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A SANE Approach to Rape
Sexual assault nurse examiners offer victims better treatment. So why doesn't liberal Boulder County have its own program?

By Pamela White (

It's 1 a.m., and Heather, 18, is trapped in a nightmare. Three hours ago she was raped. Now she sits, together with a police officer and a sympathetic victim's advocate, in the emergency room at a local hospital, waiting to be treated and examined.

They've told her she can't pee—or eat, drink or brush her teeth. She can't change her clothes. She can't take a shower. The advocate has explained that doing so would destroy evidence that has the potential to put her attacker in prison. And so she waits, her mind veering between disbelief and panic, aware of every place the rapist touched her, fighting nausea and tears, feeling his semen in her crotch, steeped in his stink.

Her body is a crime scene, and she's stuck inside it.

A drunk is brought in, shouting and swearing, the disturbance scraping like barbed wire over her already shredded nerves. An ambulance arrives with someone who's moaning and bloody—a car accident. Nearby a mother sits trying to comfort a crying baby.

Heather wonders if the other patients can tell why she's there. Would they blame her if they found out she'd been drinking at a party on The Hill? Will the doctor blame her? Will the police blame her? Should she blame herself? And what will her parents say?

Another hour goes by.

Heather tells the advocate she has to pee. She can't hold it any longer. The advocate asks her to hang on just a bit longer and goes to ask the ER staff how much longer they'll have to wait. The advocate urges the staff to hurry and reminds them that rape victims are supposed to be a priority, right behind life- and limb-threatening emergencies.

Another hour passes and another. It's now past 4 a.m. Heather is exhausted, nauseated, desperately uncomfortable. More than anything, she wants to go home, take a scalding shower and forget this ever happened. What she doesn't know is that for the past 20 minutes, male doctors have been arguing over who is going to treat her. None of them have ever done a rape kit before, and none of them are comfortable with the idea that they might one day be called to testify in court.

When Heather is finally called back, it becomes clear the doctor doesn't really want to help her—and has no idea what he's doing. At one point the doctor even asks the advocate what to do next. As he performs what feels like the most invasive exam Heather has ever endured, his seeming indifference is chilling. And for the second time in less than 24 hours, she feels irreparably violated.

It will be 6 a.m. before she leaves the hospital. Wearing green scrubs—her clothes will be confiscated as evidence—she will be driven home to pick up the pieces of her shattered life.

Although Heather is a fictional character, victim advocates say the above scenario is only too real. It is repeated hundreds of times every year in hospitals across Colorado. Ill-equipped to deal with the emotional and forensic demands of rape, many emergency rooms offer inadequate treatment to rape victims, with the quality of care varying from practitioner to practitioner.

Yet, despite this deficiency, emergency rooms are still the primary destination for many, if not most, of Colorado's rape victims. Victim advocates in the state have been working hard to change this, combining forces with law enforcement and prosecutors to bring a more victim-centered approach to rape treatment through Sexual Assault Nurse Examiner (SANE) programs.

Developed in 1976, the SANE program was designed to offer skilled evidence collection that stands up in trial together with compassionate treatment that focuses on the needs of rape victims. Staffed by specially trained female nurses, SANE programs have the endorsement of the U.S. Department of Justice, as well as women's health practitioners and victim advocates nationwide.

However, because of the public awareness, cost and collaborative work required, SANE programs are still relatively rare, with only about 120 programs operating nationwide. The good news: 11 of those programs are located in Colorado. The bad news: None of them are in Boulder County.

The first step toward healing

Anissa Jones has been a registered nurse for nine years. For the past three years, she has worked as a sexual assault nurse examiner, treating rape victims' physical and emotional injuries and gathering crucial evidence from their bodies. A forensic clinical nurse specialist with a master's of science, Jones knows how to collect evidence so that it complies with state protocols. She is also capable of offering expert testimony in court. Currently the coordinator for the SANE program at St. Anthony's North in Westminster, she has always had an interest in the law.

"I would watch those crime shows and found it interesting," Jones says.

Started in 1999, the program at St. Anthony's North got off to a rocky start, sometimes unable to provide the 24/7 on-call nursing coverage such programs require. Now on solid footing, the program last year treated 127 victims of sexual assault, some of whom came from Boulder County.

"As far as the victims are concerned, the great advantage of being seen by a SANE is we're dedicated to them," Jones says. "The victim is the only patient we have."

Unlike the fictional Heather, rape victims transported to St. Anthony's avoid the chaotic environment of the ER waiting room—and do very little waiting. They are seen in triage and then taken to a soothingly decorated private room outside the emergency department, where an on-call nurse examiner performs a thorough rape exam.

"As nurses we are compassionate and caring, but at the same time we can focus our exam so that it's done in a less amount of time and the evidence collection is better," Jones says. "As proficient collectors of evidence, we can explain to them why we need each of the items we're collecting, and that contributes to their being back in control."

Though the exam can be perceived as invasive—it involves collecting evidence from any violated orifice, photographing external and internal injuries, and pulling sample head and pubic hairs—most victims agree to whatever steps the examiner believes are key to collecting solid evidence.

"Usually, once you explain what you need that piece of evidence for or why you need to look here or why you need to photograph this, they absolutely cooperate," says Jones.

After the evidence is collected, victims are treated to prevent the transmission of sexually transmitted diseases and given a prescription for emergency contraception to prevent pregnancy.

"The Catholic Health Initiatives very clearly state that in case of sexual assault, emergency contraception is appropriate," Jones says.

When the exam and treatment are completed, victims are given a bag that contains shampoo, conditioner and lotion and are left alone to shower and reclaim their bodies. They leave St. Anthony's in donated clothing, not scrubs.

From the victim's perspective, the difference between being treated in the emergency room or in a SANE facility can be dramatic. Perhaps the biggest difference is the required wait.

"We had a case a couple of years ago where a woman—she was 16 or 17—ended up [in the emergency room] on a really busy night and waited for literally 10 hours for the exam," says Janine D'Anniballe, executive director of Moving to End Sexual Assault (MESA). "That might have been a bit of an exception, but three to five hours are standard [ER] wait times. It's an acute psychological emergency, but it takes a back seat to the heart attack or car accident that comes through the door."

But decreased wait times aren't the only advantage SANE programs offer to victims.

"Just the fact that someone is competent and specifically trained for this is a huge relief for our clients," D'Anniballe says. "The nurse is there because she wants to be there, where it's been our experience that doctors really don't want to do [rape exams]. They don't feel comfortable. They don't want to testify in court on these. This, obviously, gets passed on energetically to the victim, who is already embarrassed and ashamed. We've had situations where we've had a counselor in there for the rape kit and the doctor will ask our volunteer, 'How do I do this? What am I doing?'"

Another enormous advantage of SANE programs is the female staff. Although a tiny percentage of rape victims are male—St. Anthony's treated two men last year—they often prefer to be treated by female practitioners because they, too, have been assaulted by men.

While being a nurse means working with those who are suffering, witnessing the violence inflicted upon rape victims can take its toll on caregivers. Jones remembers the first case in which she was called to testify as an expert witness. (She has testified twice.) That victim in that case had suffered more physical trauma than any other victim she's seen. She has also examined mentally disabled people who were sexually assaulted. Those cases have stayed with her.

"It's hard. It is hard," says Jones. "Certainly, over time I have come to deal better with my emotions than I did in the beginning. I believe so strongly in what I do, and I believe so strongly in the service I provide to these women and men by being able to do these exams. That more than anything helps me through it. I know I am doing a great thing."

A world of difference

Jones isn't the only person who thinks St. Anthony's SANE program is doing great work. The University of Colorado Police Department was impressed enough with the program that CUPD detectives stopped taking rape victims to Boulder Community Hospital and started transporting them to St. Anthony's in 2004. Despite the 40-minute drive to Westminster and the higher cost of the exams—a SANE exam costs about $200 more than an exam in the ER—the decision to switch to St. Anthony's was a "no-brainer," they say.

"It's all about the victim care," says CUPD's Lieut. John Kish. "[Sexual assault nurse examiners] are specifically trained to deal with the traumas and the psychology that surround victims of sexual assault. In terms of gathering forensic evidence that is available on victims resulting from abuse or sexual assault cases, the treatment victims receive is so much more specific than if they were just to go to an emergency room at any hospital."

The outcome is not only better for victims, but also for detectives, who put long hours into investigating sexual assault cases prior to turning them over to the district attorney's office.

"Their system is so useful," Kish says. "While it's a long exam and it can be a long day, the cases we get where we go to trial where we get SANE exams have been extremely successful."

Other law enforcement agencies in Boulder County began to follow CU's example, more than willing to make the extra drive and pay the additional costs in order to receive better care for victims.

The city of Boulder Police Department has been using St. Anthony's SANE program for about seven months and finds the quality of service to be "exceptional."

"Care-wise, the nurses are very well educated," says Det. Jane Harmer, who investigates sexual assaults as part of BPD's Major Crimes Unit. "They're very compassionate. They treat the victims exceptionally. When we were just using the emergency room over at Foothills, the victims would have to sit there. Sexual assaults are pretty low on the priority list, and you would get some victims who would have to sit there for hours before they were seen by anyone. Not only is that a drag for them, it's a manpower issue for the police department to have an officer tied up for that long."

As a life-long cop, Harmer says she also appreciates the quality of the forensic work.

"I've been doing sex assault investigations for quite a while, and the forensic evidence I'm getting from St. A's as opposed to the regular ER doctors is night and day," she says.

She recalls a case in which the perpetrator violated a woman with his fingers. The nurse examiner used a colposcope to detect and photograph scratches made by the attacker's fingernails inside the victim's vagina.

"That's something that would never have been caught by an ER doc," she says.

Sheriff Joe Pelle says his department began using St. Anthony's program in February 2006.

"I think it provides better care," he says. "We spend quite a bit of extra money to do this, and we wouldn't do that if we didn't feel it was a good thing."

Pelle says the sheriff's department seeks restitution from perpetrators for the money spent on exams and hopes to defray some of the additional expense that way.

While the quality of care and the skill of practitioners in collecting evidence are superior at St. Anthony's, Pelle says SANE programs offer law enforcement another advantage. Rape victims are typically very traumatized and need attention that officers aren't necessarily intended to provide.

"The investigator needs to maintain some distance and some neutrality and be a finder of facts and a seeker of evidence, and that's why it's so beneficial to have people trained in victim advocacy who can step in and be an advocate for the young lady and take care of her personal, spiritual and emotional needs and allow the police officer to do his thing," Pelle says.

The sheriff's department began using St. Anthony's program after hearing from the Boulder District Attorney's office that prosecutors very much wanted Boulder County law enforcement to make the switch.

"We've got to look at everything in terms of how it postures the case for trial. That's the bottom line," says Chief Deputy District Attorney Ingrid Bakke, who supervises the sexual assault unit. "It's been my experience that it can make a world of difference between [when we] have a SANE examiner do the exam versus a physician."

Bakke says that, because nurse examiners are more attentive to the needs of victims, they can have a big impact on how the victim perceives her overall experience, and that can affect whether or not the victim opts to work with prosecutors.

"[Nurse examiners] are one of the up-front people," Bakke says. "Victims are still trying to deal with what happened and then make a decision about how much they want to cooperate. The SANE nurses I have worked particularly closely with have played a huge role in [victims'] comfort level."

A victim's decision to work with prosecutors oftentimes determines whether or not the perpetrator is held accountable, so the more victims who are willing to come forward, the greater chance the DA's office has of getting rapists off the streets and into prison.

Prosecutors, law enforcement and victim advocates agree that the only drawback to the SANE program at St. Anthony's is that it's in Westminster.

"Ideally, it would be wonderful if Boulder County had its own program just for the sheer matter of convenience," says MESA's D'Anniballe. "If someone is assaulted in Boulder County, it's already a pretty daunting thing to think about going in for this rape-kit exam, and then here they are going to a place that's in a different town. I think it just adds to some of the anxiety."

Bakke says prosecutors have been talking about having a Boulder-based SANE program for as long as she's worked in Boulder County.

"It absolutely needs to be here," Bakke says. "The convenience of someone getting to Westminster is a problem. I think it would serve Boulder very well if we could get one that is more local."

Det. Harmer says that although she and the Boulder Police Department do not have an issue with the commute to St. Anthony's they would prefer to see a SANE program in Boulder.

"Certainly it would be better to have it here in Boulder," she says. "But to have a SANE program that is effective, it needs to be 24/7... If we could get enough nurses trained and interested to cover that 24/7, I would very much dig it."

Why not Boulder County?

Once upon a time, Boulder County had its own SANE program. Launched in 1997, it was housed in Niwot's Child Advocacy Center, now Blue Sky Bridge. Over a two-year period, the program treated 140 victims of sexual assault. Then in 1999, conflict with the district attorney's office over questions raised about the quality of one nurse examiner's work resulted in the program's demise when all but one nurse examiner resigned.

Various efforts to start up a new program have failed to get off the ground, despite the consistent and vehement support of MESA, the DA's office, and county law enforcement.

"We have always been trying to get it back up," says Harmer.

Sheriff Pelle says he and other members of the county law enforcement community had hoped to see a SANE program launched on Boulder Community Hospital's $75-million Foothills campus, which is largely dedicated to women's health.

"We had thought that would be a wonderful place to base a SANE program," he says.

Although administrators at BCH's Foothills Hospital considered being the anchor facility for a SANE program, they ultimately opted not to participate.

Holly Pederson, director of the emergency room and intensive care unit, says that although the nurses at the hospital support the idea of a SANE program, there are currently no efforts to revive the program at Foothills due to the expense involved.

"In the long run, it comes down to the cost," she says. "We figured out the hospital in the best-case scenario would have to fork out $100,000. It's going to sound awful when I say this, but we really have focused our mission on healing. I understand that sexual assault is a bad thing, and we all like [SANE]. But it's forensic collection. It's not like, 'Gee, we're saving a life.' And so that's when you go, 'Do we put this new machine in the ICU, or do we pay $100,000 out for a SANE program?'"

Pederson says she was thrilled when St. Anthony's program was able to get on its feet. She believes it makes sense to use the SANE program there because it pools resources into that one facility and keeps the nurses busier.

"You have to have a fairly large region to even come close to support [a SANE program]," Pederson says.

D'Anniballe says that it makes sense for Boulder to participate in a program that's already running because of the expense. However, she points out that other communities in the state, some of them more rural than Boulder, have been able to launch and support SANE programs.

"They've been able to run it and sustain it, so I think it's possible," she says. "I think, in the meantime, this is a good model."

Harmer says that opening a SANE program in Boulder County might result in Boulder stealing some of St. Anthony's nurses simply because there are so few trained forensic nurses.

Nevertheless, D'Anniballe and Harmer agree it would be ideal if Boulder County's SANE program could be resurrected.

"I think what's relevant to keep in mind is that sexual assault nurse examiners have never been based in a hospital in Boulder County," says Rich Sheehan, public relations director for Boulder Community Hospital.

But experts say that's likely one reason the original program failed. The vast majority of SANE programs in Colorado are located in hospitals.

"The absolute appropriate place for SANE programs to be is in the hospital," says Val Sievers, SANE coordinator for the state of Colorado. "This is not some little advocacy-based women's program that we're going to provide in the community for an isolated sex assault here and there. It is a community service that provides forensic health care."

Rape victims often have injuries that require medical attention, such as fractures, closed-head injuries or strangulation injuries. Some have been drugged or are intoxicated.

"Those people deserve to have the complement and the backup of emergency trauma intervention should they need it. So that's why we can't be having these programs in buildings far away from the hospital," she says.

It is Sievers' job to oversee the education of nurse examiners and to provide information and support for SANE programs around the state. She says there are, indeed, obstacles to developing SANE programs, and one of those obstacles is expense.

The program has to cover the cost of nurses' training, as well their on-call fees and salaries. There is equipment to purchase. But there is a variety of funding available as well, from the Violence Against Women Act (VAWA), through Victim Assistance and Law Enforcement (VALE) funds and through reimbursement from law enforcement. Hospitals generally cover the cost of the space and the nurses' salaries.

"There are definitely start-up fees, but this is a valuable community service that would provide outreach to the citizens of Boulder and also provide a return on other health-care services," Sievers says. "If [Boulder Community Hospital is] saying what they're there to do is save lives, then certainly creating that venue for somebody to begin healing after sexual assault—whether it's attention to forensic evidence collection, meeting their emotional needs, making sure they have the availability of Plan B so they're not subjected to an unwanted pregnancy, making sure they treat these people in advance for STDs—if that's not saving a life I don't know what is."

Sievers estimates it would take about $65,000 to $75,000 to get a SANE program off the ground at Foothills Hospital.

"It's not that huge when you talk about building a hospital that cost $75 million," she says. "They do have some fiscally endowed people who live in Boulder."

Sievers says Boulder also has access to resources like MESA, as well as supportive law enforcement and a district attorney's office known for its focus on rape. Although the program would probably only see about 100 patients its first year, patient volume tends to double the second year, as women who might not have come forward before hear about the program and feel more confident in reporting. Only a small percentage of rape victims actually report the crime to police and seek help.

Seivers points to the other communities that have SANE programs—Denver, Aurora, Pueblo, Grand Junction, Fort Collins, Salida, Alamosa, Durango, Glenwood Springs, Westminster and Colorado Springs—and notes that some have smaller populations than Boulder County.

Though the various hospitals fund these programs in a variety of ways—the Colorado Springs program is paid for by the city—most rely on a combination of funding sources.

Is it feasible for Boulder County to have its own SANE program?

"Absolutely," Sievers says. "Republican Colorado Springs was the first place to have a SANE program, and our program is coming up on 11 years."

In the meantime, the nurses at St. Anthony's remain on-call to aid victims from Boulder County.

"It's really important for victims to report and come in for an exam, and no matter what, it's not their fault," says Jones. "We're here to serve."

Resources and additional information:

For counseling and support in the aftermath of a sexual assault, contact the free and confidential 24-hour hotline at Moving to End Sexual Assault: 303-443-7300.

To help support the SANE program at St. Anthony's North, send donations to: St. Anthony Health Foundation, Attn: SANE Program, 4231 W. 16th Ave., Denver, CO 80204.

To donate money to Moving to End Sexual Assault, to volunteer or for more information, call 303-443-0400, or go to Donations can be made online or mailed to: MESA, 2885 E. Aurora, Suite 10, Boulder, CO, 80303.


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