Two hospitals partner to restore local access to sexual assault exams

SANE solution

In this file photo from 2012, a man holds a sign in support of the RACS Foundation's "Walk A Mile in HER Shoes" event to raise awareness for victims of domestic abuse.
In this file photo from 2012, a man holds a sign in support of the RACS Foundation's "Walk A Mile in HER Shoes" event to raise awareness for victims of domestic abuse.

In the 1960s, Sue Carrol and her sister were sexually assaulted by her father in a small town outside of Jefferson City. The stigma of the crime often deterred victims from seeking justice.

But that stigma or any other obstacle that exists to impede the recovery of a rape victim or the prosecution of the offender shouldn't exist today, she said.

"When children are sexually assaulted, they are powerless because of their age and economic status," said Carrol, now a sexual assault advocate. "Having a rape kit accessible in the community can be a segue to recovery for any victim."

For three years before October 2016, a victim of a sexual assault or rape in Jefferson City or Cole County couldn't have a rape examination performed at local hospitals. No nurses were trained to do the examinations. Now, 14 nurses from the two hospitals have been trained as Sexual Assault Nurse Examiners (SANE) so rape examinations can be conducted locally, starting in June.

 

How prevalent are sexual assault cases?

In 2015, 91 victims were raped or sexually assaulted in Jefferson City and the surrounding areas, according to a recent community needs assessment report conducted by St. Mary's Hospital and Capital Region Medical Center.

Thirty-four of those cases were reported by the Cole County Sheriff's Department, and 72 calls pertaining to a sex crime were taken by the Jefferson City Police Department (JCPD). Campus officials at Lincoln University reported two cases of sexual assault during the 2015-16 school year.

Of the 72 calls to the local police department, only 55 rose to investigative status, based on the community needs assessment. All of the cases reported to the sheriff's department and Lincoln University rose to investigative level.

Capt. Doug Shoemaker of the JCPD told the News Tribune a variety of things can cause a case not to be investigated.

"Every case is unique," Shoemaker said. For example, he continued, "The victim can refuse to cooperate. The alleged act was consensual in nature. It occurred in another jurisdiction or it was not really a sex crime, but rather an assault. Many times, we respond to something, and it turns out to be something all together different."

When a rape occurs and the victim chooses to prosecute, inadequate access to SANE nurses can make prosecution of an offender more difficult, prosecutors said.

In this day and age, a defense counsel expects to have a rape kit, said Meghan E. Woolery, assistant prosecuting attorney in Cole County. When you don't have a rape kit, that has to be explained in the courtroom, she said.

During a community stakeholders' meeting last year, JCPD emphasized the importance of keeping the victim in mind in sexual assault/rape cases, and having the ability to provide consistent, reliable counseling services, housing and placement, and attention to their medical needs.

The department also acknowledged the need to address sexual assaults and to provide strong prosecution efforts against offenders through collaborative effort of law enforcement and prosecutors.

Woolery agreed, noting sexual assault is scary and a crime that's hard to prove; access to a rape exam can certainly help a victim in his or her case.

"Not having a rape examination available locally is definitely an obstacle for victims," Woolery said. "It can definitely have a negative impact because some people don't have the resources to travel 30 miles away or down to the Lake."

 

What happens when a rape is reported?

Once a victim of a sexual assault or rape files a report with police, the victim has the option to seek help from a medical professional and/or to call law enforcement. If a person chooses to call law enforcement, a rape examination is conducted and collected as forensic evidence of a crime.

"It's always up to a survivor to determine what is best, but if they do want counseling or other services they can be referred to a local member program like the local Rape and Abuse Crisis Center (Service)," said Jennifer Carter-Dochler, public policy coordinator at the Missouri Coalition Against Domestic and Sexual Violence.

Victims are typically taken to the hospital within 72 hours, the recommended time frame when any bruising or evidence is present, said Lt. Kevin Woodson of the Cole County Sheriff's Department.

Because local hospitals didn't have trained SANEs on staff until October 2016, the police department offered to escort victims to hospitals in Columbia or Osage Beach. Victims also can choose to have a family member or friend take them to the hospitals more than 30 miles away.

"While we have not had a SANE nurse routinely staffed in our emergency department for a number of years, we have always worked in collaboration with law enforcement, the victim of assault or other institutions to properly manage patients' medical needs," said Janet Wear-Enloe, director of business and marketing at St. Mary's Hospital.

In Missouri, 19 nurses hold SANE-A certifications, which focus on adolescents and adults; 12 nurses hold SANE-P certifications, which focus on pediatric patients, said Sally Laskey, chief executive officer at the International Association of Forensic Nurses.

She noted the number of certifications does not mean the number of people who are certified; one person may hold both certifications.

SANE training is provided by the International Association of Forensic Nurses, and costs associated with the training are different for adults certification and children certification.

Leslie Briggs, registered nurse and SANE coordinator at MU Health, reassures victims that the hospitals have options.

"If hospitals don't have SANEs, they have the option of transferring patients to a facility that does or has an attending physician who can conduct the exam."

In Columbia, the University of Missouri Health Care hospitals employ 13 trained SANE nurses who are available 24/7. Lake Regional Health System in Osage Beach currently has six SANEs available 24/7 and is in the process of training two more.

In 2016, MU Health Care conducted 130 forensic exams and Lake Regional reported 146 SANE cases in the emergency department, which includes child abuse, sexual assault, rape, elderly abuse and domestic violence cases.

SANEs work one on one with patients, Briggs said, and the administration of the rape exam can take anywhere from two to six hours, depending on injuries and how the victim is handling the encounter.

Woolery said adolescent victims treated at Lake Regional Health System had a Sexual Assault Response Team involved to help schedule forensic interviews, as well as contact a child advocacy center, law enforcement and potentially the Missouri Department of Social Services Children's Division, if necessary. These are some of the stakeholders that would be involved in a community-based SANE model.

"The need to have nurses trained (in Jefferson City) in such a manner will greatly aid the ability of law enforcement to pursue prosecution against offenders," the police department said. "A consistent SANE nurse should be made available within our community, 24 hours a day, seven days a week."

Officials from both hospitals said they plan to implement a community-based SANE model that includes both hospitals, the United Way of Central Missouri, the Rape and Abuse Crisis Center, JCPD, Cole County, as well as outside funding sources that can help sustain the program.

 

A local solution

There's no simple explanation as to why the SANE programs at Jefferson City's two hospitals were not sustainable in the past, said Wear-Enloe and Lindsay Huhman, director of public relations at Capital Regional Medical Center.

"Through natural attrition, nurse movement across departments or through elevating their licensure, SANEs moved into different roles, and there was not additional staff trained to fill the roles," Huhman said. "While both hospitals did not have SANEs, we fully cooperated with law enforcement and conducted sexual assault exams as our staff have training - however, not to the level of a SANE."

But in October 2016, St. Mary's and CRMC partnered to resolve the absence of SANE-certified staff. CRMC hired Janetta Carr as an on-call SANE, and soon there will be 14 SANEs on call.

As of May 12, 14 local nurses were trained to be SANEs - at no cost to them - at an SSM Health facility in St. Louis.

"Having sexual assault nurse examiners 24/7 in collaboration with both hospitals is a new level of service that will offer specialized training and skills to support the forensic component of the care for sexual assault patients in our community," Wear-Enloe said.

Angie Boessen, registered nurse at St. Mary's, has been interested in SANE for about 10 years but had never heard much about this type of nursing locally and assumed it was a "big city thing," she said.

During the five-day training session, Boessen and 13 other nurses completed 40 hours of training, which allows them to conduct the rape exams, complete the appropriate documentation, and help with the interviewing process victims undergo.

Boessen is trained specifically to conduct exams on adult victims age 14 and older. She noted teens ages 14-16 who are not sexually active are examined by pediatric SANEs, which requires a separate training.

"One out of six females is assaulted in their lifetime, while one out of 33 males experience an attempted or completed assault," Boessen said. "Our community is not immune to these statistics, and I think this will be an asset to Jefferson City."

She emphasized that the SANE training has prepared her to deal not only with sexual assault victims, but with anything the police may need to help with forensic evidence including domestic violence, suspect exams and gunshot victims.

Access to SANE training became a priority for the Jefferson City hospitals in the spring of 2016 after teaming up with law enforcement, crisis service advocates and other community partners to conduct a community needs assessment that revealed the need for a community-based model to enhance their coverage for victims of sexual assault/rape in the community.

"Sexual assault and domestic violence are still very taboo subjects in this day and age, but they happen, no matter how much people wish they didn't or want to ignore the subject," Boessen said.

The committee's objective was to develop sustainable and reliable SANE resources in Jefferson City so patients do not have to leave the community for care after they have been sexually assaulted.

Over the past year, the hospitals and community stakeholders said they have learned that SANE nurses need to provide a minimum of 10 forensic exams per year to retain certification. If a lesser number is done, the nurse must be retrained.

Upon agreeing to be trained as a SANE, St. Mary's and CRMC plan to have SANE nurses at each hospital work full time in other departments and serve as an on-call SANE as needed.

If a trained nurse leaves the hospital, another nurse must agree to be trained to keep the call system working effectively, Wear-Enloe said. The hospitals will ask nurses to step forward if they wish to participate in the SANE program.

St. Mary's and CRMC's goal is to establish an ongoing community-based program that involves Jefferson City, Cole County, the United Way of Central Missouri, both hospitals, and the Rape and Abuse Crisis Service, as well as outside funding opportunities through grants and/or fundraising to sustain the ongoing program.

"When someone experiences this kind of trauma, it important for the community to have a comprehensive plan with law enforcement, rape advocacy centers and the hospitals," Carter-Dochler said.

Once the SANE program is in full cycle, both hospitals will employ SANEs. The newly trained sexual assault nurse examiners will go to the hospital where the victims are present. The hospital that employs them will pay them regardless of where the exam is performed.

Huhman said law enforcement will direct the victim to the hospital of their choice or to the closest facility.

"We anticipate starting the community-based SANE program at both hospitals beginning in June," Wear-Enloe said. "Patients may present to either local hospital emergency department and a trained SANE nurse will provide care through a cooperative call program established by both hospitals."

When living in a place where there is not a lot of rape cases, like Cole County, Woolery said, it can be hard for anyone to respond because it's new and they don't quite know how to do it.

"Having a community-based model and having people dedicated to responding to sexual assault is really important, and I hope this is something that develops in the community because it is helpful and supportive element," Woolery said.