Trauma-informed nurses help sexual assault survivors. Most hospitals don’t have them.

Julie Ford doesn’t remember everything about her assault. She remembers being tired as she neared the end of her usual jogging route atop the Mississippi River levee in New Orleans. She remembers passing someone sitting on a bench. She remembers being “tackled like a football player.”

The rest comes in flashes. Fighting him off. Dragging herself through the dirt. Calling for help. Her husband, bystanders, and EMTs carrying her broken body to the ambulance, which couldn’t get to her on the river side of the levee.

She remembers pleading to be taken to West Jefferson Medical Center, a hospital she knew took her insurance. She didn’t know it yet, but her hip had been dislocated, nose broken and her arm broken so badly EMTs described it as being in the shape of a question mark.

Because she’d been assaulted, she remembers being told she had to be taken to a specific hospital to receive a forensic exam — sometimes called a “rape kit.” While a range of clinicians can conduct forensic exams, specialized nurses called sexual assault nurse examiners (SANE) receive rigorous training to provide trauma-informed care throughout the evidence collection and examination process. SANEs also connect survivors with resources and advocates.

SANEs and the advocates they connect survivors with are vital for trauma-informed patient care and for bringing perpetrators of sexual assault to justice. But there is a critical shortage of SANEs across the Gulf South. According to the International Association of Forensic Nurses, a trade group that certifies SANEs, Alabama has 44 certified SANEs for the entire state. Louisiana has 42. Mississippi only has 6 — for a population of almost three million.

Where and how sexual assault patients access this resource varies greatly across the region. Although Louisiana state law requires patients have access to forensic exams in every parish, in practice not every hospital is set up to provide them. Instead, sexual assault survivors are often funneled to specific hospitals with SANEs tasked with delivering this specialized care In the New Orleans area, one of those facilities is University Medical Center, the hospital where Ford said she was taken, even though it wasn’t in her insurance network.

What followed was another blur. She said she was put in a triage area that was “very public.” There, a detective asked her the same questions she’d already answered for patrol officers. She didn’t know where her husband was or why her leg felt like it “fell off.” She said nobody would tell her what was happening.

She was confused and scared — until she was greeted by an advocate from Sexual Trauma Awareness and Response (STAR), a group that works with survivors, and a sexual assault nurse examiner.

It was the first time she felt that somebody was here to help her, she said. SANEs are trained to reach out to advocates to sit with patients like Ford while they conduct a forensic medical exam, collecting evidence that could be used in prosecution.

It would take almost a decade before Ford’s attacker would be convicted for assaulting her. Patients can’t be charged for forensic exams in Louisiana, Mississippi and Alabama under state law. In Louisiana, hospitals are reimbursed up to $1,600 for a forensic exam from the state’s Crime Victims Reparations fund.

But this only covers the forensic exam — not the costs related to any additional injuries. Ford said for the one night she spent in the UMC emergency department, she was charged about $20,000 for medical care related to her severe injuries, which still haven’t fully healed.

Ford said she and her husband spent months making phone calls to their insurance company, and, after tearfully recounting what happened to her over and over, eventually, they were able to get most of the bills to be considered in-network. She ended up paying more than $2,300 out of pocket for medical bills, as well as around $1,000 for the ambulance ride.

“The only thing in the system that I think worked in my entire experience was that piece, the forensic medical exam and the advocate piece,” Ford said. “I felt very lucky to have that.”

After her assault, Ford stayed in touch with her advocate from STAR and used their hotline, support groups, and legal program for guidance and support. She’s had two surgeries and years of physical therapy related to her injuries.

She’s also become an advocate for other survivors. She now volunteers with Crime Survivors NOLA, which produces a free guidebook of resources for people dealing with the aftermath of violent crime. She said the practice of sending sexual assault survivors to another facility if they want a forensic exam is a huge barrier.

“It might take a lot for that person to walk into a hospital, and you want to make it as easy as possible for them to get done what they need to get done,” Ford said.

“Just telling somebody that they have to go somewhere else, that might be the difference between that report getting taken or not getting taken.”

When it comes time for her to introduce herself, nurse Gennie Cochran answers the icebreaker questions scrawled on the whiteboard like almost every other nurse in the small, brightly-lit room down the hall from the ICU at Ochsner Rush Medical Center in Meridian, Mississippi.

She’s originally from Mississippi, but she worked at West Jefferson Medical Center in Louisiana — the hospital Ford begged paramedics to take her to — from 2016 up until February, when she moved to Ochsner Rush.

“I’m always tired,” she says with a laugh. The other nurses in the room nod in understanding.

Cochran and six other nurses and nurses-in-training from across the region are here for a week-long training to become SANEs. This is day one.

The last icebreaker question on the board is: Why am I taking this course?

“This course is very near and dear to my heart,” Cochran says, tearing up as she explains that her daughter was assaulted when she was 13. She says it changed her daughter’s life and Cochran wants to be able to care for survivors. She wants to “make sure it’s done right, so they can’t throw it out in court.”

Shalotta Sharp, one of the SANEs helping to run the training, thanks Cochran for sharing her experience. After a short break, the group reconvenes and Sharp poses a question.

“How many of you learned about the SANE program or SANE nursing or forensic nursing in nursing school?” Sharp asks.

No one, including Cochran raises their hand.

“Me either,” Sharp says, cutting through the tension in the quiet room. “Forensic nursing is the best kept secret in the nursing community, in my opinion.”

Many of the nurses at the training came because the hospital where they work doesn’t have a SANE. According to the International Association of Forensic Nurses, only 17-20% of American hospitals do. They want to be able to conduct forensic exams and provide trauma-informed care to their patients.

“I work in small hospitals,” says nurse Jane Koen, who drove in for the SANE training from Choctaw County, Alabama. “We don’t have that in our small counties, so I just wanted to try to do it.”

Under the federal Emergency Medical Treatment and Labor Act, anyone who comes to an emergency room must receive an initial exam, called a medical screening, where they’re checked for serious injuries and made sure they’re stable. The law also guarantees emergency care to anyone, whether or not they have insurance or the ability to pay.

But Koen said that if sexual assault patients come ot the hospital where she works and want a forensic exam, they have to be transferred to another facility in Mississippi. It’s about an hour’s drive by car.

“We tell them, ‘We don’t do that here,’” she said.

In interviews nurses, advocates, and legal experts from Louisiana, Alabama, and Mississippi, recounted instances where patients couldn’t access forensic exams at their local hospital. Instead, they were transferred or referred elsewhere: sometimes across town, across the state, or across state lines. Sometimes, survivors drive themselves.

Exactly how often patients have to travel to receive this care isn’t clear because transfers like these are not tracked in public data. In some parts of Louisiana, regional policy states hospitals can transfer patients to a facility where a SANE is available.

Naomi Jones, a former prosecutor — who prosecuted survivor Julie Ford’s case — in New Orleans, said having to travel to another hospital to get a forensic exam is a “huge impediment.”

Jones laid out a hypothetical timeline a survivor could face: they go out one evening around 7 or 8 p.m., an assault happens between 12 and 3 a.m., they make the decision to go to a hospital that doesn’t have a SANE around 5 or 6 a.m., get their initial exam around 9 a.m., and are then told they need to go to another facility if they want a forensic exam. And it could be several hours later before the forensic exam begins, which can take as long as six hours to complete.

“At this point, that person has been up and awake for well over 24 hours,” Jones said. “They have been brutalized. They have already been prodded.”

When a patient is told they need to go to another facility, in Louisiana, there isn’t a system in place that tracks whether or not they make it to that facility. Because this data isn’t collected, there’s no way to know how many sexual assault survivors choose not to go through with getting a forensic exam.

UMC in New Orleans houses Louisiana’s largest SANE unit and many surrounding parishes send patients there for forensic exams. If an assault occurs in neighboring St. John the Baptist Parish, for example, the patient could be sent to UMC — potentially over an hour away — to meet with a SANE.

One SANE at UMC, Heidi Tujague, said when a patient is transferred, she gets a phone call from another hospital saying to expect a patient for a forensic exam. She reaches for a sticky note and jots down their basic information.

“I’ve had sticky notes with just a name and a birthday,” Tujague said. After a week or so, if a patient doesn’t come in, she has to throw the neon-colored squares away.

In the 1970s, nurses across the U.S. came together, recognizing the need for specialized care for sexual assault patients, and started the first SANE programs with the aim of improving care for patients as well as the quality of evidence collection for prosecution.

The nurses who developed these programs likely did not envision a future where lack of access to a SANE could jeopardize medical care and legal recourse for survivors of sexual assault — a “double-edged sword” as SANE-trainer Shalotta Sharp called it.

Sharp said any nurse can conduct a forensic exam by using a SAFE kit. But this can pull a nurse off an emergency room floor for several hours. Many hospitals are already understaffed, and having fewer staff available can lead to increased wait times, higher rates of patients leaving the hospital without being seen and more medical errors.

The evidence may also not be as high-quality, and there’s the risk of retraumatizing the patient if the nurse isn’t specially trained to work with survivors of sexual assault. And, according to Sharp, many nurses are worried about having to testify in court if a case goes to trial.

On the first day of the SANE training in Meridian, Mississippi, Sharp explained that administering the SAFE kit was a small fraction of what they would learn.

“What you are going to be learning about is what this patient looks like, how to recognize this patient, how to talk to this patient, how to document the findings you see on this patient,” Sharp said. “How to engage with this patient. How to listen. Listen to that patient and actually hear what is being said.”

Advocates say this approach is critical for sexual assault survivors, many whom come into a hospital physically and emotionally injured, distrustful, and scared.

“You’re dealing with trauma,” said Kimberly Young, who runs Hearts of Hope, a sexual assault resource center in Lafayette, Louisiana. “You need people like Shalotta [Sharp] in that room who are trauma-informed and know how to handle trauma.”

Jencie Olivier, the sexual assault response center coordinator at Hearts of Hope, recently started keeping track of patients who said hospitals turned them away. Since January, she’s recorded seven instances. “They’re saying, ‘We’re not trained and able to do this’ and ‘Can you call Hearts of Hope?’”

Those patients went to the Hearts of Hope facility, where they were able to meet with a SANE and get forensic exams.

The trauma-informed care SANEs provide also includes immediately contacting a local advocacy group to send someone to the hospital to sit with the patient, comfort them, advocate for them, explain the process, and connect them to any resources they might need, like support groups or legal assistance.

That’s all if the patient wants it. Consent is another huge aspect of a forensic exam conducted by a SANE, who explains each step before they do it and asks the patient for their permission before proceeding. If a patient doesn’t want to be swabbed or want photographs of certain areas, for instance, SANEs respect their choices.

Jones, the prosecutor, says SANEs are better at what’s called the “chain of custody,” which refers to the process by which evidence is properly collected and transported so it’s not damaged or contaminated.

“Chain of custody is incredibly important and [SANEs are] trained to do it and they’re good at it,” said Jones, the former prosecutor. “And that helps preserve the evidence. And evidence finds the truth.”

Jones said that when a prosecutor is making a decision about whether or not they’re going to go forward with a sexual assault case, part of that process includes looking at whether or not there’s enough evidence. “It absolutely makes for a stronger case against a defendant when you have medical evidence,” she said. “It makes a difference — a massive difference.”

Research supports this as well. A 2018 report on sexual assault and the availability of forensic examiners from the U.S. Government Accountability Office found that forensic exams conducted by people trained to perform them “may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates.”

Similarly, a 2006 study by the American Prosecutors Research Institute and Boston College found that involving a SANE or a sexual assault response team in a case could contribute to higher survivor participation in the legal process, increased suspect identification and arrests, and greater likelihood of conviction.

SANEs don’t just play a role on the evidentiary side of a sexual assault case. Because of their specialized training, they can also be qualified as experts and testify in court. Survivor Julie Ford said the testimony of the SANE that examined her was “completely critical for the case.”

Another reason why there aren’t enough SANEs is that there aren’t enough nurses. There’s currently a shortage of working nurses in the U.S., driven by factors such as a reduction in nursing program enrollments and working conditions. Concerns about adequate pay and workplace safety have driven many nurses to leave the profession.

“We have a national surplus of nurses, believe it or not. There are more than enough nurses,” said Michelle Mahon with National Nurses United, the largest nursing union in the country. “What is lacking is the nurses who are willing to work in the conditions of care that have been created by the industry.”

Rather than transfer patients between facilities, some regional health districts in Louisiana have adopted a “traveling SANE” model, where the specialized nurses come to the patients, when availability allows. For example, in Region 7, which encompasses nine parishes in the northwestern part of the state, if a patient presents to a hospital that doesn’t have a SANE, the hospital will request one be sent to that facility to meet with them and conduct a forensic exam when and if the patient requests one. In instances where no SANE is available, an emergency department physician can perform the exam.

Morgan Lamandre is president and CEO of Sexual Trauma Awareness and Response (STAR) — the organization that sent a volunteer to sit with survivor Julie Ford after her assault — which has offices in three different locations in Louisiana, one with a hospital-based SANE program at UMC and two with traveling SANE programs. She said removing the travel barrier increases the likelihood that a survivor will get a forensic exam.

“From our perspective, the model is the traveling program because it doesn’t matter where a survivor presents to a hospital, the SANE comes to them,” Lamandre said. “Who knows how long it took them to get to the point of the hospital where they were being discharged to go to another hospital and to relive and tell a million people all over again what happened to them. Sometimes they just say it’s not worth it.”

Other advocates agree that bringing SANEs to patients can help alleviate the barriers to accessing a forensic exam.

“Without a doubt, whenever you have a survivor that’s faced with an obstacle like that, they’re less likely to get a forensic exam,” said Rafael de Castro, executive director of the Louisiana Foundation Against Sexual Assault, a nonprofit that works with rape crisis centers in the state.

“Whenever you can break down obstacles for survivors to get the services that they need, you’re always going to see an increase,” de Castro said.

De Castro said this impact goes deeper than getting a forensic exam or medical care in the moment. SANEs connect survivors to local sexual assault centers and advocates who can provide long-term services like individual or group counseling, legal assistance, and other forms of support.

“If a survivor doesn’t know that those services are available,” de Castro said, “then they don’t get those services.” Studies show sexual assault survivors are at a higher risk for suicide. “It’s a life-lasting impact when those services are not there for a survivor.”

While they can benefit patients, traveling SANE programs can stretch thin the capacity of SANEs in the region they serve. Jefferson Parish only has two full-time traveling SANEs — which can also mean patients have to wait longer for a SANE to get to them.

Additionally, when the St. Tammany Parish coroner, Christopher Tape, fired all of the SANEs his office employed, which provided care for residents of five parishes, the two full-time Jefferson Parish traveling SANEs picked up the workload.

Tape said in a press statement he believed the SANE program was “illegal” because St. Tammany parish taxpayers paid for services provided to four neighboring parishes. But a former St. Tammany parish coroner said it did not pose a significant financial burden and that it was largely funded through grants and federal funds. (According to a WWL investigation, Tape was previously indicted on charges that he sexually assaulted a minor, though the charges were later quashed after the court found the state had violated his right to a speedy trial. He also settled a 2022 civil complaint from a female employee who accused him of “unwanted advances.”)

The two full-time Jefferson Parish traveling SANEs now cover 19 hospitals in six parishes, an area of 3,659 square miles with a population of more than a million people — larger than the state of Delaware and nearly the population of the state of Montana.

The workload of traveling SANEs can take a toll on the nurses themselves. Being a SANE is already difficult and demanding work. With the shortage, there are even more patients who need their care.

“Honestly, a lot of us that have been doing this have been doing it a while and we are very much on our last leg,” Ginesse Barrett, one of the two full-time Jefferson Parish traveling SANEs said in a February 26 Louisiana Sexual Assault Oversight Commission meeting.

Sexual assaults often do not occur during normal business hours. SANEs can get calls in the middle of the night to go to a hospital and meet with a survivor who has been recently traumatized. Heidi Tujague, a SANE at UMC in New Orleans, said many nurses have stopped being SANEs due to burnout — what she called “compassion fatigue.”

“I’ve seen nurses who only last a year or two because they just cannot handle the extra trauma they’re experiencing,” Tujague said.

Health care providers are exploring another potential solution for addressing the SANE shortage and the barrier travel imposes on survivors: telemedicine. A teleSANE can video call into a hospital exam room and guide an emergency nurse through a forensic exam. SANEs can be recruited from across the country under this model.

Hospitals in some states do use teleSANE programs. Shalotta Sharp, the SANE trainer in Mississippi, works remotely as a teleSANE in Arkansas. But she says she can’t do this work in her own state or in neighboring Alabama and Louisiana, which currently do not have any teleSANE programs.

Sherrie Searcy-Lyle, a SANE at the University of Arkansas for Medical Sciences, who helped start the teleSANE program in Arkansas, said the travel barrier to patients and the shortage of SANEs in the area — she said Arkansas only had four certified SANEs before — were huge factors influencing their decision to start a program.

“It eliminates that need to transport patients outside of their community unless they choose to do that,” Searcy-Lyle said. The teleSANE program is now in 27 hospitals across the state, she said.

“I know that we’ve made an impact on making things happen for patients that would not have happened before without teleSANEs,” Searcy-Lyle said.

But not all nurses feel that telemedicine is the solution to the problem of a shortage of SANEs.

“It’s very tempting to say, ‘Let’s look at this alternative model,’” said Michelle Mahon with National Nurses United. “The comparison is nothing or this . . . Nothing is unacceptable. But why are we not demanding what patients need?”

Mahon said telehealth can’t replace the in-person care that’s vital for patients, especially survivors of sexual assault. Some research supports this. In an evaluation of a temporary teleSANE model deployed during the COVID-19 pandemic, teleSANEs noted challenges in reading patients’ nonverbal cues and body language, which made it harder to ensure they were meeting their needs.

One clinician emphasized the importance of touch in sexual assault care: “It’s hard when you can’t reach out and touch somebody. Put a gentle hand on someone’s arm or whatever. That’s the part I didn’t like the most.”

Non-SANE clinicians who participated in the research also highlighted the limitations of telehealth in creating human connections. As one described: “The [teleSANE] nurse on the iPad wasn’t there to hold [the patient’s] hand or talk to her face-to-face. I was the bridge, holding her, letting her cry on me. I know it was COVID-19 and we weren’t supposed to be close, but she was crying on my shoulder.”

Some nurses say that teleSANEs can seem like attractive options for hospitals because fewer nurses can cover a wider area, which is less expensive than having a certified SANE nurse on-site in every community. But that doesn’t address the underlying factors contributing to the shortage of SANEs, and nurses more broadly, says Michelle Mahon with NNU.

This goes beyond pay increases, Mahon said. Nurses primarily leave the industry for three reasons. The first is what she called “moral injury”: working in an environment where nurses feel that they don’t have enough resources or support to provide the care they feel their patients need.

The second reason is understaffing, which puts more of a burden on the nurses that do choose to remain in the practice. The third is workplace violence: In 2023, NNU surveyed 1,000 nurses from across the country — nearly half reported an increase in workplace violence in the previous year."

Part of that underinvestment includes limited access to SANE trainings, which nurses often have to pay for themselves. Courses can range in cost from $350 to $600, though some organizations, like the one Shalotta Sharp works for, offer the education for free.

SANE programs operate in different ways depending on regional policy. Some programs in Louisiana, like Jefferson Parish, are run by the parish coroner’s office. Some are run by the individual hospital, like UMC, a public hospital with funding from the state of Louisiana.

In Louisiana, the state budget does not directly allocate funds to SANE programs.

In the February 26 Louisiana Sexual Assault Oversight Commission meeting, Louisiana State Senator Beth Mizell said there’s an “incredible disconnect” with state legislators and the severity of the issue.

“They think that the numbers are minute, they don’t realize the amount of victims that we’re talking about,” Mizell said. “It doesn't even have to be money problems. It’s whether that's going to be a priority or whether it's always gonna be something that if we have extra money and you ask nice, maybe I'll give you a little bit of it.”

In Louisiana, if the cost of the forensic exam exceeds the $1,600 reimbursed from the Crime Victims Reparations Fund, the hospital has to absorb the additional costs. Hospitals and healthcare providers with limited resources may not have the “extra buffer” to absorb the potential costs of conducting forensic exams, and a significant part of that can be paying for specialized nursing staff, said Monica Taylor, director of the Louisiana Governor’s Office on Human Trafficking Prevention.

The SANE training that Shalotta Sharp helps lead in Mississippi is provided free-of-charge by the Mississippi Coalition Against Sexual Assault. But in order to attend, nurses have to take time off work and pay for their own travel, hotels, and food — along with other potential costs such as childcare arrangements.

This difficulty in accessing SANE-training can dissuade nurses from getting it. And as more nurses leave the profession or retire and fewer enroll in nursing school or re-join the industry, there may be even fewer SANEs available to patients.

Even though she didn’t have a choice where to go, Julie Ford said her experience with a SANE and an advocate at UMC was “the one thing in my situation that functioned the way it was supposed to.”

She doesn’t know if she would have chosen to go to West Jefferson Medical Center, where her medical care would have been covered by her insurance, or to go to UMC so she could get a forensic medical exam. But she wondered why that could have been a choice she would have to make in the first place — or why other survivors might have to choose to go to another hospital if they want a forensic exam.

“If you put the ability to have forensic medical exams at every medical facility that would give people that kind of control that I think they deserve in that situation,” Ford said.

This story was produced by the Gulf States Newsroom, a collaboration between Mississippi Public Broadcasting, WBHM in Alabama, WWNO and WRKF in Louisiana and NPR. Support for health equity coverage comes from The Commonwealth Fund.