Sexual Assault Medical Forensic Examination Research Forum: Framing the Research Needs

Collect baseline data. Participants were in consensus that SAMFE technical practices vary a great deal across jurisdictions, with the extent and nature of the variations widely unknown.[1] There is a critical need for baseline data to learn more about the variations. For example —

  • What evidence is being collected and how during the SAMFE? For which practices is there standardization? Where are there variations? What are the reasons for the variations?
  • What is guiding the evidence collection — are protocols lab-based or driven by the medical community?
  • What is the decisionmaking process regarding what evidence is collected, what collection techniques and technology are used, and how the evidence is preserved and stored? To what extent is research driving practice? What other factors are influencing choice of practices?

Only with a solid foundation of basic information can researchers, in conjunction with practitioners and survivors, consider the priorities among the many research questions identified during the forum. Also, researchers need to have standardized, discipline-specific, and coordinated practices to evaluate in order to make a determination of a practice’s effectiveness. For example, researchers cannot use samples from different localities to evaluate the effectiveness of clothing evidence if examiners in those localities are following different protocols for collecting, preserving, or testing that evidence.

There was some discussion on the logistics of baseline data collection, data systems that may offer such information, whom to survey, and the logistics of surveying. The best source of information will depend on the specific questions being asked and who is best positioned to provide the answers — practitioners from individual disciplines, multiple disciplines, and/or across disciplines, as well as from survivors.

  • Consider what infrastructures are needed to collect and organize data on sexual assault cases across disciplines. Failure to manage data on a case within and across systems can mean losing the case (e.g., the FBI not knowing what the CIA is doing). We need to figure out what data can be shared, how to share it, and “connect the dots” provided by the data. What data systems already exist that can be tapped into?[2]
  • What data are most critical to track? Is there one infrastructure that is best or are different infrastructures better for different types of data? It was noted that identifiers to link the information are needed—for example, using one number to track a case across systems (now a case usually has different numbers in each system).[3]
  • Poll practitioners across disciplines and jurisdictions (tribal, local, state, and federal). Broad-based surveys and analyses of survey findings might help in identifying what research is most critical. Among other things, it may highlight practice usefulness as well as gaps (e.g., examiners are pulling pubic hair, but it is typically not analyzed by the lab or used by prosecution). There was discussion around surveying national-level member organizations. For example, the National District Attorneys Association (NDAA) and the Native American Issues Subcommittee of the Attorney General’s Advisory Committee (composed of U.S. Attorneys with Indian Country responsibility) might be willing to poll their members regarding what evidence they are using in prosecution of sexual assault cases, what kinds of evidence are most useful to prosecution, and what evidence collected they tend not to use. National law enforcement associations might be able to poll law investigators as to what is important to them as evidence in these cases and assess whether it is the same as what is important to prosecutors.
  • Consider victim and criminal justice impact. A common theme throughout the meeting was the awareness that the SAMFE impacts the victim and may have implications for case processing and legal outcomes. Some research has been conducted to better understand how SAMFE affects victim health and well-being, and studies have begun to examine the link between SAMFE and prosecutorial outcomes; however, these issues require much more study. For example —
    •  What is the impact of the variations on victim health and well-being?
    • What is the impact of the variations on legal outcomes?
    • What is the impact of the SAMFE on prosecution and conviction rates?
  • Encourage systems analysis. Forum participants talked about the need for program evaluation to describe best practices and for process evaluation to standardize care and exchange of information across disciplines and jurisdictions.These evaluations can look at what is being collected, how it is being used, outcomes, who is “driving the train” in each community related to evidence decisions, and if the outcomes are different because of the driver. It is important that the data is analyzed from a sexual assault response team (SART) perspective, in addition to discipline-specific perspectives. For example —
  • What is the stream of specific research questions related to the critical elements of the exam process? Role analysis (victim advocacy, forensic examiner, crime lab, law enforcement, prosecution, SART, etc.) that pinpoints the complexities of the process might be useful, as would different contextual factors, varying victim reactions and comfort levels, time factors, paths of evidence, etc. Similarly, what are the data points we need to know related to this process that inform victim decisions and influence responder actions?
  • What feedback loops exist among SART members to inform and strengthen their coordination and capacity to improve response? What is the nature of the communication? What additional communication is needed?
  • When crime lab personnel are on a SART and active in the feedback loop with examiners, how does it affect data collection? Forensic scientists in California are involved in the state-level SART, and their presence is critical to facilitating feedback between examiners and labs. Any suggestions for how to promote lab involvement in SARTs? A way to involve forensic scientists is in examiner training, which is a common practice.
  • Is it enough to have consensus across disciplines to end a practice (collection of pubic hair, evaluation for motile sperm, etc.)? Participants seemed to concur that research is needed to learn more about the practice first. For each debatable practice, which disciplines need to come to consensus about its usefulness? If the field is suggesting a change, is there consensus an alternative practice would be useful? What evidence supports that practice?

Incorporate issues of victim-centered care. Participants repeatedly indicated that understanding the factors associated with victim access to a SAMFE, as well as victim readiness to participate in a SAMFE, should help frame research on evidence collected and techniques used to collect and analyze evidence. Several questions were raised regarding victim access:

  • Are sexual assault victims made aware of their legal rights as victims of crime? What have they been told about a SAMFE/how to access one? Who provides this information to victims?
  • What is the impact of victims’ background (if they were drinking before the assault, have a prior arrest record, worked in the sex trade, are drug users, etc.) on whether they have a SAMFE offered and conducted and on case progression in the criminal justice system?
  • What is the impact of victims’ race, ethnicity, sexual preferences, etc., on their access to a SAMFE and case outcomes? What role might community or institutional bias play? Does/how can training for responders help minimize this type of bias?
  • Does where the exam takes place (e.g., in a hospital versus community agency versus another setting) impact victim access to a SAMFE? What about victim care and criminal justice outcomes?

The following is a key question addressing victim readiness to participate: What are the processes and interactions between the patient and the examiner that make a SAMFE effective? [4] This question is based on a belief that patients, not evidence collection kits, should drive the exam process. Related questions included —

  • How can examiners help patients be comfortable, and tolerate the exam, so they feel they can share their history, receive relevant health care, and allow evidence collection? How does getting such help impact patients — do they feel less traumatized from the exam, report more often? Are they more involved in the criminal justice process?
  • What is the impact of language used and styles of approaching patients? How does receiving culturally and linguistically appropriate care by race/ethnicity, gender, age, health literacy, etc., impact patient satisfaction with the exam process?
  • How do examiners approach informed consent with patients? Who delivers/how is it delivered in culturally diverse settings, and what is the impact of by whom/how it is delivered? What do patients need to be asked and told by examiners to be given full choice in making decisions during the SAMFE? If examiners had information about the outcomes of medical care and evidence collection (e.g., what samples are producing evidence), then patients could likely make more informed decisions. Participants noted that when seeking informed consent during the exam, examiners are challenged to collect only what is relevant to a case (as it determines what the lab will analyze), but are aware that in most cases, there is only one opportunity to collect forensic evidence.
  • How does the examiner best explain the scope of confidentiality of communications between patients and examiners? Participants recognized that confidentiality and privacy can be difficult to maintain in rural and close-knit communities.

Consider use of proxy victim populations for clinical research, to the extent possible, to get at some of the critical research questions related to victim-centered care, techniques for evidence collection, etc. This refers to the use of nonvictim populations to test some of the specific medical and forensic methods used in the exam. For example, one current NIJ-funded study is collecting swabs after consensual intercourse to look at postcoital DNA recovery using a proxy population.

Study the cost effectiveness of practices. Participants pointed out that cost feasibility is a factor that should be weighed with other factors when evaluating practices. Whether a practice is cost effective given jurisdictional resources and practice outcomes is important to consider. A SART perspective can give the fuller picture of costs and benefits of a practice.

Continue to assess what research already exists on best practices in medicine and forensic science related to the SAMFE and whether information on those practices is being disseminated to the field and utilized.[5] Some of that research was discussed during the forum as well as in the literature reviews prepared for the forum. Participants thought it might be useful to poll practitioners to find out more specifics on why a best practice might not be implemented and to get suggestions on moving forward with implementation. One of the challenges might be that while medical sciences are using advanced technology and forensic sciences, the criminal justice system is not necessarily able to keep up with advances in the medical field. National-level member organizations may be willing to help promote implementation of best practices in their respective fields.

Encourage standardization of terms used in research. Participants stressed that standardized terminology is critical so that those who conduct and use the research have a shared and accurate understanding of what was studied and relevant issues, findings, and implications.

Notes

[1] Another question: Why is there variation in a practice if there is existing national-level guidance? In some instances, national-level recommendations related to a practice exist, but are not universally implemented (e.g., guidance on evidence preservation offered by the Society of Forensic Toxicologists [SOFT]). In other instances, recommendations may not be as detailed as needed or may present numerous options for carrying out a particular practice, because there is a lack of consensus or evidence regarding best practice or the options are equally effective.

[2] In review of an early draft of this report, a participant suggested looking at Designing a Successful Quality Improvement Program: Teambuilding and Writing a QI Plan (ppt, 3.29 MB) from the Bureau of Primary Health Care, U.S. Health Resource and Services Administration, to create a template for a quality improvement (QI) process for the SAMFE/SART. Such a QI plan could potentially be a foundation for a national SAMFE/SART Center for Research, with a consortium of multidisciplinary, multijurisdictional teams of national experts to continue to define problems and research solutions.

[3] Thoughts from participants on where to start to explore these questions: Look at military data systems that track these cases across military agencies. Look at crime labs in West Virginia, Minnesota, and Massachusetts for possible best practices around tracking data on timing of assault, when exam was done, what was collected and analyzed, findings, and what is used in court. Consider how to utilize chain of custody information from the criminal justice system. Consider if the exam process within a state works better when there is a state VAWA coordinator. Are there more examiners, more training, and clearer communications between crime labs and examiners?

[4] The term “patient” is often used in this document when referring to the victim interacting with examiners and other medical providers during the SAMFE.

[5] In her review of an early draft of this report, Patricia Speck suggested that this task could represent a second tier of information gathering and research, after collection of more basic data.

Date Created: September 13, 2012