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Dr. Jones: This is a conversation about sexual assault and it might be difficult for some listeners, so feel free to leave this podcast now and either come back another time or join us for some others on the "7 Domains." But we're going to be talking about sexual assault, how you can be evaluated, how you can get care. This is the "7 Domains of Women's Health" on The Scope.

Dr. Jones: Here in the studio today, we have a specialist in Sexual Assault Examination, a SANE nurse, Haley Lichtie is here with us. And she's going to help us get the foundation of how common in Utah is sexual assault. So, can you talk to me about that, Haley? Welcome to The Scope.

Haley: Thank you, Dr. Jones. I appreciate you having me here. The one thing that I get asked over and over again is, "Do you really do that job in Utah?" And I say over and over again, "Absolutely I do."

Sexual Assault in Utah: Raising Awareness and Spreading Information

I think we like to believe we live in a bubble, but sexual assault is the only violent crime in Utah where we have a higher incidence than the national average. So, let that sink in. Sexual assault is the only violent crime where Utah is higher than the national average.

This unfortunately is happening. And when it happens, victims, patients, they don't know what to do because we don't talk about it a lot. So, a lot of people don't know that they can get a sexual assault exam for free, or that they can get prophylactic medication for infections for free.

The Role of SANE Nurses in Sexual Assault Examinations

So, I really like to tell people all about my job, mostly because they take that information, and they tell someone, and that's how information gets distributed around our community.

When I'm on call, I often hear friends say, "Okay, I hope you don't get called out. Have a good day." And I always think, "I hope I get called out." My friends are thinking if I don't get called out, it means sexual assaults are not happening. But because I've been doing this for so long, I know that sexual assaults are happening. But when I go out and I do the exam, that's a patient that is seeking healthcare after.

Dr. Jones: It's not something that you might share with your friends or family, that they were sexually assaulted, so you may not know if you are the victim, how many people actually have been in the same awful situation that you're in. And although your own journey is going to be your very own, the first step is getting evaluated and having a safe place to go.

Haley: Absolutely. And I think it's worth noting that I see patients that are at the hospital alone, and that's okay because that might be what they want. I have patients who show up accompanied by friends, moms, and significant others. And however they choose to come, whoever they choose to bring with them, is 100% okay with us. It's however they feel comfortable coming and seeking healthcare.

The SANE Exam: Seeking Healthcare After Sexual Assault

Dr. Jones: A patient comes into the ER, or they've been brought in by law enforcement, and they call you. If they come in by themselves, they may not know that they have the option to see you, but hopefully, the nurses and the docs in the ER tell them that you're available, you and the SANE nurses. So, walk me through what happens after that. Tell me what you do.

Haley: So, generally, we will get a call. We have an answering service, and we usually get a call generally either from the hospital ERs. They know that when they have a patient who comes in and says they were sexually assaulted, they get them into a room as soon as possible, and they call us. So we can get a call from the hospital, or we can get a call from law enforcement maybe that responded to a call and they're transporting the patient to a hospital.

I will let the advocacy agency that I'll be working with know that we have a case, and they will send someone to meet me at the hospital. And then when I get to the hospital, I go in the room. I obviously do introductions and tell them a little bit about why I'm there.

And one thing that I really like to tell my patients is that I'm there just for them. I don't have to worry about any other patients in the entire ER. I can focus just on them. So, I think that that's really comforting to them.

I kind of tell them what I can offer them as far as the SANE exam. Sometimes they have questions about, "Will this be reported?" Yes, it's always reported. We're mandated reporters in the state of Utah, but there is some wiggle room as far as what they want to tell the police.

So, we kind of go through options of what they have as far as do they want to do the exams. Do they not want to do the exam? Do they just want medications? Things like that.

But once the patient decides what they want to do, then I will get consent from them, as we do in every single healthcare setting, and then we'll get some demographic information from them, their phone number so we can follow up.

And just because we're nurses, we're caring for the patient holistically, so we want to know if they're on medications for something else that might affect other medications that we might want to give them. So, we'll do a brief medical history with them.

And then we will go into the assault history and we'll talk a little bit about what happened. I like to give them time just to tell me what happened to them, and then I'll go back and ask specific questions. And the reason I do that is just because I'm thinking in my brain, "Okay, what is my physical exam going to look like? What swabs am I going to want to collect? What injuries do I expect to see based on what the patient has told me?"

Collecting Evidence: Physical Examination and Clothing

So, after we talk about that, we will do the physical exam, head-to-toe exam, looking at them for injuries.

Dr. Jones: Do you take their clothes? You're going to have them take their clothes and get into a gown or . . .?

Haley: It depends. There are times that we do need to collect clothing. And the advocates always bring a change of clothing for them, so they have clothes to change into and leave the hospital in. Yeah, there are times when we need to collect clothing. Other times, that's not necessary, and we discuss that with the patient.

And of course, them handing over their clothing is always their decision. We will say, "I would like to collect this article of clothing because blank, blank, blank." And if they say, "No, that's my favorite hoodie," then I'm not going to take it away from them. They have complete control over what I do and what I take.

Dr. Jones: And some women may have gone home and had to wash in the shower, or just had to get into a shower, or just had to get into clean clothes, and so that may be part of their effort to try to calm themselves before taking the next step.

Haley: If they do that, and they have the clothes that they wore after the assault back at their house, I'll give them some paper bags and say, "Take these home, put the clothing in these bags." And then law enforcement will go to their house and collect that.

So, I do have some patients say, "Oh my gosh, I didn't bring the clothing with me." That's not a problem. We can absolutely work around that.

So, once they're in the hospital gown, that's when we'll do the head-to-toe exam. Like I said, kind of looking for injuries, bruising, lacerations, things like that. Unfortunately, strangulation is a big part of assault these days, and so we do a very thorough exam of eyes, ears, mouth, and neck, looking for any petechiae, any injuries in that area. I'll do swabs at that time as well.

And then after we do that and I take photographs of any injuries, then we'll do the genital exam, which is generally very detailed. Again, I'm telling the patient everything I'm doing. If I don't have their consent or they want to skip any part of the exam, that is absolutely their right to do. And we will respect that 100%.

Timeliness and DNA Preservation in Sexual Assault Cases

Dr. Jones: Well, I think there might be some confusion about what the quality of the evidence is in 1 hour, or 2 hours, or 120 hours. I mean, as a fertility doctor, I know how long sperm stay alive in the vaginal tract, but there's always DNA. We get DNA from Neanderthals from 10,000 years ago. So, what degrades and what doesn't?

Haley: I will always encourage patients to be seen as soon as they are comfortable. That could be right after the assault. We have patients that come right after an assault. We have patients who come a day after the assault.

So, obviously, the evidence is going to be the best the closer it is to it. But we have a lot of research that shows that in that six-day window, we are still able to get good DNA profiles off of someone.

Does that include people who have showered? Yes. Does that include people who have had a bath? Yes. That's actually a question that we ask as part of our exam, which is, "Tell me about what you've done. Have you showered? Have you gone to the bathroom? Have you wiped? Have you put in a tampon?" And all those things just help the crime lab and their testing.

Maybe if we look back on the chart and, "We didn't get a good DNA sample." Well, the patient was five days out and took four showers at that time. Then that might be a really good explanation of why we didn't get a perfect sample.

So, can DNA be taken at any time in that six-day window? Absolutely 100%. But if the patient is able and willing to be seen, closer to the assault is always better.

Medications and Treatment Options After Sexual Assault

After the genital exam, we will kind of discuss with them their options for medications. So, we like to prophylactically treat a few of the really common STIs in the area. So, we'll go through that with them, maybe some risk factors with the medication, and they can decide if they want it or not. Depending on the type of assault, we might also be able to offer them nPEP for HIV.

Dr. Jones: Yeah. How about the morning-after pill?

Haley: Absolutely. We have the morning-after pill, we have Plan B, and we also have Ella. So, kind of depending on if they're on birth control already or . . .There are a few different factors that might change which one of those we recommend, but absolutely, we offer that.

And then after that, we like to have the provider come in, have a consultation, kind of go over everything that we did. And then we kind of go over discharge.

Dr. Jones: Any labs that you get? Any bloodwork that you might get?

Haley: The only time we collect any labs is when we're starting that patient on that nPEP medication.

Dr. Jones: Right. Medication against HIV, if there's any chance that the assaulter might have had HIV.

Haley: Correct. There are some patients that have a higher risk: men who have sex with men, IV drug users, and things like that. So, we kind of evaluate their risk for getting HIV anyway, and then kind of go from there. So, definitely, the majority of our patients are not getting nPEP, but it is an option for those who may have some risk factors.

Electronic Records and Confidentiality Considerations in Sexual Assault Cases

Dr. Jones: The records that you obtain, is it part of their hospital record?

Haley: So, the hospital has their record.

Dr. Jones: Correct.

Haley: We, as forensic nurses, have a completely different electronic record. And that's some of the things that we talked about during the consent portion. "Do you give permission for law enforcement to see this record? Do you give permission for the District Attorney to see this record?"

Dr. Jones: Right. Because I think there are people who might not want their other providers to know this happened. That might be in the ER note, but your specifics may or may not be part of their medical record for all their clinicians to see unless they asked for that to be so.

Haley: Yes.

Follow-up Care and Mental Health Support for Sexual Assault Survivors

Dr. Jones: And then how do you say goodbye?

Haley: We talked a little bit about kind of the continuing mental care, but we do suggest that they go see their primary care physician, which might be their OBGYN, two to three weeks after the exam, especially if there are injuries, to make sure they're healing and they're doing okay. That way they're getting a little bit of follow-up care, and making sure injuries are healing.

Having someone to kind of ask them how they're doing mentally. "How are you doing with this? Are you sleeping okay? Are you eating okay?" Just kind of those things that at the moment, you don't think about but kind of creep into their life after.

If they want to have any type of STI testing, then they can talk to their primary care provider about that. That's something that we don't do at the time. Obviously, there's just not enough time for an infection from the assault to . . .

Dr. Jones: Right. I think that's important to know because it's not that you don't want to do the testing. It's just if it's within a matter of two or three days, or even immediately, there's no way that your test would pick up an infection yet.

Haley: Absolutely. And that's why, really, we prophylactically treat chlamydia, gonorrhea, and trichomoniasis. Those are three very common things in this area, so that's what we offer medication for prophylactically.

Sexual Assault is Never the Victim's Fault

Dr. Jones: Do you ever feel like the patient is impaired? Do you ever do a tox screen, or do you leave that up to the ER doc to do that?

Haley: No, that's not . . . If we feel like a patient is impaired to the point that they cannot give informed consent for the exam, then we can say, "Hey, why don't you come back in a few hours, in a day?" And as long as they're in that six-day time period, then that's not a problem.

As far as what they might be on, what substance they might have in their system, we don't care. Looking at the assault from the outside, we know no matter what you choose to ingest, it doesn't make this right. So, what might be in their system of their own choice, we don't care about.

Now, if they feel like maybe they were given something that they weren't aware of, then what we will do is take blood and urine samples, and then we send that to the toxicology lab at the state. That is not sent to the lab at the hospital. And no substance, illegal or not, means that it's okay for something like this to happen.

Dr. Jones: Of course.

Haley: It's just patients are really good at self-blame. And so that's something that we really try and talk to them about, and the advocate does as well, just saying, "Hey, no one has a right to touch you without your consent. Just because you were drinking or because maybe you were wearing something a little more risqué than you normally would, it does not give anyone permission to do anything that you don't want them to do."

What is a "Successful" SANE Exam?

When I started this job, I had this really "CSI," "Law & Order" view of it. I thought, "I'm going to go into the exam, I'm going to do the exam, the police are going to investigate, I'm going to testify in court, and the suspect is going to be put away for years." And it didn't take long for me to realize that's not reality. That's not what happens. And I found that I had to really rework in my mind what a successful exam was.

So, instead of having the success hang on the prosecution of the suspect, I really try and help my patients understand that their healing starts now. It starts with the exam.

You have to let the justice system do what it's going to do. Unfortunately, you don't have a lot of control there. But what you do have control over is beginning your healing right now.

So, I really try and set them up for their own healing and not wait until the suspect is behind bars or the suspect is arrested. But the fact that they took the time, they decided to go into the hospital, get the healthcare, and do the exam, they took back control right then and there when they decided to do that.

Dr. Jones: They're on their first step to their healing journey.

Haley: Absolutely.

Dr. Jones: It could be a long one, but it's their journey.

So, I want to thank Haley and all the SANE nurses who show up for people at a critically traumatic time in their lives. And for you who might be listening who might know someone in the future who's maybe been assaulted, or you've been assaulted recently, please know that there are people who are specially trained to take care of just you as far as an evaluation, medications if necessary, and help you on your own path to recovery.

It's a long path, it's an uncertain path, but being evaluated and taking your body and giving it the gift of care is your first step.

Thanks for joining us on The Scope.