“Not Without Judgment”: Sociocultural Barriers to Accessing Sexual Assault Evidence Kits in Rural and Remote Northwestern Ontario

Abstract

Sexual assault evidence kits (SAEKs) are forensic tools used in emergency departments to collect evidence of an assault from the survivor's body. We sought to determine the perceived barriers to providing sexual assault care in rural and Northwestern Ontario, as reflected through the perspectives of Northern healthcare providers. Semi-structured qualitative interviews were conducted with healthcare providers in Northwestern Ontario, and three themes depicting sociocultural barriers were developed: (a) substance use; (b) police involvement; and (c) being Indigenous. These factors were found to influence both survivor credibility and the decision to complete the SAEK. We suggest that emergency departments are an inappropriate site for SAEK use.

Introduction

Sexual assault in Canada is a crime that primarily affects women. One in three women in Canada has experienced sexual assault (Cotter & Savage, 2019), and women and girls account for 90% of the sexual assaults that are reported to police (Conroy, 2024). While most assaults go unreported, many sexual assault survivors seek medical care following the assault, usually in hospital Emergency Departments (EDs) (Conroy & Cotter, 2017). In Canada, sexual assault survivors who seek post-assault care through the public healthcare system should be offered the opportunity to have material evidence of the assault gathered by a healthcare provider, who will collect this evidence using a tool called a sexual assault evidence kit (“SAEK” or “rape kit”) (Campbell et al., 2018). Although the kits are usually administered in healthcare settings, SAEKs do not provide treatment for harms sustained through the assault. Rather, they are forensic tools used to gather evidence that could be used in legal context. Without this kind of evidence, convictions depend largely on the quality of and credibility given to assault survivors’ narratives. Yet, recounting sexual assault in legal contexts can be retraumatizing for assault survivors, and finer details may be difficult to recall (Haskell & Randall, 2019). Justice in these situations can be less likely, posing risks for perpetrators to re-offend and survivor mental health to deteriorate (Campbell et al., 2018).

Currently, the procedure for care of individuals presenting to rural hospitals following a sexual assault is to refer them to the closest regional Sexual Assault and Domestic Violence Treatment Center (SADVTC). There are 37 SADVTCs across Ontario, all operating out of hospitals within larger health centers (Ontario Network, n.d.-a). The majority of these centers, however, are concentrated in Southwestern Ontario, where the vast majority of Ontarians reside. There are only 4 SADVTCs in Northwestern Ontario, each serving a broad territorial expanse.

SADVTCs provide comprehensive sexual assault care to survivors; they staff on-call physicians and sexual assault nurse examiners (SANEs) who are specialized in the treatment of injuries (mental and physical) related to assault. SANEs in Ontario are specially qualified through annual 4-day courses led by the Ontario Network of Sexual Assault and Domestic Violence Treatment Centers, during which they learn how to conduct a forensic examination following assault using a trauma informed approach (Ontario Network, n.d.-a, n.d.-b).

Care involved during the encounter with providers at SADVTCs includes crisis intervention and emotional support, emergency contraception, testing for STIs and HIV prophylaxis, medical treatment of other injuries related to the assault as well as follow up care, safety planning and risk assessment, and counseling with social work experienced in sexual assault-related trauma (Ontario Network, n.b-c). At this time, the assault is documented, and the survivor is offered a forensic examination using the sexual assault evidence kit, which involves photos of injuries, swabbing for DNA evidence, and collection of other relevant material articles. Despite the comprehensive care provided at SADVTCs, survivors in Northern and rural areas may opt to stay at their home hospital for a multitude of reasons, the most common of which being the great distance they may need to travel to get to a SADVTC (Nonomura & Baker, 2021).

Despite high rates of sexual assault, it is estimated that 40% of hospitals in Canada either do not have SAEKs available for use and/or lack staff trained to use them (She Matters, 2021). Notably, previous research has indicated that most of these deficits are in Northern and rural regions (Carter-Snell, 2020; She Matters, 2021). It is important to recognize that Northern and rural regions experience some of the highest sexual assault rates, especially among Indigenous women and girls, with 46% of this demographic experiencing sexual violence (Heidinger, 2022). Research on SAEK access in these regions is limited, however it is known that a “justice gap” exists, whereby imperfect justice is experienced by survivors due to limitations beyond their control, such as socioeconomic and geographical factors (Haskell & Randall, 2019). Previous research has found that barriers to seeking sexual assault care included an inability to physically access care (Kamke et al., 2023; Wright et al., 2022). More specifically, socio-cultural barriers to receiving sexual assault care were found to include perceptions that medical care was not needed, fear of not being believed by care providers, and anticipation of potential negative consequences of seeking (Kamke et al., 2023). Barriers were found to exist on intrapersonal, interpersonal, community, organizational, and societal levels (Lucea et al., 2024). However, there is a gap in the literature on socio-cultural barriers to receiving sexual assault care involving rural and Northern residents, especially in the context of the Canadian healthcare and justice system.

To better understand the factors underpinning inequities in access to SAEKs and to post-sexual assault care in Northern and rural communities, we undertook a study with the following two objectives: (1) to gain insight into the current state of acute sexual assault care in Northwestern Ontario from the perspective of emergency healthcare providers and (2) to assess the challenges to SAEK access and use in the North, with the ultimate aim of informing better access and post assault care.

Throughout the course of our study, we found that the participants spoke generally about both sexual assault care and the SAEK; it was clear that for the participants, these two components of the care encounter were connected. As such, our analytic lens for this data extends to discuss both rural sexual assault care and the SAEK more generally. We still, however, recognize that despite the intrinsic connections between SAEKs and the more medical components of sexual assault care in emergency departments, SAEKs are not a replacement for “sexual assault care,” because at the root they do not directly aim to serve the health of the patient.

Methodology

This study draws from a larger mixed methods study that explored barriers and facilitators to sexual assault care in Northwestern Ontario (Timmermans, 2023). In this paper, we draw on qualitative interview data from that study to report on what we term “socio-cultural barriers” to sexual assault care. In this context, “socio-cultural barriers” refers to barriers to post-sexual assault care stemming from the social context of people's lives and/or assumptions about survivors that were expressed by healthcare providers, both of which may impact the care that rural sexual assault survivors receive. Thus, socio-cultural barriers to care do not include practical or logistical challenges, such as travel time between remote communities and sites where post-assault care can be accessed, and staffing shortages in rural Emergency Departments (given the timing of our data collection [November to December 2022], such shortages were compounded by the COVID-19 pandemic). We have published our findings on logistical barriers elsewhere (article currently undergoing peer review).

Recruitment

All participants were drawn from the Northwestern Ontario Region Local Health Integrated Network (“The Northwest LHIN”; LHINs are a form of regional health authority in the province of Ontario. The Northwest LHIN covers a vast, sparsely populated area that includes many remote communities, some of which are accessible only by air). Participants were included if they were currently working as a frontline health care provider (e.g., nurses, doctors, and nurse practitioners) or had recently worked in the ED of a hospital within the LHIN. Those who had non-medical care roles in EDs (e.g., social workers and medical secretaries) were excluded, as well as those working strictly in sexual assault advocacy roles (e.g., justice workers and victim services workers). At the time of recruitment, it was unclear if the participants worked in centers that had access to SAEKs; however, this was asked during the interview stage and reported in the findings of the study.

Data Collection

In-depth qualitative interviews were carried out with nine (9) healthcare providers in clinics and hospitals in Northwestern Ontario. The interviews, which ranged from 30 to 90 min in length, were held both on Zoom and in-person throughout November and December 2022. They were audio recorded and subsequently transcribed verbatim by the first author. The interview guide encompassed topics such as occupational background, patient population demographics, awareness of guidelines for sexual assault care and/or use of the kit, training for treating survivors and performing forensic exams, experience of SAEK usage, challenges to treating assault survivors, and the psychosocial supports available to both care providers and survivors. This guide was piloted with a registered emergency medicine nurse who worked in a rural Southwestern Ontario hospital.

Participants were recruited through an online survey (findings reported elsewhere) that was circulated to all rural clinics and EDs within the Northwest LHIN. The objectives of the survey were likewise to gain insight into SAEK access, the state of sexual assault care access, and care provider comfort level and degree of training in providing post-assault care. The final question of the survey asked if the respondent wished to explore the topics in more detail in a confidential one-on-one interview. Survey respondents who expressed interest in being interviewed were followed up via email by the first author. Several participants were also recruited through snowball sampling, via the second author's professional networks.

Ethics

Ethics approval was sought and obtained from the Faculty of Medicine at McGill University in Montreal, Quebec, and from Lakehead University in Thunder Bay, Ontario.

Data Analysis

Transcription

ST transcribed the interviews with the assistance of Otter.ai software. All identifying information (names of participants, sites, etc.) and filler words were removed during transcription. Transcripts were then downloaded and subsequently uploaded to NVivo software for data management (Release 1.7.).

Data Analysis Framework

Thematic analysis using the Clarke and Braun approach was the analytic approach used for this study (2017). ST was familiarized with the data during the interview process and the transcription process and then reread the transcripts repeatedly for further familiarization. Transcripts were also shared with the final author, and several meetings were held to discuss initial impression and interpretations. Several transcripts that were deemed representative of the data set were shared with the broader team to review. The team consisted of a graduate student pursuing a degree in family medicine research (ST); a professor of social work based in Northwestern Ontario with extensive geographical and topical expertise on sexual assault in the North (JM-O); a professor of medical anthropology with extensive topical background in sexual violence and some background in primary healthcare access in Northwestern Ontario (KR), and a clinician scientist and ED physician whose research program focuses on sexual assault in humanitarian context. All team members were cis-gender white women.

This group collectively developed the initial codes through an inductive approach. A codebook was formed from the initial codes, and then ST used this framework to code all nine transcripts in NVivo software with a deductive approach. New codes were added as necessary throughout this process, through deliberation with the second and third authors. Hereby, the flexibility of thematic analysis as a framework was suited to this project and its research question, as it allowed for both a “bottom up” and “top down” approach to the data. The resulting codes were reviewed with KR to determine which were most relevant to the research question, and also to gain a sense of how these codes interconnected and formed themes. These themes and exemplar quotes were reviewed with the committee, to generate further discussion about how to approach the data, and was interpreted through a feminist theory approach (materialist feminism theory in particular; Aranda, 2020; Clarke & Braun, 2019).

Study data were thus analyzed in relation to relevant theory and research, critical case sampling, and the specificity of the research question. This allowed us to conclude that sufficient information power was achieved by the sample size of nine interviewees (Varpio et al., 2017). Formal member checking was not used for this study, as it was not viewed as feasible, given study participants were working in busy emergency departments during the COVID-19 pandemic.

Findings

Five participants were recruited through the survey and four participants were recruited via snowball sampling. Three of the participants were registered nurses with specialized training as Sexual Assault Nurse Examiners (SANEs; care providers with this designation have expertise in providing trauma-informed emergency post sexual assault care), three were nurses without SANE training, and another two were physicians. Six participants were women and three were men. One participant identified as Indigenous. Five participants worked at remote rural clinics or hospitals, and four worked in a town that serves as a healthcare hub for many proximal remote communities. The participants who worked in the rural town were SANEs who often treated sexual assault survivors who had been transferred from remote communities to receive specialized care. Usually, these would be assaults that were deemed particularly violent and traumatic, and/or assaults of individuals deemed especially vulnerable (e.g., minors; survivors with cognitive limitations). All participants of the study were found to work in hospitals that had ready access to SAEKs.

We developed three interrelated themes that are related to sociocultural barriers to post-sexual assault care in rural communities. These themes are: (a) substance use; (b) police involvement; and (c) being Indigenous. We note that beyond being interconnected, these themes compound one another such that sexual assaults that involved more than one of these themes simultaneously (e.g., an assault survivor who is both Indigenous and intoxicated at the time of assault, and who arrives at the ED in police custody) would encounter multiple sociocultural barriers when seeking care at a rural ED, thus reducing the chance that she would be offered a SAEK and be provided with prompt and empathetic post assault care. Pseudonyms are used throughout the findings to ensure confidentiality of the participants.

Theme 1: Substance Use

Most of the assaults that healthcare providers spoke of in interviews involved care seekers who were intoxicated when they presented at the ED or had been intoxicated at the time of the assault. The perceived pervasiveness of substance use among assault survivors in Northern communities is summarized by Laura, an ED nurse, who stated “I’d say typically there's always alcohol or drugs involved [when there is a sexual assault]. Especially like, just around here.”

Alcohol was also cited as a factor related to revictimization, and with repeatedly seeking post assault care in the ED: Louise (nurse):

She [assault survivor] was in [the ED] three times in one weekend.

Interviewer:

And do you think that was more domestic violence related?

Louise:

No, I think it was alcohol involved. Most of our assaults are alcohol involved.

Our interviews suggest that the state in which the care seeker arrived at the ED or clinic had an impact on the way the survivor was perceived, and treated, by the care provider. For instance, Amanda (a SANE) remarked:

I think even still now, I have had many really difficult conversations with my colleagues and even physicians that I work with of like, “oh, well, maybe if she didn't drink, this wouldn't happen again”. Or maybe, you know, “is this a ‘real one'?” Yeah, like, there's still a lot of really big rape myths that live in our society.

Similarly, Pamela, (SANE), recounted an incident when she witnessed negative treatment of an intoxicated post-sexual assault care seeker from ED staff, who declined to provide the assault survivor with basic comforts. She recounted the following:

I noticed that there was a lighter on the stretcher [that the survivor had been lying on] and said “oh, hey, is [assault survivor] coming back?” And she [the nurse] goes “oh, no, she's going home”. I said “oh, I thought she was just going to the washroom” because her pants were all wet. So, she had been incontinent with urine at some point. So, she had been there, I guess intoxicated for the night, been incontinent of urine, was now waking up in the morning and being discharged. And that nurse was sending her home with pee pants. And I said, “oh, like, wouldn’t you go to the clothing cupboard and get her some new pants?” She goes, “hmm, I don’t know”. And I said, “oh, did you give her a sandwich for the road or anything?” And she was like, “no”. I’m like, “oh okay”. So, we were going by the shared desk area at that time. And she says, “hey, what do you guys do for your HBDs?” So, your “Has Been Drinking.” The one guy said, “I don’t give them anything. They’re lucky if they get a glass of water.”

In Pamela's view, this was evidence of how healthcare provider bias against intoxicated care-seekers caused them to withhold needed care from an individual who had recently been through a traumatic experience. She also noted that when she brought her concerns about this situation to the attention of hospital management, she was met with indifference. To her knowledge, no follow-up actions were taken after her reporting of the situation. Furthermore, referring to intoxicated patients as HBDs suggests flippancy towards vulnerable people in need of care. Several interviewees recounted conversations that showed a similar lack of empathy among some healthcare providers for assault survivors, especially given the challenging circumstances that had brought them into the ED in the first place. Besides one nurse who was quite unguarded in sharing her opinions about the integrity and credibility of sexual assault survivors, the clearest examples of this came from conversations with SANEs, in their descriptions of interactions that they have had with frontline healthcare providers who lack specialized training in post sexual assault care. For example: “I wasn't sure about the rectal exam [in a case of an assault that involved anal penetration, which the interviewee reported encountering infrequently], and so asking the physician to come and look at it. And he was quite annoyed” (Pamela), and also:

There's still a lot of really big rape myths that live in our society, and like in our emergency department (…), that's [reinforcing rape myths is] not appropriate. Stop saying that. It's not your job to … and it's not my job to determine whether this [assault] happened or not. (…) So, you should probably not say that again. (Amanda)

Intoxication was also noted by many participants to impact the assault survivor's ability to remember what had happened to them. If an assault survivor had unclear recollection of the circumstances surrounding the assault, this uncertainty meant that some healthcare providers were less likely to trust the person's claim that they had been assaulted. Participants explained that in such situations, survivors sometimes requested a SAEK, not to gather evidence to support legal action against the perpetrator, but rather as a means of determining whether they had been assaulted. The care seeker's motivation to have a SAEK completed was deemed more credible if they had not been intoxicated at the time of assault, thus prompting healthcare providers to make decisions not to complete a SAEK if the rationale did not meet their justification for the forensic exam. Interviewees’ narratives suggest that some of them do not view using a SAEK to confirm if an assault occurred as a legitimate use of the of the SAEK. One participant said the following about a survivor she treated three days post use of alcohol:

Her want from the kit wasn’t to press charges or wasn’t to have any STD testing or any of that kind of stuff. Her expectation of us doing the kit was to like, confirm or deny if she had actually been assaulted. She couldn’t remember [what had happened]. (Laura, nurse, rural hospital)

Requests like this further undermined healthcare providers’ confidence in patient narratives, making it less likely that they would receive the full spectrum of post-assault care. It also bred frustration among healthcare providers, who frequently worked in understaffed rural hospitals and felt that assault survivors kept them from patients who were more in need and deserving of care. This is shown, for instance, in a statement by Ryan (ED nurse), who commented: [when we see another assault survivor, the attitude is] It's like, “ugh I can't believe there's another patient here that needs that.” You know? Because like I said before, it takes away that nurse from the already taxed nursing staff in that department. Similarly, Amanda (a SANE) described the following situation:

Well, the patient was intoxicated. So, I was refusing to do the kit till they could sober up and give proper consent, or else the kit would be useless. And so [the physician] was annoyed by that. Because you see, keeping a patient in Emerg all night until they sober up is not what Emerg wants to do.

As we see from this statement by Amanda, frustrations were compounded even further when care seeker intoxication increased the amount of time the assault survivor spent in the ED. It is important to note, however, that although some healthcare providers made decisions to complete a SAEK with substance involvement based on the perceived misuse of healthcare provider's time in a critical care emergency department, others based these decisions on valid concerns for the care seeker's ability to provide informed consent. As Amanda explained, healthcare providers could only conduct the forensic examination when the individual was sober and able to consent, but sexual assault survivors usually require monitoring until they are able to provide informed consent. Watching over these patients took healthcare personnel away from the regular flow of rural emergency departments that have very few staff working at any given time, causing care delays that were reported to breed further frustration, which was oftentimes directed back on the sexual assault survivor.

Theme 2: Police Involvement

Police presence featured in many of the sexual assault examples provided by participants. Though their involvement is not required in order for a survivor to receive care for sexual assault or even to receive a forensic examination, the presence—or absence—of police in sexual assault cases changed the ways that some care providers perceived survivors and their stories. For example, in the following exchange, it is evident that the participant believed the involvement of police would make a survivor's assault more credible. Here, it appears that police involvement would increase the healthcare provider's enthusiasm for carrying out a forensic examination:

[The decision to do forensic examinations] is case by case, kind of how much you believe it, the validity of the claim. If we seriously think that there's something going on and that this is something that needs to be addressed, and even in saying that like, depending on if they have police involvement or not, do you know what I mean? It's kind of like, you really need to, you really should call the police here, like we really need to–then our encouragement [motivation] would be higher, right? But if it's kind of like, “no, I was drunk this past weekend and like, I can’t remember”, then it's like …. (Laura, Emergency Department nurse, rural hospital)

As this quote suggests, the presence of police for certain sexual assault incidents appeared to incline the provider to believe that an assault had truly taken place. Indeed, several participants expressed the view that individuals who had not “truly” been assaulted would prefer to avoid police involvement, and inversely, that a person who had truly been assaulted would quickly reach out to police. However, if survivors were brought in for post assault care while they were under police custody, this could undermine the assault survivor's credibility in the eyes of some healthcare providers. The claim of having been sexually assaulted was less believable to some of them if the care-seeker was incarcerated. The following quote illustrates a situation where a sexually assaulted care seeker was brought to the hospital while in custody of the police:

This girl had been picked up on outstanding warrants. (…) And she's sitting in the back of the cruiser. And she's like, “well, like, you know, I was just like raped tonight. It was his fault.” So now they [police] have a due diligence to bring her to the hospital. So, they bring her to the hospital, they [a healthcare provider] do the kit, they take her statement and everything else and then … but she's still being picked up for her warrants, right? And then they go, and they get her boyfriend, and it's just … (…) In that situation, her making that claim, in that moment … it might have happened, like I’m not going to tell her it didn’t happen. Like I’m really not. But …. (Laura, Emergency Department nurse, rural hospital)

Laura believed that some care seekers under police custody used the claim of sexual assault and the need for a forensic examination as a means of temporary “escape” from police custody. The term used by Laura and several of other interviewees to describe this type of situation was “incarceritis,” whereby the individual pretends to need medical care (in this case, post-sexual assault care) because they want a break from police monitoring. It is important, however, to point out that not all healthcare providers shared in this disbelief of survivor narratives based on the circumstances of their presentation to the ED. In fact, one healthcare provider recounted trying to prolong the care of an incarcerated survivor out of sympathy for her situation:

[She was a] very small person. Not young, but small. Two big police officers bring her in, she was really intoxicated, had been sexually assaulted. I take her in my exam room, try to do some history. I feed her a sandwich; she throws up. I give her something to drink, and then she throws up some more. The police are outside waiting to take her back to jail. I know they’re going to take her back to jail. So, I just kept her as long as I possibly could. Because for whatever reason, she needed somebody to care for her. And that happened to be me. And I’m okay with that. And she was assaulted anyway. But you know, if people fake a story like that because they need to be cared for, I’m okay with that. (Pamela, SANE)

The interviews with SANEs conveyed a nuanced understanding of how police are involved in the immediate aftermath of a sexual assault. Pamela, for instance, noted that some survivors would want police to be involved, but for many, there was a misguided perception that police would be involved if they sought any post-assault care, which served as a deterrent to care-seeking in the first place. As she put it,

Police involvement was always a choice. And that is one real, real deterrent to patients coming into Emerg[ency department] for care, whether it's sexual assault or domestic violence, it is most people don’t realize that the hospital and the police are not in cahoots. Right? So, people are afraid to come to Emerg because they think that we have to tell the police, or that we’re going to tell the police. They don’t understand that the police are a choice. I’m not sure the police always like being a choice. And I, you know, I get that. But my job is to protect the patient.

While Pamela and the other SANEs understood the importance of survivor choice for police involvement, the non-SANE care providers were not so sure. Lack of training on the specifics of police involvement resulted in confusion for some practitioners, such as Gabe, a rural physician who noted: “The legal implications of what order things get done to hand off to the OPP [Ontario Provincial Police] and stuff like that, when should OPP get called … like I have no idea.” Others still viewed police involvement as important for confirming the assault survivor's credibility (and, therefore, the quality of care that they might receive), as depicted in Laura's accounts.

Our interviews also suggest that police involvement (or lack thereof) could influence whether a test would be administered. One nurse responded rhetorically when asked what factors would influence whether a SAEK would be administered,

Well, how did [police] pick them up [were they arrested, or did they call the police themself]? Or like, where were they found? Was what was the room like or were they walking along the side of the street, right? So, we rely on [police for those details].

Here, elements of intoxication, police involvement, and circumstantial characteristics were seen as factors to be considered when care providers decided about a survivor's need of a SAEK.

Theme 3: Being Indigenous

The proportion of the population in Northwestern Ontario that is Indigenous is higher than in most parts of Canada, and many rural clinics and hospitals are either near Indigenous communities or are key healthcare access sites for remote Indigenous communities further north. Indigenous assault survivors were noted to be among some of the most marginalized patients in rural EDs and were reported by participants as being over-represented among those seeking post-sexual assault care. George (a rural ED physician), for instance, succinctly commented that “there are two reserves near or close by. And certainly, those are some of the marginalized patients that I see,” while Pamela (a SANE) noted: “the degree of violence that Indigenous women suffer is often greater than what the non-Indigenous experienced. It's just a harsher degree of violence.” Moreover, when asked if most sexual assault survivors who present in the ED are from the local community, Ryan, (ED nurse who is Indigenous), responded:

From my experience, lots [of the sexual assault survivors that we see] are from communities, like [lists two reserves by name], like, these are all First Nations reservations, right? And I do believe we get, there is quite a bit [of sexual assault] there (…) I may just get the stories of the really bad cases and that's what kind of sticks out for me …

However, despite the disproportionate representation of Indigenous people among care seekers and the apparently greater violence perpetrated against them, participants noted that Indigenous patients sometimes encounter racism when seeking post assault care. Recall the interaction in the ED that Pamela explained involving an intoxicated care seeker who had urinated themselves and was not offered a clean pair of pants: this care seeker was an Indigenous woman. Indeed, when she was asked her impressions about cultural competency and cultural safety in relation to post-sexual assault care in her region, Pamela responded bluntly: If I have one regret, in my nursing career, it is probably that I did not stand up against fellow nurses who provided horrendous care.

Furthermore, when Indigenous assault survivors were intoxicated, participants either reported increased stigmatization of the survivors, or exhibited stigmatizing views themselves. For instance, some participants associated Indigenous assault survivors with intoxication. This connection is shown by the following quote by Louise, an ED nurse at a rural hospital:

Our Indigenous people get their cheques at the end of the month, and that tends to be when more alcohol is consumed. And that's when [sexual assault] tends to happen. We have some very wealthy reserves around us and they tend to get payments every three or four months of substantial amounts. That's usually when you’ll see them [sexual assaults] too, because they’ve gone out and spent their money and drank a lot …

Participants also noted that police often respond differently to Indigenous assault survivors as compared to non-Indigenous survivors. Pamela describes the differential treatment police gave to Indigenous vs non-Indigenous survivors:

I physically worked in that department to provide SADV [sexual assault and domestic violence] care and was able to witness some really shitty things. And you know, interestingly enough, like, the police would bring in an Indigenous victim and sort of drop her off. But if they were white? They would wait. (Pamela, SANE)

Moreover, when participants were invited to reflect on why an assault survivor might not want to involve police, it became clear that many of them were aware that members of certain groups would have cause to distrust the police. For instance, Gabe (a rural nurse) offered the following reflection:

I think lack of faith in the justice system, certainly is one aspect. Often coming from marginalized groups leads them to have a real fear of the justice system which knocks onto the sexual assault bit.

Discussion

In speaking of access to sexual assault evidence kits, one study participant commented that SAEK access is “one area of health care that a woman has a right to, but it's not without judgment.” Our findings emphasize the way that healthcare providers’ judgment of sexual assault survivors based on their personal qualities, their condition, and the circumstances surrounding seeking post-assault care can enable or inhibit their access to kits, and to empathetic care. The sociocultural barriers to post-sexual assault care that we identified include racism toward Indigenous sexual assault survivors, the stigma associated with heavy alcohol and drug use, and preconceptions about what police involvement implies about the assault survivor's claims. These barriers appear to influence how survivors are perceived by care providers in ways that shape the care that they receive, and they also influence the degree of credibility afforded to care seekers presenting in rural EDs. Pre-conceived notions about sexual assault, rape myths, and who qualifies as an “ideal victim” all featured in the interviews. These factors impacted how believable and empathy worthy the care seeker seemed to the care providers. The propensity for care providers to filter care decisions such as SAEK collection through a bias lens toward sexual assault care seekers is aligned with a downstream orientation to justice. Wentz (2020) identified that both prosecutors and police officers make discretionary decisions regarding sexual assault cases based on the perceived likelihood of acceptance by the prosecutor or likelihood of conviction. Importantly, we found that assumptions, stigmas, and biases seem to influence whether or not a SAEK would be used. Less credible care seekers such as intoxicated individuals were often not provided with an option for a SAEK, thus aligning with a downstream orientation to justice in sexual assault cases.

Our findings suggest that these factors directly influence whether a SAEK will be administered, in that the patient's ethnic identity, their state of cognition, and the presence of police all played into care providers’ decisions about whether or not to conduct a forensic examination. This runs counter to how healthcare providers are supposed to provide care in this situation. According to Bill 108, hospitals are to “provide sexual assault evidence kits to any patient who is in need of them” (Collard, 2022). Not only are they not supposed to offer different levels of care depending on their moral assessment of the patient, but it is also not their responsibility to determine whether an assault took place. They are not supposed to withhold care based on whether they believe an assault survivor's claims, yet our data suggest that some rural healthcare providers do precisely that.

Biases against intoxicated survivors also seem connected to complicating the flow of patients through rural EDs, which tend to operate beyond capacity and rely on a small number of staff. As Nugus et al. (2014) note, EDs operate with a “carousel” model, whereby patients, arrive, occupy a room or bed for a specific length of time, and then are discharged to make room for the next patient. When patients “block” rooms and beds for extended periods of time, it creates a backlog of waiting patients and can mean that ED staff are unable to provide needed care to other waiting patients. Waiting for an intoxicated assault survivor to become sober enough to consent or decline the use of a SAEK blocks the carousel, disrupting the flow of work and potentially complicating the provision of care for other patients (beyond our study, other sources [Macdonald & Norris, 2007; Shah et al., 2022] confirm that inability to provide informed consent for a forensic exam while intoxicated prolongs survivors’ stay in the ED). As a result, intoxicated survivors were viewed with disdain; they prevented care providers from being able to keep the flow of patients moving in the facility. This is especially concerning when considering how substance use is more prevalent in marginalized survivor populations—such as Indigenous and/or homeless individuals (Assembly of First Nations, 2022; Urbanoski, 2017). The intersectionality of these factors may result in increased stigmatization of intoxicated survivors and negatively impact the care they receive (McCallum & Perry, 2018).

Furthermore, intoxication is linked to an abundance of stereotypes about assault survivors, and patients in general. Substance use served to decrease the care providers’ belief in the survivor's credibility, which is a trend that has been noted previously by other researchers (Chalmers et al., 2023; Ullman et al., 2019). Previous studies have found that the intoxication of patients in the ED negatively impacts the mood of care providers, increases staff stress, and increases the perceptions of workload associated with the patient (Gunasekara et al., 2011; Verelst et al., 2012; Warren et al., 2012). The combination of the extended amount of time intoxicated survivors may require as well as the stereotypes labeling substance users result in a perfect storm.

For many people with dependencies, the perception that people “choose” to consume alcohol and use drugs is misguided. Underlying trauma (including intergenerational trauma) and/or mental illness can manifest through substance use (Spillane et al., 2023). More broadly speaking, in communities where alcohol and drugs are quite ubiquitous and access to mental and psychiatric resources is limited, the “choice” to use substances is highly constrained (Pijl et al., 2022). Furthermore, sexual assault is a significant trauma, and substance use and trauma are intricately linked. However, some care providers may still view the use of substances as a moral failing, thus limiting the empathy afforded to the survivor. However, the issue of informed consent is a valid concern for healthcare providers as aspects of the SAEK are intrusive, and care seekers must be informed of the procedures that are being performed.

The presence or absence of police for sexual assault cases in the ED was also found to have an impact on the way the care seeker was perceived by care teams, but in complex ways. On the one hand, if survivors chose to have police involved, their stories were seen as more credible and legitimate. On the flip side, the casual use of the term “incarceritis” to describe patients who, allegedly, feign sexual assault to receive medical attention and avoid police custody suggests that it is the context of the police's presence that can have great bearing on how assault survivors are judged and cared for by rural healthcare providers (see also Berry, 2014). In cases where assault survivors arrived in police custody, police involvement of incarcerated survivors increased suspicion of the survivor's claim. Indeed, we also found that police support for an assault survivor influences some healthcare providers’ willingness to administer a SAEK, seemingly basing this decision at least partially on whether the police were supportive of the survivor. This is deeply problematic, as in the immediate aftermath of an assault a survivor may be undecided as to whether to pursue justice, and they may ultimately wish to do so without the presence of police. Moreover, the decision to not involve the police is viewed as an abnormal request thus meriting suspicion, and incarceration of survivors also increased suspicion of the survivor's claim. The result in both cases is care providers who disregard and disbelieve survivors. This is also especially problematic when considering the deep, longstanding, and systemic distrust between Indigenous people and police, in Canada at large and in this region especially (Brockman, 2024; Law Enforcement Complaints Agency, 2024).

Differential treatment of Indigenous and non-Indigenous assault survivors by police is evident, for instance, in claims that police are less likely to remain in the hospital with Indigenous post assault care seekers. It is important in these situations to ask, why would a survivor potentially not want the police to be involved? Certain survivors may have had negative experiences with the police, especially Indigenous people who have a historically complex and traumatic relationship with police and judicial systems (Cotter, 2022). In Murphy-Oikonen and colleagues’ (2022) recent article, Indigenous women were found to feel less believed and more likely to be dismissed by the police when reporting incidents of sexual assault. Given the high rates of sexual assault affecting Indigenous women and girls in Canada (Heidinger, 2022), as well as the high proportion of Indigenous peoples living in the Northwest LHIN, it is plausible to conclude that many individuals affected by sexual assault in this region may be Indigenous and therefore may also not wish to involve police due to the reasons presented here.

Taken together, the interconnected themes that we have identified suggest that many rural ED staff have a clear concept of the “ideal” assault survivor who is blameless, deserving of sympathy and care, and worthy of a SAEK: a sober white woman who is assaulted in a “safe” place, who then calls the police for help, and who arrives in the ED with supportive police presence. As Melanie Randall states,

The archetype of the ideal sexual assault victim still functions to disqualify many complainants’ accounts of their sexual assault experiences. To this extent, the “ideal victim” myth continues to undermine the credibility of those women who are seen to deviate too far from stereotypical notions of “authentic” victims and too far from what are assumed to be predictable and “reasonable” victim responses. (2011, pp. 397–398)

The “ideal victim” concept is also supported by rape myths, as noted by one of the SANEs who participated in the study. According to former Canadian Supreme Court Justice L’Heureux-Dubé (2001), rape myths include some of the following: the rapist is a stranger, women with any previous sexual relations or encounters are less credible and more likely to consent, and women must be emotional as a symptom of the assault. When lack of sexual assault training meets system challenges, staff shortages, institutional racism, and harmful stereotypes like these, we have found that the result is care providers who are less inclined to perform a forensic examination for a survivor. Beyond the implications that this holds for addressing the justice gap and ensuring that assault survivors receive the care they need at the time when they need it most, encountering stigma and discrimination when seeking post assault care can influence survivors’ decisions to seek emergency care from health systems in the future.

Given the small sample size of interviewees in this study, it is difficult to draw concrete conclusions regarding differences between SANE and non-SANE providers, as well as providers who work in rural vs. urban centers. However, it is beneficial to note that the 37 survey responses from a variety of rural and urban centers (including both SANE and non-SANE providers) echo the interview findings about nuances in care resulting from demographic characteristics of the care providers. Research has found that there is a significant difference in attitudes towards sexual assault patients if the provider has SANE training. Nielson et al. (2015) found that those with SANE training had more positive attitudes towards survivors than those without SANE training. This again reflects the power of sexual assault training to disprove harmful rape myths and better address the specific needs of sexual assault survivors, resulting in improved patient outcomes.

Finally, it should be noted that this study took place during the COVID-19 pandemic, which shaped and constrained the data that we were able to collect. Most notable was the difficulty in accessing emergency care providers to participant in this study. Emergency Department pressures that existed prior to the pandemic have worsened; staffing crises, capacity shortages, staff turnover, long wait times, and ED closures all impacted the ability of care providers to devote time to interviews and survey response (Canadian Association of Emergency Physicians, 2023). Due to these reasons, it was also difficult to obtain interview participants from every hospital located in the Northwest LHIN.

The rural and Northern healthcare environment of this study therefore has unique implications for sexual assault survivors. Recent findings by Miyamoto et al. (2021) have found rural sexual assault care faces barriers related to lack of clinician training, low volume of sexual assault cases (which impacts care proficiency), financial constraints, as well as turnover and burnout. Our study on logistical barriers to sexual assault care reported similar results in Northern Ontario. Therefore, it is clear that hospital specific protocol would be beneficial for outlining what unique treatment plans should be followed for rural hospitals without SANEs.

Telehealth is a form of healthcare deliverance that has gained traction since the COVID-19 pandemic, and it offers practical implications for access to care in rural areas (Patterson et al., 2022). It is described as a care interaction with a patient and care provider (s) that is facilitated by videoconferencing with a secure electronic network (Jong et al., 2019). It has also been described by previous research as well as participants of our study as a novel way to allow survivors to be treated at a facility close to their home with one of the care providers on-site, while still receiving connection to a SANE and their SA expertise through virtual connection (Allison et al., 2023). Telehealth for sexual assault care in rural areas is especially beneficial because it allows the survivor to decide about what best suits them, as described by participants in our study.

The possibility of expanding telehealth for sexual assault care has been explored very recently by several researchers across North America. Despite its potential benefit to the survivor, it is important to also recognize that implementation of such programs will still require training, organization leadership, and continual monitoring (Miyamoto et al., 2021). The two care providers both instructing and receiving guidance require training for the telehealth encounter, and proper facility equipment for virtual care is also needed (Allison et al., 2023).

Ultimately, the survivor's ability to choose between in-person vs virtual care options is paramount; telehealth simply provides another option to the survivor to ensure that care post-assault best meets their needs. Nevertheless, knowledge about the legal aspects of sexual assault, including the chain of custody of forensic evidence, are still needed for practitioners partaking in virtually assisted or in-person SA care. Furthermore, the basic tenets of antiracist trauma informed care approaches are still needed for the treatment of survivors receiving care through telehealth models.

Conclusion

It is important to place the findings of this study within the context and realities of the current Canadian legal system. An important question raised by this research is whether emergency healthcare facilities are the appropriate settings for the use of sexual assault evidence kits, which are not healthcare tools, but rather forensic ones. As evidenced by these study findings, offering SAEKs in EDs exposes assault survivors to biases and misguided assumptions about sexual assault that are harmful and are also well-documented in Canadian healthcare. The current process for SAEKs also causes increased ED stress—a lesser evil, to be sure, but one that could result in poorer quality care for another medical care seeker, and which breeds frustration that can be directed back upon the assault survivor (see also Murphy-Oikonen et al., 2022).

This is not to say that SAEKs should be disregarded or abandoned entirely. Alternatively, their use should be analyzed with a critical lens. Who decides to use a SAEK? Survivors should have the ultimate say in this decision, and it should be an informed one. There should be full transparency as to what the forensic examination will entail, and also what the legal proceedings may be if the survivor choses to report the assault. Additionally, if the survivor decides to have a forensic examination, trauma informed patient-provider communication is necessary to facilitate consent at each step of the process. Are Emergency Departments the correct place for non-medical post sexual assault care? There is the major advantage of their 24/7 service, but is this realistic in light of rurality and staff shortages? The carousel-like movements of Emergency Departments do not appear to meet the needs either of assault survivors or care providers. Certainly, overall system pressures related to emergency care in Canada need to be addressed to repair gaps in the services that are provided to not only sexual assault survivors, but all individuals seeking emergency care. However, this alone does not address the impacts of the socio-cultural barriers to care that we have identified here. We call for the development of resource specific protocols to be made by hospital leadership in conjunction with Sexual Assault Nurse Examiners and Ontario Network specialists, to better suit the needs of those who have experienced sexual assault, while remaining within the confines of the training available to the staff. We suggest further discussion into the application of telehealth models for rural sexual assault care, implication of trauma informed care training initiatives, and also call for stakeholders to engage in dialogue surrounding the use of SAEKs in rural Emergency Departments across Canada.