Editor’s note: This article is Part 2 of a two-part investigative series.
Carolina Public Press is an independent, in-depth and investigative nonprofit news service for North Carolina.
For years, if sexual assault survivors in Cumberland County sought care, they could count on going to Cape Fear Valley Medical Center in Fayetteville, where the hospital’s highly trained and certified sexual assault nurse examiners would provide treatment and gather the forensic evidence needed for law enforcement to build a criminal case against their attacker.
About a year ago, advocates for sexual assault survivors noticed a staffing change, said Deanne Gerdes, executive director of Rape Crisis of Cumberland County.
“We’re going to the emergency room … and ER nurses, not SANEs, were doing (rape) kits,” Gerdes said. “Which, I get by law, a regular ER nurse can do that, but there’s so much more into a rape kit that they need to be trained on.”
SANE nurses provide comfort during what may be the most traumatic events of a person’s life. They know to provide emergency contraception, to look for hidden injuries and to prevent HIV and hepatitis from taking hold. They guide victims to resources if they are being abused or trafficked. Many victims are also suicidal after their encounters, and the SANE nurse knows to look for that, too.
Prosecutors consider the work of a SANE nurse the gold standard in evidence collection for criminal cases, but not every county has a hospital with a certified SANE nurse, a Carolina Public Press survey of 130 hospitals and community programs shows.
The survey asked hospitals whether they had a SANE nurse program, how many certified SANE nurses worked there and when SANE services were available.
When told that Cumberland County’s Cape Fear Valley Medical Center said it did not have any SANE nurses in its November survey response, Gerdes paused for a heartbeat. Then another.
“How can they not have? How?” she then sighed. “What it used to be is, we had a SANE program. … There was always 24-hour coverage. It was a team effort, between law enforcement, advocacy, health care and the DA’s office. It was a great team.
“I knew it was bad,” Gerdes said. “I didn’t realize that the number was zero.”
Advances made in recent years
Not long ago, North Carolina had the nation’s largest backlog of untested rape kits. Throughout the state, nearly 16,200 untested kits (revised upward from around 15,000 kits, after a more recent accounting of untested kits) sat in police departments, hospitals and universities — some for decades.
North Carolina lawmakers changed the law to require tracking for all sexual assault kits. Victims who choose to pursue justice through the legal system can track theirs on a state website to view the status of their kit to see if it has been tested by the state crime lab and whether law enforcement has received the results.
In 2019, state Attorney General Josh Stein and several lawmakers unveiled a plan to eliminate the rape kit backlog and create new deadlines for testing them. Lawmakers approved millions of dollars to eliminate the backlog. Thousands of kits, each one representing a deep violation from a moment the victims cannot forget, were unearthed, cataloged and examined.
Biological material wrested from garments and swabs, at times decades old, now revealed their DNA code and, uploaded to a federal database, might match the code to a suspect’s name.
In 2019, announcing his push to hold rapists accountable and to ask lawmakers to provide millions to do it, Stein said untested kits are a “critical public safety issue.”
“To the rapists in North Carolina: No matter how long ago your crime was, we are coming for you,” Stein said then.
As of October 2020, nearly 7,000 older kits that once languished throughout the state have been or are in the process of being tested. Around 2,100 of those kits have been tested. Of those, DNA from 764 has been uploaded to a federal database — and 40% of those, around 300, have matched with others in the federal DNA database called CODIS.
Across the state, the past came rushing forward. Some 25 years after a Wilmington store clerk was robbed and assaulted, her kit was processed in 2019. The foreign DNA left behind matched the DNA record in a federal database.
Testing of old kits solved a 1993 rape and kidnapping from Winston-Salem, pointed toward a common suspect in nine sexual assaults from a decade ago in Fayetteville, identified a suspect in a 2008 Asheville sexual assault and led to 11 arrests in Durham connected to 15 cold sexual assault cases.
With more funding, the attorney general’s office estimates, the rest of those rape kits could be tested by 2023, and due to increases in the cost to process rape kits, it will take another $9 million to do so, according to an October 2020 report.
Police officers and prosecutors have recently become more aware of what the trauma from a sexual assault does to a victim’s brain. Both approach questioning victims in different ways and have become adept at explaining to juries why stories may appear disjointed or why a victim will freeze instead of fight.
A victim’s first meaningful contact with anyone after the assault may be a nurse, and prosecutors value SANE nurses because they help victims understand their options and build a rapport with them about the trauma that occurred.
“Every hospital system in North Carolina should have nurses trained to deal with these types of crises to serve people in need,” Stein said in an interview with CPP last week.
“I think a requirement that they have them would address the situation. That’s something we should talk to the legislature and talk to the health systems about.”
Such a requirement does not currently exist in North Carolina. Gerdes said hospitals should do the right thing, and a mandate should not be necessary.
“Why aren’t these hospitals that concerned about their victims — their neighbors, their daughters, their mothers or grandmothers?” Gerdes said.
Rep. Billy Richardson, D-Cumberland, said he, too, is committed to changing the law to help alleviate the SANE nurse disparity in North Carolina.
“The rapists don’t just rape one time. Studies have shown over and over that they rape multiple times,” Richardson said.
“So, if you catch them, you’re not only helping victims of this particular crime, you may be preventing numerous other crimes from occurring. Plus, and not to mention, it’s the right daggone thing to do!”
SANE training and retention
CPP sent the survey to hospitals because no agency in North Carolina was able to say where SANE nurses are located.
The state Department of Health and Human Services doesn’t track that information, nor does the state Department of Justice. The state Board of Nursing tracks nurse licenses but not SANE certifications, and the International Association of Forensic Nurses has a SANE list, but it isn’t kept up to date if someone relocates, lets the certification lapse or a program is eliminated.
According to the CPP survey, as many as 150 SANE nurses work throughout the state. Some hospitals did not say whether their SANE nurses had the specific credential, but it is not uncommon to have nurses trained in at least some forensic techniques.
Training a SANE nurse is a financial investment for hospitals. To meet the standards of the International Association of Forensic Nurses, candidates must take at least 40 hours of classroom instruction. Classes are often in person, requiring the nurse to take time away from regular job duties. Someone has to pay for travel, food and lodging. Sometimes hospitals pay for these expenses when a nurse seeks SANE training. Often the hospitals do not provide that financial help.
Many hospital systems had the same complaints regarding the availability of SANE training near them.
“SANE training is not readily available, is costly and is difficult to complete while working full time,” said Brandy Popp, spokeswoman at CarolinaEast Medical Center of New Bern in Craven County.
“Our organization is extremely supportive of staff attending SANE training and receiving this education, but once the classroom piece is complete, there are clinical requirements that must be done within a specified time frame, and oftentimes, those requirements can be a challenge.”
Clinical requirements include spending at least 16 hours documenting and performing at least three exams.
“Training and education of SANEs is difficult because it requires not only the didactic class but additional clinical hours,” according to the November survey response for UNC Medical Center in Chapel Hill.
“In essence, a nurse training to be a SANE has to wait for someone to get raped to complete their training.”
To maintain certification, a SANE nurse must complete at least 300 hours of SANE-related practice within three years, including peer review of cases, taking on-call shifts to respond to patients and providing direct patient care.
“In our area, the biggest challenge in serving sexual assault victims is the recruitment and education of staff to become SANE-certified,” said Teresa Bowleg, director of operations/associate chief nursing officer for Erlanger Murphy Medical Center in Cherokee County. The Western North Carolina hospital has one certified SANE nurse, she said.
Nationwide, SANE nurses are in short supply. A 2016 study by the U.S. Government Accountability Office found that in six states studied, a shortage of SANE nurses existed compared with the number of sexual assault exams being completed. This varied by state. Wisconsin officials said nearly half of its counties had a sexual assault examiner program. Nebraska officials said most counties in the state had no programs.
“As a consequence, officials said victims may need to travel long distances to be examined by a trained examiner,” a 2018 GAO report said.
Retention was also a deep concern, the report said. In one of the six states, the state trained 540 SANE nurses over a two-year period. At the end of that period, only 42 of them were still practicing.
Unlike other professions, SANE nurses work largely alone, often with the patient as the only other person in the exam room, and may be the only person in the hospital with that certification.
“This extrapolates to poor retention rates when SANEs are vicariously being exposed to trauma after trauma with no way to debrief,” UNC Medical Center in Chapel Hill’s November response stated. “We are slowly making gains with getting buy-in from key stakeholders who may be unaware of the prevalence of this problem.”
UNC Medical Center in Chapel Hill said it had 11 nurses who are “trained as SANEs,” of whom three are certified. Another seven have completed classroom work and were working on their clinical training, the survey response said.
Survey responses indicate rural areas are left with few or no SANE-certified nurses. Urban areas are the most likely to have around-the-clock coverage at area hospitals.
“There should be staffed nurses that are trained in every major hospital in the state prepared to help those victims of these horrible crimes,” Richardson said. “It’s just awful what a child or a woman goes through in that situation.”
Sometimes victims travel to multiple hospitals before they find a SANE nurse — or they give up searching. Hospital systems are not obligated to have SANE nurses in North Carolina, and Stein said that needs to change.
“It is a reasonable expectation for a victim of sexual assault who walks through the doors of an emergency department that he or she will be seen within a relatively short period of time,” Stein said in an interview with CPP.
Other states are approaching the problem differently from North Carolina, and some are able to point to success.
Massachusetts’ Department of Public Health runs the certification program for its SANE nurses, the only state to do so. Of the geographically compact state’s nearly 100 hospitals, 30 of them are designated as “SANE site hospitals,” where anyone can go to the emergency room and expect to have a certified nurse treat them. The hospitals are listed on the state’s website.
When a victim arrives, the hospital pages a SANE nurse and a local rape crisis center, said Katia Santiago-Taylor, policy director for Boston Area Rape Crisis Center. An advocate from the rape crisis center arrives to help the victim. The statewide, state-supported program has a victim-centered approach, she said.
SANE nurses are there to make sure rape kits are collected “in a trauma-informed way where we are not going to cause more harm,” Santiago-Taylor said. “That is what survivors need.”
There are still times when SANE nurses might not be available at a Massachusetts hospital designated as having SANE staff, such as when multiple rape victims arrive at a hospital at once, she said. In those cases, the advocate can be there to help a nurse without a SANE certification
Massachusetts also developed the TeleSANE program to videoconference into rural, military and tribal hospitals so that experts could help clinicians serve patients in the absence of a SANE nurse.
Lawmakers in Illinois recently passed legislation that requires every rape victim to be served by sexual assault nurse examiners starting in 2022. Hospitals must also respond to rape victims within 90 minutes of the patient’s arrival at the hospital.
Unique models in North Carolina
Creative approaches are also underway in parts of North Carolina.
Victims in Wake County can go to a central location, away from an emergency department, to see a qualified nurse.
Most hospitals in Wake County send patients to the Solace Center at InterAct, a nonprofit organization in Raleigh. The Solace Center has 18 certified and in-training SANE nurses, said 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.
UNC Rex Healthcare spokesman Alan Wolf said the Raleigh hospital has three SANE nurses and one in training. If a victim arrives there when a SANE is not available, the hospital can transport him or her to the Solace Center.
“All of the SANE nurses in our emergency department also contract with the Solace Center,” Wolf said. “They are on call through InterAct, making themselves available for cases that have been set up with the crisis line.”
In neighboring Johnston County, Sahari Center of Harbor is a new community-based SANE program that opened around the new year. The group is working with the director of the county health department and other community leaders, said Laurie Mayenschein, SANE coordinator for Sahari Center of Harbor.
Sahari Center has two credentialed SANE nurses, a SANE coordinator and several other registered nurses who have taken 40 hours of classroom training and a 16-hour clinical curriculum, Mayenschein said. The center also has an exam room where it helps assault victims at Johnston UNC Health in Smithfield.
“There are many challenges to developing and sustaining a SANE team, particularly in rural settings,” Mayenschein said in response to the November survey.
“Funding sources are always a priority and essential for the sustainability of any SANE program. I believe one of the biggest challenges facing any SANE program is ensuring that the volumes are enough for the SANEs to maintain their skills.”
Beyond emergency rooms
Many hospitals said they could serve assault victims better if they had a separate area to treat them, away from the emergency room.
Cape Fear Valley Medical Center in Fayetteville is among the busiest emergency departments in the nation, with more than 130,000 visits in 2018.
“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.
The majority of SANE programs are based out of emergency departments, said Catherine Rossi, president of the Academy of Forensic Nursing and the forensic nursing program coordinator for Cone Health in Guilford County.
“That is not usually a very sustainable model, because the needs of the emergency department are always going by volume,” Rossi said. “You’re not going to get the funding; you’re not going to get the support.”
It can take multiple hours for a nurse to perform a sexual assault kit exam on a victim.
If served in the emergency department, victims may be left aside until patients with more life-threatening problems are helped. In addition, a crowded emergency room may feel intimidating to victims, or they may see someone they know.
As for where victims who have questions of where to go after an assault to make sure they reach a SANE nurse, Stein, the state attorney general, said victims should call their local rape crisis center.
While generally good advice, sometimes even those in a position to know aren’t aware of changes in their county.
Gerdes, with Rape Crisis of Cumberland County, said she had no communication from Cape Fear Valley about the hospital no longer having certified SANE nurses.
“When we had a SANE program, that is not how we ran things,” Gerdes said, speaking of Cape Fear Valley Medical Center.
“Victims did not sit out in the lobby. They didn’t. We had a SANE room that they were immediately brought back into. … We would all convene and be an advocate — the nurse, law enforcement — not necessarily in the room, but it was a team effort.”
CPP sought an interview with a Cape Fear Valley Medical Center official last week. Jordan said none were available, however, the hospital’s answers to the SANE survey had already been provided.
Then late Friday, as CPP was speaking to several sources in Cumberland County about the hospital’s response, Jordan sent a modified survey, increasing the number of certified SANE nurses from zero.
“Because of our commitment to sexual assault requirements, we have 8 nurses that have recently completed the SANE training requirements and are awaiting their certification,” the new response reads in part. Jordan did not answer follow-up questions.
Richardson, the state lawmaker from Cumberland County, said he is concerned about his hometown hospital.
“I am concerned that there appears to be some ambiguity with the answers, and we need to sit down and figure out where we need to go,” Richardson said. “I intend to call such a meeting.”
Christian Green and Casey Morris also contributed to this report.