I've heard it said so many times, "We don't test for sexually transmitted infections (STI's) in a sexual assault case." or "We don't do wet preps or look for motile or non-motile sperm." When I hear words like this, I have to catch myself before I make an excited utterance. (Seriously?)
Even given that there is an incubation period for STI organisms, the examiner needs to realize that the presence of an infection during a sexual assault exam can confound what an examiner sees on inspection. Therefore if redness, irritation or bleeding are present on a body in a criminal case, then other causes of those findings need to be investigated. The alleged victim or suspect should be tested any time it is possible. Why?
If there is redness or a discharge in the genital region (cervix, vagina, labia, penis or anus) then STI's should be ruled out as a possible contributor to that redness. When redness/irritation is seen in a photograph (or video) during a sexual assault exam, the assumption by the jury, the judge and the Prosecution is that the redness is due to some form of assault. However, when questioned by the Defense, the FNE must concede, under oath on the witness stand, that redness, bleeding or tissue injury could have originated from the presence of something else other than assault. In the absence of testing for infection, it can be assumed that some sort of infection was possibly there at the time and contributed to the findings.
Redness and/or irritation could be due to infection such as a yeast infection or bacterial vaginosis. It could be due to the presence of an STI. It could also result from consensual sexual intercourse (vigorous or not vigorous depending on the person and his/her nutritional status or overall health status) or it could result from non-consensual sex or non-consensual/consensual use of some other object (finger, fist, vibrator, coke bottle...etc.).
The point being, that it is important to investigate every causative possibility for redness, injury or bleeding in order to provide the courtroom with the best evidence available to make a sound decision. It is imperative for Forensic Nurse Examiners to learn to see beyond what is traditionally expected, to think ahead concerning what the 'recommendations for care are' vs 'what the guidelines for forensic evidence collection suggest," and then their goal should be to exceed them if need be.
If what we do is 'evidence based' then we know there are alternative reasons for redness, bleeding and various injuries. When collecting evidence it's also important to rule out those reasons so the courtroom can be more informed when it makes its decision. Some nurses are uncomfortable with doing that because they lack the skills or because of cost of time, equipment or other factors. Microscopy, or the use of lab and other expert professionals (consulting urologist, Family Practice or ER MD, etc.) should be considered when examining those reporting a crime and those suspected of one.
It is by questioning the status quo that we move ahead. It is by understanding the right thing to do versus the easier thing to do, that we can bravely take steps that just might make a difference in a case. If we contribute knowledge that helps the jury and the judge make the right decision, then we not only obtain professional and ethical excellence, but we also preserve our own peace of mind.
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*Disclaimer: This blog is solely the opinions and experiences expressed by the author and in no way reflects the opinions, policies or beliefs of the U.S. Government, the DoD or United States Navy.
I think it is important to remember scope of practice issues for RN-level providers. In the USA, the Clinical Laboratory Improvement Amendments (CLIA) are very specific about what provider-performed microscopy may be allowed and under what conditions (See Code of Federal Regulations: Title 42, Volume 3,
ReplyDeleteSec. 493.19). qualitative semen analysis for presence of sperm and motility are listed as allowed provider-performed microscopy, but the section states, "(1) The examination must be personally performed by one of the following practitioners:
(i) A physician during the patient's visit on a specimen obtained from his or her own patient or from a patient of a group medical practice of which the physician is a member or an employee. (ii) A midlevel practitioner, under the supervision of a physician or in independent practice only if authorized by the State, during the patient's visit on a specimen obtained from his or her own patient or from a patient of a clinic, group medical practice, or other health care provider of which the midlevel practitioner is a member or an employee.
It would seem that a registered nurse is not considered a midlevel practitioner, and this may be considered outside of the scope of practice of the registered nurse, based on the nurse practice acts of the state wherein the nurse is practicing.
Thank you for taking time to respond, #4246.
DeleteWhile you bring up a valid argument for why RN's, who are not NP's, cannot do microscopy in some states under some Nurse Practice Acts I still believe it is essential to at least collect those labs and let someone else read them. The RN does not have to "read" them, but can still collect the microscopic sample in a test tube and send it to lab or have a specialty doc (if the case is a hospital with physicans and NP's) to LOOK at the sample and read it for them.
RN's do not "prescribe" medications in that they do not have prescriptive authority, and yet a way has been found for them to give prophylactic STI medication to patients reporting a sexual assault. Why then is it so difficult to arrange for these simple tests to be done? In the face of redness, irritation, and other factors that skew the perceptions of "why" there is trauma or redness to genital areas, the prudent thing to do is to rule out other causes if at all possible. We have the capability, whether we do it ourselves or consult with other professionals on our teams. I personally think every female who reports an acute assault should have a bimanual exam to assess for cervical, uterine and/or adnexal tenderness as well, but RN's often don't have that skill either. So here's the thing. RN's should be trained as "Advanced Practice" nurses in the field of forensic nursing, and they should have these skills. To keep coming up with reasons why a BASIC level of assessment cannot be done in a forensic exam, in a world where someone's son or daughter may go to prison for 12 years or more and be labeled as a sex offender for life, is not prudent. We want to be SURE as we possibily can that there are no alternate explanations for our findings. And if there are alternate explanations, well, there are. The courtroom makes the final judgement as to what happened.
What we need to do, as professionals, is not say "we can't" do something which is so fundamental but instead say "how can we do it?" I'm not talking rocket science here. This testing is simple. It doesn't require a lot of money. It's learning a skill. It is doable, and it is a level of testing that should be available at every sexual assault response team or treatment center. If RN's can't do it, they should send it as a lab for someone else to do or consult. I've I'm the NP working with the Defense on a case where the Forensic Nurse did not do a wet prep and assess for motile sperm, trichomonias, bacterial vaginosis or candida, I would make sure that the courtroom understood clearly that motile/non-motile sperm have implications and that these infections are alternate explanations for redness, tenderness, excoration and even fingernail scratches and blood. I would be sure to let them know that this is a simple task (doing it personally or sending the lab out/consulting) and it would not shine favorably on the examiner or the rest of the case that they didn't collect this simple information.
"Beyond reasonable doubt". Don't we have a task to help the courtroom decide this point? Shouldn't they have ALL the information we have the ability to provide them with before they make a decision? I have no loyalty to the alleged victim. I have no loyalty to the accused. I do have immense loyalty to the forensic process and to the court who has to use the information I provide to find guilt or innocense in a case. If I ever thought one person was sent to prison because I failed to collect information I knew would assist in a case, or if I thought the absence of evidence would have helped to aquit some who was guilty...then I couldn't live with myself. As long as I'm a forensic nurse, I will continue to collect all of the evidence I possibly can so that the court can make the best decision with the evidence and information it has. :)