274
Contact: Angie Zakula, RN 
Phone: (209) 688-0821

University of California Davis Medical Center 
Forensic Evaluation Team 
2315 Stockton Blvd. 
Sacramento, CA 96817 
Contact: Bill Green, MD
Phone: (916) 734-2011

Violence Intervention Program 
LAC-USC Medical Center 
1240 North Mission Road 
Los Angeles, CA 90033
Contact: Deborah Kilgore, Director
Phone: (213) 226-3961
Fax: (213) 226-2573

Western Nurse Specialists Inc. 
25809 Business Center Dr., Suite A
Redlands, CA 92373
Contact: Faye Battiste-Otto, RN, SANE, or Mary Rudolph, RN, SANE
Phone: (909) 796-6300

CANADA

Health Sciences Center Adult Emergency 
820 Sherbrook Avenue 
Winnipeg, Manitoba, Canada R3A1R9
Contact: Beth Ariss, RN
Phone: (204) 633-0886

Ontario Network of Sexual Assault Care and Treatment Centres   
c/o Women's College Hospital 
76 Grenville Street 
Toronto, Ontario, Canada M5S1B2
Contact: Sheilia McDonald
Phone: (416) 323-6400, ext. 4472

SANE Program 
Grant-MacEvan Community College
City Center Campus 
Health & Community Studies Division 
10700 - 104 Avenue 
Alberta, Canada P5J2P2
Coordinator: Elaine DeGrandpre
Phone: (403) 497-5709
Fax: (403) 497-5720

Sexual Assault Services
British Columbia Womens Center
4500 Oak Street 
Vancouver, BC Canada V6H3N1
Contact: Carolyn Dudley 
Phone: (604) 875-3284
Fax: (604) 875-3136

Sexual Treatment Center 
339 Crawford Avenue 
Windsor, Canada N9A5C6
Coordinator: Kathy McIntosh
Phone: (519) 255-2234
Fax: (519) 255-2255

Sexual Assault Treatment Program 
c/o Sudbury General Hospital 
700 Paris Street 
Sudbury, Ontario, Canada P3E3B5
Contact: Mary Carter, Coordinator
Phone: (705) 675-4743
Fax: (705) 675-4781

Surrey Memorial Hospital SANE Program 
13750 96th Avenue 
Surrey, B.C. Canada V3V1Z2
Contact: Sheila Early
Phone: (604) 581-2211 ext. 2513

Victoria Sexual Assault Service 
Royal Jubilee Hospital Victoria 
2101 Richmond Avenue 
Victoria, BC Canada V8R4R7
Contact: Sue Dean 
Phone: (604) 727-4354

COLORADO

Boulder County Rape Crisis Team
2885 East Aurora #13
Boulder, CO 80303
Contact: Judy Houchins

Memorial Hospital SANE Program 
1400 E. Boulder 
Colorado Springs, CO 80909
Contact: Sharon Stinson, RN, SANE
Phone: (719) 575-2422 or (719) 475-6820

Poudre Valley Hospital 
1024 Soth Lemay Avenue 
Fort Collins, CO 80524-3998
Contact: Susan Webster, RN 
Phone: (970) 495-7000

Pueblo Suicide Prevention & Rape Crisis Center 
1925 East Orman Avenue, Suite G-25
Pueblo, CO 81004
Contact: Shannon Richter 

SANE of Larimer County 
McKee Medical Center 
2000 Eoise Avenue 
Loveland, CO 80538
Contact: Linda Beede, FNP
Phone: (970) 203-2513

Sexual Assault Survivor, Inc.
P.O. Box 5135 
Greeley, CO 80631-0135
Contact: Nancy Raben 

DELAWARE

Medical Center of Delaware SANE Program 
4755 Ogletown-Stanton Road
Newark, DE 19718
Contact: Kathy Rainey, RN, or Peggy Humphrey, RN
Phone: (302) 733-1700

FLORIDA

NEP/Forensics 
2214 East Henry Avenue 
Tampa, FL 33610
Contact: Shirley Engleman, ARNP, Program Director
Phone: (813) 253-6000

SANE Inc. 
C/O Florida Hospital Kissimmee
200 Hilda Street 
Kissimmee, FL 34742
Contact: Pam Steioff, RN, SANE
Phone: (407) 993-6640

GEORGIA

Gwinnett Sexual Assault Resource Center 
PO Box 186 
Duluth, GA 30136
Contact: Ann Burdges, Legal Advocacy Coordinator
Phone: (770) 497-9122

Northeast Georgia Medical Center 
743 Spring Street N.E.
Gainesville, GA 30501
Contact: Cinda Anderson, RN, SANE
Phone: (770) 535-3595

SANE of N.E. Georgia 
3019 Lexington Road
Athens, GA 30605
Contact: Hillary Ruston, RN
Phone: (706) 353-1912

Southeast Georgia Forensic Nursing Service 
3100 Kemble Avenue 
Brunswick, GA 31520
Contact: Lisa Esposito 
Phone: (912) 262-3892

Southeast Georgia Regional Medical Center
161 Belle Point Parkway 
Brunswick, GA 31525
Contact: Casey Harper, RN
Phone: (912) 264-5505
Fax: (912) 262-3988

HAWAII

Hawaii Island SANE Project 
145 Uluani Street 
Hilo, HI 96720
Contact: Nancy Moser, RN
Phone: (808) 935-7141

INDIANA

Center of Hope 
St. Vincent Hospital 
2001 West 86th Street 
Indianapolis, IN 46240 
Contact: Joann Wilson, Coordinator
Phone: (317) 338-2121
Fax: (317) 338-3523

Fort Wayne Sexual Assault Treatment Center 
800 Broadway - Suite 301
Fort Wayne, IN 4680
Contact: Dawn Rice, RN, SANE
Phone: (219) 425-3333
Fax: (219) 425-3334

KANSAS

SANE/SART
Via Christi, St. Joseph Campus 
3600 East Harry 
Wichita, KS 67218
Contact: Diane Schunn, RN, BSN, SANE 
Phone: (316) 689-5252

MARYLAND

SANE
Physicians Memorial Hospital 
Box 1070
701 East Charles Street 
La Plata, MD 20646
Contact: Mary Lou Hiordahl, RN, SANE
Phone: (301) 609-4160

SANE Program
Calvert Memorial Hospital 
100 Hospital Road 
Prince Fredrick, MD 20678
Contact: Anita Efremov, RN, Clinical Coordinator 
Phone: (410) 535-8362

Sexual Assault Forensic Examiner Program
Mercy Medical Center 
Contact: Carol Kimmel, Program Coordinator
301 St. Paul Place 
Baltimore, MD 21202
Phone: (410) 332-9477

MICHIGAN

SANE Program 
C/O Emergency
Munson Medical Center 
1105 6th Street 
Traverse City, MI 49684
Contact: Paula Meyer, Director 
Phone: (616) 935-6333

Sexual Assault Nurse Examiners
Sparrow Hospital Emergency Department 
1215 East Michigan Avenue 
PO Box 30480
Lansing, MI 48909-7980
Contact: Della Hughes, RN 
Phone: (517) 483-3887

Sexual Assault Program
YMCA
24 Sheldon S.E. 
Grand Rapids, MI 49503
Contact: Sherry Arndt, RN, MP, Chief Nurse Examiner 
Phone: (616) 459-4652

MINNESOTA

Mankato Sexual Assault Access Team 
15J Hospital 
Mankato, MN 56002-8673
Contact: Kathy Smith 
Phone: (507) 389-4630
Fax: (507) 345-2926

Midwest Children's Resource Center 
360 Sherman Street, Suite 200 
St. Paul, MN 55102
Contact: Dianne McCormick, CPNP
Phone: (800) 422-0879

S.A.F.E. Program
Regina Medical Center 
1175 Nininger Road
Hastings, MN 55033
Contact: Sheri Arnett

Sexual Assault Resource Service 
525 Portland Ave. South 
Minneapolis, MN 55415
Contact: Linda Ledray, RN, PhD
Phone: (612) 347-5832
Fax: (612) 347-8751

MISSOURI

Kansas City SANE
2301 Home Street
Kansas City, MO 64108
Contact: Micky Cowdrey
Phone: (816) 454-5364
Fax: (816) 454-0431

SART Sexual Assault Response Team 
PO Box N
600 East Broadway 
Columbia Health Department 
Columbia, MO 65205
Contact: Mary Martin, RN, NP
Phone: (601) 736-2676

The Children's Mercy Hospital 
2401 Gillham Road 
Kansas City, MO 64108
Contact: Bev Arnold-Biagioli, CNS, Child Protection 
(816) 234-3000

St. Louis Children's Hospital 
400 S. Kingshighway Blvd. 
St. Louis, MO 63110
Contact: Nancy Duncan, RN, CPNP
(314) 454-6294

NEBRASKA

SANE/SART Program 
Bryan Memorial Hospital 
1600 South 48th Street 
Lincoln, NE 68506-1299 
Contact: Cindy Selig, RNC, NSN\
Phone: (402) 483-3316

NEVADA

Sexual Assault Response Program 
PO Box 669
Dayton, NV 89403
Contact: Robin Sparks, RN
(702) 885-4161

NEW HAMPSHIRE

New Hampshire/Vermont SANE Program 
RR 1 Box 384
Cornish, New Hampshire 03475
Contact: Jennifer Pierce 
Phone: (603) 675-5809
Fax: Same as above. 

NEW MEXICO

Albuquerque SANE Collaborative 
PO Box 37139
Albuquerque, NM 87176-7137
Contact: Pat Schindler, RN, SANE
Phone: (505) 266-7711

NEW YORK

Forensic Sexual Assault Examiners Inc. 
PO Box 556
Lindenhurst, NY 11757
Contact: Patricia Kelly, RN, SANE
Phone: (516) 957-1409

Rensselaer County SANE Program 
Samaritan Hospital 
2215 Burdett Avenue 
Troy, NY 12180
Contact: Ann Coonrad, Coordinator
Phone: (518) 271-3638
Fax: (518) 271-3434

Ulster County SANE Program 
c/o Office of District Attorney 
275 Wall Street 
Kingston, NY 14201
Contact: Laurel Herdman, Executive Director
Phone: (914) 339-7080
Fax: (914) 340-3185

Westchester SANE 
Victims Assistance Service
2269 Sawmill River Road 
Elmsford, NY 10523
Contact: Karen Coleman, SANE Coordinator
Phone: (614) 345-3113

NORTH CAROLINA
          
North Carolina Coalition Against Sexual Assault 
Contact: SAFE/SART Project Coordinator
174 Mine Lake Court - Suite 100
Raleigh, NC 27615
Phone: (919) 676-7611
Fax: (919) 676-1355

OHIO

SANE Program 
Blanchard Valley Regional Health Center 
145 West Wallace Street 
Findlay, OH 45840
Contact: Barb Cramer 
Phone: (419) 423-5206
Fax: (419) 423-5402

SANE/SART Project
Union County
500 Landon Avenue 
Marysville, OH
Contact: Rebecca Dillon, RN, CEN
Phone: (937) 644-3833

Summit County SANE Program 
Summa Health System 
525 East Market Street
ADM, Building Room 417 
Akron, OH 44309-2090
Contact: Renee Collette, RN, BSN, BA, CEN, SANE

OKLAHOMA

Broken Arrow Oklahoma SANE Program 
3000 South Elm Place 
Broken Arrow, OK 74012
Contact: Judy Dyke, RN NREMT-P
Phone: (918) 343-7641

Central Oklahoma Clinical Forensic Consultants Inc.
PO Box 60216
Oklahoma City, OK 73146
Contact: Robert Williamson, RN
Phone: (405) 272-0316

Forensic SANE Program 
Claremore Regional Hospital
1202 North Muskogee Place 
Claremore, OK 74017
Contact: Karen Smith, BSN
Phone: (918) 266-2632

Oklahoma City Sexual Assault Examiner Program 
P.O. Box 26307 
Room EB 319
Oklahoma City, OK 73126
Coordinator: Linda Cummins
Phone: (405) 271-5135
Fax: (405) 271-7007

Shawnee Regional Sexual Assault Nurse Examiners
1102 West MacArthur Street
Shawnee, OK 74801
Contact: Charlotte Howard, RN
Phone: (405) 878-8140

Tulsa Sexual Assault Nurse Examiners Program
c/o Tulsa Police Department 
600 Civic Center
Tulsa, OK 74113
Contact: Kathy Bell, RN 
Phone: (918) 596-7608 
Fax: (918) 596-9330

PENNSYLVANIA

Evangelical Community Hospital SANE Program
1 Hospital Drive 
Lewisburg, PA 17837
Contact: Darlene Rowe, RN, SANE
Phone: (717) 522-2657

Child Forensic Nurse Examiners 
Lenok Health Center 
21 Slocum Avenue
Tunkhannock, PA 18657
Contact: Sue Perdew, PhD, RN
Phone: (717) 836-7668

SAFE Program 
Harrisburg Hospital 
P.O. Box 8700 
Harrisburg, PA 17105
Contact: Edie Baldwin, Coordinator 
Phone: (717) 782-5713

SANE Doylestown Hospital 
595 West State Street
Doylestown, PA 18901
Contact: Patricia Vida, RN
Phone: (215) 345-2828

TENNESSEE

Chattanooga Sexual Assault Crisis and Resource Center 
300 East 8th Street 
Chattanooga, TN 37403
Contact: Cheryl Matthews, MSED
Phone: (423) 755-2720

Memphis Sexual Assault Resource Center 
1331 Union Avenue, Suite 1150
Memphis, TN 38112
Contact: Pat Speck, RNC, MSN, FNP
Phone: (901) 528-2161

"Our Kids" - Nashville 
1900 Hayes Street 
Nashville, TN 37203
Contact: Sue Ross, PNP, or Julie Rosof, ENP
Phone: (615) 862-4390 

TEXAS

CARE Team 
Dr. Leah Lamb 
Child Abuse and Evaluation      
801 7th Avenue 
Fort Worth, TX 76104
Phone: (817) 885-3953
Fax: (817) 870-7445

Hendrick Medical Center Emergency Department 1242 North 19th 
Abilene, TX 79601-2316
Contact: Connie Bowlin, RN, CEN
Phone: (915) 670-2151

Herman Hospital SANE Program 
6411 Fannin 
Houston, TX 77030
Contact: Sherry Bryan, RN, SANE, EMT-P
Phone: (713) 704-5355
Fax: (713) 704-5189

SANE Program 
Arlington Memorial Hospital 
800 West Randol Hill Road 
Arlington, TX 76102
Contact: Sandra Harris 
Phone: (817) 546-6100

SANE Program 
Department of Emergency Medicine
John Peter Smith Hospital 
1500 South Main Street 
Fort Worth, TX 76104
Contact: Dr. Audrey Jones
Phone: (817) 927-3598

SANE Program 
Emergency Services 
Harris Methodist Hospital 
1600 Hospital Parkway 
Bedford, TX 76002-6913
Contact: Karen McCurdy, RN
Phone: (817) 685-4259 

Sexual Assault Nurse Examiners Program 
Northwest Texas Hospital Health Care System 
PO Box 1110 
Amarillo, TX 79175
Contact: Jamie Ferrell, RN, SANE
Phone: (806) 354-1155
Day Harris, Resource Coordinator for ER Services 
Phone: (806) 354-1165

SANE Program of Ben Taub 
1504 Taub Loop
Houston, TX 77030
Contact: DeDe McClamrock, RN
Phone: (713) 793-2625

UTAH

Cache Valley SART
l1145 North Main
Logan, UT 84321
Contacts: Dianne Crockett and Beth Booten 
Phone: (435) 787-0000

VIRGINIA

Forensic Nurse Examiners
St. Mary's Hospital 
5801 Bremo Road 
Richmond, VA 23226
Contact: Bonnie Price, Coordinator
Phone: (281) 857-4804
Fax: (281) 285-9305
Richmond VA SART
Contact: Stacey Lasseter 
Phone: (804) 281-8574

Carilion Roanoke Community Hospital SANE Program
101 Elm Avenue SE
Roanoke, VA 24013
Contact: Melissa G. Ratcliff, RN, CEN, Coordinator
Phone: (540) 985-9887

Inova Fairfax Hospital 
3300 Gallows Road 
Falls Church, VA 22042
Contact: Sue Brown 
Phone: (703) 698-3505
Fax: (703) 280-3821

Rockingham Memorial Hospital 
235 Cantrell Avenue 
Harrisonburg, VA 22801
Contact: Linda Heatwoke, RN
Phone: (540) 433-4393

SANE Program 
Chesapeake General Hospital 
PO Box 2038
Chesapeake, VA 23320
Contact: Jeannie Leonard, RN 
Phone: (804) 482-6128

SANE Southside Regional Medical Center 
801 South Adams
Petersburg, VA 23803
Contact: Dawn Sarper, RN, SANE
Phone: (804) 862-5680

WASHINGTON

Ione Annette Arden 
Blue Mountain Medical Group 
111 South 2nd Avenue 
Walla Walla, WA 99362
Phone: (509) 522-0100

St. Peter Hospital SA Clinic 
413 Lilly Road NE
Olympia, WA 98506
Contact: Nancy Diaz 
Phone: (360) 493-4071
Fax: (509) 527-1080 

WISCONSIN

Berlin Hospital SANE Program 
225 Memorial Drive 
Berlin, WI 54923
Contact: Bonnie Manthei, RN 
Phone: (414) 498-4563

Meriter Emergency Services 
c/o SANE Program 
207 South Park Street
Madison, WI 57315
Contact: Colleen O'Brien 
Phone: (608) 267-6206

SANE Program 
St. Elizabeth ER Department 
1506 South Oneida Street 
Appleton, WI 54915
Contact: Rosemary Dvorachek, Coordinator 
Phone: (920) 738-2100 
Fax: (920) 730-5912 

SANE Program 
St. Lukes Hospital 
St. Mary's Medical Center 
3801 Spring Street 
Racine, WI 53406
Contact: Barbara Campbell, RN
Phone: (414) 636-4201

SANE St. Mary's Medical Center 
1726 Shawans Avenue 
Green Bay, WI 54303 
Contact: Marlene Scheffen 
Phone: (414) 498-4563

SANE 
St. Mary's Hospital 
1044 Kabel Avenue 
Rhinelander, WI 54501
Contact: Mary Hageny, RN 
Phone: (715) 369-6600

St. Vincent Hospital SANE Program 
PO Box 13508
Green Bay, WI 54307-3508
Contact: Paula Hafeman, RN, MSN, CEN
Phone: (414) 433-8391

Sexual Assault Treatment Center 
PO Box 0342
Milwaukee, WI 53201-0342
Contact: Marlene Putz, RN
Phone: (414) 937-5209

-------------------------------

APPENDIX C

Rape Kit Supply Resources

Sexual Assault Evidence Kit Suppliers

When seeking bids for sexual assault evidence kits, it's important to ask if
the supplier is an FDA approved packing facility. The following FDA
approved companies supply the vast majority of programs in the United
States:

Tri Tech
4019 Executive Park Blvd. S.E.
South Port, North Carolina 28461
1-800-438-7884

Sirchie Finger Print Laboratories
100 Hunter Place
Youngsville, North Carolina 27596
1-919-554-2244

Lynn Peavey
14865 W. 105th St.
Lenexa, Kansas 66219
1-913-888-0600

-------------------------------

APPENDIX D

SANE Training Programs

The following is the list of SANE training programs which accept
applications from nurses interested in attending training at their location: 

South Peninsula Hospital
4300 Bartlett Street
Homer, Alaska 99603
Colleen James, RN
907-235-0287
Once a Year: October

American Forensic Nurses 
255 North El Cielo Road
Suite 195
Palm Springs, CA 92262
Faye Battiste-Otto, RN
760-779-2280 (pager)
909-796-6300
Twice a Year: Spring and Fall

Palomar Pomerado Health System
15615 Pomerado Road
Poway, CA 92064
Diana Faugno, RN, BCFE
760-739-3444
Once a Year: Winter
Mock Trial Training: May

Forensic Nursing Specialists
P.O. Box 2512
Santa Cruz, CA 95063
Sandra Goldstein, MS, RN
408-465-9826

SANE/SART Program
Via Christi Medical Center
3600 East Harry
Wichita, KS 67218
Diana Schunn, RN
316-689-5252
Once a Year

Mercy Safe Program
Mercy Medical Center
St. Paul Place
Baltimore, MD 21202
Carole Kimmell, RN
410-332-9499
Once a Year: September

University of North Carolina Hospitals
Department of Emergency Medicine
CB 7594
Chapel Hill, North Carolina 27599
Susan Hohenhaus, RN, CEN
919-966-1088
Twice a Year: January and July

Tulsa Sexual Assault Nurse Examiner Program
Tulsa Police Department
600 Civic Center
Tulsa, OK 74103
Kathy Bell, RN
918-596-7608
Two or Three Times per Year

Memphis Sexual Assault Resource Center
2675 Union Avenue Extended
Memphis, TN 38112
Pat Speck, MS, RN
901-272-2020
Advanced Training Only

Texas Office of the A.G.
Sexual Assault Prevention & Crisis Services Division
P.O. Box 12548
Austin, TX 78711
Jamie Ferrell, SANE Program Director
512-936-1661
Scheduled based on community readiness/needs

INOVA SANE Program
INOVA Fairfax Hospital
3300 Gallows Road
Falls Church, VA 22042-3300
Sue Brown, RN, BSN
703-698-3505
Once a Year: End of March

YWCA/SANE Program
c/o Meriter Emergency Services
202 Park Street
Madison, WI 53715
Colleen O'Brien, RN, MS
608-267-6000 Ext. 7063
Once a Year: First Week in May

-------------------------------

APPENDIX E

SANE Trainers

Following is the list of SANE Trainers who are available to provide
training at the time and location of your choice:

Sherry Arndt, RN, MPA
Forensic Nursing Services
Prairie Division
RR 1 - Box 171
Comfrey, MN 56019-9713
507-877-3663

Faye Battiste-Otto, RN
American Forensic Nurses
255 North El Cielo Road
Suite 195
Palm Springs, CA 92262
760-779-2280 (pager)
909-796-6300

Kathy Bell, RN
Tulsa Sexual Assault Nurse Examiner Program
Tulsa Police Department
600 Civic Center
Tulsa, OK 74103
918-596-7608

Sue Brown, RN, BSN
INOVA SANE Program
INOVA Fairfax Hospital
3300 Gallows Road
Falls Church, VA 22042-3300
703-698-3505

Diana Faugno, RN, BCFE
Palomar Pomerado Health System
15615 Pomerado Road
Poway, CA 92064
760-739-3444

Jamie Ferrell, RN, BSN, CEN, SANE
1306 Buena Vista
Amarillo, TX 79106
512-936-1661

Sandra Goldstein, MS, RN
Forensic Nursing Services
P.O. Box 2512
Santa Cruz, CA 95063
408-465-9826

Susan Hohenhaus, RN, CEN
University of North Carolina Hospitals
Department of Emergency Medicine
CB 7594
Chapel Hill, NC 27599
919-966-1088

Colleen James, RN
South Peninsula Hospital
4300 Bartlett Street
Homer, Alaska 99603
907-235-0287

Linda E. Ledray, PhD, RN, FAAN
Professional Resource Service
Foshay Tower
Suite 1108
821 Marquette Avenue South
Minneapolis, MN 55402
612-889-0889

Diana Schunn, RN
SANE/SART Program
Via Christi Medical Center
3600 East Harry
Wichita, KS 67218
316-689-5252

-------------------------------

BIBLIOGRAPHY

Abbott, P. 1997. Same sex assault. Minnesota Coalition Against Sexual
Assault Training Manual. Minneapolis, MN: Minnesota Coalition Against
Sexual Assault.

American College of Gynecologists (ACOG). 1996. Evidence-based
guidelines for clinical issues in obstetrics and gynecology. Practice
Patterns.

Adams, J. A. 1997. Sexual abuse and adolescents. Pediatric Annals 26:5,
299-305.

Adams, J. A. and Knudson, S. 1996. Genital findings in adolescent girls
referred for suspected sexual abuse. Archives of Pediatric Adolescent
Medicine 150: 850-857.

Adams, J. A., Harper, K., Knudson, S., and Revilla, J. 1994. Examination
findings in legally confirmed child sexual abuse. It's normal to be
normal. Pediatrics 949:3:310-317.

Agger, I. 14-20 June 1987. The female political prisoner: A victim of
sexual torture. Presented at the Eighth World Congress for Sexology,
Heidelberg/FRG.

Aiken, Margaret M. 1990. Documenting sexual abuse in prepubertal girls.
MCN 15:176-177.

----. 1993. False allegation: A concept in the context of rape. Journal of
Psychosocial Nursing 31:11.

Aiken, Margaret M. and Speck, Patricia. 1991. Confidentiality in cases of
rape: A concept reconsidered. Journal of Clinical Ethics 2:1.

American Academy of Pediatrics. Committee on Child Abuse and
Neglect. 1991. Guidelines for the evaluation of sexual abuse of children.
Pediatrics 86:2.

----. November 1994. Sexual assault and the adolescent. Pediatrics 94.

American Professional Society on the Abuse of Children (APSAC). 1995.
Practice Guidelines: Use of Anatomical Dolls in Child Sexual Abuse
Assessment. Chicago, Ill: APSAC.

A message to grantseekers. 1997. http://fdncenter.org/2onlib/2ufgall.html.

Anglin, Deirdre, Spears, Kelvin, and Hutson, H. Range. April 1997.
Flunitrazepam and its involvement in date or acquaintance rape. Academy
of Emergency Medicine 4:4.

Antognoli-Toland, Paula. May/June 1985. Comprehensive program for
examination of sexual assault victims by nurses: A hospital-based project
in Texas. Journal of Emergency Nursing. 11:3.

Arndt, Sherry. October 1988. Nurses help Santa Cruz sexual assault
survivors. California Nurse.

Bell, Kathy. July, August, September 1995. Tulsa Sexual Assault Nurse
Examiners program. The Oklahoma Nurse.

----. 26 November 1996. Personal communication.

Blair, Tina M.H. and Warner, Carmen Germaine. 1992. Sexual assault.
Topics in Emergency Medicine 14:4.

Bobak, Irene M. 1992. Violence against women. Maternity and
Gynecologic Care. Chapter 43.

Bowyer, Lucy and Dalton, Maureen E. May 1997. Female victims of rape
and their genital injuries. British Journal of Obstetrics and Gynaecology
104, 617-620.

Brownmiller, Susan. 1975 Against Our Will: Men, Women, and Rape.
New York: Simon and Schuster.

Buchanan, A. E. and Brock, D. W. 1989. Deciding for Others: The Ethics
of Surrogate Decision Making. New York: Cambridge University Press. 

Burgess, Ann W. and Fawcett, Jacqueline. April 1996. The
comprehensive sexual assault assessment tool. Nurse Practitioner 21:4.

Burgess, Ann W. and Holmstrom, Linda L. May-June 1974 (A). Crisis
and counseling requests of rape victims. Nursing Research 23:3.

----. September 1974 (B). Rape trauma syndrome. American Journal of
Psychiatry 131:9.

Carpenter, C. C., Fischl, M.A., and Hammer, S. M. et al. 1996.
Antiretroviral therapy for HIV infection in 1996: Recommendations of an
international panel. Journal of the American Medical Association
276:146-154.

Cartwright, Peter S., Moore, Royanne A., Anderson, Jean R., and Brown,
Douglas, H. 1986. Genital injury and implied consent to alleged rape.
The Journal of Reproductive Medicine.

Ceci, S. J. and Bruck, M. 1993. Suggestibility of the child witness: A
historical review and synthesis. Psychological Bulletin 113:403-439.

Center for Cross-Cultural Health. 1997. Caring Across Cultures: The
Provider's Guide to Cross-Cultural Health Care. Minneapolis, MN: The
Center for Cross-Cultural Health.

Centers for Disease Control and Prevention. 1993. Sexual transmitted
diseases treatment guidelines. MMWR 42:1-102.

----. 1997. SexuallyTransmitted Diseases Treatment Guidelines.
Atlanta, Ga.: CDC.

Chadwick, D. L., Berkowitz, C. C., Kerns, D. et al. 1989. The Color Atlas
of Child Abuse. St. Louis: CV Mosby. 

Davies, Anne. 1978. A preliminary investigation using p-Nitrophenyl
Phosphate to Quantitate Acid Phosphatase on swabs examined in cases of
sexual assault. Medical Science Law 18:3.

Davies, D., Cole, J., Albertella, G., McCulloch, L., Allen, K., and
Kekevian, H. 1996. A model for conducting forensic interviews with
child victims of abuse. Child Maltreatment 1:3, 189-199.

DeJong, A. R. and Rose, M. 1991. Legal proof of child sexual abuse in
the absence of physical evidence. Pediatrics 88:3.

Dexheimer Pharris, Margaret. 1995. Adolescent suicide, Chapter 21,
Nursing Care of Infants and Children, 5th ed., eds. Whaley and Wong.
St. Louis, MO: Mosby.

Dexheimer Pharris, Margaret and Ledray, Linda E. 1997. Consent and
confidentiality in the care of the sexually assaulted adolescent. Journal of
Emergency Nursing 23:3.

DiNitto, Diana, Martin, Patricia Yancey, Norton, Diane Blum, and
Maxwell, Sharon M. May 1986. Who should examine rape survivors.
American Journal of Nursing 86:5.

Donnelly, D. A. and Kenyon, S. 1996. Honey, we don't do men. Gender
stereotypes and the provision of services to sexually assaulted males.
Journal of Interpersonal Violence 11:3.

Donovan, Patricia. January/February 1997. Can statutory rape laws be
effective in preventing adolescent pregnancy? Family Planning
Perspectives 29:1.

Draguns, Juris G. 1996. Ethnocultural considerations in treatment of
PSTD: Therapy and service delivery, Ethnocultural Aspects of
Posttraumatic Stress Disorder, eds. Marsella, Friedman, Gerrity &
Scurfield. Washington, D.C.: American Psychological Association.

Dunnuck, Chris. 25 November 1996. Personal communication.

Emans, S. J., Laufer, M.R., and Goldstein, O. P., Eds. 1998. Chapter 20:
Sexual abuse. Pediatric and Adolescent Gynecology. 4th Ed.
Philadelphia: Lippincott-Raven, 751-794.

ENA. 1991. Sexual assault nurse examiner resource list. Journal of
Emergency Nursing 17:31-35A.

English, A., Matthews, M., Extavour, K., Palamountain, C., and Yang, J.
1995. State Minor Consent Statutes: A Summary. Cincinnati: Center for
Continuing Education in Adolescent Health.

Enos, W. F. and Beyer, J. C. April 1980. Prostatic acid phosphatase,
aspermia, and alcoholism in rape cases. Journal of Forensic Sciences 25:2.

Erb, S. 1996. Disabled women and rape. Rape Crisis Advocate Training
Manual. Houston, TX: Houston Drug Action Council Rape Crisis
Program.

Federal Register, The. 14 February 1997. Final program guidelines,
Victims of Crime Act FFY 1997 Victim Compensation Program. 

Ferrell, J. 25 September 1997. Personal communication.

Foa, Edna B. 1997. Trauma and women: Course, predictors, and
treatment. Journal of Clinical Psychiatry 58:9.

Foster, I. and Bartlett, John G. 18 November 1989. Rape and subsequent
seroconversion to HIV. British Medical Journal 299.

Frank, Christina. December 1996. The new way to catch rapists. Redbook.

Gaffney, D. 5, 6, 13, and 14 June 1997. Sharing our caring: Development
of a sexual assault nurse examiner team. Columbia University School of
Nursing--Forensic Nursing Specialty.

Geissler, E. M. 1993. Pocket Guide to Cultural Assessment. St. Louis,
MO: Mosby.

Geist, Richard F. August 1988. Sexually related trauma. Emergency
Medicine Clinics of North America 6:3.

Giardino, A. P., Finkel, M. A., Giardino, E. R., Seidl, T., and Ludwig, S.
1992. A Practical Guide to the Evaluation of Sexual Abuse in the
Prepubertal Child. St. Louis, MO: Sage Publications.

Girardin, Barbara W., Faugno, Diana K., Seneski, Patty C., Slaughter,
Laura, and Whelan, Margaret. 1997. Color Atlas of Sexual Assault. St.
Louis, MO: Mosby-YearBook.

Goodyear-Smith, F. A. 1989. Medical evaluation of sexual assault findings
in the Auckland region. New Zealand Medical Journal 102:493-495.

Gostin, Lawrence O., Lazzarini, Zita, Alexander, Diane, Brandt, Allan
M., Mayer, Kenneth H., and Silverman, Daniel C. 11 May 1994. HIV
testing, counseling, and prophylaxis after sexual assault. Journal of the
American Medical Association 271:18.

Graham Walker, A. 1997. A few abbreviated suggestions for questioning
children, Child Victims and Witnesses Interviewing and Investigating,
ed. K. L. Poyer. Washington, D.C.: U. S. Attorney's Office.

Green, William. 1988. Rape: The Evidential Examination and
Management of the Adult Female Victim. Massachusetts: Lexington
Books.

Groth, A. Nicholas. 1990 Men who Rape: The Psychology of the
Offender. New York: Plenum Press.

Groth, A. Nicholas and Burgess, Ann W. 6 October 1977. Sexual
dysfunction during rape. The New England Journal of Medicine.

Hampton, Harriette L. 26 January 1995. Care of the woman who has been
raped. The New England Journal of Medicine.

Hayman, C. R. and Lanza, D. February 1971. Sexual assault on women
and girls. American Journal of Obstetrics and Gynecology 109.

Heger, A. and Emans, S. J. 1992. Evaluation of the Sexually Abused
Child: A Medical Textbook and Photographic Atlas. New York: Oxford
University Press.

Hennepin County Medical Center. 1997. Pediatric Sexual Abuse Exam
Protocol. Minneapolis, MN.

Hochmeister, M. N., Whelan, M., Borer, U. V., Gehrig, C., Binda, S.,
Berzlanovich, A., Rauch, E., and Dirnhofer, R. 1997. Effects of toluidine
blue and de-staining reagents used in sexual assault examinations on the
ability to obtain DNA profiles from postcoital vaginal swabs. Journal of
Forensic Sciences 42:2, 316-319.

Holloway, Mavis and Swan, Amanda. 28 July 1993. A & E management
of sexual assault. Nursing Standard 7:45.

Holmes, Melisa M., Resnick, Heidi S., Kilpatrick, Dean G., and Best,
Connie L. 1996. Rape-related pregnancy: Estimates and descriptive
characteristics from a national sample of women.

IAFN Statement. November 1996. Presentation. "Utility of the colposcope
in the sexual assault examination." Fourth Annual Scientific Assembly of
Forensic Nurses, Kansas City.

Jezierski, M. 1992. Sexual assault nurse examiner: A role with lifetime.
Journal of Emergency Nursing 18:2.

Kanuha, V. 1997. Minnesota Coalition Against Sexual Assault Training
Manual. Minneapolis, MN: Minnesota Coalition Against Sexual Assault.

Katz, Mitchell H. and Gerberding, Julie Louise. 1997. Postexposure
treatment of people exposed to the human immunodeficiency virus
through sexual contact or injection-drug use. The New England Journal of
Medicine 336:15.

Katz, S., Schonfeld, D. J., Carter, A. S., Leventhal, J. M., and Cicchetti,
D. V. 1995. The accuracy of children's reports with anatomically correct
dolls. Developmental and Behavioral Pediatrics 16:2, 71-76.

Kaufhold, M. 1993. Medical assessment of children who have been
recently raped. Journal of Child Sexual Abuse 2:1.

Kaufman, A., Divasto, P., Jackson, R., Voorhees, H., and Christy, J. 1980.
Male rape victims: Noninstitutionalized assault. American Journal of
Psychiatry 137, 221-223. 

Kettelson, Debby. 1995. Rape: Nurses trained to take evidence. Unit
News/District News, District of East Hawaii.

Kiffe, Barbara J. August 1996. Study evaluating nurses' reactions toward
rape victims. (Ph.D. diss., Augsburg College, Minneapolis, MN).

Kivlahan, C., Kruse, R., and Furnell, D. 1992. Sexual assault
examinations in children: The role of a statewide network of health care
providers. AJDC 146.

Kolilis, G. H. 1996. The role of law enforcement in the investigation of
child maltreatment, Recognition of Child Abuse for the Mandated
Reporter, ed. J. A. Monteleone. St. Louis, MO: G.W. Medical Publishing.

Kosse, M. P. and Harvey, M. R. 1991. The Rape Victim: Clinical and
Community Interventions. 2nd ed. New York: McGraw Hill.

Laufer, Alison, A. and Souma, Micki L. November 1982. Use of toluidine
blue for documentation of traumatic intercourse. Obstetrics and
Gynecology 60:5.

Ledray, Linda E. 1984. Sexual assault resource service. Unpublished data. 

----. 1991. Sexual assault and sexually transmitted disease: The issues
and concerns. Rape and Sexual Assault III: A Research Handbook. New
York & London: Garland Publishing.

----. 1992(A). The sexual assault nurse clinician: A fifteen-year
experience in Minneapolis. Journal of Emergency Nursing 18:3.

----.1992(B). The sexual assault exam: Overview and lessons learned in
one program. Journal of Emergency Nursing 18:3.

----. 1993 (A). Sexual assault nurse clinician: An emerging area of
nursing expertise. Clinical Issues in Perinatal and Women's Health
Nursing, ed. Linda C. Andrist. Philadelphia: J. B. Lippincott.

----. 1993 (B). Evidence collection: An update. Journal of Child Sexual
Abuse 2:1.

----. 1994. Rape or self-injury. Journal of Emergency Nursing. 20:4.

----. 1995. Sexual assault: clinical issues. Sexual assault evidentiary
exam and treatment protocol. Journal of Emergency Nursing 21:4.

----. March 1996 (A). The sexual assault resource service: A model of
care. Minnesota Medicine 79.

----. October 1996 (B). Sexual assault: Clinical issues: Sexual assault
nurse examiner (SANE) programs. Journal of Emergency Nursing 22:5.

Ledray, Linda E. and Arndt, Sherry. 1994. Examining the sexual assault
victim: A new model for --nursing care. Journal of Psychosocial Nursing
32:2.

Ledray, Linda E. and Barry, Lee. June 1998. SANE expert and factual
testimony. Journal of Emergency Nursing 24:3. Ledray, Linda E. and
Chaignot, Mary Jane. 1980. Services to sexual assault victims in Hennepin
County. Evaluation and Change (special issue).

Ledray, Linda E. and Netzel, L. April 1997. Forensic nursing: DNA
evidence collection. Journal of Emergency Nursing 23:2.

Ledray, Linda E. and Simmelink, K. February 1997. Sexual assault:
Clinical issues: Efficacy of SANE evidence collection. A Minnesota
study. Journal of Emergency Nursing 23:1.

Leininger, Madeleine. 1995. Transcultural Nursing: Concepts, Theories,
Research & Practice, 2nd Ed. New York: McGraw Hill.

Lenehan, Gail P. February 1991. Sexual assault nurse examiners: A
SANE way to care for rape victims. Journal of Emergency Nursing 17:1.

Levitt, C. J. 1993. Medical evaluation of the sexually abused child.
Primary Care 20:2.

Lewington, F. R. 1988. New initiatives in the investigation of rape.
Medico-Legal Journal 56:3.

Lewis, Ricki. June 1988. DNA fingerprints: Witness for the prosecution.
Discover.

Lipscomb, Gary H., Muram, David, Speck, Patricia M., and Mercer, Brian
M. 10 June 1992. Male victims of sexual assault. Journal of the American
Medical Association 267:22.

Lipson, J. G., Dibble, S. L. and Minarik, P. A. 1996. Culture & Nursing
Care: A Pocket Guide. San Francisco: San Francisco Nursing Press.

Lynch, Virginia A. 1993. Forensic nursing: Diversity in education and
practice. Journal of Psychosocial Nursing 31:11.

----. November 1996. Presentation. "President's report: Goals of the
IAFN." Fourth Annual Scientific Assembly of Forensic Nurses
Conference, Kansas City.

Marchbanks, Polly A., Lui, Kung-Jong, and Mercy, James A. 1990. Risk
of injury from resisting rape. American Journal of Epidemiology 132:3.

Marsella, A. J., Friedman, J. M., Gerrity, E. T., and Scurfield, R. M.
1996. Ethnocultural Aspects of Posttraumatic Stress Disorder.
Washington, D.C.: American Psychological Association.

Marullo, Geri. November 1996. Presentation. "The future and the forensic
nurse: New dimensions for the 21st century." Fourth Annual Scientific
Assembly of Forensic Nurses Conference, Kansas City.

Massachusetts Nurses Association. December 1995. MNA collaborates
with DPH to train sexual assault nurse examiners. Massachusetts Nurse.

McCann, I. L. and Pearlman, L. A. 1990. Vicarious traumatization: A
framework for understanding the psychological effects of working with
victims. Journal of Traumatic Stress 3: 131-149.

McCauley, Jeanne, Gorman, Richard L., and Guzinski, Gay. December
1986. Toluidine blue in the detection of perineal lacerations in pediatric
and adolescent sexual abuse victims. Pediatrics 78:6. 

McDonald, D. 5 September 1997. Personal communication regarding
medscope. Fairfax Hospital, VA.

McNeese, V. and Monteleone, J. A. 1996. Sexual abuse in children,
Recognition of Child Abuse for the Mandated Reporter, ed. J. A.
Monteleone. St. Louis, MO: G.W. Medical Publishing.

Miller, Jay V. Letter. Virginia A. Lynch. October 11, 1996. Fourth
Annual Scientific Assembly of Forensic Nurses Kansas City Conference.
November 1996.

Miller, P. 1997. Sexual violence and the gay and lesbian communities.
Minnesota Coalition Against Sexual Assault Training Manual.
Minneapolis, MN: Minnesota Coalition Against Sexual Assault. 

Minneapolis Police Department. Crime Analysis Unit. 1989. Police
Chief's report.

Mollica, Richard F. and Son, Linda. June 1989. Cultural dimensions in the
evaluation and treatment of sexual trauma. Psychiatric Clinics of North
America 12:2.

Muchlinski, E., Boonstra, C., and Johnson, J. 1989. Planning and
implementing a pediatric sexual assault evidentiary examination
program. Journal of Emergency Nursing 15:3.

Muram, D. 1987. Rape, incest, trauma: The molested child. Clinical
Obstetrics and Gynecology 30.

----. 1989. Child sexual abuse: Relationship between sexual acts and
genital findings. Child Abuse & Neglect 13: 211-216.

Muram, D., Speck, P. M., and Dockter, M. 1996. Child sexual abuse
examination: Is there a need for routine screening for N. Gonorrhoeae?
Journal of Pediatric Adolescent Gynecology 9.

Myers, J., Bays, J., Becker, J., Berliner, C., and Saywitz, K. J. 1989.
Expert testimony in child sexual abuse litigation. Nebraska Law Review
68:1 & 2.

Nass, D. 1991. Confidentiality and the rape victim: Ethical intent vs.
political reality. Journal of Clinical Ethics 2:1.

National Coalition Against Sexual Assault (NCASA). October 1997.
Hoffman La Roche announcement to add color-releasing agent to
Rohypnol. NCASA Annual Conference. Cleveland, OH.

Neinstein, L. S. 1996. Adolescent Health Care: A Practical Guide, 3rd Ed.
Baltimore: Williams and Wilkins.

Norvell, Mark K., Benrubi, Guy I., and Thompson, Robert J. April 1984.
Investigation of microtrauma after sexual intercourse. The Journal of
Reproductive Medicine 29:4.

O'Brien, Colleen. 1992. Medical and forensic examination by a sexual
assault nurse examiner of a 7 year-old victim of sexual assault. Journal of
Emergency Nursing 18:3.

----. 1996 (A). Sexual assault nurse examiner (SANE) program
coordinator. Journal of Emergency Nursing 23:5.

----. 25 November 1996 (B). Personal communication.

----. October 1997. Forensic nursing: Improved forensic documentation
of genital injuries with colposcopy. Journal of Emergency Nursing 23:5. 

Osborn, M. and Neff, J. May/June 1989. Patient care guidelines:
Evidentiary examination in sexual assault. Journal of Emergency Nursing
15:3.

Paradise, J. E. 1990. The medical evaluation of the sexually abused child.
Pediatric Clinics of North America 37.

Pasqualone, Georgia A. 1996. Forensic RNs as photographers:
Documentation in the ED. Journal of Psychosocial Nursing 34:10.

Pearlman, L. A. and Saakvitne, K. W. 1995. Treating Therapists with
Vicarious Traumatization and Secondary Stress Disorder. Compassion
Fatigue: Secondary Traumatic Stress Disorders from Treating the
Traumatized, ed. C. Figley. New York: Brunner/Mazel.

Pease, T. and Frantz, B. 1994. Your Safety . . . Your Rights & Personal
Safety and Abuse Prevention Education Program to Empower Adults with
Disabilities and Train Service Providers. Doylestown, PA: Network of
Victim Assistance.

Peele, Kathleen and Matranga, Myrna. April 1997. Use of a microscope
and video colposcope in sexual assault investigations. The Nurse
Practitioner 22:4.

Pope, C. and Brucker, M. 1991. Adolescents as victims: An overview of
the special impact of sexual abuse. NAACOGS Clinical Issues in Prenatal
and Women's Health Nursing 2:2.

Poyer, K. L. 1997. Child Victims and Witnesses Interviewing and
Investigating. Washington, D.C.: U. S. Attorney's Office.

Randall, B. 1986. Persistence of vaginal spermatazoa as assessed by
routine cervicovaginal (pap) smears. Journal of Forensic Science 32.

Rambow, B., Atkinson, C. Frost, T. H., and Peterson, G. F. 1992. Female
sexual assault: Medical and legal implications. Annals of Emergency
Medicine 21:727-731.

Reghr, C. 1990. Parental responses to extra-familial child sexual assault.
Child Abuse & Neglect 14.

Renz, L., Baker, K., and Read, P. 1996. The Foundation Directory. 9th
edition. Chapter 6. New York: The Foundation Center.

Roach, Barbara A. and Vladutiu, Adrian O. 1993. Letter to the Editor:
Prostatic specific antigen and prostatic acid phosphatase measured by
radioimmunoassay in vaginal washings from cases of suspected sexual
assault. Clinica Chimica Acta 216:199-201.

Rollins, J. H. 1995. Growth and development of children, Nursing Care of
Infants and Children, ed. Wong. St. Louis, MO: Mosby.

Rossum, C. 1993. How to Assess Your Nonprofit Organization with Peter
Drucker's Five Most Important Questions. San Francisco: Jossey-Bass.

Royce, Rachel A., Sena, Arlene, Cates, Jr., Willard, and Cohen, Myron S.
10 April 1997. Sexual transmission of HIV. The New England Journal
of Medicine 336:15.

Sacks, D. 1989. Canadian guidelines for health care providers for the
examination of children suspected to have been sexually abused. Canada
Diseases Weekly Report 15:3.

Sandrick, Karen M. 5 June 1996. Tightening the chain of evidence.
Hospitals and Health Networks.

Satin, Andrew J., Hemsell, David L., Stone, Jr., Irving C., Theriot, Sheri,
and Wendel, Jr., George D. May 1991. Sexual assault in pregnancy.
Obstetrics and Gynecology 77:5.

Schauben, Laura J. and Frazier, Patricia A. 1995. Vicarious trauma: The
effects on female counselors of working with sexual violence survivors.
Psychology of Women Quarterly 19: 49-64.

Schumacher, K. and Hung Lee, M. 1997. Persons who are deaf and hard
of hearing. Minnesota Coalition Against Sexual Assault Training Manual.
Minneapolis, MN: Minnesota Coalition Against Sexual Assault. 

Seattle Rape Relief. 1997. Sexual assault on people with disabilities.
Minnesota Coalition Against Sexual Assault Training Manual.
Minneapolis, MN: Minnesota Coalition Against Sexual Assault.

Sheridan, Daniel J. 1993. The role of the battered woman's specialist.
Journal of Psychosocial Nursing 31:11.

Sieving, R. E. 1995. Health promotion of the adolescent and family.
Nursing Care of Infants and Children, ed. Wong. St. Louis, MO: Mosby.

Silverman, E. M. and Silverman, A. G. 1978. Persistence of spermatozoa
in the lower genital tracts of women. Journal of the American Medical
Association 240.

Simmelink, Kathy. December 1996. Sexual assault: Clinical issues:
Lessons learned from three elderly sexual assault survivors. Journal of
Emergency Nursing 22:6.

Slaughter, Laura and Brown, Carl, R.V. January 1992. Colposcopy to
establish physical findings in rape victims. American Journal of Obstetrics
and Gynecology 166:1.

Slaughter, Laura, Brown, Carl, R. V., Crowley, Sharon, and Peck, Roxy.
March 1997. Patterns of genital injury in female sexual assault victims.
American Journal of Obstetrics and Gynecology 176:3.

Smith, Helen Guthrie. 5 June 1996. SART: Special team helps net
convictions. Press-Telegram.

Smith, Linda S. March/April 1987. Sexual assault--The nurse's role. AD
Nurse.

Soderstrom, Richard M. January 1994. Colposcopic documentation: An
objective approach to assessing sexual abuse of girls. Journal of
Reproductive Medicine 39:1.

Solola, A., Scott, C., and Severs, H. 1983. Rape: Management in a
non-institutional setting. Obstetrics and Gynecology 61.

Sorenson, Bottoms, and Perona. 22 February1997. Intake and Forensic
Interviewing in the Children's Advocacy Center Setting: A Handbook.
Washington, D.C.: National Network of Children's Advocacy Centers.

Soules, M. R., Pollard A. A., Brown, K. et al. 1978. The forensic
laboratory evaluation of evidence in alleged rape. American Journal of
Obstetrics and Gynecology 130: 142-147.

Speck, Patricia M. June 1996. Sexual assault: Clinical issues: Memphis
sexual assault resource center: Consent for pregnancy prevention. Journal
of Emergency Nursing 22:3.

----. 16 January 1997. Personal communication.

----. 1999. Chapter 31: Sexual assault. Manual of Emergency Care, 5th
Ed., eds. Susan Sheehy and Gail Lenehan. St. Louis, MO: Mosby.

Speck, Patricia M. and Aiken, Margaret M. April 1995. 20 years of
community nursing service: Memphis sexual assault resource center.
Tennessee Nurse.

Stovall, T. G., Muram, D., and Wilder, M. 1988. Sexual abuse and
assault: Comprehensive program utilizing a centralized system.
Adolescent and Pediatric Gynecology 1.

Tallmer, A. 1996. Lesbian victims. Rape Crisis Advocate Training
Manual. Houston, TX: Houston Drug Action Council Rape Crisis
Program.

Texeira, R. G. 1981. Hymenal colposcopic examination in sexual
offenses. American Journal of Forensic and Medical Pathology
2:209-214.

Thomas, Mark and Zachritz, Helenmarie. June 1993. Tulsa sexual assault
nurse examiners (SANE) program. Journal of Oklahoma State Medical
Association 86.

Tintinalli, Judith E. and Hoelzer, Marion. May 1985. Clinical findings and
legal resolution in sexual assault. Annals of Emergency Medicine 14:5.

Tipton, A. C. 1989. Child sexual abuse: Physical examination techniques
and interpretation of findings. Adolescent and Pediatric Gynecology 2.

Tobias, Gabriella. October 1990. Rape examinations by GPs. The
Practitioner 234.

Trenkman, Maggie. 24 October 1997. Personal communication.

Tucker, Sharon, Ledray, Linda E., and Werner, Joan Stehle. July 1990.
Sexual assault evidence collection. Wisconsin Medical Journal.

Turman, K. M. and Dinsmore, J. 1997. Child Victims and Witnesses: A
Handbook for Criminal Justice Professionals. Washington, D.C.: U. S.
Department of Justice, Office of the United States Attorney.

The Urban Institute. 1997. Evaluation of the S-T-O-P Formula Grants to
Combat Violence Against Women. Washington, D.C.: National Institute
of Justice, U.S. Department of Justice.

Uniform Crime Reports. October 13, 1996. Crime in the United States.
U.S. Department of Justice. Washington, DC: Federal Bureau of
Investigation. 

U.S. House of Representatives. 1996. Drug-Induced Rape Prevention and
Punishment Act of 1996, H.R. 4137.

Virginia State Council of Sexual Assault Nurse Examiners: State
Standards Task Force. 13 March 1997. Standards of Practice for Sexual
Assault Nurse Examiners. 

Warner, C. G. 1987. Rape and sexual assault, Emergency Care: A
Comprehensive Review, eds. T. Kravis and C. G. Warner. Gaithersburg,
MD: Aspen Publishers.

White, E. C. 1994. Chain, Chain Change: For Black Women in Abusive
Relationships. Seattle, WA: Seal Press.

Wilson, M. 1994. Crossing the Boundary: Black Women Survive Incest.
Seattle, WA: Seal Press.

Woodling, B. A. and Heger, A. 1986. The use of the colposcope in the
diagnosis of sexual abuse in the pediatric age group. Child Abuse and
Neglect 111:114.

Wright, C. M., Duke, L., Fraser, E., and Sviland, L. 1989. Northumbria
women's police doctor scheme: A new approach to examining victims
of sexual assault. British Medical Journal 298.

Yorker, Beatrice Crofts. January 1996. Nurses in Georgia care for
survivors of sexual assault. Georgia Nursing.   

Yuzpe, A. Albert, Smith, R. Percival, and Rademaker, Alfred W. April
1982. A multicenter clinical investigation employing ethinyl estradiol
combined with dl-norgestrel as a postcoital contraceptive agent. Fertility
and Sterility 37:4.