Sexual Assault: Information on Training, Funding, and the Availability of Forensic Examiners
Published: 2016-03-18T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In 2013, about 285,000 individuals age 12 or older were reported victims of sexual assault, according to the Bureau of Justice Statistics. Studies have shown that exams performed by sexual assault forensic examiners—medical providers trained in collecting and preserving forensic evidence—may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates. Yet, concerns have been raised about the availability of examiners. The Violence Against Women Reauthorization Act of 2013 authorized funding for DOJ grant programs that can be used by states and other eligible entities, such as nonprofit organizations, to train and fund examiners.
GAO was asked to review the availability of examiners nationwide. In this report, GAO describes (1) the prevalence and use of federal grants to train or fund sexual assault forensic examiners, (2) what is known about the availability of such examiners nationwide and in selected states, and (3) the challenges selected states face in maintaining a supply of examiners. GAO analyzed 2013 DOJ data on grantees' use of funding to train or fund examiners—the most recent full year of data available—and reviewed literature, relevant laws and DOJ documentation. GAO also interviewed grantees in six states selected based on several factors including population and geographic location, as well as DOJ officials, Department of Health and Human Services officials, and experts, such as health care association officials.
section_title: What GAO Found
paragraphs: Federal funding from three key Department of Justice (DOJ) grant programs can be used to train or fund sexual assault forensic examiners and for a range of other activities related to sexual assault, domestic violence, dating violence, and stalking. In 2013, at least one grantee in 49 states used such funds to provide training to examiners and at least one grantee in 26 states funded examiner positions. In 49 states, approximately 227 grantees or subgrantees—referred to collectively as grantees—reported providing training for over 6,000 examiners in 2013. The type of training examiners received ranged from comprehensive examiner training to training on specific topics, such as courtroom testimony. The extent of examiner training efforts supported with funds from the three DOJ grant programs varied by state. For example, in about half of the states, fewer than 100 examiners received training. In addition, in the states where at least one grantee funded examiner staff positions in 2013, grantees funded less than one position, on average. Approximately 75 grantees in 26 states funded roughly 50 full-time equivalent examiner positions in 2013.
On the basis of literature GAO reviewed as well as interviews with experts and state officials, data on the number of examiners nationwide and in selected states are limited or unavailable. However, officials in all six selected states told GAO that the number of examiners available in their state did not meet the need for exams, especially in rural areas. For example, officials in Wisconsin explained that nearly half of all counties in the state do not have any examiners available. In health care facilities where examiners are available, they are typically available in hospitals on an on-call basis, though the number available varies by facility and may not provide enough capacity to offer examiner coverage 24 hours, 7 days a week.
There are multiple challenges to maintaining a supply of examiners, according to interviews with officials in six selected states. These include:
Limited availability of training . Officials in five of six selected states reported that the availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of trained examiners.
Weak stakeholder support for examiners. Officials in five of six selected states reported that obtaining support from stakeholders, such as hospitals, was a challenge. For example, hospitals may be reluctant to cover the costs of training examiners or paying for examiners to be on-call.
Low examiner retention rates. The above-mentioned and other challenges, including the emotional and physical demands on examiners, contribute to low examiner retention rates. Officials in one state estimated that while the state trained 540 examiners over a two-year period, only 42 of those examiners were still practicing in the state at the end of those 2 years.
Officials described strategies that can help address these challenges, such as implementing web-based training courses, clinical practice labs, mentorship programs, and multidisciplinary teams that respond to cases of sexual assault.
DOJ provided technical comments on a draft of this report, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: An estimated 284,350 individuals age 12 or older were victims of rape or  other sexual assault in 2014, according to the most recently available  data from the Bureau of Justice Statistics. When victims of sexual  assault receive a medical forensic examination, the exam may be  provided by either a trained sexual assault forensic examiner—that is, a  medical provider who has received specialized training in properly  collecting and preserving forensic evidence—or a medical provider who  has not received such specialized training. Studies have shown that  exams performed by trained sexual assault forensic examiners may result  in shortened exam time, better quality health care delivered to victims,  higher quality forensic evidence collection, as well as better collaboration  with the legal system and higher prosecution rates. However, concerns  have been raised about the availability of examiners to meet victims’  needs for exams. The Violence Against Women Act (VAWA), most  recently reauthorized in 2013, authorized funding for federal grant  programs administered by the Department of Justice (DOJ) that can be  used by states and other eligible entities to, among other things, train  sexual assault forensic examiners or fund examiner positions.
You asked us to review sexual assault victims’ access to health care  facilities with medical providers trained in conducting sexual assault  forensic examinations. This report describes:  1.  the prevalence and use of federal grants to train and fund sexual  2.  what is known about the availability of sexual assault forensic  examiners nationally and in selected states; and  3.  the challenges selected states face in maintaining a supply of sexual  assault forensic examiners.
To describe the prevalence and use of federal grants to train or fund  sexual assault forensic examiners, we asked officials at DOJ and the  Department of Health and Human Services (HHS) to identify and describe  federal grant programs from which funds are available for these  purposes. Officials identified three key federal grant programs. We  reviewed relevant laws as well as DOJ guidance and reports related to  the three grant programs and to sexual assault forensic exams and  examiners. We also analyzed data submitted to DOJ by grantees of these  three programs. Specifically, we analyzed data on the number of grantees  that used funds to provide training for or fund examiner positions as well  as the number of examiners who received training or examiner positions  funded in 2013 and, where available, 2014. To assess the reliability of  the data, we reviewed documentation and interviewed DOJ officials about  how the data were collected and verified, and we checked the data for  obvious errors. We found the data to be sufficiently reliable for our  purposes of describing the prevalence and use of federal grants to train  or fund examiners. We also reviewed grantees’ open-ended responses to  questions on grantee progress reporting forms about the status of  achieving their grant goals and objectives, reported effectiveness of and  other information about their training activities, and grantee perceptions  about the most significant areas of remaining need with regard to training  or funding examiners. We restricted our review of open-ended responses  to those that mentioned terms related to sexual assault forensic  examiners. We interviewed experts, such as officials from the  International Association of Forensic Nurses (IAFN), about the availability  of federal grant funding to train or fund examiners. And, to further  examine how grantees used funds to train or fund examiners, such as the  type of training provided or examiner positions funded, we interviewed a  selection of grantees in six selected states. To select the six states  (Colorado, Florida, Massachusetts, Nebraska, Oregon, and Wisconsin),  we considered the number of grantees in each state that received funding  from any of the three grant programs; whether states had unique policies  or programs in place regarding the training of examiners; and state  population size and geographic location. We sought to achieve variation  in these characteristics when selecting the six states. In the six selected  states, we interviewed a total of nine grantees that received federal funds  in fiscal year 2014. Information from these interviews cannot be used to  generalize beyond the six selected states.
To examine what is known about the availability of sexual assault forensic  examiners nationwide and in the six selected states, we conducted a  literature review to identify studies that measured the availability of sexual  assault forensic examiners. Two analysts independently reviewed all  studies identified through a structured literature search for relevance. We  determined that a study was directly related to this objective if it  measured the extent to which examiners were available in health care  facilities at a national, state, or local level. Through these searches, we  identified a total of 214 studies, of which 8 were determined relevant to  this objective. During interviews with experts, grantees, and state sexual  assault coalition officials in the six selected states, we asked about  requirements and guidance concerning the training or availability of  examiners; data on the availability of examiners or examiner programs;  the extent to which examiner availability meets the need for exams; and  examiner staffing characteristics in facilities where they are located. Last,  we reviewed information from three health care associations on their  policies and guidance concerning the training of medical providers to  perform exams and research they conducted on the availability of  examiners.
To examine the challenges selected states face in maintaining a supply of  trained sexual assault forensic examiners, during our interviews with  grantees and coalition officials in the six selected states we asked about  challenges they experienced in training or retaining examiners and  strategies that could be used to overcome these challenges. We also  reviewed studies identified through our literature search that examined  challenges to training and retaining examiners and strategies that can be  used to address these challenges. Two analysts independently reviewed  all studies identified for relevance. We determined that a study was  directly related to this objective if it mentioned any challenges to training  or maintaining examiners or examiner programs. From the 214 studies  we identified through our literature search, we determined 16 to be  relevant for this objective.
We conducted this performance audit from April 2015 to March 2016 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.
subsections: section_title: Background
subsections: section_title: Sexual Assault Forensic Examinations and Examiners
paragraphs: Victims of sexual assault may receive a sexual assault forensic  examination by a medical provider who may or may not be a trained  sexual assault forensic examiner. Medical providers assess victims’  clinical conditions; provide appropriate treatment and medical referrals;  and, given consent by the victim, collect forensic evidence through a  sexual assault forensic examination that may follow steps and use  supplies from a sexual assault evidence collection kit. Under its protocol  for sexual assault forensic examinations, DOJ recommends that medical  providers collect a range of physical evidence, which can include, but is  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, sexual  assault forensic exams typically include documenting biological and  physical findings such as cuts or bruises, either in writing or photographs,  and a recording of a victim’s medical forensic history such as the time and  nature of the assault. Once the exam is complete, medical providers  preserve the collected evidence, which may include packaging, labeling,  and sealing evidence collection kits and storing kits in a secure location.  Medical providers typically perform such exams only for acute cases of  sexual assault, such as in cases where the assault occurred within the  previous 72 to 96 hours, when the physical and biological evidence on a  person’s body or clothes is considered most viable.
DOJ, IAFN, and the American College of Emergency Physicians (ACEP)  recommend that sexual assault forensic exams be performed by specially  trained medical providers—or sexual assault forensic examiners  (examiners). These examiners include physicians, physician assistants,  nurse practitioners, and other registered nurses who have been specially  educated and completed clinical requirements to perform sexual assault  forensic exams. Sexual assault nurse examiners (SANE) —a particular  type of sexual assault forensic examiners—are registered nurses,  including nurse midwives and other advanced practice nurses, who have  received specialized education and have fulfilled clinical requirements to  perform sexual assault forensic exams. Examiner programs have been  created in hospital or non-hospital settings whereby specially trained  examiners are available to provide first-response care and exams to  sexual assault victims. Additionally, for pediatric victims, specially trained  examiners may perform medical forensic exams in a child-specific facility,  such as a child advocacy center.
DOJ, IAFN, and some states have issued guidelines pertaining to the  minimum level of training examiners should receive in order to properly  collect and preserve evidence, identify victims’ medical and emotional  health care needs, and provide counseling and referrals for victims.  These guidelines include recommendations of objectives and topics that  training programs should cover. For example, in their guidelines, DOJ and  IAFN recommend that examiners receive comprehensive training that  covers such topics as how to identify and deliver proper elements of a  victim-centered sexual assault forensic examination where victims are  fully informed of their options during and after the exam; how to assess  patients and provide culturally competent medical care, including testing  and delivery of prophylaxis for sexual transmitted infections and  pregnancy; how to collect and document evidence in a way that protects  the evidence’s integrity; how to testify about findings in court; and how to  protect the chain of custody of evidence and coordinate care across a  multidisciplinary team. The goal of training, as outlined in the DOJ and  IAFN guidelines, is for examiners to be able to effectively evaluate and  address victims’ health concerns, minimize their trauma and promote their  healing during and after the exam, and to detect, collect, preserve, and  document physical evidence related to the assault for potential use by the  legal system.
In addition, registered nurses can become certified SANEs through IAFN  to perform exams, though no such national certification exists for  examiners who are not registered nurses. Depending on the state,  examiners may also become certified through a state certifying body,  such as a state board of nursing.
There are no federal requirements concerning the training or availability  of examiners in health care facilities outside of military, correctional, and  Indian Health Service facilities. While a Joint Commission accreditation  standard requires hospitals to establish policies for identifying and  assessing possible victims of sexual assault and to train staff on those  policies, each hospital is responsible for determining the level of  specificity of such policies, including the minimum level of training  required of its medical staff that perform exams. Some states may have  established minimum training requirements of nurses that perform sexual  assault forensic exams and require nurses to become certified either  through the IAFN or the state.
section_title: Federal Grant Programs
paragraphs: As authorized by VAWA, DOJ administers several grant programs that  aim to, among other things, improve response to and recovery from four  broad categories of victimization—domestic violence, sexual assault,  dating violence, and stalking. The grant programs aim to address these  categories of victimization through a range of activities, including public  education and prevention; improved collaboration among stakeholders;  training of law enforcement, prosecutors, court personnel, and victim  service providers; strengthening victim services; developing and  implementing more effective police, court, and prosecution policies and  services; and improving data collection and communication systems  related to these crimes. According to DOJ officials, there are three key  VAWA authorized grant programs administered by DOJ’s Office on  Violence Against Women (OVW) that can be used by grant recipients to  fund or train sexual assault forensic examiners.
In March 2011, the Indian Health Service within the Department of Health and Human  Services implemented a new policy, through its Indian Health Manual, that all Indian  Health Service-operated facilities must provide patients age 18 and older who present  themselves for sexual assault services with access to an exam on-site or by referral.  Victims who are referred elsewhere must be transported within 2 hours of the victim’s  presentation at the medical facility. All registered nurses, advanced practice nurses,  physicians, and physician assistants new to caring for adult and adolescent sexual assault  patients must complete 40 hours of examiner training as well as clinical practice  experience under the guidance of a forensically experienced medical provider. All  examiner training and clinical practice experience must conform to the SANE educational  requirements of the IAFN and the DOJ National Sexual Assault Medical Examining  Training Standards. Department of Health and Human Services, Indian Health Service,  “Chap. 29—Sexual Assault.” Pt. 3 in Indian Health Manual (Rockville, Md.: May 16, 2014).
Services-Training-Officers-Prosecutors Violence Against Women  Formula Grant Program (STOP Grant Program): The purpose of  the STOP grant program, the largest of the three key grant programs,  is to help states, courts, and local governments develop and  strengthen effective law enforcement and prosecution strategies to  combat violent crimes against women and to develop and strengthen  victim services in cases involving violent crimes against women.  Under the STOP grant program, there are 20 statutorily defined  purposes for which funds may be used, one of which pertains directly  to training examiners in the collection and preservation of evidence,  analysis, prevention, and providing expert testimony and treatment of  trauma related to sexual assault. The STOP Grant Program is a  formula grant program in which all states and territories are awarded a  minimum amount of $600,000 plus an additional amount based on  state population size. STOP Grant Program awards may support up  to 75 percent of the costs of all projects, including the cost of  administering those subgrants; the remaining 25 percent of costs  must be covered by nonfederal match sources. The average STOP  grant award to states in fiscal year 2015 was about $2.5 million and  ranged from roughly $600,000 to $13.2 million.
Once states receive funds, a designated state agency—referred to as  the state STOP administrator—is responsible for distributing funds to  subgrantees based on the state’s own subgrant award process.  However, state STOP administrators must allocate funds according to  a statutorily defined formula—that is, 25 percent of funds must be  distributed for law enforcement, 25 percent for prosecutors, 30  percent for victim services, 5 percent to state and local courts, and 15  percent for discretionary distribution within the program purpose  areas. We refer to STOP subgrantees as grantees throughout this  report.
Grants to Encourage Arrest Policies and Enforcement of  Protection Orders Program (Arrest Grant Program): The purpose  of the Arrest Grant Program is to encourage state, local and tribal  governments and courts to treat domestic violence, dating violence,  sexual assault, and stalking as serious violations of criminal law  requiring the coordinated involvement of the entire criminal justice  system. Eligible applicants include states, territories, and units of local  government; Indian tribal governments; state, local, tribal, and  territorial courts; victim service providers; state or tribal sexual assault  or domestic violence coalitions; and government rape crisis centers.  For the Arrest Grant Program, at least 25 percent of appropriated  funds must be allocated to activities that address sexual assault.  Developing, implementing, or enhancing examiner programs,  including the hiring and training of such examiners, is 1 of 22 purpose  areas for which Arrest Program grant funding can be used. The  average grant award in fiscal year 2015 was $601,361 and ranged  from $224,668 to $900,000.
Rural Sexual Assault Domestic Violence, Dating Violence, and  Stalking Assistance Program (Rural Grant Program): The purpose  of the Rural Grant Program is to enhance the safety of rural victims of  sexual assault, domestic violence, dating violence and stalking, and  support projects uniquely designed to address and prevent these  crimes in rural areas. At least 75 percent of total Rural Grant Program  funding must be allocated to eligible entities in “rural states,” as  defined by VAWA 2013. Eligible entities include states, territories,  Indian tribes, local governments, and nonprofit entities including tribal  nonprofit organizations. In addition, at least 25 percent of funds  appropriated for the Rural Grant Program must be allocated to  activities that address sexual assault in rural areas. Regardless of  whether a grantee is from a rural or nonrural state, funds must be  used for services and activities in a rural area or rural community.  Grantees are required to implement at least one of five statutorily  defined strategies, one of which includes developing, enlarging, or  strengthening programs addressing sexual assault, including  examiner programs. The average grant award in fiscal year 2015 was  $599,997 and ranged from $144,000 to $999,993.
Across these three grant programs, a total of $186.7 million in funds was  awarded to grantees in fiscal year 2015. (See table 1.)
Organizations that receive DOJ grant awards (or subgrant awards)  through the STOP, Arrest, and Rural Programs are required to submit  annual or biannual reporting forms to the OVW that include information  about how they used grant funding, including specific information about  whether funding was used to provide training for or fund sexual assault  forensic examiners.
DOJ officials told us that funding from additional DOJ grant programs may  be used to fund, train, or support the training of examiners, though  officials stated that the use of such grant funding for these purposes is  limited. Such programs include the Office for Victims of Crime’s Training  and Technical Assistance Center and its National Sexual Assault  TeleNursing Center demonstration project as well as the Bureau of  Justice Assistance’s Byrne Justice Assistance Grant Program. In addition,  OVW also administers the Technical Assistance Grant Program, which  aims to provide direct technical assistance to existing and potential  grantees to successfully implement projects supported by OVW grant  funds. The Technical Assistance Program is aimed at providing in-person  and online educational training opportunities, peer-to-peer consultations,  site visits, and other types of tailored assistance to help grantees,  including STOP, Arrest, and Rural Program grantees, implement grant- funded activities effectively. Although Technical Assistance Program  providers could also use awarded funding to provide training that would  help examiners to perform at a higher level of proficiency, DOJ officials  noted that such providers do not provide comprehensive classroom or  clinical training to medical providers aspiring to become an examiner.
According to officials from HHS, as of September 2015, HHS did not  administer any grant programs that are used to train or fund examiners  nor has it issued guidance or requirements concerning the training of  medical professionals on conducting exams or the availability of  examiners. Although HHS was authorized through VAWA 2013 to  administer the Consolidated Grants to Strengthen the Healthcare  System’s Response to Domestic Violence, Dating Violence, Sexual  Assault, and Stalking, funds were never appropriated to HHS for this  program. In addition, officials from both agencies told us that, as of  September 2015, DOJ and HHS had not collaborated on any activities  concerning the training of medical providers on conducting sexual assault  forensic exams or the availability of trained examiners.
section_title: Most States Had at Least One Grantee That Used Federal Grant Funds to Train or Fund Examiners
paragraphs: In 49 states, at least one STOP, Arrest, or Rural Program grantee— including STOP subgrantees—reported using federal grant funds to  provide training for sexual assault forensic examiners in 2013, the most  recent year for which complete data were available. Grantees used  funds for a variety of examiner training activities. In addition to training  examiners, grantees in 26 states funded examiner staff positions in 2013,  although grantees in these states funded less than one full-time  equivalent (FTE) examiner position, on average.
subsections: section_title: Grantees in 49 States Used Federal Grant Funds to Provide a Variety of Training to Examiners in 2013
paragraphs: In nearly all states in 2013, at least one STOP, Arrest, or Rural Program  grantee reported using federal grant funds to provide training for sexual  assault forensic examiners in 2013. Specifically, in 2013, approximately  227 grantees in 49 states reported using grant funds to provide training  for over 6,000 examiners. Most examiners (4,936) received training  from STOP grantees. (See table 2.) However, on the basis of available  data, it is unclear how many examiners received comprehensive  examiner training versus other training that could help enhance their  ability to serve victims.
Based on interviews with grantees in some of our six selected states and  a review of grantee progress reports submitted to DOJ in 2013, the type  of training that grantees provided for examiners ranged from  comprehensive examiner training and certification to training on specific  topics that enable examiners to improve their response to victims.  Grantees reported using federal grant funds to provide examiners with the  following types of training:
Comprehensive Examiner Training or Certification: Grantees  reported using funds to provide comprehensive examiner training that,  for example, included 40 or more hours of classroom training as well  as, in some cases, clinical practice training. For example, in 2014, a  Wisconsin grantee used STOP grant and state budget funds to  provide five 40-hour training courses and three clinical skills labs for  examiners, training a total of 115 new examiners. Although the state  neither offers nor requires examiner certification, those that  participated in the training could become certified through IAFN. In  addition, the statewide examiner training program in Colorado, which  is partially supported using STOP grant funds, both trained and  certified 74 new examiners in 2014.
Examiner Recertification or Continuing Education Training: In  addition to comprehensive examiner training or certification, some  grantees used grant funds to offer periodic recertification or  “refresher” training so that examiners can maintain competency. For  example, a grantee in Kansas provided refresher training to  examiners who were identified by forensic lab evaluation forms as  having errors in evidence collected through sexual assault forensic  exams.
Topical Training: Some grantees reported providing training to  examiners on specific topics, such as interviewing and photography  techniques, court room testimony, or victim confidentiality protocols.  For example, officials from the statewide examiner training program in  Colorado told us that in the past they have used both STOP and  Arrest Program funds to provide courtroom training for examiners.  Other grantees reported providing training to examiners on working  with certain types of victims, such as lesbian, gay, bisexual,  transgender, disabled, or elderly victims.
The extent of examiner training efforts supported with STOP, Arrest, and  Rural Grant Program funds varied by state. In 2013, the total number of  examiners who received training funded through these grant programs in  each state ranged from 0 to 604. In half of the states (26), fewer than 100  examiners received training and in 12 of these states fewer than 25  examiners received training. (See figure 1.) Further, based on interviews  with grantees in selected states, we found that while some grantees used  funds to support statewide comprehensive examiner training programs,  other grantees used funds to provide training in specific locations, such  as a single county or hospital. For example, at least one grantee each in  Colorado, Florida, Massachusetts, and Wisconsin used STOP or Arrest  Program funds, in combination with other funding, to support statewide  comprehensive examiner training programs. However, Jefferson County  in Oregon used its Rural Program funds for one examiner’s recertification  as well as other continuing education training for four examiners at a local  hospital in 2014. Additionally, the Colorado Sexual Assault Response  Project used Arrest Program funds to provide training for 44 examiners in  rural areas to perform exams. The number of grantees in each state that  used grant funds to provide training for examiners also varied. For  example, in 2013, the number of grantees that reported providing training  for examiners per state ranged from 0 to 19. While 12 grantees provided  training for a total of 43 examiners in North Carolina, two grantees  provided training for a total of 347 examiners in Illinois in 2013. (For more  detailed information on the number of grantees that reported providing  training for examiners and the number of examiners provided training in  each state by grant program, see appendix I.)
Some entities used funds from DOJ’s Technical Assistance Program to  provide training for examiners on a national scale. DOJ officials told us  that although OVW does not fund any Technical Assistance Program  award recipients to provide classroom or clinical training for examiners,  some may provide national training that assists examiners in developing  knowledge, experience, or skills to perform at a higher level of  proficiency. For example, in 2014 IAFN used Technical Assistance  Program funds to provide online and in-person training for examiners on  topics such as treating transgender victims of sexual assault and payment  policies for forensic exams. In the reporting period January through June  2014, Technical Assistance Program award recipients provided training  for 1,772 examiners. DOJ officials told us that the majority of these  examiners (1,609) received training provided by five Technical Assistance  Program award recipients.
DOJ officials told us that the STOP, Arrest, and Rural grant programs are  the key grant programs from which funds are available to train examiners,  though grantees may use funds to address four broad categories of  victimization—sexual assault, domestic violence, dating violence, and  stalking. Further, within the category of sexual assault, there is an  extensive range of issue areas that grantees can choose to address,  including providing training for examiners. For example, grantees may  choose to use funds to pay for victim services or to train other  professionals, such as law enforcement officers, judges, and prosecutors,  on issues related to sexual assault. Of all STOP, Arrest, and Rural  Program grantees, 8.4 percent reported using grant funds specifically to  provide training for examiners in 2013.
According to DOJ and state officials, grantees might not use STOP,  Arrest, or Rural Grant Program funds to provide training for examiners for  a variety reasons, including competing demands for the use of funds and  a lack of competitive grant applications from entities seeking funds for this  purpose. For example, officials in Florida reported that STOP grant funds  are not used to provide training for examiners but are instead targeted  towards other areas, such as law enforcement, victim services, or  developing and supporting sexual assault response teams. DOJ officials  and state STOP administrators also told us that not all grant applications  seeking funds to train examiners may be approved. For example, DOJ  officials told us that grant applications may be denied if they do not meet  the standardized criteria OVW uses in the review of applications for the  Arrest and Rural programs or, despite meeting OVW’s criteria and scoring  well, other applications score better. Additionally, officials told us that it  is possible that few applicants seek funding to train examiners. For  example, the Nebraska STOP Administrator told us that due to a lack of  knowledge that grant funds can be used for this purpose, the state  received only one application to train examiners, which was not approved  due to competing demands for available funds.
Some grantees in our six selected states that did not use STOP, Arrest,  or Rural Grant Program funds to provide training for examiners used  other funds, such as funds from state and hospital budgets or nonprofit  organizations, to train examiners. In Nebraska, for example, examiner  training is primarily funded by a hospital system that also employs over  half of the examiners in the state (24 out of 43 examiners). Although  Oregon did not use federal funds to provide training for examiners,  officials told us that the Oregon Sexual Assault Task Force, a statewide  nonprofit organization, uses grant funds from the state department of  justice to offer 40-hour comprehensive examiner training courses two  times per year. Finally, some grantees told us that they used federal grant  funds to provide sexual assault exam overview training for health and  other professionals. For example, one grantee in Massachusetts told us  that they used grant funds to provide basic forensic evidence collection  training to staff at hospitals that did not have trained examiners available.
section_title: Grantees in 26 States Funded Examiner Positions in 2013, and Grantees in These States Funded Less Than One Position on Average
paragraphs: In half of the states, at least one STOP, Arrest, or Rural grantee funded  examiner staff positions in 2013. Approximately 75 grantees in 26 states  funded roughly 50 FTE examiner positions in 2013, most of which (46  FTE examiner positions) were funded by STOP grantees. (See table 3).  In these 26 states, grantees funded, on average, less than one FTE  examiner position each, ranging from 0.1 to 9.8 FTEs in 2013. Further,  few STOP, Arrest, or Rural grantees used funds to pay for FTE examiner  positions in 2013. In 2013, approximately 2.5 percent of STOP grantees,  5.2 percent of Arrest grantees, and 6.3 percent of Rural Program  grantees reported using grant funds for FTE examiner positions.
Information from interviews with officials in two of our six selected states  suggests that grantees that fund examiner positions may fund an  examiner to act as an examiner program coordinator. Program  coordinator duties may include overseeing the operations of examiner  programs, training examiners, providing technical assistance, and  providing forensic exams. For example, officials in both Massachusetts  and Wisconsin told us that STOP Grant Program funds were used to pay  for a statewide coordinator in FY 2014. In addition, grantees also used  grant funds to pay for examiners to be on-call. For example, a grantee in  Hawaii reported that STOP grant funding allowed them to provide on-call  pay to examiners in the state.
section_title: Nationwide Data on the Availability of Sexual Assault Forensic Examiners Are Limited; Officials in Selected States Reported a Need for Additional Examiners
paragraphs: According to our literature review and the experts we interviewed, only  limited nationwide data exist on the availability of sexual assault forensic  examiners—that is, both the number of practicing examiners and health  care facilities that have examiner programs. While IAFN reported that, as  of September 2015, there were 1,182 nurses with active IAFN SANE  certification in the United States, such data do not represent all practicing  examiners nationwide. For example, the data do not account for  examiners who completed training through an IAFN or a state training  program but never became certified or were certified through another  entity, such as a state board of nursing. IAFN also collects data on  examiner programs nationwide—that is, data on hospitals, clinics, and  other sites where examiners practice. Such data provide an indication of  the availability of examiners, but the data are also limited. While 703  examiner programs nationwide voluntarily reported to IAFN’s examiner  program database, as of September 2015, IAFN officials noted that the  database is often not up-to-date and some health care settings where  sexual assault forensic exams are conducted, such as child advocacy  centers, are not represented. In addition, data collected on staffing  characteristics of examiner programs are often unavailable in the IAFN  examiner program database. For example, only about one-third of the  examiner programs reported on the number of examiners practicing in  their program and about one-third reported on whether examiners were  available on-site versus on-call.
In three of six selected states, STOP administrators or officials from  sexual assault coalitions were able to provide estimates of the number of  practicing examiners and, in all six states, they were able to provide  information on the estimated number of examiner program locations in  their state. Of states that reported, the number of practicing examiners  and examiner programs varied by state. (See table 4.) However, such  data may also present an incomplete picture of the availability of  examiners. For example, only one of the six selected states has a system  in place to formally track the number and location of examiners. Instead,  officials generally reported on the estimated number of examiners or  examiner locations that were part of a statewide examiner program or  were identified through an ad hoc data collection effort.
Although data are limited, STOP administrators and sexual assault  coalition officials in all six selected states nevertheless told us that the  number of examiners available does not meet the need for exams within  their states. For example, coalition officials in Wisconsin told us that  nearly half of all counties in the state do not have any examiner programs  available, and coalition officials in Nebraska told us that most counties in  the state do not have examiner programs available. In addition, in four of  six selected states—Colorado, Florida, Nebraska, and Wisconsin—state  STOP administrators and coalition officials told us that few or some health  care facilities in their state have examiners available. As a  consequence, officials said victims may need to travel long distances to  be examined by a trained examiner or be examined by a medical  professional without specialized training. For example, the Colorado  STOP administrator explained that although there is an examiner  program available in all regions of the state, not all hospitals participate in  Colorado’s statewide examiner program. As a result, in the rural Western  region of Colorado, for example, victims may have to travel more than an  hour to reach a facility with examiners available. While in the other two  selected states—Massachusetts and Oregon—state STOP administrators  and coalition officials stated that some or most facilities have examiners  available, they noted that there is still a need for additional capacity to  reduce the burden on those examiners who are available or to make  examiners available in a number of areas where examiners are currently  unavailable. For example, Massachusetts coalition officials told us that  there is an ongoing need for examiners across the state.
There were few or in some cases no examiners available in rural areas,  according to state STOP administrators or coalition officials we  interviewed in selected states. STOP administrators and coalition officials  in Colorado, Florida, and Wisconsin told us that in rural areas there may  be only one examiner or one examiner program available across multiple  counties. For example, Colorado coalition officials told us that of the five  rural counties in Central Colorado, only one county had an examiner  available. Alternatively, according to the Nebraska STOP administrator,  some victims might have to travel to a major metropolitan area to reach a  facility with examiners available, which could take 2 or more hours. In  general, state STOP administrators and coalition officials explained that it  could take a victim 30 minutes or less in urban areas to up to 2 hours in  rural areas to reach a facility that has an examiner available. STOP  administrators and coalition officials we interviewed explained that the  availability of examiners in rural areas is challenging for a number of  reasons, including the limited availability of health care providers  generally, weather-related travel restrictions that can affect the time and  distance victims must travel to reach a facility with an examiner, difficulty  recruiting qualified nurses to undergo training, and a lack of capacity in  rural areas to provide examiner training opportunities.
Even in some urban areas the availability of examiners may be limited,  according to state STOP administrators or coalition officials we  interviewed. For example, Wisconsin coalition officials explained that just  one of the five major hospitals in Milwaukee has examiners available, and  some victims may be unwilling to travel to that hospital to receive an  exam from an examiner. In addition, Florida coalition officials told us that  even in urban areas there are only a few specialized places where victims  can receive an exam from a trained examiner.
In health care facilities where examiners are available, they are typically  available through hospitals on an on-call basis, according to literature we  reviewed as well as all STOP administrators and coalition officials we  interviewed. Results from a 2005 national survey of examiner programs  showed that most programs (60 percent) were administered through  hospitals and 71 percent of examiner programs used staffed examiners  on a part-time, on-call basis. According to literature we reviewed as well  as experts and Colorado, Florida, and Oregon coalition officials we  interviewed, on-call examiners may serve “dual roles”—that is, they  simultaneously work as emergency department nurses and cover their  on-call examiner shift. Specifically, results from the 2005 survey showed  that about one-quarter of all examiner programs used nurses who  overlapped their emergency department shifts with their on-call examiner  shifts. Alternatively, according to the STOP administrators in Colorado  and Oregon, examiners in some facilities or rural areas may not work  based on an official on-call schedule. Instead, an examiner program  coordinator will call through a list of examiners practicing in a region of  the state when a victim arrives to find an examiner available to conduct  the exam. The Colorado STOP administrator noted, however, that it is  often the case that no examiners are available and the coordinator, who  is also a trained examiner, will ultimately come in to the hospital to  perform the exam instead.
In addition, among facilities that have examiners available, the number of  examiners available varies and may not provide enough capacity for  facilities to offer examiner coverage 24 hours, 7 days a week, according  to state STOP administrators and coalition officials we interviewed.  Nebraska coalition officials, for example, told us that while one hospital in  Omaha has a team of 26 examiners available, other facilities in the state  may have as few as three examiners available. Further, Florida coalition  officials and the Colorado STOP administrator told us that there are few  facilities in their states able to offer full coverage with examiners available  24 hours, 7 days a week. For example, Memorial Hospital in Colorado  Springs is the only facility in Colorado that has enough examiners  available to provide examiners on-staff 24 hours a day, 7 days a week,  according to Colorado officials we interviewed. Staff from a rural hospital  in Oregon explained that although it has two on-call examiners and one  additional examiner available if needed, there are not enough examiners  available to provide on-call coverage 24 hours, 7 days a week.
According to state STOP administrators and coalition officials we  interviewed in six selected states, health care facilities may have their  own protocols in place concerning the expected response time of on-call  examiners, transferring victims to facilities that have examiners available,  and paging on-call examiners. Florida coalition officials as well as the  Massachusetts and Oregon STOP administrators told us, for example,  that facilities with examiners available may have an agreement in place  that specifies the expected response time of examiners. State STOP  administrators or coalition officials we interviewed in five of six selected  states told us that, in general, examiners are expected to arrive at a  facility within 30 minutes to 1 hour of being paged in urban areas, though  it could take longer in rural areas. Some STOP administrators or coalition  officials in selected states informed us that facilities that do not have  examiners available may transfer or encourage victims to go to another  facility with examiners available, or they may be treated by an untrained  medical professional. One coalition official noted that victims who are  referred elsewhere for exams often do not follow through and thus never  receive an exam. This may be because, according to Florida coalition  officials, victims may be responsible for transporting themselves or they  may be transported on a case-by-case basis by law enforcement. Last,  officials told us that the timing of when on-call examiners are paged  varies. For example, Colorado and Florida officials told us that, if a victim  is being transported to another hospital, the destination facility may not  page the on-call examiner until the victim has arrived. However, officials  from one hospital in rural Oregon and Wisconsin coalition officials  explained that, in their states, local law enforcement will notify the  destination hospital when a victim is being transported to their hospital so  that an examiner can be paged in advance.
section_title: Selected States Faced Challenges Training Examiners, Maintaining Stakeholder Support, and Retaining Examiners
paragraphs: According to state STOP administrators and state sexual assault coalition  officials we interviewed in six selected states, maintaining a supply of  trained examiners that meets communities’ needs for exams is  challenging for multiple reasons, including the limited availability of  training, a lack of technical assistance and other resources, weak  stakeholder support for examiners, and low examiner retention. In order  to address these challenges, state officials told us that they have  employed a variety of strategies, such as offering web-based training  courses or clinical guidance or support for examiners, clinical practice  labs, mentorship programs, and developing multidisciplinary teams within  communities that respond to cases of sexual assault.
Limited availability of training. Officials in five of six selected states told  us that the limited availability of classroom, clinical, or continuing  education training is a barrier to maintaining a supply of trained  examiners. Regarding classroom training, some officials told us that  training may only be offered once per year in their states. Additionally,  officials from both Florida and IAFN told us that there is a need for  qualified instructors to run training sessions. Experts and officials from  Colorado, Nebraska, and Oregon also told us that medical professionals  in rural areas may have difficulty completing the clinical training  necessary to become an examiner. Obtaining clinical experience, such as  performing exams under the supervision of a trained examiner, is a  particular challenge in rural areas where hospitals may treat only a few  sexual assault cases per year. One official in Nebraska told us that  trained examiners in rural areas might not feel competent to perform  exams due to the low number of cases they treat. A lack of continuing  education opportunities may also pose a challenge for examiners in  maintaining the skills necessary to perform exams. For example, the  National Sexual Violence Resource Center (NSVRC) reported that, based  on common challenges identified through a survey of and group  discussions among examiner program coordinators, maintaining  competency may be difficult for nurses in rural areas due to a low volume  of patients presenting in need of exams and limited access to ongoing  and advanced training.
Officials told us that they have been able to increase the availability of  examiner training through alternative training methods such as web- based training courses and simulated clinical training. For example,  officials in Colorado told us that their state’s web-based examiner training  program has made training less expensive and has increased examiner  recruitment. Officials in Wisconsin told us that they developed a clinical  training lab that allows examiners to gain hands-on experience by  performing elements of exams on models who are experienced teaching  assistants and hired for the purpose of training new examiners. Further, in  2014, a DOJ-funded evaluation of examiner training programs found that  a web-based training course may help increase the availability of trained  examiners; the study also found that implementing web-based training  had benefits such as decreasing the costs associated with attending in- person training, expanding training opportunities to remote areas, and  allowing examiners to be trained by national experts.
Lack of technical assistance and other supportive resources.  Officials in four of six selected states told us that the limited availability of  technical assistance and other supportive resources for examiners poses  a challenge to maintaining a supply of trained examiners. For example,  officials in Florida, Nebraska, Oregon, and Wisconsin explained that, in  general, there is a lack of mentorship opportunities and leadership within  the examiner community. Officials also noted that the sustainability of  examiner programs may be threatened by a lack of internal capacity,  such as not having a full-time, paid examiner program coordinator  available. Further, in its survey of and group discussions with examiner  program coordinators, NSVRC found that examiners and examiner  programs needed technical assistance and support in the following areas:  aspects of performing exams, training, leadership development and policy  issues, and examiner program sustainability. Specifically, examiners  needed technical assistance and support on topics such as testifying in  court; professional development; performing certain types of procedures,  such as a colposcopy or anogenital photography; and working with  special populations.
Officials we spoke to told us about strategies that can be used to increase  support for examiners and examiner programs, such as offering web- based technical assistance. For example, officials in Massachusetts told  us that through their National Sexual Assault TeleNursing Center, trained  SANEs provide remote clinical guidance to two hospitals in the state that  do not have trained examiners available. In addition, officials from  Colorado told us that an examiner program coordinator in an urban  hospital in the state provides volunteer on-call technical assistance and  clinical guidance to examiners in rural parts of the state, where those  resources are not otherwise available. Further, one study we reviewed  found that several states were engaged in promising practices to increase  support for examiners, such as implementing state-wide mentorship  programs, developing regional examiner list-serves and online discussion  boards, creating formal leadership positions with in the examiner  community, and requiring examiner program evaluations.
Weak stakeholder support for examiners. Officials in five of six  selected states told us that limited stakeholder support for examiners and  examiner programs, such as from hospitals and law enforcement, is a  challenge to maintaining a supply of trained examiners. Some officials  told us that hospitals may be reluctant to support examiners and  examiner programs due to a low number of sexual assault cases treated  each year. As a result, medical professionals may have to cover the cost  of their examiner training courses themselves, including their travel and  lodging expenses, and face lost wages associated with attending training.  One official told us that hospitals may be reluctant to send nurses to  examiner training as it takes away from their regular shift availability.  Additionally, some hospitals do not pay examiners to be on-call. Officials  in three states told us that hospitals typically either do not pay examiners  to be on-call or pay on-call examiners significantly less than other on-call  medical professionals. For example, one official in Wisconsin estimated  that some examiners in their state receive between $1.00 and $1.50 per  hour when on-call while others are not paid for on-call time. Officials from  the American Hospital Association, when asked about whether they have  developed any requirements, policies, or protocols concerning the training  of or access to examiners in hospitals, told us that the association has not  produced any information in this area.
Apart from hospital support, officials in Colorado and Oregon explained  that there is a need for more multidisciplinary support for examiners, such  as increased law enforcement, prosecutor, and first responder  understanding of examiners’ role. The literature we reviewed also shows  that ambiguity around the role of the examiner in responding to sexual  assault, may be a source of conflict between examiners and other  professionals. For example, examiners were found to have experienced  instances where victim advocates or law enforcement questioned  examiners’ medical decisions, speed of evidence collection, or asked  examiners to comment on the credibility of a victim’s case. One nationally  representative survey of examiner programs found that examiner program  coordinators felt that ongoing education of community stakeholders on  sexual assault and examiner programs was needed due to high turnover  in staff at relevant community institutions and agencies, such as law  enforcement officers, victim advocates, and prosecutors.
Through our interviews with officials, we learned of strategies that  selected states have used to increase or mitigate limited stakeholder  support for examiners and examiner programs. For example, officials in  Colorado, Florida, Nebraska, Oregon, and Wisconsin told us that sexual  assault response teams have been developed in their states to help  community stakeholders to understand examiners’ role and better  coordinate to meet the medical and legal needs of sexual assault victims.  Further, a 2005 nationally representative survey of examiner program  coordinators found that some programs addressed limited stakeholder  support for examiner training by negotiating with employers to count  training as paid work. Officials in Colorado also suggested that one  strategy to mitigate limited hospital support for examiners would be to  partner with non-hospital facilities such as health clinics that might  support examiner programs.
Low examiner retention rates. Officials in four of six selected states told  us that low examiner retention rates can be an impediment to maintaining  a supply of trained examiners. In addition to the challenges of limited  training opportunities, technical assistance and other supportive  resources, and stakeholder support for examiners, the physically and  emotionally demanding nature of examiner work contributes to low  examiner retention rates. Further, studies have indicated that  dissatisfaction with compensation, long work hours, and lack of support,  among other things, may contribute to examiner burnout. Examiners  typically work on-call in addition to their full time jobs as, for example,  emergency department nurses. Officials in Florida told us that examiners  may be on-call for 6-hour, 12-hour, or even 24-hour shifts. Further, one  survey of examiner programs in Maryland found that examiners were  required to be on-call for an average of 159 hours per month. Wisconsin  officials estimated that although 540 SANEs were trained over a 2-year  period, only 42 (less than 8 percent) were still practicing in the state at the  end of those 2 years. In addition, the 2005 survey of examiner program  coordinators found that nearly two-thirds believed that examiner staffing,  generally, was a challenge and nearly a third believed that SANE  retention was a challenge.
section_title: Agency Comments
paragraphs: We provided a draft of this report to DOJ for review. DOJ provided  technical comments that we incorporated as appropriate.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  appropriate congressional committees, the Attorney General of the United  States, and other interested parties. In addition, the report is available at  no charge on the GAO website at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or IritaniK@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 key contributions to this report  are listed in appendix II.
section_title: Appendix I: State Data on Federal Grantees That Provided Training for Sexual Assault Forensic Examiners and the Number of Examiners Who Received Training
paragraphs: The following three tables show the number of grantees that used funding  to provide training for examiners and the number of examiners who  received training by federal grant program and state in 2013 and, where  available, 2014.
section_title: Appendix II: GAO Contact and Staff Acknowledgements
subsections: section_title: GAO Contact
section_title: Staff Acknowledgements
paragraphs: In addition to the contact named above, Kristi Peterson (Assistant  Director), Leia Dickerson, Katherine Mack, Laurie Pachter, and Emily  Wilson made key contributions to this report.