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SEXUAL ASSAULT FORENSIC EXAMINER PROGRAMGUIDELINESfor theCARE OF THE SEXUAL ASSAULT PATIENTSexual Assault Forensic Examiner ProgramOffice of the Attorney General6 State House StationAugusta, Maine 04333-0006207-626-8806January 2011
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SEXUAL ASSAULT FORENSIC EXAMINER PROGRAMThe following recommendations were developed by a subcommittee of the Sexual AssaultForensic Examiner Program Advisory Board. Reviewers included Sexual Assault ForensicExaminers, emergency department physicians, sexual assault support center advocates, andprosecutors. Many thanks to all who participated in the creation of the guidelines.Committee MembersPolly Campbell, RN, SAFE Program DirectorBarbara Covey, MDGloria DiSalvatore, RN, ME-SANE-ADottie MacCabe, RN, ME-SANE-AHannah Pressler, MHS, PNPReviewersDeb Cashman, Assistant District AttorneyCarmen Columbe, Assistant Attorney GeneralSue Hall Dreher, Executive Director, Sexual Assault Support Services of Midcoast MaineNancy Fishwick, PhD, FNP, Director, School of Nursing, University of MaineKathy Greason, Assistant Attorney GeneralRobin Matthews, RN, SANE-AGretchen Lajoie, Forensic Chemist II, Maine State Police Crime LaboratoryMary Lake, RN, ME-SANE-AJeanette Michaud, RN, SANE-AMelissa O‘Dea, Assistant Attorney GeneralPam Poisson, RN, ME-SANE-ATina Panayides, Esq.Kathy Parent, RN, ME-SANE –ALois Skillings, RN, CEO, Midcoast HospitalJoni Sephton, RN, ME-SANE-AJanice Stuver, Assistant Attorney General
Table of Contents
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Sexual Assault Forensic Examiner ProgramGuidelines for theCare of the Sexual Assault PatientTable of ContentsIntroduction . 1What is a Sexual Assault Forensic Examiner? .1What is the Need for the Guidelines .1Need for the SAFE Program .2Clinical Reference GuidelinesSection I: Adult and Adolescent Patients . 3Goals of the Sexual Assault Forensic Examination .3Criteria for Examination; Consent; Reporting Requirements .3Timing of Exam .3Consent.3Sexual Assault Nurse Examiner/Scope of Practice.3Mandated Reporting .4Intake.4Triage.4Assessment for Injury/Acute Medical Problems .4Avoid Loss of Evidence .4Call in Resources .4Protect Privacy, Comfort, and Confidentiality .5Examiner‘s Initial Contact with Patient .5Establish Rapport; Introduce Role of SAFE .5History and Documentation .5Relevant Legal Concerns.5General Principles .6Obtaining a history.6Asking questions .6Adolescent/Developmentally delayed patient .6Documentation forms.6Essential history components .6History of post-assault activities .7Medical history .7Examination .7General Principles .7i
Medical Exam and Evidence CollectionIntegration of Medical and Forensic Exam .8Patient comfort .8Conduct parallel medical/forensic exams .8Avoiding evidence contamination .9Ongoing consent .9Components of the forensic exam.9Double swab technique .9Urine, Blood and Emesis Specimen Collection .9When to Collect .9Minors .9Timing .10Method of collection .10Transport .10Packaging of Evidence, Chain of Custody, Kit Disposition .11Medical Treatment .11Pregnancy Prophylaxis .11STD Prophylaxis .12Discharge Planning .13Photodocumentation .13Documentation .14Billing .14Quality Improvement .14Section II: Pediatric Patients .15Mandated Reporting.15Use Available Resources .15History.16Pediatric Exam – General Principles .16Pediatric Exam – Who to Examine .16Pediatric Forensic Examination .17Pediatric Examination – Head to Toe Assessment .17Pediatric Genital Examination .17Prepubsecent Female &/or Young Adolescent Female .17Prepubescent Male/Young Adolescent Male .18Medical Interview of the Child .19Criteria for Focused Medical Interview .19General Principles of the Medical Interview .19Questions .19When NOT to Question .20Pediatric Exam: Sexually Transmitted Diseases.20Documentation .21Discharge Planning .21ii
Annotated GuidelinesIntroduction:The Problem . 23Incidence and Impact of Sexual Assault .23Sexual Assault Forensic Examiner Program.24Sexual Assault Response Teams .24Section I: Adult and Adolescent PatientsA. Goals of the Sexual Assault Forensic Examination .25B. Criteria for Examination; Consent and Reporting Requirements .25Timing and Collection .25Timing for the History and Physical .26Timing for Medical Treatment .26Consent .26―Anonymous‖ Reporting and Payment for Exam .28Consent and the Adolescent Patient .28Consent and the Unconscious Patient .28Sexual Assault Nurse Examiners & Scope of Practice .29Mandated Reporting .29Children .29Adults .29C Intake .29Triage.29Patient Assessment for Injuries and Medical Problems .30Strangulation .30Avoid Loss of Evidence .31Call in Resources .31SAFE; Advocate; Law Enforcement; Family & Friends .31Protecting Privacy, Comfort and Confidentiality .32D. Examiner‘s Initial Contact with Patient .32Establishing Rapport; Introduce Role of SAFE .32Gay, Lesbian, Bisexual, Transgender, Queer Patients .32Discuss Decision to Report to Law Enforcement .34Obtain Written Consent .34Payment for the Exam/Victim Compensation Fund .34E. History and Documentation .34Relevant Legal Considerations .34Hearsay Law .34Legal Definition of Gross Sexual Assault .34iii
General Principles .35Essential Components of the History of Assault.36Date and time of assault .36Place of assault .36Physical surroundings .36Number of assailants .36Description of the assailant(s) .36Description of the sexual acts .36Injuries inflicted .37Compulsion .37Weapon(s) .37Pain or other physical symptoms .37Injury to assailant .37Substances .37Loss of consciousness/memory loss .37Essential Components of History of Post Assault Activities .37Essential Components of Medical History .38F. Examination – General Principles .38Materials .38Maintain Chain of Custody .39Further General Principles .39G. Medical Examination and Evidence Collection .40Integration of the Medical and Forensic Exams .40Double Swab Technique .41Specific Instructions for Use of the Sex Crimes Kit.41Oral Examination, Swabs.41Nasal Swabs .42Debris Collection .42Clothing and Foreign Material Collection .42Skin Surface Assessment .43Dried Secretions and Skin Surface .43Secretions .43Bite Marks .44Known Head Hair Sample .45Fingernail Clippings/Swabbings .45Known Blood Collection .45Pubic Combing.46Known Pubic Hair Sample.46External Genital& Penile / Vaginal Exam .46Genital/Penile Swabbings .46Anal Examination, Swabs .47Vaginal Examination, Swabs .47Cervical Examination, Swabs .47Miscellaneous Evidence Collection .48Additional Swabs .48iv
H. Urine, Blood and Emesis Specimen Collections .48When to Collect .48Drug Facilitated Sexual Assault (Date-Rape Drugs) .48When Patient is a Minor & Drugs/Alcohol Involved .48Timing of Collections .48Method of Collection .49Urine Collection.49Blood Collection .49Emesis Collection .49I. Packaging of Evidence/Chain of Custody/Appropriate Kit Disposition .50Packaging of Evidence .50Tracking Labels .50Clothing Bags .50Collection Envelopes .50Evidence Inventory Sheet from Kit .50Anonymous Kit .50Patient Notification .50Chain of Custody .50Disposition of the Sex Crimes Kit .51J. Medical Treatment .51Pregnancy Prophylaxis.51Medications for Pregnancy Prophylaxis .52Lenonorgentrel (Plan B) .52Yuzpe Regimen .52Timing of Pregnancy Prophylaxis .53Testing Prior to Treatment .53Follow Up .53Sexually Transmitted Diseases (STD) .53Issue of Testing for STD Prior to Treatment .54Prophylactic Treatment for STDs .54Treatment Regimens for STD Prophylaxis .54Gonorrhea .54Fluoroquinolone Resistance .54Chlamydia .54Syphilis .55Bacterial Vaginosis and Trichomoniasis .55Hepatitis B .55Herpes Simplex/Genital Herpes .55Summary of STD Prophylaxis Guidelines .56Human Immunodeficiency Virus (HIV) .56HIV Testing .56HIV Post Exposure Prophylaxis (HIV PEP) .57Risk of HIV Transmission in Sexual Assault .57Evidence of Potential Benefit of HIV PEP .58HIV PEP: Risks/Costs/Compliance .58An Approach to the Question of HIV PEP .58v
Determine if Exposure meets Criteria for Evaluation .58Determine Source HIV Status or Risk Factors .59Recommendations for Treatment Based on Risk Stratification .59Guidelines Matrix .60Drug Regimens for HIV PEP.61Possible Two Drug Regimen .61Possible Three Drug Regimen .61Other Factors in Treatment .61Treatment Timing .61Duration of Treatment.61Patient Consent .61Starter Medication .61Testing.61Prior to Discharge .61Resources .61HIV Testing and Medical Follow-Up .62K. Strangulation .62L. Discharge Planning .63Medical Discharge Instructions .64Safety Planning .64Transportation .64Emotional Support .64Mental Health.64Resources and Referral .64Coordination of Follow Up .64Sexual Assault Support Centers .64Investigative Process .65M. Photodocumentation .65Patient Identification .66Photo Clarity .66Scale .66Orientation of Photos .66Follow-up Photos .67Accountability .67N. Documentation .67O. Billing.67P. Quality Improvement .68Q. Special Considerations.68Cultural Differences and Language Challenges .68Patients with Disabilities.69Male Patients .70Older Patients .70vi
AppendicesAppendix A – Body Maps .73Appendix B – Sample Medical/Forensic Exam Paperwork .89Appendix C – Community Resources.109Sexual Assault Resources .109Domestic Violence Projects .111HIV Information & Support – National /State Toll-Free Information .113Anonymous HIV Testing .113Confidential HIV Antibody Testing & Counseling Sites .114Sexually Transmitted Disease Testing Sites .117Viral Hepatitis Testing Sites .119Viral Hepatitis Vaccine Sites .119Services for Gay, Lesbian, Bisexual, Transgender & Questioning Youth .121Mental Health Crisis Hotline .123Reporting Abuse and Neglect .123Maine State District Attorney Offices .125Family Planning Association of Maine Clinic Listings .127DHHS Regional OfficesOffice of Adult with Cognitive and Physical Disabilities .131Appendix D – Maine Laws and Rules .133Title 25 Internal Security and Public Safety .133Maine Court Rules, Maine Rules of Evidence .135Hearsay .135Title 22 Health and Welfare .136Chapter 260: Consent of Minors for Health Services .136§1823. Treatment of minors .137§3577. Persons mandated to report .137§4011-A Reporting of suspected abuse or neglect .138Collection of Forensic Evidence from an Unconscious Patient .145Appendix E – Bibliography .149vii
IntroductionTAB
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Sexual Assault Forensic Examiner ProgramGuidelines for theCare of the Sexual Assault PatientIntroductionThe care of the patient who has suffered the trauma of sexual assault or sexual abuse calls forspecialized knowledge and training to appropriately meet the emotional and medical needs of thepatient, while also addressing the forensic requirements of the criminal justice system. The Stateof Maine recognizes the importance of a timely, victim-centered medical-forensic exam. Thisapproach can minimize the patient‘s trauma, may promote healing, and increases the accuracyand sensitivity of evidence collected.For many reasons discussed below, we believe Sexual Assault Nurse/Forensic Examiners are thebest providers to deliver that care. These guidelines, however, are intended not only for SexualAssault Nurse/Forensic Examiners but also for any health care provider who may need toprovide care for the sexual assault patient.What is a Nurse/Forensic Examiner (SANE/SAFE)?A Sexual Assault Forensic Examiner is a health care provider who has been specially trained toprovide comprehensive care for the sexual assault patient, demonstrates competency inconducting a forensic exam, and has the ability to be a fact and/or expert witness in court. Themajority of these providers are registered nurses with specialized training (Sexual Assault NurseExaminers
What is a Nurse/Forensic Examiner (SANE/SAFE)? A Sexual Assault Forensic Examiner is a health care provider who has been specially trained to provide comprehensive care for the sexual assault patient, demonstrates competency in conducting a forensic exam, and has the
