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entitled 'Indian Health Service: Continued Efforts Needed to Help 
Strengthen Response to Sexual Assaults and Domestic Violence' which 
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United States Government Accountability Office: 
GAO: 

Report to Congressional Committees: 

October 2011: 

Indian Health Service: 

Continued Efforts Needed to Help Strengthen Response to Sexual 
Assaults and Domestic Violence: 

GAO-12-29: 

GAO Highlights: 

Highlights of GAO-12-29, a report to congressional committees. 

Why GAO Did This Study: 

The Justice Department has reported that Indians are at least twice as 
likely to be raped or sexually assaulted as all other races in the 
United States. Indians living in remote areas may be days away from 
health care facilities providing medical forensic exams, which collect 
evidence related to an assault for use in criminal prosecution. The 
principal health care provider for Indians, which operates or funds 
tribes to operate 45 hospitals, is the Department of Health and Human 
Services’ Indian Health Service (IHS). 

In response to a Tribal Law and Order Act of 2010 mandate, GAO 
examined (1) the ability of IHS and tribally operated hospitals to 
collect and preserve medical forensic evidence involving cases of 
sexual assault and domestic violence, as needed for criminal 
prosecution; (2) what challenges, if any, these hospitals face in 
collecting and preserving such evidence; and (3) what factors besides 
medical forensic evidence contribute to a decision to prosecute such 
cases. GAO surveyed all 45 IHS and tribally operated hospitals and 
interviewed IHS and law enforcement officials and prosecutors. 

What GAO Found: 

GAO’s survey of IHS and tribally operated hospitals showed that the 
ability of these hospitals to collect and preserve medical forensic 
evidence in cases of sexual assault and domestic violence-—that is, to 
offer medical forensic services-—varies from hospital to hospital. Of 
the 45 hospitals, 26 reported that they are typically able to perform 
medical forensic exams on site for victims of sexual assault on site, 
while 19 reported that they choose to refer sexual assault victims to 
other facilities. The hospitals that provided services began to do so 
generally in response to an unmet need, not because of direction from 
IHS headquarters, according to hospital officials. Partly as a result, 
levels of available services have fluctuated over time. GAO found that 
the utility of medical forensic evidence in any subsequent criminal 
prosecution depends on hospital staff’s properly preserving an 
evidentiary chain of custody, which depends largely on coordinating 
with law enforcement agencies. 

IHS has made significant progress since 2010 in developing required 
policies and procedures on medical forensic services for victims of 
sexual assault; nevertheless, challenges in standardizing and 
sustaining the provision of such services remain. In March 2011, IHS 
took a sound first step in what is planned to be an ongoing effort to 
standardize medical forensic services by issuing its first agencywide 
policy on how hospitals should respond to adult and adolescent victims 
of sexual assault. Remaining challenges include systemic issues such 
as overcoming long travel distances between Indian reservations or 
Alaska Native villages and IHS or tribal hospitals and developing 
staffing models that overcome problems with staff burnout, high 
turnover, and compensation, so that standardized medical forensic 
services can be provided over the long term. In addition, other 
challenges include establishing plans to help ensure that IHS 
hospitals consistently implement and follow the March 2011 policy, 
such as with training guidelines, and developing policies on how IHS 
hospitals should respond to domestic violence incidents and sexual 
abuse involving children who have not yet reached adolescence-—neither 
of which is included in the March 2011 policy. GAO found that IHS is 
aware of these challenges and has initiatives under way or under 
consideration to address them. 

Decisions to prosecute sexual assault or domestic violence cases are 
based on the totality of evidence, one piece of which is medical 
forensic evidence collected by hospitals. In some cases, medical 
forensic evidence may be a crucial factor; in other cases, however, it 
may not be relevant or available. Law enforcement officers and 
prosecutors said that they also consider several other factors when 
deciding to refer or accept a case for prosecution. For example, some 
victims in small reservations or isolated villages may refuse to 
cooperate or may retract their initial statements because of pressure 
from community members who may depend on the alleged perpetrator for 
necessities. As a result, the victim may be unavailable to testify. 
Several prosecutors also told us that the availability to testify of 
the providers who perform medical forensic exams is an important 
factor, because such testimony can help demonstrate that an assault 
occurred or otherwise support a victim’s account. IHS’s March 2011 
policy, however, does not clearly and comprehensively articulate the 
agency’s processes for responding to subpoenas or requests for 
employee testimony. 

What GAO Recommends: 

GAO is making five recommendations aimed at improving IHS’s response 
to sexual assault and domestic violence, including to develop an 
implementation and monitoring plan for its new sexual assault policy 
and to modify sections of the policy regarding required training and 
subpoenas or requests to testify. The Department of Health and Human 
Services and the state of Alaska generally agreed with GAO’s findings 
and recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-12-29] or key 
components. For more information, contact Carolyn L. Yocom at (202) 
512-7114 or yocomc@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

IHS's Ability to Collect and Preserve Medical Forensic Evidence Varies 
by Hospital: 

IHS and Tribal Hospitals Face Several Challenges in Standardizing and 
Sustaining the Provision of Medical Forensic Services: 

Factors besides Medical Forensic Evidence also Contribute to Decisions 
to Prosecute Cases of Sexual Assault and Domestic Violence: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: GAO Survey of 45 IHS and Tribally Operated Hospitals: 

Appendix III: Summary of Key Survey Results on Provision of Medical 
Forensic Services for Sexual Assault Victims: 

Appendix IV: Comments from the Department of Health and Human Services: 

Appendix V: Comments from the State of Alaska: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Jurisdiction over Crimes in Indian Country Where the Federal 
Government Has Not Conferred Jurisdiction on a State: 

Table 2: Number of IHS and Tribally Operated Hospitals Performing 
Sexual Assault Medical Forensic Exams or Referring to Other 
Facilities, as of June 2011: 

Table 3: Number of Hospitals That Reported They Typically Perform 
Sexual Assault Medical Forensic Exams and Level of Training Received 
by Providers: 

Figures: 

Figure 1: General Steps from Assault through Prosecution: 

Figure 2: Steps in Collecting and Preserving Medical Forensic Evidence: 

Figure 3: Locations of the 45 IHS and Tribally Operated Hospitals: 

Figure 4: Items Used in Traditional Healing: 

Figure 5: Location of Remote and Urban Hospitals Performing Sexual 
Assault Medical Forensic Exams or Referring to Other Facilities: 

Figure 6: Small Ambulance Serving Remote Alaska Native Village: 

Figure 7: Two-Flight Itinerary from a Remote Alaska Native Village 
When Victims Need Medical Forensic Services: 

Figure 8: Locking Storage Cabinet for Medical Forensic Evidence: 

Abbreviations: 

FBI: Federal Bureau of Investigation: 

IHS: Indian Health Service: 

SANE: sexual assault nurse examiner: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

October 26, 2011: 

The Honorable Daniel Akaka:
Chairman:
The Honorable John Barrasso:
Vice Chairman:
Committee on Indian Affairs:
United States Senate: 

The Honorable Don Young:
Chairman:
The Honorable Dan Boren:
Ranking Member:
Subcommittee on Indian and Alaska Native Affairs:
Committee on Natural Resources:
House of Representatives: 

The Department of Justice has reported that Indians are at least twice 
as likely to be raped or sexually assaulted as all other races in the 
United States and that one in three Indian women have reported being 
raped at some time in their life.[Footnote 1] Similarly, over one-
third of Indian women and one-eighth of Indian men in the United 
States will experience domestic violence.[Footnote 2] Some Indians who 
are victims of sexual assault, domestic violence, or child abuse live 
in urban areas, but many live on rural reservations or in remote, 
isolated Alaska Native villages. For people in rural or remote areas, 
it can take hours--and sometimes days--to reach the closest medical 
provider who can not only treat their injuries, but also perform a 
medical forensic exam to collect assault-related evidence for use in 
the criminal justice system. 

The Department of Health and Human Services' Indian Health Service 
(IHS) is the principal federal health care provider for approximately 
1.9 million Indians across 35 states.[Footnote 3] IHS headquarters 
oversees 12 area offices representing the agency's different regions 
and either directly operates or provides funding to tribes or tribal 
organizations to operate approximately 1,200 facilities. These 
facilities include hospitals, clinics, health centers, school health 
centers, health stations, dental clinics, alcohol substance abuse 
treatment facilities, behavioral health facilities, and others. Across 
the United States, IHS provides direct medical care at its facilities, 
including primary care services and some specialty services, such as 
treatment and prevention of diabetes, and operates or provides funding 
to tribes to operate 45 hospitals, providing services to Indians from 
over 560 tribes.[Footnote 4] 

IHS defines sexual assault as sexual contact without consent, and it 
defines domestic violence as abusive behavior involving intimate 
partners or family members or household members that is used to gain 
or maintain power and control over another intimate partner or family 
member or household member.[Footnote 5] Victims of sexual assault and 
domestic violence can typically receive a sexual assault medical 
forensic examination in a hospital.[Footnote 6] A 2007 report by the 
human-rights organization Amnesty International USA called for 
Congress to increase IHS funding to ensure that victims of sexual 
assault and domestic violence can receive more timely medical forensic 
examinations and that proper protocols are followed for collecting and 
preserving evidence related to these crimes.[Footnote 7] 

Tribal, state, or federal governments may each have jurisdiction to 
prosecute those who commit crimes in Indian country,[Footnote 8] 
depending on several factors, including the nature of the crime and 
whether the victim or alleged perpetrator is Indian. For example, the 
federal government and tribal governments have jurisdiction to 
prosecute sexual assault crimes committed by Indians in Indian country 
in almost all states in which IHS has hospitals. For crimes prosecuted 
by the federal government, investigating agencies include Justice's 
Federal Bureau of Investigation (FBI) or the Department of the 
Interior's Bureau of Indian Affairs, and the crimes are prosecuted by 
1 of the 94 U.S. Attorneys' Offices. 

Victims of sexual assault or domestic violence may arrive at an IHS 
hospital in various ways: an ambulance may transport them, law 
enforcement officers may bring them, or they may arrive on their own. 
They may arrive immediately after an assault (such cases are typically 
referred to as acute cases) or weeks, months, or years later (delayed 
or nonacute cases). Thus begins a series of steps that--if proper 
protocols are followed, and the appropriate "chain of custody" of the 
evidence is maintained, among other factors--may ultimately lead to a 
decision to prosecute (see figure 1). 

Figure 1: General Steps from Assault through Prosecution: 

[Refer to PDF for image: process illustration] 

Victim assaulted: 

Victim contacts law enforcement; 
Law enforcement transports victim to hospital; 

or: 

Victim arrives at hospital; 
Hospital may notify law enforcement[A]. 

Hospital staff collects and preserves medical forensic evidence. 

Hospital staff transfers evidence to law enforcement. 

Law enforcement investigates case and may refer investigation to 
prosecutor. 

Prosecutor reviews investigation and determines whether to file a case 
in court or decline to prosecute. 

Source: GAO. 

[A] Hospital notifies law enforcement immediately; later; or, if 
victim chooses to remain anonymous, not at all. For cases involving 
children, hospitals may have a legal duty to notify appropriate 
authorities. 

[End of figure] 

Given consent by the victim, medical providers generally collect 
medical forensic evidence through a medical forensic examination that 
may follow steps and use supplies from a sexual assault evidence 
collection kit; the collected evidence is preserved until law 
enforcement takes possession of it. Under Justice's national protocol 
for sexual assault medical forensic exams,[Footnote 9] medical 
providers may collect a range of physical evidence, including but not 
limited to clothing, foreign materials on the body, hair (including 
head and pubic hair samples and combings), body swabs, and a blood or 
saliva sample for DNA analysis and comparison. In addition, medical 
forensic exams typically include documenting biological and physical 
findings such as cuts or bruises, through either writing or 
photographs, and recording a victim's medical forensic history such as 
the time and nature of the assault. This exam can take several hours. 
Once the exam is completed, medical providers preserve the collected 
evidence according to jurisdictional policies, which may include 
procedures for packaging, labeling, and sealing evidence collection 
kits and storing the kits in a secure location (see figure 2). For 
cases of domestic violence, medical providers typically do not perform 
a sexual assault medical forensic exam unless a sexual assault has 
also occurred. Instead, medical providers, and sometimes law 
enforcement officers, generally record a victim's statement of the 
incident and document injuries through writing or photographs. 

Figure 2: Steps in Collecting and Preserving Medical Forensic Evidence: 

[Refer to PDF for image: process illustration] 

Does hospital perform medical forensic exams? 
If yes, continue; 
If no: Hospital refers victim to another facility. 

Hospital staff perform exam to collect medical forensic evidence. 

Hospital staff preserve and secure evidence. 

Is law enforcement available? 
If yes: Hospital transfers evidence to law enforcement; 
If no: Hospital secures evidence until law enforcement takes 
possession. 

Source: GAO analysis of IHS information. 

[End of figure] 

The Tribal Law and Order Act of 2010--whose purpose was, among other 
things, to combat sexual and domestic violence against American Indian 
and Alaska Native women--mandated that we study the capability of IHS 
facilities in remote Indian reservations and Alaska Native villages to 
collect, maintain, and secure evidence of sexual assaults and domestic 
violence, as required for criminal prosecution.[Footnote 10] In 
response to the mandate and subsequent discussion with offices of the 
relevant congressional committees of jurisdiction, this report 
examines (1) the ability of IHS and tribally operated hospitals to 
collect and preserve medical forensic evidence for use in criminal 
prosecution in sexual assault and domestic violence cases; (2) what 
challenges, if any, these hospitals face in collecting and preserving 
such evidence, particularly in remote Indian reservations and Alaska 
Native villages; and (3) what factors besides medical forensic 
evidence collected by these hospitals contribute to a decision to 
prosecute such cases. 

For all three objectives, we collected and analyzed laws, regulations, 
and agency policies relevant to the collection and preservation of 
medical forensic evidence by IHS and tribally operated hospitals in 
cases of sexual assault and domestic violence, and we interviewed and 
gathered relevant documentation from headquarters officials at IHS, 
the Bureau of Indian Affairs, Justice, and the state of Alaska. In 
addition, we conducted over 60 semistructured interviews with several 
groups of stakeholders, including staff from IHS and tribally operated 
hospitals, victim advocacy groups, prosecutors, and law enforcement. 
Specifically, we conducted semistructured interviews with stakeholders 
(1) from hospital staff during site visits to a nonprobability sample 
of 8 IHS or tribally operated hospitals in Alaska, Arizona, and South 
Dakota and over the telephone with an additional nonprobability sample 
of 7 IHS or tribally operated hospitals in Arizona, Minnesota, 
Montana, New Mexico, North Dakota, and Oklahoma and (2) from victim 
advocacy groups; federal and state prosecutors; and federal, state, 
local, and tribal law enforcement agencies that play a role in 
responding to and prosecuting sexual assault and domestic violence 
cases in most of the locations these 15 hospitals serve.[Footnote 11] 
For these semistructured interviews, we spoke with officials about 
hospitals that (a) are performing medical forensic exams, (b) are 
developing the ability to perform such exams, and (c) are not 
performing such exams.[Footnote 12] In addition, to identify the 
ability of IHS and tribally operated hospitals to collect and preserve 
medical forensic evidence, we used a self-administered questionnaire 
to survey all 45 IHS or tribally operated hospitals. We received a 100 
percent response rate. To determine which of these hospitals are 
located in remote areas, we used rural-urban commuting area codes for 
isolated and small rural communities developed on the basis of U.S. 
Census tracts by the Department of Agriculture's Economic Research 
Service. We obtained data from IHS on the location and names of its 
hospitals, as well as data on hospital visits by IHS beneficiaries 
from fiscal year 2006 through fiscal year 2010. To assess the 
reliability of the data, we interviewed knowledgeable IHS officials 
and performed electronic testing. We determined that the data were 
sufficiently reliable to meet the objectives of this engagement. 
Appendix I presents a more detailed description of our scope and 
methodology. 

We conducted this performance audit from October 2010 through October 
2011, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

Of the 45 IHS hospitals, 28 are directly operated by IHS, and 17 are 
operated by tribes through funds provided by IHS (see figure 3). 
Specifically, under the Indian Self-Determination and Education 
Assistance Act, as amended, IHS provides funds to tribes to run their 
own hospitals through self-determination contracts or self-governance 
compacts.[Footnote 13] For example, the tribes in Alaska operate 7 
regional hospitals and 165 village clinics, mainly through a variety 
of regional health consortiums that provide services to groups of 
tribes. These self-determination contracts and self-governance 
compacts implement the act's commitment to effective and meaningful 
participation by the Indian people in the planning, conduct, and 
administration of health programs and services. IHS manages its 
facilities and staff, including the hospitals it directly operates and 
its direct staff, through the Indian Health Manual, among other 
things. This document serves as the primary reference for IHS 
employees on IHS-specific policy and procedures. In accordance with 
the Indian Self-Determination and Education Assistance Act as amended, 
however, the self-determination contracts and self-governance compacts 
under which tribes operate hospitals do not generally require 
compliance with IHS policy. Therefore, IHS policies and procedures--
including those laid out in the Indian Health Manual--do not generally 
apply to tribally operated facilities, although they can be used as 
models on which to base local tribal protocols. 

Figure 3: Locations of the 45 IHS and Tribally Operated Hospitals: 

[Refer to PDF for image: illustrated U.S. map] 

Geographic locations of the following are depicted on the map: 

IHS Hospital (28); 
Tribal Hospital (17). 

Source: GAO analysis and Map-Info (map). 

[End of figure] 

With regard to sexual assault, IHS's Indian Health Manual states that 
a person cannot give consent to sexual contact if she or he is forced, 
threatened, coerced, drugged, inebriated, or unconscious; has certain 
disabilities; or is a minor. We use the term sexual assault to refer 
to the federal sex abuse felonies and attempts to commit them--that 
is, sexual abuse and aggravated sexual abuse, abusive sexual contact, 
or sexual abuse of children. This category includes what is commonly 
known as molestation and rape, including (1) cases where the alleged 
perpetrator uses force or threats, renders the victim unconscious, or 
administers drugs or other intoxicants that substantially impair the 
victim and (2) cases where the victim is incapable of appraising the 
nature of the conduct or is physically incapable of declining to 
participate or of communicating unwillingness to engage in the sexual 
act. With regard to domestic violence, IHS's Indian Health Manual 
states that domestic violence can involve physical, sexual, emotional, 
economic, or psychological actions or threats of actions that 
influence another person. Domestic violence includes any behaviors 
that intimidate, manipulate, humiliate, isolate, frighten, terrorize, 
coerce, threaten, blame, hurt, injure, or wound someone. We use the 
term domestic violence to refer to all major crimes as defined in the 
Major Crimes Act between intimate partners or family members, 
including elders and spouses. Domestic violence also includes major 
crimes against children that are not sexual in nature. 

A medical provider specially trained in medical forensic examination 
may perform such an exam in cases of sexual assault or domestic 
violence, and law enforcement officers may interview the victim for 
his or her account of what happened.[Footnote 14] Medical providers 
typically perform such exams only for acute cases of sexual assault, 
where the assault occurred within the previous 72 to 96 hours--when 
such evidence is considered most viable--because physical and 
biological evidence on a person's body or clothes degrades over time, 
becoming unviable or too contaminated to be used. The standard of 
practice for how long such evidence is viable changes as scientific 
advancements are made, with some jurisdictions now performing medical 
forensic exams up to 7 days after an assault. In terms of sexual 
assaults, Justice's protocols describe two types of specially trained 
medical providers who conduct sexual assault medical forensic exams: 

* Sexual assault nurse examiner (SANE): a registered nurse who has 
received specialized education and has fulfilled clinical requirements 
to perform sexual assault medical forensic exams. 

* Sexual assault forensic examiner: a health care provider, including 
a physician or physician assistant, who has been specially educated 
and has completed clinical requirements to perform sexual assault 
medical forensic exams (in the same way a nurse is trained to become a 
SANE). 

The term SANE refers to registered nurses, a category including nurse 
midwives and other advanced practice nurses, among other providers; 
the term sexual assault forensic examiner refers more broadly to 
medical providers including registered nurses plus physicians, 
physician assistants, and nurse practitioners. Justice's protocol 
encourages certification of SANEs, but certification as a SANE is 
available only to registered nurses. No such national or international 
certification exists for sexual assault forensic examiners who are not 
registered nurses. Registered nurses can be certified as SANEs through 
the International Association of Forensic Nurses to perform exams for 
adult and adolescent sexual assault victims or to perform exams in 
cases of sexual assault of children who have not reached puberty. 
[Footnote 15] Nurses can become certified by meeting the association's 
eligibility requirements; completing a didactic training curriculum; 
and successfully completing a certification examination covering 
several topics, such as how to assess sexual assault patients, how to 
collect and document evidence in a way that protects the evidence's 
integrity, and how to testify about findings or chain of 
custody.[Footnote 16] Beyond cases of sexual assault, medical 
providers who are specially educated as forensic nurse examiners are 
able to collect forensic evidence for a variety of crimes other than 
or in addition to those involving sexual assault, such as in injury 
associated with domestic violence. 

Additionally, for child victims, medical providers may perform medical 
forensic exams and gather medical history in the hospital, or the 
child may be interviewed elsewhere at a child-specific facility such 
as a child advocacy center. Such facilities typically use a 
multidisciplinary, team approach to minimize the number of times a 
child is interviewed and to ensure that those individuals involved in 
the child's life, such as parents or guardians and social services 
providers, are working together. 

Jurisdiction for investigating and prosecuting crimes in Indian 
country is complex and depends on, among other factors, the nature of 
the crime and whether the victim or alleged perpetrator is Indian (see 
table 1). The federal government, rather than the state government, 
has criminal jurisdiction in Indian country in almost all states where 
IHS or tribes operate hospitals.[Footnote 17] When the alleged 
perpetrator of a crime in Indian country is an Indian, tribal 
governments also have criminal jurisdiction.[Footnote 18] As a result, 
the FBI, the Bureau of Indian Affairs, or tribal investigators conduct 
criminal investigations of sexual assault and domestic violence. Once 
the investigation or preliminary facts are reviewed, the decision is 
made as to whether the investigation should be referred to the U.S. 
Attorneys' Offices, the tribe, or both for possible prosecution. 
Prosecutors in the U.S. Attorneys' Offices decide whether to accept 
the matter for criminal prosecution in federal court. We previously 
reported that receipt of a law enforcement referral does not mean that 
a prosecutable case exists at the time the referral is made and that, 
upon further investigation, prosecutors may file the matter for 
prosecution as a case in court, decline to prosecute the matter, or 
refer the matter to tribal prosecutors.[Footnote 19] As we reported in 
February 2011, because of tribes' limited jurisdiction and sentencing 
authority, tribes often rely on the federal government to investigate 
and prosecute serious offenses, since a successful federal prosecution 
could result in a longer sentence than tribal courts might impose, 
even where tribal jurisdiction exists.[Footnote 20] 

Table 1: Jurisdiction over Crimes in Indian Country Where the Federal 
Government Has Not Conferred Jurisdiction on a State: 

Involved parties: Indian perpetrator and Indian victim; 
Federal[A]: Major crimes[B]; 
Tribal: Nonmajor crimes and major crimes (concurrent with federal); 
State: None. 

Involved parties: Indian perpetrator and non-Indian victim; 
Federal[A]: Major crimes (plus crimes included in the Indian Country 
Crimes Act[C] and Assimilative Crimes Act[D]); 
Tribal: Nonmajor crimes and major crimes (concurrent with federal); 
State: None. 

Involved parties: Non-Indian perpetrator and Indian victim; 
Federal[A]: Crimes included in the Indian Country Crimes Act and 
Assimilative Crimes Act; 
Tribal: None; 
State: None. 

Involved parties: Non-Indian perpetrator and non-Indian victim; 
Federal[A]: None; 
Tribal: None; 
State: Nonmajor crimes and major crimes. 

Source: Department of Justice, United States Attorneys' Manual 
(Washington. D.C.: 1997), and GAO analysis of relevant statutory 
provisions. 

[A] Specific statutes also grant the federal government criminal 
jurisdiction over certain sexual assault and domestic violence crimes 
in Indian country. For example, under 18 U.S.C. § 117, the federal 
government has criminal jurisdiction over persons who commit domestic 
assault in Indian country and who have two final convictions in 
federal, state, or tribal court for assault, sexual abuse, serious 
violent felony against a spouse or intimate partner, domestic 
violence, or stalking. 

[B] The Major Crimes Act, as amended, provides the federal government 
with criminal jurisdiction over Indians charged with certain specified 
crimes regardless of whether the victim is Indian. 18 U.S.C. § 
1153(a). Major crimes relevant for this review include murder, 
manslaughter, kidnapping, maiming, sexual abuse felonies and attempts 
to commit them, incest, assaults with the intent to murder or with 
dangerous weapons, assaults resulting in serious bodily injury, 
assaults against someone younger than 16 years, and felony child abuse. 

[C] 18 U.S.C. § 1152. The Indian Country Crimes Act, also known as the 
General Crimes Act or Federal Enclaves Crime Act, extends the criminal 
laws of the federal government into Indian country and establishes 
federal criminal jurisdiction over crimes committed where either the 
alleged offender or the victim, but not both, is Indian, unless the 
alleged offender was punished by the tribal government, or a treaty 
grants the tribe exclusive jurisdiction over the offense. 

[D] 18 U.S.C. § 13. Under the Assimilative Crimes Act, if a person 
allegedly commits an offense in an area where the federal government 
has criminal jurisdiction, such as in certain parts of Indian country, 
that has not been defined in federal law but has been defined in state 
law, the federal government can prosecute the alleged offender in 
federal court as if the state law offense were a federal law offense. 

[End of table] 

In some states, however, the federal government has conferred criminal 
jurisdiction over Indian country to the states and renounced federal 
criminal jurisdiction. In these states, only the state and tribes--if 
the alleged perpetrator is an Indian--have jurisdiction to investigate 
and prosecute crimes in Indian country, including sexual assault and 
domestic violence. For example, Public Law No. 83-280, which was 
enacted in 1953, gave six states criminal jurisdiction over crimes 
committed by or against Indians in Indian country and renounced 
federal jurisdiction over those crimes.[Footnote 21] Two of these so-
called mandatory Public Law 280 states--Alaska (which has 225 tribes) 
and California (which has 105 tribes)--contain over half the Indian 
tribes (330 out of 565 tribes) in the United States.[Footnote 22] In 
these six states and certain other states, the state, not the federal 
government, has jurisdiction over crimes in Indian country, and, 
except in Alaska, Indian tribes have concurrent jurisdiction over 
crimes committed by Indians. At the request of a tribe and with 
consent of the U.S. Attorney General, however, the Tribal Law and 
Order Act of 2010, among other things, permits the federal government 
to reassert jurisdiction over certain crimes in Indian country. 
[Footnote 23] In such cases, the federal, state, and tribal 
governments would have concurrent jurisdiction over major crimes 
committed by Indians against Indians and non-Indians. 

In Alaska, generally only the state--not the tribes or federal 
government--has criminal jurisdiction over Alaska Native villages. As 
a result of the Alaska Native Claims Settlement Act and a Supreme 
Court decision finding that Indian country does not generally exist in 
Alaska, neither the tribes nor the federal government has criminal 
jurisdiction, except on the Metlakatla Reservation.[Footnote 24] To 
the extent that Indian country exists beyond the Metlakatla 
Reservation, the federal government lacks criminal jurisdiction 
because of Public Law 280, unless the tribe requests that the federal 
government assume criminal jurisdiction according to the Tribal Law 
and Order Act of 2010. Consequently, the state or municipal government 
is generally responsible for investigating sexual assault and domestic 
violence crimes, and the state is generally responsible for 
prosecuting such crimes. Specifically, Alaska state troopers are 
generally responsible for investigating sexual assault and domestic 
violence crimes in Alaska Native villages, although in some cases, 
municipal police departments are responsible for investigating such 
crimes within city limits. Alaska's Department of Law is responsible 
for prosecuting sexual assault and certain domestic violence crimes. 
[Footnote 25] 

Regardless of jurisdiction, not all victims of sexual assault or 
domestic violence report these incidents to law enforcement or opt to 
receive medical forensic exams. Some stakeholders have identified 
numerous barriers to reporting sexual assault and domestic violence 
incidents, including the negative stigmas associated with being 
sexually assaulted or abused and the potential retribution a victim 
might endure from the alleged perpetrator or community, especially 
when the assaults take place in small communities where members are 
often related or depend on one another for survival. In terms of 
reports to law enforcement agencies, an average of 30.8 forcible rapes 
per every 100,000 persons were reported in the United States from 2004 
through 2009, according to data from Justice's Uniform Crime Reporting 
Program.[Footnote 26] Studies indicate, however, that many sexual 
assaults go unreported nationwide, and the precise number of sexual 
assaults and incidents of domestic violence remains unknown. 

According to data from a Justice study, Indians in 2010 experienced 
violent crimes at over twice the estimated national rate--42 violent 
crimes per 1,000 Indians annually, compared with 15 per 1,000 persons 
nationwide.[Footnote 27] We previously reported that domestic and 
sexual violence against Indian women is among the most critical public 
safety challenges, and also noted that alcohol and drug use often play 
a significant role in such violent crimes.[Footnote 28] Specifically, 
Justice reported that 38 percent of Indian women were subjected to 
domestic violence during their lives and that Indian victims reported 
alcohol use by 62 percent of alleged perpetrators, compared with 42 
percent for all races.[Footnote 29] These issues are of particular 
concern to the state of Alaska, where the governor has made ending 
domestic violence and sexual assault a top priority given that, among 
other things, 76.2 forcible rapes per every 100,000 persons were 
reported to law enforcement agencies from 2004 through 2009, according 
to Uniform Crime Reporting statistics.[Footnote 30] In addition, more 
than 9 percent of adult women in Alaska reported experiencing domestic 
violence, and more than 4 percent reported experiencing sexual 
violence in the past year, according to a state study of 
victimization.[Footnote 31] 

IHS's Ability to Collect and Preserve Medical Forensic Evidence Varies 
by Hospital: 

IHS has limited information on the ability of IHS and tribally 
operated hospitals to collect and preserve medical forensic evidence 
in cases of sexual assault and domestic violence, as needed for 
criminal prosecution--that is, on the hospitals' ability to offer 
medical forensic services. To collect this information, we surveyed 
the 45 IHS and tribally operated hospitals and found that the ability 
to provide these services varies from hospital to hospital, ranging 
from providing a broad array of on-site services, including performing 
medical forensic exams to collect physical and biological evidence, to 
choosing to refer patients to other facilities for such exams. We also 
found that the services available at a hospital generally developed 
without direction from IHS headquarters and have fluctuated over time. 
In addition, the utility of such evidence in any subsequent criminal 
prosecution depends on hospital staff's properly securing and storing 
physical evidence, which may in turn depend largely on coordinating 
with law enforcement agencies. 

IHS Had Limited Information on the Ability of Its Facilities to Offer 
Medical Forensic Services: 

IHS headquarters had limited information on the ability of its 
facilities to provide medical forensic services. We found that IHS 
could not give us comprehensive information about which of its 
facilities--including hospitals and clinics--provided medical forensic 
services for victims of sexual assault and domestic violence, although 
IHS officials identified hospitals as the facilities most likely to 
provide such services. IHS headquarters also could not identify how 
many providers at IHS hospitals have had SANE training or 
certification. In addition, we found that IHS headquarters does not 
centrally track the number of medical forensic exams performed at its 
facilities. In analyzing electronic data obtained from IHS 
headquarters on procedures done at the hospitals, we found that 
because of the way hospitals record these data, it is not possible to 
accurately isolate medical forensic exams from other medical 
activities related to incidents of sexual assault or domestic 
violence.[Footnote 32] IHS does, however, keep centralized data on 
where victims of sexual assault and domestic violence were seen and on 
the primary purpose of these patients' visits.[Footnote 33] 

Hospitals May Perform Medical Forensic Services on Site or Refer 
Victims to Other Facilities: 

The results of our survey of all 45 IHS and tribally operated 
hospitals showed that some hospitals typically provide medical 
forensic exams on site for both adult and child victims of sexual 
assault, others typically perform these exams for either adults or 
children but not both, and still others refer most or all sexual 
assault victims to other facilities (see table 2). 

Table 2: Number of IHS and Tribally Operated Hospitals Performing 
Sexual Assault Medical Forensic Exams or Referring to Other 
Facilities, as of June 2011: 

Hospitals that typically perform medical forensic exams: 

Typically for both adults and children: 
IHS: 4; 
Tribal: 3; 
Total: 7. 

Typically for adults only: 
IHS: 9; 
Tribal: 8; 
Total: 17. 

Typically for children only: 
IHS: 1; 
Tribal: 1; 
Total: 2. 

Subtotal: 
IHS: 14; 
Tribal: 12; 
Total: 26. 

Refer[A]: 
IHS: 14; 
Tribal: 5; 
Total: 19. 

Total: 
IHS: 28; 
Tribal: 17; 
Total: 45. 

Source: GAO survey. 

[A] The hospitals in this row generally refer all victims of sexual 
assault to other facilities. Two hospitals in this category reported 
sometimes performing medical forensic exams for adults, but they 
reported that they may still refer some adults and all children to 
other facilities. The remaining 17 hospitals reported they rarely or 
never perform medical forensic exams and refer all victims to other 
facilities. 

[End of table] 

Specifically, 26 of the 45 hospitals reported that they typically 
perform sexual assault medical forensic exams for adults, children, or 
both. Those hospitals reporting that they perform these exams only for 
adults refer all children to other facilities, and hospitals 
performing exams only for children refer all adults to other 
facilities. Additionally, all IHS and tribally operated hospitals 
reporting that they typically provide exams on site also aim to have 
staff present or on call so they can offer these services 24 hours a 
day, 7 days a week. Two hospitals also explained that they use 
traditional healing practices and objects when treating sexual assault 
victims (see figure 4). The remaining 19 hospitals reported that they 
generally refer all adults and children to other facilities for these 
exams. 

Figure 4: Items Used in Traditional Healing: 

[Refer to PDF for image: photograph] 

Source: GAO (April 2011). 

Note: Pictured items used in traditional healing (center left) include 
sweet grass, sage, and a shell used for burning the dried plants. 

[End of figure] 

Among the seven hospitals that typically perform medical forensic 
exams for both adults and children, one tribally operated hospital in 
Alaska has a dedicated coordinator who has received SANE training and 
is available to perform exams for both adults and children 24 hours a 
day, 7 days a week. A victim of sexual assault who arrives at this 
hospital can typically be examined within a short time and in a room 
dedicated to sexual assault exams. Similarly, an IHS hospital in 
Arizona has a group of approximately 14 nurses and doctors who have 
received specialized training in sexual assault medical forensic 
exams, as well as a room largely dedicated to these exams. When a 
sexual assault victim arrives at this hospital, hospital staff contact 
1 of the 14 nurses or doctors to perform the exam or, if none of these 
medical providers is present, a predesignated backup provider is 
called on. Children requiring an exam generally see a provider, when 
available, who has undergone specialized training in pediatric medical 
forensic exams. 

A total of 19 of 45 hospitals reported typically performing medical 
forensic exams for either adult or child victims of sexual assault but 
not for both. For example, a South Dakota IHS hospital--which offers 
medical forensic services 24 hours a day, 7 days a week, with 
providers on 24-hour call--typically performs medical forensic exams 
for adults but not children. When an adult victim arrives, the 
emergency room does an initial medical screening and then calls one of 
three SANE-trained nurses to perform the medical forensic exam. But 
because this hospital does not have a provider trained to do these 
exams for children, it refers all child victims to a hospital in 
Pierre, which is 2 hours away by car, or to a hospital in Sioux Falls, 
which is 4 hours away. In contrast, an IHS hospital in New Mexico 
performs exams only for children. The providers at this hospital are 
available from 8 a.m. to 4:30 p.m. on weekdays and on call during 
nights and weekends; overall coverage is 24 hours a day, 7 days a week. 

Hospitals that we categorized as being in remote areas[Footnote 34] 
are more likely to perform medical forensic exams and less likely to 
refer victims elsewhere for service than IHS and tribally operated 
hospitals taken as a whole. Of the 34 hospitals categorized as remote, 
22 hospitals reported that they are able to perform medical forensic 
exams for adults, children, or both; 12 of the 34 hospitals reported 
referring victims to other facilities. In contrast, the proportions 
are reversed among the 11 hospitals we categorized as urban, with 7 of 
them reporting that they refer all sexual assault victims to other 
facilities for exams (see figure 5 for map of hospitals). For example, 
officials from an IHS hospital in the Phoenix, Arizona, area explained 
during a site visit that the hospital sees too few sexual assault 
cases to warrant having its own staff trained in performing medical 
forensic exams; in the officials' view, it makes more sense for the 
hospital to leverage existing resources by referring victims to a 
nearby facility offering medical forensic services. 

Figure 5: Location of Remote (top) and Urban (bottom) Hospitals 
Performing Sexual Assault Medical Forensic Exams or Referring to Other 
Facilities: 

[Refer to PDF for image: 2 illustrated U.S. maps] 

Map depicting the locations of Remote hospitals that: 

Performs exams for adults and children (6); 
Performs exams for children only (1); 
Refers victims to other facilities (12); 
Performs exams for adults only (15). 

Map depicting the locations of Urban hospitals that: 

Performs exams for adults and children (1); 
Performs exams for children only (1); 
Refers victims to other facilities (7); 
Performs exams for adults only (2). 

Source: GAO analysis and Map-Info (maps). 

Note: Non-IHS facilities, such as child advocacy centers, also provide 
specialty services to children. For example, the tribally operated 
hospital in Anchorage refers children to the Alaska CARES clinic for 
medical forensic exams. 

[End of figure] 

IHS and tribally operated hospitals vary not only in whether and for 
whom they can provide medical forensic services but also in the 
training their providers have received (see table 3). Of the 26 
hospitals that typically perform medical forensic exams, 20 reported 
having providers who received specialized training or certification in 
sexual assault medical forensic exams. The remaining 6 hospitals 
reported offering medical forensic exams even if the providers 
performing the exams have not received this specialized training. In 
fact, several medical providers told us that traveling doctors and 
nurses, who temporarily work at an IHS hospital for a few weeks or 
months, may perform these medical forensic exams on site even if they 
have not received this specialized training. In discussions with 
hospital officials, we also found that hospitals referring sexual 
assault victims--whether adults or children--to other facilities for 
medical forensic exams may do so because they do not have medical 
providers on staff with this specialized training. 

Table 3: Number of Hospitals That Reported They Typically Perform 
Sexual Assault Medical Forensic Exams and Level of Training Received 
by Providers: 

Hospitals that typically provide medical forensic exams: 

Level of training received by providers: Medical forensic training for 
adults, children, or both[A]; 
Exams for adults and children: 7; 
Exams for adults only: 13; 
Exams for children only: 0; 
Total: 20. 

Level of training received by providers: No SANE training; 
Exams for adults and children: 0; 
Exams for adults only: 4; 
Exams for children only: 2; 
Total: 6. 

Level of training received by providers: Total; 
Exams for adults and children: 7; 
Exams for adults only: 17; 
Exams for children only: 2; 
Total: 26. 

Source: GAO survey. 

[A] This category includes hospitals with providers who have 
specialized training, including SANE training, in medical forensic 
exams. Trained staff are more prevalent than SANE-certified staff. 
Specifically, four hospitals that typically perform exams only for 
adults have SANE-certified staff, as does one hospital that typically 
performs exams for adults and children. 

[End of table] 

Many of the hospitals we surveyed reported that they typically perform 
medical forensic exams in cases of domestic violence. They may do so 
only in cases of domestic violence that also include a sexual 
component or, occasionally, when the injuries sustained from a 
discrete domestic violence incident without a sexual component are 
severe. Officials at several hospitals explained that for discrete 
domestic violence incidents (those that do not include a sexual 
component), law enforcement officers usually collect evidence, such as 
photographs of bruises or other injuries, for use in court. For 
example, officials at two separate hospitals explained that in cases 
of domestic violence, law enforcement officers take photographs of 
physical injuries, and medical providers treat any injuries requiring 
medical attention. 

Medical Forensic Services Have Developed Largely without Central 
Direction: 

In general, efforts to provide medical forensic services at the local 
level have fluctuated over time and have received limited funding from 
IHS. In discussions with hospital officials, we found that the 
provision of medical forensic services generally developed at a 
grassroots level, rather than in response to an explicit requirement 
from IHS headquarters. Local medical providers chose to provide such 
exams in response to an unmet need for such services in their area, 
not because IHS headquarters directed them to do so. For example, a 
nurse at one hospital explained that she and five other nurses 
attended SANE training after recognizing that medical providers at the 
hospital were uncomfortable doing sexual assault medical forensic 
exams. Additionally, an IHS official at another hospital explained 
that his staff began providing medical forensic services after the 
area office requested volunteers to pilot providing such services to 
better meet the area's needs. 

We also found that the ability of an IHS or tribally operated hospital 
to offer medical forensic services has fluctuated over time. Some 
hospitals, for example, have been able to sustain or even expand their 
medical forensic services. In contrast, other hospitals have lost 
staff who were willing or trained to perform medical forensic exams 
and ceased offering these exams entirely or waited until new staff 
could be hired or trained. For example, officials from one hospital 
explained during a follow-up discussion with us that they recently 
ceased performing sexual assault medical forensic exams for adults 
when a shift in staffing resources left the hospital's emergency room 
without providers specially trained in performing such exams. 
Consequently, the hospital now performs medical forensic exams only 
for children and refers adult victims to a private hospital in a 
nearby city, which helps facilitate more consistent and timely 
evidence collection, according to a law enforcement official. 
Similarly, medical providers explained during a site visit that after 
the sole provider of medical forensic exams in a remote Alaskan 
community left, the hospital ceased offering medical forensic exams 
because none of its remaining staff had specialized training. As a 
result, all adults and children have since been flown several hours 
away to Anchorage to receive medical forensic exams. Given the 
importance of providing medical forensic services locally, however, 
the hospital staff said that they recently sent several staff for 
training in sexual assault medical forensic exams and hired someone to 
serve as a coordinator for this effort. 

Furthermore, efforts by IHS headquarters to fund medical forensic 
services have been limited. The agency has provided some funding for 
training and equipment to hospitals or staff, but this funding has 
been infrequent or limited, according to IHS officials. Specifically, 

* Pilot program. In 2002 and 2003, IHS used a grant from Justice to 
fund two of its hospitals--one in Shiprock, New Mexico, and the other 
in Pine Ridge, South Dakota--to pilot offering medical forensic exams 
for adult victims of sexual assault. As part of this pilot program, 
the hospitals received funding to send their providers to SANE 
training and to purchase equipment needed for medical forensic exams, 
such as digital cameras. A hospital official at one of these hospitals 
explained that it still offers medical forensic exams and, to better 
meet patients' needs, is expanding its services to also include a 
clinic more centrally located on the vast reservation, to provide 
services closer to patients' homes. An IHS official at the other pilot-
/program hospital explained that it ceased offering medical forensic 
exams in 2007 after too many of its specially trained medical forensic 
examiners left. This hospital now sends its patients across state 
lines to a private provider. 

* Limited funds for training or equipment. IHS has at times paid for 
staff at some of its hospitals to receive SANE training, but such 
funding was not part of a comprehensive effort to develop medical 
forensic capacity at IHS facilities. From fiscal year 2003 through 
fiscal year 2011, IHS provided $45,000 for three training sessions for 
60 providers. But agency officials also explained that IHS has 
provided no additional funding for hospitals to purchase equipment to 
conduct these exams. According to staff from one IHS hospital, they 
have had to use a digital camera belonging to the local Bureau of 
Indian Affairs law enforcement office to photographically document 
physical injuries as evidence because they did not have funding to 
purchase their own camera. 

* IHS Domestic Violence Prevention Initiative. IHS received a $7.5 
million appropriation for its domestic violence prevention initiative 
in fiscal year 2009 and another $10 million appropriation in fiscal 
year 2010. The Domestic Violence Prevention Initiative expands 
prevention, advocacy, outreach, and medical forensic services in cases 
of domestic violence and sexual assault. Of this total funding, $3.5 
million funded medical forensic services such as exams, and the 
remaining funded prevention, advocacy, outreach, and coordination. In 
fact, of the 65 projects IHS funded through this initiative, 8 
projects aimed to use this money for improving medical forensic 
services at IHS or tribally operated hospitals. Further, seven of 
these eight projects funded hospitals that already had some staff on 
board who were specially trained in providing sexual assault medical 
forensic exams. 

The Preservation of Medical Forensic Evidence Depends in Large Part on 
Hospital Coordination with Law Enforcement: 

The specific policies or procedures that IHS has developed to preserve 
medical forensic evidence vary from hospital to hospital and may 
depend greatly on coordination with the law enforcement officers who 
take possession of the evidence for use in the criminal justice 
system. Improperly securing medical forensic evidence or improperly 
maintaining its chain of custody--that is, the process that 
demonstrates the chronological documentation of the collection, 
custody, control, transfer, analysis, and disposition of the evidence--
can undermine the evidence's usefulness in a criminal investigation or 
prosecution. Consequently, according to Justice protocols, it is 
imperative to properly preserve the evidence collected during a 
medical forensic exam. Proper preservation includes, among other 
things, securing the physical evidence from contamination or 
adulteration, as well as properly following and documenting the chain 
of custody. We found that some hospitals had specific procedures in 
place for storing and securing physical evidence, and others did not. 

In discussions with law enforcement officers and hospital staff, we 
found that the way a hospital does or does not preserve the medical 
forensic evidence it collects, such as biological materials or 
statements from victims, largely depends on the extent or type of 
coordination with law enforcement. For example, at one hospital, 
providers and law enforcement officers told us they jointly developed 
a protocol to store evidence from completed exams in a locked cabinet 
to which only law enforcement officers have the key. This protocol 
ensures that if a law enforcement officer cannot immediately take 
possession of the evidence, it is nevertheless stored in a fashion 
that properly maintains the chain of custody. Similarly, an official 
at another hospital explained that medical forensic evidence is stored 
in a locked filing cabinet in the SANE coordinator's office until a 
law enforcement officer signs a release form to take possession of it--
an arrangement developed between the hospital and law enforcement to 
better maintain the chain of custody. In other communities, 
multidisciplinary groups--/such as sexual assault response teams, 
which coordinate community efforts related to cases of adult sexual 
assault, or multidisciplinary teams established by prosecutors for 
cases involving children--provide opportunities for hospital staff to 
develop evidence preservation procedures.[Footnote 35] For example, 
officials from an IHS hospital in a mandatory Public Law 280 state 
told us that its new sexual assault response team was instrumental in 
determining the most appropriate law enforcement agency--tribal, 
local, or county--to call to take possession of medical forensic 
evidence. Additionally, some hospital officials told us that they do 
not specifically coordinate with law enforcement or had no specific 
evidence preservation procedures because they assume that an officer 
will immediately take possession of any medical forensic evidence 
collected. Such assumptions do not always hold, however, such as if 
the law enforcement officer is called away to investigate another 
crime or cannot wait in the hospital for completion of the multihour 
medical forensic exam. Differences in how hospitals preserve medical 
forensic evidence may also stem in part from the type of training 
received by those who perform medical forensic exams. For example, 
SANE training covers securing evidence and maintaining its chain of 
custody. Providers who do not receive such specialized training may be 
relying on following the instructions contained in an evidence 
collection kit--a process that some stakeholders told us may miss 
important steps. 

IHS and Tribal Hospitals Face Several Challenges in Standardizing and 
Sustaining the Provision of Medical Forensic Services: 

Since enactment of the Indian Health Care Improvement Reauthorization 
and Extension Act of 2009 (on March 23, 2010) and the Tribal Law and 
Order Act of 2010 (on July 29, 2010), IHS has made significant 
progress in developing policies and procedures regarding medical 
forensic services for victims of sexual abuse, as the acts 
required.[Footnote 36] IHS worked expeditiously to establish its first 
agencywide sexual assault policy within the 1-year deadline 
established by the Indian Health Care Improvement Act. The new policy, 
issued in March 2011, is an important and sound first step in what is 
planned to be a continuing effort to provide a standardized level of 
medical forensic services. As part of this effort, IHS has a number of 
important initiatives under way or under consideration, and events are 
unfolding rapidly. For example, in partnership with Justice, a new 
position was created in IHS headquarters for a sexual assault exam and 
response coordinator, and the position was filled in August 2011. 

Still, IHS faces a number of important challenges as it attempts to 
implement its new policy and continues to respond to incidents of 
sexual assault and domestic violence. These challenges include 
systemic issues--such as overcoming long travel distances and 
developing staffing models that overcome problems with staff burnout, 
high turnover, and compensation--so that standardized medical forensic 
services can be provided over the long term. Specifically, we found 
that hospitals face the following four challenges in standardizing and 
sustaining the provision of medical forensic services: 

* overcoming long travel distances; 

* establishing plans to help ensure that hospitals consistently 
implement and follow the March 2011 policy; 

* developing similar policies for domestic violence and child sexual 
abuse; and: 

* developing sustainable staffing models that overcome problems with 
staff burnout, high turnover, and compensation. 

In general, our work confirmed that IHS is aware of the challenges 
that it faces and either has initiatives under way to address them or 
is trying to formulate such initiatives. 

Overcoming Travel Distances: 

We found that long travel distances between IHS patient populations 
and hospitals--often across remote terrain with few, if any, roads--
pose a barrier to access to a full range of medical services that an 
IHS beneficiary might need, including medical forensic services. 
Distances are of particular concern in Alaska, where sexual assault or 
domestic violence victims from remote Alaska Native villages must 
travel hundreds of miles to hospitals offering on-site medical 
forensic exams. Travel is typically possible only by airplane or snow 
machine; most villages are not accessible by road. (See figure 6 for a 
picture of the ambulance used in one of the villages.) 

Figure 6: Small Ambulance Serving Remote Alaska Native Village: 

[Refer to PDF for image: photograph] 

Source: GAO (May 2011). 

[End of figure] 

Further, victims must typically rely on law enforcement to arrange air 
transportation, and bad weather may delay flights for hours or days, 
according to stakeholders. Victims living in regions where the nearest 
hospital does not provide on-site medical forensic services must often 
undertake multistage trips to find access to these services. For 
example, medical providers told us that victims from remote villages 
near Kotzebue, where the hospital does not provide on-site medical 
forensic services, must take at least two flights to reach a hospital 
that does: a first flight from their village to Kotzebue and a second 
one from Kotzebue to Anchorage (see figure 7).[Footnote 37] 

Figure 7: Two-Flight Itinerary from a Remote Alaska Native Village 
When Victims Need Medical Forensic Services: 

[Refer to PDF for image: illustrated map] 

Victim flown from village (Selawik) to hub (Kotzebue), then from hub 
to Anchorage. 

Source: GAO and Map Art (map). 

[End of figure] 

Great distances may also separate beneficiaries needing medical 
forensic services from hospitals providing these services in states 
other than Alaska. For instance, IHS hospitals in Arizona have 
contracted with an air ambulance provider to transport patients via 
helicopter or airplane to Phoenix for medical services, including 
medical forensic exams. Such trips can each cost IHS several thousand 
dollars, according to IHS officials. 

Medical providers, law enforcement, and prosecutors expressed concerns 
that long travel distances may deter victims from reporting sexual 
assault and domestic violence and delay collection of the medical 
forensic evidence needed for prosecution. They said that great 
distances may also discourage victims from reporting assaults to law 
enforcement and seeking medical forensic exams, particularly for 
victims from remote villages who may need to take two or more flights 
to obtain an exam. Also, victims in remote Alaska Native villages who 
wish to remain anonymous cannot do so because they generally rely on 
law enforcement for air transportation. Moreover, at least one 
stakeholder told us that travel delays due to bad weather may make it 
difficult to collect medical forensic evidence within the 72-to 96-
hour time frame in which such evidence is considered most viable. 
According to stakeholders we spoke with, such long delays are rare, 
but any delay increases the chance that physical evidence will become 
contaminated or lost and that victims may forget details of the 
assault. 

To help address long travel distances, some hospitals and other 
stakeholders, such as law enforcement agencies, told us they are 
considering or have suggested expanding medical forensic services to 
clinics, either through telemedicine or by training additional medical 
providers, and expanding the role of community health aides, the 
primary medical providers in remote Alaska Native villages.[Footnote 
38] Telemedicine technology uses video conference, remote monitoring 
equipment, and electronic health records to link patients in remote 
areas to medical providers located elsewhere. Telemedicine connects 
patients in remote clinics in Alaska to dental, skin, and other health 
care services and could be expanded to support treating victims of 
sexual assault, according to some stakeholders. One IHS hospital in 
Montana, for example, is considering using telemedicine to enable the 
hospital's specially trained medical forensic examiners to consult on 
child sexual abuse cases--to determine if a specific injury is 
consistent with abuse, for example--with medical providers in remote 
clinics who do not have this specialized training. Before such a plan 
could be put in place, however, officials from the organization that 
develops telemedicine technology in Alaska told us, concerns would 
need to be addressed about how to securely store and transmit medical 
files to protect victim confidentiality and maintain the evidentiary 
chain of custody. Rather than use telemedicine, the IHS hospital 
located on the edge of a vast reservation is seeking to bring medical 
forensic services closer to its beneficiary populations by developing 
the capacity to perform medical forensic exams at a centrally located 
clinic, according to an IHS official. The hospital has identified 
clinic nurses who are interested in receiving specialized training in 
conducting the exams. 

A few stakeholders also suggested to us that community health aides 
could play a larger role in collecting and preserving medical forensic 
evidence. Medical providers and community health aides themselves, 
however, voiced concerns to us about such a proposal. In cases of 
sexual assault, health aides' scope of practice and training are 
currently limited to tasks such as treating victims' injuries and 
protecting evidence, such as clothing, until law enforcement officers 
arrive; health aides are not authorized to perform medical forensic 
exams or to collect evidence themselves. Among the concerns community 
health aide officials mentioned to us is that expecting health aides 
to perform such exams, on top of the many tasks already required of 
them, may increase burnout rates; they said that such an expectation 
may also put the health aides at risk of retaliation from alleged 
perpetrators or others in a village. Other suggestions made by 
stakeholders have included that health aides should receive additional 
training on the sexual assault response tasks that are already within 
their scope of practice. For example, medical providers told us that 
health aides in Alaska's Yukon-Kuskokwim delta area attended training 
in 2010 designed to help health aides and law enforcement officers 
understand what health aides should and should not be expected to do 
when responding to sexual assault cases. The training focused on the 
actions health aides can already take to assist the response of law 
enforcement officers and hospitals in such cases, such as asking 
victims not to wash or change clothes before undergoing a medical 
forensic exam. 

Establishing Plans to Help Ensure That Hospitals Consistently 
Implement and Follow the March 2011 Sexual Assault Policy: 

Now that its initial sexual assault policy is in place, IHS faces the 
challenge of ensuring that its hospitals consistently implement the 
policy and follow its guidelines. IHS is taking initial steps to help 
hospitals implement the policy but has not yet developed written, 
comprehensive plans for implementation and monitoring. For example, 
IHS officials told us the agency is planning to use funding from the 
existing Domestic Violence Prevention Initiative to provide policy 
training to IHS hospitals and to expand specialized medical forensic 
training opportunities. IHS has also partnered with Justice's Office 
for Victims of Crime to fund a national sexual assault exam and 
response coordinator position within IHS; the position--which was 
filled in August 2011--may play a role in helping implement and 
monitor the March 2011 policy. Nevertheless, IHS has not yet developed 
plans for implementing and monitoring the policy as a whole. Justice 
officials echoed these concerns, given most hospitals' limited 
technical expertise in medical forensic exams and general lack of 
resources for responding to sexual assault. 

The Indian Health Care Improvement Act also requires IHS to report to 
Congress by September 23, 2011, on "the means and extent to which the 
Secretary has carried out" the act's requirement to establish 
appropriate policies, among other things, for responding to victims of 
sexual abuse and domestic violence.[Footnote 39] Agency officials told 
us that at the time of this report, IHS had not yet identified 
sufficient resources for implementing the policy as a whole, nor had 
it developed time frames for implementing major objectives in the 
policy. Specifically, the agency had not identified resources for 
purchasing equipment and supplies, such as digital cameras and special 
forensic evidence-drying cabinets, required under the policy for 
hospitals providing on-site medical forensic exams. Furthermore, the 
agency has set December 31, 2012, as the deadline for medical 
providers to be "credentialed and privileged" as specially trained 
medical forensic examiners, but it has not identified deadlines IHS 
hospitals should meet in implementing other parts of the policy, such 
as providing access to medical forensic exams on site or by referral, 
or collaborating with the objective of creating sexual assault 
response teams. The agency has also not made plans to monitor whether 
IHS hospitals are following the policy, such as whether hospitals 
located more than 2 hours away from other facilities are developing 
the capability to provide on-site medical forensic exams or how well 
hospitals coordinate their activities with law enforcement and 
prosecutors. 

Coordination is important because it helps ensure that medical 
providers collect and preserve evidence in a way that is useful for 
prosecution. Our review found that hospitals' coordination with law 
enforcement agencies and prosecutors varied greatly. Hospitals that do 
not coordinate regularly with law enforcement and prosecutors may 
unintentionally collect and preserve evidence in a way that hampers 
the investigation or prosecution of cases. For example, law 
enforcement officers in one location told us that before a candid 
meeting between medical providers and the prosecutor took place, 
providers were unknowingly violating the chain of custody to such a 
degree that the prosecutor could not reliably use their evidence for 
prosecution. The officers said that the meeting served as a catalyst 
for the medical providers to attend SANE training and for law 
enforcement officers, the prosecutor, and medical providers to develop 
a collaborative response to collecting and preserving evidence in 
sexual assault cases. Increased coordination between the hospital and 
law enforcement also led one hospital to install a locking cabinet 
(see figure 8) to securely store collected medical forensic evidence 
before transferring it to law enforcement. Other medical providers 
told us they had not received feedback on medical forensic evidence 
collection and preservation from law enforcement officers or 
prosecutors. In one location, providers told us they kept completed 
exam kits with them at all times--even taking the kits home overnight--
until law enforcement took possession of the kits, even though Justice 
officials told us that such practices could undermine the chain of 
custody. IHS's March 2011 sexual assault policy calls on hospitals to 
coordinate with law enforcement and prosecutors, but Justice officials 
expressed concerns that many hospitals do not have working 
relationships with law enforcement and prosecutors that would enable 
such coordination. Furthermore, the policy does not specify how IHS 
headquarters will support its hospitals in building such relationships 
or initiating a coordinated response to sexual assault. 

Figure 8: Locking Storage Cabinet for Medical Forensic Evidence: 

[Refer to PDF for image: photograph] 

Source: GAO (December 2010). 

[End of figure] 

According to an agency official, IHS did not have time to develop 
implementation and monitoring plans before the March 2011 deadline 
established for issuing a policy under the Indian Health Care 
Improvement Act. Furthermore, the agency did not seek comments from 
tribes before issuing the policy and therefore asked the tribes for 
feedback after releasing the policy. According to IHS officials, 
comments from tribes were due on May 30, 2011, and the agency was 
analyzing these comments and intending to issue a revised policy. 

One area of IHS's March 2011 policy we found to have caused some 
confusion deals with guidelines for specialized training and 
certification for medical providers. The policy stipulates that 
nurses, physicians, and physician assistants must all complete 
specialized training in performing sexual assault medical forensic 
exams.[Footnote 40] The policy is unclear, however, about whether, to 
perform these exams, medical providers need to obtain documentation of 
competency beyond this training, especially for physicians and 
physician assistants. Sections 3.29.1 and 3.29.5 of the policy use the 
terms "credentialed" and "certified" interchangeably--in defining 
sexual assault nurse and forensic examiners, in delineating 
requirements for training and determining competency to perform these 
exams, and in describing how staff obtain privileges to perform these 
exams at IHS hospitals.[Footnote 41] These sections do so even though 
"credentialing" generally refers to an internal process for allowing 
medical providers to perform specific services in IHS hospitals, and 
"certification" is the term used by Justice in its sexual assault 
protocols and is also typically used by the organization that 
developed the SANE specialty to denote someone who has demonstrated 
competency in medical forensic exams and passed a required test. By 
using these terms interchangeably, the policy leaves unclear whether 
medical providers such as physicians and physician assistants must 
obtain specialized training and certification--or just training--
before performing sexual assault medical forensic exams. IHS officials 
we spoke with provided conflicting interpretations of the policy, from 
interpreting it as calling for certification for sexual assault 
forensic examiners to calling only for training for these medical 
providers. IHS officials acknowledged, however, that no third-party 
certification exists for sexual assault forensic examiners in the same 
way it exists for nurses, which may imply that IHS would need to 
develop its own certification of sexual assault forensic examiners 
more broadly. IHS officials acknowledged to us that the agency has no 
plans to develop such a certification. 

Law enforcement officers and prosecutors told us that variable levels 
of specialized training among medical providers have sometimes led to 
inconsistencies in the quality and type of medical forensic evidence 
collected. Specifically, they said that compared with medical forensic 
exams performed by medical providers with specialized training, exams 
performed by medical providers without such training have been of 
lower quality or did not include certain pieces of evidence. A law 
enforcement officer and prosecutors told us that medical providers 
with SANE training were more familiar with procedures for collecting 
evidence and better able to document the intricacies of injuries and 
identify subtle signs of assault, such as small scratches and bruises, 
than medical providers who did not have specialized training. A law 
enforcement officer in one location told us about a child sexual abuse 
case in which a physician without specialized training found no 
evidence of abuse after performing a medical forensic exam; in 
contrast, a SANE-trained medical provider who performed a subsequent 
exam found internal injuries and other evidence of sexual abuse-- 
evidence the physician without specialized training missed. 
Stakeholders also told us that because of their specialized training, 
SANE-trained medical providers understand the importance of 
identifying and collecting evidence consistent with a victim's account 
of an assault, rather than simply following the generic step-by-step 
instructions in an evidence collection kit. For example, one victims' 
advocacy group told us about a case in which a medical provider 
without specialized training collected only vaginal swabs from a 
victim when the assault actually involved anal rape--all because the 
medical provider did not ask the victim to describe the assault. No 
consensus exists on the specific threshold of specialized training 
needed to perform adequate exams; law enforcement officers and 
prosecutors we spoke with, however, generally agreed that some level 
of specialized training helps improve the quality of evidence 
collection. 

Without clear training and certification guidelines for physicians and 
physician assistants, medical forensic exams may continue to be 
performed by medical providers with inconsistent levels of knowledge 
and expertise. As a result, IHS beneficiaries cannot be assured of 
uniform quality in medical forensic services received, and law 
enforcement entities cannot count on uniform quality in the medical 
forensic evidence collected and preserved, even with IHS's new sexual 
assault policy. Furthermore, calling for nurses to be SANE certified 
or physicians and physician assistants to be certified as sexual 
assault forensic examiners--if such a certification is developed--may 
be a difficult standard for hospitals to meet. Very few hospitals 
currently have nurses certified as SANEs, no comparable certification 
exists for physicians and physician assistants, and some medical 
providers we spoke with told us it can be challenging to complete the 
clinical training needed to be eligible for SANE certification. Some 
medical providers told us they are planning to complete their clinical 
training at another facility because their home hospital does not have 
a certified SANE provider who can validate their competency or does 
not see enough sexual assault cases to provide sufficient practical 
experience in performing medical forensic exams to demonstrate 
competency. Moreover, hospitals already face considerable challenges 
in attracting and retaining medical providers who are willing or able 
to perform the exams; calling for certification may unintentionally 
exacerbate this challenge, even though several stakeholders told us 
that it is the SANE training rather than the certification that is 
most important for performing high-quality medical forensic exams. 

In addition to the lack of clarity around training and certification 
guidelines for physicians and physician assistants under IHS's new 
sexual assault policy, we have concerns that implementing and 
monitoring the policy's overall training and certification guidelines 
may be challenging given IHS headquarters' limited knowledge about how 
many of its medical providers have such training or certification. 
Without this baseline information, the agency may be unable to 
accurately allocate resources for training or identify IHS hospitals 
with certified SANE providers who can train or validate the competency 
of providers from other IHS hospitals. The agency also does not have a 
system in place to track providers' progress toward meeting its 
training and certification guidelines. As a result, it may be unable 
to hold hospitals accountable for following this section of the policy. 

Developing Policies on Domestic Violence and Child Sexual Abuse: 

IHS's March 2011 sexual assault policy instructs IHS hospitals to 
provide a standardized response to adult and adolescent victims of 
sexual assault.[Footnote 42] Specifically, the new policy calls for 
all IHS-operated hospitals to provide adult and adolescent patients 
who arrive in need of a medical forensic exam with access to an exam 
by a medical forensic examiner, either on site or by referral to a 
nearby facility. The new policy covers adult and adolescent victims of 
sexual assault, but it does not cover whether or how hospitals should 
respond to discrete incidents of domestic violence that do not include 
a sexual component or cover cases of child sexual abuse. Consequently, 
IHS hospitals do not have specific or recently updated guidance on 
whether to provide medical forensic services for victims of domestic 
violence and child sexual abuse; as a result, these victims may not 
have access to the full range of services they need. 

Agency officials told us that IHS is deciding how to provide direction 
on responding to incidents of domestic violence and child sexual 
abuse--whether through new policies or by updating existing sections 
of the Indian Health Manual--but that the agency does not have 
concrete plans to develop policies similar in scope and specificity to 
the March 2011 sexual assault policy. The Indian Health Care 
Improvement Act requires IHS to establish "appropriate protocols, 
policies, procedures, [and] standards of practice ... for victims of 
domestic violence and sexual abuse" and to develop appropriate victim 
services, including improvements to forensic examinations and evidence 
collection.[Footnote 43] According to an IHS official, the agency did 
not have time to develop a separate domestic violence policy before 
the Indian Health Care Improvement Act's March 2011 deadline for 
establishing such a policy.[Footnote 44] In addition, the agency 
decided to limit the policy's scope to adults and adolescents because 
Justice has not yet developed child sexual abuse protocols and 
recommended against including child sexual assault and adult sexual 
assault in the same protocol. Moreover, the Tribal Law and Order Act 
of 2010 directs IHS to base its sexual assault policies and protocols 
on those established by Justice.[Footnote 45] Therefore, the March 
2011 policy does not address child sexual abuse. 

IHS officials also acknowledged that the sexual assault policy applies 
only to IHS-operated hospitals,[Footnote 46] not tribally operated 
hospitals. In accordance with the Indian Self-Determination and 
Education Assistance Act, the self-determination contracts and self- 
governance compacts under which tribes operate hospitals generally do 
not require compliance with IHS policy. An objective of the Indian 
Self-Determination and Education Assistance Act is to assure the 
maximum Indian participation in the direction of federal services to 
"Indian communities so as to render such services more responsive to 
the needs and desires of those communities."[Footnote 47] Accordingly, 
tribes are accountable for managing day-to-day operations of IHS-
funded programs, services, and activities included in their self-
determination contract or self-governance compact. Tribes thereby 
accept the responsibility and accountability to beneficiaries under 
the contract with respect to use of the funds and the satisfactory 
performance of IHS programs, functions, services, and activities 
funded under their contract. At the same time, it is the policy of the 
Secretary of Health and Human Services to facilitate tribal efforts to 
plan, conduct, and administer programs, functions, services, and 
activities under the act. To that end, as requested, IHS may provide 
technical assistance to tribes in developing their capability to 
administer quality programs. According to IHS officials, tribally 
operated hospitals may choose to use IHS's March 2011 policy as a 
model for developing their own sexual assault policies. 

IHS could negotiate contract or compact provisions requiring tribes to 
abide by IHS's sexual assault policy, but the tribes would have to 
agree to such a provision. IHS officials told us the agency is 
hesitant to pursue this approach, and has not generally used it, 
because a multitude of other issues are also up for negotiation. 
Furthermore, IHS officials indicated that they do not plan to include 
such a provision in compacts or contracts the agency negotiates. 

Developing Sustainable Staffing Models: 

Hospital officials told us they face challenges in designing staffing 
models for collecting and preserving medical forensic evidence that 
can overcome problems with staff burnout, high turnover, and 
compensation over time. In some hospitals where we conducted 
interviews, medical forensic services were not organized into a formal 
program or housed within a specific hospital department. Instead, 
several officials told us, medical forensic exams are performed by 
individual medical providers, sometimes from different departments, 
and often outside the medical providers' official job duties and 
beyond their normal working hours. For example, at one hospital, 
officials told us that nurses from different units received 
specialized training in performing medical forensic exams and agreed 
to be on call to perform the exams day or night. Performing these 
exams was not written into the nurses' formal job descriptions, 
however, and the nurses were expected to complete their official job 
duties, as well as medical forensic activities. Medical providers told 
us that burnout may occur for several reasons--/including stress, lack 
of supervisor support, and inadequate compensation--stemming from 
staffing arrangements in which medical providers perform exams in 
addition to their official job duties. 

Potential burnout is a serious concern because it can undermine a 
hospital's ability to sustain access to medical forensic services. IHS 
officials acknowledged that turnover rates for medical providers 
specially trained in performing medical forensic exams are generally 
very high, with such providers often leaving IHS facilities after only 
2 years. Some medical providers told us they find it stressful to 
balance their normal job duties with providing medical forensic 
services. For example, in one hospital, several medical providers 
described the staffing arrangement for medical forensic exams as 
relying on nurses performing the work of two full-time jobs--their 
official jobs and their medical forensic exam duties--while receiving 
compensation only for their official jobs. 

In some hospitals, moreover, medical providers told us that their 
supervisors do not consistently allow them to participate in tasks 
outside of their normal duties. For example, medical providers told us 
about instances in which supervisors did not permit them to take time 
away from their normal duties to attend sexual assault response team 
meetings; as a result, the medical providers missed the meetings or 
worked beyond their normal hours to attend. In other cases, because of 
general hospital understaffing, some medical providers were unable to 
find backup coverage for their normal duties when called away for 
several hours to perform medical forensic exams. Consequently, some 
medical providers had to leave their normal duties unattended or have 
victims wait to receive exams until the medical providers' normal 
shifts were over, which is stressful, according to at least one 
medical provider. 

In addition to issues related to understaffing, medical providers 
performing medical forensic exams over and above their normal duties 
said that they may not receive enough compensation to prevent 
attrition. The type and amount of compensation provided for performing 
medical forensic exams vary across hospitals, with some medical 
providers receiving overtime pay or compensatory time off and others 
receiving nothing beyond their normal salaries. Some medical providers 
told us they had trouble obtaining sufficient compensation. For 
example, medical providers in one hospital told us they receive 
compensatory time off for performing medical forensic exams, but they 
can rarely use the additional leave hours because the hospital is too 
short-staffed to approve time off. In another hospital, nurses who 
provided medical forensic exams in addition to their normal job duties 
found it difficult to obtain approval from their supervisors for 
overtime pay when performing the exams made them exceed their normal 
hours. The overtime rate the nurses said they were paid was 
commensurate to the nurses' regular hourly rate, not the time and a 
half usually accorded for overtime. The former SANE coordinator at 
this hospital told us that such compensation challenges contributed to 
nurses' burning out over time and ceasing their medical forensic exam 
duties. When the nurses stopped offering the exams, the hospital was 
unable to provide exams for victims who needed them and began 
referring victims to another facility, according to the coordinator. 

Concerning staffing, we have issued a guide federal agencies can use 
in maintaining or implementing effective internal control.[Footnote 
48] One of the factors this guide states that agencies should consider 
in determining whether a positive control environment has been 
achieved[Footnote 49] concerns organizational structure and whether 
the agency has the appropriate number of employees--specifically, so 
that employees do not have to work outside the ordinary workweek to 
complete their assigned tasks. Additionally, in its 2006-2011 
Strategic Plan, IHS acknowledges the difficulty the agency has long 
faced in attracting and retaining medical providers across IHS. 
Attraction and retention is particularly challenging for remote 
facilities in isolated areas, where medical providers may be offered 
incentive pay for accepting positions. The agency's strategic plan 
outlines strategies for recruiting, retaining, and developing 
employees, stating that the agency will "ensure an ongoing process to 
identify and implement the best practices related to staff retention" 
and "continue to explore options to provide adequate staffing for all 
facilities."[Footnote 50] 

Some hospitals have already identified and implemented staffing 
options for medical forensic services, which aim to address concerns 
about provider burnout and sustainability. Several hospitals have 
incorporated medical forensic services into normal job duties for 
medical providers in a specific hospital department. For example, at 
one hospital in South Dakota, medical providers told us that most 
nurse midwives within the hospital's midwife clinic receive SANE 
training and perform medical forensic exams as part of their normal 
clinic duties. In addition, several hospitals in Alaska have hired 
sexual assault response team coordinators, whose part-or full-time 
responsibilities are to manage the hospitals' medical forensic 
services and perform medical forensic exams, according to hospital 
officials. An official at one hospital told us the hospital provided 
retention pay in an effort to adequately compensate medical providers 
for performing these exams. 

Such options may help reduce medical provider stress and burnout, but 
no single staffing arrangement works for all hospitals or medical 
providers. For example, medical providers from one hospital told us 
their hospital considered incorporating the exams into providers' job 
descriptions but decided not to because doing so would make it even 
more difficult to attract candidates for already hard-to-fill 
positions. In addition, one stakeholder told us many hospitals do not 
see enough sexual assault cases to warrant a part-or full-time 
position for a sexual assault response team coordinator. Moreover, 
according to IHS officials, annual pay caps may limit the amount of 
bonus or retention pay that medical providers are eligible to receive 
for performing medical forensic exams. IHS is developing a proposal to 
separate the salary series of advanced practice nurses--the type of 
nurse likely to perform medical forensic exams within IHS--from other 
registered nurses so that advanced practice nurses can receive higher 
maximum pay. IHS officials told us this proposal may help address the 
constraints imposed by salary caps, which currently make it 
impractical for many nurses to be compensated for performing medical 
forensic exams. 

Factors besides Medical Forensic Evidence also Contribute to Decisions 
to Prosecute Cases of Sexual Assault and Domestic Violence: 

Decisions to prosecute sexual assault or domestic violence cases are 
based on the totality of evidence collected, one piece of which is 
medical forensic evidence collected by IHS and tribally operated 
hospitals. Many of the factors contributing to a decision to prosecute 
are not unique to incidents of sexual assault or domestic violence 
involving Indians in remote reservations or villages; nevertheless, 
prosecutors acknowledged, they affect the totality of the available 
evidence and thus contribute to decisions to prosecute such cases. 
Specifically, officials from the responsible law enforcement and 
prosecuting agencies told us they generally base their decisions to 
refer sexual assault or domestic violence investigations for possible 
prosecution and to accept these matters for prosecution on the total 
picture presented by the quality and quantity of available evidence. 
Prosecutors and law enforcement officials said they consider several 
factors--including medical forensic evidence collected by hospitals. 
They also said that the relative importance of these factors can 
differ from case to case. In some cases, medical forensic evidence may 
be a crucial factor; in others, however, it may not be relevant or 
available. For example, photographic evidence or DNA collected during 
a genital exam may be critical in showing that an alleged perpetrator 
had sex with the victim, but such medical forensic evidence may not be 
relevant when the victim and alleged perpetrator admit to having had 
sex but disagree as to whether the sex was consensual. In many of 
those cases where consent is the main issue, according to prosecutors 
and Justice's sexual assault protocols, medical forensic evidence does 
not reveal physical injuries that readily demonstrate a lack of 
consent. Also, law enforcement officials and prosecutors told us that 
medical forensic evidence may be unavailable if a victim reports an 
assault weeks or months later, as often happens in cases of child 
sexual abuse, because, for example, DNA evidence or relevant fibers 
would likely have washed away or become contaminated in the meantime. 

In addition to this medical forensic evidence, law enforcement 
officials told us that when deciding whether to refer an investigation 
for possible prosecution, they consider several other factors, 
including quality of the criminal investigation conducted, credibility 
of witnesses who may have been intoxicated at the time of the assault, 
and coordination with relevant agencies to obtain supporting evidence. 
For example, federal prosecutors acknowledged that quality of the 
criminal investigation is important because evidence in a criminal 
matter must meet a relatively high threshold to be accepted for 
prosecution--that is, prosecutors must believe that existing evidence 
is compelling enough to demonstrate to a jury guilt beyond a 
reasonable doubt. As a result, prosecutors acknowledged that a law 
enforcement agency that refers all criminal investigations involving 
sexual assault for possible prosecution--regardless of whether the 
extent or quality of evidence collected during its investigation would 
warrant such a referral--may find that prosecutors decline to 
prosecute some of these matters. Law enforcement officials and 
prosecutors also told us that intoxication of witnesses at the time of 
an assault can mean these witnesses may be less credible in court 
because, for example, intoxication adversely affects ability to 
clearly recall circumstances around the assault or specific statements 
made by the victim or alleged perpetrator. Additionally, law 
enforcement officials and prosecutors stated that decisions to refer 
investigations for possible prosecution are also based on obtaining 
additional evidence that supports the victim's account. Availability 
of coordinated efforts, such as sexual assault response teams, can 
greatly enhance the quality of a forensic interview with a victim 
about an assault and facilitate gathering such supporting evidence. 

Similarly, prosecutors consider additional factors besides medical 
forensic evidence when deciding whether to accept a matter for 
prosecution, including juries' increased expectation of seeing DNA 
evidence; perceived credibility of the victim, alleged perpetrator, or 
other involved party; and availability of involved parties, such as 
witnesses or hospital providers, to testify. Specifically, several law 
enforcement officials and prosecutors stated that, in light of popular 
television series featuring forensic evidence, juries have come to 
expect prosecutors to regularly present DNA and other forensic 
evidence before they are willing to convict. As a result, several 
prosecutors told us they need to factor in such juror expectations 
when deciding whether they believe they have strong enough evidence to 
obtain a conviction or plea deal. Additionally, prosecutors told us 
that decisions to accept matters for prosecution are also based on how 
believable a witness, victim, or alleged perpetrator seems to be. The 
credibility of witnesses, including the victim, can be based on a 
variety of factors, including how well he or she can recall details of 
the assault. For example, one prosecutor told us her office concluded 
that the testimony of a particular victim could be persuasive because 
the woman accurately described the layout of the room where she 
alleged she was raped, even though the alleged perpetrator told police 
she had never been inside his house. Prosecutors across the country 
told us that intoxication of victims at the time of assault is not 
alone an acceptable reason to decline a matter for prosecution. 

With regard to witness testimony, federal and state prosecutors told 
us that availability of potential witnesses to testify is also an 
important factor. Some victims in small reservations or isolated 
villages may refuse to cooperate or may retract their initial 
statement, for example, because of pressure exerted on them by family 
or community members who may depend on the alleged perpetrator for 
necessities such as food or fuel. As a result, the victim may be 
unavailable to testify. Additionally, according to several prosecutors 
with whom we spoke, the availability to testify of medical providers 
who performed the associated medical forensic exams at IHS or tribally 
operated hospitals is an important factor because such testimony can 
help demonstrate that an assault occurred or help otherwise support a 
victim's account of an assault. Specifically, some prosecutors told us 
that it may be difficult to locate traveling medical providers who 
work at these hospitals temporarily; in addition, hospital staffing 
shortages may keep supervisors from releasing staff from hospital 
duties to testify. Consequently, some medical forensic examiners at 
IHS and tribally operated hospitals may not be able to testify in 
court that evidence obtained from a medical forensic exam belongs to a 
given victim or attest to a victim's statements made during the exam 
about the assault--testimony that prosecutors repeatedly stated is 
critical to using the medical forensic evidence in court. IHS 
officials noted, however, that the Tribal Law and Order Act of 2010's 
requirement that state and tribal courts provide employees with 30-day 
notice of the request for testimony would make it much more likely 
that a traveling provider could be located and appear or a provider's 
schedule changed to accommodate a court appearance. 

In this context, section 263 of the Tribal Law and Order Act of 2010 
contains requirements for IHS regarding approval or disapproval of 
requests or subpoenas from tribal or state courts for employee 
testimony. IHS's March 2011 sexual assault policy, however, is not 
entirely consistent with section 263, and, in some cases, the policy 
is not clear. 

* First, the policy does not state that subpoenas and requests for IHS 
employee testimony in tribal or state courts not approved or 
disapproved within 30 days are considered approved. In this regard, 
the policy appears to contradict section 263 of the act, which states 
that subpoenas or requests will be considered approved if IHS fails to 
approve or disapprove a subpoena or request 30 days after receiving 
notice of it. 

* Second, it is unclear whether the prior approval discussed in the 
policy refers to the agency's approval of the subpoena, as required by 
the act, or supervisory approval of the employee's release from 
hospital duties. To the extent that the policy's discussion refers to 
release from hospital duties, the policy is silent about whether and 
under what circumstances supervisors can refuse to release a 
subpoenaed employee to testify if the subpoena or request is approved 
or considered approved. 

* Third, the policy does not specify criteria to be used to approve a 
subpoena. Specifically, the policy does not specify that, in 
accordance with section 263, the IHS Director must approve requests or 
subpoenas from tribal and state courts if they do not violate the 
Department of Health and Human Services' policy to maintain 
impartiality. Explicitly articulating these criteria is important 
because departmental officials told us requests for IHS employee 
testimony in these criminal prosecutions would likely always satisfy 
the criteria and because responding to such requests are in the 
agency's best interest. In addition, the policy does not discuss legal 
limitations placed by privacy laws on the production of medical 
records in response to state or tribal court subpoenas. 

* Fourth, the policy does not specify whether it also applies to 
subpoenas and requests from federal courts--a process currently 
governed by an unwritten policy--even though IHS officials told us 
they intended for the policy to cover federal subpoenas and requests 
as well as those from tribal and state courts. 

According to Health and Human Services officials, the department is 
drafting a more specific and comprehensive description of the subpoena 
approval process. As of September 2, 2011, however, this document, 
whose audience is officials involved in the subpoena approval process, 
had not been completed or disseminated; we have therefore not reviewed 
it. Moreover, it is unclear how widely it will be disseminated. We 
received inconsistent accounts from departmental and IHS officials 
about the extent to which the document will be made available to line 
staff--the very staff who would be subpoenaed to testify. According to 
federal standards for internal control, information should be recorded 
and communicated to management and others within an agency in a form 
and within a time frame that enables them to carry out their 
responsibilities.[Footnote 51] Moreover, the federal standards call 
for effective communication to flow down, across, and up the 
organization.[Footnote 52] Therefore, it is still uncertain when and 
by what processes IHS staff will be able to respond to subpoenas or 
testify in court about the medical forensic exams they conduct--an 
ambiguity in the policy that is of great concern, according to several 
Justice officials with whom we spoke. 

Conclusions: 

Medical providers in IHS and tribally operated hospitals are called 
upon to fulfill twin purposes when seeing patients who are victims of 
sexual assault and domestic violence--to treat the victim's injuries 
and trauma and to collect medical forensic evidence of high enough 
quality that it can be used to prosecute crimes. The provision of 
medical forensic services and collection and preservation of high- 
quality evidence, however, are highly variable across IHS and tribally 
operated hospitals, hampered in part by distances victims must travel 
and the absence, until recently, of central direction from IHS on 
what, how, and by whom these services are to be provided. IHS has made 
significant progress in the last 2 years, and its March 2011 sexual 
assault policy takes a sound first step toward addressing problems 
like these, but the agency, its hospitals, and medical providers have 
a long way to go to fulfill the policy's provisions. Without 
articulating how it plans to implement the policy and monitor progress 
toward meeting policy requirements, IHS may not be able to hold 
individual hospitals accountable to the agency, and the agency may not 
be able to hold itself accountable to its beneficiaries. The road 
ahead is likely to be particularly arduous for the more remote 
hospitals, which have long faced obstacles in attracting and retaining 
medical providers and are now faced with numerous new demands, such as 
offering medical forensic exams on site or by referral within 2 hours 
and making readily available digital cameras and other equipment and 
supplies needed to collect medical forensic evidence. In addition, 
responding to incidents of sexual assault and domestic violence 
requires a multifaceted approach involving not only medical providers 
but also law enforcement and prosecuting agencies and other 
stakeholders identified in the policy. The medical forensic evidence 
needs to be collected and preserved in a way that facilitates its use 
by law enforcement and prosecuting agencies. Not all IHS hospitals and 
staff regularly collaborate with these stakeholders or obtain regular 
feedback from them on evidence collection and preservation. Without 
considerable and concerted investment in the staff and hospitals 
responsible for providing medical forensic services--and without a 
detailed implementation plan to clarify how the agency will support 
its hospitals and staff in meeting the policy's requirements and by 
when--the agency is unlikely to meet those requirements. 

In addition, IHS's March 2011 sexual assault policy does not address 
how its hospitals should respond in cases of discrete domestic 
violence without a sexual component or in cases of child sexual abuse. 
IHS is currently considering how its hospitals should respond to such 
cases, but it has not developed policies that are similar in scope and 
specificity to its March 2011 sexual assault policy for adolescents 
and adults. This gap is significant, but IHS is only one of the 
agencies involved in the multifaceted response to incidents of sexual 
assault and domestic violence. All the responding federal agencies 
should present a consistent and coordinated response to these issues. 
Justice also has not yet developed a policy for responding to child 
sexual abuse incidents, which is critical, since the Tribal Law and 
Order Act of 2010 mandates that IHS develop standardized sexual 
assault policies and protocols based on a similar protocol established 
by Justice. 

IHS's recent effort to solicit and analyze comments from the tribes 
and Justice on the March 2011 policy presents an opportunity for the 
agency to revise areas that, as originally written, are unclear or 
inconsistent. Specifically, it is unclear whether sections 3.29.1 and 
3.29.5 of the policy require both training and certification, or only 
training, of IHS physicians and physician assistants performing sexual 
assault medical forensic exams. Also, the policy does not specify how 
physicians and physician assistants are to attain certification when 
no such certification by IHS or a third party exists for medical 
providers other than nurses. IHS's sexual assault policy is also not 
consistent with provisions in section 263 of the Tribal Law and Order 
Act of 2010, which states, among other provisions, that subpoenas and 
requests for employee testimony or documents from state and tribal 
courts not approved or disapproved within 30 days are considered 
approved. To the extent that the policy's discussion of subpoena and 
request approvals refers to release from hospital duties, the policy 
is silent about whether and how IHS plans to approve the release of 
staff providing medical forensic exams to testify or otherwise comply 
with subpoena requests. Without greater clarity in the policy's 
language--and without giving relevant staff explicit guidance on how 
to respond when subpoenaed or requested to testify--providers who 
perform sexual assault medical forensic exams may not understand the 
circumstances under which they are allowed or required to testify in 
court, a serious concern that Justice has echoed. 

Some of the prior efforts to provide medical forensic services at 
individual hospitals failed for various reasons, including staffing 
problems related to burnout, high turnover, and compensation. The 
March 2011 sexual assault policy provides the high-level management 
endorsement that had been missing in the past, but devising 
appropriate staffing models--so that the provision of standardized 
medical forensic services being developed under the new policy will 
continue well into the future--remains a challenge. At some locations, 
current staffing models present disincentives to the provision of 
these services, such as supervisory refusal to give medical providers 
permission to attend sexual assault team meetings or to approve 
adequate compensation for providing medical forensic services in 
addition to normal job duties or beyond a unit's official area of 
responsibility. Given the agency's reliance on temporary medical 
providers, as well as high burnout and turnover rates among medical 
providers, unless corrected, such disincentives are likely to 
undermine IHS's efforts to fulfill the March 2011 policy's goals over 
the long term. 

Finally, IHS also has an opportunity to incorporate comments from 
tribes that may choose to use the March 2011 policy as a model on 
which to base their own sexual assault response policies in tribally 
operated hospitals or clinics. As we discussed earlier, IHS policies 
and procedures can be used as models on which to base local tribal 
protocols even though they do not generally apply to its 17 tribally 
operated facilities. In addition, IHS recognizes that hospital 
protocols, particularly for complex and sensitive matters like sexual 
assault, need to reflect each community's individual circumstances. 
Coordinating with tribes may therefore be especially important to 
those tribally operated hospitals in Alaska, where the state, rather 
than the federal government, generally has criminal jurisdiction and 
where the state has made combating sexual assault and domestic 
violence a high priority. 

Recommendations for Executive Action: 

To improve or expand medical forensic exams and related activities for 
the 28 IHS operated hospitals, we recommend that the Secretary of 
Health and Human Services direct the Director of the Indian Health 
Service to take the following five actions: 

* Develop an implementation plan for the March 2011 IHS sexual assault 
policy (Indian Health Manual, chapter 3.29)--and monitor its progress--
to clarify how the agency will support its hospitals and staff in 
fulfilling the policy, in particular, that the hospitals or staff: 

- obtain training and certification in providing forensic medical 
exams; 

- obtain equipment like cameras needed to collect evidence; 

- provide medical forensic exams on site or at a referral facility 
within 2 hours of a patient's arrival; and: 

- collaborate with law enforcement agencies, prosecution, and other 
stakeholders identified in the policy with the objective of creating 
sexual assault response teams and obtaining regular feedback from such 
stakeholders on evidence collection and preservation. 

* Develop a policy that details how IHS should respond to discrete 
incidents of domestic violence without a sexual component and, working 
with Justice, develop a policy for responding to incidents of child 
sexual abuse consistent with protocols Justice develops for these 
incidents; such policies should be similar in scope and specificity to 
the March 2011 IHS policy on responding to adult and adolescent sexual 
assaults. 

* Clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS 
sexual assault policy call for training and certification, or only 
training, of IHS physicians and physician assistants performing sexual 
assault medical forensic exams. 

* Modify the March 2011 IHS sexual assault policy so that it 
comprehensively and clearly outlines (1) the process for approving 
subpoenas and requests for IHS employees to provide testimony in 
federal, state, and tribal courts and (2) reflects the provisions in 
section 263 of the Tribal Law and Order Act of 2010, including that 
subpoenas and requests not approved or disapproved within 30 days are 
considered approved. 

* Explore ways to structure medical forensic activities within IHS 
facilities so that these activities come under an individual's normal 
duties or unit's official area of responsibility, in part to ensure 
that providers are compensated for performing medical forensic 
services. 

Agency Comments: 

We provided a copy of our draft report to the Departments of Health 
and Human Services, the Interior, and Justice and to the state of 
Alaska. In its written response, reprinted in appendix IV, the 
Department of Health and Human Services agreed with our five 
recommendations and stated that work is now under way to implement 
each of them. The state of Alaska generally agreed with our 
conclusions and recommendations, especially the recommendation to 
develop additional policies specific to child sexual abuse, and 
expressed its willingness to collaborate with the Indian Health 
Service in developing sexual assault policies applicable to Alaska 
(see appendix V). The Department of Health and Human Services and the 
state of Alaska, as well as the Departments of the Interior and 
Justice, provided technical comments, which we incorporated into the 
report as appropriate. 

We are sending copies of this report to the appropriate congressional 
committees, the Secretary of Health and Human Services, the Secretary 
of the Interior, the Attorney General of the United States, the 
Governor of Alaska, and other interested parties. In addition, the 
report is available at no charge on the GAO website at [hyperlink, 
http://www.gao.gov]. 

If you or your staff members have any questions about this report, 
please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of this report. GAO staff who made major 
contributions to this report are listed in appendix VI. 

Signed by: 

Carolyn L. Yocom: 
Director: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

Our objectives were to determine (1) the ability of Indian Health 
Service (IHS) and tribally operated hospitals to collect and preserve 
medical forensic evidence for use in criminal prosecution in sexual 
assault and domestic violence cases; (2) what challenges, if any, 
these hospitals face in collecting and preserving such evidence, 
particularly in remote Indian reservations and Alaska Native villages; 
and (3) what factors besides medical forensic evidence collected by 
these hospitals contribute to a decision to prosecute such cases. 

For all three objectives, we collected and analyzed laws, regulations, 
and agency policies relevant to the collection and preservation of 
medical forensic evidence by IHS and tribally operated hospitals in 
cases of sexual assault and domestic violence, and we interviewed and 
gathered relevant documentation from headquarters officials at IHS, 
the Bureau of Indian Affairs, the Department of Justice, and the state 
of Alaska. In addition, we conducted over 60 semistructured interviews 
with several groups of stakeholders (1) from hospital staff during 
site visits to a nonprobability sample of 8 IHS or tribally operated 
hospitals in Alaska, Arizona, and South Dakota and over the telephone 
with an additional nonprobability sample of 7 IHS or tribally operated 
hospitals in Arizona, Minnesota, Montana, New Mexico, North Dakota, 
and Oklahoma and (2) from victim advocacy groups; federal and state 
prosecutors; and federal, state, local, and tribal law enforcement 
agencies that play a role in responding to and prosecuting sexual 
assault and domestic violence cases in most of the locations these 15 
hospitals serve. We spoke with officials about hospitals that are 
performing medical forensic exams, that are developing the ability to 
perform such exams, and that do not perform these exams. 

To determine the ability of IHS and tribally operated hospitals to 
collect and preserve medical forensic evidence, we surveyed all 45 IHS 
and tribally operated hospitals on available services, obtained 
electronic data from IHS on procedures and purpose of visits related 
to sexual assaults and domestic violence, and determined which 
hospitals were located in remote areas. 

* First, we determined the type of facility within the IHS system that 
is most likely to provide medical forensic services. From discussions 
with IHS officials and others, we found that hospitals were the most 
appropriate type of facility to include in our analysis because of the 
level of medical expertise and infrastructure available in these 
facilities relative to other types of health centers or specialized 
clinics. We then obtained an electronic list of all IHS and tribally 
operated hospitals in the United States, including location and 
contact information for each. We assessed the reliability of this list 
by validating and cross-checking the data with the IHS official who 
oversees the information. After eliminating two private hospitals that 
were erroneously included in the list, we determined that the data 
were sufficiently reliable for the purpose of this report. Using this 
list of 45 IHS and tribally operated hospitals, we e-mailed a self- 
administered questionnaire to survey each of the 45 hospitals. (See 
appendix II for a blank copy of the questionnaire.) The questions were 
designed to identify the ability of each hospital to collect and 
preserve medical forensic evidence at the time the questions were 
answered. To develop the survey questions, we reviewed existing 
interviews, interviewed IHS officials and providers at several IHS and 
tribally operated hospitals, and reviewed relevant Justice protocols. 
We took steps to minimize errors in the survey effort's development 
and data collection process. For example, the team designed specific 
questions in consultation with a social science survey specialist and 
design methodologist. We conducted several pretests with medical 
providers at three separate hospitals--two IHS-operated hospitals and 
one tribally operated hospital--to help ensure that the questions were 
clear, relevant, and unbiased and to ensure that they could be 
completed quickly. Another survey specialist also reviewed the 
questionnaire, and suggestions were included where appropriate. We 
sent the questionnaire to the most knowledgeable hospital official at 
each location--typically the clinical director and chief executive 
officer--to be the lead respondent and, if necessary, to confer with 
other representatives within the hospital to answer questions 
requiring more detailed knowledge. To maximize our response rate, we 
sent follow-up e-mails and left reminder telephone messages over a 
period of approximately 11 weeks--from March 31, 2011, when we started 
the survey effort, through June 14, 2011, when we closed it. We 
received responses from 100 percent of the hospitals, and we followed 
up to clarify specific responses as needed. Accordingly, the responses 
represent a snapshot in time of each hospital's medical forensic 
services. We entered the responses into a spreadsheet and analyzed the 
results. A separate analyst verified the accuracy of data entry and 
analyses. (See appendix III for a summary of key survey results.) 

* Second, we obtained electronic data on the reasons for hospital 
visits by IHS beneficiaries from fiscal year 2006 through fiscal year 
2010 for each of the 45 hospitals that report such data to IHS. 
[Footnote 53] To assess the reliability of the data, we interviewed 
knowledgeable IHS officials and performed electronic testing. Our 
initial intent was to determine how many medical forensic exams had 
been performed at each IHS and tribally operated hospital, but we were 
unable to do so because IHS does not centrally track the number of 
such exams, and complete data on specific procedures done during each 
patient visit were not available. We therefore used diagnosis codes 
established in the World Health Organization's International 
Statistical Classification of Diseases and Related Health Problems to 
determine from patients' "purpose-of-visit" information which 
hospitals were providing sexual assault and domestic violence services 
and the primary reason for such visits. We excluded all visits to 
mental or behavioral health clinics because such services typically 
take place after an incident and are not part of collecting or 
preserving medical forensic evidence. To determine how many sexual 
assault or domestic violence visits each hospital saw from fiscal year 
2006 through fiscal year 2010, we analyzed each patient visit by its 
codes and categorized the codes into four incident types: adult sexual 
abuse, adult domestic violence, child sexual abuse, and child physical 
abuse. If a patient had more than one record with a purpose-of-visit 
code indicating sexual assault or domestic violence, we counted only 
the first visit to avoid double-/counting of visits that may have 
pertained to the same incident. Thus, we may have undercounted the 
number of sexual assault or domestic violence incidents in this time 
frame if one patient had been involved in two or more incidents. 

* Third, we identified which hospitals were located in remote areas 
and those located in urban areas. Given that there are only 45 IHS and 
tribally operated hospitals in total, we determined that it was 
reasonable to collect information on all 45 hospitals. We determined 
which hospitals were located in remote areas by using rural-urban 
commuting area codes[Footnote 54]--developed on the basis of U.S. 
Census tracts by the Department of Agriculture's Economic Research 
Service--because IHS has no technical definitions for remote. The 
rural-urban commuting area system defines remote areas as those with 
dispersed and small populations and where travel times are longer 
because of limitations in transportation infrastructure, and it 
defines urban areas as those with large populations and short travel 
times between cities. We linked a hospital's zip code to rural-urban 
commuting area data--also broken out by zip code--to determine if a 
hospital is located in an isolated, small rural, large rural, or urban 
area, as classified by the rural-urban commuting area system. We 
refined these four categories into a two-category classification 
scheme--collapsing the "isolated" and "small rural" categories into 
one remote category and collapsing the "urban" and "large rural" 
categories into one urban category--to aid in analysis and better 
respond to our objectives. 

To determine the challenges faced by these hospitals in collecting and 
preserving medical forensic evidence, particularly in remote Indian 
reservations and Alaska Native villages, we also collected and 
analyzed pertinent laws, regulations, policies, protocols, and reports 
from IHS, Justice, and other entities. On the basis of initial 
interviews and responses from our survey of hospitals, we selected a 
nonprobability sample of IHS and tribally operated hospitals with 
which to conduct semistructured interviews on challenges they face in 
collecting and preserving medical forensic evidence. We chose 15 
hospitals according to a series of selection criteria that included 
geographic location, remoteness, whether the state or federal 
government had criminal jurisdiction in Indian country served by the 
hospital, and whether the hospital was IHS or tribally operated. 
Additionally, because we used a nonprobability sample to select these 
IHS and tribally operated hospitals to interview, the information we 
gathered in our semistructured interviews cannot be generalized to all 
hospitals and instead represents the perspectives only of these 
hospitals' providers and stakeholders. We also interviewed many victim 
advocacy groups, federal and state prosecutors, and federal and state 
and local law enforcement agencies that play a role in responding to 
and prosecuting sexual assault and domestic violence cases in most of 
the locations these 15 hospitals serve. We reviewed and analyzed our 
interviews and supporting documentation to identify systemic and 
regionally specific challenges. 

Finally, to identify additional factors that federal prosecutors may 
consider when determining whether to prosecute cases of sexual assault 
and domestic violence, we reviewed relevant studies about these crimes 
and reviewed standards related to decisions by law enforcement to 
refer, or decisions by prosecutors to accept, a matter for criminal 
prosecution. 

We conducted this performance audit from October 2010 through October 
2011, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: GAO Survey of 45 IHS and Tribally Operated Hospitals: 

United States Government Accountability Office: 
GAO: 

Indian Health Service: 
Medical Forensic Examination (FE) Program Questionnaire: 

Introduction: 

This questionnaire asks for information about medical forensic 
examinations done in cases of sexual assault or domestic violence for 
adults and/or children; and information on whether or not your 
facility has, or ever had, a program offering such medical forensic 
examination services. 

Background: 

The U.S. Government Accountability Office (GAO) is an agency that 
assists the U.S. Congress in evaluating federal programs. We have been 
asked to provide Congress with information about the capability of 
Indian Health Service (IHS) to collect and preserve evidence in cases 
of sexual assault/abuse and domestic violence (involving adults or 
children) for criminal prosecution. The intent of this questionnaire 
is to determine which IHS and tribal hospitals have medical forensic 
examiner programs or provide the services of a medical forensic 
examiner in cases of sexual assault and domestic violence (involving 
adults and/or children). For the purposes of this questionnaire, the 
medical forensic examination is the medical treatment of a patient as 
well as the collection of forensic evidence. Specifically, the 
forensic component could include performing a forensic evidence 
collection kit sometimes referred to as a "rape kit", gathering a 
medical forensic history, conducting an exam, documenting biological 
and physical findings, and collecting evidence from the patient. We 
recognize that there is a continuum of forensic evidence collection 
services that can occur depending on the availability of staff and the 
medical condition of the victim. 

Your facility was selected because it is one of the 47 hospitals 
operated by IHS, a tribe, consortium, or has a contract to provide 
services. It should take you about 5 to 10 minutes to complete this 
questionnaire. The person with the most knowledge of the forensic 
examination program should complete this questionnaire for the entire 
facility. If you feel you are not the most knowledgeable person in 
your facility about these exams, please contact Kyle Stetter (contact 
information below) and let him know who you feel would be the best 
person to complete it and we will arrange to send it to that person. 

Your cooperation is critical to providing the Congress complete and 
balanced information about the capability of IHS to collect and 
preserve evidence in cases of sexual assault/abuse and domestic 
violence. 

Completing and Returning the Questionnaire: 

Please complete and return this questionnaire as soon as possible, but 
no later than Thursday, April 7, 2011. After receiving your responses, 
we may also want to follow up with some of you by telephone to better 
understand your program or how you operate in lieu of a program. 

To answer the questions, first open the attached MS Word file and save 
the file to your computer. Then enter your responses directly to the 
saved document following the instructions below. Once the questions 
are completed, please return them by attaching the saved document to 
an e-mail message to Stetlerk@gao.gov. Or mail to 701 5th Ave., Suite 
2700, Seattle WA. 98104. 

GAO Contact: 

If you have any questions, please call or e-mail:  

Kyle Stetter: 
E-mail: StetlerK@gao.gov; 
Phone: 206-287-4844. 

Instructions for Completing the Questions Onscreen: 

* Please use your mouse to navigate, clicking on the field or check 
box you wish to answer.  

* To select a check box or a button, click on the center of the box.  

* To change or deselect a check box response, click on the check box 
and the X will disappear.  

* To answer a question that requires that you write a comment, click 
on the answer box and begin typing. The box will expand to accommodate 
your answer. You are not limited to the amount of space you see on the 
screen. 

* If you have additional clarifications or comments on any of the 
questions, please include those in the comment box at the end of this 
document or in a separate document.  

Start Here: 

Your Contact Information: 
Name: 
Title: 
Facility/Program Name: 
Email: 
Phone: 
  
Section A. Adult Victims Of Sexual Assault: 

1. Currently, if an adult victim of sexual assault comes into your 
facility, with what frequency does your facility conduct a medical 
forensic examination, that is, the medical treatment of a patient as 
well as the collection of forensic evidence? 

(Specifically, the forensic component could include such things as 
performing a forensic evidence collection kit sometime referred to as 
a "rape kit", gathering a medical forensic history, conducting an 
exam, documenting biological and physical findings, and collecting 
evidence from the patient) 

Typically or always conducts: 
Sometimes conducts: 
Rarely conducts: 
Never conducts: 

2. If the frequency with which your facility conducts these medical 
forensic examinations has substantially changed in the last five 
years, please describe below. The box will expand to fit your answer. 

NOTE: If you answered "Never conducts" to Question 1, please skip to 
Question 7. 

3. If your facility conducts medical forensic examinations in cases of 
adult sexual assault, which types of providers typically conduct 
medical forensic examinations? For each row, please check all that 
apply. 

a. Registered Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

b. Physician's Assistant: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

d. Physician: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

e. Other (Specify below): 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

4. If your facility conducts medical forensic examinations in cases of 
adult sexual assault, what is the level of training of the providers 
who typically conduct these examinations? For each row, please check 
all that apply. 

a. Registered Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

b. Physician's Assistant: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

d. Physician: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

e. Other (Specify below): 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

5. Has there ever been an extended period of time, during the last 5 
years, when there was no one available to conduct the medical forensic 
examinations for adult victims of sexual assault? 
Yes: 
No: Skip To Question #7. 

6. If yes, please describe the circumstances. The boxes will expand to 
fit your answer. 

7. Does your facility (ever) refer adult sexual assault patients 
someplace else for medical forensic examinations? 
Yes: 
No: Skip To Question #9. 

8. If checked "Yes," please specify where and under what circumstances. 

Section B. Adult Victims Of Domestic Violence: 

9. If an adult victim of domestic violence comes into your facility, 
with what frequency does your facility conduct a medical forensic 
examination, that is, the medical treatment of a patient as well as 
the collection of forensic evidence? 
Typically or always conducts: 
Sometimes conducts: 
Rarely conducts: 
Never conducts: 

10. If the frequency with which your facility conducts these medical 
forensic examinations has substantially changed in the last five 
years, please describe below. The box will expand to fit your answer.
Note: If you answered "Never conducts" to Question 9, please skip to 
Question 15. 

11. If your facility conducts medical forensic examinations in cases 
of adult domestic violence, which types of providers typically conduct 
medical forensic examinations? For each row, please check all that 
apply. 

a. Registered Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

b. Physician's Assistant: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

d. Physician: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

e. Other (Specify below): 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

12. If your facility conducts medical forensic examinations in cases 
of adult domestic violence, what is the level of training of the 
providers who typically conduct these examinations? For each row, 
please check all that apply. 

a. Registered Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

b. Physician's Assistant: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

d. Physician: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

e. Other (Specify below): 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

13. Has there ever been an extended period of time, during the last 5 
years, when there was no one available to conduct the medical forensic 
examinations for adult victims of domestic violence?
Yes: 
No: Skip To Question #15. 

14. If yes, please describe the circumstances. 

15. Does your facility (ever) refer adult domestic violence patients 
someplace else for medical forensic examinations?
Yes: 
No: Skip To Question #17. 

16. If you checked "Yes," please specify where and under what 
circumstances. 

Section C. Child Victims Of Sexual Abuse: 

17. If a child victim of sexual abuse comes into your facility, with 
what frequency does your facility conduct a medical forensic 
examination, that is, the medical treatment of a patient as well as 
the collection of forensic evidence? 
Typically or always conducts: 
Sometimes conducts: 
Rarely conducts: 
Never conducts: 

18. If the frequency with which your facility conducts these medical 
forensic examinations has substantially changed in the last five 
years, please describe below. The box will expand to fit your answer.
Note: If you answered "Never conducts" to Question 17, please skip to 
Question 23. 

19. If your facility conducts medical forensic examinations in cases 
of child sexual abuse, which types of providers typically conduct 
medical forensic examinations? For each row, please check all that 
apply. 

a. Registered Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

b. Physician's Assistant: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

d. Physician: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

e. Pediatrician; 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

f. Other (Specify below): 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

20. If your facility conducts medical forensic examinations in cases 
of child sexual abuse, what is the level of training of the providers 
who typically conduct these examinations? For each row, please check 
all that apply. 

a. Registered Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

b. Physician's Assistant: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

d. Physician: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

e. Pediatrician: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

f. Other (Specify below): 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

21. Has there ever been an extended period of time, during the last 5 
years, when there was no one available to conduct the medical forensic 
examinations for child victims of sexual abuse?
Yes: 
No: Skip To Question #23. 

22. If yes, please describe the circumstances. 

23. Does your facility (ever) refer child sexual abuse patients 
someplace else for medical forensic examinations?
Yes: 
No: Skip To Question #25. 

24. If you checked "Yes," please specify where and under what 
circumstances. 

Section D. Child Victims Of Physical Abuse: 

25. If a child victim of physical abuse comes into your facility, with 
what frequency does your facility conduct a medical forensic 
examination, that is, the medical treatment of a patient as well as 
the collection of forensic evidence?
Typically or always conducts: 
Sometimes conducts: 
Rarely conducts: 
Never conducts: 

26. If the frequency with which your facility conducts these medical 
forensic examinations has substantially changed in the last five 
years, please describe below. The boxes will expand to fit your answer.
Note: If you answered "Never conducts" to Question 25, please skip to 
Question 31. 

27. If your facility conducts medical forensic examinations in cases 
of child physical abuse, which types of providers typically conduct 
medical forensic examinations? For each row, please check all that 
apply. 

a. Registered Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

b. Physician's Assistant: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

d. Physician: 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

e. Pediatrician; 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

f. Other (Specify below): 
Always or Almost Always Conducts: 
Sometimes Conducts: 
Rarely Conducts: 
Never Conducts: 
Do not have this type of provider: 

28. If your facility conducts medical forensic examinations in cases 
of child physical abuse, what is the level of training of the 
providers who typically conduct these examinations? For each row, 
please check all that apply. 

a. Registered Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

b. Physician's Assistant: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

c. Nurse Practitioner/Advanced Practice Nurse: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

d. Physician: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

e. Pediatrician: 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

f. Other (Specify below): 
SANE-A Certified: 
SANE Trained: 
Forensic Training: 
No providers of this type have specific forensic training or do not 
have this type of provider: 

29. Has there ever been an extended period of time, during the last 5 
years, when there was no one available to conduct the medical forensic 
examinations for child victims of physical abuse?
Yes: 
No: Skip To Question #31. 

30. If yes, please describe the circumstances. 

31. Does your facility (ever) refer child physical abuse patients 
someplace else for medical forensic examinations?
Yes: 
No: Skip To Question #33. 

32. If you checked "Yes," please specify where and under what 
circumstances. 

Section E. Program Operations: 

33. Does your facility have the capacity to perform medical forensic 
examinations for adult or child victims of sexual assault and/or 
domestic violence 24 hours a day, 7 days a week? 
Yes: 
No: 
No Program: Skip to Question 36. 

34. What are the current days and hours of operation for your medical 
forensic examiner staff or program that treats adult or child victims 
of sexual assault and/or domestic violence? Please describe in the box 
below if the hours are different for children or adults. 

Please indicate time in 24-hour clock format. If you are not 
open/available during one or more time slots, please type N/A in that 
time slot. 

Monday: 
Regular Hours: 
On-Call: 

Tuesday: 
Regular Hours: 
On-Call: 

Wednesday: 
Regular Hours: 
On-Call: 

Thursday: 
Regular Hours: 
On-Call: 

Friday: 
Regular Hours: 
On-Call: 

Saturday: 
Regular Hours: 
On-Call: 

Sunday: 
Regular Hours: 
On-Call: 

35. Please describe, if applicable, other provider/staff availability 
for children or adults. 

36. Are there any (other) IHS or tribal clinics in your service area 
offering medical forensic examinations to child or adult victims of 
sexual assault or domestic violence? 
Yes: 
No: skip to Question 38; 
Don't know: skip to Question 38. 

37. If there are other HIS or tribal clinics in your service area to 
whom you may refer medical forensic examinations for child or adult 
victims of sexual assault or domestic violence, what are the names of 
the clinics and their contact information, to the extent it is 
available (please provide for up to 3 clinics): 

IHS Clinic Name: 
Contact Name: 
Contact Phone: 
Contact Email: 
  
38. Is there any additional information that you would like to provide 
in regards to medical forensic examinations? 
   
Thank you very much for your participation! 

Please save your responses before exiting and return the questionnaire 
by attaching the document to an email message to StetlerK@gao.gov. 

[End of section] 

Appendix III: Summary of Key Survey Results on Provision of Medical 
Forensic Services for Sexual Assault Victims: 

Hospital: Acoma-Canoncito-Laguna Hospital; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Alaska Native Medical Center; 
Urban or remote: Urban; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Certified[A]; 
Training for child services: None. 

Hospital: Browning Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Cass Lake Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training[B]; 
Training for child services: Medical forensic training. 

Hospital: Cherokee Indian Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Chickasaw Nation Medical Center; 
Urban or remote: Urban; 
IHS or tribal: Tribal; 
Services for adults: Does not typically perform; 
Services for children: Typically performs; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Chinle Comprehensive Health Care Facility; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Choctaw Nation Indian Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Certified; 
Training for child services: None. 

Hospital: Cherokee Nation WW Hastings Hospital; 
Urban or remote: Urban; 
IHS or tribal: Tribal; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Claremore Hospital; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Creek Nation Community Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Crow/Northern Cheyenne Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Crownpoint Healthcare Facility; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Eagle Butte Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Fort Defiance Indian Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Certified; 
Training for child services: None. 

Hospital: Fort Yates Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: Certified; 
Training for child services: None. 

Hospital: Gallup Indian Medical Center; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Harlem Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Hopi Health Care Center; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Hu-Hu-Kam Memorial Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Kanakanak Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Lawton Hospital; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Maniilaq Health Center; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Mescalero Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: MS Band of Choctaw Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Certified; 
Training for child services: None. 

Hospital: Mt. Edgecumbe Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Northern Navajo Medical Center; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Typically performs; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Norton Sound Regional Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Parker Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Phoenix Indian Medical Center; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Pine Ridge Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Quentin N. Burdick Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Rapid City Hospital; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Redlake Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Rosebud Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Sage Memorial Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Samuel Simmonds Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: San Carlos Hospital[C]; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Santa Fe Hospital; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Sells Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Does not typically perform; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Hospital: Tuba City Indian Medical Center; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Whiteriver Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Certified. 

Hospital: Winnebago Hospital; 
Urban or remote: Remote; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: Medical forensic training; 
Training for child services: None. 

Hospital: Yukon-Kuskokwim-Delta Regional Hospital; 
Urban or remote: Remote; 
IHS or tribal: Tribal; 
Services for adults: Typically performs; 
Services for children: Typically performs; 
Training for adult services: Medical forensic training; 
Training for child services: Medical forensic training. 

Hospital: Zuni Hospital; 
Urban or remote: Urban; 
IHS or tribal: IHS; 
Services for adults: Typically performs; 
Services for children: Does not typically perform; 
Training for adult services: None; 
Training for child services: None. 

Legend: 
Typically performs; 
Does not typically perform (i.e., never, rarely, or sometimes performs 
medical forensic exams). 

Source: GAO. 

[A] This category includes nurses that have obtained the sexual 
assault nurse examiner (adult, SANE-A) or sexual assault nurse 
examiner (pediatric, SANE-P) certification from the International 
Association of Forensic Nurses. 

[B] This category includes health care providers who have specialized 
training, including SANE training, in medical forensic exams. 

[C] On follow-up with San Carlos Hospital, we found that it does not 
typically perform medical forensic exams for adults, although its 
survey response said it did perform such exams. Therefore, the number 
of hospitals typically performing exams changed from a reported value 
of 27 to an actual value of 26 in our report. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

October 11, 2011: 

Carolyn L. Yocom, Director: 
Natural Resources and Environment: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. Yocom: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "Indian Health Service: Continued Efforts 
Needed to Help Strengthen Response to Sexual Assaults and Domestic 
Violence" (GAO-12-29). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled. 
"Indian Health Service: Continued Efforts Needed To Help Strengthen 
Response To Sexual Assaults And Domestic Violence" (GAO-12-29): 

The Department appreciates the opportunity to review and comment on 
this draft report. While acknowledging that the Indian Health Service 
(IHS) is in the early stages of a comprehensive sexual assault and 
domestic violence response, the MS is committed to developing and
implementing policies and protocols that are responsive to the 
immediate needs of sexual assault and domestic violence victims in 
Indian Country. The four challenges described in the GAO's assessment 
that IHS faces in "standardizing and sustaining the provision of 
medical forensic services" are areas of vital prioritization for 
moving forward. The Sexual Assault Policy was established as the first 
ever policy of its kind in the IHS. Our plan was to develop the 
initial policy, then consult with Tribes to gather their input and 
recommendations, then revise/update the policy, and to develop an 
implementation plan, all of which are currently in progress. IHS will 
address the recommendations from the report as it continues its 
implementation of the policy. 

In the ongoing effort to meet these challenges, there is a trend 
toward Tribal management and delivery of health services in American 
Indian and Alaska Native (AUAN) communities. Tribes have increasingly 
contracted or compacted via the Indian Self-Determination and 
Education Assistance Act, Public Law 93-638, to administer and provide 
those services. This evolution in health care delivery and management 
is changing the face of health services in Indian Country. 

Where IHS was previously the principal health and behavioral health 
care delivery system for AUANs, there is now a less centralized and 
more diverse network of care provided by Federal, Tribal, and Urban 
Indian health programs. The "Indian health system" denotes this larger 
network of programs and the evolving care delivery system across 
Indian Country. Meeting the needs of this system requires an evolution 
in IHS and Tribal collaboration, particularly as Tribal programs take 
more direct responsibility for services and IHS supports them in doing 
so. 

The IHS has devoted considerable effort to develop and share effective 
programs throughout the Indian health system. In particular, 
developing programs that are collaborative, community driven, and 
nationally supported, offer the most promising potential for long term 
success and sustainment. HS regularly relies on Tribal leadership and 
expertise to collaborate on a range of health and behavioral health 
problems and programs. 

The IHS National Tribal Advisory Committee (NTAC) on Behavioral 
Health, which is made up of elected Tribal leaders from each IHS Area, 
provides recommendations and advice on the range of health and 
behavioral health issues in Indian Country, including sexual assault 
and domestic violence. From making recommendations on significant 
funding allocations and service programs, to developing long term 
strategic plans for Tribal and Federal behavioral health programs for 
the future, the NTAC is the principal Tribal advisory group for all 
behavioral health services to IHS. They ensure collaboration among 
Tribal and Federal health programs, provide Tribal input into the 
development of programs and services, and also provide the inclusive 
and transparent development of processes and programs so important to 
all our communities and programs. 

The IHS National Behavioral Health Work Group (BHWG) is the technical 
advisory group to IHS. Comprised of mental health professionals from 
across the country, the BHWG furthers the agency priorities to 
strengthen partnerships with Tribes, to reform the IHS, improve 
quality and access to care for patients, and provide direct 
collaboration and input for accountable, fair, and inclusive services 
across the Indian behavioral health system. They provide expert advice 
and recommendations for services, programs, and intervention models, 
as well as long term strategic planning and goal development. As the 
national technical advisory group to the agency, they also work very 
closely with the elected Tribal leaders on the NTAC to provide 
collaborative links between the professional community and national 
Tribal leadership. 

With the LEIS Domestic Violence Prevention Initiative (DVPI), the 
numbers of providers receiving medical forensic training is now being 
tracked. Resources have been allocated to provide Sexual Assault Nurse 
Examiner (SANE), Sexual Assault Forensic Examiner (SAFE), and Sexual 
Assault Response Team (SART) training for the remaining Federal and 
Tribal facilities with 24/7 services and to assist with the purchase 
of forensic equipment. Collaborative work has begun to address 
information technology and electronic health record issues to better 
capture the number of medical forensic exams performed in Federal and 
Tribal facilities. Areas for remote case consultation, using 
telemedicine, are being addressed to meet the needs of limited 
technical expertise in most hospitals, as well as remote locations in 
need of expert consultation. 

Strategies to address domestic violence and sexual assault include 
collaborations and partnerships with Tribes and Tribal organizations, 
Urban Indian health programs, Federal, State, and local agencies, as 
well as public and private organizations. The IHS and the Department 
of Justice, Office on Victims of Crime (OVC) entered into a 
partnership involving the Federal Bureau of Investigation and the 
Department of the Interior. This partnership is the SANE-SART AUAN 
Initiative, and is funded through the OVC. Using evidence-based 
practices involving SANEs, SARTs, and victim-centered law enforcement 
practices, the initiative will support victim recovery, satisfaction, 
and cooperation with the Federal criminal justice system, as well as 
supporting victims' of sexual assault and Tribal communities' need for 
justice. 

GAO Recommendations: 

To improve or expand medical forensic exams and related activities for 
the 28 IHS operated hospitals, we recommend that the Secretary of 
Health and Human Services direct the Director of the Indian Health 
Service to take the following five actions: 

* Develop an implementation plan for the March 2011 IHS sexual assault 
policy (Indian Health Manual, chapter 3.29) — and monitor its 
progress — to clarify how the agency will support its hospitals and 
staff in fulfilling the policy, in particular, that the hospitals or 
staff: 

- obtain training and certification in providing forensic medical 
exams, 

- obtain equipment like cameras needed to collect evidence, 

- provide medical forensic exams on site or at a referral facility 
within 2 hours of a patient's arrival, and, 

- collaborate with law enforcement, prosecution, and other 
stakeholders identified in the policy with the objective of creating 
sexual assault response teams and obtaining regular feedback from such 
stakeholders on evidence collection and preservation. 

* Develop a policy that details how IHS should respond to discrete 
incidents of domestic violence without a sexual component and, working 
with Justice, develop a policy for responding to incidents of child 
sexual abuse consistent with protocols Justice develops for these 
incidents; such policies should be similar in scope and specificity to 
the March 2011 IHS policy on responding to adult and adolescent sexual 
assaults. 

* Clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS 
sexual assault policy calls for training and certification, or only 
training, of IHS physicians and physician assistants performing sexual 
assault medical forensic exams. 

* Modify the March 2011 HIS sexual assault policy so that it 
comprehensively and clearly outlines (1) the process for approving 
subpoenas and requests for IHS employees to provide testimony in 
federal, state, and tribal courts and (2) reflects the provisions in 
section 263 of the Tribal Law and Order Act of 2010, including that 
subpoenas and requests not approved or disapproved within 30 days are 
considered approved. 

* Explore ways to structure medical forensic activities with IHS 
facilities so that these activities come under an individual's normal 
duties or unit's official area of responsibility, in part, to ensure 
that providers are compensated for performing medical forensic 
services. 

IHS Response: 

In response to the five recommendations, we offer the following 
comments: 

Recommendation 1: 

To meet the challenge of ensuring that the IHS policy is consistently 
implemented in IHS operated hospitals and to ensure compliance, an 
implementation and monitoring plan is now being drafted. The 
implementation plan will address areas of standardized training and 
certification, information technology, electronic health records, 
standardized forensic equipment, telemedicine options for remote case 
consultation, and set timelines for policy revisions and development. 
The implementation plan will clarify how IHS will support its 
facilities in providing medical forensic exams, by referring to an 
outside facility, or a combination of both services. 

Recommendation 2: 

During the Tribal consultation phase of the development of the IHS 
national sexual assault policy, many Tribal leaders provided 
recommendations that encouraged establishment of separate IHS-wide 
guidance addressing operating procedures and protocols for child 
victims of abuse and neglect through the Indian Health Manual. In 
response, the IHS created a policy workgroup comprised of IHS 
professionals with extensive field experience in providing
direct services to abused and neglected Al/AN children. The resulting 
Child Maltreatment Policy Workgroup will collaborate to develop the 
foundation for local child maltreatment and child sexual abuse 
policies and procedures for hospitals and clinics managed by the IHS. 
The IHS's plan is to develop a separate, stand-alone domestic violence 
policy, without sexual assault components, for its facilities. The 
policy will be comprehensive and similar in scope and specificity to 
the sexual assault policy approved by the IHS Director on March 23, 
2011. 

Recommendations 3 and 4: 

Clarification of the IHS sexual assault policy on sections 3.29.1 and 
3.29.5 on training and certification for IBS physicians and physician 
assistants performing sexual assault medical forensic exams is part of 
the revision process for the sexual assault policy. The implementation 
plan will set timelines for revisions to the sexual assault policy. 
Tribal leaders have provided recommendations for the sexual assault 
policy and work has begun to incorporate those recommendations into 
the revised policy. 

Modifying the IHS sexual assault policy to comprehensively and clearly 
outline the process for approving subpoenas and requests is underway. 
This modification to the policy will reflect the provisions in section 
263 of the Tribal Law and Order Act of 2010, including that subpoenas 
and requests not approved or disapproved within 30 days of receipt are 
considered approved. 

Recommendation 5: 

H-IS is exploring ways to structure medical forensic activities in HIS 
facilities and to ensure that providers are compensated for performing 
medical forensic services. Within the Federal pay systems, (both Title 
5 and Title 38) medical forensic duties will fall within providing 
patient care under the Nursing series. Currently, the IHS is looking 
at other methods of recognizing the specialized nature of the duties 
and compensation for performing exams and for call back or standby 
premiums. 

[End of section] 

Appendix V: Comments from the State of Alaska: 

State of Alaska: 
Department of Public Safety: 
Sean Parnell, Governor: 
Joseph A. Masters, Commissioner: 
Office of the Commissioner: 
5700 E. Tudor Road: 
Anchorage, AK 99507: 
Voice: (907) 269-5086: 
Fax: (907) 269-4543: 
Juneau Office: 
Voice: (907) 465-4322: 
Fax: (907) 465-4362: 

October 14, 2011: 

Carolyn Yocom: 
Director: 
Natural Resources and Environment: 
US Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Director Yocom, 

Governor Parnell is strongly committed, through his administration's 
Choose Respect Initiative, to end the epidemic of domestic violence 
and sexual assault in Alaska. We appreciate you providing the State of 
Alaska the opportunity to review and comment on the United States 
Government Accountability Office Report (GAO-12-29): Indian Health
Service - Continued Efforts Needed to Help Strengthen Response to 
Domestic Violence and Sexual Assault. 

It was a pleasure working with your team as they planned and executed 
their travels to Alaska to conduct their investigation and review. We 
truly appreciate their willingness to travel to the rural and remote 
regions of our state. This provided them the opportunity to see first-
hand the challenges we often face in providing vital services for 
victims. 

After review of the report, we generally concur with the conclusions and
recommendations for executive action. However, there are a few 
significant issues that warrant specific comments. 

The first issue is that the sexual assault policy applies only to 
Indian Health Service (IHS) operated hospitals, not tribally operated 
hospitals. As you know, the seven regional hospitals in Alaska and 165 
village clinics are not IHS operated hospitals. These hospitals are 
operated tribally through self-determination contracts or self-
governance compacts. This means that IHS policies and procedures do 
not apply to Alaska. It is our understanding from this document that 
the policies and procedures may be used as models to base protocols. 
We may need to rely on the Secretary of Health and Human Services to 
"facilitate the efforts of tribes to plan, conduct and administer 
programs, functions, services and activities." Furthermore, if needed, 
Alaska may decide to call upon IHS for technical assistance in these 
matters. 

The second issue is quite simple and obvious. Alaska does not have the 
same jurisdictional issues as the Lower 48, and thus the issues with 
prosecution differ greatly in Alaska. Consequently, much of the first 
part of this document and the descriptors simply do not apply to 
Alaska. 

The third issue of note is the issue of "certification of providers." 
The State of Alaska currently does not have a requirement for 
certification. While we feel strongly that a trained provider is often 
the best person to conduct the exam (for the reasons outlined in the 
report), and the use of trained providers is nationally considered to 
be "best practice," we are concerned that this part of the policy 
could be potentially limiting to Alaska. This is an issue that we have 
been discussing at great length during our ongoing statewide meetings 
on SART sustainability. 

Lastly, we strongly agree with your recommendation to develop 
additional policies specific to child sexual abuse. We have provided 
your staff some information to help support the need for this within 
Alaska. 

We know that we cannot end this epidemic alone and welcome 
partnerships, coordination, and collaboration in our efforts on behalf 
of victims. Again, thank you for the opportunity to provide written 
comments. 

Sincerely, 

Signed by: 

Joseph A. Masters: 
Commissioner: 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov: 

Staff Acknowledgments: 

In addition to the individual contact named above, Jeffery D. Malcolm 
(Assistant Director), Ellen W. Chu, Katherine Killebrew, Ruben Montes 
de Oca, Kim Raheb, Kelly Rubin, Jeanette M. Soares, Kyle Stetler, 
Shana B. Wallace, and Tama R. Weinberg made key contributions to this 
report. 

[End of section] 

Footnotes: 

[1] Department of Justice, Bureau of Justice Statistics, A BJS 
Statistical Profile, 1992-2002: American Indians and Crime, NCJ 203097 
(Washington, D.C.: 2004), and Department of Justice, Office of Justice 
Programs, Full Report of the Prevalence, Incidence, and Consequences 
of Violence Against Women, NCJ 183781 (Washington, D.C.: 2000). 
Justice uses the term Indian in these studies to refer to persons who 
self-identify as American Indian or Alaska Native and does not limit 
the term to those enrolled in state-or federally recognized tribes. 

[2] Department of Justice, Office of Justice Programs, Extent, Nature, 
and Consequences of Intimate Partner Violence, NCJ 181867 (Washington, 
D.C.: 2000). Justice uses the term Indian in this study to refer to 
persons who self-identify as American Indian or Alaska Native and does 
not limit the term to those enrolled in state-or federally recognized 
tribes. 

[3] For the remainder of this report, unless noted otherwise, the term 
Indian refers to the American Indian and Alaska Native beneficiaries 
of the Indian Health Service. 

[4] In this report, when referring to entities that operate hospitals, 
the terms tribe and tribal refer both to federally recognized tribes 
and to tribal organizations, such as Alaska Native health corporations 
operating hospitals in Alaska. 

[5] In this report, the terms sexual assault and domestic violence 
include cases involving both adult and child victims. 

[6] In addition, nonemergency health care facilities, such as 
community clinics or mobile health clinics, may also provide sexual 
assault medical forensic exams. Our review focused on hospitals 
because, according to IHS officials, hospitals are the most likely 
type of IHS facility to have the necessary infrastructure and 
expertise to perform these exams. 

[7] Amnesty International USA, Maze of Injustice: The Failure to 
Protect Indigenous Women from Sexual Violence in the USA (New York: 
2007). 

[8] The term Indian country refers to all land within the limits of 
any Indian reservation under the jurisdiction of the U.S. government; 
all dependent Indian communities within U.S. borders; and all existing 
Indian allotments, including any rights-of-way running through an 
allotment. See 18 U.S.C. § 1151. 

[9] Department of Justice, Office on Violence Against Women, A 
National Protocol for Sexual Assault Medical Forensic Examinations: 
Adults/Adolescents, NCJ 206554 (Washington, D.C.: 2004). 

[10] Tribal Law and Order Act of 2010, Pub. L. No. 111-211, Title II, 
§ 266, 124 Stat. 2258, 2262 (2010). The act requires that we submit a 
report describing the results of the study no later than 1 year after 
the act's enactment. July 29, 2011, marked the 1-year anniversary of 
the law's enactment. We briefed staff from the Committee on Indian 
Affairs, U.S. Senate, and the Committee on Natural Resources, House of 
Representatives, on July 11 and July 14, 2011, respectively. 

[11] We selected these 15 hospitals using a series of criteria that 
included geographic location, remoteness, whether the state or federal 
government had criminal jurisdiction in Indian country served by the 
hospital, and whether the hospital was IHS or tribally operated. 

[12] Because we used a nonprobability sample to select IHS and 
tribally operated hospitals to interview, the information we gathered 
during these semistructured interviews cannot be generalized to all 
hospitals and instead represents the perspectives only of the 
interviewed hospital providers and stakeholders. 

[13] Pub. L. No. 93-638 (1975), codified as amended at 25 U.S.C. §§ 
450 to 458ddd-2. 

[14] Medical providers performing medical forensic exams can be 
specially trained and sometimes certified in performing these exams 
but may also perform these exams regardless of whether they have 
undergone such specialized training or received such certification. 

[15] The Forensic Nursing Certification Board, a functionally 
autonomous component of the International Association of Forensic 
Nurses, develops and administers SANE certification. 

[16] These eligibility requirements, for example, include that nurses 
(a) complete 40 hours of didactic training in adult and adolescent 
sexual assault education (or a parallel training curriculum in 
pediatric sexual assault) and (b) work under an expert, such as a SANE-
/certified nurse, and perform enough sexual assault exams to 
demonstrate clinical competency to this expert. 

[17] For reasons explained elsewhere in this report, in Alaska, 
generally only the state has criminal jurisdiction. In addition, the 
IHS Cass Lake hospital in Minnesota is located in Indian country 
subject to state criminal jurisdiction. 

[18] In July 2011, Justice sent a letter to the President of the 
Senate and the Speaker of the House of Representatives to consider a 
proposal to, among other things, extend tribal criminal jurisdiction 
to non-/Indians who commit domestic violence or dating violence in 
Indian country. 

[19] GAO, U.S. Department of Justice Declinations of Indian Country 
Criminal Matters, [hyperlink, http://www.gao.gov/products/GAO-11-167R] 
(Washington, D.C.: Dec. 13, 2010). The U.S. Attorneys' Offices call 
all criminal investigations referred to them by law enforcement 
matters. 

[20] GAO, Indian Country Criminal Justice: Departments of the Interior 
and Justice Should Strengthen Coordination to Support Tribal Courts, 
[hyperlink, http://www.gao.gov/products/GAO-11-252] (Washington, D.C.: 
Feb. 14, 2011). 

[21] Act of August 15, 1953 (known as Public Law 280), 67 Stat. 588 
codified as amended at 18 U.S.C. § 1162 and scattered sections of 
Title 25. Public Law 280 was amended to authorize states to assume 
criminal jurisdiction over Indian country with tribal consent; states 
that did so are known as optional Public Law 280 states. Other 
statutes, such as the Maine Indian Claims Settlement Act, grant states 
criminal jurisdiction over Indian country or particular tribes or 
reservations concurrently with the federal government or, in some 
cases, exclusively. See, e.g., Pub. L. No. 96-240 (1980), codified as 
amended at 25 U.S.C. § 1725. 

[22] The six mandatory Public Law 280 states are Alaska (except the 
Metlakatla Reservation), California, Minnesota (except the Red Lake 
Reservation), Nebraska, Oregon (except the Warm Springs Reservation), 
and Wisconsin. Of these six states, only Alaska and Minnesota have IHS 
hospitals. 

[23] Pub. L. No. 111-211, § 221 (2010), codified at 25 U.S.C. § 
1132(a)(2); 18 U.S.C. § 1162(d). On May 23, 2011, Justice issued a 
proposed rule that would establish procedures for an Indian tribe 
whose Indian country is subject to state criminal jurisdiction under 
Public Law 280 to request that the United States accept concurrent 
criminal jurisdiction within the tribe's Indian country and for the 
Attorney General to approve such a request. 76 Fed. Reg. 29675 (May 
23, 2011). 

[24] Pub. L. No. 92-203, 85 Stat. 688 (1971), codified as amended at 
43 U.S.C. §§ 1601-1629h; Alaska v. Native Village of Venetie Tribal 
Govt., 522 U.S. 520 (1998). 

[25] In Anchorage and Juneau, the municipal prosecutor's office 
handles misdemeanor domestic violence cases. 

[26] Federal Bureau of Investigation, Uniform Crime Reports, Crime in 
the United States, 2009, accessed August 22, 2011, [hyperlink, 
http://www.fbi.gov/about-us/cjis/ucr/ucr]. 

[27] Department of Justice, Bureau of Justice Statistics, National 
Crime Victimization Survey: Criminal Victimization, 2010, NCJ 235508 
(Washington, D.C.: 2011). Justice uses the term Indian in this study 
to refer to persons who self-identify as American Indian or Alaska 
Native and does not limit the term to those enrolled in state-or 
federally recognized tribes. 

[28] [hyperlink, http://www.gao.gov/products/GAO-11-252]. 

[29] Department of Justice, Extent, Nature, and Consequences of 
Intimate Partner Violence, and A BJS Statistical Profile, 1992-2002. 
As already noted, Justice uses the term Indian in these studies to 
refer to persons who self-identify as American Indian or Alaska Native 
and does not limit the term to those enrolled in state-or federally 
recognized tribes. 

[30] Federal Bureau of Investigation, Uniform Crime Reports, Crime in 
the United States, 2009. 

[31] André B. Rosay et al., "2010 Alaska Victimization Survey" 
(presentation at the University of Alaska, Anchorage, September 2010). 

[32] Some hospitals may track the number of medical forensic exams 
their staff perform, but such information may be collected by 
different hospitals using different methodologies and was not 
aggregated into IHS's centralized data systems. 

[33] This information showed that from fiscal year 2006 through fiscal 
year 2010, IHS and tribally operated hospitals recorded 2,882 visits 
for services related to adult sexual assault and 3,983 visits for 
services related to adult domestic violence. For children, during the 
same time period, 592 visits took place for services related to child 
sexual abuse and 421 visits for services related to child physical 
abuse. We do not know how many of these visits led to medical forensic 
exams, nor do we know how many other visits were not included in these 
data because they were initially given a primary purpose-of-visit code 
other than sexual assault or domestic violence: For example, a victim 
initially might have come in with a broken arm and only later be 
identified as having been involved in a sexual assault or domestic 
violence incident. These counts do not include any visits to Sage 
Memorial Hospital or Norton Sound Regional Hospital because we were 
unable to assess the reliability of data from these two hospitals. 

[34] Remote areas are those with dispersed and small populations and 
where travel times are longer because of limitations in transportation 
infrastructure. 

[35] Sexual assault response teams often include, among others, SANEs 
or sexual assault forensic examiners, representatives from relevant 
law enforcement, and a victims' advocate. Multidisciplinary teams 
often include these groups as well as a representative from the 
federal prosecutor's office. 

[36] Indian Health Care Improvement Reauthorization and Extension Act 
of 2009, Pub. L. No. 111-148, Title X, § 10221(a) (2010); throughout 
this report, we refer to this law as the Indian Health Care 
Improvement Act. Tribal Law and Order Act of 2010, Pub. L. No. 111-
211, § 265 (2010). 

[37] The flight from Kotzebue to Anchorage may have a layover in Nome. 

[38] Community health aides are trained in basic emergency and primary 
health care through a statewide training program in Alaska. They are 
typically selected from village residents and practice under 
supervision by licensed physicians. 

[39] Indian Health Care Improvement Reauthorization and Extension Act 
of 2009, Pub. L. No. 111-148, Title X, § 10221(a) (2010). The agency 
has drafted the required report to Congress, according to an IHS 
official, but it is currently under review and is thus not available. 

[40] According to IHS officials, community health aides are generally 
not eligible to perform medical forensic exams under the March 2011 
policy because they typically are not registered nurses, physicians, 
or physician assistants. 

[41] Sections 3.29.1.E.20 and 24 of the March 2011 policy define 
sexual assault nurse and forensic examiners, section 3.29.5.A 
delineates requirements for training and determining competency to 
perform medical forensic exams, and section 3.29.5.B describes how 
staff obtain privileges to perform such exams at IHS hospitals. 

[42] IHS generally defines an adolescent as an individual who has 
entered puberty but is below the age of full maturity (18 years of 
age), according to this policy, and it defines a child as an 
individual who has not yet reached adolescence. 

[43] Indian Health Care Improvement Reauthorization and Extension Act 
of 2009, Pub. L. No. 111-148, Title X, § 10221(a) (2010). 

[44] IHS officials told us they plan to develop additional guidance 
related to domestic violence, but details were not available during 
our review about the scope and specificity of this planned guidance. 

[45] Tribal Law and Order Act of 2010, Pub. L. No. 111-211, § 265 
(2010). 

[46] IHS officials also acknowledged that its policies, including the 
sexual assault policy, apply to all IHS employees even if they work at 
a tribally operated facility. 

[47] 25 U.S.C. § 450a. 

[48] GAO, Internal Control Management and Evaluation Tool, [hyperlink, 
http://www.gao.gov/products/GAO-01-1008G] (Washington, D.C.: Aug. 6, 
2001). This guide is based on GAO's Standards for Internal Control in 
the Federal Government [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-00-21.3.1], November 1999. As 
programs change and agencies strive to improve operational processes 
and implement new technological developments, management must 
continually assess and evaluate its internal, or management, control 
to assure that the control activities being used are effective and 
updated when necessary. This tool is not required to be used but is 
intended to help agencies determine how well their internal control is 
designed and functioning and to help determine what, where, and how 
improvements, when needed, may be implemented. 

[49] One of the five standards for internal control is control 
environment, which states that management and employees should 
establish and maintain an environment throughout the organization that 
sets a positive and supportive attitude toward internal control and 
conscientious management. 

[50] Department of Health and Human Services, Indian Health Service, 
Strategic Plan 2006-2011 (Washington, D.C.: 2006), 40. 

[51] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[52] Our guide for maintaining or implementing these standards states 
that agencies should consider, among other factors, whether pertinent 
information is distributed to the right people in sufficient detail, 
in the right form, and at the appropriate time. [hyperlink, 
http://www.gao.gov/products/GAO-01-1008G]. 

[53] Two hospitals--Sage Memorial Hospital in Ganado, Arizona, and 
Norton Sound Regional Hospital in Nome, Alaska--do not use IHS's 
comprehensive health information system, called the Resource Patient 
Management Information System, but a different electronic health 
records system. We were therefore unable to assess the reliability of 
their data or to use their data in any analysis. 

[54] These codes are based on concepts used by the Office of 
Management and Budget to define county-level metropolitan and 
micropolitan areas. The Department of Agriculture's Economic Research 
Service applied similar criteria to measures of population density, 
urbanization, and daily commuting to identify urban cores and adjacent 
territory economically integrated with those cores. 

[End of section] 

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