Estimates suggest that 20% of displaced and migrating women have experienced some form of sexual violence. This overall prevalence speaks to the historical and collective effects of conflict and forced migration and suggests urgent action is needed to support the needs of survivors, particularly in communities of refuge.
A sexual assault nurse exam is a specialized forensic exam that survivors can access following a sexual assault or intimate partner violence. The exam is conducted by a forensic nurse, or sexual assault nurse examiner (SANE), with specialized training in identifying and addressing the medical needs of the individual who experienced sexual violence. The exam is grounded in a trauma-informed approach to forensic interviewing and procedures. It has the potential to mitigate the health impacts of trauma in the short and long term by addressing immediate medical needs and establishing and enhancing supportive and protective resource networks for survivors. However, the experience of the exam can feel complex and intense for survivors.
The overarching goal of SANE services is establishing a balance between a systematic and comprehensive health assessment, and honoring and supporting the agency, dignity, and cultural/linguistic traditions of the patient. Establishing this balance is particularly critical at the intersection of sexual and reproductive health services and migration status. The reality is that a sensitive, specialized exam has the potential to be significantly re-traumatizing, and the purpose, structure, and activities within those exams may breach cultural sensitivities.
The joint medical and legal underpinning of the forensic exam necessitates a detailed and procedural focus, which can be experienced as invasive by the patient. Forensic exams are conducted in the immediate timeframe following sexual assault or intimate partner violence, typically within hours or days. This compressed timeframe means that the individual is navigating a new and exhausting health care encounter while also experiencing the acute effects of the trauma. Law enforcement may be involved, if an individual desires to report the assault, which for some may add an additional source of stress or fear. Ultimately, the convergence of these medical and legal factors alongside the identities, histories, and collective experiences of migration can amplify the intensity of the SANE exam.
Increasingly health equity and social determinants of health guide how systems develop and implement health services. This evolution of approach is due to a recognition that the program may not be accessible for everyone, therefore, there is a need to tailor programs in culturally responsive and sustaining ways. There are significant gaps in how specialized services are targeted to meet the needs of diverse communities of patients. These challenges include supporting community awareness of the service, willingness to access the service, the reputation of the service, and perceived cost-benefit.
One SANE describes: “It seems logical to assume that people with refugee status experience, at minimum, the average population-level prevalence of sexual violence. And if this is the case, these individuals have historically been underrepresented in our programs.”
Harborview SANE Program in Washington State
The Harborview Abuse and Trauma Center and the University of Washington Medical Center SANE program have acknowledged and responded to these gaps by bolstering the supports that surround the SANE exam in ways that are specific to refugee, immigrant, and migrant communities. Fundamental to this work was an acknowledgment that the technical forensic procedures and activities involved in the SANE exam itself do not change because of the ethnoracial or cultural background of the survivor. A SANE exam can be a SANE exam AND be culturally responsive and culturally sustaining.
Harborview created the following road map:
☑️ Cultural Consultation
The Harborview SANE program incorporated cultural consultation by walking through the steps of the forensic exam with partners who were trusted linguistically and culturally concordant community experts. Discussions focused on informed consent procedures, the terminology used throughout the exam, medications offered and the mechanisms of action of those medications, the patient experience through the flow of the clinical space, and resources to ensure a supported discharge.
☑️ Provider Partnerships
Disclosures of sexual assault, intimate partner violence, or strangulation (all of which may be the potential focus of a forensic exam depending on program scope) may more commonly occur within existing, trusted client-service provider relationships where access to forensic services is limited or does not exist. The Harborview Abuse and Trauma Center partners with refugee organizations to help identify sexual survivor needs and facilitate referral processes between agencies. The strength of provider partnerships is grounded in the program’s collaborations in the community and the education and support the program does around SANE work and providing sexual assault prevention and trauma counseling.
☑️ Interpreter Development
The Harborview SANE program uses two primary interpreter resources during SANE exams – a standard language line or an in-person interpreter response coordinated through the Community House Calls (CHC) program within Harborview Medical Center’s Interpreter Services Department. The choice between the types of interpreter resources is always discussed with the patient with an emphasis on potential concerns for confidentiality. The SANE program advocates for interpreter services facilitated through CHC because of the extensive navigation resources offered by the organization that remain available following the completion of the exam and hospital discharge.
As a result of these changes, Harborview has established culturally responsive SANE care as a standard of practice. The program attributes this to the impact of the Interpreter Services and Community House Calls initiatives. At the same time the program acknowledges that the work is not yet complete.