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Opportunities for Further Improvement
Consolidate and Enhance the Evidence Base for Practice
Promote Cross-Collaboration to Enhance Research, Education & Practice
Efforts to improve the quality and outcomes of medical evidentiary examinations
could be facilitated by consolidating and enhancing the existing knowledge base
through the promotion of cross-collaboration and communication among the
various disciplinary and organizational entities involved in education, research,
and practice. Current efforts are frustrated by a lack of a coherent body of
research in the field, i.e., a comprehensive evidence base to provide an integrated
framework for what is taught to students and providers. This problem is related to
all forms of violence, but is particularly acute for the evidence base related to
Several factors are thought to contribute to this problem. Support for research
available from Federal, State, foundation, or private industry sources is sparse and
fragmented. Thus, sexual assault as a field does not represent a viable career path
for many academic clinicians who might otherwise be attracted to it.
In addition, there is limited demand for teaching faculty who are expert in sexual
assault. There are few courses, and little prestige connected with this expertise
within the academic setting. This, combined with meager research funding, has
created a dearth of experienced researchers and university-based clinical faculty
with the skills needed to advance the field. For many, work in the field of sexual
assault is as much a personal cause as it is an academic pursuit.
Further, greater collaboration and communication is needed among researchers
and practitioners in order to integrate, consolidate, and enhance the baseline
descriptive information available on issues related to quality, outcomes, cost and
access to medical evidentiary examinations and related treatment services. Basic
- Who is currently performing medical evidentiary examinations for victims of rape and other sexual assaults? How are they trained? What services do they provide? What are the variations in practice, and in the related quality, effectiveness and outcomes of care?
- What is the experience of victims, including the types of settings where they receive care, waiting times, and access to services? To what extent are special provisions made for children who are sexually molested?
- What are the immediate and long-term costs associated with sexual assault, including the cost to providers and the health care system of an involvement with legal proceedings?
Another set of questions concern the relationship between the services that are
provided, the training received by providers, and the outcomes, costs and
effectiveness of care. Decisions about when and under what circumstances an
evidentiary examination should be performed continue to be controversial, as is
the issue of who decides. Sometimes the decision is based on the believability of
the victim and/or the likelihood of prosecution, as assessed by the law
enforcement officer on the scene. In addition, technological innovations are
changing the practice of forensic science. The time frame during which useable
evidence can be recovered is being extended and new techniques are improving
the range and reliability of other testing.
The assessment of under what circumstances examinations should be undertaken
is further complicated by the fact that examination results are frequently not
actually used in criminal proceedings. Arrests may not be possible or assailants
may plead guilty, although examination results may increase the likelihood of a
To date, study results of the usefulness in subsequent legal proceedings of
evidence from evidentiary examinations are mixed. A few studies seem to
indicate that evidentiary examinations do not strongly influence the outcomes of
court proceedings, but that outcomes tend to turn on factors such as the credibility
of the victim and the demeanor of the accused. Other studies show a selective
impact, i.e., that parts of the examination are useful. Still others conclude that
examination results provide pivotal information for prosecutors. In particular,
DNA results are often key, resulting in the conviction or confession of some
accused persons, but also conclusively exonerating other suspects.
Since evidentiary examinations are emotionally difficult for most patients to
undergo, as well as costly, further study is needed on questions such as:
- When are evidentiary exams indicated? How is the decision about whether an evidentiary exam is conducted affected by the judgments of police and prosecutors?
- What contributes to their effectiveness both in terms of meeting patient care needs and leading to successful prosecutions?
- How are services best organized and delivered?
- What are the costs and effectiveness of different models of care?
- What is the impact of enhanced training on practice and outcomes?
A variety of strategies have been recommended by experts in the field to
consolidate, integrate and enhance the infrastructure for collaboration and
communication in research and training on issues related to the examination
and treatment of sexual assault.
The IOM report on training for health professionals in family violence
recommends development of multidisciplinary education and research centers
that would be charged initially with conducting research to:
- Understand the magnitude and impact of family violence on society and the health care system.
- Evaluate existing training curricula and educational approaches.
- Expand scientific research on the magnitude of health effects and effectiveness of interventions for family violence.
The vision is that, over time, such centers would develop training programs
based on scientific evidence, and work with others to test, evaluate and
disseminate education and training programs. They might also provide
training directly and undertake a range of other activities to advance the field.
The idea of creating "Centers of Excellence" to focus on work in a specific
field has been used in many areas with considerable success. It is an approach
that, perhaps as part of centers with a more general focus on women's health or
family violence, may be useful for advancing the training and care provided to
victims of sexual assault. Support for such centers could come from a variety
of sources including existing Federal programs, States (which already support
educational programs in State schools of medicine, dentistry and nursing), and
private foundations. The California Medical Training Center at the University
of California (UC)-Davis, described in the section on Federal and State Activities, is an example of such a
comprehensive program created by a State.
A research and educational focus on examination and treatment of sexual
assault could also be built into other current multidisciplinary programs with a
women's health or family violence focus funded by Federal agencies such as
HHS, USDOJ, and DOD.
There are few existing opportunities for individuals to advance their skills in
the field of sexual assault examination and treatment. Such opportunities
could be enhanced by modifying or supplementing existing fellowship and
training programs at the State or Federal level, and encourage additional
foundation support for such training. For example, there are existing research
fellowships—public and private—that tend to focus on disease-specific topics,
that could be opened to persons interested in the field of sexual assault.
Encourage Federal, State, and Community Involvement in the
Development, Standardization, and Dissemination of Evidence-based
Training Materials and Protocols
The USDOJ has played an active role in refinement and dissemination of the
SANE programs for practicing health professionals, which now reach into
more than 24 States. There are also training models developed with State
support in Alaska, California, Texas, Ohio, and elsewhere that could be
evaluated and adopted by professional groups.
There is precedence for the Federal Government to encourage development of
specialized curricula and training programs through its role as convener and
coordinator. When legislative authority and funds are available, it can also
provide financial support for special projects of this nature.
As described in the section on Federal and State Activities, 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, and a number of States are
developing practice protocols and standardized evidence collection kits and
The exercise of developing national recommendations will require a
comparison of protocol components, with the goal of identifying optimum
approaches agreed upon by practitioners in the field. A useful follow-on
project would be to compare and test alternative models, and to convene a
group of national experts to establish a research agenda that targets areas of
In partnership with State, Federal, and professional organizations, community
organizations can also contribute by providing training and awareness-building
for health care organizations.
Encourage Access to Evidence-based Training and Education Through
the Use of Distance Learning and Other Medical Technologies
A relatively untapped resource is the use of Federal and State distance
learning facilities associated with colleges, universities, Federal facilities, and
law enforcement to provide rural and small town hospitals and professionals
with relevant training programs over time. Studies show that one-time
continuing education programs are likely to have little impact, but consistent
reinforcement and interaction with peers can change practice.
Problems with the compatibility of live video training hookups may place
limits on what can be done, though the possibilities have not yet been
explored in a systematic way across the country. These programs need to be
assessed, and a source of funding identified.
Since it is not feasible for every physician and every nurse to acquire and
maintain skill levels in an area as complex and changing as forensic medicine,
other approaches are need to assure skills are available to sexual assault
patients in rural and small town areas by fostering regional capabilities and
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Improving the Organization and Delivery of Care for Victims of Sexual
Encourage Coordination at the Community and State Levels Among
Law Enforcement, Social Service, Specially Trained Health Providers,
State and Local Public Health Agencies, Mental Health Providers,
and Community Advocates
The SART approach, advocated by many and adopted in an increasing
number of communities, brings together police, prosecutors, nurses,
physicians, hospital administrators, public health agencies, mental health
providers, and victim advocates to collaborate on a sustained basis in
providing coordinated care to sexual assault victims. A more coordinated
approach can help minimize burdens for the victim associated with long
waits at the hospital, repetitive police and medical interviews, poorly
trained or inexperienced providers, inappropriate or inadequate facilities,
and uncoordinated treatment and followup services. Coordination is
thought to help overcome fragmentation of resources and offer improved
efficiency and effectiveness in the delivery of needed services to sexual
assault victims. Community organizations can play an important role in
contributing to the viability of coordinated community response efforts, by
providing services as well as training and awareness-building activities.
Programs to encourage coordinated systems of care can be initiated at the
local, State, and Federal levels. As described in in the section on Federal and State Activities, the NIJ is
currently funding an evaluation of the SART model in Rhode Island.
Encourage Investment in Needed Facilities and Equipment
There have been quantum leaps in the sophistication of camera and
examination equipment and tests and testing procedures. This has lead to
sharp disparities in the quality and accessibility of services from city to
city, State to State, and between urban and rural areas. At the same time,
there has been little investment in upgrading crime labs that process
evidentiary material, and in the training for health and law enforcement
personnel in the use of technical advances.
Many of the improvements available have great potential for extending
consultation services to rural and isolated areas. For instance, in the
Sonoma Valley, a rural area of California, a local hospital has purchased digital cameras and colposcopes that link directly to medical consultants at
the UC Davis California Training Center. It is possible for nurse
examiners to show consultants images of victims, and then discuss
interpretation and followup with university-based experts. Consultants
can then also provide expert testimony on issues as needed, and more
consultations can be offered because the need for travel time is less.
There is considerable concern about the use of digital cameras because of
the difficulty of detecting alterations. Digital cameras are appealing
because images can be transmitted quickly to law enforcement and
technical consultants. The image clarity is also greater, especially in poor
light conditions and for persons of dark complexion. They enable the kind
of distance consultation described above. However, some jurisdictions
prohibit use of images from digital cameras as evidence. Hospitals and
forensic investigative teams should explore this issue before investing in
equipment and training. In addition to the security issues, diffusion is also
hampered by the initial high cost of equipment and training.
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