Viewpoint: What's a survivor to do? Options for post-assault care

BY ALEXANDRA DULIN

Published September 4, 2014

Currently in the United States, there is a charged discussion surrounding sexual assault. However, much of this discussion has focused on the perpetrators and does not consider the view of survivors and what they desire. Highly publicized cases such as the Steubenville, Ohio trial have highlighted the issues of victim blaming in American society, and the recent “permanent separation” of former Michigan football kicker Brendan Gibbons from our own University of Michigan has highlighted institutional biases against survivors of sexual assault. Yet, the focus of these cases has been on the perpetrators, their standing within their communities, their process navigating the justice system and ultimately their personal consequences. But these infamous cases are not the only ones in need of discussion. According to the (Rape, Abuse, and Incest National Network) 1 in 6 American women will be survivors of a completed or attempted rape, and about 3 percent of men will as well. Rates are higher on college campuses, with 1 in 4 American women surviving an attempted or completed rape, most often by an acquaintance or partner. In fact, a recent study on the University of Michigan campus by University research fellow Michelle Munro found that 80 to 90 percent of rapes were perpetrated by someone known to the survivor, which is consistent with national data. And while the Steubenville case may have ended in a conviction, and the Gibbons case in expulsion, RAINN also reports that 60 percent of sexual assault cases go unreported, and that only 3 percent of perpetrators will ever spend a day in prison. It is therefore essential that we begin to focus on the experiences, needs and desires of survivors.

Millions of rape survivors have endured the effects of rape, such as physical injury, unwanted pregnancy and sexually transmitted infections. Yet, a 2012 study with a nationwide sample found that only 21 percent of survivors of sexual assault actually sought post-assault medical services. Low conviction and reporting rates for rape cases and the small percentage of survivors seeking medical care in the post-assault period clearly indicate the need for programs that assess and comprehensively treat a survivor’s healthcare needs, while providing evidence and information that help the survivor to navigate the challenges of reporting the case and pursuing prosecution. Currently Sexual Assault Nurse Examiner programs are the gold standard approach to providing this care.

Nationwide SANE programs are intended to address medical, psychological and forensic needs. SANE programs were developed by now-director Linda Ledray in the late 1970s, for the purpose of improving the inadequate care that survivors of sexual assault were receiving. Survivors seeking medical attention generally went to the emergency room, where they could experience long wait times and treatment and evidence collection by doctors and nurses who were not familiar with post-assault care. These lengthy stints in the waiting room and inexperienced care could lead to “retraumatization” for the survivor. Not only were forensic exams done inadequately, but, should a case be pursued by law enforcement, the healthcare professionals who had treated the survivor were often unable to testify. The implementation of SANE programs has served to remedy these problems.

SANEs are nurses who have received special training in post-assault care and forensic evidence collection. In order to receive board certification through the International Association of Forensic Nurses, prospective SANEs must complete 40 hours of classroom education and clinical hours. Only nurses can receive a certification, though the training is available to other healthcare providers such as physicians and physician assistants. During their training, SANEs are instructed in compassionate care for a survivor, which can include assessment and treatment of injuries, the administration of prophylaxis (medicine for the prevention of pregnancy or STIs), and the collection and documentation of forensic evidence. SANEs are also available to testify, should a sexual assault case go to trial. As of now, according to the IAFN, there are more than 700 SANE programs operating in the U.S., Canada and Australia. SANE programs are housed in hospitals, advocacy centers, and community organizations, operate 24 hours a day and collaborate with relevant community service workers, such as sexual assault advocates and law enforcement personnel, all in order to improve post-assault care and, if the survivor chooses to press charges, increase efficacious prosecution of a case. In order to find a SANE program near you, use the search engine provided by the International Association of Forensic Nurses provided here.

So what is the SANE exam that these nurses are trained in? The usual process begins with a SANE being called in to provide care for a survivor. This can be to a variety of locations, but is usually a rape crisis center or a hospital emergency room. The SANE will first introduce themselves, obtain consent for a medical examination, and then assess any acute physical injuries that may need immediate care. Barring any injuries that require immediate medical attention, the SANE will then obtain consent for a forensic examination and escort the survivor to the exam room. Some crisis centers or emergency rooms have specific rooms just for SANE exams, and if not the exam should always be conducted in an area of the facility that guarantees privacy for the survivor. Here the SANE will ask for and record a history of the survivor and the assault. They will then proceed to do a head-to-toe examination of the survivor, checking for injury and evidence. These parts of the exam can involve physical evidence collection, such as hair, blood, semen or vaginal fluid, and photography to document injury. It is important for survivors to know that they can say no at any point in the exam, and that they do not have to consent to the exam kit being shown to law enforcement. After the exam is complete, the SANE will discuss the necessity of medications in order to prevent STIs and pregnancy (if that’s a concern), and provide prescriptions for any medication that is needed. It is possible, depending on the protocol of the state or facility that the SANE is working in, that a survivor may ask for an advocate to be present for part or all of the examination.

There are several benefits to the utilization of a SANE program. For one, SANEs have specific training in dealing with sexual assault survivors, and the nature of their work gives them more experience working with survivors than other healthcare professionals. SANEs can also act as advocates for survivors, and their connection with other community service providers means that they can direct survivors to proper advocacy groups. Their training in evidence collection means that the condition of evidence will be better, and will not suffer from undertrained providers as it did in the past. Their expertise can also be used to provide testimony in a trial, should a survivor choose to prosecute.

Data from a 2012 study by Rebecca Campbell a psychology professor at Michigan State University also suggests that participation in a SANE exam can lead to sexual assault cases progressing farther in the justice system and can increase conviction rates for perpetrators. The study underlined the utility of DNA evidence, finding that cases with DNA evidence were 1.86 times more likely to progress further in the criminal justice system, which highlights the importance of SANEs as forensic evidence collectors. In another work in 2011, Campbell indicated that SANEs might also encourage participation by survivors in the criminal justice system, by attending to survivors’ feelings of guilt or blame, making them believe that they have a stronger case by educating them on injury and how it is not always a part of a sexual assault, and by acting as an advocate during the prosecution of a case. Despite these findings by Campbell, it is important for survivors to be aware of the fact that a large majority of sexual assault survivors do not exhibit evidence of physical injury. Furthermore, collection of forensic evidence does not yield definitive results immediately; it can take months to even years for forensic evidence to be analyzed. Additionally, it is ultimately up to the justice system, specifically the prosecutor, to determine the timeframe in which forensic evidence is analyzed. These facts often leave survivors feeling frustrated and disempowered.

It is also important for survivors to understand their rights in the post-assault period, in order to get full access to all of the care that they desire. In the past, to receive a SANE exam, survivors in some states were obligated to agree to cooperate with law enforcement and report the assault. This policy was a detriment to care, as many survivors did not want to report the assault, and thus were unable to receive a SANE exam. In changes made in 2005 to the Violence Against Women Act, a fundamental piece of legislation in the protection of survivors of domestic violence and sexual assault, states are no longer able to require that survivors report a case to law enforcement in order to obtain a SANE exam. This means that survivors now have the option to have forensic evidence collected and stored, which gives survivors a longer time to decide if they want to pursue legal action. However, while states cannot require that survivors report an assault, it is possible for states to require hospitals to do so. In Michigan, law enforcement is automatically contacted when a SANE exam is given. Survivors should be informed that, if law enforcement is contacted, they are under no obligation to cooperate with the investigation, and may choose not to speak with officers. Some states, including Michigan, also have mandatory reporting laws for injuries that appear to have been caused by a crime, such as wounds from knives or firearms, which may have been perpetrated during a sexual assault. It is also important to remember that some special circumstances may require that healthcare professionals report sexual assault to law enforcement, like when the survivor is a minor or person with disabilities.

Another provision of VAWA 1994 created STOP Violence Against Women Formula Grants, in order to better victim services and improve the criminal justice system’s response to violence against women. In states receiving these grants (which is all states and the District of Columbia), healthcare institutions must provide forensic evidence exams to survivors of domestic violence and sexual assault without charge. Hospitals and crisis centers cannot ask survivors to cover the exam, or for them to forward the costs to their insurance. This does not apply to the medical examination, injury treatment, or any prescription drugs that are received in the course of a SANE exam. However, states do have crime victim compensation programs that can provide assistance in paying for medical costs and even lost wages that are the result of an assault. An overview on victim compensation and a link to the different state programs available can be found here. Another important point to note is that though the title of VAWA seems to indicate that the programs it encompasses are specifically intended for women, the law actually applies to all sexes and genders, including trans* individuals, and everyone is entitled to a SANE exam.

While SANE programs are comprehensive, some survivors may choose not to have a SANE exam or one might not be available to them. In these circumstances it is important that survivors are aware of their other options for care. Survivors can still go to the emergency room for treatment of physical injuries and STI prevention, even if a SANE is not available, or schedule an appointment with a general practitioner (it is imperative to note that by the time a general practitioner is available, it may be too late to collect forensic evidence). Additionally, survivors can pursue over-the-counter options, such as emergency contraception, in order to prevent pregnancy. Plan B®, a form of emergency contraception is available over-the-counter regardless of age, sex or gender, and is usually about $50 in a local pharmacy and $40 at the University Health Service (a $10 coupon can be found here) on the Plan B® homepage). Survivors can also seek services at rape crisis or advocacy centers and with mental health professionals. They also have the choice of reporting to law enforcement, without seeking a medical or forensic examination. College-age survivors can also choose to report to their Office of Student Conduct. And finally, survivors can also make the choice to pursue no form of care after an assault. It’s critical to understand that pursuing post-assault care is ultimately the survivor’s choice, and they should not be pressured into obtaining services that are out of their comfort level. However, survivors should be given information about all of the post-assault care options that are available to them, so that they can make autonomous decisions about what care is best for them in the post-assault period.

Alexandra Dulin is an LSA junior. Her UROP mentor was Michelle Munro, Research Fellow at the School of Nursing.