ORIGINAL ARTICLE
An examination of SANE data: Clinical considerations based on victim–assailant relationship Sharon B. Murphy, PhD, ACSW1 , Sharyn J. Potter, PhD, MPH2 , Jennifer Pierce-Weeks, RN, SANE-A, SANE-P3 , Jane G. Stapleton, MA4 , and Desiree Wiesen-Martin, MA5 1 Assistant Professor, Department of Social Work, University of New Hampshire, Durham, New Hampshire 2 Associate Professor, Department of Sociology, University of New Hampshire, 20 College Road, Durham, New Hampshire 3 Project Director, President (2009), International Association of Forensic Nurses, Forensic Nurse Examiner, Memorial Health System Forensic Nurse Examiner Program, Colorado Springs, Colorado 4 Research Instructor, Women Studies Program, University of New Hampshire, Durham, New Hampshire 5 Graduate Student, Department of Sociology, University of New Hampshire, Durham, New Hampshire
Keywords Forensic nursing; medical forensic examination; sexual assault; sexual assault nurse examiner (SANE). Correspondence Sharon B. Murphy, PhD, ACSW, Assistant Professor, Department of Social Work, University of New Hampshire, 55 College Road, Durham, NH 03824. Tel: 603-862-3826; E-mail:
[email protected] Received: September 12, 2010; accepted: February 17, 2011 doi: 10.1111/j.1939-3938.2011.01110.x
Abstract The current study analyzes adult female sexual assault data, collected by sexual assault nurse examiners (SANEs) in New Hampshire, United States, between 1997 and 2007. The purposes of this study were to (1) explore the relationship between patient and assailant, (2) examine patients’ physical findings according to assailant type, (3) describe characteristics of both the patients and the assaults, and (4) make care recommendations. Secondary analysis was conducted on data gathered by SANEs from responses to a standardized questionnaire based on the medical/forensic examination of each patient over an 11year period. Of the 741 women in this study, 53% were sexually assaulted by a nonstranger, 18% were assaulted by an intimate partner, and 11% were assaulted by a stranger. The relationship between patient and assailant is an important variable that requires SANEs to take a closer look at assessing for lethality, and assisting with safety planning, intervention, and treatment for victims.
A key member of the multidisciplinary response to sexual violence is a specially trained medical forensic professional known as the sexual assault nurse examiner (SANE). Today there are over 500 SANE programs across the U.S. that provide a dedicated healthcare response to sexual assault victims (International Association of Forensic Nurses, 2009). Evaluations of SANE programs have found enhanced forensic evidence collection and marked improvement in the quality of postassault care when these programs are in place (Campbell et al., 2006). A secondary or indirect benefit of a SANE program is improved, systematic data collection regarding the local and regional occurrence of sexual violence (Little, 2001). Data gathered by SANEs contain important information about the nature of sexual assault specific to a particular locale, including characteristics of the patients and attributes of the assault.
A study conducted by University of New Hampshire (NH), researchers—in collaboration with the NH Coalition Against Domestic and Sexual Violence and the NH Department of Health and Human Services—found that approximately 23% of women in NH have been the victim of a sexual assault, a number higher than the U.S. national average of 17.6% (Mattern et al., 2007; Tjaden & Thoennes, 2000). This represents 112,909 women in NH (Potter & Laflamme, 2011). Furthermore, 88% of the NH sexual assaults were perpetrated by someone known to the victim, and almost 20% of assaults included penetration. Because NH rates of sexual assault are significantly higher compared to national rates, we chose NH SANE data to examine the characteristics of the patients, the assaults, and the nature of the relationship between patient and assailant.
c 2011 International Association of Forensic Nurses Journal of Forensic Nursing 7 (2011) 137–144
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Contrary to the stereotype that sexual assaults are usually perpetrated by strangers, most victims are assaulted by someone they know, frequently an intimate partner (Begany & Milburn, 2002). Researchers have documented that sexual assault committed by a partner can be as traumatizing to a victim, if not more so, than sexual assault committed by a nonpartner (Koss, Dinero, Seibel, & Cox, 1988; Temple, Weston, Rodriguez, & Marshall, 2007). Research has also indicated that crimes between intimate partners are less likely to be prosecuted as opposed to crimes between strangers (Lievore, 2005; Russell, 1990). Previous research has also examined the impact that geography has on patients’ use of postsexual assault services such as medical or mental health services. For example, Logan, Evans, Stevenson and Jordan (2005) found rural and urban women share a number of perceptions of barriers to health and mental health services. These include affordability, availability, accessibility, staff incompetence, acceptability, shame, and self-blame, lack of sensitivity on the part of health and mental health workers, and pressure by family members to be silent. Indeed, rural and urban victims were more alike than different in their perceptions of barriers. However, there were some notable differences among rural and urban women suggesting that community context may be an important consideration for healthcare institutions as they design services for their patients. This information lends importance to SANEs collecting information regarding community context to assist in postsexual assault care and referral. Likewise, there is research that extends our knowledge regarding barriers victims face when seeking care postassault. One area of research points to the stereotypes held by victims regarding sexual assault and what constitutes a crime worthy of reporting to law enforcement. Adult female sexual assault victims did not routinely report the crime (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001; Rennison, 2002; Sedgwick, 2006) because they believed that their injuries were either not significant, the crime itself was not brutal enough, or they believed that their relationship to the assailant determined whether or not the assault was a criminal act (Jones, Alexander, Wynn, Rossman, & Dunnuck, 2009; Ruback, 1993). In other words, the greater the degree of injury, the more brutal the crime, and the absence of an intimate relationship were likely to increase reports to police. The information collected by SANEs is helpful in a variety of ways. Logan, Cole, and Capillo (2007) described the importance of having an understanding of sexual assault survivors’ characteristics at the time they present for medical/forensic examination. Specifically, the researchers suggested that to inform practice and research,
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we need to better understand differences among victims based on the existence or nonexistence of a relationship with the perpetrator. The purposes of the current study were to: (1) explore the relationship between patient and assailant; (2) examine patients’ physical findings according to assailant type; (3) describe characteristics of the patients, assailants, and the assaults; and (4) make care recommendations based on this information.
Method Data collection The University of New Hampshire’s (U.S.) Office of Sponsored Research Institutional Review Board approved this project. The study is a collaborative venture among university researchers, the NH SANE advisory board, and members of the Research Committee, a subcommittee of the Governor’s Commission on Domestic and Sexual Violence. The goal of this collaboration was to examine data collected by NH SANEs during medical/forensic examinations of adult female sexual assault victims that occurred during the 11-year period between January 1, 1997 and December 31, 2007. The multidisciplinary NH SANE Advisory Board, in conjunction with the statewide SANE Coordinator, created a standardized questionnaire adapted from the Comprehensive Sexual Assault Assessment Tool (CSAAT) (for a complete review of the development of the CSAAT see Burgess & Fawcett, 1996). The CSAAT was developed as a mechanism to standardize the documentation and collection of rape and sexual assault data, and could be used for training and research purposes. The NH tool was scaled back considerably from the CSAAT to create a brief, 24-item instrument applicable in the clinical setting and more likely to be consistently utilized by the examiners. Upon adoption of the NH data-collection instrument, all NH SANEs were trained in its implementation. To insure uniformity, all new SANEs received instrument administration instruction as part of their initial SANE education with follow-up instruction during routine Currency of Practice training sessions. The training was conducted by the statewide SANE Coordinator responsible for education of all SANEs. Approximately 50 SANEs have been trained to collect data using this instrument. While no specific interrater reliability was conducted, any area of questioning that may have been open to wide interpretation by the SANE was defined on the tool itself, such as what constitutes ano-genital trauma. One revision of the tool occurred, improving data points by separating out alcohol-facilitated assaults from those where drugs were suspected.
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The SANE questionnaire was designed to gather information regarding patient demographics and characteristics, assailant characteristics, assault characteristics, and other findings noted on examination of the patient. The standardized questionnaire does not contain identifiable patient data. Upon completion, each SANE forwards the instrument to the statewide program where the information is entered into an SPSS database. During the 11-yearstudy period (1997–2007), data were collected from 741 adult female sexual assault patients. Similar data were collected on men and on children under the age of 18 years; however, these two groups were not included in the present analysis. Because some SANEs completed the questionnaires after examination and discharge of the patient during retrospective chart review, there are instances in which data are missing. In other cases, data are absent because the patient did not have adequate recall of the event to provide all requested information.
Results Descriptive analysis Patient characteristics SPSS 18 was used to generate descriptive and multivariate statistics for all years combined. Subjects were adult female patients who obtained medical/forensic examinations during the study period. Subjects ranged between the ages of 18 and 87 years, with a mean age of 28 years (SD = 11.08). Ninety percent (N = 674) of the victims were Caucasian, 2% (N = 13) were African American, 1% (N = 5) were Asian, 2% (N = 15) were Hispanic, and the race of the other 5% (N = 39) was unknown. These statistics are consistent with NH demographics (U.S. Census Bureau, 2009).
Assailant characteristics Assailant types identified during the history-taking process were collapsed into four categories: intimate partner, nonstranger, stranger, and unknown. The intimate partner category included assailants who were married to, or intimately involved with, the victim, as well as those who were formerly intimately involved with the patient. The nonstranger category included assailants whom the victim knew in a limited manner, including work colleagues, neighbors, and classmates. The stranger category comprised assailants whom the victim has never seen before. Finally, the unknown category was used when the SANE was unable to obtain information regarding the assailant. Of the 741 women, 53% (N = 393) were sexually assaulted by a nonstranger, 18% (N = 133) were assaulted by an in-
timate partner, and 11% (N = 82) were assaulted by a stranger. In 18% (133) of cases, the SANE was unable to ascertain assailant type. Women who were sexually assaulted by an intimate partner were slightly older (M = 32, SD = 11.96) than women assaulted by a nonstranger (M = 27, SD = 9.95) or a stranger (M = 28, SD = 10.51 years), or when the relationship was unknown (M = 28, SD = 12.73). This relationship is significant, F(3, 741) = 7.76 (p < 0.001). Altogether, 71% (N = 531) of the women were sexually assaulted by a nonstranger. Eighty-two percent (N = 65) of patients who were assaulted by a stranger were Caucasian.
Assault characteristics The majority (60%, N = 445) of assaults occurred in urban locations; 16% (N = 121) occurred in rural sites, and the locale of 24% (N = 180) was unknown. Seventy-nine percent (N = 588) of the patients were assaulted by a single individual, 10% (N = 77) had two or more assailants. The number of attackers was unknown in 11% (N = 81) of cases. Ninety-six percent (N = 703) of the patients seeking medical/forensic examination were assaulted by males, 1% (N = 5) of the patients were assaulted by females; the gender of the remaining 3% of assailants was unknown. Weapons were used to perpetrate the assault in 8% of the cases.
Number (N = 58) of the cases The relationship between weapon involvement and assailant type is significant (χ 2 = 22.72, p < 0.001), as the majority of assailants who used weapons were described as intimate partners by the patients. Of the 58 cases where an assailant used a weapon, 35% (N = 20) of the assailants were intimate partners, 28% (N = 16) of the assailants were nonstrangers, and 21% (N = 12) of the assailants were strangers. Assailant type was unknown in 17% (N = 10) of cases in which a weapon was employed.
Exam characteristics Sixty-nine percent (N = 517) of the patients in our study received a medical/forensic exam within 24 hours of assault. Eleven percent (N = 81) of patients sought an examination within 25–48 hours, 9% (N = 69) were examined within 49–72 hours, and 8% (N = 59) received an exam more than 72 hours after the incident. Time of examination relative to the assault was unknown for 3% (N = 20) of victims. Almost 74% (73.5%, N = 548) of the assaults were reported to law enforcement agencies; 26% (N = 194) were not and the outcome of 0.5% (N = 4) is unknown. An evidence collection kit was used by the SANE in 88% (N = 659) of examinations.
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Colposcopes were used in only 7.5% (N = 56) of forensic exams. Twenty-four percent (N = 175) of the victims suffered genital injury and 38% (N = 283) experienced nongenital trauma.
Multivariate analysis In Table 1, we present the chi-square results for our analysis of the relationship between exam characteristics and assailant type. The time interval between the assault, the medical/forensic exam, and the type of assailant is significant (χ 2 = 24.01, p < 0.05). Patients whose assailants were nonstrangers (71%, N = 282) or strangers (71%, N = 54) were slightly more likely to present during the first 24 hours following sexual assault compared to patients attacked by an intimate partner (67%, N = 135). Ten percent (N = 13) of women sexually assaulted by an intimate partner delayed examination more than 72 hours following the incident, compared to 8% (N = 30) and 7% (N = 5) (respectively) of women who were the victims of nonstrangers and strangers. Assailant type was also significantly related to whether or not the crime was reported to a law enforcement agency (χ 2 = 7.76, p < 0.10). Eighty-six percent (N = 68) of the women in this study who were sexually assaulted by a stranger reported the attack compared to 75% (N = 101) of women sexually assaulted by an intimate partner and 72% (N = 284) of those assaulted by a nonstranger. An evidence collection kit was used by the SANE less frequently when the assailant was an intimate partner, compared to nonstrangers and strangers (χ 2 = 10.65, p < 0.05). There was a significant relationship (χ 2 = 19, p < 0.001) between nongenital trauma and assailant type. Nongenital trauma occurred 48% (N = 65) of the time when the assailant was an intimate partner, 54% (N = 40) of the time when the assailant was a stranger, and 35% (N = 138) of the time when the assailant was a nonstranger. Conversely, genital trauma occurred more frequently (χ 2 = 6.3, p < 0.10) when the assailant was an intimate partner (29% of the cases, N = 39) than when the assailant was a nonstranger (25% of the cases, N = 98) or a stranger (16% of the cases, N = 12). The use of a colposcope by SANEs during medical/forensic exams did not vary by assailant type. When the attacker was an intimate partner, the SANE performed a colposcope exam in 8% of cases. Colposcopy was used in 9% (N = 34) of the cases when the assailant was a nonstranger, 8% (N = 6) of the time when the assailant was a stranger, and 4% (N = 5) of the time when the assailant type was unknown. Further analysis showed that 39% (N = 47) of 140
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women who sought medical/forensic exams in rural areas suffered nongenital trauma. A slightly lower percentage of women (37%, N = 161) who sought medical/forensic exams in urban areas had nongenital injuries. Thirty percent (N = 36) of the women examined in rural areas experienced genital trauma, compared with 21% (N = 93) of victims injured in urban areas.
Discussion Data analysis revealed that 71% (N = 395) of patients knew their assailant(s). This finding is similar to the National Crime Victimization Survey (Rennison, 2002) and to other community-based hospital settings where SANEs provide medical/forensic examinations (Jones et al., 2009). Intimate partners were the assailants in 18% (N = 136) of our sample and those assailants were more likely to use a weapon during the sexual assault (34%, N = 20) compared to nonstrangers (28%, N = 16), strangers (21%, N = 12), and when the relationship was unknown (17%, N = 10). Intimate partner assaults were also much more likely to involve genital injury (29%, N = 39), the highest rate by assailant type. Patients assaulted by intimate partners accessed care later than those victimized by strangers or nonstrangers. Given that injuries improved with the passage of time, it is likely that both genital and nongenital injury rates would be higher if this population was examined closer to the time of the attack. Further research is necessary to identify the barriers to immediate care that these patients face. It was interesting to note that fewer evidence collection kits were used when the assailant was an intimate partner, even though more assaults in this category were reported to law enforcement agencies than were those in the nonstranger category. The current study suggests that this is an area for heightened SANE training. Increasing the use of evidence collection kits in the intimate partner assault population could potentially improve the prosecution rate of this group of assailants. In New Hampshire, individuals under the age of 18 years are considered minors, therefore requiring healthcare professionals to report the assault to law enforcement. Conversely, competent adults, 18 years and older, who seek medical/forensic examination following sexual assault are not required to report the assault to law enforcement. According to Bureau of Justice statistics, only 26% of U.S. sexual assaults were reported to law enforcement agencies; 59% of victims who reported the crime obtained medical care; and only 17% of nonreporters sought medical care (Rennison, 2002; U.S. Department of Justice, Bureau of Justice Statistics, 2006). Not surprisingly, victims of stranger assaults reported the assault to law enforcement agencies
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Table 1 Results of chi-square analysis that examines the relationship between exam characteristics and assailant type Assailant type All assaults
Intimate partner
Nonstranger
Stranger
Relationship unknown
Pearson X2
Time between assault and exam
