When a woman walked into Baptist Health’s hospital in suburban Louisville last year and said she’d been raped, the hospital did what they usually did: started calling around to see if there was another hospital they could send her to.
Since Baptist Health didn’t have a trained sexual assault nurse examiner (SANE) available, nursing director Denise Carter said the woman would need to go to another hospital to get a forensic sexual assault exam.
“Just to see the trauma and how distraught she was, and then to have to say, ‘I’m sorry, we have to send you to another hospital in the community,’ it just felt really wrong,” Carter said.
It was wrong.
Kentucky state law requires emergency rooms to perform forensic sexual assault exams on-site and free of charge. It’s intended to ensure victims can get a forensic exam no matter which hospital they report to. But nurses, advocates and survivors say the response at Kentucky’s hospitals is unpredictable.
A KyCIR investigation found the majority of Kentucky hospitals don’t employ a SANE nurse, and several hospitals, including Baptist Health Louisville, have used the lack of SANE nurses as a reason to send patients elsewhere. But a doctor, advanced practice registered nurse or physician’s assistant can perform the exam.
“I don’t know that I would have had the courage to get up from one hospital and go to another,” said Meghan Wright, an advocate and member of the Attorney General’s Survivor’s Council.
After Wright was sexually assaulted in 2006, a friend convinced her to go to Murray Calloway County Hospital to get checked out. She was treated by a SANE nurse, who took photos, asked personal questions and took DNA samples.
The exam was dehumanizing, she said. But she also remembers feeling like the SANE nurse was fully focused on her. She was not made to feel like an inconvenience.
“I don’t know that survivors should be asked to have the courage to make that decision twice in one day,” Wright said. “It’s not fair.”
Some Hospitals Turn Patients Away
In late August, the Office of the Attorney General announced a video training intended to help hospitals improve treatment for rape victims.
“It’s 2 a.m.,” the narrator says. “Your emergency room is already busy when a patient arrives seeking help after a sexual assault. Do your medical personnel know how to provide appropriate care?”
Appropriate care starts — “first and foremost” — with always providing forensic exams, even if the facility doesn’t have specially trained staff, the video says.
The video was produced by the Kentucky Association of Sexual Assault Programs, along with the Kentucky Hospital Association, and funded through the Office of the Attorney General. It walks healthcare providers through the process, and acknowledges that doctors may be unfamiliar or uncomfortable with the sexual assault exams, which include medical treatment, documenting injuries and gathering evidence for a rape kit.
But they have to conduct the exams anyway.
“Some hospitals consider having a SANE to do the exam as the higher level of care, and if they don’t have that higher level of care, they should be sending [victims] someplace else,” said Eileen Recktenwald, the executive director of the Kentucky Association of Sexual Assault Programs. “There was a lot of misunderstanding on the part of hospitals, so we tried to address that.”
At Baptist Health Louisville, one of Kentucky’s largest acute care facilities, Carter said the doctors weren’t comfortable conducting the forensic exams, and she respected that. She didn’t know Baptist Health Louisville was violating state law by sending patients away.
But the experience moved her to act.
She got Baptist to pay for four nurses to do the weeklong SANE training. The hospital now has two SANE nurses able to do the exams, Carter said. Two more are nearly done with the certification process, Carter said, and then the hospital will have a SANE nurse available around the clock.
“It’s tough [for victims] to admit that this happened,” Carter said. “So then for us to turn around and say, ‘Well, we have to send you elsewhere,’ we just don’t like that at all.”
That’s exactly the situation the law is intended to prevent, particularly in rural areas where the nearest hospital might be far away.
KyCIR found that SANE nurses are working in just one-third of Kentucky’s 120 counties. Hospitals in 17 counties didn’t return calls, but state data indicates most of them likely don’t have SANE nurses either. Many of the state’s SANE nurses are clustered at a few hospitals, leaving large swaths of the state without that specialized care.
That leaves other healthcare providers to perform the exam — or to illegally discharge patients to another location.
Advocates told KyCIR that confusion about the law and hesitation on the part of healthcare providers can have the same effect on victims as hospitals that explicitly sent them away.
Recently, Jillian Carden was at a hospital with a victim and saw firsthand how hospitals can discourage patients from seeking treatment. Carden is the executive director at Silverleaf, the rape crisis center in Elizabethtown that serves eight surrounding counties. State regulations require hospitals to request an advocate from the local rape crisis center when a victim discloses a sexual assault.
Carden declined to name the hospital, since her work requires maintaining good relationships with area hospitals.
She said hospital staff told her and the victim they were calling around to find a SANE nurse who could do the exam. They waited. Hours later, a physician came in and suggested the woman go to a different hospital, Carden said. The doctor asked if Carden could take her there. She explained that she could not.
“When the victim finally said, ‘I don’t have a means to get there,’ the physician kind of reluctantly said, ‘Okay, well, we’ll do this,’” Carden said.
In the end, Carden said the exam went fine. The doctor’s bedside manner was exceptional. She just wished they’d had that attitude from the beginning.
“If you’re met with victim-blaming statements, limited support, no resources, and then you add in the exam, you’re probably going to leave with a sense that this was all too much,” she said. “And the sense that, ‘I don’t ever want to experience that again. I just need to keep this to myself.’”
Nurses On-Call 24/7
SANE nurses are considered the best option for treating sexual assault victims, both because they’re specially trained in trauma-informed care and it avoids tying up a physician for the hourslong process.
But Kentucky has what Recktenwald calls a “SANE shortage,” and many hospitals have few or none of these specialized nurses.
Half of the hospitals with SANE nurses on staff or on contract told KyCIR they rely on just one nurse to respond to all calls, according to KyCIR interviews with 79 of Kentucky’s 97 acute care hospitals.
And sometimes, multiple hospitals in different counties rely on the same nurse.
Rhonda Sims is currently the only SANE nurse serving two hospitals in north-central Kentucky: Fleming County Hospital and Meadowview Regional Medical Center in Mason County, about half an hour’s drive away from each other. She’s a nursing professor and works for the hospitals on contract.
Sims got the certification 14 years ago, after reading a story in the newspaper about a rape victim being turned away from a hospital. She’s been shepherding victims through the process ever since.
“I want them to know that they’re safe with me,” Sims said.
Sims said her caseload is manageable. She says she sees 12 to 15 patients a year for sexual assault exams at Meadowview, and fewer than five a year at Fleming County.
But other SANE nurses say the burden of working solo burned them out.
KyCIR sent a survey to all of the state’s 290 certified sexual assault nurse examiners. That survey showed at least 10 percent of Kentucky’s certified SANE nurses are not actively practicing.
Multiple respondents cited the long hours, lack of extra pay for extra work and minimal institutional support as the reasons they stopped performing the sexual assault exams.
Michelle Grise was the only on-call SANE nurse at Trigg County Hospital in western Kentucky for most of the three years she worked there. She was already certified when she started at the emergency room in Cadiz, and she became the on-call SANE nurse “by default,” she said.
Grise was on-call for these exams 24/7. At the same time, Grise was the chief nursing officer, a mom and in the midst of becoming a nurse practitioner.
She only missed one exam, while she was out of state. But she still called the ER nurse to help her prepare.
Since she was salaried, she did not get paid extra to come in on her off-hours to do the exams.
“It could be a bit stressful if I was awake all day and then I’d get called in, and then spend six or seven hours in the middle of the night doing the exam,” Grise said. “But somebody needs you and you’re the only one who can help. You just get it done.”
Grise left Trigg County earlier this year to focus on school full-time. A spokesperson said the hospital has a few SANE nurses they can call to do the exam as needed, but doctors do it if they’re not available.
Asked if she felt relieved to have her free time back, Grise said no.
“I feel guilty,” she said.
When Costs Burden Hospitals, Nurses Pay
Becoming a certified SANE nurse requires a substantial commitment: a 40-hour class that costs about $250, and clinical requirements that include meeting with police, observing a trial and practicing genital exams.
Nearly half of the 61 nurses who answered our survey questions about training costs said they paid for the class and certification out of their own pockets. They also largely weren’t given paid time off, which exacerbated the cost.
Melissa Gilpin, who coordinated and taught SANE trainings for the Kentucky Association of Sexual Assault Programs until recently, said it wasn’t unusual to have nurses sign up and pay the tuition themselves, only to drop out when they learn their employer wouldn’t give them the time off.
Removing a nurse from regular shifts for a week can be difficult for a struggling community hospital, according to Donna Meador, the director of the Kentucky Hospital Improvement Innovation Network with the Kentucky Hospital Association.
“We’d love to see some source of funding for that, because for some hospitals, it’s not financially feasible for them to be able to provide that,” Meador said.
Hospitals are not incentivized to take on these costs; the reimbursement from the state’s crime victims’ compensation fund is up to $200 for the provider’s time, plus additional reimbursements for the medical procedures and other aspects of the exam.
But research shows that the value of employing SANE nurses extends beyond the hospital’s walls. Communities with SANE programs see an increase in prosecution of sexual assault cases, according to Rebecca Campbell, a professor of psychology at Michigan State University who researches how legal and medical systems affect victims of sexual assault.
“They are very skilled at knowing where and how to collect that evidence correctly,” she said. “That is instrumental for police and prosecutors in being able to build a good investigation and in securing [high] conviction rates.”
Victims treated by SANE nurses also can see better health outcomes: they report lower rates of post-assault anxiety and distress and are more likely to be connected with resources that prevent pregnancy and sexually transmitted diseases, Campbell said.
Several Kentucky hospitals have decided the investment is worthwhile, if not profitable.
Investing In Special Training
Many of the state’s SANE nurses are clustered at a few hospitals that have invested heavily in hiring, training and retaining them.
Hospitals in Louisville, Lexington, Pikeville, London, Elizabethtown and northern Kentucky have built robust rosters of SANE nurses that are able to perform forensic sexual assault exams 24 hours a day.
“We’re not really a moneymaker,” said Jill Brummett, the forensic nurse manager for the St. Elizabeth system in northern Kentucky. “The hospital eats the cost because they know it’s a necessary service.”
Brummett leads a team of 20 SANE nurses that respond to five emergency rooms in northern Kentucky. She said they have provided a SANE nurse for every patient who has needed one since the program started in 2002.
The hospital pays for the nurses to get the training, and time off for the class. In return, the nurses commit to being on call 24 hours a month. They recently started paying the nurses an on-call rate whether or not there is an exam to be done.
The funding comes from the hospital, its foundation and grants generated by the hospital’s grant writers, Brummett said.
“Our budget is probably always in the red, but they don’t ever say anything,” she said. “Part of our mission at [St. Elizabeth] is to have one of the healthiest communities in Kentucky, and this is part of that.”
University of Louisville Hospital has 18 SANE nurses, and coordinator Amanda Corzine says she knows that’s not something every hospital can replicate. To that end, Corzine is trying to build a consortium to share SANE nurses among all the city’s hospitals. Her nurses already respond to the Center for Women and Families as needed.
Beyond that, SANE access in Louisville is not universal. Jewish Hospital and Sts. Mary and Elizabeth Hospital don’t have any, for example. One full-time SANE nurse serves the entire Norton Healthcare system on-call 24/7, although a hospital spokesperson said they have seven additional SANE nurses on staff.
“I don’t think the burden should be on the victim to know what hospital to show up at,” Corzine said.
Demand Follows Good Care
In KyCIR interviews with hospital administrators and nursing directors around the state, many said they don’t see enough demand to have SANE nurses on staff.
“We’re such a small, rural facility, the frequency in which we see those situations, thankfully, is so low, we don’t feel [SANEs] could stay competent in their skills,” said Doug James, chief nursing officer at Caldwell Medical Center in Princeton.
James said the emergency room physicians conduct exams for sexual assault victims a couple of times a year.
Other hospitals said a single SANE nurse is sufficient in their communities.
“We don’t have those problems in Fleming County, knock on wood,” said Brian Springate, the CEO of Fleming County Hospital, where Sims is the on-call SANE nurse. “It’s very, very uncommon that we have to utilize that service, though it is something you do want to be able to provide.”
But the U.S. Department of Justice estimates that more than 75 percent of rapes go unreported, and experts say this attitude can become a self-fulfilling prophecy that allows hospitals to ignore a very real problem in their backyard.
“Maybe you see one a year in your ER because the people in your community aren’t comfortable coming there for this,” said Gilpin, the SANE educator. “Or maybe they do come and then they opt not to have an exam because they’re not given resources, and they don’t feel confident in the care that they’re going to receive.”
And one hospital that has built and promoted a SANE nurse program has seen the opposite — more and more rape victims willing to come and ask for an exam.
Hardin Memorial Hospital in Elizabethtown began investing heavily in a SANE nurse program in 2015. They sent nurses to training, developed a 24/7 on-call schedule and, during the hospital’s recent renovation, built two exam rooms specifically for sexual assault victims.
Director Sarah Tovar said her goal was to see the number of exams increase: not because there were more victims of sexual assault, but because more people knew about their program.
“We want to get out to the community that, ‘Hey, we’re here, we will give you these services. We want you to report,’” Tovar said.
In the program’s first year, they saw 48 sexual assault victims, which was a typical load for the hospital.
Last year, Tovar said, they provided exams for 122.
Correction: The Norton Healthcare system has one full-time SANE nurse on call 24/7, and seven additional certified SANE nurses on staff. A previous version of this story said they had only the on-call SANE nurse.
Jewél Jackson contributed to this report. Contact Eleanor Klibanoff at firstname.lastname@example.org or (502) 814.6544.