Specialized health care
Exams are free for patients reporting any kind of sexual assault and any licensed medical provider can perform one, but doing one well requires training that goes beyond the scope of standard nursing and medical school, advocates and survivors say. There is a world of difference, they say, between someone reading kit instructions for the first time and an experienced examiner.
“Of all of the people I encountered throughout the process — throughout the health care system and the justice system — the SANE nurse was the single least traumatizing person,” Griffin said.
An exam done by a trained provider moves at the patient’s pace: they can take breaks, skip any part and choose whether evidence and photos are collected. It focuses on getting them the health care they need and the resources to make informed future choices about their assault.
While sexual violence can affect anyone, the system in which victims seek help and justice has a greater burden on marginalized communities — from people of color to LGBTQ people, sex workers and other groups, said Monika Johnson-Hostler, president of the National Alliance to End Sexual Violence. “It’s the outcomes after that assault, that's where we see the disproportionate impact: the lack of access to health care, the lack of support walking through the criminal legal system.”
“For most survivors who go to the emergency department or have an evidence collection kit done, it's their first step. Many of them go to the hospital before they even call a hotline,” Johnson-Hostler said, adding that how they are treated there will affect everything that follows, regardless of if they choose to report to law enforcement.
That’s why examiner training is so important, said Shandra Witherspoon, who coordinates and supports SANEs for the Ohio Alliance to End Sexual Violence. “The extra training a SANE goes through — understanding trauma and how it relates to a sexual assault survivor — is important to giving all the power back to the survivor.”
That training covers everything from trauma-informed care to how to testify as an expert witness in a criminal trial. It typically involves at least 40 hours of instruction plus additional clinical experience. Training is largely run by nonprofits or universities — most use the training model of Nash’s organization or one similar, but some states have unique requirements.
One of the biggest challenges around the country is for nurses to get enough clinical practice. In many places, they can attend a week-long training or do IAFN’s online course to get classroom experience, but if they work at a rural hospital that sees few sexual assault patients, they may not put that training into practice for months or even years.
“There’s no actual place to practice what they’ve learned in the classroom,” said Monie Johnson of her state. Johnson runs the Arkansas Coalition Against Sexual Assault and conducts SANE trainings in Arkansas.
Retention is the biggest problem, she said. After her organization received a federal grant in 2015, it trained 48 SANEs over three years. Few went on to complete their clinical hours, and even less are still practicing. Of those 48 nurses, today only four are practicing SANEs in Arkansas.
Full-time SANE jobs are few and far between, meaning most trained examiners take on the responsibility to be on call to conduct exams in addition to their regular work hours.
Even states with strong government involvement struggle with examiner retention and burnout. Maine has had a state-wide program for 17 years. But it has always struggled with turnover among SANEs. No hospital has 24/7 services, though a new partnership between the state program and the University of New England nursing school could change that by expanding training.
“We’re seeing growth around the state,” said Polly Campbell, the clinical director of the SANE program at the University of New England. “We can do this because the state supports it.”
Most of the examiners NBC News spoke to said it is demanding but rewarding work, made more difficult by the lack of full-time jobs.
“Most hospitals, most facilities, most SANE programs — it’s not a primary job for people. It’s typically a secondary job for them,” said Megan Lechner, the director of Colorado’s largest SANE program and main training provider. “Sometimes it looks like taking on extra patients during a shift. Sometimes it’s being on call 24 hours a day.”
There’s the doctor in Maui who has been the main examiner for the island for the last 30 years; the nurse who founded a nonprofit that sends on-call SANEs to hospitals throughout much of northern Louisiana who still works full-time at a hospital; the Alaska forensic expert who regularly flies to remote parts of the state to train examiners and first responders and is available for consultation 24/7.
Given the stress of the job, sticking with it takes a lot of passion, said Broder of Oregon. “If you’re the only nurse in an entire county, that’s an enormous amount of pressure for one person. ... There needs to be a plan in place to support these SANEs.”
Where can you go?
After Griffin’s experience in 2014, she contacted her senator, Patty Murray, D-Wash. Murray commissioned a Government Accountability Office report on exam availability, which found information lacking nationwide. Researchers closely examined six states, finding that there were limited training opportunities in rural states, weak financial support from hospitals and high burnout rates among SANEs due to the demanding nature of the work.
Murray proposed a bill soon after to begin addressing the information and support gaps. If passed, it would provide national funding to study the shortage, establish a training program, develop nationwide standards for sexual assault exams and expand health care access for survivors. Though it was first proposed in 2016 and has bipartisan sponsorship, the bill has yet to get a hearing or a vote.
NBC News spoke to groups in all 50 states first in late 2019, then again in June, in an effort to answer a question at the core of Murray’s bill: Where can someone go to get an exam from a qualified provider?
Every state organizes its forensic exam system differently. Some state sexual assault coalitions had guides about exams and lists of providers on their websites. Many did not. In a few, government agencies tracked where programs were located through regularly updated online lists. In others, the only lists were maintained by volunteer nurses. In a small number, there was no tracking. Some state experts said staffing levels at hospitals change so frequently that victims should be directed to local rape crisis centers, which know where the nearest providers are.
The Covid-19 pandemic did not affect their ability to conduct exams, providers around the country told NBC News, but in March and April, there was a sharp decrease in the number of people requesting exams. They attributed the decrease to people worried about risking exposure to the coronavirus by going to a hospital emergency room or thinking services had stopped during a stay-at-home order. Some programs adapted by directing exam patients to hospital entrances away from emergency departments and or even establishing new exam sites at urgent care or child advocacy centers. Most states saw requests for exams climb back toward normal frequency as stay-at-home orders began to lift, but worry that concern over coronavirus could keep some victims from seeking health care.
Throughout the country, examiners began wearing more personal protective equipment and advocates were in many cases temporarily not allowed to accompany patients, instead participating by phone or video call. With travel discouraged, the pandemic spurred a few states that have telenursing programs, such as Alaska with its many remote villages, to push forward with expanding those services to more rural communities.
Improving access
The Department of Justice has funded state efforts to conduct more examiner trainings and increase exam access since 2005. Many states have received additional DOJ money toward these efforts in the last six years as part of grants to overhaul their sexual assault kits. Program coordinators and advocates around the country say things are improving, but they still need more examiners, more funding and better support to keep programs open and examiners around.
“Every year there’s progress made. This is an area that we’ve actually seen pretty steady movement on,” said Annie Hightower, the director of law and policy for the Idaho Coalition Against Sexual and Domestic Violence.
Idaho recently funded a SANE position at the state police to coordinate Idaho’s examiner training and has begun to train more nurses. Yet, Hightower noted, the state still has areas where someone might have to travel as much as 90 miles for an exam.
In places where SANEs are few and far between, states are adopting innovative solutions. Regional mobile SANE programs will send on-call SANEs to treat someone at their nearest facility. In some underserved areas, new telenursing programs connect local medical providers with experienced SANEs by secure video conference to guide them through exams. In many areas, resources are shared. Maine, Pennsylvania and Washington have regional agreements between hospitals to share SANEs as needed.
Harborview Hospital in Seattle, where Griffin was treated, is part of one of those agreements. Its Center for Sexual Assault and Traumatic Stress has 24/7 staffing and sends SANEs to six other local hospitals. It is the largest SANE program in the state, also providing trainings around Washington. The program has grown in recent years, expanding from having one SANE on call per shift in 2014, when Griffin was treated, to two, in an effort to reduce wait times, a spokesperson told NBC News.
Swedish Medical Center — the hospital system that owns the first ER Griffin went to — is one of those partners, though Harborview does not send SANEs to the location Griffin went to. When asked about Griffin's experience, Amy Dodgion, a social worker at Swedish, told NBC News she couldn’t comment on an individual case, but insisted it has protocols in place to ensure rape victims get examined by specially trained nurses, regardless of which ER they visit.
“We do not turn people away. We do not tell them to go elsewhere,” said Dodgion.
In the years since Griffin stepped into an ER, she has become an activist for increasing access to sexual assault forensic exams, championing Murray’s bill as well as half a dozen other sexual assault-related bills in Washington state. She serves on a statewide sexual assault forensic exam task force, has testified numerous times at the state capitol and has lobbied legislators in Washington, D.C. — even attending the State of the Union with Murray in 2018.
“I couldn’t get justice,” she said, “but I want to make a system where people can.”
Passing Murray’s bill is the next step toward that goal. “It will mean that, for the first time, we’ll have a structure in place to begin to solve this problem,” she said.
How this article was reported
Reporters contacted every statewide coalition against sexual assault, state agencies, law enforcement offices, university training programs and dozens of program coordinators and individual examiners in an effort to understand the availability of sexual assault forensic exams around the country, first in December 2019, then in June.
That availability varies widely state to state, as does the structure of training programs, laws and government oversight. Most states did not have regularly updated databases tracking where SANEs work and what facilities have programs. NBC News consulted advocates and administrators in states with minimal tracking on how best to map what is known about the state’s resources. A summary of each state’s services and any additional notes on how data was collected appears with each state.
Adiel Kaplan and Wilson Wong reported from New York City; Alexa Keyes and Catie Beck reported from Seattle.
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