The Nurse Who’s There After Sexual Assault

The public discussion over how to think about and address sexual violence has heated up in recent years, prompted by high-profile allegations like those against Nate Parker, Woody Allen, and Bill Cosby, as well as increased attention to sexual assault on college campuses. The increased coverage has also brought attention to widespread problems in how sexual assault is investigated. Across the U.S., there is a backlog of tens of thousands untested rape kits—evidence collected during examinations following sexual assaults—that are currently in police custody. In 2015, the police department in Tucson, Arizona, received a grant of more than $1 million to test its more than 1,000 backlogged kits.

Arlette Stevens Castaño, a sexual-assault nurse examiner in Tucson who conducts these examinations, acknowledges the challenges that crime labs and police departments face in getting them tested promptly. For The Atlantic’s series of interviews with American workers, I spoke with Stevens Castaño about what inspired her to work with sexual-assault survivors, a nurse’s relationship with law enforcement, and the problem of untested examination kits. This interview has been lightly edited for length and clarity.

Adrienne Green: What made you choose nursing as a career?

Arlette Stevens Castaño: Even back in high school, I knew that I wanted to take care of people. I was leaning toward health care, but I wasn’t really sure if I would become a nurse or a physician. After learning more about nursing, I decided that I liked it because I wanted to spend more time educating patients. I've always been a person who wanted to prevent bad things from happening, and that tied into the career that I chose. I still feel that preventing infection and disease is very important, not just treating things with medication.

I am a first-generation Mexican-American and I grew up in Tucson, Arizona. I’m bilingual—Spanish is my first language, and I still use it on a daily basis—and I wanted to be out more, working in the community. I attended the University of Arizona, and I have been a registered nurse now for 16 years. Working with the sexual-assault nurse examiner team was a life-changing event.

Green: How did you start doing the work you do now with sexual-assault survivors?

Stevens Castaño: I had worked at the Veterans Affairs hospital as a medical surgical floor nurse for about two and a half years before I applied to nurse-practitioner school at the University of Arizona. In my last semester, I asked a classmate of mine what her plans were, and she told me that she was also getting training to become a sexual-assault nurse examiner. I thought that seems like an area that I'd be interested in as well, because I was interested in domestic violence during my pre-nursing courses.

My classmate told me that there was a training coming up the following year in Tucson, so I called the Southern Arizona Center Against Sexual Assault, a non-profit organization that serves Southern Arizona sexual-assault survivors. I did the 40-hour, eight-day training the next February and I learned that it was an independent contractor job. So I could still work in a permanent job at the veterans’ hospital, and work as a sexual-assault examiner on the side on weekends and perhaps holidays.

Green: How did they train you to interact with sexual-assault survivors?

Stevens Castaño: It was just like being in a college course where they educate you about what sexual violence is and is not. They started out with the plain definition and then worked up to more in-depth and intense education about sexual-violence statistics. In order to take the course, you had to be a registered nurses already and have worked for a couple of years.

We learned what to look for and also the examination timeline: It's best if the examination happens within five hours of a sexual assault, for example. You're trying to get their history, assess their body, and also collect evidence from them, which will go to the crime lab. After five days—most often due to showering and wiping—all of that evidence is sometimes lost and you cannot do a full sexual-assault examination kit.

A patient can always seek help, though—that never stops.

Green: What exactly do you do when you get called about an assault?

Stevens Castaño: All centers in the state use the same sexual-assault kit. We get called by the Southern Arizona Center Against Sexual Assault and are told that there's a patient-survivor that wants a medical-forensic exam. We have an hour to respond to our center, because we're usually at home and need to get to the examination site in one of the local hospitals or emergency centers in Tucson. I have a mobile bag that I take with me and I’ve done several exams using what’s in it, but it's challenging to make sure that everything is in the bag when you get there.

Once we're with the patient, they are usually in the emergency department being or have already been medically cleared. If they've encountered any other types of trauma to the body, we want to make sure that there's nothing going on that can be life threatening to them. For example, with sexual assault there is often physical assault. They also could have been given something to ingest to that knocked them out.

Green: How is your interaction with these patients as a nurse different than a physician?

Stevens Castaño: In all cases, they do see a provider, which is not always a physician. It can be a physician's assistant or a nurse practitioner in the emergency department. The patient would call 911 and explain what happened, and hopefully law enforcement calls our center. We have a 24-hour hotline—it's bilingual, English and Spanish. If the patient also seems like they want to speak to a patient advocate, one can be called. If the patient agrees to get an exam done, they go to the emergency department. Law enforcement takes care of what they need to, and at times, they come with the patient to the hospital. If the patient decides they do not want law enforcement involved in their case, they can still proceed with our center and the advocate. They can get an exam that's paid for by the state of Arizona and get their healthcare assessed.

We're trained to assess a patient differently than a standard clinic. Knowing that patients have gone through different stages of trauma and that, at times, they may not remember what happened, and how to examine a patient head-to-toe through their history and questioning.

Green: After you proceed with the rape kit, how do you proceed with law enforcement?

Stevens Castaño: Once I'm done with examining the sexual-assault patient, I need to dry all the specimens I've collected and package them individually. Then I call law enforcement—because there is a chain of custody—and wait as little as 20 minutes if they happen to be around the corner, or up to an hour for them to respond to the hospital for a pick up.

Once they arrive, I really don't need to explain much of what happened because they may not be the person who is involved with the case. Getting the call, seeing the patient, doing all the paperwork, and drying the specimens can take up to five or six hours from start to finish; the patient time is about two-and-a-half hours maximum.

Regardless of whether the patient wants law enforcement involved, this kit goes to their crime lab. The police needs to meet with me and sign all documentation with the ID badge number, and also the date and time when they picked it up. That's the chain of custody so we know that it's been turned in from my hands to law enforcement directly. A copy of the paperwork goes to the detective, another to the crime lab, and one goes to our center. We have a copy of the chain of custody form, and we can track it that way if we ever have questions.

Green: There's a large backlog of completed rape kits in the U.S., and a lot of them go untested. Why do you think that is?

Stevens Castaño: I feel that it's wrong, and it's been going on for years across the U.S. I know it's probably because of lack of staff in the law enforcement agency and crime labs. They have a boatload to take care of.

Green: What do you think that says about the way that sexual assault is prioritized?

Stevens Castaño: A lot of things come into play. I wouldn't say it's 100 percent because they're saying, "Oh no, someone who was sexually assaulted is not as important as someone that was hurt in any other way." It has to do with a lot of things that I'm not aware of. For example, their supervisors and how they view things, whether they're short staffed—which I know happens in so many areas—especially cities, because they're constantly trying to cut back somewhere. Of course, I know it's wrong. I would hope that it's not because we don't care about what happened to sexual-assault patients regardless of their age or gender.

Stevens Castaño: The motivation began when I was young. I knew I wanted to go into health care, and to me, it's more rewarding to help someone that cannot perhaps get health care or attention, or even health education. Also, for them to have someone listen to them as much as others might to someone more economically stable. People need to be stable in all areas: mind, body, and spirit. I wish I could do more, but I can't. I just do what I can with my nursing career.

Green: What's the most challenging part of your job?

Stevens Castaño: Nursing is difficult no matter what area you work in. I was not in the military, and I can just imagine what they would have gone through. At the veterans’ hospital, I took care of patients from 22 to 98 years old. They had the bravery to do all of that, and some of them have gone through a lot of trauma like PTSD due to military issues, and military sexual trauma for men and women. That’s connected to my other job as a sexual-assault nurse examiner. They have PTSD as well. PTSD is not only war-related: It could be with sexual violence, physical violence, and also human trafficking.

Green: What are the detriments to the patient if someone without your specific training—perhaps just a regular nurse—examines a sexual-assault survivor?

Stevens Castaño: I don't know what it's like anywhere other than Tucson, but I know some hospital systems have their own sexual-assault nurse examiner teams. Here, we are independent contractor registered nurses, you just need to be a registered nurse and be specially trained through clinical training.

For survivors, there are advantages of having a sexual-assault nurse. Nursing schools don’t teach a lot about sexual-assault exams, and from what I hear medical schools do not teach very much either. If I wasn't trained as a sexual-assault nurse examiner, and I was just a regular registered nurse, I know that I would not feel comfortable, and I know that I would miss several things that are important to assess. Any medical personnel, even medical doctors, I don't think would do the work that we sexual-assault nurse examiners do. For example, oncology doctors or neurosurgeons get special training. You can't just have a doctor or physician's assistant, or nurse practitioner, go do surgical procedures on someone if they haven't been trained.

Green: How has your job changed as conversations about sexual assault, mental health, and human trafficking have become more common?

Stevens Castaño: My priorities have changed through the 16 years of my nursing career. Thankfully, as a result of becoming a sexual-violence examiner, when I am with a patient and they have certain complaints, I know I need to be a bit patient and listen to them. For example, if they were to come in with some type of physical-violence issue, I would not say, “Okay, I believe you were hit by a baseball,” or if there's some type of injury around their neck that looks like strangulation—these are things that could be a violent act.

In our jobs, time is always of the essence. But at times, I feel that I've made more time for my patients than perhaps others would, because I feel they need to tell their story to have some type of relief. I’m not treating someone's mental health, but there are different aspects that we need to watch out for more regarding sexual violence or human trafficking.

Green: It seems like a big part of your job is dealing with people who have had traumatic experiences. How do you deal with that emotional element of your job?

Stevens Castaño: I've done about 90 sexual-assault exams in my lifetime, but I always try not to express my feelings. At times, I have gotten a bit tearful, but I listen to them. I have not become traumatized. I really enjoy the sexual-assault nurse examiner role. I just really feel I am drawn to that type of patient population more than anything. It has made me more aware of how we need to be, perhaps, a bit more watchful of our surroundings. Being raped is never the survivor’s fault, no matter if you were walking out of a store late at night, or if you were dressed a certain way; the assailants did not take no for an answer, or they didn't even bother to question.

This interview is a part of a series about the lives and experiences of members of the American workforce, which includes conversations with a paramedic, a surgeon, and a therapist.