A sexual assault evidence collection kit and swab are shown at MaineGeneral Medical Center. Credit: Courtesy of MaineGeneral Medical Center

Before Sherri Thornton examines a patient who has been sexually assaulted, she spends at least 45 minutes listening as the patient describes what happened. It’s how the long-time nurse builds trust and gauges how to conduct the rest of the forensic exam, which sometimes can take up to 12 hours. Patients’ dispositions vary depending on their personal reactions to stress. Some are tearful. Others are angry, giddy or difficult — all normal. It’s also normal for a patient to have no physical injury despite experiencing immense trauma.

In the exam, Thornton lays a sheet on the floor, with another paper sheet on top to collect evidence such as clothing fibers or hairs. Depending on whether the patient has changed clothes since the assault, Thornton may collect and bag individual clothing items. She may take cervical, skin, mouth or anal swabs. She may scrape out material from under the patient’s fingernails, collect a DNA sample from the patient, document bruises and measure swelling of the neck if someone attempted to strangle the patient. She will stop at any point if the patient wants her to.

In addition to examining the patient’s entire body for injury, she may provide medications for sexually transmitted diseases or to prevent pregnancy.

Thornton, who is the coordinator for MaineGeneral Medical Center’s regional forensic examiner program in Kennebec and Somerset counties, stores all the samples and documentation in what’s known as a rape kit, which is then sealed and sent to police. If patients are open to a police investigation, the results of the sexual assault forensic exam — processed by the Maine State Police Crime Laboratory — could aid in the prosecution of an assailant, identify offenders across multiple cases or clear someone who was wrongly suspected.

Most hospitals in Maine have at least one sexual assault forensic examiner like Thornton, but currently five of the state’s 34 hospitals with emergency departments do not. Hospitals that don’t staff these positions risk harming the progress of a criminal investigation, and not providing optimum physical and mental health care, according to the U.S. Government Accountability Office, which has studied the issue. The collection of DNA evidence has been shown to increase the likelihood of prosecution.

Currently Calais Regional Hospital, Northern Light AR Gould Hospital in Presque Isle, Northern Light Blue Hill Hospital, Northern Light Maine Coast Hospital in Ellsworth and Penobscot Valley Hospital in Lincoln have no staff who have completed their sexual assault forensic examiner certification, according to the Maine Department of Health and Human Services and the University of New England, which work together to train providers, who are most often nurses. Penobscot Valley’s CEO said some staff intend to complete the required training in the spring.

Credit: Courtesy of MaineGeneral Medical Center

That means patients in some of Maine’s more rural places may have to travel far distances to seek care from staff trained in forensic medical examination. Delays can matter. Physical and biological evidence on someone’s body or clothes has traditionally been considered most viable within 72 hours of the assault — though it’s possible for useful evidence to be collected up to one week after an assault.

Or, patients might forgo the exam altogether or have someone who is not certified complete it.

Medical staff who have not been specially trained can perform the exams in Maine, but it’s not always ideal for patients, can be unfair to staff who aren’t comfortable with the process and could potentially hinder a criminal investigation, said several medical personnel across the state. Sometimes police “get kits that are a mess, because somebody didn’t have experience or didn’t have training,” said an anonymous member of law enforcement whose comments were included as part of a study produced in December 2018 for the Maine Coalition Against Sexual Assault.

“It’s important to be trained so that you as a provider are comfortable giving the best possible medical care to a patient population that is extremely vulnerable, and it’s best for the patient because, when you are specially trained, you know you are going to cover every possible resource and treatment that they might need,” Thornton said.

For instance, hospitals with certified personnel make it a policy to connect patients to an advocate at a local sexual assault support center who can help them throughout their hospital stay and afterward.

“These patients are trauma patients, and sexual assault is a huge public health problem,” said Polly Campbell, clinical director of the Advanced Nursing Education Sexual Assault Nurse Examiner Program at UNE’s School of Nursing and Population Health. “We know short-term and long-term outcomes for survivors are better if they have a forensic nurse.”

Still, she and others expressed concern that publicity about a lack of certified nurses would prompt those who have been sexually assaulted to not seek care.

“Any nurse can care for a sexual assault patient. I think it’s really important to underline that a sexual assault survivor should seek support if they choose,” said Danielle Coutu, assistant nurse manager of the emergency department at Northern Light Eastern Maine Medical Center in Bangor.

Though the number varies as medical staff leave or change positions, 29 Maine hospitals with emergency departments employ at least one sexual assault forensic examiner or have created agreements with other hospitals to share the specialized staff — as MaineGeneral Medical Center has done.

Its collaborative program requires its eight examiners to be on call 48 hours per month, in addition to their regular jobs, so they can travel to MaineGeneral Medical Center’s Augusta or Waterville locations, Redington Fairview General Hospital in Skowhegan, Northern Light Inland Hospital in Waterville, Northern Light Sebasticook Valley Hospital in Pittsfield or Togus VA Medical Center in Augusta, Thornton said. Examiners at those locations don’t just see patients who have experienced sexual assault but also domestic violence, child abuse, elder abuse and attempted strangulation.

Hospitals have always needed to have the proper staff, said Lisa Lambert, director of the emergency department at St. Joseph Hospital in Bangor, which employs five sexual assault forensic examiners. But it’s even more important today as more people come forward with reports of sexual assault.

The hospital is on track this year to exceed 160 forensic exams, quadruple the number it performed in 2016, Lambert said. Meanwhile, MaineGeneral’s regional program has seen a 40 percent increase in recent years, Thornton said.

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“People are more comfortable reporting it, and perhaps more people know it’s not OK, and it’s not their fault,” Lambert said.

Still, most assaults are not reported to the authorities. The U.S. Bureau of Justice Statistics estimates that 77 percent of rapes and sexual assaults went unreported in the United States in 2016.

St. Joseph Hospital sometimes sees sexual assault patients arrive by ambulance from another hospital where no one was certified to perform the exam, Lambert said. Police have also driven long distances to bring people directly to St. Joseph Hospital, knowing other facilities don’t have the certified personnel.

But even when a hospital employs examiners, it’s possible they won’t be available when a victim enters the emergency department. When nurse managers across Maine were asked why hospitals don’t have enough sexual assault forensic examiners, 86 percent said it was because of a lack of interest from staff, according to the 2018 study produced for the Maine Coalition Against Sexual Assault.

That lack of interest could stem from the difficult nature of the exams, the stress of frequently being on call, potentially having to testify in court, a lack of peer support within a hospital or a lack of leadership support, according to interviews with hospital staff and surveys. The positions are costly because they require one staff person, who would normally care for multiple patients, to attend to just one patient for long periods of time, sometimes preventing a hospital from filling its other beds, Lambert said.

Other states have documented extremely high rates of turnover for sexual assault forensic examiners. In Wisconsin, officials estimated that although 540 examiners were trained over a two-year period, only 42 — or, 8 percent — were still practicing in the state at the end of those two years, according to the Government Accountability Office.

“Retention can be a challenge. We are really fortunate that we have some passionate nurses who are dedicated to the care of the survivor,” said Coutu, who is also the coordinator of Northern Light Eastern Maine Medical Center’s sexual assault forensic examiner program. It has two certified sexual assault forensic examiners and seven in training.

The state Victims’ Compensation Program reimburses hospitals $750 for each sexual assault examination, which “doesn’t even begin to cover” the actual cost, Thornton said. Patients who have experienced domestic violence — with no sexual assault — pay for the exam on their own or through their insurance.

There’s also a cost associated with the time it takes to become certified as a sexual assault forensic examiner. Staff must complete a 40-hour course, complete a minimum of 10 supervised vaginal exams, observe two forensic medical exams and perform two supervised forensic medical exams. These exams are frequently done in a simulated setting with volunteers, Campbell, with UNE, said.

Staff at Calais Regional Hospital, which does not have sexual assault forensic examiners, would have to travel an hour one way to practice the required vaginal exams, given that the closest OB-GYN is in Machias, said DeeDee Travis, vice president of community relations at the hospital in Washington County.

“It is a little bit more difficult for those of us in rural areas,” Travis said. “We’d definitely be open if one of our clinicians, our nurses, were interested in going and getting that training, but it’s definitely a commitment, and it’s nothing we would require of anyone at this point.”

The hospital has considered sharing staff with other hospitals in the past. “We were never able to go further than discussions on it,” Travis said. “It’s an idea we’d be open to.”

Other rural hospitals have found ways to partner. Rumford Hospital and Bridgton Hospital, which are located more than an hour from each other, share the specialized staff, said Kate Carlisle, director of public relations and community affairs for their parent, Central Maine Healthcare. Rumford has one certified examiner, plus six in training, while Bridgton has one certified examiner, she said.

Meanwhile, St. Joseph Hospital has supplemented its funding for the positions with grants and local fundraising, said Mary Prybylo, CEO and president of St. Joseph Hospital, which is part of the Covenant Health network.

“They put me in awe,” Prybylo said of the hospital’s examiners. “Even as we might have financial difficulties, there’s never been a question about cutting the funding for that.”

It’s not a particular challenge to meet certification requirements, said Crystal Landry, CEO of Penobscot Valley Hospital in Lincoln, which currently has no sexual assault forensic examiners. She plans to change that this spring, when the next training will occur.

“I wouldn’t say we have any barriers to it currently. You just need to have a plan to complete that,” Landry said.

A spokeswoman for the Northern Light hospitals in Ellsworth and Blue Hill said they were “working toward” having certified nurses but did not answer questions about any anticipated timeline or how the hospitals currently handle patients who have been sexually assaulted. A spokeswoman for Northern Light AR Gould Hospital in Presque Isle did not respond to three requests for comment.

Would you like to share your experience with a sexual assault forensic exam? Write to erhoda@bangordailynews.com. Responses will not be published without permission.

Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to mainefocus@bangordailynews.com.

Erin Rhoda

Erin Rhoda

Erin Rhoda is editor of Maine Focus, a journalism and community engagement initiative by the Bangor Daily News.