Written by Dr. Catherine
ALTHOUGH MANY MEN AND WOMEN are sexually assaulted every day, only a small minority will
report their assault to police. As few as 5–10% report in Canada, according to repeated
Canadian General Social Survey studies1,2, and approximately 15–35%
are reported in the United States3. Given that the offender is most often
a friend or acquaintance in the community1, the limited reporting
reduces the likelihood of police awareness, investigation, evidence collection,
and (ultimately) apprehension of the individual.
Collaboration between law enforcement
and health care, however, has potential to significantly change these data.
People are three times more likely to seek health care than to report to police
after the assault2. Studies have shown that when comprehensive
sexual assault health care is provided, such as with sexual assault nurse
examiners (SANEs), the rates of police involvement increase4.
Furthermore, with SANE care, the quality of evidence collection is improved5,
as are rates of successful prosecution6.
Early comprehensive care also reduces
the considerable risks of post-traumatic stress (PTSD) faced by victims of
sexual assault7. If victims develop PTSD, they are at risk of many
other health consequences—including substance abuse, suicide, and of a repeat
sexual assault—all of which further impact police workload and investigations.
The provision of comprehensive sexual
assault services is more difficult in rural and remote areas, however. It is
well recognized that people in many rural and remote communities do not receive
the same level of services after sexual assault as those in urban centers8,9.
This occurs for many reasons, including limited personnel to conduct exams and
provide support, difficulties with transportation, and staff unfamiliarity with
components of comprehensive sexual assault services, especially when they
provide this care infrequently.
The sexual assault care in rural areas,
if provided, is typically provided by the physician. Rural areas often only
have one physician on duty, and it is difficult for them to free up sufficient
time to provide comprehensive care and evidence collection. The result is that
many smaller communities delay patients for hours until the physician is free—or
refuse to conduct a sexual assault examination at all—and potential evidence is
The purpose of this paper is to review gaps
in knowledge and comfort among professionals providing sexual assault services
in rural areas, and to present a uniquely rural solution that has been
implemented and evaluated in a number of Canadian communities. Improved rural
sexual assault services and multidisciplinary collaboration can improve the
likelihood of client reporting, evidence preservation and collection, and of
the client remaining engaged with the legal process.
Learning the Needs of Rural ProfessionalsThe author conducted a number of
consultations, studies, and quality-assurance activities in order to identify
issues for rural and remote communities. Focus groups were held with police,
counselors/advocates, and health professionals in five rural and remote
communities in one western Canadian province10. The participants all
described concern about damaging evidence, lack of familiarity with sexual
assault kit contents and collection procedures, legal issues surrounding
reporting and chain of custody of evidence, and the lack of personnel to
provide the lengthy examination and evidence collection—especially when they
did it so infrequently in areas with sparse populations.
On the other hand, they described a
desire to improve services and a conviction that clients should remain in the
rural communities for services rather than being transported out, as
professionals knew their cultural and community support resources better than
In 2012, quantitative surveys were also
sent out to all health-care centers, sexual-assault counseling centers, and
police detachments in the southern half of the province. There were 78
respondents to the survey, over half of which were nurses or physicians,
approximately 30% police officers, and a small number of counselors. They were
asked to rate their knowledge on a five-point Likert scale for various aspects
of comprehensive care, derived predominantly from the U.S. national protocols11,
as well as standards of practices for SANE teams. These protocols highlighted
the services that urban centers with SANEs would receive, so rural communities
should also implement similar services. The responses to key aspects of the
survey are shown in Table 1 and Table 2.
Additional consultations were held in
two eastern provinces with sexual-assault counseling groups, health
ministries, hospital staff, and police departments. The surveys distributed in
2012 were then used as a pre-test and post-test for subsequent training and
quality assurance. The combination of these consultations and quality-assurance
surveys were consistent with the 2012 quantitative surveys and focus-group
Communities in the focus groups,
surveys, and provincial consultations also identified an inability to implement
the SANE model in some of the communities due to factors such as financial
restrictions providing additional specialized staff, staff turnover, and
difficulties providing enough cases in small areas for SANEs to develop or
maintain their advanced skills (e.g. gynecological examinations). One of these
provinces stated they received only seven cases a year—not a sufficient
frequency for training and maintenance of new skills, and not enough to justify
the hiring and training of specialists.
Some of the common themes identified
between surveys and consultations included knowledge gaps in the following
areas that may affect reporting, investigation, or quality of the physical or
investigative evidence: assault myths and realities, comprehensive sexual
assault services, evidence preservation and collection, trauma informed
concepts, and witness testimony misconceptions.
Assault Myths and RealitiesThe prevailing perception in the
public, which includes police and health professionals, is that sexual assaults
are committed by strangers or intimate partners. Most of our data on assailants
is from those in jail, such as stranger assailants, which were the basis for
the FBI typologies of assailants and typically involve a high degree of force
and injury12. Injury is more common in stranger assaults and in
intimate partner assaults13, but these are the minority. The
majority of sexual assaults are committed by someone known to the victim, most
as friends or recent acquaintances1. Injuries are less common in
these assaults14, and the dynamics are different, which may impact
There is a blurry line between sexual
assaults by someone just met at a bar and dating violence—and, as a result, many
victims will not call it sexual assault. Young adults, typically women, have
often denied it as an assault, saying “it was my fault; I got drunk.” College-aged
men and particularly women are especially at risk due to their high-risk age
group (15-24 years of age), but also the circumstances of campus life may
increase their vulnerability or assailant’s access.
There is some consistency in findings
that a small number of college-aged men are at risk for offending (< 25%)
but as many as 10% are repeat perpetrators of sexual assaults. Lisak and Miller
(2002) termed these men “undetected serial rapists” as they were often seen as
good students and leaders, but they were found responsible for many other forms
of assault as well, including child abuse and intimate-partner violence. These
men typically have hostile attitudes toward women, are in masculine positions
or roles, and see sex as their “right”, but are often seen as “nice young men”
in the community15,16. Interviews with these men have revealed a grooming
type of behavior, in which they seek out women who are vulnerable, often due
to alcohol, offer them more alcohol and interact with them; separate them from
friends, such as offering a ride home; and then gain access to assault them17. This behavior is then used against the victim, as they may
be seen as “willing” due to their earlier interactions with the perpetrator. This
offender typology is important to the investigation and there may be a history
of prior episodes of interaction with other women in the assailant’s past. The
victim may have very few injuries and blame herself for the assault as it began
voluntarily when he approached her.
Another myth held by some of the
professionals was that a male could not really be sexually assaulted, and yet
it happens to many more men than often realized. While women are usually
assaulted by men, those who assault men can be either male or female1.
Trauma-Informed ConceptsSome of the client’s behavior may be
misleading or misinterpreted, such a lack of eye contact or not speaking with
the investigator when asked about the details. This can be interpreted as guilt
or lack of compliance. Consultations and the survey data indicated that professionals
had limited understanding of the trauma effects on behavior such as tonic
immobility, dissociation, difficulty with speech when stressed, and the impact
of stress on memory. Key principles of trauma-informed care include realization
of the impact of stress, recognition of symptoms, responding appropriately to
disclosures, and resisting revictimization18.
Realization includes awareness of the
magnitude of physical and mental health consequences of sexual assault—particularly
the physiologic impact of stress on the brain and body, as well as the risks of
eventually developing post-traumatic stress disorder (PTSD). The rates of PTSD
after sexual assault are extremely high19. Acute responses to stress
may include dissociation (e.g. gazing into space) when asked specifics about
the assault, gaps in memory, or inability to describe the order of events. The
chemicals released in stress to allow flight, fight, or freeze responses
(cortisol, adrenaline, noradrenaline) also affect the same areas of the brain
that create and store memories.
Recognition of stress responses is
important when interviewing a client, especially if the professional is aware
of the impact. For instance, if they dissociate during the interview, this is
an indicator of stress and the interview should be stopped and the client given
the choice when to resume. If stressed, they may also have difficulties
providing a correct chronology of events such with a backwards/forwards style
of interview; they may inadvertently fill in the gaps of memory with what they
would usually have done. When they are less stressed, the order and details of
the events may return. If they were significantly impaired prior to or at the
time of the assault, however, the memories may not have been encoded or
consolidated20. Memories, if encoded at the time, may be
consolidated and recovered more reliably once the client has had sleep21
and is less stressed. As a result, some number of police departments choose to
only meet the client in the emergency department to introduce themselves and
secure any evidence that may disappear (e.g. videos, evidence kits), and
postpone their interview to a few days later when the client is rested.
The response of professionals to the
client’s disclosure is important to both the quality of the interview and the
subsequent risk of victimization. Positive responses to disclosure from formal
or informal contacts are a key factor in resiliency to the trauma22.
Trauma-informed care emphasizes empowering the client to make their own choices
where possible, such as whether or not to report the assault or have evidence
collected. It is also important to recognize when clients are stressed and
intervene appropriately to reduce their stress. If someone stops talking, it
may be due to dissociation; they can be talking to the officer freely, but when
asked about specific details they may suddenly be staring off into space and
not be “present”. They could also lose speech abilities as stress may decrease
blood flow to speech centers as well as the area responsible for episodic
memory23. Another sign of a stress disorder is hypervigilance or
exaggerated startle responses. These are all indicators that the client is
stressed, and the interview should be paused until they are ready to resume.
The fourth principle is resisting retraumatization.
The impact of the trauma can be made worse by reactions from police and health
professionals24 such as disbelief, having to describe the trauma too
many times or when not ready, delays in receiving services, pushing them
through the procedures, or questioning them in a way that may result in shame,
guilt, or self-blame. All of these reactions are linked to the increased
likelihood of PTSD after sexual assault25. In turn, those with PTSD
are more at risk of being re-assaulted26,27.
As noted, positive support to
disclosure improves client resilience, which may increase the likelihood that
they remain engaged in the investigation and legal process. Police, counseling
and health care need to collaborate to support clients throughout the acute
services response. If efforts have been made to reduce stressors and the client
is still struggling, proceeding with the exam and evidence collection may
result in greater stress. In some instances, the health-care staff or
counselor/advocate may suggest that the client leave without further
intervention to reduce worsening their trauma.
Assessment and Injury IdentificationProfessionals indicated moderate to low
knowledge about injury identification and implications, especially genital injuries.
This is a concern, since the presence of injuries increases the likelihood that
the legal system will trigger charges and prosecution28. This is of
concern, particularly since many women may have no injuries after sexual
assault, especially if they were intoxicated or unconscious and not resisting
as a result13.
In the same systematic review, it was
noted that there was wide variability in injury rates based on techniques and
whether or not the injuries were from an exam or self-report to police, as well
as inconsistency in terminology used to describe injuries. This could lead to
misinterpretations of mechanisms of injury and affect the investigation or
evidence collected. For instance, emergency-department staff often call any open
injury a laceration, when in fact a laceration is from blunt trauma and
has specific characteristics, and a penetrating injury is from sharp objects
and is quite distinctive. Similarly, a bruise is from application of blunt
forces to the skin with resulting rupture of blood vessels and leakage of the
blood into surrounding tissues. Many people use the term ecchymosis
instead of bruise, but it is not a trauma finding. In fact, ecchymosis
is also the spread of blood through tissue fascia, but it occurs by gravity
(e.g. below a bruise or under eyes after a skull fracture) or from leakage of
blood though thinning vessel walls (e.g. senile ecchymosis on the arms) or with
blood disorders. An expert reading that ecchymosis and lacerations were found
would need to be confident that the former was not a trauma finding and that
the latter was a blunt injury.
Standardization of terminology is
therefore crucial to evidence. A guide to physical findings was developed by
the author to encourage professionals to use common terms and definitions for
injury called the BALD STEP guide29 as shown in Figure 1. The
abbreviations with each term can also be used to save space on the body diagram
and give a comprehensive visual representation. This is especially important in
Canada, where genital photographs are not allowed in court and where body
photographs may or may not be available, depending on the availability of
police identification personnel. The BALD STEP guide is now a part of the
national sexual assault evidence kit used by the RCMP in Canada and has been
added to the core curriculum for forensic nursing30. An
understanding of these terms, implications of presence or absence of the
injuries, and use of adjuncts like toluidine dye or palpation in the
examination are also important for police as well as health-care providers to
understand implications of injury.
Evidence Preservation and CollectionA pervasive concern in all communities,
interviews, and surveys was the professionals’ fear of potentially missing or
damaging evidence and adversely impacting the police investigation. Respondents
to the 2012 survey were unsure what types of evidence had to be collected, how
to collect it, and how to preserve it until given to the police. They were
unfamiliar with evidence options such as submitting anonymous kits to the
police if the client did not want to report, or a “third option” in which they
stored the evidence at the hospital. These options varied by region and police
The national police sexual assault
evidence kit was outdated and not revised until 2015, so respondents were
continuing to use outdated procedures like plucking hair and blood for DNA
reference samples. They relied upon reading the kit instructions as they
progressed through a case and would collect all samples regardless of the time
since the assault. For instance, they would still collect an oral sample even
though three days had passed since the assault. Conversely, tradition kept most
of them to an examination within three days of the assault and someone coming
in four days later would not be examined even though there was potential for DNA
if a vaginal-cervical swab was obtained.
Police had concerns mainly about chain
of custody, and some falsely believed they needed to be in the room during
evidence collection. In fact, in Canadian jurisdictions, police should not be
in the room to hear the client’s health history or findings, as this is a
violation of health information privacy acts. A basic understanding of the
likelihood of evidence being obtained from various parts of the body was
needed, as well as principles of evidence collection, preservation, and chain
of custody. An understanding of chain of custody is thus needed for all, being
able to account for all who have contact with the evidence, documenting it, and
not leaving kits unattended until transferred or secured.
A common question was allowing of food
or drink at triage in the emergency department, or allowing clients to urinate.
These activities could result in a loss of evidence, but not universally. Food
or drink is allowed if there are no medical reasons for abstinence, but if
there was penile-oral penetration in the last 24 hours, then an oral swab along
the gumlines is recommended—ideally a double swab. Many clients have had
something to drink prior to the assault and may not be able to wait to urinate
until after the physical examination. There may be fluid drainage in the
genital region and wiping may result in the loss of some evidence. Being forced
to wait creates further stress and revictimizes. One suggestion is to get them
to urinate but avoid wiping themselves. Alternatively, they could wipe but save
the tissues in a paper bag for the evidence kit. A urine specimen collection is
also recommended in case a toxicology sample is required for suspected drug-facilitated
Comprehensive Multidisciplinary Sexual
Assault ServicesThe use of multidisciplinary services
has been shown to improve collaborative relationships and improve quality of
care31 as well as evidence collection25. In order to
collaborate effectively, professionals need an understanding of each others’
roles in sexual assault services. The surveys and interviews both demonstrated
limited understanding between the professions involved in services. One example
was the differences between a police officer’s history of the assault (for
investigation and truth-finding) and the health professional’s history (for
risks of physical or mental-health consequences from assault).
In addition to health-care concerns
about evidence collection, examination procedures, and lack of staff, other
first responders also had concerns. Social workers were not sure what took
place during an examination, so they were less able to prepare the clients for
the health care. Police were concerned about maintaining chain of custody for
evidence, lack of familiarity with the evidence kit contents, and the
examination process. There was also a general need for information on
trauma-informed care and the impact of sexual assault on victims that may affect
their responses in interviews.
Witness TestimonyThere was also a general concern about
court involvement, particularly from health professionals. Survey and
consultation respondents worried that if they even talked to the client they
would be subpoenaed to court. There was also a concern about the long waits if
called to court, which further limited the availability of staff in the rural
areas. They were not aware that their avoidance of the client could actually
worsen their risk of trauma and reduce the client’s involvement in health care
or legal processes.
There was also limited understanding of
the differences between a fact witness and an expert witness. When prosecutors
were involved in the consultations, some suggested that they may be able to
potentially enter the health-care documentation as fact evidence, as it
included what was seen and done. In this way, front-line staff would not be
brought to court. The prosecutors would then identify an expert in sexual-assault
care to come to court to interpret their documentation and findings. This again
emphasizes the need for collaboration so that all professionals understand the
significance of presence or absence of findings and the processes in sexual-assault
A Rural Solution: Enhanced Emergency
Sexual Assault Services (EESAS)The results of these surveys and
consultations highlighted a need for something uniquely suited to rural
communities. The result was the development of a four-hour multidisciplinary
program called “Enhanced Emergency Sexual Assault Services” or EESAS
(“eeee-sas”). The program includes eight 30-minute modules designed for front-line
providers, including nurses, physicians, police, social work, and any other
providers involved in direct services to people after recent sexual assault.
The modules (Table 3) provide a
comprehensive overview of all the components of comprehensive services and are
available free online32 or in-person to communities. The provision
of the training to all personnel improves the ability to collectively support
each other through the process and to begin provision of care immediately on
the client’s arrival, rather than waiting for a specialist. Some communities
choose to do all training fully online.
In addition to the core modules, there
is a 45-minute executive-summary video for administrators, a 45-minute refresher
video for annual recertifications, a manual, and a quick-reference checklist
for what procedures are required and by whom. The intent is that all providers
know what the others are doing and can thus support each other in providing
The program is taught from a trauma-informed
perspective with a focus on what is needed within their existing scope of
practice to provide comprehensive supportive services rather than training in
new skills. For instance, the nurse could proceed with the body examination and
evidence collection, then the physician would only have to come in for the
gynecology examination. The police would be familiar with the implications of
findings from a medical perspective, and would be reassured regarding chain of
custody. Further, police would be aware of the impact of the trauma on their
investigation and client behaviors. Social workers would have an enhanced
understanding of the examination and care provided, and be better able to
support both the client and staff.
The community is encouraged to form a
Sexual Assault Response Team (SART) advisory committee (Figure 2). This
group is composed of decision makers in the core professions responding to the
assault (e.g. health care, policing, counseling) to develop supporting
protocols, procedures, and to facilitate multidisciplinary communications. The
community is also encouraged to connect regularly with a SANE or physician in a
nearby community who is familiar with sexual assault to help with quality
assurance, provide support on specific clients if questions arise, and possibly
support continuing education. The front-line providers may be called to court
as fact witnesses, but it is unlikely they will be expert witnesses unless they
see many cases. Instead, the prosecutor may also choose to approach the SANE or
forensic physician to act as an expert witness in court.
A mixed-methods trial of the program in
five western Canadian communities showed significant changes in knowledge,
skills, and comfort with services that were generally maintained up to two
years later33. The model has been adopted province-wide in one maritime
province, and personal communication with the SART advisory group also indicates
increased comfort of all teams with sexual-assault services, including police.
Their number of sexually assaulted clients has increased to health centers,
most likely due to a willingness to now provide services. The Canadian military
has also made the program a requirement for all health personnel and military
police prior to deployment. Post-course surveys and personal feedback both
indicate satisfaction with the content and improved knowledge and comfort
ConclusionEvery rural community is different in
its ability to provide sexual assault services. Some communities may be able to
afford SANE or specialized physician examiners and provide enough experiences
to maintain their skills, but many cannot. The EESAS model was proposed and
evaluated as a successful alternative to provision of SANE services. The SANE,
if available, continues to have a role in supporting the services. All
professionals stay within their scope of expertise and practice and share a
common understanding of the sexual-assault spectrum of services and trauma-informed
care. Collaboration between police, counseling, and health care can result in
improved provision of comprehensive sexual-assault services. The improved and
collaborative services are more likely to lead to police reporting and evidence
collection, improved interview data, and retention of the client in the legal
About the AuthorDr. Cathy Carter-Snell is
a professor in the School of Nursing and Midwifery at Mount Royal University in
Calgary, Canada, and a certified sexual-assault nurse examiner. She is actively
involved in teaching and research related to violence prevention, reduction of
consequences of violence for victims, injury interpretation, and provision of
comprehensive sexual assault and domestic violence services.
References1. Conrad, S., and A. Cotter. 2017.
Self-reported sexual assault in Canada,
2014 (85-002-X). Retrieved from Ottawa: https://www150.statcan.gc.ca/n1/en/pub/85-002-x/2017001/article/14842-eng.pdf?st=A_vL2gsx
2. Johnson, H., S. Canada, and
V. Fellow. 2005. Assessing the prevalence of violence against women in Canada.
Division for the Advancement of Women Expert Group Meeting. https://www.un.org/womenwatch/daw/egm/vaw-stat-2005/docs/expert-papers/johnson.pdf
3. Planty, M., L. Langton, C. Krebs,
M. Berzofsky, and H. Smiley-McDonald. 2013. Female
victims of sexual violence, 1994-2010 (NCJ 240655). https://www.bjs.gov/content/pub/pdf/fvsv9410.pdf
4. Campbell, R., D. Bybee, K. D.
Kelley, E. R. Dworkin, and D. Patterson. 2011. The impact of sexual assault nurse
examiner (SANE) program services on law enforcement investigational practices:
A mediational analysis. Criminal Justice
and Behavior. 39(2):169-184.
5. Sievers, V., S. Murphy, and J.
J. Miller. 2003. Sexual assault evidence collection more accurate when
completed by sexual assault nurse examiners: Colorado's experience. J of Emergency Nursing. 29(6):511-514.
6. Campbell, R., D. Patterson,
and D. Bybee. 2012. Prosecution of adult sexual assault cases: A longitudinal analysis
of the impact of a sexual assault nurse examiner program. Violence Against Women.
7. Dworkin, E., and J. A.
Schumacher. 2018. Preventing posttraumatic stress related to sexual assault
through early intervention: A systematic review. Trauma, Violence & Abuse.
8. Averill, J. B. R., A. O. Padilla,
and P. T. Clements. 2007. Frightened in isolation: Unique considerations for
research of sexual assault and interpersonal violence in rural areas. J of Forensic Nursing. 3(1):42-46.
9. Lamont, W. K. 2006. Sexual assault services in Alberta: A
framework of service delivery for sexual assault survivors living in rural,
remote and Northern communities. Retrieved from Calgary, AB: http://endingviolencecanada.org/wp-content/uploads/2015/04/FINAL_AASAC_Rural_Remote_and_Northern_Service_Delivery_Report.pdf
10. Jakubec, S. L., C. J. Carter-Snell,
J. Ofrim, and J. Skanderup. 2013. Identifying rural sexual assault strengths,
concerns and educational needs in rural and Aboriginal communities Alberta
Canada. Enfermeria Global. 31:427-442.
11. U.S. Department of Justice.
2004. A national protocol for sexual assault
medical forensic examinations (NCJ 206554). https://www.ncjrs.gov/pdffiles1/nij/206554.pdf
12. de Heer, B. 2016. A snapshot
of serial rape: An investigation of criminal sophistication and use of force on
victim injury and severity of the assault. J
of Interpersonal Violence. 31(4):598-619.
13. Carter-Snell, C. J. (2007b).
Understanding women's risks for injury
from sexual assault. (Dissertation/Thesis) http://search.proquest.com/docview/304796345?accountid=1343
14. Carter-Snell, C. (2007a). Understanding women's risks for injury from
sexual assault (abstract). (PhD), University of Alberta, Edmonton, AB.
15. Lisak, D., and P. M. Miller.
2002. Repeat rape and multiple offending among undetected rapists. Violence & Victims. 17(1):73-84.
16. Thompson, M., K. Swartout,
and M. P. Koss. 2013. Trajectories and predictors of sexually aggressive
behaviors during emerging adulthood. Psychology
of Violence. 3(3):247-259. https://doi.org/10.1037/a0030624
17. Lisak, D. 2000. The ‘Undetected’
Rapist. New York: National Judicial Education Program.
18. SAMSHA’s Trauma and Justice
Strategic Initiative. 2014. SAMSHA's
Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville,
MD: Substance Abuse and Mental Health Services Administration (SAMHSA). https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
19. Carter-Snell, C., and S. L.
Jakubec. 2013. Exploring influences on mental health after interpersonal
violence against women. Intl J of Child,
Youth and Family Studies. 4(1):72-99.
20. Weafer, J., D. A. Galllo, and
H. De Wit. 2016. Acute effects of alcohol on encoding and consolidation of
memory for emotional stimuli. J of
Studies on Alcohol and Drugs, 77(1):86-94.
21. Bennion, K. A., K. R. Mickley
Steinmetz, E. A. Kensinger, and J. D. Payne. 2015. Sleep and cortisol interact
to support memory consolidation. Cerebral
Cortex. 25(3):646-657. https://doi.org/10.1093/cercor/bht255
22. Ullman, S. E., and L. C. Peter-Hagene.
2016. Longitudinal relationships of social reactions, PTSD, and revictimization
in sexual assault survivors. J of
Interpersonal Violence. 31(6):1074-1094.
23. Wolf, O. T., P. Atsak, D. J.
de Quervain, B. Roozendaal, and K. Wingenfeld. 2016. Stress and memory: A selective
review on recent developments in the understanding of stress hormone effects on
memory and their clinical relevance. J of
Neuroendocrinology. 28(8). https://doi.org/10.1111/jne.12353
24. Campbell, R., S. M. Wasco, C.
E. Ahrens, T. Sefl, and H. E. Barnes. 2001. Preventing the ‘second rape’: Rape
survivor’s experiences with community service providers. J of Interpersonal Violence.
25. Allen, C. E. 2016. The indirect effect of social support on
PTSD through self-blame in sexual assault survivors and the moderating role of
gender. (10158972), Northern Illinois University, Ann Arbor. ProQuest Dissertations &
Theses Global database.
26. Anderson, J., T. Cremer, C.
Hurt, S. James, R. Warner, and C. O’Sullivan. 2004. Sexual assault revictimization.
WCSAP Research & Advocacy Digest. 6(3).
27. Casey, E. A., and P. S. Nurius.
2005. Trauma exposure and sexual revictimization risk: Comparisons across
single, multiple incident, and multiple perpetrator victimizations. Violence Against Women. 11(4):505-530.
28. Pinciotti, C. M., and A. V.
Seligowski. 2019. The influence of sexual assault resistance on reporting tendencies
and law enforcement response: Findings from the National Crime Victimization
Survey. J of Interpersonal
Violence. 886260519877946. https://doi.org/10.1177/0886260519877946
29. Carter-Snell, C. 2011.
Injury documentation: Using the BALD STEP mnemonic and the RCMP sexual assault
kit. Outlook. 34(1):15-20.
30. Carter-Snell, C., and A. Lewis-O'Connor.
2015. Forensic nursing in the healthcare setting. In B. Price & K. Maguire
(eds.), Core curriculum for forensic
nursing. 41–93. Philadelphia: Wolters Kluwer.
31. Derhammer, F., V. Lucente,
J. F. Reed, 3rd, and M. J. Young. 2000. Using a SANE
interdisciplinary approach to care of sexual assault victims. Joint Commission J on Quality Improvement. 26(8):488-496.
32. Carter-Snell, C. 2015.
Enhanced Emergency Sexual Assault Services (EESAS) Course. http://forensiceducation.ca/courses
33. Carter-Snell, C., S. L. Jakubec,
and B. Hagen. 2019. Collaborating with rural and remote communities to improve sexual
assault services. J of Community Health. 45(2):377-387.