Transcript Wound Management - PEM Database Online

Sexual Abuse
Muhammad Waseem, MD
Lincoln Hospital Bronx New York
Sexual Abuse
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Medical and psychological emergency
Time consuming
Emotionally draining
Multi-disciplinary approach
Sexual Abuse
• Medical issues
• Social issues
• Legal issues
Sexual Abuse
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Both genders
All races
All ages
All socioeconomic levels
Definition
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Legal definition varies from state to state
Nonconsensual sexual penetration
Need not involve intercourse
Invasion of the vulva, mouth or anus
not necessarily vagina
Definition
• Engagement of a child in sexual activities
for which the child is unprepared for and
can not give informed consent
Definition
• Incest
– Sexual assault perpetrated by a family
member
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
Definition
• Statutory rape has occurred even in
“consensual intercourse when one party is
not of “legal age”
Epidemiology
• Actual incidence not known
• Most underreported (10-15%)
– Fear
– Matter of privacy
– Perceived negative social stigma
Epidemiology
• 90,000 substantiated reports in 1996
• 700,000 females raped every year
• Peaks 16-19 years
• 61% rape victims are under 18 years
Epidemiology
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Perpetrator known to child (84%)
Relative (50%)
“date rape” (57%)
Male victims (5%)
Sexual Abuse
• ED is not appropriate place for evaluation
– Distracting environment
Emergent Evaluation
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Inappropriate sexual contact within 72 hr
Acute vaginal or rectal bleeding
Psychological crisis
Inability to provide safe environment
Urgent Evaluation
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Vaginal discharge/ suspicion of STD
Possibility of pregnancy
Possibility of foreign body (foul odor)
Exam requested by Child protection (CPS)
Evaluation
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History - “disclosure”
Physical examination
Forensic evidence collection
STD
Pregnancy
History
• To interview or not interview?
• Be supportive
Evaluation
• Disclosure (revelation of abusive episode)
may occur long after the event
• Children may “test the water” by making
nonspecific comments
Evaluation
• Interview the parent
• Interview the child
Interview the Parent
• Direct
– “my child’s been abused”
– Limit the discussion in front of the child
• Indirect
– Bring the possibility to open
Interview the child
• Too young to provide meaningful history
• Uncomfortable
• Requiring children to repeat stories of
sexual victimization is harmful
Interview the child
• Children have their own language
• Anatomically correct dolls
• Draw a picture
Interview the child
• Developmentally appropriate language
• Non leading open-ended questions
• Pointing to body parts may help the child
understand
Interview the child
• Asking the child to name her body parts to
determine which ones are private
• Good touch Vs bad touch
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
Interview the child
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Don’t make promises that can not be kept
Don’t lie
Don’t threaten
Don’t attempt to bribe the child into giving
information
Documentation
• Exact words
Physical Examination
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To provide reassurance
To determine treatable medical conditions
To collect forensic evidences
To assist in child protection
Physical Examination
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Explain what you are doing
Give the child maximal control
Limit interruption
Consider sedation
Never conduct the examination alone
Whole Body is the Crime Scene
Physical Examination
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General examination
Genital examination
Anal examination
Oral examination
General Examination
• General appearance
– non-genital injuries (5%)
• Emotional state
• Skin examination
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
Genital Examination
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Posterior fourchette (70%)
Labia minora (53%)
Hymen (29%)
Fossa navicularis (25%)
Colposcopy
• Becoming standard of care
• Allows close focus & magnification
• Detection of acute injuries improve by 87%
Toluidine blue
• Nuclear/DNA stain
• Adhere only to violated epidermis
• An intact superficial layers do not contain
nuclei
• Detection improves by 20-40%
Wood’s lamp
• Capable of fluorescing
– Semen stains
– Clothing fibers
– Subtle injuries (rope marks & contusions)
Wood’s lamp
• Unreliable in the detection of semen
• Not all that fluoresces is ejaculate
• Not all ejaculate fluoresces
Anal Examination
• Anal laxity (first few hours  spasm)
– “Anal wink”
• Anal tear or fissure
• Proctoscopy
Anal Examination
• 12 o’ clock (most common site)
• 10-1 o’ clock
Oral Examination
• Trismus
• Oral petechiae
• Torn frenulum
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
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
Inappropriate Conclusions
• Consent Vs without consent?
– The presence or absence of injuries do not
answer this question
• Traumatic Vs non-consensual penetration
– Not synonymous
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
Evidence Collection
• “Rape Kits” (within 72 hours)
• Officially delivered & logged in laboratory
• Chain of custody
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
Sure Signs
• Semen, sperm &/or acid phosphatase
• Pregnancy
• Positive cultures
– Neisseria gonorrhoeae
– Syphilis
DNA
• “…the suspect’s DNA profile matches that
of the semen donor….”
• Convicted offender Vs evidence sample
Pregnancy Prophylaxis
• Risk for pregnancy (5%)
• 60-90% effective within 72 hour
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
Documentation
• Wouldn’t it be great to do whatever you do
without having to write it down?
Documentation
• Watch your language
– Alleged (Do you write alleged abdominal pain)
– Claims?
– Superficial or minor
– External genitalia
– NAD - “not actually done”
Drug Facilitated Sexual Assault
Drug Facilitated Sexual Assault
• Sexual assault facilitated by the offender’s
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
“Date Rape” Drugs
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GHB (Gamma hydroxybutyrate)
GBL (Gamma butyrolactone)
Rohypnol (Flunitrazepam)
Ketamine
Ecstacy (MDMA)
LSD
Alcohol
GHB
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Gamma hydroxybutyrate
CNS depressant
Dissociative state
Enhanced by alcohol
Colorless & odorless liquid
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 don’t remember
anything
GBL
• Gamma butyrolactone
• GBL  GHB
• Dissociative state
Rohypnol
• Sedation, muscle relaxation & memory
impairment
• Rapidly dissolved in liquid
– Blue dye in new formulation
Ketamine
• Dissociative anesthesia
Ecstacy
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CNS stimulant
Hyperthermia
Hyponatremia
Seizure
Not detected on routine toxicology screen
“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
Reporting
• You need not be correct in your suspicion
in order to report
Reporting
• 2221
• Obtain case ID #
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
Conclusion
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Medical, social & psychological implication
Know the elements of assessment
Be familiar with genital anatomy & STD
Collaborate with multiple disciplines