Editor’s note: This article is part 1 of a two-part investigative series from Carolina Public Press.
After a sexual assault, survivors have choices to make.
Do they seek help at a hospital? If they do, they might be in for a wait.
If they are lucky, they’ve arrived at a hospital with nurses who are trained to help sexual assault victims. Called sexual assault nurse examiners, or SANE nurses, these specialized medical professionals train for months to understand how to help a victim take care of her or his health after a traumatic experience.
SANE nurses are experts at collecting and cataloging the evidence of the assault, which can be used in a criminal investigation and prosecution. They also help prevent sexually transmitted infections after an assault. SANE nurses’ training helps them provide a sympathetic ear after a tumultuous event.
However, finding a SANE nurse at the first hospital a victim approaches can be a roll of the dice. The dice are loaded in their favor if they live in a big city. In rural areas, it can be hit or miss.
“I’ve had people come in an ambulance from out of state to get care, from Virginia,” said Catherine Rossi, president of the Academy of Forensic Nursing and the forensic nursing program coordinator for Cone Health in Guilford County.
“It’s a concern. It is not uncommon, unfortunately, for a patient to present at a facility that is 45 minutes or an hour away from here. They will wait five to seven hours” for a SANE nurse.
Patients will wait, Rossi said, because a local hospital says it has a nurse, who may not arrive for her shift for several hours or may not be available at that moment.
“I’ve had a couple of experiences in the last year,” Rossi said. “We were the third facility they made it to, 17 or 19 hours after they sought care.”
But asking victims to endure an hourslong forensic examination after so much time waiting can be too much to ask.
No way to tell where SANEs are
At least 150 SANE nurses work in North Carolina, according to a Carolina Public Press survey of nearly 130 hospitals conducted over the last three months.
But the true number of such nurses in the state is unknown.
Spokespeople for nearly 40 hospitals did not respond to the survey despite repeated inquiries. Many others did not provide a meaningful response and did not answer survey questions.
A response from Vidant, a Greenville-based hospital chain that serves patients in nine mostly eastern counties, did not indicate where the hospital system employs SANE nurses, or how many, and did not say when SANE services are available throughout the week.
“Vidant has extensive protocols in place to ensure we are providing compassionate care and support for those tragically affected by a sexual assault,” Vidant spokesman Jason Lowry said in a statement.
“We continue to expand our sexual assault nurse examiner/sexual assault response team program. Importantly, all emergency medicine physicians throughout the Vidant system are qualified to examine patients and collect evidence. This requires a careful, caring approach. Vidant also partners closely with community organizations and agencies to provide support to those that have been tragically affected by sexual assault.”
Survey questions included those about hospital staffing levels for SANE nurses and what stands in the way of helping victims.
Challenges usually revolved around funding and time. It costs money to send nurses to training — to travel to the training and pay for food and hotels. Those nurses also have to take time off from work, and other nurses need to fill those shifts for them.
No SANE-certified nurses are currently employed at Cape Fear Valley Medical Center in Fayetteville, despite it seeing more than 130,000 people in its emergency department in 2018 — 12th in the nation, according to Becker’s Hospital Review.
The situation at Cape Fear is similar to some other hospitals in the state, where the emergency department nurses have some training to complete and collect evidence in the sexual assault kit.
“In most cases, victims of sexual assault do not have immediate, life-threatening injuries and may be forced to wait until the patients with more acute problems are cared for,” said Chaka Jordan, vice president of marketing and communications, in her response to the survey.
When asked what her hospital’s greatest need was to serve sexual assault victims, Jordan said there needs to be a space, away from the emergency department, that is dedicated to helping assault victims without other emergent medical needs.
“This would reduce (emergency department) crowding and prevent further stress on victims resulting from spending hours in overburdened emergency departments,” Jordan wrote.
Iredell Memorial Hospital in Statesville has three trained SANE nurses, but the hospital would need more to cover all hours of the day and night, said Rhonda Ruppe, emergency department director. If a victim comes in when none of the nurses are currently working, she said, the nurses are asked to come in.
“They are not required to come in,” but often do anyway, Ruppe said.
Otherwise, a nurse without the certification will complete an exam, or the hospital transfers the patient to another hospital with SANE services about 45 minutes away, she said.
To better serve victims, Ruppe said, the hospital would like either more SANE nurses or the opportunity to participate with another hospital to share a pool of SANE nurses. Such agreements are not uncommon in North Carolina, but a nurse pool is typically shared among hospitals under the same ownership.
At UNC Health Southeastern in Lumberton, Chief Nurse Executive Renae Taylor said in her December response that the hospital has six trained SANE nurses, with around-the-clock coverage on weekdays and an on-call nurse to cover part of the weekend.
When asked what the hospital’s biggest challenge in serving assault victims was, she said resources to support ongoing training and education for SANE nurses were lacking.
“I would like to see the county have a response team that we could call at the time the victim arrives that would come in to support staff and, most of all, the patient. If we had funds, we could have a dedicated SANE program,” Taylor said.
Nearly half of North Carolinians live in a county where a SANE nurse is available 24 hours per day, seven days per week. But that distribution is clustered largely around urban areas, an analysis of CPP survey results showed.
Neither N.C. Department of Health and Human Services nor any other state agency tracks the location of SANE nurses, nor does the state require hospital systems to employ SANE nurses. The state Board of Nursing also does not track where SANE nurses are currently employed.
Often, the only way victims find out whether a SANE nurse is at the hospital is when they arrive.
What SANEs do
While medical professionals can and do administer the rape kit to victims, the SANE nurse is the gold standard for treatment, Rossi said.
Rossi said nurses learn about evidence collection and cross-contamination when they become certified as SANE nurses. They may not understand the patterns of injuries for different types of sexual assaults.
“We’re finding evidence across the breasts and chest far more frequently that we are from orifices in some cases,” Rossi said. “Somebody who doesn’t do this as a job isn’t going to know that.”
Evidence collection is only one of a SANE nurse’s roles. From intake to discharge, nurses care for a victim’s physical and emotional health, she said.
“We know there’s a really high prevalence of suicidal ideation in these patients, and we make sure that you’re connected with community resources,” Rossi said.
“There’s a lot that goes into this, and that’s why forensic nursing is a recognized specialty.”
Lauren Schwartz, director of sexual assault services and the director of the Solace Center, located at InterAct Family Safety and Empowerment Center in Wake County, said SANE nurses know to order specific lab tests and to prescribe medication to prevent sexually transmitted infections. Time is of the essence in some cases.
“If there is a possible HIV or hepatitis exposure, we have only 72 hours to get them on that life-changing medication,” Schwartz said.
Nurses can also prescribe emergency contraception or medicine to prevent sexually transmitted infections up to five days after an assault, she said. Evidence such as DNA degrades over time. Schwartz said the state crime lab recommends all sexual assault kits be completed within five days of an assault.
But in many areas of the state, a SANE nurse is not an option. Local and nearby hospitals may not have any SANE nurses, or they may not be available when a victim arrives. The victim then has a choice. She can get the exam done where she is by someone who isn’t certified, she can go to another hospital, or she can stop trying altogether.
“That first disclosure is so important,” Schwartz said. “It impacts so much about whether they are going to go forward with an exam or go forward with getting mental health care or getting the right prophylaxis.”
When they finally arrive at a hospital that can help them, patients can also be upset, she said, not only because of what happened to them but “because this is the second or third place they’ve come to.”
SANE nurses are also hard to keep. They have to take classes to maintain certifications. The emotional cost of helping people get through the most traumatic point in their lives can take a toll. Some nurses also enter the profession hoping to help increase prosecutions and are disappointed when that doesn’t seem to be the case.
Rossi started her training to become a SANE nurse in the late 1990s.
“When I first started doing that, I was like, OK, we’re going to do this and we’re going to increase prosecutions and more people are going to jail,” Rossi said.
“And that’s really not what happened. About two years into my forensic nursing career, I took a really hard look at what was happening, and I realized I’m not going to court. I’m not testifying. What am I doing, and why am I actually doing this?”
In her reflection, she realized she wasn’t here for the prosecutors or the police.
“I’m here for my patients, I’m there to make that moment, when they have one of those horrible things that has ever occurred to them in their life, bearable,” Rossi said. “I need them to feel safe again.”
Now, Rossi is the instructor. She tells up-and-coming SANEs that they have to be there for the right reasons and that they won’t be going to court often.
“Our prosecution rate in this country for sexual assault and rape is abysmal,” Rossi said in Guilford County.
Jason Arnold, chief assistant district attorney for the seven westernmost counties in the state, said not getting called to testify means the SANE nurse is doing a good job.
“If she’s not getting called to court, the defense attorney sees nothing to cross-examine,” Arnold said. “That’s probably why she’s never been called … because she’s doing a good job, and her experience is showing in her work product.”
Toward a higher prosecution rate
Some prosecutors say they want to see higher levels of prosecution of these cases in North Carolina.
An analysis of court data by Carolina Public Press in 2019 showed fewer than 1-in-4 people charged with sexual assault were eventually convicted of that or a similar crime; the CPP analysis examined 4½ years of court data.
Rural areas fared worse than urban areas. In 38 counties, there were no recorded convictions — not even on plea deals reducing original sexual assault charges to lesser offenses.
N.C. Attorney General Josh Stein told CPP last week that victims should not have to wait for hours or drive to multiple hospitals for the first step on their path to justice. He said victims, no matter where they are in North Carolina, need equitable access to these highly trained nurses.
Conviction rates are higher when exams are performed by a SANE nurse, Stein said.
“There is a higher conviction rate,” he said, “which makes all of us, the people in the public, safer.”
A New Mexico study from the early 2000s bears this out. It examined the changes in crime reporting, kit collection and reports to police before and after a SANE program was established in Albuquerque.
Victims served by SANE nurses received “more consistent and broad health care services,” including sexually transmitted disease treatment, than those who did not have a SANE present. In addition, 72% of those served by SANEs reported the crime to the police compared with half who were not.
The study said that when a SANE nurse was present, 88% of victims had a sexual assault kit collected, compared with only 30% before the SANE program was established. Conviction rates also improved, from 57% before the SANE program to 69% after it was established.
Another study from 2006 noted that criminal cases that included evidence collected by a SANE nurse were 3.5 times more likely to result in a conviction. Mock jurors in a 2012 study also were more likely to render guilty verdicts and view the victim as credible if medical testimony came from a SANE nurse rather than a registered nurse.
The evidence in these kits is oftentimes essential to prosecutors in securing convictions against rapists, Arnold said. While other medical professionals can follow the instructions to collect the evidence, the gold standard is a SANE nurse, he said.
“In the case of a sexual assault, you’re looking for physical evidence to corroborate what the victim is telling you,” Arnold said. “Are there any scratches? Is there any bruising? Also, you are looking for physical evidence, such as the bodily fluids of the alleged perpetrator.”
SANE nurses have the training and expertise to know what to look for, he said. They also have the compassion to ease into uncomfortable topics and help victims talk with others about what happened to them.
“These are private, intimate matters,” Arnold said. With a SANE nurse, “It’s better for the integrity of your case.”
Disclosure to a SANE nurse can lead to disclosure to police, he said.
Hospitals must stabilize victims who go to emergency rooms with injuries, but in North Carolina, they are not required to perform a sexual assault kit on victims, Stein said. Those and other laws need to be examined and possibly changed, he said.
“I want to engage the legislature on this,” Stein said. “I think that we do need to change North Carolina’s laws so that they are more protective of victims of sexual assault.”
Coming Tuesday: The loss of SANE nurses affect providers and survivors in some North Carolina communities. Other states are employing models that may be more successful for ensuring access to SANE nurses, while innovative partnership programs in some North Carolina counties also offer solutions.
Carolina Public Press Special Event
Learn more about this investigation, and how the story was told, when you join us for a virtual Q&A with Lead Investigative Reporter Kate Martin on Feb. 4 at 12 p.m. (ET). Registration is free.
Christian Green and Casey Morris also contributed to this report.