As an emergency-room nurse in southwest Wisconsin, I sometimes received patients who had been sexually assaulted, and I was expected to help conduct an exam to collect and preserve DNA evidence, though I didn't have the appropriate training.
I would try to make sense out of the rape kit: a cardboard box packed with numerous envelopes holding a mess of long-handled swabs and slides. Instructions were printed on both sides of a sheet in type so small I could barely read it. Often the doctor on call was as uncertain about what to do as I was and had only 10 or 15 minutes before needing to return to other emergency department duties. I felt inadequate to meet my patients' needs. And I was always worried. What if I mess something up in the rape kit and ruin her court case?
Although jurisdictions are required by the Violence Against Women Act to provide free forensic exams to victims of sexual assault, there's no requirement that the exams be carried out by people trained in evidence collection or rape-victim support. A 2013 report by the Justice Department stated that "all communities should strive to ensure that victims of a recent sexual assault have access to specially educated and clinically prepared examiners." But no funding came with that recommendation.
My fear that I wasn't serving my patients motivated me to become certified as a sexual assault nurse examiner (SANE) in 2014, and we now have seven trained nurses in Platteville, Wis. But nationwide the need for trained examiners outpaces their availability, especially in rural areas. That means rape victims aren't always treated with the urgency and attention they deserve.
Research shows that rape kits completed by health-care workers without special training are routinely compromised. One study conducted in Colorado and published in the Journal of Emergency Nursing found that 29 percent of such kits didn't include the correct number of swabs for evidence, 25 percent were improperly sealed, and 19 percent didn't follow the proper chain of custody on their way to law enforcement. The integrity of the kits was much higher when specially trained nurses were involved. For those kits, 12 percent had the wrong number of swabs, 9 percent were improperly sealed and 8 percent had an incomplete chain of custody.
Several case studies have suggested that jurisdictions with SANE nurses on their hospital staffs have higher prosecution rates for rape and sexual assault than districts without them, possibly because those nurses provide law enforcement with more consistently useful forensic evidence.
Still, if I had become a trained examiner primarily to aid prosecution, I would be too frustrated to go on. Many victims either choose not to pursue their cases or hit dead ends in the justice system. And there's the widely publicized backlog of untested rape kits numbering in the tens of thousands, dating back decades. So the evidence I take extreme care to collect may end up sitting in a storage room somewhere. But providing patients with thorough medical care, along with emotional support and referrals to local resources, is just as vital as the forensic part of these exams.
I once heard a sexual assault victim tell a detective that her exam with an emergency-room doctor made her feel like she'd had an oil change. In contrast to the 10 minutes ER physicians may be able to give to victims, SANE nurses may spend up to four hours with them. Unsurprisingly, more time means better care. Studies have found that victims seen by specially trained nurses are more likely to be tested for sexually transmitted diseases, to receive emergency contraception, and to have any physical injuries identified and documented.
More time with patients also means time to answer questions and offer emotional support. Many victims come into our emergency room exhausted after explaining the details of their allegations to police. I'm the first person who says, "I'll believe what you tell me." Some patients, especially minors, may be confused about medical versus slang terminology for body parts and sex acts.
I call each victim we examine about a week after they see us. Many understandably don't remember exactly what treatments they received during a very traumatic period. So I make sure they're aware of what medications we gave them, what diseases they're probably protected against and what additional care they might need to seek.
There's a limit to how much help I can give within the confines of an exam and a follow-up call. But I can direct patients to local, reliable support services. In two of the last three cases we had at my hospital, our patients ended up using domestic violence services we directed them to. In another case, I worked with a teenage victim from one of the nearby Amish communities, which don't use electronics. I gave her my card and phone numbers before she left the hospital, knowing that it would probably be difficult for her to make use of them. But, using a telephone at her employer's office, she was able to connect with some of the resources for sexual assault victims that I talked to her about.
Despite the clear importance of having someone who knows what they're doing conduct a sexual assault exam, trained examiners remain inaccessible to many victims. "We know that there are challenges, particularly in rural communities," Rebecca O'Connor, vice president of public policy at the Rape, Abuse and Incest National Network, said when it comes to having examiners available who can "address victims' needs at the outset to avoid a domino effect."
A recent report from the Government Accountability Office surveyed six states--Colorado, Florida, Massachusetts, Nebraska, Oregon and Wisconsin--and found that there were not enough trained examiners to meet demand, especially in rural areas. The same report found that nearly half of all counties in Wisconsin have no nurses with sexual assault examination training.
Colorado district attorney Sherry Caloia says that for some sexual assault victims in her state, the nearest trained examiners are 90 minutes away. That distance can deter victims from accessing treatment, which can in turn pose problems for their legal cases. "When you're in an uncomfortable position of having to talk about a sexual assault already to a police officer, and you've already spent two hours or more making the report, it is hard to then get a victim to go all the way to Summit County or Grand Junction," Caloia said. She added that a victim's refusal to travel for a forensic exam with a trained professional could be used against her in court, while also causing prosecutors to miss out on important DNA evidence.
Recently Sen. Patty Murray (D-Wash.) introduced the Survivors' Access to Supportive Care Act, which aims to address the dearth of trained examiners and an absence of national standards for certification. The legislation would provide for data-gathering on the availability of examiners, the costs of training and states' current funding for sexual assault examinations. It also calls for the creation of a task force that would come up with a suite of best practices for the treatment of sexual assault victims. And it would create a $10 million pilot grant program to expand sexual assault examiner training, with a special focus on rural areas.
I'm grateful that Southwest Health, where I work, agreed to my proposal to build a nursing staff trained to handle the aftermath of sexual assault. But for many communities that's just not possible. Tuition for a five-day training course can cost hundreds of dollars, plus there's the cost of hotels, meals and substitute coverage back at the hospital. The financial commitment can be prohibitive. Another challenge is keeping rural nurses competent and confident in providing this care when the number of cases per year can be low. Nursing turnover rates are already high, and rural SANE nurses, because of their small numbers and stressful work, are at special risk for burnout.
I manage to keep going because I can see I'm making a difference. Living in a rural area with a small population, it isn't uncommon for me to cross paths with victims I've examined. A little while ago at a gym, a woman stepped up on the treadmill beside me and gave me a brief look of recognition. I knew she'd been a patient of mine, and I hoped she was doing well, but I didn't want to violate her privacy by bringing up the exam. So I didn't say anything. Still, I saw her turn toward me and smile. That's all the feedback I needed.
Terri Slapak-Fugate is the director of emergency/urgent care and the SANE program manager at Southwest Health hospital in Platteville, Wis.
Editorial on 05/29/2016