How the Critical Shortage of Sexual Assault Nurses Harms Survivors Across the US
As a nurse, training to administer rape kits can be prohibitively costly and expensive—and many hospitals lack sufficient programs and support systems.
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The minutes, hours, and days after a rape are often both traumatic and confusing. In addition to the immediate, physical triage sexual assault survivors require, an immense amount of psychological healing needs to take place as well. Sexual assault nurse examiners (or SANEs) are trained not only to collect DNA samples and take notes on testimony that can later be used as evidence in court, but to support patients and help them process their emotional pain.
In practice, though, SANEs can be few and far between, especially in rural areas. According to a report released in May by the Government Accountability Office (GAO), "Officials in one state [Wisconsin] estimated that while the state trained 540 examiners over a two-year period, only 42 of those examiners were still practicing in the state at the end of those two years."
The turnover rate for registered nurses in general is already quite high—a 2014 survey found that nearly one in five nurses leave their first job within the first year and one in three leave within two years—but a .08 percent retention rate is shocking.
Terri Slapak-Fugate, the Director of Emergency and Urgent Care and the SANE program manager at Southwest Health Hospital in Platteville, Wisconsin, says she's surprised by that statistic. "A year and a half ago I had heard that maybe 50 percent of the nurses who get trained don't do [rape] cases, and was surprised to hear that," she tells Broadly. "The statistic you had shared was alarming."
Slapak-Fugate has been a registered nurse and manager of nursing programs for many years. In a recent op-ed in the Washington Post, she detailed the importance of the SANE program and called on hospitals to train more nurse examiners. "Despite the clear importance of having someone who knows what they're doing conduct a sexual assault exam, trained examiners remain inaccessible to many victims," she wrote.
It's clear that Slapak-Fugate views her own SANE program as a shining example of what hard work and dedication can accomplish. However, such dedication comes at a steep price: Slapak-Fugate estimates the cost of training one nurse to be a SANE will cost about $3,000, a figure that includes lost wages. "Plus, the classes are different places around the state, so you're talking hotel, mileage, food," she adds.
I ask her to walk me through the steps of a rape kit exam. "It's interviewing the assault victim to help document what occurred, in case they want to go to court later. So documentation is very important," she says. "Then a head-to-toe physical assessment looking for any injuries. Then it's evidence collection, then it goes into offering options for STIs, prophylactics—so medications that prevent sexually transmitted infections—and then also offering emergency contraception, be it Plan B or ella. And finally, hooking them up with an advocate."
This process can take up to four hours.
Slapak-Fugate stresses that her SANE program—which is comprised of a team of seven nurses—is actually a comparatively large one. "A lot of the programs that I see, hospitals will try to get away with just having maybe two nurses trained, because there's not a high volume of cases within a year," she said. "The thought is, Well, if we just train two nurses, because we only get four or five cases a year, that's plenty. What happens then is that nurses are transient—we tend to move from one place to another. And so just like that, the program falls apart."
The truth is there are short- and long-term very significant health consequences to sexual abuse and assault.
A major reason a SANE may stop giving exams is the accumulation of vicarious trauma. Hearing other women's rape stories day in and day out can be exhausting, especially if you're working as the sole SANE at a hospital that doesn't have a strong support system. "We talk a lot about secondary trauma, and also empathetic trauma," Slapak-Fugate says, speaking of her own program. "It's a very strong sisterhood of SANEs. You meet one another and immediately have that connection. I think it's a shared vicarious trauma. "
Jen Pierce-Weeks, the interim CEO and education director for the International Association of Forensic Nurses, similarly emphasizes secondary trauma as an obstacle for SANEs, though she clarifies that she does not think sexual assault examiners are at any greater risk for it than any other registered nurse. "I believe vicarious trauma contributes to nurses not staying in the work because oftentimes it is not taken seriously, nor recognized when it is occurring," she says.
However, she doesn't believe that vicarious trauma is the sole reason behind the shortage of nurse examiners. She listed a few other contributing factors to burnout: First, while classroom training is easy, acquiring the clinical skills that the role requires is much more difficult. Second, she says, hospital administrators "may not be willing or able to devote the resources necessary to support ongoing SANE services."
Finally, Pierce-Weeks notes, many healthcare workers believe the SANE program is "a social and criminal justice issue" rather than a healthcare issue. "This leads them to believe it is not health care's duty to respond," she says. "This also leads them to believe SANE is an 'arm of law enforcement,' when nothing could be further from the truth."
"The truth is there are short- and long-term very significant health consequences to sexual abuse and assault," she elaborates. "They are costly—physical cost, mental health cost, financial cost—to the patient as well as the health system. It is healthcare's responsibility to build a way forward in recovery that includes long-term health."
The irony is that SANE programs perform a much different role in rape survivors' experiences than police officers do. And while the data the programs collect would undoubtedly be useful to police, it is often ignored by law enforcement agencies: hundreds of thousands of untested rape kits are languishing in police evidence storage facilities and crime labs across the country; perhaps unsurprisingly, statistics show that 97 out of 100 rapists will never be punished for their crimes.
In fact, exasperation with prosecutors was floated more than once as a source of disappointment and possibly burnout. As Slapak-Fugate confesses, "a big frustration a lot of us had was that we're not really seeing a lot of cases. Cases aren't being prosecuted—they're being plead out, and they're not going to trial."
"When nurses become SANEs and begin giving testimony in cases, or seeing how infrequently they are called to court, they can become disheartened by the criminal justice system response," Pierce-Weeks says.
Fortunately, the spotty patchwork of SANE programs could soon be getting an overhaul. In May, several Democratic senators introduced the Survivors' Access to Supportive Care Act. If it passes, the bill would "provide for state-level reviews of current practices in order to better understand care, develop best practices and guidelines, and provide public awareness of sexual assault examinations."
Quite often, a sexual assault nurse examiner is the first person a survivor will talk to about her rape. It's a heavy burden to bear, but it's one Slapak-Fugate shoulders with pride. "It is very much the first step," she says. "It's a privilege and an honor to be involved in that first step of helping someone go from being a victim to a survivor. And that's how I see my role."
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