Handbook on Sexual Violence (101 page)

truly comprehensive care involves the efforts of multiple service providers. Many SANE programmes today operate as part of multidisciplinary response teams (e.g. sexual assault response teams (SARTs) or co-ordinated community response initiatives (Littel 2001)). Recognising the importance of collaboration, some states require all SANE programmes that apply for state funding to have a multidisciplinary team to oversee the implementation (Littel 2001). Many SANE programmes continue to work closely with the members of the multidisciplinary team after implementation to review cases and verify that victims/survivors received comprehensive care (Littel 2001). Some SANE programmes also offer formalised multidisciplinary trainings on sexual assault that address strategies for working effectively with survivors, why injuries may or may not be present, and how forensic evidence can be used in law enforcement investigations and prosecution (Littel 2001; Stone
et al
. 2006).

SANE programmes have spread quite quickly since their inception in the

1970s and 1980s, to nearly 500 programmes currently in existence (IAFN 2010a). The vast majority of these programmes are located in the United States and Canada, but similar interventions exist in the United Kingdom, Europe, Australia, and New Zealand (IAFN 2010a). It is somewhat unusual for an intervention model to take root so quickly and in such large numbers, but Rogers’ (2003) diffusion of innovation theory (DOI) can help explain why these programmes have been so transferable. DOI theory stipulates five conditions that facilitate the spread of novel practices, all of which are clearly evident in this short history of SANE programmes. The relative advantage of SANE programmes versus traditional ED care was readily apparent, and the intervention model was highly
compatible
with the values of nursing practice, not surprisingly because it was created by the nurses themselves. Although the intervention is very high in
complexity
, the formation of the International Association of Forensic Nurses in 1992 created a reasonably well-standardised intervention model with codified training and practice standards for SANE programmes. The investment in training required to become a forensic nurse was extensive, so
trialability
of the intervention was quite limited, but the
observable benefits
to rape survivors and community stakeholders were so immediate that these disadvantages hardly slowed the diffusion of the innovation. Recently, the US Department of Justice (2004, 2006) sanctioned this intervention model in its national protocol for sexual assault medical forensic

examinations, which would also be expected to contribute to further growth of these programmes.

The promise of SANE programmes: emerging data regarding their effectiveness

The widespread diffusion of SANE programmes has occurred despite
very
minimal evaluative research on their effectiveness (Campbell 2008). Nevertheless, emerging data suggest that these programmes have beneficial effects on victims’ health care experiences and psychological well-being, and may also be instrumental in increasing legal prosecution rates. First, the medical forensic exam and evidence collection kit performed by SANEs is more thorough and accurate than what victims receive in traditional emergency department care. Ledray and Simmelink (1997) conducted an audit study of rape kits sent to the Minnesota Bureau of Criminal Apprehension. Twenty-seven kits conducted by SANEs were compared with 73 kits collected by physicians or non-SANEs with respect to completeness of specimens collected, documentation and maintenance of chain of custody. Overall, the SANE-collected kits were more thorough and had fewer errors than the non- SANE kits. A larger-scale study by Sievers
et al
. (2003) explicitly tested differences between SANE and non-SANE kits, and also found support for better evidence collection by SANEs. Specifically, this study compared 279 kits collected by SANEs and 236 by doctors/non-SANEs on ten quality control criteria, and found that in nine of these ten categories, the SANE-collected kits were significantly better. The kits collected by SANEs were significantly more likely than kits collected by physicians to include the proper sealing and labelling of specimen envelopes, the correct number of swabs and other evidence (pubic hairs and head hairs), the correct kind of blood tubes, a vaginal motility slide and a completed crime lab form. The Sievers
et al
. study provides the strongest evidence to date that SANEs collect forensic evidence correctly, and in fact, do so better than physicians. However, it is important to note that training and experience, not job title or professional degree, are the likely reasons behind these findings. Because SANEs have made it a professional priority to obtain extensive forensic training and practice, it is not surprising that current data suggest they are better forensic examiners than physicians and nurses who have not completed such training.

Forensic exams performed by SANE tend to be more technically accurate, but perhaps more importantly,
how
they are performed from the perspective of the survivors is qualitatively different. SANEs provide a full explanation of the process
before
the exam begins, and then continue to describe what they find throughout the exam, giving patients the opportunity to reinstate some control over their bodies by participating when appropriate (e.g. combing their own hair). In an evaluation of a midwestern US SANE programme, victims gave strong positive feedback about their exam experiences: all patients indicated that they were fully informed about the process, and the nurses took their needs and concerns seriously and allowed them to stop or pause the exam if needed (Campbell
et al
. 2008). This patient-centred care also seems to help

victims’ psychological well-being as survivors reported feeling supported, safe, respected, believed and well-cared-for by their SANE nurses (see also Ericksen
et al
. 2002).

As noted previously, the rape exam is more than forensic evidence

collection, it is an opportunity to address survivors’ health care needs as well. With respect to STI and emergency contraception care, national surveys of SANE programmes find service provision rates of 90 per cent or higher (Campbell
et al
. 2006; Ciancone
et al
. 2000). As with traditional emergency department medical care, SANE programmes affiliated with Catholic hospitals are significantly less likely to conduct pregnancy testing or offer emergency contraception (but do so at higher rates than non-SANE Catholic-affiliated emergency departments) (Campbell
et al
. 2006). In a quasi-experimental longitudinal study, Crandall and Helitzer (2003) compared medical service provision rates two years before to four years after the implementation of a hospital-based SANE programme, and found significant increases in STI prophylaxis care (89 per cent to 97 per cent) and emergency contraception (66 per cent to 87 per cent).

In addition to beneficial effects on victims’ health, SANE programmes may be instrumental in increasing legal prosecution of reported cases. Multiple case studies suggest that SANE programmes increase prosecution, particularly plea bargains, because when confronted with the forensic evidence collected by the SANEs, assailants will plead guilty (often to a lesser charge) rather than face trial (see Campbell
et al
. 2005a for a review). Case study designs are often used in evaluations of new interventions (Rossi
et al
. 2004) and are useful for providing rich descriptive information about programmes and identifying outcomes (Yin 2009). However, it is difficult to determine whether the effects documented in case study research (e.g. increased prosecution) can be attributed to the focal intervention because this methodology does not include comparison groups or other methodological controls that permit causal inferences. To date, only three studies have rigorously evaluated whether SANE programmes increase prosecution.

With respect to research specifically on SANE interventions, Crandall and Helitzer (2003) used a quasi-experimental pre-post design to compare prosecution rates in a New Mexico jurisdiction two years before to three years after the implementation of a SANE programme. Their results indicated that significantly more victims/survivors treated in the SANE programme reported to the police than before the SANE programme was launched in this community (72 per cent versus 50 per cent) and significantly more victims/ survivors had evidence collection kits taken (88 per cent versus 30 per cent). Police filed more charges of sexual assault post-SANE as compared with pre- SANE (7.0 charges/perpetrator versus 5.4). The conviction rate for charged SANE cases was also significantly higher (69 per cent versus 57 per cent), resulting in longer average sentences (5.1 versus 1.2 years).

In a more recent and comprehensive study on this issue, Campbell and colleagues (2009) conducted a multi-study, mixed-methods evaluation of a US midwestern SANE programme. Overall, the purpose of this project was to examine whether adult sexual assault cases were more likely to be investigated and prosecuted after the implementation of a SANE programme within the

focal county. In Study 1, they used a rigorous quasi-experimental design to determine whether there was a change in prosecution rates pre-SANE to post- SANE. The pre and post cases were equivalent on multiple criteria, except that the pre-SANE cases were examined by hospital emergency department personnel and the post-SANE cases were examined in the focal SANE programme. Using longitudinal multilevel ordinal regression modelling, Campbell and colleagues found that case progression through the criminal justice system significantly increased pre- to post-SANE: more cases reached the ‘final’ stages of prosecution (i.e. conviction at trial and/or guilty plea bargains) post-SANE. These findings suggest that the implementation of the county’s SANE programme was instrumental in achieving higher adult sexual assault prosecution rates in this community.

To understand whether implementation of the SANE programme affected criminal justice system case processing, Campbell
et al
. also examined what factors predict case progression. What makes some cases more or less likely to move further through the system? Therefore, in Study 2, they tested a model that compared the predictive utility of victim characteristics (e.g. race, age), assault characteristics (e.g. victim–offender relationship) and forensic medical evidence (e.g. injury, DNA) in explaining case progression in the post-SANE era. In the hierarchical ordinal regression models, two victim characteristics were significant: survivors between the ages of 18 and 21 (i.e. younger women in the sample) were significantly more likely to have their cases move to higher case disposition outcomes; and alcohol use by the victim prior to assault significantly decreased the likelihood that the case would be prosecuted. Two assault characteristics were significant: penetration crimes (versus fondling crimes) and assaults in which the offender was an intimate partner/husband, ex-intimate partner/husband, dating partner, or family member (i.e. stronger relationship bonds between the victim and offender) were more likely to advance to higher disposition levels. After accounting for these victim and assault characteristics, medical forensic evidence could still predict significant variance in case outcomes. The more delay there was between the assault and when the survivor had the medical forensic exam, the less likely the case would progress through the system. Positive DNA evidence significantly increased the likelihood of case progression. With respect to specific findings in the medical forensic evidence exam, physical or anogenital redness was associated with increased likelihood of case progression.

The results of Studies 1 and 2 indicated that the SANE programme had been instrumental in increasing successful prosecution, but it is also important to understand how and why those changes occurred: what are the mediating mechanisms that contributed to these changes? To identify these mechanisms, Campbell
et al
. (2009) conducted in-depth qualitative interviews with law enforcement personnel and prosecutors regarding their perceptions of how the emergence of the SANE programme affected their work investigating and prosecuting adult sexual assault cases (Study 3). The findings of the study indicated that the SANE programme has been instrumental in the creation of more complete, fully corroborated cases. With the medical forensic evidence safely in the hands of the SANEs, law enforcement put more investigational effort into other aspects of the case. The training and ongoing consultation

provided by SANEs often suggested investigational leads that law enforcement could pursue to further develop a case. As a result, the cases that were put forward to prosecutors reflect the collective efforts and expertise of law enforcement and the SANEs, and not surprisingly, the cases were stronger. Consequently, prosecutors were more inclined to move forward with charging cases, and over time, the prosecution rates did increase.

These qualitative findings were replicated and triangulated with quantitative data in Study 4. A quantitative content analysis of police reports revealed multiple significant mediated effects indicating that SANE involvement in a case was associated with increased law enforcement investigational effort, which in turn predicted case referral to prosecutors. Specifically, in cases in which the victim had a medical forensic exam, police collected more kinds of
other
evidence to support the case, which was associated with increased likelihood of case referral. In addition, in cases where SANE conducted a suspect exam (i.e. a forensic medical exam of the
suspect
’s body), police were also more likely to collect other evidence to support the case, and more likely to interview the suspect, both of which were associated with increased likelihood of case referral. In other words, evidence begets more evidence: the medical forensic evidence collected by SANEs may suggest specific leads that law enforcement can follow up on to obtain more evidence, and/or the efficiency of the SANE programme frees up law enforcement time to obtain other evidence. The additive effect of evidence from the SANEs plus the evidence collected by law enforcement created more complete documentation of the crime.