Coordinated Team Approach
Recommendations at a glance for jurisdictions to facilitate a coordinated team approach:
- Understand that the purpose of the exam is to address patients’ health care needs and collect evidence when appropriate for potential use within the criminal justice system.
- Identify key responders and their roles.
- Develop quality assurance measures to ensure effective response during the exam process.
Communities should ensure that victims, regardless of their backgrounds or circumstances, have access to medical, legal, and advocacy services. Use of a coordinated, multidisciplinary approach in conducting the medical forensic examination can afford victims access to comprehensive immediate care, help minimize trauma they may be experiencing, and encourage the use of community resources. Such a response can also enhance public safety by facilitating investigation and prosecution, thereby increasing the likelihood that offenders will be held accountable for their behavior and further sexual assaults will be prevented. Raising public awareness about the existence and benefits of a coordinated response to sexual assault may lead more victims to disclose the assault and seek the help they need.1
Understand that the purpose of the exam is to address patients’ health care needs and collect evidence when appropriate for potential use within the criminal justice system. The medical/forensic examination in its entirety addresses the medical and evidentiary needs of the consenting patient:
- Conducting prompt examinations.
- Providing support, crisis intervention, and advocacy.
- Obtaining a history of the assault.
- Performing a complete assessment.
- Documenting exam findings.
- Evaluating and treating injuries.
- Properly collecting, handling, and preserving potential evidence.
- Providing information, treatment, and referrals for STIs and pregnancy.
- Providing follow-up care for medical and emotional needs as well as further forensic evaluation.
- Providing language assistance services for limited English proficient, Deaf and hard-of-hearing individuals, and those with sensory or communication disabilities.
It is also possible that examiners may provide the following as a routine part of their post-examination process depending upon the criminal justice system response:
- Interpreting and analyzing examination findings.
- Presenting findings and providing factual and/or expert opinion related to the medical forensic examination.
- Coordination among involved disciplines is strongly recommended to simultaneously address the needs of both victims and the justice system. Ensuring that victims’ needs are met often can increase their level of comfort and involvement with the legal system.
Identify key responders and their roles.
Two types of teams are recommended to facilitate a coordinated community response to sexual assault. Some form of a sexual assault response team (SART/SARRT) is useful to coordinate immediate interventions and services, including victim support, medical care, evidence collection and documentation, and the initial criminal investigation. A communitywide coordinating group (often called a “council”) can help promote efforts to improve comprehensive response to sexual violence, including prevention education and outreach2 , training and technical assistance, improvement of victim services, protocol development, public policy advocacy, dissemination of materials, and evaluation of the effectiveness of these efforts.3 A communitywide coordinating council may also oversee activities of a SART/SARRT. Military bases, school campuses, and tribes may develop coordinating councils or SARTs or SARRTs of their own to allow for a more specialized response tailored to the needs of their populations. Coordinating councils may also exist to encourage consistent responses across a state, territory, tribal land or region.
SART/SARRT membership. A SART/SARRT is composed of professionals involved in immediate response to disclosures of sexual assault. A core SART/SARRT commonly includes health care providers, law enforcement representatives, and victim advocates. Prosecutors and forensic scientists also are often involved, but more as consultants than first responders. Civil attorneys who represent victims are sometimes involved as well. Broad roles for SART/SARRT members include (listed in alphabetical order):4
- Advocates may be involved in initial victim contact (via 24-hour hotline or face-to-face meetings), offer victim advocacy, support, crisis intervention, information, translation or interpretation, and referrals before, during, and after the exam process, and facilitate transportation for the victim to and from the exam site. They often provide comprehensive, longer term services designed to aid victims in addressing any needs related to the assault, including but not limited to counseling and legal (civil, criminal, and immigration) and medical systems advocacy.
- Civil attorneys protect the interests of sexual assault victims, address concerns that affect immediate everyday life and long-term wellbeing of victims, and represent victims in civil legal matters. Civil legal matters may include: privacy, safety, immigration, education, housing, employment, and financial issues. Because civil attorneys represent the individual victim, and not the prosecutor, they play a very different role from that of the prosecutor.
- Forensic scientists analyze forensic evidence and provide results of the analysis to investigators and/or prosecutors. They may respond to crime scenes to assist in the collection and processing of evidence. They also testify at trial regarding the results of their analysis.
- Health care providers assess patients for acute medical needs and provide stabilization, treatment, and/or consultation. Ideally, sexual assault forensic examiners perform the medical forensic exam, gather information for the medical forensic history, collect and document forensic evidence, and document pertinent physical findings from patients. They offer information, treatment, and referrals for sexually transmitted infections (STIs), pregnancy, and other nonacute medical concerns. They may also testify in court if needed. They coordinate with advocates to ensure that patients are offered crisis intervention, support, and advocacy during and after the exam process and encourage use of other victim services. They may follow up with patients for medical and forensic purposes. Other health care personnel that may be involved include, but are not limited to, emergency medical technicians, staff at hospital emergency departments, gynecologists, surgeons, private physicians, and/or local, tribal, campus, or military health services personnel.
- Law enforcement representatives (e.g., 911 dispatchers, patrol officers, officers who process crime scene evidence, investigators, and federal law enforcement officers) respond to initial complaints, work to enhance victims’ safety, arrange for victims’ transportation to and from the exam site as needed, interview victims, coordinate collection and delivery of evidence to designated labs or law enforcement property facilities, and investigate cases (e.g., interviewing suspects and witnesses, requesting crime lab analysis, reviewing medical and lab reports, preparing and executing search warrants, writing reports, and presenting the case to a prosecutor).
- Prosecutors determine if there is sufficient evidence for prosecution and, if so, prosecute the case. They should be available to consult with first responders as needed. A few jurisdictions more actively involve prosecutors, paging them after initial contact and having them respond to the exam site so that they can become familiar with the case and help guide the investigation.5
- Victims’ rights attorneys ensure victims’ rights are upheld during the criminal justice process. Examples in the sexual assault cases include independent motions to quash subpoenas filed in the criminal case (e.g., subpoenas for counseling, medical, educational, and employment records), independent rape shield arguments, motions to close courtrooms or limit media access, and motions for alternative means of testifying and/or support during testifying.
Each responder should be able to explain to victims the roles of other team members. Depending on the case and jurisdictional policies, other professionals or agencies – from perhaps multiple jurisdictions – may also be involved in immediate interventions and service provision. They need information about the SART/SARRT and its procedures to guide their responses and facilitate coordination of activities with the SART/SARRT. SART/SARRT members also need information about those professionals and agencies, their roles in sexual assault response, and how to contact and interact with them.
Team efforts are enhanced when SART/SARRT members reflect the communities being served. At the least, SART/SARRT members should strive to understand the needs and concerns of specific populations living in the area served. SART/SARRTs should reach out to agencies that serve these populations so that team members can promptly access their services if needed.
See Appendix B for more information on the creation of SARTs/SARRTs.
Membership of a coordinating council.
A coordinating council typically comprises a wide array of professionals and citizens who develop the community’s response to sexual assault. Organizations with an interest in or a responsibility for sexual assault victims should be considered for membership.6 For example, members might include7 victim advocates; legal services providers (civil, criminal, and immigration); survivors of sexual assault and their families and friends; health care workers; public health and safety officials; law enforcement personnel; prosecutors; victim/witness staff; judicial personnel;8 corrections and probation staff; sex offender treatment providers; forensic lab personnel; staff from mental health agencies; personnel serving persons with disabilities; substance abuse treatment staff, staff from residential living settings such as nursing homes, assisted living programs, and group homes; educators from all levels; legislators and government policymakers; exam site administrators; religious and spiritual leaders; and the media and business community. Representation from all levels of government that potentially have jurisdiction over these cases in the area served should be involved. Equally important are members who can address the needs of diverse populations in the community (e.g., racial and cultural groups, senior citizens, persons with disabilities, immigrants, the poor and homeless, runaways and adolescents in foster care, domestic violence victims, college students, military personnel and dependents, and populations with differing sexual orientations and gender identities or expressions). Agencies that provide qualified interpreters in sexual assault cases should also be invited to participate.
Attempting to involve all agencies and individuals listed above is an enormous task and could prove to be a barrier to council formation and initial council efforts. Therefore, communities should make their own decisions about which stakeholders are critical to initial efforts and form a core membership, and then identify which agencies and individuals would be useful to have at the table at some point but are not essential to getting started.9
Develop quality assurance measures to ensure effective response during the exam process.
Involved agencies should have mechanisms to ensure that the quality of discipline-specific response and coordinated response is optimal. Some tools to ensure consistent, high-quality response by involved professionals professionals include training, ongoing education, supervision, periodic performance evaluations, and peer reviews (e.g., medical forensic reports). Also useful in facilitating improvements to immediate response are feedback from victims and involved professionals and collection and analysis of data from the exam process (as discussed below). Review of both active and resolved cases provides many opportunities to improve the performance of individual team members and the team as a whole, although certain team members, such as community based advocates, may need to be careful about confidentiality in case discussions
Obtain feedback on victim impact, the exam process, and criminal justice outcomes. All involved responders can benefit from victims’ feedback about whether they felt response to the crime was adequate and if anything could have been done to improve response or better address their needs. It can be useful to talk with victims about their experiences during the exam process, including the location of the exam, and explore how the process might be changed to better minimize trauma. Victim feedback can be obtained in several ways: by requesting completion of an evaluation form (not immediately after the exam), conducting a follow-up phone survey, and inviting participation in focus group discussions. It is important to solicit feedback from diverse populations in the community (e.g., racial and cultural groups, senior citizens, persons with disabilities, persons with limited English proficiency, immigrants, the poor and homeless, runaways and adolescents in foster care, domestic violence victims, college students, military personnel and dependents, and populations with differing sexual orientations and gender identities). Ask victims prior to medical discharge if they will allow such subsequent contacts and the best method of contacting them. Responders should be careful to ask victims for a safe manner to contact them, particularly in situations involving sexual assault by intimate partners. Advocates can help design a victim feedback system that is sensitive, does not harm victims, and has mechanisms to quickly link victims with appropriate victim services if needed. Families and friends of victims may also be able to provide useful feedback.
Obtaining feedback from and facilitating dialogue among the first responders (law enforcement, advocate, medical personnel) to the sexual assault and the individual who conducted the exam is also critical. Some of this information could be routinely solicited and discussed at SART/SARRT meetings and jurisdictional sexual assault coordinating council meetings (to assess what works and what needs improvement). Also, periodic evaluation of the exam process by examiners, medical supervisors/examiner program directors, advocates, law enforcement representatives, and prosecutors can help ensure that victims’ needs are addressed, problems are resolved, cutting-edge practices and technologies are utilized as much as possible, and training needs are identified. In terms of getting feedback on how the exam process impacts criminal justice outcomes, examiners can benefit from access to crime lab reports on evidence collected and feedback from crime lab personnel about improving their evidence collection techniques. Prosecutors can provide examiners and law enforcement representatives with information about the usefulness of evidence collected in case prosecution. Advocates can encourage discussion on how the exam process can affect victims’ interest in and willingness to be involved in the criminal justice system. Law enforcement representatives and other first responders can discuss with examiners and crime lab personnel optimal methods to preserve evidence from victims prior to their arrival at the exam site. Again, review of both active and resolved cases by the team as a whole is a rich opportunity for improvement These are but a few examples of how first responders could use feedback on criminal justice outcomes to improve the exam process.
Consider collecting and analyzing data from the exam process to better understand the nature of assaults in the community and evaluate effectiveness of responses. (Information that identifies victims should not be included in collected data. Attention must be given to protecting victims’ identity in communities where residents tend to know one another or word of a crime travels quickly). Over time, such data may help to: 10
• Track the participation of involved responders, agencies, and facilities.
• Evaluate the strengths and weaknesses of agency and coordinated responses.
• Assess the effectiveness of response in different types of cases (e.g., stranger assaults versus nonstranger assaults).
• Improve the quality of the examination.
• Evaluate the impact of the collected evidence on criminal justice outcomes.
• Track and evaluate victim service outcomes.
Some jurisdictions have developed centralized databases to collect and analyze information across disciplines. However, such a venture requires significant resources, coordination, and thought regarding how to maintain victims’ confidentiality. Coordination can be particularly challenging in communities where cross-jurisdictional issues arise frequently (e.g., in tribal lands). A centralized database may be more easily accomplished if it is built into multidisciplinary coordination planning. For example, involved agencies can together determine how to utilize existing resources, seek new funding, maintain victims’ privacy, and systematically obtain data. Jurisdictions considering such databases should take into consideration the fact that pooling empirical data (such as patient age, Zip Code, or use of a weapon) is likely to be reliable while use of pooled interpretive data(such as blunt cervical trauma or findings of strangulations) is risky and may be unreliable because of uncontrollable variables in examiner training and experience.
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1 This paragraph is drawn partially from American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 1999, p. 7.
2 Although victim advocacy programs and coordinating councils often lead local prevention efforts, SARTs play a role in prevention by helping victims plan for their safety and well-being and connecting them with resources that may reduce the likelihood of their future revictimization (e.g., emergency shelters and longer term housing programs, protective orders, programs offering free cell phones that automatically dial 911 when activated, or businesses that can help change locks and install alarm systems). Initial evidence collection and investigative efforts can play a pivotal role in holding offenders accountable and preventing them from reoffending.
3 American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 1999, p. 19.
4 Bulleted section partially adapted from Pennsylvania’s SART Guidelines, 2002, created by the Pennsylvania Coalition Against Rape.
5 In addition to seeking prosecution of offenders, victims who attend institutions of higher education may have the option of filing disciplinary charges. When that happens, members of the judiciary board review the case to decide if the institutional code of conduct has been violated and, if so, to determine sanctions. Tribes may also have their own codes related to sexual assault and/or processes through which victims can seek remedies, beyond what is available through state or federal prosecution.
7 American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 1999, p. 19.
8 List adapted from the American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 1999, p. 19.
9 Judges’ conduct in and out of the courtroom is governed by a code of judicial conduct that requires that they do nothing that would give the appearance of partiality. Depending on local interpretation of the code, the participation of judicial personnel on a council should not negate their ability to be impartial in court. In the unlikely instance that the council is involved with individual cases, judges can excuse themselves from those activities.
10 The protocol does not further explore issues related to more comprehensive coordinated response to sexual assault. However, one useful resource for communities interested in the development of a multidisciplinary response is the National Center Victim’s Looking Back, Moving Forward: A Guidebook for Communities Responding to Sexual Assault.