By CRISTINA JANNEY
Hays Post
Although a new forensics nurse program opened this spring in northwest Kansas, access to these exams for rape and incest victims is still difficult to access in rural areas of the state.
Many victims have to drive for hours to find nurses who are trained Sexual Assault Nurse Examiners, which can significantly delay treatment and evidence collection.
New legislation went into effect in July 2022 to increase access to SANE exams.
Although hospitals, as defined in state statute, must collect a sexual assault evidence kit if it is requested by the victim, only two hospitals in northwest Kansas — Goodland and Hays — have staff who are trained Sexual Assault Nurse Examiners, who are also known as SANEs.
Jessica Albers is a SANE from Hays who works as a statewide clinical consultant for the Kansas Coalition Against Sexual and Domestic Violence.
"In terms of rape kits and SANE exams, I think there is a huge lack of access,” Albers said.
Victims travel across state to receive services
HaysMed's SANE program cared for 43 victims from Ellis County in 2022 and 35 in 2021. In 2022, the program cared for 106 victims from 23 Kansas counties from as far away as Barber County on the Oklahoma border and Sherman County on the Colorado border and Butler County in southeast Kansas.
“Three or four hours is a long way to drive for a sexual assault exam, especially after you have been sexually assaulted,” Jennifer Hecker, executive director of Options Domestic and Sexual Violence Services said. The advocacy and victims services organization is based in Hays but serves 18 counties in northwest Kansas.
Hays has been the most northwest program for 12 to 13 years until Goodland opened its program this spring and Great Bend opened a program in October. In southwest Kansas, there are SANE programs in Dodge City, Garden City and Liberal. The Western Kansas Child Advocacy Center Medical Mobile Unit based out of Scott City does exams for children through its Medical Mobile Unit.
However, not all programs have 24-7 coverage.
As a SANE, Albers has worked with patients who traveled great distances to receive exams from a certified provider — some traveling hours one way to get an exam.
Albers said she is concerned that some health care facilities may not be aware that providing sexual assault exams is required by the law. Patients also don’t always know where to go. All sexual assault exams exams are free.
The new law has expanded where kits can be collected, including health clinics, health departments and child advocacy clinics.
“We are hopeful that language will open access among those facilities,” Albers said, “and they will be willing to provide the service to victims."
In some rural communities, health departments or clinics may be patients' only health care choice. According to the Kansas Hospital Association, 10 counties in Kansas including Bourbon, Chase, Doniphan, Elk, Gray, Linn, Osage, Wabaunsee, Wallace and Woodson have no hospital. HaysMed's SANE program cared for four victims from Wallace County in 2022.
Everyone has a job
Few hospitals in the state have SANE programs.
The advantage of a SANE performing the exam is the victim is receiving a more specialized exam, Albers said. They may take forensics photos if that is appropriate and approved by the victim. Alternative light sources can help detect fibers or dried secretions or enhance the visibility of bruises.
The SANE exam is one step in a multi-tier approach to caring for sexual crime victims and gathering evidence to hold perpetrators accountable.
“The police officer’s role is to hold the perpetrator accountable and to just get information. The nurse's job is to collect the evidence and to provide health care," Hecker said. "The advocate’s job is to be a voice for the survivor while they are going through this and to attend to their emotional safety and make sure they know what’s going to happen.
“There are already so many unknowns, and that is one of the most frightening pieces,” Hecker said. “We want to reduce those barriers about what is about to happen. We are trying to tie them back all the control that has been lost.”
SANEs are trained to work with trauma victims and try to help ease fears as they walk victims through the exam process.
“The fear of the unknown of the exam is probably stressful for the victim anyways," Albers said. "Then if you have the complication of not knowing where they can get an exam or having to travel to get to an exam or having to wait for an exam to happen it's an extra hurdle for them to get through."
Albers said if a victim has to wait for an exam she said she hoped at least that victim could be connected with an advocate. Those advocacy services are provided by organizations such as Options.
Hecker said although the law allows medical professionals who are not SANE trained to perform sexual assault exams, she was concerned providers who are not trained may retraumatize victims. Improperly collected evidence might not be able to be used in the prosecutions of perpetrators, she said.
“We as a community and a culture, tell survivors to go and get that exam, so their perpetrator can be held accountable,” Hecker said. “If we are telling people to do that, then we have a responsibility as a community to make sure the safety net is there so the survivors can do that.
“There is a gap between what we tell people what services are available or that they should be able to engage with and what is actually available in their communities. That is also very disheartening.”
“We are really not helping survivors in the best way possible,” she said.
What happens during a SANE exam?
Albers emphasized all parts of a SANE exam are voluntary. A victim can stop the exam at any time and refuse any portion of the exam.
“We work really hard to build a rapport with the patient and make sure we are offering them choices, supporting the choices and decisions they make and how they want to proceed through the exam," she said.
Hecker said victims don't have to go through the exam alone. They can have a family member, friend or advocate with them during the exam. They are allowed to have someone in the room with them holding their hand if they choose.
Advocates will meet with the victim as soon as possible. SANEs, advocates and law enforcement try to work together so the victim doesn't have to tell his or her story over and over.
Although clothing is often taken as evidence, an advocate or SANE will provide fresh clothing for the victim to wear home. Advocates follow up with the victim and can offer a variety of support services as well as meet with family members if the victim requests.
The SANEs are also well connected to the other resources in the communities, including law enforcement and advocacy organizations such as Options in northwest Kansas.
Consenting to a sexual assault exam does not automatically mean the case will be reported. The exam preserves the evidence. The adult victim can choose to make a report with law enforcement at a later date or never. Unreported kits are sent to the KBI where they are stored for 20 years untested.
Testing evidence
According to state law, all reported sexual assault exam kits have to be submitted for testing.
In 2015, a backlog of 2,200 untested kits was discovered in evidence property rooms in Kansas. All of the untested kits were processed, and the law was changed in an attempt to prevent a future backlog, Albers said.
Although physical evidence from a sexual assault exam is not a guarantee of a conviction, Hecker said it helps.
“Rape kits are so important because so many victims of sexual assault are simply not believed,” she said.
She added, “The community has to do better. We have to make sure that the system accepts the report and collects the evidence, and we do something with the evidence, and we take action afterward. Rape is not he said/she said, but we like to think they are.”
Sexual assault exams are health care
The victim can receive treatment to prevent infection or any other injuries at the time of a SANE exam.
Trisha Haskell, forensic program coordinator for HaysMed, said SANE exams are not just about collecting evidence. They allow for expert assessment of all areas of the body.
"Forensic exams help to ensure the health and safety of our patients," she said. "This exam is performed by a specially trained nurse who has expertise in providing patient-centered care that includes history taking, collection of evidence and documentation. This creates an unbiased, objective opportunity to preserve evidence from a patient’s body while facilitating the healing process."
Based on history, patients are offered medication to help prevent sexually transmitted infections and HIV.
Working closely with a physician, the program offers testing, treatment and follow-up care, Haskell said.
Time is also important for the health of the victim, Haskel said.
"As with many medical conditions, timely treatment is always the preferred situation," she said. "Before HaysMed offered the SANE program, people in western Kansas had to travel to eastern Kansas to be treated.
"Having the program here in Hays has improved access for many patients in the rural areas of the state. Prompt response times are advantageous no matter what the situation is."
Overcoming misconceptions
Although access is a barrier, so are myths, Albers said.
“There is the misconception that our exam is really invasive," Albers said, "'and we don’t want to put people through that.’ We work really hard to make sure to not make it traumatic. We don’t want to retraumatize the victim. That’s why it’s so important to build the rapport and comfort level with the patient before we start getting into the exam itself.”
Twenty-five of the victims cared for by HaysMed in 2022 were 17 years old or younger. Albers wanted to reassure parents that SANE exams are not invasive for children.
"They (mothers) think it’s like their pap smear. Before a girl reaches puberty, all we do is external examination. We don’t put anything in the vagina. We don’t pull put swabs from inside the vagina," she said.
SANEs are trained to work with victims of any gender. This includes gender nonconforming or transgender individuals.
Although the majority of SANE exams are performed on women and girls, five to 15 exams per year at HaysMed are performed on men or boys.
“We want everyone to know they are welcome to come for services regardless of their age, gender or identity,” Albers said. “We want to help. We want to help start them on that journey to healing and preserve that evidence so that if it can be used in the criminal justice system it can be preserved and the information is documented by us.”
Barriers to expanding services
The training to become SANE is long and costly. Training requires 160 to 180 hours.
You do not have to acquire your certification to practice as a SANE-trained nurse. However, a nurse must accrue 300 hours of SANE practice before he or she can test for SANE certification. As of April, Kansas had only 30 SANE-certified nurses in the state, according to Haskel.
"It is a really tough area to work in," Albers said. "You have to be the right kind of person, and it has to be something you want to do."
A hospital or clinic also must have the space and equipment to have a SANE program.
“Administration has to recognize that this is really a community benefit service that is being offered, but it isn’t a department that is going to make money for the facility,” she said.
Most programs require more than one or two SANE-trained staff members, Albers said. Most SANEs hold a full-time job in addition to being on-call for sexual assault exams.
Turnover is high in the field, she said.
The Kansas Coalition Against Sexual and Domestic Violence provides one-day training for medical providers who are not SANE trained.
The agency has offered the class for three years, but it has been hard getting health care providers to sign up to take the class, Albers said.
“I think it is extremely important to have another access point for the northwest part of the state,” Albers said. “That will give one additional access point for care and hopefully [victims will ] not have to drive three hours to Hays, instead drive 30 minutes to Goodland.”
Not just a Kansas problem
Albers and Haskel both said multiple barriers exist to expanding SANE programs in rural areas, and it's not just a problem in Kansas.
"With most of the United States being rural, it has been identified as a challenge nationwide," Haskel said. "Collaboration and education allow for all rural areas to expand their reach and knowledge to ensure all persons seeking care after experiencing violence receive adequate care.
"Kansas as a whole does a great job of ensuring equal access for sexual assault survivors regardless of their location. It is a state statute that all medical care facilities within the state offer a sexual assault evidence collection kit to any person requesting one."