Recommendations that jurisdictions may take to maintain confidentiality of patients: • Be sure jurisdictional policies address the scope and limitations of confidentiality as it relates to the exam process and with whom information can be legally and ethically shared. • Increase the understanding of relevant confidentiality issues. . • Consider the impact of the federal privacy laws regarding health information on victims of sexual assault. • Strive to resolve intrajurisdictional conflicts. 5. Reporting to law enforcement: Reporting the crime provides the criminal justice system with the opportunity to offer immediate protection to victims, collect evidence from all crime scenes, investigate cases, prosecute if there is sufficient evidence, and hold offenders accountable for crimes committed. Given the danger that sex offenders pose to the community, reporting can serve as a first step in efforts to stop them from reoffending. Equally important, reporting gives the justice system the chance to help victims address their needs, identify patterns of sexual violence in the jurisdiction, and educate the public about such patterns. Service providers should discuss all reporting options with victims in a language they understand 6 and the pros and cons of each, including the fact that delayed reporting may be detrimental to the prosecution of an offender. Even if a victim does not get a forensic medical exam, the victim can still report the crime at a later time. However, it will be much more difficult for criminal justice personnel to investigate and prosecute the crime if evidence was not collected. Reporting requirements in sexual assault cases vary from one jurisdiction to another. Every effort should be made to facilitate treatment and evidence collection (if the patient agrees), regardless of whether the decision to report has been made at the time of the exam. Victims who are undecided about reporting who receive respectful and appropriate care and advocacy at the time of their exam are more likely to assist law enforcement and prosecution. Because immigrant victims may be more reticent to report crimes, they need to be aware of crime victim protections for immigrants. Access to immigration relief for crime victims will enhance the ability of law enforcement to detect, investigate, and prosecute crimes. (SEE PAGES 55-59) Recommendations for jurisdictions and responders to facilitate victim-centered reporting practices: • Except in situations covered by mandatory reporting laws, patients, not health care workers, make the decision to report a sexual assault to law enforcement. • Inform patients about reporting consequences. • As a result of VAWA 2005, many jurisdictions have implemented alternatives to standard reporting procedures. • Promote a victim-centered reporting process. 6. Payment for the examination under VAWA: Under the Violence Against Women Act (VAWA),9 a state, territory, or the District of Columbia is entitled to funds under the STOP Violence Against Women Formula Grant Program only if it, or another governmental entity, incurs the full out-of-pocket cost of medical forensic exams for victims of sexual assault. “Full out-of-pocket costs” means any expense that may be charged to a victim in connection with the exam for the purpose of gathering evidence of a sexual assault.10 In addition, under the Violence Against Women Act of 2005, states may not require victims to participate in the criminal justice system or cooperate with law enforcement in order to receive a forensic medical exam.11 (SEE PAGES 61-62) Recommendations for jurisdictions to facilitate payment for the sexual assault medical forensic exam: • Understand the scope of the VAWA provisions related to exam payment. • Notify victims of exam facility and jurisdictional policies regarding payment for medical care and the medical forensic exam. B. Operational Issues 1. Sexual Assault Forensic Examiners: These are the health care professionals who conduct the examination. It is critical that all examiners, regardless of their discipline, are committed to providing compassionate and quality care for patients disclosing sexual assault, performing the physical examination, collecting evidence competently, documenting all findings, and testifying in court as needed. (SEE PAGES 65-67) Recommendations for jurisdictions to build the capacity of examiners performing these exams: • Encourage the development of specific knowledge, skills, and victim-centered approaches in examiners. • Encourage advanced education and supervised clinical practice of examiners, as well as certification for all examiners. 9 42 U.S.C. § 3796gg-4. 10 28 C.F.R. § 90.14(a). 11 42 U.S.C. 3796gg-4(d). 7 • Provide access to experts on anti-sexual assault initiatives who can participate in sexual assault examiner training, mentoring, proctoring, case review, photograph review, and quality assurance. 2. Facilities: Health care facilities have an obligation to provide services to sexual assault patients. Designated exam facilities or sites served by specially educated and clinically prepared examiners increase the likelihood of a state-of-the-art exam, enhance coordination, encourage quality control, and increase quality of care for patients. (SEE PAGES 71-74) Recommendations for jurisdictions to build capacity of health care facilities to respond to sexual assault cases: •