1. 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)

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. WHY ARE THESE CASES SO CHALLENGING?

9. SEXUAL ASSAULT

11. 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

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

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

14. 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?

15. 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)

16. 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)

17. 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

18. SAFE Kit

19. 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

20. 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.

21. 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…

22. 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

23. Navy Medicine West Sexual Assault Medical Forensic Contact
CDR Michelle French – SAMFE Training Officer
SAPR Officer/SAMFE Program Manager