Working with people on some of the worst days of their lives is not atypical in the medical field, but a team of local nurses also must support sexual assault survivors and collect criminal evidence.

Heidi Rockwell, the UnityPoint Health – Marshalltown trauma supervisor, said the five sexual assault nurse examiners (SANE) deal with situations which are often perverse and personal. When a sexual assault survivor comes to the hospital, every step of the process is up to what the patient is comfortable with and staff seek written consent before conducting any part of the exam.

Beyond the challenges of giving any exam, the SANE staff work with patients raw from a traumatic situation.

“It’s either for you or not for you,” Rockwell said of the work. “It takes a special kind of person to be able to do it because some of the cases are difficult — really difficult. Sometimes we need debriefings just like you would in any kind of trauma.”

T-R PHOTO BY EMILY BARSKE - Police supply sexual assault evidence kits to the hospital. Once complete, the SANE stamps it as evidence.

When a victim comes into the ER, they first talk to a triage nurse who determines what kind of care they need and takes them to a private room. That nurse makes sure there aren’t injuries that need immediate attention from a doctor and takes vitals before a SANE nurse takes over. If a sexual assault nurse examiner isn’t already on hand, the one on call will come in.

The situation isn’t uncommon. In Marshalltown during the period July 1, 2017 to June 30, 2018, police investigated 41 sexual assault incidents. Those numbers are only part of the picture as statistics show less than a quarter of sexual assaults ever get reported to law enforcement.

The response team

Partnerships between local agencies form the sexual assault response team. The team believes in giving control back to the victim by letting them decide how to move forward. SANEs are able to alert the response team. On-call advocates from the Assault Care Center Extending Shelter and Support along with law enforcement are made aware of the situation so they can head to the emergency room. In other cases, law enforcement or ACCESS may be the first agency alerted and victims later go to the hospital for an exam.

Every survivor gets to decide how they want to move forward. If a victim decides to have an exam performed, sexual assault evidence collection kits — commonly referred to as rape kits — are collected by the SANEs. The nurses, advocates and law enforcement explain all the options moving forward. Some are:

T-R PHOTO BY EMILY BARSKE - A colposcope can take high definition photos of the cervix, vagina and vulva.

• Testing for STDs or pregnancy.

• Counseling and other resources for coping.

• Submitting a full rape kit to law enforcement — naming a suspect if one can be identified. The victim can also determine whether they want to press charges or simply have the kit on file in case they choose to later.

• Submitting a rape kit anonymously without their name on it. Doing so may help in cases where a perpetrator has had multiple victims.

• Doing nothing at all if they choose.

“It’s going to look different for every survivor,” said Lydia Wolken, the Marshall and Tama County sexual assault services coordinator at ACCESS.

Some survivors may bring a support system, like a family member or friend, while others may come to the hospital alone. The on-call ACCESS advocate who responds help however they’re asked. They may be a neutral sounding board for victims about their options. They sometimes keep survivors calm while nurses do their exam. Sometimes parents who come in with a child also want their own support. And sometimes victims don’t want ACCESS involved, Wolken said.

She praised the sexual assault nurse examiners for their adaptability. In the course of a visit, a victim may change their mind multiples times about what they’d like to do. Victims may be in denial or may be juggling the guilt of incriminating someone they know and possibly love.

“The SANEs want to care for you,” Wolken said. “They’re not going to force you to do something you don’t want to do.”

Conducting the exam

Each evidence kit includes the exact same materials and victims can submit whichever parts they want. Victims are encouraged to come to the ER within 72 hours of the assault and are advised not to wash clothes or shower because doing so can wash away DNA evidence, Rockwell said.

“The sooner they come, the better our chances of getting DNA,” she said.

SANE staff go through extensive training, including 40 hours of classroom work, to do what they do. They also have regular continuing education opportunities and look for ways to improve.

Steps in evidence collection:

• The SANE fills out all the information about the patient and the description of the assault.

• Collect underwear.

• Collect blood sample.

• Swab DNA from inside the mouth.

• Swab vagina, anus, etc. depending on details of the assault.

• Swab skin where contact may have occurred, such as bite marks.

• Swab clothing.

The evidence collection is nearly the same for male and female victims, although the biological differences make for slight differences. The hospital received a grant last year to purchase its own colposcope. The machine can take high definition photos of the cervix, vagina and vulva. Rockwell said the machine is a great benefit in evidence collection.

The exams could be quick if a victim only wants to provide a statement and have STD testing, for example. Or it could take as long as four to six hours depending on the case.

“It’s up to them where the exam goes,” Rockwell said. “They don’t have to do anything when they come to our room. We’re here for them on what could be the worst day of their life. So we’re here to be whatever it is they need in that moment.”

Start of a case

The police supply the evidence kits to the hospital and once completed, the nurse stamps it as evidence and keeps it until detectives are able to take it per the required chain of custody. Very strict guidelines must be followed.

Detective Dawn Blahnik of Marshalltown Police is always on call to respond to the hospital when an adult reports a sexual assault. A team of three from the department are able to respond to cases with children.

Iowa law allows police to automatically open cases for kids 15 and younger. The theory behind the law is children at that age may not be able to discern what’s right or wrong, Blahnik said. Children may also live with or obtain vital resources from the suspect. Depending on the age of the child, they may not be examined at UnityPoint but rather sent to a Child Protective Center. The centers in Waterloo, Hiawatha and Des Moines have people specifically trained to interview child victims.

If a criminal investigation is opened, the police coordinate efforts with the sexual assault response team to collect the kit, interview the alleged perpetrator if one was identified or obtain a search warrant for physical evidence, which all may be happening at the same time. Blahnik said in most cases, the victim is able to identify who the perpetrator was. Most perpetrators of sexual violence are someone the victim knows, though stranger rape also happens.

Rape kits are processed by the Division of Criminal Investigation’s crime lab. In recent years, attention has been brought to the backlog of hundreds of kits still needing tested. Some states have required turnaround times, but Iowa isn’t one of them. Blahnik said some testing is sped up with an impending trial.

Meanwhile, victims have free services from ACCESS available, regardless of going through a criminal investigation. Services include criminal justice advocacy, helping advocate for the victim in their workplace or school and making connections with resources like counseling. The staff can assist the victim in finding a safe place to stay if necessary.

Hopes for a SANE room

Rockwell hopes to soon have a designated SANE room at the hospital. While victims are currently provided a private space. The SANE room would be more inviting and have the specific equipment ready to go. An attached bathroom would be ideal so victims could shower since many come in without having done so in awhile to preserve evidence, Rockwell said.

Some organizations donate clothes so victims have some to change into after they turn in theirs for evidence. Those could also be kept in the room.

Wolken said such a room could feel like a safe space away from other patients at the hospital, especially if it was separated from the rest of the ER. Victims commonly fear they’ll see someone they know when going in for the examination, she said.

Awareness

Rockwell said by nature it’s not a word-of-mouth business, so people don’t often know of the resources available. Many people don’t want to think sexual assault happens here. Members of the sexual assault response team can connect victims to the right resource if they don’t know where to go.

The advocates see many stereotypes surrounding sexual assaults.

“Movies and TV portray a rape culture where it’s a stranger, the act is violent, the victim fights back … usually it’s the exact opposite,” Blahnik said.

Some survivors may put off coming forward because they don’t feel what happened to them was “bad enough,” Wolken said. She encouraged anyone confused or unsure whether they’d been assaulted to seek help.

“We see people of all different ages, races and walks of life,” Wolken said.

Blahnik said consensual sex already has a lot of shame, so many people just don’t want to talk about unconsensual sex. She said when survivors come forward, they’ll work with a team of Marshalltown Police investigators trained to support victims. Some immigrants may fear deportation if they report an assault, but the victim’s status doesn’t matter, Blahnik said.

“We really just want to help victims and put perpetrators behind bars,” Blahnik said.

Ultimately, Rockwell said the bottom line needs to be understood.

“It’s never OK for someone to force you to do something you don’t want to do,” Rockwell said.

The ACCESS 24-hour hotline can be reached at 1-800-203-3488. Assaults can be reported to police by stopping in, calling or texting 911 or reporting through DHS. Assaults can be reported at the emergency room. Rockwell, Erin Williams, Sarah Stone and Teresa Struchen are all sexual assault nurse examiners.

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