1 / 67

Sexual Abuse

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

ogden
Download Presentation

Sexual Abuse

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Sexual Abuse Muhammad Waseem, MD Lincoln Hospital Bronx New York

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

  3. Sexual Abuse • Medical issues • Social issues • Legal issues

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

  5. 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

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

  7. Definition • Incest • Sexual assault perpetrated by a family member

  8. 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

  9. Definition • Statutory rape has occurred even in “consensual intercourse when one party is not of “legal age”

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

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

  12. Epidemiology • Perpetrator known to child (84%) • Relative (50%) • “date rape” (57%) • Male victims (5%)

  13. Sexual Abuse • ED is not appropriate place for evaluation • Distracting environment

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

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

  16. Evaluation • History - “disclosure” • Physical examination • Forensic evidence collection • STD • Pregnancy

  17. History • To interview or not interview? • Be supportive

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

  19. Evaluation • Interview the parent • Interview the child

  20. Interview the Parent • Direct • “my child’s been abused” • Limit the discussion in front of the child • Indirect • Bring the possibility to open

  21. Interview the child • Too young to provide meaningful history • Uncomfortable • Requiring children to repeat stories of sexual victimization is harmful

  22. Interview the child • Children have their own language • Anatomically correct dolls • Draw a picture

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

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

  25. 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

  26. 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

  27. Documentation • Exact words

  28. Physical Examination • To provide reassurance • To determine treatable medical conditions • To collect forensic evidences • To assist in child protection

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

  30. Whole Body is the Crime Scene

  31. Physical Examination • General examination • Genital examination • Anal examination • Oral examination

  32. General Examination • General appearance • non-genital injuries (5%) • Emotional state • Skin examination

  33. 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

  34. Genital Examination • Posterior fourchette (70%) • Labia minora (53%) • Hymen (29%) • Fossa navicularis (25%)

  35. Colposcopy • Becoming standard of care • Allows close focus & magnification • Detection of acute injuries improve by 87%

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

  37. Wood’s lamp • Capable of fluorescing • Semen stains • Clothing fibers • Subtle injuries (rope marks & contusions)

  38. Wood’s lamp • Unreliable in the detection of semen • Not all that fluoresces is ejaculate • Not all ejaculate fluoresces

  39. Anal Examination • Anal laxity (first few hours  spasm) • “Anal wink” • Anal tear or fissure • Proctoscopy

  40. Anal Examination • 12 o’ clock (most common site) • 10-1 o’ clock

  41. Oral Examination • Trismus • Oral petechiae • Torn frenulum

  42. 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

  43. 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

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

  45. 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

  46. Evidence Collection • “Rape Kits” (within 72 hours) • Officially delivered & logged in laboratory • Chain of custody

  47. 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

  48. Sure Signs • Semen, sperm &/or acid phosphatase • Pregnancy • Positive cultures • Neisseria gonorrhoeae • Syphilis

  49. DNA • “…the suspect’s DNA profile matches that of the semen donor….” • Convicted offender Vs evidence sample

  50. Pregnancy Prophylaxis • Risk for pregnancy (5%) • 60-90% effective within 72 hour

More Related