[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


  EXAMINING THE AVAILABILITY OF SAFE KITS AT HOSPITALS IN THE UNITED 
                                 STATES

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           DECEMBER 12, 2018

                               __________

                           Serial No. 115-175
                           
                           
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                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas            ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee          GENE GREEN, Texas
STEVE SCALISE, Louisiana             DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio                MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington   JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
PETE OLSON, Texas                    JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia     JERRY McNERNEY, California
ADAM KINZINGER, Illinois             PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            PAUL TONKO, New York
BILL JOHNSON, Ohio                   YVETTE D. CLARKE, New York
BILLY LONG, Missouri                 DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana               KURT SCHRADER, Oregon
BILL FLORES, Texas                   JOSEPH P. KENNEDY, III, 
SUSAN W. BROOKS, Indiana             Massachusetts
MARKWAYNE MULLIN, Oklahoma           TONY CARDENAS, California
RICHARD HUDSON, North Carolina       RAUL RUIZ, California
KEVIN CRAMER, North Dakota           SCOTT H. PETERS, California
TIM WALBERG, Michigan                DEBBIE DINGELL, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina

                                 ______

              Subcommittee on Oversight and Investigations

                       GREGG HARPER, Mississippi
                                 Chairman
H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana             PAUL TONKO, New York
TIM WALBERG, Michigan                YVETTE D. CLARKE, New York
MIMI WALTERS, California             RAUL RUIZ, California
RYAN A. COSTELLO, Pennsylvania       SCOTT H. PETERS, California
EARL L. ``BUDDY'' CARTER, Georgia    FRANK PALLONE, Jr., New Jersey (ex 
GREG WALDEN, Oregon (ex officio)         officio)

                                  (ii)
                                  
                                  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Gregg Harper, a Representative in Congress from the State of 
  Mississippi, opening statement.................................     1
    Prepared statement...........................................     3
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     4
    Prepared statement...........................................     6
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     7
    Prepared statement...........................................     9
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................    10
    Prepared statement...........................................    11

                               Witnesses

A. Nicole Clowers, Managing Director, Healthcare, Government 
  Accountability Office..........................................    13
    Prepared statement...........................................    15
Sara Jennings, President-elect, International Association of 
  Forensic Nurses................................................    29
    Prepared statement...........................................    31
Lynn Frederick-Hawley, Executive Director, Sexual Assault and 
  Violence Intervention Program, Mount Sinai Hospital............    46
    Prepared statement...........................................    48
Kiersten Stewart, Director of Public Policy and Washington 
  Office, Futures Without Violence...............................    51
    Prepared statement...........................................    53

                           Submitted Material

Subcommittee memorandum..........................................    80
Responses from hospitals and associations to letter from 
  committee, submitted by Mr. Harper \1\
List of databases of SANE programs and SAFE-ready facilities, 
  committee staff document, December 12, 2018, submitted by Mr. 
  Harper.........................................................    84

                               ----------
\1\ The information has been retained in committee files and also 
  is available at https://docs.house.gov/Committee/Calendar/
  ByEvent.aspx?EventID=
  108782.

 
  EXAMINING THE AVAILABILITY OF SAFE KITS AT HOSPITALS IN THE UNITED 
                                 STATES

                              ----------                              


                      WEDNESDAY, DECEMBER 12, 2018

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:04 a.m., in 
room 2123, Rayburn House Office Building, Hon. Gregg Harper 
(chairman of the subcommittee) presiding.
    Members present: Representatives Harper, Griffith, Burgess, 
Brooks, Walberg, Costello, Carter, Walden (ex officio), 
DeGette, Castor, Clarke, Ruiz, Peters, and Pallone (ex 
officio).
    Staff present: Jennifer Barblan, Chief Counsel, Oversight 
and Investigations; Karen Christian, General Counsel; Ali 
Fulling, Legislative Clerk, Oversight and Investigations, 
Digital Commerce and Consumer Protection; Brighton Haslett, 
Counsel, Oversight and Investigations; Zach Hunter, 
Communications Director; Sarah Matthews, Press Secretary, 
Energy and Environment; Jeff Carroll, Minority Staff Director; 
Chris Knauer, Minority Oversight Staff Director; Jourdan Lewis, 
Minority Policy Analyst; Perry Lusk, Minority GAO Detailee; 
Andrew Souvall, Minority Director of Communications, Member 
Services, and Outreach; and C.J. Young, Minority Press 
Secretary.

  OPENING STATEMENT OF HON. GREGG HARPER, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF MISSISSIPPI

    Mr. Harper. The subcommittee will come to order.
    Today, the subcommittee on Oversight and Investigations is 
holding a hearing entitled ``Examining the Availability of SAFE 
Kits at Hospitals in the United States.''
    Sexual assault is a vicious and deeply traumatizing crime 
inflicted against hundreds of thousands of Americans each year. 
As policymakers, it is our responsibility to do everything we 
can to help those survivors and hold the perpetrators of those 
crimes accountable. To accomplish that, we must improve and 
expand access to critical forensic and healthcare services that 
survivors seek after an assault.
    In 2016, the Bureau of Justice Statistics reported that 
more than 323,450 people were the victims of sexual assault. 
However, the actual number of survivors may be much higher. 
According to the National Crime Victimization Survey, sexual 
assault is the most underreported crime in the country. In 
fact, aggregate data from the FBI and DOJ indicates that only 
23 percent of rapes were reported between 2012 and 2017.
    The first step towards prosecuting these vicious crimes is 
often the collection of a sexual assault forensic exam or 
commonly known as a rape kit. A rape kit can be performed by a 
specially trained sexual assault nurse examiner, a SANE, or by 
a nurse or medical professional that does not have SANE 
training. However, rape kits performed by trained SANEs, what 
we shall call SAFE kits, result in better outcomes for 
patients, including shortened exam time, better quality 
healthcare, higher quality forensic evidence collection, and 
certainly higher prosecution rates.
    These kits can be vital to securing a prosecution and 
conviction. But in many areas of the country, it can prove 
shockingly difficult for a survivor of sexual assault to obtain 
a SAFE kit. One of our witnesses today, the International 
Association of Forensic Nurses, estimates that only about 15 
percent of hospitals in the United States provide SAFE kits. We 
don't know what happens to many of the survivors that visit a 
hospital that does not have SANE nurses available.
    In 2016, the GAO published a report entitled Sexual 
Assault: Information on Training, Funding, and Availability of 
Forensic Examiners. The report examined the challenges that 
hospitals face in providing access to SANEs and SAFE kits, 
including limited availability of SANE training, weak 
stakeholder support for examiners, and low examiner retention 
rates. We need to explore each of these issues today.
    Over the course of our work, we sent letters to 15 
hospitals and 10 hospital associations across the country to 
assess what services those hospitals offer and what challenges 
they face in making those services available. Their responses 
were enlightening, and have not only helped the committee 
better understand the challenges to provide access to SANEs and 
SAFE kits, but also identifies some of the solutions.
    I want to thank all of those hospitals and groups for their 
assistance. And without objection, I ask unanimous consent to 
enter these 25 responses to the committee's letters into the 
record.
    Without objection, they are so entered.\1\
---------------------------------------------------------------------------
    \1\ The information has been retained in committee files and also 
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=108782.
---------------------------------------------------------------------------
    Finally, adding to the issue of lack of access is the fact 
that very little data is available about where survivors can 
find SAFE kits. The nationwide database compiled by the 
Forensic Nurses appears to be the best in the country, but it 
is not comprehensive. For example, the database lists only two 
locations in my home State of Mississippi, but my staff was 
able to locate at least 10 SANE programs online. That is not a 
criticism at all of the Forensic Nurses, but a call to action. 
And I hope that one result of today's hearing will be to 
motivate communities around the country to raise awareness of 
where SAFE kits can be found, and move towards making that 
information widely available.
    To that end, I'd also like to ask unanimous consent to 
enter into the record a statement--or a document that the 
committee created, which includes every list or database our 
staff could find for SANE programs and SAFE-ready facilitates 
across the country.
    Without objection, so entered.
    [The information appears at the conclusion of the hearing:]
    Mr. Harper. I would also like to submit into the record a 
letter from the Joyful Heart Foundation about SAFE kits, which 
we received actually this morning.
    Without objection, so entered.
    It is our hope that this can be a resource to survivors 
across the country and that we can lead the charge in educating 
the public about this important issue.
    I'd like to thank all of our witnesses for joining us in 
sharing your expertise and perspectives today. I know this is a 
very sensitive topic, but it's a very important one for our 
country, and we look forward to hearing your testimony shortly.
    Before I introduce the ranking member for her statement, I 
would like to take a moment of personal privilege. This will be 
my last hearing chairing this subcommittee before I begin my 
eagerly anticipated retirement in a few weeks, not from work, 
just from Congress. I would like to thank Chairman Walden for 
the opportunity to chair this subcommittee through so many 
important hearings, including this one. And I would also like 
to thank the ranking member and all of my colleagues on both 
sides of the aisle for their assistance on so many important 
matters that face this committee and our country.
    [The prepared statement of Mr. Harper follows:]

                Prepared statement of Hon. Gregg Harper

    The subcommittee will come to order. Today, the 
Subcommittee on Oversight and Investigations is holding a 
hearing entitled ``Examining the Availability of SAFE Kits at 
Hospitals in the United States.''
    Sexual assault is a vicious and deeply traumatizing crime 
inflicted against hundreds of thousands of Americans each year. 
As policymakers, it is our responsibility to do everything we 
can to help those survivors and hold the perpetrators of those 
crimes accountable. To accomplish that, we must improve and 
expand access to critical forensic and healthcare services that 
survivors seek after an assault.
    In 2016, the Bureau of Justice Statistics reported that 
more than 323,450 people were the victims of sexual assault. 
However, the actual number of survivors may be much higher. 
According to the National Crime Victimization Survey, sexual 
assault is the most underreported crime in the country. In 
fact, aggregate data from the FBI and DOJ indicates that only 
23 percent of rapes were reported between 2012 and 2017.
    The first step toward prosecuting these vicious crimes is 
often the collection of a sexual assault forensic exam, more 
commonly known as a rape kit. A rape kit can be performed by a 
specially trained Sexual Assault Nurse Examiner - a ``SANE''--
or by a nurse or medical professional that does not have SANE 
training. However, rape kits performed by trained SANEs - what 
we will call ``SAFE kits''--result in better outcomes for 
patients, including shortened exam time, better quality health 
care, higher quality forensic evidence collection, and higher 
prosecution rates.
    These kits can be vital to securing a prosecution and 
conviction, but in many areas of the country, it can prove 
shockingly difficult for a survivor of sexual assault to obtain 
a SAFE kit. One of our witnesses today, the International 
Association of Forensic Nurses (IAFN), estimates that only 
about 15 percent of hospitals in the United States provide SAFE 
kits. We don't know what happens to many of the survivors that 
visit a hospital that does not have SANE nurses available.
    In 2016, the GAO published a report entitled ``Sexual 
Assault: Information on Training, Funding, and the Availability 
of Forensic Examiners.'' The report examined the challenges 
that hospitals face in providing access to SANEs and SAFE kits, 
including limited availability of SANE training, weak 
stakeholder support for examiners, and low examiner retention 
rates. We intend to explore each of those issues today.
    Over the course of our work, we've sent letters to 15 
hospitals and 10 hospital associations across the country to 
assess what services those hospitals offer, and what challenges 
they face in making those services available. Their responses 
were enlightening, and have not only helped the committee 
better understand the challenges to providing access to SANEs 
and SAFE kits, but also identify some of the solutions. I want 
to thank all of those hospitals and groups for their 
cooperation and, without objection, I ask unanimous consent to 
enter their responses into the record.
    Finally, adding to the issue of lack of access is the fact 
that very little data is available about where survivors can 
find SAFE kits. The nationwide IAFN database appears to be the 
best in the country, but is not comprehensive. For example, the 
IAFN database lists only 2 locations in my home State of 
Mississippi, but my staff was able to locate at least 10 SANE 
programs online.
    That is not a criticism of IAFN, but a call to action: I 
hope that one result of today's hearing will be to motivate 
communities around the country to raise awareness of where SAFE 
kits can be found and move toward making that information 
widely available. To that end, I'd also like to ask unanimous 
consent to enter into the record a document the committee 
created which includes every list or database our staff could 
find for SANE programs and SAFE-ready facilities across the 
country. It is our hope that this can be a resource to 
survivors across the country, and that we can lead the charge 
in educating the public about this important issue.
    I'd like to thank all of our witnesses for joining us and 
sharing your expertise today. I know this is a sensitive topic, 
but it's a very important one. We look forward to hearing your 
testimony.
    Before I introduce the ranking member for her statement, I 
would like to take a moment of personal privilege. This will be 
my last hearing chairing this subcommittee before I begin my 
eagerly anticipated retirement in a few weeks. I would like to 
thank Chairman Walden for the opportunity to chair this 
subcommittee through so many important hearings, including this 
one. I would also like to thank the ranking member and all of 
my colleagues on both sides of the aisle for their assistance 
on so many important matters.

    Mr. Harper. With that, I will yield to recognize Ranking 
Member DeGette.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you, Mr. Chairman.
    And taking a moment of personal privilege myself, I will 
say that it's been a real privilege to work with you as the 
chairman. This is a venerable committee of Energy and Commerce. 
I think it's the best subcommittee in the House, and I'm really 
happy that you got the opportunity to chair it.
    We've had a number of really solid and important 
investigative hearings. I think it's really fitting and a 
reflection on you and your commitment to Americans that the 
last hearing that we're going to have is a hearing about 
keeping patients safe and getting the evidence we need.
    So please join me, colleagues, in thanking the chairman for 
his wonderful service.
    [Applause.]
    Mr. Harper. Thank you so much.
    Ms. DeGette. For a survivor of sexual assault, it's 
critical to protect people's health in the aftermath of an 
attack and to receive critical timely medical services that 
address the unique needs of each victim. Compassionate care and 
the diligent collection of evidence are essential for the 
victims' well-being and for the hopes for justice.
    The Department of Justice estimates that, nationwide, over 
160,000 people were raped or sexually assaulted in 2016, the 
last year for which we have data. Yet these crimes go woefully 
underprosecuted. According to the Rape, Abuse, and Incest 
National Network, only 230 out of 1,000 rapes are reported to 
the police. Forty-six out of 1,000 leads to an arrest. And only 
nine are ever referred to a prosecutor for trial.
    One important tool for successfully treating and 
prosecuting sexual assault is to have a trained sexual assault 
examiner collect a wide variety of forensic evidence from the 
victim, and, of course, that's what's called a sexual assault 
evidence collection kit. This kit include a victim's clothes, 
hair, blood, and saliva for DNA testing and analysis. DNA 
evidence significantly increases the likelihood of identifying 
a perpetrator, it increases the likelihood of holding the 
perpetrator accountable, and it can even prevent further 
assaults by identifying repeat offenders.
    And, shockingly, though, if a victim shows up to a hospital 
after an assault today, it's far from guaranteed that she would 
be able to get a sexual assault examination, even if she knows 
to ask for one. In 2016, the GAO conducted a study assessing 
the availability of sexual assault forensic examiners 
nationwide. As part of this study, GAO found that only one of 
the 23 sexual assault programs in Colorado is large enough to 
have examiners available 24 hours a day, 7 days a week.
    Furthermore, according to the GAO, officials in the six 
States they reviewed did not know exactly how many practicing 
examiners there were in their States. There was no national 
database of sexual assault examiners. And what databases did 
exist were often out of date and did not cover all of the 
settings where an exam might occur. This suggests to me that we 
must do more to get good data on our Nation's capacity for 
sexual assault examinations so we can then evaluate these 
programs and ensure they have the resources they need to serve 
victims.
    Keep in mind, these are the barriers that exist just for 
getting a kit done in the first place. While not the focus of 
this hearing, there's also a huge backlog of kits that were 
either never sent to a crime lab to be tested or were sent to a 
lab but were left to linger for a period of months or longer. 
This is, to say the least, disturbing.
    Today, I look forward to hearing from the witnesses about 
what we can do to train additional examiners to do this 
difficult but necessary work and also to retain the examiners 
that we do have. I also want to hear more about how successful 
sexual assault examination programs are built and what we can 
do to address the unique challenges inherent in providing these 
services in rural areas.
    I hope the committee can shed some light on these problems 
and find ways that will make it easier for any American to get 
a sexual assault kit from a trained examiner in a time that is 
admittedly a very emotionally stressful and difficult time for 
these victims.
    And, finally, Mr. Chairman, I have to note the importance 
of the Violence Against Women Act. This act supports a number 
of programs that address health issues associated with sexual 
assault, including three grant programs that can be used to 
fund or train sexual assault forensic examiners.
    Unfortunately, this law, which has enjoyed bipartisan 
support for over 20 years, is going to expire in a little over 
a week. We've got to act to reauthorize this law before the 
115th Congress ends so that the programs can continue the 
important work they're doing and to make sure the victims get 
the care they need.
    Thank you, and I yield back.
    [The prepared statement of Ms. DeGette follows:]

                Prepared statement of Hon. Diana DeGette

    Addressing the problem of rape and sexual assault is of 
critical importance. The Department of Justice estimates that 
nationwide, over 160,000 people were raped or sexually 
assaulted in 2016, the last year for which we have data.
    And yet these crimes go woefully under-prosecuted. 
According to the Rape, Abuse & Incest National Network, only 
230 out of 1,000 rapes are reported to the police, 46 out of 
1,000 leads to an arrest, and only 9 are referred to a 
prosecutor for trial.
    One important tool for successfully prosecuting sexual 
assault is to have a trained sexual assault examiner collect a 
wide variety of forensic evidence from the victim, through 
what's called a sexual assault evidence collection kit.
    This can include a victim's clothes, hair, blood and saliva 
for DNA analysis and testing. DNA evidence significantly 
increases the likelihood of identifying a perpetrator, 
increases the likelihood of holding a perpetrator accountable, 
and can even prevent future assaults by identifying repeat 
offenders.
    And yet today, if a victim shows up to a hospital after an 
assault, it is not at all guaranteed that she would be able to 
get a sexual assault examination if she asks for one.
    In 2016, GAO conducted a study assessing the availability 
of sexual assault forensic examiners nationwide. As part of 
this study, GAO found that there are only 23 programs with 
trained sexual assault examiners covering my entire home State 
of Colorado. Furthermore, GAO reported that only one of the 
sexual assault programs in Colorado is large enough to have 
examiners available 24 hours a day, 7 days a week. In certain 
places in western Colorado, victims may have to travel well 
over an hour to get to a facility that has an examiner on 
staff.
    Unfortunately, according to GAO, officials in the six 
States in their review did not know exactly how many practicing 
examiners there were in their States. There was no national 
database of sexual assault examiners, and what databases did 
exist were often out-of-date and did not cover all settings 
where an exam might occur. This suggests to me that there's 
more we need to do to get good data on our Nation's capacity 
for sexual assault examinations, so that we can evaluate these 
programs and ensure that they have the resources they need to 
serve victims.
    Keep in mind, these are the barriers that exist just for 
getting a kit done in the first place. While not the focus of 
this hearing, there is also an enormous backlog of kits that 
were either never sent to a crime lab to be tested, or that 
were sent to a lab but were left to linger untested for 
prolonged periods.
    This is all, to put it bluntly, disturbing. Today, I look 
forward to hearing from our witnesses about what we can do to 
train additional examiners to do this difficult but necessary 
work, and to retain those examiners that we do have. I also 
want to hear more about how successful sexual assault 
examination programs are built, and what we can do to address 
the unique challenges inherent in providing access to these 
services in rural areas.
    I hope this committee can shed some light on these problems 
and find ways to make it easier for all Americans to get a 
sexual assault kit from a trained examiner in the unfortunate 
event that they need one.
    Finally, Mr. Chairman, I must again note the importance of 
the Violence Against Women Act. The act supports a number of 
programs that address health issues associated with sexual 
assault, including three grant programs that can be used to 
fund or train sexual assault forensic examiners.
    Unfortunately, this law--which has enjoyed bipartisan 
support for over 20 years--is set to expire in a little over a 
week. We must act quickly to reauthorize this law so that these 
programs can continue the important work that they are doing, 
and to make sure that victims get the care they need.
    I yield back.

    Mr. Harper. The gentlewoman yields back.
    The Chair will now recognize the chairman of the full 
committee, Chairman Walden, for 5 minutes for the purpose of an 
opening statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Well, thank you very much, Mr. Chairman.
    And I too want to thank you for your great leadership and 
service, your civil demeanor, your intellectual curiosity on 
the issues that have come before the Oversight and 
Investigations Subcommittee, and the great way you've worked to 
get things done here. It really has made a difference for the 
country, and you've left the place far better than you found 
it. And so we thank you for your service and wish you Godspeed 
in doing your next bit of service with family and elsewhere. So 
thanks for all you've done, Gregg. You've done a great job. We 
really appreciate it.
    And I want to follow up on Ms. DeGette's comments as well, 
because in September, I wrote to the Speaker, along with 
others, saying we need to reauthorize VAWA. It's very, very 
important to do. I've supported it every time. It's essential. 
And I think on this SAFE kits issue that we're dealing with 
today, this will be a perfect priority going forward, it would 
have been if we were in the majority first thing up in the next 
year, and I think we should be able to find common ground on 
this matter as well. And I greatly appreciate the witnesses 
coming today.
    This is the last, I think, subcommittee hearing on 
Oversight, although in talking to some of my friends from the 
Senate, it appears they're going to come back the day after 
Christmas. So maybe we'll have time for another hearing, Mr. 
Harper, just before New Year's or something. I thought I'd 
throw that out.
    Over the past year, the committee has been investigating 
access to SANEs and SAFE kits at hospitals across the U.S., as 
you've heard. And throughout our investigation, we've spoken to 
more than 40 trauma Level I and II hospitals. Some of these 
hospitals have very robust SANE programs that are well-equipped 
to provide the best care to survivors of sexual assault, 
including one of our witnesses today, Mount Sinai Health 
Systems. So we appreciate what you're doing.
    Others, however, seemed ill-prepared to address the needs 
of sexual assault survivors. One hospital even asked a member 
of my staff, and I'm going to quote, ``what is a rape kit,'' 
close quote. There are currently no Federal requirements 
regarding SANEs in the healthcare facilities. As is made clear 
in the responses to the committee's letters, some States and 
hospital associations have made great strides, while others 
have not put the same emphasis on the problem.
    I'd like to commend hospitals in my home State of Oregon 
for being forthcoming and helpful in our push to expand access 
to services for survivors of sexual assault in communities 
urban and rural. Their partnership with the Oregon District 
Attorney Sexual Assault Task Force is an example of the work we 
hope to see spread across the Nation.
    As Chairman Harper mentioned, we don't know what happens to 
many of the survivors that visit a hospital and are unable to 
obtain a SAFE kit. Some survivors may be forced to travel 
several hours to the nearest SAFE-ready hospital to obtain a 
kit. Others may simply return home and choose never to report 
this horrific crime.
    There's currently no data or tracking of these trends at 
the Federal level; however, through the course of our 
investigation, we've spoken with several survivors who have 
faced just that situation. One survivor we spoke to, Leah 
Griffin, shared her experience of trying to get a SAFE kit in 
2014 after being drugged and raped. When she went to her local 
hospital, she was told, quote, ``we don't do rape kits here,'' 
close quote. The hospital told Leah that her options were to 
drive herself to another hospital or to pay out of pocket for 
an ambulatory transfer. Leah told us, and I quote, ``I was so 
shocked, I just went home.''
    Hours later, Leah drove to the other hospital to get a SAFE 
kit, where it was discovered that she had internal injuries. 
Ultimately, the prosecutors in Leah's case declined to bring 
charges because the delay in obtaining a rape kit meant the 
evidence in her case was weak. Leah asked herself, and again I 
quote, at her--by the way, she allowed us to share her name--
``how do we have a justice system that demands empirical 
evidence from survivors of sexual assault and then denies 
access to that evidence collection?''
    Leah's is not the only such story we've heard and read 
about; there's also Megan Rondini, Dinisha Ball, and 
unfortunately, many others. The day that an individual is 
sexually assaulted can be the worst day in her or his life. The 
thought of turning to a hospital after such a trauma and then 
being told, sorry, we can't help you, is unimaginable and, 
frankly, unacceptable.
    These stories are heartbreaking. And, unfortunately, due to 
the lack of data and tracking within hospitals, we cannot 
estimate how many sexual assault survivors face this very same 
experience when they attempt to report these crimes.
    I want to thank Leah and the other survivors we spoke to 
for sharing their experiences with us, I know that cannot have 
been easy, as well as those hospitals, hospital associations, 
and survivor advocacy groups that shared their expertise and 
experience with us over the course of this investigation. I 
hope that we can begin identifying some successful models that 
other hospital systems can apply to their own communities. And 
in particular, I hope the use of technology, such as online 
training programs and telehealth, can begin to solve the issues 
of access in our rural communities. Many health centers and 
hospitals in my district have a hard time recruiting healthcare 
professionals already, so expanding options for these 
communities is an extra challenge that we have to take on.
    And, finally, I want to thank Representative Poe, who is in 
the audience today, who has been a real leader on this, along 
with Mr. Griffith and others on the committee. But, Ted, we 
thank you for your leadership on this, and I know there's 
legislation that's being put together here that hopefully we 
can move before the end of the year, if we can get everybody on 
the same page.
    Again, Mr. Chairman, thanks for your wonderful leadership 
on this and so many other topics. And I yield back the balance 
of my time.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    Mr. Chairman, thank you for holding this important hearing 
today.
    Over the past year, the committee has been investigating 
access to SANEs and SAFE kits at hospitals across the United 
States. Throughout our investigation, we've spoken to more than 
40 Trauma Level I and II hospitals. Some of these hospitals 
have robust SANE programs that are well equipped to provide the 
best care to survivors of sexual assault--including one of our 
witnesses today, Mount Sinai Health System. Others seemed ill-
prepared to address the needs of sexual assault survivors. One 
hospital even asked a member of my staff, ``What is a rape 
kit?''
    There are currently no Federal requirements regarding SANEs 
in healthcare facilities. As is made clear in the responses to 
the committee's letters, some States and hospital associations 
have made great strides, while others have not put the same 
emphasis on the problem. I'd like to commend hospitals in my 
home State of Oregon for being forthcoming and helpful in our 
push to expand access to services for survivors of sexual 
assault, in communities urban and rural. Their partnership with 
the Oregon District Attorney's Sexual Assault Task Force is an 
example of the work we hope to see more of across the country.
    As Chairman Harper mentioned, we don't know what happens to 
many of the survivors that visit a hospital and are unable to 
obtain a SAFE kit. Some survivors may be forced to travel 
several hours to the nearest SAFE-ready facility to obtain a 
kit. Others may simply return home and choose not to report the 
crime. There is currently no data or tracking of these trends 
at the Federal level. However, through the course of our 
investigation we've spoken with several survivors who have 
faced just that situation.
    One survivor we spoke to, Leah Griffin, shared her 
experience of trying to get a SAFE kit in 2014 after being 
drugged and raped. When she went to her local hospital, she was 
told, ``We don't do rape kits here.'' The hospital told Leah 
that her options were to drive herself to another hospital or 
to pay out of pocket for an ambulatory transfer. Leah told us, 
``I was so shocked, I just went home.'' Hours later, Leah drove 
to the other hospital to get a SAFE kit, where it was 
discovered that she had internal injuries. Ultimately, the 
prosecutors in Leah's case declined to bring charges because 
the delay in obtaining a rape kit meant the evidence in her 
case was weak. Leah asked herself, ``How do we have a justice 
system that demands empirical evidence from survivors of sexual 
assault and then denies access to that evidence collection?''
    Leah's is not the only such story we have heard or read 
about. There is also Megan Rondini, Dinisha Ball, and, 
unfortunately, many others.
    The day that an individual is sexually assaulted can be the 
worse day in her or his life. The thought of turning to a 
hospital after such a trauma and being told ``We can't help 
you'' is unimaginable and, frankly, unacceptable.
    These stories are heartbreaking. Unfortunately, due to the 
lack of data and tracking within hospitals, we cannot estimate 
how many sexual assault survivors face this very same 
experience when they attempt to report these crimes.
    I want to thank Leah and the other survivors we spoke to 
for sharing their stories with us, as well as those hospitals, 
hospital associations, and survivor advocacy groups that shared 
their expertise and experience with us over the course of this 
investigation. I hope that we can begin identifying some 
successful models that other hospital systems can apply to 
their own communities. In particular, I hope the use of 
technology, such as online training programs and telehealth, 
can begin to solve the issue of access in rural communities. 
Many health centers and hospitals in my rural district have a 
hard time recruiting healthcare professionals already, so 
expanding options for these communities is an extra challenge 
that we must take on.
    I want to thank our witnesses for being here with us today. 
We look forward to hearing your testimony. I yield back.

    Mr. Harper. The gentleman yields back.
    The Chair will now recognize the ranking member of the full 
committee, Mr. Pallone, for 5 minutes for the purposes of an 
opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman.
    Sexual assault is a horrific crime, and we must continue to 
work to end the cycle of violence. Sexual assault forensic 
examiners, otherwise known as SAFEs, play an important role in 
helping those who are victims of these crimes. SAFEs provide 
care to victims of sexual assault, and with the use of a 
forensic exam kit, can collect a wide variety of DNA evidence 
that can be used to prosecute an offender.
    Thanks to the Violence Against Women Act, States must 
provide sexual assault kits free of charge to anyone who needs 
it. The law also authorizes three Department of Justice grant 
programs that fund and train sexual assault forensic examiners.
    Despite the strides we've made in the last 20 years, it can 
still be quite difficult for a victim to find a trained 
examiner when they need one. For example, according to media 
reports, only one hospital here in the DC area has a program 
with sexual assault nurse examiners on staff. Unfortunately, 
the problem is occurring nationwide. For example, according to 
a 2016 report from the GAO, officials in the six States they 
studied said there were not enough examiners in their States to 
meet the demand for exams, particularly in rural areas.
    In some States, entire counties do not have any SAFE 
programs available. In some cases, victims must travel over an 
hour to a facility with a trained examiner. In that time, a 
victim must avoid bathing, showering, using the restroom, or 
changing clothes, or else risk damaging the evidence before it 
can be collected. And this is unacceptable, and we must find 
ways to make these services more widely available.
    The GAO report also found that there was no national 
database that captures the number of examiners, where they are, 
and what their capabilities are. The only data available is 
limited in scope and collected on a voluntary basis. And this 
means that victims do not have to update information and cannot 
easily identify all healthcare settings where sexual assault 
forensic exams might be conducted. This kind of information 
should be easily accessible to victims in their most vulnerable 
moments,
    Moreover, even when a facility provides these kits and 
related SAFE services, States and hospitals have struggled to 
retain enough examiners. State officials reported to GAO that 
they face challenges such as limited availability of classroom 
and clinical training, weak support for programs from 
stakeholders, and the emotional and physical demands on 
examiners. And taken together, these findings demonstrate the 
challenges we still face in ensuring that all victims of sexual 
assault can get access to a forensic exam kit and services 
provided by a trained examiner, should they request it.
    This is not to say there are no success stories. Clearly, 
there are many hospitals and other facilities that provide 
sexual assault kits and SAFE services for those who need it, 
and we should learn from those cases and determine what we can 
replicate on a broader scale.
    So I look forward to hearing from each of our witnesses 
here today about what we can do to get our arms around this 
problem and what we can do to expand and retain our workforce 
of trained sexual assault forensic examiners.
    And, finally, I just would like to reiterate the importance 
of the Violence Against Women Act. This act is a critical part 
of the Federal Government's response to sexual assault and it 
funds many of the programs we'll be talking about today, but 
the law is set to expire in just over a week. We must ensure 
this act is reauthorized so that these critical programs 
continue to receive funding and victims can receive the care 
and services they need.
    So I want to thank our panelists for sharing their 
expertise on this important issue as we move forward.
    I yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Thank you, Mr. Chairman. Sexual assault is a horrific 
crime, and we must continue to work to end the cycle of 
violence.
    Sexual Assault Forensic Examiners, otherwise known as 
SAFEs, play an important role in helping those who are victims 
of these crimes. SAFEs provide care to victims of sexual 
assault, and--with the use of a forensic exam kit--can collect 
a wide variety of DNA evidence that can be used to prosecute an 
offender.
    Thanks to the Violence Against Women Act states must 
provide sexual assault kits free of charge to anyone who needs 
it. The law also authorizes three Department of Justice grant 
programs that fund and train sexual assault forensic examiners.
    Despite the strides we have made in the last 20 years, it 
can still be quite difficult for a victim to find a trained 
examiner when they need one. For example, according to media 
reports, only one hospital here in the DC area has a program 
with sexual assault nurse examiners on staff.
    Unfortunately, his problem is occurring nationwide. For 
example, according to a 2016 report from the Government 
Accountability Office (GAO), officials in the six States they 
studied said there were not enough examiners in their States to 
meet the demand for exams, particularly in rural areas. In some 
States, entire counties did not have any SAFE programs 
available.
    In some cases, victims must travel over an hour to a 
facility with a trained examiner. In that time, a victim must 
avoid bathing, showering, using the restroom, or changing 
clothes, or else risk damaging the evidence before it can be 
collected. This is unacceptable, and we must find ways to make 
these services more widely available.
    The GAO report also found that there was no national 
database that captures the number of examiners, where they are, 
and what their capabilities are. The only data available is 
limited in scope and collected on a voluntary basis.
    This means that victims do not have up-to-date information 
and cannot easily identify all healthcare settings where sexual 
assault forensic exams might be conducted. This kind of 
information should be easily accessible to victims in their 
most vulnerable moments.
    Moreover, even when a facility provides these kits and 
related SAFE services, States and hospitals have struggled to 
retain enough examiners. State officials reported to GAO that 
they face challenges such as limited availability of classroom 
and clinical training, weak support for programs from 
stakeholders, and the emotional and physical demands on 
examiners.
    Taken together, these findings demonstrate the challenges 
we still face in ensuring that all victims of sexual assault 
can get access to a forensic exam kit and services provided by 
a trained examiner, should they request it.
    That is not to say that there are no success stories. 
Clearly, there are many hospitals and other facilities that 
provide sexual assault kits and SAFE services for those who 
need it. We should learn from those cases and determine what we 
can replicate on a broader scale.
    I look forward to hearing from each of our witnesses here 
today about what we can do to get our arms around this problem, 
and what we can do to expand and retain our workforce of 
trained sexual assault forensic examiners.
    Finally, I would like to reiterate the importance of the 
Violence Against Women Act. This act is a critical part of the 
Federal Government's response to sexual assault. It funds many 
of the programs we will be talking about today but the law is 
set to expire in just over a week. We must ensure this act is 
reauthorized so that these critical programs continue to 
receive funding, and victims can receive the care and services 
they need.
    I thank our panelists for sharing their expertise on this 
important issue.
    Thank you, I yield back.

    Mr. Harper. The gentleman yields back.
    I ask unanimous consent that the Members' written opening 
statements be made part of the record. Without objection, will 
be entered into the record.
    Additionally, we welcome non-Energy and Commerce Committee 
members who are with us today. Pursuant to House rules, Members 
not on the committee are able to attend our hearings but not 
ask questions, and we've already recognized Representative Ted 
Poe from Texas, who is the only other Member that I see, and 
that's just the way it is.
    I would now like to introduce our witnesses for today's 
hearing. Today, we have Ms. Nicole Clowers, managing director 
of healthcare at the GAO. Next is Ms. Sara Jennings, president-
elect of the International Association of Forensic Nurses. Then 
we have Ms. Lynn Frederick-Hawley, executive director of the 
SAVI Program at Mount Sinai Hospital. And, finally, Ms. 
Kiersten Stewart, director of Public Policy and the Washington 
Office of Futures Without Violence.
    As you are aware, the committee is holding an investigative 
hearing, and when doing so, has had the practice of taking 
testimony under oath. Do any of you have any objection to 
testifying under oath?
    All witnesses have indicated no.
    The Chair then advises you that under the rules of the 
House and the rules of the committee, you are entitled to be 
accompanied by counsel. Do any of you desire to be accompanied 
by counsel during your testimony today?
    All of the witnesses have indicated no.
    In that case, if you would, please rise and raise your 
right hand and I will swear you in.
    Do you swear that the testimony you are about to give is 
the truth, the whole truth, and nothing but the truth?
    All the witnesses have anticipated--have answered and 
responded in the affirmative.
    You're now under oath and subject to the penalties set 
forth in Title 18, Section 1001 of the United States Code. You 
may now give a 5-minute summary of your written statement, and 
I will now first call on Nicole Clowers, managing director of 
healthcare for the U.S. Government Accountability Office.
    You are recognized for 5 minutes, Ms. Clowers.

STATEMENTS OF A. NICOLE CLOWERS, MANAGING DIRECTOR, HEALTHCARE, 
   GOVERNMENT ACCOUNTABILITY OFFICE; SARA JENNINGS,PRESIDENT-
   ELECT, INTERNATIONAL ASSOCIATION OF FORENSIC NURSES; LYNN 
   FREDERICK-HAWLEY, EXECUTIVE DIRECTOR, SEXUAL ASSAULT AND 
   VIOLENCE INTERVENTION PROGRAM, MOUNT SINAI HOSPITAL; AND 
  KIERSTEN STEWART, DIRECTOR OF PUBLIC POLICY AND WASHINGTON 
                OFFICE, FUTURES WITHOUT VIOLENCE

                 STATEMENT OF A. NICOLE CLOWERS

    Ms. Clowers. Thank you.
    Chairman Harper, Ranking Member DeGette, and members of the 
subcommittee, thank you for having me here today to discuss our 
2016 report on the availability of sexual assault forensic 
examiners.
    Studies have documented the benefits of using trained 
examiners in the cases of sexual assault. As the chairman 
noted, these benefits include shorter exam times, more 
comprehensive medical care, better health outcomes for the 
victims, better collection and documentation of the evidence, 
and higher prosecution rates. However, concerns have been 
raised about the availability of examiners to meet the need for 
exams.
    To help inform today's discussion, I will summarize key 
findings from our 2016 report, which include what is known 
about the availability of sexual assault forensic examiners 
nationwide, as well as in selected States, as of 2016, and the 
challenges selected States face to maintaining a supply of 
sexual assault examiners.
    With respect to the availability of examiners, we found 
that only limited nationwide data exist on the availability of 
sexual assault examiners; that is, both the number of 
practicing examiners and the number of healthcare facilities 
that have examiner programs. While some national estimates are 
available, they are not comprehensive, as they only capture 
examiners with select certifications or program information 
that is voluntarily reported.
    We also found limited information at the State level. While 
officials from all six States that we contacted were able to 
provide information on the number of examiner programs located 
within their States, only three could provide estimates of the 
number of practicing examiners. And the State data available at 
the time of our audit were likely incomplete, as only one of 
the six States had a system in place to formally track the 
number and location of examiners.
    Despite these data limitations, officials in all six States 
told us that the number of examiners available in their State 
did not meet the need for exams, especially in rural areas. For 
example, officials in Wisconsin explained that nearly half of 
all the counties in the State do not have any examiner programs 
available. As a result, officials said victims may need to 
travel long distances to be examined by a trained examiner. The 
challenge of long travel distances can be further complicated 
for rural residents due to weather-related travel restrictions 
during certain times of the year.
    Finally, we found that there are multiple challenges to 
maintaining the supply of examiners, including, one, the 
limited availability of training, which includes limited 
classroom, clinical, and continuing education training 
opportunities; two, low retention rates of examiners due to the 
emotional and physical demands of the job, coupled with low 
pay; and, three, weak stakeholder support for examiners, such 
as hospitals being reluctant to cover the cost of training or 
paying for examiners to be on call.
    Officials told us about a number of strategies they have 
used to help address these challenges, such as web-based 
training and mentoring programs. For example, officials in 
Colorado told us that an examiner program coordinator in an 
urban hospital provides volunteer, on-call technical assistance 
and clinical guidance to the examiners in rural parts of the 
State where those resources are not otherwise available.
    Chairman Harper, Ranking Member DeGette, and members of the 
subcommittee, this completes my prepared statement. I would be 
pleased to respond to any questions at the appropriate time. 
Thank you.
    [The prepared statement of Ms. Clowers follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Harper. Thank you so much for your testimony.
    The Chair will now recognize Sara Jennings, RN--and I'm 
partial to RNs since I'm married to one--who is the president-
elect of the International Association of Forensic Nurses.
    You are hereby recognized for 5 minutes for testimony.

                   STATEMENT OF SARA JENNINGS

    Ms. Jennings. Thank you.
    Chairman Harper, Ranking Member DeGette, and members of the 
subcommittee, thank you for the opportunity to testify today. 
On behalf of the 4,300 forensic nurses who make up the 
membership of the International Association of Forensic Nurses, 
I am pleased to be here this morning in relation to the 
availability of SAFE kits at hospitals in the United States, 
and to discuss issues impacting patients' access to essential 
services following an assault. This is an important topic, and 
the IFN appreciates the active role of the committee to address 
it.
    My name is Sara Jennings, and I'm a forensic nurse since 
2006, and I'm the president-elect for the IFN. First, let me 
tell you a bit about forensic nursing. A forensic nurse is a 
registered nurse or advanced practice nurse who's received 
specialized education and training. Forensic nurses provide 
specialized care for patients who are experiencing acute or 
long-term health consequences associated with victimization or 
violence and/or have unmet evidentiary needs relative to having 
been victimized or accused of victimization. In addition, 
forensic nurses provide consultation and testimony for civil 
and criminal proceedings relative to nursing practice, care 
given, and opinions rendered regarding findings.
    Since forensic nursing is a recognized nursing specialty of 
the American Association of Nurses, a person must first become 
a registered nurse before becoming a forensic nurse. Forensic 
nurses work in a variety of fields, including sexual assault, 
domestic or intimate partner violence, child abuse and 
negligent, elder maltreatment, human trafficking, death 
investigations, corrections, and in the aftermath of mass 
disasters. In the United States, forensic nurses most 
frequently work in hospitals, community anti-violence programs, 
coroners, or medical examiners' offices, corrections 
institutions, and psychiatric hospitals.
    Sexual assault nurse examiners, or SANEs, are registered 
nurses who have completed specialized education and clinical 
preparation in the medical forensic care of the patient who has 
experienced sexual assault or abuse. To become a SANE you must 
first be a registered nurse with 2 years or more of experience 
in areas of practice, such as emergency department nursing. The 
same training should meet the IFN SANE educational guidelines 
and will consist of both classroom and clinical components.
    The Bureau of Justice Statistics within the Department of 
Justice reports in its National Crime Victimization Survey for 
2016 that there were 298,410 rapes or sexual assaults in the 
United States. There were also 1,068,120 incidents of domestic 
violence.
    In March of 2016, the General Accountability Office issued 
a report investigating the availability of trained examiners on 
a national level. The report identified major flaws and 
survivor access to sexual assault examination services. 
Specifically, the report showed a disturbing lack, and in some 
cases a complete absence, of information and data on the number 
of sexual assault examiners in most States.
    The IFN is pleased that Congress is increasingly aware of 
the problem and the need to ensure appropriate access to 
necessary services and supplies. Several bills have been 
introduced to try to address this problem. The IFN is 
supportive of the Survivors' Access to Supportive Care, or 
SASCA, and also encourages efforts to improve the Violence 
Against Women Act. IFN strongly supports the SASCA, which was 
introduced in the Senate by Senator Patty Murray and Senator 
Lisa Murkowski.
    IFN believes this bill would expand access to qualified 
examiner services and help strengthen national standards of 
care for survivors of sexual assault. SASCA would also provide 
guidance and support to States and to hospitals providing 
sexual assault examination services and treatment to survivors.
    IFN also strongly supports the swift reauthorization of the 
Violence Against Women Act; however, IFN does believe that 
there are several key improvements that must be made to this 
law, including establishing a standardized national sexual 
assault evidence collection kit, requiring health insurance to 
be the primary payer, and establishing evidence-based, trauma-
informed national medical forensic exam protocols for intimate 
partner violence. It is imperative for the long-term health and 
recovery of these patients that a standardized approach be 
developed and a plan for effective implementation.
    Thank you for this opportunity to testify today, and I'm 
available at the appropriate time for questions.
    [The prepared statement of Ms. Jennings follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Harper. Thank you for your testimony.
    The Chair will now recognize Lynn M. Frederick-Hawley--
that's Hawley, I'm sorry, my apologies.
    Ms. Frederick-Hawley. No problem.
    Mr. Harper [continuing]. Executive director at SAVI Program 
at Mount Sinai Hospital.
    And you're now recognized for 5 minutes.

               STATEMENT OF LYNN FREDERICK-HAWLEY

    Ms. Frederick-Hawley. Thank you.
    Good morning. Chairman Harper, Ranking Member DeGette, and 
members of the committee, thank you for the opportunity to 
testify before you today. I would also like to acknowledge 
Representative Tonko and Representative Clarke from New York.
    My name is Lynn Frederick-Hawley. I am the executive 
director of the Sexual Assault and Violence Intervention 
Program of the Mount Sinai Hospital, otherwise known as SAVI. 
Makes it easier for you to say it. Founded in 1852, the Mount 
Sinai Hospital is one of the Nation's largest and most 
respected hospitals, acclaimed internationally for excellence 
in clinical care. Ranked among the top hospitals nationwide, we 
serve one of the most diverse populations in the world as well.
    It has been a priority at the Mount Sinai Hospital for 
decades to maintain a comprehensive program to address the 
needs of sexual assault survivors. Our goal is to provide the 
highest quality medical care and compassionate client-centered 
services to address both the patient's physical and 
psychological trauma. We believe it's critical to validate, 
heal, and empower survivors and their supporters to lead safe, 
healthy lives through advocacy, free and confidential therapy 
and counseling, and education.
    The Mount Sinai Hospital is one of the few institutions 
with a dedicated program exclusively focused on providing 
outreach, comprehensive training, emergency department 
advocacy, and counseling services to address the needs of past 
and present victims of sexual assault and intimate partner 
violence. SAVI was founded in 1984, and we have grown 
exponentially in the past 34 years to meet the evolving needs 
of survivors and our communities, including creating our sexual 
assault forensic examiner program.
    I should emphasize that this evolution has been made 
possible by the support of Mount Sinai leadership, the 
availability of funding for this kind of programming, and the 
backing of the communities we serve. We work very intensively 
with our community. Our sexual assault forensic examiner 
program has been designated a center of excellence since 2006 
by the New York State Department of Health.
    In addition to the SAFE program, we maintain over 150 
highly trained volunteer advocates who are certified and go on 
call 24/7 to respond to all instances of sexual assault in our 
hospitals. The advocates, together with the trained SAFE 
clinician, work seamlessly to provide comprehensive services to 
the sexual assault survivors seeking care at the Mount Sinai 
Hospital. SAVI therapists are then available to support the 
survivor beyond the immediate crisis services received in the 
emergency department.
    Specifically, the Mount Sinai Hospital and its affiliate 
medical school, the Icahn School of Medicine at Mount Sinai, 
employ 24 medical professionals who have decided to take the 
additional steps to become a SAFE examiner with the SAVI 
program. Currently that includes 10 nurses, 7 physicians 
assistants, and 7 physicians, including residents. All are 
employed by the Mount Sinai Hospital in other capacities, they 
are then screened by SAVI for this particular role, have 
completed extensive additional 40-hour training to qualify as a 
SAFE, and then they complete a preceptorship with our program 
specifically. Many of the SAFE-trained staff work in the 
emergency department, and they are able to provide services to 
a patient if the on-call SAFE clinician, for whatever reason, 
is unexpectedly unavailable.
    I would like to take you through the protocol quickly for 
treating survivors of sexual violence in our program. As an 
initial matter, we have a strong protocol in place for 
clinicians and staff to identify potential survivors of sexual 
assault and respond sensitively. Once a patient discloses 
sexual assault, they are triaged to a private, safe equipped 
room. Both the on-call SAFE and the SAVI advocate are contacted 
to come to our hospital to provide care and treatment to the 
patient.
    The advocate is a certified volunteer who provides 
counseling, support, information, referral, advocacy, safety 
planning to the survivor and any family member or supportive 
person who is there. The advocate remains with the survivor 
throughout their stay in the hospital. The SAFE conducts the 
medical and evidence collection exam consistent with the 
patient's consent and their wishes.
    Specific medical protocols and regimens are followed in the 
event the survivor is a candidate for a variety of prophylaxis 
treatment. The patient receives detailed discharge instructions 
and treatment counseling options, including followup for any 
medical care or continued prescriptions they need.
    SAVI follows up with every patient after they have spent 
time in the emergency department. We also work closely with the 
NYPD and with our security department in the event that the 
survivor hasn't yet let the kit go over to the police 
department.
    In order to provide this multilayered response, many 
resources must be invested. This is not care that survivors 
should be expected to underwrite. None of SAVI services, 
including our SAFE program, generate income. So it's the vision 
of an institution like Mount Sinai that sees the overarching 
benefit and necessity of providing the care to survivors and 
provides the context in which it can happen, as well as the 
availability/accessibility of funding from our city, State, 
Federal, and community partners that makes this even possible.
    On that note, 36 seconds over, I'll be quiet, and I'm happy 
to answer any questions as we go forward.
    [The prepared statement of Ms. Frederick-Hawley follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Harper. The chair wants to thank Ms. Frederick-Hawley, 
the executive director of the SAVI program at Mount Sinai 
Hospital, for your testimony.
    And the chair now recognizes Kiersten Stewart, who's the 
director of public policy and the Washington office for Futures 
Without Violence.

                 STATEMENT OF KIERSTEN STEWART

    Ms. Stewart. Thank you, Mr. Chairman, thank you, Ranking 
Member DeGette, and thank you members of the committee for your 
leadership in paying attention to this issue. I would also like 
to call out Congresswoman Clarke and Congresswoman Castor, who, 
along with Mrs. Walters and Mr. Costello, recently introduced 
the Violence Against Women Health Act, which will also make 
progress on this goal.
    For those of you who do not know FUTURES, we are a national 
nonprofit organization that works to end violence against women 
and children here in the U.S. and around the world. We also 
house the National Health Resource Center on violence against 
women. Less well known is that our work actually began--we 
began as an organization about 35 years ago simply with a chair 
in an emergency room at San Francisco General Hospital, trying 
to provide whatever help we could to every woman who came in a 
victim of violence. I'm proud to say we've progressed since 
then, but the mission remains the same.
    Some things to understand. Please know that sexual assault 
is painfully common and a crime largely committed against young 
people. More than 80 percent of rapes are committed against 
those under the age of 25, and about half of those are 
committed against those under the age of 18, children. While 
young girls and women are those most likely to be victims of 
rape and sexual assault, men and boys are also victims, as are 
individuals who do not always fit our traditional norms of male 
and female.
    American Indian and Alaska Native women, people who live in 
rural areas, as well as individuals with disabilities, also 
experience higher rates of sexual violence. As we analyze who 
has access to forensic exams, as well as all healing services 
for sexual violence, it is important to keep in mind the needs 
of all victims.
    The consequences of sexual violence are often severe and 
often long lasting. While different people respond differently 
to sexual violence, sexual violence often leaves a deeply 
painful mark that some never fully heal from. New economic 
estimates also create a staggering picture of the cost 
associated with rape. Using 2014 dollars, the estimated 
lifetime cost of rape at a population level is nearly $3.1 
trillion. This is based on the fact that 25 million Americans 
have been raped.
    The Government, our tax dollars, pay an estimated $1 
trillion, or about a third of that lifetime economic burden. 
These numbers do not capture the personal pain of rape and 
sexual assault on individuals or their families, but they do 
create a call for action.
    Forensic examines, as you've heard, help improve 
prosecution of sexual assault, but training is essential. I 
will not duplicate the testimony you've heard from others, but 
we can't just view training as a one-off act. It needs to be 
integrated into broader hospital quality improvement measures, 
attention needs to be paid to the vicarious trauma often 
experienced by the nurse examiners, and training needs to 
engage the entire health entity, from intake to billing to risk 
management to the front line medical personnel. We also 
strongly recommend models that are patient-centered and trauma-
informed.
    We also believe we need to expand training for healthcare 
providers beyond the forensic exam. Most victims still never 
make it to the emergency room. Providers need to be trained. 
Mental health providers, adolescent health, and OB/GYNs, as 
well as campus health centers, need training to understand and 
address the impacts of sexual abuse and trauma.
    As you've already heard, sexual violence is also an often 
unrecognized element of abusive relationships. In fact, maybe 
as much as half of sexual assaults are actually perpetrated by 
partners. So that's about 22 million women who've experienced 
sexual violence by an intimate partner, nearly 3 million a 
year.
    Importantly, we have evidence-based clinical interventions 
that improve the health outcomes and can reduce the violence. 
So we also need to be putting resources into those.
    Specifically, what can we ask you to do in the next year? 
One, increase funding. The Health Resources and Services 
Administration has an advanced nursing education SANE program 
out of the Bureau of Healthcare Workforce. There was $8 million 
that recently went out. That is an important first step, but we 
need to do more.
    Provide dedicated funding to project catalysts out of the 
Office of Women's Health at HRSA. Pass legislation like the 
Megan Rondini Act that would increase requirements on hospitals 
to provide all survivors access to a SANE or information on how 
to get a rape kit if it is not at their hospital. As you've 
heard, though, we can't do the requirements if we don't have 
the workforce. We need to do both.
    Pass the Violence Against Women Act, as we've heard by many 
of you, but include this new and improved health. As the GAO 
report pointed out, there is a VAWA health program, it has no 
dedicated funding, so we would ask for your help in supporting, 
creating a designated funding line.
    We also have the Family Violence Prevention and Services 
Act that is also up for reauthorization. This is out of the 
Department of Health and Human Services, and so that is also 
awaiting reauthorization similar to VAWA.
    And the final thing I would ask. As you heard me say, 
Native American and Alaska--Alaska Native victims experience 
violence at the highest rates. So we would ask included in VAWA 
the protections for Native women who are victims of sexual 
assault and child abuse.
    Thank you.
    [The prepared statement of Ms. Stewart follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Harper. I want to thank each of you for your testimony. 
We look forward to asking you questions. I think this is such 
an important hearing, and we appreciate your attendance today. 
This is very helpful to us. We know we have some challenges, 
but this is not really a bipartisan topic; it's really a 
nonpartisan topic. This is something that has to be done to 
make sure that we improve greatly on what we're doing right 
now. So thank you.
    This is now the opportunity for the Members to have the 
chance to ask each of you questions. I'll begin by recognizing 
myself for 5 minutes for questions at this time.
    You know, I certainly think that it's important that 
everyone understand why access to SANEs and SAFE kits is so 
important. According to the GAO report, when a survivor of 
sexual assault receives a sexual assault forensic exam, that 
exam can be done by a SANE that has specialized training in how 
to collect those kits or by a nurse or medical professional 
that does not have that training. But GAO, I believe, correctly 
noted that exams performed by SANEs have several advantages, 
including higher quality healthcare, and from a prosecution 
standpoint, a much higher quality evidence collection.
    So, Ms. Jennings, I'd like to start with you, if I may. 
Explain to us briefly, what does SANE training entail and does 
that vary State by State?
    Ms. Jennings. Sure. Thank you for the question. Our SANE 
training is two parts. So there is the adult component and then 
the pediatric component. The adult component consists of a 40-
hour training, the didactic, so your actual classroom training. 
The pediatric is another 40-hour training in the classroom 
setting. And then there's a combined training of both adult and 
pediatrics, which is a 64-hour class that you can also take.
    There are many options for both in-live classroom settings 
and there's also an option with IFN to attend an online 
training, which is very accessible to anyone in any setting. 
Once you complete the classroom setting, there is a clinical 
component, and that's where we see the biggest struggle to 
actually find sites to do the clinical training. We have a 
really good access to the classroom component, but we have a 
very hard time finding sites for the clinical component.
    Mr. Harper. You raised an interesting point because you 
have a separate training for pediatric.
    Ms. Jennings. Yes.
    Mr. Harper. But you may only have one staffer that's 
trained that may be there available on-call or at that time. Do 
you recommend that someone complete both components in the 
shorter combined class?
    Ms. Jennings. In rural areas where there is smaller patient 
populations that they may not see large numbers of pediatric 
patients, that would probably be the best route to go so that 
you have both the adult and the pediatric component. Pediatric 
patients, from a forensic perspective and sexual assault 
perspective, are very different than adult patients. So it does 
take a bit more time to be very familiar and very competent 
with the pediatric patient population.
    Mr. Harper. Are you able to tell us generally the cost for 
this training or certification?
    Ms. Jennings. Sure. So if you take the training through the 
IFN, it's roughly $500, based off of the online training. There 
are trainings that are State specific in addition to that that 
may cost an additional amount. I'm not familiar with that. I 
apologize.
    Mr. Harper. Sure. You know, as we noted and I spoke of in 
my opening statement, the GAO found that limited availability 
of training is one of the major impediments that hospitals face 
in providing access to these services. So my question--follow-
up question, Ms. Jennings, would be, where is training 
generally available? And how does availability--and you said 
online, of course, but how does availability of training vary 
across different regions? Is there an urban versus rural 
component or is it a State-by-State issue? Can you elaborate a 
little bit?
    Ms. Jennings. Sure. So the training I mentioned is through 
the IFN, the online component, which is both the adult, the 
pediatric component, the combined course. However, there are 
States that choose to do actual in-person trainings; those can 
be approved by the IFN. Some of those trainings are just done 
by providers within certain facilities.
    Mr. Harper. Approximately, how many States offer in-person 
training? Do you have a general idea?
    Ms. Jennings. I don't. I can tell you, I'm from Virginia, 
and we do offer several trainings throughout the State several 
times a year, but of course, that varies State to State.
    Mr. Harper. Thank you very much. I appreciate that.
    Another challenge that hospitals identified to the 
committee was the financial challenge of administering a SAFE 
program; however, several of the letter recipients were able to 
identify grant programs to fund SANE training.
    So, Ms. Clowers, if I could ask you. The GAO report touched 
on various sources of funding for SANE training. Could you 
briefly describe how those funding sources and how hospitals 
can take advantage of those opportunities?
    Ms. Clowers. Yes, sir. We identified three key grant 
programs at the time of our audit. All were administered by the 
Department of Justice, with the STOP grants being the largest, 
that's a formula-based grant, where all territories and States 
receive a set amount. At the time it was $600,000, and then 
could get additional funding based on population.
    And what we found is that the amounts that locations 
receive varied greatly depending on the size of the population. 
And we also found that the entities that received those grants 
typically used the money for training. Forty-nine States 
reported--grantees in 49 States reported using funding for 
training, which would include types of training that Ms. 
Jennings mentioned, whether it be classroom training, clinical 
training, and then importantly, the continuing education as 
well. In addition to the training, States reported using some 
funding for funding of positions. But less States reported 
using funds for those purposes. Only about--grantees in about 
half of the States reported using funds for positions. And if 
they were using them for positions, it was typically for a 
program coordinator.
    Mr. Harper. Thank you very much.
    The Chair will now recognize the ranking member, Ms. 
DeGette, for 5 minutes.
    Ms. DeGette. Thank you very much.
    Well, Ms. Clowers, following up on your testimony about the 
grant programs at the Department of Justice, those programs are 
of course included in the Violence Against Women Act 
reauthorization, which is set to expire December 21. So I want 
to ask you about--and everybody here agrees, all of the 
witnesses, everybody in the audience, all of the Members of 
Congress sitting up here on the dais, we all agree this needs 
to be reauthorized. This is kind of one of the mysteries of 
Congress to me, why we have haven't done it.
    So maybe you can tell me, Ms. Clowers, about the 
effectiveness of these three grant programs through DOJ, and 
why it would be important to reauthorize those in a timely 
fashion.
    Ms. Clowers. Thank you. We heard from the officials from 
the States that we interviewed and contacted for our review 
that these funds are very important. While some States have 
used--grantees use State money or other types of sources of 
funding, the Federal dollars are a primary source of funding, 
and they go for the purposes that I just mentioned in terms of 
the training, the classroom training, the clinical training, 
the continued education, as well as funding needed positions.
    Ms. DeGette. Ms. Stewart, are these--some of the hospital 
associations told us that the hospitals did not have more 
robust sexual assault programs because of the cost of 
maintaining the programs. Are these programs costly to 
hospitals, and it is a prohibitive issue? What are the possible 
solutions to that barrier?
    Ms. Stewart. So they certainly have a cost. Doing a good 
exam requires time. To be honest, when we talked to hospitals, 
there are so many things that they do that are so much more 
expensive.
    Ms. DeGette. Right, that's what I would think.
    Ms. Stewart. And, if anything--you know, we are just having 
conversation, you know, that they lose far more on certain 
other things. And so we do not view this as prohibitive. Plus, 
as you pointed out, the Violence Against Women Act, can cover 
costs. Private insurance can cover many of the costs. We also 
share the view that victims themselves should not have to share 
the cost, but there are--Victims of Crime Act funding also can 
cover some of the costs.
    So we do believe this issue of training and ongoing 
certification is important and needs to get figured out. I 
think the other pieces are largely fairly easily fixable.
    Ms. DeGette. And do you think there's some kind of bias in 
some of the hospitals against providing these services?
    Ms. Jennings, you're nodding, maybe you want to tackle 
that.
    Ms. Jennings. The reason I nod is I think hospitals 
historically see this as a criminal justice issue as opposed to 
a health issue. And there is significant health consequences 
that are surrounding victims of sexual assault, and, therefore, 
we very much see it as a health determinant that we need to 
address as opposed to a separate criminal justice issue.
    Ms. DeGette. Right. Well, I mean, it's health and it is 
criminal justice, but if you do it correctly, then it's patient 
centered, and that's what we really care about in the 
hospitals. And I've also got to say, you know, I'm from Denver, 
Colorado, where I have a really wonderful district attorney, 
Beth McCann, who is working quite closely with all of our 
hospitals, and then we have a wonderful hospital association, 
and we have--and everybody understands how important it is to 
have these kits and how important it is to have trained people.
    But the challenge, I would think, Ms. Clowers, is to expand 
that everywhere, not just in places where there's a certain 
number of people who think it's important, particularly in 
rural areas, I would think.
    Ms. Clowers. Absolutely. In your State, I think we found 
that in the five rural counties in central Colorado, there was 
only one examiner program.
    Ms. DeGette. Right.
    Ms. Clowers. And so it's--the need for the consistency 
across the State, making sure that victims, regardless of where 
they live, have access to timely care. I would say that it's 
also, though, capacity is needed in urban areas as well, even 
when there's an examiner program. What we found is there's not 
sufficient capacity to offer 24/7 care.
    Most of the trained examiners are often wearing multiple 
hats, and so they're doing two jobs at once and more than two 
jobs. In addition, they're on call quite a bit. One study that 
we reviewed found, in Maryland, for example, trained examiners 
are on call 160 hours a month.
    Ms. DeGette. Yes. Ms. Jennings, do you have some thoughts 
about how we could expand the accessibility to people for 
SANEs, the nurse examiners?
    Ms. Jennings. To follow up with Ms. Clowers, the piece of 
that, the program that I work for is a 24/7 operation with 14 
full-time forensic nurses. So our model has shifted from a PRN 
on-call basis to truly being in-house 24/7, which has been very 
key in sustaining our nurses. We saw a 2-year turnover prior to 
that. And now we've had nurses that have been with us 4 and 5 
years. So we've been able to retain those nurses, continue with 
their continuing education, and be able to have true competency 
within that group as opposed to constantly turning over staff.
    So I think that a model shift from being an ER nurse that 
gets pulled out of staffing to take care of a sexual assault 
patient really needs to be the shift of the hospital focus.
    Ms. DeGette. Thank you very much, Mr. Chairman. I yield 
back.
    Mr. Harper. The ranking member yields back.
    I have a quick question before I recognize the next Member. 
And, Ms. Frederick-Hawley----
    Ms. Frederick-Hawley. Yes.
    Mr. Harper [continuing]. I know you, looking at your 
response, the committee's letter, you had talked about the cost 
of the program, the SAVI program----
    Ms. Frederick-Hawley. Yes.
    Mr. Harper [continuing]. That had been slowly rising for 
the past few years. I think you indicated it was $294,000 in 
2017. Could you tell me how much of that cost was covered by 
grants and other outside funding opportunities?
    Ms. Frederick-Hawley. Sure. The vast majority of the grants 
that we use for the SAFE program cover the cost of the 
coordination of it. So it's our full-time staff that manage the 
SAFE scheduling, the recruitment, the training, the support of 
those SAFE examiners, and the advocates. Some of it goes 
towards training, some of it goes towards equipment in the 
emergency department.
    Up to this point this year, we have spent $111,000 on the 
stipends that cover the on-call payment and the additional 
payment to the SAFE for when they come in on an actual case. We 
pay them both. We pay them just for being on call and also for 
coming in on a case.
    Mr. Harper. Thank you very much. That's helpful.
    The Chair will now recognize the vice chairman of the 
subcommittee, Mr. Griffith, for 5 minutes.
    Mr. Griffith. What a personal privilege to begin with. I do 
want to thank you, Mr. Chairman. It has been great serving as 
your vice chairman, and if we have another hearing that would 
be great, too, but you have been a great chairman and just all-
around good guy. I appreciate having worked with you these 
years. Thank you.
    I do think that--and I forget now who the testimony was 
from, but I do think it is important that we recognize it is 
both a health concern and a law enforcement concern, and so I 
have rearranged the way I'm asking my questions, but, Ms. 
Frederick-Hawley, can you tell me a little bit about how your 
hospital and the Sexual Assault and Violence Intervention, 
SAVI, Program partnered with law enforcement and how that 
partnership benefits your patients?
    Ms. Frederick-Hawley. Absolutely. One of our funding 
sources, the New York State Division of Criminal Justice 
Services implemented that we have sexual assault task forces in 
all of the boroughs of New York City. So for instance, the work 
that we do in Manhattan once a month it is the special victims 
bureau of the Manhattan DA's office, it is the special victims 
division of NYPD for Manhattan, it is us, it is other SAFE 
Programs, it is other community partners that all come around a 
table and discuss different issues that arise. It has a benefit 
in two ways. We get to discuss cases and ongoing issues, but we 
also get to develop relationships such that if there is a 
concern about something that is going on with law enforcement 
around a particular case I can very easily pick up the phone 
and call special victims in Manhattan and say, I need help with 
this. And they're very responsive. So we have the good fortune 
where I work that it is sort of built into our model that we 
work with law enforcement.
    Mr. Griffith. And as a part of that have you found that--I 
mean, obviously the victim when they first present themselves 
to the medical providers are distraught and not necessarily 
thinking clearly, has it been your experience that it is later 
that they realize how important it is or how they want to have 
some emotional closure or solace from the fact that the case is 
brought forward and that the evidence is preserved?
    Ms. Frederick-Hawley. The last time we did a statistical 
analysis it was about 67 percent of our sexual assault 
survivors report to NYPD during the time that they're in our 
emergency department and turn the kit over. The rest we hold 
them in security and then we continue to follow up with them 
until they make a decision. Many times they don't. Lots of 
times without certain supports in place they could fall through 
a crack, so if it is just them working with NYPD the likelihood 
of being able to carry forward under that kind of condition of 
trauma is--it is very challenging, so the more we can be 
involved and support them the better the outcome.
    Mr. Griffith. I appreciate that. Ms. Jennings, we have 
heard about the lack of appropriate transportation to the 
nearest sexual assault forensic examiner and that that is 
sometimes a barrier. I know you work in the Richmond area. My 
district is between 3 and 7 hours away from Richmond. One 
hospital that received our letter noted that they may provide a 
sexual assault patient with a taxi voucher. Obviously that can 
create problems on the criminal justice side because it can 
corrupt--possibly corrupt the evidence. You got to go through a 
whole line of what happened in the taxicab, what kind of 
taxicab was it, you know, et cetera. And so that creates a real 
problem in the criminal justice system.
    So that being said, for survivors that visit a hospital 
that doesn't have a SANE nurse on staff or does not provide 
that how do we best transport these victims to another 
facility?
    Ms. Jennings. And it is interesting that you actually asked 
that question. Recently in Virginia we do have about 13 healthy 
forensic nursing programs, and our program experienced a 
patient that presented to us after travelling to three 
different hospitals being told there's not a forensic nurse 
here, there's no way to do a SANE exam here, go somewhere else, 
and not provided with an actual facility.
    In regards to the transportation what we primarily see is 
the patient either being transferred by ambulance so they'll go 
from one facility to our facility via an ambulance provider, so 
there's two people in the back potentially with the patient, 
but also law enforcement does transport some of these patients. 
Best case scenario is that the patient knows what hospital to 
go to, obviously.
    Mr. Griffith. Right. Right. And obviously I represent a 
large and very rural district. Telemedicine, you touched on 
that in your written comments, and I'm a big fan, it may mean 
more witness time for certain SANE nurses, but what do you 
suggest on telemedicine if there's a rural hospital that 
doesn't have somebody, doesn't have the money to have somebody 
with the training?
    Ms. Jennings. I do see benefits of telemedicine. I think 
that one piece of it there needs to be a very well trained 
forensic nurse on one end and then the nurse on the other end 
does need to have some basic training in forensic nursing. It 
may be a very brief course on evidence collection, but they 
need to have a little bit of knowledge prior to having that 
telemedicine piece set up.
    Mr. Griffith. And my time is up, but I do want to find out, 
at some point I may ask a written question later about the 
clinical component of what we can do to make that better. Thank 
you. I yield back.
    Mr. Harper. The gentleman yields back. The Chair will now 
recognize Ms. Clarke for 5 minutes for the purposes of 
questions.
    Ms. Clarke. I thank you, Mr. Chairman, and I thank our 
ranking member. Good morning, everyone, and good morning to our 
panelists. The subject matter that we're discussing here today 
is so very important. I want to thank the chairman and the 
ranking member for today's hearing on such a very important, 
sensitive topic that's often gone woefully unaddressed with 
long lasting harmful impact on our Nation's survivors.
    The subject of sexual violence in our country impacts 
millions of Americans, more specifically 23 million women and 
1.7 million men that we know of. These staggering numbers do 
not even take into account the incidence of unreported assault 
survivors, who live in fear, in shame and in the shadows, and 
are often afraid to even come forward.
    One of the major reasons individuals who have survived 
sexual assault are scared to report their attack is because the 
process is arduous and retraumatizes victims, causing them 
anxiety to face their assailant. That is why we are gathered in 
this room today to understand how the Congress can provide 
support to those who need it the most and to obtain justice.
    There is both a shortage of supply of sexual assault 
forensic examination kits, SAFE as we have been talking about, 
as well as sexual assault nurse home examiners, SANE. As one of 
the wealthiest most advanced civil societies in the world there 
should be no barriers to care for the most vulnerable in 
society, especially at the critical stage of collecting 
forensic evidence to provide justice to those brave women and 
men.
    To add insult to injury victims of sexual assault should 
not be required to pay for the forensic exam or emergency room 
visit. In the Ninth Congressional District of New York that I 
proudly represent just as recent as November 30 of 2018 the New 
York Attorney General Barbara Underwood announced that at least 
200 sexual assault survivors were illegally sent bills from 
seven New York City hospitals requiring payments ranging from 
$46 to $3,000. Thankfully the New York State Attorney General 
committed to righting this wrong and protecting survivors, as 
well as their rights.
    And I'm so proud to hear from Ms. Frederick-Hawley today of 
Mount Sinai who has a hospital site in my district here today, 
and I want to open with my questions to Ms. Hawley.
    I would like to take a few minutes to discuss the details 
of Mount Sinai's program and to see what best practices you 
would offer to other hospitals looking to develop and expand a 
sexual assault program. Ms. Frederick-Hawley, could you tell us 
a bit more about how your program got started?
    Ms. Frederick-Hawley. Well, originally in 1984 we had a 
sexual assault survivor come into the emergency department, and 
there were a couple of medical students working that evening. 
And after this patient was discharged they looked at each other 
and said, We have got to be able to do better than that. And so 
they started to think through what a rape crisis program would 
like. They found a donor for the hospital. They sat at her 
kitchen table and developed SAVI. So it was a very grassroots 
based out of the need to do more for survivors sort of effort, 
and we carry it forward from there.
    The moment we hear of an emerging need we try to address it 
the best way possible, and I'm fortunate that I get to do this 
work at the Mount Sinai Hospital because they have been 
incredibly supportive and have always recognized that this is 
an important aspect of the kind of medical care that we want to 
provide.
    Ms. Clarke. Absolutely. And would you tell us a bit more 
about the services that SAVI provides through this program and 
the impact it's had on victims?
    Ms. Frederick-Hawley. Absolutely. So since 1984 we are not 
just a rape crisis program anymore. We currently send advocates 
of--our certified volunteer advocates that we train on a 40-
hour basis, it is a DOH-certified training curriculum that we 
have developed. We send them to eight hospitals, including some 
city hospitals, private hospitals and throughout the Mount 
Sinai system to service survivors of any kind of sexual 
violence and intimate partner violence.
    We have a court program and an ongoing therapy program for 
sex trafficking survivors, both domestic and international. We 
have a three full-time staffed education and training 
department where we're working on primary prevention. We have a 
component called Talkanote, which is specifically for Orthodox 
Jewish survivors of any kind of sexual violence or intimate 
partner violence.
    We have therapists, trauma therapists in six different 
locations in Manhattan and Queens who provide mostly short-term 
brief trauma therapy, but it can go on a longer term depending 
on what the person needs, and also we do all of this extensive 
emergency department care with our SAFEs and our advocates in 
terms of providing anything they need in that moment from a 
medical and psychological standpoint to any ongoing need that 
is going to come up that we want to be able to help empower 
them to either find service for or that we can provide service 
for. All of our services are free, and we provide them in 10 
different languages currently.
    Ms. Clarke. Outstanding. I thank you for all of your 
service. And I yield back, Mr. Chairman.
    Mr. Harper. The gentleman yields back. The Chair will now 
recognize the chairman of the full committee, Mr. Walden, for 5 
minutes.
    Mr. Walden. Thank you, Mr. Chairman. Again, I want to thank 
our witnesses for being here today and for the testimony you 
submitted for the record.
    Ms. Jennings, you noted in your testimony that telemedicine 
can be used to improve care for patients in rural and low 
volume communities, and I certainly know that my--just point of 
reference my district is bigger than almost any State east of 
the Mississippi, so it is enormous territory, very rural.
    Would you tell us a little more about telemedicine and how 
it can be used to expand access to these types of services and 
what are some of the challenges you see facing telemedicine to 
treat survivors of sexual assault?
    Ms. Jennings. Absolutely. Thank you. Telemedicine is for 
sure an answer to some of the more rural communities that don't 
have access to forensic nursing care. They could have to 
travel, as we mentioned before, as many as 3 to 7 hours to have 
a trained provider. Telemedicine would allow a nurse or another 
provider in the ED setting to care for that patient via 
telemedicine with another trained provider on the opposite end, 
walking them through the evidence collection process, walking 
them through injury identification, walking them through any 
prophylactic medications that the patient may need at time of 
discharge and then go through discharge planning, whether it be 
follow-up with a rape crisis advocate or whomever. The person 
on the other end would be able to elaborate on those services 
and care via telemedicine.
    Mr. Walden. Are there any statutory barriers, regulatory 
barriers either at the State or Federal levels you're aware of 
that would--that hamper this ability?
    Ms. Jennings. I'm not aware of specifics, but I do know 
that there are some challenges specific to that, and it will 
vary State-by-State.
    Mr. Walden. Any other panelists want to weigh in on that 
from your experiences on telemedicine?
    Because it is really hard again in a district such as mine 
just to recruit healthcare providers period, nurses, et cetera, 
and then when you get into something specific and the more we 
regulate the training the less likely it is they can find 
somebody like that to be there.
    Ms. Clowers. We through our work in talking to officials 
from different States this was one of the best practices or 
promising practices we heard about. Using web-based training, 
for example, to get both the sort of classroom as well as some 
clinical training opportunities, but then as Ms. Jennings was 
describing too providing that clinical guidance real time.
    We heard about examples in Colorado where a program 
coordinator in an urban area will be on call to help those in 
rural communities that don't have an examiner program. And then 
also we heard about the program, the SANE program in 
Massachusetts, which provides clinical guidance real time to 
nurses across the State.
    Mr. Walden. Very good. In addition to the challenges noted 
in the GAO report on volume versus competency issues one issue 
we have heard expressed by hospitals is that they're able to 
have SANEs on staff because they have so few--or they're not 
able because they have so few patients seeking kits each year 
that their nurses are not able to maintain competency in 
performing the SAFE kits. So I wonder, I understand at Mount 
Sinai you have had 23 SANEs on staff. How many kits do you 
perform on an average basis annually?
    Ms. Frederick-Hawley. Year to date as of this morning we 
had 55 cases of sexual assault at the Mount Sinai Hospital.
    Mr. Walden. Wow.
    Ms. Frederick-Hawley. And only one of them did not have a 
SAFE examiner, person got sick at the last minute.
    Mr. Walden. Ah. So 23 nurses and about 55 cases this year. 
Is it fair to say you may have some nurses that do not perform 
any kits at all then?
    Ms. Frederick-Hawley. Absolutely. And I should clarify that 
there are now 24, and they're not all nurses on our particular 
program.
    Mr. Walden. OK.
    Ms. Frederick-Hawley. So I have physicians assistants, RNs, 
APRNs and residents and----
    Mr. Walden. So other healthcare providers.
    Ms. Frederick-Hawley. Other healthcare providers. It is 
possible there are some times when we allow our SAFE examiners 
who are on the roster to take a leave, they need kind of a 
break from that work.
    Mr. Walden. I'm sure.
    Ms. Frederick-Hawley. And so we have an intensive number of 
people who take many more on-call shifts. So there are periods 
of time sometimes when one of the SAFEs hasn't done an exam in 
quite a while. We do have things in place for them where our 
assistant medical director for our SAFE Program is available to 
talk them through if they're back to do a case for the first 
time after a hiatus.
    Mr. Walden. I was going to ask about that. How do you 
maintain that competency in training then in the interim?
    Ms. Frederick-Hawley. There's also always a SAVI staff 
person on call to the SAFE examiner in case any questions come 
up or if they just want to kind of touch base and know that 
they're not out there alone. Often times, too, our SAFE 
examiners work in the emergency department, so you will often 
find that while the person who is on call is coming in to 
respond to that patient there is another SAFE-trained person 
there that they can bounce things off of if they need to. So 
there are a lot of layers of support for our particular 
examiners.
    Mr. Walden. Excellent. Thank you. And thanks again for your 
testimony, all of you. I appreciate that. Mr. Chairman, I yield 
back.
    Mr. Harper. The chairman yields back. The Chair will now 
recognize the gentlewoman from Florida, Ms. Castor, for 5 
minutes.
    Ms. Castor. Well, thank you, Mr. Chairman, and I have to 
say, Mr. Chairman, it has been a pleasure serving with you and 
working with you on legislation. Thank you for your service on 
the committee and to the country.
    Mr. Harper. And if the gentlewoman will yield, it was 
certainly a pleasure for me to be able to serve with you at the 
very beginning on our Ethics Committee and the great work that 
you did there.
    Ms. Castor. Especially the caregivers bill.
    Mr. Harper. That's right. Particularly that. That was this 
year. Thank you.
    Ms. Castor. And thank you to our witnesses for being here 
and helping raise awareness to this critical issue for sexual 
assault survivors. Back home in Florida in the Tampa Bay area 
we're very fortunate, we have an outstanding crisis center of 
Tampa Bay that has been a leader for decades, and I guess I was 
naive in assuming that a lot of this the services the 
integrated services with hospitals and providers and on-call 
experts and forensic nurses and specialists that was just the 
standard across the country, but it is clear that it is not, 
and we have got to do more to make sure that professional 
forensic specialists are available to everyone in America no 
matter where they live.
    The other issue that has been an issue in the State of 
Florida and other areas is actual processing of the sexual 
assault kits. And for anyone that's interested in this, the 
State of Florida, the Florida Department of Law Enforcement 
posted on their website a progress report because it came to 
light a few years ago they had over 8,500 kits that had not 
been processed. And to their credit, they appropriated some 
money, and right now they have completed over 7,000 of those 
kits but still have a thousand waiting.
    Ms. Clowers how are we doing on processing kits across the 
country?
    Ms. Clowers. We have an ongoing work looking at the issues 
of processing kits and the backlog of kits that are out there 
and I'm happy to arrange a briefing for you or your staff on 
that work as it comes to fruition.
    Ms. Castor. Good. Thank you very much. The other big issue 
as Ranking Member DeGette has mentioned is the impending 
expiration of the Violence Against Women Act. It is December 21 
that it would lapse, and this Congress has got to get it 
together to pass this landmark law and reauthorize it. It 
contains several provisions that address health issues 
associated with sexual violence, including the grant programs 
that we previously discussed that help fund and train sexual 
assault forensic examiners and address the public health 
response to domestic abuse.
    Ms. Stewart, your organization has had a long history in 
advocating on behalf of Violence Against Women Act. Again, why 
is it so important that the act be reauthorized as soon as 
possible?
    Ms. Stewart. So VAWA serves as a cornerstone of the 
Nation's response to domestic and sexual violence as you have 
pointed out. It includes both provisions that set standards for 
the law but it also provides grant programs to do exactly the 
things you have heard us discuss today. We also would 
advocate--I know we're talking primarily about the response 
after a sexual assault has happened and the effort to try to 
prosecute and hold offenders accountable. VAWA also has 
numerous programs that fund what we call the coordinated 
community response, which is really the ideal response to these 
forms of violence. We can't just wait until people are raped, 
and we need--we appreciate this hearing, we appreciate the 
focus on giving people the best care and holding offenders 
accountable, but that cannot be our Nation's response to sexual 
assault.
    We need to stop it through prevention and early 
intervention programs, through programs that bring law 
enforcement together with health, together with advocates, 
which we haven't really touched on yet, but so much of the 
success of these programs really is these partnership issues, 
how do we bring healthcare and law enforcement together? VAWA 
does that.
    Ms. Castor. I strongly agree, and I also--as you mentioned 
before I also believe it is time to improve the VAWA health 
title as you mentioned Mrs. Dingell and Mr. Costello along with 
Ms. Clarke, who was here and I we have filed legislation and 
that is to do more on the behavioral health side, but clearly 
we have got to help, we have got to put more dollars into 
training sexual assault examiners.
    And you mentioned--you all mentioned a bill by Senator 
Murray. Is that--that I believe has been replicated here by in 
legislation by Rep Jayapal. Are there other bills that you 
would highlight to us today that we need to work on as soon as 
possible?
    Any of the witnesses.
    Ms. Stewart. You know, we still obviously look to VAWA and 
the VAWA health provisions as you said, and I think what's 
important that you pointed out was the relationship between 
suicide prevention--you know, we're looking at a lot of the 
report language in some cases, and we look at we have a huge 
epidemic in this country primarily of male suicides. What we 
see from some of the data is really unaddressed sexual violence 
in childhood in some of those cases.
    Our opioid addiction, which I know, you know, so many 
frankly, Members on this committee have been focused on, how do 
we address violence as a driver as that and as part of our 
treatment. So some of those laws, some have passed, some are 
still sort of close to the final stretches, and integrating 
violence prevention language into those other programs is 
critical.
    We have also obviously discussed the Megan Rondini Act that 
Judge Poe has been advocating, and we think that that's an 
important legislative goal that we would encourage the 
committee to pursue.
    Ms. Castor. Thank you very much.
    Mr. Griffith [presiding]. I thank the gentlelady. I now 
recognize the gentleman from Texas, Dr. Burgess, for 5 minutes.
    Mr. Burgess. Thank you, Mr. Chairman. I was going to 
recognize your long service as chairman and how much I regret 
the fact that you're leaving, but you're not the one who is 
leaving, so I'll save that.
    Mr. Harper. I am here.
    Mr. Burgess. Oh, you are here. I do regret that you're 
leaving, Mr. Harper.
    Let me just ask, and this has been a fascinating discussion 
this morning, but just to orient me, Ms. Frederick-Hawley, 
you're in New York at Mount Sinai Hospital. Is that correct?
    Ms. Frederick-Hawley. Yes.
    Mr. Burgess. Ms. Stewart, San Francisco General Hospital?
    Ms. Stewart. Our organization is based in San Francisco, 
I'm here in DC.
    Mr. Burgess. You're here in DC, OK. And Ms. Jennings, your 
hospital?
    Ms. Jennings. Bon Secours in Richmond, Virginia.
    Mr. Burgess. Very good. I was a medical student 10 years 
before your medical students that you discussed in 1984. I did 
my residency training at Parkland Hospital in Dallas, and even 
back in the seventies and early eighties Parkland had I thought 
at the time a very forward leaning program in this regard. And 
I'll tell you one of the things that always impressed me about 
it as an OB/GYN resident. We were not tasked with covering a 
case when a patient came in complaining of sexual assault. That 
immediately went to a faculty member, who was onsite in 
hospital 24 hours day and available. And part of me at the time 
always resented having a faculty member in hospital, but in 
these cases it was clear that--and I think Norman Gant and Jack 
Pritchard, at the time, recognized that in order to have the 
availability of someone to precisely collect the information 
and then provide expert testimony in the courtroom was critical 
in the satisfactory resolution of these cases.
    And I don't have numbers, but I remember getting the 
impression that some defendants would plead before getting to 
the courtroom because the case would be so strong against them. 
And again, you had a faculty member from Southwestern Medical 
School as the expert witness, so that was always pretty 
powerful to take that into court.
    And then, of course, as a resident I ended up staying in 
the area, but I certainly recognize that somebody completes 
their residency after 4 years they may be gone miles and miles 
and miles away and not available for a court case, and then a 
case could be lost because of lack of the availability of the 
person who is to present the testimony. So I became convinced 
early even before I began my private practice that this was the 
correct approach.
    Now, I did not practice in Dallas County. I was a county 
removed, and I remembered trying to set up a similar program in 
our hospital, community hospital, and there was significant 
barriers to doing so. At the time there were not the advanced 
nurse practitioners who were--who you talk about this morning 
as available to do this.
    Of course in 1988 this Congress, not this Congress, but 
Congress passed a law called EMTALA. Can any of you speak to me 
as to whether or not your screening exams, for somebody who 
comes in complaining of sexual assault, does that satisfy the 
EMTALA requirements as set forth by Congress in 1988?
    And anyone who feels that they can answer that.
    Ms. Jennings. Thank you. So our facilities that we do 
receive transfers from we do ask that they follow the EMTALA 
process. There are some facilities that, again, don't see this 
as a healthcare issue, therefore, they don't follow the 
appropriate EMTALA proceedings.
    So we ask for a doc-to-doc transfer, and we do ask for a 
nurse-to-nurse report, but many times that's not happening, 
they're just telling the patient we don't have that here and 
you need to go elsewhere, so it is not occurring.
    Mr. Burgess. Yes, Ms. Frederick-Hawley, were you going to 
say something?
    Ms. Frederick-Hawley. We don't have an EMTALA issue in New 
York State because of sexual assault. It is actually required 
that if a patient presents in an emergency department in New 
York State saying they have been raped and they would like to 
have a kit done there every hospital has to be able to conduct 
a kit. It is not necessarily done by someone who is SAFE 
trained, but someone's got to figure out what to do and how to 
do it.
    Fortunately for the most part in New York City there are 
ways that people can be trained or they have exposure to the 
idea of providing a sexual assault forensic exam. A lot of it 
is anxiety on the part of someone. They want to do the right 
thing, they want to do it well----
    Mr. Burgess. Sure.
    Ms. Frederick-Hawley [continuing]. And are concerned that 
they won't be able to, and their instinct may be to we need to 
send this patient to some place else, but if the patient wants 
to stay in that particular ED and that's where they want their 
exam done then that hospital needs to figure out how to do it, 
and every hospital has to have kits on hand to perform.
    Mr. Burgess. And will you generally because if a patient is 
a regular patient of a practice in your communities will you 
call the doctor or practitioner who is the regular provider of 
care for that patient?
    Ms. Frederick-Hawley. Call their like their OB/GYN, for 
instance, into the emergency department to do----
    Mr. Burgess. Even to let them know their patient is being 
seen with that complaint?
    Ms. Frederick-Hawley. Everything that we do is based on 
what that survivor, that patient wants and allows us to do at 
that moment.
    Mr. Burgess. So if they request you call their doctor----
    Ms. Frederick-Hawley. If they request it we would call 
anyone that they wanted us to, yes.
    Mr. Burgess. And I know I have gone over time, but how do 
you address the freestanding emergency rooms that we see so 
frequently cropping up in our communities, are these facilities 
equipped to handle these types of exams that you all provide?
    Ms. Frederick-Hawley. I think it varies. So, for instance, 
Mount Sinai has several urgent care centers that we will send 
our SAFEs to if someone presents and wants to have their 
evidence collection done there. But I can't speak for all of 
those kinds of----
    Ms. Jennings. I don't see freestanding EDs as being a 
barrier to care, to service. We also in our facility we have 
two freestanding emergency departments, and we provide the same 
care and have not seen it as barrier, but it differs, of 
course, from State-to-State.
    Mr. Burgess. And I recognize that, and, of course, I'm in 
full favor of States being in charge of their sovereignty, but 
CMS is a national--I mean, Medicare is a national program so 
CMS oversees the EMTALA, so it seems like there's--I'll be the 
last person to say I want EMTALA to be bigger, or stronger, or 
harder, but at the same time they do exist, and CMS is the 
oversight of that program not State-by-State. Thanks. Mr. 
Chairman. I'll yield back.
    Mr. Harper [presiding]. The gentleman yields back. The 
Chair now recognizes the gentleman from Michigan, Mr. Walberg, 
for 5 minutes.
    Mr. Walberg. Thank you, Mr. Chairman. And I, too, want to 
say thank you for your service, your leadership, your 
friendship. We're going to miss you, and every time I go back 
to the base of my district in Jackson, Michigan I'll think of 
you in Jackson, Mississippi.
    Thanks to the panel for being here as well on this 
important topic, and it is a shame that it continues to be such 
a massive concern, but it is a concern, and we have to address 
it so thank you for your efforts and probably your sacrifice 
that you go through in dealing with this topic and these 
issues.
    GAO's report noted that only limited nationwide data exists 
on the availability of SANEs and that only one of the six 
States examined had a system in place to formally track the 
number and location of the SANEs. Some States, including 
Massachusetts, Colorado and Texas I'm told make public a list 
of SAFE ready facilities. Other States do not appear to make 
these sorts of resources publicly available.
    Let me ask each of you if you care to answer would this 
kind of national database or at least statewide databases be 
helpful to survivors?
    Ms. Clowers. I would think a national database or some type 
of centralized information about the availability would be 
helpful to patients. It would eliminate some of the challenges 
that were discussed earlier about arriving at a hospital maybe 
after a long distance, especially if you're in a rural area you 
have traveled an hour, 2 hours to get to a hospital after a 
very traumatic experience only to be told we can't serve you 
here, you need to go somewhere else and being told to get in a 
taxi or to drive yourself.
    You know, what we heard is once the patient leaves the 
hospital the chances of them returning to the hospital for care 
diminishes.
    Mr. Walberg. OK.
    Ms. Jennings. I would also agree. Many hospitals are 
already scored based on services that they provide, and I think 
this should be something that's included and something that is 
very accessible to patients. We're in a digital age, and if 
someone can flip open their phone and say where is the closest 
facility to receive this type of care I think the care would be 
much more accessible, and that could then also be translated to 
law enforcement and to many other of our community partners so 
that they immediately know if they are referred a patient where 
they need to send them to very quickly.
    Mr. Walberg. Jumping on that, what other digital resources 
could be offered online, for instance, to assisting that type 
of information getting out?
    Ms. Jennings. Sure. Something that we have seen is within 
our college student patient population they have apps from 
their school that will say if this happens to you this is what 
you need to do, whether it talks about evidence preservation or 
it talks about what type of medical services they could 
receive, whether it be a forensic nurse or the student health 
center. So some of those types of apps that are very 
accessible--I know many of the rape crisis centers also utilize 
some of those similar resources.
    Mr. Walberg. How widely is that used or known, those apps?
    Ms. Frederick-Hawley. In my experience running into college 
students who know is kind of like running into a polar bear on 
the street of Manhattan. It is kind of rare at this point, but 
I think that it is potentially growing, but there are always 
glitches to figure out with that, and then how to get the 
education and the availability of it to those students and to 
the larger population when you have a sort of technology 
divide. Not everybody has the same access to technology, which 
is problematic when you're talking about a really important 
basic service that you want everyone to have.
    Mr. Walberg. We're so app-based today----
    Ms. Frederick-Hawley. I know.
    Mr. Walberg. It seems like that would be just an automatic, 
but something to think about. Thank you.
    Ms. Frederick-Hawley, does Mount Sinai track information 
relative to data available for SANE programs? I guess what I 
would say is one of the questions the committee asked in our 
letter to hospitals was whether each hospital tracked any data 
as it relates to sexual assault such as number of sexual 
assault survivors treated each year and how many kits are 
requested and completed.
    Does Mount Sinai track this information as it relates to 
patients?
    Ms. Frederick-Hawley. Yes, we track an incredible amount of 
information on our sexual assault patients, the relationship 
they had to the assailant, how acute was the assault before 
they came into the emergency department, whether they were 
eligible for emergency contraception and other kinds of 
prophylaxis and beyond eligibility whether they decided to 
avail themselves of it, including HIV prophylaxis.
    We track, you know, who the SAFE examiner was that saw 
them, who was the advocate, other kinds of services they needed 
at the moment and then all of our follow-up care, as well.
    Mr. Walberg. I'm certain that that shapes your SAVI Program 
then to a great degree.
    Ms. Frederick-Hawley. Absolutely. Yes. And we have to 
report that at this point to a variety of our funders all 
confidentially; we don't include any kind of identifying 
information, but that's the kind of data that the New York 
State Department of Health and New York State Division of 
Criminal Justice Services and to a certain extent the New York 
State Office of Victims Services because of our funding streams 
requires us to provide to them.
    Mr. Walberg. Thank you. I yield back.
    Mr. Harper. The gentleman yields back. The Chair will now 
recognize the gentleman from Georgia, Mr. Carter, for 5 
minutes.
    Mr. Carter. Thank you, Mr. Chairman. I certainly would be 
remiss, Mr. Chairman, if I didn't offer my thanks to you as 
well for your leadership in this committee and for your service 
in Congress. Thank you.
    Ladies, thank you for being here today. This is a very 
important subject and it is very important to me personally 
because we have had this issue in the State of Georgia. We have 
had a problem here.
    And I want to start off by asking about the shortage of 
kits. Is that a problem, just the shortage being able to get 
the kits to where you can perform the--and I would offer this 
to anyone who wants to answer to where you can perform the 
examination?
    Ms. Frederick-Hawley. It is sort of our responsibility as a 
program. We keep track of how many kits we have on hand both 
drug facilitated sexual assault kits and the sort of more 
general forensic evidence collection kit. And as we start to 
get low we have to reach out to the Division of Criminal 
Justice Services and say, hey, send us some more----
    Mr. Carter. So is it their responsibility, the criminal 
services to provide the kits, is it the State's responsibility, 
is it health systems responsibility? Whose responsibility?
    Ms. Frederick-Hawley. The Division of Criminal Justice 
Services in the State of New York is the one responsible for 
pulling the kit together and--every few years we review what's 
in the kit, and if there are changes that need to be made to 
the samples or the envelopes or the content or anything like 
that it is up to them to build what kit is used in a 
standardized way across the State, and then it is up to the 
facilities to identify----
    Mr. Carter. Make sure that they have enough. Is anybody 
different from that?
    Ms. Jennings. We receive our kits in Virginia from the 
Department of Forensic Science.
    Mr. Carter. OK.
    Ms. Jennings. So very similar, once we recognize that we 
are running low on our kits we call and have a courier bring us 
to do, but it is our responsibility to actually have those kits 
in our facility.
    Mr. Carter. OK. One of the things that I wanted to touch 
on, and I recognize that this is not necessarily why you were 
here or your responsibility but is the processing of the kits. 
We had a big problem in the State of Georgia, I think it was 
also alluded to by one of my colleagues in their State, but we 
had a big backlog, and that was causing all kind of problems. 
This whole system doesn't work until we complete it.
    I mean, we need SANE nurses. We need the whole process to 
work, including processing the kits. We had examples in the 
State of Georgia where we had, you know, a serial rapist, if we 
had simply processed the kit from before we could have 
identified him. Is that a problem anywhere else that you're 
aware of?
    And, by the way, we have caught up in the State of Georgia, 
so I'm very proud to say that and to report that.
    Ms. Stewart. So thank you so much, Congressman, and 
congratulations to the State of Georgia, as well. I was 
actually going to commend Congressman Walden because Oregon is 
also one of those States that made a concerted effort and has 
reduced their backlog. It varies tremendously by State, but you 
identify a critical issue, which is why in some cases many--I 
shouldn't say many.
    Some victims do not go and why to get the kit is if the kit 
isn't going to be processed anyway or why law enforcement 
themselves sometimes and why we have burnout. And we hear from 
some of the providers that if the kit is not even going to be 
tested it is a very difficult, difficult thing for a victim to 
go through a rape kit. You don't do it lightly or easily----
    Mr. Carter. OK. Let me ask you this, and please bear with 
me on this. I'm not suggesting that the program itself is not 
needed or valid, but I'm a pharmacist and right now I'm 
cramming in 30 hours of continuing ed by the end of the year so 
that I can keep my license, OK, but are there any continuing ed 
programs out there that perhaps even if you don't get the 
certification it would certainly help to have some kind of 
knowledge for the nurse to be able to have a continuing ed 
program or something?
    Ms. Jennings. There are many opportunities for continuing 
education specific to the forensic component sexual assault 
many other types of victims of violence, so yes, that is 
definitely an opportunity.
    Mr. Carter. And I would ask you this to take it just a 
little bit further, what are we doing to educate other 
healthcare professionals besides nurses and law enforcement, 
making sure that, you know, because again as I stated earlier 
this process only works if it is completed. If we have a law 
enforcement officer who is trying to determine whether there 
was a rape involved here and whether this person needs this 
help, are there programs like that available?
    Ms. Clowers. There are. In talking to officials from the 
States that we interviewed this gets back to the 
multidisciplinary teams. Bringing law enforcement and 
healthcare providers together to make sure they understand each 
others' roles, to make sure they understand the availability of 
the examinations and the process that they'll go through. So, 
again, that was an important element that we saw in the States.
    And to your question about continuing education while there 
are opportunities available this goes to one of the challenges 
we found was weak stakeholder support for that training. 
Because some hospitals may receive only a low volume of 
patients not a great number of patients that need this care, 
hospitals may be reluctant to send their nurses or other 
practitioners to the training. And, in fact, some cases won't 
pay for the training so the providers if they go to the 
training they're taking annual leave, they're paying for all 
the costs associated with the training.
    Mr. Carter. Right, right, right. The last thing I would 
add, and I know we have talked about it, but I represent the 
coast of Georgia in Southern Georgia, a very rural area 
telemedicine, telehealth we need to look at that. That's our 
only option in the rural areas because we just, you know, we 
have enough trouble attracting physicians and healthcare 
professionals, much less specialists like this, so I hope that 
you'll continue to work on that because it is vital to rural 
areas in our country.
    Thank you, Mr. Chairman. I yield back.
    Mr. Harper. The gentleman yields back. The Chair will now 
recognize Mrs. Brooks for 5 minutes for the purposes of 
questions.
    Mrs. Brooks. Thank you, Mr. Chairman, and I want to thank 
you for your leadership of the committee, but I also want to 
thank you and the ranking member for bringing this topic to our 
last hearing of the year. And I want to thank all of the 
panelists for this incredibly important work.
    Many, many years ago in the late nineties when I was deputy 
mayor in Indianapolis and focused on crime issues I had the 
opportunity to have a SANE nurse or people demonstrate for me 
what the SANE project was in the late nineties and what the 
concept was and how it worked and how incredibly important it 
is, but I have to admit until there was that big article about 
the lack of testing of rape kits and so forth there hasn't been 
tremendous amount of attention on the lack of SANE and SAFE 
Programs and on all of the challenges, and so I want to thank 
you for the recommendations you have been giving to us.
    I also want you to know that we have been and are going to 
continue to push for the Violence Against Women Act to get 
included in whatever package comes at the end of this year. 
Myself and others have written letters to the leadership asking 
them and imploring them to please ensure that the Violence 
Against Women Act is included and that the funding continues. 
And so we're going to continue to push on that.
    But I want to just ask a couple of questions about the 
retention rates and the challenges because when people finally 
agree, and you might have to convince people to enter into this 
work because it is so incredibly difficult, but I know that 
there has been and Ms. Jennings you mentioned some significant 
retention issues but your hospital system is doing a lot.
    Ms. Frederick-Hawley, is your system, what are you doing 
for the retention of the people who finally agree to go through 
because GAO found that in one situation 540 SANEs were trained 
over a 2-year period in one State, fewer than 8 percent stayed 
because of the difficulty of the work.
    So what are you doing? Is it compensation, what are you 
doing to keep the retention rates high first at Mount Sinai and 
then if you would like to go on further?
    Ms. Frederick-Hawley. We see it as a multi pronged effort 
to keep people on the roster, recognizing what my colleagues up 
here have said about it being very difficult and taxing 
psychologically and physically to do the SAFE exams. We try to 
provide as much support as possible as close to the time of the 
case as possible.
    So every SAFE is required to call our SAFE coordinator and 
debrief everything about that case after they have gone in on 
it. And it is not just were there, you know, how did the camera 
work, were there any problems with anything like that, how was 
law enforcement, all of those other pieces.
    But how are you, how did this go for you. We keep track. It 
is why coordination is so important in my opinion because we 
can keep track of who is taking an absurd number of on-call 
shifts and say maybe we can ratchet that back a little bit and 
to take care of them as a person.
    We also provide in-house ongoing continuation education. We 
do a monthly support meeting. We bring in outside speakers, but 
we also will sit them down and, you know, retrain them or 
reorient them to the colposcope equipment, so we try to do a 
lot of things that are on an ongoing basis to----
    Mrs. Brooks. Are they compensated in any way for their 
additional training or do you have any incentives to at Mount 
Sinai or at your system?
    Ms. Frederick-Hawley. We pay the SAFE examiner for being 
just on call.
    Mrs. Brooks. OK.
    Ms. Frederick-Hawley. And then we also pay them an 
additional amount when they are called in to do an actual case. 
So their time is always important to us and considered 
valuable, which I think makes a difference. We pay for their 
certification training so they don't have to worry about that. 
And we also will provide resources to be able to cover their 
ongoing continuing education.
    Mrs. Brooks. And Ms. Jennings----
    Ms. Frederick-Hawley. I'm sorry, if they're called in to 
testify we will also work out compensation for the time for 
preparation and things like that.
    Mrs. Brooks. Good. And, Ms. Jennings, anything that your 
organization is promoting relative to compensation of----
    Ms. Jennings. Absolutely. Very similar to Ms. Frederick we 
compensated for any training. We provide compensation for their 
SANE-A and their SANE-P certification from the IAFN, so that's 
the certification exam once they have completed their clinical 
and didactic training.
    We also compensate for any time that they're coming into 
the hospital for meetings. We keep them very engaged within the 
hospital system, but we also keep them very engaged with our 
community partners. So we have our nurses assigned to our 
sexual assault response team. Our program serves 26 different 
counties and jurisdictions within the Commonwealth of Virginia. 
So each of our nurses has a jurisdiction that they partner 
with, and so those relationships are extremely important.
    One other thing that we have done that's been huge for our 
retention rates we have transitioned from more 12-hour shifts 
to 8-hour shifts. We saw that nurses truly were having high 
burnout rates when they were there for 12 hours. A shift 
typically didn't end at the 12-hour mark, it was going into the 
13th and 14th hour, so we have transitioned back to 8-hour 
shifts.
    Mrs. Brooks. Thank you. I may submit a couple of written 
questions for our witnesses because I had more, but thank you 
for your work. I yield back.
    Mr. Harper. The gentlewoman yields back. The Chair will now 
recognize the gentleman from Pennsylvania, Mr. Costello, for 5 
minutes.
    Mr. Costello. Thank you. First, I just want to recognize 
the leadership and service of the subcommittee chairman here as 
he winds down. It has been a pleasure to work with you, and I 
want to thank you for your service as well as those testifying 
here today.
    My question is for Ms. Clowers and for Ms. Jennings. I'm 
going to try and speed through these. In your testimony, Ms. 
Jennings, you mentioned that one of IAFN's goals would be to 
establish a standardized national sexual assault evidence 
collection kit. Could you tell us what makes up the actual kit 
and some of the discrepancies you have seen in different 
localities? Can this lead to issue with prosecution if a kit is 
collected in one State but the crime is prosecuted in another 
State?
    Ms. Jennings. Thank you for your question. One of the 
issues that we see is that there are many variations in the 
kits themselves. Some are received from the Department of 
Forensic Science, some are received from actual online ordering 
options, so the kits can vary by State. I would venture to say, 
yes, that could create issues with them being different, but 
that also creates a huge barrier in training. If we had one 
standardized kit it would be much easier to educate----
    Mr. Costello. To train. To train, good point.
    Ms. Jennings. To train.
    Mr. Costello. What's in the actual kit?
    Ms. Jennings. In the actual kit, many different swabs from 
areas, so when we're obtaining a history from a patient we're 
asking them what actually occurred so it guides our evidence 
collection, whether it be an oral assault or a vaginal assault 
we know where to collect our swabs from very much like a Q-tip 
and a slide you would use in biology class. We do take hair 
samples, and we take blood samples also.
    Mr. Costello. What are the most notable discrepancies, most 
common discrepancies?
    Ms. Jennings. For example, the kit in Virginia is about a 
shoe box size, but a kit that may be in another State is the 
size of an envelope. So the actual number of the swabs in the 
kit may be less or there may be not blood samples in one but 
there would be blood samples in another.
    Mr. Costello. How about reimbursement or processing of 
kits, difference?
    Ms. Jennings. I can't speak for every State. In Virginia we 
go through our Virginia Victims Fund for our compensation for 
our sexual assault exams.
    Mr. Costello. OK. If there's nothing to add I'll go to the 
next question. Anyone else want to add to that?
    Is there a need to create a national standard of care for 
the treatment of sexual assault survivors, whether that means a 
standardized training program as you mentioned or standardized 
procedures for hospitals that are not equipped to collect SAFE 
kits?
    Ms. Jennings. Yes. We think that that is very important. 
That would also create the consistency amongst trained 
providers so that everyone is practicing the same.
    Mr. Costello. Anyone else? You can't really add to a yes, 
can you? OK.
    In addition to a lack of standardization of the kits 
themselves one issue we heard expressed by a hospital 
association is that, quote, ``lack of reciprocity to allow 
nurses who are not part of an independent team to go from one 
hospital to another,'' end quote.
    For any of our witnesses, is this a problem you have seen 
in your experience and can you identify a solution to this 
issue?
    It is a problem would you agree? And so the challenge 
becomes what's the solution.
    Ms. Jennings. It is a problem. I don't have a necessary 
solution at the moment in our particular area. It would be 
difficult to go from I work for Bon Secours, but if I went to 
another healthcare system that I was not employed by that could 
create some issues.
    Mr. Costello. Could I ask each of you to submit in writing, 
just think about that a little bit and share with the committee 
some thoughts, just kind of brainstorm it through.
    Ms. Frederick, you were shaking your head, which presumably 
means you agree and you probably struggle with that issue, as 
well. Anything to add from what Ms. Jennings said?
    She said it expertly. OK.
    Let me see if I have anything else that I would like to 
ask. OK. One of our letter recipients noted that they have used 
an online training program to train their nurses. How can we 
overcome the issue of making clinical training available even 
if we can make the classroom training available online? How can 
we overcome the issue of making clinical training available?
    Ms. Frederick-Hawley. In my opinion to be honest I don't 
think you should ever overcome the clinical training part. I 
believe that maybe moving away from didactic in some ways and 
doing online modules, and we do a combination of those things, 
but the hands-on work with a patient that you are going to be 
seeing in a much more traumatized state the first time you're 
doing a real exam it is invaluable to use a gynecology teaching 
associate in a clinical setting to actually go through what 
kind of sensitive approaches you're going to need, what your 
anxieties are that come up in that sort of----
    Mr. Costello. That's an excellent point. In other words, do 
not ever supplant entirely or only up to a certain percentage 
the amount of--and related to that I know I'm out of time, can 
you tell us more about the practice transporting nurses from 
rural low volume areas having them spend more time in more 
urban high volume settings in order to gain expertise and 
experience, do you recommend that and how does that take shape?
    Ms. Clowers. It is certainly a strategy for maintaining 
clinical expertise, but it would require the support of the 
hospitals. And again, that's one of the challenges we found is 
that there is weak stakeholder support for those types of 
initiatives.
    Mr. Costello. Very good. I know that what we have heard is 
some groups have advocated that as being a thing, and you have 
identified what the chief impediment of having that be a 
solution.
    Ms. Clowers. Yes.
    Mr. Costello. Thank you very much. I yield back.
    Mr. Harper. The gentleman yields back. I want to thank each 
of the witnesses for being here for the valuable insight and 
suggestions that you have given to us.
    One thing that we can say is that no victim of sexual 
assault should ever be turned away from any hospital, bottom 
line.
    Certainly I thank the Members for their input today as 
well, and as I conclude what in theory should be my last 
hearing to chair for this term, I want to thank our staff at 
Oversight and Investigations, what a great job they have done. 
They have succeeded in making me look a whole lot smarter than 
I am, and I am most grateful for their hard work and dedication 
to all that they have done for our country and specifically for 
this committee.
    I want to remind Members that they have 10 business days to 
submit questions for the record, and I ask the witnesses to 
agree to answer those as promptly as you can should you receive 
any written questions.
    Again, we thank you, and this subcommittee is adjourned.
    [Whereupon, at 11:57 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
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