Victims of sexual assault may receive a sexual assault forensic examination by a medical provider who may or may not be a trained sexual assault forensic examiner. Medical providers assess victims’ clinical conditions; provide appropriate treatment and medical referrals; and, given consent by the victim, collect forensic evidence through a sexual assault forensic examination that may follow steps and use supplies from a sexual assault evidence collection kit. Under its protocol for sexual assault forensic examinations, the Department of Justice (DOJ) recommends that medical providers collect a range of physical evidence. In addition, sexual assault forensic exams typically include documenting biological and physical findings such as cuts or bruises and a victim’s medical forensic history, such as the time and nature of the assault. Once the exam is complete, medical providers preserve the collected evidence, which may include packaging, labeling, and sealing evidence collection kits and storing kits in a secure location. Medical providers typically perform such exams only for acute cases of sexual assault, such as in cases where the assault occurred within the previous 72 to 96 hours, when the physical and biological evidence on a person’s body or clothes is considered most viable. DOJ, IAFN, and the American College of Emergency Physicians (ACEP) recommend that sexual assault forensic exams be performed by specially trained medical providers—known as sexual assault forensic examiners (examiners). These examiners include physicians, physician assistants, nurse practitioners, and other registered nurses who have been specially educated and have completed clinical requirements to perform sexual assault forensic exams. Sexual assault nurse examiners (SANE) —a particular type of sexual assault forensic examiner—are registered nurses, including nurse midwives and other advanced practice nurses, who have received specialized education and have fulfilled clinical requirements to perform sexual assault forensic exams. Examiner programs have been created in hospital or non-hospital settings whereby specially trained examiners are available to provide first-response care and exams to sexual assault victims. DOJ, IAFN, and some states have issued guidelines pertaining to the minimum level of training examiners should receive in order to properly collect and preserve evidence, identify victims’ medical and emotional health care needs, and provide counseling and referrals for victims. These guidelines include recommendations of objectives and topics that training programs should cover. DOJ administers several grant programs that aim to, among other things, improve response to and recovery from four broad categories of victimization—domestic violence, sexual assault, dating violence, and stalking. In our March 2016 report we describe three key grant programs administered by DOJ’s Office on Violence Against Women that could be used by grant recipients—including states or other eligible entities—to fund or train sexual assault forensic examiners. In our March 2016 report examining the availability of sexual assault forensic examiners, we found that only limited nationwide data exist on the availability of sexual assault forensic examiners—that is, both the number of practicing examiners and health care facilities that have examiner programs. While IAFN reported that, as of September 2015, there were 1,182 nurses with an active IAFN SANE certification in the United States, such data do not represent all practicing examiners nationwide. For example, the data do not account for examiners who completed training through an IAFN or a state training program but never became certified or were certified through another entity, such as a state board of nursing. IAFN also collects data on examiner programs nationwide—that is, data on hospitals, clinics, and other sites where examiners practice. Such data provide an indication of the availability of examiners, but the data are also limited. While 703 examiner programs nationwide voluntarily reported to IAFN’s examiner program database, as of September 2015, IAFN officials noted that the database is often not up to date; and some health care settings where sexual assault forensic exams are conducted, such as child advocacy centers, are not represented. In addition, data collected on staffing characteristics of examiner programs are often unavailable in the IAFN examiner program database. For example, only about one-third of the examiner programs reported on the number of examiners practicing in their program, and about one-third reported on whether examiners were available on-site versus on-call. In three of the six selected states we reviewed in our March 2016 report, grant administrators or officials from sexual assault coalitions were able to provide estimates of the number of practicing examiners, and, in all six states, they were able to provide information on the estimated number of examiner program locations in their state. Of states that reported, the number of practicing examiners and examiner programs varied by state. (See table 1.) However, such data may also present an incomplete picture of the availability of examiners. For example, only one of the six selected states has a system in place to formally track the number and location of examiners. Instead, officials generally reported on the estimated number of examiners or examiner locations that were part of a statewide examiner program or were identified through an ad hoc data collection effort. Although data are limited, grant administrators and sexual assault coalition officials in all six selected states nevertheless told us that the number of examiners available does not meet the need for exams within their states. For example, coalition officials in Wisconsin told us that nearly half of all counties in the state do not have any examiner programs available, and coalition officials in Nebraska told us that most counties in the state do not have examiner programs available. In addition, in four of the six selected states—Colorado, Florida, Nebraska, and Wisconsin— state grant administrators and coalition officials told us that few or some health care facilities in their state have examiners available. As a consequence, officials said victims may need to travel long distances to be examined by a trained examiner or be examined by a medical professional without specialized training. While in the other two selected states—Massachusetts and Oregon—state grant administrators and coalition officials stated that some or most facilities have examiners available, they noted that there is still a need for additional capacity to reduce the burden on those examiners who are available, or to make examiners available in a number of areas where examiners are currently unavailable. In health care facilities where examiners are available, they are typically available through hospitals on an on-call basis, according to literature we reviewed as well as all grant administrators and coalition officials we interviewed for our report. In addition, among facilities that have examiners available, the number of examiners available varies and may not provide enough capacity for facilities to offer examiner coverage 24 hours, 7 days a week, according to state grant administrators and coalition officials we interviewed. Nebraska coalition officials, for example, told us that while one hospital in Omaha has a team of 26 examiners available, other facilities in the state may have as few as three examiners available. Further, officials from Florida and Colorado told us that there are few facilities in their states able to offer full coverage with examiners available 24 hours, 7 days a week. In our March 2016 report, we found that maintaining a supply of trained examiners that meets communities’ needs for exams is challenging for multiple reasons, and that state officials have employed a variety of strategies to address these challenges, as described below. Limited availability of training. Officials in five of the six selected states told us that the limited availability of classroom, clinical, or continuing education training is a barrier to maintaining a supply of trained examiners. Regarding classroom training, some officials told us that training may only be offered once per year in their states. Additionally, officials from both Florida and IAFN told us that there is a need for qualified instructors to run training sessions. Experts and officials from Colorado, Nebraska, and Oregon also told us that medical professionals in rural areas may have difficulty completing the clinical training necessary to become an examiner. Obtaining clinical experience, such as performing exams under the supervision of a trained examiner, is a particular challenge in rural areas where hospitals may treat only a few sexual assault cases per year. One official in Nebraska told us that trained examiners in rural areas might not feel competent to perform exams due to the low number of cases they treat. A lack of continuing education opportunities may also pose a challenge for examiners in maintaining the skills necessary to perform exams. For example, the National Sexual Violence Resource Center (NSVRC) reported that— based on common challenges identified through a survey of, and group discussions among, examiner program coordinators—maintaining competency may be difficult for nurses in rural areas due to a low volume of patients presenting in need of exams and limited access to ongoing and advanced training. Officials told us they have been able to increase the availability of examiner training through alternative training methods such as web- based training courses and simulated clinical training. For example, officials in Colorado told us their state’s web-based examiner training program has made training less expensive and has increased examiner recruitment. Officials in Wisconsin told us they developed a clinical training lab that allows examiners to gain hands-on experience by performing elements of exams on experienced teaching assistants hired for the purpose of training new examiners. Further, in 2014, a DOJ- funded evaluation of examiner training programs found that a web-based training course may help increase the availability of trained examiners; the study also found that implementing web-based training had benefits such as decreasing the costs associated with attending in-person training, expanding training opportunities to remote areas, and allowing examiners to be trained by national experts. Lack of technical assistance and other supportive resources. Officials in four of the six selected states told us that the limited availability of technical assistance and other supportive resources for examiners poses a challenge to maintaining a supply of trained examiners. For example, officials in Florida, Nebraska, Oregon, and Wisconsin explained that, in general, there is a lack of mentorship opportunities and leadership within the examiner community. Officials also noted that the sustainability of examiner programs may be threatened by a lack of internal capacity, such as not having a full-time, paid examiner program coordinator available. Further, in its survey of and group discussions with examiner program coordinators, NSVRC found that examiners and examiner programs needed technical assistance and support in the following areas: aspects of performing exams, training, leadership development and policy issues, and examiner program sustainability. Officials we spoke to told us about strategies that can be used to increase support for examiners and examiner programs, such as offering web- based technical assistance. For example, officials in Massachusetts told us that, through their National Sexual Assault TeleNursing Center, trained SANEs provide remote clinical guidance to two hospitals in the state that do not have trained examiners available. In addition, officials from Colorado told us an examiner program coordinator in an urban hospital in the state provides volunteer on-call technical assistance and clinical guidance to examiners in rural parts of the state, where those resources are not otherwise available. Further, one study we reviewed found several states were engaged in promising practices to increase support for examiners, such as implementing state-wide mentorship programs, developing regional examiner list-serves and online discussion boards, creating formal leadership positions within the examiner community, and requiring examiner program evaluations. Weak stakeholder support for examiners. Officials in five of the six selected states told us that limited stakeholder support for examiners and examiner programs, such as from hospitals and law enforcement, is a challenge to maintaining a supply of trained examiners. Some officials told us that hospitals may be reluctant to support examiners and examiner programs due to a low number of sexual assault cases treated each year. One official told us that hospitals may be reluctant to send nurses to examiner training, as it takes away from their regular shift availability. Additionally, some hospitals do not pay examiners to be on call. Officials in three states told us that hospitals typically either do not pay examiners to be on call or pay on-call examiners significantly less than other on-call medical professionals. Apart from hospital support, officials in Colorado and Oregon explained there is a need for more multidisciplinary support for examiners, such as increased law enforcement, prosecutor, and first-responder understanding of examiners’ role. The literature we reviewed also shows that ambiguity around the role of the examiner in responding to sexual assault may be a source of conflict between examiners and other professionals. For example, examiners were found to have experienced instances where victim advocates or law enforcement questioned examiners’ medical decisions, speed of evidence collection, or asked examiners to comment on the credibility of a victim’s case. One nationally representative survey of examiner programs found that examiner program coordinators felt ongoing education of community stakeholders on sexual assault and examiner programs was needed due to the high turnover in staff at relevant community institutions and agencies, such as law enforcement officers, victim advocates, and prosecutors. Through our interviews with officials, we learned of strategies selected states have used to increase or mitigate limited stakeholder support for examiners and examiner programs. For example, officials in Colorado, Florida, Nebraska, Oregon, and Wisconsin told us that sexual assault response teams have been developed in their states to help community stakeholders to understand examiners’ role and better coordinate to meet the medical and legal needs of sexual assault victims. Low examiner retention rates. Officials in four of the six selected states told us that low examiner retention rates can be an impediment to maintaining a supply of trained examiners. In addition to the challenges of limited training opportunities, technical assistance and other supportive resources, and stakeholder support for examiners, the physically and emotionally demanding nature of examiner work contributes to low examiner retention rates. Further, studies have indicated that dissatisfaction with compensation, long work hours, and lack of support, among other things, may contribute to examiner burnout. Examiners typically work on call in addition to their full time jobs as, for example, emergency department nurses. Officials in Florida told us that examiners may be on call for 6-hour, 12-hour, or even 24-hour shifts. Further, one survey of examiner programs in Maryland found that examiners were required to be on call for an average of 159 hours per month. Wisconsin officials estimated that, although 540 SANEs were trained over a 2-year period, only 42 (less than 8 percent) were still practicing in the state at the end of those 2 years. Chairman Harper, Ranking Member DeGette, and Members of the Subcommittee, this concludes my prepared statement. I would be pleased to respond to any questions that you may have at this time. For further information about this statement, please contact A. Nicole Clowers at (202) 512-7114 or clowersa@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony. In addition to the contact named above, key contributors to this statement were Kristi Peterson (Assistant Director), Patricia Roy, Katherine Mack, Laurie Pachter, and Emily Wilson. This is a work of the U.S. government and is not subject to copyright protection in the United States. 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In 2016, about 323,000 individuals age 12 or older were reported victims of sexual assault, according to the Bureau of Justice Statistics. Studies have shown that exams performed by sexual assault forensic examiners—medical providers trained in collecting and preserving forensic evidence—may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates. Yet, concerns have been raised about the availability of such examiners. The Department of Justice administers grant programs that can be used by states and other eligible entities to train and fund examiners. This statement summarizes GAO's findings from its March 2016 report ( GAO-16-334 ) describing (1) what was known in 2016 about the availability of sexual assault forensic examiners nationally and in selected states and (2) the challenges selected states faced in maintaining a supply of sexual assault forensic examiners. For that report, GAO reviewed literature on the availability of examiners and challenges training and retaining them. GAO also interviewed knowledgeable officials, including recipients of federal sexual assault examiner related grants and officials from sexual assault coalitions in six states (Colorado, Florida, Massachusetts, Nebraska, Oregon, and Wisconsin) selected to achieve variation in factors such as population and geographic location. GAO's March 2016 report examining the availability of sexual assault forensic examiners found that only limited nationwide data existed on the availability of sexual assault forensic examiners—both the number of practicing examiners and health care facilities that had examiner programs. At the state level, GAO found that, in three of the six states it selected to review, grant administrators or officials from sexual assault coalitions were able to provide estimates of the number of practicing examiners and, in all six states, they were able to provide information on the estimated number of examiner program locations in their state. However, officials in all six selected states told GAO that the number of examiners available in their state did not meet the need for exams, especially in rural areas. For example, officials in Wisconsin explained that nearly half of all counties in the state did not have any sexual assault examiner programs available and officials in Nebraska told GAO that most counties in the state did not have examiner programs available. As a consequence, officials said victims may need to travel long distances to be examined by a trained examiner. In health care facilities where examiners were available, they were typically available in hospitals on an on-call basis, though the number available varied by facility and may not provide enough capacity to offer examiner coverage 24 hours, 7 days a week. GAO's March 2016 report also found there were multiple challenges to maintaining a supply of examiners, according to its review of the literature and interviews with officials in the six selected states. These challenges include: Limited availability of training . Officials in five of the six selected states reported that the limited availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of trained examiners. For example, officials told us that there is a need for qualified instructors to run training sessions. Weak stakeholder support for examiners. Officials in five of the six selected states reported that obtaining support from stakeholders, such as hospitals, was a challenge. For example, hospitals may be reluctant to cover the costs of training examiners or pay for examiners to be on call. Low examiner retention rates. The above-mentioned and other challenges, including the emotional and physical demands on examiners, contribute to low examiner retention rates. Officials in one of the selected states estimated that while the state trained 540 examiners over a two-year period, only 42 of those examiners were still practicing in the state at the end of those 2 years. Officials described a variety of strategies they have employed that can help address these challenges, such as implementing web-based training courses, clinical practice labs, mentorship programs, and multidisciplinary teams that respond to cases of sexual assault.