April is Sexual Assault Awareness and Prevention month, an annual campaign dedicated to ending sexual violence by raising awareness and highlighting potential solutions at the community, state, and national levels. Sexual violence cannot be prevented through individual action; instead, societal perceptions of sexual assault, its survivors, and its perpetrators must be addressed. Public education and trauma-informed approaches to healing are necessary to make communities a safe space for survivors, whether they seek justice or simply support.
Sexual Assault Exam Nurses, also referred to as SANE nurses, are in a unique position to serve as a bridge between trauma and recovery, helping support and validate survivors as they process their sexual assault. Jennifer Sonsiadek, MSN-FN, BSN, BA, RN, SANE-A, is the clinical forensic care manager for Saint Luke’s Health System. Prior to her current role, she served the emergency department, where she encountered her first patient presenting as a sexual assault survivor. She located a dedicated forensic SANE nurse to assist the patient and watched in awe, inspired by the process and the trauma-informed care being provided.
“I promised myself in that moment that being an ER nurse meant that I would be ready and available to receive whatever might come my way and be placed in one of my rooms under my care,” she said. Since then, she underwent rigorous training through Saint Luke’s, became certified as a SANE through the International Association of Forensic Nurses, and received both her Bachelor of Science and Nursing and Master of Science and Nursing with a specialization in Nursing. Currently, she is midway through her doctorate program for Doctor and Nursing Practice.
Through her robust career serving sexual assault survivors, Sonsiadek is able to offer an expert perspective on how to support survivors at all levels and what steps communities can take to improve outcomes for survivors. Sexual assault is a sensitive, traumatizing, and often misunderstood subject, creating a myriad of concerns for those seeking support. Understanding the experiences and challenges survivors face can combat these concerns by addressing misconceptions and broadening awareness of available treatment options and resources.
According to the Rape Abuse and Incest National Network (RAINN), sexual assault refers to sexual contact or behavior that occurs without explicit consent of the victim. This includes, but is not limited to: attempted rape, fondling or unwanted sexual touching, forcing a victim to perform sexual acts, or penetration of the victim’s body – known as rape.
Rape is a form of sexual assault, but not all sexual assault involves penetration. Perpetrators of sexual assault may use direct physical force, psychological force, emotional coercion, or manipulation to coerce a victim into a sexual act.
Approximately eight out of 10 sexual assaults are committed by someone known to the victim, such as a partner, date, classmate, neighbor, acquaintance, or family member. Sexual assault committed by a stranger may occur through a variety of ways, including:
- Blitz sexual assault: when a perpetrator quickly and brutally assaults the victim with no prior contact.
- Contact sexual assault: when a perpetrator contacts the victim and gains their trust prior to coercing them into a situation where sexual assault will occur.
- Home invasion sexual assault: when a stranger breaks into the victim’s home to commit the assault.
In the immediate aftermath of an assault, victims are traumatized and may feel a variety of conflicting emotions, ranging from fear and anger to guilt and shame. Victims often blame themselves for their sexual assault, believing they somehow deserved it or could have taken steps to better protect themselves.
However, it’s important to understand that sexual assault is a behavior that exhibits patterns and is based in a need for control and power, rather than individual circumstance or sexual attraction. According to Sonsiadek, perpetrators of sexual assault are often repeat offenders, committing violent crimes before and after committing the assault. Examples of these crimes include domestic and intimate partner violence, assault on officers, disorderly conduct, and armed criminal actions, among others.
Public misconceptions of sexual assault, paired with the overwhelming shame felt by survivors, create hesitancies surrounding getting help. Many survivors avoid seeking immediate care out of fear they will be forced to undergo an exam or report their assault. However, immediate medical treatment may be needed to avoid further harm or complications.
Sonsiadek believes one of the greatest hesitations preventing survivors from seeking treatment is the fear that they’ll be forced or coerced to take an exam – which is far from true. “They’ve already gone through something where they’ve been forced or coerced or threatened and so coming to the hospital to receive services is going to be a least-resistance situation where we are going to truly listen to what their thoughts and worries are,” she said. “We’re going to empower them with knowledge so they know what their options are and then we’re going to protect those choices that they make and make sure they have the resources to continue the healing process.”
SANE nurses such as Sonsiadek undergo rigorous training to ensure they provide trauma-informed care to survivors, including stabilization and testing for any immediate concerns. “The goal is that we understand the kind of care that a patient who has experienced sexual assault would need in order to have their medical needs met,” she said. “That’s first and foremost our primary goal, is to make sure that they’re provided medical, stabilizing care.”
SANE nurses allow patients to guide their treatment, ensuring they are being heard and having their concerns addressed. Survivors may worry about having contracted a sexually transmitted infection (STI), contracting HIV, or getting pregnant – SANE nurses are able to provide immediate testing, treatment, and emergency contraception to soothe those fears.
If a patient is interested in collecting evidence and completing a rape kit, they can choose to do so even if they are not interested in reporting the assault to law enforcement. SANE nurses collect any information and evidence necessary to report and ensure the chain of custody to the investigating agency if and when patients do decide to pursue justice.
Forensic Exams and Rape Kits
Typically, sexual assault patients are referred to Saint Luke’s, either from rape crisis advocacy centers or law enforcement entities who were reported to. Specialized nurses are available around the clock to meet patients in the emergency department and perform a medical screening to address anything that may need immediate attention or stabilization. Physicians ensure the patient’s needs are met while SANE nurses stay by their side and get a sense for the objectives the survivor has, including whether they want an exam and/or to report.
The SANE nurse then explains each option available to the patient and what they can expect so survivors have informed consent and are able to make decisions that align with the outcomes they are seeking. Patients in Missouri have a number of rights, including: collecting a rape kit without notifying law enforcement, showering immediately after a forensic exam, choosing the preferred gender of their reporting officer if they do report, and having a presence of rape crisis advocacy or other support person by their side throughout the entire process, among others.
The forensic process for collecting the rape kit can cause hesitancy itself as it is a vulnerable process that puts patients at risk of re-traumatization. Verbalizing what just happened to them over and over not only makes it more real, but also can compound their trauma and increase their chance of developing post-traumatic stress disorder (PTSD) according to Sonsiadek.
SANE nurses can minimize this issue by ensuring a physician and any wanted presence of law enforcement or advocacy support is present during the initial retelling of the event, so patients do not have to continuously repeat the traumatic details. They also must understand that memories of trauma are stored in the body and its senses, and that revisiting locations on the body where trauma occurred can cause a visceral reaction.
“We want to make sure that we’re not causing a cascade of hormones and an anxiety attack or replicating the dynamics of the original trauma and making sure that their goals are achieved,” said Sonsiadek. “Trauma-informed care is focused on making the patient’s priorities our priorities and advocating for that – whatever that looks like.”
During the exam, SANE nurses gather a history of what has occurred so they know what pertinent evidence to collect, even if time has passed since the assault. “We can always do a modified exam for anyone who presents anytime after an assault,” said Sonsiadek. “I think one of the misconceptions out there is that if they’ve taken a shower then there’s nothing anybody can do, and that’s not the case at all. There are so many things that we can do, and we can still absolutely collect evidence and also walk them through the kinds of evidence they may not have even thought about that we can actually collect.”
Following the exam, SANE nurses verify that there is a follow-up plan in place to ensure that patients see a provider within two weeks and have a support system identified and in place. They also ensure patients have direct, actionable steps to continue the reporting process (if applicable) but especially for self-care and healing.
Sexual assault forensic exams are provided free of charge by certain agencies – for example, the Missouri Department of Public Safety is reimbursed for forensic exams through their Sexual Assault Forensic Examination (SAFE) program so patients do not have to pay, whether they choose to report using the collected evidence kit or not. Patients also have options available to assist with the cost of medical care, even if they are uninsured.
“One thing I think is important for folks to know, specifically in Missouri, is that the laws changed in 2018 allowing a person that received a forensic exam for sexual assault to potentially have access to crime victim’s compensation to help accommodate that bill,” Sonsiadek said. “One thing that I think is special about Saint Luke’s is that if one of our patients has a concern about that medical bill, that is something we can address with them.”
If patients don’t have insurance and are also ineligible for crime victim’s compensation, Saint Luke’s can potentially adjust their bill so patients don’t have to worry about incurring a cost for care. “Not all hospitals do that,” she said. “It is the right of the health institution to decide how they’re going to handle billing for medical care provided during the SANE exam.”
Seeking Justice and Support
According to Sonsiadek, the difficulties with pursuing justice for sexual assault lie within society and will take public education and awareness to address. “The folks that are going to be making that decision in a courtroom are going to be a jury and those folks are pulled from our general population,” she said. “Depending upon their level of understanding of sexual assault, that is going to have a huge impact on how they perceive the information that is presented to them in court. It becomes even more important that we’re educating our community on the impact of sexual assault, the truth about sexual assault.”
Saint Luke’s offers a variety of education and training services for community partners, including the advocacy centers they work with. This education provides insight on what the SANE exam involves and what to expect as they watch patients undergo this exam, as well as how they can support survivors throughout the process, including setting up follow-up services.
As a post-provider, Sonsiadek offers post-education year-round for law enforcement agencies on a variety of topics, including the most recent panel and discussion on Title IX. Saint Luke’s offers quarterly multidisciplinary education and training for law enforcement agencies, nurses, advocates, and others.
Sonsiadek credits cultural moments and movements to helping highlight sexual assault and related issues among the public, including the I Am Evidence movie about the backlog of rape kits in the U.S. and the Me Too movement highlighting survivors’ personal experiences. Though the backlog is being addressed through the Sexual Assault Kit Initiative (SAKI), Missouri is still working to address this initiative, including looking at expanding reimbursement options to cover medications and medical treatment.
The Me Too movement, which brought about personal and heartbreaking stories from celebrities and citizens alike, showed just how pervasive sexual violence is – and how little people know. Those who have not experienced sexual assault themselves or within their immediate social circles sometimes believe it is a far-removed concern.
However, Sonsiadek ensures this is not the case, even if they are unaware. “They do know someone who has been sexually assaulted, they absolutely do,” she said. “That person likely has not disclosed to them but I guarantee they have people in their life they are close to that have experienced sexual assault.”
Because sexual assault can be incredibly difficult to admit to and especially discuss in detail, many survivors struggle to speak up. When they do, it’s important that those on the receiving end provide unconditional support and keep the focus on the survivor and their needs.
“Many times, a person who is experiencing something like this is most likely to disclose it to someone close to them and that person may have a lot of opinions on what should or shouldn’t happen,” she said. “I want the public to know that when they come to the hospital, we will explain all of the different options that are available and we will advocate for what that patient wants because they’re the one going through it, not anyone else.”
According to Sonsiadek, support systems sometimes misdirect their emotions, such as wanting revenge or vengeance for their loved one, which can be more harmful than helpful. Instead, she recommends channeling those strong emotions into something helpful and productive, including:
- Listening to the survivor.
- Reminding the survivor they are not alone.
- Holding space for the survivor where they can have company without being expected to talk or do anything.
- Accompanying the survivor to the hospital, follow-up visits, or the reporting process.
- Asking the survivor what they want, need, or think they might need, and reminding them it’s okay if they do not know.
- Reaching out to advocacy agencies to ask questions and see what help is available.
The healing process for survivors of sexual assault is a lifelong process, not something that can be undone in a matter of days. Survivors, especially those who develop PTSD, can be triggered by memories of the event and even feel as though they are reliving it, requiring continuous care and treatment. “It’s kind of like peeling an onion,” Sonsiadek said. “As soon as they feel like they’ve gotten to a good place, they find another layer to themselves that’s been injured that they weren’t aware of.”
Sonsiadek wants support systems, and communities in general, to understand the enormous amount of bravery and strength it takes to come forward to disclose a sexual assault. “I am continuously in awe of the strength that I get to witness on a regular daily basis working with patients who have had this kind of experience and are trusting me with that information after what they’ve experienced,” she said. “It doesn’t make sense that they’d trust anyone. That is what motivates me to continue in this line of work.”
Most importantly, Sonsiadek wants to remind survivors and their loved ones that they are not alone and they are not the first to need answers or support. Saint Luke’s works with a variety of rape crisis centers that can provide education and resources for survivors and their loved ones. “This is what they do, this is their work, this is their life’s mission,” she said. “They can help guide folks through the process and let them know what’s available.”
Crisis center partners of Saint Luke’s include the Metropolitan Organization to Counter Sexual Assault (MOCSA), Green Hills Womens Shelter, and Hope Unlimited. For those outside Missouri, Saint Luke’s recommends contacting the National Sexual Assault Hotline (1.800.656.4673) or RAINN for information, support, and local resources.