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GENERAL
INFORMATION |
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The Importance of Medical Care |
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Sexual Assault is NEVER the fault of the victim,
regardless of the circumstances. Every sexual assault
victim should have a medical check-up as quickly as
possible to determine whether the he or she has sustained
internal injuries that could lead to complications, to
determine the risk of pregnancy, and to collect evidence
of the sexual assault. A sexual assault victim can choose:
(1) no medical exam; (2) a medical exam for personal
medical care only; or (3) a medical exam for personal
medical care and to collect evidence of the sexual
assault. |
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The reasons vary as to whether a victim of a sexual
assault may or may not choose to report the assault. A
victim who remains uncertain about reporting has the
option of allowing the collection of evidence at the time
of the medical examination without making a report. |
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It should be made clear to the sexual assault victim that
although it is more difficult for the State to prosecute a
sexual assault case without the victim’s report or
cooperation, the decision to prosecute is the State’s and
not the victim’s. Note also that reporting by certain
professionals is mandated by law. Nevertheless, the victim
should be encouraged to consider both the possible
negative and positive consequences of reporting the
assault. |
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Negative Consequences |
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The assailant
may have threatened the victim and the victim will have to
deal with the fears he or she has about the threats. |
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In most
instances, a non-identified description of the assault
will be published in the local newspaper. However, there
are no guarantees that the victim’s name will not be
published. |
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A victim does
have not control over whether or not a crime of sexual
assault is prosecuted. The prosecution becomes the State’s
case with the victim as the State’s witness. |
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The victim may
find his or her lack of knowledge about the criminal
justice system intimidating or threatening. |
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There may be
long delays in court procedures. |
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Possible Positive
Consequences |
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Punishing the
perpetrator for the crime. |
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Stopping the
perpetrator from committing another sexual assault. |
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Having a
healthy way to channel anger. |
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Standing up
for the individual victim’s rights. |
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Talking about
the assault openly over time may assist the victim in
dealing with feelings of shame and embarrassment. |
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Reporting will
enable the police to pursue the assailant more
effectively. |
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If a victim
does not immediately report and changes his or her mind
later, the chances of a successful prosecution are remote. |
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Reporting may
assist the victim in regaining some of the feelings of
control that are because of the trauma of sexual assault. |
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Advocates are
available to assist the victim throughout the court
process. |
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The expense of
the medical exam may be covered under North Dakota’s Crime
Victim Reparation Act. |
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The SANE Program |
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A sexual assault examiner
performs the exam for the sexual assault. This is a broad
term used to describe the medical professionals who
perform the exam. Most often a nurse will collect all of
the evidence except for the evidence resulting from pelvic
exam. A physician will perform the pelvic exam and collect
the related swabs. Other healthcare professionals who can
perform the pelvic exams are Nurse Practitioners,
Physicians Assistants, or Sexual Assault Nurse Examiners
(SANEs). |
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A SANE is a Registered Nurse
or Nurse Practitioner who has completed training to
perform sexual assault examinations. The training
typically includes 40 hours of classroom information
specific to completing sexual assault exams, such as
chain-of-custody, forensic evidence collection,
documentation, courtroom testimony, sexually transmitted
diseases and preventative care, pregnancy risk and
prevention, working with special populations (males,
elderly, persons with disabilities), and cultural
specimens care. Another aspect of training includes
obtaining clinical experience with performing speculum
exams. |
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SANE programs have been
developed nation-wide throughout the last 25 years. SANE
programs were developed as medical and professional and
advocacy counselors recognized that the needs of the
sexual assault victim were not being met. The SANE
development and Operation Guide identifies these as long
waits in the ER lobby during which victims were not
allowed to drink or urinate due to fear of losing
evidence, ER staff with little or no orientation to
perform medical forensic exams, and physicians unwilling
to perform the exams. Nurses were already performing most
of the evidence collection and a few took it upon
themselves to improve the services for victims by
developing SANE. Currently in North Dakota, known SANE
programs operate in Williston and Fargo and are being
developed in Bismarck. |
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The role of the sexual assault
examiner is to perform a forensic examination on an
alleged perpetrator or victim of a sexual assault for the
purpose of evidence collection, documentation, and
preservation of evidence. The following professionals may
be utilized in the role of sexual assault examiner
(hereinafter “attending medical personnel”): |
Sexual Assault Nurse
Examiner
A registered nurse, R.N., who has advanced education in
forensic examination of sexual assault victims. |
Advanced Practice
Registered Nurse
A licensed advanced practice registered nurse with either
a graduate degree with a nursing focus or has completed
the education requirements in effect when the person was
initially licensed. N.D.C.C. § 43-12.1. The advanced
practice registered nurse has the authority to assess,
diagnose, and prescribe as defined in their scope of
practice. |
Physician
A medical school graduate with a completed a residency
program in a chosen specialty of practice. Must be
certified or eligible for certification in the chosen
specialty and licensed to practice in the state of North
Dakota. |
Physician Assistant
A graduate of an accredited physician assistant program
with a completed national certification exam. |
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Sensitivity to Victim Needs |
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Some sexual assault victims
suffer severe physical injuries, contract a sexually
transmitted or other communicable infection, or become
pregnant as a result of the attack. Many others do not. In
each situation, however, victims will experience varying
degrees of psychological trauma. The effects of this type
of trauma are more difficult to recognize than physical
trauma. |
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The perceptions of those
providing assistance to sexual assault victims of how a
victim should look, dress, or act and the way those
perceptions are conveyed can have a major effect upon
victim recovery processes in the weeks and months
following the crime. Each person has his or her own method
of coping with sudden stress. A severely traumatized
victim can appear to be calm, indifferent, submissive,
jocular, angry, or even uncooperative and hostile toward
those who are trying to help them. However, all of these
responses are within the normal range of anticipated
reactions. |
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All responses to information
concerning the circumstances surrounding the assault or a
misinterpretation of a victim’s reaction to the assault
may lead to further traumatization and hinder the
interview or evidence gathering process. |
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Victim Populations |
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The Female Victim |
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The age of the female victim
is an important factor to consider when responding to any
victim of a sexual assault. It is also an important factor
when determining the proper method of administering an
interview, conducting a medical examination, and/or
providing psychological support. |
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In certain cultures, the loss
of virginity is an issue of paramount importance as it may
render the victim unacceptable for an honorable marriage.
In other cultures, the loss of virginity may not be as
great an issue as that of the assault itself. Religious
doctrines may prohibit a female from being disrobed in the
presence of a male who is not her husband, or forbid a
genital examination by a male sexual assault examiner.
Such practices are considered a further violation. In such
circumstances, a female sexual assault examiner should be
made available for patients who request them. |
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The Male Victim |
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It is believed that only a
small percentage of male victims of sexual assault report
the crime, or seek medical care or counseling. Although
many adult males do not seek medical care unless they also
have been seriously injured, more male child victims are
now being seen at hospitals in increasing numbers. |
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There has been significant
progress in educating the public toward an understanding
of the concept of sexual assault of both sexes as an act
of violence. However, there still remains a great
reluctance on the part of many male victims to report a
sexual assault. Present social and cultural values can
increase the trauma of the reporting experience by the
male victim. |
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The male victim may have
serious trauma because of concerns over his inability to
resist the assault or confusion about the nature of his
role as victim/participant because of a possible
involuntary physiological response to the assault, such as
stimulation to ejaculation. It is important for males to
be reassured that they were victims of a violent crime
that was not their fault, and that other sexually
assaulted males survive to function normally in every way.
Referrals to available therapists or advocacy groups with
expertise in the area of sexual assault of males are vital
to assist in the recovery process. |
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The Child Victim |
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Many of the forensic issues
apply equally to adult and child victims of sexual
assault. However, the needs of child victims of sexual
assault are different than those of an adult. Particular
issues regarding the needs of the child victim are
discussed in the Child Protocol section below. While this
section is included to assist child victims and those that
respond, the collection of evidence is only once aspect of
investigating child sexual assault. The dynamics involved
in caring for child victims are too many to sum up in a
few paragraphs. It is the recommendation of the 2001 team
that a pediatrician collect evidence from a child victim. |
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The Gay or Lesbian Victim |
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As with all persons who have
been sexually assaulted, victim’s recovery depends upon
their support network and the response of individuals to
their report of sexual assault. Gay and lesbian victims of
sexual assault confront issues similar to all victims of
sexual assault. They may question whether the assault was
their fault, question their sexuality if they were
assaulted by a perpetrator of the opposite sex, fear
pregnancy if a female, or fear contracting an Sexually
Transmitted Infection. It is important to individuals
responding to sexual assault to have sorted through their
feelings about same gender relationships so that they can
treat victims with dignity, respect, and compassion. |
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The Elderly Victim |
As with other sexual assault
victims, the elderly victim can experience extreme
humiliation, shock, disbelief, and denial. However, the
full emotional impact of the assault may not be felt until
the victim is alone after his or her initial contact with
advocates, attending medical personnel, and the police. It
is at this time that older victims must deal with having
been violated and possibly made ill, and when they become
more acutely aware of their physical vulnerability and
mortality. Fear, anger or depression can be especially
severe in older victims who many times are isolated, have
no confidant, and live on fixed incomes.
In general, the elderly are physically more fragile than
the young, and injuries from an assault are more likely to
be lifethreatening. In addition to possible pelvic injury
and sexually transmitted infections, the older victim may
be more at risk for other tissue or skeletal damage and
exacerbation of existing illnesses and vulnerabilities.
The recovery process for elderly victims also tends to be
lengthier than for younger victims. |
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Hearing impairment and other
physical conditions attendant to advancing age, coupled
with the initial reaction to the crime, often render the
elderly victim unable to make his or her needs known. This
may result in an unnecessarily prolonged period before
reporting and inappropriate treatment. It is also not
unusual for hospital and law enforcement personnel to
mistake this confusion and distress for senility. |
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Medical and social followup
services must be made easily accessible to older victims,
or they may not be willing or able to seek or receive
help. Without encouragement and assistance in locating
services, the majority of older victims may be reluctant
to proceed with the prosecution of their offenders. |
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The Disabled Victim |
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Criminal and sexual acts
committed against persons who are disabled (physically,
mentally, or communicatively) generally are unreported and
seldom successfully prosecuted. Offenders are often family
members, caretakers, or friends who repeat their abuse
because their victims are not able to report the crimes
against them. |
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The difficulty of providing an
adequate response to the sexual assault victim is
compounded when the victim is disabled. Some have limited
mobility, cognitive defects which impair perceptual
abilities, impaired and/or reduced mental capacity to
comprehend questions, or limited language or communicative
skills to tell what happened. They may be confused or
frightened, unsure of what has occurred, or they may not
understand that they have been exploited and are victims
of a crime. |
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Disabled victims and their
families should be given high priority and attention in
the emergency room situation. Additional time should be
allotted for evaluation, medical examination and the
collection of evidence. The physically disabled victim may
be more vulnerable to a brutalizing assault and may need
special assistance to assume the positions necessary for a
complete examination and collection of evidence.
Improvisation of guidelines may be indicated in some
instances. |
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In sexual assault cases
involving the communicatively disabled victim, the use of
anatomically correct dolls has proved to be a successful
method of communication. Also, under § 504 of the Federal
Rehabilitation Act of 1973, any agency (including
hospitals and police departments) that directly receives
federal assistance or indirectly benefits from such
assistance, must be prepared to offer a full variety of
communication options in order to ensure that
hearingimpaired persons are provided effective health
care services. This variety of options, which must be
provided at no cost to the patient, also includes an
arrangement to provide interpreters who can accurately and
fluently communicate information in sign language and in
languages other than English. |
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Finally, referrals to
specialized support services and reports to law
enforcement agencies are particularly necessary for the
developmentally and physically disabled who may need
protection, physical assistance or transportation for
followup treatment and counseling. |
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The Refugee or Immigrant
Victim |
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Refugees and immigrants
seeking political asylum in the United Stated may be
particularly vulnerable to victimization. Perpetrators may
rely on their limited ability to communicate, their legal
residency status, or their fear of reporting due to
previous incidents with police in their home country. Many
refugees and immigrants may have faced torture and/or
sexual assault as part of the political conflict in their
home country. As a result, the trauma inflicted by an
assault in the United States may lead to reliving previous
assaults. |
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Extra care must be given to
refugees and immigrants since the likelihood of them
revealing past torture is low. Often time medical
personnel were present during torture in their home
country and as a result, the medical attention to be
received in the United States may induce overwhelming
anxiety and fear in the victim. The medical procedures and
examination events should be explained so that the victim
clearly understands what is occurring and so they
understand that they may refuse any part of the process.
To reduce the occurrence of flashbacks, the victim should
be encouraged to keep their eyes open during the
examination process. Interpreters and specially trained
support persons should be available to support the victim. |
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The Victim Deceased |
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Death investigations sometimes
indicate an associated sexual assault. When such a case
arises, it is appropriate to collect specimens and
standards from the victim’s body during the postmortem
examination (autopsy). The Sexual Assault Evidence
Collection Kit described in this Protocol can be used for
deceased persons. The basic collection instructions can be
modified to require the collection of all necessary and
obtainable evidence specimens such as the known blood
sample, saliva sample, pulled head hair and pulled pubic
hair. It is important that evidence specimens are adequate
and representative, as the autopsy is the last opportunity
to obtain these specimens from a deceased victim. |
