Forensic Nurse Examiners versus Doctors for the Forensic Examination of Rape and Sexual Assault Complainants: A Systematic Review

Sexual assault nurse examiners (SANE) or Forensic nurse examiners (FNE) are fully qualified nurses, trained to gather forensic evidence in rape and sexual assault cases. This review compares the reliability and efficacy of FNE/SANE health professionals with that of doctors. FNE/SANE provides cheaper services and better clinical care. However, more research is needed, as the evidence base is weak. Treatment by forensic nurses results in better outcomes than treatment by doctors in a number of cases. Complainants receive better medical care: they are more likely to have a forensic examination (rape kit) and to have it documented, and they are more likely to receive STI and pregnancy prophylaxis than those in the non‐SANE group. More rape kits in the SANE group were admissible as evidence in court from complainants handled by forensic nurses than doctors. However, no difference was found in conviction or prosecution rates. There was no data available on the complainant quality of life. Sexual assault nurse examiners are less expensive than their doctor counterparts. Abstract BACKGROUND Within the UK, the complainants of rape and sexual assault are typically referred to regional sexual assault referral centres (SARCs) where their medical and psychological needs are addressed and, if they consent, a forensic medical examination will be conducted, usually by a forensic physician. In the USA, this service is typically nurse‐led. OBJECTIVES To compare the reliability and efficacy of Sexual Assault Nurse Examiners (SANEs)/Forensic Nurse Examiners (FNEs) with that of non‐SANE health professionals in the conduct of the forensic medical examination and the collection of forensic evidence (rape kit) from the complainants of rape and sexual assault. The following outcomes are used to quantify the efficacy of the SANEs: complainant quality of life, conviction and prosecution rates, complainant mortality within 30 days, time from complaint to examination, provision of STI, pregnancy and HIV prophylaxis, collection and documentation of rape kits and forensic examination, number of rape kits admissible as evidence, and the average cost per case. SEARCH STRATEGY The following databases were searched: The Cochrane Library, MEDLINE, EMBASE, AMED, CINAHL, PsychInfo, BNI, Health Business Elite, HMIC, Social Policy and Practice, Google Scholar, and the Scientific Citation Index. Relevant studies were selected by two independent reviewers and no restrictions were placed on either the year or language of publication. SELECTION CRITERIA This review included studies comparing outcomes for complainants of rape and/or sexual assault who were treated by a SANE, with those treated by a non‐SANE health professional, irrespective of the study design and the age of the complainants. DATA COLLECTION AND ANALYSIS Two reviewers were involved in the data collection and analysis. Risk ratios (RR) or mean differences (MD) with 95% confidence intervals (95% CI) were calculated with both the random‐effects and fixed‐effects model using RevMan 5.1 software. Where differences were noted between the results, both models have been reported. Where no significant differences have been found, only the results from the random‐effects model are reported (data from both models can be found in Appendix 1). RESULTS A total of eight studies were included in the systematic review, six of which were included in the meta‐analysis. This provided an overall sample size of 2700 complainants; 1223 complainants were examined by a SANE (SANE group) and 1477 were examined by a non‐SANE health professional (non‐SANE group). No data were available on complainant quality of life. Two studies compared the conviction and prosecution rates, with no significant differences found (relative risk (RR) 1.00, 95% confidence interval (CI) 0.64 to 1.55 and RR 1.04, 95% CI 0.73 to 1.48 respectively). Significantly more rape kits in the SANE group were admissible as evidence in court (RR 1.20, 95% CI 1.06 to 1.35). No data were reported for 30‐day mortality or time from complaint to examination. In terms of clinical care, complainants in the SANE group were significantly more likely to have received STI and pregnancy prophylaxis than those in the non‐SANE group (RR 1.07, 95% CI 1.01 to 1.13 and RR 1.32, 95% CI 1.19 to 1.46 respectively). No significant differences were found regarding the provision of HIV prophylaxis (RR 1.29, 95% CI 0.87 to 1.89). Using a fixed‐effects model, complainants in the SANE group were significantly more likely both to have a forensic examination (rape kit) and to have it documented (RR 3.94, 95% CI 3.21 to 4.84 and RR 3.21, 95% CI 2.71 to 3.80 respectively). However, the results were not significant with a random‐effects meta‐analysis (RR 2.79, 95% CI 0.21 to 36.38 and RR 2.28, 95% CI 0.65 to 8.01). In terms of cost, the SANEs were found, on average, to be £68 cheaper per case than their physician counterparts. Confidence interval data were not available for this outcome and it is not clear if this difference is significant. AUTHORS' CONCLUSIONS While there does not appear to be any benefit gained in terms of prosecution and conviction by substituting forensic doctors with forensic nurse examiners (FNEs), the FNEs do seem to be statistically significantly better in the provision of clinical care and are able to provide a cheaper service than that led by physicians. However, due to the limited data available to this review, it should be borne in mind that the evidence base for these conclusions is very weak, and, without further research, should not necessarily be used to form the basis for any significant services changes.