State’s program for sex-assault victims has flaws, experts say

A program touted by Gov. Gretchen Whitmer as an immediate medical support intervention for sexual assault survivors is unlikely to have a significant impact across the state, despite claims it would protect Michiganders. 

Sexual assault survivors are being given access to emergency contraception as well as prevention of sexually transmitted infections. Paramedics are also being trained to provide basic evidence collection as well. 

But experts say the public-facing push on the program was misleading and could result in failures for patients and paramedics. In addition, they express concerns the program fails to account for the costs of medications or help people navigate the medical system to get timely care. 

Elizabeth Hertel, the state health and human services director, announced Nov. 2 that “these critical new protocols will help ensure that survivors have access to crucial reproductive care treatment and appropriate medical care as soon as possible.” 

The catch is that many of these services are provided through private ambulance companies — and only those with specially trained Community Integrated Paramedics.  As of mid-2021, only 22 communities in Michigan are operating with CIPs, private or public, according to data from Michigan State University. Lansing is not one, Lansing Deputy Fire Chief Michael Tobin confirmed.

CIPs take on additional duties above and beyond their paramedic role of emergency intervention. 

The protocols were seen as a defense in the event a ballot proposal to enshrine reproduction health rights in the state’s Constitution failed and the Michigan Supreme Court upheld a 1931 ban on abortion. The proposal passed in the General Election in November. 

“Today, Michigan is setting a national example by providing first responders the opportunity to carry emergency contraception so they can get survivors of sexual assault the care they need,” said Whitmer in that Nov. 2 announcement. “With the threat of a 1931 law banning abortion even in cases of rape or incest taking effect in Michigan, sexual assault survivors deserve our support and resources more than ever. I am proud of today’s changes to make Michigan a leader in sexual assault response by ensuring that EMS responders can deliver emergency contraception and appropriate medical care. Let’s keep working together to protect Michiganders and ensure they can get the care they need.” 

Outreach to several domestic and sexual violence organizations nationally found that Michigan was leading the way in providing immediate support and care for sexual assault survivors, even with just 22 CIP programs operating statewide. 

Despite the groundbreaking move, there are concerns from a medical standpoint. Dr. Erik Wert, an internal medicine doctor in Lansing who is licensed to treat people living with and at risk for HIV, reviewed the protocols and found “multiple issues.”

Wert said the cost of delivering the antibiotics recommended in the protocol may be prohibitive. One drug, ceftriaxone, can run as much as $1,000 for a course. He said prescribing metronidazole to men is not recommended. It treats the STD trichomoniasis, which is rarely transmitted to men. Wert was concerned about the provision of prescribing the antibiotic doxycycline to women, particularly women who may be unaware they are pregnant, for whom it is contraindicated.

Spokesperson Lynn Sutfin said MDHHS will be providing training to CIPs on when and how to deliver the antibiotics. 

“These programs handle medications in different geographic areas,” Sutfin said. “Some always carry a variety of antibiotics with them as they treat other infections as well, some work with partner hospital pharmacies and some obtain medications from local pharmacies on an as-needed basis for patients.”

She said the protocol adopted in October and announced in November was not a stand-alone protocol for CIPs. Instead, it was part of interconnected “suites of protocols.” She also said the protocols are not separate from the need for survivors to have follow-up medical care. The protocols are designed “for use when an individual does not desire to be seen by someone else and one of the main goals is to advise the patient about accessing additional resources in a timely manner, including PEP (Post-Exposure Prophylaxis).”

PEP is a medical intervention to prevent a person from contracting HIV after exposure. The CDC reports that if initiated within 72 hours of exposure, the intervention is “highly effective” in the prevention of HIV infection.

The Nov. 2 announcement highlighted the program as having CIP “programs carry emergency contraception kits and sexually transmitted infection treatment (HIV/STI prophylaxis).” That is not an accurate reflection of the adopted protocol, however. The voluntary program would provide referrals and information about HIV PEP, but not the drugs themselves. 

Wert found that troubling.  

“How is the patient supposed to get the PEP medication within 72 hours?” he asked. “It is going to be difficult to get into an infectious disease specialist, so their primary care provider would have to prescribe and many are not comfortable with prescribing PEP. Their PCP or an ID specialist may not have an appointment available in the 72-hour timeframe.”

Kristina Schmigdall, the executive director of the Lansing Area AIDS Network, also expressed her concerns about accessing PEP, echoing Wert’s concerns.

“With the initial press release, I thought that PEP would be offered by the responders, but now it seems that they will educate individuals about the medication,” she said. “While this is a step in the right direction, there is a need to address accessibility.”

Responding to Wert’s written concerns, MDHHS’ Sutfin said the department is developing the training around the new protocols and that the department “welcomes feedback to ensure clinicians are fully able to address a variety of issues.”

“I fear that this protocol may have been written with the best of intentions,” Wert said, “but seems to have been poorly thought out to provide the care a patient needs.”