n addition to the innovative strategies being employed to encourage the development and success of SANE programs illustrated earlier in this bulletin, a number of "promising practices" are
Expanded Role for SANEs
Recognizing the vital service that SANEs provide in sexual assault cases, some hospitals, like St. Mary's Hospital in Richmond, Virginia, have expanded their SANEs' role to include conducting evidentiary exams on domestic violence victims, accident victims, and other populations where forensic evidence may be useful.71
Use of the Medscope as an Alternative to the Colposcope72
A colposcope magnifies genital tissue and is an important asset for the identification of genital trauma. Photographic equipment, both still and video, can be attached easily to the colposcope. In the legal arena, the use of the colposcope is well documented as an accepted practice in the examination of both child and adult sexual assault victims. The basic colposcope, without photographic equipment, costs between $10,000 and $15,000, although the price is falling as the technology becomes more available.
The medscope is an adapted dental camera and provides photographic documentation that has a greater depth of field than the colposcope and can be used to document injuries elsewhere on the body.73 The complete medscope package is more affordable than the colposcope ($3,500 for the basic model and $11,500 including camera, internal lens, camera holder, monitor, printer, foot switch, VCR, and cart). Suzanne Brown, SANE Program Coordinator at Inova Fairfax Hospital, Virginia, noted that the medscope is portable and less cumbersome than the colposcope, is easier to operate, and takes digital prints instead of 35mm prints. Photographic images are taken using the foot instead of the hand, which frees the SANE's hands to conduct the exam and reduces the risk of contaminating the evidence. Digital images can be viewed on the monitor to make sure that they are well focused and clear whereas 35mm prints cannot be viewed prior to development. Digital prints, however, cannot be enlarged or reprinted like 35mm prints. The medscope does not have definite magnification ranges like the colposcope, but Brown indicated that the lack of this feature has not presented problems in court.
Uniform Statewide Colposcope and Forensic Equipment Protocols
New Jersey has recently implemented a statewide funding initiative to acquire identical, state-of-the-art forensic colposcope equipment for SANE programs participating in a Statewide Sexual Assault Standards Project. The project provides a specially designed forensic colposcope to all exam sites that are part of SANE programs approved and funded by the State Office of Victim/Witness Advocacy. The initiative is designed to maximize the ability to collect competent forensic evidence while supporting the provision of sensitive victim-centered care to sexual assault victims. The equipment consists of a traditional binocular colposcope with an advanced digital image-capturing system to enable the examiner to see the image quality before capture to ensure that high-quality, accurate photographic documentation is part of every forensic examination. Specially designed software has been developed to ensure the highest quality of photo documentation, evidence preservation, and the usefulness of the images for trial.
One of the important aspects of this program involves protocols providing for the strict confidentiality of evidentiary photographs taken, especially photographs of genital injury. The protocols provide that the images are secured with the program and not routinely printed and produced with a patient's forensic file. This helps to reassure victims who may be reluctant to proceed and allows the assurance of confidentiality to victims. Additionally, the security level of the specially developed forensic photo documentation software program eliminates the need to capture facial photographs when there is no injury to that area. The specially designed software provides the ability to securely transmit data and images for child and adolescent forensic sexual assault evaluations. Finally, the design and purchase of specialized equipment on a statewide basis allows for considerable price reduction and improves resource allocation by providing colposcopes to programs with limited funds.
A regional SANE program is an important alternative to each locality having its own program from a staff training and competency perspective. By serving a larger regional area, SANEs will most likely see more clients, and each SANE will be able to complete a sufficient number of exams to develop and maintain clinical competence. Regional programs may be the only cost-effective way to provide SANE services in rural and remote areas where no one medical facility sees large numbers of sexual assault cases.
When the SANE program of Inova Fairfax Hospital in Virginia began in 1990, it took only adult cases in Fairfax County. It gradually expanded to serve child victims and widened its service area, allowing nurses to increase proficiency because they had more cases. It now serves a region of 20 jurisdictions. While some of these jurisdictions have SANE programs that handle adult cases locally, they tend to refer their cases of child sexual assault to the Fairfax program.74
The hospital-based SANE program in Bethel, Alaska, serves a remote region (three people per square mile) approximately the size of Oregon that is 400 miles from the state road system. Victims are transported by plane, boat, or snowmobile to the hospital. Between 130 and 150 exams are conducted each year.75 The Matanuska-Susitna Valley SANE program is based at Valley Hospital in Palmer, Alaska, and serves a region the size of West Virginia. Since the region is on the road system, city police or Alaska State Troopers drive most clients to the SART center. The commute may take up to 3 hours. Since the SANEs from Palmer examine fewer than 50 cases per year, they are required to participate in case review meetings and to attend educational programs to maintain proficiency as forensic examiners.76
Child Sexual Abuse Diagnostic System
In rural or remote areas where SANEs may rarely see child victims, more experienced forensic examiners could assist SANEs in properly identifying and evaluating abnormalities. Better quality or more detailed evidence obtained through collaboration of numerous experienced clinicians could increase the likelihood of successful prosecution. The Fairfax, Virginia, SANE program is involved in a pilot project to develop a model regional diagnostic system for forensic examination of children who have been sexually abused. Using camera and computer-imaging equipment that is attached to the medscope, the nurse or physician conducting the forensic exam is able to immediately transmit photographic images of genital trauma to the computers of identified experts for their feedback during the examination. In addition to SANE programs, child advocacy center staff and pediatric emergency medicine specialists are participating in the project.77 Although this model is still in the preliminary stages of development, it shows exciting promise. It has the potential to bring clinical expertise to every forensic evaluation of sexually abused children, regardless of the examination location.