Thursday, March 29, 2018
Hospitals are too cheap to train nurses to care for rape victims
The myth is that if only people knew about a particular problem, it would be halfway solved.
The reality is that the status quo has an inertia, that change is hard, and outrage tends to fade.
The Tribune ran an article this week about how few nurses in Illinois are trained to handle rape kits. I read it with interest, because I wrote a similar article six years ago. It isn't the sort of piece I usually write, but the issue is particularly galling, and the attorney general's office was unusually helpful—Lisa Madigan wanted this fixed. The paper gave it prominent play. Maybe the Tribune will have better success in lighting a fire under the public and the medical profession. But I'm not holding my breath.
After Katie Feifer was raped at knifepoint by a man who pushed his way into her Oak Park home, her assailant tied her up in the basement and left.
She freed herself and called police, who took her to the emergency room at West Suburban Hospital.
"It's funny how vivid the memories are, even after all these years," Feifer says of her treatment after the 1988 attack. "A resident came in, and had this rape kit, and started opening envelopes and vials. He was fumbling around and he was very, very nervous. He did a pelvic exam, and kept apologizing. 'I'm sorry I have to do this. I'm sorry. I'm sorry.'
"I remember feeling I had to comfort him and make him feel OK. This guy was supposed to be examining me and helping me, and he didn't know what he was doing."
There is no shortage of jarring rape statistics.
Illinois State Police data reported 5,300 rapes statewide last year - more than 14 a day - though experts believe the actual number is triple that. Most go unreported, in part because the majority of rape victims are children - 54 percent, according to the Illinois Attorney General's office.
Another reason rapes go unreported is that the process of seeking medical care after a rape can itself be traumatic, since the vast majority of nurses at most hospitals fail to undergo the training needed to properly treat a rape victim.
Even though in Illinois such training is free through a program called SANE, or Sexual Assault Nurse Examiners, a course designed to teach nurses to handle sexual assault cases and make sure they are paired with victims as they arrive at the hospital.
Of the more than 200 hospitals in Illinois, how many fully participate in the SANE program?
"The baseline we're at is two programs, for the state, where a victim is guaranteed to have a specially trained SANE," said Shannon Liew, SANE coordinator at the Attorney General's office.
The two are Advocate Condell Medical Center in Libertyville and Carle Foundation Hospital in Urbana.
Two hospitals and neither is in Chicago. The other 200 don't take part because the training takes too much time, and, in the hospital's view, not enough people are raped to justify the trouble.
"There's just not a community need for it," said Michelle Ruther, emergency department nurse manager at Loyola University Medical Center's Emergency Department. The Loyola ER has 80 nurses; two have SANE training.
"We don't get the amount of rape cases here you'd think," she said. "The program itself is nice. You go through how to talk to these people, to help with the grieving process. It's a really great program, and we'd love to have it at Loyola if they could make the requirements less stringent."
Hospitals in other cities manage to run SANE programs.
"Milwaukee has a SANE program, Los Angeles does, Houston does, Indianapolis does," said Liew. "The reasons we hear from hospitals is that one hospital might get 40 victims a year, and they say we can't create a program around 40 patients. I believe every single patient every single time deserves the best possible care they can at a hospital."
The SANE training takes 40 hours: 24 in a classroom, 16 online.
"A lot of time, to send nurses for a whole week," said Edward Gutierrez, in charge of patient care management at the adult emergency department at the University of Chicago Medical Center. "It's a huge financial commitment."
And that is just the formal training; to be certified, a nurse needs to put in hours more of clinical training: pelvic exams, courtroom observation.
But without training, an ER nurse who might have never administered a rape kit has to figure out what to do on the spot.
The kits are designed to collect evidence. There are complicated instructions, and the nurse must guide the victim while she or he—10 percent of rape victims are male—disrobes over a plastic mat.
"When you are a busy ER nurse and you are untrained, it's very difficult to read through all the instructions while you are trying to do this exam and then get through your other three or four patients," said Liew. "But that is what happens. Sometimes nurses are actually reading the instructions in front of patients, if they are untrained, or they skim the instructions and do the best they can."
Untrained nurses contaminate evidence. They scoff at rape victims. "They literally can say things like 'I don't know if this person was really assaulted,' " said Liew.
Training is so spotty that volunteers try to fill the gap.
"Our advocates step in to navigate the situation," said Sharmili Majmudar, executive director of Rape Victim Advocates, which works with 11 Chicago-area hospitals. But advocates are not trained nurses.
"Having a SANE nurse is extremely important," Majmuder said, pointing out that not only is the nurse treating the patient before them, but also is gathering evidence that could help prevent future rapes.
"It's connected to overall public safety," she said. "It really does make a difference when it comes to the criminal justice piece, absolutely. The SANEs are in a position to make sure the kit is completed. They're available as an expert witness, to testify. How victims are responded to makes a difference in what victims do, whether or not they choose to report the rape to the police."
"SANEs are seen as that critical link between the survivor and putting forward a case, because you are also trained to testify," said Natalie Bauer, a spokesperson for the Attorney General's office.
The program began in Memphis in 1976. The first pilot program in Illinois started in 1999 at Carle Foundation Hospital, which still runs it.
"One of the things a lot of hospitals have missed is that you have to have someone that coordinates the program," said Patty Metzler, SANE coordinator at Carle. "We've incorporated it into our staff, which makes a difference."
"It takes a hospital commitment, it absolutely does," said Jody Jesse, director of emergency medicine at Condell, the other Illinois hospital in the SANE program. "The second issue many hospitals face is, you need physician support."
Lack of this coordination keeps most of the 650 or so nurses who have had SANE training from using their skills—their hospitals don't have a system to call them when rape victims arrive.
Metzler said that though the training takes time, SANE "actually saves the emergency department time, because when we have a sexual assault come in, we have somebody who can do it. It doesn't take hours and hours. The doctors don't have to disrupt their whole practice. Our physicians love it. Police officers love it because they know they're not going to be here for hours and hours. Our administration has supported it since 1999. We have really good results, really good feedback."
As with any hospital that emphasizes a medical speciality, running a SANE program draws patients. Carle saw 125 rape victims last year, more than were seen by the University of Chicago Medical Center.
"This gets repaid by the state," said Majmudar. "The Sexual Assault Survivors Emergency Treatment Act—SASETA—governs what the victims' rights are. One thing we run into is hospitals that didn't even realize they were supposed to comply with SASETA."
When Lisa Madigan took office as attorney general in 2003, she began to learn more about the program.
"It sounded like a no-brainer," Madigan said. Her first priority was getting the rape kits tested—it doesn't matter how skillfully evidence is collected if the police crime lab lets it sit unexamined for years.
"Two years ago, we passed this bill ensuring that all rape kits are being tested by state police," said Madigan.
Only recently has she realized how neglected the SANE program is.
"And I'm talking to people about the training, they're giving me feedback, and they say, we need to let you know, virtually none of us become certified," Madigan said.
Of the 650 nurses with SANE training, only 75 completed the follow-up component of clinical work and courtroom observation.
"I was really drop-jawed in front of these nurses," said Madigan. "I said, 'You're kidding me?' "
Last summer, the Attorney General's office announced a goal of trying to bring 15 more hospitals into the SANE program.
The good news is that hospitals are realizing the importance of SANE. The University of Chicago plans to put the program in place.
"This is a program we would like to start," said Gutierrez. "Our goal is to have SANE nurses on the unit 24/7. Evidence shows greater prosecution rates, more compassionate care to patients."
"We have taken anti-violence as one of our big umbrella projects," said Vikas Ghayal, U of C's director of emergency services. "We really are taking on, as a hospital, this concept of trying to end violence in the community, and this is just one component."
"It's really the right thing to do for these victims," said Jody Jesse. "The bottom line is hospitals, to me, have a certain commitment to their community. This is the right thing for the community."
The man who attacked Katie Feifer was arrested within three hours, pled guilty and spent 15 years in prison. He got out, murdered a hotel worker, and is currently serving life without parole in Nevada. Feifer lives in California and is research director for The Voice and Faces Project, which encourages survivors to talk about their experiences.
"I'm happy to talk about what was done to me," she says. "Survivors need to tell their stories in order to change public policies about rape."
—Originally published in the Sun-Times, Feb. 5, 2012