Jackie Flanagan has treated more than 100 victims of sexual assault, everything from violent rape to the inappropriate touching of children.
It’s not an easy job.
“When I get done with a case, I am emotionally drained,” said Flanagan, a night charge nurse in the emergency room at Memorial Hospital in Belleville. “The average forensic kit takes five to six hours from start to finish. I’ve had cases that have taken me 12 hours. They needed more documentation and more photos. You have to describe the wounds. Some of these cases are very horrific.”
Flanagan is one of nine nurses at four metro-east hospitals who have completed sexual assault nurse examiners (SANE) training, which focuses on treating patients physically and mentally; providing information and support; and gathering forensic evidence such as semen, saliva and hair that could be used in court cases. Those hospitals are Memorial, Memorial East in Shiloh, St. Elizabeth’s in O’Fallon and Anderson in Maryville.
The other seven metro-east hospitals have no forensic nurse examiners. Patients are treated by emergency room staff who may or may not have experience with sexual-assault cases.
“Right now, in the state of Illinois, you do not have to be a SANE-trained nurse to do a rape kit,” said Amy Signore, a nurse at St. Elizabeth’s Hospital who, like Flanagan, has undergone both the classroom and clinical training needed to practice as a forensic nurse examiner.
The landscape will change dramatically for many of the state’s 213 hospitals if Gov. Bruce Rauner signs legislation passed by the Illinois General Assembly this spring.
House Bill 5245 requires any hospital that identifies as a sexual-assault treatment facility to have a forensic nurse examiner (or specially-trained doctor or physician’s assistant) on call and available to get to the ER within 90 minutes of a patient’s arrival, 24 hours a day, seven days a week, beginning in 2022. The employee also must be qualified to handle the type of case, whether adult/adolescent or pediatric.
Other hospitals can identify as transfer facilities, agreeing to transport all sexual-assault patients or just child victims to facilities that have forensic nurse examiners. But if someone is taken to an out-of-state hospital, such as one in St. Louis, its staff still must follow Illinois’ rules and regulations for handling sex-crime cases.
The legislation also allows patients younger than 13 to be treated at approved pediatric clinics, where they might feel less frightened and more comfortable.
“Sexual-assault survivors deserve compassionate care that treats their physical and emotional trauma,” according to a statement by Illinois Attorney General Lisa Madigan, who helped write the legislation. “It is past time for Illinois hospitals to provide appropriately trained medical professionals to the thousands of women, children and men who need specialized care after a sexual assault.”
Some 161 hospitals in Illinois, including all 11 in the metro-east, now are treating sexual-assault victims. Statewide, ER staffs collect evidence for an average 2,500 forensic-exam kits a year.
Child victims sparked action
The roots of House Bill 5245, which revises the Illinois Sexual Assault Survivors Emergency Treatment Act, date back to 2016, when state Rep. Michael Unes (R-East Peoria), pushed to improve care for children who have been sexually assaulted. His legislation was expanded to include adults and adolescents.
Fewer than 20 forensic nurse examiners in Illinois have completed specialized pediatric training, according to Jaclyn Rodriguez, SANE coordinator for the attorney general’s office. None practice in the metro-east. Flanagan is now doing her clinicals.
“There’s a lot of child victims of sexual assault,” she said. “Not too long ago, I did three (exams) in one day.”
An amended House Bill 5245 sailed through the Illinois General Assembly in May, passing 49-0 in the Senate and 108-0 in the House. It’s seen as a way to hold hospitals accountable and improve care for sexual-assault victims, but also to increase successful prosecutions of offenders.
The attorney general’s office has provided free 40-hour SANE classroom training to more than 1,500 nurses in Illinois since 2004, yet only 300 have completed up to 80 hours of clinical training required to become forensic nurse examiners. Madigan blames this on lack of hospital support. Some nurses complain that they don’t get fairly compensated for time off, travel, exam fees and other expenses.
“At present, only 150 SANEs are practicing in emergency departments in Illinois hospitals, and no hospital has a 24/7 SANE program,” according to a press release from Madigan’s office.
There are two forensic nurse examiners at Memorial Hospital and four at Memorial East; two forensic nurse examiners and seven nurses with SANE classroom training at Anderson; and one forensic nurse examiner and three classroom-trained nurses at St. Elizabeth’s.
Nurses at some of the other seven metro-east hospitals have classroom training, but there are no forensic nurse examiners at these hospitals: Gateway Regional Medical Center in Granite City, Touchette Regional Hospital in Centreville, Red Bud Regional Hospital in Red Bud, Alton Memorial Hospital, St. Anthony’s Medical Center in Alton, St. Joseph’s Hospital in Breese and St. Joseph’s Hospital in Highland.
Only about 30 forensic nurse examiners in Illinois have completed the 300 hours or three years of clinical training required to take an exam and become SANE-certified with the International Association of Forensic Nurses.
“It’s mainly a validation of your competency in practice,” said association CEO Jennifer Pierce-Weeks. “But the key is not certification. It’s whether hospitals have SANE nurses available to conduct medical forensic sexual-assault exams.”
Pierce-Weeks also stressed the importance of talking to patients about long- and short-term treatment options, both physical and mental; rape consequences such as pregnancy, HIV and sexually-transmitted diseases; counseling and advocacy services; and legal rights and representation.
Pierce-Weeks called it a “common occurrence” for U.S. hospitals without forensic nurse examiners to tell sexual-assault victims that they have to seek treatment elsewhere.
“They’re turned away, and that should never happen,” she said.
Rural hospitals face challenges
Some small Illinois hospitals, particularly those in rural areas, have argued that it’s a challenge to recruit regular nurses, let alone forensic nurse examiners; and it’s difficult to provide clinical, on-the-job training with so few victims seeking treatment.
“We did oppose (House Bill 5245), primarily because of concerns about implementation of it and the costs associated with it,” said David Gross, senior vice president of government relations at the Illinois Health and Hospital Association, a group of more than 200 health-care facilities. “It’s going to be a burden in some areas of the state.”
Up to 500 additional forensic nurse examiners would be needed for hospitals to comply with the new legislative mandate. Gross wonders how that many nurses can be trained by 2022 and how long they will stay in practice, noting that it’s “grueling work” with high turnover and burnout rates.
Recouping costs also could be a factor. More than half of sexual-assault victims who seek ER treatment are covered by Medicaid or have no insurance, according to Sandy Kraiss, the hospital group’s vice president of health policy and finance.
The attorney general’s office is encouraging hospitals to cut costs by creating SANE pools rather than independently trying to hire or train enough forensic nurse examiners for 24/7 coverage. It plans to test this approach with a pilot project in central Illinois, using a U.S. Department of Justice grant.
“One of the goals of the legislation is to get hospitals in a community or region to form collaborative relationships and share these resources,” Rodriguez said. “(In the metro-east) you could very easily have 24/7 coverage with the SANE nurses you already have.”
The hospital group hasn’t rejected the idea of SANE pools, but Gross sees potential complications. Should clinicians not employed by a hospital have access to its drug supply? How can forensic nurse examiners live in locations that are centralized enough to serve multiple hospitals in rural areas with a 90-minute response time?
Such challenges will be addressed by public and private officials on a state “implementation task force.” The hospital group plans to recommend an expedited SANE training system for ER doctors and SANE courses built into nursing-school curriculums.
“We do support the public-policy objective (of the legislation),” Gross said, pointing out that larger hospitals already employ forensic nurse examiners without a mandate.
Stressful, heart-wrenching job
Flanagan and Signore, the local nurses, agree that the work of forensic nurse examiners can be stressful, disturbing and sometimes heart-wrenching, and that many nurses don’ t want to do it.
Hours can be long. Patients are upset, sometimes hysterical. The frequency and timing of cases are unpredictable. Sometimes a month or two goes by without any sexual-assault victims seeking hospital treatment, and then several will show up in one week. Both Flanagan and Signore have been called in at all hours of the day and night.
Incest cases involving children are particularly tough, and in recent years, Flanagan has noticed an increase in cases related to human trafficking.
“We’re mandated reporters,” she said. “(Sexual assault is) considered a violent crime, so we are mandated by law to call the police. Now, victims don’t have to talk to them. They have up to five years to decide whether they want to file a police report.”
Nursing is a second career for Signore, 48. She volunteered for SANE training because she saw a need in the community, and she feels empathy for sexual-assault victims.
Signore starts each exam by letting the patient know he or she is in control.
“It’s not just physical,” she said. “It’s also an emotional attack. The power has been taken away from them.”
Beyond that, every sexual-assault case is different. Forensic nurse examiners may have to perform genital or anal exams; take samples of semen, saliva, hair, urine, blood or fingernail dirt; and photograph bruises, lacerations and other injuries. They often double as detectives, asking questions to help them figure out exactly what happened to patients.
In the past, most perpetrators charged in cases handled by Flanagan, 54, have made plea deals, keeping them from going to trial. But she is preparing for her first court testimony in August.
The defendant is Leondre McClendon, a teenager who last year pleaded guilty but mentally ill to carjacking and rape in Belleville. He was sentenced to 70 years in prison in November in St. Clair County Circuit Court but withdrew his plea in March, and now he will be tried before a jury.
Flanagan examined the female in her 20s who allegedly was raped by McClendon at gunpoint in her garage in 2016. DNA evidence helped police identify him as a suspect.
“Now we’re re-victimizing this young girl,” Flanagan said. “She has to go though the whole process again. It was a violent, horrific crime.”
Advocates applaud legislation
House Bill 5245 is strongly supported by Call for Help, a non-profit agency in Belleville that mans a 24-hour hotline and provides other services to sexual-assault victims in St. Clair, Madison, Monroe and Randolph counties.
The agency receives an average of 15 calls a month from hospitals, asking for advocates to show up at emergency rooms to offer information, support and resources to distraught patients.
“From the advocate’s perspective, we see an immense difference in the care that folks are provided by SANE nurses and those providers who are not trained,” said Michelle Cates, director of the agency’s Sexual Assault Victims Care Unit.
If victims contact Call for Help before seeking treatment, volunteers tell them which metro-east hospitals have forensic nurse examiners. The idea is to reduce the chance of treatment by ER staff who aren’t familiar with criminal laws or experienced with forensic-exam kits. One misstep — such as leaving a room with evidence unattended, even for a few minutes — could hurt a prosecution.
Cates also noted that forensic nurse examiners are “trauma-informed” or trained on how to treat sexual-assault patients without re-traumatizing them.
“Trauma can affect the way that we behave and think, and we know from the low instances of reporting, it’s a hard thing to do, going to a hospital,” she said. “So to go there and to get a nurse who has never looked at a kit before, or they’ve never collected evidence, and they’re asking questions themselves ... That can be terrifying.”
One Call for Help client, who asked to remain anonymous, had two very different treatment experiences at two metro-east hospitals after allegedly being drugged and raped at a friend’s house earlier this year. The woman hasn’t filed a police report.
At the first hospital, which she declined to name, ER personnel tested for drugs and sexually-transmitted diseases but didn’t do a physical exam. She went to another hospital two days later after learning that exams can be done within seven days of a sexual assault.
At the second hospital, the nurse seemed more knowledgeable and kind.
“It was night and day different,” the woman said. “She not only talked about the medical options but also the legal options. ... The emotional state that you’re in when you decide, ‘Hey, I’m going to do this,’ even if it’s a couple days later, it’s indescribable. It’s beyond words. You need someone who can help you work through the emotions.”