Improving Health Care Access for Survivors of Sexual Assault

Improving Health Care Access for Survivors of Sexual Assault

One in three women and one in four men have experienced sexual violence involving physical contact during their lifetimes,   according to the Centers for Disease Control and Prevention (CDC).

This type of trauma necessitates urgent medical attention from trained sexual assault nurse examiners (SANEs), yet several obstacles exist for many survivors seeking specialized care. Depending on where a patient lives, he or she may have to travel for hours to reach the closest available provider for a Sexual Assault Forensic Exam (SAFE)—a critical step when a patient decides to report an assault to the police.

“It’s very much a deterrent for rural [residents] to drive for any type of care,” said Pamela Biernacki, DNP, FNP-C, faculty member in the Georgetown University School of Nursing & Health Studies.

The gap in availability of appropriate care after a sexual assault affects the safety of individuals, families, and entire communities. Health care professionals, hospitals, and community stakeholders can make substantial improvements to SANE access.

How Many Sexual Assault Programs Are There?

Despite the prevalence of sexual assault in the United States and the need for SANE intervention, access to specialized care for survivors of sexual assault is limited.

The International Association of Forensic Nurses (IAFN) database of SANE providers shows that there are approximately 959 programs that offer SANE care in the United States. IAFN reported that 1,732 nurses are SANE-certified through their organization. Of those, about 1,230 nurses are SANE-A certified, meaning their training is specific to adults and adolescents, and 502 are SANE-P certified and are trained to work on pediatric cases. Approximately 381 nurses are dual-certified.

Nonetheless, research has shown that survivors lack access to SANE care. The GAO’s 2018 report on sexual assault and the availability of forensic examiners (PDF, 191 KB) reflects data from six states that served as case studies. Officials in every state reported a shortage of SANE providers, especially in remote areas.

“When you’re in some place like rural Colorado, the closest SANE program could be 100 miles away, or a two-hour drive,” Metz said.

Distance is a significant barrier for an individual who wants to be treated by a sexual assault nurse examiner. In a 2018 hearing on the availability of forensic exam kits in hospitals, New Jersey Congressman Frank Pallone Jr. explained that a survivor “must avoid bathing, showering, using the restroom, or changing clothes, or else risk damaging the evidence before it can be collected.”

These recommendations for preserving evidence leave an individual who lives hours away from a SANE-designated hospital with the options of experiencing extreme discomfort, risking the outcome of their forensic exam, or not receiving specialized care at all.

Why Do Survivors of Sexual Assault Need Specialized Care?

There were 298,410 instances of sexual assault in the United States in 2016, as reported by the Bureau of Justice Statistics (BJS) in a bulletin on criminal victimization (PDF, 669 KB). When any survivor seeks medical attention after an assault, they require care that addresses both physical and mental health needs.

Triage often includes a forensic exam, which calls for specific equipment and a clinician trained to perform the assessment. To facilitate this specialized form of care, some hospitals have implemented SANE programs that staff certified nurses to treat patients who require interventions tailored to their needs.

Designated SANE facilities can make a difference in a survivor’s path to healing, from initial assessment and treatments to the criminal justice process (should the survivor choose to report the assault). Studies have shown that exams performed by SANEs “may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates,” according to a 2018 report on sexual assault and the availability of forensic examiners (PDF, 191 KB) from the U.S. Government Accountability Office (GAO).

The BJS bulletin indicates that many survivors choose not to involve law enforcement—nearly 80% of sexual assaults went unreported in 2016. However, receiving treatment from a SANE who fully understands a patient’s trauma can make a substantial difference regardless of whether the results of a forensic exam are used in a criminal case, said Michelle Metz, SANE Coordinator for Denver Health.

“Sometimes we’re the only person who is there,” said Metz. “We bear witness. We may be the only person who says ‘I’m really sorry this happened to you. I’m really glad you came in.’”

Survivors who are unable to seek care from a SANE-designated facility may miss out on the diagnosis and treatment of infections related to their assault, as well as emotional support and guidance on follow-up care, Biernacki said.

SANEs often provide survivors with referrals for mental health care. In her professional experience as a Nurse Practitioner, Biernacki has observed the long-term effects of trauma, particularly among women, who did not seek out treatment immediately following their assault.

“Depression and anxiety are the [most prominent conditions] I’ve seen,” she said. “It also comes out in physical symptoms, like insomnia or gastrointestinal problems.”

In some cases, women Biernacki spoke with did not fully understand their experiences, underlining the need for more education on what to do in the case of a sexual assault. “Until we had a conversation after taking a thorough sexual history, [patients] didn’t realize that what they experienced is considered assault,” she said. “They had not identified it or did not want to take that emotional step to say, ‘Yes, I have been sexually violated.’”

What is Causing the Shortage of Sexual Assault Nurse Examiners?

A number of factors contribute to the scarcity of SANE care. Based on its findings, the GAO report on sexual assault and the availability of forensic examiners (PDF, 191 KB)  cited the following three barriers to increasing accessibility to SANE programs.

Lack of Funding from Hospitals or Law Enforcement

Officials in five of the six states selected for the GAO case study reported that obtaining support from key stakeholders was a challenge. For example, hospitals may be reluctant to cover the costs of training SANEs or to pay for SANEs to be on call.

Limited Availability of Training

In five of the six states, officials reported that the diminished availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of SANEs.

Clinical training requires 300 hours of SANE-related practice, which can be an obstacle in areas with smaller patient populations, said Jennifer Pierce-Weeks, CEO of IAFN.

“It can be difficult to establish competency as a sexual assault nurse examiner,” she said. “The classroom training [can be done] online or in-person, but then there is the clinical training which can be difficult for people to access.”

Low Retention Rates of SANEs

Officials in one of the selected states reported that while the state trained 540 SANEs during a two-year period, only 42 were still practicing in the state at the end of those two years, as a result of the challenges of working in a trauma setting.

Metz explained that in her experience as a SANE coordinator, “the nurses who do this work last either 18 months or more than five years.”

Biernacki emphasized the importance of establishing support systems for nurses, something that can be a challenge for smaller, rural facilities.

“With any type of burnout, it is about having that support,” she said. “But since [nurses] typically do work alone or have very few individuals that are part of that team, how do they build that sense of community and support?”

What Can Be Done to Improve Health Care Access for Survivors of Sexual Assault?

In the effort to improve access to sexual assault care, Biernacki said a good first step is to further educate student clinicians about this specialty and the needs of sexual assault survivors.

“We have started teaching about human trafficking, and we talk about intimate partner violence,” she said. Delving further into sexual assault would be an appropriate next step.

While there are currently no national guidelines on sexual assault care, state and federal legislators are making efforts to make this type of health care more accessible.

In 2018, the Survivors’ Access to Supportive Care Act (SASCA) was re-introduced in the U.S. Senate to expand access to qualified examiner services and develop national standards of care for survivors of sexual assault.

Further Information

Below are links to recent stories on SANE shortages in states across the US:

“It’s a public health crisis:” Indiana short-staffed on sexual assault nurse examiners

Lack of SANE nurse causing issues for sexual assault investigations (Michigan)

Critical shortage of sexual assault nurses in Ohio poses risk to survivors, cases

There’s a shortage of Sexual Assault Nurse Examiners (Pennsylvania)

There’s a Shortage of Sexual Assault Nurse Examiners in Kentucky

Not enough nurses have specialized training to handle rape victims in Missouri

Full-length article originally published by [email protected]

What Women Need to Know About Strokes and Heart Attacks

What Women Need to Know About Strokes and Heart Attacks

When it comes to serious health conditions like heart attack and stroke, women are more likely to be misdiagnosed and receive delayed care.

When Andrea thought she was having a heart attack and called 911, the emergency medical technicians told the 35-year-old Nashville, Tennessean that she was likely just experiencing a bout of anxiety.

“They made me walk outside, down my driveway to the ambulance. They never turned on the sirens or lights and stopped at every light on the way to the hospital,” she told Today. 

But Andrea was not having an anxiety attack. As it transpired, she had experienced a major cardiac event as a result of a spontaneous coronary artery dissection, an uncommon condition that can affect otherwise healthy individuals.

“The delay in my care caused me to have severe heart damage and heart failure that I am still living with” she said.

While Andrea’s condition is rare, her experience with emergency care is not.

How Are Symptoms of Heart Attack and Stroke Different for Women?

Myocardial infarction, more commonly known as a heart attack, occurs when the flow of oxygen-rich blood to the heart becomes blocked.

A heart attack can be caused by:

  • The full or partial blockage of an artery as a result of plaque buildup.
  • A coronary spasm, in which a coronary artery tightens and cuts off blood flow.

When people think of what a heart attack looks like, they might picture a man grabbing his chest and describing severe pain that extends to his arm. While chest pain is the most notable symptom of a heart attack, many people— especially women—experience less common symptoms. This can lead to misdiagnosis and delayed treatment among female patients.

According to a study from the American Heart Association, almost 62% of women who have a heart attack experience more than three non–chest pain symptoms, compared to 54.8% of men.

The perception of which symptoms necessitate emergency care can lead women to delay seeking treatment, which affects their chances of surviving and making a full recovery.

“If you have nausea and vomiting and back pain or epigastric pain … the first thing that comes to you is not, ‘I’m having a heart attack,’” said Melissa Frisvold, PhD, CNM, APRN, faculty at the Georgetown University School of Nursing & Health Studies.

Symptoms of Heart Attack in Women

Heart Attack warning signs in women
Less commonly known symptoms of heart attack that are more likely to be present in women than men include stomach pain, shortness of breath, chest palpitations, nausea, and dizziness.

Strokes in Women

For women, perceptions of symptoms can also affect treatment of another life-threatening condition — stroke.

Sometimes referred to as a “brain attack,” a stroke occurs when a clot blocks the blood supply to the brain or when a blood vessel in the brain bursts.

The three main types of stroke include:

  • Ischemic stroke — occurs when blood flow through the artery that supplies oxygen-rich blood to the brain becomes blocked.
  • Hemorrhagic stroke — caused by a leak or rupture in an artery in the brain.
  • Transient ischemic attack — also referred to as a “mini-stroke,” blood flow to the brain is blocked for a short time and is a warning for future stroke.

In a 2014 study, researchers found that women experiencing a stroke were at greater risk than men for misdiagnosis in the emergency room. They attributed this disparity to a greater frequency of non-classic stroke presentations, including headache and dizziness.

In addition to having misinformation about symptoms of heart attack and stroke, Frisvold said women may also put more focus on other health risks that they perceive to be bigger threats.

According to the Centers for Disease Control and Prevention’s (CDC) report on the leading causes of death in 2017 (PDF, 2.4 MB), women were most likely to die as a result of heart disease, followed by cancer. Stroke was the fourth-leading cause of death in women.

“Women worry about breast cancer or cervical cancer,” she said. “But heart disease is the leading cause of death in women, not breast cancer or cervical cancer.”

Symptoms of Stroke in Women

Stroke symptoms in women
Less commonly known symptoms of stroke that are more likely to be present in women than men include loss of consciousness, general weakness, difficulty breathing, disorientation, sudden behavioral change, hallucination, nausea or vomiting, seizures, and hiccups.

How Does Gender Affect Health Care?

The misdiagnosis of heart attack and stroke in women is part of the larger issue of gender bias in health care. This stems in part from how clinical research has been performed in the past, which informs how care is provided to patients today.

In a research study on sex bias in clinical studies from the Allen Institute for Artificial Intelligence, researchers examined medical research from 1993 to 2018 and found that women were underrepresented subjects in the research of several health conditions, including cardiovascular health.

“Women worry about breast cancer or cervical cancer, but heart disease is the leading cause of death in women.”

— Melissa Frisvold, PhD, CNM, APRN

Another study on clinical trials for stroke treatment indicated that women were underrepresented in such trials, leading to suboptimal conclusions for women in outcomes and stroke care delivery.

Implicit Bias Affects Treatment

The exclusion of marginalized groups, including women and people of color, may lead to a misunderstanding of the many ways a health condition can present itself and how it should be treated. “Medical bias,” a term for that disparity, refers to cases in which an individual may receive different care from a provider who is unknowingly acting on partial judgement.

The consequences of implicit bias in health care can be seen in how women receive treatment in comparison to men in life-threatening situations.

For example, a study from the American Stroke Association found that in cases of ischemic stroke, men were more likely than women to receive ultrafast Alteplase administration, a clot-busting drug that helps restore blood flow to the brain.

Additionally, in the aforementioned study from the American Heart Association, 53% of young women (aged 18 to 55) said their health care provider did not think their initial symptoms were heart-related, compared to only 37% of young men who said their provider got it right. These researchers also discovered a pattern in female patients who said they hesitated to seek help because they feared being labeled a hypochondriac.

Because of women’s experiences with the health care system, these biases may affect how women view their own health.

How to Advocate for Women’s Health

Women, their family members and friends, and even bystanders can take steps to help improve care for heart attack and stroke. From advocating for oneself in the emergency room to taking action when someone is in distress, the following resources are a starting point for women’s health advocacy.

How to Communicate With Your Clinician

Women sometimes express that they do not feel heard by their provider when sharing health concerns. Frisvold provided these tips for self-advocacy:

BRING A FRIEND OR FAMILY MEMBER

Another person can provide support, ask additional questions, and help navigate the treatment process.

BE DIRECT

If an individual believes he or she may be having a heart attack or stroke, being prepared to specifically communicate all concerns to the clinician can help.

ASK QUESTIONS

Engaging in dialogue allows for an individual to push back in a way that is specific and may help a provider check his or her bias.

DON’T LET SELF-BIAS GET IN THE WAY

“When you talk to somebody who had a heart attack, they [often] say, ‘I just knew something wasn’t right, but I just kept trying to downplay it.’ You’re better off going to the emergency room and finding out it was nothing than to err the other way,” Frisvold said.

How Bystanders Can Take Action in Health Emergencies

When another person appears to be experiencing a heart attack or stroke, there are steps you can take to help improve the chances of a positive health outcome:

DON’T HESITATE TO CALL 911

“Time is of the essence,” Frisvold said. “Those early moments are critical. Take steps early in the process to improve the health outcome of the person experiencing a heart attack or stroke.”

ASK QUESTIONS

If a stroke is suspected and the person is conscious, the bystander should ask what symptoms the individual is experiencing so the information can be shared with emergency responders if the situation worsens and requires an advocate.

GIVE CPR IF NEEDED

A 2019 study showed that women were less likely to receive CPR from a bystander than men. This step is critical in cases where an individual goes into cardiac arrest while waiting for emergency response. If the bystander has no CPR training, a 911 dispatcher can provide guidance in performing chest compressions.

Resources for Further Reading

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

The Problem of Pain: Prescribing Opioids to Addicted Populations

The Problem of Pain: Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

Opioid Dependence and Addiction in the United States

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence
  • Taking painkillers more frequently than prescribed
  • Taking higher doses than prescribed
  • Seeking a euphoric effect to counter physical pain
  • Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Commonly Used Alternatives to Opioids

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Pharmacological alternatives to opioids

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Acetaminophen can be used for pain relief and fever reduction, but it does not reduce inflammation. It’s one of the most common pain relievers among Americans, used by roughly 23% of adults each week.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can treat acute pain and inflammation. A 2018 report found that NSAIDs make up 5% to 10% of all medications prescribed each year.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids
  • Localized numbing
  • Ice
  • Massage
  • Exercise
  • Physical therapy
  • Acupuncture
  • Relaxation

Supporting Patients in Recovery

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully. Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors:

Common Drug-Seeking Behaviors
Requests and complaints
  • Describing a need for a controlled substance
  • Asking for specific opioids by brand name
  • Requesting to have a dose increased
  • Citing multiple allergies to alternative pain therapies
Inappropriate self-medicating
  • Taking more doses than recommended by the provider
  • Hoarding a controlled substance
  • Using a medication despite not being in pain
  • Injecting an oral formula instead of consuming orally
Inappropriate use of general practice
  • Visiting multiple providers for controlled substances
  • Calling clinics when providers who prescribe controlled substances are on call
  • Frequent unscheduled visits, especially for early refills
  • Consistently disruptive behavior
Patterns of resistance
  • Hesitancy to consider alternative pain treatments
  • Declining to sign controlled substances agreement
  • Resisting diagnostic workup or consultation
  • Being more interested in the medication than solving the medical problem
Illegal activity
  • Obtaining controlled drugs from family members or illicit sources
  • Using aliases or forging prescriptions
  • Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

  1. Get to know the patient
  2. Use analgesics to address pain symptoms
  3. Use non-pharmacological treatments as intervention for side effects
  4. Encourage patient to stop smoking and drinking alcohol
  5. Eliminate foods that irritate the stomach or digestive system
  6. Reflect on previous steps: Did you really exhaust everything?
  7. Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: [email protected], the online DNP program from the School of Nursing & Health Studies

From Forensics to Advocacy: What it’s Like to be a SANE (Sexual Assault Nurse Examiner)

From Forensics to Advocacy: What it’s Like to be a SANE (Sexual Assault Nurse Examiner)

When people experience sexual assault, they may sustain more than just physical injuries; trauma also affects short- and long-term mental health. The medical treatment needed may require a provider to examine parts of the body that were recently violated, which can cause more distress. When reporting an assault, survivors often lack the information they need about how to proceed.

Sexual assault nurse examiners (SANEs) are trained to help survivors across this spectrum of patient care. From providing evidence-based treatment to performing assessments to collect forensic evidence that can be used in a criminal trial, these nurses play a critical role in supporting survivors at the beginning of their recovery process.

What Is the Role of a Sexual Assault Nurse Examiner?

When a sexual assault survivor comes to a SANE-certified hospital or community health center, a sexual assault nurse examiner is the first point of care, according to Kim Day, forensic nursing director for the International Association of Forensic Nurses (IAFN). SANEs ask the patient if they would like a forensic exam, which can be completed even if the patient decides to not report their assault to law enforcement.

“Just going through the process with someone and providing holistic patient-centered care for that patient during a traumatic time in their life can really impact the way they leave the hospital,” Day said.

Forensic exams are meant to document trauma from the assault and collect evidence that could be used in a criminal trial. This includes taking a medical history; documenting scratches, bruises, abrasions, and other injuries on a body map diagram; taking photos of injuries; collecting DNA swabs to be processed; and observing the patient’s behavior. In cases where toxicology information is relevant, SANEs will also perform those tests on a patient.

In addition to performing a forensic exam, the main duty of a SANE is to provide holistic nursing care for the patient. Survivors of assault may need access to testing for pregnancy, as well as prophylactic antibiotics to prevent the contraction of diseases. Depending on the patient’s needs, SANEs also provide referrals to see other specialists, such as a licensed professional counselor, who can help them in their recovery process.

The SANE in Court: It’s Not Like “Law and Order”

Beyond working in the clinical setting, SANEs are qualified to testify in court if a patient’s case goes to trial. The specialized training SANEs receive prepares them to effectively answer questions regarding evidence discovered during a forensic exam. However, while SANEs can play a critical role in the trial process, the legal aspect of the job is not the main focus, Day said.

“If the nurse goes into this work thinking that they’re going to get the bad guy and put him behind bars, they will fail at this… because that is not what we do,” she said. “The work we do is nursing. We take care of the patients.”

This is a key factor to consider when choosing to become a SANE. Nearly 80 percent of sexual assaults are not reported to law enforcement, according to a Justice Department analysis of violent crime in 2016 (PDF, 669 KB). While performing a forensic exam and being prepared to provide evidence in court is a requirement of the job, the emotional and medical needs of a patient come first.

SANEs are trained to work within a multidisciplinary team, also known as a Sexual Assault Response Team (SART), which includes survivor advocates, members of law enforcement, and mental health providers. Together, these professionals coordinate the response to survivors of sexual assault.

What Is a Sexual Assault Response Team?

SANEs and other trained health care providers: When an individual decides they would like to have a sexual assault forensic exam (SAFE), health care providers like Nurse Practitioners (NPs) or SANEs address the initial physical and psychological needs the patient might have as a result of their assault.

Survivor advocates: Individuals who need access to information and emotional support can work with an advocate to navigate their path to recovery. A survivor may reach out to an advocate via a crisis center, or one may be brought in to support someone who has decided to seek treatment at a hospital or report their assault to the police.

Law enforcement: In cases where an individual decides to report their assault, police officers and detectives are responsible for taking statements, coordinating with the hospital to receive the results of the forensic exam, and investigating the alleged assault.

Prosecutors: In cases where the survivor has chosen to report their assault and enough evidence is present, prosecutors are tasked with making the decision on whether to bring the case to court.

Therapists and counselors: In the aftermath of an assault, whether a case goes to trial or not, survivors need additional support to continue their recovery process. Mental health professionals trained in working with sexual assault survivors may provide care at any step in the recovery process, from coping with the immediate aftermath of an attack to navigating long-lasting trauma.

Why Is Access to SANE Care Important?

According to the Centers For Disease Control and Prevention (CDC), one in three women and one in four men have experienced sexual violence involving physical contact during their lifetimes. The effects of experiencing an assault can be both physical and psychological, necessitating specialized care that embodies the concept of cura personalis, or care for the entire person. This holistic attention to the entire individual is the expertise of clinicians like nurses.

SANE education programs are designed to train nurses to address survivors’ specific needs. After completion of this training, SANEs become uniquely qualified to treat this vulnerable patient group. This means that they can provide trauma-informed care to minimize the harm of invasive exams that may trigger a patient. In doing so, they can also equip their patients with forensic evidence that can be used if they decide to report their assault.

Not all hospitals have SANE programs. IAFN’s database of registered SANE programs   indicates that there are currently 962 in the United States. As a result, patients are sometimes required to travel long distances to access SANE care, according to a 2016 report on the availability of forensic examiners (PDF, 191 KB).   This means that the facilities with SANE expertise must be ready to do what they can to help every patient who walks in the door.

Trauma-Informed Care and Practicing Consent

One of the key challenges of completing a sexual assault forensic exam (SAFE) is examining a patient’s physical injuries without retraumatizing them. To help survivors feel comfortable, SANEs ask for consent during each step of the way while providing information on why they are doing each test.

“Consent is not just a piece of paper with a signature on it,” Day said. “It’s a process throughout the exam.”

In practice, the process of asking for consent may resemble the following:

  1. The SANE will inform the patient what body part they will examine and ask permission to do so.
    “I’m going to examine your neck now to see if there are any injuries. Do I have your permission to do so?”
  2. If the patient grants this permission and the SANE notices something that may require a sample collection, the nurse will again ask for permission to collect a specimen and explain why collecting that evidence is appropriate.
    “I notice a scratch that wasn’t mentioned when I documented your health history. There may be DNA or other materials near this wound, so I would like to swab it. Is that OK with you?”

In any instance where the patient does not want a test performed, the SANE is directed to honor the patient’s request. This integration of consent throughout the exam is meant to give the patient a sense of control, a feeling that may have been lost during their assault.

What Are the Requirements to Become a SANE?

Because SANEs work with a patient population that requires specialized care, nurses are required to meet certain expectations in order to take on this role. While some nurses go through training at the local level or through smaller programs, IAFN offers the most recognized certification for SANEs. Nurses can become certified as a SANE-A to care for adults and adolescents or a SANE-P to work in pediatrics. Some nurses elect to pursue both certifications so they can provide care to patients across all age groups.

Steps to SANE Certification
  • Education: To become a certified SANE, a nurse must have the minimum of a registered nursing (RN) license.
  • Experience: Prior to starting the certification process, a nurse must have at least two years of clinical experience working as an RN or at a higher level, such as an NP.
  • Training: As part of the certification process, nurses are expected to complete 300 hours of SANE clinical skills training.
  • Testing: The final requirement to become a certified SANE is to pass a certification examination. IAFN holds exams two times a year.

Information for Further Reading

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

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