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Vyom Iyer

IM 3 / 12 AP

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Sexual Assault Victims and The Healthcare System: SANE Programs

Sexual assault is a prominent, global issue which affects every country on earth, and

serves a challenging problem to solve for legislation and healthcare systems. Sexual assault is

defined as unwanted sexual contact and rape is defined as “sexual intercourse committed by the

perpetrator without the victim’s consent” (Smith, 2004). While prevention of the issue is

becoming a more widespread issue, the crime is not slowing down. In the United States, more

4than 300,000 women and 90,000 men are forcibly raped each year, however these figures are

thought to be lower than “the actual incidence, and they only include forcible rape – which does

not include most forms of sexual assault” (National, 2017). In Maryland alone, “1,758 rapes

were reported in 2015” (General, 2018). While these figures are alarmingly high, action is being

taken to stop this crime. The core of the solution, however, must be the survivors and their

recovery journey. There is also the issue of “the secondary rape” and “secondary

traumatization.” This is what the process of reporting an assault is called due to the invasive and

emotionally taxing nature of the exercise. Victims are subjected to a reliving of their assault or

rape, generally doing so completely alone and without any support. Over time, legislators and

doctors have worked to find effective solutions to make reporting an assault less of a trauma.

One of the major solutions that was the introduction of Sexual Assault Nurse Examiner (SANE)

programs. These programs are specially designed to help survivors of sexual assault and rape

through the medical testing process as well as provide them with more resources for their
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recovery after they leave a hospital. The implementation of this program throughout Maryland

counties would be completed through the Maryland House of Delegates and Senate, as well as

with the assistance of local organizations.

Sexual assault and rape victims have had a unique relationship with the healthcare system

as their treatment has been highly generalized. These patients were overlooked and ignored for

decades because doctors were intimidated by the legal aspects of these cases, or due to their lack

of familiarity with the unique needs of assault victims. During much of the 20th century, sexual

assault victims were rarely even treated in hospitals after their trauma. This continued until the

1970s, when the the rape crisis movement occurred. This prompted the government to become

involved in the writing of protocols for medical treatment of survivors. and since then, medical

treatment for survivors has changed greatly. It was in 1976 that the first SANE program was

developed in Memphis, Tennessee. However, the widespread implementation of SANE

programs has proven to be challenging and time consuming. There have been a handful of major

changes in the healthcare system, some of which have been enforced by the government, and

some of which have been through the efforts of local clinics and organizations. In 1992, this

issue became one of national importance as Congress decided to get involved. The Joint

Commission for the Accreditation of Healthcare Organizations “required hospitals to develop

official protocols for the treatment of victims of abuse” (Ahrens, 2000). This was a significant

step in the right direction as it forced hospitals to reevaluate how they were treating the victims

who seeked medical attention. In the last 3 decades, the number of SANE programs present

nationwide has increased rapidly. This action has been taken on a federal and state level with

proposed bills and advisory committees in the House of Representatives and the Maryland House
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of Delegates. In 2014, the MD House of Delegates proposed a bill which outlined the actions

which all hospitals in Maryland must complete for the safety and care of patients who seek

medical attention in their emergency departments. The bill specified the creation of a committee

to review how sexual assault evidence kits are handled and tested in the medical and legal

systems. It is also stated that for facilities that do not have a SANE program, victims must be

provided with transportation to a facility with this resource. Over the last five years, this bill has

been edited several times and has travelled through the Maryland Senate and Governor’s

office.House Bill 963/Chapter 627, Section 2(g) of the Acts of 2014) states the following “each

hospital that provides emergency medical services shall have a protocol to provide timely access

to a sexual assault medical forensic examination by a forensic nurse examiner (FNE) or a

physician to a victim of an alleged rape or sexual offense who arrives at the hospital for

treatment” (Sexual-Assault, 2015). This shows the increased dedication to improving care for

sexual assault victims. The government’s involvement in implementing these programs has

greatly increased the amount of resources given to hospitals. The time and money which

facilities are given allows for nurses, the core of SANE programs, to be trained properly. Nurses

are trained to specifically treat survivors of sexual assaults in the hope of aiding their recovery

process as well as assisting them with the legal system. The availability of these nurses with

specified training, provides victims of sexual assault and rape with more resources and specified

treatment. SANE programs also foster patient-centered and trauma-informed care which make

the process of reporting an assault smoother and less retraumatizing for the victim. SANE nurses

review the patient using holistic methods, “being mindful of both the acute and long-term

consequences of sexual violence victimization” (SANE, 2019). The thoughtful creation of SANE
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programs gives survivors of sexual assault and rape more resources and assistance immediately

after their trauma, and makes the reporting process easier.

While SANE programs have become more popular and are understood to be an effective

practice, not every facility in Maryland has the resources to support this. This leads to many

victims who are unable to receive the care that is best for them. In order to provide these services

in some capacity, select facilities have methods in place to provide patients with transportations

to those facilities with a SANE program. In the next 5 to 10 years, it is reasonable to expect all

hospitals to have these protocols in place as to ensure that all survivors receive the best care

available. This type of care is victim-oriented and trauma-informed, and involves several benefits

which assist victims through the medical process.

When determining the benefits of SANE programs, it is important to also examine the

limitations of current methods of treatment. These limitations are extensive and damaging,

however, SANE programs have been carefully designed to correct these shortcomings. Current

disadvantages do not only affect the patients as they subsequently influence nurses and doctors

through the emergency department protocols, which “dictate treatment of medical injuries, a

forensic rape examination, treatment of sexually transmitted diseases, emergency contraception,

and psychiatric intervention” (Ahrens, 2000). These protocols and exams are detailed and

extensive, and therefore, require advanced training and resources. Due to this necessity of

resources, an inadequate amount of doctors and nurses are able to treat these patients. Many

patients must “wait for up to 6 hours for an available doctor,” because of the lack of staff

(Ahrens, 2000). Emergency department staff is also met with limitations in that they may be

“rushed and perfunctory in their treatment of sexual assault survivors, having little time to
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explain procedures or comfort victims” (Ahrens, 2000). The consequences of this make victims

less aware of their rights and the process becomes more retraumatizing. It has been found that

even physicians “may also be reluctant to work with sexual assault victims due to the length of

the examination and the possibility of future legal involvement,” neither for which they are

adequately trained (Ahrens, 2000). The last major limitation is that patients are also often met

with a sizeable bill and are “generally expected to pay for the exam out of pocket and then apply

for reimbursement through the state’s compensation program” (Ahrens, 2000). The process of

reimbursement is another lengthy one, causing more stress and trouble for the victim. These

considerable limitations, victims are denied the best care available, and the lengthy procedure

makes other victims more wary of reporting their own assaults. These issues are what SANE

programs target, which makes them more effective and less retraumatizing for the victim.

The majority of this program is through the work of the nurses. These nurse examiners go

through extensive training and learn how to handle the medical exam as well as the legal system.

The holistic approach to providing care and support makes this a better approach. SANE nurses

must complete a detailed, 40 to 60 hour training session which covers several topics concerning

the medical exam, how to converse with the victim, and preparation for subsequent legal

encounters. Training topics include Victim Responses and Crisis Intervention, Collaborating

with Community Agencies, Medical Forensic History Taking, Medical Forensic Documentation,

Discharge and Follow-Up Planning, and Legal Considerations and Judicial Proceedings (Sexual

Assault Nurse, 2018). This expansive training differentiates SA nurses from otherwise qualified

nurses. The topics covered here are generally only applicable to these cases, but emphasize the

thoughtful care that must be given to these patients, and continuously maintains the goal of
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victim-based, trauma-informed care. The training separates SA nurses from other nurses as they

are given a separate set of skills to use in these situations. Many doctors and nurses are reluctant

to treat SA victims because of the possibility of having to deal with the legal proceedings which

follow. This is also another limitation of the current model. Nurses are specifically trained to be

“prepared to testify in a criminal or civil trial as a fact or expert witness when necessary, and

understands the ethical obligations of their testimony and the limitations as well” (SANE, 2019).

This provides support for the victim when reporting their assault to the proper legal authorities.

Many victims have difficulty handling this part of the process, so having a trained individual by

their side can make this step less stressful. Another aspect of the program which was taken into

consideration is the gender of the nurses. SANEs are generally female nurses because it has been

found that victims are more likely to be open to treatment by a female than a male. One study

states that “many survivors express mistrust of men following sexual victimization...and a

preference for female providers” (Ahrens, 2000). SANE nurses are also trained on how to assist

the families who have also been affected by this trauma, as they suffer as well. The SANE

education guidelines identifies the patient “as an individual and as part of a family or community

system, which is affected by all forms of violence,” ensuring that each part of the affected

community is cared for (Sexual Assault Nurse, 2018). Creating this environment of safety and

trust is one of the main goals of SANE programs as victims are generally in a state of shock and

reluctant to trust anyone openly. The nurse is trained to “gather a culturally and developmentally

appropriate medical history and a history of the assault, with an essential understanding of the

medical and legal implications of bot,” so as to not overlook any detail of the case (SANE,

2019). She also is taught to provide “culturally sensitive, developmentally appropriate,

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trauma-informed, and patient-specific evaluation and treatment,” which is different from classic

nursing training (SANE, 2019). The extensive training which nurses are provided with foster an

environment of trust while supporting the patient every step of the way.

These programs have numerous benefits which demonstrate why they should be available

to every patient. One part of the training is making sure that nurses are able to convey to a patient

all of the rights they have in terms of stopping the exam or deciding which parts they are or are

not willing to go through. It is crucial for patients to understand that they “can go through the

entire exam, and even though they sign the consent form, they have a right to stop the exam.

They are able to pick and choose what they will and will not have done” (Smith, 2004). This

conversation is a part of the short term relationship which forms. SANEs are encouraged to

foster a “caring relationship, which encompasses patient participation, consent and mutuality,

teaching, and a warm and open environment” (Sexual Assault Nurse, 2018). There is heavy

emphasis put on creating a relationship between the nurse and the patient so that history can be

taken and an account of injuries can be completed easily. The relationship becomes “the base

that the nurse and the patient use to share information, thoughts, feelings, and concerns” (Sexual

Assault Nurse, 2018). This environment of comfort and trust allows for higher quality outcomes

as the victims is more relaxed and willing to trust the SANE. Trainings also encourage “mutual

problem-solving, attentive reassurance, human respect, an encouraging manner, appreciation of

unique meanings, a healing environment, affiliation needs, and basic human needs,” in order to

give the patient the most respect possible while giving them the unique care they deserve (Sexual

Assault Nurse, 2018). These values contribute to making this process far less traumatic for the

victim. Nurses are also given guidance on the next part of reporting an assault: their discussion
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with law enforcement. This process asks victims to relive their trauma almost immediately after

the medical testing, which can be stressful and incredibly harmful to their recovery. SANEs are

trained to aid them in this retelling and explain to law enforcement the injuries sustained. In

addition, they are trained to provide accurate testimony in any judicial proceedings which may

follow. Education guidelines concerning this part of the process include training in“Consent,

Reimbursement, Confidentiality, Medical screening examinations, Mandated reporting

requirements, Judicial proceedings, etc” (Sexual Assault Nurse, 2018). The extension of SANE

training past the medical testing is what makes this program more unique and provides more

assistance in the most difficult steps in reporting an assault.

Victim advocates are an additional part of the process for patients and are highly

recommended because they offer a different perspective of support for the patient. However, the

resources are not always available for all SANE programs to have victim advocates. Victim

advocates are volunteers, sometimes survivors, who stay with the patient as they go through the

medical exam. They provide emotional support and also help the nurse in her examination,

however they are not directly involved with the medical testing as they are not trained for this.

Victim advocates receive a different training which is focused more on how to converse with

patients and offer different care than nurses. These advocates “assist survivors in hospital

emergency departments (ERs) and police departments by guiding them through the process of

medical forensic evidence collection and legal prosecution” (Campbell, 2006). Victim advocates

also work to prevent the “second rape” which is defined as “insensitive, victim-blaming

treatment from social system personnel that exacerbates the trauma of the rape” (Campbell,

2006). Their perspective is generally one from experience, and so, they are able to connect with
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the patients in ways that a nurse or law officer cannot. Advocates often help SANE nurses get

information to the patient clearly as well as talk to the police after the exam, which helps both

the SANE and the patient provide all information possible. They are “usually present for the

exam to support the survivor and clarify the information presented by the doctors and nurses.

Survivors usually talked with the police after the exam and, hence, had the support of an

advocate for that process as well” (Campbell, 2006). This additional support offered to the

patient augments all efforts to jumpstart their recovery as quickly as possible.

The various limitations that come with current models to care for sexual assault victims

lead to the creation of SANE programs, which utilize nurses to better the type of care which

these unique victims receive. The extensive trainings which nurses are required to attend ensure

that the care is trauma-informed and victim-centered, so the survivors understand their rights in

the situation and that they have ample support throughout the process. This support includes

victim advocates who are present to aid the nurse and explain details of the process to the victim.

These various benefits demonstrate the incredible need for SANE programs in all Maryland

hospitals so victims can receive the type of care which will help them recover the most.

The implementation of these programs across Maryland is a lengthy process which will

require funding, resources, and the cooperation of officials in hospitals and several legal

departments. For SANE programs to be successful throughout Maryland, hospitals will need

assistance from legislation, community professionals who can offer help immediately, and local

organizations.

When looking to the future, the government’s involvement with this process will be

through bills which ultimately go to the governor. These bills must propose protocols for
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hospitals which can support a SANE program and for facilities that cannot. As of 2018, several

bills concerning sexual assault treatment in the criminal and medical systems were passed. These

bills also include budgets for Rape Crisis Centers (RCCs) and other resources which are needed

to operate SANE and SART programs. The Maryland Coalition Against Sexual Assault issued a

statement concerning the various 2018 legislative priorities which concerned sexual assault

victims and resources available to them. The documents states that the General Assembly

“enacted dedicated funding for rape crisis centers and created new position in the Attorney

General’s Office to staff the Committee on Sexual Assault Evidence Kit Policy and Funding”

(Legislative Priorities, 2018). The Maryland Department of Health and Mental Hygiene is a also

major force behind ensuring that hospitals have the proper protocols in place. They have

provided details from several studies which support many of the suggested actions in House Bill

963. The government’s involvement in implementation provides a higher quality of resources to

train nurses and provide victims with all possible resources.

Other community organizations are also heavily involved as this is not a medical or legal

issue only. The police and emergency response teams must also be specifically prepared to

handle these situations and must receive specific training. In Maryland, Sexual Assault Response

Teams (SART) work closely with SANE nurses to make “system-wide improvements in

response to sexual violence” (Sexual Assault Response, 2018). The makeup of the SART allows

for more change because several perspectives are taken into consideration, and all outlets for

change are represented. The MCASA states that the core members of a SART should include

“the Sexual Assault Forensic Examiner (SAFE) or medical care provider, a rape crisis advocate,

a law enforcement officer, and a prosecutor...domestic violence victim advocates, military

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members, Title IX staff, state crime laboratory personnel, social services staff, and other

professionals who provide services to survivors of sexual violence” (Sexual Assault Response,

2018). This diverse team of professionals provides the victim with the most aid possible to help

them through this trauma. The varied skills of each member allows these teams to work towards

improving “protocol, providing cross-training, reviewing cases, and implementing a coordinated,

victim-centered community response” (Sexual Assault Response, 2018).

This work, however, cannot be done without the use of local organizations which are

dedicated to this cause and providing support for survivors. Utilizing local organizations to help

provide resources for SANE programs could also serve as a motivator for executing this

endeavor. One example is HopeWorks of Howard County in Columbia, Maryland, which has a

volunteer program in place that trains adult volunteers to be victim advocates in hospitals. This

organization works closely with the local hospital, Howard County General Hospital, to offer

assistance whenever a victim comes into the emergency room (Medeiros, 2019). Throughout

Maryland, there are several local organizations which are there to provide resources for survivors

of sexual assault. Many of these survivors get the most out of these organizations and have a

desire to help other victims and so they become volunteers. Local volunteer organizations can

assist hospitals in their area with providing victim advocates as well as attempting to fill holes in

some of the program trainings. These organizations serve to compound the efforts of SANE

nurses and the medical and legal professionals.

As with most programs, SANE programs cannot function without the support of other

professionals who can offer other resources at different times in the victim’s process of reporting

their assault.
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Sexual assault and rape victims have had a complicated relationship with hospitals and

the healthcare system. Initially their treatment was denied because of the lengthy process and the

fact that many doctors were not trained enough to deal with this specific situation so the

treatment was not comprehensive. Over time, a new program was introduced which trained

nurses to treat sexual assault victims with a different type of care and attention. The creation of

SANE programs has improved the treatment of victims greatly as they are given more care and

resources. The extensive training the nurses recieve make these programs more comprehensive

and assist the victims in more ways than just examining injuries. Every hospital should have a

SANE program or the ability to get patients to a facility with one because of the various benefits

and issues with the current model that the program fixes. The implementation of SANE

programs is also not unreasonable as the government, both national and local, are involved and

striving to make this type of patient care the most effective. The utilization of local organizations

will only make this endeavor more accessible and ultimately help more survivors. In a world

with an immense amount of victim-blaming, victims need the support provided by SANE nurses

and victim advocates. Today, victims, are discouraged from seeking help and reporting their

assaults and rapes because they are scared of the stigma and how much their lives will be ruined

by what others say, but SANE nurses and a caring environment for treatment can change this

reality.