Sexual Assault Forensic Exams Overcoming the Challenges CDR Michelle A. French, NC, USN Navy Medicine West SAMFE Training Officer Navy Medicine West SAPR Officer and SAMFE Program Manager (Interim)

Objectives 1) Define SAMFE 2) Describe components of a SAFE 3) Explore why SAFE cases are challenging 4) Review priorities for sexual assault patients 5) Highlight recommendations for shipboard medical providers

SAMFE A sexual assault medical forensic examiner (SAMFE) is a healthcare provider (privileged or non-privileged) trained to conduct a sexual assault forensic examination (SAFE) on adult patients. Providers functioning in this role require specialized education and clinical experience in the treatment of sexual assault patients (victims and suspects) and the collection of forensic evidence. 80 hour SAMFE Course required following NDAA-15 Follow-on annual clinical training and competency validation

SAMFE Roles and Responsibilities Provide medical care for victims and suspects Collect samples from victims and suspects for SAFE kit when requested Ensure maintenance of chain of custody Provide expert and fact witness testimony Collaborate with SARC/VA to develop safety and discharge planning

Basic Principles Patient may initially present to medical, SARC or SAPR victim advocate, law enforcement, chaplain, chain of command Service members and adult military dependent victims of sexual assault shall receive timely access to comprehensive medical and psychological treatment Sexual assault victims shall be treated as emergency cases

SAFE Exam is optional – patient elects to have evidence collected Must be clinically competent to consent to evidence collection Can decline any portion of the exam Exam performed up to 7 days following a sexual assault For both medical and forensic reasons, the earliest possible time is recommended Exam can take approximately 2-4 hours Multiple variables can change the timeframe

Documentation Standardized form DD2911 is utilized in documenting the forensic exam Consent Focused medical history Assault history Physical exam Summary of evidence collected Chain of custody

WHY ARE THESE CASES SO CHALLENGING?

SEXUAL ASSAULT

Sexual predator Blacked out Didn’t fight back Alleged sexual assault Underage drinking Inconsistent story Sexual predator Choice misunderstanding Didn’t fight back Drunk Sex Credibility RAPE or REGRET? Victim rights Alleged sexual assault Delayed reporting Lack of physical findings Wrongfully accused Retaliation You know you wanted it Consensual sex Blacked out No signs of trauma

Consider the priorities immediately following a sexual assault Forensic/ Criminal Justice Medical Psychosocial/ Advocacy Legal

Priorities Emergent/Urgent medical care Evidence preservation Safety- victim/suspect considerations, medical staff considerations Support of DOD policy Restricted/unrestricted reporting options

Challenges with drug facilitated sexual assault Unique barriers to reporting – shame, guilt No memory = poor historian, questionable suspect, no eyewitness or eyewitnesses not credible Unconscious victim – competing medical priorities Lack of physical/biological/toxicological evidence Photographic evidence may paint a picture that appears inconsistent with a crime Societal view on drugs and sex -Did a crime actually occur?

Steps following patient presentation Medically screen and stabilize Victim advocate notification Maintain privacy, dignity and safety Law enforcement notification if unrestricted Transfer to location capable of performing a SAFE if patient elects this option (reports within 7 days of assault)

SAFE Components Medical Forensic Provide medical evaluation and care Sexually transmitted infection screening/treatment Pregnancy prevention and counseling Safety Assessment Provide referrals as needed Forensic History of sexual assault Collect evidence Document injuries Written and photographic Release documentation & evidence to: NICS or Local Law Enforcement (Unrestricted) Mail to NCIS Repository (Restricted)

If a SAFE is to be performed Recommend against the following: Bathing Washing hands Brushing teeth Eating, drinking or smoking Urinating or defecating Removing a tampon, diaphragm or NuvaRing Changing clothing Do not turn a patient away from the SAFE if some or all of the above were performed. There is still value in obtaining a detailed assault history and providing comprehensive medical care. Furthermore, there is still (a good) possibility of obtaining semen/DNA samples from the vaginal or anal canal. -The above are relative recommendations with consideration given to transport time to a SAFE capable facility. -If all of the above were performed, there is still potential to obtain evidence

SAFE Kit

Forensic Exam PURPOSE Obtain a history of the events To document any injuries patient may have Written and photographic Collect DNA and/or trace evidence Collect toxicology if indicated To compare evidence that may corroborate the patient’s history

Takeaways Develop a process for timely medical and forensic care for sexual assault patients Notify victim advocates early Safety is paramount Victim, suspect, medical provider and shipmate considerations Walk through the process in your spaces Privacy, safety, medical capabilities, transport considerations Consider timing of patient presentation and coordination with SAFE capable facility in coordinating medical care STI and pregnancy prophylaxis, behavioral health referral etc.

Consider… “A small percentage of our patients will ever see the inside of the courtroom, but 100% of them have the potential to develop healthcare sequelae from the violence they’ve experienced (research is clear on this, from child abuse to elder abuse; trafficking, sexual violence, domestic violence – you name it). If you’re only focused on the forensic part of the job, you are doing a disservice to the majority of your patients…

Continued …Take the potential legal implications of the patient encounter seriously, and perform the sample collection meticulously so that patients have all of the criminal justice options available to them if that’s the route they choose. But do not put patients in a position where they are receiving a lesser standard of healthcare than if they just wandered into any ED in the US because the focus is on the kit or the photography.” – Jenifer Markowitz Forensic Healthcare Online

Navy Medicine West Sexual Assault Medical Forensic Contact CDR Michelle French – SAMFE Training Officer SAPR Officer/SAMFE Program Manager 619-767-6017 Michelle.a.french4.mil@mail.mil