Forensic Evidence Collection in Texas Nursing CE Course

• assessment
• diagnosis
• outcomes
• planning
• implementation
  • coordination of care
  • health teaching and health promotion
• evaluation (Narcavage-Bradley et al., 2021)

Assessment

As the first standard of forensic nursing, assessment includes collecting data such as patient demographics, physical, emotional, psychosocial, cognitive, sexual, and developmental. The assessment is designed to help the nurse understand the patient's needs and preferences and comprehend the situation (Narcavage-Bradley et al., 2021).

Diagnosis

The nurse will analyze the data obtained to determine an actual or potential diagnosis. The nurse will use clinical findings to prioritize problems with the patient. Diagnoses will be used to determine appropriate testing and follow-up (Narcavage-Bradley et al., 2021).

Outcomes

              The nurse will work with the patient and multidisciplinary team to identify expected outcomes. Each situation will have unique outcomes determined by the patient's status and their response to the situation. All outcomes must be measurable, reviewed, and modified based on the patient's response. An example of an appropriate outcome is the need for the patient to verbalize an understanding of the risk and prevention of pregnancy from the assault (Narcavage-Bradley et al., 2021).

Planning

              The nurse will work with the patient and multidisciplinary team to develop a plan of care to preserve and restore the patient's health. The plan will be based on the patient's needs and consider the potential short- and long-term effects of violent assault. An example of an appropriate plan is scheduling counseling for the patient and referring the patient to a crime victim's fund for financial assistance (Narcavage-Bradley et al., 2021).

Implementation

The plan is implemented in collaboration with a multidisciplinary team and will be documented appropriately. Health teaching and promotion should also be incorporated. The examiner must be able to identify what is needed for a healthy and safe environment for the patient while identifying any appropriate disease prevention interventions required, such as vaccinations or medication prophylaxis. The patient's developmental level, readiness to learn, culture, and socioeconomic status should be considered when individualizing the implementation. The examiner will anticipate the patient's needs to decrease the risk of negative health outcomes (Narcavage-Bradley et al., 2021).

Evaluation

The final standard of practice is evaluation. The examiner will assess the plan of care throughout the process, revising goals and outcomes as needed. The SANE will consider whether their plan is patient-centered, effective, efficient, safe, and timely (Narcavage-Bradley et al., 2021).

Physical Examination and Interview of the Forensic Patient

The Texas government code chapter 420, also known as the Texas Sexual Assault Prevention and Crisis Services Act, puts forth procedures that a nurse must follow to collect evidence during a forensic examination of a sexual assault or abuse victim. After a patient has sustained an assault, the personal nature of the exam requires specialized professional learning and expertise. To ensure compliance with Texas law, the Texas Board of Nursing requires nurses practicing in the emergency room and those who may perform a forensic examination on a sexual assault victim to receive specific forensic evidence collection training (TAG, 2022).

The purpose of the Texas Evidence Collection Protocol (TECP) is to offer guidance for healthcare professionals in Texas who provide forensic assessments on patients presenting with sexual victimization or suspected of committing sexual offenses. The goal is to provide timely, comprehensive care while minimizing additional trauma to the patient. While the entire TECP can be accessed on the Texas Attorney General's website, the key points of the protocol are (TAG, 2022):

• Sexual assault is traumatic whether or not physical injuries are present.
• Emergent medical conditions should be treated before or concurrently with forensic issues (i.e., evidence collection).
• Non-fatal strangulation is a life-threatening medical event requiring specialized assessment and patient monitoring.
• Patients guide the assessment and have the right to decline the examination or evidence collection.

The protocol offers basic information for examiners and minimum requirements for forensic care. Other points mentioned in the care of the forensic patient include (TAG, 2022):

• Examiners should use open-ended questions.
• All care providers should be mindful of maintaining confidentiality.
• Access to a sexual assault advocate during the forensic medical assessment is mandated by Texas law. The advocate is a distinct and separate entity from the healthcare providers and law enforcement personnel.
• The reporting of abuse is mandatory if the victim is a child, a person with a disability, or an older adult. These incidents must be reported regardless of the wishes of the patient, family, or friends in Texas.
• A forensic expert should see pediatric patients and suspected perpetrators (this includes SANEs and forensic nurse examiners).
• Contamination of potential evidence should be avoided while examining the patient and collecting evidence.
• Nurses should stay within their professional practice guidelines. This can be difficult when caring for suspected abusers or survivors of trauma.
• For military-affiliated survivors, reporting options must be given to them by someone knowledgeable about the US Department of Defense policies.
• Institutional policies should exist regarding obtaining photographs, identifying patients in photographs, and documenting the existence of such photographs in the patient's medical records. This includes the requirement for informed consent before photographing a patient.
• A sexual assault examination can occur without using a sexual assault evidence kit (SAEK). These kits should only be used when necessary.

Adult survivors of sexual assault (those without disability under the age of 65) can choose to report or not report the offense to law enforcement. When a patient chooses to report the incident, the assault should be reported to law enforcement in the jurisdiction where the incident occurred. The patient should be given access to all support services, including healthcare treatment, evidence collection, and advocacy. If a patient chooses not to report the incident to law enforcement immediately, sexual assault evidence can be collected and processed up to 5 years later if the patient chooses to report the crime at a later date. Nonreporting sexual assault evidence can be submitted to the Texas DPS Crime Laboratory Service for storage. The evidence should be packaged in a box sealed with heavy tape. The examiner should initial the box so that part of the initials is on the tape and part on the box. The box should be appropriate for standard shipping. No liquid (e.g., blood or urine) samples should be included. These patients should be given access to all the same support services. The payment for medical services may initially be the patient's responsibility, although they should be encouraged to file for reimbursement through the Crime Victims’ Compensation. The forensic services are the responsibility of the facility/provider, who can also file for reimbursement through the Crime Victims’ Compensation (TAG, 2022).

A Victim-Centered and Trauma-Informed Approach

Sexual assault is a traumatic event that negatively affects overall health and well-being. A victim-centered approach consistently focuses on the victim, including their specific needs and concerns. This technique should be practiced by the entire multidisciplinary team (including medical providers, law enforcement, victim advocates, social workers, etc.). This approach aims to convey compassion and empathy and avoid judgment. Trauma-informed care starts with understanding the source of the trauma endured by the patient. Sources of trauma will include the recent assault but may also involve previous experiences of abuse and historical trauma. Members of the healthcare team should seek to understand potential connections between the patient’s symptoms (and behavior) and their trauma history. Trauma-informed care also recognizes the trauma's effect on the victim's family and friends, including their ability to care for the victim. A trauma-informed approach requires attending to the victim's emotional safety as diligently as their physical safety. The goal of care is to reduce the risk of further injury (i.e., retraumatization) while recognizing the patient's recent neurobiological trauma (NIJ, 2017; OVW, 2016).

According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2017), retraumatization is defined as “stress reactions experienced as a result of a traumatic event when faced with a new, similar incident” (p. 1). The care team should use language and terminology that is thoughtful, deliberate, and easy to understand. Nurses should provide culturally sensitive care and use self-identifying gender preferences and trauma-informed practices when discussing assigned sex at birth (NIJ, 2017; OVW, 2016). Human behavior is affected by the neurobiological changes that occur during trauma. For example, a traumatic event will often trigger dissociation, a reduction in the functioning of the prefrontal cortex (our brain’s center of logic and rational decision-making), and a fight, flight, or freeze response (University of Northern Colorado, 2022). There is no expected or "normal" behavior after a sexual assault. Some behaviors that may be observed in a patient following a sexual assault are:  

• blunt or flat affect
• agitation
• fidgeting or poor eye contact
• somnolence
• difficulty remembering details
• difficulty with why questions
• indecisiveness
• emotional lability (Narcavage-Bradley et al., 2021)

       Patients can experience decreased cognitive function following a sexual assault. Patients should be informed about each step of the process before it happens during the exam and offered choices whenever possible to reinforce their self-determination and autonomy. Patients should be allowed ample time to answer questions, stopping for a break if the patient appears to be overwhelmed. When in doubt, the examiner should ask the patient what they need to feel safe. Challenging and sensitive topics must be discussed honestly and openly to treat the patient properly and prevent further injury. However, this conversation should be humane, respectful, and sensitive. It is best practice to start with less stressful questions about general health information. Explain the rationale for all questions asked. Once the interview focuses on the incident in question, the examiner should explain to the patient that it is necessary to review exactly what occurred so that they can provide the best treatment available. Questions should be open-ended, and the examiner should avoid questions that begin with "why." Patients may have more difficulty with memory when seen immediately following the sexual assault if they have not slept. Since trauma can lead to serious conditions such as post-traumatic stress disorder and acute stress disorder, patients' mental and physical needs should be addressed. A sexual assault (or victim) advocate should be provided whenever available to enhance the patient's comfort level. A sexual assault advocate's role is to provide counseling and support services to victims of sexual assault or violent crimes. Non-English-speaking patients or patients with vision or hearing impairments should be provided interpreters or alternative communication tools to ensure effective and honest communication (OVW, 2013).

The patient should be counseled on the potential benefits and consequences of reporting the assault to law enforcement in cases where reporting is not mandatory (adult patients). The patient decides whether to report the incident to law enforcement; the nurse should support their decision-making by answering their questions and providing objective information. The victim’s advocate may also provide valuable support and insight into the legal processes and procedures should they decide to report the incident. Some jurisdictions have alternative methods for reporting. As with other facets of the process, the reporting should be victim-centered. The medical exam can be done whether the patient has decided to report the incident immediately or not. The evidence can be submitted later if the patient chooses to report (OVW, 2013).

Before the Examination

Before beginning an examination, verbal and written consent will be obtained. In the case of an adolescent or pediatric patient, this consent may need to be obtained from the legal guardian, depending on the local jurisdiction’s regulations. Informed consent should include an explanation of the purpose of the samples, how the samples/kit may be used, and that consent can be partial (certain parts of the exam) and withdrawn at any time. If possible, the examiner should also include time frames, processing procedures, and how the patient may be notified regarding test results. A forensic examination should occur in a quiet, safe environment that offers the patient privacy. The patient assessment should not be interrupted by the outside environment. Recommended equipment and space include the following:

• an image-capturing system, such as a digital camera (personal photography equipment or phones should not be used as the chain of custody cannot be maintained on personal devices)
• a colposcope or other magnification system
• a SAEK and associated forensic medical documentation forms
• a DFSA or toxicology testing kit (DFSA urine should be frozen or refrigerated to maintain the chain of custody)
• paper bags
• evidence tape
• marking pens
• indicated personal protective equipment (PPE)
• a drying area for evidence
• locked and secured temporary storage space for any evidence awaiting release to law enforcement (NIJ, 2017)

Adult/Adolescent Protocol

Adults, including older adults, will have similar protocols regarding evidence collection and physical examination. Adolescent patients require examination by a certified forensic professional, such as a SANE (NIJ, 2017).

Initial Presentation

Adult and adolescent patients who present with reports of an assault have the right to receive a forensic medical assessment. These patients should be triaged as a medical emergency and assigned a 3 or above designation on the 5-tier emergency severity index (ESI) triage system (Subramanian & Green, 2015). In Texas, it is recommended that sexual assault patients are triaged at a level 2 (TAG, 2022). If not present, the forensic examiner and a sexual assault advocate should be notified of the patient's arrival. In the meantime, standard healthcare providers should see the patient as soon as possible. The patient should be escorted to a private waiting area, ensuring the patient is safe and the suspect is not present. Speaking to the patient alone is often necessary to obtain this information. The examiner should assess the patient's pain level and inquire about any bleeding. Once the patient is stable, a forensic medical assessment should be offered. The patient should avoid using the restroom, washing, changing clothes, smoking, eating, or drinking until the exam is completed. If the patient must use the restroom, the urine should be collected (if DFSA is suspected) using the prepackaged DFSA specimen cup included in the SAEK, and the patient should avoid wiping until after all evidence has been collected. The chain of custody on all specimens must be maintained (NIJ, 2017).

Forensic Examiner/Nurse

The forensic examiner should obtain informed consent after introducing themselves to the patient and explaining what to expect from the forensic exam. The examiner should determine if the patient wishes to report the incident to law enforcement. For older adults (over 65), reporting is typically mandatory. The medical assessment may occur before or during the forensic sexual assault assessment and varies depending on facility policy. The examiner should obtain a detailed description of the incident. Along with a verbatim description of the assault, the examiner should document the following:

• all persons present during patient history and assessment
• the time, date, and location of the assault
• any physical contact and penetrative acts by the perpetrator
• any possible injuries to the suspect
• the use of lubricant, including saliva
• any patient actions between the assault and arriving at the facility (e.g., oral care, changing clothes, vomiting, smoking, swimming, douching, or bathing)
• the presence or absence of menstruation and the use of a menstrual cup or tampon during the assault or forensic assessment
• the use of a condom or other barrier
• the occurrence of ejaculation by the patient or suspect
• any weapon or physical force used (NIJ, 2017)

The steps for evidence collection and packaging include (NIJ, 2017):

1. Obtain written consent/authorization.
2. Apply powder-free gloves when handling kit contents, changing gloves between each item of potential evidentiary value.
3. The examiner should inspect the SAEK's integrity before opening the sealed kit.
4. The examiner should not cough or sneeze over the evidence.
5. Each item of clothing should be individually sealed in a paper bag. The patient's underwear should go in the SAEK.
6. A prepackaged DFSA specimen kit should be utilized to collect urine if appropriate. Indications for this include unexplained memory loss, loss of consciousness, nausea, vomiting, and dizziness.
   1. Place blood or urine DFSA samples in a sealed and labeled biohazard bag that is then placed into a sealed and labeled cardboard box. Urine should not be placed in the SAEK to maintain the chain of custody.
   2. When a prepackaged DFSA kit is unavailable, the examiner may use one gray top tube of blood and a dirty (i.e., not sterile or clean-catch) urine specimen.
7. Swabs should be placed directly into swab boxes. All other wet evidence (e.g., clothing, underwear, etc.) should be air-dried before packaging, if possible. When air drying is not possible, wet evidence should be refrigerated. Law enforcement can take specimens for drying.
8. Envelopes that contain evidence should be sealed with self-adhesive labels or tape, not saliva.
9. All evidence should be sealed and labeled with the date and time of collection and the examiner's initials.

Sexual Assault Evidence Kit (SAEK)

              SAEKs should meet or exceed minimum national guidelines. Standardizing kits within a jurisdiction and across a state or territory is recommended. In Texas, an Attorney General-approved SAEK should be used if available (TAG, 2022). Regardless of how kit contents vary, every kit should meet the following minimum guidelines:

• a container with a blank label for identifying information and documenting the chain of custody (most items will be placed in the container after being dried, packaged, labeled, and sealed, although bags should be provided for bulky items that will not fit in the container);
• an instruction sheet or checklist that guides the examiner in collecting evidence and maintaining the chain of custody;
• a set of forms that facilitate evidence collection and analysis, including patient authorization to collect and release evidence, the medical forensic history, and anatomical diagrams;
• any materials necessary for collecting and preserving the following evidence:
  • clothing, underwear, and foreign material dislodged from clothing
  • foreign material on the patient's body, including debris and dried secretions
  • fibers, loose hairs, fingernail cuttings or scrapings, various types of swabs
  • plucked or pulled hair
  • vaginal and cervical swabs
  • penile swabs
  • anal/perianal swabs
  • oral swabs
  • body swabs
  • known blood, saliva, or buccal swab for DNA analysis and comparison (OVW, 2013)

Swabbing and Evidence Collection

Forensic evidence deteriorates with time, so evidence must be collected as soon as possible. Evidence should be collected whether the patient is seen directly after the assault or days later, even if the patient has showered, douched, swam, etc. Sexual assault samples can be taken for 5 days or longer post-assault. As technology advances, that period expands, and in some instances, can be up to 9 days. When swabbing a patient, it is best practice to collect evidence using two swabs from each site (OVW, 2013). Before swabbing each site, the process and reason for swabbing should be explained. Photographs can be taken at this time per facility protocol. Taking photographs during evidence collection prevents the patient from having injured areas exposed multiple times. It also allows photographs of the evidence and injuries before they are disturbed or altered (NIJ, 2017). The procedure for collecting swabs and evidence includes the following steps (NIJ, 2017; OVW, 2013):

1. Moisten swabs with sterile water when necessary or directly before evidence collection. Swabs can be air-dried or placed in the swab box without being dried.
2. Prevent cross-contamination with strict practices such as changing gloves between sites and not coughing over swabs.
3. Seal swabs from left and right body parts in the same envelope but in different boxes. For example, swabs from the left and right breasts are placed in separate boxes and sealed inside the same envelope.
4. Examiners should wear gloves during evidence collection. Examiners should avoid cross-contaminating the evidence by changing gloves often and placing each sample into a separate container as instructed. The examiner should avoid speaking or coughing while handling swabs to avoid examiner contamination (TAG, 2022).
5. The purpose of the oral swab is to recover foreign DNA. Foreign DNA degrades quickly in the oral cavity. If oral penetration is suspected or the patient is unconscious, oral swabs should be collected as soon as possible.
   1. The oral swab collection process includes putting on new gloves and using two swabs to swab the inside of the patient's mouth around the gum lines. The two swabs should be sealed together in a labeled swab box and placed in the oral swab envelope.
6. The known DNA buccal swabs/Whatman Flinders Technology [FTA] card is used to determine the patient's DNA for comparison to other samples. The swabs for foreign DNA should be obtained first. The examiner should wait 15-20 minutes, have the patient swish their mouth with water, and then wait another 15-20 minutes. The patient's known DNA should then be collected, sealed, labeled, and placed within the SAEK as directed.
7. Any matted head hair should be clipped or swabbed with lightly moistened swabs. Depending on facility policy and kit instructions, reference samples should be collected by cutting or pulling/plucking hair (deceased patients ONLY). As with previous samples, these should be sealed, labeled, and placed in the SAEK as directed.
8. To collect head hair combings, the patient's hair should be combed over a piece of paper after putting on new gloves. When appropriate, the patient can comb their own hair if preferred. The comb/hair/debris should be folded up with the paper, placed in the provided envelope, sealed, labeled, and placed in the SAEK as directed.
9. Clothing should be collected to recover possible foreign matter or DNA. Any existing damage to clothing should be documented and photographed. The collection protocol and process for different articles of clothing are as follows:
   1. Always collect the patient's underwear when allowed, even if the patient has changed since the assault. This applies to underwear in contact with genitals, not bras. If the patient is not wearing underwear, collect the articles of clothing touching the patient's anal and genital areas. Do not cut through any holes or rips in the underwear.
   2. Any clothing worn during the assault or immediately afterward may have foreign DNA, including bras, pants, and shirts. Coats, socks, and shoes do not always need to be collected. The articles chosen for collection should be based on the patient's description of the assault and the examiner's judgment. Only the patient's underwear should be placed into the SAEK.
   3. After putting on new gloves, the examiner should place a clean sheet on the floor, followed by the large changing paper in the SAEK on top of the clean sheet. A gown can be held up to provide the patient privacy while removing clothing. The patient should be instructed to stand in the middle of the changing paper and place individual clothing items separately on the paper. The changing paper should be labeled, and each article of clothing should be inspected, documenting the item, color, and any damage. Damaged or stained clothing may be photographed. Each item of clothing should then be placed in a separate paper bag to prevent cross-contamination. Any wet clothing should be dried when possible. If unable to dry wet clothing, it should be arranged for release to law enforcement, notifying them that the clothing is wet.
10. Any dried secretions and debris found on the patient should be collected. After changing gloves, the patient should be inspected from head to toe, and any suspected foreign material should be collected in the dried/secretions/debris envelope.
    1. Any debris should be placed in the paper provided in the SAEK, sealed in an envelope, and labeled with the site.
    2. Any dried secretions should be flaked onto a paper bindle from the SAEK. The site should be swabbed twice with two swabs moistened with sterile water.
    3. Touch DNA is collected to assess for foreign DNA on the patient. The collection of touch DNA should be based on the patient's description of the assault and assessment findings. Any sites the patient states may have foreign DNA should be swabbed. If the patient lives with the suspect, touch DNA may not be as valuable forensically. Each area should be swabbed using two lightly moistened swabs. Each swab's site and source should be documented using the patient's own words.
11. Fingernail swabs are collected to obtain foreign DNA. If the patient describes scratching the suspect, clippings may be more appropriate. New gloves should be worn, and one moistened swab should be run under the fingernails of one hand, using a separate swab for each hand. Using wooden sticks (or similar tools) to scrape under the nails is not recommended, as this may injure the patient. The two swabs should be sealed separately, labeled, and placed in SAEK as directed.
12. Any matted pubic hair can be clipped or swabbed with moistened swabs. If reference samples are taken, they should be collected by cutting or pulling (deceased patients ONLY) per policy or kit instructions. Placed in the provided envelope, sealed, labeled, and placed in the SAEK as directed.
13. Pubic hair combings (and comb) are collected to obtain trace evidence, including foreign hairs. This is most useful in the case of unknown or acquaintance sexual assault. The process is similar to combing head hair described above. The paper is placed under the patient’s buttock, and the pubic hair is combed over the paper. Again, the patient can comb their own hair if preferred. The paper and comb should be sealed in the provided envelope, labeled, and placed in SAEK as directed.
14. Vulva swabs are collected to recover foreign DNA. New gloves should be worn to swab the vulva with two swabs simultaneously. The inner labia majora, labia minora, and the hymen should be included, avoiding the urinary meatus. The swabs can be premoistened with sterile water if instructions on the kit allow. Swabs should be sealed together, labeled, and placed in SAEK as directed.
15. Vaginal or cervical swabs are collected to recover foreign DNA. Vaginal and cervical swabs should only be collected on adolescents or adults unless the pediatric patient is sedated under physician direction or supervision. Vaginal washings are not recommended, as they can dilute the sample obtained. New gloves should be worn to insert a vaginal speculum after photographs of any genital injuries have been obtained. Two dry swabs should be gently placed into the cervical os and held in place for 5-10 seconds; they should then be used to swab the surface of the cervix and the posterior fornix of the vagina. Swabs should be sealed together, labeled, and placed in SAEK as directed.
16. Penile swabs are collected to recover foreign DNA. A male patient may be allowed to swab their own penis at the discretion of the examiner. New gloves should be worn to swab the head of the penis with two premoistened swabs, avoiding the urethral meatus. The same two swabs should be used to swab under the foreskin and the shaft of the penis. Swabs should be sealed together, labeled, and placed in SAEK as directed.
17. Scrotal swabs are used to recover foreign DNA. Male patients may also swab their own scrotums when appropriate. New gloves should be worn to swab the scrotum using two premoistened swabs. Swabs should be sealed together, labeled, and placed in SAEK as directed.
18. Anal swabs are collected to recover foreign DNA. New gloves should be worn to swab around the external anus using two premoistened swabs. Swabs should be sealed together, labeled, and placed in SAEK as directed.
19. Retained objects in the vagina or rectum are collected to recover foreign DNA or evidence. This includes collecting tampons, menstrual cups, or retained objects. Any retained objects in prepubertal females should be collected under sedation by a physician or a supervised SANE. The object(s) should be allowed to air dry, if possible, and placed in a dried secretion/debris envelope labeled and sealed.

Once the evidence is collected, it should be documented and photographed. All evidence should be labeled and sealed in a corresponding envelope or paper bag. Each evidence sample should be labeled with the patient's identifying information, including their legal name, date of birth, and medical record number; the date; time; and examiner's signature or initials. All collection bags or envelopes should be put into the primary SAEK container. After removing the red evidence labels and orange biohazard labels from the kit, the examiner should change into new/clean gloves and seal the SAEK with the red tape provided in the kit. The biohazard label should be affixed to the front of the SAEK. All documentation on the front of the kit should be completed. The examiner must sign their name and write the date and time over the evidence tape so that the signature goes from the kit across the label back to the kit to demonstrate a lack of tampering during legal proceedings (Kleypas & Badiye, 2023; TAG, 2022). The summary of collecting evidence in adult and pediatric patients is outlined in Table 1, while Table 2 reviews samples that are not routinely recommended for collection.

Table 1

Summary of Evidence Collection Recommendations

                                                                                                             (NIJ, 2017; OVW, 2013, 2016)

Table 2

Evidence Collection Not Recommended

                                                                                                             (NIJ, 2017; OVW, 2013, 2016)

Pediatric Protocol

If a pediatric patient presents following sexual assault, they should have an assessment regardless of when the assault occurred or what the child states occurred. A trained forensic professional should evaluate all children. Forensic experts are trained to ask the most appropriate questions to obtain a history. Forensic medical assessments completed by a qualified expert can yield additional medical findings, new information, information regarding sexually transmitted infections (STIs), and the presence of other victims. When a forensic professional is unavailable, another healthcare provider can complete the forensic medical history, assessment, and acute evidence collection. The patient should then be referred to a forensic expert for additional assessment when possible (OVW, 2016).

Initial Presentation

Pediatric patients presenting to the ER with reports of sexual assault should be triaged at a level 2. As with an adult or adolescent patient, the patient should be seen as soon as possible, stabilized, and a forensic medical exam offered. The care leading up to the forensic medical exam will be the same as for an adult or adolescent patient (OVW, 2016).

Forensic Examiner/Nurse

The forensic examiner will obtain informed consent after introducing themselves to the patient and explaining what to expect. Verbal assent should also be sought from pediatric patients, as they can refuse all or part of the exam. If the patient refuses, the examiner should try to discern what is preventing them from assenting. Adjusting or slightly changing the process or the current environment may make the patient feel more comfortable. If the patient continues to decline, they should be allowed to return at another time for assessment. If the patient returns within 120 hours of the assault, an SAEK can still be obtained. All cases of suspected sexual assault of a child under 18 must be reported to law enforcement. As mentioned above, the medical assessment may occur before or during the forensic sexual assault assessment, depending on facility policy. The examiner should obtain a detailed description of the incident and document the same information as with an adult exam. Evidence is collected following the same procedure as adult patients (OVW, 2016).

Documentation

Facilities should develop and approve forensic medical assessment documentation forms for their institution. The term alleged should be replaced with reported or stated when documenting the patient's history. The term suspect is preferred when referencing the assailant/attacker. If an interpreter is used, this should be documented. The patient's pertinent medical and surgical history (including obstetric history), the last menstrual period, and current medications should be documented. Once the forensic medical assessment is documented, one copy should be placed in the SAEK, and a second copy should be made available to law enforcement. All originals should stay at the healthcare facility (NIJ, 2017).

When documenting the attack, the adolescent or adult patient should be asked to start from just before the assault to when they arrived at the facility. The examiner should document exactly what the patient says and place quotation marks at the beginning and end of their history, as direct quotes are best practice. The patient should be allowed to proceed at a pace that is comfortable for them. Extensive interviewing should be avoided for prepubertal children if the examiner is not forensically trained. If the patient is uncomfortable repeating their trauma aloud, they should be offered the option of writing their story down. Patients should be asked to clarify any unclear statements relevant to the medical forensic exam (NIJ, 2017).

              Injuries should be documented using body diagrams and photographs, or "no visible trauma noted" if no injuries can be observed. Only acute injuries should be recorded for adults unless the patient reports a pattern of abuse. All pertinent injuries should be documented in the case of a pediatric patient. The body diagram should include each injury's measurements (i.e., in millimeters [mm] or centimeters [cm]), descriptions, and locations. The type of injury should be documented using the definitions provided above. Anal and genital injuries should be recorded using clock positions when the patient is supine. For example, an injury to the urethral meatus would be placed at 12 o'clock (NIJ, 2017).

Photographs

Informed consent must be obtained before taking photographs. Assent from a pediatric patient is also recommended, but informed consent must be obtained from an adult parent or guardian. Patients should be notified of how the photographs will be stored and used. Patients should be reassured that the photographs will only be used for medical forensic purposes and are protected in medical facilities. A court order can seal photographs after the legal proceedings. The institutional policy should outline the process for taking photographs, how the patient is identified in the photograph, and how the photographs are linked to the permanent medical record. Photographs may allow for additional expert opinions without requiring patients to undergo further assessments. Photographs are typically used during legal proceedings to show physical findings, and quality photos may be used to evaluate recurrent sexual abuse in children. Anal and genital pictures should not be released to law enforcement unless a subpoena or written patient consent is obtained (OVW, 2013). Tips for clear and accurate photographs include:

• use adequate lighting (avoid using a flash in the exam room as this can change the color of evidence and include a color bar in the photograph to ensure accurate colors)
• maintain focus, keep the camera steady, and keep the perspective undistorted
• use a forensic scale or ruler for size reference
• take at least two photographs of each area, one with and one without scale
• photograph evidence in place before removing it or collecting it
• minimize background distractions
• take at least two shots at three orientations: a medium-range photograph of each injury, regional shots with injuries in context that show orientation on body parts, and close-up images of particular injuries with scale
• shield uninvolved breasts or genitals when possible (highly graphic photos are sometimes deemed inadmissible in court, leaving the case less credible)
• close-up images of hands and fingernails should include damaged or missing nails
• photograph any restraint marks or signs of bondage on wrists, ankles, or neck
• photograph any transfer evidence present, such as dirt, gravel, or plants
• photograph any bite marks (OVW, 2013)

STI Testing and Treatment

Informed consent is required for all testing performed on collected samples during the exam. Laboratory testing following a sexual assault may include the following:

• nucleic acid amplification tests (NAATs) for chlamydia and gonorrhea of any suspected penetration or contact sites
• wet prep or urine/vaginal NAAT for trichomoniasis
• wet prep or vaginal pH and potassium hydroxide for bacterial vaginosis (BV) and candidiasis
• serum samples for HIV, hepatitis B, and syphilis (CDC, 2021)

Trichomoniasis, BV, gonorrhea, and chlamydia are the most frequently diagnosed STIs among victims of sexual assault. The presence of STIs does not necessarily indicate that the infection was transmitted during the attack, so the forensic exam presents an opportunity to identify preexisting infections. The CDC's (2021) treatment guidelines for sexual assault include an empiric antimicrobial regimen for the prophylaxis of chlamydia, gonorrhea, and trichomoniasis for adult females; a regimen for the prophylaxis of chlamydia and gonorrhea is recommended for males. Medication and dosing information include the following:

• a single dose of ceftriaxone (Rocephin) 500 mg IM (1 g if over 150 kg)
• doxycycline (Doryx) 100 mg PO twice daily for 7 days
• metronidazole (Flagyl) 500 mg PO twice daily for 7 days (female patients only; CDC, 2021)

No prophylactic antimicrobial treatment is recommended in pediatric patients due to the very low rates of STIs in children after assault or abuse. Testing can be considered individually in pediatric patients if risk factors are present for transmitting STIs. Postexposure hepatitis B vaccination should be offered if the patient does not have evidence of hepatitis B immunity and the assailant's status is unknown. If the suspect is known to have hepatitis, unvaccinated patients should receive the hepatitis B vaccine and immunoglobulin (HBIG) therapy. The vaccine and HBIG should be administered at the time of examination if indicated, with follow-up doses of the vaccine at 1-2 and 4-6 months. Patients who were previously vaccinated but have not had postvaccination testing of immunity should receive a single vaccine booster dose. Human papillomavirus (HPV) vaccination is recommended in patients aged 9-26 who are unvaccinated or incompletely vaccinated. Follow-up doses should be administered at 1-2 months and 6 months after the primary dose in those over 15. Adolescent patients under the age of 15 can be given a single second dose of the vaccine at 6-12 months. Recommendations for HIV postexposure prophylaxis (PEP) should be based on individual patient risk factors according to the CDC post-exposure HIV risk assessment. If the patient is felt to be at risk of HIV exposure, PEP should be started immediately to enhance effectiveness (within 72 hours). A 28-day course of zidovudine (Retrovir) can be started immediately by providing the patient with a 3 or 5-day starter pack and a prescription for the remainder of the treatment (CDC, 2021).

The TAG's (2022) treatment guidelines for sexual assault mirror the CDC's. TAG encourages providers to consider post-exposure hepatitis B vaccination, HIV prophylaxis, and HPV vaccination (for sexual assault patients over 9 years of age and under 27 who have not previously been vaccinated). For patients under 45 kg, TAG recommends:

• a single dose of ceftriaxone (Rocephin) 25-50 mg/kg IM (not to exceed 250 mg)
• erythromycin (Erythrocin) 50 mg/kg/day PO for 14 days, divided QID (TAG, 2022).

Emergency contraception should be offered or considered for any female patients of reproductive age (CDC, 2021). This can be taken within 5 days after sexual assault to decrease pregnancy risk. Emergency contraception works by preventing ovulation, fertilization, or implantation. All females need informed consent for pregnancy prophylaxis. Catholic patients should be directed to the Ethical and Religious Directives for Catholic Health Care Services if they seek additional ethical guidance. Emergency contraception should not be confused with taking medications to induce abortions; it is a method of birth control to be used occasionally in specific situations and not as a primary form of birth control. Emergency contraception will not interfere with an existing pregnancy. Most women with contraindications to estrogen-containing birth control can use emergency contraception, as it is only taken for one day. The standard prophylaxis is a single dose of levonorgestrel (Plan B One-Step) 1.5 mg PO or a two-dose regimen of 0.75 mg PO. It is most effective within 72 hours of exposure, but it can be taken up to 5 days after exposure (OVW, 2013).

Discharge Planning and Follow-up Care

Discharge instructions should include a summary of the sexual assault exam, with information such as evidence collected, tests conducted, medications prescribed or administered, and any other treatments received. The patients should be made aware of any follow-up appointments that were scheduled, or that need to be scheduled. The discharge paperwork should also contain information on local sexual assault advocacy programs with contact information and business hours. Instructions for follow-up for re-evaluation should be given clearly. Also, the patient should be educated on what to expect following the assault concerning the healing of injuries and any other expected findings or changes. A patient may be scheduled for follow-up at least 2-4 weeks after the assault for STI care, HIV testing, and administration of repeat Hepatitis B vaccine. Screening should be done for intimate partner violence (IPV) or other forms of abuse. The patient's physical safety and emotional well-being should be addressed (NIJ, 2017). According to the NIJ (2017), it is not obtrusive to ask questions such as:

• "Where are you going after discharge?"
• "Who will you be leaving and staying with?"
• "Will these people be able to provide you with adequate support?"
• "If you feel unsafe, what will you do to get help?"

Verify that the patient does not need an emergency shelter or alternative housing option. Some patients will be eligible for protection orders. The nurse must ensure that the patient feels safe upon discharge or should assist the patient in developing a plan to feel safe. Any planning must consider personal and specific concerns (e.g., a patient with a physical disability will necessitate placement in a shelter that can meet the needs of a patient who requires assistance with activities of daily living; Subramanian & Green, 2015).

Evidence Preservation

Drying and Storage

Improperly drying and storing evidence may lead to mold or bacterial growth that destroys the evidence, so kit instructions should be read and followed carefully. Wet evidence should be air-dried in a clean environment to prevent contamination. Dry evidence should be placed in paper (not plastic) containers to prevent mold growth (OVW, 2013). Each sample should be stored according to the following recommendations from the NIJ (2017) to optimize the usefulness and validity of the samples collected. This temporary storage (less than 72 hours) will maintain the integrity of the evidence until it is picked up by law enforcement and brought to the forensic laboratory. Serum/blood samples should be refrigerated between 2°C and 8°C (36 to 46 °F), while urine samples should be frozen if not immediately processed. Wet items that cannot be dried should be frozen (preferred) or refrigerated. Dry biological stained items, hair, swabs with biological materials (dried), and buccal swabs can be temperature controlled between 15.5 and 24°C (60 to 75°F) and less than 60% humidity. Alternatively, swabs with biological materials can be refrigerated if wet. Law enforcement should submit evidence to the forensic laboratory as soon as possible but within 7 days of collection. Long-term storage of kits is the responsibility of law enforcement and the forensic laboratory and mirrors most of the recommendations above for short-term storage (NIJ, 2017).

Chain of Custody

Evidence should be collected with care to be admissible in legal proceedings. The chain of custody must be maintained and documented throughout the assessment and collection process. This includes documentation of the dates and times of each transfer and every individual handling the evidence. Evidence should be labeled with the patient's name, date of birth, medical identification number, examiner's initials, date, and time. Facility policy should dictate how the evidence inside the SAEK is labeled (NIJ, 2017). With each transfer, the chain of custody documentation should include:

• receipt of evidence
• storage of evidence
• transfer of evidence
• date and time of transfer
• printed name and signature of each person transferring, receiving, or possessing evidence (NIJ, 2017)

Providing Testimony

It is recommended that jurisdictions notify examiners promptly if there will be a need for testimony in court. Pretrial preparation of examiners is recommended. Examiners should be prepared to testify as factual or expert witnesses if needed. Every examination should be documented with the expectation of a trial and the need to testify. Broad education on testifying in court is encouraged for examiners. The examiner should familiarize themself with typical courtroom proceedings, expectations, the types of testimony, and what can be said during each type. Testifying in court can be difficult, and cross-examination will likely occur. Examiners can perceive questions from defense counsel as hostile or intimidating and should be prepared to handle these situations effectively. Speaking to defense attorneys to help with pretrial preparations can educate examiners on defense perspectives and tactics. Examiners may want to prepare by reviewing new practices and related case law (OVW, 2013).

References

Centers for Disease Control and Prevention. (2021). 2021 sexually transmitted infection treatment guidelines: Sexual assault and abuse and STIs. https://www.cdc.gov/std/treatment-guidelines/sexual-assault.htm

Centers for Disease Control and Prevention. (2022). Fast facts: Preventing sexual violence. https://www.cdc.gov/violenceprevention/sexualviolence/fastfact.html

Center for Forensic Nursing Excellence International (n.d.). Multidisciplinary glossary on sexual violence. Retrieved October 25, 2023, from https://www.cfnei.com/glossary-index

Duffy, J. R., & Hoskins, L. M. (2003). The quality-caring model: Blending dual paradigms. Advances in Nursing Science, 26(1), 77–88. https://doi.org/10.1097/00012272-200301000-00010

International Association of Forensic Nurses. (n.d.). What is forensic nursing? Retrieved October 25, 2023, from https://www.forensicnurses.org/page/WhatisFN

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Kleypas, D. & Badiye, A. (2023). Evidence collection. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK441852

Narcavage-Bradley, C., Pozar, T., & Pierce-Weeks, J. (2021). IAFN sexual assault nurse examiner certification: A review for the SANE-A® and SANE-P® exams. (J. Robinson, Ed.). Springer Publishing.

National Institute of Justice. (2017). National best practices for sexual assault kits: A multidisciplinary approach. US Department of Justice https://nij.ojp.gov/topics/articles/national-best-practices-sexual-assault-kits-multidisciplinary-approach

Office on Violence Against Women. (2013). A national protocol for sexual assault medical forensic examinations: Adults/adolescents. 2^nd edition. US Department of Justice https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf

Office on Violence Against Women. (2016). A national protocol for sexual abuse medical forensic examinations: Pediatric. US Department of Justice https://www.justice.gov/ovw/file/846856/download

SAFEta.org. (n.d.). Use of terms. Retrieved October 25, 2023, from https://www.safeta.org/page/ProtocolUseofTerms

Subramanian, S. & Green, J. (2015). The general approach and management of the patient who discloses a sexual assault. Journal of the Missouri State Medical Association, 112(3), 211-217. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170132

Substance Abuse and Mental Health Services Administration. (2017). Tips for survivors of a disaster or other traumatic event: Coping with retraumatization. HHS Publication No. SMA-17-5047. https://store.samhsa.gov/sites/default/files/d7/priv/sma17-5047.pdf

Texas Attorney General. (2022). Texas evidence collection protocol. Texas Attorney General Sexual Assault Prevention and Crisis Services Program. https://www.texasattorneygeneral.gov/sites/default/files/files/divisions/crime-victims/TXEP.0202301a.pdf

University of Northern Colorado. (2022). Neurobiology of trauma. https://www.unco.edu/assault-survivors-advocacy-program/learn_more/neurobiology_of_trauma.aspx

US Department of Homeland Security. (2022). What is human trafficking? https://www.dhs.gov/blue-campaign/what-human-trafficking

US Department of Justice Archives. (2012). An updated definition of rape. https://www.justice.gov/archives/opa/blog/updated-definition-rape