Potentially Misleading Phrases in Sexual Assault Nurse Examiner (S.A.N.E.) Reports

Commonly seen phrases in SANE/SAFE1reports such as “consistent with” and “as expected” have the potential to be misleading.

The history and physical components of the sexual assault exam conclude with an “impression”. An impression is not a diagnosis, but this section of the report can be misused by sexual assault nurses in a manner that implies a diagnosis.

Recently, I testified in a trial that had in evidence the following impression: “Sexual assault per pt. history. Exam findings as expected given details of the assaults and chronic timeline”.

That impression demonstrates two potentially misleading mistakes.

First, sexual assault is not a diagnosis. Rather, it is a legal determination, a matter of jurisprudence. “Alleged sexual assault” is a more accurate impression and avoids the implication of bias.

Second, the impression is not a place for narration. An unbiased examiner details the objective findings, period. There is a time for testimony, but it is not in the impression.

That same report also included this physical finding: “Irregular shaped area of hypopigmentation consistent with scarring …”

Hypopigmented skin is whiter than adjacent tissue. But all skin patches that are white are not scars.

Here the nurse examiner reported a white area as consistent with just one thing – scarring - when there are multiple common causes of hypopigmentation unrelated to sexual trauma. In addition to the linea vestibularis (a normal variant), any condition that causes inflammation of these tissues can result in so called post-inflammatory hypopigmentation. For deeper discussion of this issue, there is a peer reviewed differential diagnosis of white patches and plaques on the vulva.2


1Sexual Assault Nurse Examiner/Sexual Assault Forensic Examiner

2Margesson, L.J.et al, Vulvar lesions: Differential diagnosis based on morphology. UpToDate.com, literature review current through May 2017