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Beyond the Box: The history of Canada’s RCMP Sexual Assault Evidence Kit (Episode 6)
11 Plays20 hours ago
Content warning: This episode discusses sexual violence, forensic evidence collection, and the barriers Survivors face within legal and health systems.
Canada's national sexual assault evidence kit didn't happen by accident. It was built by someone who understood both the science and the stakes.
In this episode of Beyond the Rape Kit: Canada's Forensic Frontline, we sit down with Cathy Carter-Snell, experienced forensic nurse examiner and one of the professionals behind the revision of Canada's RCMP Sexual Assault Evidence Kit. Cathy takes us inside the process of building the kit-- the collaborations, the decisions, and the work that went into turning a patchwork of outdated protocols into something consistent, credible, and grounded in forensic expertise.
Together, we trace the history of sexual assault response in Canada before standardization existed, examine what the revised kit contains and why those choices were made, and explore the ongoing questions practitioners, Survivors, and advocates continue to raise. Does the kit serve Survivors as well as it serves the legal system? What role do forensic nurses play when a standardized tool exists? And how do we keep evolving the kit as science, practice, and survivor-centered care continue to develop?
A must-listen for forensic nurses, front-line health workers, legal practitioners, policymakers, and anyone invested in the systems that shape what justice looks like for Survivors.
If you have been recently hurt or assaulted, stalked, or harassed, please seek medical care at your closest emergency department, connect with support services, or contact your local police. This is Beyond the Rape Kit: Canada's Forensic Frontline -- a podcast by the Canadian Forensic Nurses Association.
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Transcript
Introduction to 'Beyond the Rape Kit'
00:00:07
Speaker
This is not just another medical podcast or true crime series. This is the voice of forensic nursing in Canada. This is Beyond the Rape Kit, Canada's Forensic Frontline.
00:00:20
Speaker
We're the Canadian Forensic Nurses Association.
Forensic Nursing in Trauma Care and Justice
00:00:23
Speaker
We're pulling back the curtain on what really happens when trauma meets healthcare, when survivors seek justice, and when nurses stand at the front lines of both.
Revisions of the Sexual Assault Evidence Kit
00:00:32
Speaker
Follow us today Spotify, Facebook, LinkedIn, and Blue Or check us out on the Canadian Forensic Nurses Association website.
00:00:50
Speaker
Canada revised and updated its standardized sexual assault evidence kit in about 2017. And before that, that kit was over 20 years old, and the process of collecting forensic evidence from survivors included outdated and invasive practices, lengthy instructions, and added to that hospitals that were really uncomfortable and unfamiliar with the protocols. And that meant that survivors of sexual assault were often turned away or given incomplete care.
00:01:18
Speaker
The whole process, as we know, was not trauma-informed. Then came the revision of the RCMP's Sexual Assault Evidence Kit by a team of experienced forensic nurse examiners.
00:01:30
Speaker
It was a box that promised consistency, credibility, and finally a national standard. So today I'm asking how did this kit come to be and what does it really mean for survivors, providers, and the legal system?
00:01:44
Speaker
Is it even worth doing a kit these days? How much training is really needed to to use this revised sexual assault evidence kit? Is there too much focus on a kit for survivors?
Introduction of Key Figures in Kit Revision
00:01:57
Speaker
So today we're going beyond that kit, beyond the swabs and forms to uncover the story of how Canada built part of its forensic response to sexual assault. Joining us is Cathy Carter-Snell, who will take us beyond this box as one of the forensic nurse examiners that led the way to what we now know today.
00:02:15
Speaker
Cathy is a professor in the School of Nursing and Midwifery, and she is faculty lead in the Simulation Centre at Mount Royal University in Calgary. She has been a forensic nurse since 1998.
00:02:27
Speaker
She was the first Canadian to pass the SANE-A exam and one of the co-founders of the CFNA in 2006. Her clinical practice was many years as an yeah ER nurse and then she focused on sexual assault and intimate partner violence.
00:02:42
Speaker
Her PhD research and subsequent studies have focused on the effects of sexual assault and intimate partner violence and how to reduce these consequences. Examples include injury identification, crisis and PTSD, improving rural sexual assault responses, and disaster nursing.
Outdated Sexual Assault Response Practices
00:02:58
Speaker
Welcome, Kathy. Let's start with a bit of an overview of sexual assault responses in Canada before 2017. Okay. um our As you mentioned, our kits were extremely outdated.
00:03:11
Speaker
um The practices were very uncomfortable. We didn't start having sexual assault nurse examiners until about 1995 to 1998 in a neighboring in Ontario, BC and Manitoba.
00:03:27
Speaker
um And so they started to expand past then. So we still ended up with specialized examiners just in some of the urban centers. So rural and outpost sexual assault responses were sketchy patchy at best.
00:03:44
Speaker
The kit had a lot of outdated equipment and unfortunately if you've never used a kit before, the people looking at it were A, overwhelmed and B, they thought they had to do it from step one to step 40. So it didn't matter what type of contact you had with the assailant or what the history was, they would do every blessed sample in the kit because it was there.
00:04:07
Speaker
So there's a real lack of understanding for it. So especially when there was antiquated pieces in it, such as having to pluck head hair, having to pluck pubic hair, and and and including getting the roots of the hair follicle so that you've got the DNA.
00:04:23
Speaker
And you needed at least 20 to 40 hairs from each site. So you can imagine what the patients were going through. So you're telling me that this old kit used to require healthcare person, whoever's doing the kit to this survivor who's just been assaulted, we are plucking 20 to 40 pubic hairs to the point where we get the root?
00:04:47
Speaker
Absolutely. that was That was the principle from practice. Do we still do this today? oh gosh, no. No, we got rid of that real fast. We actually got rid of it before the kits got revised.
00:04:57
Speaker
um But then trying to get the word out to people that had the kits that still had that in the instructions was very difficult. But the teams that had examiners stopped doing that quite a long time before 2017.
00:05:11
Speaker
Oh, thank goodness. All
Design and Usage of the New Evidence Kit
00:05:13
Speaker
right. so mar um So walk us through the revision and what was involved in revising the kits into what we have today. like So we know we're not plucking head hairs and pubic hairs anymore. That's great. yeah But how, I mean, is it still 40 plus steps or how did how did we change it?
00:05:33
Speaker
um Well, the steps the steps got refined, but also the techniques for it. For instance, we used to do a blood sample on an FTA paper, so a circle about the size of ah of a loonie on a piece of of a specialized paper.
00:05:48
Speaker
to do the patient's DNA reference. And we've gotten rid of that now. We can actually do it with a buckle swab with the epithelial cells on the inside the cheek.
00:05:59
Speaker
And so there's less need for refrigeration of the kits and and things like that. The old kits had a huge number of garbage bags. Like you could take your trash out for a week with what was in the kits.
00:06:12
Speaker
and And we know that plastic degrades DNA, so that was that had to be gone. And people didn't know if they had all these garbage bags, should they take every piece of clothing the patient had, or what was the principle behind that? And so, starting about 2013, 2014, the reached out to the CFNA and to their local labs to get recommendations for people to chat to about revising the kits.
00:06:38
Speaker
And it took us about three years of meetings and finding out best practices to start to look at where what we needed in the kits.
00:06:50
Speaker
And so it sounds like you went from plastic to paper, which is great. And I was a forensic nurse in 2002, dating myself here as well. And I remember doing that FDA paper as well. And you had to have very specific protocol, like you had to wear a mask so that your DNA didn't land from your breath on the paper. And then it also, of course, included either a finger prick or taking some sort of blood to get there as well, which not all all people loved that idea of. That's right. And so tell us about the design, what the kit actually does include today.
00:07:25
Speaker
um Well, what we envisioned it would include and what it ended up including are two different things. um We told them what we needed for for basic practice. So essentially,
00:07:36
Speaker
Most of the urban centers have very small kits about the size of a makeup bag. And it's got a handful of swabs in it and and a paper bag for panties and that's about it.
00:07:49
Speaker
um That's kind of what we thought we'd get. But it went out to a vendor and the vendor decided, i don't know if they employed an educational person or not, but they decided to make it simple. when In fact, they made it look so complicated that it's ah more overwhelming than the original kit.
00:08:06
Speaker
And so I actually had to create a a professional video just for what the contents of the kit are and how to use them. So what they did was they took the 16-page bilingual instruction manual and cut and pasted the English and French instructions for each step. So if it's body swabs, it has this big envelope and it has four body swabs in it. And then it has four smaller envelopes in it that you could put your body swab sample in.
00:08:35
Speaker
When in fact, we don't need any of the envelopes, we just stick a label on the swabs and that's good. So I did the video to give people permission to get rid of all the extra envelopes. So they thought it made made sense because if you picked up the body swabs envelope, then you see that you've got lots of extra swabs. Or if you pick up the external labial swabs, there's two in there. So it should be intuitive that you take two.
00:08:59
Speaker
But when people open this kit and see all these envelopes, they kind of go, but essentially what's in it is is exactly that. it's It's a series of fab swabs. The old swabs were a hard plastic, but they were self-drying, and so are these ones.
00:09:15
Speaker
They've got a ah paper wrapper at the bottom of them that allows it to breathe. So we we don't need drying kits and all of those sorts of things that you see in a lot of the American kits. So we've got a handful of those swabs for the different types of sampling that might be possible.
00:09:31
Speaker
And then we have more paper bags than we need again, but but there's at least two small paper bags and about four or five. The part that is consistent between the two kits is that there's, I really like the RCMP label system.
00:09:46
Speaker
So there's a set of labels with a specific number. So every sample in that kit will have that number on it. And so that helps with anonymous kits as well if if we do those, or third option, whatever you call it in your province.
00:10:01
Speaker
and And essentially, that's that's all that's in it. We got rid of the um vaginal wash that we used to do. We got rid of the blood sample.
00:10:15
Speaker
We moved the toxicology swabs. That was kind of um kind of blew up in our face. One of the things that bothered us was the RCMP kits had an expirer date and we tried to find out what that was about. And it turned out that the expirer date related to the Grey Talk tubes with the sodium fluoride. and And those, the toxicology tubes have to have that preservative in it because so samples like cocaine will continue to degrade after you've collected them.
00:10:43
Speaker
on the way to the RCMP toxicology lab, so it'll be zero by the time it gets there. So the the preservative in it stops that. But unfortunately, the preservative expires. And so that's why we took them out of the kit.
00:10:56
Speaker
Well, now when we get the new kits back, we found that the they still have an expiry date. But it's because the vendor is not willing to certify that the sterile swabs in there are still sterile after a certain date.
00:11:12
Speaker
And we don't care if they're still sterile. We just don't want anybody else's DNA on them. So if they're still sealed, well, we can still use them. So the RCMP are now sending out instructions to the different detachments that they can still use them if expired.
00:11:24
Speaker
So what do we do for potential drug-facilitated sexual assault evidence collection? Well, they have they have another, again, a fancy kit. um You don't need it. it's It's got a separate piece of paper that just asks you, like, what drugs have they take do you think they might have taken? What drugs have you given and them in Emerge or and when you saw them?
00:11:44
Speaker
And what are their symptoms so that they can narrow down the Toxodrome, but they're going to run it through this a gas spectrometer anyways, it doesn't really matter what the symptoms are um in in a provincial lab, then that would be important because then they could look at specific groups of drugs.
00:12:00
Speaker
So all it is is a as a urine container with the O-ring in it and and two grey top tubes. So if you don't have, and the RCMP often don't realize that they have a separate toxicology kit.
00:12:11
Speaker
So if you don't have one, the the practitioners can just use two gray top soups and urine container.
00:12:20
Speaker
What part did forensic nurses play in the development of this newer version of the, of the kit?
Evidence-Based Approach in Kit Development
00:12:31
Speaker
Um, because we, because we know, um,
00:12:35
Speaker
the process for the patients and and we know the impact it has such as plucking hairs and things like that. We also wanted an evidence informed approach to it. So we wanted to know what the recovery rates were for the evidence that they were getting and what the if you could get as reliable a sample as with A versus B. So that was a lot of the two or three years working with the lab and getting that evidence and looking at the research from from other forensic labs in different countries. um For instance, there's great debate over the drop sheet, whether we needed the drop sheet.
00:13:09
Speaker
i We have the patient stand on that while they undress in case there's trace evidence and and then bindle it up and put it back with the kit. um I've personally, in hundreds of cases that I've seen, have have probably only had two or three that ever had anything drop onto the sheet, but they still wanted it. So if That was the only thing that sort of was contentious with with some of it, but they were quite happy to get rid of the hair plucking and the blood sampling if if that was better.
00:13:38
Speaker
And we changed the wording of the documentation. it used to be called the Physician's Guide. It's now the Health Practitioner's Guide. um and And we who directed the process for how it could be done in terms of of how to describe that.
00:13:55
Speaker
We also integrated the BALSTEP findings guide to have some more consistency in naming of injuries because we know that ecchymosis and bruises are not the same thing.
00:14:07
Speaker
And you know a number of lacerations and penetrating injuries. So that's in there now to guide the documentation. We also added in the provision for toiludine.
00:14:18
Speaker
for agencies that don't have colposcopy, because we know that toiodine and colposcopy with mag magnification will increase your injury identification from about 65% to 85% to 90%.
00:14:32
Speaker
So smaller hospitals don't have colposcopy, so a cheap bottle of toiodine will do the trick for them. So basically the languaging of that and And the step-by-step process that we that we put into place influenced by the the scenes.
00:14:51
Speaker
So everything that you're talking about here, Kathy, you're speaking my language. I've been a forensic nurse for many years. i know what you mean by toleden blue and colposcopy and all of those sorts of things. And it got me thinking, if I'm just run-of-the-mill emergency department nurse,
00:15:06
Speaker
Maybe I have two or three years experience under my belt, but never had any specific forensic training. And let's face it, most nursing schools, even med schools and as a nurse practitioner, we didn't get almost anything about sex assault or anything about a forensic exam. That's for sure.
00:15:22
Speaker
How much training does this, you know, ER nurse of two years or three years experience need in order to do these sexual assault kits? Uh, I don't, as a SANE, obviously I'm biased, but, and I don't want to downplay what we do, ah but the training I do in rural hospitals, I say basically it's good comprehensive care with a Q-tip.
00:15:45
Speaker
um and And that's the bottom line. It's how you treat the patient and not how many swabs you take. And and that's what will be remembered. It's like Maya Angelou. It's not what you said or what you did. It's how you made them feel.
00:15:58
Speaker
um And we know that that's the key part in the resiliency. So we've made this big deal of the kit. And in fact, when I do rural training, I take away the kit for the first simulation we do.
00:16:09
Speaker
And I just have a handful of swabs nearby and we talk about the patient's history and talk about where do you think you might find evidence? But we talk about how to take a trauma informed history from them, how to give them consent.
00:16:22
Speaker
they don't have to have evidence. And quite frankly, the latest stats Canada showed that 89% of assailants are known to the victim. So it's, the DNA is not going to be a deal breaker. The crown still likes us to have the swabs to prove that yes, something happened in there, but if they're, but we can't prove consent ever. That's not our role.
00:16:45
Speaker
And there's no physical exam in the world that will help us prove it's consensual. So, um so basically I'm trying to, resolve the fear. I developed a four hour training, free training program for hospitals to use that it basically goes through sexual assault from a forensic perspective.
00:17:06
Speaker
and and emphasizes the health care with it. So they already know what they need to know. So it's if if they're going to do it on their own, they they need to have knowledge about, as the same does, about ah changes in in physiology with over the lifespan and assessment findings and risks.
00:17:25
Speaker
This is why I really value RNs doing it or physicians because we have the extra path of physiology, pharmacology to do that. But if you're in a smaller hospital trying to keep SANE's when you only see seven or eight cases a year, how do you do that? so um So the program that I've developed is is for anybody to emphasize just good comprehensive health care and everybody stays in their own lane.
00:17:53
Speaker
So the nurse does the consent, the trauma informed explanation of of the options the patient has and emphasizing that it's their choice, whether they want an exam, whether they want a kit done, whether they want the police involved.
00:18:08
Speaker
And then based on what the patient wants, then they proceed.
Urban vs. Rural Healthcare in Sexual Assault Response
00:18:11
Speaker
And if they want an exam, then if the nurse can do the head to toe exam and any swabs from there, And then the physician or the nurse practitioner or midwife or would come in, or the medic in the military, because they use my program as well, the medic would come in and do the speculum exam or the male genital exam and do the diagnostic ordering and anything from there and collaborate with the nurse. And then the patient gets discharged. So they get the comprehensive care. So In the urban centers, it's a specialized nurse or physician that's doing it. In the rural centers, it's a combination collaborating. and But either way, the patient gets that comprehensive care.
00:18:54
Speaker
It's got me thinking a lot about some of the, i guess, well-intended programs, often grants, maybe to non-profit organizations or whatnot, with this idea of let's make sure either every nurse is trained to do a kit or that there is a kit everywhere any person wants it. um And it seems to get away from the fact that survivors of violence sexual assault deserve good medical care and health care and it's not just about doing a kit no in fact I've had a number of cases go to court successfully where a kit was never done it was how how we documented the findings that we had and so which is good nursing care
00:19:42
Speaker
and And that's really what I emphasize. So it's not the kit, it's what's behind the kit. And as I say, most of the time we know who the person is or the victim note does. So it's it's just look at it. And that's why so many sexual assault cases are not successful because it's really hard to prove consent in court, especially with the burden of proof in criminal court versus civil court.
00:20:03
Speaker
um So that doesn't mean we haven't done our job, but if If I have looked after, and and and I tend to call them clients so that we're not biased, but many patients have said that they are they don't consider themselves a survivor until they get out and they start healing.
00:20:20
Speaker
So some call them victims, but as a healthcare practitioner, we need to remind ourselves, this is a healthcare care visit. We've had a lot of people say you need standalone clinics, you need to demedicalize it, but the first five to seven days is about the healthcare that we provide.
00:20:33
Speaker
and so And if you have to go to a separate institution, to get blood work done or diagnostics or whatever, they just won't go. And so so, providing point of care, ah one of the problems we've had in the in the rural areas is if they have to send them an hour and a half away to another urban center, many people in rural areas don't have transportation. They need the RCMP to drive them. Maybe they haven't planned on reporting to the RCMP, but that's the only person that can get them there.
00:21:03
Speaker
Some places have gotten grants to have taxis bring them in, but then when you finish the exam in the urban centre trying to find a taxi that will drive you an hour and half away, again, you're waiting for that. And we know that re-victimization occurs with delays in care, incomplete care, being stigmatized and we know that shame and blame are are drivers of PTSD.
00:21:25
Speaker
And there was a really good systematic review by Dworkin in 2018 that showed that comprehensive health care as soon as possible after the sexual assault significantly reduces the rate of PTSD.
00:21:39
Speaker
And when I did one of my surveys across Alberta, the rural areas, although they were uncomfortable with the kids, said they'd still rather keep the patients in their community because they already have the counseling resources, they have the um the support peer support within the diaspora that they have with the immigrant populations and whatnot. And when they go away for care and come back, they never get a consistent communication about what kind of follow-up they need or referrals or anything like that. So the patient falls between the crack again.
00:22:13
Speaker
Does having these sexual assault evidence kits so, I guess, simple that almost any health care provider with, say, the four-hour training whatnot can do them, does it remove the need to have our specialized, highly trained sexual assault nurses or forensic nurse examiners?
00:22:35
Speaker
And do you think that maybe governments are like, oh, well, if anybody can do it, why do we need these specially trained people? No, not at all. um it's it's part of
Supporting Forensic Nursing Practices in Hospitals
00:22:45
Speaker
a larger picture. So one of the things that i that we need, even in small hospitals, um i can I can teach till the cows come home, um but and the nurses and or paramedics or whoever might be enthusiastic about providing the care, but if the physicians don't agree with it, or if the A manager isn't willing to bring an extra nurse back to backfill the emergency nurse that's going to do it or or the police don't think that that's chain of custody. It's just, it's going to fall down. So we need an advisory group. So what I recommend is a spectrum of care.
00:23:16
Speaker
um So our specialized nurses in these larger centers, because they're seeing large volumes, five or 600 cases in a year and in most the urban been centers. um And so it's easy for them to keep their practice up and become even more specialized.
00:23:32
Speaker
And so then then if the rural areas need something, for instance, um in Alberta, we we have our rapid referral line. So if the physicians need to transfer a patient or they need some information, they can call into it. But our nurses can as well. So if you're providing care to sexual assault patient in a small town, you can call into the rapid referral line and be connected with the same.
00:23:56
Speaker
and and get some advice from the scene. Because sometimes it's just that quick 10 minute call, like this is what I've got. What would you recommend? Anything I'm missing with this? And that's reassuring to have.
00:24:07
Speaker
So the scene forms an important part of that advisory. It forms an important community resource for them. um And in a way that, for instance, nurses bring a a level of of
00:24:24
Speaker
balance, I think, to it. which is often why it's why Dr. Butts started using nurses as death investigators. He just felt nurses were the right to blend for that. We have the compassion, the communication skills. An example would be, at the risk of being indelicate, the rectal sample.
00:24:42
Speaker
we know that the anal swabs are external, but the rectal sample has to be up past the dentate line. So you need to have the both sphincters relaxed and you need to put some pressure on the perineum for three to five minutes, which is an uncomfortable process for the patient.
00:25:01
Speaker
So we reiterate the process and give them the option as to whether they want it, if if it's indicated, because it's only indicated if there's been anal penetration. And And so we do that, but in the medical textbooks, it says the patient should be in a prone knee chest with their bum in the air.
00:25:21
Speaker
And any any adult adolescent or adult who's been anally penetrated, that's that's re-traumatizing for them to be in that position. So I don't know of a saint alive that would do it in that position. we we are If we do it, even though that's the best way to do it, we will do it in the left sideline or in the lobloardomid position.
00:25:42
Speaker
but not without informing the patient. And so I haven't had a lot of patients that have needed it percentage wise, but then if if we have recommended it to them, we've explained that to them and given the option and very few of them want to go ahead.
00:25:56
Speaker
But knowing the evidence recovery probability, I'm not too sweated about that. And so for me, it's always a balance between um the probability of getting evidence and what the patient needs with that versus following the protocol because that's the best way to do it Quite honestly, if somebody comes in in a white coat, says you need a rectal swab, okay, fine.
00:26:18
Speaker
But the nurse comes in and says this is what's probably needed or what we would recommend, but here's the process for doing it. Is that something that you think you want to do?
00:26:30
Speaker
It's interesting because I know that some critics of sexual assault evidence kits suggest that survivor perspectives are not taken into account. And sometimes I think suggest that forensic nurses or physicians performing these SAE kits are doing this in an invasive way that is trauma-inducing and it doesn't necessarily serve the survivor needs.
00:26:57
Speaker
How do we respond to those critics?
Addressing Invasive Practices and Patient Comfort
00:27:01
Speaker
I would like to argue that that's that's becoming less and less. I think especially if nurses in, but I don't have data on that, but I just know that we tend to um really, really stick to consent and that trauma informed approach um because physicians also get very little instruction in it. They tend to just follow the guideline and if has 16 steps, they follow 16 steps.
00:27:28
Speaker
and Many nurses would do, but nurses are a little bit more reluctant and they they tend to say, well, why are we doing this? And and the patient looks disturbed by this and and should we do it? So the message we're trying to get out with this training is is the trauma-informed approach and what that looks like with the patient. I had had one nurse say to me that it was training up in Edmonton and she said, I didn't do any anything for the patient.
00:27:51
Speaker
All she wanted was the STI medications and and the pregnancy prophylaxis. And I said, did you explain all of her options? Yes. Did you explain the pros and cons of each of those options and the implications? Yes. And the patient had capacity? Yes.
00:28:07
Speaker
And that's all she chose? Yes. Then you did trauma-informed care and you let her choose. and And that's the whole, it's it's information choice and control.
00:28:18
Speaker
And that's what we have to aim for. So nursing students are getting information about trauma-informed care. And then the application of it to sexual assault is is what I'm trying to get the word out about. And I know that many other programs are doing the same thing. And and physicians are like, I also do training for residents now. And so it's it's interesting that we have stigmatized sexual assault in all of our programs.
00:28:45
Speaker
Even in my own university, we have programs for child abuse, for elder abuse, for domestic violence. But They haven't integrated, even integrated, I have the four-hour trainings, eight half-hour modules, and it's free.
00:28:59
Speaker
And they haven't integrated that because they said, well, it could be triggering to the students. Or we already talk about trauma-informed care, i say but I'm talking about it as it affects sexual assault patients. And it's very different.
00:29:10
Speaker
And so we had to offer a special training on a weekend for free for the students to come in. um And it shouldn't be optional. You can't, because we know that, especially in Alberta, but one in three people in Canada, women in Canada, one in six men in Canada, but one in two women in Alberta and one in five men in Alberta have been sexually assaulted.
Impact of Trauma on Healthcare and PTSD Prevention
00:29:31
Speaker
So what we're seeing, and that was, that was my, my, um, gobsmacked moment in 98 when I did some training in Virginia and realized the impact of trauma like adverse childhood experiences trauma in the ACEs study.
00:29:47
Speaker
And what I was seeing in emergency with the people coming in repeatedly with overdoses, with suicidal ideation, with anxiety reactions, with abdominal pain not yet diagnosed, and we were getting so frustrated, like, why can't you just go to a rehab program? Why can't you succeed with that?
00:30:04
Speaker
And finally, we realize i realized from that training that the question should be, what's happened to you? Because if we're not dealing with the original trauma, then they're kind going to keep using their coping mechanisms. so And we know that women who get PTSD have have more severe symptoms.
00:30:21
Speaker
They need more medications because things like estrogen receptors interfere with many of the medications. And so it's it's better to prevent the PTSD. So giving comprehensive point-of-care treatment immediately after the sexual assault or as soon as they come to us is just so important.
00:30:39
Speaker
And I think we're getting the message out, but it's slow. I would argue that there's a lot of things in healthcare care that we learn about and study that could potentially be triggering depending on your past. And I hesitate to support, well, then let's not learn about it. Rather, let's learn about it and you're entering into this field. And if it is triggering, perhaps... the schools and universities have supports for you to work through some of that triggering thing. Maybe you don't choose to enter into that specific area of practice if something specifically is triggering for you. But um I can't imagine the like, well, it might be triggering, so let's not talk about it or let's not learn about it at all.
00:31:22
Speaker
Yeah, we're going to see it everywhere. Even going into an endoscopy clinic. I mean, that could be triggering for a patient if they've been aurally assaulted. So you don't know where you're going to run into it. and we had I heard of a student in one university who wanted to be exempted from the death and dying class because it was triggering. Well, what do you say when your first patient dies? Like, sorry, I skipped that class. So A, we have to look at how who we're picking for the classes, not just on grades, in terms of stress, resilience, and critical thinking. And then through the programs, we have to work through them because there's a lot in it.
00:31:59
Speaker
that we deal with that um is very difficult. I think we overuse the word triggering to start with, but um you know that's different than triggering PTSD. But some of the work I'm doing right now is looking at critical incident stress in students and how to um how to help prepare them to be resilient when they graduate. I mean, my very first patient in my very first clinical died on me. I've never seen a death before.
00:32:22
Speaker
um and And I was 17. So how do we move on from that? So yes, you might be very anxious in first year, but we want you to succeed and and thrive when you graduate. and and not Because it's hard enough. When we graduate, we expect we're all ready. And if you look at Benner's work, you're really not considered competent for one to two years after you graduate, and yet we give them a full load. and so um The data just before COVID showed that 40 to 60% of new grads left nursing within two years because of moral distress and PTSD.
00:32:58
Speaker
So we need to work on this. Many of them have been victims themselves. I know in psychology programs, in a master's in psychology, you cannot graduate until you've you've gone through counseling yourself. We don't do that in nursing. And yet we deal with a lot of really tough stuff.
00:33:16
Speaker
I agree. I think that our healthcare provider and clinician schools really do need to train some of the resilience and that it's okay if you have feelings or emotions about things that we see and deal with. There's a lot of hard stuff no matter what area of practice you enter into. It doesn't have to be violence or forensic specifically.
00:33:40
Speaker
Any area you're going to deal with hard stuff. And people sometimes in the worst moments of their life and dealing with loss and the the morbidity of ah of an awful diagnosis and those sorts of things. And so I agree, Kathy, we need to be training some resilience and response and resilience.
00:33:59
Speaker
I think the idea of like, let's just not learn about it then doesn't do that at all. So I'm going to skip a little bit here because I had an interesting conversation last week specifically about
Exploring Remote Forensic Exams and Innovations
00:34:12
Speaker
Telesafe. And that's, you know, sexual assault forensic exams with an experienced forensic nurse examiner on the other side of, say, an iPad or a telephone, potentially supporting the rural and remote areas where, like you said, there might be someone who only sees a handful of cases a year. So keeping them up to date and competent in these rural areas is not always possible. So there's the Telesafe. There's and other innovations like a self-collection kit that are both being purported to expand access to forensic exams, especially in rural and remote areas.
00:34:46
Speaker
But I have a fear that this is also letting services or governments who should be funding things like forensic nursing programs off the hook by finding these potential workarounds.
00:35:01
Speaker
i'm I'm kind of split on that, to be honest. I'm not i'm not a supporter of the self-collection kit because, again, we go back to the kit. It's not the kit. It's the person behind the kit and how they're treated.
00:35:13
Speaker
So depending on how the Telesafe program is operating, I'm i'm in support of that rather than the self-collection kit, much like the the consulting line with with Rapid that I was explaining in Edmonton.
00:35:27
Speaker
um you've got an experienced examiner on the other end. So that increases the comfort level for the nurse that's with the patient um and or can. It depends on whether the focus is just on the evidence collection and and what part they play in it.
00:35:44
Speaker
um So as long as the Telesafe is trauma-informed and in encouraging the nurse that's with the patient to be trauma-informed, I'm in support of that. If it's just like, let's get this evidence done,
00:35:56
Speaker
Again, it's not about the evidence. It's how we treat person. So, um, so if they're coming in as a consult and just saying, yeah, these are the swabs that you've taken, I'll, I'll, I'll walk you through that part, but make sure that you support the patient in this way and look at safety and suicide and, and give them time and let them choose the timing. I mean, so, so much of that, I'm just trying to picture how long the call would be.
00:36:21
Speaker
Um, You and I know that the exam itself, it's it's a physical exam. It doesn't take that long. But it could take three or four hours with the patient because they they lose their speech when they start to relate the history. They need some time to decompress. Give them a cup of tea, a warm blanket. Let them choose it if if and when they want to resume. And and getting through those difficult moments or having to use grounding techniques on them because they've they've dissociated while while you're doing part of the exam.
00:36:53
Speaker
um Will the telesafe nurse help them with that? I don't know. Or are they just going to focus on the swabs? So long answer to a short question. The self-collection, again, there's no Heeslaw, there's no testing of that in court to see if it would hold up.
00:37:09
Speaker
I'm not even sure what the recovery would be. And does the patient know when the evidence window would be? So if it's, ah you know, if it's, and what about injuries? If they've used a condom, there's probably not going to be DNA there.
00:37:24
Speaker
So it's, yeah, and we know that oral swabs are not really useful after the first day and vaginal swabs might be okay at five to seven days, but um how much support is that? And again, where are they getting the support? What kind of counseling do they have with that?
00:37:42
Speaker
I wonder though, if it does come down to choice. I know that many patients, they show up because they want a kit, not necessarily a full exam. Of course, they may not always know what they don't know or what maybe we think they need or maybe they do need. um but that it's choice. So, you know, plan A ideally is to have a team or ah a very highly specialized forensic nurse, you know, second plan, a tele-safe, you know, where they've got an expert consult on the other end of a line,
00:38:16
Speaker
And maybe it's just choice, like if you really don't know what you need, you get a kit. Maybe the kits are stored at doctor's offices. I don't know. I think we're into a world where we're looking at choice. But it also concerns me at the same time that we're like letting our governments off the hook in actually funding forensic programs sometimes by looking at workarounds.
Challenges and Advocacy in Forensic Nursing
00:38:38
Speaker
For example, Kathy, as you know, yeah many forensic nurses, this is a side gig, and yet it's a highly specialized field. You've demonstrated that today, just the way that you talk you talk my language, but you can you can show your specialty.
00:38:53
Speaker
And yet we're still expected to have nurses working on call and then being available for whatever number of hours it might take, two hours, eight hours, How do you have a family? How do you pay your mortgage like that? And I think we're coming into a crisis of forensic nursing.
00:39:09
Speaker
And are we doing any service? I think I'm of two minds as well here. But are we doing any service by trying to find these workarounds because we're compensating for the lack of actual positions of forensic nurses?
00:39:25
Speaker
Okay. um Yeah, I see exactly where you're headed. One of the problems with nursing, um i think I think our best friends are social workers, to tell you the truth, because they're they're born and bred on on activism and advocacy, whereas we're nose down and bum up. We get the job done and we don't say too much about what we're doing.
00:39:44
Speaker
I know when we started the team in Edmonton, we actually volunteered our time. And so... um ah For two years, we volunteered it, but we had to do and a quality assurance project with a women's group that was looking at patient satisfaction when they went to the counselling centres after they've had seen been seen by the team.
00:40:02
Speaker
So that's how we got funding from the ah to go with the Alberta Health Services, but we had to prove that we made a difference. um we need We need to continue doing that to show the difference, but I'm not i'm not i'm not advocating the ESAS as a workaround.
00:40:18
Speaker
I'm advocating the ESAS as because you you can't be proficient if you're not seeing four or five cases a month. um And so you need to stay in your lane and do what you do well, but you still ideally will be able to connect with the same.
00:40:32
Speaker
And so having that as as part of of the solution and and having a commitment to having Well organized funded same teams in every urban center that to support the rural centers that doesn't mean they have to come into the
Survivor-Centered Reforms in Forensic Nursing
00:40:48
Speaker
centers. But they can advise or do this teleconferences or the telusafe or, or whatever, but, but it's up to forensic nurses to have a voice and to start advocating and, and to create some political discomfort for it and show them the governance. We had it in three provinces, Ontario, and Nova Scotia and Manitoba, where the governments stood up in the House of Commons or in in the legislature and said, we need more kits. And I didn't hear a single nurse stand up and say, it's not about the kits, it's about the health care.
00:41:19
Speaker
and and the specialized healthcare and the resources that we offer to it. And the same thing with disasters. So I'm starting to make some noise in both areas right now, because that's what we have to do to change. And I think that's an important place for CFNA to get involved.
00:41:33
Speaker
I think there's a lot of work to do. We've come a long way, but there's still a lot of work to do is what I'm hearing here. um And we have to ensure that I think our reforms are survivor-centered, victim-centered, patient-centered, and we keep our attention to choice and to trauma-informed practice always at the forefront and not this idea of doing a kit.
00:41:57
Speaker
Yeah. but But the choice, you know going back to your self-collection kits, they might think it's a choice, but For every action, there's an equal and opposite reaction. The women's groups wanted Plan B available in in the pharmacies.
00:42:11
Speaker
And the pharmacists used to have to give patients instruction when they handed out Plan b over the behind the counter of sexual assault centers. They don't have to give that education anymore. They can just hand it out.
00:42:21
Speaker
But the patient may not realize, I've had so many young women that have said, well, it wasn't sexual assault. I was drunk and passed out, so it's my own fault. But that's sexual assault. So they don't realize that, but they don't also realize they have other options like STI medications and and things like that. So if you do a self-collection kit, where are you getting that other information? How do you find out about counseling centers that are available to you to help you become resilient to that?
00:42:45
Speaker
um So to me, it's only choice if you've had the information and how do we get that information to them? And unfortunately, it's getting them to the health center to get that information or some sort of center. And I think every hospital and every nurse should be educated in what those choices are.
00:43:04
Speaker
Looking for some final thoughts here, Kathy. I think we have a future couple of podcasts for other conversations and other topics. But final thoughts today.
00:43:17
Speaker
um it's It's not about the kit. I'm glad that we've changed the kit. There's still some changes we'd like to make to it. Unfortunately, now the documentation is inside the kit, so you have to open it up before you get the consent signed. So there's a few tweaks that we have to make to it. but um And it could be smaller and simpler.
00:43:34
Speaker
But it's really de de-stigmatizing the kit and sexual assault and um reassuring people that it's how you treat the patient. If you forget the swab, I know we'd like to have it, but it's how they treat the patient.
00:43:49
Speaker
THAT'S THE MOST IMPORTANT PART. THANK YOU SO MUCH, CATHY. The sexual assault evidence kit might be standardized, but the conversations around it seem to be anything but. And I think we'll keep poking at the serious stuff with curiosity and maybe a dash of mischief, it sounds like, because that's how change happens, of course. Sometimes the most important evidence is the questions that we keep asking and we keep exploring. So I want to thank you today, Cathy, for joining me on Beyond the Rape Kit, Canada's Forensic Frontline.
00:44:23
Speaker
So while the RCMP sexual assault evidence kit may look like just a box of swabs and forms, it's really a box of stories, science, and systemic change. The question is, how do we keep evolving it to serve survivors first? And I think that's something worth chewing on, maybe over our next cup of coffee.
00:44:41
Speaker
The kit is both a tool of justice and a symbol of systemic challenges. And we've gone beyond the kit today, peeling back the layers of history, policy, and survivor experiences.
00:44:52
Speaker
It's a bit like opening a mystery box, and you never know what you're going to find, but you know that it matters. Until next time, keep asking, what's inside the systems that we take for granted?
Final Remarks and Support Resources
00:45:02
Speaker
If you've recently been hurt or assaulted, stalked or harassed, please seek medical care at your closest emergency department or health center. Connect with support services or your local police.
00:45:14
Speaker
I'm forensic nurse practitioner Hannah Varto, and this is Beyond the Rape Kit, Canada's Forensic Frontline, podcast by the Canadian Forensic Nurses Association. Thanks for listening. Stay safe.