April is Sexual Assault Awareness Month. Courts often rely on the results of a patient’s screenings and examinations as their only means of evidence in sexual assault cases. Accurate and rigorous screening tools ensure that justice is properly served and that patients get the care they need after a traumatic experience. With proper training, screening tools, and resources, a licensed provider, from a physician to a registered nurse, can screen and examine a patient who has been sexually assaulted. Amy Rogers, BSN, RN, Director of AFMC’s Clinical Services team, is a specially trained Sexual Assault Nurse Examiner with over nine years of experience helping survivors to ensure they get the care they need through proper forensic examination and advocacy.
“Because sexual assault is such a personal and traumatic experience,” Amy says, “many people, especially children, are hesitant to share what happened to them.” This hesitance may stem from several factors:
- Concern for the assailant (i.e., that the assailant may be prosecuted if the attack is reported)
- Concern for their own safety
- Fear of guilt or embarrassment
- Emotional or psychological trauma that is difficult to face
- Blocked out/repressed memories of the event
- Downplaying the abuse
- Lack of support (e.g., financial, medical, insurance) if they leave the abuser
Many times, the exams and reports written by nurses and doctors are the most tangible pieces of evidence victims have in court.
Regardless of the hesitance or fear a victim may have upon initial discussion, Amy says it’s important that nurses and providers use screening methods that are fair, equitable, and effective. “Many times, the exams and reports written by nurses and doctors are the most tangible pieces of evidence victims have in court,” she says. Without proper screening, some signs of sexual assault may go unnoticed, leaving the victim vulnerable to future attacks.
Recent research from George Mason University reveals something nurses and providers may never have considered when examining victims of abuse with darker skin: the visibility of their bruises. According to the study, Katherine Scafide, an associate professor at George Mason University who worked as a forensic nurse for eight years, noticed that it was hard to see injuries and bruises on victims with darker skin. Not seeing bruises or injuries limits a forensic nurse’s ability to fully document a victim’s medical record. Whether physically or emotionally, every victim’s experience is different. It’s this difference that supports the need for unbiased screening tools.
While screening methods differ depending on whether the patient is an adult or a child, the goals are the same—finding physical or verbal evidence supporting the victim’s claim of abuse to avoid wrongful conviction.
Pediatric Screenings
One of the most commonly overlooked injuries from child abuse trauma is bruising. Typical bruising resulting from general clumsiness normally appears on common bony points of the body. However, clinical professionals should proceed with screening when the evidence of an injury does not match the reason given for how the child obtained the injury. The TEN-4 FACESp bruising clinical decision rule is the mnemonic for a screening tool clinical professionals can use when screening children younger than four years presenting with any complaint.
You don't have to be a sexual assault nurse examiner to use the TEN-4 FACESp tool.
TEN stands for bruising of the Torso, Ear, and Neck. The 4 is a reminder to check these areas for bruising on children 4 years old or younger (or any bruising for a child less than 4 months). FACES stands for Frenulum, Angle of the jaw, Cheeks, Eyelids, and Subconjunctivae. And the lowercase p at the end stands for patterned bruising. TEN-4 FACESp is only intended to be a screening tool, not a diagnostic tool. “The TEN-4 FACESp tool can be used in any setting,” Amy says. “You don’t have to be a sexual assault nurse examiner to use this tool.” This mnemonic helps keep nonaccidental trauma top of mind when providers evaluate and treat children for any and all complaints.
Memorizing the mnemonic reminds nurses to refer the child to a pediatric abuse specialist who can confirm a diagnosis if they see nonaccidental bruising. “While it can be hard to tell a parent their child has a bruise that’s not from regular play, it’s a necessary conversation,” Amy says. “Just knowing the TEN-4 FACESp tool and what to look for facilitates the diagnostic process.”
For children with darker skin, blue or purple light has proven to be five times more effective at detecting bruises. Simultaneously using the TEN-4 FACESp mnemonic with blue or purple light to help detect bruises will maximize the effectiveness of screenings and guarantee that examiners are as inclusive and unbiased as possible.
Adult Screenings
Adult sexual assault cases are more acute. Most adult screenings take place via face-to-face interviews with sexual assault nurse examiners. Screenings look different across the state. “Some hospitals here in Arkansas have forensic nurses in-house,” Amy says. “For hospitals in Fort Smith, if a patient comes in for sexual assault, the nurse or provider would call the crisis center who facilitates and coordinates a forensic examination with a forensic nurse who is specially trained in forensic examination for sexual assault.
Some patients will volunteer to tell you what happened to them, and some won't. It all depends on the person.
During the interview with an adult victim, some patients may volunteer to tell the forensic nurse what happened, but some won’t. It all depends on the person. Regardless of how much or how little the victim tells, forensic nurses have to go off what the adult said in their medical report. Forensic nurses may perform physical exams. “When bruising or other visible injuries are present, we take pictures of the injured areas. Also, as a part of the examination, we collect forensic swabs from the victim in an effort to collect a potential foreign DNA sample,” Amy says.
Know Your Resources
Whether a forensic nurse, provider, or health care professional is screening after a complaint, it’s important to know the available resources to help make informed decisions. “It all goes back to resources,” Amy says. “If you don’t have the experience, that’s not a bad thing. Not everybody has experience in these types of screenings.” Regardless of how many years of medical training are at play, it’s important that professionals know what to do or whom to refer the victim to so that they can receive a diagnosis.
If you don't have the experience, that's not a bad thing. Not everybody has experience in these types of screenings. But it's important that you know what to do or whom to refer the victim to so that they can receive a proper diagnosis.
The Arkansas Crisis Center created a hotline for victims of sexual assault. Providers with patients who have exhibited any of the following signs should encourage the victim or their loved ones to call 988 for assistance:
- Signs of depression
- Avoiding specific situations or places
- Increased alcohol or drug use
- Engaging in self-harming behaviors
- Low self-esteem
- Signs of physical abuse
- Changes in hygiene or appearance
- Sexually transmitted infections
Crisis Center receptionists are there to listen to the victim in a nonjudgmental way. The victim may feel that what happened to them is their fault. Receptionists can help encourage the victim to seek medical attention and offer assistance in finding ongoing help and support. If a patient reveals they are in immediate danger while in a provider’s care, that provider should call 911.
The University of Arkansas for Medical Sciences runs a TeleSANE program designed to “provide clinicians with real-time access to the knowledge and support they need to care for patients who have experienced a sexual assault.” The TeleSANE program uses telemedicine to connect clinicians with consultants who are specially trained in caring for patients who have experienced a sexual assault. The consultation can help the clinician make informed, evidence-based decisions about the patient’s care. This program even offers ongoing training and education to keep clinicians confident that, when presented with a patient who has experienced a sexual assault, they’ll know what to do.
