How could it be legal for multiple Houston, Texas, emergency rooms to refuse Dinisha Ball a rape kit? The complicated, infuriating, little-known reasons why women can be denied emergency care after a sexual assault.

Dinisha Ball and her best friend Loraine* pushed their way through a crush of people at Houston’s upscale Belvedere Club to an empty space near the back of the courtyard, where a crowd had gathered outside to hear the live band. The friends had left their partners at home — Dinisha’s fiancé, Daniel Koza, and Loraine’s boyfriend, Charles* — in favor of a girls’ night to celebrate Dinisha’s new job and a promotion for Loraine that would relocate her to California. It might be one of their last times together for a while. They had to make it count.

The women had taken their time getting ready at Loraine’s hotel room at the nearby Marriott, where she was temporarily living in preparation for the cross-country move. After their first round of vodka cranberries at the club, they moved inside and claimed two spots at the corner of the bar, where they’d have more room to talk.

As the dance floor came alive, Dinisha caught the bartender’s attention and ordered another vodka cranberry. "I can’t finish this by myself," she shouted to Loraine over the noise. "I’ll help," Loraine said. Soon the women left their drink to dance. Various men approached them, but they demurred — they wanted to be alone.

At some point, a tall man in an expensive-looking suit approached Dinisha. He leaned in, but the music was too loud for her to make out his words; she just smiled and nodded, taking note of his nice white teeth. "What’s your phone number?" he shouted. Dinisha called back, "I have a fiancé," she said, shaking her head no.

That’s when the night fades out.

Dinisha’s eyes creaked open. She blinked, confused. Where was she? Where was Loraine? She felt dizzy; her head was shrouded in fog. Then terror started to wash over her as she realized she wasn’t at home, in her own bed, with Daniel.

Another face came in to focus next to her. White teeth. The man in the expensive suit.

"I can’t be here," Dinisha muttered, scared and disoriented, as she pushed him away. "I have a fiancé; we have a kid."

She stumbled off the bed and staggered down the hallway, repeating Loraine’s hotel room number aloud to herself like a mantra. In her confusion, Dinisha assumed she was at her friend’s hotel; if she could just find Loraine’s room, everything would be fine. She didn’t feel drunk — it was something different, like her body was completely disconnected from her mind.

The man followed Dinisha down the hallway, grabbing her arm and steering her back to his room. "I’m taking you to see your son," he said.

Hours later, Dinisha woke up again, still wearing her black-and-orange striped club dress. The man was on top of her. Now she felt more in control. "Get off me!" she screamed.

He didn’t argue. Instead, he stood up and handed Dinisha her underwear, as casually as a waiter would hand her a bill.

How could I have gone home with this guy? she wondered, horrified, as she pulled on her underwear with shaky hands. She would never cheat on Daniel.

"Do you want a ride back to your car?" the man offered. Dinisha just wanted to get away, but as she looked around, she found she had nothing with her: No cell phone or purse. Numbly, she followed him out of the apartment. As she left, she noticed that there was no furniture in the apartment other than a bed. And a pile of shoes, stacked up by the door.

A bang on the front door woke up Charles, who’d drifted into an uneasy sleep after putting Loraine under a cold shower. He’d discovered her at the Belvedere at 1 a.m., making out with a stranger — her eyes glassy, a blank expression on her face — after he’d gone to pick up the duo. When he tried to call Dinisha’s cell, it rang from inside Loraine’s clutch, where he also found Dinisha’s credit cards, cash, and keys. Charles had assumed Daniel had come to pick her up; it crossed his mind that maybe Dinisha had gone home with someone else, but he didn’t want to cause trouble by calling Daniel to check.

He opened the hotel room door to find Dinisha, sobbing and gasping for breath. She pushed past Charles, crawled under the covers, and curled up next to Loraine. She didn’t really know how to explain what had happened: The man with the white teeth had given her a ride to the hotel in his black BMW and driven away. She was too distraught to say anything else.

Loraine, now fully coherent, gave Charles a look. "Call Daniel," she said.

Daniel had been frantic since he’d woken up at 4 a.m. and realized Dinisha wasn’t there. He’d called her 23 times by now. (He didn’t know Loraine or Charles well enough to have their phone numbers.) Dinisha was too upset to talk to Daniel herself, so she gave Charles Daniel’s phone number. When Daniel arrived, with their 2-year-old trailing him, he found Dinisha lying in Loraine’s lap, sobbing. He knew right away that they’d both been drugged.

"I’ve never seen her look like this before," Daniel said to Charles, as panic rose in his chest. Charles agreed: "I think they were roofied."

Dinisha reached out to her son, but he recoiled, scared to see his mother crying. "Just take me home," she begged Daniel.

"We need to get you to a doctor," Daniel insisted, staying calm and logical, as he usually did in high-stress situations.

Daniel carried her to their gray Dodge and buckled their son into his car seat. Dinisha stared out the window and tried to take deep breaths. At the hospital, she’d be safe.

"I think she’s been sexually assaulted," Daniel said, gesturing to Dinisha and holding their son on his hip, when they walked up to the counter of St. Michael’s Emergency Room-Westheimer, the emergency room closest to Loraine’s hotel, about 20 minutes away. Still in shock and fuzzy from the drugs she’d been given, Dinisha hadn’t been able to tell Daniel exactly what happened, but Daniel knew that if she’d been raped, she’d need a rape kit — a forensic evidence-collecting exam that can lead to identifying an assailant through their DNA.

The receptionist hesitated. "Do you have any insurance?" she asked. Dinisha and Daniel looked at each other in disbelief. That was it? Dinisha’s new job did offer health insurance, but she had to wait 90 days before it kicked in, and she’d only started a few days prior.

"That shouldn’t be the first question that you ask me when we ask for a rape kit," Daniel said, his voice rising in anger. "We can pay."

"We need insurance to perform anything," the receptionist explained. "If she doesn’t have any insurance, we can’t see her."

This would be the first time that an emergency room turned Dinisha away on that day. It wouldn’t be the last.

It’s hard enough for sexual assault survivors to report a rape at all: Only 15.8 to 35 percent of survivors do, according to the U.S. Bureau of Justice. (Rape is so woefully underreported that exact statistics are impossible to come by.) And while the rape kit backlog has been well reported — the hundreds of thousands of untested kits sitting in police departments nationwide — what’s lesser-known is that getting a rape kit is not as simple as heading to the nearest emergency room. Once there, survivors are often faced with compounding obstacles to care, from the lack of emergency personnel trained to accurately perform rape kits, to buck-passing between insurers and hospitals around who is billed for that care, to loophole-filled state and federal laws that are often murky and unclear even to legal experts.

Daniel didn’t understand. Why did they have to go somewhere else? Wasn’t rape an emergency?

St. Michael’s Emergency Room-Westheimer has since closed down, but it was part of a Texas-based chain of for-profit freestanding emergency departments. In Texas, licensed and operating freestanding ERs are not supposed to turn away patients based on an ability to pay, said Christine Mann, a press officer at the Texas Department of State Health Services. A federal law passed in 1986 known as EMTALA (the Emergency Medical Treatment and Labor Act) requires that anyone who walks into an emergency room be treated, whether they can pay or not; while freestanding ERs in Texas are not mandated to follow EMTALA, a section of the Texas Administrative Code, which Mann is referring to, uses similar language.

Another state law — Texas Senate Bill 1191, passed in 2013 — should have offered Dinisha further options. S.B. 1191 mandates that all Texas emergency rooms have staff trained in basic forensic evidence collection, even though most emergency doctors receive little to no training in how specifically to treat sexual assault patients, administer rape kits, or collect forensic evidence. (In fact, there is no standard forensic medicine training protocol for emergency medicine residents at all.) If they don’t have anyone on staff who can perform a rape kit, they’re supposed to help patients get to a hospital that does. So at the very least, Dinisha was legally entitled to a screening exam and a transfer to another ER.

In an email, St. Michael’s chief financial officer Brian Orsak said that its

facilities don’t have to comply with S.B. 1191, because the law only

applies to "licensed hospitals with emergency departments" — not to "licensed

free-standing emergency medical care [facilities]." (Chris Van Deusen, another Texas Department of State Health Services press officer, confirmed Orsak’s interpretation of

S.B. 1191 — which points to a significant loophole, since freestanding emergency rooms look identical to hospital-affiliated ones to patients.)

For her part, Dinisha was still too much in shock to register what had happened and followed Daniel back to the car. As they walked through the parking lot, Daniel noticed Dinisha was barefoot. "I have extra sneakers in the trunk," he offered. But Dinisha just shook her head, silent. She climbed into the passenger seat, curled up into a fetal position, and closed her eyes.

After driving for half an hour through Houston’s choking, muggy traffic, Dinisha and Daniel arrived at West Houston Medical Center. The receptionist asked for Dinisha’s ID, but as she didn’t have any identification on her — her belongings were still with Loraine — Daniel gave her his own ID instead.

Dinisha collapsed into an office chair, staring at the ground. Daniel stood, keeping one eye on their son, who played with a Batman toy, and one eye on Dinisha. Minutes passed in silence and turned into hours. Finally, Daniel called his mother to collect their son.

A nurse took Dinisha’s vitals: her blood pressure, her temperature, and did some basic blood work. But when first Daniel, and then Dinisha, asked for a rape kit multiple times, they were told to wait. "You need to see a doctor," a nurse replied. "We can’t do it."

When a doctor finally appeared in the waiting room, he said the same thing — that he couldn’t perform one. "You don’t have a rape kit on hand?" Daniel replied, increasingly frustrated.

"It’s not that we don’t have one on hand..." the doctor said, handing Daniel a list with the names of two other hospitals. "It’s that you need to go to one of these."

The doctor didn’t specify the reason why he couldn’t perform a rape kit, but Dinisha’s experience likely would have been much different if the hospital had a Sexual Assault Nurse Examiner (SANE) on staff — a registered nurse who receives specialized training in how to collect forensic evidence for rape kits and care for sexual assault survivors’ physical and emotional needs. West Houston Medical Center did not have any SANEs at the time of Dinisha’s assault, and still does not.

In the mid-1970s, in response to reports of rape victims waiting in emergency departments for hours for inadequate care, nurses launched the first SANE forensic training programs. According to Jennifer Pierce-Weeks, the interim CEO of the International Association of Forensic Nurses (IAFN), most SANEs today also have other nursing jobs, often in emergency departments or maternal child health. The job isn’t standardized from state to state: Some emergency departments have SANEs on call 24 hours a day, but many do not. Some emergency departments pay SANEs a higher salary, but many do not.

The value of SANEs is undeniable, however. When a trained forensic nurse administers a rape kit, the "quality and consistency of collected evidence" improves dramatically, found a study from the Office for Victims of Crime Bulletin. That study also found that kits collected by trained examiners are more likely to include proper collection and labeling of evidence, a complete crime lab form, and the correct number of swabs and other evidence, such as pubic hairs and head hairs. This increased quality of evidence translates into higher rates of convictions.

But many hospitals don’t have enough sexual assault certified providers to meet patient need. "We don’t know how many SANEs or SANE programs there are across the United States because there is no mandated tracking system in place for that information," said Pierce-Weeks. Based on voluntarily entered information, though, she estimates that only about 13 percent of hospitals have a SANE on staff, or a SANE program. (There are currently 331 certified sexual assault nurse examiners in Texas, says Rose Luna, the deputy director of the Texas Association Against Sexual Assault; it is unknown how many of those are in the Houston area.)

It doesn’t cost much to train a SANE. IAFN’s course in sexual assault care for adult patients is $350. The course in pediatric sexual assault care is $450. The formal IAFN certification exam costs an additional $275 to $400. It’s also not logistically prohibitive. Courses are available both in person and online, and take roughly 40 hours to complete. An April 2016 Government Accountability Office Report blamed the shortage on limited availability of training, weak support for examiners from hospitals and other stakeholders, and low retention rates. "Some hospitals may not make SANE training a priority," explained Pierce-Weeks. "Others have limited availability of education funds for nurses. Others prefer ’live’ versus online training." She added that low retention rate is due to limited resources — money, clinical mentorship programs, support from hospital administration — for continuing education and the high stress of the job. "You are listening to people’s trauma all the time. There’s no way you won’t be impacted by that," she said. "In many instances, vicarious trauma takes a toll on nurses, and they don’t stay in the profession."

Crystal Law

"While we are not a certified Sexual Assault Nurse Examiner program, we have caregivers trained in basic forensic evidence collection for sexual assault kits," West Houston Medical Center hospital spokeswoman Selena Mejia wrote in an email to Cosmopolitan.com. "The emergency room physicians and nurses at the hospital strive to provide the best possible treatment at the time of the patient’s visit, and we work with them, their family members and other healthcare providers to help ensure patients receive the appropriate level of care, based on their needs. Our hearts go out to all victims of sexual assault." (When asked why Dinisha was not able to see one of those "caregivers trained in basic forensic evidence collection," Mejia said the hospital would not comment on specific cases.)

Daniel gazed down at the paper the doctor had given him. In Houston, the fourth-most populous city in the United States, with 2.3 million people, the paper listed only two hospitals where Dinisha could get a rape kit. The first option was in Galveston, Texas — 68 miles away. The second option, Memorial Hermann Texas Medical Center, was 14 miles away. While it didn’t sound far, Dinisha and Daniel knew that Houston’s weekend traffic might make it an hourlong — or more — drive.

Daniel asked the receptionist for his ID. The receptionist handed him papers to sign. "I’m not going to sign this," Daniel scoffed. "You didn’t do anything for us!"

"You have to fill this out before I give back your ID," the receptionist said. Cursing under his breath, Daniel scribbled his name and Social Security number onto the papers.

Faced with the prospect of spending hours in the car en route to a third emergency room, Dinisha was ready to give up. "Let’s just go home," she begged Daniel, exhausted and discouraged. She desperately had to use the bathroom, but hadn’t yet, assuming that a urine sample might be able to tell which drug had knocked her out.

Daniel squeezed her hand. He tried to stay calm: If he lost it, he knew that Dinisha would break down too. "We can’t," he insisted, mentally preparing them both for another long wait. "We have to keep trying."

Daniel noticed two other hospitals along the way along the way to Memorial Hermann — a 45-minute drive to cover 14 miles. Did they not offer rape kits? But he had been told to go to Memorial Hermann, so he stayed the course.

When they finally arrived at the receptionist’s desk, Daniel repeated what had become a familiar refrain. "We need a rape kit," he recited. "She’s been sexually assaulted."

The receptionist paused.

"Actually, we suggest you go to Ben Taub [Hospital]," she replied.

At that, Daniel snapped. "We’ve been to two hospitals already," he yelled. "I have the paperwork from the other hospital telling us this is where we needed to go! Can you do a rape kit here or not?"

"Yes, but—"

"Make it happen," Daniel interrupted her. He and Dinisha settled into a plastic chairs to wait — and decided it was time to call the police. (In Texas, medial providers are not required to report sexual assault claims to law enforcement unless the patient requests it, said Luna.) Two officers from the Houston Police Department came to take Dinisha’s statement, while a representative from the Texas Crime Victims Compensation Program also showed up, describing different programs to help Dinisha pay her medical bills. The police promised to call Dinisha within a week.

That evening, at 6 p.m., Dinisha was given a rape kit. Even though too much time had passed to detect any drugs in her system, she peed into a test cup anyway — the first time she’d used the bathroom all day. A nurse completed the exam in 30 minutes, far less than the minimum of two to three hours it takes a certified sexual assault nurse examiner to complete an adequate forensic evidence collection. Afterward, Dinisha and Daniel still had to wait for a doctor to administer antibiotics and a shot for gonorrhea, just in case.

When they left the hospital to go home at 9 p.m., it was dark outside. Dinisha and Daniel walked across the pavement toward their car. The soles of Dinisha’s bare feet were thick with dirt.

Even for people who have spent years trying to help victims of sexual assault, it’s still jarring that something like this can happen. In July 2015, Washington Sen. Patty Murray sent a letter to the Washington State Hospital Association to express concerns after a woman told her about being turned away from a hospital where she tried to get a rape kit.

"I assumed that if you show up at a hospital door and you are a victim of sexual assault, they’ll know what to do," said Sen. Murray, who had previously focused on sexual assault from a judicial and criminal perspective as a key advocate for the Violence Against Women Act. "I am as shocked as everyone else that that’s not the case. There is a real lack of access to trained medical examiners." Broadening the conversation to look at sexual violence from a medical perspective, she said, is a logical next step.

"Nobody has ever required people to provide information [about how extreme the shortage of sexual assault forensic nurses is] before," she said. "So hospitals, states, and the federal government — each of which has a role to play in supporting survivors — have gotten away with not doing it."

Drew Anthony Smith

To that end, in May 2016, Sen. Murray introduced the Survivors’ Access to Supportive Care Act, which would direct $12 million to address deficits in health care for sexual assault survivors. Among other things, the bill would establish a national training and continuing education program for SANEs and establish surveys to determine state-level needs.

Months after Dinisha’s hospital visit — and not, as promised, within a week — she received a follow-up call from the Houston Police Department. There was nothing they could do, they told her. She didn’t remember the man’s license plate number or any other identifying details. But something did arrive, soon after, in the mail: a series of bills, totaling $1,400, for the blood work and other tests done at West Houston Medical Center and Memorial Hermann Hospital. Her application for help from the Texas Crime Victims Compensation Program had been denied — because, it claimed, Dinisha had not cooperated with the police.

"I was equally victimized by this system as I was by the guy [who raped me]," says Dinisha now, nine months later. "I tried to handle the situation responsibly, but it was out of my hands. I had no control."

Cosmopolitan.com contacted the Texas Attorney General’s Office, which oversees the Crime Victims Services Division, to ask how, exactly, Dinisha did not cooperate with the police. They refused to detail specific cases. But five days after Cosmopolitan.com reached out, Dinisha received a letter from a Crime Victims Compensation Program appeals reviewer. (She had not submitted an appeal.) "After a telephone interview with officer Nicole Rose with the Houston Police Department," it read, "I was advised that you have been cooperative with the investigation. Specifically, you gave a statement regarding the incident. Additionally, male DNA was found, and it is apparent that sexual contact occurred. Therefore, this application is now approved."

In a year without many victories for Dinisha, this is a small one: She’ll no longer have to pay out of pocket for the tests performed to investigate her rape.

Still, she says, the letter "open[ed] that wound again."

"I know something did happen now, but I have no recollection of it," she says. "It’s a level of violation I will most likely never be able to move past." She and Daniel recently drove by the Belvedere, she says, and "my heart sunk. I don’t have faith in the justice system, especially since I haven’t heard anything about the rape kit results. I’m just a number on a box to the police."

*Names have been changed

Photography by Drew Anthony Smith • Edited by Whitney Joiner • Design by Katja Cho • Senior photo editor Jennifer Newman • Research by TJ Carlin • Animation by Crystal Law