The Forensic Nurse

While most people in the industry know the acronym IAFN, as the International Association of Forensic Nurses, is also as a same industry acronym “Imaging And Forensic Networking“. This phrase was coined by the SDFI Telemedicine group. SDFI stands for Secure Digital Forensic Imaging.

The SDFI camara system is meant to be a colposcope replacement, offering increased clarity, file encryption, and secure sharing of images across organizations.

Often we field many requests from interested readers who are asking, “What does it take to become a forensic nurse?” or “what are the requirements to become a forensic nurse?”.

There are various designations that can also be acheived. a CFN, a  

 The problem is, there is no one right answer currently. While there is a national standard that is currently being considered, each state currently makes its own rules for its licensing. So what requirements there are in New Jersey  to become a forensic nurse are not necessarily the same as the requirements in say Georgia or Michigan.

But for the sake of conversation. In general, you must complete / possess the following requirements to become a forensic nurse:

• A valid and active nursing license (without any restrictions)
• successfully complete a formal didactic educational program in forensic nursing. This should include a minimum of 40 contact hours in the core areas of forensic nursing. These core areas include; the history of forensic nursing; the forensic nursing process; violence and victimology; injury identification, interpretation, and documentation; criminalistics and forensic science; and nursing and the interdisciplinary process with law enforcement / and legal process.

Child Sex offenders can be exceptionally resourceful at finding ways to place themselves around children in settings that may allow them to abuse their position and sexually assault children. 

While most agencies, and places of employment targeted toward children (like day care centers, foster child homes, etc) are mandated to conduct a background screening for past child sexual assault (or any sexual assaults for that that matter), this type of arrest history check is ineffective at stopping child predators.

A simple arrest record check in most cases will come back clean. Study statistics vary from study to study, but in general they indicate that less than 1-5% of child sex abusers have a prior criminal record. Unfortunately, most child sexual abusers have dozens of victims before they are ever arrested for their crimes.

But what if there was a way to help detect these people before allowing them to commit their crimes.  While this may sound like a far fetched hollywood movie idea like “the Minority Report“, a company called Abel Screening claims to be able to do just that for detecting child sexual predators.

They call it The Diana Screen. This two part computerized test is used to determine the risk of the test-taker having sexually abused a child in the past. According to their website:

The Diana is a pass / fail test, it goes beyond a simple questionnaire to include objectively measured sexual interest in children. The technology that identifies sexual interest, which is a major part of The Diana Screen^® formula, is empirically validated and has been used by therapists and criminal justice professionals more than 100,000 times.

The website further claims The Diana Screen^®identifies over 50% of actual child sexual abusers.

It may sound like a simple question, “Does mandatory reporting help?”, but it’s one that can be a much more difficult than most health care providers think under the surface.

As a health care provider, you can provide documenation of current injuries, and in many cases in past injuries as well. As a Forensic Nurse, you have the training to collect evidence that may be used in trial to prove the types of offenses that happened. Your medical charting of events can provide a detailed interpretation of facts and injuries than the victim himself/herself would have been able to provide on their own.

Obviously, by reporting that an event of domestic violence or sexual violence against a patient has occurred brings the situation out into the open where other agencies like law enforcement, DFACS, counciling services, and others can offer help and support to the victim, and even counciling to the perpetrator.

What if the patient doesnt want to report?

Informed consent is one of the principle foundations of modern medicine. This empowerment of patients to make informed decisions over their treatments and what happens to their bodies.  For a victim of sexual assult, or domestic violence, this control has been taken away from them. As a mandatory reporter, you are again taking away any sense of control away from the victim. They have no choice in the matter, since you are obligated to notify proper authorities.

The knowledge of confidentiality and essense of trust can be critical components in getting any successful intervention of a sexual assult or domestic violence. Mandatory reporting may directly affect that relationship though, since in effect a mandatory reporter must violate that patient confidentiality to inform proper authorities. Here is an excerpt from a battered woman focus group

“What made it difficult for me to confide was the fact that I feared for my life, you know. And I knew that if I was to tell them what actually happened, that they would call the police and I would have to file a report and they couldn’t guarantee me that they would be there 24 hours to protect me from this maniac. So, therefore, I wasn’t taking that chance on my life. … What would make it easier for me would be….to be my choice….[I] f this happened to me but I don’t want the police involved, can you please treat me and keep my confidentiality? There’s supposed to be a law that they keep confidentiality between the patient and the physician.”

Because of this violation of trust, some will argue that in order to get an accurate story from a patient that you should not tell the person that you are a mandatory reporter until after they have given their recount of events. Others will say that is ethically wrong, and that you should tell that person up front about your reporting status and in effect, give them the choice of reporting what actually happened, or just receiving their medical care and moving on.

Mandatory reporting laws were developed to provide a safety outlet for individuals who may be too afraid or unable to seek help (children, elderly, controlled spouse ,etc). The question that many of these victims ask is that “what are you going to do to protect me?”. Law enforcement can’t be in a home 24 hours a day. So what happens when the victim goes home, and the victimizer gets released from custody in a few hours or days? Is that person(s) safer now?

“Abused women hare had their autonomy taken away by their abusive partners. Forcing me to report her abuse again takes that autonomy and control away from her. She is a better judge than I of the consequences to her of reporting.” - PhysicianSurvey Statement

Right or wrong, mandatory laws exist for many health care providers.  What do you think ?? 

Addtional Resources:

http://www.endabuse.org/

The Georgia Bureau of Investigation  has published a document for the requirements needed to submit evidence collection kits for processing.

 http://www.ganet.org/gbi/labmanual.html 

Law enforcement agencies (local, state and federal)
Judicial systems
Medicolegal community
Other government laboratories
Regulatory and public service governmental agencies
Non-law enforcement security departments (for criminal cases only)

HOURS OF OPERATION

Laboratory hours are from 8:00 a.m. to 4:30 p.m., Monday through Friday.

Evidence receiving hours are from 8:00 a.m. to 3:30 p.m. , Monday through Friday .

The Crime Laboratory observes the State of Georgia official holiday schedule.

A gang rape is when a group of two or more attackers sexually assault one or more victims. This type of group rape is sometimes referred to as a “gang bang” or “running a train”. Approximately 10-20% of all sexual assualts are gang rapes. The word tournante is a French adjective meaning “turning” and is used as a slang term to mean a gang rape. According to the testimony of numerous victims, young Muslim women who stray from traditional conduct in the immigrant neighborhoods, such as behaving and dressing like a westerner, or wanting to live as Europeans or refusing to wear the traditional clothing, have been considered by some to be “fair game” for tournantes.

According to Samira Bellil in a CNN interview, there was a trial in Lille regarding a 13-year-old girl who had been allegedly gang-raped by 80 men.

Samira was first gang-raped when she was 14, by a gang led by someone she knew. They beat her viciously and raped her all night. A month later, one of the most violent attackers in the gang followed her and dragged her off a train by her hair, while other passengers looked the other way. She was then brutally gang-raped by the gang members again.

She did not report her rapes until two friends told her that the same gang had raped them too. The typical scenario that takes place is that the targeted young woman is drawn or lured into a secluded area where she is brutalized and repeatedly raped by groups of men who take turns raping her. The victim is usually insulted for behaving in a Westernized manner. Typically the girls are often released afterwards, but rapes are often unreported for fear of reprisals against their families. In nearly every case on record the young victim who does report the crimes committed on them says that days later they would again be caught by the gang and gang-raped again.

These types of attacks can also be further categorized into sub categories like: opportunistic rape, street gang rape, male rape, aquaintance rape.

Opportunistic Rape: The most common scenario is during a burglary or robbery. During the process of committing the robbery the attacker(s) may be startled or interupted by a female who happened upon them. Rather than fleeing the scene they may linger and decide to “take advantage” of the situation by raping her. Often these types of attacks are not especially violent, but may escalate into a violent situtation due to the impulsive nature. Because the attackers were suprized by the person being there, they typically have not planned out what or how to deal with the person. They may use improvised restraining devices or no restraints at all, and simply threaten or imply violence if the victim does not comply.

This type of impromtu sexual assault is usually short in duration. If they were there to commit a robbery in the first place, they may still be trying to get away with the stolen goods. A condom is rarely used since the rape was not premeditated and opportunistic. Ejaculation may or may not occur. Recent SANE-SART statistics on ejaculation sites.

Street Gang Rape: This type of rape is almost completely intracial. Rarely does it cross racial boundaries. Increasingly this type of sexual assault is used as part of the gang initiation process. Sometimes it may involve a younger member of a sister gang who is also being initiated, sometimes it may be a random target chosen off the streets, and in other cases, it may involve a same sex target of a rival gang. This is meant to humiliate and degrade the rival while proving that the attacking gang is stronger.

In many cases there are many levels of insult and intimidation. Forced oral (fellatio) and anal sex are common. Urination  on the victim, especially by later members of the “train procession” as a way to further degrade the victim may occur. With each “round” the levels of degredation, torture, and acts tend to escalate.

 Male Rape: Males who are sexually assualted typically are lower reporters than female victims. Depending on the study used, most statisitics show about 5-10% of victims are male. One study indicated that approximately 36% of male prisoners are sexually assualted by more than one perpetrator. Usually the first time prisoner, illegal immigrants, or phyiscally handicapped (weaker and more vulnerable targets) are the ones targeted for repeated assaults. The majority of these rapes are done by heterosexual males, much like the rival gang rapes listed above.  Violence is much more likely on male on male rapes, as well are the demanding of multiple physical acts. Weapons are also more common method to enduce coersion.
Gang Acquaintance Rapes:  In most instances in a gang aquaintance rape the victim has been carefully selected and includes some group collaberation and forethought before the attack occurs. The victim may have one or more of the following characteristics:

• New student, or new to the area with few friends
• unpopular
• unattractive
• overweight
• already had sex with one of the group members
• intoxicated
• drug use
• low self esteem, may be easily lured / flattered by attention before an assault
• Sorority sister

College campuses are a common location for such incidents. Often at parties or on the way home from a group date. While most acquaintance rapes involve one perpetrator and one victim, the campus gang rape is far too prevelant.

Incoming freshmen females are the most targeted for gang rape. They are usually more naive, tend to be more vulnerable, have fewer friends, and be more willing to be lured into a position of isolation. The first few weeks of the new school semester are the most vulnerable times for gang rape for incoming freshmen.

These types of gang rapes are often planned well in advance and can endure for hours as each group member has their turn. The use of alcohol and other narcotics to subdue the victim. It is not all that uncommon for their to be multiple spectators to the events, and even video taping of the assault. In most cases there is limited to no physical injury to the victim, except for any genital injuries as the result of repeated intercourse.

When and if defendants are ever charged in such cases, they most often don’t deny that sex occured, but that the victim was consentual, or that “she never said no or stop”.

The Northside Hospital - Forsyth, Sexual Assualt Nurse Examiner program is proud to announce that they have become the only SANE  program in the state of Georgia to use employ the use of SDFI technology.  

Secure Digital Forensic Imaging technology offers digital imaging clarity that is on the cutting edge. This technology is also fully compliant with federal rules of evidence, ensuring that the images stored will be admissible in court if necessary.

The use of digital forensic photography is steadily gaining in popularity almost everywhere, but one item that is almost universally raised is the authenticity of these photographs.

Digital Photographs are much easier to manipulate or alter than a traditional photograph. I’m sure that just about everyone reading this has seen some kind of ‘photoshop’ doctor’d image. From the supermodel airbrushing, or cellulite adding for shock value, to the bin laden doing various activities, the use of digital photograph editing is widespread.  (Browse thru your local supermarket checkout tabloids if you would like some fresh examples.)

But not all altering of digital photographs is necessarily harmful, at least in intent. Take for example, the straightening or cropping of a photograph to help highlight that perfect shot, or the masks and filters that take the annoying red eye out of a photograph caused by the lense flash.

These are often innocent “enhancements” to photographs to make the captured subject more pronounced, or centered into the picture. But be careful treading into this arena if these photographs are going to be used in a criminal or forensic proceeding.  

Image Enhancements

Any process intended to improve the visual appearance of the image falls under the category of an image enhancement. That includes contrast, brightness, color adjustments, color rebalancing, cropping, bluring, dodging and burning.

Unless the photograph is admitted and agreed to by the stipulation of both parties, the party attempting to admit the photograph into evidence must be prepared to offer testimony that the photograph is an accurate representation. Or more to the point, be prepared to testify in court that the image being submitted into evidence is accurate and unaltered in any way.

Federal Rules of Evidence, Article X (Contents of Writings, Recordings, and Photographs), Rule 101 defines writings and recordings to include magnetic, mechanical or electronic recordings. Rule 101 states that if data are stored in a computer or similar device, any printout or other output readable by sight, shown to reflect data accurately, is an “original.” A “duplicate” is defined as a counterpart produced by the same impression as the original…by mechanical or electronic re-recording … or by other equivalent techniques which accurately reproduces the original. Rule 103 (Admissibility of Duplicates) states a duplicate is admissible to the same extent as an original unless a genuine question is raised as to the authenticity of the original or in the circumstances it would be unfair to admit the duplicate in lieu of the original. This means a photograph can be stored digitally in a computer, that a digital photograph stored in a computer is considered an original, and that any exact copy of the digital photograph is admissible as evidence.

In part Two, we will discuss the proper chain of custody for digital evidence

The IAFN does allow for the re-take of the certification exam. below is an excerpt from their website regarding the re-examination process.

A candidate who does not pass the examination has one year to re-take the examination at a reduced fee.  The fee is $150 for IAFN members and $275 for nonmembers. A candidate who does not pass the second examination is considered failed.  Any repeat examination will require completion of a new application and payment of the full fee.A total score of approximately 75% correct is required to pass the certification examination.  Candidates will be notified of their scores approximately four (4) weeks after test administration. C-NET will forward all examination scores to the candidate as follows: 1.     A total score will be provided for candidates        who successfully pass the examination. 2.     A total score and sub-scores in all the major        test areas of concentration will be provided for        candidates who do not pass the examination.

Most forensic nurses, work out of an emergency room setting or in a freestanding clinic. The Emergency Nurses Association, or ENA published an official statement on their stance of forensic evidence collection by nurses in the emergency room setting for Victims of sexual assault, child maltreatment, elder abuse and other violent incidents are often brought to the emergency department (ED) for care.

· ENA believes that it is the emergency nurse’s role not only to provide physical and emotional

· ENA supports collaboration with emergency physicians, social service, and law enforcement

· ENA encourages emergency nurses to become familiar with the concepts and skills of