Indian Health Service
Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence Gao ID: GAO-12-29 October 26, 2011The Justice Department has reported that Indians are at least twice as likely to be raped or sexually assaulted as all other races in the United States. Indians living in remote areas may be days away from health care facilities providing medical forensic exams, which collect evidence related to an assault for use in criminal prosecution. The principal health care provider for Indians, which operates or funds tribes to operate 45 hospitals, is the Department of Health and Human Services' Indian Health Service (IHS). In response to a Tribal Law and Order Act of 2010 mandate, GAO examined (1) the ability of IHS and tribally operated hospitals to collect and preserve medical forensic evidence involving cases of sexual assault and domestic violence, as needed for criminal prosecution; (2) what challenges, if any, these hospitals face in collecting and preserving such evidence; and (3) what factors besides medical forensic evidence contribute to a decision to prosecute such cases. GAO surveyed all 45 IHS and tribally operated hospitals and interviewed IHS and law enforcement officials and prosecutors.
GAO's survey of IHS and tribally operated hospitals showed that the ability of these hospitals to collect and preserve medical forensic evidence in cases of sexual assault and domestic violence--that is, to offer medical forensic services--varies from hospital to hospital. Of the 45 hospitals, 26 reported that they are typically able to perform medical forensic exams on site for victims of sexual assault on site, while 19 reported that they choose to refer sexual assault victims to other facilities. The hospitals that provided services began to do so generally in response to an unmet need, not because of direction from IHS headquarters, according to hospital officials. Partly as a result, levels of available services have fluctuated over time. GAO found that the utility of medical forensic evidence in any subsequent criminal prosecution depends on hospital staff's properly preserving an evidentiary chain of custody, which depends largely on coordinating with law enforcement agencies. IHS has made significant progress since 2010 in developing required policies and procedures on medical forensic services for victims of sexual assault; nevertheless, challenges in standardizing and sustaining the provision of such services remain. In March 2011, IHS took a sound first step in what is planned to be an ongoing effort to standardize medical forensic services by issuing its first agencywide policy on how hospitals should respond to adult and adolescent victims of sexual assault. Remaining challenges include systemic issues such as overcoming long travel distances between Indian reservations or Alaska Native villages and IHS or tribal hospitals and developing staffing models that overcome problems with staff burnout, high turnover, and compensation, so that standardized medical forensic services can be provided over the long term. In addition, other challenges include establishing plans to help ensure that IHS hospitals consistently implement and follow the March 2011 policy, such as with training guidelines, and developing policies on how IHS hospitals should respond to domestic violence incidents and sexual abuse involving children who have not yet reached adolescence--neither of which is included in the March 2011 policy. GAO found that IHS is aware of these challenges and has initiatives under way or under consideration to address them. Decisions to prosecute sexual assault or domestic violence cases are based on the totality of evidence, one piece of which is medical forensic evidence collected by hospitals. In some cases, medical forensic evidence may be a crucial factor; in other cases, however, it may not be relevant or available. Law enforcement officers and prosecutors said that they also consider several other factors when deciding to refer or accept a case for prosecution. For example, some victims in small reservations or isolated villages may refuse to cooperate or may retract their initial statements because of pressure from community members who may depend on the alleged perpetrator for necessities. As a result, the victim may be unavailable to testify. Several prosecutors also told us that the availability to testify of the providers who perform medical forensic exams is an important factor, because such testimony can help demonstrate that an assault occurred or otherwise support a victim's account. IHS's March 2011 policy, however, does not clearly and comprehensively articulate the agency's processes for responding to subpoenas or requests for employee testimony. GAO is making five recommendations aimed at improving IHS's response to sexual assault and domestic violence, including to develop an implementation and monitoring plan for its new sexual assault policy and to modify sections of the policy regarding required training and subpoenas or requests to testify. The Department of Health and Human Services and the state of Alaska generally agreed with GAO's findings and recommendations.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Carolyn L. Yocom Team: Government Accountability Office: Natural Resources and Environment Phone: (202) 512-4931GAO-12-29, Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
October 2011:
Indian Health Service:
Continued Efforts Needed to Help Strengthen Response to Sexual
Assaults and Domestic Violence:
GAO-12-29:
GAO Highlights:
Highlights of GAO-12-29, a report to congressional committees.
Why GAO Did This Study:
The Justice Department has reported that Indians are at least twice as
likely to be raped or sexually assaulted as all other races in the
United States. Indians living in remote areas may be days away from
health care facilities providing medical forensic exams, which collect
evidence related to an assault for use in criminal prosecution. The
principal health care provider for Indians, which operates or funds
tribes to operate 45 hospitals, is the Department of Health and Human
Services‘ Indian Health Service (IHS).
In response to a Tribal Law and Order Act of 2010 mandate, GAO
examined (1) the ability of IHS and tribally operated hospitals to
collect and preserve medical forensic evidence involving cases of
sexual assault and domestic violence, as needed for criminal
prosecution; (2) what challenges, if any, these hospitals face in
collecting and preserving such evidence; and (3) what factors besides
medical forensic evidence contribute to a decision to prosecute such
cases. GAO surveyed all 45 IHS and tribally operated hospitals and
interviewed IHS and law enforcement officials and prosecutors.
What GAO Found:
GAO‘s survey of IHS and tribally operated hospitals showed that the
ability of these hospitals to collect and preserve medical forensic
evidence in cases of sexual assault and domestic violence-”that is, to
offer medical forensic services-”varies from hospital to hospital. Of
the 45 hospitals, 26 reported that they are typically able to perform
medical forensic exams on site for victims of sexual assault on site,
while 19 reported that they choose to refer sexual assault victims to
other facilities. The hospitals that provided services began to do so
generally in response to an unmet need, not because of direction from
IHS headquarters, according to hospital officials. Partly as a result,
levels of available services have fluctuated over time. GAO found that
the utility of medical forensic evidence in any subsequent criminal
prosecution depends on hospital staff‘s properly preserving an
evidentiary chain of custody, which depends largely on coordinating
with law enforcement agencies.
IHS has made significant progress since 2010 in developing required
policies and procedures on medical forensic services for victims of
sexual assault; nevertheless, challenges in standardizing and
sustaining the provision of such services remain. In March 2011, IHS
took a sound first step in what is planned to be an ongoing effort to
standardize medical forensic services by issuing its first agencywide
policy on how hospitals should respond to adult and adolescent victims
of sexual assault. Remaining challenges include systemic issues such
as overcoming long travel distances between Indian reservations or
Alaska Native villages and IHS or tribal hospitals and developing
staffing models that overcome problems with staff burnout, high
turnover, and compensation, so that standardized medical forensic
services can be provided over the long term. In addition, other
challenges include establishing plans to help ensure that IHS
hospitals consistently implement and follow the March 2011 policy,
such as with training guidelines, and developing policies on how IHS
hospitals should respond to domestic violence incidents and sexual
abuse involving children who have not yet reached adolescence-”neither
of which is included in the March 2011 policy. GAO found that IHS is
aware of these challenges and has initiatives under way or under
consideration to address them.
Decisions to prosecute sexual assault or domestic violence cases are
based on the totality of evidence, one piece of which is medical
forensic evidence collected by hospitals. In some cases, medical
forensic evidence may be a crucial factor; in other cases, however, it
may not be relevant or available. Law enforcement officers and
prosecutors said that they also consider several other factors when
deciding to refer or accept a case for prosecution. For example, some
victims in small reservations or isolated villages may refuse to
cooperate or may retract their initial statements because of pressure
from community members who may depend on the alleged perpetrator for
necessities. As a result, the victim may be unavailable to testify.
Several prosecutors also told us that the availability to testify of
the providers who perform medical forensic exams is an important
factor, because such testimony can help demonstrate that an assault
occurred or otherwise support a victim‘s account. IHS‘s March 2011
policy, however, does not clearly and comprehensively articulate the
agency‘s processes for responding to subpoenas or requests for
employee testimony.
What GAO Recommends:
GAO is making five recommendations aimed at improving IHS‘s response
to sexual assault and domestic violence, including to develop an
implementation and monitoring plan for its new sexual assault policy
and to modify sections of the policy regarding required training and
subpoenas or requests to testify. The Department of Health and Human
Services and the state of Alaska generally agreed with GAO‘s findings
and recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-12-29] or key
components. For more information, contact Carolyn L. Yocom at (202)
512-7114 or yocomc@gao.gov.
[End of section]
Contents:
Letter:
Background:
IHS's Ability to Collect and Preserve Medical Forensic Evidence Varies
by Hospital:
IHS and Tribal Hospitals Face Several Challenges in Standardizing and
Sustaining the Provision of Medical Forensic Services:
Factors besides Medical Forensic Evidence also Contribute to Decisions
to Prosecute Cases of Sexual Assault and Domestic Violence:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: GAO Survey of 45 IHS and Tribally Operated Hospitals:
Appendix III: Summary of Key Survey Results on Provision of Medical
Forensic Services for Sexual Assault Victims:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: Comments from the State of Alaska:
Appendix VI: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Jurisdiction over Crimes in Indian Country Where the Federal
Government Has Not Conferred Jurisdiction on a State:
Table 2: Number of IHS and Tribally Operated Hospitals Performing
Sexual Assault Medical Forensic Exams or Referring to Other
Facilities, as of June 2011:
Table 3: Number of Hospitals That Reported They Typically Perform
Sexual Assault Medical Forensic Exams and Level of Training Received
by Providers:
Figures:
Figure 1: General Steps from Assault through Prosecution:
Figure 2: Steps in Collecting and Preserving Medical Forensic Evidence:
Figure 3: Locations of the 45 IHS and Tribally Operated Hospitals:
Figure 4: Items Used in Traditional Healing:
Figure 5: Location of Remote and Urban Hospitals Performing Sexual
Assault Medical Forensic Exams or Referring to Other Facilities:
Figure 6: Small Ambulance Serving Remote Alaska Native Village:
Figure 7: Two-Flight Itinerary from a Remote Alaska Native Village
When Victims Need Medical Forensic Services:
Figure 8: Locking Storage Cabinet for Medical Forensic Evidence:
Abbreviations:
FBI: Federal Bureau of Investigation:
IHS: Indian Health Service:
SANE: sexual assault nurse examiner:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
October 26, 2011:
The Honorable Daniel Akaka:
Chairman:
The Honorable John Barrasso:
Vice Chairman:
Committee on Indian Affairs:
United States Senate:
The Honorable Don Young:
Chairman:
The Honorable Dan Boren:
Ranking Member:
Subcommittee on Indian and Alaska Native Affairs:
Committee on Natural Resources:
House of Representatives:
The Department of Justice has reported that Indians are at least twice
as likely to be raped or sexually assaulted as all other races in the
United States and that one in three Indian women have reported being
raped at some time in their life.[Footnote 1] Similarly, over one-
third of Indian women and one-eighth of Indian men in the United
States will experience domestic violence.[Footnote 2] Some Indians who
are victims of sexual assault, domestic violence, or child abuse live
in urban areas, but many live on rural reservations or in remote,
isolated Alaska Native villages. For people in rural or remote areas,
it can take hours--and sometimes days--to reach the closest medical
provider who can not only treat their injuries, but also perform a
medical forensic exam to collect assault-related evidence for use in
the criminal justice system.
The Department of Health and Human Services' Indian Health Service
(IHS) is the principal federal health care provider for approximately
1.9 million Indians across 35 states.[Footnote 3] IHS headquarters
oversees 12 area offices representing the agency's different regions
and either directly operates or provides funding to tribes or tribal
organizations to operate approximately 1,200 facilities. These
facilities include hospitals, clinics, health centers, school health
centers, health stations, dental clinics, alcohol substance abuse
treatment facilities, behavioral health facilities, and others. Across
the United States, IHS provides direct medical care at its facilities,
including primary care services and some specialty services, such as
treatment and prevention of diabetes, and operates or provides funding
to tribes to operate 45 hospitals, providing services to Indians from
over 560 tribes.[Footnote 4]
IHS defines sexual assault as sexual contact without consent, and it
defines domestic violence as abusive behavior involving intimate
partners or family members or household members that is used to gain
or maintain power and control over another intimate partner or family
member or household member.[Footnote 5] Victims of sexual assault and
domestic violence can typically receive a sexual assault medical
forensic examination in a hospital.[Footnote 6] A 2007 report by the
human-rights organization Amnesty International USA called for
Congress to increase IHS funding to ensure that victims of sexual
assault and domestic violence can receive more timely medical forensic
examinations and that proper protocols are followed for collecting and
preserving evidence related to these crimes.[Footnote 7]
Tribal, state, or federal governments may each have jurisdiction to
prosecute those who commit crimes in Indian country,[Footnote 8]
depending on several factors, including the nature of the crime and
whether the victim or alleged perpetrator is Indian. For example, the
federal government and tribal governments have jurisdiction to
prosecute sexual assault crimes committed by Indians in Indian country
in almost all states in which IHS has hospitals. For crimes prosecuted
by the federal government, investigating agencies include Justice's
Federal Bureau of Investigation (FBI) or the Department of the
Interior's Bureau of Indian Affairs, and the crimes are prosecuted by
1 of the 94 U.S. Attorneys' Offices.
Victims of sexual assault or domestic violence may arrive at an IHS
hospital in various ways: an ambulance may transport them, law
enforcement officers may bring them, or they may arrive on their own.
They may arrive immediately after an assault (such cases are typically
referred to as acute cases) or weeks, months, or years later (delayed
or nonacute cases). Thus begins a series of steps that--if proper
protocols are followed, and the appropriate "chain of custody" of the
evidence is maintained, among other factors--may ultimately lead to a
decision to prosecute (see figure 1).
Figure 1: General Steps from Assault through Prosecution:
[Refer to PDF for image: process illustration]
Victim assaulted:
Victim contacts law enforcement;
Law enforcement transports victim to hospital;
or:
Victim arrives at hospital;
Hospital may notify law enforcement[A].
Hospital staff collects and preserves medical forensic evidence.
Hospital staff transfers evidence to law enforcement.
Law enforcement investigates case and may refer investigation to
prosecutor.
Prosecutor reviews investigation and determines whether to file a case
in court or decline to prosecute.
Source: GAO.
[A] Hospital notifies law enforcement immediately; later; or, if
victim chooses to remain anonymous, not at all. For cases involving
children, hospitals may have a legal duty to notify appropriate
authorities.
[End of figure]
Given consent by the victim, medical providers generally collect
medical forensic evidence through a medical forensic examination that
may follow steps and use supplies from a sexual assault evidence
collection kit; the collected evidence is preserved until law
enforcement takes possession of it. Under Justice's national protocol
for sexual assault medical forensic exams,[Footnote 9] medical
providers may collect a range of physical evidence, including but not
limited to clothing, foreign materials on the body, hair (including
head and pubic hair samples and combings), body swabs, and a blood or
saliva sample for DNA analysis and comparison. In addition, medical
forensic exams typically include documenting biological and physical
findings such as cuts or bruises, through either writing or
photographs, and recording a victim's medical forensic history such as
the time and nature of the assault. This exam can take several hours.
Once the exam is completed, medical providers preserve the collected
evidence according to jurisdictional policies, which may include
procedures for packaging, labeling, and sealing evidence collection
kits and storing the kits in a secure location (see figure 2). For
cases of domestic violence, medical providers typically do not perform
a sexual assault medical forensic exam unless a sexual assault has
also occurred. Instead, medical providers, and sometimes law
enforcement officers, generally record a victim's statement of the
incident and document injuries through writing or photographs.
Figure 2: Steps in Collecting and Preserving Medical Forensic Evidence:
[Refer to PDF for image: process illustration]
Does hospital perform medical forensic exams?
If yes, continue;
If no: Hospital refers victim to another facility.
Hospital staff perform exam to collect medical forensic evidence.
Hospital staff preserve and secure evidence.
Is law enforcement available?
If yes: Hospital transfers evidence to law enforcement;
If no: Hospital secures evidence until law enforcement takes
possession.
Source: GAO analysis of IHS information.
[End of figure]
The Tribal Law and Order Act of 2010--whose purpose was, among other
things, to combat sexual and domestic violence against American Indian
and Alaska Native women--mandated that we study the capability of IHS
facilities in remote Indian reservations and Alaska Native villages to
collect, maintain, and secure evidence of sexual assaults and domestic
violence, as required for criminal prosecution.[Footnote 10] In
response to the mandate and subsequent discussion with offices of the
relevant congressional committees of jurisdiction, this report
examines (1) the ability of IHS and tribally operated hospitals to
collect and preserve medical forensic evidence for use in criminal
prosecution in sexual assault and domestic violence cases; (2) what
challenges, if any, these hospitals face in collecting and preserving
such evidence, particularly in remote Indian reservations and Alaska
Native villages; and (3) what factors besides medical forensic
evidence collected by these hospitals contribute to a decision to
prosecute such cases.
For all three objectives, we collected and analyzed laws, regulations,
and agency policies relevant to the collection and preservation of
medical forensic evidence by IHS and tribally operated hospitals in
cases of sexual assault and domestic violence, and we interviewed and
gathered relevant documentation from headquarters officials at IHS,
the Bureau of Indian Affairs, Justice, and the state of Alaska. In
addition, we conducted over 60 semistructured interviews with several
groups of stakeholders, including staff from IHS and tribally operated
hospitals, victim advocacy groups, prosecutors, and law enforcement.
Specifically, we conducted semistructured interviews with stakeholders
(1) from hospital staff during site visits to a nonprobability sample
of 8 IHS or tribally operated hospitals in Alaska, Arizona, and South
Dakota and over the telephone with an additional nonprobability sample
of 7 IHS or tribally operated hospitals in Arizona, Minnesota,
Montana, New Mexico, North Dakota, and Oklahoma and (2) from victim
advocacy groups; federal and state prosecutors; and federal, state,
local, and tribal law enforcement agencies that play a role in
responding to and prosecuting sexual assault and domestic violence
cases in most of the locations these 15 hospitals serve.[Footnote 11]
For these semistructured interviews, we spoke with officials about
hospitals that (a) are performing medical forensic exams, (b) are
developing the ability to perform such exams, and (c) are not
performing such exams.[Footnote 12] In addition, to identify the
ability of IHS and tribally operated hospitals to collect and preserve
medical forensic evidence, we used a self-administered questionnaire
to survey all 45 IHS or tribally operated hospitals. We received a 100
percent response rate. To determine which of these hospitals are
located in remote areas, we used rural-urban commuting area codes for
isolated and small rural communities developed on the basis of U.S.
Census tracts by the Department of Agriculture's Economic Research
Service. We obtained data from IHS on the location and names of its
hospitals, as well as data on hospital visits by IHS beneficiaries
from fiscal year 2006 through fiscal year 2010. To assess the
reliability of the data, we interviewed knowledgeable IHS officials
and performed electronic testing. We determined that the data were
sufficiently reliable to meet the objectives of this engagement.
Appendix I presents a more detailed description of our scope and
methodology.
We conducted this performance audit from October 2010 through October
2011, in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
Of the 45 IHS hospitals, 28 are directly operated by IHS, and 17 are
operated by tribes through funds provided by IHS (see figure 3).
Specifically, under the Indian Self-Determination and Education
Assistance Act, as amended, IHS provides funds to tribes to run their
own hospitals through self-determination contracts or self-governance
compacts.[Footnote 13] For example, the tribes in Alaska operate 7
regional hospitals and 165 village clinics, mainly through a variety
of regional health consortiums that provide services to groups of
tribes. These self-determination contracts and self-governance
compacts implement the act's commitment to effective and meaningful
participation by the Indian people in the planning, conduct, and
administration of health programs and services. IHS manages its
facilities and staff, including the hospitals it directly operates and
its direct staff, through the Indian Health Manual, among other
things. This document serves as the primary reference for IHS
employees on IHS-specific policy and procedures. In accordance with
the Indian Self-Determination and Education Assistance Act as amended,
however, the self-determination contracts and self-governance compacts
under which tribes operate hospitals do not generally require
compliance with IHS policy. Therefore, IHS policies and procedures--
including those laid out in the Indian Health Manual--do not generally
apply to tribally operated facilities, although they can be used as
models on which to base local tribal protocols.
Figure 3: Locations of the 45 IHS and Tribally Operated Hospitals:
[Refer to PDF for image: illustrated U.S. map]
Geographic locations of the following are depicted on the map:
IHS Hospital (28);
Tribal Hospital (17).
Source: GAO analysis and Map-Info (map).
[End of figure]
With regard to sexual assault, IHS's Indian Health Manual states that
a person cannot give consent to sexual contact if she or he is forced,
threatened, coerced, drugged, inebriated, or unconscious; has certain
disabilities; or is a minor. We use the term sexual assault to refer
to the federal sex abuse felonies and attempts to commit them--that
is, sexual abuse and aggravated sexual abuse, abusive sexual contact,
or sexual abuse of children. This category includes what is commonly
known as molestation and rape, including (1) cases where the alleged
perpetrator uses force or threats, renders the victim unconscious, or
administers drugs or other intoxicants that substantially impair the
victim and (2) cases where the victim is incapable of appraising the
nature of the conduct or is physically incapable of declining to
participate or of communicating unwillingness to engage in the sexual
act. With regard to domestic violence, IHS's Indian Health Manual
states that domestic violence can involve physical, sexual, emotional,
economic, or psychological actions or threats of actions that
influence another person. Domestic violence includes any behaviors
that intimidate, manipulate, humiliate, isolate, frighten, terrorize,
coerce, threaten, blame, hurt, injure, or wound someone. We use the
term domestic violence to refer to all major crimes as defined in the
Major Crimes Act between intimate partners or family members,
including elders and spouses. Domestic violence also includes major
crimes against children that are not sexual in nature.
A medical provider specially trained in medical forensic examination
may perform such an exam in cases of sexual assault or domestic
violence, and law enforcement officers may interview the victim for
his or her account of what happened.[Footnote 14] Medical providers
typically perform such exams only for acute cases of sexual assault,
where the assault occurred within the previous 72 to 96 hours--when
such evidence is considered most viable--because physical and
biological evidence on a person's body or clothes degrades over time,
becoming unviable or too contaminated to be used. The standard of
practice for how long such evidence is viable changes as scientific
advancements are made, with some jurisdictions now performing medical
forensic exams up to 7 days after an assault. In terms of sexual
assaults, Justice's protocols describe two types of specially trained
medical providers who conduct sexual assault medical forensic exams:
* Sexual assault nurse examiner (SANE): a registered nurse who has
received specialized education and has fulfilled clinical requirements
to perform sexual assault medical forensic exams.
* Sexual assault forensic examiner: a health care provider, including
a physician or physician assistant, who has been specially educated
and has completed clinical requirements to perform sexual assault
medical forensic exams (in the same way a nurse is trained to become a
SANE).
The term SANE refers to registered nurses, a category including nurse
midwives and other advanced practice nurses, among other providers;
the term sexual assault forensic examiner refers more broadly to
medical providers including registered nurses plus physicians,
physician assistants, and nurse practitioners. Justice's protocol
encourages certification of SANEs, but certification as a SANE is
available only to registered nurses. No such national or international
certification exists for sexual assault forensic examiners who are not
registered nurses. Registered nurses can be certified as SANEs through
the International Association of Forensic Nurses to perform exams for
adult and adolescent sexual assault victims or to perform exams in
cases of sexual assault of children who have not reached puberty.
[Footnote 15] Nurses can become certified by meeting the association's
eligibility requirements; completing a didactic training curriculum;
and successfully completing a certification examination covering
several topics, such as how to assess sexual assault patients, how to
collect and document evidence in a way that protects the evidence's
integrity, and how to testify about findings or chain of
custody.[Footnote 16] Beyond cases of sexual assault, medical
providers who are specially educated as forensic nurse examiners are
able to collect forensic evidence for a variety of crimes other than
or in addition to those involving sexual assault, such as in injury
associated with domestic violence.
Additionally, for child victims, medical providers may perform medical
forensic exams and gather medical history in the hospital, or the
child may be interviewed elsewhere at a child-specific facility such
as a child advocacy center. Such facilities typically use a
multidisciplinary, team approach to minimize the number of times a
child is interviewed and to ensure that those individuals involved in
the child's life, such as parents or guardians and social services
providers, are working together.
Jurisdiction for investigating and prosecuting crimes in Indian
country is complex and depends on, among other factors, the nature of
the crime and whether the victim or alleged perpetrator is Indian (see
table 1). The federal government, rather than the state government,
has criminal jurisdiction in Indian country in almost all states where
IHS or tribes operate hospitals.[Footnote 17] When the alleged
perpetrator of a crime in Indian country is an Indian, tribal
governments also have criminal jurisdiction.[Footnote 18] As a result,
the FBI, the Bureau of Indian Affairs, or tribal investigators conduct
criminal investigations of sexual assault and domestic violence. Once
the investigation or preliminary facts are reviewed, the decision is
made as to whether the investigation should be referred to the U.S.
Attorneys' Offices, the tribe, or both for possible prosecution.
Prosecutors in the U.S. Attorneys' Offices decide whether to accept
the matter for criminal prosecution in federal court. We previously
reported that receipt of a law enforcement referral does not mean that
a prosecutable case exists at the time the referral is made and that,
upon further investigation, prosecutors may file the matter for
prosecution as a case in court, decline to prosecute the matter, or
refer the matter to tribal prosecutors.[Footnote 19] As we reported in
February 2011, because of tribes' limited jurisdiction and sentencing
authority, tribes often rely on the federal government to investigate
and prosecute serious offenses, since a successful federal prosecution
could result in a longer sentence than tribal courts might impose,
even where tribal jurisdiction exists.[Footnote 20]
Table 1: Jurisdiction over Crimes in Indian Country Where the Federal
Government Has Not Conferred Jurisdiction on a State:
Involved parties: Indian perpetrator and Indian victim;
Federal[A]: Major crimes[B];
Tribal: Nonmajor crimes and major crimes (concurrent with federal);
State: None.
Involved parties: Indian perpetrator and non-Indian victim;
Federal[A]: Major crimes (plus crimes included in the Indian Country
Crimes Act[C] and Assimilative Crimes Act[D]);
Tribal: Nonmajor crimes and major crimes (concurrent with federal);
State: None.
Involved parties: Non-Indian perpetrator and Indian victim;
Federal[A]: Crimes included in the Indian Country Crimes Act and
Assimilative Crimes Act;
Tribal: None;
State: None.
Involved parties: Non-Indian perpetrator and non-Indian victim;
Federal[A]: None;
Tribal: None;
State: Nonmajor crimes and major crimes.
Source: Department of Justice, United States Attorneys' Manual
(Washington. D.C.: 1997), and GAO analysis of relevant statutory
provisions.
[A] Specific statutes also grant the federal government criminal
jurisdiction over certain sexual assault and domestic violence crimes
in Indian country. For example, under 18 U.S.C. § 117, the federal
government has criminal jurisdiction over persons who commit domestic
assault in Indian country and who have two final convictions in
federal, state, or tribal court for assault, sexual abuse, serious
violent felony against a spouse or intimate partner, domestic
violence, or stalking.
[B] The Major Crimes Act, as amended, provides the federal government
with criminal jurisdiction over Indians charged with certain specified
crimes regardless of whether the victim is Indian. 18 U.S.C. §
1153(a). Major crimes relevant for this review include murder,
manslaughter, kidnapping, maiming, sexual abuse felonies and attempts
to commit them, incest, assaults with the intent to murder or with
dangerous weapons, assaults resulting in serious bodily injury,
assaults against someone younger than 16 years, and felony child abuse.
[C] 18 U.S.C. § 1152. The Indian Country Crimes Act, also known as the
General Crimes Act or Federal Enclaves Crime Act, extends the criminal
laws of the federal government into Indian country and establishes
federal criminal jurisdiction over crimes committed where either the
alleged offender or the victim, but not both, is Indian, unless the
alleged offender was punished by the tribal government, or a treaty
grants the tribe exclusive jurisdiction over the offense.
[D] 18 U.S.C. § 13. Under the Assimilative Crimes Act, if a person
allegedly commits an offense in an area where the federal government
has criminal jurisdiction, such as in certain parts of Indian country,
that has not been defined in federal law but has been defined in state
law, the federal government can prosecute the alleged offender in
federal court as if the state law offense were a federal law offense.
[End of table]
In some states, however, the federal government has conferred criminal
jurisdiction over Indian country to the states and renounced federal
criminal jurisdiction. In these states, only the state and tribes--if
the alleged perpetrator is an Indian--have jurisdiction to investigate
and prosecute crimes in Indian country, including sexual assault and
domestic violence. For example, Public Law No. 83-280, which was
enacted in 1953, gave six states criminal jurisdiction over crimes
committed by or against Indians in Indian country and renounced
federal jurisdiction over those crimes.[Footnote 21] Two of these so-
called mandatory Public Law 280 states--Alaska (which has 225 tribes)
and California (which has 105 tribes)--contain over half the Indian
tribes (330 out of 565 tribes) in the United States.[Footnote 22] In
these six states and certain other states, the state, not the federal
government, has jurisdiction over crimes in Indian country, and,
except in Alaska, Indian tribes have concurrent jurisdiction over
crimes committed by Indians. At the request of a tribe and with
consent of the U.S. Attorney General, however, the Tribal Law and
Order Act of 2010, among other things, permits the federal government
to reassert jurisdiction over certain crimes in Indian country.
[Footnote 23] In such cases, the federal, state, and tribal
governments would have concurrent jurisdiction over major crimes
committed by Indians against Indians and non-Indians.
In Alaska, generally only the state--not the tribes or federal
government--has criminal jurisdiction over Alaska Native villages. As
a result of the Alaska Native Claims Settlement Act and a Supreme
Court decision finding that Indian country does not generally exist in
Alaska, neither the tribes nor the federal government has criminal
jurisdiction, except on the Metlakatla Reservation.[Footnote 24] To
the extent that Indian country exists beyond the Metlakatla
Reservation, the federal government lacks criminal jurisdiction
because of Public Law 280, unless the tribe requests that the federal
government assume criminal jurisdiction according to the Tribal Law
and Order Act of 2010. Consequently, the state or municipal government
is generally responsible for investigating sexual assault and domestic
violence crimes, and the state is generally responsible for
prosecuting such crimes. Specifically, Alaska state troopers are
generally responsible for investigating sexual assault and domestic
violence crimes in Alaska Native villages, although in some cases,
municipal police departments are responsible for investigating such
crimes within city limits. Alaska's Department of Law is responsible
for prosecuting sexual assault and certain domestic violence crimes.
[Footnote 25]
Regardless of jurisdiction, not all victims of sexual assault or
domestic violence report these incidents to law enforcement or opt to
receive medical forensic exams. Some stakeholders have identified
numerous barriers to reporting sexual assault and domestic violence
incidents, including the negative stigmas associated with being
sexually assaulted or abused and the potential retribution a victim
might endure from the alleged perpetrator or community, especially
when the assaults take place in small communities where members are
often related or depend on one another for survival. In terms of
reports to law enforcement agencies, an average of 30.8 forcible rapes
per every 100,000 persons were reported in the United States from 2004
through 2009, according to data from Justice's Uniform Crime Reporting
Program.[Footnote 26] Studies indicate, however, that many sexual
assaults go unreported nationwide, and the precise number of sexual
assaults and incidents of domestic violence remains unknown.
According to data from a Justice study, Indians in 2010 experienced
violent crimes at over twice the estimated national rate--42 violent
crimes per 1,000 Indians annually, compared with 15 per 1,000 persons
nationwide.[Footnote 27] We previously reported that domestic and
sexual violence against Indian women is among the most critical public
safety challenges, and also noted that alcohol and drug use often play
a significant role in such violent crimes.[Footnote 28] Specifically,
Justice reported that 38 percent of Indian women were subjected to
domestic violence during their lives and that Indian victims reported
alcohol use by 62 percent of alleged perpetrators, compared with 42
percent for all races.[Footnote 29] These issues are of particular
concern to the state of Alaska, where the governor has made ending
domestic violence and sexual assault a top priority given that, among
other things, 76.2 forcible rapes per every 100,000 persons were
reported to law enforcement agencies from 2004 through 2009, according
to Uniform Crime Reporting statistics.[Footnote 30] In addition, more
than 9 percent of adult women in Alaska reported experiencing domestic
violence, and more than 4 percent reported experiencing sexual
violence in the past year, according to a state study of
victimization.[Footnote 31]
IHS's Ability to Collect and Preserve Medical Forensic Evidence Varies
by Hospital:
IHS has limited information on the ability of IHS and tribally
operated hospitals to collect and preserve medical forensic evidence
in cases of sexual assault and domestic violence, as needed for
criminal prosecution--that is, on the hospitals' ability to offer
medical forensic services. To collect this information, we surveyed
the 45 IHS and tribally operated hospitals and found that the ability
to provide these services varies from hospital to hospital, ranging
from providing a broad array of on-site services, including performing
medical forensic exams to collect physical and biological evidence, to
choosing to refer patients to other facilities for such exams. We also
found that the services available at a hospital generally developed
without direction from IHS headquarters and have fluctuated over time.
In addition, the utility of such evidence in any subsequent criminal
prosecution depends on hospital staff's properly securing and storing
physical evidence, which may in turn depend largely on coordinating
with law enforcement agencies.
IHS Had Limited Information on the Ability of Its Facilities to Offer
Medical Forensic Services:
IHS headquarters had limited information on the ability of its
facilities to provide medical forensic services. We found that IHS
could not give us comprehensive information about which of its
facilities--including hospitals and clinics--provided medical forensic
services for victims of sexual assault and domestic violence, although
IHS officials identified hospitals as the facilities most likely to
provide such services. IHS headquarters also could not identify how
many providers at IHS hospitals have had SANE training or
certification. In addition, we found that IHS headquarters does not
centrally track the number of medical forensic exams performed at its
facilities. In analyzing electronic data obtained from IHS
headquarters on procedures done at the hospitals, we found that
because of the way hospitals record these data, it is not possible to
accurately isolate medical forensic exams from other medical
activities related to incidents of sexual assault or domestic
violence.[Footnote 32] IHS does, however, keep centralized data on
where victims of sexual assault and domestic violence were seen and on
the primary purpose of these patients' visits.[Footnote 33]
Hospitals May Perform Medical Forensic Services on Site or Refer
Victims to Other Facilities:
The results of our survey of all 45 IHS and tribally operated
hospitals showed that some hospitals typically provide medical
forensic exams on site for both adult and child victims of sexual
assault, others typically perform these exams for either adults or
children but not both, and still others refer most or all sexual
assault victims to other facilities (see table 2).
Table 2: Number of IHS and Tribally Operated Hospitals Performing
Sexual Assault Medical Forensic Exams or Referring to Other
Facilities, as of June 2011:
Hospitals that typically perform medical forensic exams:
Typically for both adults and children:
IHS: 4;
Tribal: 3;
Total: 7.
Typically for adults only:
IHS: 9;
Tribal: 8;
Total: 17.
Typically for children only:
IHS: 1;
Tribal: 1;
Total: 2.
Subtotal:
IHS: 14;
Tribal: 12;
Total: 26.
Refer[A]:
IHS: 14;
Tribal: 5;
Total: 19.
Total:
IHS: 28;
Tribal: 17;
Total: 45.
Source: GAO survey.
[A] The hospitals in this row generally refer all victims of sexual
assault to other facilities. Two hospitals in this category reported
sometimes performing medical forensic exams for adults, but they
reported that they may still refer some adults and all children to
other facilities. The remaining 17 hospitals reported they rarely or
never perform medical forensic exams and refer all victims to other
facilities.
[End of table]
Specifically, 26 of the 45 hospitals reported that they typically
perform sexual assault medical forensic exams for adults, children, or
both. Those hospitals reporting that they perform these exams only for
adults refer all children to other facilities, and hospitals
performing exams only for children refer all adults to other
facilities. Additionally, all IHS and tribally operated hospitals
reporting that they typically provide exams on site also aim to have
staff present or on call so they can offer these services 24 hours a
day, 7 days a week. Two hospitals also explained that they use
traditional healing practices and objects when treating sexual assault
victims (see figure 4). The remaining 19 hospitals reported that they
generally refer all adults and children to other facilities for these
exams.
Figure 4: Items Used in Traditional Healing:
[Refer to PDF for image: photograph]
Source: GAO (April 2011).
Note: Pictured items used in traditional healing (center left) include
sweet grass, sage, and a shell used for burning the dried plants.
[End of figure]
Among the seven hospitals that typically perform medical forensic
exams for both adults and children, one tribally operated hospital in
Alaska has a dedicated coordinator who has received SANE training and
is available to perform exams for both adults and children 24 hours a
day, 7 days a week. A victim of sexual assault who arrives at this
hospital can typically be examined within a short time and in a room
dedicated to sexual assault exams. Similarly, an IHS hospital in
Arizona has a group of approximately 14 nurses and doctors who have
received specialized training in sexual assault medical forensic
exams, as well as a room largely dedicated to these exams. When a
sexual assault victim arrives at this hospital, hospital staff contact
1 of the 14 nurses or doctors to perform the exam or, if none of these
medical providers is present, a predesignated backup provider is
called on. Children requiring an exam generally see a provider, when
available, who has undergone specialized training in pediatric medical
forensic exams.
A total of 19 of 45 hospitals reported typically performing medical
forensic exams for either adult or child victims of sexual assault but
not for both. For example, a South Dakota IHS hospital--which offers
medical forensic services 24 hours a day, 7 days a week, with
providers on 24-hour call--typically performs medical forensic exams
for adults but not children. When an adult victim arrives, the
emergency room does an initial medical screening and then calls one of
three SANE-trained nurses to perform the medical forensic exam. But
because this hospital does not have a provider trained to do these
exams for children, it refers all child victims to a hospital in
Pierre, which is 2 hours away by car, or to a hospital in Sioux Falls,
which is 4 hours away. In contrast, an IHS hospital in New Mexico
performs exams only for children. The providers at this hospital are
available from 8 a.m. to 4:30 p.m. on weekdays and on call during
nights and weekends; overall coverage is 24 hours a day, 7 days a week.
Hospitals that we categorized as being in remote areas[Footnote 34]
are more likely to perform medical forensic exams and less likely to
refer victims elsewhere for service than IHS and tribally operated
hospitals taken as a whole. Of the 34 hospitals categorized as remote,
22 hospitals reported that they are able to perform medical forensic
exams for adults, children, or both; 12 of the 34 hospitals reported
referring victims to other facilities. In contrast, the proportions
are reversed among the 11 hospitals we categorized as urban, with 7 of
them reporting that they refer all sexual assault victims to other
facilities for exams (see figure 5 for map of hospitals). For example,
officials from an IHS hospital in the Phoenix, Arizona, area explained
during a site visit that the hospital sees too few sexual assault
cases to warrant having its own staff trained in performing medical
forensic exams; in the officials' view, it makes more sense for the
hospital to leverage existing resources by referring victims to a
nearby facility offering medical forensic services.
Figure 5: Location of Remote (top) and Urban (bottom) Hospitals
Performing Sexual Assault Medical Forensic Exams or Referring to Other
Facilities:
[Refer to PDF for image: 2 illustrated U.S. maps]
Map depicting the locations of Remote hospitals that:
Performs exams for adults and children (6);
Performs exams for children only (1);
Refers victims to other facilities (12);
Performs exams for adults only (15).
Map depicting the locations of Urban hospitals that:
Performs exams for adults and children (1);
Performs exams for children only (1);
Refers victims to other facilities (7);
Performs exams for adults only (2).
Source: GAO analysis and Map-Info (maps).
Note: Non-IHS facilities, such as child advocacy centers, also provide
specialty services to children. For example, the tribally operated
hospital in Anchorage refers children to the Alaska CARES clinic for
medical forensic exams.
[End of figure]
IHS and tribally operated hospitals vary not only in whether and for
whom they can provide medical forensic services but also in the
training their providers have received (see table 3). Of the 26
hospitals that typically perform medical forensic exams, 20 reported
having providers who received specialized training or certification in
sexual assault medical forensic exams. The remaining 6 hospitals
reported offering medical forensic exams even if the providers
performing the exams have not received this specialized training. In
fact, several medical providers told us that traveling doctors and
nurses, who temporarily work at an IHS hospital for a few weeks or
months, may perform these medical forensic exams on site even if they
have not received this specialized training. In discussions with
hospital officials, we also found that hospitals referring sexual
assault victims--whether adults or children--to other facilities for
medical forensic exams may do so because they do not have medical
providers on staff with this specialized training.
Table 3: Number of Hospitals That Reported They Typically Perform
Sexual Assault Medical Forensic Exams and Level of Training Received
by Providers:
Hospitals that typically provide medical forensic exams:
Level of training received by providers: Medical forensic training for
adults, children, or both[A];
Exams for adults and children: 7;
Exams for adults only: 13;
Exams for children only: 0;
Total: 20.
Level of training received by providers: No SANE training;
Exams for adults and children: 0;
Exams for adults only: 4;
Exams for children only: 2;
Total: 6.
Level of training received by providers: Total;
Exams for adults and children: 7;
Exams for adults only: 17;
Exams for children only: 2;
Total: 26.
Source: GAO survey.
[A] This category includes hospitals with providers who have
specialized training, including SANE training, in medical forensic
exams. Trained staff are more prevalent than SANE-certified staff.
Specifically, four hospitals that typically perform exams only for
adults have SANE-certified staff, as does one hospital that typically
performs exams for adults and children.
[End of table]
Many of the hospitals we surveyed reported that they typically perform
medical forensic exams in cases of domestic violence. They may do so
only in cases of domestic violence that also include a sexual
component or, occasionally, when the injuries sustained from a
discrete domestic violence incident without a sexual component are
severe. Officials at several hospitals explained that for discrete
domestic violence incidents (those that do not include a sexual
component), law enforcement officers usually collect evidence, such as
photographs of bruises or other injuries, for use in court. For
example, officials at two separate hospitals explained that in cases
of domestic violence, law enforcement officers take photographs of
physical injuries, and medical providers treat any injuries requiring
medical attention.
Medical Forensic Services Have Developed Largely without Central
Direction:
In general, efforts to provide medical forensic services at the local
level have fluctuated over time and have received limited funding from
IHS. In discussions with hospital officials, we found that the
provision of medical forensic services generally developed at a
grassroots level, rather than in response to an explicit requirement
from IHS headquarters. Local medical providers chose to provide such
exams in response to an unmet need for such services in their area,
not because IHS headquarters directed them to do so. For example, a
nurse at one hospital explained that she and five other nurses
attended SANE training after recognizing that medical providers at the
hospital were uncomfortable doing sexual assault medical forensic
exams. Additionally, an IHS official at another hospital explained
that his staff began providing medical forensic services after the
area office requested volunteers to pilot providing such services to
better meet the area's needs.
We also found that the ability of an IHS or tribally operated hospital
to offer medical forensic services has fluctuated over time. Some
hospitals, for example, have been able to sustain or even expand their
medical forensic services. In contrast, other hospitals have lost
staff who were willing or trained to perform medical forensic exams
and ceased offering these exams entirely or waited until new staff
could be hired or trained. For example, officials from one hospital
explained during a follow-up discussion with us that they recently
ceased performing sexual assault medical forensic exams for adults
when a shift in staffing resources left the hospital's emergency room
without providers specially trained in performing such exams.
Consequently, the hospital now performs medical forensic exams only
for children and refers adult victims to a private hospital in a
nearby city, which helps facilitate more consistent and timely
evidence collection, according to a law enforcement official.
Similarly, medical providers explained during a site visit that after
the sole provider of medical forensic exams in a remote Alaskan
community left, the hospital ceased offering medical forensic exams
because none of its remaining staff had specialized training. As a
result, all adults and children have since been flown several hours
away to Anchorage to receive medical forensic exams. Given the
importance of providing medical forensic services locally, however,
the hospital staff said that they recently sent several staff for
training in sexual assault medical forensic exams and hired someone to
serve as a coordinator for this effort.
Furthermore, efforts by IHS headquarters to fund medical forensic
services have been limited. The agency has provided some funding for
training and equipment to hospitals or staff, but this funding has
been infrequent or limited, according to IHS officials. Specifically,
* Pilot program. In 2002 and 2003, IHS used a grant from Justice to
fund two of its hospitals--one in Shiprock, New Mexico, and the other
in Pine Ridge, South Dakota--to pilot offering medical forensic exams
for adult victims of sexual assault. As part of this pilot program,
the hospitals received funding to send their providers to SANE
training and to purchase equipment needed for medical forensic exams,
such as digital cameras. A hospital official at one of these hospitals
explained that it still offers medical forensic exams and, to better
meet patients' needs, is expanding its services to also include a
clinic more centrally located on the vast reservation, to provide
services closer to patients' homes. An IHS official at the other pilot-
/program hospital explained that it ceased offering medical forensic
exams in 2007 after too many of its specially trained medical forensic
examiners left. This hospital now sends its patients across state
lines to a private provider.
* Limited funds for training or equipment. IHS has at times paid for
staff at some of its hospitals to receive SANE training, but such
funding was not part of a comprehensive effort to develop medical
forensic capacity at IHS facilities. From fiscal year 2003 through
fiscal year 2011, IHS provided $45,000 for three training sessions for
60 providers. But agency officials also explained that IHS has
provided no additional funding for hospitals to purchase equipment to
conduct these exams. According to staff from one IHS hospital, they
have had to use a digital camera belonging to the local Bureau of
Indian Affairs law enforcement office to photographically document
physical injuries as evidence because they did not have funding to
purchase their own camera.
* IHS Domestic Violence Prevention Initiative. IHS received a $7.5
million appropriation for its domestic violence prevention initiative
in fiscal year 2009 and another $10 million appropriation in fiscal
year 2010. The Domestic Violence Prevention Initiative expands
prevention, advocacy, outreach, and medical forensic services in cases
of domestic violence and sexual assault. Of this total funding, $3.5
million funded medical forensic services such as exams, and the
remaining funded prevention, advocacy, outreach, and coordination. In
fact, of the 65 projects IHS funded through this initiative, 8
projects aimed to use this money for improving medical forensic
services at IHS or tribally operated hospitals. Further, seven of
these eight projects funded hospitals that already had some staff on
board who were specially trained in providing sexual assault medical
forensic exams.
The Preservation of Medical Forensic Evidence Depends in Large Part on
Hospital Coordination with Law Enforcement:
The specific policies or procedures that IHS has developed to preserve
medical forensic evidence vary from hospital to hospital and may
depend greatly on coordination with the law enforcement officers who
take possession of the evidence for use in the criminal justice
system. Improperly securing medical forensic evidence or improperly
maintaining its chain of custody--that is, the process that
demonstrates the chronological documentation of the collection,
custody, control, transfer, analysis, and disposition of the evidence--
can undermine the evidence's usefulness in a criminal investigation or
prosecution. Consequently, according to Justice protocols, it is
imperative to properly preserve the evidence collected during a
medical forensic exam. Proper preservation includes, among other
things, securing the physical evidence from contamination or
adulteration, as well as properly following and documenting the chain
of custody. We found that some hospitals had specific procedures in
place for storing and securing physical evidence, and others did not.
In discussions with law enforcement officers and hospital staff, we
found that the way a hospital does or does not preserve the medical
forensic evidence it collects, such as biological materials or
statements from victims, largely depends on the extent or type of
coordination with law enforcement. For example, at one hospital,
providers and law enforcement officers told us they jointly developed
a protocol to store evidence from completed exams in a locked cabinet
to which only law enforcement officers have the key. This protocol
ensures that if a law enforcement officer cannot immediately take
possession of the evidence, it is nevertheless stored in a fashion
that properly maintains the chain of custody. Similarly, an official
at another hospital explained that medical forensic evidence is stored
in a locked filing cabinet in the SANE coordinator's office until a
law enforcement officer signs a release form to take possession of it--
an arrangement developed between the hospital and law enforcement to
better maintain the chain of custody. In other communities,
multidisciplinary groups--/such as sexual assault response teams,
which coordinate community efforts related to cases of adult sexual
assault, or multidisciplinary teams established by prosecutors for
cases involving children--provide opportunities for hospital staff to
develop evidence preservation procedures.[Footnote 35] For example,
officials from an IHS hospital in a mandatory Public Law 280 state
told us that its new sexual assault response team was instrumental in
determining the most appropriate law enforcement agency--tribal,
local, or county--to call to take possession of medical forensic
evidence. Additionally, some hospital officials told us that they do
not specifically coordinate with law enforcement or had no specific
evidence preservation procedures because they assume that an officer
will immediately take possession of any medical forensic evidence
collected. Such assumptions do not always hold, however, such as if
the law enforcement officer is called away to investigate another
crime or cannot wait in the hospital for completion of the multihour
medical forensic exam. Differences in how hospitals preserve medical
forensic evidence may also stem in part from the type of training
received by those who perform medical forensic exams. For example,
SANE training covers securing evidence and maintaining its chain of
custody. Providers who do not receive such specialized training may be
relying on following the instructions contained in an evidence
collection kit--a process that some stakeholders told us may miss
important steps.
IHS and Tribal Hospitals Face Several Challenges in Standardizing and
Sustaining the Provision of Medical Forensic Services:
Since enactment of the Indian Health Care Improvement Reauthorization
and Extension Act of 2009 (on March 23, 2010) and the Tribal Law and
Order Act of 2010 (on July 29, 2010), IHS has made significant
progress in developing policies and procedures regarding medical
forensic services for victims of sexual abuse, as the acts
required.[Footnote 36] IHS worked expeditiously to establish its first
agencywide sexual assault policy within the 1-year deadline
established by the Indian Health Care Improvement Act. The new policy,
issued in March 2011, is an important and sound first step in what is
planned to be a continuing effort to provide a standardized level of
medical forensic services. As part of this effort, IHS has a number of
important initiatives under way or under consideration, and events are
unfolding rapidly. For example, in partnership with Justice, a new
position was created in IHS headquarters for a sexual assault exam and
response coordinator, and the position was filled in August 2011.
Still, IHS faces a number of important challenges as it attempts to
implement its new policy and continues to respond to incidents of
sexual assault and domestic violence. These challenges include
systemic issues--such as overcoming long travel distances and
developing staffing models that overcome problems with staff burnout,
high turnover, and compensation--so that standardized medical forensic
services can be provided over the long term. Specifically, we found
that hospitals face the following four challenges in standardizing and
sustaining the provision of medical forensic services:
* overcoming long travel distances;
* establishing plans to help ensure that hospitals consistently
implement and follow the March 2011 policy;
* developing similar policies for domestic violence and child sexual
abuse; and:
* developing sustainable staffing models that overcome problems with
staff burnout, high turnover, and compensation.
In general, our work confirmed that IHS is aware of the challenges
that it faces and either has initiatives under way to address them or
is trying to formulate such initiatives.
Overcoming Travel Distances:
We found that long travel distances between IHS patient populations
and hospitals--often across remote terrain with few, if any, roads--
pose a barrier to access to a full range of medical services that an
IHS beneficiary might need, including medical forensic services.
Distances are of particular concern in Alaska, where sexual assault or
domestic violence victims from remote Alaska Native villages must
travel hundreds of miles to hospitals offering on-site medical
forensic exams. Travel is typically possible only by airplane or snow
machine; most villages are not accessible by road. (See figure 6 for a
picture of the ambulance used in one of the villages.)
Figure 6: Small Ambulance Serving Remote Alaska Native Village:
[Refer to PDF for image: photograph]
Source: GAO (May 2011).
[End of figure]
Further, victims must typically rely on law enforcement to arrange air
transportation, and bad weather may delay flights for hours or days,
according to stakeholders. Victims living in regions where the nearest
hospital does not provide on-site medical forensic services must often
undertake multistage trips to find access to these services. For
example, medical providers told us that victims from remote villages
near Kotzebue, where the hospital does not provide on-site medical
forensic services, must take at least two flights to reach a hospital
that does: a first flight from their village to Kotzebue and a second
one from Kotzebue to Anchorage (see figure 7).[Footnote 37]
Figure 7: Two-Flight Itinerary from a Remote Alaska Native Village
When Victims Need Medical Forensic Services:
[Refer to PDF for image: illustrated map]
Victim flown from village (Selawik) to hub (Kotzebue), then from hub
to Anchorage.
Source: GAO and Map Art (map).
[End of figure]
Great distances may also separate beneficiaries needing medical
forensic services from hospitals providing these services in states
other than Alaska. For instance, IHS hospitals in Arizona have
contracted with an air ambulance provider to transport patients via
helicopter or airplane to Phoenix for medical services, including
medical forensic exams. Such trips can each cost IHS several thousand
dollars, according to IHS officials.
Medical providers, law enforcement, and prosecutors expressed concerns
that long travel distances may deter victims from reporting sexual
assault and domestic violence and delay collection of the medical
forensic evidence needed for prosecution. They said that great
distances may also discourage victims from reporting assaults to law
enforcement and seeking medical forensic exams, particularly for
victims from remote villages who may need to take two or more flights
to obtain an exam. Also, victims in remote Alaska Native villages who
wish to remain anonymous cannot do so because they generally rely on
law enforcement for air transportation. Moreover, at least one
stakeholder told us that travel delays due to bad weather may make it
difficult to collect medical forensic evidence within the 72-to 96-
hour time frame in which such evidence is considered most viable.
According to stakeholders we spoke with, such long delays are rare,
but any delay increases the chance that physical evidence will become
contaminated or lost and that victims may forget details of the
assault.
To help address long travel distances, some hospitals and other
stakeholders, such as law enforcement agencies, told us they are
considering or have suggested expanding medical forensic services to
clinics, either through telemedicine or by training additional medical
providers, and expanding the role of community health aides, the
primary medical providers in remote Alaska Native villages.[Footnote
38] Telemedicine technology uses video conference, remote monitoring
equipment, and electronic health records to link patients in remote
areas to medical providers located elsewhere. Telemedicine connects
patients in remote clinics in Alaska to dental, skin, and other health
care services and could be expanded to support treating victims of
sexual assault, according to some stakeholders. One IHS hospital in
Montana, for example, is considering using telemedicine to enable the
hospital's specially trained medical forensic examiners to consult on
child sexual abuse cases--to determine if a specific injury is
consistent with abuse, for example--with medical providers in remote
clinics who do not have this specialized training. Before such a plan
could be put in place, however, officials from the organization that
develops telemedicine technology in Alaska told us, concerns would
need to be addressed about how to securely store and transmit medical
files to protect victim confidentiality and maintain the evidentiary
chain of custody. Rather than use telemedicine, the IHS hospital
located on the edge of a vast reservation is seeking to bring medical
forensic services closer to its beneficiary populations by developing
the capacity to perform medical forensic exams at a centrally located
clinic, according to an IHS official. The hospital has identified
clinic nurses who are interested in receiving specialized training in
conducting the exams.
A few stakeholders also suggested to us that community health aides
could play a larger role in collecting and preserving medical forensic
evidence. Medical providers and community health aides themselves,
however, voiced concerns to us about such a proposal. In cases of
sexual assault, health aides' scope of practice and training are
currently limited to tasks such as treating victims' injuries and
protecting evidence, such as clothing, until law enforcement officers
arrive; health aides are not authorized to perform medical forensic
exams or to collect evidence themselves. Among the concerns community
health aide officials mentioned to us is that expecting health aides
to perform such exams, on top of the many tasks already required of
them, may increase burnout rates; they said that such an expectation
may also put the health aides at risk of retaliation from alleged
perpetrators or others in a village. Other suggestions made by
stakeholders have included that health aides should receive additional
training on the sexual assault response tasks that are already within
their scope of practice. For example, medical providers told us that
health aides in Alaska's Yukon-Kuskokwim delta area attended training
in 2010 designed to help health aides and law enforcement officers
understand what health aides should and should not be expected to do
when responding to sexual assault cases. The training focused on the
actions health aides can already take to assist the response of law
enforcement officers and hospitals in such cases, such as asking
victims not to wash or change clothes before undergoing a medical
forensic exam.
Establishing Plans to Help Ensure That Hospitals Consistently
Implement and Follow the March 2011 Sexual Assault Policy:
Now that its initial sexual assault policy is in place, IHS faces the
challenge of ensuring that its hospitals consistently implement the
policy and follow its guidelines. IHS is taking initial steps to help
hospitals implement the policy but has not yet developed written,
comprehensive plans for implementation and monitoring. For example,
IHS officials told us the agency is planning to use funding from the
existing Domestic Violence Prevention Initiative to provide policy
training to IHS hospitals and to expand specialized medical forensic
training opportunities. IHS has also partnered with Justice's Office
for Victims of Crime to fund a national sexual assault exam and
response coordinator position within IHS; the position--which was
filled in August 2011--may play a role in helping implement and
monitor the March 2011 policy. Nevertheless, IHS has not yet developed
plans for implementing and monitoring the policy as a whole. Justice
officials echoed these concerns, given most hospitals' limited
technical expertise in medical forensic exams and general lack of
resources for responding to sexual assault.
The Indian Health Care Improvement Act also requires IHS to report to
Congress by September 23, 2011, on "the means and extent to which the
Secretary has carried out" the act's requirement to establish
appropriate policies, among other things, for responding to victims of
sexual abuse and domestic violence.[Footnote 39] Agency officials told
us that at the time of this report, IHS had not yet identified
sufficient resources for implementing the policy as a whole, nor had
it developed time frames for implementing major objectives in the
policy. Specifically, the agency had not identified resources for
purchasing equipment and supplies, such as digital cameras and special
forensic evidence-drying cabinets, required under the policy for
hospitals providing on-site medical forensic exams. Furthermore, the
agency has set December 31, 2012, as the deadline for medical
providers to be "credentialed and privileged" as specially trained
medical forensic examiners, but it has not identified deadlines IHS
hospitals should meet in implementing other parts of the policy, such
as providing access to medical forensic exams on site or by referral,
or collaborating with the objective of creating sexual assault
response teams. The agency has also not made plans to monitor whether
IHS hospitals are following the policy, such as whether hospitals
located more than 2 hours away from other facilities are developing
the capability to provide on-site medical forensic exams or how well
hospitals coordinate their activities with law enforcement and
prosecutors.
Coordination is important because it helps ensure that medical
providers collect and preserve evidence in a way that is useful for
prosecution. Our review found that hospitals' coordination with law
enforcement agencies and prosecutors varied greatly. Hospitals that do
not coordinate regularly with law enforcement and prosecutors may
unintentionally collect and preserve evidence in a way that hampers
the investigation or prosecution of cases. For example, law
enforcement officers in one location told us that before a candid
meeting between medical providers and the prosecutor took place,
providers were unknowingly violating the chain of custody to such a
degree that the prosecutor could not reliably use their evidence for
prosecution. The officers said that the meeting served as a catalyst
for the medical providers to attend SANE training and for law
enforcement officers, the prosecutor, and medical providers to develop
a collaborative response to collecting and preserving evidence in
sexual assault cases. Increased coordination between the hospital and
law enforcement also led one hospital to install a locking cabinet
(see figure 8) to securely store collected medical forensic evidence
before transferring it to law enforcement. Other medical providers
told us they had not received feedback on medical forensic evidence
collection and preservation from law enforcement officers or
prosecutors. In one location, providers told us they kept completed
exam kits with them at all times--even taking the kits home overnight--
until law enforcement took possession of the kits, even though Justice
officials told us that such practices could undermine the chain of
custody. IHS's March 2011 sexual assault policy calls on hospitals to
coordinate with law enforcement and prosecutors, but Justice officials
expressed concerns that many hospitals do not have working
relationships with law enforcement and prosecutors that would enable
such coordination. Furthermore, the policy does not specify how IHS
headquarters will support its hospitals in building such relationships
or initiating a coordinated response to sexual assault.
Figure 8: Locking Storage Cabinet for Medical Forensic Evidence:
[Refer to PDF for image: photograph]
Source: GAO (December 2010).
[End of figure]
According to an agency official, IHS did not have time to develop
implementation and monitoring plans before the March 2011 deadline
established for issuing a policy under the Indian Health Care
Improvement Act. Furthermore, the agency did not seek comments from
tribes before issuing the policy and therefore asked the tribes for
feedback after releasing the policy. According to IHS officials,
comments from tribes were due on May 30, 2011, and the agency was
analyzing these comments and intending to issue a revised policy.
One area of IHS's March 2011 policy we found to have caused some
confusion deals with guidelines for specialized training and
certification for medical providers. The policy stipulates that
nurses, physicians, and physician assistants must all complete
specialized training in performing sexual assault medical forensic
exams.[Footnote 40] The policy is unclear, however, about whether, to
perform these exams, medical providers need to obtain documentation of
competency beyond this training, especially for physicians and
physician assistants. Sections 3.29.1 and 3.29.5 of the policy use the
terms "credentialed" and "certified" interchangeably--in defining
sexual assault nurse and forensic examiners, in delineating
requirements for training and determining competency to perform these
exams, and in describing how staff obtain privileges to perform these
exams at IHS hospitals.[Footnote 41] These sections do so even though
"credentialing" generally refers to an internal process for allowing
medical providers to perform specific services in IHS hospitals, and
"certification" is the term used by Justice in its sexual assault
protocols and is also typically used by the organization that
developed the SANE specialty to denote someone who has demonstrated
competency in medical forensic exams and passed a required test. By
using these terms interchangeably, the policy leaves unclear whether
medical providers such as physicians and physician assistants must
obtain specialized training and certification--or just training--
before performing sexual assault medical forensic exams. IHS officials
we spoke with provided conflicting interpretations of the policy, from
interpreting it as calling for certification for sexual assault
forensic examiners to calling only for training for these medical
providers. IHS officials acknowledged, however, that no third-party
certification exists for sexual assault forensic examiners in the same
way it exists for nurses, which may imply that IHS would need to
develop its own certification of sexual assault forensic examiners
more broadly. IHS officials acknowledged to us that the agency has no
plans to develop such a certification.
Law enforcement officers and prosecutors told us that variable levels
of specialized training among medical providers have sometimes led to
inconsistencies in the quality and type of medical forensic evidence
collected. Specifically, they said that compared with medical forensic
exams performed by medical providers with specialized training, exams
performed by medical providers without such training have been of
lower quality or did not include certain pieces of evidence. A law
enforcement officer and prosecutors told us that medical providers
with SANE training were more familiar with procedures for collecting
evidence and better able to document the intricacies of injuries and
identify subtle signs of assault, such as small scratches and bruises,
than medical providers who did not have specialized training. A law
enforcement officer in one location told us about a child sexual abuse
case in which a physician without specialized training found no
evidence of abuse after performing a medical forensic exam; in
contrast, a SANE-trained medical provider who performed a subsequent
exam found internal injuries and other evidence of sexual abuse--
evidence the physician without specialized training missed.
Stakeholders also told us that because of their specialized training,
SANE-trained medical providers understand the importance of
identifying and collecting evidence consistent with a victim's account
of an assault, rather than simply following the generic step-by-step
instructions in an evidence collection kit. For example, one victims'
advocacy group told us about a case in which a medical provider
without specialized training collected only vaginal swabs from a
victim when the assault actually involved anal rape--all because the
medical provider did not ask the victim to describe the assault. No
consensus exists on the specific threshold of specialized training
needed to perform adequate exams; law enforcement officers and
prosecutors we spoke with, however, generally agreed that some level
of specialized training helps improve the quality of evidence
collection.
Without clear training and certification guidelines for physicians and
physician assistants, medical forensic exams may continue to be
performed by medical providers with inconsistent levels of knowledge
and expertise. As a result, IHS beneficiaries cannot be assured of
uniform quality in medical forensic services received, and law
enforcement entities cannot count on uniform quality in the medical
forensic evidence collected and preserved, even with IHS's new sexual
assault policy. Furthermore, calling for nurses to be SANE certified
or physicians and physician assistants to be certified as sexual
assault forensic examiners--if such a certification is developed--may
be a difficult standard for hospitals to meet. Very few hospitals
currently have nurses certified as SANEs, no comparable certification
exists for physicians and physician assistants, and some medical
providers we spoke with told us it can be challenging to complete the
clinical training needed to be eligible for SANE certification. Some
medical providers told us they are planning to complete their clinical
training at another facility because their home hospital does not have
a certified SANE provider who can validate their competency or does
not see enough sexual assault cases to provide sufficient practical
experience in performing medical forensic exams to demonstrate
competency. Moreover, hospitals already face considerable challenges
in attracting and retaining medical providers who are willing or able
to perform the exams; calling for certification may unintentionally
exacerbate this challenge, even though several stakeholders told us
that it is the SANE training rather than the certification that is
most important for performing high-quality medical forensic exams.
In addition to the lack of clarity around training and certification
guidelines for physicians and physician assistants under IHS's new
sexual assault policy, we have concerns that implementing and
monitoring the policy's overall training and certification guidelines
may be challenging given IHS headquarters' limited knowledge about how
many of its medical providers have such training or certification.
Without this baseline information, the agency may be unable to
accurately allocate resources for training or identify IHS hospitals
with certified SANE providers who can train or validate the competency
of providers from other IHS hospitals. The agency also does not have a
system in place to track providers' progress toward meeting its
training and certification guidelines. As a result, it may be unable
to hold hospitals accountable for following this section of the policy.
Developing Policies on Domestic Violence and Child Sexual Abuse:
IHS's March 2011 sexual assault policy instructs IHS hospitals to
provide a standardized response to adult and adolescent victims of
sexual assault.[Footnote 42] Specifically, the new policy calls for
all IHS-operated hospitals to provide adult and adolescent patients
who arrive in need of a medical forensic exam with access to an exam
by a medical forensic examiner, either on site or by referral to a
nearby facility. The new policy covers adult and adolescent victims of
sexual assault, but it does not cover whether or how hospitals should
respond to discrete incidents of domestic violence that do not include
a sexual component or cover cases of child sexual abuse. Consequently,
IHS hospitals do not have specific or recently updated guidance on
whether to provide medical forensic services for victims of domestic
violence and child sexual abuse; as a result, these victims may not
have access to the full range of services they need.
Agency officials told us that IHS is deciding how to provide direction
on responding to incidents of domestic violence and child sexual
abuse--whether through new policies or by updating existing sections
of the Indian Health Manual--but that the agency does not have
concrete plans to develop policies similar in scope and specificity to
the March 2011 sexual assault policy. The Indian Health Care
Improvement Act requires IHS to establish "appropriate protocols,
policies, procedures, [and] standards of practice ... for victims of
domestic violence and sexual abuse" and to develop appropriate victim
services, including improvements to forensic examinations and evidence
collection.[Footnote 43] According to an IHS official, the agency did
not have time to develop a separate domestic violence policy before
the Indian Health Care Improvement Act's March 2011 deadline for
establishing such a policy.[Footnote 44] In addition, the agency
decided to limit the policy's scope to adults and adolescents because
Justice has not yet developed child sexual abuse protocols and
recommended against including child sexual assault and adult sexual
assault in the same protocol. Moreover, the Tribal Law and Order Act
of 2010 directs IHS to base its sexual assault policies and protocols
on those established by Justice.[Footnote 45] Therefore, the March
2011 policy does not address child sexual abuse.
IHS officials also acknowledged that the sexual assault policy applies
only to IHS-operated hospitals,[Footnote 46] not tribally operated
hospitals. In accordance with the Indian Self-Determination and
Education Assistance Act, the self-determination contracts and self-
governance compacts under which tribes operate hospitals generally do
not require compliance with IHS policy. An objective of the Indian
Self-Determination and Education Assistance Act is to assure the
maximum Indian participation in the direction of federal services to
"Indian communities so as to render such services more responsive to
the needs and desires of those communities."[Footnote 47] Accordingly,
tribes are accountable for managing day-to-day operations of IHS-
funded programs, services, and activities included in their self-
determination contract or self-governance compact. Tribes thereby
accept the responsibility and accountability to beneficiaries under
the contract with respect to use of the funds and the satisfactory
performance of IHS programs, functions, services, and activities
funded under their contract. At the same time, it is the policy of the
Secretary of Health and Human Services to facilitate tribal efforts to
plan, conduct, and administer programs, functions, services, and
activities under the act. To that end, as requested, IHS may provide
technical assistance to tribes in developing their capability to
administer quality programs. According to IHS officials, tribally
operated hospitals may choose to use IHS's March 2011 policy as a
model for developing their own sexual assault policies.
IHS could negotiate contract or compact provisions requiring tribes to
abide by IHS's sexual assault policy, but the tribes would have to
agree to such a provision. IHS officials told us the agency is
hesitant to pursue this approach, and has not generally used it,
because a multitude of other issues are also up for negotiation.
Furthermore, IHS officials indicated that they do not plan to include
such a provision in compacts or contracts the agency negotiates.
Developing Sustainable Staffing Models:
Hospital officials told us they face challenges in designing staffing
models for collecting and preserving medical forensic evidence that
can overcome problems with staff burnout, high turnover, and
compensation over time. In some hospitals where we conducted
interviews, medical forensic services were not organized into a formal
program or housed within a specific hospital department. Instead,
several officials told us, medical forensic exams are performed by
individual medical providers, sometimes from different departments,
and often outside the medical providers' official job duties and
beyond their normal working hours. For example, at one hospital,
officials told us that nurses from different units received
specialized training in performing medical forensic exams and agreed
to be on call to perform the exams day or night. Performing these
exams was not written into the nurses' formal job descriptions,
however, and the nurses were expected to complete their official job
duties, as well as medical forensic activities. Medical providers told
us that burnout may occur for several reasons--/including stress, lack
of supervisor support, and inadequate compensation--stemming from
staffing arrangements in which medical providers perform exams in
addition to their official job duties.
Potential burnout is a serious concern because it can undermine a
hospital's ability to sustain access to medical forensic services. IHS
officials acknowledged that turnover rates for medical providers
specially trained in performing medical forensic exams are generally
very high, with such providers often leaving IHS facilities after only
2 years. Some medical providers told us they find it stressful to
balance their normal job duties with providing medical forensic
services. For example, in one hospital, several medical providers
described the staffing arrangement for medical forensic exams as
relying on nurses performing the work of two full-time jobs--their
official jobs and their medical forensic exam duties--while receiving
compensation only for their official jobs.
In some hospitals, moreover, medical providers told us that their
supervisors do not consistently allow them to participate in tasks
outside of their normal duties. For example, medical providers told us
about instances in which supervisors did not permit them to take time
away from their normal duties to attend sexual assault response team
meetings; as a result, the medical providers missed the meetings or
worked beyond their normal hours to attend. In other cases, because of
general hospital understaffing, some medical providers were unable to
find backup coverage for their normal duties when called away for
several hours to perform medical forensic exams. Consequently, some
medical providers had to leave their normal duties unattended or have
victims wait to receive exams until the medical providers' normal
shifts were over, which is stressful, according to at least one
medical provider.
In addition to issues related to understaffing, medical providers
performing medical forensic exams over and above their normal duties
said that they may not receive enough compensation to prevent
attrition. The type and amount of compensation provided for performing
medical forensic exams vary across hospitals, with some medical
providers receiving overtime pay or compensatory time off and others
receiving nothing beyond their normal salaries. Some medical providers
told us they had trouble obtaining sufficient compensation. For
example, medical providers in one hospital told us they receive
compensatory time off for performing medical forensic exams, but they
can rarely use the additional leave hours because the hospital is too
short-staffed to approve time off. In another hospital, nurses who
provided medical forensic exams in addition to their normal job duties
found it difficult to obtain approval from their supervisors for
overtime pay when performing the exams made them exceed their normal
hours. The overtime rate the nurses said they were paid was
commensurate to the nurses' regular hourly rate, not the time and a
half usually accorded for overtime. The former SANE coordinator at
this hospital told us that such compensation challenges contributed to
nurses' burning out over time and ceasing their medical forensic exam
duties. When the nurses stopped offering the exams, the hospital was
unable to provide exams for victims who needed them and began
referring victims to another facility, according to the coordinator.
Concerning staffing, we have issued a guide federal agencies can use
in maintaining or implementing effective internal control.[Footnote
48] One of the factors this guide states that agencies should consider
in determining whether a positive control environment has been
achieved[Footnote 49] concerns organizational structure and whether
the agency has the appropriate number of employees--specifically, so
that employees do not have to work outside the ordinary workweek to
complete their assigned tasks. Additionally, in its 2006-2011
Strategic Plan, IHS acknowledges the difficulty the agency has long
faced in attracting and retaining medical providers across IHS.
Attraction and retention is particularly challenging for remote
facilities in isolated areas, where medical providers may be offered
incentive pay for accepting positions. The agency's strategic plan
outlines strategies for recruiting, retaining, and developing
employees, stating that the agency will "ensure an ongoing process to
identify and implement the best practices related to staff retention"
and "continue to explore options to provide adequate staffing for all
facilities."[Footnote 50]
Some hospitals have already identified and implemented staffing
options for medical forensic services, which aim to address concerns
about provider burnout and sustainability. Several hospitals have
incorporated medical forensic services into normal job duties for
medical providers in a specific hospital department. For example, at
one hospital in South Dakota, medical providers told us that most
nurse midwives within the hospital's midwife clinic receive SANE
training and perform medical forensic exams as part of their normal
clinic duties. In addition, several hospitals in Alaska have hired
sexual assault response team coordinators, whose part-or full-time
responsibilities are to manage the hospitals' medical forensic
services and perform medical forensic exams, according to hospital
officials. An official at one hospital told us the hospital provided
retention pay in an effort to adequately compensate medical providers
for performing these exams.
Such options may help reduce medical provider stress and burnout, but
no single staffing arrangement works for all hospitals or medical
providers. For example, medical providers from one hospital told us
their hospital considered incorporating the exams into providers' job
descriptions but decided not to because doing so would make it even
more difficult to attract candidates for already hard-to-fill
positions. In addition, one stakeholder told us many hospitals do not
see enough sexual assault cases to warrant a part-or full-time
position for a sexual assault response team coordinator. Moreover,
according to IHS officials, annual pay caps may limit the amount of
bonus or retention pay that medical providers are eligible to receive
for performing medical forensic exams. IHS is developing a proposal to
separate the salary series of advanced practice nurses--the type of
nurse likely to perform medical forensic exams within IHS--from other
registered nurses so that advanced practice nurses can receive higher
maximum pay. IHS officials told us this proposal may help address the
constraints imposed by salary caps, which currently make it
impractical for many nurses to be compensated for performing medical
forensic exams.
Factors besides Medical Forensic Evidence also Contribute to Decisions
to Prosecute Cases of Sexual Assault and Domestic Violence:
Decisions to prosecute sexual assault or domestic violence cases are
based on the totality of evidence collected, one piece of which is
medical forensic evidence collected by IHS and tribally operated
hospitals. Many of the factors contributing to a decision to prosecute
are not unique to incidents of sexual assault or domestic violence
involving Indians in remote reservations or villages; nevertheless,
prosecutors acknowledged, they affect the totality of the available
evidence and thus contribute to decisions to prosecute such cases.
Specifically, officials from the responsible law enforcement and
prosecuting agencies told us they generally base their decisions to
refer sexual assault or domestic violence investigations for possible
prosecution and to accept these matters for prosecution on the total
picture presented by the quality and quantity of available evidence.
Prosecutors and law enforcement officials said they consider several
factors--including medical forensic evidence collected by hospitals.
They also said that the relative importance of these factors can
differ from case to case. In some cases, medical forensic evidence may
be a crucial factor; in others, however, it may not be relevant or
available. For example, photographic evidence or DNA collected during
a genital exam may be critical in showing that an alleged perpetrator
had sex with the victim, but such medical forensic evidence may not be
relevant when the victim and alleged perpetrator admit to having had
sex but disagree as to whether the sex was consensual. In many of
those cases where consent is the main issue, according to prosecutors
and Justice's sexual assault protocols, medical forensic evidence does
not reveal physical injuries that readily demonstrate a lack of
consent. Also, law enforcement officials and prosecutors told us that
medical forensic evidence may be unavailable if a victim reports an
assault weeks or months later, as often happens in cases of child
sexual abuse, because, for example, DNA evidence or relevant fibers
would likely have washed away or become contaminated in the meantime.
In addition to this medical forensic evidence, law enforcement
officials told us that when deciding whether to refer an investigation
for possible prosecution, they consider several other factors,
including quality of the criminal investigation conducted, credibility
of witnesses who may have been intoxicated at the time of the assault,
and coordination with relevant agencies to obtain supporting evidence.
For example, federal prosecutors acknowledged that quality of the
criminal investigation is important because evidence in a criminal
matter must meet a relatively high threshold to be accepted for
prosecution--that is, prosecutors must believe that existing evidence
is compelling enough to demonstrate to a jury guilt beyond a
reasonable doubt. As a result, prosecutors acknowledged that a law
enforcement agency that refers all criminal investigations involving
sexual assault for possible prosecution--regardless of whether the
extent or quality of evidence collected during its investigation would
warrant such a referral--may find that prosecutors decline to
prosecute some of these matters. Law enforcement officials and
prosecutors also told us that intoxication of witnesses at the time of
an assault can mean these witnesses may be less credible in court
because, for example, intoxication adversely affects ability to
clearly recall circumstances around the assault or specific statements
made by the victim or alleged perpetrator. Additionally, law
enforcement officials and prosecutors stated that decisions to refer
investigations for possible prosecution are also based on obtaining
additional evidence that supports the victim's account. Availability
of coordinated efforts, such as sexual assault response teams, can
greatly enhance the quality of a forensic interview with a victim
about an assault and facilitate gathering such supporting evidence.
Similarly, prosecutors consider additional factors besides medical
forensic evidence when deciding whether to accept a matter for
prosecution, including juries' increased expectation of seeing DNA
evidence; perceived credibility of the victim, alleged perpetrator, or
other involved party; and availability of involved parties, such as
witnesses or hospital providers, to testify. Specifically, several law
enforcement officials and prosecutors stated that, in light of popular
television series featuring forensic evidence, juries have come to
expect prosecutors to regularly present DNA and other forensic
evidence before they are willing to convict. As a result, several
prosecutors told us they need to factor in such juror expectations
when deciding whether they believe they have strong enough evidence to
obtain a conviction or plea deal. Additionally, prosecutors told us
that decisions to accept matters for prosecution are also based on how
believable a witness, victim, or alleged perpetrator seems to be. The
credibility of witnesses, including the victim, can be based on a
variety of factors, including how well he or she can recall details of
the assault. For example, one prosecutor told us her office concluded
that the testimony of a particular victim could be persuasive because
the woman accurately described the layout of the room where she
alleged she was raped, even though the alleged perpetrator told police
she had never been inside his house. Prosecutors across the country
told us that intoxication of victims at the time of assault is not
alone an acceptable reason to decline a matter for prosecution.
With regard to witness testimony, federal and state prosecutors told
us that availability of potential witnesses to testify is also an
important factor. Some victims in small reservations or isolated
villages may refuse to cooperate or may retract their initial
statement, for example, because of pressure exerted on them by family
or community members who may depend on the alleged perpetrator for
necessities such as food or fuel. As a result, the victim may be
unavailable to testify. Additionally, according to several prosecutors
with whom we spoke, the availability to testify of medical providers
who performed the associated medical forensic exams at IHS or tribally
operated hospitals is an important factor because such testimony can
help demonstrate that an assault occurred or help otherwise support a
victim's account of an assault. Specifically, some prosecutors told us
that it may be difficult to locate traveling medical providers who
work at these hospitals temporarily; in addition, hospital staffing
shortages may keep supervisors from releasing staff from hospital
duties to testify. Consequently, some medical forensic examiners at
IHS and tribally operated hospitals may not be able to testify in
court that evidence obtained from a medical forensic exam belongs to a
given victim or attest to a victim's statements made during the exam
about the assault--testimony that prosecutors repeatedly stated is
critical to using the medical forensic evidence in court. IHS
officials noted, however, that the Tribal Law and Order Act of 2010's
requirement that state and tribal courts provide employees with 30-day
notice of the request for testimony would make it much more likely
that a traveling provider could be located and appear or a provider's
schedule changed to accommodate a court appearance.
In this context, section 263 of the Tribal Law and Order Act of 2010
contains requirements for IHS regarding approval or disapproval of
requests or subpoenas from tribal or state courts for employee
testimony. IHS's March 2011 sexual assault policy, however, is not
entirely consistent with section 263, and, in some cases, the policy
is not clear.
* First, the policy does not state that subpoenas and requests for IHS
employee testimony in tribal or state courts not approved or
disapproved within 30 days are considered approved. In this regard,
the policy appears to contradict section 263 of the act, which states
that subpoenas or requests will be considered approved if IHS fails to
approve or disapprove a subpoena or request 30 days after receiving
notice of it.
* Second, it is unclear whether the prior approval discussed in the
policy refers to the agency's approval of the subpoena, as required by
the act, or supervisory approval of the employee's release from
hospital duties. To the extent that the policy's discussion refers to
release from hospital duties, the policy is silent about whether and
under what circumstances supervisors can refuse to release a
subpoenaed employee to testify if the subpoena or request is approved
or considered approved.
* Third, the policy does not specify criteria to be used to approve a
subpoena. Specifically, the policy does not specify that, in
accordance with section 263, the IHS Director must approve requests or
subpoenas from tribal and state courts if they do not violate the
Department of Health and Human Services' policy to maintain
impartiality. Explicitly articulating these criteria is important
because departmental officials told us requests for IHS employee
testimony in these criminal prosecutions would likely always satisfy
the criteria and because responding to such requests are in the
agency's best interest. In addition, the policy does not discuss legal
limitations placed by privacy laws on the production of medical
records in response to state or tribal court subpoenas.
* Fourth, the policy does not specify whether it also applies to
subpoenas and requests from federal courts--a process currently
governed by an unwritten policy--even though IHS officials told us
they intended for the policy to cover federal subpoenas and requests
as well as those from tribal and state courts.
According to Health and Human Services officials, the department is
drafting a more specific and comprehensive description of the subpoena
approval process. As of September 2, 2011, however, this document,
whose audience is officials involved in the subpoena approval process,
had not been completed or disseminated; we have therefore not reviewed
it. Moreover, it is unclear how widely it will be disseminated. We
received inconsistent accounts from departmental and IHS officials
about the extent to which the document will be made available to line
staff--the very staff who would be subpoenaed to testify. According to
federal standards for internal control, information should be recorded
and communicated to management and others within an agency in a form
and within a time frame that enables them to carry out their
responsibilities.[Footnote 51] Moreover, the federal standards call
for effective communication to flow down, across, and up the
organization.[Footnote 52] Therefore, it is still uncertain when and
by what processes IHS staff will be able to respond to subpoenas or
testify in court about the medical forensic exams they conduct--an
ambiguity in the policy that is of great concern, according to several
Justice officials with whom we spoke.
Conclusions:
Medical providers in IHS and tribally operated hospitals are called
upon to fulfill twin purposes when seeing patients who are victims of
sexual assault and domestic violence--to treat the victim's injuries
and trauma and to collect medical forensic evidence of high enough
quality that it can be used to prosecute crimes. The provision of
medical forensic services and collection and preservation of high-
quality evidence, however, are highly variable across IHS and tribally
operated hospitals, hampered in part by distances victims must travel
and the absence, until recently, of central direction from IHS on
what, how, and by whom these services are to be provided. IHS has made
significant progress in the last 2 years, and its March 2011 sexual
assault policy takes a sound first step toward addressing problems
like these, but the agency, its hospitals, and medical providers have
a long way to go to fulfill the policy's provisions. Without
articulating how it plans to implement the policy and monitor progress
toward meeting policy requirements, IHS may not be able to hold
individual hospitals accountable to the agency, and the agency may not
be able to hold itself accountable to its beneficiaries. The road
ahead is likely to be particularly arduous for the more remote
hospitals, which have long faced obstacles in attracting and retaining
medical providers and are now faced with numerous new demands, such as
offering medical forensic exams on site or by referral within 2 hours
and making readily available digital cameras and other equipment and
supplies needed to collect medical forensic evidence. In addition,
responding to incidents of sexual assault and domestic violence
requires a multifaceted approach involving not only medical providers
but also law enforcement and prosecuting agencies and other
stakeholders identified in the policy. The medical forensic evidence
needs to be collected and preserved in a way that facilitates its use
by law enforcement and prosecuting agencies. Not all IHS hospitals and
staff regularly collaborate with these stakeholders or obtain regular
feedback from them on evidence collection and preservation. Without
considerable and concerted investment in the staff and hospitals
responsible for providing medical forensic services--and without a
detailed implementation plan to clarify how the agency will support
its hospitals and staff in meeting the policy's requirements and by
when--the agency is unlikely to meet those requirements.
In addition, IHS's March 2011 sexual assault policy does not address
how its hospitals should respond in cases of discrete domestic
violence without a sexual component or in cases of child sexual abuse.
IHS is currently considering how its hospitals should respond to such
cases, but it has not developed policies that are similar in scope and
specificity to its March 2011 sexual assault policy for adolescents
and adults. This gap is significant, but IHS is only one of the
agencies involved in the multifaceted response to incidents of sexual
assault and domestic violence. All the responding federal agencies
should present a consistent and coordinated response to these issues.
Justice also has not yet developed a policy for responding to child
sexual abuse incidents, which is critical, since the Tribal Law and
Order Act of 2010 mandates that IHS develop standardized sexual
assault policies and protocols based on a similar protocol established
by Justice.
IHS's recent effort to solicit and analyze comments from the tribes
and Justice on the March 2011 policy presents an opportunity for the
agency to revise areas that, as originally written, are unclear or
inconsistent. Specifically, it is unclear whether sections 3.29.1 and
3.29.5 of the policy require both training and certification, or only
training, of IHS physicians and physician assistants performing sexual
assault medical forensic exams. Also, the policy does not specify how
physicians and physician assistants are to attain certification when
no such certification by IHS or a third party exists for medical
providers other than nurses. IHS's sexual assault policy is also not
consistent with provisions in section 263 of the Tribal Law and Order
Act of 2010, which states, among other provisions, that subpoenas and
requests for employee testimony or documents from state and tribal
courts not approved or disapproved within 30 days are considered
approved. To the extent that the policy's discussion of subpoena and
request approvals refers to release from hospital duties, the policy
is silent about whether and how IHS plans to approve the release of
staff providing medical forensic exams to testify or otherwise comply
with subpoena requests. Without greater clarity in the policy's
language--and without giving relevant staff explicit guidance on how
to respond when subpoenaed or requested to testify--providers who
perform sexual assault medical forensic exams may not understand the
circumstances under which they are allowed or required to testify in
court, a serious concern that Justice has echoed.
Some of the prior efforts to provide medical forensic services at
individual hospitals failed for various reasons, including staffing
problems related to burnout, high turnover, and compensation. The
March 2011 sexual assault policy provides the high-level management
endorsement that had been missing in the past, but devising
appropriate staffing models--so that the provision of standardized
medical forensic services being developed under the new policy will
continue well into the future--remains a challenge. At some locations,
current staffing models present disincentives to the provision of
these services, such as supervisory refusal to give medical providers
permission to attend sexual assault team meetings or to approve
adequate compensation for providing medical forensic services in
addition to normal job duties or beyond a unit's official area of
responsibility. Given the agency's reliance on temporary medical
providers, as well as high burnout and turnover rates among medical
providers, unless corrected, such disincentives are likely to
undermine IHS's efforts to fulfill the March 2011 policy's goals over
the long term.
Finally, IHS also has an opportunity to incorporate comments from
tribes that may choose to use the March 2011 policy as a model on
which to base their own sexual assault response policies in tribally
operated hospitals or clinics. As we discussed earlier, IHS policies
and procedures can be used as models on which to base local tribal
protocols even though they do not generally apply to its 17 tribally
operated facilities. In addition, IHS recognizes that hospital
protocols, particularly for complex and sensitive matters like sexual
assault, need to reflect each community's individual circumstances.
Coordinating with tribes may therefore be especially important to
those tribally operated hospitals in Alaska, where the state, rather
than the federal government, generally has criminal jurisdiction and
where the state has made combating sexual assault and domestic
violence a high priority.
Recommendations for Executive Action:
To improve or expand medical forensic exams and related activities for
the 28 IHS operated hospitals, we recommend that the Secretary of
Health and Human Services direct the Director of the Indian Health
Service to take the following five actions:
* Develop an implementation plan for the March 2011 IHS sexual assault
policy (Indian Health Manual, chapter 3.29)--and monitor its progress--
to clarify how the agency will support its hospitals and staff in
fulfilling the policy, in particular, that the hospitals or staff:
- obtain training and certification in providing forensic medical
exams;
- obtain equipment like cameras needed to collect evidence;
- provide medical forensic exams on site or at a referral facility
within 2 hours of a patient's arrival; and:
- collaborate with law enforcement agencies, prosecution, and other
stakeholders identified in the policy with the objective of creating
sexual assault response teams and obtaining regular feedback from such
stakeholders on evidence collection and preservation.
* Develop a policy that details how IHS should respond to discrete
incidents of domestic violence without a sexual component and, working
with Justice, develop a policy for responding to incidents of child
sexual abuse consistent with protocols Justice develops for these
incidents; such policies should be similar in scope and specificity to
the March 2011 IHS policy on responding to adult and adolescent sexual
assaults.
* Clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS
sexual assault policy call for training and certification, or only
training, of IHS physicians and physician assistants performing sexual
assault medical forensic exams.
* Modify the March 2011 IHS sexual assault policy so that it
comprehensively and clearly outlines (1) the process for approving
subpoenas and requests for IHS employees to provide testimony in
federal, state, and tribal courts and (2) reflects the provisions in
section 263 of the Tribal Law and Order Act of 2010, including that
subpoenas and requests not approved or disapproved within 30 days are
considered approved.
* Explore ways to structure medical forensic activities within IHS
facilities so that these activities come under an individual's normal
duties or unit's official area of responsibility, in part to ensure
that providers are compensated for performing medical forensic
services.
Agency Comments:
We provided a copy of our draft report to the Departments of Health
and Human Services, the Interior, and Justice and to the state of
Alaska. In its written response, reprinted in appendix IV, the
Department of Health and Human Services agreed with our five
recommendations and stated that work is now under way to implement
each of them. The state of Alaska generally agreed with our
conclusions and recommendations, especially the recommendation to
develop additional policies specific to child sexual abuse, and
expressed its willingness to collaborate with the Indian Health
Service in developing sexual assault policies applicable to Alaska
(see appendix V). The Department of Health and Human Services and the
state of Alaska, as well as the Departments of the Interior and
Justice, provided technical comments, which we incorporated into the
report as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, the Secretary
of the Interior, the Attorney General of the United States, the
Governor of Alaska, and other interested parties. In addition, the
report is available at no charge on the GAO website at [hyperlink,
http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix VI.
Signed by:
Carolyn L. Yocom:
Director:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
Our objectives were to determine (1) the ability of Indian Health
Service (IHS) and tribally operated hospitals to collect and preserve
medical forensic evidence for use in criminal prosecution in sexual
assault and domestic violence cases; (2) what challenges, if any,
these hospitals face in collecting and preserving such evidence,
particularly in remote Indian reservations and Alaska Native villages;
and (3) what factors besides medical forensic evidence collected by
these hospitals contribute to a decision to prosecute such cases.
For all three objectives, we collected and analyzed laws, regulations,
and agency policies relevant to the collection and preservation of
medical forensic evidence by IHS and tribally operated hospitals in
cases of sexual assault and domestic violence, and we interviewed and
gathered relevant documentation from headquarters officials at IHS,
the Bureau of Indian Affairs, the Department of Justice, and the state
of Alaska. In addition, we conducted over 60 semistructured interviews
with several groups of stakeholders (1) from hospital staff during
site visits to a nonprobability sample of 8 IHS or tribally operated
hospitals in Alaska, Arizona, and South Dakota and over the telephone
with an additional nonprobability sample of 7 IHS or tribally operated
hospitals in Arizona, Minnesota, Montana, New Mexico, North Dakota,
and Oklahoma and (2) from victim advocacy groups; federal and state
prosecutors; and federal, state, local, and tribal law enforcement
agencies that play a role in responding to and prosecuting sexual
assault and domestic violence cases in most of the locations these 15
hospitals serve. We spoke with officials about hospitals that are
performing medical forensic exams, that are developing the ability to
perform such exams, and that do not perform these exams.
To determine the ability of IHS and tribally operated hospitals to
collect and preserve medical forensic evidence, we surveyed all 45 IHS
and tribally operated hospitals on available services, obtained
electronic data from IHS on procedures and purpose of visits related
to sexual assaults and domestic violence, and determined which
hospitals were located in remote areas.
* First, we determined the type of facility within the IHS system that
is most likely to provide medical forensic services. From discussions
with IHS officials and others, we found that hospitals were the most
appropriate type of facility to include in our analysis because of the
level of medical expertise and infrastructure available in these
facilities relative to other types of health centers or specialized
clinics. We then obtained an electronic list of all IHS and tribally
operated hospitals in the United States, including location and
contact information for each. We assessed the reliability of this list
by validating and cross-checking the data with the IHS official who
oversees the information. After eliminating two private hospitals that
were erroneously included in the list, we determined that the data
were sufficiently reliable for the purpose of this report. Using this
list of 45 IHS and tribally operated hospitals, we e-mailed a self-
administered questionnaire to survey each of the 45 hospitals. (See
appendix II for a blank copy of the questionnaire.) The questions were
designed to identify the ability of each hospital to collect and
preserve medical forensic evidence at the time the questions were
answered. To develop the survey questions, we reviewed existing
interviews, interviewed IHS officials and providers at several IHS and
tribally operated hospitals, and reviewed relevant Justice protocols.
We took steps to minimize errors in the survey effort's development
and data collection process. For example, the team designed specific
questions in consultation with a social science survey specialist and
design methodologist. We conducted several pretests with medical
providers at three separate hospitals--two IHS-operated hospitals and
one tribally operated hospital--to help ensure that the questions were
clear, relevant, and unbiased and to ensure that they could be
completed quickly. Another survey specialist also reviewed the
questionnaire, and suggestions were included where appropriate. We
sent the questionnaire to the most knowledgeable hospital official at
each location--typically the clinical director and chief executive
officer--to be the lead respondent and, if necessary, to confer with
other representatives within the hospital to answer questions
requiring more detailed knowledge. To maximize our response rate, we
sent follow-up e-mails and left reminder telephone messages over a
period of approximately 11 weeks--from March 31, 2011, when we started
the survey effort, through June 14, 2011, when we closed it. We
received responses from 100 percent of the hospitals, and we followed
up to clarify specific responses as needed. Accordingly, the responses
represent a snapshot in time of each hospital's medical forensic
services. We entered the responses into a spreadsheet and analyzed the
results. A separate analyst verified the accuracy of data entry and
analyses. (See appendix III for a summary of key survey results.)
* Second, we obtained electronic data on the reasons for hospital
visits by IHS beneficiaries from fiscal year 2006 through fiscal year
2010 for each of the 45 hospitals that report such data to IHS.
[Footnote 53] To assess the reliability of the data, we interviewed
knowledgeable IHS officials and performed electronic testing. Our
initial intent was to determine how many medical forensic exams had
been performed at each IHS and tribally operated hospital, but we were
unable to do so because IHS does not centrally track the number of
such exams, and complete data on specific procedures done during each
patient visit were not available. We therefore used diagnosis codes
established in the World Health Organization's International
Statistical Classification of Diseases and Related Health Problems to
determine from patients' "purpose-of-visit" information which
hospitals were providing sexual assault and domestic violence services
and the primary reason for such visits. We excluded all visits to
mental or behavioral health clinics because such services typically
take place after an incident and are not part of collecting or
preserving medical forensic evidence. To determine how many sexual
assault or domestic violence visits each hospital saw from fiscal year
2006 through fiscal year 2010, we analyzed each patient visit by its
codes and categorized the codes into four incident types: adult sexual
abuse, adult domestic violence, child sexual abuse, and child physical
abuse. If a patient had more than one record with a purpose-of-visit
code indicating sexual assault or domestic violence, we counted only
the first visit to avoid double-/counting of visits that may have
pertained to the same incident. Thus, we may have undercounted the
number of sexual assault or domestic violence incidents in this time
frame if one patient had been involved in two or more incidents.
* Third, we identified which hospitals were located in remote areas
and those located in urban areas. Given that there are only 45 IHS and
tribally operated hospitals in total, we determined that it was
reasonable to collect information on all 45 hospitals. We determined
which hospitals were located in remote areas by using rural-urban
commuting area codes[Footnote 54]--developed on the basis of U.S.
Census tracts by the Department of Agriculture's Economic Research
Service--because IHS has no technical definitions for remote. The
rural-urban commuting area system defines remote areas as those with
dispersed and small populations and where travel times are longer
because of limitations in transportation infrastructure, and it
defines urban areas as those with large populations and short travel
times between cities. We linked a hospital's zip code to rural-urban
commuting area data--also broken out by zip code--to determine if a
hospital is located in an isolated, small rural, large rural, or urban
area, as classified by the rural-urban commuting area system. We
refined these four categories into a two-category classification
scheme--collapsing the "isolated" and "small rural" categories into
one remote category and collapsing the "urban" and "large rural"
categories into one urban category--to aid in analysis and better
respond to our objectives.
To determine the challenges faced by these hospitals in collecting and
preserving medical forensic evidence, particularly in remote Indian
reservations and Alaska Native villages, we also collected and
analyzed pertinent laws, regulations, policies, protocols, and reports
from IHS, Justice, and other entities. On the basis of initial
interviews and responses from our survey of hospitals, we selected a
nonprobability sample of IHS and tribally operated hospitals with
which to conduct semistructured interviews on challenges they face in
collecting and preserving medical forensic evidence. We chose 15
hospitals according to a series of selection criteria that included
geographic location, remoteness, whether the state or federal
government had criminal jurisdiction in Indian country served by the
hospital, and whether the hospital was IHS or tribally operated.
Additionally, because we used a nonprobability sample to select these
IHS and tribally operated hospitals to interview, the information we
gathered in our semistructured interviews cannot be generalized to all
hospitals and instead represents the perspectives only of these
hospitals' providers and stakeholders. We also interviewed many victim
advocacy groups, federal and state prosecutors, and federal and state
and local law enforcement agencies that play a role in responding to
and prosecuting sexual assault and domestic violence cases in most of
the locations these 15 hospitals serve. We reviewed and analyzed our
interviews and supporting documentation to identify systemic and
regionally specific challenges.
Finally, to identify additional factors that federal prosecutors may
consider when determining whether to prosecute cases of sexual assault
and domestic violence, we reviewed relevant studies about these crimes
and reviewed standards related to decisions by law enforcement to
refer, or decisions by prosecutors to accept, a matter for criminal
prosecution.
We conducted this performance audit from October 2010 through October
2011, in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
[End of section]
Appendix II: GAO Survey of 45 IHS and Tribally Operated Hospitals:
United States Government Accountability Office:
GAO:
Indian Health Service:
Medical Forensic Examination (FE) Program Questionnaire:
Introduction:
This questionnaire asks for information about medical forensic
examinations done in cases of sexual assault or domestic violence for
adults and/or children; and information on whether or not your
facility has, or ever had, a program offering such medical forensic
examination services.
Background:
The U.S. Government Accountability Office (GAO) is an agency that
assists the U.S. Congress in evaluating federal programs. We have been
asked to provide Congress with information about the capability of
Indian Health Service (IHS) to collect and preserve evidence in cases
of sexual assault/abuse and domestic violence (involving adults or
children) for criminal prosecution. The intent of this questionnaire
is to determine which IHS and tribal hospitals have medical forensic
examiner programs or provide the services of a medical forensic
examiner in cases of sexual assault and domestic violence (involving
adults and/or children). For the purposes of this questionnaire, the
medical forensic examination is the medical treatment of a patient as
well as the collection of forensic evidence. Specifically, the
forensic component could include performing a forensic evidence
collection kit sometimes referred to as a "rape kit", gathering a
medical forensic history, conducting an exam, documenting biological
and physical findings, and collecting evidence from the patient. We
recognize that there is a continuum of forensic evidence collection
services that can occur depending on the availability of staff and the
medical condition of the victim.
Your facility was selected because it is one of the 47 hospitals
operated by IHS, a tribe, consortium, or has a contract to provide
services. It should take you about 5 to 10 minutes to complete this
questionnaire. The person with the most knowledge of the forensic
examination program should complete this questionnaire for the entire
facility. If you feel you are not the most knowledgeable person in
your facility about these exams, please contact Kyle Stetter (contact
information below) and let him know who you feel would be the best
person to complete it and we will arrange to send it to that person.
Your cooperation is critical to providing the Congress complete and
balanced information about the capability of IHS to collect and
preserve evidence in cases of sexual assault/abuse and domestic
violence.
Completing and Returning the Questionnaire:
Please complete and return this questionnaire as soon as possible, but
no later than Thursday, April 7, 2011. After receiving your responses,
we may also want to follow up with some of you by telephone to better
understand your program or how you operate in lieu of a program.
To answer the questions, first open the attached MS Word file and save
the file to your computer. Then enter your responses directly to the
saved document following the instructions below. Once the questions
are completed, please return them by attaching the saved document to
an e-mail message to Stetlerk@gao.gov. Or mail to 701 5th Ave., Suite
2700, Seattle WA. 98104.
GAO Contact:
If you have any questions, please call or e-mail:
Kyle Stetter:
E-mail: StetlerK@gao.gov;
Phone: 206-287-4844.
Instructions for Completing the Questions Onscreen:
* Please use your mouse to navigate, clicking on the field or check
box you wish to answer.
* To select a check box or a button, click on the center of the box.
* To change or deselect a check box response, click on the check box
and the X will disappear.
* To answer a question that requires that you write a comment, click
on the answer box and begin typing. The box will expand to accommodate
your answer. You are not limited to the amount of space you see on the
screen.
* If you have additional clarifications or comments on any of the
questions, please include those in the comment box at the end of this
document or in a separate document.
Start Here:
Your Contact Information:
Name:
Title:
Facility/Program Name:
Email:
Phone:
Section A. Adult Victims Of Sexual Assault:
1. Currently, if an adult victim of sexual assault comes into your
facility, with what frequency does your facility conduct a medical
forensic examination, that is, the medical treatment of a patient as
well as the collection of forensic evidence?
(Specifically, the forensic component could include such things as
performing a forensic evidence collection kit sometime referred to as
a "rape kit", gathering a medical forensic history, conducting an
exam, documenting biological and physical findings, and collecting
evidence from the patient)
Typically or always conducts:
Sometimes conducts:
Rarely conducts:
Never conducts:
2. If the frequency with which your facility conducts these medical
forensic examinations has substantially changed in the last five
years, please describe below. The box will expand to fit your answer.
NOTE: If you answered "Never conducts" to Question 1, please skip to
Question 7.
3. If your facility conducts medical forensic examinations in cases of
adult sexual assault, which types of providers typically conduct
medical forensic examinations? For each row, please check all that
apply.
a. Registered Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
b. Physician's Assistant:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
d. Physician:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
e. Other (Specify below):
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
4. If your facility conducts medical forensic examinations in cases of
adult sexual assault, what is the level of training of the providers
who typically conduct these examinations? For each row, please check
all that apply.
a. Registered Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
b. Physician's Assistant:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
d. Physician:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
e. Other (Specify below):
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
5. Has there ever been an extended period of time, during the last 5
years, when there was no one available to conduct the medical forensic
examinations for adult victims of sexual assault?
Yes:
No: Skip To Question #7.
6. If yes, please describe the circumstances. The boxes will expand to
fit your answer.
7. Does your facility (ever) refer adult sexual assault patients
someplace else for medical forensic examinations?
Yes:
No: Skip To Question #9.
8. If checked "Yes," please specify where and under what circumstances.
Section B. Adult Victims Of Domestic Violence:
9. If an adult victim of domestic violence comes into your facility,
with what frequency does your facility conduct a medical forensic
examination, that is, the medical treatment of a patient as well as
the collection of forensic evidence?
Typically or always conducts:
Sometimes conducts:
Rarely conducts:
Never conducts:
10. If the frequency with which your facility conducts these medical
forensic examinations has substantially changed in the last five
years, please describe below. The box will expand to fit your answer.
Note: If you answered "Never conducts" to Question 9, please skip to
Question 15.
11. If your facility conducts medical forensic examinations in cases
of adult domestic violence, which types of providers typically conduct
medical forensic examinations? For each row, please check all that
apply.
a. Registered Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
b. Physician's Assistant:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
d. Physician:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
e. Other (Specify below):
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
12. If your facility conducts medical forensic examinations in cases
of adult domestic violence, what is the level of training of the
providers who typically conduct these examinations? For each row,
please check all that apply.
a. Registered Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
b. Physician's Assistant:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
d. Physician:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
e. Other (Specify below):
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
13. Has there ever been an extended period of time, during the last 5
years, when there was no one available to conduct the medical forensic
examinations for adult victims of domestic violence?
Yes:
No: Skip To Question #15.
14. If yes, please describe the circumstances.
15. Does your facility (ever) refer adult domestic violence patients
someplace else for medical forensic examinations?
Yes:
No: Skip To Question #17.
16. If you checked "Yes," please specify where and under what
circumstances.
Section C. Child Victims Of Sexual Abuse:
17. If a child victim of sexual abuse comes into your facility, with
what frequency does your facility conduct a medical forensic
examination, that is, the medical treatment of a patient as well as
the collection of forensic evidence?
Typically or always conducts:
Sometimes conducts:
Rarely conducts:
Never conducts:
18. If the frequency with which your facility conducts these medical
forensic examinations has substantially changed in the last five
years, please describe below. The box will expand to fit your answer.
Note: If you answered "Never conducts" to Question 17, please skip to
Question 23.
19. If your facility conducts medical forensic examinations in cases
of child sexual abuse, which types of providers typically conduct
medical forensic examinations? For each row, please check all that
apply.
a. Registered Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
b. Physician's Assistant:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
d. Physician:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
e. Pediatrician;
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
f. Other (Specify below):
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
20. If your facility conducts medical forensic examinations in cases
of child sexual abuse, what is the level of training of the providers
who typically conduct these examinations? For each row, please check
all that apply.
a. Registered Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
b. Physician's Assistant:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
d. Physician:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
e. Pediatrician:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
f. Other (Specify below):
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
21. Has there ever been an extended period of time, during the last 5
years, when there was no one available to conduct the medical forensic
examinations for child victims of sexual abuse?
Yes:
No: Skip To Question #23.
22. If yes, please describe the circumstances.
23. Does your facility (ever) refer child sexual abuse patients
someplace else for medical forensic examinations?
Yes:
No: Skip To Question #25.
24. If you checked "Yes," please specify where and under what
circumstances.
Section D. Child Victims Of Physical Abuse:
25. If a child victim of physical abuse comes into your facility, with
what frequency does your facility conduct a medical forensic
examination, that is, the medical treatment of a patient as well as
the collection of forensic evidence?
Typically or always conducts:
Sometimes conducts:
Rarely conducts:
Never conducts:
26. If the frequency with which your facility conducts these medical
forensic examinations has substantially changed in the last five
years, please describe below. The boxes will expand to fit your answer.
Note: If you answered "Never conducts" to Question 25, please skip to
Question 31.
27. If your facility conducts medical forensic examinations in cases
of child physical abuse, which types of providers typically conduct
medical forensic examinations? For each row, please check all that
apply.
a. Registered Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
b. Physician's Assistant:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
d. Physician:
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
e. Pediatrician;
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
f. Other (Specify below):
Always or Almost Always Conducts:
Sometimes Conducts:
Rarely Conducts:
Never Conducts:
Do not have this type of provider:
28. If your facility conducts medical forensic examinations in cases
of child physical abuse, what is the level of training of the
providers who typically conduct these examinations? For each row,
please check all that apply.
a. Registered Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
b. Physician's Assistant:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
c. Nurse Practitioner/Advanced Practice Nurse:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
d. Physician:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
e. Pediatrician:
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
f. Other (Specify below):
SANE-A Certified:
SANE Trained:
Forensic Training:
No providers of this type have specific forensic training or do not
have this type of provider:
29. Has there ever been an extended period of time, during the last 5
years, when there was no one available to conduct the medical forensic
examinations for child victims of physical abuse?
Yes:
No: Skip To Question #31.
30. If yes, please describe the circumstances.
31. Does your facility (ever) refer child physical abuse patients
someplace else for medical forensic examinations?
Yes:
No: Skip To Question #33.
32. If you checked "Yes," please specify where and under what
circumstances.
Section E. Program Operations:
33. Does your facility have the capacity to perform medical forensic
examinations for adult or child victims of sexual assault and/or
domestic violence 24 hours a day, 7 days a week?
Yes:
No:
No Program: Skip to Question 36.
34. What are the current days and hours of operation for your medical
forensic examiner staff or program that treats adult or child victims
of sexual assault and/or domestic violence? Please describe in the box
below if the hours are different for children or adults.
Please indicate time in 24-hour clock format. If you are not
open/available during one or more time slots, please type N/A in that
time slot.
Monday:
Regular Hours:
On-Call:
Tuesday:
Regular Hours:
On-Call:
Wednesday:
Regular Hours:
On-Call:
Thursday:
Regular Hours:
On-Call:
Friday:
Regular Hours:
On-Call:
Saturday:
Regular Hours:
On-Call:
Sunday:
Regular Hours:
On-Call:
35. Please describe, if applicable, other provider/staff availability
for children or adults.
36. Are there any (other) IHS or tribal clinics in your service area
offering medical forensic examinations to child or adult victims of
sexual assault or domestic violence?
Yes:
No: skip to Question 38;
Don't know: skip to Question 38.
37. If there are other HIS or tribal clinics in your service area to
whom you may refer medical forensic examinations for child or adult
victims of sexual assault or domestic violence, what are the names of
the clinics and their contact information, to the extent it is
available (please provide for up to 3 clinics):
IHS Clinic Name:
Contact Name:
Contact Phone:
Contact Email:
38. Is there any additional information that you would like to provide
in regards to medical forensic examinations?
Thank you very much for your participation!
Please save your responses before exiting and return the questionnaire
by attaching the document to an email message to StetlerK@gao.gov.
[End of section]
Appendix III: Summary of Key Survey Results on Provision of Medical
Forensic Services for Sexual Assault Victims:
Hospital: Acoma-Canoncito-Laguna Hospital;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Alaska Native Medical Center;
Urban or remote: Urban;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Certified[A];
Training for child services: None.
Hospital: Browning Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Cass Lake Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training[B];
Training for child services: Medical forensic training.
Hospital: Cherokee Indian Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Chickasaw Nation Medical Center;
Urban or remote: Urban;
IHS or tribal: Tribal;
Services for adults: Does not typically perform;
Services for children: Typically performs;
Training for adult services: None;
Training for child services: None.
Hospital: Chinle Comprehensive Health Care Facility;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Choctaw Nation Indian Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Certified;
Training for child services: None.
Hospital: Cherokee Nation WW Hastings Hospital;
Urban or remote: Urban;
IHS or tribal: Tribal;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Claremore Hospital;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Creek Nation Community Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Crow/Northern Cheyenne Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Crownpoint Healthcare Facility;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Eagle Butte Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Fort Defiance Indian Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Certified;
Training for child services: None.
Hospital: Fort Yates Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: Certified;
Training for child services: None.
Hospital: Gallup Indian Medical Center;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Harlem Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Hopi Health Care Center;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Hu-Hu-Kam Memorial Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Kanakanak Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Lawton Hospital;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Maniilaq Health Center;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Mescalero Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: MS Band of Choctaw Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Certified;
Training for child services: None.
Hospital: Mt. Edgecumbe Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Northern Navajo Medical Center;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Typically performs;
Training for adult services: None;
Training for child services: None.
Hospital: Norton Sound Regional Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Parker Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Phoenix Indian Medical Center;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Pine Ridge Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Quentin N. Burdick Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Rapid City Hospital;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Redlake Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Rosebud Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Sage Memorial Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Samuel Simmonds Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: San Carlos Hospital[C];
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Santa Fe Hospital;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Sells Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Does not typically perform;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Hospital: Tuba City Indian Medical Center;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Whiteriver Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Certified.
Hospital: Winnebago Hospital;
Urban or remote: Remote;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: Medical forensic training;
Training for child services: None.
Hospital: Yukon-Kuskokwim-Delta Regional Hospital;
Urban or remote: Remote;
IHS or tribal: Tribal;
Services for adults: Typically performs;
Services for children: Typically performs;
Training for adult services: Medical forensic training;
Training for child services: Medical forensic training.
Hospital: Zuni Hospital;
Urban or remote: Urban;
IHS or tribal: IHS;
Services for adults: Typically performs;
Services for children: Does not typically perform;
Training for adult services: None;
Training for child services: None.
Legend:
Typically performs;
Does not typically perform (i.e., never, rarely, or sometimes performs
medical forensic exams).
Source: GAO.
[A] This category includes nurses that have obtained the sexual
assault nurse examiner (adult, SANE-A) or sexual assault nurse
examiner (pediatric, SANE-P) certification from the International
Association of Forensic Nurses.
[B] This category includes health care providers who have specialized
training, including SANE training, in medical forensic exams.
[C] On follow-up with San Carlos Hospital, we found that it does not
typically perform medical forensic exams for adults, although its
survey response said it did perform such exams. Therefore, the number
of hospitals typically performing exams changed from a reported value
of 27 to an actual value of 26 in our report.
[End of table]
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
October 11, 2011:
Carolyn L. Yocom, Director:
Natural Resources and Environment:
U.S. Government Accountability Office:
441 G Street NW:
Washington, DC 20548:
Dear Ms. Yocom:
Attached are comments on the U.S. Government Accountability Office's
(GAO) draft report entitled, "Indian Health Service: Continued Efforts
Needed to Help Strengthen Response to Sexual Assaults and Domestic
Violence" (GAO-12-29).
The Department appreciates the opportunity to review this report prior
to publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
[End of letter]
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled.
"Indian Health Service: Continued Efforts Needed To Help Strengthen
Response To Sexual Assaults And Domestic Violence" (GAO-12-29):
The Department appreciates the opportunity to review and comment on
this draft report. While acknowledging that the Indian Health Service
(IHS) is in the early stages of a comprehensive sexual assault and
domestic violence response, the MS is committed to developing and
implementing policies and protocols that are responsive to the
immediate needs of sexual assault and domestic violence victims in
Indian Country. The four challenges described in the GAO's assessment
that IHS faces in "standardizing and sustaining the provision of
medical forensic services" are areas of vital prioritization for
moving forward. The Sexual Assault Policy was established as the first
ever policy of its kind in the IHS. Our plan was to develop the
initial policy, then consult with Tribes to gather their input and
recommendations, then revise/update the policy, and to develop an
implementation plan, all of which are currently in progress. IHS will
address the recommendations from the report as it continues its
implementation of the policy.
In the ongoing effort to meet these challenges, there is a trend
toward Tribal management and delivery of health services in American
Indian and Alaska Native (AUAN) communities. Tribes have increasingly
contracted or compacted via the Indian Self-Determination and
Education Assistance Act, Public Law 93-638, to administer and provide
those services. This evolution in health care delivery and management
is changing the face of health services in Indian Country.
Where IHS was previously the principal health and behavioral health
care delivery system for AUANs, there is now a less centralized and
more diverse network of care provided by Federal, Tribal, and Urban
Indian health programs. The "Indian health system" denotes this larger
network of programs and the evolving care delivery system across
Indian Country. Meeting the needs of this system requires an evolution
in IHS and Tribal collaboration, particularly as Tribal programs take
more direct responsibility for services and IHS supports them in doing
so.
The IHS has devoted considerable effort to develop and share effective
programs throughout the Indian health system. In particular,
developing programs that are collaborative, community driven, and
nationally supported, offer the most promising potential for long term
success and sustainment. HS regularly relies on Tribal leadership and
expertise to collaborate on a range of health and behavioral health
problems and programs.
The IHS National Tribal Advisory Committee (NTAC) on Behavioral
Health, which is made up of elected Tribal leaders from each IHS Area,
provides recommendations and advice on the range of health and
behavioral health issues in Indian Country, including sexual assault
and domestic violence. From making recommendations on significant
funding allocations and service programs, to developing long term
strategic plans for Tribal and Federal behavioral health programs for
the future, the NTAC is the principal Tribal advisory group for all
behavioral health services to IHS. They ensure collaboration among
Tribal and Federal health programs, provide Tribal input into the
development of programs and services, and also provide the inclusive
and transparent development of processes and programs so important to
all our communities and programs.
The IHS National Behavioral Health Work Group (BHWG) is the technical
advisory group to IHS. Comprised of mental health professionals from
across the country, the BHWG furthers the agency priorities to
strengthen partnerships with Tribes, to reform the IHS, improve
quality and access to care for patients, and provide direct
collaboration and input for accountable, fair, and inclusive services
across the Indian behavioral health system. They provide expert advice
and recommendations for services, programs, and intervention models,
as well as long term strategic planning and goal development. As the
national technical advisory group to the agency, they also work very
closely with the elected Tribal leaders on the NTAC to provide
collaborative links between the professional community and national
Tribal leadership.
With the LEIS Domestic Violence Prevention Initiative (DVPI), the
numbers of providers receiving medical forensic training is now being
tracked. Resources have been allocated to provide Sexual Assault Nurse
Examiner (SANE), Sexual Assault Forensic Examiner (SAFE), and Sexual
Assault Response Team (SART) training for the remaining Federal and
Tribal facilities with 24/7 services and to assist with the purchase
of forensic equipment. Collaborative work has begun to address
information technology and electronic health record issues to better
capture the number of medical forensic exams performed in Federal and
Tribal facilities. Areas for remote case consultation, using
telemedicine, are being addressed to meet the needs of limited
technical expertise in most hospitals, as well as remote locations in
need of expert consultation.
Strategies to address domestic violence and sexual assault include
collaborations and partnerships with Tribes and Tribal organizations,
Urban Indian health programs, Federal, State, and local agencies, as
well as public and private organizations. The IHS and the Department
of Justice, Office on Victims of Crime (OVC) entered into a
partnership involving the Federal Bureau of Investigation and the
Department of the Interior. This partnership is the SANE-SART AUAN
Initiative, and is funded through the OVC. Using evidence-based
practices involving SANEs, SARTs, and victim-centered law enforcement
practices, the initiative will support victim recovery, satisfaction,
and cooperation with the Federal criminal justice system, as well as
supporting victims' of sexual assault and Tribal communities' need for
justice.
GAO Recommendations:
To improve or expand medical forensic exams and related activities for
the 28 IHS operated hospitals, we recommend that the Secretary of
Health and Human Services direct the Director of the Indian Health
Service to take the following five actions:
* Develop an implementation plan for the March 2011 IHS sexual assault
policy (Indian Health Manual, chapter 3.29) ” and monitor its
progress ” to clarify how the agency will support its hospitals and
staff in fulfilling the policy, in particular, that the hospitals or
staff:
- obtain training and certification in providing forensic medical
exams,
- obtain equipment like cameras needed to collect evidence,
- provide medical forensic exams on site or at a referral facility
within 2 hours of a patient's arrival, and,
- collaborate with law enforcement, prosecution, and other
stakeholders identified in the policy with the objective of creating
sexual assault response teams and obtaining regular feedback from such
stakeholders on evidence collection and preservation.
* Develop a policy that details how IHS should respond to discrete
incidents of domestic violence without a sexual component and, working
with Justice, develop a policy for responding to incidents of child
sexual abuse consistent with protocols Justice develops for these
incidents; such policies should be similar in scope and specificity to
the March 2011 IHS policy on responding to adult and adolescent sexual
assaults.
* Clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS
sexual assault policy calls for training and certification, or only
training, of IHS physicians and physician assistants performing sexual
assault medical forensic exams.
* Modify the March 2011 HIS sexual assault policy so that it
comprehensively and clearly outlines (1) the process for approving
subpoenas and requests for IHS employees to provide testimony in
federal, state, and tribal courts and (2) reflects the provisions in
section 263 of the Tribal Law and Order Act of 2010, including that
subpoenas and requests not approved or disapproved within 30 days are
considered approved.
* Explore ways to structure medical forensic activities with IHS
facilities so that these activities come under an individual's normal
duties or unit's official area of responsibility, in part, to ensure
that providers are compensated for performing medical forensic
services.
IHS Response:
In response to the five recommendations, we offer the following
comments:
Recommendation 1:
To meet the challenge of ensuring that the IHS policy is consistently
implemented in IHS operated hospitals and to ensure compliance, an
implementation and monitoring plan is now being drafted. The
implementation plan will address areas of standardized training and
certification, information technology, electronic health records,
standardized forensic equipment, telemedicine options for remote case
consultation, and set timelines for policy revisions and development.
The implementation plan will clarify how IHS will support its
facilities in providing medical forensic exams, by referring to an
outside facility, or a combination of both services.
Recommendation 2:
During the Tribal consultation phase of the development of the IHS
national sexual assault policy, many Tribal leaders provided
recommendations that encouraged establishment of separate IHS-wide
guidance addressing operating procedures and protocols for child
victims of abuse and neglect through the Indian Health Manual. In
response, the IHS created a policy workgroup comprised of IHS
professionals with extensive field experience in providing
direct services to abused and neglected Al/AN children. The resulting
Child Maltreatment Policy Workgroup will collaborate to develop the
foundation for local child maltreatment and child sexual abuse
policies and procedures for hospitals and clinics managed by the IHS.
The IHS's plan is to develop a separate, stand-alone domestic violence
policy, without sexual assault components, for its facilities. The
policy will be comprehensive and similar in scope and specificity to
the sexual assault policy approved by the IHS Director on March 23,
2011.
Recommendations 3 and 4:
Clarification of the IHS sexual assault policy on sections 3.29.1 and
3.29.5 on training and certification for IBS physicians and physician
assistants performing sexual assault medical forensic exams is part of
the revision process for the sexual assault policy. The implementation
plan will set timelines for revisions to the sexual assault policy.
Tribal leaders have provided recommendations for the sexual assault
policy and work has begun to incorporate those recommendations into
the revised policy.
Modifying the IHS sexual assault policy to comprehensively and clearly
outline the process for approving subpoenas and requests is underway.
This modification to the policy will reflect the provisions in section
263 of the Tribal Law and Order Act of 2010, including that subpoenas
and requests not approved or disapproved within 30 days of receipt are
considered approved.
Recommendation 5:
H-IS is exploring ways to structure medical forensic activities in HIS
facilities and to ensure that providers are compensated for performing
medical forensic services. Within the Federal pay systems, (both Title
5 and Title 38) medical forensic duties will fall within providing
patient care under the Nursing series. Currently, the IHS is looking
at other methods of recognizing the specialized nature of the duties
and compensation for performing exams and for call back or standby
premiums.
[End of section]
Appendix V: Comments from the State of Alaska:
State of Alaska:
Department of Public Safety:
Sean Parnell, Governor:
Joseph A. Masters, Commissioner:
Office of the Commissioner:
5700 E. Tudor Road:
Anchorage, AK 99507:
Voice: (907) 269-5086:
Fax: (907) 269-4543:
Juneau Office:
Voice: (907) 465-4322:
Fax: (907) 465-4362:
October 14, 2011:
Carolyn Yocom:
Director:
Natural Resources and Environment:
US Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Director Yocom,
Governor Parnell is strongly committed, through his administration's
Choose Respect Initiative, to end the epidemic of domestic violence
and sexual assault in Alaska. We appreciate you providing the State of
Alaska the opportunity to review and comment on the United States
Government Accountability Office Report (GAO-12-29): Indian Health
Service - Continued Efforts Needed to Help Strengthen Response to
Domestic Violence and Sexual Assault.
It was a pleasure working with your team as they planned and executed
their travels to Alaska to conduct their investigation and review. We
truly appreciate their willingness to travel to the rural and remote
regions of our state. This provided them the opportunity to see first-
hand the challenges we often face in providing vital services for
victims.
After review of the report, we generally concur with the conclusions and
recommendations for executive action. However, there are a few
significant issues that warrant specific comments.
The first issue is that the sexual assault policy applies only to
Indian Health Service (IHS) operated hospitals, not tribally operated
hospitals. As you know, the seven regional hospitals in Alaska and 165
village clinics are not IHS operated hospitals. These hospitals are
operated tribally through self-determination contracts or self-
governance compacts. This means that IHS policies and procedures do
not apply to Alaska. It is our understanding from this document that
the policies and procedures may be used as models to base protocols.
We may need to rely on the Secretary of Health and Human Services to
"facilitate the efforts of tribes to plan, conduct and administer
programs, functions, services and activities." Furthermore, if needed,
Alaska may decide to call upon IHS for technical assistance in these
matters.
The second issue is quite simple and obvious. Alaska does not have the
same jurisdictional issues as the Lower 48, and thus the issues with
prosecution differ greatly in Alaska. Consequently, much of the first
part of this document and the descriptors simply do not apply to
Alaska.
The third issue of note is the issue of "certification of providers."
The State of Alaska currently does not have a requirement for
certification. While we feel strongly that a trained provider is often
the best person to conduct the exam (for the reasons outlined in the
report), and the use of trained providers is nationally considered to
be "best practice," we are concerned that this part of the policy
could be potentially limiting to Alaska. This is an issue that we have
been discussing at great length during our ongoing statewide meetings
on SART sustainability.
Lastly, we strongly agree with your recommendation to develop
additional policies specific to child sexual abuse. We have provided
your staff some information to help support the need for this within
Alaska.
We know that we cannot end this epidemic alone and welcome
partnerships, coordination, and collaboration in our efforts on behalf
of victims. Again, thank you for the opportunity to provide written
comments.
Sincerely,
Signed by:
Joseph A. Masters:
Commissioner:
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov:
Staff Acknowledgments:
In addition to the individual contact named above, Jeffery D. Malcolm
(Assistant Director), Ellen W. Chu, Katherine Killebrew, Ruben Montes
de Oca, Kim Raheb, Kelly Rubin, Jeanette M. Soares, Kyle Stetler,
Shana B. Wallace, and Tama R. Weinberg made key contributions to this
report.
[End of section]
Footnotes:
[1] Department of Justice, Bureau of Justice Statistics, A BJS
Statistical Profile, 1992-2002: American Indians and Crime, NCJ 203097
(Washington, D.C.: 2004), and Department of Justice, Office of Justice
Programs, Full Report of the Prevalence, Incidence, and Consequences
of Violence Against Women, NCJ 183781 (Washington, D.C.: 2000).
Justice uses the term Indian in these studies to refer to persons who
self-identify as American Indian or Alaska Native and does not limit
the term to those enrolled in state-or federally recognized tribes.
[2] Department of Justice, Office of Justice Programs, Extent, Nature,
and Consequences of Intimate Partner Violence, NCJ 181867 (Washington,
D.C.: 2000). Justice uses the term Indian in this study to refer to
persons who self-identify as American Indian or Alaska Native and does
not limit the term to those enrolled in state-or federally recognized
tribes.
[3] For the remainder of this report, unless noted otherwise, the term
Indian refers to the American Indian and Alaska Native beneficiaries
of the Indian Health Service.
[4] In this report, when referring to entities that operate hospitals,
the terms tribe and tribal refer both to federally recognized tribes
and to tribal organizations, such as Alaska Native health corporations
operating hospitals in Alaska.
[5] In this report, the terms sexual assault and domestic violence
include cases involving both adult and child victims.
[6] In addition, nonemergency health care facilities, such as
community clinics or mobile health clinics, may also provide sexual
assault medical forensic exams. Our review focused on hospitals
because, according to IHS officials, hospitals are the most likely
type of IHS facility to have the necessary infrastructure and
expertise to perform these exams.
[7] Amnesty International USA, Maze of Injustice: The Failure to
Protect Indigenous Women from Sexual Violence in the USA (New York:
2007).
[8] The term Indian country refers to all land within the limits of
any Indian reservation under the jurisdiction of the U.S. government;
all dependent Indian communities within U.S. borders; and all existing
Indian allotments, including any rights-of-way running through an
allotment. See 18 U.S.C. § 1151.
[9] Department of Justice, Office on Violence Against Women, A
National Protocol for Sexual Assault Medical Forensic Examinations:
Adults/Adolescents, NCJ 206554 (Washington, D.C.: 2004).
[10] Tribal Law and Order Act of 2010, Pub. L. No. 111-211, Title II,
§ 266, 124 Stat. 2258, 2262 (2010). The act requires that we submit a
report describing the results of the study no later than 1 year after
the act's enactment. July 29, 2011, marked the 1-year anniversary of
the law's enactment. We briefed staff from the Committee on Indian
Affairs, U.S. Senate, and the Committee on Natural Resources, House of
Representatives, on July 11 and July 14, 2011, respectively.
[11] We selected these 15 hospitals using a series of criteria that
included geographic location, remoteness, whether the state or federal
government had criminal jurisdiction in Indian country served by the
hospital, and whether the hospital was IHS or tribally operated.
[12] Because we used a nonprobability sample to select IHS and
tribally operated hospitals to interview, the information we gathered
during these semistructured interviews cannot be generalized to all
hospitals and instead represents the perspectives only of the
interviewed hospital providers and stakeholders.
[13] Pub. L. No. 93-638 (1975), codified as amended at 25 U.S.C. §§
450 to 458ddd-2.
[14] Medical providers performing medical forensic exams can be
specially trained and sometimes certified in performing these exams
but may also perform these exams regardless of whether they have
undergone such specialized training or received such certification.
[15] The Forensic Nursing Certification Board, a functionally
autonomous component of the International Association of Forensic
Nurses, develops and administers SANE certification.
[16] These eligibility requirements, for example, include that nurses
(a) complete 40 hours of didactic training in adult and adolescent
sexual assault education (or a parallel training curriculum in
pediatric sexual assault) and (b) work under an expert, such as a SANE-
/certified nurse, and perform enough sexual assault exams to
demonstrate clinical competency to this expert.
[17] For reasons explained elsewhere in this report, in Alaska,
generally only the state has criminal jurisdiction. In addition, the
IHS Cass Lake hospital in Minnesota is located in Indian country
subject to state criminal jurisdiction.
[18] In July 2011, Justice sent a letter to the President of the
Senate and the Speaker of the House of Representatives to consider a
proposal to, among other things, extend tribal criminal jurisdiction
to non-/Indians who commit domestic violence or dating violence in
Indian country.
[19] GAO, U.S. Department of Justice Declinations of Indian Country
Criminal Matters, [hyperlink, http://www.gao.gov/products/GAO-11-167R]
(Washington, D.C.: Dec. 13, 2010). The U.S. Attorneys' Offices call
all criminal investigations referred to them by law enforcement
matters.
[20] GAO, Indian Country Criminal Justice: Departments of the Interior
and Justice Should Strengthen Coordination to Support Tribal Courts,
[hyperlink, http://www.gao.gov/products/GAO-11-252] (Washington, D.C.:
Feb. 14, 2011).
[21] Act of August 15, 1953 (known as Public Law 280), 67 Stat. 588
codified as amended at 18 U.S.C. § 1162 and scattered sections of
Title 25. Public Law 280 was amended to authorize states to assume
criminal jurisdiction over Indian country with tribal consent; states
that did so are known as optional Public Law 280 states. Other
statutes, such as the Maine Indian Claims Settlement Act, grant states
criminal jurisdiction over Indian country or particular tribes or
reservations concurrently with the federal government or, in some
cases, exclusively. See, e.g., Pub. L. No. 96-240 (1980), codified as
amended at 25 U.S.C. § 1725.
[22] The six mandatory Public Law 280 states are Alaska (except the
Metlakatla Reservation), California, Minnesota (except the Red Lake
Reservation), Nebraska, Oregon (except the Warm Springs Reservation),
and Wisconsin. Of these six states, only Alaska and Minnesota have IHS
hospitals.
[23] Pub. L. No. 111-211, § 221 (2010), codified at 25 U.S.C. §
1132(a)(2); 18 U.S.C. § 1162(d). On May 23, 2011, Justice issued a
proposed rule that would establish procedures for an Indian tribe
whose Indian country is subject to state criminal jurisdiction under
Public Law 280 to request that the United States accept concurrent
criminal jurisdiction within the tribe's Indian country and for the
Attorney General to approve such a request. 76 Fed. Reg. 29675 (May
23, 2011).
[24] Pub. L. No. 92-203, 85 Stat. 688 (1971), codified as amended at
43 U.S.C. §§ 1601-1629h; Alaska v. Native Village of Venetie Tribal
Govt., 522 U.S. 520 (1998).
[25] In Anchorage and Juneau, the municipal prosecutor's office
handles misdemeanor domestic violence cases.
[26] Federal Bureau of Investigation, Uniform Crime Reports, Crime in
the United States, 2009, accessed August 22, 2011, [hyperlink,
http://www.fbi.gov/about-us/cjis/ucr/ucr].
[27] Department of Justice, Bureau of Justice Statistics, National
Crime Victimization Survey: Criminal Victimization, 2010, NCJ 235508
(Washington, D.C.: 2011). Justice uses the term Indian in this study
to refer to persons who self-identify as American Indian or Alaska
Native and does not limit the term to those enrolled in state-or
federally recognized tribes.
[28] [hyperlink, http://www.gao.gov/products/GAO-11-252].
[29] Department of Justice, Extent, Nature, and Consequences of
Intimate Partner Violence, and A BJS Statistical Profile, 1992-2002.
As already noted, Justice uses the term Indian in these studies to
refer to persons who self-identify as American Indian or Alaska Native
and does not limit the term to those enrolled in state-or federally
recognized tribes.
[30] Federal Bureau of Investigation, Uniform Crime Reports, Crime in
the United States, 2009.
[31] André B. Rosay et al., "2010 Alaska Victimization Survey"
(presentation at the University of Alaska, Anchorage, September 2010).
[32] Some hospitals may track the number of medical forensic exams
their staff perform, but such information may be collected by
different hospitals using different methodologies and was not
aggregated into IHS's centralized data systems.
[33] This information showed that from fiscal year 2006 through fiscal
year 2010, IHS and tribally operated hospitals recorded 2,882 visits
for services related to adult sexual assault and 3,983 visits for
services related to adult domestic violence. For children, during the
same time period, 592 visits took place for services related to child
sexual abuse and 421 visits for services related to child physical
abuse. We do not know how many of these visits led to medical forensic
exams, nor do we know how many other visits were not included in these
data because they were initially given a primary purpose-of-visit code
other than sexual assault or domestic violence: For example, a victim
initially might have come in with a broken arm and only later be
identified as having been involved in a sexual assault or domestic
violence incident. These counts do not include any visits to Sage
Memorial Hospital or Norton Sound Regional Hospital because we were
unable to assess the reliability of data from these two hospitals.
[34] Remote areas are those with dispersed and small populations and
where travel times are longer because of limitations in transportation
infrastructure.
[35] Sexual assault response teams often include, among others, SANEs
or sexual assault forensic examiners, representatives from relevant
law enforcement, and a victims' advocate. Multidisciplinary teams
often include these groups as well as a representative from the
federal prosecutor's office.
[36] Indian Health Care Improvement Reauthorization and Extension Act
of 2009, Pub. L. No. 111-148, Title X, § 10221(a) (2010); throughout
this report, we refer to this law as the Indian Health Care
Improvement Act. Tribal Law and Order Act of 2010, Pub. L. No. 111-
211, § 265 (2010).
[37] The flight from Kotzebue to Anchorage may have a layover in Nome.
[38] Community health aides are trained in basic emergency and primary
health care through a statewide training program in Alaska. They are
typically selected from village residents and practice under
supervision by licensed physicians.
[39] Indian Health Care Improvement Reauthorization and Extension Act
of 2009, Pub. L. No. 111-148, Title X, § 10221(a) (2010). The agency
has drafted the required report to Congress, according to an IHS
official, but it is currently under review and is thus not available.
[40] According to IHS officials, community health aides are generally
not eligible to perform medical forensic exams under the March 2011
policy because they typically are not registered nurses, physicians,
or physician assistants.
[41] Sections 3.29.1.E.20 and 24 of the March 2011 policy define
sexual assault nurse and forensic examiners, section 3.29.5.A
delineates requirements for training and determining competency to
perform medical forensic exams, and section 3.29.5.B describes how
staff obtain privileges to perform such exams at IHS hospitals.
[42] IHS generally defines an adolescent as an individual who has
entered puberty but is below the age of full maturity (18 years of
age), according to this policy, and it defines a child as an
individual who has not yet reached adolescence.
[43] Indian Health Care Improvement Reauthorization and Extension Act
of 2009, Pub. L. No. 111-148, Title X, § 10221(a) (2010).
[44] IHS officials told us they plan to develop additional guidance
related to domestic violence, but details were not available during
our review about the scope and specificity of this planned guidance.
[45] Tribal Law and Order Act of 2010, Pub. L. No. 111-211, § 265
(2010).
[46] IHS officials also acknowledged that its policies, including the
sexual assault policy, apply to all IHS employees even if they work at
a tribally operated facility.
[47] 25 U.S.C. § 450a.
[48] GAO, Internal Control Management and Evaluation Tool, [hyperlink,
http://www.gao.gov/products/GAO-01-1008G] (Washington, D.C.: Aug. 6,
2001). This guide is based on GAO's Standards for Internal Control in
the Federal Government [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1], November 1999. As
programs change and agencies strive to improve operational processes
and implement new technological developments, management must
continually assess and evaluate its internal, or management, control
to assure that the control activities being used are effective and
updated when necessary. This tool is not required to be used but is
intended to help agencies determine how well their internal control is
designed and functioning and to help determine what, where, and how
improvements, when needed, may be implemented.
[49] One of the five standards for internal control is control
environment, which states that management and employees should
establish and maintain an environment throughout the organization that
sets a positive and supportive attitude toward internal control and
conscientious management.
[50] Department of Health and Human Services, Indian Health Service,
Strategic Plan 2006-2011 (Washington, D.C.: 2006), 40.
[51] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[52] Our guide for maintaining or implementing these standards states
that agencies should consider, among other factors, whether pertinent
information is distributed to the right people in sufficient detail,
in the right form, and at the appropriate time. [hyperlink,
http://www.gao.gov/products/GAO-01-1008G].
[53] Two hospitals--Sage Memorial Hospital in Ganado, Arizona, and
Norton Sound Regional Hospital in Nome, Alaska--do not use IHS's
comprehensive health information system, called the Resource Patient
Management Information System, but a different electronic health
records system. We were therefore unable to assess the reliability of
their data or to use their data in any analysis.
[54] These codes are based on concepts used by the Office of
Management and Budget to define county-level metropolitan and
micropolitan areas. The Department of Agriculture's Economic Research
Service applied similar criteria to measures of population density,
urbanization, and daily commuting to identify urban cores and adjacent
territory economically integrated with those cores.
[End of section]
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