What do nurses need to know about caring for a patient who has been sexually assaulted and working with a sexual assault nurse examiner (SANE)?
Carrie Edwards, PhD, RN, AFN-BC, CA-CP SANE; Donna Scott Tilley, PhD, RN, CA-CP SANE, Faan; and Beth Maeker, BSN, RN, CA-CP SANE, SANE-A, SANE-P respond-Sexual violence, which is sexual contact or behavior that occurs without the explicit consent of the victim or against someone unable to provide consent or refuse, is a pervasive healthcare problem in the US.1 Researchers estimate that about 1 in 4 women and about 1 in 26 men have experienced completed or attempted rape.1 When a patient has experienced sexual assault, a SANE and the nurse assigned to the patient collaborate closely to provide care and help the patient toward recovery. A SANE is usually called after the patient is admitted to the ED. There are key points that a SANE would want nurses to know.
If the patient comes in immediately after the assault, do not ask them to change into a hospital gown or give them anything to eat or drink as there may be evidence on their clothes and in their mouth that the SANE can collect. Instead, offer a warm blanket, which is a comfort measure that does not affect forensic specimen collection. If they need to use the restroom before the SANE arrives, collect a urine specimen and save it for the SANE.
Patients do not always come to the ED immediately after a sexual assault. This can be due to many reasons, but research indicates that victims often know their attacker and may not see themselves as victims.2 When they tell friends or family members about the incident, they may be encouraged to seek a SANE exam. Ideally, the exam is done immediately after the assault. Most jurisdictions require that evidence be collected between 5 and 7 days following the assault.
One of the first calls to be made, with the patient's permission, should be to the local crisis center or advocacy agency if available. An advocate can be very helpful to both the nurse and the patient. If an advocate is not available, a chaplain, social worker, or child life specialist can be called, depending on the patient's needs and preferences. The advocate becomes a member of the patient's care team and will stay with the patient for the entire ED visit if the patient prefers.
The patient's permission should also be obtained before notifying law enforcement. Patients who have been sexually assaulted may not want to involve law enforcement. They may just want to have someone like a SANE assess for any physical injuries and make sure that they do not contract a sexually transmitted infection (STI) or have an unwanted pregnancy as a result of the assault. The United States Violence Against Women Act (VAWA), passed in 1994, creates and supports comprehensive, cost-effective responses to sexual assault, intimate partner violence, dating violence, and stalking.3 VAWA also allows for sexual assault exams without requiring law enforcement involvement.3 The Violence Against Women Reauthorization Act of 2013 has made it easier for patients between the ages of 18 and 65 years to have a nonreport option,4 which means evidence is collected and stored but the patient is given the option to report the assault to law enforcement at a later date. If the patient chooses to notify law enforcement, the nurse should call those with jurisdiction over where the assault occurred. At times, the SANE is the one who notifies law enforcement. It is also possible for patients to change their minds about reporting the assault after they meet with the SANE.
Depending on state laws, reporting a sexual assault or possible sexual assault of a child or vulnerable adult may be required. In either case, the nurse can collaborate with the SANE to make sure that appropriate reporting is done.
The nurse should perform a thorough physical assessment and document findings. Sometimes when nurses hear the words "sexual assault," they immediately stop looking for other injuries. Patients who have been sexually assaulted may have injuries from the assault that must be treated before a sexual assault exam is conducted. It is important to rule out injuries such as head trauma or fractures before the patient is seen by the SANE.
While the nurse should ask the patient about where they might be injured, the nurse should avoid asking the patient to recount the details of the assault. The patient will need to repeat their story, which often includes details they may consider embarrassing, to the SANE and possibly to law enforcement. In order to understand where injuries and pieces of evidence might be and how to best treat the patient, the SANE must ask detailed questions that might include questions about where penetration occurred (vaginal, anal, oral); if the alleged perpetrate was male and if he ejaculated and where; and how recently the victim engaged in consensual sex, so investigators can disregard a consensual partner's evidence that may also be collected.
Patients may also find it very difficult to describe the event, so it is best to minimize the times they have to do so. If the patient volunteers details of the assault, listen without asking for further details. People who have experienced trauma, such as sexual assault, may have difficulty recalling details and may tell their stories in a way that seems to leave out details.5 This may cause the healthcare professional to doubt the veracity of the patient's story; however, the healthcare professional must remember that the patient is experiencing symptoms of trauma. It is important to let the patient speak without being interrupted and tell their story in the order that makes sense to them.
In addition to a thorough exam and evidence collection, various lab testing is often completed. Screening for STIs is not necessary when prophylactic treatment is to be given, as is often the case. Lab testing should include pregnancy testing in females of childbearing age. A negative pregnancy test is required for patients who want emergency contraception. Baseline serology for syphilis and hepatitis B may be useful, and HIV counseling should be provided. Drug screening may be warranted if the victim was found unconscious or experiences amnesia at any time surrounding the event.6
The SANE will usually discuss the exam findings with the ED nurse and physician or advanced practice clinician. They will also discuss treatment options, such as prophylaxis for STIs and emergency postcoital contraception, postexposure prophylaxis against HIV infection, and other needed interventions, including acute crisis counseling. In most cases, the patient can be discharged from the ED with recommendations for outpatient follow-up, including psychosocial counseling.
Caring for a patient who has been sexually assaulted requires thoughtful and clear communication between the healthcare team and the patient. When in doubt about the right approach, one can never go wrong with kindness and patience.
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