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.
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.
“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?
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?
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:
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
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.
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 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.
“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
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.”
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.
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.
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
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.
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.
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.'”
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.
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
Get to know the patient
Use analgesics to address pain
symptoms
Use non-pharmacological treatments
as intervention for side effects
Encourage patient to stop smoking
and drinking alcohol
Eliminate foods that irritate the
stomach or digestive system
Reflect on previous steps: Did you
really exhaust everything?
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:
Nursing@Georgetown, the online DNP program from the School of Nursing
& Health Studies
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.
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.
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:
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?”
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.
