Two years ago Lisa Iyotte, a rape survivor of Sicangu Lakota and White Clay descent, stood at a White House podium and explained why the Tribal Law and Order Act President Barack Obama was poised to sign was so significant. Between long pauses and persistent tears, she recounted how she was beaten and raped in front of her daughters on the Rosebud Reservation in South Dakota 16 years prior.

"I received medical treatment at Indian Health Service hospital, but no doctors talked to me about the rape. I had to wait all night for someone to come and collect the DNA," she told the crowd of advocates, tribal leaders, lawmakers, law enforcement and press. "Tribal police suspected a local man but no federal investigators interviewed me. Federal authorities declined to get involved because the attacker did not use a weapon. A few months later the same man assaulted another woman. It wasn’t until he raped a teen-age girl that he was finally arrested and convicted. He was never prosecuted for raping me. The Tribal Law and Order Act will prevent cases like mine from falling through the cracks."

Iyotte isn’t alone. A staggering one in three Native American women will be raped in their lifetime–three and a half times the national average. The law Iyotte testified about was designed to cut through the jurisdictional red tape that too often allowed rapists to go unchecked. It also requires the federal Indian Health Service (IHS)–which runs or oversees most reservation-based clinics, hospitals and mobile units–to create and adopt standard sexual assault policies based on those used by the U.S. Department of Justice.

In a new roundtable report by the Native American Women’s Health Education Resource Center (NAWHERC), more than 50 indigenous sexual assault and domestic violence advocates from Oklahoma, New Mexico and South Dakota say that IHS hasn’t held up its end of the law.

Drawing on roundtable discussions with the advocates held last spring and fall, previous research, and cold calls to IHS units across the Albuquerque Area, the report asserts that, in practice, many IHS facilities either haven’t adopted standardized sexual assault policies or haven’t properly conveyed them to staffers. The report also claims that indigenous women who have been sexually assaulted are being denied consistent access to the over-the-counter emergency contraceptive Plan B or its generic form. Here, NAWHERC executive director Charon Asetoyer gives us her take on IHS, Plan B and how we can help.

The Tribal Law and Order Act was a big moment for Native American women. Tell me what’s happened since then. 

IHS was mandated by [the 2010 Tribal Law and Order Act] to develop and implement sexual assault policies and protocols. While the national agency did create a set of [rules], it sent word out to local service units that they could adopt their own standards, that they only had to use IHS standards as a base. To my knowledge, the IHS hasn’t given these service units a timeline, nor have they said, ‘In the interim, you are to use our standardized sexual assault policies.’ Basically, they’ve given the local units a way out of adopting the standards.

That defies the definition of standards, doesn’t it?

For some reason the IHS doesn’t like standardization. As a result, indigenous women aren’t covered by a policy that would ensure that they have adequate healthcare after a sexual assault. It is dangerous and unethical for a woman not to know what to expect when she enters an Indian Health Service unit emergency room after she’s been raped.

Why do you think there’s such a disconnect between IHS official policy and what you’re seeing on the ground?

Well, IHS staff is overworked and underpaid. But that doesn’t excuse them from mandating policies and coming up with solutions. Take Plan B, for example. Last week I was on the radio show Native America Calling with Dr. Susan Karol, chief medical officer for Indian Health Service. She said that Plan B is available at all of the units IHS manages, over the counter, but we know that it isn’t. Callers were even telling her that it wasn’t. It shows that you can make up a policy in headquarters, but if you don’t notify local service units it doesn’t matter.

So are you saying that IHS facilities don’t offer emergency contraception to rape victims?

They do offer it, but they’re using the old, harsh formula of several high-dose birth control pills. First of all, why would a woman have to go through that? And second of all, to get the old treatment, you have to have a prescription. A lot of women who have experienced spousal rape or date rape don’t want to report it to a physician. Even if they do, the [only] clinic within 100 miles is closed for the weekend and there’s no emergency room close by. Basically they’re being denied a service they’re entitled to under the Affordable Care Act.

This is going to sound like a silly question, but bear with me. Why can’t they walk up to the pharmacy counter and get a few doses of Plan B in advance?

To get Plan B from Indian Health Service pharmacies, you still have to see a provider first. You have to get their approval before the pharmacy will release the drug to you. As for commercial pharmacies, oftentimes there are none on the reservation–and keep in mind that some reservations are bigger than some states. Even if there is a commercial pharmacy, you’d have to have a car or hire someone to drive you there, pay $50 for the drugs and find your way back home. That is financially inaccessible for many Native women.

In one part of the report, you talk about how IHS providers had to jump through bureaucratic hoops to serve as forensic witnesses in rape trials. I thought that was another powerful example of the red tape you’re describing now.

Right. Before the Tribal Law and Order Act, an IHS provider would have to get an approval from their [local] service unit director, their area director and national headquarters in Rockville, Maryland, to serve as a witness. Often this process would take months; the prosecutor would be ready to go to court but [the delay] led to cases being dropped because [defendants] have a right to a speedy trial. This red tape was denying us Native women our due process. Now, under the law, if an IHS doesn’t hear back from his or her supervisors and headquarters within a certain amount of time, it’s assumed that they’ve been approved. That’s changing the dynamic.

Are women even aware that Plan B should be available to them without a prescription if they are 17 or older?

Many aren’t, which means Indian Health Service isn’t notifying them. Also, in bellweather states like Oklahoma, they’ve gotten a lot of propaganda and inaccurate information. A lot of women have heard through their churches that you don’t take RU-486, the abortion pill, and you don’t take Plan B because it’s also abortive. Anti-choice clergy have convinced the parishoners that Plan B isn’t really a contraceptive.

Is there any way that non-indigenous people can pitch in?

We want the Department of Health and Human Services to mandate all Indian Health Service providers to make Plan B or its generic form available to women age 17 or older over the counter and on demand. This could [also] be accomplished if the head of Indian Health Service, Dr. Yvette Roubideaux, writes out a directive to all service units. Please spread the word and help us create a groundswell around this issue.