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 sexual assault.

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 questions include:

• 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 guilty plea.

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 forms.

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 uncertainty.

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 training.

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Improving the Organization and Delivery of Care for Victims of Sexual Assault

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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