Today, the U.S. House Committee on Energy and Commerce’s Subcommittee on Oversight and Investigations held a hearing on “Examining the Availability of SAFE Kits at Hospitals in the United States.” The Joyful Heart Foundation strongly supports increased funding and training for Sexual Assault Nurse Examiner (SANE) and Sexual Assault Forensic Examiner (SAFE) programs across the country, and the expansion of innovative programs to address SANE/SAFE shortages. It is critical that survivors have the most supportive experience possible as they process what may be the worst event in their lives. We were honored to be invited to submit the following statement for the congressional record:
December 12, 2018
Dear Chairman Harper and Ranking Member DeGette:
Thank you for your attention to this important matter for survivors of sexual assault.
Joyful Heart is one of the leading national organizations working to end the rape kit backlog and reform policies for handling rape kits and engaging sexual assault survivors in the criminal justice system. We thank you for taking the time to examine the issue of the availability of, funding for, and training of Sexual Assault Nurse Examiners (SANEs) across the United States.
SANE programs were created to provide treatment and care to sexual assault survivors in a way that is sensitive to their experiences of trauma, injuries, and other physical health concerns. These programs intended to provide free medical care to encourage timelier visits and more coordinated practices to treat survivors and investigate and prosecute crimes. Empirical studies examining the determinants of sexual assault case processing decisions have shown positive associations between the completion of a rape kit examination and prosecution and conviction in the United States, Canada, and the United Kingdom (Davis et al).
In many situations, a SANE may be the first person with whom a sexual assault survivor engages. How that survivor is treated has everything to do with how and if they choose to pursue a case against their assailant. As an organization that has made the elimination of the backlog our number one priority since 2010, we see the availability and training of SANEs as a critical issue that must get the attention it deserves.
About the Joyful Heart Foundation
Joyful Heart was founded by director, producer, actor, and advocate Mariska Hargitay in 2004 with the intention of helping survivors heal and reclaim a sense of joy in their lives. Today, we are a national organization with a mission to transform society’s response to sexual assault, domestic violence and child abuse, support survivors’ healing, and end this violence forever.
Our team, along with researchers and partners with expertise in this work, is at the forefront of identifying backlogs in cities across the country; advocating for funding to test backlogged kits and investigate cases; appealing for laws and policies to improve criminal justice responses to sexual violence; and working with jurisdictions to assist them to develop and implement survivor-centered reforms. Through endthebacklog.org, the first and only comprehensive online hub for information about the rape kit backlog in the United States, we are sharing best practices, progress on reform, and are offering a way for people to join this growing effort.
Undergoing a Medical Forensic Examination
Every 98 seconds, someone is sexually assaulted in the United States. In the immediate aftermath of a sexual assault, a victim may choose—or may be asked—to undergo a medical forensic examination to collect any evidence left behind in the assault. A doctor, nurse, or SANE will conduct the four- to six-hour examination, and will preserve this evidence in a sexual assault evidence collection kit, commonly referred to as a “rape kit.”
There are many benefits of testing rape kit evidence; it can identify an unknown assailant, confirm the presence of a known suspect, affirm a survivor’s account of the attack and discredit the suspect, and connect the suspect to other crime scenes. But the experience of having a rape kit exam can be an invasive and arduous experience. A step-by-step description of what happens when a rape kit is taken can be hard for people to hear. But we believe it is important that policymakers understand just how invasive this process can be, and how courageous a step it is for a survivor to endure after an assault. We believe identifying the steps below underscores how important it is that multiple, trained SANEs be available to facilitate the following:
- First, the examiner obtains a thorough medical history from the survivor.
- Then, the survivor stands on a large sheet of paper while undressing in order to catch any hair or fiber evidence that may fall from their body. The survivor’s clothing and the sheet are collected for testing of hair, fibers and any additional evidence.
- Next during a physical examination, any injuries from the attack are documented and treated, and evidence is collected. The examiner collects biological evidence, such as saliva, blood, semen, urine, skin cells, and hair by taking swabs of the survivor’s skin, genitalia, anus, and mouth, scraping under the victim’s fingernails and combing through the survivor’s hair.
- The survivor’s body is photographed head to toe to preserve evidence of bruising and injuries. When the rape kit exam is complete, the evidence collected is carefully packaged and labeled to prevent contamination.
The contents of the kit vary from state to state, but most kits include the following items:
- Detailed instructions for the examiner;
- Forms for documenting the procedure and evidence gathered;
- Tubes and containers for blood and urine samples;
- Paper bags for collecting clothing and other physical evidence;
- Swabs for biological evidence collection;
- A large sheet of paper on which the survivor undresses to collect hairs and fibers;
- Dental floss and wooden sticks for fingernail scrapings;
- Glass slides;
- Sterile water and saline; and
- Envelopes, boxes, and labels for each of the various stages of the exam.
Research has shown that more often than any other crime, law enforcement frequently does not believe sexual assault survivors or blames them,and that survivors withdraw from the criminal justice process because of how they are treated. We hear over and over again from survivors that the responses they are met with – from medical personnel, friends, family, police and prosecutors matter – and have an impact on a survivor’s healing and decision to report a rape and participate in the criminal justice process. The individual who responds to a survivor in the hospital can have a very positive impact on their well-being and decision to participate in the criminal justice process.
While any doctor or nurse can perform the examination by following the instructions provided in the kit, some hospitals have Sexual Assault Forensic Examiners (SAFEs) or SANEs to perform the rape kit examination. Research shows that programs with trained examiners significantly improve evidence collection and investigation in sexual assault cases, which results in significantly higher prosecution rates. Further, SANEs and SAFEs are trained to conduct exams that are sensitive, dignified, and reduce retraumatiza
The trauma of sexual assault can bring deep pain and suffering—physical, mental, emotional,and spiritual. We at Joyful Heart honor the process of healing and know that it looks different for each individual. Deciding what choices to make in the aftermath of an assault is a complex and deeply personal part of this process. But engaging with a trained SANE from the beginning can help ensure that a survivor feels supported, cared for, and aware of their rights, including about whether or not to pursue a case.
For example, not every survivor is advised that they can choose to skip any steps of the exam. They can also have evidence collected without choosing to file a police report, immediately or ever. A survivor can also seek medical treatment at a hospital or rape crisis center without choosing to undergo a rape kit examination. These are options we believe must be laid out for every survivor, so that they have the agency to make whatever choice is right for them.
In addition, research shows that SANE programs increase prosecution rates and conviction in the United States. The importance of properly collecting forensic evidence and the specialized treatment of sexual assault survivors by SANEs highlight how important access to exams are.
Barriers to High Quality Forensic Medical Examiners
Despite the proven benefits of SANE-performed forensic medical exams (FMEs), there is a severe shortage of SANEs and other trained examiners across the U.S. As a result, there are several barriers that prevent survivors from receiving this type of high-quality FME. In fact, many survivors who present to a hospital for an FME will not be treated by a SANE and may not even receive an FME at all. Several barriers factor into the lower rates of SANE-performed exams, including the limited number of SANEs, the limited time frame of evidence collection, the hardships related to transportation, and the costs associated with an FME.
Concentration of SANEs or Trained Examiners
There are currently not enough SANEs to treat all survivors, and SANEs are not equally distributed geographically; shortages of SANEs are more common in rural areas across the United States. As a result, patients who may already have to drive farther to access a hospital may also be less likely to receive a forensic exam performed by a SANE. A Government Accountability Office study of six states found that none had sufficiently trained examiners to meet demand for requested sexual assault exams. For example, in Colorado, the report found only one hospital that offers exams by trained professionals twenty-four hours per day, seven days per week.
The study also found high turnover rates among SANEs. In Wisconsin, out of 540 trained examiners, only 42 were still practicing 2 years later. While it is difficult to pinpoint the reason for such high attrition, examination volume may be an important factor. SANEs are required to renew their licenses every three years, and, in that time, they must have practiced as a SANE or provided clinical instruction for SANEs for a minimum of 300 hours. SANEs in the most remote areas may feel as though they are not performing enough exams for the amount of time they are dedicating to maintaining their certification, leading them to voluntarily lose their licenses.
With the current shortage of SANEs, it is not possible for every survivor to access a SANE-performed examination. This issue combined with the disproportionately high rates of sexual assault in rural communities, necessitates an alternative until there are enough trained examiners at every hospital.
Transportation
All survivors of sexual assault seeking an FME may face difficulties in traveling to a hospital; however, due to the scarcity of hospitals in rural communities, survivors in these communities may face an even greater burden. In many rural areas, patients must drive more than an hour in order to get to a hospital that will perform an FME, which may discourage these individuals from seeking an exam. Additionally, low-income women are both disproportionately likely to be victims of rape and less likely to have the resources necessary to get to a hospital with a SANE. Limitations may include a lack of childcare, a car, gas, or the ability to miss work.
Limited Time Frame for Evidence Collection
Current technology limits the timeframe in which an FME can be collected following a sexual assault, and survivors in rural areas are more likely to have to travel long distances to get to a hospital. Current DNA analysis methods often cannot produce a complete DNA profile when evidence is collected more than 72 hours post-assault. Bathing, showering, using the restroom, changing clothes, and combing hair can all damage evidence, making it harder to collect sufficient DNA to produce a full profile. When patients have to travel longer distances to reach a hospital—which may or may not have a SANE—they are more likely to need to partake in the behaviors that may damage evidence. An exam can still be performed if some of these actions have taken place, although the evidence collected may be less likely to produce a reliable DNA profile. Medical treatment has a more flexible timeframe than evidence collection, so experts encourage survivors to receive an FME, regardless of how much time has elapsed from the assault.
Cost
Cost is an additional burden to survivors of sexual assault, especially low-income women, who are less likely to have health insurance. Survivors of sexual assault with private insurance pay, on average, $950 in medical expenses for the medical treatment received with the examination. (In contrast, victims of other violent crimes do not have to pay for any of the damages resulting from the crime.) Although the rape kit itself is technically free under VAWA, the cost of the accompanying medical services can be a barrier to seeking treatment.
These barriers are not mutually exclusive. Many survivors will face some combination, if not all, of these challenges in their effort to obtain a high-quality FME. When combined, these problems may make it impossible for survivors to access the care they deserve. While perhaps the most apparent solution would be to increase the number of SANEs or decrease the incidence of sexual assaults, something must be done in the short-term to address these problems.
Approaches to Improve Care
In response to the aforementioned barriers, certain organizations have proposed innovative methods of surpassing these limitations. These approaches, which use a combination of technology and creativity, are not a replacement for SANEs; rather, they are temporary solutions to the larger problem.
Telemedicine
As technology has improved, connecting patients and healthcare professionals via video conferencing has become a promising alternative when direct access between the two is not possible. Several studies of telemedicine have identified key benefits, especially in addressing the barriers to accessing high-quality FMEs common to rural areas.
Telemedicine can connect survivors with SANEs or other trained professionals when there is not one available at the hospital in which they are receiving the exam. For example, a study that connected child sexual abuse experts with rural emergency departments through video calling found positive impacts on the completeness of the examination and the accuracy of evidence collection. These results are consistent with those showing that SANE-collected kits are more thorough and free of error than non-SANE-collected kits, suggesting that telemedicine conferencing could be effective when SANEs are not available.
For survivors who cannot make it to a hospital, telemedicine can still prove to be useful in providing medical care, including prescriptions for emergency contraception or STI treatment. Existing apps for smartphones allow patients to pay for a Skype call with a doctor in which the doctor may prescribe medications. While such technology cannot address the forensic evidence collection aspect of the FME, it could provide critical medical care for survivors who otherwise would not receive any post-assault treatment.
Although not a replacement for a SANE-performed FME, telemedicine provides a promising solution where this type of exam is not feasible. When combined, the demonstrated benefits from these studies fill in the gaps that occur when untrained healthcare professionals perform the FME. Providing a SANE through video-call to lead the exam and/or prescribe medical treatment has the potential to improve both completeness and accuracy of FMEs. These results are critical to successful prosecution and conviction.
Case Study: Pennsylvania Sexual Assault Forensic Examination and Telehealth (SAFE-T) Center
To further study the implications of telemedicine, the College of Nursing at the Pennsylvania State University is implementing a pilot program with the goal of “creat[ing] a sustainable solution to enhance access to high-quality forensic sexual assault care in underserved areas.” This program, which will operate 24/7, will provide a mentoring and support network for nurses in rural areas to connect with experienced SANEs.
The program aims to address three key barriers in accessing high-quality FMEs. First, by connecting patients with SANEs, the project aspires to offer survivors emotional and mental support during the exam. Second, by operating 24/7, the project aims to increase both the skills of clinicians and the retention of SANEs. Finally, by providing SANE-assisted FMEs, the project hopes to collect higher quality evidence and produce successful investigations, prosecutions, and convictions.
This pilot project, which opened recently on July 26th, 2017, promises to improve access to high-quality FMEs; however, further research is needed to track its outcomes and impact. Positive results would further reinforce the potential benefits of telemedicine, encouraging other hospitals to set up similar programs.
Alternatives to SANEs
Although access to high-quality FMEs is limited across rural areas, the problem is particularly acute in indigenous communities. American Indian (AI)/Alaska Native (AN) communities face disproportionately high rates of sexual assault, as one in three women and one in five men in these communities will be sexually assaulted in their lifetime, an incidence two and a half times that of the rest of the population. The need for high-quality FMEs is critical for this population; however, less than one-third of tribal land is located within an hour of a facility offering these services. This issue is further complicated by the history of oppression and exploitation of tribal populations in the U.S., which has resulted in a lack of trust in the healthcare system. This combination of high prevalence, low access, and mistrust creates a clear need for an alternative.
Case Study: Sexual Assault Forensic Examination Support, Training, Access, and Resources (SAFESTAR) Program
To address this issue, the International Association of Forensic Nurses joined the Southwest Center for Law and Policy and the federal Office on Violence Against Women to create the Sexual Assault Forensic Examination Support Training Access and Resources (SAFESTAR) program, which provides an alternative for AI/AN populations in which SANEs are not available. The community selects a woman, known as a SAFESTAR, to complete a 40-hour training course approved by the U.S. Department of Justice, the Federal Bureau of Investigation, and the International Association of Forensic Nurses. The course—which has been adapted to be culturally appropriate—provides SAFESTARs with the certifications to provide emergency first aid and healthcare referrals, give ongoing support, and perform forensic examinations, all while maintaining confidentiality. SAFESTARs are community-based, lay healthcare providers, such as midwives, traditional healers, and community health representatives. They are often trusted female figures who members of the community would typically seek out in an emergency. Due to their status as well-respected women, survivors of sexual assault are more likely to feel comfortable reaching out for an FME and the supporting resources.
SAFESTAR-collected evidence can be used in tribal, state, or federal criminal prosecutions, just as SANE-collected evidence would be. After completing the training, SAFESTARs meet with Federal, Tribal, and State criminal justice professionals to develop a protocol for transporting evidence kits to an appropriate crime laboratory. SAFESTARs may also be “fact witnesses” or “eye witnesses,” meaning they can testify in court as to what they did, saw, heard, smelled, and felt, but they can not testify as “expert witnesses.”
The SAFESTAR project was piloted on the Tohono O’odham reservation in Southwest Arizona. Before the implementation of the SAFESTAR program, there were no trained examiners and no equipment to perform rape kit examinations following a sexual assault. As a result, survivors on the reservation could not receive an FME. In addition to introducing SAFESTARs to perform FMEs, the program aimed to improve community education in Tohono O’odham nation and address the low number of tribal and federal prosecutions that were occurring as a result of a lack of available evidence.
Initial results showed that this program was a success for the Tohono O’odham population. In the first six months, rates of sexual assault reporting and referrals to physical/mental health services on the reservation increased, showing that survivors felt more comforable coming forward and getting help. Furthermore, results indicated an increased awareness of the long-term health effects of sexual violence and widespread discussion of traditional responses to sexual violence and historical trauma. These initial results show promising improvements in the treatment of sexual assault assault patients in rural areas. While SAFESTARs are not a replacement for SANEs, they provide an innovative solution where SANE programs are not currently available.
The Rape Kit Backlog
Access to medical forensic examinations is a critical issue. The biological evidence on a victim’s body by the perpetrator must be collected properly in order for it to yield a DNA profile of the perpetrator that can be entered into the DNA database. When survivors submit to a forensic exam, they do so because they are told and believe that the evidence will be used to attempt to apprehend and prosecute the offender. They are right to think so. DNA evidence is a powerful law enforcement tool to solve crimes. Yet, all too often the decision is made not to send a kit for testing.
It is estimated that hundreds of thousands of rape kits sit untested in police department and crime lab storage facilities across the country in what is known as the rape kit backlog. Each kit represents a lost opportunity to bring healing and justice to a survivor of sexual violence and safety to a community.
Experts agree that every rape kit booked into evidence and connected to a reported sexual assault should be submitted to a crime lab for testing, and that crime labs must commit to testing rape kit evidence in a timely manner. Mandating the swift testing of every sexual assault kit sends a powerful message to survivors that they – and their cases – matter. It sends a message to perpetrators that they will be held accountable for their crimes. It demonstrates a commitment to survivors to do everything possible to bring healing and justice. It is also the pathway to a more effective criminal justice system and safer communities across the country.
However, we believe special consideration must be given to unreported or anonymous kits. Law enforcement must allow survivors to decide the path to healing and justice that works best for them. It is critical to a survivor’s wellbeing that their choices about engaging in the criminal justice system are honored.
Untested Rape Kits in the United States
Joyful Heart has identified more than 225,000 untested rape kits sitting in police, crime lab or other storage facilities across the United States. And, with nearly 20 states remaining that have yet to count the untested rape kits in their possession, we anticipate that there could be several hundred thousand more yet to be discovered. Because most law enforcement agencies do not have systems for tracking or counting rape kits, we cannot be sure of the total number. That was true a decade ago, and sadly, it remains true today. Often times, the number of untested kits in a particular jurisdiction remains unknown until journalists, nonprofit organizations, or concerned citizens step in to investigate.
But that does not mean that we are not seeing reform. Joyful Heart has launched a national campaign to pass comprehensive rape kit reform legislation in all 50 states. Our campaign, now in its second year, was developed in consultation with trusted experts across the country—advocates, survivors, prosecutors, investigators, and crime lab personnel—and local, state, and national leaders. The assessment formalized six essential pillars for comprehensive rape kit reform.
In 2017, we advocated for and secured the passage of 19 laws and 4 resolutions in 18 states. This year, 15 states have passed 16 laws including one or more of our six pillars, bringing the total to 36 states. There is also one bill in New York awaiting the governor’s signature. Through the 2018 legislative successes to date, progress will be made on 62,865 kits. This is amazing progress.
Need for Continued Federal Oversight
Only when law enforcement agencies account for the untested kits in their custody can communities begin to take steps to test those kits, hold offenders accountable, and bring justice to sexual assault survivors whose cases have languished, often for years—or even decades.
The first step in this process is how a survivor is treated when he or she reports the crime and chooses whether or not to have a rape kit exam conducted. His or her interaction with a trauma informed SANE can literally make all of the difference. If the survivor is undecided about reporting the assault to law enforcement, state laws will dictate how long the kit is to be stored, either at a police station or crime lab—or in some cases, at the hospital—depending on the state’s procedures.
As a result of the proliferation of SANE programs, several outcomes related to survivor wellbeing and criminal justice processing have improved. Survivors perceive their post-assault examination process to be much more positive, sensitive, victim-centered, and procedurally just at the hands of trained examiners.
We strongly support increased funding and training for SANE/SAFE programs across the country, and the expansion of innovative programs to address SANE/SAFE shortages. It is critical that survivors have the most supportive experience possible as they process what may be the worst event in their lives. Collecting important evidence to stop dangerous offenders is a benefit to public safety as a path to safer communities.
The federal government has played a key role in helping jurisdictions address their backlogs by investing in justice for survivors, accountability for perpetrators, and safety for America’s communities. But we need your continued oversight to ensure that the job is finished, and that includes increasing the availability of SANEs in cities across the United States.
We thank you for taking the time today to examine this critical issue, and support every effort the federal government is putting forward to address sexual assault. While we are seeing a cultural shift in terms of the rape kit backlog, we do not yet see a change of the magnitude that would satisfy us. This is a multifaceted challenge whose burden is shared by many disciplines. We ask that you continue to ensure that the federal dollars disseminated through grant and formula programs to medical facilities, law enforcement (to include crime labs and prosecutors), and academia for necessary research are monitored, that clear metrics are reached, and transparency and accountability are reinforced.
Many members of the Committee represent states where reform is not yet fully realized. Representatives and their staff can use our interactive map to get the latest information about the status of the backlog and reform efforts in their state at: http://www.endthebacklog.org/backlog/where-backlog-exists-and-whats-happ…. We welcome the opportunity to work with your offices to identify how we might leverage your advocacy to move this work forward.
We look forward to continuing our work with you until every sexual assault survivor has access to a trained forensic examiner, every backlogged rape kit has been tested, and every state has enacted comprehensive rape kit reform, so that no matter a survivor’s zip code, the standard of care is the same. The stakes are too high to strive for anything less.