Charts Unwritten

Content Warning: This post discusses sexual violence, forensic exams, and trauma-informed care.

The first time I witnessed a forensic exam, I didn’t fully understand what I was watching. The room was quiet, and the survivor—barely out of her teens—sat hunched on the edge of the hospital gurney, fists clenched around a hospital gown two sizes too big. A SAFE (Sexual Assault Forensic Examiner) was preparing a kit nearby, her movements slow and intentional. She explained each step with a calm, steady voice.

At one point, the survivor asked, “Can I stop if it’s too much?”

The SAFE looked her in the eye and said, “Absolutely. You are in control the entire time.”

That moment hit me like a tectonic shift. For the survivor, it was one of the worst nights of her life. For me, it was the first time I understood how clinical presence could also be protective.

A System Not Built for Survivors

Emergency rooms are not known for gentleness. They’re designed to triage, stabilize, and move. But when a survivor of sexual assault walks through those sliding doors, they’re not looking for efficiency—they’re looking for safety. Often, they’re not sure they’ll even find it.

While some hospitals are fortunate enough to have SAFE programs, many still don’t. Even in major cities. Even in trauma centers. And even when survivors are willing to report, the absence of trained personnel can lead to retraumatization, poor evidence collection, or lost legal windows. According to the International Association of Forensic Nurses (IAFN), only about 17% of U.S. hospitals have access to trained SAFE/SANE staff.

That means many physicians, residents, and medical students are placed in situations where they are expected to care for survivors without the tools, training, or trauma-informed framework to do so. The results can be unintentionally harmful—even in well-meaning hands.

SAFE Training Isn’t Optional—It’s Urgent

I’ve supported survivors in the ER who couldn’t name what happened to them out loud but still wanted help. Others were confused by the forensic process, terrified they wouldn’t be believed. I’ve had survivors ask if they were “allowed” to say no to parts of the exam, or whether saying “I don’t remember” would disqualify them from care.

In every one of those moments, clinical presence made the difference—not just skill.

SAFE training teaches clinicians more than just how to swab, document, and preserve evidence. It teaches:

• How to obtain affirmative, ongoing consent
• How to speak clearly and gently without minimizing or assuming what happened
• How to offer choices, not instructions
• How to protect chain-of-custody without compromising patient trust
• How to explain next steps so that survivors can make informed decisions

These are skills that all physicians—not just nurses or forensic specialists—should be equipped with. Survivors don’t only show up for rape kits. They show up for emergency contraception, urinary tract infections, anxiety attacks, and routine checkups, too. Their trauma doesn’t go away just because it isn’t spoken aloud.

The Cost of Silence

Here’s what happens when clinicians aren’t trained: survivors walk out. They don’t return for follow-up care. They suffer in silence. Or worse, they’re retraumatized by language that invalidates or interrogates.

A 2021 study in Global Qualitative Nursing Research found that many patients seeking post-exposure HIV prevention either did not initiate or did not complete the full 28-day medication regimen—a gap strongly influenced by experiences of trauma and mistrust in healthcare. In other words, when survivors feel dismissed or misunderstood, they opt out—not just of that moment, but of the entire system.

Similarly, in the pivotal article published in Trauma Surgery & Acute Care Open by Grossman et al. (2021), offers a compelling roadmap for how health systems must evolve to meet the needs of trauma-exposed individuals. The authors expanded on the definition of trauma beyond the traditional boundaries of violence or accidents. They include structural racism, poverty, community violence, and historical trauma as critical, often invisible, forces that shape health outcomes. It’s a timely reminder that trauma is not always visible, but it is often present.

Thus it’s essential that healthcare professionals attempt to build clinical trust for better outcomes.

Why Medical Education Needs to Catch Up

SAFE training is not currently a required part of medical education at most institutions. It often falls under “electives,” “continuing education,” or niche rotations. But that marginalizes it.

Survivors are not marginal cases.

They are a major population in emergency care, OB/GYN, family medicine, psychiatry, and even pediatrics. According to RAINN (Rape, Abuse & Incest National Network), nearly 1 in 6 women and 1 in 33 men experience attempted or completed rape in their lifetime. If medicine doesn’t treat this as a core competency, it fails to meet the realities of patient need.

What I’ve Learned by Witnessing, Not Performing

I’m not a physician—yet. But I’ve sat beside survivors during exams, wrapped blankets around their shoulders, helped them ask for breaks, and whispered, “You can stop anytime.”

One survivor looked at me afterward and said, “Thank you for not treating me like a checklist.”

That line stayed with me. Because so much of medicine is measured in forms, codes, metrics. But survivors remember how you made them feel. SAFE training brings that feeling—of safety, control, and respect—into the heart of medical care.

The Intersection of Policy and Practice

SAFE training isn’t just a clinical issue—it’s a policy issue. Hospitals need funding to sustain 24/7 SAFE coverage. Providers need liability protections. Survivors need assurance that they won’t be billed for forensic care (which still happens in some states). And residency programs need to require trauma-informed care modules, not just recommend them.

In 2021, The Survivors’ Access to Supportive Care Act (SASCA) was introduced in Congress to increase funding for SAFE programs nationwide. But policy moves slowly. Medicine must move faster.

A Call to Medical Schools

If I had one request for every medical school admissions committee or curriculum dean, it would be this:

Teach students how to sit in silence. Teach them how to stay present. And teach them how to hold the weight of another person’s pain without rushing to fix it.

SAFE training offers that. Not just technical skill, but human skill.

Closing Thoughts: Why This Matters to Me

I want to be a physician advocate who shows up for the moments no one wants to talk about. I want to work in emergency departments where survivors are met with dignity and care. I aspire to help design protocols that prevent re-traumatization all the while teaching future students how to stay present in the storm.

This isn’t just a goal—it’s a commitment. And it starts with medical education catching up to what survivors have been asking for all along: safety, consent, and care that doesn’t feel like a second violation.

We can do better. And SAFE training is one place to start.

— Advocate in Scrubs