Vyom Iyer

IM 3 /12 AP
1/3/19
Sexual Assault Victims and The Healthcare System: SANE Programs
I. Sexual assault is an issue that every country in the world has faced for centuries and

continues to face today. 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 than 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). Action is being taken in every area, legislation, healthcare, and

legally to stop this crime, but the focus must be on survivors and their recovery. There is

also the issue of “the secondary rape” and “secondary traumatization” which is inflicted

upon victims when they are treated medically and then questioned by the police to

provide an account of the trauma. Victims are subjected to a reliving of their assault or

rape, generally without the support of anyone who can help them or anyone at all. The

introduction of SANE programs in all hospitals in Maryland will help survivors of sexual

assault and rape through the medical testing process as well as provide them with more

resources than those available to them in facilities without this program. The

implementation of this program through Maryland counties would be completed through

the Maryland House of Delegates and Senate, as well as with the assistance of local

organizations.
II. Sexual assault and rape victims have had a very unique relationship with the healthcare
system as their treatment has been over generalized.
A. Sexaul assault victims were generally not treated in hospitals after their trauma
until the 1970s. Since then, medical treatment for survivors has changed greatly,
however it has proven to take an incredible amount of time and deliberation for
real change to occur.
1. There have been a handful of major changes in the healthcare system,
some of which have been enforced by the government.
2. Until the advent of the rape crisis movement in the early 1970s, sexual
assault victims were often denied services in hospitals (Ledray & Arndt,
1994).
3. Two decades later, in 1992, the Joint Commission for the Accreditation of
Healthcare Organizations required hospitals to develop official protocols
for the treatment of victims of abuse (McFarlane, Greenberg, Weltge, &
Watson, 1995).
4. Today, when victims of sexual assault seek community assistance, they
are usually referred to hospital emergency departments (EDs) for
treatment and forensic evidence collection.
5. The first SANE program was developed in 1976 in Memphis, Tennessee
(Ledray & Arndt, 1994; Ledray & Simmelink, 1997)
B. After the rape crisis movement in the 1970s, the government started to become
involved in the writing of protocols for medical treatment of survivors. 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 of
Delegates.
1. The house of delegates proposed a bill in 2014 which outlined the actions
that must be put in place in all hospitals in Maryland.
2. 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.
3. It is also states that for facilities that do not have a SANE program,
victims must be provided with transportation to a facility with this
resource.
4. This bill has been edited several times over the last 5 years and has
travelled through the Maryland Senate and Governor’s office.
5. House Bill 963/Chapter 627, Section 2(g) of the Acts of 2014)
a) 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
b) Planning Committee to Implement Improved Access to Sexual
Assault Medical Forensic Examinations in Maryland be
established
C. Sexual Assault Nurse Examiner (SANE) programs were first introduced in the
1970s, however, they have become increasingly more common in the last 20
years. These programs train nurses specifically to treat survivors of sexual
assaults in the hope of aiding their recovery process as well as assisting them with
the legal system.
1. Special programs in hospitals which provide victims of sexual assault and
rape with more resources and specified treatment.
2. These programs involve nurses who are specially trained to interact with
victims differently than other nurses are trained.
3. SANE nurse s review the patient using holistic methods, ​“being mindful of
both the acute and long-term consequences of sexual violence
victimization.”
III. While SANE programs have become more popular and are understood to be an effective
practice, they are not in every hospital in Maryland. Several counties also do not have
methods in place to provide patients with transportation to 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 the best care for all survivors.
A. One reason for SANE programs is that there are several limits in the current
method of treatment. These are problems that SANE programs are able to handle
and solve.
1. Emergency department protocols dictate treatment of medical injuries, a
forensic rape examination, treatment of sexually transmitted diseases,
emergency contraception, and psychiatric intervention
2. Wait for up to 6 hours for an available doctor
3. ED staff may be rushed and perfunctory in their treatment of sexual
assault survivors, having little time to explain procedures or comfort
victims (Lenehan, 1991)
4. Other nurses and doctors also do not have the required training to treat an
SA survivor, so the do not provide the best possible service.
a) 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
 5. 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”
B. The nurses are what make up the majority of this program, so they must go
through extensive training and learn how to handle the medical exam as well as
the legal system.
1. SANE nurses must complete a detailed, 40 to 80 hour training session
which covers several topics concerning the medical exam, how to
converse with the victim, and preparation for subsequent legal encounters.
a) Training topics include ​Victim Responses and Crisis Intervention,
Collaborating with Community Agencies, Medical Forensic
History Taking, Observing and Assessing Physical Examination
Findings, Medical Forensic Specimen Collection, Medical
Forensic Photography, Sexually Transmitted Disease Testing and
Prophylaxis, Pregnancy Risk Evaluation and Care, Medical
Forensic Documentation, Discharge and Follow-Up Planning, and
Legal Considerations and Judicial Proceedings.
b) This expansive training differentiates between SA nurses and
otherwise qualified nurses. The topic covered here are generally
only applicable to these cases, but emphasize the thoughtful care
that must be given to these patients.
2. The training separates SA nurses from other nurses as they are given a
separate set of skills to work in these situations.
a) Many doctors and nurses are reluctant to treat SA victims because
they are aware of the possibility of having to deal with the legal
proceedings which follow. This is one of the limitations in current
models.
b) 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.
c) SANE nurses 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, who traditionally conducted the medical exam.

(1) Many survivors express mistrust of men following sexual

victimization (Arndt, 1988; Ledray & Arndt, 1994) and a
preference for female providers (Ledray, 1992a)
d) SANE nurses are also trained on how to assist the families who
have also been affected by this trauma.
 (1) SANE educational courses identify the patient as an
individual and as part of a family or community system,
which is affected by all forms of violence
3. Creating an environment of safety and trust is incredibly important to
SANE nurses as victims are generally in a state of shock and reluctant to
trust anyone openly.
a) The SANE can 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 both.
b) provides culturally sensitive, developmentally appropriate,
trauma-informed, and patient-specific evaluation and treatment.
c) The dynamic between the SANE and the patient is a caring
relationship, which encompasses patient participation, consent and
mutuality, teaching, and a warm and open environment.
C. These programs have ample benefits which demonstrate why they are necessary
to be available for all victims.
1. One part of the training which nurses receive is that they understand all of
the rights a patient has to stop the exam or decide which parts of the exam
they are willing to go through and which they are not.
a) let them know 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
2. 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.
a) “The relationship, therefore, becomes the base that the nurse and
the patient use to share information, thoughts, feelings, and
concerns. As this relationship is forged, caring is developed and
quality outcomes are achieved" (Duffy, 2009).
b) mutual problem-solving, attentive reassurance, human respect, an
encouraging manner, appreciation of unique meanings, a healing
environment, affiliation needs, and basic human needs
3. Nurses are also given guidance on their discussion with law enforcement
and other events which occur after testing.
a) Nurses are trained to be able to provide accurate testimony in
judicial proceedings.
 b) Consent, Reimbursement, Confidentiality, Medical screening
examinations, Mandated reporting requirements, Judicial
proceedings, etc.
D. Victim advocates are an additional part of the process for patients and are highly
recommended, however the resources are not always available for all SANE
programs to have victim advocates.
1. 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.
a) Rape victim 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
2. Victim advocates also work to prevent the “second rape” - ​insensitive,
victim-blaming treatment from social system personnel that exacerbates
the trauma of the rape
3. 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.
a) advocates were 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.
IV. 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.
A. The government’s involvement with this process will be through bills which
ultimately go to the governor. These bills must propose protocols for hospitals
which can support a SANE program and for facilities that cannot.
1. 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.
a) 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.
2. The Maryland Department of Health and Mental Hygiene is a 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.
B. 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.”
1. The makeup of the SART allows for more change because several
perspectives are taken into consideration, and all outlets for change are
represented.
2. core membership 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. Other members may include
domestic violence victim advocates, military members, Title IX staff, state
crime laboratory personnel, social services staff, and other professionals
who provide services to survivors of sexual violence.
3. These teams are able to work towards improving ​protocol, providing
cross-training, reviewing cases, and implementing a coordinated,
victim-centered community response
C. Utilizing local organizations to help provide resources for SANE programs could
be a motivator for executing this endeavor.
1. HopeWorks has a volunteer program in place that trains adult volunteers
to be victim advocates in hospitals.
2. 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.
3. 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.
V. Obstacles (does this get put as its own counterclaim)
VI. 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.

 Works Cited
Ahrens, Courtney E., et al. “Sexual Assault Nurse Examiner (SANE) Programs.” ​Journal of
Interpersonal Violence​, vol. 15, no. 9, 2000, pp. 921–943.,
doi:10.1177/088626000015009002.
Campbell, Rebecca. “Rape Survivors’ Experiences With the Legal and Medical Systems: Do
Rape Victim Advocates Make a Difference?” ​Violence Against Women,​ vol. 12, no. 1,
2006, pp. 30–45, doi:​10.1177/1077801205277539​.
“Every Question You’ve Ever Wanted to Ask a Forensic Nurse.” ​National Sexual Violence
Resource Center​,
https://www.nsvrc.org/blogs/every-question-youve-ever-wanted-ask-forensic-nurse​.
Accessed 18 Nov. 2018.
GeneralMDSexualAssaultFSUpdated_4.25.18.Pdf.​
https://mcasa.org/assets/files/GeneralMDSexualAssaultFSUpdated_4.25.18.pdf​.
Accessed 7 Jan. 2019.
Legislative_Priorities_-_2018_-_Final_Report_-_bills_that_passed.Pdf.​
https://mcasa.org/assets/files/Legislative_Priorities_-_2018_-_Final_Report_-_bills_that_
passed.pdf​. Accessed 7 Jan. 2019.
National Protocol for Sexual Assault Medical Forensic Examinations.Pdf.
https://mcasa.org/assets/files/National_SA_Prevalence_Updated1_10.24.17.pdf​.
Accessed 7 Jan. 2019.
SANE Program Development and Operation Guide.​
https://www.ovcttac.gov/saneguide/introduction/what-is-a-sane/​. Accessed 6 Jan. 2019.
Sexual-Assault-Forensic-Exam-Report-2015.Pdf.​
https://phpa.health.maryland.gov/Documents/Sexual-Assault-Forensic-Exam-Report-201
5.pdf​. Accessed 19 Dec. 2018.
Sexual Assault Nurse Examiner (SANE) Education Guidelines.Pdf​.
https://cdn.ymaws.com/www.forensicnurses.org/resource/resmgr/education/2018_sane_e
dguidelines.pdf​. Accessed 7 Jan. 2019.
“Sexual Assault Response Teams (SARTs) | Maryland Coalition Against Sexual Assault.”
Maryland Coalition Against Sexual Assault | MCASA,​
https://mcasa.org/providers/resources/sarts​. Accessed 7 Jan. 2019.
Smith, ed. by Merril D. (2004). ​Encyclopedia of rape​ (1st publ. ed.). Westport, Conn. [u.a.]:
Greenwood Press. pp. 169–170. ​ISBN​ ​978-0-313-32687-5​.

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