Something Was Wrong

S25 Ep12: Trauma-Informed SANE Exams with Kayla Hartman, MSN, RN, FNP-BC, NYSAFE

March 3, 2026

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  • Sexual Assault Nurse Examiners (SANEs) are nurses with specialized training in forensics and trauma-informed care who serve survivors of various forms of violence, not just sexual assault. 
  • Trauma-informed care in SANE exams is built on six principles: safety, trustworthiness/transparency, peer support, collaboration/mutuality, empowerment/voice/choice, and cultural/historical/gender awareness, all aimed at restoring patient autonomy. 
  • A rape kit is entirely optional, requires both consent and assent, and while evidence collection is most successful within 96 hours, survivors should still seek care even if they have showered or waited longer. 

Segments

Defining the SANE Role
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(00:02:06)
  • Key Takeaway: SANE nurses are nurses first, specializing in forensics and trauma-informed care through rigorous training like the 40-hour course from the International Association of Forensic Nurses (IAFN).
  • Summary: Sexual Assault Nurse Examiners (SANEs) are nurses who have undergone specialized training covering trauma-informed care and forensic medicine. This training, which includes didactic and clinical portions, prepares them to serve survivors of sexual assault, domestic violence, human trafficking, elder abuse, and physical assaults. Kayla Hartman’s training involved a 40-hour course through the IAFN and subsequent on-call clinical practice.
Motivation for Forensic Nursing
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(00:04:01)
  • Key Takeaway: The motivation for becoming a SANE nurse often stems from a desire to intervene proactively and help victims transition mentally into survivors.
  • Summary: Kayla Hartman was inspired to pursue SANE training due to personal connections with survivors of gender-based violence, wishing for an intervention that could set them on a better path. She views the role as aligning her passions and skills to provide essential companionship and support. Her initial nursing goal was the ICU, but she found the SANE training after starting on a pulmonary intensive care unit step-down unit.
SANE Training and Legal Content
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(00:06:42)
  • Key Takeaway: SANE training covers trauma-informed care, the legal history of sexual assault, anatomy, STDs, and legal advocacy.
  • Summary: Becoming a SANE nurse requires didactic education covering trauma-informed care and the legal context of sexual assault, with specific licensing applying to the nurse’s state, such as New York. The curriculum also includes content on variations in anatomy and physiology, violence prevention, and relevant medications. This specialized education ensures comprehensive care beyond standard nursing practice.
Principles of Trauma-Informed Care
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(00:07:43)
  • Key Takeaway: Trauma-informed care mandates safety, transparency, peer support via advocates, collaboration based on patient goals, empowerment through choice, and awareness of cultural/historical issues.
  • Summary: The six principles of trauma-informed care guide all interactions, starting with ensuring physical and environmental safety. Building rapport through trustworthiness and transparency is crucial for obtaining sensitive disclosures, often supported by crime victims advocates who provide long-term navigation assistance. Collaboration means aligning the nurse’s actions with the patient’s stated goals, whether that includes evidence collection or just medical assessment.
Availability of SANE Programs
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(00:11:01)
  • Key Takeaway: SANE programs are not universally available across the U.S., though New York State mandates 24/7 availability, leading to care delays in underserved rural areas.
  • Summary: SANE programs are unfortunately not present in every hospital nationwide, particularly in rural settings, which can force survivors to travel, causing anxiety and delays in care. New York State recently passed a law requiring all hospitals to have SANE nurses available 24/7, indicating a push for expansion in that region. Travel difficulties can present significant barriers to accessing necessary forensic examination services.
Emergency Department Protocol
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(00:12:09)
  • Key Takeaway: Medical stability always takes priority over forensic evidence collection, and survivors are immediately moved to a private, safe space away from the general waiting area.
  • Summary: Upon arrival at the ED, a triage nurse assesses priority, and survivors are directed to a designated safe space to avoid public exposure, which is a trauma-informed practice. If the patient is medically unstable due to injuries like head trauma, medical intervention supersedes paging the forensic examiner. Once stable, the SANE nurse and advocate arrive, typically within one hour, to ascertain the patient’s goals for the hospital visit.
Reporting and Evidence Collection
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(00:14:37)
  • Key Takeaway: Survivors are never required to report to police to receive medical care, and the rape kit is entirely optional, requiring explicit consent and assent.
  • Summary: Medical care is provided regardless of whether a survivor chooses to make a police report, though mandated reporters must contact specific agencies to ensure future safety. The rape kit is completely optional, and no one can be forced to undergo it; assent (voluntary agreement from someone unable to give legal permission) is required alongside consent. Assent is crucial, especially for minors or incapacitated individuals, and it ultimately dictates willingness to participate.
Rape Kit Components Explained
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(00:17:48)
  • Key Takeaway: A rape kit involves a head-to-toe assessment using labeled envelopes to collect various optional evidence, including saliva, touch evidence, semen, hair, and trace debris like fibers or gravel.
  • Summary: The rape kit is a set of materials used for a head-to-toe assessment to collect evidence, with the New York State kit having about 15 optional steps. Evidence collection involves swabbing areas like the lips, breasts, and inner thighs, as well as collecting physical items like clothing or items brought by the survivor, such as a beer bottle. Evidence supports establishing time and place of the assault, and while 96 hours offers the highest success rate, exams are still valuable outside that window.
Medical Treatments Accompanying Exam
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(00:24:57)
  • Key Takeaway: STI testing, prophylactic antibiotics, HIV post-exposure prophylaxis (PEP) for one month, pregnancy prophylaxis, and hepatitis prophylaxis are often offered alongside the forensic exam.
  • Summary: STI testing is generally performed, and prophylactic treatments are offered to prevent infection following potential exposure. This includes antibiotics administered at the hospital and HIV PEP, a medication regimen taken over a month. The SANE nurse also checks candidacy for various treatments and offers prophylaxis against conditions like hepatitis.
Observing Trauma Responses
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(00:25:50)
  • Key Takeaway: There is no ‘correct’ reaction to trauma or the examination, as responses vary widely, including crying, laughing, anger, or a flat affect, encompassing fight, flight, freeze, and fawn responses.
  • Summary: Trauma responses during the examination are highly individualized, requiring the nurse to ‘read the room’ and remain non-reactive to the survivor’s display. The classic responses are fight, flight, and freeze, with ‘fawn’ (appeasement) now also recognized as a common reaction. Survivors should be reassured that there is no right or wrong way to react to the trauma or the examination process itself.
Barriers to Seeking Care
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(00:27:02)
  • Key Takeaway: Denial, fear of the unknown hospital experience, and historical medical mistreatment, especially among marginalized groups, are significant barriers preventing survivors from seeking care.
  • Summary: Denial is a major barrier as acknowledging the event makes it real, and fear of the unknown examination process is also significant. Survivors from marginalized communities, including the LGBT community, people with disabilities, and people of color, face additional barriers due to historical inequitable treatment in healthcare. This fear of how they will be treated can be daunting enough to prevent seeking care for any injury or illness.
SANE Nurse Advocacy with Police
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(00:28:16)
  • Key Takeaway: SANE nurses advocate for survivors during police interviews, interrupting victim-blaming questions, but separate documentation like charting and photographs requires a specific subpoena.
  • Summary: SANEs maintain a collaborative approach with law enforcement and can be present during police interviews to act as advocates. If inappropriate or victim-blaming questions arise, the nurse will intervene to request reframing to protect the survivor. While the collected rape kit evidence is handed over if a report is filed, other documentation created by the nurse, such as photographs or charting notes, requires a separate subpoena for law enforcement access.
Supporting Loved Ones During Exam
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(00:29:41)
  • Key Takeaway: Support persons should actively listen, advocate for the survivor’s stated goals, and absorb information, avoiding attempts to dictate the path taken.
  • Summary: Support persons should focus on actively listening and advocating for the survivor’s specific goals for the hospital visit, rather than imposing their own motivations or feelings. They should avoid pressuring the survivor into any specific action, such as pursuing evidence collection if the survivor declines. Being present as an extra set of ears is helpful because survivors under high stress may not absorb all the information provided by the medical team.
Essential Skills for SANE Nurses
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(00:31:14)
  • Key Takeaway: Key skills for SANE nurses include remaining non-judgmental, actively listening, separating personal bias, and being willing to intervene and advocate when necessary.
  • Summary: A crucial skill for forensic nurses is maintaining a non-judgmental stance while standing up for the patient when situations become difficult or heated. Nurses must commit to separating personal bias from their work, recognizing the patient as the expert of their own experience. It is important to remain empathetic, acknowledge shocking disclosures without becoming overly reactive, and be humble enough to admit when unsure how to respond.
Public Understanding of Exams
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(00:36:38)
  • Key Takeaway: The public should understand that SANE exams aim to be warm and collaborative, focused on empowering the patient by offering choices to counteract the loss of autonomy experienced during the assault.
  • Summary: The examination process strives to be warm and comfortable, countering the public assumption that it is cold and clinical. The nurse’s role is to guide the patient through choices to restore a sense of control, which was taken away during the assault. Understanding one’s rights and what to expect helps break down barriers and builds confidence when entering a vulnerable medical situation.
Testifying in Court
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(00:38:48)
  • Key Takeaway: SANE nurses may testify in court regarding the forensic exam process, evidence collected, and interpreting injuries for consistency with reported history, though most cases do not proceed to trial.
  • Summary: The SANE nurse is responsible for testifying if questioned by the prosecutor or defense about the forensic exam procedure or the evidence collected. Testimony can involve explaining why certain evidence was or was not collected, or interpreting lab results and injuries for consistency with the survivor’s history. The nurse notes that a small proportion of survivors proceed through the entire legal process, which can be time-consuming and traumatizing.
Cost of Forensic Exams in NY
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(00:40:16)
  • Key Takeaway: In New York State, if the survivor consents, the Office of Victim Services covers the cost of the rape kit and related relevant hospital expenses, making it free to the survivor.
  • Summary: In New York State, the Office of Victim Services provides forensic reimbursement for all rape kits, provided the patient signs consent for the state to be billed. This coverage extends to relevant hospital expenses associated with the forensic visit. Follow-up outpatient medications or visits may involve more complexity, but the initial exam is free under this state provision.
Follow-up Care Recommendations
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(00:41:29)
  • Key Takeaway: Follow-up care includes repeat STI testing at three, six, and nine months, and connecting with a trauma-informed counselor, which SANE programs can often facilitate referrals for.
  • Summary: It is recommended that survivors follow up with their primary care provider after the hospital visit. SANE nurses counsel patients to undergo repeat STI testing at three, six, and nine-month intervals. Connecting with a trauma-informed counselor is highly encouraged, and many SANE programs have systems in place to immediately place referrals for this ongoing support.
Survivor Rights and Autonomy
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(00:43:20)
  • Key Takeaway: Survivors retain the right to autonomy, including the ability to ask for a new examiner if they experience subtle negative changes or feel uncomfortable with the provider.
  • Summary: Survivors always have the right to request a different examiner if they feel uncomfortable or perceive bias, such as racism, from the provider. Examiners must remain humble, acknowledge their privilege, and promote a collaborative environment to prevent such barriers. The overarching goal is to give choice back to the survivor, even in the smallest moments of the examination process.
Exam Nuances for Male Survivors
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(00:44:56)
  • Key Takeaway: Forensic exams are handled on an individual basis regardless of anatomy or gender presentation, and the SANE nurse’s role is to explain available evidence collection options clearly.
  • Summary: There are no specific restrictions on the type of evidence collected based on a person’s anatomy or gender presentation during a forensic exam. The challenge often lies in ensuring survivors of varying anatomies fully understand the services and evidence collection options available to them. It is the SANE nurse’s responsibility to collaborate closely and ensure they are collecting evidence in a manner that respects the individual survivor’s needs.
Duration and Delays in Exams
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(00:45:53)
  • Key Takeaway: The evidence collection itself is quick, but the overall process is time-consuming due to necessary history taking, medical prioritization, breaks, and arranging safe discharge plans.
  • Summary: While the physical evidence collection portion of the exam can be completed quickly, the entire process often takes an extended time due to hospital logistics. Medical needs, such as head injury assessment or waiting for blood work, always take precedence over forensic procedures. Time is also dedicated to organizing evidence collection based on history, taking necessary breaks, and coordinating complex discharge plans, including childcare or safe housing.
Provider Self-Care
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(00:47:56)
  • Key Takeaway: SANE nurses manage the emotional weight of the work by finding it both energizing and exhausting, relying on peer support, personal coping mechanisms like yoga, and recognizing the privilege of walking with survivors.
  • Summary: The work is emotionally demanding, leading to potential burnout if peer support is lacking, which is why having a strong team to process cases is vital. Self-care for the provider includes leaning on colleagues and engaging in personal activities like hot yoga or watching trash TV. Despite the difficulty, providers find the work energizing when they successfully align with a survivor’s goals and see a moment of relief.