Nursing Forensics Assignment -
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ForensicsforMedicalProviders_Review.pptxSexual assault – forensics Linda bush, rn,ms,grh-c,fnp-c sane a-p, nys safe
What is sexual assault?
The term sexual assault refers to sexual contact or behavior that occurs without explicit consent of the victim. Some forms of sexual assault include:
Attempted rape
Fondling or unwanted sexual touching
Forcing a victim to perform sexual acts, such as oral sex or penetrating the perpetrator’s body
Penetration of the victim’s body, also known as rape
FBI defines rape as “penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.”
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One in four girls and one in six boys will be sexually abused before they turn 18 years old
96% of people who sexually abuse children are male, and 76.8% of people who sexually abuse children are adults
Only 12% of child sexual abuse is ever reported to the authorities
Statistics -
17 years old, age of consent however there is an affirmative defense to rape and/or sexual acts when the defendant was less than four years older than the victim at the time of the act
In the U.S., one in three women and one in six men experienced some form of contact sexual violence in their lifetime - 51.1% of female victims of rape reported being raped by an intimate partner and 40.8% by an acquaintance - 34% of people who sexually abuse a child are family members of the child.
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Sexual Assault Nurse Examiner (SANE) Sexual Assault Forensic Examiner (SAFE)
SANE – Registered Nurse or Nurse Practitioner
SAFE - NP, MD, Physician Assistant or RN
Specialized education & clinical preparation in medical forensic care of the patient who has experienced sexual assault or abuse
Skills in injury identification, evaluation, and documentation
NP, PA, MD will also manage injuries
Evidence collection and maintaining the “CHAIN OF CUSTODY”
Provides medical testimony in court and consults with legal authorities
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A SANE np or SAFE is an expert in:
history taking
Complete physical assessment & medical documentation of injury
treatment of trauma and injury
documentation and collection of evidence and its management
emotional and social support with appropriate referrals including safety plans
testimony required to bring such cases through the legal system
SAFE OR SANE NP
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FORENSIC INTERVIEW initial(mini) and complete
Pediatric patients should NOT be interviewed unless a trained SANE-P or SAFE is available. The child’s non-offending parent or guardian should be interviewed out of the presence and “ear shot” of the child
When children are interviewed “open ended”, non-leading questions are always used in a developmentally appropriate manner
Children age 3 or older s/b interviewed w/o A parent present if possible – brief initial interview to drive your plan
Document in quotes…
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Pediatric patients should be referred to the local Child Advocacy Center for further interview (MDI) and law enforcement collaboration
Remember the perpetrator is most often known to the child who trusts and even loves this person
A rape crisis advocate should be offered to the adolescent patient and can be present during the interview and exam, (with patient approval) to reassure the patient and provide support.
Child life advocates are extremely helpful however must be reminded not to interview the child or to ask questions concerning the event…
Forensic interview
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Health Care & Evidentiary Examinations
Primary focus is on assessing the immediate health care needs of the patient and THEN the collection and preservation of evidence….
The patient is often the only witness to the crime, and their body and clothing the only crime scene..
A health care assessment must be done regardless of the time frame of the assault – however if the assault occurred within 96 hours a NEW YORK STATE SA EVIDENCE COLLECTION KIT is used- BASED on exposure and potential for evidence, pre-pubertal evidence collection often within 24 hours….
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Photo Documentation of Injuries all findings thought to be anything but normal should be documented with high quality still photos or video
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Photo documentation recommended esp if + findings
physical evidence is short-lived and if not recorded, may be lost.
The appearance of injuries can change significantly over time
Serve as an aid to memory
They permit the court and jurors to see the evidence “as it was”
Always photograph patient identifier before and after their images
Photograph the child’s face as well…
Never a substitute for detailed written descriptions of exam findings – or lack of….
Photo Documentation
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PURPOSE IS TO COLLECT BIOLOGIC TRANSFER OF POTENTIAL EVIDENCE
SEMEN, SALIVA, BLOOD, OR DEBRIS SUCH AS DIRT OR GRASS ETC…
SA EVIDENCE COLLECTION KIT “THE RAPE KIT”
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Equipment to assist in collection
TOLUDINE BLUE
Blue dye which aids in visualization of skin disruptions
Dye is taken up by nucleated cells and only the very top layer of the epidermis is made up of cells without nuclei, anything that disrupts the superficial epidermis will allow dye uptake by the cell layer just below
Woods lamp or blue or ultraviolet light source
Aids in identifying semen stains on skin or clothing…
The fluorescing stains can be swabbed for forensic analysis
Semen will exhibit white to yellowish green fluorescence, fades after 28 hours
Limitations – false neg & false pos results
A&D ointment, surgilube, barrier creams, soaps, infant formula etc will also fluoresce.
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DFSA kit drug facilitated sexual assault
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There has been an increase in the use of some drugs to render a person incapacitated and more susceptible to sexual assault. Ingestion of drugs can result in a loss of consciousness and an inability to resist. Some drugs cause memory loss and incapacitation. Many victims may not remember the assault itself…..
Blood and serum samples are obtained and secured in a DFSA kit within 96 hours of the assault
Urine samples are the primary source for detecting – best prior to 36 hours
DFSA DRUG FACILITATED SEXUAL ASSAULT
a mentally incapacitated person, which includes a person that is rendered temporarily incapable of appraising or controlling his conduct owing to the influence of a narcotic or intoxicating substance administered to him without his consent, is incapable of giving consent.
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~Labs~
Pre-pubertal
testing for Chlamydia, Gonorrhea, (Trich) to all potentially exposed orifices
Initially a urine based (NAAT) “dirty catch” specimen is sent for Gc, Chlam, Trich with confirmatory testing sent on any positive results….and of course treatment after
rarely serum labs initially unless hiv pep indicated
Pubertal - adolescent
Urine hCg
Serum Testing for HIV, HEPATITIS (B&C), syphilis
CBC, CMP for those receiving HIV PEP
We do not test for gc, chlamydia and trich (we presumptively treat)
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medications
Pre-pubertal
No medication as prophylaxis – children are tested – if positive for CT or GC:
< 45 kg
Ceftriaxone and erythromycin
> 45 kg
Ceftriaxone and azithromycin
Weight based….
Pubertal - adolescent
Medications to treat STI’s are offered/encouraged – parental consent not required
Emergency contraception is offered-encouraged – plan b
aZithromycin, ceftriaxone, metronidazole
Give Zofran prior to ab’s
HIV (PEP) Post Exposure Prophylaxis, should be offered to patients reporting for SA evaluations when significant exposure may have occurred – ideally no more than 36 hours post exposure – HOWEVER CLINICAL JUDGEMENT IS IMPORTANT….
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Multiple studies have reported that the rate of anogenital injury In adolescent sexual assault victims ranges from 12 - 83%
Possible explanations include stranger vs acquaintance SA….injury rates are higher and more violent when the assaults involve a stranger versus a “known” person committing the assault...
However there can be increased severity with anal trauma – as much as 61%
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6 yo with injury
Injuries are rare – most sexually abused children will not have signs of genital or anal injury – especially when examined non-acutely
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Photo documentation of oral injuries
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Testifying…The healthcare professional evaluating for suspected SA will inevitably come in contact with the people and practices of the legal system…
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