[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
EXAMINING THE AVAILABILITY OF SAFE KITS AT HOSPITALS IN THE UNITED
STATES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
DECEMBER 12, 2018
__________
Serial No. 115-175
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energycommerce.house.gov
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COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
KEVIN CRAMER, North Dakota SCOTT H. PETERS, California
TIM WALBERG, Michigan DEBBIE DINGELL, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
______
Subcommittee on Oversight and Investigations
GREGG HARPER, Mississippi
Chairman
H. MORGAN GRIFFITH, Virginia DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
JOE BARTON, Texas JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana PAUL TONKO, New York
TIM WALBERG, Michigan YVETTE D. CLARKE, New York
MIMI WALTERS, California RAUL RUIZ, California
RYAN A. COSTELLO, Pennsylvania SCOTT H. PETERS, California
EARL L. ``BUDDY'' CARTER, Georgia FRANK PALLONE, Jr., New Jersey (ex
GREG WALDEN, Oregon (ex officio) officio)
(ii)
C O N T E N T S
----------
Page
Hon. Gregg Harper, a Representative in Congress from the State of
Mississippi, opening statement................................. 1
Prepared statement........................................... 3
Hon. Diana DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 4
Prepared statement........................................... 6
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 7
Prepared statement........................................... 9
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 10
Prepared statement........................................... 11
Witnesses
A. Nicole Clowers, Managing Director, Healthcare, Government
Accountability Office.......................................... 13
Prepared statement........................................... 15
Sara Jennings, President-elect, International Association of
Forensic Nurses................................................ 29
Prepared statement........................................... 31
Lynn Frederick-Hawley, Executive Director, Sexual Assault and
Violence Intervention Program, Mount Sinai Hospital............ 46
Prepared statement........................................... 48
Kiersten Stewart, Director of Public Policy and Washington
Office, Futures Without Violence............................... 51
Prepared statement........................................... 53
Submitted Material
Subcommittee memorandum.......................................... 80
Responses from hospitals and associations to letter from
committee, submitted by Mr. Harper \1\
List of databases of SANE programs and SAFE-ready facilities,
committee staff document, December 12, 2018, submitted by Mr.
Harper......................................................... 84
----------
\1\ The information has been retained in committee files and also
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=
108782.
EXAMINING THE AVAILABILITY OF SAFE KITS AT HOSPITALS IN THE UNITED
STATES
----------
WEDNESDAY, DECEMBER 12, 2018
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:04 a.m., in
room 2123, Rayburn House Office Building, Hon. Gregg Harper
(chairman of the subcommittee) presiding.
Members present: Representatives Harper, Griffith, Burgess,
Brooks, Walberg, Costello, Carter, Walden (ex officio),
DeGette, Castor, Clarke, Ruiz, Peters, and Pallone (ex
officio).
Staff present: Jennifer Barblan, Chief Counsel, Oversight
and Investigations; Karen Christian, General Counsel; Ali
Fulling, Legislative Clerk, Oversight and Investigations,
Digital Commerce and Consumer Protection; Brighton Haslett,
Counsel, Oversight and Investigations; Zach Hunter,
Communications Director; Sarah Matthews, Press Secretary,
Energy and Environment; Jeff Carroll, Minority Staff Director;
Chris Knauer, Minority Oversight Staff Director; Jourdan Lewis,
Minority Policy Analyst; Perry Lusk, Minority GAO Detailee;
Andrew Souvall, Minority Director of Communications, Member
Services, and Outreach; and C.J. Young, Minority Press
Secretary.
OPENING STATEMENT OF HON. GREGG HARPER, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MISSISSIPPI
Mr. Harper. The subcommittee will come to order.
Today, the subcommittee on Oversight and Investigations is
holding a hearing entitled ``Examining the Availability of SAFE
Kits at Hospitals in the United States.''
Sexual assault is a vicious and deeply traumatizing crime
inflicted against hundreds of thousands of Americans each year.
As policymakers, it is our responsibility to do everything we
can to help those survivors and hold the perpetrators of those
crimes accountable. To accomplish that, we must improve and
expand access to critical forensic and healthcare services that
survivors seek after an assault.
In 2016, the Bureau of Justice Statistics reported that
more than 323,450 people were the victims of sexual assault.
However, the actual number of survivors may be much higher.
According to the National Crime Victimization Survey, sexual
assault is the most underreported crime in the country. In
fact, aggregate data from the FBI and DOJ indicates that only
23 percent of rapes were reported between 2012 and 2017.
The first step towards prosecuting these vicious crimes is
often the collection of a sexual assault forensic exam or
commonly known as a rape kit. A rape kit can be performed by a
specially trained sexual assault nurse examiner, a SANE, or by
a nurse or medical professional that does not have SANE
training. However, rape kits performed by trained SANEs, what
we shall call SAFE kits, result in better outcomes for
patients, including shortened exam time, better quality
healthcare, higher quality forensic evidence collection, and
certainly higher prosecution rates.
These kits can be vital to securing a prosecution and
conviction. But in many areas of the country, it can prove
shockingly difficult for a survivor of sexual assault to obtain
a SAFE kit. One of our witnesses today, the International
Association of Forensic Nurses, estimates that only about 15
percent of hospitals in the United States provide SAFE kits. We
don't know what happens to many of the survivors that visit a
hospital that does not have SANE nurses available.
In 2016, the GAO published a report entitled Sexual
Assault: Information on Training, Funding, and Availability of
Forensic Examiners. The report examined the challenges that
hospitals face in providing access to SANEs and SAFE kits,
including limited availability of SANE training, weak
stakeholder support for examiners, and low examiner retention
rates. We need to explore each of these issues today.
Over the course of our work, we sent letters to 15
hospitals and 10 hospital associations across the country to
assess what services those hospitals offer and what challenges
they face in making those services available. Their responses
were enlightening, and have not only helped the committee
better understand the challenges to provide access to SANEs and
SAFE kits, but also identifies some of the solutions.
I want to thank all of those hospitals and groups for their
assistance. And without objection, I ask unanimous consent to
enter these 25 responses to the committee's letters into the
record.
Without objection, they are so entered.\1\
---------------------------------------------------------------------------
\1\ The information has been retained in committee files and also
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=108782.
---------------------------------------------------------------------------
Finally, adding to the issue of lack of access is the fact
that very little data is available about where survivors can
find SAFE kits. The nationwide database compiled by the
Forensic Nurses appears to be the best in the country, but it
is not comprehensive. For example, the database lists only two
locations in my home State of Mississippi, but my staff was
able to locate at least 10 SANE programs online. That is not a
criticism at all of the Forensic Nurses, but a call to action.
And I hope that one result of today's hearing will be to
motivate communities around the country to raise awareness of
where SAFE kits can be found, and move towards making that
information widely available.
To that end, I'd also like to ask unanimous consent to
enter into the record a statement--or a document that the
committee created, which includes every list or database our
staff could find for SANE programs and SAFE-ready facilitates
across the country.
Without objection, so entered.
[The information appears at the conclusion of the hearing:]
Mr. Harper. I would also like to submit into the record a
letter from the Joyful Heart Foundation about SAFE kits, which
we received actually this morning.
Without objection, so entered.
It is our hope that this can be a resource to survivors
across the country and that we can lead the charge in educating
the public about this important issue.
I'd like to thank all of our witnesses for joining us in
sharing your expertise and perspectives today. I know this is a
very sensitive topic, but it's a very important one for our
country, and we look forward to hearing your testimony shortly.
Before I introduce the ranking member for her statement, I
would like to take a moment of personal privilege. This will be
my last hearing chairing this subcommittee before I begin my
eagerly anticipated retirement in a few weeks, not from work,
just from Congress. I would like to thank Chairman Walden for
the opportunity to chair this subcommittee through so many
important hearings, including this one. And I would also like
to thank the ranking member and all of my colleagues on both
sides of the aisle for their assistance on so many important
matters that face this committee and our country.
[The prepared statement of Mr. Harper follows:]
Prepared statement of Hon. Gregg Harper
The subcommittee will come to order. Today, the
Subcommittee on Oversight and Investigations is holding a
hearing entitled ``Examining the Availability of SAFE Kits at
Hospitals in the United States.''
Sexual assault is a vicious and deeply traumatizing crime
inflicted against hundreds of thousands of Americans each year.
As policymakers, it is our responsibility to do everything we
can to help those survivors and hold the perpetrators of those
crimes accountable. To accomplish that, we must improve and
expand access to critical forensic and healthcare services that
survivors seek after an assault.
In 2016, the Bureau of Justice Statistics reported that
more than 323,450 people were the victims of sexual assault.
However, the actual number of survivors may be much higher.
According to the National Crime Victimization Survey, sexual
assault is the most underreported crime in the country. In
fact, aggregate data from the FBI and DOJ indicates that only
23 percent of rapes were reported between 2012 and 2017.
The first step toward prosecuting these vicious crimes is
often the collection of a sexual assault forensic exam, more
commonly known as a rape kit. A rape kit can be performed by a
specially trained Sexual Assault Nurse Examiner - a ``SANE''--
or by a nurse or medical professional that does not have SANE
training. However, rape kits performed by trained SANEs - what
we will call ``SAFE kits''--result in better outcomes for
patients, including shortened exam time, better quality health
care, higher quality forensic evidence collection, and higher
prosecution rates.
These kits can be vital to securing a prosecution and
conviction, but in many areas of the country, it can prove
shockingly difficult for a survivor of sexual assault to obtain
a SAFE kit. One of our witnesses today, the International
Association of Forensic Nurses (IAFN), estimates that only
about 15 percent of hospitals in the United States provide SAFE
kits. We don't know what happens to many of the survivors that
visit a hospital that does not have SANE nurses available.
In 2016, the GAO published a report entitled ``Sexual
Assault: Information on Training, Funding, and the Availability
of Forensic Examiners.'' The report examined the challenges
that hospitals face in providing access to SANEs and SAFE kits,
including limited availability of SANE training, weak
stakeholder support for examiners, and low examiner retention
rates. We intend to explore each of those issues today.
Over the course of our work, we've sent letters to 15
hospitals and 10 hospital associations across the country to
assess what services those hospitals offer, and what challenges
they face in making those services available. Their responses
were enlightening, and have not only helped the committee
better understand the challenges to providing access to SANEs
and SAFE kits, but also identify some of the solutions. I want
to thank all of those hospitals and groups for their
cooperation and, without objection, I ask unanimous consent to
enter their responses into the record.
Finally, adding to the issue of lack of access is the fact
that very little data is available about where survivors can
find SAFE kits. The nationwide IAFN database appears to be the
best in the country, but is not comprehensive. For example, the
IAFN database lists only 2 locations in my home State of
Mississippi, but my staff was able to locate at least 10 SANE
programs online.
That is not a criticism of IAFN, but a call to action: I
hope that one result of today's hearing will be to motivate
communities around the country to raise awareness of where SAFE
kits can be found and move toward making that information
widely available. To that end, I'd also like to ask unanimous
consent to enter into the record a document the committee
created which includes every list or database our staff could
find for SANE programs and SAFE-ready facilities across the
country. It is our hope that this can be a resource to
survivors across the country, and that we can lead the charge
in educating the public about this important issue.
I'd like to thank all of our witnesses for joining us and
sharing your expertise today. I know this is a sensitive topic,
but it's a very important one. We look forward to hearing your
testimony.
Before I introduce the ranking member for her statement, I
would like to take a moment of personal privilege. This will be
my last hearing chairing this subcommittee before I begin my
eagerly anticipated retirement in a few weeks. I would like to
thank Chairman Walden for the opportunity to chair this
subcommittee through so many important hearings, including this
one. I would also like to thank the ranking member and all of
my colleagues on both sides of the aisle for their assistance
on so many important matters.
Mr. Harper. With that, I will yield to recognize Ranking
Member DeGette.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you, Mr. Chairman.
And taking a moment of personal privilege myself, I will
say that it's been a real privilege to work with you as the
chairman. This is a venerable committee of Energy and Commerce.
I think it's the best subcommittee in the House, and I'm really
happy that you got the opportunity to chair it.
We've had a number of really solid and important
investigative hearings. I think it's really fitting and a
reflection on you and your commitment to Americans that the
last hearing that we're going to have is a hearing about
keeping patients safe and getting the evidence we need.
So please join me, colleagues, in thanking the chairman for
his wonderful service.
[Applause.]
Mr. Harper. Thank you so much.
Ms. DeGette. For a survivor of sexual assault, it's
critical to protect people's health in the aftermath of an
attack and to receive critical timely medical services that
address the unique needs of each victim. Compassionate care and
the diligent collection of evidence are essential for the
victims' well-being and for the hopes for justice.
The Department of Justice estimates that, nationwide, over
160,000 people were raped or sexually assaulted in 2016, the
last year for which we have data. Yet these crimes go woefully
underprosecuted. According to the Rape, Abuse, and Incest
National Network, only 230 out of 1,000 rapes are reported to
the police. Forty-six out of 1,000 leads to an arrest. And only
nine are ever referred to a prosecutor for trial.
One important tool for successfully treating and
prosecuting sexual assault is to have a trained sexual assault
examiner collect a wide variety of forensic evidence from the
victim, and, of course, that's what's called a sexual assault
evidence collection kit. This kit include a victim's clothes,
hair, blood, and saliva for DNA testing and analysis. DNA
evidence significantly increases the likelihood of identifying
a perpetrator, it increases the likelihood of holding the
perpetrator accountable, and it can even prevent further
assaults by identifying repeat offenders.
And, shockingly, though, if a victim shows up to a hospital
after an assault today, it's far from guaranteed that she would
be able to get a sexual assault examination, even if she knows
to ask for one. In 2016, the GAO conducted a study assessing
the availability of sexual assault forensic examiners
nationwide. As part of this study, GAO found that only one of
the 23 sexual assault programs in Colorado is large enough to
have examiners available 24 hours a day, 7 days a week.
Furthermore, according to the GAO, officials in the six
States they reviewed did not know exactly how many practicing
examiners there were in their States. There was no national
database of sexual assault examiners. And what databases did
exist were often out of date and did not cover all of the
settings where an exam might occur. This suggests to me that we
must do more to get good data on our Nation's capacity for
sexual assault examinations so we can then evaluate these
programs and ensure they have the resources they need to serve
victims.
Keep in mind, these are the barriers that exist just for
getting a kit done in the first place. While not the focus of
this hearing, there's also a huge backlog of kits that were
either never sent to a crime lab to be tested or were sent to a
lab but were left to linger for a period of months or longer.
This is, to say the least, disturbing.
Today, I look forward to hearing from the witnesses about
what we can do to train additional examiners to do this
difficult but necessary work and also to retain the examiners
that we do have. I also want to hear more about how successful
sexual assault examination programs are built and what we can
do to address the unique challenges inherent in providing these
services in rural areas.
I hope the committee can shed some light on these problems
and find ways that will make it easier for any American to get
a sexual assault kit from a trained examiner in a time that is
admittedly a very emotionally stressful and difficult time for
these victims.
And, finally, Mr. Chairman, I have to note the importance
of the Violence Against Women Act. This act supports a number
of programs that address health issues associated with sexual
assault, including three grant programs that can be used to
fund or train sexual assault forensic examiners.
Unfortunately, this law, which has enjoyed bipartisan
support for over 20 years, is going to expire in a little over
a week. We've got to act to reauthorize this law before the
115th Congress ends so that the programs can continue the
important work they're doing and to make sure the victims get
the care they need.
Thank you, and I yield back.
[The prepared statement of Ms. DeGette follows:]
Prepared statement of Hon. Diana DeGette
Addressing the problem of rape and sexual assault is of
critical importance. The Department of Justice estimates that
nationwide, over 160,000 people were raped or sexually
assaulted in 2016, the last year for which we have data.
And yet these crimes go woefully under-prosecuted.
According to the Rape, Abuse & Incest National Network, only
230 out of 1,000 rapes are reported to the police, 46 out of
1,000 leads to an arrest, and only 9 are referred to a
prosecutor for trial.
One important tool for successfully prosecuting sexual
assault is to have a trained sexual assault examiner collect a
wide variety of forensic evidence from the victim, through
what's called a sexual assault evidence collection kit.
This can include a victim's clothes, hair, blood and saliva
for DNA analysis and testing. DNA evidence significantly
increases the likelihood of identifying a perpetrator,
increases the likelihood of holding a perpetrator accountable,
and can even prevent future assaults by identifying repeat
offenders.
And yet today, if a victim shows up to a hospital after an
assault, it is not at all guaranteed that she would be able to
get a sexual assault examination if she asks for one.
In 2016, GAO conducted a study assessing the availability
of sexual assault forensic examiners nationwide. As part of
this study, GAO found that there are only 23 programs with
trained sexual assault examiners covering my entire home State
of Colorado. Furthermore, GAO reported that only one of the
sexual assault programs in Colorado is large enough to have
examiners available 24 hours a day, 7 days a week. In certain
places in western Colorado, victims may have to travel well
over an hour to get to a facility that has an examiner on
staff.
Unfortunately, according to GAO, officials in the six
States in their review did not know exactly how many practicing
examiners there were in their States. There was no national
database of sexual assault examiners, and what databases did
exist were often out-of-date and did not cover all settings
where an exam might occur. This suggests to me that there's
more we need to do to get good data on our Nation's capacity
for sexual assault examinations, so that we can evaluate these
programs and ensure that they have the resources they need to
serve victims.
Keep in mind, these are the barriers that exist just for
getting a kit done in the first place. While not the focus of
this hearing, there is also an enormous backlog of kits that
were either never sent to a crime lab to be tested, or that
were sent to a lab but were left to linger untested for
prolonged periods.
This is all, to put it bluntly, disturbing. Today, I look
forward to hearing from our witnesses about what we can do to
train additional examiners to do this difficult but necessary
work, and to retain those examiners that we do have. I also
want to hear more about how successful sexual assault
examination programs are built, and what we can do to address
the unique challenges inherent in providing access to these
services in rural areas.
I hope this committee can shed some light on these problems
and find ways to make it easier for all Americans to get a
sexual assault kit from a trained examiner in the unfortunate
event that they need one.
Finally, Mr. Chairman, I must again note the importance of
the Violence Against Women Act. The act supports a number of
programs that address health issues associated with sexual
assault, including three grant programs that can be used to
fund or train sexual assault forensic examiners.
Unfortunately, this law--which has enjoyed bipartisan
support for over 20 years--is set to expire in a little over a
week. We must act quickly to reauthorize this law so that these
programs can continue the important work that they are doing,
and to make sure that victims get the care they need.
I yield back.
Mr. Harper. The gentlewoman yields back.
The Chair will now recognize the chairman of the full
committee, Chairman Walden, for 5 minutes for the purpose of an
opening statement.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Well, thank you very much, Mr. Chairman.
And I too want to thank you for your great leadership and
service, your civil demeanor, your intellectual curiosity on
the issues that have come before the Oversight and
Investigations Subcommittee, and the great way you've worked to
get things done here. It really has made a difference for the
country, and you've left the place far better than you found
it. And so we thank you for your service and wish you Godspeed
in doing your next bit of service with family and elsewhere. So
thanks for all you've done, Gregg. You've done a great job. We
really appreciate it.
And I want to follow up on Ms. DeGette's comments as well,
because in September, I wrote to the Speaker, along with
others, saying we need to reauthorize VAWA. It's very, very
important to do. I've supported it every time. It's essential.
And I think on this SAFE kits issue that we're dealing with
today, this will be a perfect priority going forward, it would
have been if we were in the majority first thing up in the next
year, and I think we should be able to find common ground on
this matter as well. And I greatly appreciate the witnesses
coming today.
This is the last, I think, subcommittee hearing on
Oversight, although in talking to some of my friends from the
Senate, it appears they're going to come back the day after
Christmas. So maybe we'll have time for another hearing, Mr.
Harper, just before New Year's or something. I thought I'd
throw that out.
Over the past year, the committee has been investigating
access to SANEs and SAFE kits at hospitals across the U.S., as
you've heard. And throughout our investigation, we've spoken to
more than 40 trauma Level I and II hospitals. Some of these
hospitals have very robust SANE programs that are well-equipped
to provide the best care to survivors of sexual assault,
including one of our witnesses today, Mount Sinai Health
Systems. So we appreciate what you're doing.
Others, however, seemed ill-prepared to address the needs
of sexual assault survivors. One hospital even asked a member
of my staff, and I'm going to quote, ``what is a rape kit,''
close quote. There are currently no Federal requirements
regarding SANEs in the healthcare facilities. As is made clear
in the responses to the committee's letters, some States and
hospital associations have made great strides, while others
have not put the same emphasis on the problem.
I'd like to commend hospitals in my home State of Oregon
for being forthcoming and helpful in our push to expand access
to services for survivors of sexual assault in communities
urban and rural. Their partnership with the Oregon District
Attorney Sexual Assault Task Force is an example of the work we
hope to see spread across the Nation.
As Chairman Harper mentioned, we don't know what happens to
many of the survivors that visit a hospital and are unable to
obtain a SAFE kit. Some survivors may be forced to travel
several hours to the nearest SAFE-ready hospital to obtain a
kit. Others may simply return home and choose never to report
this horrific crime.
There's currently no data or tracking of these trends at
the Federal level; however, through the course of our
investigation, we've spoken with several survivors who have
faced just that situation. One survivor we spoke to, Leah
Griffin, shared her experience of trying to get a SAFE kit in
2014 after being drugged and raped. When she went to her local
hospital, she was told, quote, ``we don't do rape kits here,''
close quote. The hospital told Leah that her options were to
drive herself to another hospital or to pay out of pocket for
an ambulatory transfer. Leah told us, and I quote, ``I was so
shocked, I just went home.''
Hours later, Leah drove to the other hospital to get a SAFE
kit, where it was discovered that she had internal injuries.
Ultimately, the prosecutors in Leah's case declined to bring
charges because the delay in obtaining a rape kit meant the
evidence in her case was weak. Leah asked herself, and again I
quote, at her--by the way, she allowed us to share her name--
``how do we have a justice system that demands empirical
evidence from survivors of sexual assault and then denies
access to that evidence collection?''
Leah's is not the only such story we've heard and read
about; there's also Megan Rondini, Dinisha Ball, and
unfortunately, many others. The day that an individual is
sexually assaulted can be the worst day in her or his life. The
thought of turning to a hospital after such a trauma and then
being told, sorry, we can't help you, is unimaginable and,
frankly, unacceptable.
These stories are heartbreaking. And, unfortunately, due to
the lack of data and tracking within hospitals, we cannot
estimate how many sexual assault survivors face this very same
experience when they attempt to report these crimes.
I want to thank Leah and the other survivors we spoke to
for sharing their experiences with us, I know that cannot have
been easy, as well as those hospitals, hospital associations,
and survivor advocacy groups that shared their expertise and
experience with us over the course of this investigation. I
hope that we can begin identifying some successful models that
other hospital systems can apply to their own communities. And
in particular, I hope the use of technology, such as online
training programs and telehealth, can begin to solve the issues
of access in our rural communities. Many health centers and
hospitals in my district have a hard time recruiting healthcare
professionals already, so expanding options for these
communities is an extra challenge that we have to take on.
And, finally, I want to thank Representative Poe, who is in
the audience today, who has been a real leader on this, along
with Mr. Griffith and others on the committee. But, Ted, we
thank you for your leadership on this, and I know there's
legislation that's being put together here that hopefully we
can move before the end of the year, if we can get everybody on
the same page.
Again, Mr. Chairman, thanks for your wonderful leadership
on this and so many other topics. And I yield back the balance
of my time.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
Mr. Chairman, thank you for holding this important hearing
today.
Over the past year, the committee has been investigating
access to SANEs and SAFE kits at hospitals across the United
States. Throughout our investigation, we've spoken to more than
40 Trauma Level I and II hospitals. Some of these hospitals
have robust SANE programs that are well equipped to provide the
best care to survivors of sexual assault--including one of our
witnesses today, Mount Sinai Health System. Others seemed ill-
prepared to address the needs of sexual assault survivors. One
hospital even asked a member of my staff, ``What is a rape
kit?''
There are currently no Federal requirements regarding SANEs
in healthcare facilities. As is made clear in the responses to
the committee's letters, some States and hospital associations
have made great strides, while others have not put the same
emphasis on the problem. I'd like to commend hospitals in my
home State of Oregon for being forthcoming and helpful in our
push to expand access to services for survivors of sexual
assault, in communities urban and rural. Their partnership with
the Oregon District Attorney's Sexual Assault Task Force is an
example of the work we hope to see more of across the country.
As Chairman Harper mentioned, we don't know what happens to
many of the survivors that visit a hospital and are unable to
obtain a SAFE kit. Some survivors may be forced to travel
several hours to the nearest SAFE-ready facility to obtain a
kit. Others may simply return home and choose not to report the
crime. There is currently no data or tracking of these trends
at the Federal level. However, through the course of our
investigation we've spoken with several survivors who have
faced just that situation.
One survivor we spoke to, Leah Griffin, shared her
experience of trying to get a SAFE kit in 2014 after being
drugged and raped. When she went to her local hospital, she was
told, ``We don't do rape kits here.'' The hospital told Leah
that her options were to drive herself to another hospital or
to pay out of pocket for an ambulatory transfer. Leah told us,
``I was so shocked, I just went home.'' Hours later, Leah drove
to the other hospital to get a SAFE kit, where it was
discovered that she had internal injuries. Ultimately, the
prosecutors in Leah's case declined to bring charges because
the delay in obtaining a rape kit meant the evidence in her
case was weak. Leah asked herself, ``How do we have a justice
system that demands empirical evidence from survivors of sexual
assault and then denies access to that evidence collection?''
Leah's is not the only such story we have heard or read
about. There is also Megan Rondini, Dinisha Ball, and,
unfortunately, many others.
The day that an individual is sexually assaulted can be the
worse day in her or his life. The thought of turning to a
hospital after such a trauma and being told ``We can't help
you'' is unimaginable and, frankly, unacceptable.
These stories are heartbreaking. Unfortunately, due to the
lack of data and tracking within hospitals, we cannot estimate
how many sexual assault survivors face this very same
experience when they attempt to report these crimes.
I want to thank Leah and the other survivors we spoke to
for sharing their stories with us, as well as those hospitals,
hospital associations, and survivor advocacy groups that shared
their expertise and experience with us over the course of this
investigation. I hope that we can begin identifying some
successful models that other hospital systems can apply to
their own communities. In particular, I hope the use of
technology, such as online training programs and telehealth,
can begin to solve the issue of access in rural communities.
Many health centers and hospitals in my rural district have a
hard time recruiting healthcare professionals already, so
expanding options for these communities is an extra challenge
that we must take on.
I want to thank our witnesses for being here with us today.
We look forward to hearing your testimony. I yield back.
Mr. Harper. The gentleman yields back.
The Chair will now recognize the ranking member of the full
committee, Mr. Pallone, for 5 minutes for the purposes of an
opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
Sexual assault is a horrific crime, and we must continue to
work to end the cycle of violence. Sexual assault forensic
examiners, otherwise known as SAFEs, play an important role in
helping those who are victims of these crimes. SAFEs provide
care to victims of sexual assault, and with the use of a
forensic exam kit, can collect a wide variety of DNA evidence
that can be used to prosecute an offender.
Thanks to the Violence Against Women Act, States must
provide sexual assault kits free of charge to anyone who needs
it. The law also authorizes three Department of Justice grant
programs that fund and train sexual assault forensic examiners.
Despite the strides we've made in the last 20 years, it can
still be quite difficult for a victim to find a trained
examiner when they need one. For example, according to media
reports, only one hospital here in the DC area has a program
with sexual assault nurse examiners on staff. Unfortunately,
the problem is occurring nationwide. For example, according to
a 2016 report from the GAO, officials in the six States they
studied said there were not enough examiners in their States to
meet the demand for exams, particularly in rural areas.
In some States, entire counties do not have any SAFE
programs available. In some cases, victims must travel over an
hour to a facility with a trained examiner. In that time, a
victim must avoid bathing, showering, using the restroom, or
changing clothes, or else risk damaging the evidence before it
can be collected. And this is unacceptable, and we must find
ways to make these services more widely available.
The GAO report also found that there was no national
database that captures the number of examiners, where they are,
and what their capabilities are. The only data available is
limited in scope and collected on a voluntary basis. And this
means that victims do not have to update information and cannot
easily identify all healthcare settings where sexual assault
forensic exams might be conducted. This kind of information
should be easily accessible to victims in their most vulnerable
moments,
Moreover, even when a facility provides these kits and
related SAFE services, States and hospitals have struggled to
retain enough examiners. State officials reported to GAO that
they face challenges such as limited availability of classroom
and clinical training, weak support for programs from
stakeholders, and the emotional and physical demands on
examiners. And taken together, these findings demonstrate the
challenges we still face in ensuring that all victims of sexual
assault can get access to a forensic exam kit and services
provided by a trained examiner, should they request it.
This is not to say there are no success stories. Clearly,
there are many hospitals and other facilities that provide
sexual assault kits and SAFE services for those who need it,
and we should learn from those cases and determine what we can
replicate on a broader scale.
So I look forward to hearing from each of our witnesses
here today about what we can do to get our arms around this
problem and what we can do to expand and retain our workforce
of trained sexual assault forensic examiners.
And, finally, I just would like to reiterate the importance
of the Violence Against Women Act. This act is a critical part
of the Federal Government's response to sexual assault and it
funds many of the programs we'll be talking about today, but
the law is set to expire in just over a week. We must ensure
this act is reauthorized so that these critical programs
continue to receive funding and victims can receive the care
and services they need.
So I want to thank our panelists for sharing their
expertise on this important issue as we move forward.
I yield back.
[The prepared statement of Mr. Pallone follows:]
Prepared statement of Hon. Frank Pallone, Jr.
Thank you, Mr. Chairman. Sexual assault is a horrific
crime, and we must continue to work to end the cycle of
violence.
Sexual Assault Forensic Examiners, otherwise known as
SAFEs, play an important role in helping those who are victims
of these crimes. SAFEs provide care to victims of sexual
assault, and--with the use of a forensic exam kit--can collect
a wide variety of DNA evidence that can be used to prosecute an
offender.
Thanks to the Violence Against Women Act states must
provide sexual assault kits free of charge to anyone who needs
it. The law also authorizes three Department of Justice grant
programs that fund and train sexual assault forensic examiners.
Despite the strides we have made in the last 20 years, it
can still be quite difficult for a victim to find a trained
examiner when they need one. For example, according to media
reports, only one hospital here in the DC area has a program
with sexual assault nurse examiners on staff.
Unfortunately, his problem is occurring nationwide. For
example, according to a 2016 report from the Government
Accountability Office (GAO), officials in the six States they
studied said there were not enough examiners in their States to
meet the demand for exams, particularly in rural areas. In some
States, entire counties did not have any SAFE programs
available.
In some cases, victims must travel over an hour to a
facility with a trained examiner. In that time, a victim must
avoid bathing, showering, using the restroom, or changing
clothes, or else risk damaging the evidence before it can be
collected. This is unacceptable, and we must find ways to make
these services more widely available.
The GAO report also found that there was no national
database that captures the number of examiners, where they are,
and what their capabilities are. The only data available is
limited in scope and collected on a voluntary basis.
This means that victims do not have up-to-date information
and cannot easily identify all healthcare settings where sexual
assault forensic exams might be conducted. This kind of
information should be easily accessible to victims in their
most vulnerable moments.
Moreover, even when a facility provides these kits and
related SAFE services, States and hospitals have struggled to
retain enough examiners. State officials reported to GAO that
they face challenges such as limited availability of classroom
and clinical training, weak support for programs from
stakeholders, and the emotional and physical demands on
examiners.
Taken together, these findings demonstrate the challenges
we still face in ensuring that all victims of sexual assault
can get access to a forensic exam kit and services provided by
a trained examiner, should they request it.
That is not to say that there are no success stories.
Clearly, there are many hospitals and other facilities that
provide sexual assault kits and SAFE services for those who
need it. We should learn from those cases and determine what we
can replicate on a broader scale.
I look forward to hearing from each of our witnesses here
today about what we can do to get our arms around this problem,
and what we can do to expand and retain our workforce of
trained sexual assault forensic examiners.
Finally, I would like to reiterate the importance of the
Violence Against Women Act. This act is a critical part of the
Federal Government's response to sexual assault. It funds many
of the programs we will be talking about today but the law is
set to expire in just over a week. We must ensure this act is
reauthorized so that these critical programs continue to
receive funding, and victims can receive the care and services
they need.
I thank our panelists for sharing their expertise on this
important issue.
Thank you, I yield back.
Mr. Harper. The gentleman yields back.
I ask unanimous consent that the Members' written opening
statements be made part of the record. Without objection, will
be entered into the record.
Additionally, we welcome non-Energy and Commerce Committee
members who are with us today. Pursuant to House rules, Members
not on the committee are able to attend our hearings but not
ask questions, and we've already recognized Representative Ted
Poe from Texas, who is the only other Member that I see, and
that's just the way it is.
I would now like to introduce our witnesses for today's
hearing. Today, we have Ms. Nicole Clowers, managing director
of healthcare at the GAO. Next is Ms. Sara Jennings, president-
elect of the International Association of Forensic Nurses. Then
we have Ms. Lynn Frederick-Hawley, executive director of the
SAVI Program at Mount Sinai Hospital. And, finally, Ms.
Kiersten Stewart, director of Public Policy and the Washington
Office of Futures Without Violence.
As you are aware, the committee is holding an investigative
hearing, and when doing so, has had the practice of taking
testimony under oath. Do any of you have any objection to
testifying under oath?
All witnesses have indicated no.
The Chair then advises you that under the rules of the
House and the rules of the committee, you are entitled to be
accompanied by counsel. Do any of you desire to be accompanied
by counsel during your testimony today?
All of the witnesses have indicated no.
In that case, if you would, please rise and raise your
right hand and I will swear you in.
Do you swear that the testimony you are about to give is
the truth, the whole truth, and nothing but the truth?
All the witnesses have anticipated--have answered and
responded in the affirmative.
You're now under oath and subject to the penalties set
forth in Title 18, Section 1001 of the United States Code. You
may now give a 5-minute summary of your written statement, and
I will now first call on Nicole Clowers, managing director of
healthcare for the U.S. Government Accountability Office.
You are recognized for 5 minutes, Ms. Clowers.
STATEMENTS OF A. NICOLE CLOWERS, MANAGING DIRECTOR, HEALTHCARE,
GOVERNMENT ACCOUNTABILITY OFFICE; SARA JENNINGS,PRESIDENT-
ELECT, INTERNATIONAL ASSOCIATION OF FORENSIC NURSES; LYNN
FREDERICK-HAWLEY, EXECUTIVE DIRECTOR, SEXUAL ASSAULT AND
VIOLENCE INTERVENTION PROGRAM, MOUNT SINAI HOSPITAL; AND
KIERSTEN STEWART, DIRECTOR OF PUBLIC POLICY AND WASHINGTON
OFFICE, FUTURES WITHOUT VIOLENCE
STATEMENT OF A. NICOLE CLOWERS
Ms. Clowers. Thank you.
Chairman Harper, Ranking Member DeGette, and members of the
subcommittee, thank you for having me here today to discuss our
2016 report on the availability of sexual assault forensic
examiners.
Studies have documented the benefits of using trained
examiners in the cases of sexual assault. As the chairman
noted, these benefits include shorter exam times, more
comprehensive medical care, better health outcomes for the
victims, better collection and documentation of the evidence,
and higher prosecution rates. However, concerns have been
raised about the availability of examiners to meet the need for
exams.
To help inform today's discussion, I will summarize key
findings from our 2016 report, which include what is known
about the availability of sexual assault forensic examiners
nationwide, as well as in selected States, as of 2016, and the
challenges selected States face to maintaining a supply of
sexual assault examiners.
With respect to the availability of examiners, we found
that only limited nationwide data exist on the availability of
sexual assault examiners; that is, both the number of
practicing examiners and the number of healthcare facilities
that have examiner programs. While some national estimates are
available, they are not comprehensive, as they only capture
examiners with select certifications or program information
that is voluntarily reported.
We also found limited information at the State level. While
officials from all six States that we contacted were able to
provide information on the number of examiner programs located
within their States, only three could provide estimates of the
number of practicing examiners. And the State data available at
the time of our audit were likely incomplete, as only one of
the six States had a system in place to formally track the
number and location of examiners.
Despite these data limitations, officials in all six States
told us that the number of examiners available in their State
did not meet the need for exams, especially in rural areas. For
example, officials in Wisconsin explained that nearly half of
all the counties in the State do not have any examiner programs
available. As a result, officials said victims may need to
travel long distances to be examined by a trained examiner. The
challenge of long travel distances can be further complicated
for rural residents due to weather-related travel restrictions
during certain times of the year.
Finally, we found that there are multiple challenges to
maintaining the supply of examiners, including, one, the
limited availability of training, which includes limited
classroom, clinical, and continuing education training
opportunities; two, low retention rates of examiners due to the
emotional and physical demands of the job, coupled with low
pay; and, three, weak stakeholder support for examiners, such
as hospitals being reluctant to cover the cost of training or
paying for examiners to be on call.
Officials told us about a number of strategies they have
used to help address these challenges, such as web-based
training and mentoring programs. For example, officials in
Colorado told us that an examiner program coordinator in an
urban hospital provides volunteer, on-call technical assistance
and clinical guidance to the examiners in rural parts of the
State where those resources are not otherwise available.
Chairman Harper, Ranking Member DeGette, and members of the
subcommittee, this completes my prepared statement. I would be
pleased to respond to any questions at the appropriate time.
Thank you.
[The prepared statement of Ms. Clowers follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Harper. Thank you so much for your testimony.
The Chair will now recognize Sara Jennings, RN--and I'm
partial to RNs since I'm married to one--who is the president-
elect of the International Association of Forensic Nurses.
You are hereby recognized for 5 minutes for testimony.
STATEMENT OF SARA JENNINGS
Ms. Jennings. Thank you.
Chairman Harper, Ranking Member DeGette, and members of the
subcommittee, thank you for the opportunity to testify today.
On behalf of the 4,300 forensic nurses who make up the
membership of the International Association of Forensic Nurses,
I am pleased to be here this morning in relation to the
availability of SAFE kits at hospitals in the United States,
and to discuss issues impacting patients' access to essential
services following an assault. This is an important topic, and
the IFN appreciates the active role of the committee to address
it.
My name is Sara Jennings, and I'm a forensic nurse since
2006, and I'm the president-elect for the IFN. First, let me
tell you a bit about forensic nursing. A forensic nurse is a
registered nurse or advanced practice nurse who's received
specialized education and training. Forensic nurses provide
specialized care for patients who are experiencing acute or
long-term health consequences associated with victimization or
violence and/or have unmet evidentiary needs relative to having
been victimized or accused of victimization. In addition,
forensic nurses provide consultation and testimony for civil
and criminal proceedings relative to nursing practice, care
given, and opinions rendered regarding findings.
Since forensic nursing is a recognized nursing specialty of
the American Association of Nurses, a person must first become
a registered nurse before becoming a forensic nurse. Forensic
nurses work in a variety of fields, including sexual assault,
domestic or intimate partner violence, child abuse and
negligent, elder maltreatment, human trafficking, death
investigations, corrections, and in the aftermath of mass
disasters. In the United States, forensic nurses most
frequently work in hospitals, community anti-violence programs,
coroners, or medical examiners' offices, corrections
institutions, and psychiatric hospitals.
Sexual assault nurse examiners, or SANEs, are registered
nurses who have completed specialized education and clinical
preparation in the medical forensic care of the patient who has
experienced sexual assault or abuse. To become a SANE you must
first be a registered nurse with 2 years or more of experience
in areas of practice, such as emergency department nursing. The
same training should meet the IFN SANE educational guidelines
and will consist of both classroom and clinical components.
The Bureau of Justice Statistics within the Department of
Justice reports in its National Crime Victimization Survey for
2016 that there were 298,410 rapes or sexual assaults in the
United States. There were also 1,068,120 incidents of domestic
violence.
In March of 2016, the General Accountability Office issued
a report investigating the availability of trained examiners on
a national level. The report identified major flaws and
survivor access to sexual assault examination services.
Specifically, the report showed a disturbing lack, and in some
cases a complete absence, of information and data on the number
of sexual assault examiners in most States.
The IFN is pleased that Congress is increasingly aware of
the problem and the need to ensure appropriate access to
necessary services and supplies. Several bills have been
introduced to try to address this problem. The IFN is
supportive of the Survivors' Access to Supportive Care, or
SASCA, and also encourages efforts to improve the Violence
Against Women Act. IFN strongly supports the SASCA, which was
introduced in the Senate by Senator Patty Murray and Senator
Lisa Murkowski.
IFN believes this bill would expand access to qualified
examiner services and help strengthen national standards of
care for survivors of sexual assault. SASCA would also provide
guidance and support to States and to hospitals providing
sexual assault examination services and treatment to survivors.
IFN also strongly supports the swift reauthorization of the
Violence Against Women Act; however, IFN does believe that
there are several key improvements that must be made to this
law, including establishing a standardized national sexual
assault evidence collection kit, requiring health insurance to
be the primary payer, and establishing evidence-based, trauma-
informed national medical forensic exam protocols for intimate
partner violence. It is imperative for the long-term health and
recovery of these patients that a standardized approach be
developed and a plan for effective implementation.
Thank you for this opportunity to testify today, and I'm
available at the appropriate time for questions.
[The prepared statement of Ms. Jennings follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Harper. Thank you for your testimony.
The Chair will now recognize Lynn M. Frederick-Hawley--
that's Hawley, I'm sorry, my apologies.
Ms. Frederick-Hawley. No problem.
Mr. Harper [continuing]. Executive director at SAVI Program
at Mount Sinai Hospital.
And you're now recognized for 5 minutes.
STATEMENT OF LYNN FREDERICK-HAWLEY
Ms. Frederick-Hawley. Thank you.
Good morning. Chairman Harper, Ranking Member DeGette, and
members of the committee, thank you for the opportunity to
testify before you today. I would also like to acknowledge
Representative Tonko and Representative Clarke from New York.
My name is Lynn Frederick-Hawley. I am the executive
director of the Sexual Assault and Violence Intervention
Program of the Mount Sinai Hospital, otherwise known as SAVI.
Makes it easier for you to say it. Founded in 1852, the Mount
Sinai Hospital is one of the Nation's largest and most
respected hospitals, acclaimed internationally for excellence
in clinical care. Ranked among the top hospitals nationwide, we
serve one of the most diverse populations in the world as well.
It has been a priority at the Mount Sinai Hospital for
decades to maintain a comprehensive program to address the
needs of sexual assault survivors. Our goal is to provide the
highest quality medical care and compassionate client-centered
services to address both the patient's physical and
psychological trauma. We believe it's critical to validate,
heal, and empower survivors and their supporters to lead safe,
healthy lives through advocacy, free and confidential therapy
and counseling, and education.
The Mount Sinai Hospital is one of the few institutions
with a dedicated program exclusively focused on providing
outreach, comprehensive training, emergency department
advocacy, and counseling services to address the needs of past
and present victims of sexual assault and intimate partner
violence. SAVI was founded in 1984, and we have grown
exponentially in the past 34 years to meet the evolving needs
of survivors and our communities, including creating our sexual
assault forensic examiner program.
I should emphasize that this evolution has been made
possible by the support of Mount Sinai leadership, the
availability of funding for this kind of programming, and the
backing of the communities we serve. We work very intensively
with our community. Our sexual assault forensic examiner
program has been designated a center of excellence since 2006
by the New York State Department of Health.
In addition to the SAFE program, we maintain over 150
highly trained volunteer advocates who are certified and go on
call 24/7 to respond to all instances of sexual assault in our
hospitals. The advocates, together with the trained SAFE
clinician, work seamlessly to provide comprehensive services to
the sexual assault survivors seeking care at the Mount Sinai
Hospital. SAVI therapists are then available to support the
survivor beyond the immediate crisis services received in the
emergency department.
Specifically, the Mount Sinai Hospital and its affiliate
medical school, the Icahn School of Medicine at Mount Sinai,
employ 24 medical professionals who have decided to take the
additional steps to become a SAFE examiner with the SAVI
program. Currently that includes 10 nurses, 7 physicians
assistants, and 7 physicians, including residents. All are
employed by the Mount Sinai Hospital in other capacities, they
are then screened by SAVI for this particular role, have
completed extensive additional 40-hour training to qualify as a
SAFE, and then they complete a preceptorship with our program
specifically. Many of the SAFE-trained staff work in the
emergency department, and they are able to provide services to
a patient if the on-call SAFE clinician, for whatever reason,
is unexpectedly unavailable.
I would like to take you through the protocol quickly for
treating survivors of sexual violence in our program. As an
initial matter, we have a strong protocol in place for
clinicians and staff to identify potential survivors of sexual
assault and respond sensitively. Once a patient discloses
sexual assault, they are triaged to a private, safe equipped
room. Both the on-call SAFE and the SAVI advocate are contacted
to come to our hospital to provide care and treatment to the
patient.
The advocate is a certified volunteer who provides
counseling, support, information, referral, advocacy, safety
planning to the survivor and any family member or supportive
person who is there. The advocate remains with the survivor
throughout their stay in the hospital. The SAFE conducts the
medical and evidence collection exam consistent with the
patient's consent and their wishes.
Specific medical protocols and regimens are followed in the
event the survivor is a candidate for a variety of prophylaxis
treatment. The patient receives detailed discharge instructions
and treatment counseling options, including followup for any
medical care or continued prescriptions they need.
SAVI follows up with every patient after they have spent
time in the emergency department. We also work closely with the
NYPD and with our security department in the event that the
survivor hasn't yet let the kit go over to the police
department.
In order to provide this multilayered response, many
resources must be invested. This is not care that survivors
should be expected to underwrite. None of SAVI services,
including our SAFE program, generate income. So it's the vision
of an institution like Mount Sinai that sees the overarching
benefit and necessity of providing the care to survivors and
provides the context in which it can happen, as well as the
availability/accessibility of funding from our city, State,
Federal, and community partners that makes this even possible.
On that note, 36 seconds over, I'll be quiet, and I'm happy
to answer any questions as we go forward.
[The prepared statement of Ms. Frederick-Hawley follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Harper. The chair wants to thank Ms. Frederick-Hawley,
the executive director of the SAVI program at Mount Sinai
Hospital, for your testimony.
And the chair now recognizes Kiersten Stewart, who's the
director of public policy and the Washington office for Futures
Without Violence.
STATEMENT OF KIERSTEN STEWART
Ms. Stewart. Thank you, Mr. Chairman, thank you, Ranking
Member DeGette, and thank you members of the committee for your
leadership in paying attention to this issue. I would also like
to call out Congresswoman Clarke and Congresswoman Castor, who,
along with Mrs. Walters and Mr. Costello, recently introduced
the Violence Against Women Health Act, which will also make
progress on this goal.
For those of you who do not know FUTURES, we are a national
nonprofit organization that works to end violence against women
and children here in the U.S. and around the world. We also
house the National Health Resource Center on violence against
women. Less well known is that our work actually began--we
began as an organization about 35 years ago simply with a chair
in an emergency room at San Francisco General Hospital, trying
to provide whatever help we could to every woman who came in a
victim of violence. I'm proud to say we've progressed since
then, but the mission remains the same.
Some things to understand. Please know that sexual assault
is painfully common and a crime largely committed against young
people. More than 80 percent of rapes are committed against
those under the age of 25, and about half of those are
committed against those under the age of 18, children. While
young girls and women are those most likely to be victims of
rape and sexual assault, men and boys are also victims, as are
individuals who do not always fit our traditional norms of male
and female.
American Indian and Alaska Native women, people who live in
rural areas, as well as individuals with disabilities, also
experience higher rates of sexual violence. As we analyze who
has access to forensic exams, as well as all healing services
for sexual violence, it is important to keep in mind the needs
of all victims.
The consequences of sexual violence are often severe and
often long lasting. While different people respond differently
to sexual violence, sexual violence often leaves a deeply
painful mark that some never fully heal from. New economic
estimates also create a staggering picture of the cost
associated with rape. Using 2014 dollars, the estimated
lifetime cost of rape at a population level is nearly $3.1
trillion. This is based on the fact that 25 million Americans
have been raped.
The Government, our tax dollars, pay an estimated $1
trillion, or about a third of that lifetime economic burden.
These numbers do not capture the personal pain of rape and
sexual assault on individuals or their families, but they do
create a call for action.
Forensic examines, as you've heard, help improve
prosecution of sexual assault, but training is essential. I
will not duplicate the testimony you've heard from others, but
we can't just view training as a one-off act. It needs to be
integrated into broader hospital quality improvement measures,
attention needs to be paid to the vicarious trauma often
experienced by the nurse examiners, and training needs to
engage the entire health entity, from intake to billing to risk
management to the front line medical personnel. We also
strongly recommend models that are patient-centered and trauma-
informed.
We also believe we need to expand training for healthcare
providers beyond the forensic exam. Most victims still never
make it to the emergency room. Providers need to be trained.
Mental health providers, adolescent health, and OB/GYNs, as
well as campus health centers, need training to understand and
address the impacts of sexual abuse and trauma.
As you've already heard, sexual violence is also an often
unrecognized element of abusive relationships. In fact, maybe
as much as half of sexual assaults are actually perpetrated by
partners. So that's about 22 million women who've experienced
sexual violence by an intimate partner, nearly 3 million a
year.
Importantly, we have evidence-based clinical interventions
that improve the health outcomes and can reduce the violence.
So we also need to be putting resources into those.
Specifically, what can we ask you to do in the next year?
One, increase funding. The Health Resources and Services
Administration has an advanced nursing education SANE program
out of the Bureau of Healthcare Workforce. There was $8 million
that recently went out. That is an important first step, but we
need to do more.
Provide dedicated funding to project catalysts out of the
Office of Women's Health at HRSA. Pass legislation like the
Megan Rondini Act that would increase requirements on hospitals
to provide all survivors access to a SANE or information on how
to get a rape kit if it is not at their hospital. As you've
heard, though, we can't do the requirements if we don't have
the workforce. We need to do both.
Pass the Violence Against Women Act, as we've heard by many
of you, but include this new and improved health. As the GAO
report pointed out, there is a VAWA health program, it has no
dedicated funding, so we would ask for your help in supporting,
creating a designated funding line.
We also have the Family Violence Prevention and Services
Act that is also up for reauthorization. This is out of the
Department of Health and Human Services, and so that is also
awaiting reauthorization similar to VAWA.
And the final thing I would ask. As you heard me say,
Native American and Alaska--Alaska Native victims experience
violence at the highest rates. So we would ask included in VAWA
the protections for Native women who are victims of sexual
assault and child abuse.
Thank you.
[The prepared statement of Ms. Stewart follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Harper. I want to thank each of you for your testimony.
We look forward to asking you questions. I think this is such
an important hearing, and we appreciate your attendance today.
This is very helpful to us. We know we have some challenges,
but this is not really a bipartisan topic; it's really a
nonpartisan topic. This is something that has to be done to
make sure that we improve greatly on what we're doing right
now. So thank you.
This is now the opportunity for the Members to have the
chance to ask each of you questions. I'll begin by recognizing
myself for 5 minutes for questions at this time.
You know, I certainly think that it's important that
everyone understand why access to SANEs and SAFE kits is so
important. According to the GAO report, when a survivor of
sexual assault receives a sexual assault forensic exam, that
exam can be done by a SANE that has specialized training in how
to collect those kits or by a nurse or medical professional
that does not have that training. But GAO, I believe, correctly
noted that exams performed by SANEs have several advantages,
including higher quality healthcare, and from a prosecution
standpoint, a much higher quality evidence collection.
So, Ms. Jennings, I'd like to start with you, if I may.
Explain to us briefly, what does SANE training entail and does
that vary State by State?
Ms. Jennings. Sure. Thank you for the question. Our SANE
training is two parts. So there is the adult component and then
the pediatric component. The adult component consists of a 40-
hour training, the didactic, so your actual classroom training.
The pediatric is another 40-hour training in the classroom
setting. And then there's a combined training of both adult and
pediatrics, which is a 64-hour class that you can also take.
There are many options for both in-live classroom settings
and there's also an option with IFN to attend an online
training, which is very accessible to anyone in any setting.
Once you complete the classroom setting, there is a clinical
component, and that's where we see the biggest struggle to
actually find sites to do the clinical training. We have a
really good access to the classroom component, but we have a
very hard time finding sites for the clinical component.
Mr. Harper. You raised an interesting point because you
have a separate training for pediatric.
Ms. Jennings. Yes.
Mr. Harper. But you may only have one staffer that's
trained that may be there available on-call or at that time. Do
you recommend that someone complete both components in the
shorter combined class?
Ms. Jennings. In rural areas where there is smaller patient
populations that they may not see large numbers of pediatric
patients, that would probably be the best route to go so that
you have both the adult and the pediatric component. Pediatric
patients, from a forensic perspective and sexual assault
perspective, are very different than adult patients. So it does
take a bit more time to be very familiar and very competent
with the pediatric patient population.
Mr. Harper. Are you able to tell us generally the cost for
this training or certification?
Ms. Jennings. Sure. So if you take the training through the
IFN, it's roughly $500, based off of the online training. There
are trainings that are State specific in addition to that that
may cost an additional amount. I'm not familiar with that. I
apologize.
Mr. Harper. Sure. You know, as we noted and I spoke of in
my opening statement, the GAO found that limited availability
of training is one of the major impediments that hospitals face
in providing access to these services. So my question--follow-
up question, Ms. Jennings, would be, where is training
generally available? And how does availability--and you said
online, of course, but how does availability of training vary
across different regions? Is there an urban versus rural
component or is it a State-by-State issue? Can you elaborate a
little bit?
Ms. Jennings. Sure. So the training I mentioned is through
the IFN, the online component, which is both the adult, the
pediatric component, the combined course. However, there are
States that choose to do actual in-person trainings; those can
be approved by the IFN. Some of those trainings are just done
by providers within certain facilities.
Mr. Harper. Approximately, how many States offer in-person
training? Do you have a general idea?
Ms. Jennings. I don't. I can tell you, I'm from Virginia,
and we do offer several trainings throughout the State several
times a year, but of course, that varies State to State.
Mr. Harper. Thank you very much. I appreciate that.
Another challenge that hospitals identified to the
committee was the financial challenge of administering a SAFE
program; however, several of the letter recipients were able to
identify grant programs to fund SANE training.
So, Ms. Clowers, if I could ask you. The GAO report touched
on various sources of funding for SANE training. Could you
briefly describe how those funding sources and how hospitals
can take advantage of those opportunities?
Ms. Clowers. Yes, sir. We identified three key grant
programs at the time of our audit. All were administered by the
Department of Justice, with the STOP grants being the largest,
that's a formula-based grant, where all territories and States
receive a set amount. At the time it was $600,000, and then
could get additional funding based on population.
And what we found is that the amounts that locations
receive varied greatly depending on the size of the population.
And we also found that the entities that received those grants
typically used the money for training. Forty-nine States
reported--grantees in 49 States reported using funding for
training, which would include types of training that Ms.
Jennings mentioned, whether it be classroom training, clinical
training, and then importantly, the continuing education as
well. In addition to the training, States reported using some
funding for funding of positions. But less States reported
using funds for those purposes. Only about--grantees in about
half of the States reported using funds for positions. And if
they were using them for positions, it was typically for a
program coordinator.
Mr. Harper. Thank you very much.
The Chair will now recognize the ranking member, Ms.
DeGette, for 5 minutes.
Ms. DeGette. Thank you very much.
Well, Ms. Clowers, following up on your testimony about the
grant programs at the Department of Justice, those programs are
of course included in the Violence Against Women Act
reauthorization, which is set to expire December 21. So I want
to ask you about--and everybody here agrees, all of the
witnesses, everybody in the audience, all of the Members of
Congress sitting up here on the dais, we all agree this needs
to be reauthorized. This is kind of one of the mysteries of
Congress to me, why we have haven't done it.
So maybe you can tell me, Ms. Clowers, about the
effectiveness of these three grant programs through DOJ, and
why it would be important to reauthorize those in a timely
fashion.
Ms. Clowers. Thank you. We heard from the officials from
the States that we interviewed and contacted for our review
that these funds are very important. While some States have
used--grantees use State money or other types of sources of
funding, the Federal dollars are a primary source of funding,
and they go for the purposes that I just mentioned in terms of
the training, the classroom training, the clinical training,
the continued education, as well as funding needed positions.
Ms. DeGette. Ms. Stewart, are these--some of the hospital
associations told us that the hospitals did not have more
robust sexual assault programs because of the cost of
maintaining the programs. Are these programs costly to
hospitals, and it is a prohibitive issue? What are the possible
solutions to that barrier?
Ms. Stewart. So they certainly have a cost. Doing a good
exam requires time. To be honest, when we talked to hospitals,
there are so many things that they do that are so much more
expensive.
Ms. DeGette. Right, that's what I would think.
Ms. Stewart. And, if anything--you know, we are just having
conversation, you know, that they lose far more on certain
other things. And so we do not view this as prohibitive. Plus,
as you pointed out, the Violence Against Women Act, can cover
costs. Private insurance can cover many of the costs. We also
share the view that victims themselves should not have to share
the cost, but there are--Victims of Crime Act funding also can
cover some of the costs.
So we do believe this issue of training and ongoing
certification is important and needs to get figured out. I
think the other pieces are largely fairly easily fixable.
Ms. DeGette. And do you think there's some kind of bias in
some of the hospitals against providing these services?
Ms. Jennings, you're nodding, maybe you want to tackle
that.
Ms. Jennings. The reason I nod is I think hospitals
historically see this as a criminal justice issue as opposed to
a health issue. And there is significant health consequences
that are surrounding victims of sexual assault, and, therefore,
we very much see it as a health determinant that we need to
address as opposed to a separate criminal justice issue.
Ms. DeGette. Right. Well, I mean, it's health and it is
criminal justice, but if you do it correctly, then it's patient
centered, and that's what we really care about in the
hospitals. And I've also got to say, you know, I'm from Denver,
Colorado, where I have a really wonderful district attorney,
Beth McCann, who is working quite closely with all of our
hospitals, and then we have a wonderful hospital association,
and we have--and everybody understands how important it is to
have these kits and how important it is to have trained people.
But the challenge, I would think, Ms. Clowers, is to expand
that everywhere, not just in places where there's a certain
number of people who think it's important, particularly in
rural areas, I would think.
Ms. Clowers. Absolutely. In your State, I think we found
that in the five rural counties in central Colorado, there was
only one examiner program.
Ms. DeGette. Right.
Ms. Clowers. And so it's--the need for the consistency
across the State, making sure that victims, regardless of where
they live, have access to timely care. I would say that it's
also, though, capacity is needed in urban areas as well, even
when there's an examiner program. What we found is there's not
sufficient capacity to offer 24/7 care.
Most of the trained examiners are often wearing multiple
hats, and so they're doing two jobs at once and more than two
jobs. In addition, they're on call quite a bit. One study that
we reviewed found, in Maryland, for example, trained examiners
are on call 160 hours a month.
Ms. DeGette. Yes. Ms. Jennings, do you have some thoughts
about how we could expand the accessibility to people for
SANEs, the nurse examiners?
Ms. Jennings. To follow up with Ms. Clowers, the piece of
that, the program that I work for is a 24/7 operation with 14
full-time forensic nurses. So our model has shifted from a PRN
on-call basis to truly being in-house 24/7, which has been very
key in sustaining our nurses. We saw a 2-year turnover prior to
that. And now we've had nurses that have been with us 4 and 5
years. So we've been able to retain those nurses, continue with
their continuing education, and be able to have true competency
within that group as opposed to constantly turning over staff.
So I think that a model shift from being an ER nurse that
gets pulled out of staffing to take care of a sexual assault
patient really needs to be the shift of the hospital focus.
Ms. DeGette. Thank you very much, Mr. Chairman. I yield
back.
Mr. Harper. The ranking member yields back.
I have a quick question before I recognize the next Member.
And, Ms. Frederick-Hawley----
Ms. Frederick-Hawley. Yes.
Mr. Harper [continuing]. I know you, looking at your
response, the committee's letter, you had talked about the cost
of the program, the SAVI program----
Ms. Frederick-Hawley. Yes.
Mr. Harper [continuing]. That had been slowly rising for
the past few years. I think you indicated it was $294,000 in
2017. Could you tell me how much of that cost was covered by
grants and other outside funding opportunities?
Ms. Frederick-Hawley. Sure. The vast majority of the grants
that we use for the SAFE program cover the cost of the
coordination of it. So it's our full-time staff that manage the
SAFE scheduling, the recruitment, the training, the support of
those SAFE examiners, and the advocates. Some of it goes
towards training, some of it goes towards equipment in the
emergency department.
Up to this point this year, we have spent $111,000 on the
stipends that cover the on-call payment and the additional
payment to the SAFE for when they come in on an actual case. We
pay them both. We pay them just for being on call and also for
coming in on a case.
Mr. Harper. Thank you very much. That's helpful.
The Chair will now recognize the vice chairman of the
subcommittee, Mr. Griffith, for 5 minutes.
Mr. Griffith. What a personal privilege to begin with. I do
want to thank you, Mr. Chairman. It has been great serving as
your vice chairman, and if we have another hearing that would
be great, too, but you have been a great chairman and just all-
around good guy. I appreciate having worked with you these
years. Thank you.
I do think that--and I forget now who the testimony was
from, but I do think it is important that we recognize it is
both a health concern and a law enforcement concern, and so I
have rearranged the way I'm asking my questions, but, Ms.
Frederick-Hawley, can you tell me a little bit about how your
hospital and the Sexual Assault and Violence Intervention,
SAVI, Program partnered with law enforcement and how that
partnership benefits your patients?
Ms. Frederick-Hawley. Absolutely. One of our funding
sources, the New York State Division of Criminal Justice
Services implemented that we have sexual assault task forces in
all of the boroughs of New York City. So for instance, the work
that we do in Manhattan once a month it is the special victims
bureau of the Manhattan DA's office, it is the special victims
division of NYPD for Manhattan, it is us, it is other SAFE
Programs, it is other community partners that all come around a
table and discuss different issues that arise. It has a benefit
in two ways. We get to discuss cases and ongoing issues, but we
also get to develop relationships such that if there is a
concern about something that is going on with law enforcement
around a particular case I can very easily pick up the phone
and call special victims in Manhattan and say, I need help with
this. And they're very responsive. So we have the good fortune
where I work that it is sort of built into our model that we
work with law enforcement.
Mr. Griffith. And as a part of that have you found that--I
mean, obviously the victim when they first present themselves
to the medical providers are distraught and not necessarily
thinking clearly, has it been your experience that it is later
that they realize how important it is or how they want to have
some emotional closure or solace from the fact that the case is
brought forward and that the evidence is preserved?
Ms. Frederick-Hawley. The last time we did a statistical
analysis it was about 67 percent of our sexual assault
survivors report to NYPD during the time that they're in our
emergency department and turn the kit over. The rest we hold
them in security and then we continue to follow up with them
until they make a decision. Many times they don't. Lots of
times without certain supports in place they could fall through
a crack, so if it is just them working with NYPD the likelihood
of being able to carry forward under that kind of condition of
trauma is--it is very challenging, so the more we can be
involved and support them the better the outcome.
Mr. Griffith. I appreciate that. Ms. Jennings, we have
heard about the lack of appropriate transportation to the
nearest sexual assault forensic examiner and that that is
sometimes a barrier. I know you work in the Richmond area. My
district is between 3 and 7 hours away from Richmond. One
hospital that received our letter noted that they may provide a
sexual assault patient with a taxi voucher. Obviously that can
create problems on the criminal justice side because it can
corrupt--possibly corrupt the evidence. You got to go through a
whole line of what happened in the taxicab, what kind of
taxicab was it, you know, et cetera. And so that creates a real
problem in the criminal justice system.
So that being said, for survivors that visit a hospital
that doesn't have a SANE nurse on staff or does not provide
that how do we best transport these victims to another
facility?
Ms. Jennings. And it is interesting that you actually asked
that question. Recently in Virginia we do have about 13 healthy
forensic nursing programs, and our program experienced a
patient that presented to us after travelling to three
different hospitals being told there's not a forensic nurse
here, there's no way to do a SANE exam here, go somewhere else,
and not provided with an actual facility.
In regards to the transportation what we primarily see is
the patient either being transferred by ambulance so they'll go
from one facility to our facility via an ambulance provider, so
there's two people in the back potentially with the patient,
but also law enforcement does transport some of these patients.
Best case scenario is that the patient knows what hospital to
go to, obviously.
Mr. Griffith. Right. Right. And obviously I represent a
large and very rural district. Telemedicine, you touched on
that in your written comments, and I'm a big fan, it may mean
more witness time for certain SANE nurses, but what do you
suggest on telemedicine if there's a rural hospital that
doesn't have somebody, doesn't have the money to have somebody
with the training?
Ms. Jennings. I do see benefits of telemedicine. I think
that one piece of it there needs to be a very well trained
forensic nurse on one end and then the nurse on the other end
does need to have some basic training in forensic nursing. It
may be a very brief course on evidence collection, but they
need to have a little bit of knowledge prior to having that
telemedicine piece set up.
Mr. Griffith. And my time is up, but I do want to find out,
at some point I may ask a written question later about the
clinical component of what we can do to make that better. Thank
you. I yield back.
Mr. Harper. The gentleman yields back. The Chair will now
recognize Ms. Clarke for 5 minutes for the purposes of
questions.
Ms. Clarke. I thank you, Mr. Chairman, and I thank our
ranking member. Good morning, everyone, and good morning to our
panelists. The subject matter that we're discussing here today
is so very important. I want to thank the chairman and the
ranking member for today's hearing on such a very important,
sensitive topic that's often gone woefully unaddressed with
long lasting harmful impact on our Nation's survivors.
The subject of sexual violence in our country impacts
millions of Americans, more specifically 23 million women and
1.7 million men that we know of. These staggering numbers do
not even take into account the incidence of unreported assault
survivors, who live in fear, in shame and in the shadows, and
are often afraid to even come forward.
One of the major reasons individuals who have survived
sexual assault are scared to report their attack is because the
process is arduous and retraumatizes victims, causing them
anxiety to face their assailant. That is why we are gathered in
this room today to understand how the Congress can provide
support to those who need it the most and to obtain justice.
There is both a shortage of supply of sexual assault
forensic examination kits, SAFE as we have been talking about,
as well as sexual assault nurse home examiners, SANE. As one of
the wealthiest most advanced civil societies in the world there
should be no barriers to care for the most vulnerable in
society, especially at the critical stage of collecting
forensic evidence to provide justice to those brave women and
men.
To add insult to injury victims of sexual assault should
not be required to pay for the forensic exam or emergency room
visit. In the Ninth Congressional District of New York that I
proudly represent just as recent as November 30 of 2018 the New
York Attorney General Barbara Underwood announced that at least
200 sexual assault survivors were illegally sent bills from
seven New York City hospitals requiring payments ranging from
$46 to $3,000. Thankfully the New York State Attorney General
committed to righting this wrong and protecting survivors, as
well as their rights.
And I'm so proud to hear from Ms. Frederick-Hawley today of
Mount Sinai who has a hospital site in my district here today,
and I want to open with my questions to Ms. Hawley.
I would like to take a few minutes to discuss the details
of Mount Sinai's program and to see what best practices you
would offer to other hospitals looking to develop and expand a
sexual assault program. Ms. Frederick-Hawley, could you tell us
a bit more about how your program got started?
Ms. Frederick-Hawley. Well, originally in 1984 we had a
sexual assault survivor come into the emergency department, and
there were a couple of medical students working that evening.
And after this patient was discharged they looked at each other
and said, We have got to be able to do better than that. And so
they started to think through what a rape crisis program would
like. They found a donor for the hospital. They sat at her
kitchen table and developed SAVI. So it was a very grassroots
based out of the need to do more for survivors sort of effort,
and we carry it forward from there.
The moment we hear of an emerging need we try to address it
the best way possible, and I'm fortunate that I get to do this
work at the Mount Sinai Hospital because they have been
incredibly supportive and have always recognized that this is
an important aspect of the kind of medical care that we want to
provide.
Ms. Clarke. Absolutely. And would you tell us a bit more
about the services that SAVI provides through this program and
the impact it's had on victims?
Ms. Frederick-Hawley. Absolutely. So since 1984 we are not
just a rape crisis program anymore. We currently send advocates
of--our certified volunteer advocates that we train on a 40-
hour basis, it is a DOH-certified training curriculum that we
have developed. We send them to eight hospitals, including some
city hospitals, private hospitals and throughout the Mount
Sinai system to service survivors of any kind of sexual
violence and intimate partner violence.
We have a court program and an ongoing therapy program for
sex trafficking survivors, both domestic and international. We
have a three full-time staffed education and training
department where we're working on primary prevention. We have a
component called Talkanote, which is specifically for Orthodox
Jewish survivors of any kind of sexual violence or intimate
partner violence.
We have therapists, trauma therapists in six different
locations in Manhattan and Queens who provide mostly short-term
brief trauma therapy, but it can go on a longer term depending
on what the person needs, and also we do all of this extensive
emergency department care with our SAFEs and our advocates in
terms of providing anything they need in that moment from a
medical and psychological standpoint to any ongoing need that
is going to come up that we want to be able to help empower
them to either find service for or that we can provide service
for. All of our services are free, and we provide them in 10
different languages currently.
Ms. Clarke. Outstanding. I thank you for all of your
service. And I yield back, Mr. Chairman.
Mr. Harper. The gentleman yields back. The Chair will now
recognize the chairman of the full committee, Mr. Walden, for 5
minutes.
Mr. Walden. Thank you, Mr. Chairman. Again, I want to thank
our witnesses for being here today and for the testimony you
submitted for the record.
Ms. Jennings, you noted in your testimony that telemedicine
can be used to improve care for patients in rural and low
volume communities, and I certainly know that my--just point of
reference my district is bigger than almost any State east of
the Mississippi, so it is enormous territory, very rural.
Would you tell us a little more about telemedicine and how
it can be used to expand access to these types of services and
what are some of the challenges you see facing telemedicine to
treat survivors of sexual assault?
Ms. Jennings. Absolutely. Thank you. Telemedicine is for
sure an answer to some of the more rural communities that don't
have access to forensic nursing care. They could have to
travel, as we mentioned before, as many as 3 to 7 hours to have
a trained provider. Telemedicine would allow a nurse or another
provider in the ED setting to care for that patient via
telemedicine with another trained provider on the opposite end,
walking them through the evidence collection process, walking
them through injury identification, walking them through any
prophylactic medications that the patient may need at time of
discharge and then go through discharge planning, whether it be
follow-up with a rape crisis advocate or whomever. The person
on the other end would be able to elaborate on those services
and care via telemedicine.
Mr. Walden. Are there any statutory barriers, regulatory
barriers either at the State or Federal levels you're aware of
that would--that hamper this ability?
Ms. Jennings. I'm not aware of specifics, but I do know
that there are some challenges specific to that, and it will
vary State-by-State.
Mr. Walden. Any other panelists want to weigh in on that
from your experiences on telemedicine?
Because it is really hard again in a district such as mine
just to recruit healthcare providers period, nurses, et cetera,
and then when you get into something specific and the more we
regulate the training the less likely it is they can find
somebody like that to be there.
Ms. Clowers. We through our work in talking to officials
from different States this was one of the best practices or
promising practices we heard about. Using web-based training,
for example, to get both the sort of classroom as well as some
clinical training opportunities, but then as Ms. Jennings was
describing too providing that clinical guidance real time.
We heard about examples in Colorado where a program
coordinator in an urban area will be on call to help those in
rural communities that don't have an examiner program. And then
also we heard about the program, the SANE program in
Massachusetts, which provides clinical guidance real time to
nurses across the State.
Mr. Walden. Very good. In addition to the challenges noted
in the GAO report on volume versus competency issues one issue
we have heard expressed by hospitals is that they're able to
have SANEs on staff because they have so few--or they're not
able because they have so few patients seeking kits each year
that their nurses are not able to maintain competency in
performing the SAFE kits. So I wonder, I understand at Mount
Sinai you have had 23 SANEs on staff. How many kits do you
perform on an average basis annually?
Ms. Frederick-Hawley. Year to date as of this morning we
had 55 cases of sexual assault at the Mount Sinai Hospital.
Mr. Walden. Wow.
Ms. Frederick-Hawley. And only one of them did not have a
SAFE examiner, person got sick at the last minute.
Mr. Walden. Ah. So 23 nurses and about 55 cases this year.
Is it fair to say you may have some nurses that do not perform
any kits at all then?
Ms. Frederick-Hawley. Absolutely. And I should clarify that
there are now 24, and they're not all nurses on our particular
program.
Mr. Walden. OK.
Ms. Frederick-Hawley. So I have physicians assistants, RNs,
APRNs and residents and----
Mr. Walden. So other healthcare providers.
Ms. Frederick-Hawley. Other healthcare providers. It is
possible there are some times when we allow our SAFE examiners
who are on the roster to take a leave, they need kind of a
break from that work.
Mr. Walden. I'm sure.
Ms. Frederick-Hawley. And so we have an intensive number of
people who take many more on-call shifts. So there are periods
of time sometimes when one of the SAFEs hasn't done an exam in
quite a while. We do have things in place for them where our
assistant medical director for our SAFE Program is available to
talk them through if they're back to do a case for the first
time after a hiatus.
Mr. Walden. I was going to ask about that. How do you
maintain that competency in training then in the interim?
Ms. Frederick-Hawley. There's also always a SAVI staff
person on call to the SAFE examiner in case any questions come
up or if they just want to kind of touch base and know that
they're not out there alone. Often times, too, our SAFE
examiners work in the emergency department, so you will often
find that while the person who is on call is coming in to
respond to that patient there is another SAFE-trained person
there that they can bounce things off of if they need to. So
there are a lot of layers of support for our particular
examiners.
Mr. Walden. Excellent. Thank you. And thanks again for your
testimony, all of you. I appreciate that. Mr. Chairman, I yield
back.
Mr. Harper. The chairman yields back. The Chair will now
recognize the gentlewoman from Florida, Ms. Castor, for 5
minutes.
Ms. Castor. Well, thank you, Mr. Chairman, and I have to
say, Mr. Chairman, it has been a pleasure serving with you and
working with you on legislation. Thank you for your service on
the committee and to the country.
Mr. Harper. And if the gentlewoman will yield, it was
certainly a pleasure for me to be able to serve with you at the
very beginning on our Ethics Committee and the great work that
you did there.
Ms. Castor. Especially the caregivers bill.
Mr. Harper. That's right. Particularly that. That was this
year. Thank you.
Ms. Castor. And thank you to our witnesses for being here
and helping raise awareness to this critical issue for sexual
assault survivors. Back home in Florida in the Tampa Bay area
we're very fortunate, we have an outstanding crisis center of
Tampa Bay that has been a leader for decades, and I guess I was
naive in assuming that a lot of this the services the
integrated services with hospitals and providers and on-call
experts and forensic nurses and specialists that was just the
standard across the country, but it is clear that it is not,
and we have got to do more to make sure that professional
forensic specialists are available to everyone in America no
matter where they live.
The other issue that has been an issue in the State of
Florida and other areas is actual processing of the sexual
assault kits. And for anyone that's interested in this, the
State of Florida, the Florida Department of Law Enforcement
posted on their website a progress report because it came to
light a few years ago they had over 8,500 kits that had not
been processed. And to their credit, they appropriated some
money, and right now they have completed over 7,000 of those
kits but still have a thousand waiting.
Ms. Clowers how are we doing on processing kits across the
country?
Ms. Clowers. We have an ongoing work looking at the issues
of processing kits and the backlog of kits that are out there
and I'm happy to arrange a briefing for you or your staff on
that work as it comes to fruition.
Ms. Castor. Good. Thank you very much. The other big issue
as Ranking Member DeGette has mentioned is the impending
expiration of the Violence Against Women Act. It is December 21
that it would lapse, and this Congress has got to get it
together to pass this landmark law and reauthorize it. It
contains several provisions that address health issues
associated with sexual violence, including the grant programs
that we previously discussed that help fund and train sexual
assault forensic examiners and address the public health
response to domestic abuse.
Ms. Stewart, your organization has had a long history in
advocating on behalf of Violence Against Women Act. Again, why
is it so important that the act be reauthorized as soon as
possible?
Ms. Stewart. So VAWA serves as a cornerstone of the
Nation's response to domestic and sexual violence as you have
pointed out. It includes both provisions that set standards for
the law but it also provides grant programs to do exactly the
things you have heard us discuss today. We also would
advocate--I know we're talking primarily about the response
after a sexual assault has happened and the effort to try to
prosecute and hold offenders accountable. VAWA also has
numerous programs that fund what we call the coordinated
community response, which is really the ideal response to these
forms of violence. We can't just wait until people are raped,
and we need--we appreciate this hearing, we appreciate the
focus on giving people the best care and holding offenders
accountable, but that cannot be our Nation's response to sexual
assault.
We need to stop it through prevention and early
intervention programs, through programs that bring law
enforcement together with health, together with advocates,
which we haven't really touched on yet, but so much of the
success of these programs really is these partnership issues,
how do we bring healthcare and law enforcement together? VAWA
does that.
Ms. Castor. I strongly agree, and I also--as you mentioned
before I also believe it is time to improve the VAWA health
title as you mentioned Mrs. Dingell and Mr. Costello along with
Ms. Clarke, who was here and I we have filed legislation and
that is to do more on the behavioral health side, but clearly
we have got to help, we have got to put more dollars into
training sexual assault examiners.
And you mentioned--you all mentioned a bill by Senator
Murray. Is that--that I believe has been replicated here by in
legislation by Rep Jayapal. Are there other bills that you
would highlight to us today that we need to work on as soon as
possible?
Any of the witnesses.
Ms. Stewart. You know, we still obviously look to VAWA and
the VAWA health provisions as you said, and I think what's
important that you pointed out was the relationship between
suicide prevention--you know, we're looking at a lot of the
report language in some cases, and we look at we have a huge
epidemic in this country primarily of male suicides. What we
see from some of the data is really unaddressed sexual violence
in childhood in some of those cases.
Our opioid addiction, which I know, you know, so many
frankly, Members on this committee have been focused on, how do
we address violence as a driver as that and as part of our
treatment. So some of those laws, some have passed, some are
still sort of close to the final stretches, and integrating
violence prevention language into those other programs is
critical.
We have also obviously discussed the Megan Rondini Act that
Judge Poe has been advocating, and we think that that's an
important legislative goal that we would encourage the
committee to pursue.
Ms. Castor. Thank you very much.
Mr. Griffith [presiding]. I thank the gentlelady. I now
recognize the gentleman from Texas, Dr. Burgess, for 5 minutes.
Mr. Burgess. Thank you, Mr. Chairman. I was going to
recognize your long service as chairman and how much I regret
the fact that you're leaving, but you're not the one who is
leaving, so I'll save that.
Mr. Harper. I am here.
Mr. Burgess. Oh, you are here. I do regret that you're
leaving, Mr. Harper.
Let me just ask, and this has been a fascinating discussion
this morning, but just to orient me, Ms. Frederick-Hawley,
you're in New York at Mount Sinai Hospital. Is that correct?
Ms. Frederick-Hawley. Yes.
Mr. Burgess. Ms. Stewart, San Francisco General Hospital?
Ms. Stewart. Our organization is based in San Francisco,
I'm here in DC.
Mr. Burgess. You're here in DC, OK. And Ms. Jennings, your
hospital?
Ms. Jennings. Bon Secours in Richmond, Virginia.
Mr. Burgess. Very good. I was a medical student 10 years
before your medical students that you discussed in 1984. I did
my residency training at Parkland Hospital in Dallas, and even
back in the seventies and early eighties Parkland had I thought
at the time a very forward leaning program in this regard. And
I'll tell you one of the things that always impressed me about
it as an OB/GYN resident. We were not tasked with covering a
case when a patient came in complaining of sexual assault. That
immediately went to a faculty member, who was onsite in
hospital 24 hours day and available. And part of me at the time
always resented having a faculty member in hospital, but in
these cases it was clear that--and I think Norman Gant and Jack
Pritchard, at the time, recognized that in order to have the
availability of someone to precisely collect the information
and then provide expert testimony in the courtroom was critical
in the satisfactory resolution of these cases.
And I don't have numbers, but I remember getting the
impression that some defendants would plead before getting to
the courtroom because the case would be so strong against them.
And again, you had a faculty member from Southwestern Medical
School as the expert witness, so that was always pretty
powerful to take that into court.
And then, of course, as a resident I ended up staying in
the area, but I certainly recognize that somebody completes
their residency after 4 years they may be gone miles and miles
and miles away and not available for a court case, and then a
case could be lost because of lack of the availability of the
person who is to present the testimony. So I became convinced
early even before I began my private practice that this was the
correct approach.
Now, I did not practice in Dallas County. I was a county
removed, and I remembered trying to set up a similar program in
our hospital, community hospital, and there was significant
barriers to doing so. At the time there were not the advanced
nurse practitioners who were--who you talk about this morning
as available to do this.
Of course in 1988 this Congress, not this Congress, but
Congress passed a law called EMTALA. Can any of you speak to me
as to whether or not your screening exams, for somebody who
comes in complaining of sexual assault, does that satisfy the
EMTALA requirements as set forth by Congress in 1988?
And anyone who feels that they can answer that.
Ms. Jennings. Thank you. So our facilities that we do
receive transfers from we do ask that they follow the EMTALA
process. There are some facilities that, again, don't see this
as a healthcare issue, therefore, they don't follow the
appropriate EMTALA proceedings.
So we ask for a doc-to-doc transfer, and we do ask for a
nurse-to-nurse report, but many times that's not happening,
they're just telling the patient we don't have that here and
you need to go elsewhere, so it is not occurring.
Mr. Burgess. Yes, Ms. Frederick-Hawley, were you going to
say something?
Ms. Frederick-Hawley. We don't have an EMTALA issue in New
York State because of sexual assault. It is actually required
that if a patient presents in an emergency department in New
York State saying they have been raped and they would like to
have a kit done there every hospital has to be able to conduct
a kit. It is not necessarily done by someone who is SAFE
trained, but someone's got to figure out what to do and how to
do it.
Fortunately for the most part in New York City there are
ways that people can be trained or they have exposure to the
idea of providing a sexual assault forensic exam. A lot of it
is anxiety on the part of someone. They want to do the right
thing, they want to do it well----
Mr. Burgess. Sure.
Ms. Frederick-Hawley [continuing]. And are concerned that
they won't be able to, and their instinct may be to we need to
send this patient to some place else, but if the patient wants
to stay in that particular ED and that's where they want their
exam done then that hospital needs to figure out how to do it,
and every hospital has to have kits on hand to perform.
Mr. Burgess. And will you generally because if a patient is
a regular patient of a practice in your communities will you
call the doctor or practitioner who is the regular provider of
care for that patient?
Ms. Frederick-Hawley. Call their like their OB/GYN, for
instance, into the emergency department to do----
Mr. Burgess. Even to let them know their patient is being
seen with that complaint?
Ms. Frederick-Hawley. Everything that we do is based on
what that survivor, that patient wants and allows us to do at
that moment.
Mr. Burgess. So if they request you call their doctor----
Ms. Frederick-Hawley. If they request it we would call
anyone that they wanted us to, yes.
Mr. Burgess. And I know I have gone over time, but how do
you address the freestanding emergency rooms that we see so
frequently cropping up in our communities, are these facilities
equipped to handle these types of exams that you all provide?
Ms. Frederick-Hawley. I think it varies. So, for instance,
Mount Sinai has several urgent care centers that we will send
our SAFEs to if someone presents and wants to have their
evidence collection done there. But I can't speak for all of
those kinds of----
Ms. Jennings. I don't see freestanding EDs as being a
barrier to care, to service. We also in our facility we have
two freestanding emergency departments, and we provide the same
care and have not seen it as barrier, but it differs, of
course, from State-to-State.
Mr. Burgess. And I recognize that, and, of course, I'm in
full favor of States being in charge of their sovereignty, but
CMS is a national--I mean, Medicare is a national program so
CMS oversees the EMTALA, so it seems like there's--I'll be the
last person to say I want EMTALA to be bigger, or stronger, or
harder, but at the same time they do exist, and CMS is the
oversight of that program not State-by-State. Thanks. Mr.
Chairman. I'll yield back.
Mr. Harper [presiding]. The gentleman yields back. The
Chair now recognizes the gentleman from Michigan, Mr. Walberg,
for 5 minutes.
Mr. Walberg. Thank you, Mr. Chairman. And I, too, want to
say thank you for your service, your leadership, your
friendship. We're going to miss you, and every time I go back
to the base of my district in Jackson, Michigan I'll think of
you in Jackson, Mississippi.
Thanks to the panel for being here as well on this
important topic, and it is a shame that it continues to be such
a massive concern, but it is a concern, and we have to address
it so thank you for your efforts and probably your sacrifice
that you go through in dealing with this topic and these
issues.
GAO's report noted that only limited nationwide data exists
on the availability of SANEs and that only one of the six
States examined had a system in place to formally track the
number and location of the SANEs. Some States, including
Massachusetts, Colorado and Texas I'm told make public a list
of SAFE ready facilities. Other States do not appear to make
these sorts of resources publicly available.
Let me ask each of you if you care to answer would this
kind of national database or at least statewide databases be
helpful to survivors?
Ms. Clowers. I would think a national database or some type
of centralized information about the availability would be
helpful to patients. It would eliminate some of the challenges
that were discussed earlier about arriving at a hospital maybe
after a long distance, especially if you're in a rural area you
have traveled an hour, 2 hours to get to a hospital after a
very traumatic experience only to be told we can't serve you
here, you need to go somewhere else and being told to get in a
taxi or to drive yourself.
You know, what we heard is once the patient leaves the
hospital the chances of them returning to the hospital for care
diminishes.
Mr. Walberg. OK.
Ms. Jennings. I would also agree. Many hospitals are
already scored based on services that they provide, and I think
this should be something that's included and something that is
very accessible to patients. We're in a digital age, and if
someone can flip open their phone and say where is the closest
facility to receive this type of care I think the care would be
much more accessible, and that could then also be translated to
law enforcement and to many other of our community partners so
that they immediately know if they are referred a patient where
they need to send them to very quickly.
Mr. Walberg. Jumping on that, what other digital resources
could be offered online, for instance, to assisting that type
of information getting out?
Ms. Jennings. Sure. Something that we have seen is within
our college student patient population they have apps from
their school that will say if this happens to you this is what
you need to do, whether it talks about evidence preservation or
it talks about what type of medical services they could
receive, whether it be a forensic nurse or the student health
center. So some of those types of apps that are very
accessible--I know many of the rape crisis centers also utilize
some of those similar resources.
Mr. Walberg. How widely is that used or known, those apps?
Ms. Frederick-Hawley. In my experience running into college
students who know is kind of like running into a polar bear on
the street of Manhattan. It is kind of rare at this point, but
I think that it is potentially growing, but there are always
glitches to figure out with that, and then how to get the
education and the availability of it to those students and to
the larger population when you have a sort of technology
divide. Not everybody has the same access to technology, which
is problematic when you're talking about a really important
basic service that you want everyone to have.
Mr. Walberg. We're so app-based today----
Ms. Frederick-Hawley. I know.
Mr. Walberg. It seems like that would be just an automatic,
but something to think about. Thank you.
Ms. Frederick-Hawley, does Mount Sinai track information
relative to data available for SANE programs? I guess what I
would say is one of the questions the committee asked in our
letter to hospitals was whether each hospital tracked any data
as it relates to sexual assault such as number of sexual
assault survivors treated each year and how many kits are
requested and completed.
Does Mount Sinai track this information as it relates to
patients?
Ms. Frederick-Hawley. Yes, we track an incredible amount of
information on our sexual assault patients, the relationship
they had to the assailant, how acute was the assault before
they came into the emergency department, whether they were
eligible for emergency contraception and other kinds of
prophylaxis and beyond eligibility whether they decided to
avail themselves of it, including HIV prophylaxis.
We track, you know, who the SAFE examiner was that saw
them, who was the advocate, other kinds of services they needed
at the moment and then all of our follow-up care, as well.
Mr. Walberg. I'm certain that that shapes your SAVI Program
then to a great degree.
Ms. Frederick-Hawley. Absolutely. Yes. And we have to
report that at this point to a variety of our funders all
confidentially; we don't include any kind of identifying
information, but that's the kind of data that the New York
State Department of Health and New York State Division of
Criminal Justice Services and to a certain extent the New York
State Office of Victims Services because of our funding streams
requires us to provide to them.
Mr. Walberg. Thank you. I yield back.
Mr. Harper. The gentleman yields back. The Chair will now
recognize the gentleman from Georgia, Mr. Carter, for 5
minutes.
Mr. Carter. Thank you, Mr. Chairman. I certainly would be
remiss, Mr. Chairman, if I didn't offer my thanks to you as
well for your leadership in this committee and for your service
in Congress. Thank you.
Ladies, thank you for being here today. This is a very
important subject and it is very important to me personally
because we have had this issue in the State of Georgia. We have
had a problem here.
And I want to start off by asking about the shortage of
kits. Is that a problem, just the shortage being able to get
the kits to where you can perform the--and I would offer this
to anyone who wants to answer to where you can perform the
examination?
Ms. Frederick-Hawley. It is sort of our responsibility as a
program. We keep track of how many kits we have on hand both
drug facilitated sexual assault kits and the sort of more
general forensic evidence collection kit. And as we start to
get low we have to reach out to the Division of Criminal
Justice Services and say, hey, send us some more----
Mr. Carter. So is it their responsibility, the criminal
services to provide the kits, is it the State's responsibility,
is it health systems responsibility? Whose responsibility?
Ms. Frederick-Hawley. The Division of Criminal Justice
Services in the State of New York is the one responsible for
pulling the kit together and--every few years we review what's
in the kit, and if there are changes that need to be made to
the samples or the envelopes or the content or anything like
that it is up to them to build what kit is used in a
standardized way across the State, and then it is up to the
facilities to identify----
Mr. Carter. Make sure that they have enough. Is anybody
different from that?
Ms. Jennings. We receive our kits in Virginia from the
Department of Forensic Science.
Mr. Carter. OK.
Ms. Jennings. So very similar, once we recognize that we
are running low on our kits we call and have a courier bring us
to do, but it is our responsibility to actually have those kits
in our facility.
Mr. Carter. OK. One of the things that I wanted to touch
on, and I recognize that this is not necessarily why you were
here or your responsibility but is the processing of the kits.
We had a big problem in the State of Georgia, I think it was
also alluded to by one of my colleagues in their State, but we
had a big backlog, and that was causing all kind of problems.
This whole system doesn't work until we complete it.
I mean, we need SANE nurses. We need the whole process to
work, including processing the kits. We had examples in the
State of Georgia where we had, you know, a serial rapist, if we
had simply processed the kit from before we could have
identified him. Is that a problem anywhere else that you're
aware of?
And, by the way, we have caught up in the State of Georgia,
so I'm very proud to say that and to report that.
Ms. Stewart. So thank you so much, Congressman, and
congratulations to the State of Georgia, as well. I was
actually going to commend Congressman Walden because Oregon is
also one of those States that made a concerted effort and has
reduced their backlog. It varies tremendously by State, but you
identify a critical issue, which is why in some cases many--I
shouldn't say many.
Some victims do not go and why to get the kit is if the kit
isn't going to be processed anyway or why law enforcement
themselves sometimes and why we have burnout. And we hear from
some of the providers that if the kit is not even going to be
tested it is a very difficult, difficult thing for a victim to
go through a rape kit. You don't do it lightly or easily----
Mr. Carter. OK. Let me ask you this, and please bear with
me on this. I'm not suggesting that the program itself is not
needed or valid, but I'm a pharmacist and right now I'm
cramming in 30 hours of continuing ed by the end of the year so
that I can keep my license, OK, but are there any continuing ed
programs out there that perhaps even if you don't get the
certification it would certainly help to have some kind of
knowledge for the nurse to be able to have a continuing ed
program or something?
Ms. Jennings. There are many opportunities for continuing
education specific to the forensic component sexual assault
many other types of victims of violence, so yes, that is
definitely an opportunity.
Mr. Carter. And I would ask you this to take it just a
little bit further, what are we doing to educate other
healthcare professionals besides nurses and law enforcement,
making sure that, you know, because again as I stated earlier
this process only works if it is completed. If we have a law
enforcement officer who is trying to determine whether there
was a rape involved here and whether this person needs this
help, are there programs like that available?
Ms. Clowers. There are. In talking to officials from the
States that we interviewed this gets back to the
multidisciplinary teams. Bringing law enforcement and
healthcare providers together to make sure they understand each
others' roles, to make sure they understand the availability of
the examinations and the process that they'll go through. So,
again, that was an important element that we saw in the States.
And to your question about continuing education while there
are opportunities available this goes to one of the challenges
we found was weak stakeholder support for that training.
Because some hospitals may receive only a low volume of
patients not a great number of patients that need this care,
hospitals may be reluctant to send their nurses or other
practitioners to the training. And, in fact, some cases won't
pay for the training so the providers if they go to the
training they're taking annual leave, they're paying for all
the costs associated with the training.
Mr. Carter. Right, right, right. The last thing I would
add, and I know we have talked about it, but I represent the
coast of Georgia in Southern Georgia, a very rural area
telemedicine, telehealth we need to look at that. That's our
only option in the rural areas because we just, you know, we
have enough trouble attracting physicians and healthcare
professionals, much less specialists like this, so I hope that
you'll continue to work on that because it is vital to rural
areas in our country.
Thank you, Mr. Chairman. I yield back.
Mr. Harper. The gentleman yields back. The Chair will now
recognize Mrs. Brooks for 5 minutes for the purposes of
questions.
Mrs. Brooks. Thank you, Mr. Chairman, and I want to thank
you for your leadership of the committee, but I also want to
thank you and the ranking member for bringing this topic to our
last hearing of the year. And I want to thank all of the
panelists for this incredibly important work.
Many, many years ago in the late nineties when I was deputy
mayor in Indianapolis and focused on crime issues I had the
opportunity to have a SANE nurse or people demonstrate for me
what the SANE project was in the late nineties and what the
concept was and how it worked and how incredibly important it
is, but I have to admit until there was that big article about
the lack of testing of rape kits and so forth there hasn't been
tremendous amount of attention on the lack of SANE and SAFE
Programs and on all of the challenges, and so I want to thank
you for the recommendations you have been giving to us.
I also want you to know that we have been and are going to
continue to push for the Violence Against Women Act to get
included in whatever package comes at the end of this year.
Myself and others have written letters to the leadership asking
them and imploring them to please ensure that the Violence
Against Women Act is included and that the funding continues.
And so we're going to continue to push on that.
But I want to just ask a couple of questions about the
retention rates and the challenges because when people finally
agree, and you might have to convince people to enter into this
work because it is so incredibly difficult, but I know that
there has been and Ms. Jennings you mentioned some significant
retention issues but your hospital system is doing a lot.
Ms. Frederick-Hawley, is your system, what are you doing
for the retention of the people who finally agree to go through
because GAO found that in one situation 540 SANEs were trained
over a 2-year period in one State, fewer than 8 percent stayed
because of the difficulty of the work.
So what are you doing? Is it compensation, what are you
doing to keep the retention rates high first at Mount Sinai and
then if you would like to go on further?
Ms. Frederick-Hawley. We see it as a multi pronged effort
to keep people on the roster, recognizing what my colleagues up
here have said about it being very difficult and taxing
psychologically and physically to do the SAFE exams. We try to
provide as much support as possible as close to the time of the
case as possible.
So every SAFE is required to call our SAFE coordinator and
debrief everything about that case after they have gone in on
it. And it is not just were there, you know, how did the camera
work, were there any problems with anything like that, how was
law enforcement, all of those other pieces.
But how are you, how did this go for you. We keep track. It
is why coordination is so important in my opinion because we
can keep track of who is taking an absurd number of on-call
shifts and say maybe we can ratchet that back a little bit and
to take care of them as a person.
We also provide in-house ongoing continuation education. We
do a monthly support meeting. We bring in outside speakers, but
we also will sit them down and, you know, retrain them or
reorient them to the colposcope equipment, so we try to do a
lot of things that are on an ongoing basis to----
Mrs. Brooks. Are they compensated in any way for their
additional training or do you have any incentives to at Mount
Sinai or at your system?
Ms. Frederick-Hawley. We pay the SAFE examiner for being
just on call.
Mrs. Brooks. OK.
Ms. Frederick-Hawley. And then we also pay them an
additional amount when they are called in to do an actual case.
So their time is always important to us and considered
valuable, which I think makes a difference. We pay for their
certification training so they don't have to worry about that.
And we also will provide resources to be able to cover their
ongoing continuing education.
Mrs. Brooks. And Ms. Jennings----
Ms. Frederick-Hawley. I'm sorry, if they're called in to
testify we will also work out compensation for the time for
preparation and things like that.
Mrs. Brooks. Good. And, Ms. Jennings, anything that your
organization is promoting relative to compensation of----
Ms. Jennings. Absolutely. Very similar to Ms. Frederick we
compensated for any training. We provide compensation for their
SANE-A and their SANE-P certification from the IAFN, so that's
the certification exam once they have completed their clinical
and didactic training.
We also compensate for any time that they're coming into
the hospital for meetings. We keep them very engaged within the
hospital system, but we also keep them very engaged with our
community partners. So we have our nurses assigned to our
sexual assault response team. Our program serves 26 different
counties and jurisdictions within the Commonwealth of Virginia.
So each of our nurses has a jurisdiction that they partner
with, and so those relationships are extremely important.
One other thing that we have done that's been huge for our
retention rates we have transitioned from more 12-hour shifts
to 8-hour shifts. We saw that nurses truly were having high
burnout rates when they were there for 12 hours. A shift
typically didn't end at the 12-hour mark, it was going into the
13th and 14th hour, so we have transitioned back to 8-hour
shifts.
Mrs. Brooks. Thank you. I may submit a couple of written
questions for our witnesses because I had more, but thank you
for your work. I yield back.
Mr. Harper. The gentlewoman yields back. The Chair will now
recognize the gentleman from Pennsylvania, Mr. Costello, for 5
minutes.
Mr. Costello. Thank you. First, I just want to recognize
the leadership and service of the subcommittee chairman here as
he winds down. It has been a pleasure to work with you, and I
want to thank you for your service as well as those testifying
here today.
My question is for Ms. Clowers and for Ms. Jennings. I'm
going to try and speed through these. In your testimony, Ms.
Jennings, you mentioned that one of IAFN's goals would be to
establish a standardized national sexual assault evidence
collection kit. Could you tell us what makes up the actual kit
and some of the discrepancies you have seen in different
localities? Can this lead to issue with prosecution if a kit is
collected in one State but the crime is prosecuted in another
State?
Ms. Jennings. Thank you for your question. One of the
issues that we see is that there are many variations in the
kits themselves. Some are received from the Department of
Forensic Science, some are received from actual online ordering
options, so the kits can vary by State. I would venture to say,
yes, that could create issues with them being different, but
that also creates a huge barrier in training. If we had one
standardized kit it would be much easier to educate----
Mr. Costello. To train. To train, good point.
Ms. Jennings. To train.
Mr. Costello. What's in the actual kit?
Ms. Jennings. In the actual kit, many different swabs from
areas, so when we're obtaining a history from a patient we're
asking them what actually occurred so it guides our evidence
collection, whether it be an oral assault or a vaginal assault
we know where to collect our swabs from very much like a Q-tip
and a slide you would use in biology class. We do take hair
samples, and we take blood samples also.
Mr. Costello. What are the most notable discrepancies, most
common discrepancies?
Ms. Jennings. For example, the kit in Virginia is about a
shoe box size, but a kit that may be in another State is the
size of an envelope. So the actual number of the swabs in the
kit may be less or there may be not blood samples in one but
there would be blood samples in another.
Mr. Costello. How about reimbursement or processing of
kits, difference?
Ms. Jennings. I can't speak for every State. In Virginia we
go through our Virginia Victims Fund for our compensation for
our sexual assault exams.
Mr. Costello. OK. If there's nothing to add I'll go to the
next question. Anyone else want to add to that?
Is there a need to create a national standard of care for
the treatment of sexual assault survivors, whether that means a
standardized training program as you mentioned or standardized
procedures for hospitals that are not equipped to collect SAFE
kits?
Ms. Jennings. Yes. We think that that is very important.
That would also create the consistency amongst trained
providers so that everyone is practicing the same.
Mr. Costello. Anyone else? You can't really add to a yes,
can you? OK.
In addition to a lack of standardization of the kits
themselves one issue we heard expressed by a hospital
association is that, quote, ``lack of reciprocity to allow
nurses who are not part of an independent team to go from one
hospital to another,'' end quote.
For any of our witnesses, is this a problem you have seen
in your experience and can you identify a solution to this
issue?
It is a problem would you agree? And so the challenge
becomes what's the solution.
Ms. Jennings. It is a problem. I don't have a necessary
solution at the moment in our particular area. It would be
difficult to go from I work for Bon Secours, but if I went to
another healthcare system that I was not employed by that could
create some issues.
Mr. Costello. Could I ask each of you to submit in writing,
just think about that a little bit and share with the committee
some thoughts, just kind of brainstorm it through.
Ms. Frederick, you were shaking your head, which presumably
means you agree and you probably struggle with that issue, as
well. Anything to add from what Ms. Jennings said?
She said it expertly. OK.
Let me see if I have anything else that I would like to
ask. OK. One of our letter recipients noted that they have used
an online training program to train their nurses. How can we
overcome the issue of making clinical training available even
if we can make the classroom training available online? How can
we overcome the issue of making clinical training available?
Ms. Frederick-Hawley. In my opinion to be honest I don't
think you should ever overcome the clinical training part. I
believe that maybe moving away from didactic in some ways and
doing online modules, and we do a combination of those things,
but the hands-on work with a patient that you are going to be
seeing in a much more traumatized state the first time you're
doing a real exam it is invaluable to use a gynecology teaching
associate in a clinical setting to actually go through what
kind of sensitive approaches you're going to need, what your
anxieties are that come up in that sort of----
Mr. Costello. That's an excellent point. In other words, do
not ever supplant entirely or only up to a certain percentage
the amount of--and related to that I know I'm out of time, can
you tell us more about the practice transporting nurses from
rural low volume areas having them spend more time in more
urban high volume settings in order to gain expertise and
experience, do you recommend that and how does that take shape?
Ms. Clowers. It is certainly a strategy for maintaining
clinical expertise, but it would require the support of the
hospitals. And again, that's one of the challenges we found is
that there is weak stakeholder support for those types of
initiatives.
Mr. Costello. Very good. I know that what we have heard is
some groups have advocated that as being a thing, and you have
identified what the chief impediment of having that be a
solution.
Ms. Clowers. Yes.
Mr. Costello. Thank you very much. I yield back.
Mr. Harper. The gentleman yields back. I want to thank each
of the witnesses for being here for the valuable insight and
suggestions that you have given to us.
One thing that we can say is that no victim of sexual
assault should ever be turned away from any hospital, bottom
line.
Certainly I thank the Members for their input today as
well, and as I conclude what in theory should be my last
hearing to chair for this term, I want to thank our staff at
Oversight and Investigations, what a great job they have done.
They have succeeded in making me look a whole lot smarter than
I am, and I am most grateful for their hard work and dedication
to all that they have done for our country and specifically for
this committee.
I want to remind Members that they have 10 business days to
submit questions for the record, and I ask the witnesses to
agree to answer those as promptly as you can should you receive
any written questions.
Again, we thank you, and this subcommittee is adjourned.
[Whereupon, at 11:57 a.m., the subcommittee was adjourned.]
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