By Lauren DeLaunay Miller
On August 18, 2021, Dr. Sean Dugan sent out a letter to his colleagues. He practices medicine in Redding, which had just reported its highest rates of COVID hospitalizations yet. His message began simply and grimly. He wrote, “It’s hard to recall a time that was more trying on the forensic medical community.”
In addition to being a practicing physician, Dr. Dugan directs the California Clinical Medical Forensic Training Center (CCFMTC) in Sacramento, where he and others train sexual assault forensic examiners. Across the state, examiners are struggling. They’ve been short-staffed for years, fighting inconsistent hours and vicarious trauma that contribute to low retention. But the pandemic has exacerbated all of that, especially in rural communities. With burnout pushing nurses out of rural areas or out of the field entirely, examiners and the programs they run are barely hanging on.
Why sexual assault forensic exams matter
If a sexual assault survivor seeks medical care after an assault, one option they might want to pursue is a sexual assault forensic exam, often known as a rape kit. The term rape kit refers to the physical kit which includes all the materials needed to complete a forensic exam, like envelopes, materials for blood samples, swabs, and documentation forms. But an exam is much more than the collection of evidence, and they can take hours to complete.
Forensic exams cover the patient’s health history, including detailed descriptions of the assault. A head-to-toe examination is then completed, which may include the collection of physical evidence, like fluids and hair, as well as documentation of injuries. Finally, the exam will include critical follow-up care, like prevention treatment for sexually transmitted infections. For many patients, this is the first place they will share their stories. Victims are not required to work with law enforcement to get an exam, but if they ever do decide to work with law enforcement, the results from this exam will be important evidence in court.
Time is critical in the effectiveness of this type of forensic testing, and to help preserve the physical evidence as much as possible, survivors are instructed to avoid bathing, eating, drinking and using the bathroom. That can be uncomfortable for any survivor seeking an exam, even those who live near a testing facility. But for survivors in rural areas who may need to travel hours before they receive an exam, the physical and emotional toll of waiting can add to an already devastating situation.
Hiring examiners was always a challenge, the pandemic made it worse
Dr. Dugan, CCFMTC director, said that before the pandemic, the center was holding three sexual assault forensic examiner training sessions every year. And while the center was proud of the regular, consistent schedule of in-person training opportunities, not everyone who completes the training will go on to work as an examiner.
Sending a nurse to the week-long training also means taking them off their shift for a week, and the pandemic has made that impossible for some hospitals.
“Everything that is bad has increased with COVID,” said Kristen Marin, the Emergency Department and Trauma Coordinator for Mendocino County.
Marin explained that for smaller hospitals, being an examiner isn’t even close to a full-time job. Most examiners are emergency room nurses who may be asked to come in during their time off to perform an exam.
“Forensic examiners have day jobs,” Dr. Dugan said. “We spent ridiculous amounts of time on call.”
If they don’t, he said, “programs crumble.”
Both Marin and Dugan said that even if nurses want to receive the training to become forensic examiners, they often can’t get time off their shifts to attend. Emergency rooms are deeply under-staffed, and for rural counties that might only perform a few exams per year, it’s difficult to justify taking nurses out of packed emergency rooms.
The pandemic has changed everything for hospitals, and in many cases, sexual assault resources have been put in the backburner. Before COVID, Marin said Mendocino County had a robust Sexual Assault Response Team, or SART. An interdisciplinary group of community members, SARTs usually include medical providers, law enforcement, and crisis center staff, and each county in California is supposed to have one. Mendocino County SART used to meet quarterly to talk about local issues like human trafficking, fentanyl use, and assault on illegal marijuana farms. But the meetings “fell to the wayside during COVID,” Marin said.
The same is true in Inyo County. Matias Bernal, the executive director for Wild Iris Family Counseling and Crisis Center in Bishop, said that their county SART team did not meet in 2020 and has only recently started up again to respond to an alarming situation at Northern Inyo Healthcare District: there are no trained examiners left.
Retaining nurses in rural counties
An August 2021 study by the University of California, San Francisco found that an alarming number of nurses had retired in 2020 due to the pandemic, and further studies indicate that much of that is caused by feelings of burnout and post-traumatic stress. Nurses who don’t leave the field altogether are moving to positions with better pay, often at more urban hospitals. “People are exiting in droves from rural Mendocino County,” said Marin, citing signing bonuses of up to $20,000 at hospitals in Santa Rosa as a key force behind the shift. She knows that small hospitals can’t compete with the wages being offered in cities.
In rural hospitals, forensic nurses might only be needed a few times a year, but there are often plans in place to make sure that one is always available. For rural communities, that usually means a complicated web of on-call shifts and schedules with plans to defer to a nearby hospital if their own providers are not available.
Jacqueline Winters-Hall is the Sexual Assault Forensic Examiner (SAFE) Coordinator at Enloe Medical Center in Chico. Her team serves both Butte and Glenn Counties.
“It’s difficult to keep nurses because of the nature of the work, and then the hours are horrible and unpredictable,” said Winters-Hall.
Winters-Hall and Dr. Dugan both agreed that examiners often face vicarious trauma from performing these exams. Not all those who complete a forensic exam training stick with the role, due to the emotionally taxing nature of the work.
Christina Pritchett, program manager at CCFMTC, added that many nurses also go through this training because they themselves have been victims of abuse, and they want to make sure that no one goes without an exam.
“It’s their right as a victim of sexual assault to have this exam, and we will move mountains to get them that exam,” said Brookelyn Stafft, Sexual Abuse Response Team (SART) program coordinator of Empower Tehama in Red Bluff. Stafft said Empower Tehama went into the COVID-19 pandemic with only two forensic nurses
In rural parts of the state, entire programs are often built around just a handful of examiners, adding to the increased pressure and potential for burnout. There are days, said Dr. Dugan, that “if you weren’t there as an examiner, the rape exam wouldn’t get done.”
Giving sexual assault forensic examiners the resources they need
The pandemic has revealed the house of cards sexual assault forensics is built upon, one in which access to care guaranteed under the Violence Against Women Act relies entirely on the goodwill and dedication of examiners, not the integrity of the system.
That lack of structure frustrates Dr. Dugan, who remembers the absence of information about domestic and sexual violence when he was in medical school. “Statistically,” he said, “violence affects more women than any other medical condition.”
According to Dr. Dugan, one-third of women will experience violence in their lifetime, and one in five will experience a cardiovascular emergency. But while all emergency rooms are equipped to handle cardiovascular emergencies, few are prepared to respond to violence.
“Medicine has turned a blind eye to this,” he said.
Dr. Dugan said he hopes the center can train more forensic medical examiners equipped to do this essential work. While the CCFMTC had to stall in-person trainings during the pandemic, he said they have recently restarted. His team is developing virtual trainings to help make up for the difficulty of traveling for an in-person training.
Need for exams increasing during the pandemic
While Dr. Dugan has seen an “implosion” of the number of examiners across the state, he has also seen an “explosion” in the request for exams. Rates of sexual and domestic violence have increased nearly everywhere since the pandemic began, and forensic nurses are feeling the impact.
Kristen Marin in Mendocino County believes that, for her community, the pandemic pushed people toward substance abuse and mental health crises which, in turn, have increased cases of domestic violence and sexual assault.
A study from the University of California, Davis found that the economic stress of the pandemic has exacerbated intimate partner violence. At the same time, stay-at-home orders have made it more difficult for those being abused to seek care and for friends and family to check in on those they worry about.
Despite the challenges, dozens of nurses across California are dedicated to providing forensic exams to those who need them.
COVID has left everyone exhausted, said Winters-Hall, but she knows how important these exams are to her patients and refuses to let them miss out on the care they need. “I meet my patients on the worst night of their life,” she said, “and I help them move toward their path to healing.”
