Sexual Assault Exam: An Insiders Guide

Sexual assault is traumatic.

I know that isn’t news to anyone, but I think we forget that sometimes when trying to help our friends or family members who are going through it. We expect them to act “rationally,” like we would, or like we want them to.

But sexual assault is traumatic, and making decisions during and after trauma is complicated. Decisions about who to talk to - the police, a healthcare provider, a friend, a teacher - can feel incredibly complicated. Are they going to believe me? Are they going to listen to me? Are they going to call the police even though I don’t want that? What is going to happen next?

These are just some of the thoughts and concerns that patients have expressed to me during my career as a forensic nurse and sexual assault nurse examiner (SANE) I have had a lot of experience in talking to people who have experienced sexual violence. And while I wish I had all the answers, I don’t. I am hoping that I can provide a few answers regarding one of those options where I have a lot of experience - the sexual assault medical forensic examination.

As the nurse who sees you when you come to the hospital after a sexual assault, I’ve learned that people have really different ideas about what to expect. Sometimes that’s because the ER is so busy you haven’t had a chance to see a physician yet. Sometimes it’s because post-trauma brain has a hard time keeping track of details. And sometimes it’s because TV shows us some really terrible examples of what a sexual assault exam can look like. Hopefully this can help clarify some of the pieces.

One of the things that I offer patients is the chance to have evidence collected. This evidence consists primarily of the “rape kit” you may have heard about in the media, but other aspects of the exam, like photographs and written documentation, can become evidence as well.

The correct term for the kit is actually a physical evidence recovery kit (PERK) or sexual assault evidence kit (SAEK). At its core it’s a cardboard box, envelopes, and swabs that we use to collect and package potential evidence.

But what I do is so much more than collecting a kit. Not all patients even want a kit. So what else happens during a forensic medical exam?

Well, we are nurses (or sometimes physicians or physicians assistants) so we provide health care. That can look like:

  1. Addressing your urgent medical concerns. A lot of patients don’t have any specific medical needs, but some do. It is super common for folks to come in to be checked out after an assault and for me to say, “Physically everything looks okay. I’m still glad you came to the hospital to see me. I hope that having a nurse listen to you and tell you that you’re physically okay can be one small step in helping you move forward from this experience.” But sometimes sexual violence includes physical violence elements as well. So evaluating and treating any cuts, burns, fractures, injuries from strangulation is one piece of what I do.
  2. Evaluation and treatment for sexually transmitted infections (STIs). The Centers for Disease Control recommends preventative treatment for gonorrhea, chlamydia, and trichamonas as standard treatment for everyone who seeks care following sexual assault. That means if you had genital, anal, or oral contact during an assault, you should be offered the appropriate medications to prevent those infections. For those STIs we don’t have preventative treatment for (hepatitis C, syphilis), or for which preventative medications require more than a one time dose (HIV), or that you might already be vaccinated for (hepatitis B, tetanus), we talk about medication, testing, and follow up options to see what makes the most sense for you.
  3. Pregnancy prevention. If you have a uterus I’m going to talk to you about the potential for pregnancy as a result of the assault and offer you emergency contraception (EC) if needed and within a time window it would be helpful. Even if you are taking some types of birth control or a condom was used during the assault, offering EC as additional protection is standard; you should be able to talk over the pros and cons of taking it in your particular situation with your nurse.

Given the number of times in my life I’ve explained what I do, I have also come to recognize some of the most common myths associated with sexual assault care.

One of the most common myths I hear about sexual assault exams is that they are long, invasive, and universally terrible. The Netflix series Unbelievable highlights how having a nurse who is focused on the tasks and not on the patient can make this seem true. This is never what an exam should look like. In case you were curious, I have never asked a patient to stand naked while I take photographs of them, and no one ever should. An exam that is completed by a forensic nurse examiner who is trained in trauma-informed care as well as evidence collection should never look like this (yup, I just said that twice, that’s how much I mean it). While some of the technical evidence collection pieces are similar to what is shown in the Netflix series (we use swabs to collect evidence, and blue dye to look for injuries), a trained examiner is there for you. I talk to you a lot. I ask you what your concerns are, if you are ok as we go, if you need a break, and if you understand why I’m asking you specific sets of questions. I want you to ask questions, to tell me what you are worried about, and to make sure that we are working together to achieve what you want during the time you are with me.

Every exam is different and tailored to the patient in front of me. Some people want things done as fast as possible, others want time to process and take breaks along the way. On average I’d say I spend about 1.5-2 hours total in the exam room with you during an exam. Some are longer, for example if there are a lot of injuries to photograph, or if I have to coordinate getting a CAT scan, or if I work with the police and advocates to coordinate making sure you have a safe place to go when you leave the hospital. Sometimes it’s faster - if all you want is medications for STI prevention we still have to review some history to make sure you’re getting the right medications, but its quicker than a full exam with evidence collection. While an exam has several standard parts, it is also a “Choose Your Own Adventure” in that not every patient wants all the pieces. (And because its a hospital, there is also some paperwork and waiting that can sometimes make the whole process longer.)

Three primary components make up the exam: history taking, a head-to-toe physical examination, and the option of evidence collection. You can opt into or out of any of these components, or even just parts of them.

History taking. We ask a lot of questions. About your medical history, about the specific things that happened to you that brought you to the hospital (so we know what body parts touched what body parts and where we should be evaluating closely for injury and swabbing for potential evidence). If the event included strangulation, we want to make sure we look closely at your eyes, behind your ears, in your mouth, and may ask for additional imaging tests. If there was kissing, licking, or biting, we want to make sure to swab the areas that were invo.ved. Did you lose consciousness or have gaps in your memory? We may want to send extra labs to test for drugs and alcohol. These tests are not designed to penalize you, they are because we are concerned about whether or not you were able to provide consent as a result of substance you might have been given or taken voluntarily. The most common “date rape” drug is alcohol, and knowing how much alcohol is left in your body when you come to the hospital can be helpful in court sometimes. We also ask a lot of questions about things that matter to us when we do an exam or when evidence is examined by the crime lab that patients might not remember to tell us otherwise - like have you had consensual sex in the past week? Or have you ever had an STI? Remember, everything about this exam is voluntary, so if you aren’t comfortable with any of these questions or these tests, we can skip them.

Physical examination. This shouldn’t look terribly different than any other trip to see your primary care or sexual health care provider. The nurse usually starts at your head and works down, asking about pain and other symptoms you might be having and writing things down as they go. You should always be able to keep some clothes on. We do often ask to take the clothes you wore to the hospital and/or when the assault happened as part of the evidence, so it can be more physically and mentally comfortable if you bring (or have someone bring you) an extra set of comfy clothes to wear when you’re done, instead of fighting with the one-size-fits-nobody hospital scrubs.

Evidence collection. During the exam, the forensic nurse might collect swabs from your mouth, neck, chest, genitals, etc. based on the history. We will also ask to take a standard DNA sample from you (a cheek swab, or drop of blood) as a reference sample for the lab. Photographs are often a part of this process - especially if you have visible injuries. The nurse may use an alternate light source to look for potential injuries or evidence on your body during this stage as well.

Again: all parts of a medical forensic exam are voluntary - no one (not your parents, not a physician or nurse, not the police) can force you to have any part of an exam you don’t want. My goal is to support you in making the decision that is best for you in that moment.

Let’s bust another common myth: I don’t work for the police. I’m a nurse and I work for a hospital. My primary goal is to provide patient care. This includes awesome evidence collection and, if you decide to report, collaborating with the police to make sure they receive the kit with an intact chain of custody. But I don’t collect things just because the police ask me to, and I don’t make patients talk to the police if they don’t want to, unless the law forces me to. (More on that in a minute). In the United States you are entitled to have someone like me collect forensic evidence without making a report to law enforcement. How exactly this gets enacted varies from state to state (and sometimes city to city). For example, some places will hold evidence for 20 years in order for patients to have time to change their mind and make a report. In others regions it’s two years, and there a variety of local laws that fall in between those two points.

Here’s the legal stuff: if you’re under 18, some states require reporting of sexual assault as child abuse. In most states with this kind of law, the report goes to the local child protective services agency, but it’s not the same everywhere. Similarly, some states may require your parent to sign the consent form along with you saying that you having the exam is okay. In both these cases, neither the child protective services or your parents can make you have the exam if you tell me you don’t want it, but unfortunately they do throw up some extra barriers for folks in some places.

I also don’t work alone. I work with amazing sexual violence advocates. While I am there to provide you high quality, evidence-based, trauma-informed healthcare and evidence collection during a hospital visit, advocates are there to help you through all the other stuff that comes with surviving sexual violence. They are usually associated with the local rape crisis system and provide services like hotlines, emergency shelter, legal assistance, and partnerships with mental health and counceling services. They can provide you with important support and follow up that is outside my nurse sandbox. Ideally, you are lucky enough (as I have been) to be some place where advocates are available 24/7/365 to come to the hospital and be with you before, during, and after the exam. At this point, their role is to focus 100% on supporting you when I am focusing on collecting a sample, taking a photograph, or documenting in your health record. If not there are still some awesome options, including the message boards, live chat and text services offered by the great folks right here at Scarleteen.

Having a sexual assault exam means that something terrible has already happened. But the exam itself should not be traumatic. You have the right to always: be in control of what is happening, be able to stop at any time, decide what pieces you want and don’t want, and be offered options to help you address your physical, psychological, and forensic concerns.

I know it can be scary to decide to what to do after a sexual assault. Those Scarleteen support lines I mentioned earlier are an awesome first place to reach out if you are unsure about what to do or how to help someone else going through this situation. Free, anonymous, confidential, and they can help you talk through the specifics of your situation in ways that an online article can’t do. If you decide to go to the hospital they can help you find one with a forensic nurse on staff. If you decide to talk to the police they can help connect you to your local advocacy services to be with you when you make that call. Or you can just chat with them whatever you decide is okay. That’s the whole point - you should be getting to make the choices.

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