Sexual Abuse Muhammad Waseem MD Lincoln Hospital Bronx

Sexual Abuse Muhammad Waseem, MD Lincoln Hospital Bronx New York

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

Sexual Abuse • Medical issues • Social issues • Legal issues

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

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

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

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

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

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

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