Introduction

Sexual assault evidence collection is the process of collecting specimens and documenting injuries of sexual assault victims to be used in a court of law. Forensic examination for evidence collection is performed in emergency departments 90% of the time and 10% in other locations such as urgent care, OBGYN, and primary care offices.[1][2] Sexual Assault Nurse Examiners (SANEs) often perform evidence collection.[3]

 The protocol for evidence collection is as follows:

1. Completion of consent and forms in the Sexual Assault Evidence Collection Kit (SAECK)
2. A thorough history involving recent genital procedures, symptoms since the assault, details of the assault, number of assailants, specific threats, type of penetration, nongenital acts, loss of consciousness, amnesia, and activities after the assault.
3. Control swabs
4. Toxicologic testing within 72 hours, especially if there is a loss of consciousness, to determine what drugs the patient used or ingested
5. Blood or saliva swabs for patient’s DNA
6. Oral swabs/smears if <24 hours since oral penetration
7. Fingernail scrapings if the patient was able to scratch the perpetrator
8. Foreign material collection is material that falls off patients when undressing. Collect sheets on the exam table and from an ambulance as evidence may be in the debris.
9. Clothing collection. If cutting clothes off the patient, providers should pay special attention to preserving holes in clothing and stains that would corroborate the use of force against the patient.
10. Examine the full body for injuries, lesions, and secretions. Document with photos when possible. If bite marks are present, swab the area twice.
11. Head-hair combings
12. Pubic hair combings
13. For female patients, examine for anogenital injuries in the lithotomy position. Take external genital swabs, vaginal swabs, and perianal swabs.
14. For male patients, examine penile and anal injuries. Take penile swabs, urethral swabs, and anorectal swabs.
15. Complete forms and seal envelopes inside the sexual assault evidence collection kit with specimens.[3]

The examiner should go through each step with the patient before performing them and then allow the patient to decline individual steps. The patient must provide written and verbal consent to the forensic exam, and this becomes problematic in the case of minors, elderly patients, and intoxicated patients. The exam's primary focus should be treating injuries before collecting evidence. The evidence collection process could take up to 6 hours by a trained professional. The optimal time frame for a forensic evaluation is within 72 hours of the assault to be able to collect as much DNA evidence as possible. However, a kit can still be useful in gathering evidence after this period, up to 7 days, due to advancements in DNA technology. Only physical and medical treatments are possible after this window of time, or if the patient does not give consent.[4]

Function

SANE programs have extensive support across the United States and show demonstrably improved patient outcomes. Outcomes include psychological recovery from the trauma, providing acute medical treatment, enhanced evidence collection, and improved prosecution of sexual assault cases.[5] A study involving 515 evidence kits was audited and divided into 2 groups, SANE and non-SANE, according to who completed the kits. When comparing SANE to non-SANE, the SANE SAECKs were more likely to be correctly sealed (91% SANE vs 75% non-SANE), to include the appropriate number of swabs (88% vs 71%), to include the proper number of blood tubes (95% vs 80%), and to maintain a completed chain of custody (92% vs 81%).[6]

However, there are issues with the accessibility and experience of SANEs across the United States, especially in rural communities. Rural communities have high rates of sexual assault (some as high as 30%), and most research on forensic examinations takes place in urban settings.[7] These programs are also limited in rural areas. This situation causes patients to travel a long distance to a rural hospital that provides forensic exams or go to an urban area. Unfortunately, this creates a vicious cycle where patients must travel to urban areas, but preliminary evidence suggests that telemedicine services for forensic examination may have a positive impact.[8] In rural areas, the lower caseload for SANEs places a burden on nurse examiners to find ways to maintain their competencies and skills. Also, it creates a burden on hospitals to staff and pay for an underutilized program.[7]

Another issue of concern with forensic examination is the significance juries place on having DNA evidence. Since the arrival of crime scene investigation television shows, there has been this impression that collecting DNA evidence is easy and quick. This notion is wildly misleading; DNA evidence is usually challenging to obtain and takes extensive time to process. In a study on forensic evidence found in sexual assault cases, only about 55% of cases that reported penetration and ejaculation found spermatic material.[9] The processing of evidence also needs to be standardized for the best outcomes. Hospital laboratories may use alcohol or betadine to process samples, compromising the report's integrity. Meanwhile, state laboratories where evidence is normally processed know which chemicals to use and which to avoid during the processing.[10] While other forms of forensic evidence are often available, attorneys are less likely to move forward with prosecution without significant DNA evidence.[7][11]

Pediatrics is another issue of concern since pediatric sexual assault is much less studied and cared for in the ED in comparison to adult sexual assault. Few SANE programs are designed with the pediatric patient in mind, so some cases are not being cared for appropriately. Older children and young adults are more likely to receive appropriate STI and pregnancy screening and treatment than younger patients; this is likely due to the lack of protocol for treating pediatric patients in the forensic process. Also, due to a patient's age and developmental level, it may be difficult to consent and comply with a forensic exam.[12]

Issues of Concern

According to 2019 data collected by the US Department of Justice, sexual assault occurs every 73 seconds in the United States and every 9 minutes for pediatric victims. The lifetime rates of sexual assault are between 17 to 18% for women and 3% for men. These numbers are likely under-estimations of the true values and do not account for rates of LGBT sexual assaults, for which the rates are higher. This demonstrates that sexual assault has a clinically significant impact on patients, of which physicians, nurses, and other healthcare practitioners need to be cognizant, especially in the documentation and forensic examination of these patients. Particularly because a SANE response team is not available at every healthcare location, providers should be familiar with the process and locations where patients can receive a referral for examination.[13]

Initial evidence for SANE programs has suggested improved outcomes in patient psychological recovery, treatment, evidence collection, and prosecution of cases. However, there is still a need for more rigorous and standardized procedures for SANE program assessment.[5] A review comparing the historical control of no SANE practitioner to SANE practitioners in pediatric emergency departments found improved quality of care in cases managed by pediatric SANEs. This improvement included testing for STIs, documentation of injury, and pregnancy assessment.[14]

Forensic examination demonstrates the intersectionality of medicine and law. One of the most multifaceted issues facing the medical and judicial systems is obtaining just outcomes for victims of sexual assault. Even with the availability of specialized forensic evidence collection, many survivors of sexual assault do not complete a sexual assault evidence kit, and even fewer release the evidence to police for investigation.[15] Emergency departments are a common entry point into the healthcare system, especially for cases of sexual assault, so this location is of extreme importance to the medical-judicial system. Evidence collected during the forensic exam has a significant role in legal decision-making by the prosecution.[16]

Clinical Significance

The first step to treatment is taking care of the physical ailments. Once the patient is medically stable, measures are necessary for proper hospital monitoring and follow-up appointments. During the emergency department visit or initial encounter, the patient is taken care of by way of pain control, antibiotic prophylaxis for STDs, nutritional services, and sleep improvement strategies. It is essential to monitor the patient’s emotional and psychological well-being by ordering a psychiatric consult. These victims are at higher risk of psychosocial disturbances such as PTSD, depression, sexual dysfunction, and chronic substance abuse.[4]

Follow-up psychiatric counseling is suggested, as the victim can experience psychological reactions as well as behavioral and somatic manifestations. This condition is known as rape trauma syndrome and is the immediate post-assault period that can present in up to 16% of patients.[17] In the acute phase, also called the disorganized phase, the victim may experience sleep disturbances, generalized physical pain, and mood and eating disturbances. The victim usually feels a sense of disorganization in their lives, with fear and blame being the predominant constituents. The delayed phase of sexual assault can include phobias, nightmares, and flashbacks consistent with PTSD, but it can also result in sexual dysfunction, making intimacy challenging. Long-term consequences for these patients can be depression, chronic pelvic pain, and overall diminished quality of life; this is why it is imperative to have these patients follow up with a psychologist/psychiatrist who specializes in sexual assault cases. This process also includes screening for intimate partner violence since over half of sexual assault cases happen from a partner.[4]

Other monitoring strategies involve following up with an OBGYN or PCP and managing any physical complaints appropriately. The clinician can monitor any lingering infections or pregnancies during these follow-up appointments and give appropriate vaccinations. An appointment 2 weeks after the initial assault should be scheduled to check for STIs, along with a 6-week appointment for repeat pregnancy testing, HIV screening, and hepatitis C. Subsequent appointments at 12 and 24 weeks should be made for follow-up HIV and hepatitis C testing.[4] If the patient is pregnant at the time of the assault, an OBGYN should monitor the status of the fetus during the mother’s hospital stay. Gynecological trauma and physical abuse may have impacted the pregnancy.

Patients should receive an offer for legal counseling, even if they deny legal consultation during the initial evaluation. Although most patients decide not to press charges, a well-documented account of the assault, as done during a SANE exam, can aid in prosecution.[18] The provider has a duty to ensure accurate and complete medical records and maintain the chain of custody for evidence.[4] In patients where drug-facilitation is suspected or confirmed, confirmation of the type of agent used is via a UDS. This process helps identify what type of hospital monitoring is needed and withdrawal tactics to use. The most common substances used in a drug-facilitated sexual assault are flunitrazepam, gamma-hydroxybutyrate, and ketamine, although other agents such as benzodiazepines and opioids are also possibilities.[4] It is important to monitor the patient and optimize their hospital medications as the drugs metabolize and leave the body.

Enhancing Healthcare Team Outcomes

Working as a healthcare team leads to the best results in evidence collection and improves patient outcomes.