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Medical Examination and Treatment for Victims of Sexual Assault

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Federal and State Activities

Federal Programs and Initiatives

Administration on Aging (AOA)

The AOA (www.aoa.gov) provides home and community-based services to millions of older persons through the programs funded under the Older Americans Act. They are well-known for management of programs which provide home-delivered meals programs or nutrition services in congregate settings, adult day care, and other social services to older Americans. However, they also fund the long-term care ombudsman program, which is designed to prevent abuse of residents in nursing homes and similar facilities by investigating complaints, and by providing a regular community presence in facilities.

Centers for Disease Control and Prevention (CDC)

The CDC (www.cdc.gov) provides surveillance data, supports community development and research on prevention of sexual assault, and offers technical assistance. The CDC published a comprehensive compendium of training materials for health professionals: Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Health Care Providers (Osatlin and Short, 1998). The authors identified 36 sets of training materials intended to show providers how to identify and treat partner violence and sexual assault. Few of the programs are sufficiently detailed to be useful to providers in performing medical evidentiary examinations.

CDC staff at the National Center for Injury Prevention and Control (NCIPC) have substantial experience in the field of sexual assault.

Injury Center staff work with their counterparts at the National Institute of Justice and in other offices within USDOJ on a variety of projects. They supported the first National Violence Against Women Survey, which provides estimates of intimate partner violence, sexual violence, and stalking, and are now developing a pilot test for an ongoing national survey.

For several years, CDC has provided national leadership in the effort to improve the consistency and comparability of data on violence against women. They are pilot testing uniform definitions and recommended data elements on intimate partner violence, and are working to develop similar standards for sexual violence.

The Injury Prevention Center has an active research and dissemination program and agenda that includes attention to prevention of sexual violence and child maltreatment. Beginning in FY 2000, the CDC initiated projects to implement and evaluate culturally appropriate early intervention and prevention programs to prevent intimate partner and sexual violence among racial and ethnic populations. They also administer funding and technical assistance for health departments in states and territories to develop rape prevention and education programs, that will include training programs for professionals.

The Injury Center is promoting development of a public-private network of training and technical assistance resources, many of which proved useful in the development of this report. In 1999, the CDC awarded a grant to the Pennsylvania Coalition Against Rape to establish the National Sexual Violence Resource Center (NSVRC). The Center provides resources, training materials, and information to State and national sexual assault organizations and coalitions, as well as to community-based programs. Its extensive collection of materials is easily accessible online (www.nsvrc.org.)

CDC, along with more than a dozen partner organizations, supported the American College of Emergency Physicians (ACEP) in the development of a basic protocol for conducting medical evidentiary examinations of adult and pediatric/adolescent patients.

Health Resources and Services Administration (HRSA)

Bureau of Health Professions (BHPr)

The Bureau of Health Professions in the Health Resources and Services Administration (www.hrsa.gov) has extensive data and analytic initiatives related to the number and type of health professions training programs and students.

Most data on health professions training programs is obtained from relevant professional organizations, including the Association of American Medical Colleges (AAMC), the American Association of Colleges of Nursing (AACN), and other professional entities. For the most part, the data from professional associations is insufficiently detailed to provide a picture of what course-work related to sexual assault or medical evidentiary exams is available to students in a given type of training program.

The National Health Service Corps (NHSC) offers a detailed clinical training module on Child Abuse, Neglect and Domestic Violence for students and providers in rural and urban, inner-city areas. Funding for a General Preventive Medicine residency program at the University of Texas Medical Branch included elective rotations in forensic psychiatry and medical management.

The Division of Nursing obtained survey data collected by the AACN in 1999 that provides information on the curriculum content of baccalaureate nursing programs. The information was used by a HHS consortium to examine how women's health and sex/gender issues are taught in the academic and clinical course of study for baccalaureate nursing students. HRSA and others in HHS have worked with schools of nursing to assist development of improved curriculum content related to violence against women.

The Division of Nursing funded the College of Nursing at Seton Hall University in New Jersey to develop a new specialty in violence prevention that will educate students to become Sexual Assault Forensic Examiners. The Division has also supported development of training materials for nurse-midwife program faculty and providers on caring for survivors of sexual assault, elder abuse or child abuse. Some Area Health Education Center Program (AHEC) and Geriatric Education Center Program (GEC) grantees are offering education programming related to sexual assault and elder abuse.

Maternal and Child Health (MCH) Bureau

In 1997, HRSA's Maternal and Child Health Bureau supported the American College of Emergency Physicians (ACEP) in an effort to develop a consensus-driven national training protocol for performing medical evidentiary examinations of victims of sexual assault. The ACEP worked in collaboration with more than a dozen other public and private entities in drafting material, and subsequently published a protocol in 1999. The protocol continues to be widely used within the emergency medicine community (ACEP, 1999) and as a guide for many of the protocols being developed by States.

HRSA's MCH Bureau also supports program interventions to prevent child maltreatment, including child abuse and neglect. It funds the Children's Safety Network (CSN), which provides training, technical assistance and resources to state and local departments of public health, maternal and child directors and staff, injury prevention and control directors, and health professionals. Available resources include a State-by-State statistical summary of costs associated with child sexual, physical, and mental abuse and related deaths. The CSN Web site is www.csneirc.org.

Bureau of Primary Health Care

Another HRSA activity related to domestic violence is the Bureau of Primary Health Care, Office of Minority and Women's Health profile of programs that addresses domestic violence at community health care organizations supported by the Bureau of Primary Health Care. The February 1992 publication, Healing Shattered Lives: An Assessment of Selected Domestic Violence Programs in Primary Health Care Setting, is designed to encourage primary health care providers to treat domestic violence among their client base and to engage providers, administrators, policymakers and others in a coordinated, communitywide response to domestic violence.

Other HRSA Resources and Initiatives

There are two additional HRSA activities that, while related to domestic violence issues, provide good prototypes for possible future work related to sexual assault and medical evidentiary examinations:

  • The HRSA Action Plan to Prevent Family and Intimate Partner Violence trains managers and program officials on domestic violence to heighten awareness of family, and to pave the way for changes to be made in health care and professional training settings.
  • In 2000, HRSA's Office of Minority Health worked with the Bureau of Primary Health Care and others to coordinate delivery of two satellite provider training programs that were targeted to providers in the Community and Migrant Health Center Programs and others serving rural and inner-city areas. The training featured an inter-cultural approach and was designed to raise awareness, build provider skills, define resources, and develop community partnerships.3

Substance Abuse and Mental Health Services Administration (SAMHSA)

SAMHSA (www.samhsa.gov) is currently sponsoring the Women, Co-Occurring Disorders and Violence (WCDV) Study, which began in 1998 and will be completed in September, 2003. This study is the first Federal effort to address the significant lack of appropriate models of integrated services for women with co-occurring substance abuse and mental health disorders who have experienced trauma. The study is generating empirical knowledge on the development of trauma focused comprehensive, integrated service approaches and the effectiveness of these approaches for women.

National Institutes of Health/National Institute of Mental Health (NIH/NIMH)

In 1997, in response to a congressional request, NIH(www.nih.gov) established an NIH Child Abuse and Neglect Working Group (CANWG) consisting of the major research Institutes and Offices supporting research in the field. CANWG has worked to review NIH research efforts in child abuse and neglect, clarify Institute responsibilities to differentiate areas of overlap, identify accomplishments and future research needs, coordinate child abuse-related research across NIH, plan conferences and workshops, and develop funding mechanisms. The CANWG has met with representatives of other Federal agencies including the Administration for Children and Families, National Institute of Justice, Office of Juvenile Justice and Delinquency Prevention, Department of Education, and the Department of Defense. The Committee's review revealed that $33.7 million is devoted primarily to child abuse and neglect research and another $48 million is relevant to understanding the precursors and consequences of abuse and neglect.

NIMH (www.nimh.nih.gov) sponsors a broad array of research related to the psychosocial impact of sexual and physical assault; development and testing of treatment protocols and training programs; research on preventive interventions to reduce posttraumatic mental disorders; training of mental health researchers; and research on the organization, delivery and effectiveness of care to victims. In 1995, NIMH issued a Program Announcement to solicit research on Violence and Traumatic Stress. One of the three major areas addressed was victims of child abuse, rape, sexual assault, family violence, and other kinds of interpersonal violence and crime. NIMH has issued fact sheets on Post-Traumatic Stress Disorder and Helping Children and Adolescents Cope with Violence and Disasters.

Agency for Healthcare Research and Quality (AHRQ)

AHRQ (www.ahrq.gov) has awarded $5.5 million for four extramural research projects to evaluate health care interventions with the purpose of improving treatment and outcomes for victims of domestic violence. This research should assist health care organizations with evidence-based findings about the most effective treatment approaches for domestic violence victims. The studies are intended to develop new knowledge in the prevention of domestic violence, improve the identification of female patients at risk, and evaluate outcomes and effectiveness of health care interventions designed to treat domestic violence victims.

AHRQ has also issued a new evaluation instrument that hospitals can use to assess the quality and effectiveness of their domestic violence programs (http://www.ahrq.gov/research/domesticviol/). Hospitals can use this instrument to assess how well hospital-based programs provide training for health care professionals in recognizing domestic violence, patient screening to determine their risk of domestic violence and future injury, and interventions, including medical treatment and victim advocacy services and followup.

HHS Violence Against Women Act Steering Committee

The HHS Violence Against Women Act Steering Committee meets bimonthly and is managed by the HHS Office on Women's Health in the Office of the Secretary. Meetings are attended by staff from HHS Agencies and Offices, as well as by staff from USDOJ. The Committee's primary focus is promoting exchange of information and collaboration on issues related to intimate partner violence, but most members share a strong interest in sexual assault and child abuse as well.

Stop Family Violence Fundraising Stamp

The Stop Family Violence postal stamp was unveiled by the Secretary, HHS on June 14, 2003, to raise awareness and generate money for the victims of domestic violence. The price of the stamp is 45 cents, with the difference between the sales price of the stamp and the underlying postage consisting of a tax-deductible contribution. By using this stamp on their cards, letters, and packages, customers will contribute to a nationwide fight against domestic violence.

U.S. Department of Justice (USDOJ)

USDOJ (www.usdoj.gov) has developed an impressive and useful array of scientific papers related to sexual assault and forensic issues. These include published survey findings and statistical analyses, white papers, conference summaries, and other reports and training materials. The primary resources on sexual assault at the Office of Justice Programs (OJP) are managed by the following offices:

National Institute of Justice (NIJ)

NIJ is the research, development, and evaluation agency of the USDOJ, and is solely dedicated to researching crime control and justice issues. NIJ funds a range of research, including an annual solicitation for Research on Sexual Violence, that allows for awards of up to $1,000,000 to support research on sexual violence in understudied populations, drug-facilitated sexual assault, and the effect of criminal justice reforms (including use of DNA evidence) on the outcomes of sexual assault cases.

The NIJ is currently funding an evaluation of the Sexual Assault Response Team (SART) model in Rhode Island. Outcomes for victims and perpetrators will be compared in communities that have SART programs and those that do not. The study will be completed at the end of 2004.

The NIJ also supports a number of projects in collaboration with the CDC, including development and analysis of the National Violence Against Women Survey.

Bureau of Justice Statistics (OJS)

OJS is the source for national police statistics on sexual assault and conviction rates used in this report. Its mandate within USDOJ is to compile and analyze data on crime, criminal justice, and crime victimization. Its Sourcebook of Criminal Justice Statistics, 2000, compiles statistics from more than 100 sources to profile all aspects of criminal justice in the United States and is published in hard copy, CD-ROM format, and online (USDOJ, NCJ, 2001).

Office for Victims of Crime (OVC)

OVC was established under the 1984 Victims of Crime Act (VOCA) to oversee programs that benefit victims of crime. It funds state victim assistance and compensation programs, and supports training programs to educate criminal justice and allied professionals regarding the rights and needs of crime victims. It operates a comprehensive program of training, technical assistance materials, and publications related to rape and sexual assault, and manages a Speakers Bureau for contacting experts on sexual assault issues. In 1999, the OVC published an online and hard copy guide for development of SANE programs (Ledray, 1999). A more recent publication, Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims, provides an overview of SANE programs and their contributions to improving community response to victims, and identifies promising practices and practical guidelines for establishing a SANE program (USDOJ, NCJ, 2001).

Office on Violence Against Women

This Office works with others in the Office of Justice Programs to implement a variety of programs authorized by the Violence Against Women Act. One of these is the STOP Violence Against Women Formula Grant Program, which provide funds to state, tribal, and local governments, and to community-based agencies. States may choose to use the funds for any of a number of listed purposes, including development of specialized domestic violence and sexual assault units, and for the training of sexual assault forensic medical personnel examiners in the collection and preservation of evidence, analysis, prevention, provision of expert testimony, and treatment of trauma related to sexual assault. The Office supports a limited program of research on sexual assault issues.

Under the Violence Against Women Act of 2000, the Attorney General is required to develop national recommendations for a protocol for sexual assault forensic examinations. The Violence Against Women Office has convened national experts and solicited advice from technical sources and the public. The Office is working with medical experts, advocates, experts from the criminal justice system, forensic scientists, and with others at USDOJ and HHS, in the development of a protocol. The recommended national protocol is anticipated to be completed in December, 2003 (USDOJ, 2003).

The DNA Analysis Backlog Elimination Act

The DNA Analysis Backlog Elimination Act of 2000 (42 U.S.C. § 14135 (2000)) provides Federal funding of $45 million over 3 years to States for DNA sample analysis. The money is intended to enable labs to hire the additional personnel needed to eliminate backlogs and to decrease processing times. To be eligible, States must promise to implement a comprehensive plan for the expeditious analysis of DNA samples, including those collected but not analyzed prior to enactment.

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State Programs and Initiatives

Reporting Requirements

In 48 States, physicians and other health 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 (Children's Bureau, HHS, 2002). Four States (California, Colorado, Rhode Island, and Kentucky) specifically require physicians to report intimate partner abuse (National Academy Press, 2002).

Practice Protocols and Standardized Evidence Collection Kits

Background research conducted by the Department of Justice, derived from State and professional materials, has documented that there are approximately 35 States which have or are developing practice protocols on sexual assault for use in the State, and approximately 45 States that have or are developing State standardized evidence collection kits and forms.

Mandatory Educational Requirements

A few States have established mandatory educational requirements for health professionals. California, Iowa and New York require health providers to receive training on identification and reporting of child abuse and neglect. Alaska, Florida, and Kentucky require training to familiarize providers with intimate partner violence and community resources; and Iowa mandates two hours of training every five years on identification and reporting of elder maltreatment (National Academy Press, 2002).

Promotion of SART/SANE Programs

Facilitated by the support from the USDOJ Office for Victim Services, SART programs now reach into at least two dozen States. Many states have vigorously adopted SART/SANE programs, including Texas, Wisconsin, Colorado, and Pennsylvania. For example, Texas provides financial support and technical assistance for development of SANE/SART training programs and has a full time unit to encourage SANE training programs. The State of Rhode Island is participating in a study funded by NIJ to evaluate the effectiveness of their SART program.

State Supported Training Models

Training models have been developed with State support in Alaska, California, Ohio and Texas. As an example, the California Medical Training Center at the University of California (UC)-Davis is a product of the State legislature, which passed laws which mandate reporting of sexual assault and abuse by health professionals, and which also acted to provide financial support for a statewide system. The program is based at the UC (Davis) Medical School, and provides specialized clinical training for examination and treatment of four types of victims (sexual assault, child abuse and molestation, domestic violence, and elder abuse). The CMTC offers training to physicians, nurses, emergency responders and other professionals. Training is offered on site, in hospitals and other facilities around the State, and through distance learning facilities available through college, hospital or law enforcement training networks. Trainees include physicians, nurses, law enforcement officers, Emergency Medical Service (EMS) personnel and others. Medical technology is used to link rural providers with specialized consultation services, and faculty are able to offer their services as expert witnesses.


3. These training sessions on domestic violence are available from the HRSA Information Center or 1-888-ASK-HRSA.


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