A file photo of the Astoria-Megler bridge. Midwives on Oregon's North Coast will soon train to be sexual assault nurse examiners to address a gap in care in the region.
Alan Sylvestre / OPB
A shortage of sexual assault nurse examiners has left a gap in care on Oregon’s North Coast. Survivors who want to report their assaults often have to travel hours to Portland to be examined by a certified nurse in a chaotic emergency room. But a recent federal grant will soon change that.
Rebeckah Orton is the executive director of the Astoria Birth Center, and Terri Steenburgen is the executive director of The Harbor, which provides support services for sexual assault survivors. They join us to talk about how their organizations are partnering to train midwives to be certified sexual assault nurse examiners.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. A shortage of sexual assault nurse examiners has led to a serious gap in care on Oregon’s North Coast. Survivors who want to report their assaults often have to travel two hours to Portland, only to find themselves in a chaotic emergency room where they can be examined by a special certified nurse. A recent federal grant aims to change this. It will provide money, so midwives on the North Coast can be trained as sexual assault nurse examiners. Rebeckah Orton is the executive director of the Astoria Birth Center and Family Medicine. Terri Steenburgen is the executive director of The Harbor, which provides support services for survivors of sexual assault and domestic abuse. They both join me now. Thanks very much for coming onto the show.
Rebeckah Orton: Thanks Dave, thanks for having us.
Terri Steenburger: Thank you.
Miller: Terri Steenburgen first. If somebody on the North Coast wants to report a sexual assault right now, what are their options?
Steenburgen: I guess it depends on what kind of report they would like to make. So all sexual assault survivors have the right to medical care. And I think that is the first thing to note is that after sexual assault, there’s a certain amount of medical care that you want. So, they can report to a hospital or they can report to the police or they can call us, and I think the thing that people think about the most is medical care. When folks report to the hospital, they have the right to see a sexual assault nurse examiner as you mentioned, who is somebody who is trained to provide the appropriate care to survivors of sexual assault, and we just don’t have those on the coast. People often have to wait or go to Portland, and when that is the case, they often give up and go home, because it’s been such a traumatic experience to begin with, they don’t want to do it any more.
Miller: In other words, if they say, ‘Yes, I would like to see a sexual assault nurse examiner,’ and you or somebody says, ‘Okay but you have to go to Portland,’ they just say, ‘Well I’m not gonna drive two hours right now?’
Steenburgen: Well yeah, I guess it wouldn’t be me that says that, it would be the emergency room. There is a nurse examiner in Clatsop County that works part time, and so that is an option. But that person also is a nurse in an emergency room. They would be doing whatever it is that they’re supposed to be doing at that moment in time.
That’s the thing, it’s like they either would have to wait until that person is available - so that could be a couple hours, could be the next day - or the hospital would suggest that these folks go to Portland just two hours away. Then if you live in Astoria and you don’t go to Portland that much, maybe you’re not that familiar with it. A lot of sexual assaults happen at night. It could be the middle of the night. Maybe you have to work the next day and you can’t get out or you don’t want to tell your job why you need to take the day off, or you can’t get childcare. It’s not that easy to just drive two hours to get a sexual assault exam, which actually can take up to four to six hours, and then just totally disrupts your life. And a lot of people will just opt to go home instead.
Miller: Rebeckah Orton, can you give us a sense for the work that a sexual assault nurse examiner does?
Orton: I can give you some sense of it, yeah, but we’re learning about it ourselves, as well. As Terri said, we haven’t had very good access to this on the coast before. But effectively, a sexual assault nurse examiner, which can be an RN or above - that could be a Nurse Practitioner or just a standalone RN - that person would be responsible for receiving an individual who has experienced sexual assault and assessing them, doing a full head to toe physical assessment, to rule out any urgent injuries, stitches, bleeding, and documenting those things, because that then becomes a legal document for the police.
Meeting that individual also in the emotional space that they’re in, right then. It involves a huge amount of trauma-informed care training to be able to approach somebody who’s just been traumatized and help them to enter a space where they feel safe and that they can discuss what’s just happened. Importantly, it also involves a specialized pelvic examination where semen or other samples can be collected for forensics.
Miller: I imagine that time is of the essence, in terms of collecting that evidence?
Orton: Yes, it is. I don’t know what the specific cut off is yet, but I do know that it is a time sensitive exam.
Miller: Why would midwives be well suited to this kind of care? I mean, that is the novel aspect of this federal grant, that the two of you have teamed up to get. And obviously, it was awarded to you, that’s why we’re talking. Why train midwives to do this work?
Orton: I was hoping you would ask that question. This is a huge question and it has a pretty simple answer, but the shortest answer is, why not? Midwives first and foremost, are trained in this way; trauma-informed care, consent-based care, and a holistic viewing, the whole human as a center of your care, and shared decision-making is absolutely central and foundational to midwifery and nurse midwifery at large.
If I can back up a little bit, the Surgeon General issued a call to action in 2021, saying that they wanted to improve access to nurse midwives and improve maternal health care. He talked in depth about something called ‘risk appropriate care,’ which means sending low risk people to providers who specialize in low risk, and sending high risk people to people who specialize in high risk. When you have somebody who’s been assaulted, channeling them to a risk-appropriate provider is ideal. So first of all, an emergency room may not be needed. That level of care may not be needed after an assault. And midwives are uniquely qualified for that type of thing. Not only is it that they are very trauma-informed and very women-centric - as Dr. Peters was saying, very human and vulvar anatomy centric - they also do pelvic exams all the time. This is a thing that it’s just inherent to their job. They’re always doing pap smears and doing cervical exams and things like that. They know how to do them. It’s just inherent.
Miller: At the same time, this work does seem, from an outsider’s point of view, to be pretty different emotionally from midwifery. How many of the midwives in your practice said, ‘Yes, I want to go through this training?’
Orton: All of them.
Miller: Why do you think that is? What did you hear from them?
Orton: I think it was a no brainer. For all of them. The types of people that are drawn to midwifery, already have this on their mind, all the time. We know that pregnant women, about 20% of them, experience sexual assault during their pregnancy. That’s huge. It’s inexcusable and it’s huge. So it’s a big part of the training. It’s a big part of what even draws people to midwifery to begin with. When they said, ‘What would you think about pursuing this and making it an option for people who’ve been assaulted, to not only not have to go to a hospital, but to be able to see you,’ and 100% of people said ‘Yeah, let’s do it. Why would we not?’
Miller: Terri Steenburgen, do you have a sense for how likely it is that somebody on Oregon’s North Coast right now, who is sexually assaulted, will report it in any way, will go out to seek any kind of help or care?
Steenburgen: It is extremely unlikely, unfortunately. I think statistically speaking, one in three women have experienced some sort of sexual violence in their lifetime. And that number is actually higher in rural parts of the country and we’re not seeing anywhere near that number of folks reporting. So it’s definitely something that folks aren’t reporting because they’re not able to receive the services that they need.
There’s still a lot of shame and stigma around being the survivor of sexual violence, right? We want the shame and stigma to be focused on rapists and people who cause harm, but right now the shame and stigma is really focused on the survivor. People feel really uncomfortable coming forward and telling somebody about what happened. I think that we find that also is especially true in places like Clatsop County, in rural areas where everybody knows each other. It’s hard to let somebody know that something like that happened to you and that you probably think is your fault because that’s sort of what the narrative has been for such a long time. It’s hard to come out and say something to somebody and try to get support.
So that’s another reason that we’re working on this grant and working with the birth centers, just to really make sure that survivors understand that it’s never their fault. That we want to help them. And that we are a safe place to report to. That we are a confidential service and that we will get them what they need.
Miller: Is it your hope, or your assumption, that having nurse examiners actually in Astoria, in Clatsop County, will lead more people to report assaults?
Steenburgen: I guess it also depends on what you mean by report. I don’t know that we’re looking for people, necessarily, to report to the criminal justice system more. Maybe we are, but just to give you an idea of what that looks like, for every 1,000 reported rapes, only 25 of those end in a conviction, only 25 rapists are actually convicted in those cases. That’s 2.5% of reported rapes that actually end in conviction. So it is a traumatic experience for people to go through.
We want to make sure that people are well and that they are healthy and that they are able to go through some sort of healing process, and that can’t happen unless they tell somebody. I think having the birth center provide sexual assault response and making sure that folks are able to go in and get a confidential wellness exam, just make sure that their body is okay, that they get the prophylaxis they need, so that they don’t end up with an STI. And they can find out everything that’s going on with their bodies and just make sure that they’re okay. Then they can also get a forensic exam if that’s what they want to do and they can get all of the evidence taken.
To answer your question from before, three days was when we want the forensic exam to happen. Because otherwise, we start to lose evidence. But that evidence can be taken, and then somebody can decide a week later or a few months later or a year later that, yes, they want to report it to the police, but they don’t have to decide that immediately. Being able to actually do that in the right amount of time and find out that they’re okay and start the healing process. And then also connect with one of our advocates to help them understand what the processes look like and just have somebody there with them who cares for them and will tell them that it was not their fault, is so important after a sexual fault. That’s really what we’re looking for is to provide that support for people.
Miller: Rebeckah Orton, you were talking earlier, and passionately, about why you see midwives as being really perfect people to do this important and difficult work. I’m curious about the built environment here. How is the feel of your birth center different from an emergency room?
Orton: I’d love for you to come see it. It’s very different. Our particular birth center is built right on top of the Columbia River and it’s overlooking nothing but water. Each room looks like a nice hotel. There’s a bed with cozy blankets and pillows. We have all of this medical equipment that we need in order to do our jobs, but it’s tucked away in drawers and cabinets and things. The overall feel when you come in is homey and cozy. It’s got kind of a mid-century Scandinavian design. So when you walk in, most frequently we’re told it just feels like a breath of fresh air. That has an effect on people of course when they’re in labor, but anyone else who is coming in. It’s frequently commented, ‘Oh, it just feels so relaxing.’ And that’s important.
Miller: What went through your mind when you heard that you had gotten this grant?
Orton: I was in the middle of Costco and started ugly crying on the spot. I was shocked. I didn’t think we had any chance of getting it, but that pitted against this deep desire to be able to offer something like this. Just kind of exploded right on the spot. Overwhelmed with gratitude. Overwhelmed with optimism and the excitement that comes with being able to do something that’s not been done before.
Miller: Rebeckah Orton and Terri Steenburgen. Thanks very much.
Orton / Steenburgen: Thank you. [In unison]
Miller: Rebeckah Orton is the executive director of the Astoria Birth Center and Family Medicine. Terri Steenburgen is the executive director of The Harbor.
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