She remembers leaving the neighborhood bar at closing time and walking down the street with the guy who kept an eye on her drink while she ducked into the restroom. She remembers telling him she didn’t want to have sex. She remembers the pool of blood between her legs.
What happened in between to this Seattle-area teacher got lost in a haze — the result of a drug slipped into her drink, toxicology reports would later show. But by the next morning, at home and still bleeding, she knew what she had to do.
Her husband was out of town. So she drove herself to the nearest hospital, went into the emergency room and said she needed a rape exam.
What followed turned Leah, 30, into a relentless activist on behalf of rape survivors.
Swedish Medical Center in Ballard told Leah it didn’t do rape kits and directed her to the one place in King County that could help her: Harborview, a facility 30 minutes away. Leah, still bleeding and dazed, said she didn’t think she could make the drive. When hospital staff offered to send her by ambulance, she says she told them she couldn’t afford that. Plus, how was she supposed to get home?
Leah’s outrage is palpable still, two years after the fact and through the phone.
“They literally shrugged their shoulders at me.”
In a statement to TV station KING 5 last year, the emergency director explained.
“Like other hospitals in King County, Swedish does not have Sexual Assault Nurse Examiners (SANE) onsite,” the director said. “Protocol for sexual assault victims was to refer patients to Harborview for care should the patient wish to do so.”
Leah went on to take every other step a rape survivor must to seek justice: She said she filed a police report. She met with prosecutors. She identified her attacker in a photo.
She also went to the other hospital the next day to have a rape kit collected.
But Leah’s experience of being turned away at the first hospital is not unique; sexual assault advocates say it represents a hurdle that could and should be erased.
No federal oversight or standards
A recent government report (PDF) identified major gaps in access to sexual assault examinations at hospitals nationwide, including a lack of trained sexual assault nurse examiners, or SANEs, whose job is to not only provide uninterrupted compassionate care but to collect the evidence critical to successful prosecutions.
Advocates for sexual assault survivors have long reported stories of vulnerable victims being rebuffed at hospitals, forced to make hours-long trips in rural areas — if they make the trips at all.
Survivors — and their efforts to seek criminal prosecution — suffer as a result, they argue.
The report’s findings, coupled with accounts like Leah’s, have spurred new legislation that aims to help survivors get access to specialized care.
The Survivors’ Access to Supportive Care Act, introduced in Congress on Wednesday by Sen. Patty Murray (D-Washington), aims to improve access to qualified examiners through various means.
Echoing findings in the report, the bill addresses a fundamental deficit in health care for sexual assault survivors: no federal oversight of SANE programs and no national standards for training and certifying examiners.
The bill “would direct the Department of Health and Human Services to establish a national training and continuing education program, to be tested and incorporated by health care providers nationwide,” a Murray aide said.
The bill would appropriate $12 million to support a pilot grant program that would expand training and state-level surveys to evaluate needs.
‘It has to change’
Even if a hospital does not have trained examiners or rape kits available, advocates said, there are minimal steps emergency room staffers can take. For one, they can offer rape survivors morning-after pills and antiviral medications.
Any medical professional, however, can perform a basic sexual assault exam, said Jennifer Pierce-Weeks, a sexual assault nurse examiner serving as interim chief executive officer of the International Association of Forensic Nurses. When a sexual assault victim shows up at an emergency room, the staff is obligated to see that person to rule out or address an emergency medical condition, she said.
But the medical community has long recognized the benefits of specially trained medical professionals who can provide a “victim-centered” approach that includes evidence collection and caring for a patient’s physical and emotional needs.
Research has shown that exams conducted by trained SANE nurses take less time, offer better care to victims, result in the most thorough collection of forensic evidence and, in turn, lead to greater prosecution rates, said Katherine M. Iritani, director of the U.S. Government Accountability Office’s Health Care team, which released the new report.
The report noted the absence of federal standards for training sexual assault examiners.
Leah knows firsthand the importance of that training. Before leaving the first hospital she went to, she agreed to an emergency room exam because she was desperate for help, even if that help didn’t include a rape exam.
That initial exam, she believes, tainted the evidence inside her and “destroyed the crime scene.” The doctor told her she was fine and failed to spot the 1½-inch laceration in her vagina that later required stitches.
“I’d been told by an ER doctor that nothing was wrong,” Leah says. “It was incredibly humiliating, degrading and awful.”
She went home and showered before going in the middle of the night to the second hospital to get a rape kit exam. At that point, she says, she’d bled through nine overnight maxi-pads.
Though Leah identified her attacker, he was never charged.
For months, she felt so traumatized, she couldn’t keep food down. She took the rest of the school year off from her job and holed up at home. But later, fueled by her experiences, driven by anger and bolstered by counseling and the ceaseless support of her feminist husband, Leah reached out to lawmakers. One of them was Murray.
“I am an employed, white, educated woman with no kids, with access to transportation and the internet. I don’t have a criminal history, no history of drug use, and I’ve never been a sex worker,” Leah says. “I feel incredible pressure to use my privilege to get something done because if I couldn’t do it, nobody can do it. It has to change.”
Training and keeping nurses a challenge
Emergency room doctors and nurses used to care for sexual assault survivors before SANEs came into existence in the 1990s, Pierce-Weeks said. In many communities without SANEs, ER personnel still perform those services.
“The difference is, ER personnel receive minimal to no training in these exams,” she said.
Nurses, hospital staff and patient advocates told CNN it was fairly common for hospitals to send patients to other facilities with trained examiners, especially in rural areas. Some defended the practice, saying it can be in the patient’s best interest.
The GAO report identified various challenges to training and retaining sexual assault examiners. Presently, 2,284 sexual assault examiners are registered with the International Association of Forensic Nurses, an incomplete number considering SANEs are not required to register with the organization.
Officials in five of the six states studied in the report said the lack of classroom, clinical and continuing education training makes it difficult to maintain a supply of trained examiners.
In addition, hospitals may be reluctant to cover costs for the initial 40-hour training as well as additional retraining, the report said. In rural areas, clinics may balk at paying for on-call examiners for the infrequent instances when they are needed.
These factors, plus the emotional and physical demands on examiners, lead to low retention rates, the report said.
“It gets complicated quickly,” said Iritani, the report co-author. “The major challenge states faced was having the resources to maintain a training program and keep the constant supply of trainers.”
Many trained examiners remain on the clock after they leave the hospital floor, especially in rural communities. They might be on call after hours and on weekends as the only trained examiner in the region.
Then there’s the time needed to prepare for court as well as time spent in court being grilled by defense lawyers attempting to cast doubt on their findings.
All of that is time for which they may not get paid.
“We were told in some states that some hospitals didn’t pay trained examiners to be on call,” Iritani said. “It was considered an act of duty.”
Tough conversations
Then there’s the “emotional investment” required to do the job.
Angela Brady knows it well.
For nine years, she worked as a sexual assault nurse examiner at St. Luke’s Wood River Medical Center in Ketchum, Idaho, a mountain town two to three hours from Boise, depending on the route.
For years, she was one of three SANE nurses. When the others quit, she shouldered all of the responsibility while serving as a bedside nurse and a critical care supervisor. She was on call around the clock, required to come to the hospital if a rape victim needed an exam. Dedicated to her profession for 30 years, she was willing to do that.
“When victims come in,” she said, “they need comfort. They need calm. They need to be heard and treated.”
In the hours after a rape, a sexual assault exam is crucial to yield DNA evidence that might lead to an attacker’s arrest and conviction, she said. A sexual assault nurse is trained to take a patient through the traumatizing experience — an exam can last four hours — and listen to them.
“If a patient says, ‘He pushed me down in the gravel,’ I’m listening to them; I’m going to look for signs of that injury,” Brady said. “It’s about being focused as you would be focused doing any kind of investigative work.”
Two years ago, Brady, now 52, decided she could no longer be the only sexual assault examiner at St. Luke’s. She quit and became a nurse in the hospital’s emergency room. She anguished over the decision but felt it was the best move for her patients and for her career.
Brady worried that because there were so few rape victims who came to the hospital in this rural area of the state, she was unable to practice her skills regularly. If she were called to testify in a criminal proceeding, could an attorney shoot holes in her credibility?
“I needed to be able to go on the witness stand and feel total confidence,” she said.
St. Luke’s spokeswoman Beth Toal confirmed that there is no sexual assault nurse examiner currently working at the facility because there are simply too few rape victims who arrive there, and that results in little training for the staff. Toal said that both adult and juvenile sexual assault victims are given the option to travel to Boise to a facility that is staffed with SANE nurses and provides specialized care. St. Luke’s provides transportation, Toal said.
She and Brady stressed that rape victims are never turned away from the hospital. All doctors and nurses there are trained in how to perform a sexual assault exam, they said.
But the atmosphere in which those exams take place — an emergency room — is not ideal, Brady said. Survivors may have to sit in the waiting room for hours. They may be examined by a doctor or nurse whose gender makes them feel uncomfortable. The doctor or nurse performing the exam may be interrupted to tend to other patients with life-threatening conditions, she said.
That’s why victims are told when they arrive that the hospital will provide them transportation to the Boise facility.
“We are trying to move victims out of the emergency room and put them in an environment that is slower-paced, an environment where they won’t feel like a victim again,” said Brady. “I want them to have a better experience in Boise.”
It’s not easy to explain that to victims, she said. Some can’t bear the thought of traveling more than two hours to get treatment after it took them so much energy to muster the strength to go to St. Luke’s.
“That conversation can be tough,” she said.
To some, asking a victim to make that decision is unacceptable.
“The victims are refusing to go to Boise, which is understandable. They don’t want to wait,” said Tricia Swartling, CEO of The Advocates, an area victim advocacy group. “This is not a good experience. This is not a good system.”
‘Unknown unknowns’
Some prosecutors say it’s not good for justice, either.
Brent Eaton, the prosecuting attorney in Hancock County, Indiana, said that a lack of trained examiners in the area hinders his ability to prosecute sexual assaults.
Eaton said he’s heard of survivors showing up at Hancock Regional Hospital only to be told they have to drive elsewhere for an exam. As a result, he has no idea how many rape victims simply leave the hospital and choose not to report their assault.
“The unknown unknowns are something that really concern me,” he said. “It concerns people in law enforcement.”
Steve Long, president and CEO of Hancock Regional Hospital, said every patient who shows up to the emergency department is provided a medical evaluation and necessary follow-up treatment.
Patients can request the additional forensic exam to evaluate the sexual assault and collect evidence for prosecution, but Long believes that sending them to a regional partner that has a trained sexual assault nurse examiner is a “better alternative.”
“There is a difference between a forensic examination provided by a sexual assault nurse examiner-certified nurse and one completed by a non-specialized physician or nurse,” he said.
“SANE-certified nurses are highly educated not only in the proper collection and handling of evidence, they are also trained and experienced in victim-centered care and helping the patient through a very traumatic experience,” he said in an email.
Hancock Regional has never staffed sexual assault nurse examiners because “the certification requires significant ongoing hands-on experience,” Long said. With eight sexual assault visits to the hospital in 2015 out of more than 24,000 emergency room visits, “our county does not have a sufficient number of cases to meet continuing certification requirements for our nurses,” he said.
Instead, staff members encourage patients to visit Community Hospital of Anderson, about 40 minutes from Hancock, for sexual assault exams.
“We believe a better alternative for the patient is the transfer to the specialized center that focuses just on patients requiring these services,” he said.
Victims have to front the cost of transportation, Long said, though the hospital is working on a way to change that with input from Eaton.
Murray’s legislation recognizes that a one-size-fits-all approach won’t work, an aide said. That’s why it appropriates $2 million to fund state-level surveys to identify training and infrastructure needs. It also authorizes $10 million for a pilot grant program to expand medical forensic exam training and services to new providers like physician assistants, as well as to Federally Qualified Health Centers and Title X-funded clinics to expand access in rural areas.
‘An easy win’?
More than two years have passed since Leah’s rape. She’s grown stronger with time and continues to fight for herself and others like her. She’s joined task forces and spoken out, and to this day, she is still battling to get a sexual assault restraining order against her attacker.
She does what she does because she feels an obligation but also because she’s flat-out angry.
“I didn’t know what anger really was before this happened to me, and I didn’t know how powerful anger could be,” she says. “If there was ever anything to express rage over, this is it.”
The fact that she played a part in inspiring new legislation is “the proudest achievement of my life,” she says.
This new bill may have the power to defy partisanship, she says. It’s a cause any person — man or woman, Republican or Democrat — should get behind.
“It should be an easy win,” Leah says. “And if it’s not, the problem is worse than I think it is.”
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