Law requires hospitals to have care plan for rape victims

States beginning to increase forensic exam access

In 1993, at the age of 20, Kate Rush-Cook said she became a statistic.

“I was kidnapped, robbed and repeatedly raped by a man I had never seen before.”

That night, Rush-Cook became one of the 237,868 victims, the U.S Department of Justice estimates are sexually assaulted in the United States each year.

It's quite possibly the most traumatizing event in a victim's life.

"A lot of people don't want to speak about it and there's a lot of shame around it,” Rush-Cook said.

When a person is sexually assaulted, a clock immediately starts ticking for evidence collection.

"It's very scary,” Rush-Cook said. “You've just been through probably one of the most, I think it's the most, horrific things that can ever happen.”

More than 20 years after the horrific event, Rush-Cook tells her story as a survivor. She was just 20 years old when she was kidnapped, repeatedly raped and strangled. Later that same night came the exams and the rape kit.

“(You) have your body plucked and swabbed,” Rush-Cook said. “Every piece of your clothing is taken from you: your socks, your shoes, your underwear, your shirt, your pants....a lot of people don't realize that."

The exam Rush-Cook described is a medical forensic exam. It’s the next step in ensuring physical safety for the victim and making sure evidence is properly collected for a potential future conviction of the attacker. It incorporates special training and is administered by A Sexual Assault Nurse Examiner -- or a SANE.

The exam can seem intense and intrusive for victims. It includes a medical forensic history, a detailed physical and emotional assessment, written and photographic documentation of injuries, collection and management of forensic samples, and providing emotional and social support and resources, according to the International Association of Forensic Nurses.

“The exams are especially important in stranger rapes,” Greg Bernstein, Baltimore City State’s Attorney said. "They (SANEs) do it in a safe, secure environment. They know how to maintain the chain of custody and the evidence; so, that's where they become enormously important."

Having a sufficient forensic exam is not always as easy as showing up at the nearest hospital Emergency Room.

"I was in a ride-along with a firefighter and we got a call from someone who was raped and taken to the wrong hospital,” Maryland state lawmaker Ariana Kelly said. “They were taken to the local hospital that I knew was not the hospital that provided sexual assault services.”

Access to care
The American Hospital Association estimates there are more than 5,700 registered hospitals across the country.

IAFN estimates there are little more than 700 forensic SANE programs in the United States.

Carey Goryl, CEO of IAFN, said that means about 13 percent of hospitals in the U.S. might have a forensic nurse on staff part of the time. In rural areas, it means the likelihood of a victim finding easy access to these services can be difficult.

“The public really would be appalled at the lack of qualified providers available to them if they were to become a victim of sexual assault, domestic violence, elder abuse or child abuse,” Goryl said.  “And with what we know about the long term health consequences of violence, it’s a shame our health system hasn't rallied behind the hard work of forensic nurses and our few forensic physician colleagues as well.”

IAFN is an international professional membership organization comprised of 3,000 members around the world. Along with setting guidelines for training and education requirements for forensic nurses and SANEs, the agency tracks where SANE and a Sexual Assault Response Teams are located. A SART is usually made up of a SANE, a victim advocate and a member of a law enforcement agency. The team also will work to develop a close relationship with prosecutors and the state’s attorney’s office in their areas.

There is not a national tracking agency or registration service for SANE services in the United States, according to Goryl. To make up for it IAFN collects information about SANE program locations. Their database is voluntary and self-reported.

Click here to search the IAFN database and find a SANE/SART location near you.

SANE and SART programs across the country depend heavily on grants and partnerships with hospitals and government entities. According to Goryl, forensic nurses do this work as a part of a second job a majority of the time; working as nurses in a health setting by day and on-call by night.

“There has been a tremendous burden placed on the compassion and charity of nurses who want to do the right thing for people who have been victimized,” Goryl said. “There has also been a general unwillingness by healthcare as a whole to want to take accountability for providing (what we think is) a basic standard of care -- a medical forensic exam by someone who has done more than read the directions in the box.”

In Maryland, there is about one hospital per county that has specialized nurses on staff that can provide the right exams.

"It still horrifies me,” Goryl said. “I've been doing this for 20 years. It's shocking to me that if you don't know the rules, if you don't know the inside system, you're probably not going to get a forensic nurse. Not yet at least."

Not a one-stop shop
A new law in Maryland aims to cut back on what some are calling a 'flawed' system. HB 963, requires all Maryland hospitals to have a protocol on how to handle rape victims who walk through any hospital ER door.

"In some cases, rape victims would be turned away and told, 'you need to go to this other hospital down the road,' and there was no process in place for getting them there seamlessly in a supportive way,” Maryland State Delegate Kelly said.  “In other cases, they might've been treated by a provider who was not well trained to provide that treatment to do the forensic exam."

Kelly, a rape survivor herself, sponsored the bill and says for a rape victim the mere fact of being told you can't be treated at the hospital where you showed up could mean turning away altogether.

Monica, a Baltimore rape victim, has lived a version of the worst case scenario Kelly detailed. 

“The whole hospital situation was shocking because I was sitting there traumatized and nobody was helping me," she said.

Monica said she was attacked in 2012. She said she didn’t know where to go, so she ended up waiting hours in a Maryland hospital, never getting the forensic exam she needed. Eventually, Monica said she went to a DC hospital, the day after her rape.

"If someone comes in for a rape kit or someone comes in for anything at a hospital,” Monica said. “They need to be seen."

Under the Emergency Medical Treatment & Labor Act,  hospitals essentially have to provide access to emergency services to the public regardless of ability to pay. It’s known as the “patient anti-dumping law.” Under this act, put into place by Congress in 1986, hospitals are required to stabilize the patient. If a hospital cannot stabilize a patient with their tools and resources then a transfer is implemented.

Experts said emergency rooms across the country, even those considered top notch, aren't equipped with the dedicated staff and equipment to do these specific sexual assault exams. As a result, victims may be transported to another facility or simply sent on their way, opening victims up to potentially bail on the exam altogether.

The U.S. Department of Justice estimates 60 percent of sexual assaults go unreported to police. Victim advocates and law enforcement officers argue making emergency care more accessible and comprehensive could change that.


"The last thing we need to be doing is creating a system that ends up punishing a victim of a crime or putting a burden on the victim of a crime to get the healthcare and medical services they need," Kelly said.

State regulations
Right now, in Maryland and most other states, a local hospital unofficially becomes the designated as the "SANE Hospital.”

Goryl said, this means first responders in the community work together to transfer sexual assault patients to that facility with trained examiners. “It’s not a perfect system, but it reduces the number of sexual assault patients seen by an ER physician or nurse who has had no additional training on the medical forensic exam. It’s good for everyone when patients are seen by trained examiners.”

Research supports Goryl. More than 500 audits were completed by crime laboratory analysts on sexual assault evidence kits submitted to the Colorado Bureau of Investigation from October 1999 to April 2002.

Evidence kits collected by SANEs were more likely to have a completed chain of custody, properly sealed individual specimen envelopes, to have the appropriate amount of pubic hair and head hair, include the appropriate number of blood tubes, the appropriate amount of swabs and include a vaginal fluid slide than those collected by non-SANE professionals.

Despite this research, an analysis by E.W. Scripps Company reporters shows 10 states have laws mandated by legislation relating to SANEs and hospital service requirements for sexual assault victims. Those laws range from establishing requirements for SANEs (Vermont and Kentucky) to setting up pilot SANE programs (Illinois) to requiring counties to have SANE/SART programs or alternative solutions in place (New Jersey and Indiana).

The analysis by Scripps reporters looked at state laws mandating SANE/SART programs, SANE certification and hospital or county sexual assault response plans. Reporters found that while a lot of state attorney general offices or victims services departments had policies in place addressing the issues, most are not mandated or backed by legislation.

The analysis also found that while some states will have SANE/SART or forensic nurse committees or associations overseeing education and training requirements for these professionals, Kentucky is one of few states that has legislated a SANE credential.

In most states the credentials of a SANE are monitored by the state board of nursing and are not mandated by any state law. Almost all of the state boards or designated programs/committees look to IAFN for training recommendations and continuing education requirements.

Since Sept. 1, 2013, all Texas hospitals with emergency rooms have been required to have staff trained in basic forensic evidence collection. This training is not the same as the training required for a SANE. In Texas, having a SANE is an enhancement, not a requirement for hospitals.

To become a SANE, it usually requires 40 hours of classroom training followed by hands-on clinical training and then being precepted with a physician or qualified medical professional.

On average the 40 hours of training costs around $2,000 and continuing education will cost about $350, two years after becoming a SANE and then every three years after that, according to Goryl.

Goryl said the Texas law has, at the least, started a great conversation.

“What they did in Texas is being looked at in other states and it's getting people to look at, 'What do you mean I can't go to any hospital and get a medical forensic exam?' And that's a great question."

For prosecutors, putting an alleged rapist behind bars depends on developing a solid relationship with the victim. Through the examination process, SANEs can develop an emotional and personal connection that can provide law enforcement with valuable information, Bernstein said.

"Not only are they conducting the physical examination but they're getting information from the victim about the offense itself,” he said. “They're getting statements, narratives that tell us what happened."

For victims, the exam process and care can be very critical to their survival.

“There are so many things that can devastate you down the road and retraumatize you if they're not done properly,” Rush-Cook said. "I left wearing somebody else’s clothes and the little footies they gave me at the hospital.”

A step backward for hospitals?
While the Maryland law isn't a "one size fits all,” it is one of the first in the country to require hospitals to have a plan in place to properly respond to sexual assault victims.

Every hospital in the state has to submit their plan of action by July 1. A planning committee will review the protocols and decide whether the plan is acceptable and perhaps what recommendations for changes need to be made.

In Maryland, a hospital's protocol could be simply transporting the victim to the right location. And although everyone wants the best for the victims, not everyone sees eye to eye on the new law in Maryland.

“If that hospital is two hours away in traffic, it's not going to change things right away,” Goryl said.

"I really feel it's a step backward and right now we already have a good plan and process in place that's been working well since 2006,” said Dr. Cynthia Buchman Webb, head of the ER Department at Medstar Union Memorial in Baltimore.

Medstar Union Memorial is a hospital that typically doesn't perform sexual assault exams. They have a plan in place to complete a medical screening then provide the transportation to a designated hospital.

"Once we explain the fact of all of the resources they (the victims) have and that the best place to have that forensic exam done is with a specialist, then they understand why we're doing it and they do not have a problem,” Dr. Buchman said.

She said they only see a handful of sexual assault victims each year so changing their policies and perhaps training their own staff might not be as beneficial as continuing to send victims to a hospital specifically focusing on sexual assault cases.

"It's not so much the cost, because, again, it's a pretty rare event,” she said. “It's more the collection of that evidence. So, if you're not used to doing it, that collection of evidence and that chain of command it's very difficult to remember all of the details and all of the steps that have to take place."

Delegate Kelly says since the rape kits are federally funded, it's really no added cost to the state of Maryland. The Violence Against Women Act, reauthorized in 2013, provides some federal funds for state sexual assault programs and services.

The Iowa Department of Public Health used some funding from VAWA to update the protocol for sexual assault forensic and medical examination.

Just this year, in Colorado, Memorial Hospital, University of Colorado Health assumed responsibility of the Colorado state SANE/SAFE Project using federal funds. The project will provide statewide SANE/SAFE education to all of the programs in Colorado based on IAFN, SANE education guidelines.

For Delegate Kelly, the new law in Maryland, is a step in the right direction. A way to get the word out about where to go, or simply how to help.

"It was just incredibly frustrating for me to know that system, which wants to help people, wasn't able to do so because of these administrative and procedural roadblocks,” she said. “It was clear to me that it was the system that needed to be changed, not the people who are on the ground trying to help the folks who need help."

Goryl says the issue goes beyond just how the healthcare system is handling rape victims. According to her, forensic nurses are needed, full-time, full-staff and at every hospital.

"Forensic nurses, the skills that they have, are really universal to all victims of crime,” Goryl said. “Whether you've been hurt in a car accident, hurt by your partner, whether you've been hurt by a parent, a dog bite, a slip and fall, all of these things there's a criminal justice component and a medical component. And when you marry the two you want a forensic nurse to be there."

WMAR Investigative Reporter Joce Sterman contributed to this story.

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