Summary of Research Questions Identified Through the 

Sexual Assault Medical Forensic Examination Research Forum

March 28–29, 2012

Washington, D.C.

This forum, sponsored by the Office for Victims of Crime (OVC) and the National Institute of 

Justice (NIJ), explored gaps in the existing research related to the technical aspects of sexual 

assault medical forensic examination (SAMFE). The goal was to identify what research is 

needed to bring a stronger evidence base to the SAMFE. The forum focused on the following 

topics: 

 Types of evidence gathered;

 Examination technology;

 Standardizing the evidence kit;

 Evolving DNA technology; and 

 Potential use and logistics of telemedicine during the examination.

Forum discussion was limited to adult/adolescent examinations, not pediatric, and the research 

issues applicable at the national level. The forum builds upon a congressional requirement 

pursuant to the Violence Against Women Act of 2000 (VAWA) that mandated the Attorney 

General to develop national standards related to the SAMFE. This mandate led the U.S. 

Department of Justice (DOJ) to develop the National Protocol for Sexual Assault Medical 

Forensic Examinations (Adults/Adolescents) and the National Training Standards for Sexual 

Assault Medical Forensic Examiners, and to offer technical assistance resources to encourage 

jurisdictions to implement a standardized approach to the SAMFE process. It has since become 

evident that evidence-based SAMFE practices are essential to support standardization across 

jurisdictions and ultimately to increase the effectiveness of the examination process in 

facilitating victim healing and case investigation and prosecution. Due to a number of factors—

such as variations in circumstances of individual sexual assault cases, the multifaceted nature of 

the SAMFE process and potential involvement of practitioners from multiple disciplines and 

jurisdictions, and differences in SAMFE protocol implementation across jurisdictions—there has 

been great debate regarding the merits, problems, and gaps associated with each detail of the 

process. OVC and NIJ sought feedback during this forum on what specific research is critical to 

inform debate regarding best practices for the above topics.

Forum participants included sexual assault forensic examiners (SAFE), victim advocates, law 

enforcement officers, prosecutors, forensic laboratory personnel, researchers, federal agency 

personnel, and one identified sexual assault survivor.1 Participants were asked to identify 

SAMFE technical practice concerns and challenges, research gaps and unique issues, and, 

subsequently, relevant research questions. Practitioners and survivors were asked to use their 

experiences to give context to issues. Researchers were asked to share information from

applicable studies and help translate identified knowledge gaps into research questions. Several 

participants were asked in advance to make a brief presentation on one or more of the above 

 1 One participant, who was a victim advocate by profession, was identified by meeting planners as a survivor and 

asked specifically to speak from that perspective during the forum. Other participants also spoke from the 

victim/victim advocate perspective during the meeting.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

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topics—what are the current practices, what research is guiding those practice decisions, and 

what else we need to know about the practices—to lead the group into focused discussions.

This diverse group of participants was highly supportive of the translational criminology 

approach to research. Translational criminology is a strategy for transforming criminal justice 

through research. By bringing evidence to bear on crime policies and practices, researchers can 

form a bridge between the work of research and the real-life challenges of fighting crime and 

enhancing justice. Transformation through research is a cyclical process. Continually, NIJ draws 

on the needs of practitioners to inform its research agenda; the cycle of transformation continues 

as research findings are conveyed and translated by researchers in ways that reshape practice and 

policy.

FRAMING THE RESEARCH NEEDS

Collect baseline data. Participants were in consensus that SAMFE technical practices vary a 

great deal across jurisdictions, with the extent and nature of the variations widely unknown.2

There is a critical need for baseline data to learn more about the variations. For example—

• What evidence is being collected and how during the SAMFE? For which practices is there 

standardization? Where are there variations? What are the reasons for the variations?

• What is guiding the evidence collection—are protocols lab-based or driven by the medical 

community?

• What is the decisionmaking process regarding what evidence is collected, what collection 

techniques and technology are used, and how the evidence is preserved and stored? To what 

extent is research driving practice? What other factors are influencing choice of practices?

Only with a solid foundation of basic information can researchers, in conjunction with 

practitioners and survivors, consider the priorities among the many research questions identified 

during the forum. Also, researchers need to have standardized, discipline-specific, and 

coordinated practices to evaluate in order to make a determination of a practice’s effectiveness. 

For example, researchers cannot use samples from different localities to evaluate the 

effectiveness of clothing evidence if examiners in those localities are following different 

protocols for collecting, preserving, or testing that evidence.

There was some discussion on the logistics of baseline data collection, data systems that may 

offer such information, whom to survey, and the logistics of surveying. The best source of

information will depend on the specific questions being asked and who is best positioned to 

provide the answers—practitioners from individual disciplines, multiple disciplines, and/or 

across disciplines, as well as from survivors. 

• Consider what infrastructures are needed to collect and organize data on sexual assault 

cases across disciplines. Failure to manage data on a case within and across systems can 

 2 Another question: Why is there variation in a practice if there is existing national-level guidance? In some 

instances, national-level recommendations related to a practice exist, but are not universally implemented (e.g., 

guidance on evidence preservation offered by the Society of Forensic Toxicologists [SOFT]). In other instances, 

recommendations may not be as detailed as needed or may present numerous options for carrying out a particular 

practice, because there is a lack of consensus or evidence regarding best practice or the options are equally effective. 
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

3

mean losing the case (e.g., the FBI not knowing what the CIA is doing). We need to figure 

out what data can be shared, how to share it, and “connect the dots” provided by the data.

What data systems already exist that can be tapped into?3 What data are most critical to 

track? Is there one infrastructure that is best or are different infrastructures better for 

different types of data? It was noted that identifiers to link the information are needed—for 

example, using one number to track a case across systems (now a case usually has different 

numbers in each system).4

• Poll practitioners across disciplines and jurisdictions (tribal, local, state, and federal).

Broad-based surveys and analyses of survey findings might help in identifying what research 

is most critical. Among other things, it may highlight practice usefulness as well as gaps 

(e.g., examiners are pulling pubic hair, but it is typically not analyzed by the lab or used by 

prosecution). There was discussion around surveying national-level member organizations.

For example, the National District Attorneys Association (NDAA) and the Native American 

Issues Subcommittee of the Attorney General’s Advisory Committee (composed of U.S.

Attorneys with Indian Country responsibility) might be willing to poll their members

regarding what evidence they are using in prosecution of sexual assault cases, what kinds of 

evidence are most useful to prosecution, and what evidence collected they tend not to use.

National law enforcement associations might be able to poll law investigators as to what is 

important to them as evidence in these cases and assess whether it is the same as what is 

important to prosecutors.

• Consider victim and criminal justice impact. A common theme throughout the meeting 

was the awareness that the SAMFE impacts the victim and may have implications for case 

processing and legal outcomes. Some research has been conducted to better understand how 

SAMFE affects victim health and well-being, and studies have begun to examine the link 

between SAMFE and prosecutorial outcomes; however, these issues require much more 

study. For example—

• What is the impact of the variations on victim health and well-being?

• What is the impact of the variations on legal outcomes?

• What is the impact of the SAMFE on prosecution and conviction rates?

• Encourage systems analysis. Forum participants talked about the need for program 

evaluation to describe best practices and for process evaluation to standardize care and 

exchange of information across disciplines and jurisdictions. These evaluations can look at 

 3 In review of an early draft of this report, a participant suggested looking at 

www.hrsa.gov/publichealth/guidelines/designqualityimprove.ppt from the Bureau of Primary Health Care, U.S. 

Health Resource and Services Administration, to create a template for a quality improvement (QI) process for the 

SAMFE/SART. Such a QI plan could potentially be a foundation for a national SAMFE/SART Center for Research, 

with a consortium of multidisciplinary, multijurisdictional teams of national experts to continue to define problems 

and research solutions.

4 Thoughts from participants on where to start to explore these questions: Look at military data systems that track 

these cases across military agencies. Look at crime labs in West Virginia, Minnesota, and Massachusetts for possible 

best practices around tracking data on timing of assault, when exam was done, what was collected and analyzed, 

findings, and what is used in court. Consider how to utilize chain of custody information from the criminal justice 

system. Consider if the exam process within a state works better when there is a state VAWA coordinator. Are there 

more examiners, more training, and clearer communications between crime labs and examiners?
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

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what is being collected, how it is being used, outcomes, who is “driving the train” in each 

community related to evidence decisions, and if the outcomes are different because of the 

driver. It is important that the data are analyzed from a sexual assault response team (SART) 

perspective, in addition to discipline-specific perspectives. For example—

• What is the stream of specific research questions related to the critical elements of the exam 

process? Role analysis (victim advocacy, forensic examiner, crime lab, law enforcement, 

prosecution, SART, etc.) that pinpoints the complexities of the process might be useful, as 

would different contextual factors, varying victim reactions and comfort levels, time factors, 

paths of evidence, etc. Similarly, what are the data points we need to know related to this 

process that inform victim decisions and influence responder actions?

• What feedback loops exist among SART members to inform and strengthen their coordination 

and capacity to improve response? What is the nature of the communication? What 

additional communication is needed?

• When crime lab personnel are on a SART and active in the feedback loop with examiners, 

how does it affect data collection? Forensic scientists in California are involved in the statelevel SART, and their presence is critical to facilitating feedback between examiners and 

labs. Any suggestions for how to promote lab involvement in SARTs? A way to involve 

forensic scientists is in examiner training, which is a common practice.

• Is it enough to have consensus across disciplines to end a practice (collection of pubic hair, 

evaluation for motile sperm, etc.)? Participants seemed to concur that research is needed to 

learn more about the practice first. For each debatable practice, which disciplines need to 

come to consensus about its usefulness? If the field is suggesting a change, is there consensus 

an alternative practice would be useful? What evidence supports that practice?

Incorporate issues of victim-centered care. Participants repeatedly indicated that 

understanding the factors associated with victim access to a SAMFE, as well as victim readiness 

to participate in a SAMFE, should help frame research on evidence collected and techniques 

used to collect and analyze evidence. Several questions were raised regarding victim access:

• Are sexual assault victims made aware of their legal rights as victims of crime? What have 

they been told about a SAMFE/how to access one? Who provides this information to victims?

• What is the impact of victims’ background (if they were drinking before the assault, have a 

prior arrest record, worked in the sex trade, are drug users, etc.) on whether they have a 

SAMFE offered and conducted and on case progression in the criminal justice system?

• What is the impact of victims’ race, ethnicity, sexual preferences, etc., on their access to a 

SAMFE and case outcomes? What role might community or institutional bias play?

Does/how can training for responders help minimize this type of bias?

• Does where the exam takes place (e.g., in a hospital versus community agency versus 

another setting) impact victim access to a SAMFE? What about victim care and criminal 

justice outcomes?

The following is a key question addressing victim readiness to participate: What are the 

processes and interactions between the patient and the examiner that make a SAMFE effective?5

 5 The term “patient” is often used in this document when referring to the victim interacting with examiners and other 

medical providers during the SAMFE.
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This question is based on a belief that patients, not evidence collection kits, should drive the 

exam process. Related questions included—

• How can examiners help patients be comfortable, and tolerate the exam, so they feel they can 

share their history, receive relevant health care, and allow evidence collection? How does 

getting such help impact patients—do they feel less traumatized from the exam, report more

often? Are they more involved in the criminal justice process?

• What is the impact of language used and styles of approaching patients? How does receiving

culturally and linguistically appropriate care by race/ethnicity, gender, age, health literacy, 

etc., impact patient satisfaction with the exam process?

• How do examiners approach informed consent with patients? Who delivers/how is it 

delivered in culturally diverse settings, and what is the impact of whom/how it is delivered?

What do patients need to be asked and told by examiners to be given full choice in making 

decisions during the SAMFE? If examiners had information about the outcomes of medical 

care and evidence collection (e.g., what samples are producing evidence), then patients could 

likely make more informed decisions. Participants noted that when seeking informed consent 

during the exam, examiners are challenged to collect only what is relevant to a case (as it 

determines what the lab will analyze), but are aware that in most cases, there is only one 

opportunity to collect forensic evidence.

• How does the examiner best explain the scope of confidentiality of communications between 

patients and examiners? Participants recognized that confidentiality and privacy can be 

difficult to maintain in rural and close knit communities.

Consider use of proxy victim populations for clinical research, to the extent possible, to get at 

some of the critical research questions related to victim-centered care, techniques for evidence 

collection, etc. This refers to the use of non-victim populations to test some of the specific 

medical and forensic methods used in the exam. For example, one current NIJ- funded study is

collecting swabs after consensual intercourse to look at post-coital DNA recovery using a proxy 

population.

Study the cost effectiveness of practices. Participants pointed out that cost feasibility is a factor 

that should be weighed with other factors when evaluating practices. Whether a practice is cost 

effective given jurisdictional resources and practice outcomes is important to consider. A SART 

perspective can give the fuller picture of costs and benefits of a practice.

Continue to assess what research already exists on best practices in medicine and forensic 

science related to the SAMFE and whether information on those practices is being

disseminated to the field and utilized.

6 Some of that research was discussed during the forum 

as well as in the literature reviews prepared for the forum. Participants thought it might be useful 

to poll practitioners to find out more specifics on why a best practice might not be implemented 

and to get suggestions on moving forward with implementation. One of the challenges might be 

that while medical sciences are using advanced technology and forensic sciences, the criminal 

justice system is not necessarily able to keep up with advances in the medical field. National-

 6 In her review of an early draft of this report, Patricia Speck suggested that this task could represent a second tier of 

information gathering and research, after collection of more basic data.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

6

level member organizations may be willing to help promote implementation of best practices in 

their respective fields.

Encourage standardization of terms used in research. Participants stressed that standardized 

terminology is critical so that those who conduct and use the research have a shared and accurate 

understanding of what was studied and relevant issues, findings, and implications.

TOPIC 1: TYPES OF EVIDENCE GATHERED

The broad research questions posed to forum participants relative to this topic were: What is the 

impact of having specific types of evidence gathered on victims, the investigation, and likelihood 

of prosecution and conviction? How are exam findings used during the criminal justice process?

Norm Gahn, with the Milwaukee District Attorney’s Office, first presented a prosecutorial 

perspective on this topic. He and the participants raised the following questions (several of which 

are addressed again later in this report):

• For examiners, what factors go into making decisions about collecting evidence? What 

samples are routinely collected? What is collected based on what victims tell or don’t tell 

examiners during the oral medical forensic history? What impact does the evidence 

collection kit have on what is collected?

• What guidelines can help ensure examiner consistency in taking the oral history from 

patients as the first step in determining what evidence to gather? Guidelines are important, 

both generally and also in cases of alcohol- or drug-facilitated sexual assault, when the 

victim is incapacitated and may not be able to consent to the exam or evidence collection, or 

if the oral history is fragmented. How should examiners proceed when they do not have an 

oral history from the patient to guide the evidence collection process?

• What is the extent of feedback between examiners and crime labs on evidence collected and 

what to collect and how to collect it? How could increased communication contribute to 

increased quality of evidence collection and its usefulness in a case?

• What is a crime lab’s protocol for testing evidence in sexual assault cases? Why? For 

example, a lab may go straight to DNA testing rather than focus on identifying the biological 

substance.

• What is the relationship between prosecutors and crime labs? A suggestion was made to 

track the history of interactions on cases between the lab and prosecution.

• How often does the prosecutor ask the crime lab for additional testing? And why?

• What is the linkage between DNA and the assault?7 How much of an impact do DNA and 

other forensic evidence have on the prosecution in cases of nonstranger sexual assault? How 

often does DNA evidence help establish an element of the crime? For example, does it 

establish a sequence of events, corroborate statements of the victim, and/or verify or impeach 

a statement?

 7 Norm Gahn stressed that prosecutors need to first believe the victim’s account and then seek scientific evidence to 

back up that account. He stressed that DNA and other forensic evidence, where available, can be useful to build a 

case, in part because juries expect it (see next bullet).
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

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• How do juries receive and react to forensic evidence? What is compelling? What is not?

What is confusing? What might cloud the victim narrative and what supports it? How much 

does chain of custody of evidence/scientific evidence matter to jurors in consent cases?

• Are injuries the most compelling evidence for law enforcement, for prosecution, for juries, 

and for victim? Several participants noted that injuries are compelling; however, there is not 

a hierarchy of what is the most important evidence in every case. In particular, prosecutors 

need further research and case law to establish the relevance of ano-genital microtrauma/injuries in consent cases.

SPECIFIC TYPES OF EVIDENCE

Linda Ledray and Patricia Speck presented on this topic, looking at cervico-vaginal swabs and 

vulvar swabs; oral, anal, and skin swabs; debris; pubic hair; and toxicological samples in 

alcohol- and drug-facilitated sexual assault cases. With all types of evidence gathered during the 

SAMFE, there is a need for summative and formative program and process evaluation. Several 

participants indicated that examiner practices related to evidence collection were driven 

primarily by state crime labs via the sexual assault evidence collection kit. There were general 

questions that appeared to be applicable for each type of evidence: 

• What specific evidence is requested by the crime labs? 

• What is specifically recommended for inclusion in the evidence collection kit?

• How long post-assault can the sample be collected and positive results be obtained when 

analyzed by the crime lab?

• What is the decisionmaking process behind determining if a sample should be routinely 

collected or collected only if indicated (e.g., by the patient’s oral history and/or presence of 

injuries)?

• What do examiners need to ask/tell patients to seek informed consent to collect a sample? 

• Where specifically are samples taken from, how are they collected, and how much of a 

sample/how many samples are collected? Why?

• Which evidence collection techniques are the most patient-centered?

• What collection methods help avoid contamination?

• What can the attending medical providers and examiners do to preserve the evidence when 

life-saving actions for acute injuries must be taken?

• What collection sites and methods produce probative evidence? The most? The least?

• Is there a type of swab that is most effective in collecting samples (e.g., foam or cotton, 

plastic caps or boxes, paper or plastic tips)? Do samples have to be dried? 

• What is the most effective storage practice?

• When and why is the sample sent to the lab for testing? How is the sample analyzed?

• What is the impact of collection of the sample and method of collection on legal outcomes?

Some questions related to specific types of evidence:

• Oral samples. Can chewing gum better collect oral specimens than swabs?
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• Anal samples. Several participants indicated that patients are often reluctant to talk about 

anal sexual activity, so there was a question of whether it should be collected routinely, or 

just as dictated by the oral history, or if there is injury in the ano-rectal area. It was noted that 

if the claim is anal intercourse, then an anal swab is needed as it would be probative evidence 

and corroborative. If the patient can’t recall what happened at all or the details of an assault

(e.g., due to it being alcohol- or drug-facilitated), there might be reason to collect anal 

samples. Should anal samples be collected both from the anus and rectum?

• Skin samples. Is a double swab technique (one moistened swab to loosen the cells, followed 

by a dry swab to collect the loosened cells) most effective for DNA analysis of a skin 

sample/touch evidence? Compared to using multiple swabs to the area? Compared to a 

stubbing method (tape-lifting)? What are crime labs requesting? What are examiners 

collecting? Are these samples analyzed differently?

• Debris. Participants appeared to agree that the oral history should guide debris collection (as 

well as all other aspects of the exam). What constitutes debris? What materials will yield 

debris? What do examiners and law enforcement know about identifying/preserving debris 

evidence? If there are different methods for collecting different specimens, which produce 

probative evidence (fingernail swabbing, scraping, clipping, and/or cutting; hair taping, 

pulling, combing, cutting, and/or tweezing; grab marks, etc.)? What are the most victimcentered approaches? What is the impact of these different collection methods on 

prosecution outcomes and on victims?

• Pubic Hair. Questions focused on determining whether the collection of pubic hair, 

particularly pulled versus cut samples, has value in producing probative evidence and on 

investigative/prosecutorial outcomes. Some state crime labs no longer require pulled pubic 

hair. How often is pubic hair analyzed by crime labs and then used in case investigation or 

prosecution? Are the outcomes to the case of pulling and/or cutting pubic hair worth the 

pain/discomfort it may cause victims? Even if research would indicate that pubic hair 

samples generally do not impact legal outcomes, are there circumstances in which it would 

be appropriate to collect pulled and/or cut pubic hair? Does it depend completely on the 

patient’s oral history? If not, what are other factors to consider?

Toxicological Evidence in Alcohol-/Drug-Facilitated Sexual Assault (A/DFSA). Participants 

estimated that alcohol and/or drugs are factors in at least 50 percent of sexual assault cases. What 

are the criteria for medical forensic care in these cases? Do jurisdictions have A/DFSA 

guidelines for evidence collection and documentation? What do they encompass? In addition to 

the above general questions applicable to all types of evidence, some questions relate specifically 

to toxicology evidence:

• Are responding law enforcement officers being trained to collect the first available urine if 

the victim cannot wait to go to the bathroom until arrival at the exam site? A suggestion was 

made to look at lab and prosecutorial outcomes in communities where it is law enforcement 

procedure to collect versus those whose procedure is to wait until the victim gets to the exam

site.

• What is the timeframe after an A/DFSA that jurisdictions are collecting urine samples? The 

Society of Forensic Toxicologist (SOFT) currently recommends that urine be collected up to 

120 hours after an A/DFSA. Given the SOFT time frame for collection of urine, there were 

two related questions: What drug/alcohol evidence is being lost in states that are not doing 
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

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evidence collection beyond 72 and 96 hours after an incident? What is the impact of delayed 

reporting on A/DFSA cases?

• Are toxicology samples routinely collected in cases where alcohol was involved in the 

assault? Is a gray top toxicology blood specimen routinely collected? Why? Why not?

• Should examiners encourage victims to submit to toxicology evidence collection always and 

put it in the chain of evidence to analyze later if needed?

• What are best practices in cases where the patient is incapacitated or unconscious due to 

alcohol and/or drugs and not able to provide informed consent to evidence collection? What 

is the appropriate level for informed consent needed to collect evidence in these cases (e.g., is 

waiting until all drugs/alcohol wear off required)? Participants noted that if a patient does not 

have a surrogate, evidence typically cannot be collected until there is a court order or a 

surrogate who can give permission. Some states have statutes that guide evidence collection 

in some of these situations (e.g., in the case of an unconscious patient).

• What are hospital screening levels for toxicology, and when should examiners go beyond that 

screening with patients? For example, when alcohol and/or drugs are involved, medical 

providers may routinely take blood samples from patients to test blood/alcohol content and to 

determine if patients are capable of giving informed consent to an exam. If there is indication 

that drugs were ingested within 24 hours of the exam, they also may take a urine specimen as 

it may show more specifically when the drug was ingested and the effect of the drug on the 

individual.

• Do examiners take toxicology samples for medical purposes separate from ones they take for 

forensic purposes? For example, in California, they do take separate samples when collecting 

for medical and forensic reasons.

• What percentage of forensic results used during an investigation and/or prosecution are 

obtained from hospital labs versus crime labs? How often are forensic decisions based on 

hospital data?

• Are there specific storage issues related to toxicology samples? SOFT suggests refrigeration 

of toxicology samples (within a reasonable amount of time, which means as soon as 

possible).8

• How many jurisdictional crime labs have the capacity to do toxicology analysis? If they have 

a capacity, to what extent? For example, can they test for some drugs but not others?

• What do examiners/law enforcement officers do in jurisdictions where the crime labs do not 

have this capacity? Or only test for certain drugs? How many are using commercial labs and 

how does this logistically work?

• How extensive is the impact of alcohol and/or drugs on case outcomes? What are the specific 

problems with the evidence in those cases that are prejudiced by this evidence?

• How many A/DFSA cases do not proceed in the criminal justice system because the victim 

has a drug problem or withdraws once she/he sees what she/he is up against? What about 

victim populations who do not come forward at all? Participants indicated that studies were 

needed to examine vulnerable populations, the impact of voluntary versus involuntary use of 

alcohol/drugs in these cases, and the impact of the criminal justice response on victims’ lives.

 8 There was a question regarding why SOFT guidelines are not always included as crime and/or commercial lab 

procedures, despite the fact that the United Nations is mirroring SOFT’s guidelines. What needs to happen for 

jurisdictional and commercial labs to implement practices recommended by SOFT?
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

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TOPIC 2: EXAM TECHNOLOGY

During this discussion, several broad questions were explored: What is the effect of the 

application of specific technology and techniques to collect evidence and detect injuries on case 

investigation and prosecution? What is the impact on the level of discomfort and side effects that 

victims experience from a specific technology/technique? Michael Weaver, of St. Luke’s 

Hospital, and Kim Day, of the International Association of Forensic Nurses, presented on this 

topic, focusing on wet mount evaluation for motile sperm, use of an alternative light source, 

anoscopy, use of Toluidine Blue dye, magnification/photography of injuries, and the use of the 

Foley catheter.

SPECIALTY TECHNIQUES/TECHNOLOGY

Wet Mount Evaluation for Motile Sperm

• What are the medical and forensic reasons for doing wet mount evaluation for motile sperm?

• Which medical professionals receive training on this technique? Several participants 

indicated that physicians and advanced nurse practitioners may be trained; this is not a 

component of basic SANE training for registered nurses. Which professionals are conducting 

these evaluations?

• In what percentage of SAMFEs are these evaluations conducted?

• Who decides whether or not this evaluation is needed (e.g., is it a directive from the crime 

lab via the kit versus the individual decision of the examiner)?9

• If conducted for forensic reasons, what are the criminal justice outcomes of this evaluation?

Are the results used in court; are they impactful? It might be helpful to query prosecutors to 

gain consensus on whether it is used and useful. Some questions to ask: Have you ever used 

motile sperm in sexual assault cases? If you do that preliminary test, how often does that go 

to the lab? If the evaluation is positive, then do you collect a kit? And then, how often does 

the kit go to the crime lab? Does the crime lab also test for sperm to move it forward? How 

do results of this test affect the victim? How does it affect prosecution? If you find injury or 

semen, what difference does it make?

• If conducted for medical reasons, what is the impact on the victim’s emotional health?

Several participants concurred that if there was a quick test for presence of seminal content, it 

might make a difference to victims who are uncertain of what happened to them but have 

concerns (e.g., pregnancy or sexually transmitted disease—STI). Would the test results help 

them decide whether to have the exam, seek prophylactic treatment, and/or report?

Alternative Light Source (ALS)

• What can be identified using ALS (e.g., semen stains and early bruising)? In the case of an 

injury, how soon after the incident/presence of the injury can it be identified as such, and 

what are the health outcomes for the victim? Is there a need for multiple and matching 

images along the way—routinely or on a case-by-case basis?

 9 There was a trial program used in Arizona that taught SANEs to do a presumptive test for sperm and fast track the 

most probative pieces of evidence to the crime lab to get results more quickly (initially to link serial cases right 

away with DNA). It would be useful to get more specifics on this study.
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11

• More generally, how are examiners and other responders asking victims about injury? Do 

examiners always ask SAMFE patients about strangulation? Several participants noted that 

response to strangulation is evolving in medicine and hospital emergency department 

management as to when and what to evaluate, which patients are at greatest risk, etc.

Forensic documentation on strangulation should be informed by medical advances.

Anoscopy

• Are examiners trained to use the anoscope? What training do they receive?

• To what extent is the use of anoscopy necessary in a case? What is the impact of sample 

collection and injury identification/documentation using the anoscope on the patient and 

investigative/prosecutorial outcomes? What are the benefits/costs of collecting an anal 

sample using a swab versus gaining an anal sample via the anoscopy?

• What are the issues around contamination of anal samples? Will the examiner be able to get 

a “pure” sample when using the anoscope, as opposed to when using an anal swab? Several 

participants noted this was a training issue.

• Why subject patients to anoscopy for evidence collection if it is over 120 hours post-assault?

Several participants noted that evidence in this area is typically not available after this time.

• What techniques are used for injury identification in the ano-rectal area? If examiners see 

injury in the ano-rectal area, how should they proceed without causing further injuries? Do 

examiners receive training to use the anoscope when injuries are involved and not harm 

patients more by stretching the tissue? Several participants mentioned that if examiners were

not qualified to use the anoscope, they would call in either a gastroenterologist or emergency 

department physician who is trained.

Toluidine Dye (TB Dye)

10

• With which patients should examiners use TB dye? Why and where should it be applied? 

Why would an examiner decide not to use it? Not all examiner programs use it. Several 

participants noted that there is disparity in identifying injury with TB dye in lighter versus 

darker skin toned patients. It may not accurately interpret injuries across skin types due to 

lack of contrast.

• What techniques are employed to apply TB dye to identify ano-genital injury? Are examiners 

being trained to properly use TB dye? It was noted there were standards to follow, although 

there may be variations by program. Apply dye with a cotton tip applicator and, after drying 

 10 Concerned that TB dye had a carcinogenic effect, Michael Sheppo, of NIJ, provided participants with a material 

safety data sheet (MSDS) on Toluidine Blue O. In review of an early draft of this report, a participant commented 

that the published carcinogenic effect related to the laboratory stain was based on large quantities injected 

intravenously into mice. The TB dye used by examiners is Toluidine Blue O1 percent, containing 1percent 

Toluidine Blue O in 99 percent aqueous solution. The reviewer could find no data sheet identifying this 1 percent 

solution used by health care providers as a carcinogen; in fact, this dye is used to diagnose oral and genital cancers, 

is washed off within a minute, and on any other MSDS and under several laws that require reporting the 

carcinogenic effects, there is no reported carcinogenic effect. The worst potential side effect is mild burning or 

irritation with vulvar use. The reviewer stated that the key is to be patient focused, tell them the risks, and let them 

decide on whether they will allow its use.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

12

for a few seconds, wipe gently with cotton swab moistened with lubricating jelly. Diffuse 

uptake would be considered negative; to be positive it had to be linear with specific margins.

• Are there times examiners should use colposcope or digital cameras instead of, or in 

addition to, TB dye to identify, document, or measure various facets of images? For example, 

several participants noted that cameras with reverse images may help detection with darker 

skins.

• Is TB dye helpful in cases where the issue is consent? Is it the consensus that the presence of 

micro-trauma is not helpful in determining if force was used because micro-trauma is also 

found after consensual intercourse? Can digital images and written documentation using TB 

dye help inform whether the injury is more likely associated with consent or lack of consent?

How would such information be used by the prosecutor? The defense? Do images using TB 

dye make a difference in court? It was noted that there is some research suggesting that 

micro-trauma should not be discounted: Marilyn Sommers, of the University of 

Pennsylvania’s School of Nursing, conducted research comparing 600 women with 

consensual intercourse with 600 rape victims. Many had micro-trauma after intercourse, but 

there was a difference in the type of injury that might be associated with lack of consent.

• Using TB dye with children and adolescents appears to improve identification and 

documentation of injury/trauma, but what about with adults? Are there different criteria in 

assessing injury with TB dye at different ages? Also, how does injury look different using TB 

dye at different stages of recovery, and what do examiners actually document?

Magnification/Photography. Broad questions included: What equipment is being used to take 

photographs of injuries, what techniques are used, who is taking the photographs,

11 what is their 

level of applicable training, and how are photographs stored and protected? How is photodocumentation of bodily and ano-genital injuries being used from the victim’s health and 

criminal justice standpoints? Participants cited the potential usefulness of photographs to the 

investigation and prosecution, medical care, and examiner quality assurance, peer review, and 

education. Surveying the field for basis data and doing cost-benefit analyses were suggested:

• What are the benefits and costs of the various photo technologies used to detect bodily and 

ano-genital injuries in different populations (children, adolescents, and adults)? What does 

each piece of equipment allow examiners to do that other equipment doesn’t (does it provide 

better magnification, allow a more thorough exam, require less training, etc.)? Several 

participants noted how examiner programs that treat adults and adolescents are moving 

toward using digital cameras, whereas if they see a combination of children and 

adults/adolescents, they often use a colposcope. With examiner programs for children, the 

colposcope appears to be used. Also noted was the use of video capacity with the 

colposcope.12 Several participants noted their concern regarding anecdotal reports of use of 

personal devices such as smartphones to photo-document.

 11 It was noted that examiners should be doing forensic photo documentation of patients in these cases, not law 

enforcement officers.

12 A question posed to examiners during the forum: When you have practice in looking through the colposcope and 

seeing fine injuries, does the time come when you can see these injuries without it? One participant noted that 

research data are suggesting no statistical differences between what examiners can see with the colposcope versus a 

visual exam. It was also noted that SANEs in Canada have made convincing arguments against this technology. 
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

13

• Is the practice of photo documentation worth the technological investment? What are the 

initial costs of equipment, maintenance costs, impact of multiple users, and ongoing 

adjustments needed to customize use for each patient/user? When equipment wears out, do 

examiner programs repair/update it or move on to other equipment? 

• Are patients adequately informed regarding all potential uses of photo documentation and its

possible impact on them?

• How often are ano-genital images used in prosecution (as in most cases there are no

injuries)? Are they only used if they show injury? Are the actual images used or are diagrams 

more effective? Are they shown to the jury? If there are images shown in court, are they 

explained by the examiner? How does displaying these images in court impact the emotional 

health of victims? Does use of photo documentation make a difference to criminal justice 

outcomes? Does the quality of the photographs make a difference? 

• Are the benefits to victims and case outcomes worth the cost of potentially retraumatizing 

patients when taking these photographs, if/when these photographs are displayed in court, or 

if/when these photographs are used for other purposes?

• What could examiners do to make taking photographs more tolerable for the patient if it is 

part of the examination? What equipment, techniques, and procedures are most acceptable?

• What is the comfort level and level of skill among examiners in using the various types of 

technology to photo document? What is the impact on the victim’s health and criminal justice 

outcomes of an experienced versus inexperienced photographer?

• Who has custody and control of these photographs (are they in medical storage, law 

enforcement storage, or lab storage)? Who should control the photographs from a victimcentered perspective? What potential confidentiality breaches are associated with different 

photo documentation equipment? What storage and security procedures are in place for each 

technology to address those potential breaches? (More discussion is needed on this topic to 

speak to the multitude of problems associated with using personal technology.) Several 

participants noted anecdotal reports of exam reports and photographs not being secured.

Ultimately, the field needs standardized procedures for the storage, security, and 

confidentiality of forensic photographs.13

Foley Catheter. Several participants noted that examiners sometimes use the Foley catheter to 

get better images of hymen margins and detect micro-trauma in adolescent girls.

• What is the best technique for using the Foley catheter? What are the related costs and 

benefits?14

• What is the forensic value of the details of potential micro-trauma gained through use of the 

Foley catheter to criminal justice outcomes? Are images and documentation gained using the 

Foley catheter used in prosecution? What are case outcomes? Do the findings help examiners

decide what additional evidence to collect from a patient?

 13 This conversation raised general questions related to how involved agencies within jurisdictions deal with storage, 

security, and confidentiality of medical and forensic records in these cases. Where are records stored, how are they 

protected, who has access to them, and how do they gain access (e.g., through a password available only to them)?

14 It was noted that “fox” 8-inch swabs with glove rayon tips can be used to collect samples in adolescent girls.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

14

• What is the medical value of the images and information gained through use of the Foley 

catheter? What is the impact on patients in terms of level of discomfort or retraumatization?

It is not an uncomfortable procedure.

TOPIC 3: FEASIBILITY OF A NATIONAL STANDARDIZED KIT

Linda Ledray presented on this topic. While several participants indicated that a national 

standardized sexual assault evidence collection kit would be ideal, they stressed that logistically,

it would be extremely difficult to develop and implement. Many states, via their crime labs,

currently have standardized kits for sexual assault forensic evidence collection, but there is great 

variation among them as far as instructions, what is collected, and how it is collected, preserved, 

and stored. Participants stressed that before the field can begin to consider the feasibility of a 

national kit, there needs to be a broad-based epidemiological survey to identify what is currently 

consistent and what varies across kits. Elements to compare include (1) specific types of 

evidence to be collected, (2) time frame to collect specific types of evidence post-assault, (3) 

sequence of specimens collected, (4) techniques used to collect specific types of evidence, and 

(5) paperwork required. These practices also need to be examined in light of whether they are 

supported by research or if more research is needed to identify best practices. Some additional 

questions that participants identified for an initial query included:

• Why are there disparities in kit requirements among crime labs? To what extent do 

examiners follow kit directives? Under what circumstances do they deviate from the 

directives, and why? How are labs updating kits to keep up with medical and forensic 

technology? If they are not updating it, why? What is the cost-benefit analysis of updating

the kit to make use of new technology versus waiting (e.g., until those technologies are 

accepted in local courts)?

• What is the probative value of the evidence? Does the collection method impact its value?

• What is the impact of patients declining collection of a specific type of evidence on case 

investigation and prosecution? Does the kit instruct seeking the patient’s informed consent to 

the entire exam and/or to each piece of evidence to be collected? How could the defense 

potentially use patient declination to the entire exam and/or a particular piece of evidence? 

• What training do judges, prosecutors, law enforcement, examiners, and advocates receive 

related to the kit? Does the crime lab provide the training?

• Are jurisdictional exam protocols in sync with their respective evidence collection kits?

TOPIC 4: EVOLVING DNA TECHNOLOGY

COLLECTION

Patricia Speck presented on this topic. Questions raised included

• What is the impact of the medical forensic history on gathering DNA evidence? Several 

participants mentioned that it can improve documentation of offender characteristics and 

provide direction for evidence collection.

• What training do examiners receive to guide their decision on whether to collect DNA 

evidence?
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

15

• What training do examiners receive regarding methods of DNA collection? From the lab 

perspective, how should examiners collect blood samples for DNA testing specifically? Is 

there evidence to create a consistent method for DNA collection given a type of assault?

• What training and information is disseminated to law enforcement and examiners about the 

scope and limitations of DNA evidence insofar as what it tells us (about infertile or 

vasectomized males, about identity but not consent, etc.)?

• Where and under what circumstances should touch DNA be collected? Who collects touch 

DNA samples will likely vary. For example, one participant noted that if an offender may 

have touched a pen at the crime scene, law enforcement will likely collect it. If it is 

potentially on the victim’s skin, examiners should swab the areas touched. What training do 

examiners, law enforcement, and prosecution receive around touch DNA? (One participant 

noted that his local crime lab has done studies showing some low-level profiles and a few 

single ID profiles from specimens collected as touch DNA, but the chance of getting a profile 

is remote and sometimes works against a case if the profile is so low that the contribution of 

the defendant can not be determined.)

• What is the future of DNA collection in terms of specimens (saliva, urine, blood, etc.), 

methods, and timeframes for collection? What could the impact be on victims, lab processes 

and findings, case outcomes, and costs? What is the economic impact of extending time for 

DNA collection? A cost-benefit analysis might be useful.

Body Fluid vs. DNA

• How do labs decide what samples to test first? Does the medical forensic history affect this 

decision?

• How important is identification of bodily fluid for prosecution purposes? Does screening for 

bodily fluid have to be done? What are the costs, time, and workforce implications for the 

crime lab of going straight to DNA analysis (e.g., Y-STRs)? Several participants noted it 

would save both money and staff time. Even though serology is less costly, going straight to 

DNA analysis saves 30 to 60 days of waiting for serology testing results. What is the 

benefit/cost of going straight to DNA analysis and not doing serology testing on the court

outcomes? It was noted that NIJ-funded research is being done in Detroit and Houston on 

this question. It may be possible to get DNA first and then go back later to do a bodily fluid 

analysis if needed.

• What are labs asking for in their kits regarding DNA and bodily fluids? Why are some labs 

better at finding forensic results?

A further question is: How often is the lack of kit findings that speak to these weak links in a case

a crutch for investigators and prosecutors not to take a case? To get feedback on this question, it 

may be useful to survey law enforcement and prosecutors using vignettes and ask them how they 

would proceed given case circumstances and kit findings. How can training for prosecutors, law 

enforcement, examiners, and advocates make a difference in whether cases with these perceived 

weaknesses go forward? What additional evidence can be collected through the SAMFE to 

corroborate a victim’s account in cases where consent is contested or there was drug-facilitated 

or incapacitated sexual assault?
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

16

Kit Backlogs

• Why are kits left untested? Are some kits left untested because they are cases the criminal 

justice system doesn’t want to pursue (when victims have used alcohol or drugs, work in the 

sex trade, or gave consent is the question)? To what extent does kit evidence matter in nonstranger cases? Offenders often follow a serial pattern, assaulting both strangers and 

acquaintances, thereby potentially linking evidence to both a stranger case and an 

acquaintance case.

• What are reasons for collecting DNA samples in consent cases? For example, if the defense 

is consent, the prosecutor wants the kit analyzed by a lab in order to suggest how careful 

everyone was with the evidence, from the examiner to crime lab. It may not add anything 

initially, but it is important in cases where there are consent issues to be able to say all the 

evidence affirms the victim and lends credibility to the case.

• What is the real impact of DNA on cases? What is the real importance of creating a database 

on offender DNA? Researchers need to better understand the concept of forensic hits and 

usefulness of DNA in consent-only cases. Participants noted an Arizona State University 

study that looked at prosecution and the decisionmaking process in Los Angeles County, 

California. Findings indicated that the lack of good evidence predicted whether the district 

attorney took or dropped a case. On the other hand, the perceived risk-taking behavior of 

victims was associated with the likelihood of the case being dropped. It would be helpful to 

gather similar information about case outcomes in other parts of the country.

DNA PRESERVATION QUESTIONS

Cecilia Doyle presented on this topic. It appears that there were answers to some of the questions

raised at the forum related to DNA preservation—for example, what samples need refrigeration 

and how quickly refrigeration is required—but there is a gap in consistently getting accurate 

information to examiners and law enforcement. What are crime labs across jurisdictions 

instructing examiners and law enforcement to do with regard to preserving evidence? Why are 

labs giving different information? What are the resources in the lab to preserve evidence? A 

broad-based survey of crime labs might be useful to gather baseline data.

• As new devices/techniques are available to collect DNA (e.g., nylon swabs), are they more 

resistant to harsh conditions? What if DNA samples are collected in areas where it may take 

longer to get samples to refrigeration or they are subjected to higher levels of moisture and 

heat? 

• How quickly is refrigeration of urine or blood samples necessary? For example, are 6 hours 

in a locked file at room temperature okay or would these samples need refrigeration sooner?

• Is there research that can help providers who have to make decisions about how to best 

preserve liquid samples? Several participants indicated the answer is yes. For example,

numerous studies of GHB in urine samples indicate the drug breaks down at a fast rate, so it

is important to refrigerate it as soon as possible. Studies of body fluids and DNA have been 

done that show heat and moisture will break down the samples. If they can be cooled, that is 

the best option, but if drying a sample, put it in a cool environment to dry and then send it to 

the lab. One participant noted that limited research suggests that adding a certain type of 

preservative to blood samples might be helpful in preservation.
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17

• Are dried samples still best for DNA evidence and on what type of swab? 

• Is active or passive drying best practice? Active drying should not be done using heat. 

Passive drying is best depending on how wet the item is and how fast it can be moved to the 

next step. Do not introduce a breeze across it for drying. Protect evidence from 

contamination. Air should go through a filter.

• What if patient has vomited on her/his shirt? Do not air dry in open space; instead, air dry 

under paper, under air movement, to protect from people talking, walking by. Put it in a room 

no one is going to be around to protect it from extraneous DNA. Is there a drying closet 

designated for large items?

Information Sharing

• What information/findings are crime labs sharing? Participants indicated that labs can only 

share with their clients, which are law enforcement agencies and prosecutors.15

• What is the process for ensuring the SART, including the crime lab, is collaborative and 

communicating on cases? What do we need to put a feedback loop in place? Who can make 

that happen? It would be useful to learn if there are jurisdictions that have such a feedback 

loop and how it works. One participant noted that in her system, it was the advocate who 

coordinated the feedback loop.

• How can we help communities in tracking kits—where they go (what percentage sit in a 

closet), if they get analyzed, if they yield probative evidence, their impact on the case, etc.?

RETENTION AND STORAGE

• What are the practices across states? The conversation focused broadly on the kit rather than 

just DNA evidence. It appears that there is much variation in practices across states, 

particularly in the length of time the kits are stored in reported and unreported cases and 

where the kits are stored. It would be useful to find out specifically what the practices are and

the rationales for the variations. Two studies were discussed that begin to provide this 

baseline data:

o Janine Zweig, of the Urban Institute, presented data she and her colleagues collected on 

kit storage practices across states as part of an NIJ-funded study of payment practices 

related to the SAMFE. Sexual assault coalitions and state STOP administrators were 

invited to be part of a survey.

o While coalitions and STOP administrators tended to know if kits in reported cases 

were stored (majority were stored), they often did not know how long they were 

stored.

o For those who did know, the timeframes they reported ranged from 1 month to 50 

years, as well as indefinite storage time.

o In the case of unreported cases, about a quarter of coalitions and STOP 

administrators did not know if the state stored the kit. For those who did know,

 15 A related question arose during a review of an early draft of this report: Why does this barrier in information 

sharing exist when many SAFE programs, which send the evidence to the lab, are currently receiving the results to 

add to the medical forensic record?
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

18

the timeframes they reported ranged from 1 month to 30 years, as well as 

indefinite storage time.

o Storage models for non-reporting victims included—

 No law enforcement involvement, with medical facilities performing the 

exam and securely storing the evidence (43 percent);

 Law enforcement storage only, with medical facilities performing the 

exam and transferring the evidence to a local, county, or state law 

enforcement agency (62 percent);

 Anonymous/blind reporting, with information provided to law 

enforcement without identifying information about the victim or 

perpetrator, and if the victim has an exam, law enforcement stores any 

evidence that is provided (36 percent); and

 Other (16 percent).

o There were efforts in California to gather data on what happens in the case of 

anonymous examinations. Questions include: How many exams are done? What 

percentage of those who have anonymous exams later convert to reporting? What 

is the time frame between the sexual assault, the exam, and conversion? How 

many of the converted cases are referred to the prosecutor’s office? What is the 

criminal justice outcome? Why do cases fall out? Why do law enforcement and/or 

prosecutors not pursue a case? What about victims who choose never to convert?

What was involved in their decision? This research could be replicated across 

jurisdictions, different underserved groups, refugees, correctional systems, etc.

Storage period for non-reporting/anonymous kits

• How many rape kits are collected annually and how many are non-reporting? How many of 

those non-reporting/anonymous cases “convert” to reporting and/or are prosecutable? 

• Is there research or guidance about how long non-reporting/anonymous kits should be kept?

For jurisdictions with a short window for holding the anonymous kits, is there a storage 

issue? A resource issue? Should there be a centralized state holding system for non-reporting 

kits so that the window can be widened?

• Why do states have such different procedures for storage of anonymous kits? Which 

challenges are really barriers and which can be removed? One example of storage practices 

comes from West Virginia. Anonymous kits are stored at a state university lab (Marshall 

University Forensic Science Center) for at least 18 months (but are currently being stored 

indefinitely). In the 4 years this procedure has been used in West Virginia, 52 non-reported 

case/kits have been stored and 3 converted to reporting. In two of the three cases, law 

enforcement did not investigate. The one that did move forward was not prosecuted for lack 

of evidence. What would be the impact (cost-benefit, victim satisfaction, etc.) if all states had

a tracking system like West Virginia? Is it feasible for a state crime lab to work with another 

lab (e.g., a university lab) to do quality assurance on samples and upload that information to 

a data base for analysis/case tracking?

• Are jurisdictions processing kits from non-reporting victims? If so, are they uploading DNA

profiles into the state database? (Access to CODIS is limited to situations where there is a 

direct link to a crime, which would require a report.) Participants warned that this was a 
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

19

slippery slopeif the victim chooses not to report, then giving data to the criminal justice

system is problematic. The Office on Violence Against Women advises not to process the kit 

if the victim is not reporting. To process a kit in such instances removes the victim from the 

center of care because it is taking the choices about the kit out of the hands of the victim.

TOPIC 5: USE OF TELEMEDICINE/TELEHEALTH

Patricia Speck presented on this topic. The field needs information on what SAMFE 

telemedicine practices exist around the country (not all do real-time exams) and the benefits, 

challenges, and limitations of telemedicine. Programs that are using telemedicine in conjunction 

with the SAMFE need to be studied regarding their practices, such as the California program that 

uses/will use telemedicine with adult, adolescent, and pediatric patients (previously only used

with pediatric patients), and the Florida program that works with pediatric patients. There are 

also examiners who act as expert consultants who could be surveyed. Ultimately, standards in 

using telemedicine in these cases are needed.16

• When and how is telemedicine being used in sexual assault cases (to guide real-time SAMFE, 

for training purposes, quality assurance, case review and consultation, and testimony 

preparation for local examiners)? Should there be a priority activity—e.g., telemedicine used 

for training and case review purposes versus for real-time exams? Bill Green noted that in 

California, they will mostly do training, case review, quality assurance, and testimony 

preparation rather than real-time exams. It is more complicated to be involved in real-time 

exams. The plan is to set up their system first and then revisit the issue of real-time exams.

• What are the roles and limitations of the remote expert?

• Who is considered the examiner in a criminal justice system when telemedicine is used in 

conjunction with the SAMFE? How telemedicine is used may make a difference—this may 

be more of an issue in real-time exams than in cases where telemedicine is used for other 

purposes. Who is in danger of malpractice? What about licensure?

• What is the remote expert’s responsibility in terms of the criminal justice system? Who will 

be subpoenaed for testimony—e.g., the remote expert or the inexperienced examiner in the

field? Again, how telemedicine is used can make a difference. The implications in the case of 

real-time exams need to be considered. With the California program, if remote experts are

involved in quality assurance activities, they are not subpoenaed in a case. They can review a 

case and help local examiners with testimony preparation. Ideally, they would have the 

prosecutor and local examiner onsite for this preparation so everyone is on the same page.

• Will judges accept that remote experts are quality assurance rather than direct care 

providers and therefore not require the remote experts to testify? Is that in the judges’ 

training and practice?

• What technology systems exist to provide adequate encryption and confidentiality (HIPAA)? 

Quality images for evaluation? Interface with electronic health records?

• What are the factors to consider in sustaining a SAMFE telemedicine system? Do facilities in 

Indian Country and rural communities have the technical capability for telemedicine?

 16 Note that during this conversation, it was not always clear whether participants’ comments were in reference to 

real-time telemedicine practices or more broadly to any telemedicine practice.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

20

• When telemedicine is used during a SAMFE, does there need to be a SART in place to be 

effective? Several participants felt that was the case. For example, a prosecutor can help the 

team determine how information gained through telemedicine will be used and when/what 

telemedicine practices are appropriate. An advocate can help ensure that, regardless of the 

methods used to do the examination and who is involved, the patient has adequate onsite 

emotional support and information about her/his options.

There were concerns related to privacy when using telemedicine (for example, whether a 

videotape made by the telemedicine consultant would be discoverable material). Participants did 

not know of existing protocols that addressed privacy issues in using telemedicine to provide 

consultation, training, case review, or real-time exams. Guidelines related to privacy will have to 

be developed as part of best practices and differentiate for different uses. Among other issues, 

the guidelines will need to speak to the secure storage and chain of custody of electronic images.

Participants spent time discussing additional real-time exam issues. They identified the need for 

evaluation of 24/7/365 remote access programs and processes (involving, but necessarily limited 

to, real-time applications of telemedicine). Some questions included

• What is involved in having a remote expert involved in a real-time exam? What synchronous 

and asynchronous communication will be employed?17

• When is it okay to use telemedicine in general? To use real-time telemedicine? Should exams 

that involve use of real-time remote experts only be used when a face-to-face interaction 

between the patient and an experienced examiner is not possible? When real-time 

telemedicine is involved in a SAMFE, what basic examiner skills are needed onsite?

• How does/can a SAMFE telemedicine program promote patient-centered care and informed 

consent? What is the impact/reaction of victims to telemedicine technology and their 

satisfaction with services provided?

• What related issues exist around cultural appropriateness, use of translators, and the 

advocate’s role? On which “side of the camera” should these issues be addressed?

• What kind of documentation should the remote expert do? For pediatric patients in the 

California program, it was unresolved whether the remote reviewer was to make notes.

Several participants said no—no formal documentation should be created by the distant 

expert in quality assurance instances. Would the same go for real-time exams?

• Are there other legal implications for real-time exams (in addition to what was discussed 

above)? What are the legal outcomes when real-time telemedicine is used in SAMFEs? Does 

information/evidence gained through real-time telemedicine impact case investigations, lab 

analyses, and prosecutions differently than information/evidence from live exams?

Any program that offers telemedicine will need to build an infrastructure to define its priorities 

and limitations and how to address the variety of issues that might arise.

 17 Note that there are a variety of synchronous (real-time) and asynchronous (store and forward transmission of 

medical images and information) tools that can be used in telemedicine. Some examples of real-time tools:

telephone, audio, Web, and video conferencing, conferencing with peripheral devices to aid in an interactive 

examination, chat, and instant messaging. Some examples of asynchronous tools are e-mailing, streaming audio and 

video, discussion boards, and blogs. See What is Telemedicine at www.icucare.com/PageFiles/Telemedicine.pdf.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

21

CONCLUSION AND NEXT STEPS

Researchers, practitioners, and survivors worked collaboratively during the forum to identify a 

multitude of potential research questions related to the technical aspects of the SAMFE. They 

also discussed a number of broad-based considerations to be interwoven into evaluation of the 

technical practices (e.g., assessing for a victim-centered approach). Many of the questions posed 

could be further molded into more specific research questions. Questions could also be 

condensed into different categories, for example, by discipline. Ultimately, participants were 

clear that the field needs to ascertain: How do specific technical practices during the SAMFE 

impact the victim and legal outcomes? Which practices are victim-centered, produce probative 

evidence, and help facilitate investigation, prosecution, and conviction? It is those practices they 

want to recommend as best practices. Getting to those evidence-based best practices will require 

some discernment as to (1) which questions are the most critical to research first, (2) which need 

to be asked and answered before we can study other questions, and (3) which questions do we 

already have data for and only require secondary analyses of the data to provide answers.

As summarized in the Framing the Research Needs section of this report, forum participants 

provided initial guidance around what they saw as the necessary next steps:

• First, the focus of research efforts should be gathering basic data from across the country 

regarding what evidence is being collected, collection techniques and technology, evolving 

DNA technology, what SAMFE kits instruct, and use of telemedicine in the SAMFE. Many 

of those basic questions can be extracted from this report. Determination will need to be 

made regarding what are the most important baseline data to seek and the logistics of 

gathering and analyzing different data sets. 

• With basic data compilation and analyses as a foundation, researchers, practitioners, and 

survivors will be better positioned to work together to re-evaluate the potential research 

questions posed in this report: In which areas are there still gaps in knowledge about best 

practices? Which among the remaining research questions are high priority, medium priority, 

and low priority respectively?

It is the hope of OVC and NIJ to share this report with forum participants and relevant

governmental agencies, practitioners, and researchers for their input on adding and refining the 

potential research questions. OVC and NIJ envision future forums to allow the field to continue 

dialoging with one another and building consensus about the most urgent research needs related 

to the technical aspects of the SAMFE.

APPENDIX 1: PARTICIPANTS AND FORUM AGENDA
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22

APPENDIX 1: PARTICIPANTS AND FORUM AGENDA

This report reflects the opinions, experiences, and expertise of forum participants. OVC and NIJ are grateful for

their input. Participants included (**indicates a participant who also was a forum planning group member and * 

indicates a participant who was a meeting presenter)—

Mitra Ahadpour, Agency for Healthcare Research and Quality

Carolyn Aoyama, Office of Public Health Support, Indian Health Services

Bethany Backes, National Institute of Justice, Office of Justice Programs, U.S. Department of Justice **

Virginia Baran, Office on Violence Against Women, U.S. Department of Justice

Cameron Crandall, Department of Emergency Medicine, University of New Mexico

Theodore Cross, University of Illinois Urbana-Champaign

Kim Day, International Association of Forensic Nurses*

Cecilia Doyle, Illinois State Police Forensic Science Center at Chicago*

Ivette Estrada, Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice

Joye Frost, Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice*

Norm Gahn, Milwaukee County District Attorney’s Office*

William Green, California Clinical Forensic Medical Training Center

Leslie Hagen, Executive Office for U.S. Attorneys, U.S. Department of Justice

Bea Hanson, Office on Violence Against Women, U.S. Department of Justice*

John Klofas, Rochester Institute of Technology

John Laub, National Institute of Justice, Office of Justice Programs, U.S. Department of Justice*

Helena Lazaro, Consultant, Los Angeles

Marc LeBeau, Federal Bureau of Investigation

Linda Ledray, Sexual Assault Resource Service*

Debra Lopez-Bonasso, West Virginia Foundation for Rape Information and Services

James Markey, Investigative Lead, LLC

Lisa Newmark, George Mason University

Debra Patterson, Wayne State University

Heidi Resnick, National Crime Victims Center

Michael Rizzo, National Law Enforcement Leadership Initiative on Violence Against Women, International 

Association of Chiefs of Police

Kristina Rose, National Institute of Justice, Office of Justice Programs, U.S. Department of Justice **

Marilyn Sawyer Sommers, University of Pennsylvania, School of Nursing

Michael Sheppo, National Institute of Justice, Office of Justice Programs, U.S. Department of Justice

Marnie Shiels, Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice**

Patricia Speck, Health Science Center College of Nursing*

Kelly Walsh, The Urban Institute

Michael Weaver, Saint Luke’s Hospital*

Debra Whitcomb, Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice**

Caroline Zervos, Federal Bureau of Investigation

Janine Zweig, The Urban Institute*

OVC and NIJ also thank the following individuals for their involvement in forum planning/implementation:

Jean Strohl, Office for Victims of Crime Training and Technical Assistance Center

Jennifer Markowitz, AEquitas: The Prosecutors’ Resource on Violence Against Women

Patricia Speck: University of Tennessee Health Science Center

Fernanda Webster, Office for Victims of Crime Training and Technical Assistance Center

Appreciation goes to Kristin Littel for assisting with meeting planning, facilitating the forum, and authoring this 

report.
Summary of Research Questions Identified Through the SAMFE Research ForumMarch 28–29, 2012

23

SEXUAL ASSAULT MEDICAL FORENSIC EXAMINATION RESEARCH FORUM

March 28-29, 2012

Washington, DC

Day 1

8:00 a.m. Registration

8:30 a.m. Opening Remarks

• Joye Frost, Acting Director, Office for Victims of Crime

• John Laub, Director, National Institute of Justice

9:00 a.m. Meeting Overview

9:10 a.m. Participant Introductions

9:30 a.m. Presentation and Dialogue on Research Questions: Evidence Gathered

• Impact of specific types of evidence gathered during the examination—on the victim, case 

investigation, and the likelihood of prosecution and conviction

10:30 a.m. Break

10:45 a.m. Presentation and Dialogue on Research Questions: Evidence Gathered (continued)

12:15 p.m. Lunch on Your Own

1:15 p.m. Presentation and Dialogue on Research Questions: Exam Technology

• Effect of application of specific technology used to collect evidence during the examination 

on case investigation and prosecution, and effect on level of victim discomfort/side effects

3:15 p.m. Break

3:30 p.m. Presentation and Dialogue on Research Questions: Standardizing the Kit

• Effects/feasibility of standardizing evidence collection kits at national, state, and tribal levels 

4:30 p.m. Closing Comments/Feedback

4:45 p.m. Adjourn for Day 1

Day 2

8:30 a.m. Opening Remarks

• Bea Hanson, Office on Violence Against Women

8:40 Comments on Day 1 

8:50 a.m. Presentation and Dialogue on Research Questions: DNA Technology

• Effects of evolving DNA technology relevant to collection, preservation, and storage of 

forensic evidence prior to testing of such evidence

10:30 a.m. Break

10: 45 a.m. Presentation and Dialogue on Research Questions: Telehealth

• Use of telemedicine in examination process in rural, remote, and poor communities 

11:45 a.m. Pick up Lunch on Your Own and Return for Working Lunch 

12:15 p.m. Presentation and Dialogue on Research Questions: Telehealth (continued)

1:15 p.m. Identification of Additional Pressing Research Issues 

1:30 p.m. Next Steps

1:45 p.m. Adjourn for Day 2