A shortage of sexual assault nurse examiners leaves a critical gap in access on the North Coast

Jun. 16—Most people who are sexually assaulted on the North Coast do not seek medical care afterward.

Shame, embarrassment, anxiety and not knowing what to expect are among the main deterrents. The fewsurvivors that do go to local hospitalsoften have to wait hours for forensic exams.

Many are referred to hospitals in Portland instead.

"For someone who's already experienced trauma, knowing that you have to take a two-hour trip one way, and then wait for hours at a hospital to have an exam done and then find your way back here, it's really discouraging," said Jessica Klein, the deputy director at The Harbor, an advocacy center in Astoria for survivors of domestic violence and sexual assault.

Few people opt to make the trip.

"The rest of the survivors typically just turn and walk out and they leave the hospital without receiving any care," she said, "which is really unfortunate because even if someone doesn't get the forensic exam, there's still other services that are available to them."

According to advocates, law enforcement and medical experts on the North Coast, the medical response to sexual assault does not adequately meet the needs of survivors, a critical gap in access that can compound trauma.

A survey last year by The Harbor found that 83% of survivors who participated did not receive any medical care after their assault and only 15% reported their assault to law enforcement. Thirty percent did not know medical services were an option, while 16% cited a lack of transportation.

Insufficient funding, burnout and limited opportunities for training have led to a persistent shortage of sexual assault nurse examiners, who are needed to treat survivors and collect evidence.

A trained nurse can conduct a sexual assault forensic evidence exam within 120 hours of an assault. The exam includes an interview about the assault, which takes the majority of the three-to-five hour process, and a physical to look for injuries and gather evidence.

The process also involves a wellness check, a pregnancy test, Plan B emergency contraception and medication for sexually transmitted infections and HIV prevention. Each part of the exam is optional.

The number of sexual assault nurse examiners has been an issue on the North Coast for over a decade.

The state first required hospitals to contract or employ the trained nurses in 2011. In 2014, in the aftermath of a sexual assault of a 10-year-old girl who had to be driven to a Portland hospital for an exam, The Astorian reported that Columbia Memorial Hospital in Astoria had three of the trained nurses and Providence Seaside Hospital had five. Neither hospital had a nurse who was certified to conduct the exams, which is obtained by meeting the training and clinical practice requirements.

Today, there is one Portland-based certified sexual assault nurse examiner who works intermittently at Columbia Memorial and no certified nurse at Providence Seaside.

A handful of local nurses in training for certification juggle the cases that come in when time allows. When trained nurses are not available, survivors are told they must go to Portland.

Facing long waits, some survivors leave hospitals without getting an exam.

"CMH offers compassionate care to any patient who is a survivor of sexual assault. We do our best to see patients in a timely manner and give them a comfortable space to wait in when it is available," the hospital said in a statement to The Astorian. "We are proud to have several SANE-trained caregivers who provide patients with a safe space to talk about their experience and discreetly obtain the necessary information and evidence to move forward with their case."

Hospitals without a trained nurse available to collect evidence kits can still treat injuries caused by an assault, test for sexually transmitted infections and take steps to prevent pregnancy and HIV.

The exam and associated treatment are free of charge for survivors within seven days of an assault. Providers are reimbursed by the state sexual assault victims emergency medical response fund. The crime victims' compensation program can also cover associated expenses and treatment, not including HIV prophylaxis.

Providers don't always know to tell survivors about available services beyond the forensic exam, said Savannah Powell, the sexual assault nurse examiners coordinator for the Oregon Attorney General's Sexual Assault Task Force.

Powell recently published her master's capstone project on the medical response to sexual assault on the North Coast in conjunction with Providence Health & Services.

"If there's not a (sexual assault nurse examiner) available they may or may not get the medication that they need," she said. "This is because an emergency room physician has to know a lot of things, and they may not understand the risks and may not have the time to really sit down and listen to every detail of what happened in the assault and the risk that patient has for these diseases or for pregnancy."

'I'm always surprised'

Typically, a forensic exam after a sexual assault is the first step toward filing criminal charges.

For survivors who choose to have an exam, DNA evidence will be collected and sealed anonymously until the survivor decides to pursue a case. Kits are stored for up to 60 years.

Providers are required to report to law enforcement if the survivor is under 18 or over 65.

Exams on children under 15 require additional training certification that no one working in Clatsop County has at the moment. Anyone under 15 is automatically referred to Portland, like the 10-year-old girl was when this issue was in the spotlight back in 2014.

Ryan Humphrey, a detective with the sheriff's office who works on cases involving sex crimes, remembers one case where the victim was hours from her 15th birthday and a local hospital referred her to Portland.

The detective has driven several survivors to Portland with his partner, who is a woman.

"I'm always surprised when there is (a sexual assault nurse examiner) available. Like, 'Hey, we need to go to the hospital, they just did a (sexual assault forensic evidence) kit.' I'm like, 'Oh, that's amazing. Great.' That surprises me more than when I get the call saying, 'Hey, the hospital just turned this victim away, can you take them to Portland?' Because that's been the more common thing.

"And I know the hospitals want to improve this, but again it's like anything else. There's specialists in Portland that handle this stuff on a daily basis. It's hard to maintain a specialist in a rural community where they're only going to see their specialty one or two times a month."

Evidence kits improve the chances an assault case will lead to conviction. Along with collecting physical evidence of the assault, trained nurses are also able to measure bruises, take photographs and collect DNA samples.

Choosing to open a case is still a gamble for survivors, though. Nationally, only 9% of reported sexual assaults lead to felony convictions, according to the Rape, Abuse & Incest National Network.

Over 1 in 3 women and nearly 1 in 4 men experience sexual violence in their lifetime, according to the federal Centers for Disease Control and Prevention.

These rates increase among people of color, people with disabilities and people in the LGBTQ community, who are at greater risk of sexual assault.

"Reporting these crimes to law enforcement is not something someone should ever be forced to do because I'm aware of what that entails. And it's unfortunate that it's not a quick, clean and easy process," Humphrey said. "I can understand why somebody would not want that."

When hospitals refer survivors to Portland, they may ride in an ambulance, with law enforcement, or drive themselves.

Humphrey said he volunteers to drive survivors because he doesn't want transportation to be a barrier.

"We want to investigate these cases. We live in this community. I don't want rapists wandering the streets of Astoria where I live," he said. "If somebody sees a barrier, make me aware of that barrier and I'm going to help tear it down."

'Gold standard'Jackson County, which includes Medford and Ashland, faced a similar shortage of sexual assault nurse examiners two decades ago. The county has since become a state model for effective medical response.

It began in 2000, when Susan Moen, who had worked at a Los Angeles rape crisis center, and the late Judy Ferris wanted to address eight-hour wait times for exams at local hospitals and improve the low reporting rates for sexual assault.

They launched the Jackson County Sexual Assault Response Team, a nonprofit that educates and trains nurses to contract to hospitals.

"We decided the gold standard would be a strictly on-call program that would respond to the hospitals, but was not associated with the hospitals," Moen said.

The response team employs between 13 and 16 nurses at a time, allowing for 24/7 on-call coverage with response times under 30 minutes in Jackson County. The program recently expanded to Josephine County.

Nurses are typically on call for 48 hours a month. Moen said she limits burnout by paying well and giving nurses sufficient time off.

"I'm paying somebody to sit around and wait for a phone call that might never come. That's a really hard thing for folks outside of these systems to understand. I mean, our program is about $220,000 a year. That's a huge amount of money," she said.

The majority of the response team is funded by grants, foundations and donations, including money from the Victims of Crime Act.

"I would hope that programs coming in now would be able to actually get the hospitals to provide the majority of the funding. Unfortunately, I didn't know better when we started, so my pitch to the hospitals was, 'Oh, this won't cost you anything,'" she said.

The response team does an average of 11 exams a month.

Before the program launched, around 40% of survivors who came to hospitals reported their assault to law enforcement. Now, that rate ranges between 85% to 95%.

"Having that first contact of the system be somebody who can walk into that room and say, 'I'm really sorry, and I'm here just for you,' and answer all of their questions, and give them reassurance that they're OK, and get the medications and get them resources and connect them to whatever they need afterwards, it is so crucial.

"I truly think it makes a huge difference in how the rest of their journey unfolds. Just kinder, gentler first contact," Moen said.

Powell, who works with the attorney general's sexual assault task force , said she's not sure if a similar program would be realistic on the North Coast given the region's staffing challenges.

"It would be nice to have, in each community, a couple of SANE nurses who could travel to other hospitals. Someone who's in Columbia County, someone who's in Clatsop County, someone who's in Tillamook County, that if they are available and they would have a network to communicate," she said. "Just so the patient doesn't have to drive, that would be ideal."

While more robust state and grant funding would be beneficial, Powell said hospitals are in the most immediate position to address the issue. She recognizes that many smaller, rural hospitals have budget constraints.

"So it kind of puts a little bit of weight on the ethics of it," she said. "Ethically, we need to take care of these patients in our community and these survivors, and so, are we willing to put funding there as kind of a charitable aspect of the hospital?"

'It's something the community needs'

The Harbor, hoping to increase the number of sexual assault nurse examiners , has applied for a $750,000 federal grant from the Office on Violence Against Women to train midwives at the Astoria Birth Center.

The nonprofit will find out this fall whether it will receive the grant.

Local hospitals have been making an effort to improve availability. Three nurses at Columbia Memorial and two nurses at Providence Seaside are training to become certified.

"The (sexual assault nurse examiner) program at Providence Seaside has a formal connection to, and the support of, the Providence medical forensic program based in Portland to ensure access to ongoing training opportunities and 24/7/365 telephone consultations with a goal of increasing access to sexual assault services within our community," Mike Antrim, the communications manager for Providence Seaside, said in an email to The Astorian.

Casseopia Fisher, a nurse supervisor, is in training for certifcation at Columbia Memorial.

Working as a supervisor, Fisher said she saw the need and decided to help despite knowing the intensity.

"It doesn't feel to me like it's hard to necessarily hear these sometimes very sad and potentially frightening stories as long as I feel like I could come into that situation and make a difference in and help improve it," she said.

Fisher started by taking the national 40-hour online course while recovering from a minor surgery in 2018. Since then, she has taken the state sexual assault task force's weeklong course and built experience under mentorship.

While training at Columbia Memorial, Fisher can collect evidencekits, but cannot do the pelvic exam, which is often the most uncomfortable for patients. If a survivor chooses to have one performed, which can sometimes be beneficial for building a criminal case, Fisher must ask a physician to do it.

"We have really great physicians at the hospital, and they're all very compassionate people. But sometimes it's difficult if I've just been working with somebody for a really long time and we've built some trust together for me to bring somebody else into that to do what is oftentimes the most difficult piece of the exam," she said.

When she collects evidencekits, Fisher lets survivors know that every part is optional. She gives recommendations, but asks for consent every step along the way.

"The biggest, most important thing that I want people to know is that they're in control. Because they've just experienced something where they didn't have control, and giving that back to them is probably the most important thing I can do," she said.

Certification requires an average of 16 hours a month in relevant practice, court observations and meetings with law enforcement, the district attorney's office and advocacy organizations. It also requires demonstrating competence as outlined by the hospital. With the county's low reporting rates for sexual assault, it can be difficult to get training within the community.

Dr. Regina Mysliwiec, the emergency department director at Columbia Memorial, who is also on the sexual assault nurse examiner certification board, said budget and burnout are the biggest obstacles to local availability.

"These survivors of assault are coming to the department on their own, or they're being brought in by police. They're traumatized. They just want it all to go away. They want it to be over. And then what we have to do is find a way to take care of them as quickly as possible. And limit the trauma as much as possible," Mysliwiec said. "But we only have a handful of nurses who are trained to do this process."

Fisher was the nurse who collected the two evidence kits taken at Columbia Memorial so far this year. She was called in a third time, but the patient left before she could get there several hours later.

"I personally have had to call Cassie in to do these exams just after she finished working. I imagine her sitting down to have dinner with her family and then just picking up the phone," Mysliwiec said. "It's asking a lot, but it's something the community needs."