In this Report to Congress, the Agency for Healthcare Research and Quality (AHRQ) provides an overview of current systems for training and practice in provision of medical evidentiary exams to victims of sexual assault and other abuse. It also discusses major gaps in service and training and summarizes the current scientific evidence base.
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Purpose and Background
Study Methods and Approach
Health Professions Education, Training, Professional Standards and Guidelines
Clinical Practice: Issues of Cost, Quality, and Access
Federal and State Activities
Opportunities for Further Improvement
Reference
Section 916 (d) of the Healthcare Research and Quality Act of 1999 (P.L. 106-129) charged the Agency for Healthcare Research and Quality (AHRQ) with developing and disseminating a report on:
The legislation did not establish a due date for the report, and no funds were appropriated. This report provides an overview of current systems for training and practice in the provision of medical evidentiary examinations to victims of sexual assault and other abuse. The report also:
Estimates of the number of victims of sexual assault and other abuse in the United States vary considerable from study to study. By any estimate, however, the number is substantial and affects all strata of society across all geographic regions, populations, and ages. Recurrent findings regarding rape and sexual assault indicate that most victims are young women, most incidents are not reported, and most assaults are perpetrated by husbands or other intimate partners, friends, or relatives.
A medical evidentiary examination is an examination done by a health professional that includes attention to the medical needs of the victim as well as to the gathering of evidence for law enforcement purposes. It typically includes medical evaluation and crisis intervention, forensic evidence collection, evaluation of emotional needs, and referral for followup care.
A medical evidentiary examination can be a key element in the successful prosecution of sexual assault and other violent crimes. When examining a victim, providers 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 must be done in a painstaking, yet respectful, 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 required by a court, a health provider needs training and experience in what procedures are needed and how they should be done. Unfortunately, most providers are not routinely trained or familiarized with the management of victims of sexual assault and other abuse or in the performance of evidentiary examinations.
In developing this report, AHRQ staff conducted an extensive search of the peer-reviewed literature as well as an Internet search of national clearinghouses and other relevant sites. In addition, letters inviting submission of any relevant training materials, practice guidelines, policy statements, or position papers were sent to a large number of professional organizations and individuals thought to be knowledgeable about or having professional training or clinical practice standards related to sexual assault. As a result of these efforts, training materials, protocols, and position statements were received from over 40 organizations including the major professional societies as well as providers, public health agencies, advocacy organizations, and research institutions.
Information was also obtained from telephone discussions with experts from around the country or site visits to a number of professional or training organizations and through exchanges at relevant meetings and conferences. Experts in the legal system were consulted and information about the study was presented to the National Advisory Council on Violence and Abuse, and the International Association of Forensic Nurses. There was substantial consultation with staff and Committee members at the National Academy of Sciences' Institute of Medicine (NAS/IOM), who developed a 2002 report on the adequacy of training for health professionals in family violence: Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Finally, a number of components within the Department of Health and Human Services (HHS) and at the U.S. Department of Justice (DOJ) were consulted.
Little is known about who and how many health professionals have received training in the examination and treatment of victims of sexual assault and other forms of abuse, or the content, duration, and scientific basis for the training. There is no central source of data on this skill and no specific credentialing requirements.
Although little factual information is available on what programs exist, it is evident that the number of programs and support for training in forensic sciences is growing. This is attributed to expanded State reporting requirements. Nonetheless, based on a recent review performed by the IOM Committee on training for family violence, there currently exist only a handful of university-based academic training programs for health professionals that include significant content related to performing medical evidentiary examinations. The IOM committee concluded, moreover, that those that exist are frequently inadequate.
There are a number of organizations that offer continuing education or training and related materials to health professionals already in practice. A training model that is growing rapidly and bringing substantial change to the field is the Sexual Assault Nurse Examiner (SANE)/Sexual Assault Response Team (SART) program. Through these programs, trained nurses may receive supplemental certification as nurse examiners. These programs are often integrated into a Sexual Assault Response Team (SART) model in which medical and mental health providers, law enforcement, prosecutors, and victim assistance agencies and public health organizations work together to facilitate continuity and quality of care. The number of these programs across the country has grown from 20 in 1991 to over 400 in 2001 (Ledray, 2001).
Other organizations that offer continuing education (CE) programs to develop the skills needed to perform medical evidentiary examinations include a handful of State-funded programs. Prominent examples include:
Several professional organizations have developed materials, policies, and course offerings related to sexual assault, including the American College of Obstetricians and Gynecologists (ACOG). The American College of Emergency Physicians (ACEP) has developed a detailed examination protocol as well as other materials and training.
Distinct from educational programs offered at a particular time and place and which are part of a formal training process, guidelines, professional standards and clinical practice protocols are developed by professional organizations or quality improvement bodies to help guide practicing providers toward improved health outcomes. In recent years, the development of guidelines and protocols has grown, as evidence-based medicine has become a dominant force in the way medicine is practiced.
A number of specialty-specific professional organizations and accrediting bodies have developed clinical protocols, training materials, professional standards, and policy statements to assist their members in practice. These organizations include: the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); the American Academy of Pediatrics (AAP); ACEP; ACOG; the American Medical Association (AMA); the American Professional Society on the Abuse of Children (APSAC); the American Academy of Child and Adolescent Psychiatry (AACAP), the American Society for Testing and Materials (ASTM); and the Centers for Disease Control and Prevention (CDC).
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 and other forms of abuse in urban, suburban, and rural areas.
There are few studies of the short- or long-term medical costs associated with sexual assault and other forms of abuse. The most recent study to assess both immediate and long-term costs was published by the National Institute of Justice (NIJ) at the Department of Justice in 1996. The report indicated that costs associated with nonfatal rape and sexual assault averaged $87,000 per incident for adults and $99,000 per incident for children. The estimates consider both immediate use of medical care and mental health services, lost productivity, and permanent disability as well as the cost of less tangible impacts such as pain, suffering, fear, and lost quality of life. Interestingly, the researchers estimated that between 5 and 10 percent of all mental health expenditures in the United States might be attributable to victims of child abuse (all forms) who receive treatment as adults.
Issues with respect to quality of care and variations in practice include:
What little data exist suggest wide variations in access to and quality of services received by victims of sexual assault. These include:
Access to medical evidentiary examinations is not uniform across the United States, and access can be compromised by payment issues. Although numerous Federal and State laws have been enacted to ensure that victims of sexual assault do not have to pay for medical evidentiary examinations, some States limit payment to victims who indicate a willingness to report the assault, a decision the victim may not want or be able to make immediately. Even when the victim is willing to commit to formally filing a report and cooperating with prosecution, the law enforcement agency or prosecutor still may not be willing to approve payment for an examination if they feel the case is weak, a decision that is made in the early stages of an investigation. In addition, it is the opinion of many experts working in the field that despite legal prohibitions, billing of the patient/victim continues to be widespread.
There are a number of Federal and State activities that address issues in research, training, and practice related to the examination and treatment of victims of sexual assault and other forms of abuse.
The HHS Violence Against Women Act Steering Committee includes representatives from HHS Agencies and Offices and from the Department of Justice (DOJ). It promotes the exchange of information and collaboration on issues related to intimate partner violence. CDC collects surveillance data, supports community development and research on prevention, and offers technical assistance. The Health Resources and Services Administration (HRSA) collects data and conducts analyses related to health professions training programs. The Division of Nursing, in particular, has funded initiatives to develop improved curriculum and training programs related to violence against women. In addition, there are a variety of programs aimed at improving prevention and care for violence victims among primary care providers and in community care settings. CDC and HRSA also joined forces in supporting the American College of Emergency Physicians in the development of a consensus-driven national training protocol for performing medical evidentiary examinations.
The Administration on Aging funds a long-term care ombudsman program to address abuse of residents in nursing homes and other facilities. The Substance Abuse and Mental Health Services Administration (SAMHSA) is currently sponsoring a 5-year study on integrated service models for women who have experienced trauma. The National Institutes of Health (NIH) established the Child Abuse and Neglect Working Group in 1997, which coordinates research efforts in child abuse and neglect across all the major research Institutes and offices at NIH. The National Institute of Mental Health (NIMH) sponsors a broad array of research related to:
AHRQ is funding four research grants on the outcomes, effectiveness, and cost effectiveness of programs for early identification and treatment of domestic violence, and recently released a Web-based tool to assist hospitals in assessing the quality and effectiveness of their domestic violence programs.
The DOJ is the source for national statistics on crime, criminal justice and crime victimization. It also supports research on sexual violence, including a current evaluation of the Sexual Assault Response Team (SART) model in Rhode Island. DOJ also oversees programs to support the victims of crime and supports training programs to educate criminal justice and allied health professionals regarding rights and needs of victims, including a comprehensive program of training, technical assistance and publications related to rape and sexual assault. The DOJ also funds grants to State, tribal and local governments and community agencies for development of programs and training related to sexual assault. The DOJ has been in the forefront of promoting expansion of SANE/SART programs and is currently developing national recommendations for a protocol for sexual assault forensic examinations. Finally, DOJ funds States to hire additional personnel in order to eliminate backlogs in the processing and analysis of DNA samples.
Almost all States have mandatory reporting requirements for child abuse and elder abuse. Over three-fifths have, or are developing, practice protocols on sexual assault and 45 States have, or are developing, standardized evidence collection kits. A few States have established mandatory educational requirements for health professionals. Approximately half of the States have SART/SANE programs and a few States have well-developed training models, including the California Medical Training Center, which provides specialized clinical training for examination and treatment of victims of sexual assault and other abuse and uses advanced medical technology to link rural providers with specialized consultation services.
Ledray LE. Forensic evidence collection and care of the sexual assault survivor: the SANE-SAT response. Washington, DC: U.S. Department of Justice, Office of Justice Programs. Violence Against Women Online Resources. Available at: www.vaw.umn.edu/documents/commissioned/2forensicevidence/2forensicevidence.html. Accessed August 2001.
AHRQ Publication No. 03-R210
Current as of September 2003
Internet Citation:
Medical Examination and Treatment for Victims of Sexual Assault: Evidence-based Clinical Practice and Provider Training. Report to Congress. September 2003. AHRQ Publication No. 03-R210. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/victsexual.htm
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