Credit: Kiichiro Sato/AP

Since its inception in 2016, the In Power program at Howard Brown Health (HBH) has served a desperately needed role as the first in the nation designed specifically to serve LGBTQI+ survivors of sexual violence. 

A handful of former and current nurses and social service workers at HBH, however, say that their ability to carry out the program’s mission and provide high-quality care is being undermined by executive and medical leadership at the organization. They cite burnout and “moral injury” due to a chronic lack of support and outright hostility from leadership toward staff and patients, chaotic understaffing, and trouble even finding rooms to meet with patients. 

“It’s an organization that prides itself on equity, but there’s no equity for frontline workers,” says Lindsay Cogan, who worked at In Power as a case-management consultant from February 2021 to February 2022. “And it’s incredibly demoralizing.”

In January, HBH suspended Jules Gelbort, who had been the only Sexual Assault Nurse Examiner (SANE) on staff. Gelbort says they were hired in January of 2021 due to their 1.5 years of experience doing medical forensic examinations (MFEs) in an ER, and were brought on specifically to start the MFE program at In Power. The official reasons for their suspension are still being discussed via an investigatory process between HBH’s human resources and the Illinois Nurses Association (INA), which represents nurses at HBH. But Gelbort and several of their colleagues say they’re being retaliated against for advocating for a patient when HBH refused to support them during an MFE, also known as a “rape kit.” 

Julia Bartmes, the INA’s executive director, says the union has seen a troubling pattern of retaliation from HBH against nurses who raise concerns about management practices and patient care. “We will also be pursuing unfair labor practice charges against Howard Brown in instances where there has been retaliation against union leaders, which we feel that there has been,” she says. 

The INA already has three grievances on file with HBH that involve claims of retaliation against union leaders and nurses who’ve pushed back against management, including one the union announced last month behalf of Gelbort, and Bartmes says they will probably file more soon.

Now, medical forensic exams at the clinic have been halted altogether. During a meeting on February 2 between Gelbort, the INA, and HBH leadership, Bartmes asked HBH chief clinical officer Magda Houlberg if the clinic was going to tell the community that they had halted MFEs.

The next day—more than three weeks after Gelbort was suspended—Paviella Foster, HBH’s chief program officer, sent an internal email that said that “due to staffing shortages, Howard Brown Health is placing a temporary pause on performing Medical Forensic Exams (MFE) through our sexual harm recovery program, In Power.”  The clinic updated their website to state they are “temporarily unable to offer Medical Forensic Exams at our clinic sites.” 

HBH did not respond to the Reader’s questions. 

When the program started in 2016, In Power nurses and case managers would accompany LGBTQI+ patients to the ER for medical forensic exams as advocates, then provide free trauma-informed follow-up care, counseling, and help with housing and other resources at HBH to help patients access safety afterwards. 

Many of these patients are gender-nonconforming, experiencing homelessness, using substances, or doing survival-based sex work, and had a history of trauma in ER settings as a result. Several told In Power staff that they hadn’t been believed by ER workers or police in the past, were told that their assault was due to their own behaviors or circumstances, or that the ER exams were re-traumatizing. Many patients had never been offered the sort of care and support that In Power was designed to provide.  

“A lot of agencies are very cis woman-centered, and the reality is that sexual harm and intimate partner violence happens to everybody,” Cogan says. In a competent and affirming setting, “you don’t need to justify your existence to receive care.” 

The data surrounding assault against LGBTQI+ people is staggering. According to a 2010 report by the Centers for Disease Prevention and Control in 2010, 44 percent of lesbians will be raped, experience physical violence or stalking at the hands of an intimate partner, compared to 35 percent of straight women. Gay and bisexual men are twice as likely as straight men to experience sexual violence. Half of all bisexual women and trans people will experience sexual violence. The pandemic has also increased the risk of intimate partner violence. And most survivors of sexual violence, regardless of sexual orientation or gender identity, don’t report their assaults to police.  

In June 2020, at the urging of advocates such as psychologist Paige Baker-Braxton and registered nurse Katie Luedecke, Governor J.B. Pritzker signed an amendment to the Sexual Assault Survivors Emergency Treatment Act to allow Federally Qualified Health Centers (FQHCs) such as Howard Brown Health to provide medical forensic exams (MFEs) for survivors of sexual harm during the public health emergency declaration for COVID-19. Previously, these exams had only been available in hospital ERs. As COVID patients filled emergency rooms, advocates felt that allowing certified nurses to perform these exams in a clinic like HBH’s In Power program was not only a way to relieve overwhelmed hospitals, but could also help create a more affirming way to support trans and queer survivors of sexual assault.

It is illegal to charge survivors for treatment for their assault, such as medical forensic exams, emergency contraception, STI treatment, PEP, patient follow-up care, and sometimes even counseling, as long as the survivor goes to an ER or FQHC. The state is supposed to cover the entirety of those costs, although studies examining state payment practices have found that many survivors are still charged by hospitals erroneously. 

According to the Illinois Attorney General’s Office, which oversees the state’s SANE program, HBH is no longer eligible to use the state’s sexual assault services voucher without a SANE nurse on staff or a treatment plan on file with the Illinois Department of Public Health. Howard Brown is the largest LGBTQI+ federally qualified health center in the midwest and currently the only FQHC in Illinois that provides MFEs. What all of this means for patients seeking services at In Power is unknown.

A typical MFE takes four to six hours. It’s a thorough head-to-toe exam that also includes an interview about the incident. The survivor can stop, pause, or skip a step whenever they want, and restoring a sense of safety and decision-making power to the person who experienced their choices being violated is of the utmost importance. SANE nurses go through a 40-hour training and learn how to provide trauma-informed care. And as a trans person, Gelbort was able to provide culturally competent and affirming care for the population that HBH serves. Of the 194,597 registered nurses licensed in Illinois, fewer than 500 are SANE certified. There are no stats about how many are queer or trans, but Gelbort estimates that the percentage is even smaller. 

While the results of MFEs are often used as evidence to build a stronger case in court against an aggressor, some survivors who ask for the exam do so without that in mind. “For some people [the MFE] can be validating or part of a healing process to make sure that their bodies are healthy and safe. For a lot of people it can help them move forward,” Gelbort says. Survivors are not required to report their assault to the police, though they have that option.

“When people feel supported by an organizational structure, they’re more resilient in the face of that vicarious trauma. But if the organization you’re working for doesn’t let you do the job that you’re there to do, you feel it so much worse.”

Jules Gelbort

The program at HBH has performed ten medical forensic exams since March 2020 and has served 430 survivors since November 2020. As the clinic’s only SANE registered nurse, Gelbort conducted all of the MFEs. They were suspended from HBH the day after the last one. 

According to Gelbort, medical leadership never gave them an official reason for their dismissal, citing “clinical issues” and “what happened during the medical forensic exam.” The decision to suspend them boils down to an exchange they had over HBH’s internal messaging program, Gelbort says. When they felt the patient’s needs and their own were not being met, they advocated for them in the chat log, and they say that’s what prompted their suspension. 

As a certified sexual assault nurse examiner in the clinic’s In Power Program, Gelbort was able to conduct medical forensic exams without a doctor or physician present, although best practices state that a dedicated provider should be available immediately during an MFE should a need arise outside of a SANE’s scope of practice as a nurse. Gelbort says they had been asking HBH to hire someone for that position for months.

During the last medical forensic exam they would perform at HBH, Gelbort says they noticed something that may have been a pathology. Diagnosing is outside of their scope of practice as a nurse, so they took a photo to show one of the MDs or PAs. Forensic photography is a standard of care in MFEs, and is often used to get an expert second opinion from a busy clinician who wasn’t present during the exam, as well as in a criminal trial as evidence. 

Gelbort says that in a series of back-and-forth messages in HBH’s internal chat—which the Reader has not independently reviewed—multiple members of medical leadership refused to look at the photo, and withdrew all clinical assistance, saying that all the providers were busy. They ultimately told Gelbort to refer the patient to OB-GYN for a follow-up appointment. 

The whole purpose of the program is to create the most trauma-informed process possible, and Gelbort says they wrote in the chat that subjecting the patient to another invasive and potentially unnecessary exam did the opposite. And why was the provider initially assigned to them for this exam now no longer available? 

“I wouldn’t have started this exam if I knew I wouldn’t have support,” Gelbort wrote in the chat. 

Eventually, someone in medical leadership told Gelbort that they wouldn’t sign off on their chart unless they dismissed the patient and referred her to an OB-GYN. With their license hanging in the balance (there could be consequences for not having their charts signed by a higher-up) Gelbort says they felt like they had no other choice but to do that, against their own expertise and advice. The half-hour conversation in the chat happened while the patient waited in the examining room. 

The next day, Gelbort was filling out paperwork in their shared office when their phone rang. It was the director of nursing calling to tell them that they needed to pack up their stuff and vacate the premises immediately. Their shifts were canceled until further notice. Gelbort was allowed to finish their paperwork, then grabbed their things and left.

In Power medical and social services staff can be traumatized by bearing witness to the trauma and violence their patients have experienced, a phenomenon called vicarious trauma. “When people feel supported by an organizational structure, they’re more resilient in the face of that vicarious trauma,” Gelbort says. “But if the organization you’re working for doesn’t let you do the job that you’re there to do, you feel it’s so much worse. I think that’s really weighed on the entire In Power team.” 

Current and former staff who are calling for accountability from HBH leadership say they’ve previously tried to steer the program in a better direction. When the MFE program shut down for a month last fall, Gelbort, Cogan, and their team created a detailed proposal on how to establish sustainable medical support and infrastructure grounded in patient needs in order to restart medical forensic exams. But according to Gelbort, medical leadership didn’t respond, and they were ordered to resume the MFE program with no new supports in place. Gelbort documented three people who were turned away during that time who came to the clinic seeking an MFE. 

A registered nurse who works at HBH and who spoke to the Reader on the condition of anonymity says that people who are critical of medical leadership get remanded. “Why did HBH leadership spend all this time and energy lobbying the governor to have MFEs to just not support the people who run the program?” they said. 

According to Katie Luedecke, who worked as a registered nurse at HBH from 2015 to 2020 and helped start the In Power program, while HBH claims to center community care, “they are always going to put their own financial needs ahead of that.” This shift in priorities, according to Luedecke, is occurring because of the way the clinic relies on funding from insurance reimbursement. Nurses are not billable for their time, but providers (doctors, nurse practitioners, and physician assistants, as opposed to registered nurses) are, she says. Uninsured and Medicare patient visits with providers are billed to the state per appointment, not for the amount of time they spend with them. 

Luedecke says she and others believe that Howard Brown is optimizing their billing practices by overworking providers and minimizing the role of nurses, which is something that galvanized her and her colleagues when they started organizing for union representation in 2018.

Being seen by an RN who has been trained in trauma-informed care, and doesn’t have a time constraint, “means that there are better outcomes for the patient when it’s a nurse-led initiative,” according to Luedecke. But when the organization puts pressure on providers to see as many patients as possible in order to bill for their time, “it’s going to be a problem for the patient.”

The amendment to the Sexual Assault Survivors Emergency Treatment Act that allows MFEs to take place at FQHCs was renewed in November and will be in effect at least through 2023. In the meantime, staff members say they’ll continue to speak out about the ways that HBH leadership fails them and their patients. “We really have the potential to have such an incredible thing here, and [executive and medical leadership] just keep blocking us from doing it,” Cogan says. “I truly cannot express to you the hours that I have spent in frustration and tears.” 

“I know a lot of people in the community who have had more and more negative experiences at Howard Brown,” Gelbort says. “And I really encourage patients if you’re able, and if it’s safe for you to speak up about that, to file grievances, to use your voices. There needs to be some pressure on Howard Brown to be accountable to our community and to the workers who are part of that community.”

If you or someone you know is experiencing intimate partner violence, or need help accessing an MFE or other resources for survivors of sexual harm, please follow the links below. Currently, In Power is the only LGBTQI++ focused sexual harm program in Illinois. The 24-hour Chicago rape crisis hotline is 888-293-2080 and more information is available at Resilience (formerly called Rape Victim Advocates) which provides counseling and other services, along with Between Friends, The Network, and Mujeres Latinas En Accion.