Historically, medical evaluations of acute sexual abuse/assault were performed in emergency departments (EDs) by attending physicians and/or residents. Concerns arose regarding potential iatrogenic trauma caused to victims of sexual abuse/assault as a result of the medical evaluation from providers with limited training and experience in evidence collection for acute sexual assault, and long waits in the ED (Derhammer, Lucente, Reed, & Young, 2010; Girardin, 2005; Hutson, 2002; Plichta, Clements, & Houseman, 2007). Due to these concerns, the sexual assault nurse examiner (SANE) role was developed to provide care to adults and older adolescents and later expanded to include children and younger adolescents.
A SANE is a registered nurse educated to provide expert assessment of victims of sexual assault including documentation of injuries (both genital and non-genital), and collection as well as preservation of forensic evidence (Ort, 2002). SANEs are also trained to provide emotional support to the victim and family, sexually transmitted diseases (STIs) and pregnancy testing and prophylaxis, referrals to appropriate counseling resources, and expert testimony in court. The first program using a trained SANE began in the late 1970s. Today there are over 600 programs in the United States; approximately half of which provide care to pediatric patients (Campbell, Paterson, & Lichty, 2005; Ledray, 2010).
Although P-SANEs (pediatric sexual assault nurse examiners) have been providing care to victims of sexual abuse/assault for over two decades, there is a paucity of literature describing the quality of P-SANE care and legal outcomes associated with their cases especially in comparison to the standard of care by other care providers. The purpose of this study was to compare quality indicators of care in a pediatric emergency department (PED) before and after the implementation of a P-SANE program by describing frequency of trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault.
Review of literature
Pediatric forensic evidence
Pediatric trace forensic evidence yield is not widely discussed in the literature. Recent studies found little evidence yield from children's bodies after 24 hours suggesting a possible change in practice regarding the timing of the collection of forensic evidence. Christian, Lavelle, DeJong, Loiselle, Brenner, and Joffe (2000) reviewed the medical records of 273 children less than 10 years of age who were evaluated for an acute (less than 72 hours since sexual abuse/assault) concern of alleged sexual abuse/assault and also had forensic evidence collected. Forensic evidence collection and examination was performed by ED attending physicians, supervising medical residents. In that study, all children were examined within 44 hours of the abuse/assault and 25% of the children were positive for some form of forensic evidence. Over 90% of the children with positive forensic evidence findings were examined within 24 hours of their abuse/assault. Clothing and linens yielded most of the forensic evidence (64%). No swabs taken from the child's body were positive for semen/sperm after 9 hours and blood after 13 hours. Christian et al. (2000) found that genital injury and a child's history of perpetrator ejaculation were associated with an increased likelihood of positive forensic evidence, however, two children had evidence of semen found on their bodies yet only gave history of digital-genital contact.
Young, Jones, Worthington, Simpson, and Casey (2006) reviewed the records of 80 children and adolescents who were seen for an acute concern of sexual abuse/assault and had forensic evidence collected. All patients were examined within 24 hours after the alleged sexual abuse/assault. Forensic evidence collection and examination were performed by medical residents supervised by ED attending physicians. Notable findings included 20% of the children were found to be positive for semen; the majority (81%) of whom were adolescents. No prepubertal children had semen recovered from their bodies and only three had forensic evidence recovered from their clothing.
Palusci, Cox, Shatz, and Schultze (2006) reviewed the medical records of 92 children/adolescents who presented with an acute concern of alleged sexual abuse/assault and had forensic evidence collected. Six children had at least one positive forensic body swab and, in children less than 10 years of age, there were no positive forensic body swabs. Children/adolescents with abnormal ano-genital exam findings, those who did not change their clothing after their abuse/assault, and those who had contact with a perpetrator greater than 15 years of age were more likely to have a positive forensic body swab. Palusci et al. (2006) noted that forensic body swabs were positive for adolescents examined 0–12 hours after assault (11%), 13–24 hours after assault (4%), and 49–72 hours after assault (13%). Forensic evidence collection and examination was completed by ED attending physicians and residents in collaboration.
Pediatric SANE literature
Several studies have examined the role of the adult SANE nurse, many of which suggest an improved quality of care with incorporation of the SANE nurse into patient care (Derhammer, Lucente, Reed, & Young, 2000; Stermac & Stirpe, 2002). Efforts to measure the quality of P-SANE care especially in comparison to physician care have been limited. Hornor, Scribano, and Hayes (2006) described SANE knowledge and recognition of normal prepubertal anatomy and clinical indicators of acute child sexual abuse. A 33-item questionnaire previously utilized in studies assessing physician (Ladson, Johnson, & Dody, 1987; Lentsch & Johnson, 1999) and pediatric nurse practitioner (Hornor & McCleary, 2000) knowledge was mailed to 412 SANE programs in the United States and Canada. Participants were shown a photo of normal prepubertal female genitalia and were asked to identify anatomical structures. The hymen was correctly identified by 89% of SANE participants compared to 59% of PNPs and 59% (1987) and 62% (1999) of general pediatricians and pediatric subspecialists. Although SANE understanding of sexually transmitted infection scenarios and recognition of abnormal prepubescent genital exam findings was not as strong as their ability to recognize normal prepubescent anatomy, SANEs ability to recognize normal and abnormal anatomy and to report appropriate management of acute sexual assault was superior to that of PNPs and physicians reported in each of the previous studies.
Bechtel, Ryan, and Gallagher (2008) evaluated whether the use of pediatric SANEs in a PED improved the care of pediatric and adolescent sexual assault victims. Medical records of 114 patients who presented to the PED with a concern of sexual assault requiring forensic evidence collection were reviewed; 60 patients were evaluated by pediatric SANE and 54 by PED physicians. The authors examined frequencies of ano-genital examination completion, documentation of injury, appropriate evaluation for STIs appropriate prophylaxis for STIs and pregnancy, evaluation by PED social worker, and referral to the rape crisis center. Patients who received care from a pediatric SANE were more likely to have an ano-genital exam completed (71% vs. 41%) and to have an injury documented (21% vs. 0%). SANE involvement in care resulted in increased testing for gonorrhea and Chlamydia (98% vs. 76%), increased testing for Hepatitis B and C (95% vs. 80%) and HIV (93% vs. 72%), increased pregnancy prophylaxis (85% vs. 64%), and increased referrals to the rape crisis center for mental health counseling (98% vs. 30%). However, whether these clinical differences actually improved outcomes was not evaluated in this study.
In evaluating the judicial outcomes for pediatric sexual assault, Patterson and Campbell (2009) examined the contributory role of the P-SANE in the process of prosecution of child sexual abuse. Using a quasi-experimental design they compared prosecution outcomes for child sexual abuse victims examined by a pediatric SANE (95) and those examined by non-pediatric SANE (54). Non-pediatric SANE examiners included pediatricians and ED physicians. P-SANEs saw significantly younger children aged less than 6 years (56% v 46%) and there were fewer cases that involved penetration (52% vs. 68%). There were fewer positive evidence collection kits by P-SANEs (13% vs. 33%), although the authors note that this may be the result of having younger children seen by P-SANE, resulting in a potentially lower risk of sexual maltreatment with a resultant lower potential for evidence. Interestingly, more cases seen by P-SANEs resulted in a plea bargain/trial conviction (36% vs. 17%).
To compare quality indicators of care in a PED before and after the implementation of a P-SANE program, this study was designed to report the frequencies of key clinical indicators, trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault. The key clinical indicators included: identification and documentation of acute and chronic ano-genital injuries, evaluation of pregnancy status, and testing for N. gonorrhea and C. trachomatis. Comparisons were made between pre-implementation of P-SANE support (PED physician care only) to post-implementation with P-SANE support.
Our pediatric sample included both male and female children and adolescents between the ages of 1–20 years. A retrospective review of medical and legal records for all children and adolescents presenting with concerns of acute sexual abuse/assault requiring forensic evidence collection from 1/1/04 to 12/31/07 were used. The children and adolescents received care in the ED at Nationwide Children's Hospital, a large urban pediatric Hospital in the Midwest. In the fall of 2005, a P-SANE program was established in this clinical site. The time frame of record abstraction for our study was selected to allow comparison of care provided during the pre-implementation of P-SANE (2004–2005) to post-implementation of P-SANE support (2006–2007). Institutional Review Board approval was obtained prior to initiating the study.
Variables collected from the medical and legal records were chosen by the research team based upon pertinent forensic evidence and pediatric SANE literature. See Table 1 for complete listing of data extracted from medical and legal records.
Medical records were reviewed for the following:
- History of sexual abuse/assault.
- Ano-genital examination and the presence of ano-genital or other injury.
- STI and pregnancy testing.
- Medical provider (PED physician only vs. P-SANE and PED physician).
- Victim age.
- Perpetrator age.
- Time between abuse/assault and exam.
- Bathing since abuse/assault.
- Changing clothes since abuse/assault.
Legal records were reviewed for the following:
- Forensic evidence kit results (presence of semen, amylase, or blood).
- Prosecution outcomes.
The medical and legal records criteria for acute sexual abuse/assault evaluation with forensic evidence collection include:
- Child/adolescent presents within 72 hours of the latest reported incident of sexual abuse/assault.
- Child/adolescent gives a history of sexual abuse involving genital–genital, anal-genital, oral-genital, and/or digital–genital contact.
- Injury to anus or genitalia appears acute and is concerning for sexual abuse/assault.
- Reason to believe that acute sexual abuse/assault has occurred despite child/adolescent unable to give history.
Statistical analyses were performed using STATA statistical software. Descriptive statistics of the study population are reported. Univariate analyses were conducted to compare quality indicators prior to the P-SANE support vs. with P-SANE support in the PED.
Four hundred sixty-four children and adolescents underwent forensic medical assessments at Nationwide Children's Hospital and required forensic evidence collection. One hundred twenty-seven (27%) of the forensic evidence kits were not submitted by law enforcement for processing. Reasons for this include: patient recanted history of abuse/assault, sexual activity was deemed to be consensual, perpetrator confession, or unable to determine police jurisdiction. Non-processing of the forensic evidence kit resulted in exclusion from the study. Forensic evidence kits of 336 (73%) children and adolescents seen during the time period were processed at one of two crime labs and their medical and legal records comprised the study sample. See Table 2 for demographic characteristics of patients with processed rape evidence kits. Over half (65%; n= 218) of patients received care within 24 hours following abuse/assault; 70% (n= 237) of children/adolescents gave history of sexual abuse involving genital–genital or anal–genital contact; and 29% (n= 97) of children/adolescents had an abnormal ano-genital finding on exam.
Legal records were reviewed for forensic evidence kit results and prosecution outcomes (see Table 3). Eighty-nine (27%) forensic evidence kits were positive; 71 (80%) for semen; 22 (25%) for amylase; and 2 (2%) for blood. Semen was isolated from the clothing (30%; n= 27), bodies (27%; n= 24), and both clothing and bodies (27%; n= 24) of positive patients. Amylase was isolated from the clothing (10%; n= 9), bodies (10%; n= 9), and both (5%; n= 4) of positive patients and blood from the clothing (2%; n= 2) and bodies (0%; n= 0). Trace forensic evidence was found in 8% (n= 28) of forensic evidence kits collected on pre-pubertal children. Over half (51%; n= 45) of positive forensic evidence kits were collected less than 24 hours after abuse/assault. A perpetrator DNA profile was identified in 42% (n= 37) cases with positive forensic evidence kits. Charges were filed in 41% (n= 138) of total cases with 40% (n= 131) of cases indicted. Perpetrators either pled guilty or were found guilty by trial in 31% (n= 105) of cases.
P-SANEs performed 61% (n= 204) of rape evidence kit collections and ano-genital exams. See Table 4 for a description of ano-genital exam findings, rape evidence kit results, and judicial outcomes per provider type. P-SANE support demonstrated greater likelihood of: identifying and documenting an acute and/or non-acute ano-genital injury (34% vs. 20%; p= 0.006); evaluating and documenting pregnancy status (59% vs. 47%; p= 0.030); and testing for N. gonorrhea and C. trachomatis (95% vs. 80%; p < 0.0001), when compared to pre-implementation of the P-SANE support. No significant difference in provider group was noted for the following: rape evidence kit positive for trace forensic evidence (P-SANE 27% vs. pre-implementation of P-SANE support, 26%; p= 0.807); ability to identify perpetrator DNA profile from trace forensic evidence (P-SANE 20% vs. pre-implementation of P-SANE support 16%; p= 0.390); and judicial outcomes (charges filed P-SANE 43% vs. pre-implementation of P-SANE support 38%; p= 0.339). There was a difference in the timing of forensic care with more patients seen by P-SANE receiving care less than 24 hours after abuse/assault compared to pre-implementation of P-SANE support (71% vs. 56%; p= 0.010).
In this study, the addition of P-SANE support to the PED team in providing care to child/adolescent victims of acute sexual abuse/assault resulted in improved detection and documentation of ano-genital injury, evaluation and documentation of pregnancy status, and testing for N. gonorrhea and C. trachomatis. These findings support previous findings of Hornor et al. (2006), which indicated that SANEs demonstrated enhanced ability to recognize normal and abnormal prepubertal ano-genital anatomy as well as interpret STI scenarios as related to child sexual abuse. Bechtel et al (2008) also found P-SANEs more likely than PED physicians to document ano-genital injury and test for N. gonorrhea and C. trachomatis. These indicators are essential to the care of sexual abuse/assault victims and suggest that the additional didactic and clinical training that P-SANEs receive may result in higher quality care. The testing of menarchal females for pregnancy is crucial for both the physical and psychological health of the adolescent sexual abuse/assault victim. Knowing baseline pregnancy status could assist the adolescent and family in making moral and legal decisions if pregnancy results from the sexual abuse/assault. Baseline testing for sexually transmitted infections also has important health and legal ramifications. Testing for Chlamydia and gonorrhea via DNA amplification (genital or urine) may provide evidence of organism immediately following sexual abuse/assault even if no disease occurs and could be significant information to share with law enforcement to assist with their investigation. Additionally, many prepubertal children who experience acute sexual abuse/assault are not routinely provided antibiotic prophylaxis for Chlamydia or gonorrhea due to the low incidence of the infections in the prepubertal sexually abused population; therefore baseline testing via DNA amplification is essential to insure the health of the child.
P-SANE care was comparable to PED physician care in the yield of positive trace forensic evidence and judicial outcomes in our study. Given that more exams performed by pediatric SANE nurses yielded a higher detection rate of physical finding consistent with sexual abuse/assault, it is curious that judicial outcomes were similar for P-SANEs and PED physicians. It is possible that the younger age of child victim seen by P-SANEs may have contributed to the judicial outcomes. This phenomena has been noted in previous studies (Edinburgh, Saewyc, & Levitt, 2008; Hansen et al., 2009). However, in one study, Patterson and Campbell (2009) found more cases where a plea bargain/conviction resulted when care was provideld by a P-SANE compared to a pediatrician or ED physician. Further evaluation is necessary to describe the impact of P-SANEs on the prosecution of child sexual abuse/assault.
There are several limitations to this study. Given the differences in the population of children/adolescents seen by P-SANE versus PED physicians such as age of child victim and frequency of care provided within 24 hours after abuse/assault, the ability to provide a valid comparison between the two groups is limited. The quality indicators measured are somewhat narrow and do not comprehensively measure acute sexual abuse/assault care. Examples of other quality indicators not measured in this study include: time of care from ED admission to discharge, STI/pregnancy prophylaxis, referral to mental health counseling, and others. Future research comparing a more comprehensive set of quality indicators is needed. Judicial outcomes and forensic evidence kit results may be influenced by a number of factors unrelated to the type of health care provider performing the examination/rape evidence kit collection, including quality of the forensic evidence analysis at the crime lab. Although a statistically significant difference was noted when comparing P-SANE recognition vs. PED recognition and documentation of abnormal ano-genital exam findings and evaluation for pregnancy and STIs, the clinical significance of these differences may not exist. Lastly, there may be a selection bias due to the number of forensic kits chosen by law enforcement for non-processing, although we do not have any reason to believe that this potential bias would have been different during the pre-SANE support vs. post-implementation with P-SANEs support.
Implications for forensic nursing practice
Acute sexual abuse/assault care is crucial to the health and protection of children and adolescents. P-SANEs play a vital supporting role in the care of child and adolescent victims of acute sexual abuse/assault. Acute sexual abuse/assault care involves the collection of trace forensic evidence, physical assessment including ano-genital examination, STI/pregnancy testing and prophylaxis, providing emotional support, providing appropriate follow-up referrals, collaboration with child protective services and law enforcement, and later perhaps court testimony. P-SANE education and training prepares registered nurses to competently complete these essential tasks. The addition of a P-SANE program to the health care team helps to maximize comprehensive care delivery to these patients. This study documented P-SANEs to be more likely to recognize and document an abnormal ano-genital exam finding and to evaluate for pregnancy and STIs, yet additional research is needed to fully document the impact of P-SANEs on patient care outcomes.
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