Sexual%20Abuse

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Sexual Abuse

• Muhammad Waseem, MD
• Lincoln Hospital Bronx New York

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Sexual Abuse

• Medical and psychological emergency
• Time consuming
• Emotionally draining
• Multi-disciplinary approach

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Sexual Abuse

• Medical issues
• Social issues
• Legal issues

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Sexual Abuse

• Both genders
• All races
• All ages
• All socioeconomic levels

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Definition

• Legal definition varies from state to state
• Nonconsensual sexual penetration
• Need not involve intercourse
• Invasion of the vulva, mouth or anus
  not necessarily vagina

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Definition

• Engagement of a child in sexual activities for
  which the child is unprepared for and can not
  give informed consent

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Definition

• Incest
• Sexual assault perpetrated by a family member

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Definition

• Statutory rape
• Sexual intercourse with a minor (either with or
  without consent) who is under the age of majority
  as defined by the state in which the incident
  occurs

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Definition

• Statutory rape has occurred even in consensual
  intercourse when one party is not of legal age

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Epidemiology

• Actual incidence not known
• Most underreported (10-15)
• Fear
• Matter of privacy
• Perceived negative social stigma

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Epidemiology

• 90,000 substantiated reports in 1996
• 700,000 females raped every year
• Peaks 16-19 years
• 61 rape victims are under 18 years

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Epidemiology

• Perpetrator known to child (84)
• Relative (50)
• date rape (57)
• Male victims (5)

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Sexual Abuse

• ED is not appropriate place for evaluation
• Distracting environment

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Emergent Evaluation

• Inappropriate sexual contact within 72 hr
• Acute vaginal or rectal bleeding
• Psychological crisis
• Inability to provide safe environment

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Urgent Evaluation

• Vaginal discharge/ suspicion of STD
• Possibility of pregnancy
• Possibility of foreign body (foul odor)
• Exam requested by Child protection (CPS)

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Evaluation

• History - disclosure
• Physical examination
• Forensic evidence collection
• STD
• Pregnancy

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History

• To interview or not interview?
• Be supportive

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Evaluation

• Disclosure (revelation of abusive episode) may
  occur long after the event
• Children may test the water by making
  nonspecific comments

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Evaluation

• Interview the parent
• Interview the child

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Interview the Parent

• Direct
• my childs been abused
• Limit the discussion in front of the child
• Indirect
• Bring the possibility to open

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Interview the child

• Too young to provide meaningful history
• Uncomfortable
• Requiring children to repeat stories of sexual
  victimization is harmful

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Interview the child

• Children have their own language
• Anatomically correct dolls
• Draw a picture

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Interview the child

• Developmentally appropriate language
• Non leading open-ended questions
• Pointing to body parts may help the child
  understand

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Interview the child

• Asking the child to name her body parts to
  determine which ones are private
• Good touch Vs bad touch

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Interview the child

• Establish rapport
• Tell patients that you have seen children who had
  bad things happen to them, even by having someone
  they trusted treat them in a wrong way
• If disclosure was made, tell them this was a
  courageous and good act

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Interview the child

• Dont make promises that can not be kept
• Dont lie
• Dont threaten
• Dont attempt to bribe the child into giving
  information

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Documentation

• Exact words

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Physical Examination

• To provide reassurance
• To determine treatable medical conditions
• To collect forensic evidences
• To assist in child protection

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Physical Examination

• Explain what you are doing
• Give the child maximal control
• Limit interruption
• Consider sedation
• Never conduct the examination alone

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Whole Body is the Crime Scene
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Physical Examination

• General examination
• Genital examination
• Anal examination
• Oral examination

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General Examination

• General appearance
• non-genital injuries (5)
• Emotional state
• Skin examination

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Genital Examination

• Imagine the hymen as the face of a clock with the
  urethra at the 12 o'clock
• Between the 3 o'clock and 9 o'clock positions

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Genital Examination

• Posterior fourchette (70)
• Labia minora (53)
• Hymen (29)
• Fossa navicularis (25)

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Colposcopy

• Becoming standard of care
• Allows close focus magnification
• Detection of acute injuries improve by 87

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Toluidine blue

• Nuclear/DNA stain
• Adhere only to violated epidermis
• An intact superficial layers do not contain
  nuclei
• Detection improves by 20-40

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Woods lamp

• Capable of fluorescing
• Semen stains
• Clothing fibers
• Subtle injuries (rope marks contusions)

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Woods lamp

• Unreliable in the detection of semen
• Not all that fluoresces is ejaculate
• Not all ejaculate fluoresces

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Anal Examination

• Anal laxity (first few hours ? spasm)
• Anal wink
• Anal tear or fissure
• Proctoscopy

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Anal Examination

• 12 o clock (most common site)
• 10-1 o clock

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Oral Examination

• Trismus
• Oral petechiae
• Torn frenulum

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Physical Examination

• The absence of findings does not mean that a
  sexual assault did not occur
• Normal or nonspecific physical examination is
  common in sexual abuse

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Physical Examination

• Children, even if they don't have an injury, have
  a magical thinking that their body has been
  damaged
• Everything looks good is often the first step in
  the healing process

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Inappropriate Conclusions

• Consent Vs without consent?
• The presence or absence of injuries do not answer
  this question
• Traumatic Vs non-consensual penetration
• Not synonymous

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Inappropriate Conclusions

• Rape consent are legal principles - not medical
  diagnoses
• Examiner can verify the findings
• The jury will determine the credibility of
  history
• Neither rape nor consent can be diagnosed from
  the examination

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Evidence Collection

• Rape Kits (within 72 hours)
• Officially delivered logged in laboratory
• Chain of custody

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Evidence Collection Tips

• Use paper bags, never plastic
• Never place photographs in rape kits
• Always tape each individual sample closed label
  thoroughly
• Always write your name over tape edge and edge of
  container

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Sure Signs

• Semen, sperm /or acid phosphatase
• Pregnancy
• Positive cultures
• Neisseria gonorrhoeae
• Syphilis

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DNA

• the suspects DNA profile matches that of the
  semen donor.
• Convicted offender Vs evidence sample

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Pregnancy Prophylaxis

• Risk for pregnancy (5)
• 60-90 effective within 72 hour

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Emergency Contraception

• Ovral (Yuzpe regime)
• 50 ?g of ethinyl estradiol
• 0.5 mg of norgestrel
• 2 tablets within 72 hours of unprotected
  intercourse and 2 tablets 12 hours later

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Documentation

• Wouldnt it be great to do whatever you do
  without having to write it down?

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Documentation

• Watch your language
• Alleged (Do you write alleged abdominal pain)
• Claims?
• Superficial or minor
• External genitalia
• NAD - not actually done

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Drug Facilitated Sexual Assault
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Drug Facilitated Sexual Assault

• Sexual assault facilitated by the offenders use
  of an anesthesia type drug which when
  administered to the victim rendered the victim
  physically incapacitated or helpless and thus
  incapable of giving or not giving consent

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Date Rape Drugs

• GHB (Gamma hydroxybutyrate)
• GBL (Gamma butyrolactone)
• Rohypnol (Flunitrazepam)
• Ketamine
• Ecstacy (MDMA)
• LSD
• Alcohol

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GHB

• Gamma hydroxybutyrate
• CNS depressant
• Dissociative state
• Enhanced by alcohol
• Colorless odorless liquid

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GHB

• My feet felt like cement. It was like pins and
  needles wothout tingling. I could slap myself and
  there would be no response, no feeling at all.
  Then I dont remember anything

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GBL

• Gamma butyrolactone
• GBL ? GHB
• Dissociative state

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Rohypnol

• Sedation, muscle relaxation memory impairment
• Rapidly dissolved in liquid
• Blue dye in new formulation

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Ketamine

• Dissociative anesthesia

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Ecstacy

• CNS stimulant
• Hyperthermia
• Hyponatremia
• Seizure
• Not detected on routine toxicology screen

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Date Rape Drugs

• If the patient believes that something was put in
  her drink or does not remember everything that
  happened
• Urine specimen (100 ml)
• 2 gray topped tubes of serum

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Reporting

• You need not be correct in your suspicion in
  order to report

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Reporting

• 2221
• Obtain case ID

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Sexual abuse myths

• Children usually disclose abuse immediately
• Vaginal N. gonorrhea can be acquired from commode
  seat
• The use of tampons often causes
• Female infants can be born with a congenital
  absence of the hymen

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Conclusion

• Medical, social psychological implication
• Know the elements of assessment
• Be familiar with genital anatomy STD
• Collaborate with multiple disciplines