Coming home from the ballet at Lincoln Center one night, a young businesswoman was handcuffed, blindfolded, and then raped with a knife held to her throat in the lobby of her apartment building.

The trauma didn’t end when the perpetrator fled the scene, according to the woman. Not only did the 911 operator question whether she had actually been raped, but she was asked to tell her story more than six times to different officers and doctors. The night of her attack was a busy one for the hospital – and as a consequence, no social workers and none of the community volunteers known as advocates found the time to guide her through the grueling physical examinations or support her through the ordeal. The police and doctors were just doing their job, she said, and they seemed businesslike but lacking all compassion.

“All you can think about in your head is, ‘Is this is my fault?'” the woman said. “‘Was it something I wore? Was it too provocative? Was it too brightly colored? Should I have tied my hair back? Was I foolish to walk home alone?'”

***

Many rape counselors and social workers have been saying for decades that the way a rape victim is treated at hospitals has potential importance not only for the woman’s well-being but also for the way the case is prosecuted. If, they say, the victim is taken to a hospital that has a special rape-crisis program – with a private examination room, a nurse or doctor trained in the intricacies of evidence collection and the documentation of genital injuries, and an advocate to guide her through the experience – then she is more likely to heal quickly and the perpetrator is more likely to end up behind bars.

In a city of 8 million people, with 1,428 reports of rape in 2004, many victims aren’t treated at hospitals with specialized rape programs – especially those who are victimized outside Manhattan.

Of 43 acute-care hospitals in the five boroughs, only 10 have specialized centers for victims of rape. A half-dozen other hospitals receive support from those centers, but the imbalance between Manhattan and the other boroughs is apparent.

While Manhattan has a 48% rate of convictions for reports of rape last year, Brooklyn, the most populous borough, saw a conviction rate of 21%, according to statistics from the state Division of Criminal Justice. (The office of the Brooklyn district attorney said that the courts in Kings County handle rape cases differently and that a temporary logjam has cropped up. If about 50 delayed cases end in convictions, then the county’s conviction rate would be 36%, according to the head of the sex crimes unit of the district attorney’s office, Rhonnie Jaus.)

In the Bronx, which has precincts with some of the highest numbers of reported rapes in the city, the rate of convictions is 32%. In the past five years, Queens has generally had the highest conviction rate, and last year it was 56%.

Many factors go into a rape conviction rate, a professor at John Jay College, Eugene O’Donnell, said, but the variations raise significant questions about the care and prosecution in the five boroughs.

“Some offices receive a larger share of viable cases than others,” he said.

One county may have more wealthy and articulate victims, with whom juries may be more sympathetic, while another may be filled with poorer victims who don’t speak English, or victims who may have been committing a crime at the time of the rape, he said.

Of the 20 precincts with the most reports of rape last year according to the New York Police Department’s CompStat tracking system, 19 are in the Bronx, Brooklyn, and Queens, but most of the city’s specialized rape crisis centers are at hospitals in Manhattan.

The problem is a lack of funds, according to the director of the rape victims’ advocacy group the New York City Alliance Against Sexual Assault, Harriet Lessel. The public and the politicians have been slow to understand the importance of treating rape victims with more than emergency room procedures, she said.

“It’s not just an ob-gyn case,” the medical director of the Sexual Assault Response Team program at the North Central Bronx Hospital, Brigitte Alexander, said.

A clinician and social worker at the Sexual Assault Intervention Program at Mount Sinai Hospital, Jennifer Lorell, said people simply don’t realize there is an imbalance among hospitals in treatment of rape.

“I don’t think people know that the expertise is not in all hospitals,” she said. “If they don’t have specialized programs, the care isn’t there.”

Even a hospital without a full rape crisis center can provide that specialized care, Ms. Lessel said. At the very least, a nurse or a doctor who is specially trained as a sexual assault forensic examiner, known as Safe, can perform the examination of the patient and preserve the evidence properly. Those procedures don’t treat the patient’s emotional distress, however, and sometimes there is no medical evidence of an assault, she said.

In addition, a patient who doesn’t meet with a social worker or advocate is less likely to press charges, she and others said.

Moreover, rape victims are still held to a higher standard of proof than victims of other crimes, according to Ms. Jaus, of the Brooklyn D.A.’s office. Without strong evidence, she said, the trial reverts to the old “he said, she said” debate, which makes it more difficult to secure a conviction.

A case in point is Mary, who asked that her last name not be used. A man dragged her away from a bike-storage area near her residence on the Upper East Side and raped her twice. The responding police officers wanted to take her to the nearest hospital, but she demanded to be taken to Mount Sinai, which she knew, from her volunteer work with teenagers, has a special program for rape victims. When police refused, she took a taxi there by herself, she said.

An advocate helped get her through that night and many more nights afterward, Mary said. Three years after the rape, the case was brought to trial, with the accused representing himself. When Mary took the stand, he grilled her for three hours about the experience.

“The survivor has no rights in this,” she said. “I did quite well until the trial. When it finally happened, I fell apart.”

Mary eventually went on to become an advocate herself – in part, to give back to the system that helped her get through her rape, she said.

The director of the Sexual Assault Intervention Program at Mount Sinai Hospital, Iona Siegel, said treatment after the fact, even years later, can be crucial to victims’ recovery.

“Talking to someone is of enormous help in their recovery,” she said. “They think if they don’t talk about it, it’s going to go away. It doesn’t happen that way. It doesn’t go away.”

In between operating expensive, labor-intensive crisis centers and having a few Safe examiners on staff is the highly successful Sart, the Sexual Assault Response Team, which has been in the municipal hospitals in the Bronx for the past year and Brooklyn since the beginning of June.

The program is based on a model developed in the 1970s that uses a team approach to respond to reports of rape, with advocates, doctors, police officers, and the district attorney’s office working together to treat victims.

Under the Sart program, when someone is brought into the emergency room with a report of rape, she is immediately listed as a high-priority medical emergency – a change from the old days, when a victim would be forced to wait in a busy waiting room for hours, sometimes wearing only a hospital gown. The victims are isolated in a quiet room, and treatment is guaranteed to begin within one hour.

The advocate, who has undergone 40 hours of training by the Department of Health, is taught how to deal with the police officers taking the victim’s report and how to explain to the victim the details of the excruciatingly thorough physical exam.

The Brooklyn and Bronx Sart examination rooms are equipped with technology not available in many ordinary emergency rooms: a device, called a colposcope, that allows the examiner to document genital injuries invisible to the naked eye, and sometimes a UV lamp, called a Wood lamp, that reveals secretions and bleeding under the skin.

The one element that has meant the greatest change in rape examinations is DNA, which can be collected from evidence as small as a single hair or drop of saliva and has led to the ar rests of dozens of rapists in cases that have been closed for years known as cold cases.

“DNA has revolutionized the way rape crimes are prosecuted,” Ms. Jaus said.

Even DNA evidence, however, can be botched if it isn’t collected correctly. There was a time when rape kits would be stored in cabinets or doctor’s desk drawers, according to the medical director of the Sart program at Kings County Hospital, Maria Schaffer. Now, examiners must maintain a strict chain of custody, and strict protocols have been promulgated for preservation and storage of evidence, she said. The risk of compromised evidence is multiplied when someone without forensic rape credentials is conducting the examination, Ms. Schaffer said.

The teamwork approach taken by the crisis programs also helps eliminate what some victims call the gruff, doubting nature of police questioning, Ms. Lessel, of the Alliance Against Sexual Assault, said.

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The woman raped as she was returning home from Lincoln Center is Jennifer Goodale. She does not request anonymity – rather, since her attack, she has spoken at public events and otherwise campaigned for improved crisis treatment for rape victims.

About a month after she was attacked, Ms. Goodale said, a policeman asked her: “Are you sure you didn’t just have a drink?”

“No matter what you do, they make you feel like you had something to do with it,” she said.

In 1972, the New York Police Department created a unit – now called the Special Victims Unit – to make arrests related to sex crimes and to investigate reports of rape. The unit’s detectives are on call only for two of the three shifts of the day, however, which leaves the crucial hours of the early morning to ordinary night watch detectives, who often have no training in dealing with trauma patients.

Under Mayor Bloomberg, advocates of expanding sexual-assault treatment have begun to get an answer to their pleas for funds. Using a grant from the federal government and with the support of City Hall, the Sart program was started in three public hospitals in the Bronx last year.

In that time, Sart responders treated about 255 victims of rape – and the results have impressed decision makers at City Hall enough for the Bloomberg administration to expand the program to all the municipal hospitals in the fall, according to the deputy criminal justice coordinator at the mayor’s office, Rich Plansky.

Last year, fully 96% of rape victims brought to the three city hospitals in the Bronx were treated within an hour, which was 52% better than the year before. In more than half of the cases, examiners using a colposcope found genital injuries – twice as often as in the previous year.

In Brooklyn, too, although the program began only this summer, Sart appears to be an early success. So far the response time has been within an hour in every case, and in many more cases than before, examiners have found genital injury.

Still, expansion of rape crisis treatment is limited by the reach of hospitals with specialized programs.

Ms. Jaus said a potential solution would be to change ambulance policies so that rape victims would always be taken to a hospital with a rape crisis program. In a decade of negotiations between her office and the Fire Department, however, no new ambulance protocol has been agreed upon, she said.

The current policy is to take a victim to the nearest hospital unless her emergency fits into the department’s trauma categories, which include severed limbs and burns, but not rape.

Even with services expanded to all city hospitals, many victims of rape will still be brought to emergency rooms at non-municipal hospitals where they might not get a Safe examiner, much less an advocate, advocates said.

In the struggle to increase public awareness of the need for more specialized programs at hospitals, Ms. Lessel and the Alliance are seeking funds to conduct research on the relationship among conviction, recovery, and rape crisis programs – something never documented in New York City.

Ms. Goodale said that despite the leaps and bounds made in the past several decades, rape crisis treatment still has a long way to go.

“If you are mugged, you can talk about it. If your arm is cut off, you can talk about it,” she said. “But when you are raped, because people think it’s sexual and private, you can’t talk about it. That needs to change.”