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Charge to AHRQ
The Agency for Healthcare Research and Quality (AHRQ) is an operating division
within the U.S. Department of Health and Human Services (HHS). AHRQ is
charged with enhancing the quality, appropriateness, and effectiveness of health care
services, and access to such services. AHRQ accomplishes these goals through
scientific research and promotion of improvements in clinical practice and in the
organization, financing, and delivery of health care services (42 U.S.C. 299-299c-7, as
amended by P.L. 106-129 (1999)). Over the last decade, the Agency has pioneered
the development of evidence-based medicine, which promotes improvement in clinical
practice based on rigorous review and assessment of relevant scientific evidence.
This report was prepared in response to Section 916 (d) of the Healthcare
Research and Quality Act of 1999 (P.L. 106-129), which reads as follows:
MEDICAL EXAMINATION OF CERTAIN VICTIMS—
(a) IN GENERAL—The Director shall develop and disseminate a report on
evidence-based clinical practices for—
(1) the examination and treatment by health professionals of individuals
who are victims of sexual assault (including child molestation) or
attempted sexual assault; and
(2) the training of health professionals, in consultation with the
Health Resources and Services Administration, on performing
medical evidentiary examinations of individuals who are victims
of child abuse or neglect, sexual assault, elder abuse, or domestic
(b) CERTAIN CONSIDERATIONS—In identifying the issues to be
addressed by the report, the Director shall, to the extent practicable,
take into consideration the expertise and experience of Federal and
State law enforcement officials regarding the victims referred to in
paragraph (a), and of other appropriate public and private entities
(including medical societies, victim services organizations, sexual
assault prevention organizations, and social services organizations).
The legislation did not establish a due date for the report, and no funds were
Purpose of the Study
The legislative mandate from Congress requires AHRQ to review the scientific
evidence that supports the immediate clinical care for victims of sexual assault,
and to examine the evidence base for training providers to perform the specialized
clinical procedures that make up a medical evidentiary examination.1 Given the
dual nature of the task, AHRQ staff consulted with an array of professional and
service-oriented individuals to assure that we identified information about the
most important aspects of the examination and immediate treatment of adult and
child victims of sexual assault and the training of clinicians in the provision of
medical evidentiary examinations for victims of sexual assault, child abuse,
domestic violence and elder abuse.
The report presents a picture of current practices and systems of care for the
examination and treatment of victims of sexual assault and child molestation. The
report also addresses what is known about the training of providers who may be
called upon to conduct medical evidentiary examinations, whether for victims of
sexual assault, or for other forms of abuse including child abuse, elder abuse, and
domestic violence. The data is insufficient to permit an evaluation of the many
response systems in place across the country. However, the report:
- Discusses the major weaknesses and gaps in service and training as identified in discussions with providers, law enforcement officials, policymakers, researchers and others who are active in responding to the needs of victims and society.
- Summarizes the science which provides the foundation for clinical practices used in providing medical evidentiary examinations to victims of sexual assault and other forms of abuse.
- Describes existing State and Federal activities.
- Identifies additional opportunities for improvements in terms of training, practice and systems of care.
Sexual assault, including rape and attempted rape, is a common problem in our
society. Estimates of the prevalence of rape and other forms of sexual assault
vary from study to study, but even the most narrowly focused estimates provide a
sense of the breadth of the problem. In 2000, almost 147,000 persons over age
12, male and female, were victims of rape or attempted rape (USDOJ, Bureau of Justice Statistics, 2001). Thousands of children were also molested, many by
their own parent(s). Elder abuse, including sexual abuse, is also very prevalent,
though there are few reliable studies available. Victims need a health care system
which can provide timely, competent, and compassionate care that will help them
What Is a Medical Evidentiary Examination?
A medical evidentiary examination is given to victims of sexual assault and other
forms of abuse and is performed to collect physical evidence and document
findings that can be used to identify, prosecute and convict an assailant. While an
evidentiary examination includes an array of medical components, including
assessment of injuries and crisis intervention, its main purpose is to meet the
needs of the legal system. It may also be called a "medico-legal examination," or
a "sexual assault forensic examination" (SAFE). Basic components usually
- Medical evaluation and crisis intervention. Recognition and treatment of physical injuries, risk evaluation and counseling for sexually transmitted diseases (STDs) and pregnancy.
- Forensic evidence collection. Evaluation, collection and preservation of evidence, interpretation of findings, and the documentation of examination results for law enforcement purposes.
- Evaluation of emotional needs. Assessment of psychological functioning, response to the immediate emotional needs of the victim, and referral for appropriate followup mental health evaluation and treatment.
- Referral for followup care. Assessment of the need for followup treatment and services, with written instructions for the patient on recommendations for further treatment of injuries, laboratory testing and mental health services, and the names and phone number of referral organizations.
Optimally, the examination is based on an integrated clinical approach that
considers and responds to cultural issues for victims of diverse racial, ethnic, and
economic backgrounds. Culturally congruent care includes sensitivity to victims
who may be intimidated by police, such as an immigrant or homeless person; to
victims who need translation services; or to women who cannot admit being
"violated" without being ostracized from family and community.
An evidentiary examination is not a linear process. The way it is conducted is
affected by such varied factors as:
- The clinical protocols used in a particular facility.
- The type and contents of the "rape kit" that is available at the hospital.
- The length of time elapsed since the attack (which affects the viability of some types of evidence).
- Whether police believe that drugs may have been used in the attack.
- The nature of the attack.
- Whether the victim has bathed or changed clothes.
Examination of young children presents special challenges,
as do the frail elderly and others having physical or mental limitations which
make cooperation with procedures difficult.
The Importance of Medical Evidentiary Examinations to Victims and
Sexual assault and child abuse crimes often go unpunished. Many cases are not
reported, and even when victims do come forward, it can be a difficult crime to
prosecute. A recent study which looked at survey figures for the years 1992-2000
found that only about 36 percent of forcible rapes experienced by females over
age 12 were reported to law enforcement officials (Rennison, 2002; USDOJ, Bureau of Justice Statistics, 2001). Studies by other researchers indicate that of
reported assaults, only about one-fifth actually result in arrest, prosecution, and
successful conviction (Langan and Farrington, 1998).
It takes courage for the victim of a sexual assault to report the crime. A rape is
physically and emotionally traumatic, often leaving the person who is assaulted
both frightened and ashamed, and sometimes even feeling that they are
responsible for the abuse or assault that occurred. Reporting a sexual assault can
be even more difficult, and sometimes dangerous, when the assault was
committed by a person the victim knows, which is often the case. One study
found that in about three out of four assaults, the victim and offender are
acquainted, an intimate partner, or from the same family (Greenfeld, 1997). In
another study of police-recorded data on children under age 12, some 90 percent
of the children raped knew the offender (USDOJ, Bureau of Justice Statistics, 1993).
A medical evidentiary examination is often a key element in the successful
prosecution of sexual assault, and is also used to eliminate suspects. One reason
the examination can be pivotal is that there are seldom witnesses to a sexual
assault and officials may be reluctant to pursue and prosecute an assailant unless
forensic evidence is available. The examination needs to be done well if the
evidence gathered is to stand up in an adversarial court proceeding that may
occur weeks, months, and sometimes years, after an assault.2
Provider as caregiver and scientist. When doing a medical evidentiary
examination, the physician, nurse, physician's assistant or other health
professional caring for a victim takes on the dual roles of caregiver treating a
patient as well as that of a scientist working for law enforcement purposes.
The patient-provider relationship can be especially problematic in States and
jurisdictions that have mandatory reporting laws that require physicians, and
often nurses, other health professionals, and clergy, to report actual or suspected
sexual assault and other types of abuse and neglect. In 48 States, physicians and
other health care professionals are required to report known or suspected
instances of actual or suspected child abuse and most states also require
physicians to report if they believe that elder abuse has occurred (U.S. HHS
Children's Bureau, 2002). Four States (California, Colorado, Rhode Island, and
Kentucky) specifically require physicians to report intimate partner abuse, even if
the victim's wishes are otherwise (Stobo, 2002). A much larger number of States
(42) require physicians to report injuries resulting from firearms, knives, and
other weapons (Houry, Sachs, et al, 2002).
In talking with victims and providers, one finds that many favor medical reporting
of abuse injuries to police, but not if the reporting is a mandatory requirement
(Rodriguez, 1998). Reasons for opposing mandatory laws that are often
- Mandatory reporting may expose a victim to retaliation, since many know their assailant.
- A lack of informed consent around the reporting issue compromises the patient-provider relationship.
- It takes away the autonomy of sexual assault victims, for whom a sense of regained control over their life can be an important step to recovery.
There may also be a
discrepancy between the legal requirements and the provider's personal threshold
of what they feel constitutes abuse.
When examining a victim of rape or sexual assault, the provider must
systematically gather evidence that will document injuries and assist in
identifying the assailant, yet must also avoid or reduce further psychological
distress and retraumatization of the patient. Discussions with the patient about the
assault, gathering and storing of specimens that may eventually link the assailant
to the crime, and documentation of injuries, all must be done in a painstaking, yet
respectful and compassionate way. Evidence must be preserved and stored
without contamination or risk of tampering. As a scientist serving law
enforcement, the provider may be asked to testify in court about any statements
made by the victim and their demeanor at the time of the examination, and about
the evidence collected.
To do an examination correctly and to ensure that the process meets the test of
reliability that a court will one day demand, a health provider needs training and
experience in what procedures are needed and how they should be done.
However, most providers are not routinely trained or familiarized with the
management of sexual assault victims and the performance of an evidentiary
examination (Stobo, 2002; Voelker, 1996).
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Scope of the Problem
As noted previously, estimates of the number of rapes and other types of sexual
assault vary substantially and depend on how terms are defined and what types of
sexual assaults are included. In addition, there are usually differences in the time
frame during which the data was collected, in the sampling methods used, and in
the age and gender of the population being studied.
What is being counted? As a general matter, rape is a term that refers to forced
or attempted sexual intercourse with a male or female, by an offender that may be
of the same sex or a different sex from the victim. Sexual assault is usually
defined to encompass rape, attempted rape, forced oral and anal sex, penetration
with objects, touching of intimate parts, and other types of threats or coercion in
which unwanted sexual contact is attempted or occurs between the victim and
Most research studies and surveys count rape and attempted rape as one of several
types of sexual assault. However, the largest national household survey does not:
the National Crime Victimization Survey (NCVS) instead defines sexual assault
to mean "a wide range of victimizations separate from rape or attempted rape."
Thus, the survey findings on the number and rate of sexual assaults will be quite
different from those in most other studies, since rape/attempted rape is excluded.
In legal terms, rape and sexual assault are defined by each state. States differ in
terms of what specific acts are included or excluded, how terms like "unwanted,"
"threat," and "sexual contact" are used, what the age of consent for sexual
intercourse is, and in other details that affect prosecution, penalties, and
The key Federal legislation addressing child abuse and neglect is the Child Abuse
Prevention and Treatment Act (CAPTA), which views any person under age 18
(or the age specified by the child protection law of the State in which the child
resides), as a child. Child sexual assault, one of several forms of child abuse, is
defined in the law as the use, persuasion, inducement, enticement, or coercion of a
child to engage in sexually explicit conduct or simulation of such conduct for the
purpose of producing a visual depiction of such conduct; or, the rape, .... statutory
rape, molestation, prostitution, or other form of sexual exploitation of children, or
incest with children. Beyond this threshold definition, each State provides further
definition and elaboration of terms. While sexual abuse of young and adolescent
girls has been well studied, there has been less attention paid to the sexual abuse
of boys. Nonetheless, sexual abuse of boys appears to be common, though under
reported, under recognized and under treated (Holmes, 1998).
Elder abuse is generally defined broadly to encompass not only sexual abuse
(nonconsensual sexual contact of any kind), but also physical abuse (use of force,
violence, unwarranted use of drugs and physical restraints, force-feeding, and
physical punishment,) and emotional abuse (insults, threats, intimidation,
humiliation, and isolation). Abuse is often lumped with elder neglect (the failure
of responsible parties to provide life necessities), abandonment, and financial and
material exploitation. The studies available indicate that most incidents are by
family members and go unreported.
Table 1 provides a snapshot of data available on rape, sexual
assault, and child and elder abuse, and is followed by narrative which provides
further detail. Recurrent findings indicate that most sexual assault victims are
young women; most rapes and other assaults are not reported; and most assaults
are perpetrated by husbands, intimate partners, friends, or relatives.
Rape and Sexual Assault
The FBI Uniform Crime Report (UCR) 2001. This FBI/U.S. Department
of Justice (USDOJ) annual report summarizes the number of rapes and
attempted rapes of females of any age, as reported to U.S. law enforcement
agencies. Because data relates to cases reported to police, the data base
captures only a portion of the number of rapes that actually occurred.
Statutory rape, rape of men, and other types of sexual assault also are
accounted for elsewhere.
The UCR report indicates that 90,491 forcible rapes/attempted rapes of
females were reported in 2001, a slight increase over the previous year
(USDOJ, FBI, 2002). However, the rate of rapes continued a downward
trend and declined from 70.3 rapes per 100,000 females in 1997 to 62.2 per
100,000 females reported in 2001.
The National Crime Victimization Survey (NCVS). This survey is
conducted by the Bureau of Justice Statistics at USDOJ and provides
information on the violent victimization of men and women over age 12,
including rape, robbery and physical assault. It is one of the largest
randomly selected household surveys conducted in the U.S. NCVS results
indicate that about 147,000 persons were victims of rape or attempted rape in
the year 2000. This represents a 33.3 percent decrease from the previous
year's estimates, and continues a long-term decline (Rennison, 2002). As
noted earlier, figures related to sexual assault are not comparable to those
used in other national surveys because the number of rapes/attempted rapes
are not included with the sexual assault category.
National Violence Against Women Survey (NVAWS). This national
telephone sample survey gathered information from 8,000 women and 8,000
men on their experiences with violent victimization. It took place between
November 1995 through May 1996 and was jointly sponsored by the
National Institute of Justice (NIJ) and the Centers for Disease Control and
Prevention (CDC), and conducted by the Center for Policy Research (Tjaden
and Thoennes, 2000).
- An estimated 302,000 women experienced at least one rape or attempted rape in the 12 months preceding the survey. Three-fourths of the women were assaulted by a husband, former husband, cohabiting partner, or date, and many were assaulted multiple times. The findings indicate that approximately 876,000 rapes occurred in 12 months prior to the survey, reflecting the fact that victims are sometimes raped repeatedly over time.
- An estimated 93,000 men were raped within the previous 12 months, most often by a stranger or acquaintance, rather than by an intimate partner.
- The survey found that 31.5 percent of adult female rape victims and 16 percent of men were injured, most often suffering scratches, bruises or welts. However, 25 percent had other types of injuries, including knife wounds, broken bones, dislocated joints, head and spinal injuries, internal injuries and broken teeth.
- Rates of intimate partner violence (IPV) vary significantly by ethnic group: Reports of IPV are lower for Asian/Pacific Islander women and men, while rates for African-Americans and American Indians/Alaskan Native women and men are higher. Differences diminish when socioeconomic status is considered.
- Only one-fifth of all rapes against women were reported to police, and the percentage of male rapes reported was even lower.
National Women's Study (NWS). The NWS was a longitudinal study of risk
factors for substance abuse that was funded by the National Institute on Drug
Abuse, NIH/HHS. The study ran from 1989 through 1993 and sampled
some 4,000 women age 18 and older, including an over-sample of women
between age 18 and 34. The women were asked about any history of
physical and sexual assault, other traumatic events, post-traumatic stress
disorder, alcohol and drug abuse, depression, suicidal ideation and attempts,
and related topics. Three waves of assessment were conducted via
telephone: an initial assessment and further assessments at one year and two
The NWS estimates indicate that 683,000 women were forcibly raped during
the one year period between the initial assessment and the followup
assessment. Most women (84 percent) did not report the offense to police.
About 61 percent of assailants were husbands, boyfriends, or other relatives
or friends; 24 percent were strangers (Kilpatrick, 1993).
Child Abuse, Neglect and Maltreatment
The National Child Abuse and Neglect Data System (NCANDS). This
information system collects data from states annually on the number of child
abuse and neglect cases reported to Child Protective Services (CPS) agencies
in the United States. The most recent report, Child Maltreatment 2000:
Reports from the States to the National Child Abuse and Neglect Data
System, indicates that approximately 2.8 million reports of abuse and neglect
were referred to CPS agencies, and 879,000 cases of child abuse and neglect
were substantiated (USHHS, ACYF, 2002).
Most children (83 percent) were abused by one or both birth parents. Ten
percent of the substantiated cases involved sexual abuse.
The NCANDS system is sponsored by the Children's Bureau, a component
of the Administration for Children, Youth and Families (ACYF), in the
Administration on Children and Families (ACF), HHS. The data collection
had been a voluntary effort on the part of the States until the Child Abuse
Prevention and Treatment Act Amendments of 1996 (P.L. 104-235), which
required to the extent practicable that States submit seven new elements not
previously included in the voluntary effort.
Third National Incidence Study of Child Abuse and Neglect (NIS-3).
This 1993 study was sponsored by the National Center on Child Abuse and
Neglect, a part of ACYF at HHS. The findings are based on reports from
Child Protective Service (CPS) agencies, and reports from community
professionals who saw cases that were not reported to CPS or which were
screened out by CPS without investigation (Sedlak and Broadhurst, 1996).
The study found:
- About 1.6 million children in the United States were harmed by abuse or neglect of all types in 1993, including an estimated 300,000 cases of sexual abuse and 614,000 cases of physical abuse. Most of those children who were injured or harmed were victims of their birth parents, including about one-fourth of those children subjected to sexual abuse (75,000 cases).
- The 1993 estimate was a 67 percent increase over an earlier study done in 1986, and a 149-percent increase over the first such survey conducted in 1980.
- Researchers considered whether the dramatic increase in child abuse was due to an actual increase in the number of cases which occurred, or whether they reflected an increased sensitivity by providers to signals that abuse is occurring. They concluded that there was greater sensitivity, but that a real increase in the level of abuse had also occurred.
Elder Abuse and Neglect
There are few national estimates of the prevalence or incidence of elder abuse and
neglect and none provide national estimates specific to sexual abuse in older
In October 2000, the Attorney General brought together public health and law
enforcement professionals, prosecutors, health care providers and forensic experts
to discuss research and training needs related to elder abuse (USDOJ, NIJ, 2000).
The participants noted the scarcity of data on the prevalence and incidence of
elder abuse and neglect, as well as on all aspects of the topic, and agreed that there
was a "desperate need" for basic research on elder abuse and neglect.
National Elder Abuse Incidence Study (NEAIS). This 1996 study is the
primary source of national data on elder abuse occurring in domestic (noninstitutionalized)
settings. The estimates are based on information drawn
from a nationally representative sample of Adult Protective Services (APS)
agencies and reports from professionals working in community agencies
having frequent contact with the elderly living at home.
The study suggests that an "iceberg" effect occurs in reporting, i.e., many
more cases of abuse and neglect occur than are reported to APS agencies.
This theory is based on the substantial number of additional cases they found
in this study that were reported to the sentinel community professionals, but
not to APS.
The best estimate from the study indicates that about 450,000 cases of elder
abuse and/or neglect occurred in 1996. This includes 71,000 cases reported
to APS agencies and substantiated, and an estimated 379,000 cases that were
derived from reports from the community-based sentinel agencies. However,
the standard error for the study indicates that between 211,000 to 689,000
elders could have been victims that year.
The NEAIS found that females over age 60 were abused at a higher rate than
males over age 60, and that persons over age 80 are at highest risk of abuse
and neglect. Results indicate that ninety percent of the known perpetrators
are family members, and two-thirds are adult children or spouses.
The number of cases of elder abuse reported to APS agencies grew by 150
percent in the ten years from 1986 to 1996, while the population of persons
over age 60 grew by only ten percent. It is unclear how much of the
incremental increase in APS reports represents an increase in the incidence
of abuse and how much is attributed to an increase in the proportion of abuse
cases that are actually reported to APS agencies (Cook-Daniels, 1999).
The study was requested by Congress and conducted in 1996 by the National
Center on Elder Abuse at the American Public Human Services Association
and Westat, Inc. It was prepared for the ACF and the Administration on Aging (AOA) at the HHS (USHHS, AOA, ACF, 1998).
Pilot Study—Sexual Abuse of Nursing Home Residents. There are few
studies of abuse issues affecting residents of nursing homes, and most that
have been done focus on physical and psychological forms of abuse. In a
rare pilot study of 20 sexually abused nursing home residents, researchers
Burgess, Dowdell, and Prentky found that about half of those abused had
reported the sexual assault directly (Burgess, et al., 2002). Cognitive and
neurological disorders limited the ability of many victims to report sexual
assaults; physical and communication impediments also limited the ability of
many to undergo a physical and forensic examination. More than half of the
patients studied died within a year. While many were medically
compromised at the time of the assault, the authors speculate that the rape
trauma may also have been a contributing factor to some of these deaths.
Report from the National Research Council's Committee on National
Statistics—Elder Mistreatment: Abuse, Neglect, and Exploitation in an
Aging America. This study was commissioned by the NIH National Institute
on Aging, and cosponsored by AHRQ (Bonnie, et al., 2002). It provides a
review of conceptual, methodological, logistical and other issues related to
developing a health research agenda. While several sources of data on elder
abuse and neglect were identified, for the most part, sexual abuse was not
separately addressed. However, it references a study based on 1998 data
from the AOA's National Ombudsman Reporting System which found that
physical abuse was one of the five most frequent allegations filed on behalf
of nursing home residents. They also note that one researcher identified
1,700 complaints of sexual abuse filed with an Ombudsman over a two-year
Sexual Violence Against People with Disabilities
There has been very little research available on the incidence and prevalence of
sexual assault among women with disabilities. Much of what is available is out of
date. In 1999, researchers at the CDC published an online fact sheet which
summarized the findings that could be gleaned from a review of about 15 studies
on sexual violence against non-institutionalized adults with disabilities. Most were
published in the early to mid-1990's, though the review period runs from 1984
through 1996 (NCIPC, CDC, 1999). The review of the study findings indicates
- Disabled women appear to be at high risk of sexual assault. The lifetime incidence of sexual assault of disabled women was between 51 and 79 percent, depending on the study.
- Among disabled adults with cognitive impairments such as mental retardation and learning disabilities, the lifetime rate of sexual assault ranged from 25 percent to 67 percent, depending on the study.
- The studies reviewed indicate that most assailants of disabled persons are male and are known to the victim. Assailants are frequently family members, acquaintances, others with disabilities, and health care providers (especially for the institutionalized disabled). In most sexual assault cases (75 to 81 percent), the victim was assaulted more than once.
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AHRQ Study Approach
This report responds to a specific request to AHRQ from Congress for information on
evidence-based clinical practices for the examination and treatment of victims of sexual
assault and child molestation, and training related to performance of medical
evidentiary examinations for victims of sexual assault and other forms of abuse. As a
usual matter, the Agency seeks to identify evidence-based practices though systematic
reviews of the scientific literature that attempt to minimize bias. Reviews include a
comprehensive and reproducible search and selection of articles, an assessment of the
methodological quality of articles, and an evaluation of the overall strength of the
resulting body of evidence.
Unfortunately, in this instance, the research base is very thin. A review of the peer-reviewed
literature identified few studies that were strong in terms of methodology and
study design, and almost none that were of experimental or quasi-experimental design.
Most articles that turned up in the search were descriptive studies or other reports that
present opinions based on clinical experience or on the work of expert panels,
committees, or other authorities.
This report summarizes survey data and the findings from the handful of published
studies available. However, we also turned to health and law enforcement experts in
the field to describe current knowledge and practice. Our goal was to determine if a
reliable scientific basis exists for existing clinical practice or for the development of
training programs, and to identify remaining research gaps and the priorities for future
study and improved training for practitioners in the field.
AHRQ staff conducted a MEDLINE® search of peer-reviewed
medical journals and a HealthSTAR review of nonclinical journals related to
medicine, as published through April 2001. Search terms included population-based
terms, including sexual assault, child abuse, child molestation, and elder
abuse; and procedure and program related terms, including forensic, medical
evidentiary, Sexual Assault Nurse Examiner (SANE), and Sexual Assault Forensic
Examination (SAFE). Articles on intimate partner violence were included if they
were linked to sexual assault or forensic examination.
In addition, an Internet search of national clearinghouses and other sites yielded
excellent data, articles, training materials and unpublished protocols related to
sexual assault and child abuse, and on legal and clinical examination issues related
to examination and treatment. The USDOJ site was searched for health terms,
forensics, multidisciplinary training, and sexual assault, as well as for data on
incidence, conviction rates, and other issues related to law enforcement aspects.
The attached bibliography also contains a handful of studies published more
recently which were flagged for our attention by individuals working in the field,
or which otherwise came to our attention.
Consultation with the Public and Professional Communities
AHRQ staff wrote to the principal health professions organizations that represent
medical, nursing, social work, dental and other specialty disciplines in the field.
The letters described the Agency's legislative mandate and invited each to give
AHRQ copies of any training materials, practice guidelines, policy statements, or
position papers about the topic. Interested organizations were invited to have a
representative contact AHRQ staff to discuss policies, issues, or programs
sponsored or initiated by the organization.
Over 30 individuals from more than 18 professional and advocacy organizations
contacted the Agency's staff. They were generous with their time, providing
extensive materials for the Agency's use, and many insights on clinical practice
and training issues. In addition, many provided the Agency with the names of
individual experts that they recommended we contact for additional information.
As a result of the literature search as well as consultation with the relevant
professional, health care, and other organizations, training materials, protocols, and
position papers were received from over 40 organizations including the major
professional societies as well as providers, public health agencies, advocacy
organizations and research institutions.
The Agency also sought to contact experts in the legal system for expertise and
perspectives on practice and training issues. We consulted with Federal law
enforcement experts in USDOJ, and with the Police Education and Research
Foundation (PERF), a non-profit agency in Washington, DC, which focuses
primarily on law enforcement issues. PERF is evaluating interdisciplinary
community training programs in which law enforcement and health professionals
work together to prevent homicides by working together to intervene early in the
cycle of domestic violence. Local law enforcement agencies contacted included
the Napa County District Attorney's Office in Napa, CA.
AHRQ staff presented information on the study to the National Advisory Council
on Violence and Abuse, which is composed of representatives from the American
Medical Association (AMA), the American Academy of Pediatrics (AAP), state
medical societies, and other member organizations. AHRQ staff also met with
several groups at the first National Sexual Violence Prevention Conference,
"Coming Together to End Sexual Assault," convened in Dallas, Texas.
Representatives of the International Association of Forensic Nurses (IAFN)
convened a special roundtable on the development and scientific standards for
Sexual Assault Nurse Examiner (SANE) programs.
AHRQ staff benefited from consultation with staff and Committee members at the
National Academy of Science/Institute of Medicine (NAS/IOM) responsible for a
study on the adequacy of training for health professionals in family violence that
was mandated by Congress and sponsored by the CDC. The report presents the
most comprehensive analysis available of education and training on family
violence. Although the emphasis of the report is on training and education of
providers in relationship to family violence, the study includes a useful discussion
of the need for providers to have competency in forensic services, and suggests a
model for providing training that would establish core competencies for various
types of professionals. Their final report is entitled Confronting Chronic Neglect:
The Education and Training of Health Professionals on Family Violence (Stobo, 2002).
AHRQ staff visited training and clinical service sites and talked with academic
faculty, medical and nursing practitioners, and law enforcement experts who work
with sexual assault victims and the legal justice system. Programs and facilities
visited included the State-funded California Medical Training Program at the
University of California-Davis, which offers training and consultation to providers,
emergency medical technicians, social workers, law officers, and others who work
with the victims of child and adult sexual assault, elder and dependent adult abuse,
and domestic violence.
Staff also visited the Victim's Intervention and Prevention Center (VIP), a fairly
new facility based at Parkland Hospital in Dallas, Texas. The Center serves an
unusual cross-section of victims of violence, including victims of sexual assault,
domestic violence, and survivors of torture. It is structured to respond to the needs
of a culturally and economically diverse population, and maintains both education
and research components that involve hospital staff and close connections to
Others organizations visited included the Napa/Solano Sexual Assault Response
Team (SART)-Sexual Assault Nurse Examiner (SANE) Program at Queen of the
Valley Hospital in Napa, CA, the Forensic Nursing Services in Santa Cruz, CA,
and the Family Violence Prevention Fund in San Francisco, CA.
Consultations with HHS and Other Federal Agencies
AHRQ staff also consulted with a number of HHS components, including the
Administration on Aging, the Centers for Disease Control and Prevention, and the
Health Resources and Services Administration, as well as with the U.S.
Department of Justice. Select for a summary of existing Federal and State activities.
1. The need for evaluation, referral, and followup care for the mental health needs of victims is critical, as is the
importance of minimizing potential retraumatization related to forensic examinations. While the importance of
including initial evaluation and referral for mental health needs in the forensic examination is addressed, an
assessment of evidence regarding the effectiveness of interventions and systems of care for the ongoing mental
health needs of victims was considered to be outside the scope of this report.
2. The extent to which forensic evidence actually influences legal outcomes, and which components
of an examination are most essential, are separate questions discussed later in this report.
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