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Medical Examination and Treatment for Victims of Sexual Assault

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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.

Legislative Mandate

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:


(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 violence.

(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 appropriated.

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 recover.

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 include:

  • 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 Prosecutors

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 mentioned include:

  • 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 offender.

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 sentences.

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 years later.

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 populations.

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 period.

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 that:

  • 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.

Literature Review

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 community agencies.

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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