For the most part, rural parts of South Dakota have gone without specialized nurses who help treat survivors of sexual assault. But underserved areas are getting more resources through a statewide program, including telehealth assessments.

In the past couple years, an initiative has worked to get more health-care professionals onboard in South Dakota as Sexual Assault Nurse Examiners. Kristi Kranz, who heads the SANE program through the Center for the Prevention of Child Maltreatment, said these individuals play an important role in working with someone who's just experienced a very traumatic event, "both on the medical side, to ensure that they're receiving the best medical care, and then also on the forensic side, to collect the potential evidence if the victim wants to move forward with reporting that to law enforcement."

One of the emerging elements of the program is through Avera Health, which now offers around-the-clock telehealth exams in rural emergency rooms. Trained SANE staff help with patient assessments as the person is being tended to by onsite medical personnel. Avera provides these exams at 17 locations in South Dakota.

Prior to these options, said Jen Canton, SANE supervisor at Avera Health, survivors often were sent two to three hours to the state's largest cities, such as Sioux Falls or Rapid City. She said having immediate, specialized care much closer helps prevent setbacks in an assault survivor's attempt to confront the situation.

"It kind of sets the pathway for their healing," she said. "So, if they have a bad experience in the ER, it can negatively affect their healing. If they have a positive one, it sets them on a positive road to healing."

She said launching this part of the program has been slow at times due to the pandemic, but all 17 sites now are in a position to help. Canton said being ready this time of year is crucial, because holidays can see an uptick in assault and domestic-violence cases. Leaders behind South Dakota's broader SANE program have said it has been renewed for another year of funding, in hopes of training more nurses.

A new statewide initiative aims to help connect domestic-violence survivors with medical providers, with a focus on treating traumatic brain injury.

Rachel Ramirez, founder the Ohio Domestic Violence Network's Center on Partner-Inflicted Brain Injury, said survivors often experience severe violence aimed directly at the head, neck and face. But there's been a longstanding gap in accessing the right medical services when individuals come into shelters.

She said $5.12 million dollars in funding will be used to pay for medical services.

"To pay for health care that people are not able to get reimbursed through other means, through Medicaid or insurance. We want to investigate the possibilities of working with occupational therapy to help with brain-injury rehabilitation," Ramirez said.

The three-year project in collaboration with the Ohio Association of Community Health Centers will cover four to six areas of the state. According to data from the Ohio Domestic Violence Network, the state suffered 112 domestic violence-related fatalities between June 2021 and June 2022. More than twenty of those killed were children.

Ramirez said advocates are also working on developing a statewide virtual and call-in center known as the Care Health Connection.

"That will be a place where domestic-violence programs and survivors can also talk to an advocate when they have health-related needs to help them get better connected to either telehealth services, behavioral-health services or other health services in their community," she said.

Emily Kulow, director of mobile advocacy and meaningful access at the Ohio Domestic Violence Network, said the goal is to eliminate barriers that prevent survivors from seeking help, and then providing a holistic approach once a connection has been made.

"So checking in with the survivor about what's going on with their housing, what's going on with their health care. When was the last time they were even seen by a doctor," she said.

According to the National Center for Health Research, women who experience domestic abuse are more likely to suffer from diabetes, asthma, lower back pain, headaches and other chronic conditions.

A bill headed to President Joe Biden's desk addresses a long-standing problem for domestic violence survivors, ending their ties to their abusers' cellphone plans.

A North Dakota coalition predicts the changes will be helpful. The Safe Connections Act recently cleared its final Congressional hurdle. It removes financial penalties for survivors who are trying to separate their phone lines and their dependents' lines from an abuser.

Dana Mees, administrative director of the North Dakota Council on Abused Women's Services, said unresolved phone plans can be a major obstacle for someone from trying to move on from an abusive situation.

"They do give abusers access to call logs, text messages, voice mails, or family tracking features that can be used to monitor, stalk and harass survivors," Mees explained.

She added survivors are forced to pay a lot of money in termination fees, often making it difficult to transition to a safer environment. The bill had bipartisan support, but other advocates say they would have preferred policymakers not include a provision requiring the survivor to provide documentation they were abused, arguing it added to their trauma.

A separate aspect of the bill calls on the Federal Communications Commission to create rules requiring cellphone providers to expunge any calls or texts to hotlines, such as those operated by crisis centers. Mees noted it is another important tool.

"If they're calling a crisis line, and that shows up in their call log, that can tip an abuser off that they're thinking of leaving," Mees pointed out. "It can put them in a more dangerous situation."

As for financial barriers, the bill expands eligibility for the FCC's Lifeline Program, which provides monthly cellphone plan subsidies.

Collectively, Mees believes the actions should help survivors move forward with their lives without having to change a number or get another phone. President Biden is expected to sign the measure.

Rape crisis centers assist sexual abuse survivors and educate about violence prevention, and collaboration is a key aspect of their work.

The Ohio Alliance to End Sexual Violence supports rape crisis centers throughout Ohio, and recent regional meetings offer insight into what is happening on the ground.

Elle Fullenkamp, manager of training and technical assistance for the organization, said many centers are stepping 'outside the box' when it comes to prevention programs.

"Whether that's youth programs, like funding youth centers so that people can have spaces to have healthy relationships," Fullenkamp explained. "There are also community-based prevention programs and collaborations. We saw some tattoo shop and faith-based training projects. That's a really cool thing that we saw happening."

A common theme, she noted, is inadequate funding, which can create staffing shortages and the inability to sustain the programs needed to help survivors.

Caitlin Burke, the group's director of prevention and public health, said some programs are holding listening circles to help them tailor their prevention-based work to meet local needs.

"So, even if the community isn't necessarily worried about sexual violence, maybe they're worried about gun violence, or maybe they're worried about community or gang violence," Burke outlined. "How can we work together? Because we know that if we're working to reduce gun violence, we're likely also going to be working to reduce sexual violence. Violence is often intertwined."

Fullenkamp added many centers shared concerns about how to engage educators and parents about violence prevention in their school-based programs. She emphasized evidence-based programming is needed at an early age, as junior-high students already report they've experienced forms of violence.

"Unhealthy relationships or sexual harassment, bullying, being teased for their bodies, or things like this that are covered in the types of trainings that our programs do in junior highs," Fullenkamp pointed out. "Even at that age it's too late; these things are being experienced by these junior-high students."

Due to the pandemic, it is the first time in two years the regional meetings were held in-person. Burke stressed it allowed for providers to share their successes and concerns, and brainstorm ways to support each other.

"Collaboration just gives chances for innovation; for us to think bigger and learn from each other, and be more creative," Burke remarked." With any sort of project, it's really crucial that folks are able to get together and bounce ideas off each other. And in that way, we are also collectively working towards the same goals."

While sexual violence data is underreported, at least 25,000 survivors are estimated to be served by rape crisis centers and the Ohio Alliance to End Sexual Violence each year.