Welcome, and thank you for joining us to further explore and discuss the importance of the Medical Forensic Exam, Tips for the Title IX Coordinator. My name is Sarah Jennings, and thank you again for being here with us today. This presentation was produced by the International Association of Forensic Nurses under grant number 15POVC21GK04059SAFE, awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. The authors, presenters, and planning committee for this educational activity have no relevant financial relationships with ineligible companies to disclose. We're going to talk more about the learning outcomes for this presentation. Title IX Coordinators and Offices will report an increased knowledge of the importance of the Medical Forensic Exam and overall benefit of the multidisciplinary approach for the student who has experienced violence. Let's talk about some definitions of SANE, SAFE, and Forensic Nurse Examiner. The Sexual Assault Nurse Examiner, or SANE, is a registered or advanced practice nurse who has received specific education for the provision of comprehensive care to patients who disclose sexual abuse or assault, including, but not limited to, evidence collection and testimony. Education is guided by the 2018 IAFN SANE Education Guidelines, which we will also post a link for you to see, and we'll send those out at the conclusion of the presentation. A Sexual Assault Forensic Examiner, or SAFE, is a registered nurse, physician assistant, or physician who has been specially trained to provide comprehensive sexual assault care, including evidence collection and testimony. The Forensic Nurse Examiner, or FNE, are registered or advanced practice nurses who have received specialized education and training to address the acute and long-term health care consequences of patients impacted by violence. You may see the terms SANE and SAFE used interchangeably in many settings. The Forensic Nurse Examiner may also be a SANE and vice versa. How do you become a SANE? The IAFN SANE Education Guidelines serve as a standardized body of knowledge for a specific area of nursing practice. They specify the minimum level of instruction that's required to ensure competent practice. Practitioners, teachers, and other leaders in the forensic nursing profession have developed, reviewed, and endorsed the Forensic Nursing Education Guidelines. These guidelines serve to define our patient population, establish the minimum duration of instruction, include recommendations for trainers or educators, and set forth a detailed content outline and specify recommendations for clinical preceptorship. We'll also post a link to where these can be found. Let's dig deeper into the roles and responsibilities of the SANE. Roles and responsibilities of the SANE or forensic nurse include providing comprehensive nursing care, obtaining a medical history, performing a complete assessment, identification, collection, preservation, and documentation of forensic evidence, photography of injuries, comprehensive documentation of injuries, and conducting safety screenings, for example, human trafficking screenings, offering medications as appropriate, conducting safety planning, providing information for referrals that are relevant to this patient population, for example, advocacy, and providing fact or expert witness testimony. It is important to recognize that the medical cannot be separated out from the forensic care. The entirety of the medical exam can be brought into trial whether or not evidence is collected. Per the CDC, sexual violence is sexual activity when consent is not obtained or not freely given. The World Health Organization defines sexual violence as any sexual act, attempt to obtain a sexual act, or other act directed against a person's sexuality using coercion by any person regardless of their relationship to the victim in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object, attempted rape, unwanted sexual touching, and other non-contact forms. This is common in intimate partner violence. It is not always recognized by the victim as assault. And patients have stated, I didn't say no, but I've learned he will beat me worse when I try to say no. So these are important things when you're considering the definition. Let's talk more about the medical forensic exam and what that means for you as a Title IX coordinator or the Title IX office. Each exam is tailored to the specific circumstances and is oriented to each patient. The patient assists in making decisions and is the one who is ultimately in control of the entire exam. It is the patient's choice to receive and complete the medical forensic exam. Who decides if the exam is done? The patient. The patient must provide written consent prior to performing an exam and continued verbal consent throughout the duration of the exam. It's their decision to have the medical forensic exam or not. What does a medical forensic exam include? The medical forensic history, including a past medical history and patient narrative of what happened during the assault. Physical assessment, a complete head to toe exam, or potentially focused, this is also per the patient request as they are guiding our exam. A detailed anogenital exam, including the use of a speculum to visualize the vagina or anoscope to assess the rectum for any potential injuries. Collection of forensic evidence using a sexual assault evidence collection kit. There may be times when evidence collection is not done because the window has passed or the patient declines this component of the exam. Despite this, the exam is still a medical forensic exam and if the patient reports, the medical forensic exam is still considered evidence at a criminal proceeding. Treatment. Treatment is based on risk and need. And then, of course, discharge planning. This is the connection with advocacy and other services as needed. Follow-up care planning and referrals as needed, which may include referrals to other medical providers as indicated, or a follow-up visit with the forensic nurse, sane or safe. As we learned before, those terms may be used interchangeably. The medical forensic exam may also include forensic photography using a digital camera and or a cold scope. The medical forensic exam serves as a valuable link to services such as medical counseling and advocacy services. Now that we've completed the medical forensic exam, what can it tell you and why is it important? In adult sexual assault, it is common for there to be no anal or genital injuries following a sexual assault. There are several factors that may contribute to the lack of injury. First, the delay between the assault and the exam. The genital structures are very vascular and heal quickly. And second, the genital structures are stretchy and pliable in preparation for pregnancy and vaginal delivery. From a physiological perspective, so substantial injury is uncommon. Estrogen also contributes to the general malleability of the genital tissue. And lack of injury does not mean that an assault did not occur. And I'm going to say that one more time because I think it's very important to remember that lack of injury does not mean an assault did not occur. So why is the medical forensic exam important? Patient health care needs should be at the center of the care of this patient population. Violence, both short and long-term health care implications are included. It is imperative that the medical forensic exam be trauma-informed. The medical forensic exam provides the patient with a detailed and thorough assessment of injuries as well as access to treatment for short and long-term needs such as treatment for STIs, pregnancy, and HIV prophylaxis. So who should receive a medical forensic exam? Any student who reports a sexual or physical assault should be offered a medical forensic exam. It is important to note that the student has a right to accept or decline any or all parts of the exam. Some more considerations for the student. There are several things to take into consideration for the student that may be seeking a medical forensic exam. Again, any student who reports a sexual assault should be offered a medical forensic exam. Students may be referred to the local hospital or other agencies that provide the medical forensic exam services. Options for reporting. Several options exist in reporting in regards to the assault. Students may choose to not report to law enforcement and have a blind or anonymous medical forensic exam. Students may choose to receive medical care only or students may choose to have a medical forensic exam regardless of the option that the student elects. Consideration should be given to their immediate safety, their long-term safety, and any follow-up considerations. The next concern and consideration that we've taken is from a billing perspective. Students should not receive a bill for the medical forensic exam. However, there is no guarantee that the patient or the caregiver, if they are the insurance subscriber as the caregiver, will not receive an explanation of benefits. So again, there's no guarantee that they will not receive that. It is important that this be communicated to the student when they're seeking care. Guidelines or talking points should be in place to talk through any financial questions or concern the student may have. Another consideration is the patient's safety. Ensure that the student or the patient feels safe. This may mean physical safety as well as emotional safety. Consider how the student is contacted after the care is received. Are you potentially putting this patient in danger? This may be in the form of survey or phone. Ensure that this does not place them in an unsafe situation. And then another consideration is follow-up care. It is important that the student be able to seek follow-up care as warranted. This may mean returning to see the forensic nurse, SANE or SAFE, or another health care or mental health practitioner. Many follow-up services may be able to be coordinated through your student health services. So, consider student health members as a key stakeholder in the multidisciplinary campus SART process. Let's dig deeper into intimate partner violence and strangulation and how this impacts the student population on campuses. Students on campus and off campus may experience intimate partner violence and or strangulation. Frequently, this goes hand-in-hand with sexual violence. Students who have experienced IPV or strangulation should be offered a medical forensic exam. IPV definitions can vary from state to state or region, territory, or tribe, even from country to country. They each can define IPV in their own terms. Most definitions include physical, emotional, sexual, and financial abuse. But please know, often when there is one form, there are also many others. Many students are limited to physical abuse, but not that added component of sexual assault. Victims of IPV may be male, female, any gender identity, adult, adolescent, elder, so you can see that it's all encompassing. You might hear me say this a time or two, but violence does not discriminate. Those who are reporting IPV could include individuals within current relationships, a former relationship, which could be a spouse, a marriage, some type of civil union, boyfriends, girlfriends, partners, dating partners, or ongoing sexual partner. The Center for Disease Control, or CDC, defines IPV that includes physical violence, sexual violence, stalking, psychological aggression, including coercive attacks by a current or a former intimate partner. So again, violence is a healthcare issue. There are acute and long-term physical and mental health implications that being a victim of violence do contribute to. This is what makes violence a healthcare issue. We do have a position statement on this that we are also happy to share with you in the reference section and resources. Let's talk more about the multidisciplinary team approach. The overall response to campus sexual assault and violence is a very complex process in nature. This process may span across many different disciplines, such as legal, criminal, justice, community-based agencies, healthcare, and advocacy, just to name a few. The development of a multidisciplinary team, or MDT, and active participation in an MDT ensure a coordinated and cohesive response, which ultimately leads to better long-term outcomes. The Title IX coordinator in office should be an active participant in the campus or community SART. Title IX coordinators that are actively involved in the SART promote better information sharing, a more comprehensive approach, and overall reduction of campus sexual violence, and a more coordinated approach with community and on-campus stakeholders and members of the SART. The overall role of the Title IX coordinator office, as you're aware, is very complex. Title IX coordinator helps to maintain a safe school and campus environment, as well as coordinating the investigation and resolution of reported assault. It is also very important for the Title IX coordinator to collaborate with the multidisciplinary partners, including your local SANE safe forensic nurses, that provide care to these campus patients. While the SANE and the Title IX coordinator will not share student or patient information, it is important to have a working relationship in order to best serve these students, including knowing what SANE services are available both on-campus and off-campus in the local community. It is important for the Title IX coordinator to understand that the medical forensic exam record created at a post-secondary institution is a treatment record as long as it is only disclosed to treatment providers for treatment purposes. The health record is not integrated with the student record. I'd like to share a case study or a case scenario with you all to have some thinking of what would we do, and you're welcome to put your thoughts in the chat. So we're going to talk through this case scenario. A 19-year-old female contacts your Title IX office. She states that she was sexually assaulted two days ago while she was at a fraternity party with friends. She wants to report to law enforcement and says she would like to have a rape kit performed. As the Title IX coordinator, what are your next steps? So I'd love to see you insert your answer or your response into the chat to see what you would do, and I'll give you just a few moments to do that. Our chat may be a little slow today, so I'm going to go ahead, but it is very important for this particular student to be supported and encouraged to seek care as soon as possible. As time passes, important evidence may be lost and not preserved. Have a plan in place for referrals for this student. You will need the student to potentially go to the local hospital for a medical forensic exam if they're willing. So again, we're offering to this student to have a medical forensic exam. Also take into consideration if the exam will be performed on campus or at Student Health. Having a plan in place for that is also important. How will the patient be transported? Will the patient be transported with an advocate? These are things to keep in mind as you plan your process for if these students present to your office. Do you have advocacy in place and will advocacy be a community response or campus-based program? Many campuses will have advocacy on site or they may be utilizing services from within the community. It's important to keep the student informed in the process because the student should be empowered to make decisions about their care and the medical forensic exam process. A coordinated approach to this patient population is key. Key for both long-term success of the patient and their overall health care outcome. Check back to the box. Great. Julia had commented to explain their rights and encourage them to have the medical forensic exam. Great response, Julia. On the next slide, we're going to see some references and resources and you'll also be provided a copy of this presentation, which also has links to each of these things. I would encourage you to check out all of the resources and references that are listed as they are great when you're planning your process and how these things will be implemented on your campus. Jennifer, thank you also. Call the campus forensic nurse liaison. That is a great point that you make. Many campuses may have that, but they may also not have a campus forensic nurse liaison. It's important to know what your resources are and have that plan in place before the student presents complaining of being sexually assaulted and needing to make a plan for that. It's a really good response. Our next slide is the resources that I also mentioned, the national protocols. We also do have several frequently asked question documents that I would encourage you to also take a look at from the perspective of FERPA and also advocacy. We'll make sure that you have copies of all of those. Thank you all so much. I have enjoyed presenting today on this topic. I would encourage you if you do have questions, I will make sure to also put my email in the chat. You're welcome to reach out with further questions and we will connect you with the right person. So again, thank you for attending today and have a wonderful day.

Medical Forensic Exam

Title IX coordinators

sexual assault

forensic evidence

trauma-informed

multidisciplinary team approach

Sexual Assault Nurse Examiners

evidence collection

intimate partner violence

patient empowerment