Forensic Nursing: Crime and Care

What do you call a job that combines nursing with detective work—where you can examine rape victims for evidence of the crime or study corpses for clues to the killer's identity? It's called forensic nursing. And, given the popularity of crime shows like "CSI," you can expect to hear a lot more about it in the future.

Forensic nursing was launched as a specialty in the 1970s, when it became clear that hospital emergency rooms didn't have the resources to deliver proper treatment to rape victims. Violated women were assigned low priority because medical staff didn't regard their cases as urgent when compared with, say, a heart-attack victim—and physicians weren't enthusiastic about caring for patients for whom they were probably going to have to testify in court. The brusque treatment only compounded victims' trauma. So a handful of ER nurses formed a specialty they called sexual-assault forensic examination. It was only in 1992, however, that the International Association of Forensic Nurses was founded—and only this summer that the Department of Justice's Office on Violence Against Women issued national training standards. The profession is clearly on the upswing, with 2,600 members in the IAFN today and membership growing every year. More than half of forensic nurses currently specialize in sexual assault. Others work in the areas of homicide, child abuse or domestic violence.

To get a sense of what the work actually entails, NEWSWEEK's Anne Underwood spoke with Beryl Skog, one of six forensic nurses employed by Bergen County, N.J. Excerpts:

NEWSWEEK: What do you actually do as a forensic nurse?

Beryl Skog: We've taken on a sort of medical-examiner role. There are two main areas: homicide and sexual assault. I'm a sexual-assault nurse examiner. When a rape victim comes to the emergency room, I have a commitment to go there within an hour, as a consultant to the county, to do a head-to-toe examination to make sure the victim is OK and collect any evidence. Together with the detective and rape-crisis advocate, I interview the patient. We give prophylaxis for sexually transmitted diseases and give a morning-after pill.

Why do hospitals need someone from the outside to do this? Why not a nurse who's on staff?

In the past, lots of [sexual-assault examination] work was done informally by ER nurses, but they weren't happy about it. The victim's body is the crime scene. Once somebody touches the evidence, you can't leave the room or leave the evidence unguarded. The chain of custody has to be maintained. Otherwise, the evidence is suspect. The process can take five hours or more, but no ER nurse can spare five hours to stay with one patient. It takes them away from their other patients. They're very, very happy to see me arrive.

Why does it take so long?

First we conduct the interview. My technique is to not interrupt the victim's story. I've learned from work with posttraumatic-stress disorder [patients] that in retelling a story, the patient retraumatizes herself. The same chemicals flood the brain as when the attack was actually taking place. But we provide the victim—the survivor—with tools to cope. I will say, "When you get to the point where you're overwhelmed with terrible feelings again, you can stop. Take a few deep breaths and imagine a place where you feel absolutely safe, such as a green forest, a sea shore, maybe a beautiful vacation spot. Go to that place and stay in it a couple minutes. When you're ready, I'll be here." Just giving a person control of the interview is important.

In general, the interview takes an hour or longer. Then the detective and I go back over the testimony and pull it apart. We ask things that the victim might have been embarrassed to say. If there are injuries, we have to document every single scratch or bruise in detail. We'll call in the police photographer from the sheriff's office. There's a 17-page chart we fill out. Then I look for the evidence.

Tell me about collecting the evidence.

Unfortunately, victims have a tendency to go home and take a shower afterward. They throw out their clothes or even burn them because they feel dirty, and there goes a lot of our evidence. They come to us spanking clean. That's a big problem. Also, rapists have learned from "CSI" and other TV shows to wear gloves and use condoms.

So if the victim has showered and the rapist has used a condom, what evidence is left to collect?

If the victim has said the rapist was licking her neck or back, I'll pay lots of attention to that part of her body. I'll use a black light, and in many cases, it will show saliva or semen. I'll do a nail swab, because it's natural to scratch an offender or push him away. There might be DNA under her nails. I'll comb her hair to check for fibers or hair from the offender. Often times, there is dried semen or blood in the hair. If she said they were in a hotel room with an orange carpet, I'll look for fibers that verify, yes, she was telling the truth. Between each sample, I'm changing my gloves and putting the samples in a different envelope that's labeled as to where each specimen came from.

I've had to go to court to testify in rape cases, when we've collected evidence. The defense will plea bargain. They know they don't have a leg to stand on.

But even if you obtain evidence, how do you know if the act was consensual or not? Do you look for bruises?

There are rarely physical injuries. Most women are so easily victimized and terrorized, they don't have to be bruised or in any way hurt.

What about tears in the vagina?

The vagina heals quickly. But we use a culposcope, which is a very fancy magnifying glass that allows you to look very closely at the genital areas for little tears. We also use a dye, called toluidine glue, which helps visualize any changes in the skin surface. But even if we can document injury, it doesn't necessarily indicate force. That's the frustration with these cases.

Women aren't the only victims, by the way. Men can be victims of homosexual assault. Anyone who's handicapped is at greater risk. The newest susceptible population is people in nursing homes. This illustrates that rape is not a sexual act, it's an act of violence. There's not necessarily an attraction there. The victim is just an available person to take it out on.

It sounds like you have a tough job.

I feel it's a privilege. It's like holding an injured bird in my hand, knowing that what I do can help that person's recovery.

In the minutes following an assault, an untrained person can unintentionally do a lot of damage. If someone insinuates blame in any way—"Why did you walk down that dark alley alone?"—that's basically implying it's the woman's fault. I want to be incredibly careful to avoid blame. The rape-crisis counselor and I always say, "You did the best you could. If you hadn't, you might not be here." That's such an important message to leave. They just happened to be in the wrong place at the wrong time.

So part of what you do is offering comfort and support.

That's why it's an excellent job for me. I don't want to be part of the assembly line that nursing has become. So much energy in nursing goes into machinery and technology today that nurses don't have time for hands-on care. I don't do this job for the money. It's the interaction, the chance to help when somebody really needs it.

Forensic Nursing: Crime and Care | News