Clinical Practice: Issues of Cost, Quality, and Access to Sexual Assault Services

The Agency's discussions with experts in the field pinpointed a number of issues in cost, quality and access to services for victims of sexual assault in urban, suburban and rural areas.

Costs Associated with Sexual Assault

There are few studies of the economic or medical costs associated with sexual assault, and little data on the use of medical services, either immediately, or over the long term. The studies that are available indicate that the long-term costs may be quite substantial in terms of ongoing visits to providers, missed work, and treatment for trauma (Rennison, 2002).

A 1996 NIJ Report (NIJ, 1996) supplements information obtained from the NCVS, which collects information only on short-term, out-of-pocket losses due to victimization. The NIJ report provides cost estimates for various types of violent crime that include longer range costs (e.g., those due to permanent disability and for mental health treatment) and intangibles such as pain, suffering, fear, and lost quality of life. The findings of the report include:

• Between 10 and 20 percent of mental health care expenditures in the U.S. may be attributable to crime victims who seek treatment as a result of their victimization. About half of these expenditures are for victims of child abuse who receive treatment as adults.
• Total costs per incident of non-fatal rape and sexual assault are estimated at $87,000, including $2,200 in productivity losses, $500 for medical care expenses, $2,200 for mental health care, and $81,400 associated with reduced quality of life.
• The average total cost per incident of child abuse is $60,000, including $2,200 in lost productivity, $430 in medical care costs, $2,500 for mental health care, and $52,371 in reduced quality of life. The greatest losses are associated with sexual abuse ($99,000 per incident), followed by physical abuse ($67,000) and emotional abuse ($27,000). (Note: The quality of life estimates were derived from the analysis of 1,106 jury awards and settlements to assault, rape and burn survivors to compensate for pain, suffering and lost quality of life [excluding punitive damages].)
• Total annual losses in the United States associated with child abuse (including sexual, physical, and emotional abuse) are estimated at $56 billion, including $23 billion specifically for rape and sexual assault.
• Total annual losses associated with rape and sexual assault of adults are estimated at $127 billion, including $4 billion in medical costs, $3.5 billion in other tangible costs, and $119 billion in quality of life.
• Total annual losses associated specifically with adult domestic violence (including fatalities, rape, other assaults and robbery) are estimated at $67 billion, including $1.8 billion for medical care, $7 billion for other tangible costs, and $58 billion for quality of life (these figures overlap substantially with those reported above for rape and sexual assault).

The 1995-96 NVAWS, a telephone sample survey that collected information on medical services provided to adult victims of rape, found that:

• About one-third (31 percent) of female rape victims reported physical injuries. Almost three-quarters of the injuries (73 percent) were minor (e.g., scratches, bruises or welts).
• About one third (36 percent) of those injured received some type of medical care. The majority of injured female victims who received care were treated in a hospital (82 percent). While most of those treated in a hospital were seen in the emergency room or an outpatient department, about 13 percent stayed for at least one night, with an average stay of 3.6 nights for those admitted on an inpatient basis.
• About half (55 percent) of all women who received medical care were treated by a physician outside of a hospital and averaged 4.8 office visits related to the injury. Somewhat less than a fifth received dental care (16.9 percent). A similar proportion visited a physical therapist (16.7 percent).

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Variations and Deficiencies in the Quality of Care

Among the issues identified with respect to quality of care and variations in practice are the following:

• Lack of standardized protocols, procedures, and rape testing kits in use. A number of protocols and procedures have been developed, but there is considerable overlap and many States end up reinventing well accepted standards. However, there remain important differences among the protocols in use and none have been compared or rigorously assessed. Even components which are fairly standardized have neither been systematically taught nor thoroughly evaluated.
• A lack of trained providers and expert consultants. There are curricula for teaching how to perform a medical evidentiary examination, but programs have reached only a few, self-selected providers (National Academy Press, 2002; Voelker, 1996). While there have been notable efforts by States to extend and support forensic training programs to health professionals already in practice, the sheer number and types of providers who may see a sexual assault victim is daunting. The IOM report, Confronting Chronic Neglect (National Academy Press, 2002) makes the point that all providers need basic competencies. Specific training needs will vary by profession, specialty and practice setting. In particular, special training and skills are required for addressing the needs of child victims as compared to adults.
• Uneven quality of examination facilities and technologies available. Most victims who seek medical care, though not all, are examined in a hospital setting. Many hospitals have developed special areas and separate facilities for examining patients, to provide a place where the lengthy examination will not impede care for other types of patients coming into an emergency room, to make available the special equipment and storage facilities used in such examinations, and to provide the victim a sanctuary that protects her or him from further traumatic experiences. Quiet, age-appropriate environments are thought to be especially important when examining children, who are particularly vulnerable to retraumatization and who also need examiners who are trained to meet the specialized needs of child victims. Specialized and separate sexual assault units within or near a hospital are viewed by many as ideal from a patient's perspective, but such facilities are not available in all hospitals. Reasons include lack of space; too few patients to make it an effective use of reserved space; an unwillingness or inability to spend the resources needed to establish and maintain a dedicated sexual assault unit; and a lack of understanding by administrators and/or the community about the importance of specialized care. Equipment and space are expensive resources, and smaller, rural hospitals may have particular difficulty creating a viable program, facility and trained staff.
• Poor quality and limited capability to test for drugs and DNA. Most hospitals do not routinely test for the full range of drugs (including substances used in drug-facilitated rape). Even fewer have the skills and technology to handle DNA testing, which has assumed additional importance with the advent of State DNA banks. DNA evidence can easily be compromised by untrained providers who are involved in the collection and preservation process. The sample can be contaminated if someone sneezes or coughs over the evidence, or even if the examiner touches his/her own hair or body and then touches the area to be tested. It is also affected by heat and humidity, and is easily degraded (Turman, 2001). Forensic DNA testing is a lengthy and expensive process, but one which is often paid for by the police department or prosecutor's office. However, even police labs often lack adequate forensic testing capabilities.

In partial response to these issues, a Federal law, the Paul Coverdell National Forensic Sciences Improvement Act, was enacted in 2000 (42 U.S.C. §§ 3797j et seq. (2002)). The Act authorizes about $500 million in Federal funds over a five-year period to be used by States to: improve procedures for testing DNA samples; hire and train personnel; modernize laboratory equipment; and improve the quality and timeliness of forensic science services.

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Access to Services

There are only sketchy descriptions available of the types and quality of services available to sexual assault victims. The reports available indicate wide variations in the types and quality of services received.

The NWS found that 55 percent of rape victims surveyed had not been given information on HIV testing and that one-third were not given information about other STD testing. The practice of immediate testing for STDs is controversial because any infection found would reflect prior exposure, and not all assaults will expose a patient to STD risks. However, others favor it as baseline information, and virtually all experts agree that the provider should stress the need for followup STD evaluation and treatment for patients at risk (CDC, 2002).

A 1996 survey of 130 Florida hospitals also provides a startling picture of the high degree of variation in services provided to sexual assault victims (Maxwell and Soubielle, 1996). Highlights of the findings from the 64 hospitals responding (49 percent) include:

• Most of the Florida hospitals surveyed (88 percent) saw rape victims through the emergency room.
• Some hospitals (six) reported that law enforcement personnel assist in the exam, a violation of the State's evidence collection protocol. Most experts in the field agree that, except in rare cases, there is no medical or legal reason for law enforcement representatives, male or female, to be present during the exam. Maintaining the chain of custody during the examination is a function and responsibility of the attending medical personnel and one that should not require outside assistance.
• Although the JCAHO requirements call for ongoing in-service training, only about one-fourth of hospitals reported that they provided such training for the personnel conducting examinations. (Information on followup activity initiated in response to findings about adherence to JCAHO requirements is not available.)
• Most hospitals only involve the local rape crisis center personnel if requested to do so by the victim, many of whom do not know that such services exist.
• Fewer than half of the hospitals reported that they provide written material on common rape reactions and community resources as a usual practice. Fifteen percent said they do not provide the victim with any information on resources.
• Just over half of the hospitals set aside separate rooms for rape victims and some provide showers for the rape victims after the exam, or maintain a clothing closet, or provide underwear or paper jump suits to patients whose clothing was collected.
• Most hospitals (82 percent) discussed HIV screening with patients and dispensed prophylactic drugs for sexually transmitted diseases (88 percent).

While interesting, these data, collected from 130 hospitals in Florida, may not be entirely reflective of national practices.

Access Issues Involving Payment for Evidentiary Exams

When a sexual assault victim presents to a hospital or clinic, medical staff will typically assess and respond to serious or life-threatening injuries. However, the decision to do a formal evidentiary examination is dependent on the patient who must give written consent, and is affected both by State laws and the judgment of local law enforcement officials or prosecutors as to whether an examination will be useful and can be justified.

Numerous Federal and State laws have been enacted to ensure that victims of sexual assault do not have to pay for medical evidentiary examinations. However, some States limit payment only to victims who are willing to report the assault to police and/or to cooperate in any prosecution. If the assault is not reported, or the case is not prosecuted, the victim may be unable to obtain a full examination, or may have to pay for the costs of an examination.

A number of States place responsibility for payment on the county where the sexual offense occurred, or on the entity who requests the examination, most often the investigating law enforcement agency or the prosecuting attorney. If the county official, police officer, or prosecutor is told that the victim does not plan to formally report the assault (a decision that the victim may not want or be able to make immediately, and a decision which sometimes changes), they may not approve payment for an examination. Similarly, if they believe that the victim's account is weak or that successful prosecution is unlikely, they may act to preserve limited resources and not provide approval for payment.

Even when State laws mandate that victims not be charged for the expense of evidentiary exams, there are cases in which claims may be submitted to third party insurance companies, compromising the victims' privacy, as insurance companies may not only be informed of the sexual assault but may also learn about exposure to HIV or other aspects of treatment that could affect insurance coverage in the future. Victims may also be forced to disclose the assault to the primary person on the insurance, such as a family member or even an employer.

Victims of crime are not generally required to cover the costs of evidence collection incurred in the investigation of their cases. Despite the fact that most States have laws that designate payment sources to cover the costs of forensic exams for sexual assault victims, and some even specifically prohibit billing of victims, billing of sexual assault victims continues to be widespread (National Center for Victims of Crime, 2003; National Center for Victims of Crime, 2001). Victims need to be informed of their rights and of avenues of recourse when rights are violated.

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