Sexual Assault Forensic Examination Research Articles

Variation in rates of sexual assault crisis counsellor usage during forensic examination in California: an observational study

ObjectivesA critical asset to post-assault care of survivors is support from sexual assault crisis counsellors (SACCs). We sought to elucidate variation in implementation between California counties in SACC accompaniment during...

289 Utilization of Sexual Assault Forensic Examiners in Emergency Department Child Maltreatment Evaluations

289 Utilization of Sexual Assault Forensic Examiners in Emergency Department Child Maltreatment Evaluations

Compassion, collaboration, and community: Strategies for staff well-being.

Compassion, collaboration, and community: Strategies for staff well-being.

Characteristics of acute sexual assault care in New England emergency departments.

Interventions such as written protocols and sexual assault nurse examiner programs improve outcomes for patients who have experienced acute sexual assault. How widely and in what ways such interventions have been implemented is largely unknown. We sought to characterize the current state of acute sexual assault care in New England. We conducted a cross-sectional survey of individuals acute with knowledge of emergency department (ED) operations in relation tosexual assault care at New England adult EDs. Our primary outcomesincluded the availability and coverage of dedicated and non-dedicated sexual assault forensic examiners in EDs. Secondary outcomes included frequency of and reasons for patient transfer; treatment before transfer; availability of written sexual assault protocols; characteristics and scope of practice of dedicated and non-dedicated sexual assault forensic examiners (SAFEs), provision of care in SAFEs' absence; availability, coverage, and characteristics of victim advocacy and follow-up resources; and barriers to and facilitators of care. We approached all 186 distinct adult EDs in New England to recruit participants; 92 (49.5%) individuals participated, most commonly physician medical directors (n=34, 44.1%). Two thirds of participants reported they at times have access to a dedicated (n=52, 65%, 95% confidence interval [CI], 54.5%-75.5%) or non-dedicated (n=50, 64.1%; 95% CI, 53.5%-74.7%) SAFE, but fewer reported always having this access (n=9, 17.3%; 95% CI, 7%-27.6%; n=13, 26%; 95% CI, 13.8%-38.2%). We describe in detail findings related to our secondary outcomes. Although SAFEs are recognized as a strategy to provide high-quality acute sexual assault care, their availability and coverage is limited.

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

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

Voices of Female Sexual Assault Survivors: Striving for Survivor-Centered Reporting Processes in the U.S. Criminal Justice System

In the present qualitative study, we analyzed voices of female sexual assault survivors to enhance the survivor-centered framework. We reviewed over 1,000 comments from a survey asking participants to share experiences following their sexual assault. Participants were 460 female survivors, including 163 reporters (those who reported their sexual assault to police officers) and 297 nonreporters. We identified four core themes ( safety, empowerment and choice, collaboration, and explanation of procedures) as desired characteristics for the five key response personnel groups: patrol officers, detectives, sexual assault forensic examiner nurses, State's Attorney's Office staff, and victim advocates. We identified the strengths and weaknesses of each group based on the shared experiences of culturally marginalized and nonmarginalized reporters. A general free-text question answered by participants reflected on the four core themes, but also stressed the need for multiple layers of intervention in responding to sexual assault, as seen in two secondary themes ( extra support and systemic change). Nonreporters also stressed barriers to reporting and regrets about not reporting. The power of survivors’ narratives can be used to guide the criminal justice system to uphold a truly survivor-centered approach. The complexities of gender and power inequality between the perpetrators, survivors, and response personnel should also be addressed.

Exploring child life specialists’ perspective on the role and benefits of child life in pediatric sexual assault forensic examinations

ABSTRACT The purpose of this study was to describe Certified Child Life Specialists’ (CCLSs) perspectives on their role and the benefits of their role during pediatric sexual assault forensic examinations (PSAFEs). Using a structured interview, discussed roles included preparing the patient for and supporting the patient during the examination and supporting the multidisciplinary team. Perceived benefits of child life services included increasing patient coping and completion of the examination, decreasing re-traumatization, and minimizing parent stress. The findings highlight how CCLSs feel they support the emotional safety of PSAFE patients and families. Thus, healthcare programs providing PSAFEs should consider staffing a CCLS.

Innovative Assessments for Retention of Sexual Assault Nurse Examiners.

The Southeast Kansas (SEK) comprehensive rural Sexual Assault Nurse Examiners (SANE) program was developed as part of an effort to increase the availability of SANE services nationwide. The primary goal of the program is to provide education to assist with training and certification of registered nurses and advanced practice registered nurses in SEK to conduct sexual assault forensic examinations and become certified. This will provide better physical and mental health care for survivors and better evidence collection and higher prosecution rates in a rural, medically underserved area. The project established a rural academic-practice-community partnership to provide longitudinal immersive SANE clinical training. The success of the project in SEK will be impacted by the retention of SANEs; therefore, the integration of the Professional Quality of Life (ProQOL) self-assessment was seen as an important component of the grant implementation. ProQOL determines compassion satisfaction, burnout, and secondary traumatic stress. The data collected from SANEs on their self-assessments with the ProQOL lead to early identification of SANEs experiencing negative effects of forensic nursing and the ability to intervene for decreased attrition.

Factors Affecting Telemedicine Implementation in Emergency Departments and Nurses' Perceptions of Virtual Sexual Assault Nurse Examiner Consultation for Sexual Assault Survivors.

Emergency department (ED) nurses play a critical role in caring for sexual assault patients, but many have not received training on how to conduct a proper sexual assault forensic medical examination. Live or real-time sexual assault nurse examiner (SANE) consultation provided via telemedicine (known as "teleSANE") during sexual assault examinations is a promising new practice to address this issue. The purpose of this study was to assess ED nurses' perceptions of influences on telemedicine use, as well as the utility and feasibility of teleSANE, and identify potential influences on teleSANE implementation in EDs. Guided by the Consolidated Framework for Implementation Research, this developmental evaluation involved semistructured qualitative interviews with 15 ED nurses from 13 EDs. Interviews revealed facilitators and barriers to current telemedicine use across Consolidated Framework for Implementation Research levels. Facilitators included state-level grant funding and technical assistance. Barriers included clinician discomfort being on video and access to ongoing training. Participants believed teleSANE consultation would improve patient care and forensic evidence collection but had concerns for patient privacy and acceptability. Most participants worked in EDs that have the information technology support and telemedicine equipment needed to support teleSANE implementation, although many requested ongoing education and trainings on teleSANE and sexual assault care to improve clinician confidence and account for high staff turnover. Findings highlight the unique needs of sexual assault survivors receiving telemedicine services in EDs, particularly those in rural communities with heightened privacy concerns and limited access to specialty care.

Sexual Assault Forensic Examiner Recruitment and Retention: Using Simulation to Teach a Trauma-Informed Interview.

Traditionally, sexual assault nurse examiner training focuses on examination skills and evidence collection. Gathering history and supporting the patient in a trauma-informed approach are equally important components of postassault care. Simulation is an established tool in healthcare education; however, there is limited research on applying simulation to the training of sexual assault nurse examiners. The Sexual Assault Forensic Examiner Recruitment and Retention program developed and delivered standardized patient-simulated scenarios to teach elements of trauma-informed sexual assault interviews. Simulation allowed trainees the opportunity to practice interviews and receive direct feedback from the standardized patient actor and experienced examiners. Evaluation results showed that learners valued this opportunity, endorsing that it improved their ability to conduct a forensic interview. This innovative program introduced a framework for training new examiners on trauma-informed interview techniques, using standardized patients.

Speculum examinations: Clinicians' attitudes and approaches to obtaining consent in a sexual assault context

BackgroundIn many countries, a forensic medical examination by a trained professional is offered to people who have experienced recent sexual assault. The consultation may include a vaginal speculum examination to visualise injuries and collect forensic evidence, but not all patients will consent to the examination. Clinicians’ attitudes to a speculum examination in a sexual assault context and the consequent wording when obtaining consent may influence uptake rates and ultimately health outcomes for sexual assault survivors. ObjectivesThis survey study identifies (i) factors affecting clinician attitudes towards the use of speculum examinations in sexual assault forensic medical examinations; (ii) situations in which they would offer a speculum examination; and (iii) approaches to seeking consent. MethodsAn online survey was sent to all eligible forensic examiners working in sexual assault services across New South Wales (NSW), Australia (n = 100), between August and September 2019. The survey recorded demographic data, experience with speculum examinations, opinions regarding the main purpose of the speculum examination, circumstances in which clinicians would offer a speculum examination, and the wording of their consent process based upon two detailed clinical scenarios (differing only in the hours elapsed since the assault (24 h vs 72 h)). A mixed method approach was used to analyse the data and was completed using SPSS and NVivo. ResultsOf the 100 invited participants, there were 32 respondents. Twenty-eight respondents (87.5%) stated that the main purpose of a speculum examination is to both check for injuries and collect evidence. Clinicians were more likely to offer a speculum examination to patients presenting with symptoms (i.e., pelvic pain, bleeding) or presenting more than 24 h after the event. Twenty-seven participants (84.4%) stated that patient-centred factors (i.e., time of presentation, patient comfort with speculum examination) were the main influences in whether they would/would not offer a speculum examination. Clinicians felt more comfortable performing speculum examinations in a forensic setting if they felt comfortable performing speculum examinations in a non-forensic setting (p = 0.004) and less comfortable as time increased from introductory sexual assault training (p = 0.0029). Eight participants (26.7%) would not offer a speculum examination acutely (< 24 h post assault) but only one (0.03%) would not offer it 72 h post assault. ConclusionsThis study is the first to explore clinicians’ attitudes towards the speculum examination component of the adult sexual assault forensic medical examination and provides foundations for future research. Current guidelines should be reviewed and updated to ensure that speculum examinations are routinely offered, rather than only when endocervical samples are being considered, to ensure potential injuries are not missed.

Sleep, waking and sleep inertia in sexual assault: A retrospective descriptive study

Women who wake from sleep during sexual assault commonly report confusion and disorientation. Confusion and disorientation, with impaired decision making after waking, are symptoms of ‘sleep inertia’, and part of the normal transition from sleep to full wakefulness which is maximal in the minutes after wakening and can be prolonged.In this study of 305 adult females (median age 26, range 18–68), who presented for a sexual assault forensic medical examination, 38 (12%) (median age 27, range 18–51) woke to find sexual acts already in progress. For 25 of these women (25/38 for 66%), an act of penile-vaginal penetration was already occurring when the woman woke.Of the 38 women (12%) who woke during the sexual assault, several had factors known to enhance the impairment of sleep inertia including forced arousal (38/38, 100%) and age under 25 (15/38, 39%).17 (17/38 for 45%) of these women who woke had consumed varying amounts of alcohol prior to sleep and these 17 woke fully during the assault and then stayed awake. A further 16 women, (16/38 for 42%) woke during the sexual assault but returned to sleep during or after the assault, and all these 16 gave a history of intoxication by drugs or alcohol prior to sleep.Importantly 5, (5/38 for 13%) of the women who woke during the assault had consumed no intoxicating substances.A further 68 (23%) of the 305 women, (median age 26, range 18–58) had no memory on waking of the alleged sexual assault despite having other reasons to believe that a sexual assault had occurred.Forensic medical examiners can assist both the justice process, and patient care, by considering the possibility of sleep inertia among victims who report disorientation and slow or confused decision making on waking during a sexual assault.

Evidence in forensic practice

Evidence supporting much of clinical forensic medicine practice is deficient or dated. This presentation highlights the results from two local research projects which looked at various aspects of the sexual assault forensic examination.1.Do they who slide first, slide best: Jurisdictions within Australia and internationally differ with regard to preference for who creates the smear from those swabs taken to find DNA from semen. This research sought to articulate the function of slide preparation in sexual assault and to identify whether slide preparation by the forensic examiner, at time of examination, was preferable to slide preparation by forensic laboratory staff, at a later date. It also provided a review of the limited research in this area and posed questions for potential future research.2.Patient perception of forensic imaging: Historically, photography used in forensic documentation of injuries (especially genital injuries), sustained during an alleged sexual assault, has been controversial. This study explored the immediate and short-term experiential impacts of forensic photography from the victims’ perspective and supports the case for the routine use of forensic photography, with patient consent.

Clinical forensic medicine and Covid-19 challenges: the melbourne experience

The rapidly evolving context of the COVID-19 pandemic necessitated profound modifications to the provision of healthcare services globally. The concomitant requirements of lockdowns and social distancing and their subsequent isolating effects had marked ramifications for vulnerable individuals at risk of violence. The experiences of conducting sexual assault forensic examinations of suspected and confirmed COVID-19 positive patients in Melbourne hospital COVID-19 hot zones are presented, including the development of a modified forensic examination protocol.

The Implementation of the Sexual Assault Forensic Examination Telehealth Center: A Program Evaluation.

Substantial disparities in the quality of post-sexual-assault (SA) care exist in the United States, particularly in rural areas. This study evaluates the implementation of the Sexual Assault Forensic Examination Telehealth Center, a program to improve SA care by increasing access to experienced sexual assault nurse examiners via telehealth, in three rural hospitals. The Dynamic Sustainability Framework (DSF) guided the implementation of the intervention. Survey and implementation data were evaluated 1 year after implementation using a nonexperimental pre-post design. Outcomes include patient and nurse perceptions of telehealth, local site nurse (LSN) confidence, and hospital protocol/policy changes. Forty-one telehealth consultations were completed in the program's first year. An average of 34 system-level protocol changes were made per site. LSNs demonstrated statistically significant increases in confidence to provide SA care at 1 year. LSNs and telehealth sexual assault nurse examiners (expert consultants) reported that quality of SA care improved (87% and 83%, respectively). Patients highly rated the care they received (83%), reported telehealth improved care (78%), and reported feeling better after the examination (74%). Using the DSF for implementation supported a tailored approach and successful adoption and also allowed for program iteration based on lessons learned. The Sexual Assault Forensic Examination Telehealth model resulted in improved local nurse confidence in provision of SA care, nurse perception of improvement in care quality, and high patient care experience ratings. These findings and the use of the DSF have implications for SA specialty care implementation in rural communities.

Supporting Children Experiencing a Pediatric-Sexual Assault Forensic Examination: Preparation for and Perceptions of the Role of the Child Life Specialist

To help minimize negative outcomes, child life specialists can provide psychosocial care to patients undergoing a pediatric sexual assault forensic examination (P-SAFE). This exploratory study used a survey to examine child life specialists’ perspectives on their preparation for and role in P-SAFEs. Participants reported their main duties with this population include procedure support, play, and building rapport. The benefits of having child life involved in P-SAFEs were noted as decreasing re-traumatization, increasing cooperation, increasing coping, and decreasing stress and anxiety. Participants reported that most child life services were provided in preparation for the exam and during the exam. The services utilized were preparation, play, and distraction to help patients cope. Results indicated child life specialists felt valued by the multidisciplinary team, especially for their role in procedure support. Lastly, child life specialists reported training for this role occurring most often through informal on the job training. In summary, child life specialists acknowledged the stressors associated with a P-SAFE and perceived their role as beneficial in minimizing such stressors. Health care facilities that provide P-SAFEs should further consider the benefits of child life services to these patients and advocate for their services during P-SAFEs.

Discriminating between consensual intercourse and sexual assault: Genital-anal injury pattern in females

BackgroundAssessment of genital-anal (GA) injuries following sexual assault promotes health and assists prosecutors to build a case. The pattern of injuries may help differentiate between consensual and non-consensual intercourse, bolster the survivors' credibility, and increase prosecutions in sexual assault cases. ObjectivesTo identify the constellation of G-A injury-related characteristics that most effectively discriminated between consensual sexual intercourse and sexual assault in females when controlling for intercourse-related variables. MethodsWe employed a comparative study with two groups: a prospective cohort group with consensual participants and a group derived from an existing sexual assault registry. In the prospective cohort, we performed a sexual assault forensic examination at baseline and following consensual sexual intercourse with females ≥21 years. We compared their injury patterns to the injury records of females ≥21 years who were sexual assaulted. ResultsWe enrolled a sample of 834 females: 528 consensual (63.3%) participants and 306 non-consensual (36.7%) registry cases. After controlling for race/ethnicity, age, and time between intercourse and examination, logistic regression analyses showed that the presence of an external genital tear increased the odds of non-consensual intercourse more than two times (adjusted odds ratio [AOR] = 2.70, 95% CI = 1.28–5.56). Logistic regression analyses also showed that the odds of non-consensual sexual intercourse were significantly greater with a lower prevalence and frequency of external and internal genital redness, lack of condom use and lubrication, and presence of anal penetration. Latent class analysis identified high and low G-A injury prevalence subgroups among both consensual and non-consensual samples. One subset of results emerged that may be indicative of non-consensual as compared to consensual intercourse: a higher prevalence of external genital and anal tears. ConclusionExternal genital tears occurred more frequently in the non-consensual sample and increased the odds of non-consensual intercourse more than two times. Anal tears, swelling, and ecchymosis and anal penetration were markers for non-consensual intercourse and should increase suspicion for lack of consent.

Sexual assault examination and COVID-19: risk reduction strategies in conducting forensic medical examinations of a suspected or confirmed COVID-19 positive patient in Melbourne hospital hot zones.

The rapidly evolving context of the COVID-19 pandemic has necessitated profound modifications to the provision of health care services on a global scale. The concomitant requirements of lockdowns and social isolation has had marked ramifications for vulnerable individuals at risk of violence. This ripple effect of the pandemic has been observed globally. It is crucial that clinical forensic medical units continue to provide quality and timely essential services to those affected by interpersonal violence. As such, processes in this field must be modified as COVID-19 cases present and knowledge about the disease changes. The experiences of conducting sexual assault forensic examinations of suspected and confirmed COVID-19 positive (S/COVID-19) patients in a hospital hot zone are presented, and additional forensic issues specific to the emerging COVID-19 context are discussed.

Using Telehealth for Pediatric, Adolescent, and Adult Sexual Assault Forensic Medical Examinations: An Integrative Review.

Improved access to qualified nurse examiners to perform sexual assault forensic examinations is needed. This integrative review examines the current research literature on synchronous "real-time or live" telehealth support and guidance during pediatric, adolescent, and adult sexual abuse/assault forensic examinations. Informational databases (CINAHL, Health Source: Nursing/Academic Edition, Medline, PsychInfo, and Violence & Abuse Abstracts) were searched, and research articles including live telehealth for sexual assault survivors were reviewed (n = 98). Review of the articles resulted in the inclusion of seven studies that utilized live video telehealth during the sexual assault forensic examination. The current research literature supports the premise that synchronous telehealth is a promising modality for this patient population. However, the lack of large comprehensive studies warrants additional research to understand outcomes and develop best practices. Additional research studies are needed to evaluate the effectiveness, cost, and criminal justice impact of this intervention.

Factors Associated With Knowledge Retention 3 Months After a Sexual Assault Forensic Examiner Blended Learning Course.

A blended learning continuing education course may appeal to busy healthcare professionals because the primary content can be learned online while an in-person component can hone clinical skills. The current study assessed knowledge retention in a sample of healthcare professionals who participated in a nationwide sexual assault forensic examiner blended learning course (12-week online course and 2-day in-person patient simulation). Participants' characteristics, motivation, and external barriers were collected through a precourse web-based survey. Participants' knowledge was assessed through pretests and posttests for 12 modules and a 3-month postcourse examination. Utilizing repeated measures analysis of variance, the study examined whether participants retained their knowledge at the 3-month follow-up point. Multiple linear regression was utilized to explore the factors associated with knowledge retention. The results found a knowledge score from 77.92% to 68.83% correct. The findings indicate that participants who were interested in the blended learning course because of the 2-day patient simulation were more likely to retain knowledge. Learners with more years of experience also had slightly higher knowledge retention. Conversely, participants who were interested in becoming a sexual assault forensic examiner because of a sexual assault experience had lower knowledge retention. Participation in a past online course also was associated with a reduction in knowledge retention. The findings indicate a modest knowledge loss 3 months after the blended learning course. Still, some participants experienced less knowledge retention than others. Postcourse activities such as a brief refresher course may be useful to help these participants maintain their knowledge gains.