Acceptability of Forensic Sexual Assault Telehealth Consultation

Abstract

Introduction:

Telehealth shows promise in increasing access to specialty care for individuals who experience sexual assault.

Methods:

This study analyzed 466 cases from rural and urban hospitals between September 2018 and March 2024, examining telehealth acceptability rates and reasons for declination. Of 362 eligible cases, 89.5% accepted telehealth consultation. Among those who declined, 65.8% were not given the opportunity to interact with a telehealth sexual assault nurse examiner (teleSANE) during decision-making.

Results:

These findings indicate high acceptability of forensic sexual assault telehealth and suggest that providing patients the opportunity to interact with teleSANEs before deciding may further increase acceptance.

Conclusion:

The study contributes to understanding telehealth’s viability for sexual assault care across diverse settings and demographics, supporting the potential of teleSANE programs to enhance equitable access to specialty care, particularly in underserved areas. This research addresses gaps in existing literature by exploring acceptability in a wide range of settings, demographics, and circumstances.

Introduction

Sexual assault (SA) is a pervasive public health concern that 54% of women and 31% of men in the United States experience in their lifetimes.¹ The short- and long-term health impacts associated with SA are severe, including sexually transmitted infections,² pregnancy,³ mental health symptoms,^4,5 suicidal thoughts,⁶ chronic disease,^7,8 premature death,^9,10 and loss of productivity due to interrupted educational/work trajectories.¹¹

In this study, we use the terms “survivor/victim” (S/V) to identify individuals who have experienced SA, recognizing that the term “victim” may be most appropriate for someone who has recently been affected by sexual violence and that “survivor” best refers to someone who has started down a recovery pathway.¹² We use the term “patient” to describe S/Vs as they engage in the health care process.

Medical providers, particularly sexual assault nurse examiners (SANEs), play a crucial role in supporting S/Vs of SA. SANEs are registered nurses with specialty training in providing trauma-informed forensic care. The medical forensic examination (MFE) they conduct is guided by the immediate needs and wishes of the survivor and includes assessment and treatment of physical injuries, evidence collection, and connection to resources.¹³

Despite the benefits of high-quality MFEs from trained SANEs, many S/V do not have access to this specialty care, especially in rural settings. A study of SANE availability in Pennsylvania showed that only 20.7% of rural hospitals have certified SANEs.¹⁴ While some states permit transferring patients seeking forensic care to another facility, in many states, hospitals lacking SANEs must still make forensic exams available, even if care is provided by clinicians without specialized training.

Telehealth has emerged as a viable solution to ensure all S/Vs have access to high-quality care. Programs like the Sexual Assault Forensic Examination Telehealth (SAFE-T) Center use telehealth to enable a trained and certified clinician (teleSANE) to be virtually present in the examination room, providing guidance and support for the SANE trained local site nurse (LSN) and for the survivor throughout the examination.^15
–18

While limited studies have found telehealth to be promising for pediatric and adult S/Vs, with acceptance rates of 86–97%,¹⁸ more research is needed to understand telehealth SA MFE acceptability across diverse settings. This study aims to assess acceptability of telehealth consultation for SA MFEs across diverse hospital settings and to identify reasons why patients may decline teleSANE support.

Our research questions were:

1. What is the acceptance rate of teleSANE consultations among eligible patients seeking care after SA?

2. What are the reasons patients decline teleSANE support?

3. How does the opportunity to interact with a teleSANE before deciding affect acceptance rates?

By addressing these questions, this study aims to contribute to a more comprehensive understanding of telehealth’s viability for SA care, particularly in underserved areas, thus advancing efforts to enhance care quality for S/Vs of sexual assault.

Methods

PROCEDURE

Data on telehealth acceptability was collected between September 2018 and March 2024 from hospital sites partnered with the SAFE-T Center telehealth program. When individuals sought care for SA at partner hospitals, local providers contacted SAFE-T consultants (teleSANEs) to discuss case eligibility. English-speaking patients aged 12 years and older eligible for an MFE were offered teleSANE consultation. Reasons for ineligibility or declination were documented in REDCap, a secure, web-based research data storage platform.^19,20 This study was deemed exempt by the Institutional Review Board at Pennsylvania State University.

For patients not receiving an MFE, teleSANEs documented one of nine standardized reasons (e.g., patient declined, examination not recommended, beyond evidence collection time limits).

When patients declined the MFE, declined teleSANE but received a local MFE, or when the exam was postponed/not recommended, providers documented contributing circumstances using five standardized categories (e.g., patient anxious/overwhelmed, acute medical management required).

TeleSANEs documented whether they had the opportunity to explain their role and answer questions via telehealth technology for patients who accepted an MFE but declined teleSANE.

When documentation was incomplete, secondary sources (teleSANE postcall documentation, consultation pager logs, and forensic examination documentation) were reviewed to ascertain reasons for declination.

DATA ANALYSIS

All calls were categorized by MFE eligibility, reasons MFEs were not conducted, acceptance of teleSANE consultation, and reasons/circumstances for declining teleSANE consultation. Data analysis focused on calculating acceptability rates and examining demographic information to characterize the study sample. To compare the distributions of baseline age and gender between those who accepted teleSANE consultation and those who declined teleSANE consultation, we used the Mann−Whitney U test. This nonparametric test was chosen because baseline age and gender data did not meet assumptions of normality as assessed by Shapiro–Wilk test (p < 0.05). Statistical significance was set at p < 0.05. Analyses were performed using IBM SPSS Statistics (Version 29.0). Bivariate analyses were also planned to compare differences in race and ethnicity. However, large amounts of missing racial and ethnic data among individuals who declined services prevented analysis.

Results

ELIGIBILITY FOR MFE AND TELESANE CONSULTATION

From September 2018 to March 2024, 12 partner hospitals (7 rural and 5 urban) made 466 calls to SAFE-T to request advice or a teleSANE consultation for patients presenting with concerns of sexual assault. Demographic information for patients seeking SA care is summarized in Table 1. Analysis of the demographic data revealed no significant difference in mean age or gender between those who accepted teleSANE consultation and those who declined.

Table 1.

Comparison of Demographic Characteristics Across Patient Groups in Relation to Medical Forensic Examination and TeleSANE Consultation Acceptance

DEMOGRAPHICS	DECLINED MFE, n = 29	ACCEPTED MFE AND ELIGIBLE FOR TELESANE CONSULTATION		TOTAL ELIGIBLE PARTICIPANTS, n = 362
DEMOGRAPHICS	DECLINED MFE, n = 29	DECLINED TELESANE CONSULTATION, n = 38	ACCEPTED TELESANE CONSULTATION, n = 324	TOTAL ELIGIBLE PARTICIPANTS, n = 362
Age group distribution	n (%)	n (%)	n (%)	n (%)
<12 years	0 (0)	0 (0)	0 (0)	0 (0)
12–17 years	9 (31.0)	2 (5.3)	73 (22.5)	75 (20.7)
18–24 years	3 (10.3)	6 (15.8)	102 (31.5)	108 (29.8)
25–29 years	4 (13.8)	4 (10.5)	45 (13.9)	49 (13.5)
30–39 years	1 (3.4)	2 (5.3)	58 (17.9)	60 (16.6)
40–49 years	0 (0)	1 (2.6)	24 (7.4)	25 (6.9)
50–59 years	0 (0)	0 (0)	13 (4.0)	13 (3.6)
>60 years	0 (0)	1 (2.6)	9 (2.8)	10 (2.8)
MISSING	12 (41.4)	22 (57.9)	0 (0)	22 (6.1)
Age Mean (SD)	20.3 (6.5)	26.9 (11.3)	27.3 (13)	27.3 (12.9)
Gender Identity	n (%)	n (%)	n (%)	n (%)
Female	20 (69.0)	25 (65.8)	287 (88.6)	312 (86.2)
Male	2 (6.9)	2 (5.3)	22 (6.8)	24 (6.6)
Transgender/genderqueer/gender nonconforming	0 (0)	0 (0)	13 (4.0)	13 (3.5)
Unknown or prefer not to answer	2 (6.9)	2 (5.3)	2 (0.6)	4 (1.1)
MISSING	5 (17.2)	9 (23.7)	0 (0)	9 (2.5)
Race	n (%)	n (%)	n (%)	n (%)
American Indian or Alaskan Native	0 (0)	0 (0)	2 (0.6)	2 (0.6)
Asian	0 (0)	0 (0)	4 (1.2)	4 (1.1)
Black or African American	1 (3.4)	4 (10.5)	27 (8.3)	31 (8.6)
Native Hawaiian or Other Pacific Islander	0 (0)	0 (0)	1 (0.3)	1 (0.3)
White	2 (6.9)	7 (18.4)	233 (71.9)	240 (66.3)
Multiracial	0 (0)	0 (0)	7 (2.2)	7 (1.9)
Unknown or prefer not to answer	15 (51.7)	10 (26.3)	28 (8.6)	38 (10.5)
MISSING	11 (37.9)	17 (44.7)	22 (6.8)	39 (10.7)
Ethnicity	n (%)	n (%)	n (%)	n (%)
Hispanic or Latino	0 (0)	0 (0)	16 (4.9)	16 (4.4)
Non-Hispanic or Latino	2 (6.9)	2 (5.3)	240 (74.1)	242 (66.9)
Unknown or prefer not to answer	15 (51.7)	17 (44.7)	47 (14.5)	64 (17.7)
MISSING	12 (41.4)	19 (50)	21 (6.5)	40 (11.0)

MFE, medical forensic examination; teleSANE, tele-sexual assault nurse examiner; SD, standard deviation.

Fig.1 outlines the eligibility of cases for an MFE and/or for teleSANE consultation. Of the total calls reviewed in this study, 362 (77.7%) patients were eligible for teleSANE services. Most cases deemed ineligible were either not eligible for an MFE or declined to have an MFE when given the option.

Fig. 1.

Cases of possible sexual assault presenting to partner hospitals for evaluation (n = 466). Cases were categorized by eligibility for SA medical forensic examination (MFE), for teleSANE consultation, and finally by whether they accepted or declined the services offered to them.

TELESANE CONSULTATION ACCEPTANCE

Most patients who were eligible for an MFE, accepted teleSANE consultation for the care they received (n = 324 [89.5%]).

REASONS FOR DECLINING TELESANE CONSULTATION

The 38 patients who declined teleSANE consultation (10.5%) received an MFE from the local nurse without teleSANE support. Of those, 25 (65.8%) were not given the opportunity to interact with a teleSANE during their decision-making process, meaning that they did not get to meet or hear directly from the consultant the purpose or potential value to the patient of their involvement in the MFE (Table 2). It is noteworthy that 13 (76.5%) of the 17 patients who were identified as exhibiting anxiety or were overwhelmed and/or agitated and therefore declined teleSANE consultation were not given the opportunity to meet the teleSANE prior to making their decision. Based on LSN documentation, acute patient crisis resulted in some patients being unable to provide informed consent and/or necessitated mental health intervention before an MFE could be offered.

Table 2.

Reasons for Declining a TeleSANE Consultation and Details of How the Service Was Offered

FACTORS INFLUENCING TELESANE CONSULTATION DECLINATION	TELESANE CONSULTATION PRESENTATION		TOTAL N (%)
FACTORS INFLUENCING TELESANE CONSULTATION DECLINATION	TELESANE CONSULTANT MET WITH PATIENT TO EXPLAIN PURPOSE OF CONSULTATION, N (%)	TELESANE CONSULTANT NOT GIVEN THE OPPORTUNITY TO MEET PATIENT AND EXPLAIN PURPOSE OF CONSULTATION, N (%)	TOTAL N (%)
Patient anxious, overwhelmed, and/or agitated	4 (10.5)	13 (34.2)	17 (44.7)
Guardian refused teleSANE consultation (adolescent patient)	0 (0)	1 (2.6)	1 (2.6)
Patient believed they knew the teleSANE consultant	1 (2.6)	0 (0)	1 (2.6)
Patient did not see the value of teleSANE consultation	1 (2.6)	0 (0)	1 (2.6)
No reason provided in documentation	7 (18.4)	11 (28.9)	18 (47.3)
TOTAL	13 (34.2)	25 (65.8)	38 (100)

Discussion

Nearly 90% of eligible patients accepted teleSANE consultation when seeking SA care, aligning with prior research on telehealth for sexual violence survivors.^18,21 This high acceptance rate underscores the potential of teleSANE consultation to enhance access to specialized care.

While the decline rate was low (∼10%), understanding the reasons for refusal is crucial for improving telehealth acceptability in MFEs. Two-thirds of those who declined did so without interacting with a teleSANE, and over half exhibited signs of acute mental health crisis. This suggests that patients in challenging circumstances or acute crises might benefit most from experienced teleSANE assessment, emphasizing the importance of patient-teleSANE interaction before decision-making.

Previous research of a telehealth model on which the SAFE-T model was built demonstrated that telehealth consultation resulted in changes to history-taking and data collection, use of advanced examination techniques, and change to forensic evidence collection.²² Additionally, a study revealed that forensic SA examination consultations resulted in significantly higher quality evaluations, more complete examinations, and more accurate diagnoses than examinations conducted at comparison hospitals that did not have access to telehealth consultation.²³ Recent patient experience evaluations of SAFE-T have shown that teleSANE consultations can alleviate patient concerns and resulted in over 90% of patients rating the care they received as “excellent” or “very good.”²⁴ These positive outcomes, coupled with the ethical imperative to provide access to trained providers for all violence survivors, underscore the importance of offering teleSANE services to patients in all settings where that higher standard of care is available.

Service uptake relies on LSNs facilitating patient-teleSANE connections. This interaction allows teleSANEs to explain their role, qualifications, and the benefits of their involvement. This practice allows the patient to ask the teleSANE any questions about the service prior to deciding whether to accept or decline the service. Based on our findings, we recommend that all patients at partner hospitals be given the opportunity to engage with a teleSANE before deciding on their care.

Review of demographic characteristics indicates patients aged 12–17 years declined MFE at higher rates than other age groups. While this finding is limited by substantial missing data (41.4%), this is concerning given that nearly half of female rape victims in the United States report their first assault occurs before age 18.¹ Early intervention by SANEs may positively impact the physical and mental health support available for survivors of childhood sexual abuse,²⁵ as well as the outcomes of their cases in the justice system.²⁶ Additional research is needed to further investigate potential age and/or racial/ethnic differences.

LIMITATIONS

Study limitations include reliance on existing data recorded by LSNs and teleSANEs, and a sample primarily consisting of White women. Future studies should assess acceptance among more diverse populations. Despite these limitations, this study provides valuable insights into telehealth acceptability for S/Vs seeking MFEs, particularly in rural areas.

Our findings emphasize the value of offering telehealth as a default resource rather than by request. This approach, similar to established practices in victim advocacy, may increase the likelihood of patients accepting specialized care. The observation that twice as many patients declined telehealth without first interacting with a teleSANE supports this recommendation.

Conclusions

TeleSANE consultations demonstrate high acceptability (89.5%) among SA survivors, particularly in rural and underserved areas. This study underscores telehealth’s potential to expand access to quality care for all SA survivors. Acceptability rates may further increase by enhancing patient–teleSANE interactions, improving information accessibility, and empowering patients to make informed decisions about their care. These findings highlight telehealth as a promising solution to address disparities in forensic care access and quality for SA survivors.

Footnotes

Acknowledgments

The authors are grateful to their partners for their commitment to addressing access issues to quality, specialized sexual assault care in their communities, allowing S/V to begin their journey toward healing and recovery. The authors also thank our teleSANE team for their expertise, dedication, and commitment to patient well-being and for supporting local nurses in the provision of high-quality care.

Authors’ Contributions

S.M.: Conceptualization, funding acquisition, methodology, supervision, writing—reviewing, and editing. J.D.: Data curation, investigation, methodology, and writing—reviewing and editing. E.G.: Visualization, writing—original draft, and writing—reviewing and editing. Y.S.H.: Methodology and data analysis. M.M.: Writing—original draft.

Author Disclosure Statement

Proofreading and streamlining content for clarity was conducted with the assistance of Claude.ai, an artificial intelligence language model. Content was generated exclusively by the authors and all edits were approved by the authors.

Funding Information

This work was supported by the National Institute of Health (NIH), Eunice Kennedy Shriver National Institute on Child Health and Human Development through awards P50 HD089922 and T32 HD101390. The project described was supported by the National Center for Advancing Translational Sciences, NIH, through Grant ULl TR002014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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