Improving Rural Sexual Assault Evidence and Investigation
Written by Dr. Catherine Carter-Snell   

This article appeared in the May-June 2020 issue of Evidence Technology Magazine.
You can view that issue here.

ALTHOUGH MANY MEN AND WOMEN are sexually assaulted every day, only a small minority will report their assault to police. As few as 5–10% report in Canada, according to repeated Canadian General Social Survey studies1,2, and approximately 15–35% are reported in the United States3. Given that the offender is most often a friend or acquaintance in the community1, the limited reporting reduces the likelihood of police awareness, investigation, evidence collection, and (ultimately) apprehension of the individual.

Collaboration between law enforcement and health care, however, has potential to significantly change these data. People are three times more likely to seek health care than to report to police after the assault2. Studies have shown that when comprehensive sexual assault health care is provided, such as with sexual assault nurse examiners (SANEs), the rates of police involvement increase4. Furthermore, with SANE care, the quality of evidence collection is improved5, as are rates of successful prosecution6.

Early comprehensive care also reduces the considerable risks of post-traumatic stress (PTSD) faced by victims of sexual assault7. If victims develop PTSD, they are at risk of many other health consequences—including substance abuse, suicide, and of a repeat sexual assault—all of which further impact police workload and investigations.

The provision of comprehensive sexual assault services is more difficult in rural and remote areas, however. It is well recognized that people in many rural and remote communities do not receive the same level of services after sexual assault as those in urban centers8,9. This occurs for many reasons, including limited personnel to conduct exams and provide support, difficulties with transportation, and staff unfamiliarity with components of comprehensive sexual assault services, especially when they provide this care infrequently.

The sexual assault care in rural areas, if provided, is typically provided by the physician. Rural areas often only have one physician on duty, and it is difficult for them to free up sufficient time to provide comprehensive care and evidence collection. The result is that many smaller communities delay patients for hours until the physician is free—or refuse to conduct a sexual assault examination at all—and potential evidence is lost.

The purpose of this paper is to review gaps in knowledge and comfort among professionals providing sexual assault services in rural areas, and to present a uniquely rural solution that has been implemented and evaluated in a number of Canadian communities. Improved rural sexual assault services and multidisciplinary collaboration can improve the likelihood of client reporting, evidence preservation and collection, and of the client remaining engaged with the legal process.

Careful collection and documentation of evidence, and its subsequent transfer to the custody of law enforcement, are a key part of sexual assault services. Photo courtesy Dr. Cathy Carter-Snell

Learning the Needs of Rural Professionals
The author conducted a number of consultations, studies, and quality-assurance activities in order to identify issues for rural and remote communities. Focus groups were held with police, counselors/advocates, and health professionals in five rural and remote communities in one western Canadian province10. The participants all described concern about damaging evidence, lack of familiarity with sexual assault kit contents and collection procedures, legal issues surrounding reporting and chain of custody of evidence, and the lack of personnel to provide the lengthy examination and evidence collection—especially when they did it so infrequently in areas with sparse populations.

On the other hand, they described a desire to improve services and a conviction that clients should remain in the rural communities for services rather than being transported out, as professionals knew their cultural and community support resources better than urban centers.

In 2012, quantitative surveys were also sent out to all health-care centers, sexual-assault counseling centers, and police detachments in the southern half of the province. There were 78 respondents to the survey, over half of which were nurses or physicians, approximately 30% police officers, and a small number of counselors. They were asked to rate their knowledge on a five-point Likert scale for various aspects of comprehensive care, derived predominantly from the U.S. national protocols11, as well as standards of practices for SANE teams. These protocols highlighted the services that urban centers with SANEs would receive, so rural communities should also implement similar services. The responses to key aspects of the survey are shown in Table 1 and Table 2.

Table 1. Knowledge of Initial Inverventions and Reactions

Table 2. Knowledge of Legal or Evidence Issues

Additional consultations were held in two eastern provinces with sexual-assault counseling groups, health ministries, hospital staff, and police departments. The surveys distributed in 2012 were then used as a pre-test and post-test for subsequent training and quality assurance. The combination of these consultations and quality-assurance surveys were consistent with the 2012 quantitative surveys and focus-group findings.

Communities in the focus groups, surveys, and provincial consultations also identified an inability to implement the SANE model in some of the communities due to factors such as financial restrictions providing additional specialized staff, staff turnover, and difficulties providing enough cases in small areas for SANEs to develop or maintain their advanced skills (e.g. gynecological examinations). One of these provinces stated they received only seven cases a year—not a sufficient frequency for training and maintenance of new skills, and not enough to justify the hiring and training of specialists.

Some of the common themes identified between surveys and consultations included knowledge gaps in the following areas that may affect reporting, investigation, or quality of the physical or investigative evidence: assault myths and realities, comprehensive sexual assault services, evidence preservation and collection, trauma informed concepts, and witness testimony misconceptions.

Assault Myths and Realities
The prevailing perception in the public, which includes police and health professionals, is that sexual assaults are committed by strangers or intimate partners. Most of our data on assailants is from those in jail, such as stranger assailants, which were the basis for the FBI typologies of assailants and typically involve a high degree of force and injury12. Injury is more common in stranger assaults and in intimate partner assaults13, but these are the minority. The majority of sexual assaults are committed by someone known to the victim, most as friends or recent acquaintances1. Injuries are less common in these assaults14, and the dynamics are different, which may impact the investigation.

There is a blurry line between sexual assaults by someone just met at a bar and dating violence—and, as a result, many victims will not call it sexual assault. Young adults, typically women, have often denied it as an assault, saying “it was my fault; I got drunk.” College-aged men and particularly women are especially at risk due to their high-risk age group (15-24 years of age), but also the circumstances of campus life may increase their vulnerability or assailant’s access.

There is some consistency in findings that a small number of college-aged men are at risk for offending (< 25%) but as many as 10% are repeat perpetrators of sexual assaults. Lisak and Miller (2002) termed these men “undetected serial rapists” as they were often seen as good students and leaders, but they were found responsible for many other forms of assault as well, including child abuse and intimate-partner violence. These men typically have hostile attitudes toward women, are in masculine positions or roles, and see sex as their “right”, but are often seen as “nice young men” in the community15,16. Interviews with these men have revealed a grooming type of behavior, in which they seek out women who are vulnerable, often due to alcohol, offer them more alcohol and interact with them; separate them from friends, such as offering a ride home; and then gain access to assault them17. This behavior is then used against the victim, as they may be seen as “willing” due to their earlier interactions with the perpetrator. This offender typology is important to the investigation and there may be a history of prior episodes of interaction with other women in the assailant’s past. The victim may have very few injuries and blame herself for the assault as it began voluntarily when he approached her.

Another myth held by some of the professionals was that a male could not really be sexually assaulted, and yet it happens to many more men than often realized. While women are usually assaulted by men, those who assault men can be either male or female1.

Trauma-Informed Concepts
Some of the client’s behavior may be misleading or misinterpreted, such a lack of eye contact or not speaking with the investigator when asked about the details. This can be interpreted as guilt or lack of compliance. Consultations and the survey data indicated that professionals had limited understanding of the trauma effects on behavior such as tonic immobility, dissociation, difficulty with speech when stressed, and the impact of stress on memory. Key principles of trauma-informed care include realization of the impact of stress, recognition of symptoms, responding appropriately to disclosures, and resisting revictimization18.

Realization includes awareness of the magnitude of physical and mental health consequences of sexual assault—particularly the physiologic impact of stress on the brain and body, as well as the risks of eventually developing post-traumatic stress disorder (PTSD). The rates of PTSD after sexual assault are extremely high19. Acute responses to stress may include dissociation (e.g. gazing into space) when asked specifics about the assault, gaps in memory, or inability to describe the order of events. The chemicals released in stress to allow flight, fight, or freeze responses (cortisol, adrenaline, noradrenaline) also affect the same areas of the brain that create and store memories.

Recognition of stress responses is important when interviewing a client, especially if the professional is aware of the impact. For instance, if they dissociate during the interview, this is an indicator of stress and the interview should be stopped and the client given the choice when to resume. If stressed, they may also have difficulties providing a correct chronology of events such with a backwards/forwards style of interview; they may inadvertently fill in the gaps of memory with what they would usually have done. When they are less stressed, the order and details of the events may return. If they were significantly impaired prior to or at the time of the assault, however, the memories may not have been encoded or consolidated20. Memories, if encoded at the time, may be consolidated and recovered more reliably once the client has had sleep21 and is less stressed. As a result, some number of police departments choose to only meet the client in the emergency department to introduce themselves and secure any evidence that may disappear (e.g. videos, evidence kits), and postpone their interview to a few days later when the client is rested.

The response of professionals to the client’s disclosure is important to both the quality of the interview and the subsequent risk of victimization. Positive responses to disclosure from formal or informal contacts are a key factor in resiliency to the trauma22. Trauma-informed care emphasizes empowering the client to make their own choices where possible, such as whether or not to report the assault or have evidence collected. It is also important to recognize when clients are stressed and intervene appropriately to reduce their stress. If someone stops talking, it may be due to dissociation; they can be talking to the officer freely, but when asked about specific details they may suddenly be staring off into space and not be “present”. They could also lose speech abilities as stress may decrease blood flow to speech centers as well as the area responsible for episodic memory23. Another sign of a stress disorder is hypervigilance or exaggerated startle responses. These are all indicators that the client is stressed, and the interview should be paused until they are ready to resume.

The fourth principle is resisting retraumatization. The impact of the trauma can be made worse by reactions from police and health professionals24 such as disbelief, having to describe the trauma too many times or when not ready, delays in receiving services, pushing them through the procedures, or questioning them in a way that may result in shame, guilt, or self-blame. All of these reactions are linked to the increased likelihood of PTSD after sexual assault25. In turn, those with PTSD are more at risk of being re-assaulted26,27.

As noted, positive support to disclosure improves client resilience, which may increase the likelihood that they remain engaged in the investigation and legal process. Police, counseling and health care need to collaborate to support clients throughout the acute services response. If efforts have been made to reduce stressors and the client is still struggling, proceeding with the exam and evidence collection may result in greater stress. In some instances, the health-care staff or counselor/advocate may suggest that the client leave without further intervention to reduce worsening their trauma.

Assessment and Injury Identification
Professionals indicated moderate to low knowledge about injury identification and implications, especially genital injuries. This is a concern, since the presence of injuries increases the likelihood that the legal system will trigger charges and prosecution28. This is of concern, particularly since many women may have no injuries after sexual assault, especially if they were intoxicated or unconscious and not resisting as a result13.

In the same systematic review, it was noted that there was wide variability in injury rates based on techniques and whether or not the injuries were from an exam or self-report to police, as well as inconsistency in terminology used to describe injuries. This could lead to misinterpretations of mechanisms of injury and affect the investigation or evidence collected. For instance, emergency-department staff often call any open injury a laceration, when in fact a laceration is from blunt trauma and has specific characteristics, and a penetrating injury is from sharp objects and is quite distinctive. Similarly, a bruise is from application of blunt forces to the skin with resulting rupture of blood vessels and leakage of the blood into surrounding tissues. Many people use the term ecchymosis instead of bruise, but it is not a trauma finding. In fact, ecchymosis is also the spread of blood through tissue fascia, but it occurs by gravity (e.g. below a bruise or under eyes after a skull fracture) or from leakage of blood though thinning vessel walls (e.g. senile ecchymosis on the arms) or with blood disorders. An expert reading that ecchymosis and lacerations were found would need to be confident that the former was not a trauma finding and that the latter was a blunt injury.

Standardization of terminology is therefore crucial to evidence. A guide to physical findings was developed by the author to encourage professionals to use common terms and definitions for injury called the BALD STEP guide29 as shown in Figure 1. The abbreviations with each term can also be used to save space on the body diagram and give a comprehensive visual representation. This is especially important in Canada, where genital photographs are not allowed in court and where body photographs may or may not be available, depending on the availability of police identification personnel. The BALD STEP guide is now a part of the national sexual assault evidence kit used by the RCMP in Canada and has been added to the core curriculum for forensic nursing30. An understanding of these terms, implications of presence or absence of the injuries, and use of adjuncts like toluidine dye or palpation in the examination are also important for police as well as health-care providers to understand implications of injury.

Figure 1. BALD STEP29

Evidence Preservation and Collection
A pervasive concern in all communities, interviews, and surveys was the professionals’ fear of potentially missing or damaging evidence and adversely impacting the police investigation. Respondents to the 2012 survey were unsure what types of evidence had to be collected, how to collect it, and how to preserve it until given to the police. They were unfamiliar with evidence options such as submitting anonymous kits to the police if the client did not want to report, or a “third option” in which they stored the evidence at the hospital. These options varied by region and police force.

The national police sexual assault evidence kit was outdated and not revised until 2015, so respondents were continuing to use outdated procedures like plucking hair and blood for DNA reference samples. They relied upon reading the kit instructions as they progressed through a case and would collect all samples regardless of the time since the assault. For instance, they would still collect an oral sample even though three days had passed since the assault. Conversely, tradition kept most of them to an examination within three days of the assault and someone coming in four days later would not be examined even though there was potential for DNA if a vaginal-cervical swab was obtained.

Police had concerns mainly about chain of custody, and some falsely believed they needed to be in the room during evidence collection. In fact, in Canadian jurisdictions, police should not be in the room to hear the client’s health history or findings, as this is a violation of health information privacy acts. A basic understanding of the likelihood of evidence being obtained from various parts of the body was needed, as well as principles of evidence collection, preservation, and chain of custody. An understanding of chain of custody is thus needed for all, being able to account for all who have contact with the evidence, documenting it, and not leaving kits unattended until transferred or secured.

A common question was allowing of food or drink at triage in the emergency department, or allowing clients to urinate. These activities could result in a loss of evidence, but not universally. Food or drink is allowed if there are no medical reasons for abstinence, but if there was penile-oral penetration in the last 24 hours, then an oral swab along the gumlines is recommended—ideally a double swab. Many clients have had something to drink prior to the assault and may not be able to wait to urinate until after the physical examination. There may be fluid drainage in the genital region and wiping may result in the loss of some evidence. Being forced to wait creates further stress and revictimizes. One suggestion is to get them to urinate but avoid wiping themselves. Alternatively, they could wipe but save the tissues in a paper bag for the evidence kit. A urine specimen collection is also recommended in case a toxicology sample is required for suspected drug-facilitated assault.

Comprehensive Multidisciplinary Sexual Assault Services
The use of multidisciplinary services has been shown to improve collaborative relationships and improve quality of care31 as well as evidence collection25. In order to collaborate effectively, professionals need an understanding of each others’ roles in sexual assault services. The surveys and interviews both demonstrated limited understanding between the professions involved in services. One example was the differences between a police officer’s history of the assault (for investigation and truth-finding) and the health professional’s history (for risks of physical or mental-health consequences from assault).

In addition to health-care concerns about evidence collection, examination procedures, and lack of staff, other first responders also had concerns. Social workers were not sure what took place during an examination, so they were less able to prepare the clients for the health care. Police were concerned about maintaining chain of custody for evidence, lack of familiarity with the evidence kit contents, and the examination process. There was also a general need for information on trauma-informed care and the impact of sexual assault on victims that may affect their responses in interviews.

Witness Testimony
There was also a general concern about court involvement, particularly from health professionals. Survey and consultation respondents worried that if they even talked to the client they would be subpoenaed to court. There was also a concern about the long waits if called to court, which further limited the availability of staff in the rural areas. They were not aware that their avoidance of the client could actually worsen their risk of trauma and reduce the client’s involvement in health care or legal processes.

There was also limited understanding of the differences between a fact witness and an expert witness. When prosecutors were involved in the consultations, some suggested that they may be able to potentially enter the health-care documentation as fact evidence, as it included what was seen and done. In this way, front-line staff would not be brought to court. The prosecutors would then identify an expert in sexual-assault care to come to court to interpret their documentation and findings. This again emphasizes the need for collaboration so that all professionals understand the significance of presence or absence of findings and the processes in sexual-assault care.

A Rural Solution: Enhanced Emergency Sexual Assault Services (EESAS)
The results of these surveys and consultations highlighted a need for something uniquely suited to rural communities. The result was the development of a four-hour multidisciplinary program called “Enhanced Emergency Sexual Assault Services” or EESAS (“eeee-sas”). The program includes eight 30-minute modules designed for front-line providers, including nurses, physicians, police, social work, and any other providers involved in direct services to people after recent sexual assault.

The modules (Table 3) provide a comprehensive overview of all the components of comprehensive services and are available free online32 or in-person to communities. The provision of the training to all personnel improves the ability to collectively support each other through the process and to begin provision of care immediately on the client’s arrival, rather than waiting for a specialist. Some communities choose to do all training fully online.

Table 3. EESAS Modules

In addition to the core modules, there is a 45-minute executive-summary video for administrators, a 45-minute refresher video for annual recertifications, a manual, and a quick-reference checklist for what procedures are required and by whom. The intent is that all providers know what the others are doing and can thus support each other in providing care.

The program is taught from a trauma-informed perspective with a focus on what is needed within their existing scope of practice to provide comprehensive supportive services rather than training in new skills. For instance, the nurse could proceed with the body examination and evidence collection, then the physician would only have to come in for the gynecology examination. The police would be familiar with the implications of findings from a medical perspective, and would be reassured regarding chain of custody. Further, police would be aware of the impact of the trauma on their investigation and client behaviors. Social workers would have an enhanced understanding of the examination and care provided, and be better able to support both the client and staff.

The community is encouraged to form a Sexual Assault Response Team (SART) advisory committee (Figure 2). This group is composed of decision makers in the core professions responding to the assault (e.g. health care, policing, counseling) to develop supporting protocols, procedures, and to facilitate multidisciplinary communications. The community is also encouraged to connect regularly with a SANE or physician in a nearby community who is familiar with sexual assault to help with quality assurance, provide support on specific clients if questions arise, and possibly support continuing education. The front-line providers may be called to court as fact witnesses, but it is unlikely they will be expert witnesses unless they see many cases. Instead, the prosecutor may also choose to approach the SANE or forensic physician to act as an expert witness in court.

Figure 2. The EESAS Model

A mixed-methods trial of the program in five western Canadian communities showed significant changes in knowledge, skills, and comfort with services that were generally maintained up to two years later33. The model has been adopted province-wide in one maritime province, and personal communication with the SART advisory group also indicates increased comfort of all teams with sexual-assault services, including police. Their number of sexually assaulted clients has increased to health centers, most likely due to a willingness to now provide services. The Canadian military has also made the program a requirement for all health personnel and military police prior to deployment. Post-course surveys and personal feedback both indicate satisfaction with the content and improved knowledge and comfort providing services.

Every rural community is different in its ability to provide sexual assault services. Some communities may be able to afford SANE or specialized physician examiners and provide enough experiences to maintain their skills, but many cannot. The EESAS model was proposed and evaluated as a successful alternative to provision of SANE services. The SANE, if available, continues to have a role in supporting the services. All professionals stay within their scope of expertise and practice and share a common understanding of the sexual-assault spectrum of services and trauma-informed care. Collaboration between police, counselling, and health care can result in improved provision of comprehensive sexual-assault services. The improved and collaborative services are more likely to lead to police reporting and evidence collection, improved interview data, and retention of the client in the legal process.

About the Author
Dr. Cathy Carter-Snell is a professor in the School of Nursing and Midwifery at Mount Royal University in Calgary, Canada, and a certified sexual-assault nurse examiner. She is actively involved in teaching and research related to violence prevention, reduction of consequences of violence for victims, injury interpretation, and provision of comprehensive sexual assault and domestic violence services.

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