U.S. Department of Justice

Office of Justice Programs

Office for Victims of Crime

Sexual Assault Nurse Examiner

(SANE) Programs: Improving

the Community Response to

Sexual Assault Victims

by Kristin Littel

APRIL 2001

A

SANE is a registered nurse

(R.N.) who has advanced education and clinical preparation in

forensic examination of sexual assault

victims.

1 In the 1990s, sexual assault

nurse examiner (SANE) programs sprang

up in hundreds of communities across the

country to address the inadequacy of the

traditional model for sexual assault medical evidentiary exams. Those who work

with sexual assault victims have long 

recognized that victims are often retraumatized when they come to hospital

emergency departments for medical care

and forensic evidence collection. Not

only have victims had to wait for a long

time to be examined, but those who perform the exams often lack training and

experience in working with sexual assault

victims and in gathering forensic evidence. The SANE program can be tailored to the needs of any locality or

region to provide a victim-sensitive solution to systemic gaps in the medical-legal

response to these victims.

Where they exist, SANE programs have

made a profound difference in the quality

of care provided to sexual assault victims.

SANEs offer victims prompt, compassionate care and comprehensive forensic

evidence collection. In addition to helping preserve the victim’s dignity and 

reduce psychological trauma, SANE programs are enhancing evidence collection

for more effective investigations and better prosecutions. Particularly in nonstranger sexual assault cases, thorough

documentation of evidence corroborating

a victim’s account of an assault by establishing lack of consent has led to more

successful prosecutions. 

The Office for Victims of Crime (OVC)

has provided strong leadership in promoting the development of SANE programs.

Through OVC’s funding and resources,

the SANE Development and Operation

Guide was created to assist communities

in developing a SANE program, a Web

site was established to offer information

and technical assistance to SANEs, and

About This

Bulletin

In 1997, OVC granted funding to 

the Sexual Assault Resource Service 

in Minneapolis to develop a practical

“how-to guide,” the SANE Development

and Operation Guide, for starting and administering a SANE program.At that

time, only 86 SANE programs existed in

this country.Today, there are hundreds

of these programs, and new ones are

started every month.The OVC-funded

Guide has been a valuable training and

technical assistance tool, but 3 years

later, we at OVC believed it was time

to pause and take a look at the impact

of SANE programs on victims of sexual

assault, the practitioners who serve

these victims, and their communities. It

was time to check back with some of

the older, established programs and the

newer programs to find out what is

working and why. Although most of the

data reported in this bulletin are anecdotal, we believe it offers valuable insight into the difference that a SANE

program makes to victims and their

communities. In addition, as the number

of SANE programs has grown, so have

the information, technical assistance,

and resources that are available to support these programs.This bulletin describes some of the resources that are

available through the Office for Victims

Continued on page 2
OVC Bulletin

2

of Crime and other public and professional organizations.

Finally, with every success come new

challenges. How can a SANE program

find funding to sustain itself after its initial development? What is the role of

the SANE within the framework of a

sexual assault response team (SART)?

What is involved in establishing SANE

standards of practice, training, and certification? We believe the information and

promising practices presented in this

report will assist programs and communities as they address these and many

other emerging issues.

One of the global challenges that OVC

has embraced is to support, improve,

and replicate promising practices in victims’ rights and services. Our support of

SANE programs moves us, and the field,

closer to the goal of ensuring that every

victim receives fundamental justice and

needed services. In many ways, this bulletin is a salute to the field—to the

SANEs and countless others in the victim advocacy, criminal justice, and medical fields who have embraced the SANE

model and worked ceaselessly to bring

SANE services to their communities.

Continued from page 1

About This Bulletin

regional workshops about how to start a

SANE program have been presented.

This bulletin provides information, ideas,

and resources that will encourage individuals and agencies nationwide to explore the possibility of starting a SANE

program in their areas.

Victim Benefits

O ne advocate contended that the

SANE program was “the best development in victim services” that

she had seen “in the last 10 years.”2 SANE 

programs address several problems in the

medical-legal response to sexual assault

victims in hospital emergency departments, including the following:

■ Emergency department staff frequently regard the needs of sexual

assault victims as less urgent than

other patients because the majority

of these victims do not sustain severe physical injuries.3

■ Sexual assault victims often endure

long waits in busy public areas 

(4- to 10-hour waits are not 

uncommon).

■ Sexual assault victims often are not

allowed to eat, drink, or urinate

while they wait for a physician or

nurse to conduct the evidentiary

exam, to avoid destroying evidence. 

■ Physicians or nurses who perform

evidentiary exams often have not

been trained in forensic evidence

collection procedures or do not perform these procedures frequently

enough to maintain proficiency.

■ Some physicians are reluctant to

perform evidentiary exams because

they know that they might be called

from the hospital to testify in court

and that their qualifications to 

conduct the exam might be questioned due to a lack of training and

experience.

■ Emergency department staff may not

understand sexual assault victimization (e.g., they may blame victims

for their assaults or may not believe

a “real rape” occurred) and overlook

the need to treat victims with sensitivity and respect.

■ Emergency department staff may fail

to gather and/or document all available forensic evidence, particularly

in nonstranger cases. 

With the advent of SANE programs, it

became possible for sexual assault victims

to consistently receive prompt and compassionate emergency care from medical

professionals who understand victimization issues (e.g., SANEs recognize that

the majority of victims are assaulted by

intimate partners or acquaintances). A

SANE can speed up the evidentiary examination process by reducing the time

victims have to wait in a hospital’s emergency department and the time it takes

to complete the examination.4 The quality of the examination is usually improved

because an experienced SANE is adept at

identifying physical trauma and psychological needs, ensuring that victims receive appropriate medical care, knowing

what evidence to look for and how to

document injuries and other forensic evidence, and providing necessary referrals.

Evidence collected by SANEs can help

link the victim and suspect to the crime

scene, indicate sexual penetration or activity, and establish lack of victim consent (e.g., bumps on the back of the

head, abrasions on the back, and nongenital bruising). Establishing lack of consent is particularly important in the

prosecution of nonstranger cases. 

Recognizing the horror of sexual assault

and the devastation it can cause victims

and their significant others, SANEs ultimately strive to ensure that victims are

not retraumatized by the evidentiary

exam and to facilitate the healing process.

SANE Program Director Jamie Ferrell,

with the Sexual Assault Prevention and

Crisis Services Division of the Texas

Office of the Attorney General, remarked that “it’s incredible to work with

victims at possibly their lowest level of

functioning and see them walk away

with their heads held high.’’5 SANE

Coordinator Suzanne Brown, at Inova

Fairfax Hospital in Fairfax, Virginia,

noted that it was not uncommon for 

victims and their families to express 
3

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS

gratitude to SANEs for the caring and efficient treatment they provided. On the

few cases she has worked where victims of

repeat assaults had evidentiary exams performed at different times by non-SANEs

and SANEs, the victims commented that

they wished they had been treated by a

SANE the first time.6

SANE Program

Development 

Nurses established the first SANE

programs in the mid- to late

1970s, in Minneapolis, Minnesota;

Memphis, Tennessee; and Amarillo,

Texas. It was not until the late 1980s,

however, that these programs came together with other groups to promote this

role for nurses. By 1991, the Journal of

Emergency Nursing reported on the existence of 20 SANE programs. SANE

programs developed rapidly after the

mid-1990s, as localities learned about the

benefits SANEs offer. The Journal of

Emergency Nursing noted that 86 SANE

programs were known to exist by 1996.

In 1997, the SANE Development and

Operation Guide identified 116 programs.

The Guide’s author, Linda Ledray, estimated that more than 300 programs had

been established by July 1999 and that

the number is likely to expand much

more rapidly in the years to come.7

SANE programs that are not listed in

the Guide are urged to register on the

Sexual Assault Resource Service Web

site at www.sane-sart.com—the Guide

can be viewed through the Web site.

SANEs are forensic nurses; however,

not all forensic nurses are trained to be

SANEs. Forensic nurses also conduct evidentiary exams in cases involving other

types of interpersonal violence, public

health and safety, emergencies or trauma,

patient care facilities, and police and corrections custody abuse.8 To support their 

work, SANEs and other forensic nurses

have worked to build networking opportunities and to encourage the field to 

officially recognize the importance of

forensic nursing. In 1992, representatives

from 31 SANE programs from the United

States and Canada met and founded the

International Association of Forensic

Nurses (IAFN). 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. The American Nurses

Association (ANA) recognized forensic

nursing as a specialty area in 1995. 

Program Operation 

While SANE programs may operate

differently depending on factors

such as community-specific coordinated response protocols and SANE

program location, their primary function

is to provide objective forensic evaluation

of victims of sexual assault. SANEs have

embraced the challenge to be technically

skilled evidence collectors who display

compassion and acknowledge the patient’s dignity during every step of the 

examination. 

Most SANE programs use a pool of

SANEs who are on call 24 hours a day.

The on-call SANE is paged whenever a

sexual assault victim enters the community’s response system9 and usually responds

within 30 to 60 minutes.10 The SANE or

other medical personnel (e.g., emergency

department physicians or nurses) first assess the victim’s need for emergency medical care and ensure that serious injuries

are treated. After the victim’s medical

condition is stabilized or it is determined

that immediate medical care is not required, the SANE can begin the evidentiary examination. During the course of

exams, SANEs— 

■ Obtain information about the victim’s pertinent health history and

the crime.

■ Assess psychological functioning sufficiently to determine whether the

victim is suicidal and is oriented to

person, place, and time.

■ Perform a physical examination to

inspect and evaluate the body of the

victim (not a routine physical

exam).

■ Collect and preserve all evidence

and document findings.

■ Collect urine and blood samples

and send them to designated laboratories for analysis in cases where

drug-facilitated sexual assault is 

suspected.11

■ Treat and/or refer the victim for

medical treatment (a SANE may

treat minor injuries such as minor

cuts and abrasions, but further evaluation and care of serious trauma is

referred to a designated medical facility or physician).

■ Provide the victim with prophylactic

medications for the prevention of

sexually transmitted diseases (STDs)

and other care needed as a result of

the crime.

■ Provide the victim with referrals for

medical and psychological care and

support.

In many jurisdictions, community-based

sexual assault victim advocates are involved in the initial medical-legal response to sexual assault victims. SANEs

often collaborate with these advocates

during examinations to ensure victims receive crisis intervention, help with safety

planning prior to discharge, and referrals 
for other types of assistance and ongoing

support.

SANEs should interact with victims and

their families in an objective and neutral

manner that promotes informed decisions

regarding evidence collection and available treatment options.12 To facilitate 

decisionmaking, SANEs provide information regarding evidence collection procedures and reporting options. An exam is

never done against the victim’s will, no

matter what age.13 SANEs release evidence to law enforcement agencies only

with the victim’s consent in cases where

the victim has agreed to report or has already reported the crime. SANEs are

mandated, however, to report to the

proper authorities in cases of sexual assault of vulnerable adults (e.g., an older

person dependent on a caregiver); sexual

assault of minors by family members,

caretakers, or persons in positions of authority over them; or sexual assaults of

minors that were the result of parental

neglect.14 Depending on state statutes and

local enforcement policies, SANEs may

or may not be mandated to report cases

of statutory rape if adult perpetrators were

not caretakers or were not in positions of

authority over minors.15

In cases where victims are uncertain

whether they want to report, the evidence can be collected and held in a

locked refrigerator for a specified time,

as mandated by state statutes. Victims

should be informed of the time period in

which they must decide how the evidence will be disposed if they choose not

to report. If victims choose not to report

and do not have evidence collected, the

SANE ensures that they receive appropriate medical treatment and community referrals and are informed about advocacy

services.

SANEs also conduct evidentiary examinations of suspects in sexual assault cases.

These exams are usually conducted at

local law enforcement agencies or jails.

Meticulously collected evidence in 

suspect exams can be invaluable in case

investigation and prosecution because the

evidence can corroborate the victim’s 

account of the assault.

If the case goes to trial, SANEs may be

asked to provide testimony about forensic

evidence they collected during victim

and suspect exams. They view testifying

as an integral part of their job and will

readily adjust their schedules to be in

court as needed. Prior to testifying, they

often communicate with prosecutors so

that they are informed about the issues

involved in the case.

Data Collection by

SANE Programs

Because SANE programs follow

cases from the initial evidence collection through prosecution, they

often gather valuable data on the results

of the evidence collected. Data can include information such as the likelihood

of finding sperm at a specific site at a specific time and the likelihood of a sexual

assault victim being injured during the 

assault.16 Such data can aid law enforcement and prosecution efforts. For example, the above information can help

prosecutors who need to explain that the

lack of injuries or the absence of sperm

does not mean that a woman was not

raped.17 

Data that SANEs collect can also help

build a more accurate picture of the nature of specific types of victimization

(e.g., drug-facilitated assaults), victims’

health care needs, and reasons why victims report or do not report to law 

enforcement.

The Memphis, Tennessee, Sexual Assault

Resource Center has kept frequency data

on cases since its inception 25 years ago.

Recognizing the importance of this information to ongoing improvement in community response to victims, staff members

(which include SANEs, legal advocates,

and counselors) are involved in several

collaborative research and data-sharing

projects. Through a U.S. Department of

Justice grant, a community task force is

examining situations where adolescent

girls are sexually assaulted by an acquaintance after getting into or being forced

into the offender’s vehicle. The purpose

of the project is to identify risk factors

and to develop interventions. Another

research project through the University

of Memphis, Center for Research on

Women, is using center data to look more

broadly at sexual assault victimization.

Center staff members also participate in

weekly multidisciplinary case reviews of

child sexual abuse cases. The review

meetings ensure that all investigative data

on each case are considered and have facilitated more cases being accepted by

prosecutors and more plea bargains.18

Given the recent emergence of SANE

programs, it is important to gather qualitative and quantitative data to ensure the

efficacy of the SANE evidence collection

model and victim satisfaction with the

quality of care and treatment received.

Such data could be useful in garnering

support to continue SANE programs and

to facilitate ongoing improvements in the

SANE response.

The Sexual Assault Resource Service

(SARS), a SANE program based in

Minneapolis, Minnesota, worked with the

State Bureau of Criminal Apprehension

in 1996 to complete an audit of rape kits

sent to their laboratory for analysis from

jurisdictions around the state. Of the 97

kits analyzed, SANEs from SARS completed 24 kits and non-SANEs completed

OVC Bulletin

4
5

73 kits (SARS was the only SANE program in the state at the time). SANE kits

were significantly more complete and

better documented. They maintained the

proper chain of evidence more consistently than kits completed by other nurses or physicians. Also, SANEs made no

major errors that threatened the integrity

of the evidence collected. Evidence from

13 of the 73 kits collected by non-SANEs,

however, would not be admissible in

court because it was impossible to identify

the person who collected the evidence.19

In addition, SARS periodically conducts

patient-satisfaction surveys in conjunction with other studies of treatment outcome. A 1996 study asked 34 patients to

rate their satisfaction with the care they

received by the police, hospital staff, and

SANE on a 5-point Likert scale. The 29

patients (85 percent) who responded

rated their satisfaction with the police at

3.4, with hospital staff at 4.0, and with

SANEs at 4.4.20

SANEs as Key

Responders in a

Coordinated Response

S

uccessful SANE programs do not operate in isolation. They work closely

with other members of the community sexual assault response system (e.g.,

advocates from sexual assault crisis centers, law enforcement officers, prosecutors, judges, other court personnel,

forensic lab staff, victim/witness specialists based in justice system offices, and

child protective services workers) to meet

the multiple needs of victims and to hold

offenders accountable for their crimes.21

Many communities have created multidisciplinary bodies, such as sexual assault

response teams (SARTs), to oversee 

coordination and collaboration related

to immediate response to sexual assault

cases, ensure a victim-centered approach

to service delivery, and explore ways to

prevent future victimization. In localities

where SANE programs exist, SANEs

must be integral in these community coordination efforts to facilitate comprehensive and effective response. 

The SANE program in Madison, Wisconsin, is collaborating with law enforcement

agencies, the prosecution office, and child

protective services to develop a childprotection team to coordinate response in

child sexual abuse cases. The goal is to

conduct one videotaped interview with

each child, involving all relevant case responders.22 SANEs will continue to conduct child medical-forensic exams at the

hospital.

The SANE program in Monmouth

County, New Jersey, as a SART member,

works with the Women’s Center of

Monmouth County to educate high

school-aged youth about the dangers of

drugs used to facilitate sexual assault.

These drugs are typically available at allnight “rave” parties.23

The SART of Memphis, Tennessee, collaborated with the state department of

health to develop voluntary standards for

response to victims of sexual violence.

The standards were developed for use by

all counties in the state. They recommend collaboration among law enforcement officers, sexual assault victim

advocates, and health care providers for a

more systematic approach that ensures

every victim in the state receives appropriate services.24

SARTs and other multidisciplinary

coordinating bodies can also play a critical role in developing SANE programs

and in ensuring their continuance. For

instance, part of the program implementation process should include training for

all those involved in the coordinated

response to sexual assault cases. In addition to instructing them on revised

coordination protocols, training can

teach them how SANEs improve emergency victim care and forensic evidence

collection and provide credible testimony

in court.

The Nurse Examiner Program in Grand

Rapids, Michigan, was developed by a

multidisciplinary group coordinated

through the YWCA sexual assault advocacy program. The group hired a consultant to conduct a feasibility study and

formed a task force to implement the program. Chris Dunnuck, Coordinator of the

Nurse Examiner Program, noted that the

3-year planning process was critical to

overcome obstacles and ensure the program’s financial security.25

The Texas Attorney General’s Office, the

New Jersey Attorney General’s Office,

and the Colorado Coalition Against

Sexual Assault require communities that

apply for state funding for SANE training

to demonstrate collaboration among

agencies that interact with sexual assault

victims. Texas also requests that local

multidisciplinary teams form to oversee

the implementation of their SANE 

programs.26

Collaboration

Between SANEs and

Victim Advocates 

Community-based sexual assault 

victim advocacy programs (often

called rape or sexual assault crisis

centers) have long pushed, at both local

and state levels, to eliminate the wide

variability in quality of emergency medical care and forensic evaluation for 

sexual assault victims. Recognizing that

SANEs offer a solution to problems with

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
the medical-legal response, advocates

from these programs are now leading 

efforts in many communities to promote

the SANE model. Over time, strong 

alliances between advocates and SANEs

have the potential to facilitate a comprehensive and timely community response

to sexual assault that is truly victim

centered. 

Roles and Limitations

With the emergence of SANE programs in their communities, agencies involved in the community response system

to sexual assault must work together to

reexamine response protocols and revise

them as necessary to ensure effective service delivery. In the course of successfully 

integrating SANE programs into response

systems, some conflicts will arise. These

issues must be resolved as early as possible

to avoid power struggles. In particular,

SANE coordinators and advocacy center

directors may need to collaborate to 

identify past problems in coordinated

medical-legal service delivery and areas

where blurring of roles could occur. A few

issues that should be considered are— 

■ Shift in the advocate’s focus of 

attention. The need for advocates

to monitor the medical-forensic response is greatly diminished when

SANEs are conducting evidentiary

exams, because of their education,

training, and experience. Trusting

that SANEs will provide sensitive

and competent care and forensic

nursing evaluation, advocates can

more fully concentrate on providing

crisis counseling, emotional support,

and information to victims and their

families.

■ By profession, SANEs are not 

victim advocates. SANEs support

victims by providing caring, respectful, and efficient emergency medicallegal treatment. Victim support provided by SANEs, however, is not a

substitute for services offered by advocates. Staff from sexual assault advocacy programs have specialized

training, experience, and access to

program resources that allow them

to address a wide range of victim

needs during the emergency 

medical-legal process and beyond.27

■ Victim use of advocacy services.

Although victims should decide for

themselves whether they would like

an advocate present during the

exam, SANEs can inform victims of

opportunities to use advocacy services and can explain the benefits

of advocate assistance.

■ Clarification of responsibilities.

SANE programs and sexual assault

crisis centers in the same locality

may offer a few similar victim services during emergency medical-legal

procedures, including crisis intervention or provision of information

about reporting options. Agency directors should work together to

clearly delineate separate functions,

eliminate duplication, and/or determine the appropriateness of collaboratively delivering some services.

■ Support for SANE work. When

advocates provide emotional support

for victims during exams, SANEs

can more easily maintain a neutral

and objective stance. Victims are

usually able to talk with advocates

in confidence,28 whereas statements

they make to SANEs may become

part of the medical-forensic report

that is passed on to detectives (if the

case is reported).

■ Competency of volunteer advocates. In addition to paid staff,

many sexual assault crisis centers

use trained volunteers to provide

advocacy services. Volunteers typically receive ongoing supervision

from center staff. Any concerns that

SANEs have about the quality of

services provided by volunteers

should be discussed with the local

center director or designated contact

person.

In Santa Fe, New Mexico, 4 SANEs, a

small number of law enforcement officers

and detectives, and a pool of 35 advocates respond to sexual assault calls at the

hospital emergency department. While

nurses and detectives have built good

working relationships because they interact frequently, they may only work with

each advocate once or twice. Sharon

Moscinski, Advocacy Program Coordinator for Santa Fe Rape Crisis Center,

Inc., is trying to determine how to better

integrate advocates as members of the response team. She is considering one possibility that provides advanced training to

a smaller pool of advocates who would respond solely to emergency department

calls and function as short-term case

managers. These advocates, who ideally

would be paid, could help prevent survivors from falling through the cracks in

the critical weeks following the assault.

They would provide followup crisis intervention, referrals and information, assistance through the initial legal process,

and followup with the application for victim compensation.29

SANEs and advocates tend to agree that

there is more than enough work for

everyone involved in sexual assault victim response. By resolving differences,

recognizing the benefits of working collaboratively, and clarifying roles, SANEs

and advocates can support one another

in their effort to serve victims. Agencyspecific and joint trainings are invaluable

tools in making sure advocates and

SANEs understand each other’s roles and

OVC Bulletin

6
7

limitations and avert problems in service

delivery. Sara Donohue, Coordinator of

the Sexual Assault Resource and Awareness Program in Alexandria, Virginia,

also recommends that cooperative agreements be created to standardize response

and build commitment of responding

agencies to work together.30

After attending a SANE training, Gail

Hutchison, the Sexual Assault Services

Coordinator for Virginians Aligned

Against Sexual Assault in Charlottesville,

Virginia, felt better prepared to support

the development of SANE programs in

localities across the state and to encourage collaboration among advocates, 

nurses, law enforcement officers, and

prosecutors.31

Judy Casteele, Associate Director of the

Women’s Resource Center of the New

River Valley in Radford, Virginia, attended a SANE training about 4 years ago.

Impressed by what she learned, she asked

the trainers to present information on

SANE programs to law enforcement officers, prosecutors, nurses, emergency room

doctors, and other physicians in Radford.

An enthusiastic response to the presentation led Casteele to urge area hospitals to

consider implementing a SANE program.

One hospital agreed and subsequently involved Casteele in the selection of the

SANEs. Casteele maintains regular communication with the SANEs and supports

them in their work.32

The Rape, Abuse and Incest National

Network (RAINN) and the Santa Fe

Rape Crisis Center, Inc., are in the

process of surveying RAINN’s member

agencies (sexual assault crisis centers that

take calls routed through the RAINN

hotline) regarding the impact of SANE

programs in their communities.33 The

Rape Crisis Center initiated, developed,

and pilot tested the survey. RAINN will

provide the results of the survey to OVC,

to be published on the SANE–SART

Web site. 

Impact on Law

Enforcement and

Prosecution

Law Enforcement 

SANE programs “have taken response

to sexual assault victims at the emergency

department out of the dark ages,” according to Mark Purcell, a detective with the

Sex Crimes Unit of the Alexandria,

Virginia, Police Department.34 Purcell

noted that SANEs present victims with a

positive first impression of the community response system, increasing the likelihood that they will cooperate with law

enforcement and prosecution. Officers

know that victims are in good hands with

SANEs because victims will be treated

with kindness and respect. Officers also

recognize the increased efficiency that

SANEs bring to the evidentiary exam

process, and as a result, the time they

spend waiting for evidence and waiting

to interview victims can often be greatly

reduced. 

Detectives realize that SANEs can contribute to investigations by providing

meticulously collected forensic evidence

and extensive documentation that complement crime scene evidence and witness statements. SANEs have greatly

improved the quality and consistency of

collected evidence, according to Pat

Calhoun, a sergeant with the Sex Crimes

Unit, Tulsa, Oklahoma, Police Department.35 Pat Groot, with the National

Alliance of Sexual Assault Coalitions,

noted that because of their forensic expertise and access to equipment such as

the colposcope and medscope, SANEs

may obtain evidence in cases involving

acquaintance rapes and child sexual abuse

that might have gone undetected with

less experienced examiners.36 Calhoun 

remarked that he finds it useful to

compare the police report with the

nurse’s report—sometimes SANEs obtain

new or different information. Since the

Tulsa, Oklahoma, SANE program office

is located at the police department,

Calhoun said he counts on the SANE coordinator to answer questions he and

other detectives may have about the

exam and collected evidence. Ultimately,

the work of SANEs increases the chance

that law enforcement will be able to

move a case forward to prosecution.

Prosecution 

SANEs’ thorough evidence collection,

particularly evidence corroborating lack

of consent, and SANE testimony have

been critical in helping prosecutors obtain increased numbers of guilty pleas

from defendants.37 Recognizing the positive impact SANEs can have on outcomes in sexual assault cases, many local

and state prosecution offices are supporting the implementation of SANE programs. In both New Jersey and Texas, for

example, statewide efforts to develop

SANE programs and SARTs are being led

by the states’ offices of the attorney general. Endorsement at this level encourages

local prosecution offices and law enforcement agencies to support these initiatives.

Prosecutors have found SANEs to be

credible witnesses in court as a result of

their extensive experience and expertise

in conducting evidentiary exams. The

Director of a Wisconsin SANE program

reported that during a 31

/2-year period,

they had a 100-percent conviction rate in

cases where a SANE testified at trial.38

Patricia A. Smith, Coordinator of the

SART/SANE program in Palmer, Alaska,

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
noted that SANEs also save money at

prosecution because the strength of photographic evidence taken by SANEs promotes more plea bargains, thus saving the

state the cost of a trial.39

Sandra Sylvester, an assistant commonwealth attorney for Prince William

County, Virginia, praised SANE programs

in particular for their contributions to

child sexual abuse cases. All pediatric

SANE exams done in the county are referred to nearby Inova Fairfax Hospital.

She said that with SANEs conducting pediatric evidentiary exams, children are

less traumatized, evidence gathered has

helped increase the number of pleas, and

children often do not have to testify.

Because the evidence SANEs collect can

make a dramatic difference in whether a

case gets prosecuted, Sylvester also would

like to use forensic nursing in cases involving battered children.40

Case Law41

With the growth of SANE programs

throughout the country, court systems are

processing greater numbers of cases of

sexual assault in which the victim has undergone a forensic exam. As more of

these cases go to trial and result in increased numbers of convictions, state and

federal appellate courts are reviewing

constitutional and evidentiary challenges

by defendants. To date, these courts have

rejected all defense challenges to convictions based on SANE testimony. 

These appellate reviews include evaluating the qualifications of a SANE as an

expert witness and analyzing the nature

and scope of SANE forensic testimony

(both fact and expert testimony). These

cases may establish precedent on the

weight and admissibility of forensic evidence collected and testimony given by

SANEs in particular jurisdictions

throughout the country. In turn, these

cases can help guide nurse examiners,

prosecutors, defense attorneys, and courts.

For example, Gonzalez v. State of Texas,

1991 WL 67061 (Tex. App. Hous. (14

Dist.)), renders an analysis that a court

may apply to qualify a SANE as an expert

witness. Gonzalez was found guilty of sexual assault in a jury trial and sentenced

to 50 years enhanced punishment. He asserted that he was deprived of effective

assistance of counsel because his attorney

failed to object to the qualifications of

the SANE as an expert witness. Gonzalez

asserted that the state failed to establish

the SANE’s qualifications as an expert

witness as a predicate to her opinion testimony, and the failure of his counsel to

object deprived him of his right to counsel. The Texas Court of Appeals, however, affirmed the conviction, recognizing

the expert qualifications of the SANE,

and ruled that the trial court properly admitted the opinion testimony.42

Getting Started

OVC Support for Replicating

SANE Programs

OVC has been an unwavering proponent of SANE programs. Its efforts to

promote program development have focused primarily on the three projects described below. Through a competitive

grant solicitation process, Dr. Linda

Ledray, Director of the Sexual Assault

Resource Service in Minneapolis,

Minnesota, was selected by OVC to

spearhead these initiatives.

SANE Development and

Operation Guide

This publication, released in 1999,

facilitates the development of SANE

programs in communities across the

country by providing comprehensive information based on the collective wisdom

of those who have been operating SANE

programs. The Guide includes chapters on

the history and development of SANE

programs, the SANE program model,

community approaches to sexual assault

response, assessing the feasibility of a

SANE program, funding information,

program implementation, staffing information, training needs, program coverage

and operation, pediatric SANE exams,

policies and procedures, and maintaining

a healthy program. The Guide offers invaluable detailed information not available from any other single source to those

interested in starting a SANE program. 

Web Site

The Sexual Assault Resource Service

(SARS) Web site at www.sane-sart.com

offers information and technical assistance to individuals and institutions interested in developing new SANE

programs and improving existing ones.

The goal of the Web site is to facilitate

communication among SANE programs

and provide them with resources to help

them overcome obstacles. Features include a live chatroom (under construction), an online version of the SANE

Development and Operation Guide that can

be viewed or downloaded, information on

upcoming related conferences and training programs, and information about

starting a SANE program. 

SANE programs can register at the Web

site at no cost. If programs agree to provide case information, Web site staff will

provide them with program data analysis

and comparison data from other registered programs. Ledray is particularly 

interested in data collection on drugfacilitated sexual assaults.43 By using the

data collected through the Web site, she

hopes to obtain a better estimate of the

occurrence of suspected and confirmed

drug-facilitated sexual assaults, in addition to data for the estimated timeframe

for SANE collection of a urine specimen

and results of the drug analysis.

OVC Bulletin

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9

Regional Workshops

To supplement the technical assistance

available through the Guide and the Web

site, OVC grant funding supported a series of regional workshops during 1998

and 1999 to SARTs interested in developing SANE programs. Ledray, Project

Director, trained SARTs from at least

three localities at each regional workshop. The workshops’ purpose was to help

SARTs evaluate the feasibility of a SANE

program in their region, to consider how

to develop a program that suits the needs

of their community, and to brainstorm

how to overcome obstacles. These workshops helped SARTs save time, money,

and energy that otherwise would have

been spent seeking out information and

advice. Ultimately, the workshops can

help regions more rapidly develop and

implement successful SANE programs.

Since grant funding for these workshops

has ended, OVC’s Training and Technical

Assistance Center (TTAC) will continue

to assess community interest in developing SANE programs and will offer additional regional training and technical

assistance. Contact information for

TTAC is available in the Resources 

section of this bulletin.

Standards, Training, and

Certification

Communities interested in starting a

SANE program can benefit from the experiences of pioneers in the field who recognized the importance of providing

quality medical care and forensic evaluation to every sexual assault victim, no

matter the place, time, or circumstance.

Based on their early experiences, standards of practice, training curricula, and

training and certification requirements

have developed.

Standards of Practice

Standards of practice have emerged

to ensure that SANEs respond to the

medical-legal needs of victims in a consistent and appropriate fashion. The SANE

Council of IAFN adopted the first SANE

Standards of Practice in 1996. Several

states have or are in the process of developing state-specific SANE standards. For

example, the Virginia State Council of

Forensic Nurses created Standards of Practice for SANEs in 1997. These standards

are based on the IAFN standards but address state policies and standards relevant

to the operation of SANE programs in

Virginia. Since there is no regulatory

body for enforcement, programs are asked

to voluntarily adhere to the standards.44

Other states have incorporated SANE response into broad standards for the provision of comprehensive services to sexual

assault victims. In New Jersey, for example, a multidisciplinary council coordinated through the Office of the Attorney

General released Standards for Providing

Services to Survivors of Sexual Assault in

1998. The protocols are geared to improve provision of information and services to victims; encourage coordination

among service providers; enhance the

collection, preservation, and transmission

of forensic evidence; and contribute to

the prosecution of sex crimes. The protocols recommended the development of

standardized training and state standards

for SANEs and SARTs and a certification

process for SANEs in every county.45

Training and Certification

SANEs require specialized training.

Basic training programs typically consist

of at least 40 hours of classroom instruction. Topics can include the definition 

of the SANE role, collection of evidence, testing and treatment of STDs,

evaluation of other care needed, victim 

responses and crisis intervention, assessment of injuries, documentation, courtroom testimony, corroborating with

community agencies, competent completion of an exam, and forensic photography.46 Some programs also specify a

designated number of clinical hours to

build SANE experience. Continuing 

education and competency requirements

should be routinely met to maintain 

active SANE status. 

IAFN recently published the SANE

Education Guidelines to serve as a framework for the specialized training and education of SANEs. The document set forth

a minimum level of required instruction.

To further ensure consistency in practice

and credibility in the courtroom, IAFN is

also working to establish a national-level

certification for SANEs. In the meantime, several states have developed statelevel training programs and certification

criteria. 

In 1997, the Texas legislature passed a bill

directing the Sexual Assault Prevention

and Crisis Services Division of the state

attorney general’s office to adopt rules establishing minimum standards for SANE

certification. Certification rules were not

part of the bill and can be revised without

legislative approval. Certification addresses “currency of practice,” meaning the

formal process by which training and

continuing education and the number of

exams performed per year by a SANE

are documented. Nurses can seek adult

and/or pediatric certification. Several

prosecutors have asked their local SANEs

how they can help them get certified,

since it will further validate SANEs’ education and currency of practice in court.

A 56-hour SANE training, based on certification rules, is offered at no cost to local

multidisciplinary teams willing to make the

commitment to start a SANE program. 

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
Nurses are expected to complete clinical

hours and to begin program operation

within 8 months of classroom training.47

The Colorado Coalition Against Sexual

Assault (CCASA) offers a 48-hour SANE

training to nurses from communities in

the state willing to develop a SANE site.

Nurses are asked to contribute $200 

toward the training. Interested organizations or communities are asked to apply

for training and provide victim-centered

care in accordance with clinical and 

operational standards that have been developed by a multidisciplinary SANE advisory board. The CCASA SANE

coordinator will also provide ongoing

technical assistance to the sites (e.g., conducting site visits, providing ongoing education, developing evaluation tools, and

facilitating networking among SANE

programs).48

The Wisconsin Coalition Against Sexual

Assault is offering free SANE training in

various regions of the state. Faculty members come from several Wisconsin SANE

programs. Participation requires commitment by the sponsoring hospital or facility to start a SANE program.49

Program Location

One of the basic decisions in establishing a new program is determining where

it will be located. Considerations for site

selection include safety and security for

victims and staff, physical and psychological comfort of the victim, access to medical support services that provide care of

injuries, access to a pharmacy or medication, access to laboratory services, and access to necessary supplies and equipment

to complete an exam.50 Rather than basing location decisions on what is convenient for service providers, SANE program

planners should develop sites that meet

the needs of victims in their community.

Addressing victim needs also requires

that, regardless of the location of the program site, SANEs communicate and coordinate their efforts with others involved

in the community response system (e.g.,

through active participation in sexual 

assault response teams).

Hospital-Based Exam Sites

The majority of SANE exam sites are

located in hospital emergency departments. The emergency department offers

a secure site, is open 24 hours a day, and

provides access to a wide array of medical

and support services.51 Physicians are

available to treat victim injuries, and

SANEs can conduct evidentiary exams

and treat victims for STDs at the same

location. Emergency department overhead and physician fees, however, can

represent a sizable sum charged to victims, their insurance, SANE programs, or

state compensation programs.52 To control

these costs, some SANE programs have

negotiated reasonable fees for use of the

emergency department and the department’s staff time.53

The SANE program in Madison, Wisconsin, recently became a hospitalbased program. The program was moved

from the local YWCA to an office in the

hospital emergency department where

exams were already being performed.

While the SANE program is still expected to seek outside funding, Coordinator

Jill Poarch hopes that locating in the hospital will offer her program more financial

security, a better clinical fit, and easier access to exam supplies and equipment.54

SANE programs, like the one in Tulsa,

Oklahoma, have opted to locate in 

hospital-based clinics designed specifically

for sexual assault victims that are in close

proximity to the emergency department

for urgent care and other hospital services.

If victims in Tulsa do not require emergency department treatment, they generally do not have to register as hospital

patients.55

Other SANE programs perform exams

at more than one hospital as well as in

places other than hospitals including

health departments, women’s clinics, and

morgues (in cases where the victim is deceased). SANEs may also conduct suspect

exams at law enforcement agencies or

jails. The SANEs in Minneapolis,

Minnesota, go to eight local hospitals.56

The SANE Program in Middlesex

County, New Jersey, is based out of the

county Health Department and uses public health nurses who are SANE trained.57

Nurses from the Monmouth County, New

Jersey, SANE Program conduct forensic

examinations at three local hospital

emergency departments. These three hospitals agreed to have expedited registration for sexual assault victims, private

waiting areas, and exam rooms stocked

with the necessary equipment and 

supplies.58

Numerous programs that do hospital

exams base their administrative offices at

sites other than hospitals. The Monmouth County SANE program office is

located in the prosecutor’s office.59 The

Minneapolis program office is in a health

center.60 The Tulsa SANE program office

is based in the police department.61

Those interested in starting hospitalbased SANE sites should recognize that

some hospitals may be reluctant to 

support such a program. For example,

emergency department staff may be uncomfortable with the idea of working 

collaboratively with SANEs and allowing

them to use their resources, particularly 

if SANEs are not hospital employees. 

To overcome resistance, planners can

OVC Bulletin

10
11

establish dialogue with hospital administrators and emergency department physicians and nurses to explain the benefits of

SANE programs, to identify potential

problems, and to take action to resolve

them. (See also the Funding Issues section of this bulletin for a discussion

on building hospital financial support.)

Community-Based Exam Sites

Community-based programs typically

offer victims more privacy than hospital

exam sites and are not mandated to report felony crimes as hospitals are required to do in some states.62 Victims are

usually not billed for medical care and

services. A community-based program

may be more committed to coordinating

service provision with other members of

the response team. For example, some

SANE programs may be one component

of a comprehensive response center for

sexual assault victims.

The Sexual Assault Resource Center in

Memphis, Tennessee, is a communitybased program. It employs SANEs, legal

advocates, and counselors. SANEs conduct forensic examinations. Legal advocates assist victims who are involved in

the criminal justice system. Regardless of

whether victims report the assaults to the

police, counselors offer short- and longterm counseling. The Memphis Police

Department lab is also located on the

center’s premises. All center staff members participate in weekly meetings to 

review cases.63

Community-based programs, however,

must tackle several difficult issues during

the implementation process. Program developers should ensure that individuals

with clinical backgrounds, preferably

SANEs, administer their programs. They

need to work with area hospital emergency departments to create protocols

around timely evaluation and treatment

of victim injuries and for medication

standing orders. Developers need to consider whether resources and budgets are

sufficient to support their SANE programs. Developers also must confer with

prosecutors to determine whether forensic

evidence and SANE testimony could be

perceived as being biased because of the

location of the program and then must

determine how to overcome this problem. 

Val Sievers, SANE Coordinator for the

Colorado Coalition Against Sexual

Assault, noted that the SANE site requirements and practice standards typically have not been difficult for most

hospital-based programs to apply.

Hospitals function in accordance with

standards of practice and have existing

mechanisms for quality improvement,

continuing education, and protocol 

development. In addition, hospital organizations that employ nurses have an understanding of professional licensure and

scope of practice. Applying clinical and

practice standards is often more challenging for community-based programs,

which historically have not worked with

licensed registered nurses and are not familiar with issues that influence nursing

practice. In order for community-based

programs to be successful, Sievers encourages them to work with nurses in their

area to ensure that clinical issues are 

addressed.64

The Grand Rapids, Michigan, SANE

program is administratively and clinically

located in a suite of rooms at the YWCA

sexual assault advocacy center. To ensure

that all sexual assault victims who go to

local hospitals are offered SANE services,

the SANE program developed a triage

protocol with the hospitals and negotiated with two facilities to allow SANEs to

do exams in their emergency departments

in cases where victims sustain serious 

injuries.65

Funding Issues

Funding is another important issue to

address when considering the feasibility of

a SANE program. Existing SANE programs demonstrate that it is possible to

obtain needed funding with a sufficient

commitment of time, research, fundraising, and creativity. Like many sexual assault crisis centers, SANE programs often

must seek out a variety of funding sources

to support their work. The sooner a

SANE planning team begins to think

about how it will cover program startup

and ongoing operational costs, the quicker it can seek out assistance from potential partners and funders. 

In 1997, a pilot SANE program and

SART were implemented in Monmouth

County, New Jersey, by the state attorney

general’s office.66 The pilot provided an

affordable way to introduce SANEs, evaluate benefits and obstacles, and create a

model for statewide duplication. 

SANE program startup costs include

community and institutional needs assessments, facilities and utilities, office and

exam supplies and equipment, staff advertising and selection, staff training, media

promotion, and staff salaries for the first

year.67 Planning teams should be careful

in estimating how many trained SANEs

are needed to ensure that the program

has the capacity to consistently and

promptly respond to incoming calls on a

24-hour basis. Otherwise, the program

will fail to significantly reduce medicallegal response time to sexual assaults.

Beyond the issue of securing funds for initial expenses, it is critical that planners

also consider how the program will be

sustained financially over the long term.

Stable funding will allow SANE program

coordinators to spend more time on dayto-day clinical operations and less time

obtaining grants and donations. 

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
Hospital Support

The local medical community is an obvious place to begin seeking financial support. Hospitals may be willing to donate

space, supplies, and equipment and to

help cover operating costs. Some hospital

administrators, however, may be reluctant

to develop new programs that they perceive will increase their costs and decrease profits. SANE program planners

can help administrators understand how

such a program can enhance hospital

services in a more cost-effective manner.

Part of this task involves revealing the

hidden costs involved in treating sexual

assault victims in the emergency department without a SANE program. Indirect

and overhead costs include physician and

nursing time to do the exam and testify in

court, supplies, and staff training. It is also

important to highlight the less tangible

benefits of SANE programs. Planners

should stress that not only do SANEs

provide quality, patient-centered care,

their services often enhance the hospital’s

reputation, allowing it to stand out

among other local medical facilities.

SANEs are also invaluable resources for

hospital community outreach and education initiatives.68

In 1996, The Urban Institute visited 12

states as part of its study of the STOP

(Services*Training*Officers*Prosecutors)

grant implementation process. It reported

that forensic exams cost hospitals about

$800 when a physician conducts the

exam and between $200 and $300 when

a trained nurse, such as a SANE, conducts it.69 

Reimbursement for Services

Some SANE programs operate on feefor-service reimbursement from the hospitals served, police department, or

county prosecutor’s office. They, or the

hospital they contract with, are reimbursed for costs associated with forensic

exams through funding from state victim

compensation programs, funded partially

through the federal Victims of Crime

Act (VOCA). Reimbursement varies

tremendously from state to state. It is

often limited to a set maximum dollar

amount for each exam completed, ranging from as little as $50 per exam to $750

or more per exam. Compensation to the

SANE program for exams often does not

cover the majority of costs. Reimbursement gets complicated because only part

of the procedure is forensic—it also entails medical components. Some states

pay for evidence collection but not followup medical care.70

Victim Assistance Funds

SANE programs are also encouraged to

apply for state VOCA victim assistance

grants. In making the decision about

whether to fund SANE programs, state

VOCA administrators should recognize

that SANE programs address critical

medical-legal needs of sexual assault victims. Federal final program guidelines for

the VOCA Assistance Grant Program

permit the use of these funds to purchase

colposcopes, and several states have approved requests to purchase colposcopes

using VOCA funds. For more information about VOCA funds, visit the OVC

Web site at www.ojp.usdoj.gov/ovc.

Other Justice Department Resources

SANE programs may also be able to 

obtain funding through other U.S.

Department of Justice grant projects, 

such as STOP grants of the Violence

Against Women Act (VAWA) and the

Edward Byrne Formula Grant Program.

Call the U.S. Department of Justice

Response Center at 1–800–421–6770 to

be placed on their mailing lists to receive

updated information on funding resources

for violence against women programs. 

Other Funding Sources

In addition to the U.S. Department

of Justice, there is the potential for 

funding from other federal and state

agencies, private foundations, community foundations, grant-making public

charities, individual donors, and fundraising campaigns. The Foundation Center

provides a wide array of information 

on grant funding resources through 

its library holdings, publications, and 

online services. Visit its Web site at 

www.fdncenter.org. 

Local hospitals may be willing to assume

SANE program costs that exceed reimbursement for services from grants and

donations, especially if the hospital administration understands that it is already

assuming hidden costs associated with

treating victims in a less efficient manner

without SANEs. Community-based 

programs may have more difficulty absorbing costs because of limited resources 

and budgets. 

Promising Practices

I

n addition to the innovative strategies

being employed to encourage the development and success of SANE programs illustrated earlier in this bulletin, a

number of “promising practices” are 

presented below.

Expanded Role for SANEs

Recognizing the vital service that

SANEs provide in sexual assault cases,

some hospitals, like St. Mary’s Hospital in

Richmond, Virginia, have expanded their

SANEs’ role to include conducting evidentiary exams on domestic violence 

victims, accident victims, and other populations where forensic evidence may be

useful.71

Use of the Medscope as an Alternative

to the Colposcope72

A colposcope magnifies genital tissue

and is an important asset for the identification of genital trauma. Photographic

OVC Bulletin

12
13

equipment, both still and video, can be

attached easily to the colposcope. In the

legal arena, the use of the colposcope is

well documented as an accepted practice

in the examination of both child and

adult sexual assault victims. The basic

colposcope, without photographic equipment, costs between $10,000 and

$15,000, although the price is falling as

the technology becomes more available.

The medscope is an adapted dental camera and provides photographic documentation that has a greater depth of field

than the colposcope and can be used to

document injuries elsewhere on the

body.73 The complete medscope package

is more affordable than the colposcope

($3,500 for the basic model and $11,500

including camera, internal lens, camera

holder, monitor, printer, foot switch,

VCR, and cart). Suzanne Brown, SANE

Program Coordinator at Inova Fairfax

Hospital, Virginia, noted that the medscope is portable and less cumbersome

than the colposcope, is easier to operate,

and takes digital prints instead of 35mm

prints. Photographic images are taken

using the foot instead of the hand, which

frees the SANE’s hands to conduct the

exam and reduces the risk of contaminating the evidence. Digital images can be

viewed on the monitor to make sure that

they are well focused and clear whereas

35mm prints cannot be viewed prior to

development. Digital prints, however,

cannot be enlarged or reprinted like

35mm prints. The medscope does not

have definite magnification ranges like

the colposcope, but Brown indicated that

the lack of this feature has not presented

problems in court.

Uniform Statewide Colposcope and

Forensic Equipment Protocols

New Jersey has recently implemented 

a statewide funding initiative to acquire

identical, state-of-the-art forensic colposcope equipment for SANE programs

participating in a Statewide Sexual

Assault Standards Project. The project

provides a specially designed forensic colposcope to all exam sites that are part of

SANE programs approved and funded by

the State Office of Victim/Witness

Advocacy. The initiative is designed to

maximize the ability to collect competent

forensic evidence while supporting the

provision of sensitive victim-centered

care to sexual assault victims. The equipment consists of a traditional binocular

colposcope with an advanced digital

image-capturing system to enable the examiner to see the image quality before

capture to ensure that high-quality, accurate photographic documentation is part

of every forensic examination. Specially

designed software has been developed to

ensure the highest quality of photo documentation, evidence preservation, and

the usefulness of the images for trial. 

One of the important aspects of this program involves protocols providing for the

strict confidentiality of evidentiary photographs taken, especially photographs of

genital injury. The protocols provide that

the images are secured with the program

and not routinely printed and produced

with a patient’s forensic file. This helps to

reassure victims who may be reluctant to

proceed and allows the assurance of confidentiality to victims. Additionally, the security level of the specially developed

forensic photo documentation software

program eliminates the need to capture

facial photographs when there is no injury to that area. The specially designed

software provides the ability to securely

transmit data and images for child and

adolescent forensic sexual assault evaluations. Finally, the design and purchase of

specialized equipment on a statewide basis

allows for considerable price reduction

and improves resource allocation by providing colposcopes to programs with limited funds. 

Regional Programs

A regional SANE program is an important alternative to each locality having its own program from a staff training

and competency perspective. By serving a

larger regional area, SANEs will most

likely see more clients, and each SANE

will be able to complete a sufficient

number of exams to develop and maintain clinical competence. Regional programs may be the only cost-effective way

to provide SANE services in rural and remote areas where no one medical facility

sees large numbers of sexual assault cases. 

When the SANE program of Inova

Fairfax Hospital in Virginia began in

1990, it took only adult cases in Fairfax

County. It gradually expanded to serve

child victims and widened its service

area, allowing nurses to increase proficiency because they had more cases. It

now serves a region of 20 jurisdictions.

While some of these jurisdictions have

SANE programs that handle adult cases

locally, they tend to refer their cases

of child sexual assault to the Fairfax 

program.74

The hospital-based SANE program in

Bethel, Alaska, serves a remote region

(three people per square mile) approximately the size of Oregon that is 400

miles from the state road system. Victims

are transported by plane, boat, or snowmobile to the hospital. Between 130 and

150 exams are conducted each year.75

The Matanuska-Susitna Valley SANE

program is based at Valley Hospital in

Palmer, Alaska, and serves a region the

size of West Virginia. Since the region is

on the road system, city police or Alaska

State Troopers drive most clients to the

SART center. The commute may take up

to 3 hours. Since the SANEs from Palmer

examine fewer than 50 cases per year,

they are required to participate in case review meetings and to attend educational

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
programs to maintain proficiency as

forensic examiners.76

Child Sexual Abuse Diagnostic System

In rural or remote areas where SANEs

may rarely see child victims, more experienced forensic examiners could assist

SANEs in properly identifying and evaluating abnormalities. Better quality or

more detailed evidence obtained through

collaboration of numerous experienced

clinicians could increase the likelihood

of successful prosecution. The Fairfax,

Virginia, SANE program is involved in a

pilot project to develop a model regional

diagnostic system for forensic examination of children who have been sexually

abused. Using camera and computerimaging equipment that is attached to

the medscope, the nurse or physician

conducting the forensic exam is able to

immediately transmit photographic images of genital trauma to the computers of

identified experts for their feedback during the examination. In addition to

SANE programs, child advocacy center

staff and pediatric emergency medicine

specialists are participating in the

project.77 Although this model is still in

the preliminary stages of development, it

shows exciting promise. It has the potential to bring clinical expertise to every

forensic evaluation of sexually abused

children, regardless of the examination

location.

Conclusion

S

ANE programs are emerging in

small and large localities across the

nation to improve the quality of sexual assault evidentiary exams. All adults

and children who are sexually assaulted

deserve to receive the prompt and compassionate emergency medical-forensic

care that SANEs offer. Thorough evidence collection in each case opens the

door to the possibility of offender conviction. Where SANE programs do not

exist, agencies involved in coordinated

responses to sexual assault victims should

not delay in considering implementing

such a promising model in their community. The list of resources that follows this

section may help communities organize a

SANE program.

Resources

Organizations and Programs

Office for Victims of Crime

U.S. Department of Justice 

810 Seventh Street NW.

Eighth Floor

Washington, DC 20531

202–307–5983

Fax: 202–514–6383 

Web site: www.ojp.usdoj.gov/ovc

Violence Against Women Office

U.S. Department of Justice

810 Seventh Street NW.

Washington, DC 20531

202–307–6026

Fax: 202–305–2589

Web site: www.ojp.usdoj.gov/vawo

Office for Victims of Crime Training

and Technical Assistance Center

2277 Research Boulevard

Rockville, MD 20850

1–800–627–6872

Fax: 301–519–5533

E-mail: TTAC@ovcttac.org

Office for Victims of Crime 

Resource Center

P.O. Box 6000

Rockville, MD 20849–6000

1–800–627–6872 or 301–519–5500

E-mail for print publication orders: 

puborder@ncjrs.org

E-mail for questions: askovc@ncjrs.org

Web site: www.ncjrs.org

Sexual Assault Resource Service

(SARS)

Web site: www.sane-sart.com 

International Association of Forensic

Nurses 

Web site: www.forensicnurse.org

National Alliance of Sexual Assault

Coalitions

Web site: www.taasa.org/coalitions.htm

Rape, Abuse and Incest National

Network (RAINN)

Web site: www.rainn.org

Publications, Curricula, and

Videos

SANE Development and Operation Guide

Linda E. Ledray, Ph.D, R.N., F.A.A.N.;

Office for Victims of Crime (OVC),

Washington, D.C., 1999. Available on

the Internet at www.sane-sart.com,

through the OVC Web site at

www.ojp.usdoj.gov/ovc, or by contacting

the OVC Resource Center at

1–800–627–6872.

SANE Standards of Practice (1996) and

SANE Education Guidelines (1999)

International Association of Forensic

Nurses (IAFN). For more information on

these publications, contact IAFN at 6900

Grove Road, Thorofare, NJ 08086–9447,

or call 856–848–8356.

Standards for Providing Services to Survivors

of Sexual Assault

State of New Jersey, 1998. On the

Web site of the Office of the Attorney

General, New Jersey Division of Criminal Justice, at www.state.nj.us/1ps/dcj/

stand.htm. Deputy Attorney General

James A. Gilson can also be contacted at

609–984–6500 for more information

about the standards. 

OVC Bulletin

14
15

Standards of Practice for SANEs

Virginia State Council of Forensic Nurses

Contact: Stacey Lasseter, R.N., M.S.N.,

Coordinator, Forensic Nurse Examiners 

St. Mary’s Hospital

5801 Bremo Road

Richmond, VA 23226 

804–281–8574

SANE Currency of Practice Certification

Rules

Texas Office of the Attorney General 

Sexual Assault Prevention and Crisis

Services Division

Contact: Jo Halligan, C.T.S., Director of

Certification

P.O. Box 12548

Austin, TX 78711

512–936–1272

Fax: 512–936–1650

Evaluation and Management of the Sexually

Assaulted or Sexually Abused Patient

American College of Emergency

Physicians (ACEP)

P.O. Box 619911

Dallas, TX 75261–9911

1–800–798–1822

Fax: 972–580–2816

Web site: www.acep.org

This 134-page handbook, released in June

1999, covers topics including the development of a coordinated community response plan; the development of a SART;

clinical evaluation and management of

pediatric, adolescent, and adult patients

who have been sexually assaulted or

abused; forensic laboratory testing; development of a SANE program; bite mark

guidelines; medical-legal photography;

use of toluidine blue; and use of the colposcope. The document also addresses 

issues relating to STDs, HIV, and emergency treatment. The handbook may be

ordered at no cost by calling ACEP (dial

phone number, then dial 6) or by downloading the document from the ACEP

Web site.

The Sexual Assault Examination: Essential

Forensic Techniques 

American Forensic Nurses 

Faye Battiste-Otto, President and CEO

255 North El Cielo Road, Suite 195

Palm Springs, CA 92262

760–324–1121

Fax: 760–321–2750

Web site: www.amrn.com

The 1-hour video and accompanying

training manual cover the following topics: role of SART members, including

sexual assault crisis center advocates; role

of forensic nurse examiners; the interview

process; the medical-legal examination;

forensic evidence collection and photography; chain of custody; and followup

care. The video and manual can be purchased through the Internet or by phone

for $295.

Sexual Assault: The Health Care Response

Manfred Hochmeister, M.D., and Jamie

Ferrell, R.N., R.S.N.

Institute of Legal Medicine 

University of Bern 

Buehlstrasse 20, CH–3012

Switzerland

Fax: (0041) 011 31 31 631 84 15

The videotape, released in 1999, is a

comprehensive guide to the forensic examination and evidence collection of

adult female and male sexual assault

clients. One version is available for medical personnel and another version for

nonmedical personnel. The video, which

costs $95, can also be ordered directly

from the IAFN Web site listed above or

by calling 856–256–2425. 

Video on the Tulsa SANE Program

Kathy Bell, Coordinator 

Tulsa SANE Program 

Tulsa Police Department 

600 Civic Center

Tulsa, OK 74103

918–596–7608

Fax: 918–596–9330

This free 9-minute videotape provides an

overview of the Tulsa, Oklahoma, SANE

Program. It discusses sexual assault victims’ experiences with the medical-legal

system prior to the establishment of the

program and how the SANE program improves system response to victims.

Prosecution of Rohypnol and GHB Related

Sexual Assault Cases

American Prosecutors Research Institute

(APRI)

99 Canal Center Plaza, Suite 510

Alexandria, VA 22314

703–549–4253

This video and binder set was produced

as part of the training series Violence

Against Women: The Prosecution of Sexual

Assault Cases. It addresses general characteristics of both drugs, offers investigative

suggestions, and provides a checklist for

possible charges in these cases. It can be

purchased through APRI for $30.

Contributors

Eileen Allen, R.N., B.S.N., SANE

Program Coordinator, Monmouth County

Prosecutor’s Office, Freehold, NJ.

Debbie Andrews, Executive Director,

Rape, Abuse and Incest National

Network, Washington, DC.

Kathy Bell, R.N., Coordinator, SANE

Program, Tulsa Police Department, 

Tulsa, OK.

Suzanne Brown, R.N., B.S.N., SANE

Coordinator, Inova Fairfax Hospital,

Fairfax, VA.

Pat Calhoun, Sergeant, Sex Crimes Unit,

Tulsa Police Department, Tulsa, OK.

Judy Casteele, Associate Director,

Women’s Resource Center of the New

River Valley, Radford, VA.

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
Sara Donohue, Coordinator, Sexual

Assault Resource and Awareness

Program, Alexandria, VA.

Chris Dunnuck, R.N.C., M.S.N.,

Coordinator, YWCA Nurse Examiner

Program, Grand Rapids, MI. 

Jamie Ferrell, R.N., B.S.N., C.E.N., 

SANE Program Director, Sexual Assault 

Prevention and Crisis Services Division,

Office of the Attorney General, Austin,

TX.

James A. Gilson, Deputy Attorney

General, New Jersey Division of Criminal

Justice, Trenton, NJ.

Pat Groot, Co-Chair, National Alliance

of Sexual Assault Coalitions,

Charlottesville, VA.

Gail Hutchison, Sexual Assault Services

Coordinator, Virginians Aligned Against

Sexual Assault, Charlottesville, VA.

Stacey Lasseter, R.N., M.S.N., Coordinator,

Forensic Nurse Examiners, St. Mary’s

Hospital, Richmond, VA.

Linda E. Ledray, R.N., Ph.D., L.P.,

F.A.A.N., Director, Sexual Assault

Resource Service, Hennepin County

Medical Center, Minneapolis, MN.

Cecelia McKenzie, Director, Sexual

Assault Prevention and Crisis Services

Division, Texas Office of the Attorney

General, Austin, TX. 

Sharon Moscinski, Advocacy Program

Coordinator, Santa Fe Rape Crisis

Center, Inc., Santa Fe, NM.

Carol Odinzoff, R.N., Nurse Coordinator,

SART Unit, Bethel, AK.

Suzanna Parkinson, Coordinator, Rape

Crisis Center, City of Memphis Sexual

Assault Recovery Service, Memphis, TN. 

Jill Poarch, R.N., B.S.N., SANE Program

Coordinator, Meriter Emergency Services,

Madison, WI.

Mark Purcell, Detective, Sex Crimes Unit,

Alexandria Police Department, Alexandria, VA.

Diana M. Riveira, Program Manager and

Senior Attorney, Violence Against

Women Program, American Prosecutors

Research Institute, Alexandria, VA.

Val Sievers, SANE Coordinator, Colorado

Coalition Against Sexual Assault.

Patricia A. Smith, R.N., B.S.N., M.S.N.,

SART/SANE Coordinator, MatanuskaSusitna Valley Sexual Assault Response

Team, Palmer, AK.

Pat Speck, R.N., M.S.N., C.S., F.N.P.,

Coordinator of Nursing Services, City of

Memphis Sexual Assault Recovery

Service, Memphis, TN. 

Sandy Sylvester, Assistant Commonwealth’s Attorney, Office of the

Commonwealth’s Attorney, Prince

William County, Manassas, VA.

Mary Szaro, President, New Jersey

Chapter of the Association of Forensic

Nurses.

Alexandra Walker, Staff, An Agenda for

the Nation on Violence Against Women,

Center for Effective Public Policy, Silver

Spring, MD.

Notes

1. Although the SANE Council of the

International Association of Forensic

Nurses (IAFN) decided in 1996 to use

the title of sexual assault nurse examiner

or SANE, different terminology has been

used across the country because programs

developed independently. For the purposes of this bulletin, the term SANE is

used.

2. Phone interview with Judy Casteele,

Associate Director, Women’s Resource

Center of the New River Valley, Radford,

VA, June 25, 1999.

3. Linda E. Ledray, SANE Development

and Operation Guide, Office for Victims of

Crime, Office of Justice Programs, U.S.

Department of Justice, Washington, DC,

1999, p. 69. In a review of 372 hospital

emergency department cases of sexual assault, 68 percent of the victims had no

injuries, 26 percent had mild injuries, 5

percent had moderate injuries, and less

than 1 percent were severely injured.

4. Linda E. Ledray and Kathy Simmelink,

“Sexual Assault: Clinical Issues, Efficacy

of SANE Evidence Collection, A

Minnesota Study,” Journal of Emergency

Nursing, 23(1), 1997, p. 75.

5. Phone interview with Jamie Ferrell,

SANE Program Director, Sexual Assault

Prevention and Crisis Services Division,

Office of the Attorney General, Austin,

TX, July 5, 1999.

6. Phone interview with Suzanne Brown,

SANE Coordinator, Inova Fairfax Hospital, Fairfax, VA, December 17, 1999.

7. Phone interview with Linda E. Ledray,

Director, Sexual Assault Resource

Service, Hennepin County Medical

Center, Minneapolis, MN, July 2, 1999.

8. Information drawn from IAFN’s Web

site, June 1999.

9. Victims usually enter the system by

calling law enforcement or the sexual assault crisis hotline or by going directly to

the hospital emergency department or

SANE facility.

OVC Bulletin

16
17

10. An adequate number of SANEs

should be available to promptly respond

to calls and to handle multiple calls 

simultaneously.

11. For more information on drugfacilitated assaults, review the training

materials produced by the American

Prosecutors Research Institute on the

prosecution of rohypnol- and GHBrelated sexual assaults (see the publications list on page 15 of this bulletin).

12. IAFN, SANE Standards of Practice,

1996, p. 2.

13. Ledray, SANE Development and

Operation Guide, p. 97. See pp. 97–99 for

more information on consent, confidentiality, and reporting in cases involving

minors.

14. Ibid., p. 114. States have different

laws regulating mandatory reporting for

child sexual abuse, vulnerable adults,

felony sexual assaults of adults, and statutory rape. It is important for SANEs to be

aware of these laws and applicable federal

laws.

15. Ibid., p. 123–124.

16. Ibid., p. 21.

17. Ibid.

18. Phone interviews with Pat Speck,

Coordinator of Nursing Services, City 

of Memphis Sexual Assault Recovery

Service, Memphis, TN, June 22, 1999,

and Suzanna Parkinson, Coordinator,

Rape Crisis Center, City of Memphis

Sexual Assault Recovery Service, June

28, 1999. 

19. Ledray and Simmelink, “Sexual

Assault: Clinical Issues, Efficacy of SANE

Evidence Collection, A Minnesota

Study,” Journal of Emergency Nursing,

23(1), 1997 p. 77.

20. Ibid., p. 76.

21. Other agencies that may be part of

the response system include hospitals and

other medical facilities; public health departments; mental health agencies; victim

compensation offices; battered women’s

programs; schools; organizations serving

victims from underserved populations; 

social and human services; civic, faithbased, and neighborhood groups; youth

organizations; and sex-offender management programs.

22. Phone interview with Jill Poarch,

SANE Program Coordinator, Meriter

Emergency Services, Madison, WI, July 5,

1999.

23. Phone interview with Eileen Allen,

SANE Program Coordinator, Monmouth

County Prosecutor’s Office, Freehold, NJ,

June 22, 1999.

24. Phone conversation with Speck,

September 13, 1999.

25. Phone interview with Chris

Dunnuck, Coordinator, YWCA Nurse

Examiner Program, Grand Rapids, MI,

June 28, 1999.

26. Phone interviews with Cecelia

McKenzie, Director, July 14, 1999, and

Jamie Ferrell, July 5, 1999, Sexual

Assault Prevention and Crisis Services

Division, Office of the Attorney General,

Austin, TX; James A. Gilson, Deputy

Attorney General and Project Director,

New Jersey Sexual Assault Standards

Implementation Project; and Val Sievers,

SANE Coordinator, Colorado Coalition

Against Sexual Assault, CO, June 28,

1999.

27. Some communities may not have a

sexual assault victim advocacy program.

In these circumstances, SANEs should

identify community resources that can

help victims through this difficult period

(e.g., 24-hour crisis lines, counseling services and support groups, programs that

provide financial assistance, and victim/

witness programs that guide victims in

the justice system). They can also encourage the community to develop an advocacy program with a medical-legal advocacy

component. 

28. Most community-based sexual assault

advocacy programs have internal 

confidentiality policies that prohibit advocates from disclosing information about

victims to third parties without victim

consent—a protection based on state

statute in some states. If victims oppose

sharing requested information, advocates

typically will contest attempts to obtain

their records. If a subpoena is upheld despite challenges, however, an advocate

must disclose the requested information

or risk being held in contempt of court.

(Exceptions to these policies include

cases of sexual assaults of vulnerable

adults; sexual assaults of minors perpetrated by family members, caretakers, or persons in positions of authority over them;

and sexual assaults of minors that are the

result of parental neglect. Confidentiality

is also limited in cases with clients who

indicate that they are in imminent danger

of serious harm to themselves or others.)

29. Phone interview with Sharon

Moscinski, Advocacy Program

Coordinator, Santa Fe Rape Crisis

Center, Inc., Santa Fe, NM, June 25,

1999.

30. Phone interview with Sara Donohue,

June 25, 1999.

31. Phone interview with Gail

Hutchison, Sexual Assault Services

Coordinator, Virginians Aligned Against

Sexual Assault, Charlottesville, VA, 

June 17, 1999.

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS
32. Phone interview with Casteele, June

25, 1999.

33. Phone interviews with Debbie

Andrews, Executive Director, Rape,

Abuse and Incest National Network,

Washington, DC, June 24, 1999, and

Moscinski, June 25, 1999.

34. Phone interview with Mark Purcell,

Detective, Sex Crimes Unit, Alexandria,

VA, Police Department, June 24, 1999.

Purcell works with the SANE program at

Inova Fairfax Hospital in Fairfax, VA. 

35. Phone interview with Pat Calhoun,

Sergeant, Sex Crimes Unit, Tulsa, OK,

Police Department, June 25, 1999.

Additional comments by Calhoun in this

paragraph come from the interview.

36. Phone interview with Pat Groot, CoChair, National Alliance of Sexual

Assault Coalitions, Charlottesville, VA,

June 29, 1999.

37. Ledray, SANE Development and

Operation Guide, p. 22.

38. Ledray and Simmelink, “Sexual

Assault: Clinical Issues, Efficacy of SANE

Evidence Collection, A Minnesota

Study,” Journal of Emergency Nursing,

23(1), 1997, p. 76. 

39. Phone interview with Patricia A.

Smith of the Matanuska-Susitna Valley

Sexual Assault Response Team, Palmer,

AK, June 25, 1999.

40. Phone interview with Sandra

Sylvester, Assistant Commonwealth’s

Attorney, Office of the Commonwealth’s

Attorney, Prince William County,

Manassas, VA, June 1999.

41. James A. Gilson, Deputy Attorney

General, New Jersey Division of Criminal

Justice, Trenton, NJ, provided the information for this section on case law.

42. An upcoming OVC bulletin will further explore case law pertaining to SANE

testimony. 

43. Phone interview with Ledray, July 2,

1999.

44. Phone interview with Stacey Lasseter,

Coordinator, Forensic Nurse Examiners,

St. Mary’s Hospital, Richmond, VA, June

24, 1999.

45. Phone interview with Gilson, June

23, 1999.

46. Ledray, SANE Development and

Operation Guide, p. 50.

47. Phone interviews with McKenzie, July

14, 1999, and Ferrell, July 5, 1999.

48. Phone interview with Sievers, June

28, 1999.

49. Phone interview with Poarch, July 5,

1999.

50. Ledray, SANE Development and

Operation Guide, pp. 35–36.

51. Ledray, “Sexual Assault: Clinical

Issues, SANE Program Locations Pros

and Cons,” Journal of Emergency Nursing,

23(2), 1997, p. 183.

52. Ledray, SANE Development and

Operation Guide, p. 38.

53. Ibid., p. 39.

54. Phone interview with Poarch, July 5,

1999.

55. Phone interview with Kathy Bell,

Coordinator, SANE Program, Tulsa

Police Department, June 23, 1999.

56. Phone interview with Ledray, July 2,

1999.

57. Communications with Mary Szaro,

President, New Jersey Chapter of the

Association of Forensic Nurses.

58. Phone interview with Allen, June 22,

1999.

59. Ibid.

60. Phone interview with Ledray, July 2,

1999.

61. Phone interview with Bell, June 23,

1999.

62. Ledray, SANE Development and

Operation Guide, p. 38.

63. Phone interviews with Speck, June

22, 1999, and Parkinson, June 28, 1999.

64. Phone interview with Sievers, June

28, 1999.

65. Phone interview with Dunnuck, June

28, 1999.

66. Phone interview with Allen, June 22,

1999.

67. Ledray, SANE Development and

Operation Guide, p. 26.

68. Ibid., p. 25.

69. Ibid., p. 32.

70. Ibid. In these cases, medical facilities

may then either cover the remaining

costs or attempt to bill the victim for any

additional medical services.

71. Phone interview with Lasseter, June

24, 1999.

72. This section was drawn from a phone

interview with Brown, June 23, 1999.

73. Communication between D.

McDonald, Inova Fairfax Hospital,

Fairfax, VA, and Ledray, September 5,

OVC Bulletin

18
19

SEXUAL ASSAULT NURSE EXAMINER (SANE) PROGRAMS

About the Author

Kristin Littel is a consultant for the Office for Victims of Crime Training and

Technical Assistance Center. She has served as advocate for a center serving

battered and sexually assaulted women and as assistant coordinator for a sexual

assault program. At the Center for Sex Offender Management, she worked on

the Comprehensive Approaches to Sex Offender Management project. In

1999, she was editor of Washington Crime News and produced Crime Control

Digest for law enforcement professionals. As writer and coordinator of the

Promising Practices Initiative, Ms. Littel worked for the STOP Violence

Against Women Grants Technical Assistance Project and produced the manual Promising Practices: Improving the Criminal Justice System’s Response to Violence

Against Women.

NCJ 186366

1997. Information from Ledray, SANE

Development and Operation Guide, p. 101.

74. Phone interview with Brown, June

23, 1999.

75. Phone interview with Carol Odinzoff,

Nurse Coordinator, SART Unit, Bethel,

AK, June 28, 1999.

76. Phone interview with Smith, June

25, 1999.

77. Phone interview with Brown, June

23, 1999.

Preparation of this document was supported by the Office for Victims of Crime,

Office of Justice Programs, U.S. Department of Justice.The opinions, findings, conclusions, and recommendations expressed

in this document are those of the author

and do not necessarily represent the official position or policies of the U.S. Department of Justice.

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

Washington, DC 20531

Official Business

Penalty for Private Use $300

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