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

GAO-12-29 Published: Oct 26, 2011. Publicly Released: Oct 26, 2011.
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Highlights

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..

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to 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: (1) obtain training and certification in providing forensic medical exams; (2) obtain equipment like cameras needed to collect evidence; (3) provide medical forensic exams on site or at a referral facility within 2 hours of a patient's arrival; and (4) 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.
Closed – Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that the Indian Health Service (IHS) had not yet developed written, comprehensive plans for implementing and monitoring its March 2011 sexual assault policy. Specifically, we found that implementing and monitoring the policy's training and certification guidelines may be challenging and that IHS had not identified resources for purchasing equipment and supplies or identified deadlines IHS hospitals should meet in implementing parts of the policy such as providing access to medical forensic exams on site or by referral, or...
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to 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.
Closed – Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that Indian Health Service (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. We recommended that IHS 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...
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to 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.
Closed – Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that the Indian Health Service's (IHS) March 2011 sexual assault policy left 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. We found that without clear training and certification guidelines for physicians and physician assistants, medical forensic exams may be performed by medical providers with inconsistent levels of knowledge and expertise, and that as a result, IHS...
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to 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.
Closed – Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that the Indian Health Service's (IHS) March 2011 policy on responding to adult and adolescent sexual assaults did not clearly and comprehensively articulate the agency's processes for responding to subpoenas or requests for testimony of providers who perform medical forensic exams. We recommended that IHS modify its 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 court and (2) reflects the provisions in...
Department of Health and Human Services To improve or expand medical forensic exams and related activities for the 28 IHS operated hospitals, the Secretary of Health and Human Services should direct the Director of the Indian Health Service to 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.
Closed – Not Implemented
In an October 2011 report, "Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence," we found that in some Indian Health Service (IHS) 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 were performed by individual medical providers, sometimes from different departments, and often outside the medical providers' official job duties and beyond their normal working hours. We recommended that IHS explore ways to structure medical forensic activities within IHS...

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Case management servicesCrime preventionDomestic violenceEvidence-based practicesHealth care facilitiesHealth care servicesHospital care servicesHospitalsInvestigations by federal agenciesJurisdictional authorityLaw enforcementMedical examinationsNative AmericansSex crimesPolicies and procedures