Domestic Violence and Sexual Assault

1. Domestic Violence and Sexual Assault Phil Ukrainetz - MD Dr. Pauline Head - MD, FRCPS, Sexual Assault Response Team Director March 28, 2002

2. Case 1 • 18 year old female comes to the ED saying four witnesses saw her being fondled as she was passed out at a party. She comes to the ED because she thinks something was put in her drink. She is very upset about the situation, saying she was sexually assaulted.

3. Legal Definition of Sexual Assault Carnal knowledge: • Complete vaginal penetration, • Incomplete penile or digital penetration • Intentional fondling or touching, • Coercion of the victim to fondle or touch the assailant’s genitals

4. Legal Definition of Sexual Assault Lack of consent: • Say “No” • Minors • Drugged • Asleep • Mentally incompetent Use of fear, force, threat of force, or fraud

5. Drugged Sexual Assault and drug Screens • In three years of doing drug screens only 2 positive for anything other than alcohol • Why: pts present late, short half lifes, drugs not commonly used • Rohypnol(sp?) has never been detected on a Calgary drug screen • Getting a drug screen is only helpful if victim wants prosecution and police involved - otherwise do not order • Does not change how we medically treat patient (unless obtunded)

6. Case 2 • 34 year old woman was raped four years ago. She was compliant with the initial Sexual Assault Team Treatment but never followed through with the counselling. Now she presents depressed, with panic attacks and flashbacks. She says she cannot believe she was raped by a former boyfriend.

7. The Stats • Fastest-growing violent crime • Estimated that 1 in 5 women will be sexually assaulted during lifetime • As few as 10% will report crime • 70-80% are victims of acquaintance rape

8. Post Traumatic Stress Disorder • Sleep disturbances • Feelings of guilt • Memory impairment • Detachment from the world

9. Rape Trauma Syndrome • One in the same with PTSD - incapacitating • Depression, flashbacks, anxiety, sexual dysfunction • Could very likely present as our chronic abdo, pelvic pain and H/A’s - so ask about abuse

10. Psychologic Support • Part of sexual assault team • Very low compliance rate • Rape crisis centre will optimize follow up • 25% follow up is optimistic

11. In the Rural Setting • 28 year old women, raped hours ago. There has been anal and vaginal penetration. You are in Peace River. What do you need to do?

12. General Principles • Provide medical treatment for the complications of the assault • Wounds • Psychologic support • Pregnancy • STD’s • Tetanus

13. Legal Role • Communicate with law enforcement • Chain of evidence - don’t let kit out of your site or know who has it at all times • Collect physical evidence • Historical information is the responsibility of law enforcement and you if your doing the kit

14. Rural Assessment • You will have to do it • Contact the RCMP they will bring the kit • Nearly every rural kit is done improperly and is useless as evidence • Call Calgary Sexual Assault so they can help • Store evidence dry and instruct RCMP • Takes about 5 hours and with a legal report will pay $600.00

15. History • If you are not doing the kit then have minimal history: patient states “Sexually assaulted” • If you are doing the kit: Kit will walk you thru a paraphrased comprehensive history, full gynecologic history/exam and details of rape • Watch subjective statements • Historical discrepancies will be exploited in court

16. Physical exam • Head to toe - describe like you are a camera • Gynecologic • Anoscopic • Wood’s lamp - flouresce semen • Toluidine blue dye - binds to nuclei of damaged cells • Kit will walk you through every step of exam

17. Sexually Assaulted but Refuses Evidence Collection • You cannot prosecute an assailant without a willing witness • Patient has the right to decline investigation • You can suggest evidence collection and hold off prosecution for 6 months • If victim does not want prosecution evidence can be discarded • Explain that if you do not do it within 72 hours the evidence will be lost

18. Sexually Transmitted Disease • What is the risk of getting an STD from a sexual assault? • Should you empirically treat? • What should you treat for?

19. Sexually Transmitted Disease • Gonorrhea and chlamydia risk is 4-17% • Ann Emerg Med 19:587-590, 1990 • Bacterial vaginosis 10% • Trichomoniasis 6% • HIV risk is less than 1% • Syphilis risk is less than 1%

20. STD Treatment in Calgary • G & C: Azithromycin 1 gm PO ASAP and then Cefixime 400 mg PO x 1 dose • BV & Tricomonas: Metronidazole 2 gm PO x 1 dose 2 days later • If at risk for Hep B: HBIG(start within 12 days) + Hep B vaccine • Tetanus: Td 0.5 mls IM prophylactically with breaches of the skin • HIV: if at risk • NB; at risk: speak to local ID specialist

21. Pregnancy • Rule out preexisting pregnancy • Not sure why - Morning after pill will not affect a pre-existing pregnancy • Risk is about 1 %, estrogen preparation to be given within 72 hrs • Plan B(Norgestrel) two tablets at presentation followed by 2 tablets in 12 hrs • Nausea and spotting • Failure rate is less than 2% • If GI tolerated Ovral works as well

22. Pediatric Rape • 5 year old girl comes in with Dad. With prompting she admits to being sexually assaulted by her step-brother multiple times over the last few months. The latest time was within 36 hours?

23. Characteristics of Pediatric Assault • Assailant is often known to the victim • Look for signs of recurrent abuse (80% will have no signs of abuse) • May have to examine under conscious sedation • Child will need protection from the appropriate social service agency

24. Pediatric Stats • 25-30% of children • 10-15% of boys (far less likely to admit abuse - so likely under-reported) • Peak age 8-13 years of age • All social classes but lower classes over represented

25. Pediatric Sexual Assault Risk Factors • 75% of offenders are well known and trusted by child (baby-sitter, scout leader) • Reconstituted families (previous marriage, step-siblings) • Violence is unusual • Emotional blackmail and threats are common

26. Pediatric STD’s • The father of the 5 year old wants to know about sexually transmitted diseases and what you are going to do about them.

27. Pediatric STD’s • Take swabs from the vagina not the cervix • Swabs will be useless half the time(just don’t grow) so take a urine and send for chlamydia • Treat with the same antibiotics

28. Pediatric Sexual Abuse Contacts • >72 hrs refer to Janice Heard & Jennifer McPherson, they run a sexual abuse clinic every Wednesday • <72 hours call the Sexual Assault Team • Always contact the CART, the Child Abuse Response Team (Police and social worker) • Child protection services

29. Sexual Assault Response Team • Physician, nurse, rape crisis counsellor • Physician does history, exam, kit • Nurse does the teaching • Rape crisis counsellor addresses psychosocial issues and follow up • Almost all lost to follow-up (stigma, embarrassed, feel responsible, societal views)

30. Improvements to Our Approach • Sexual Assault Centre (familiar , supportive place that is easy to find) • More effective prosecution of assailants • One dedicated sexual assault counsellor who actively follows up victims ( as in Vancouver) • Research: • Prevention, treatment,evidentiary

31. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 • Objective: take magnified (culposcopic) images of genital trauma in rape victims versus women engaging in consensual sex to see if there are differences.

32. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 • Study Design: Physical exams on 311 rape victims between 1985 and 1993 by Sexual Abuse Team and contemporaneously on 75 women after consensual intercourse.

33. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 • Results: • 76% (162/213)of rape victims had 3.1 sites of injury • 11% (8/75)of consensual women had 1 site of injury • 94% (200/213)rape victims had trauma at one or more of four locations

34. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 • Tears on the posterior fourchette and fossa • Abrasions on the labia • Ecchymosis on the hymen

35. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 Conclusion: A localized pattern of genital injury can frequently be seen in women reporting nonconsensual sexual intercourse; such findings can be useful for the clinical forensic examiner

36. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 Strengths: • Standardized approach approach stated up front • Experienced examiners • Good numbers

37. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 Cons: • Retrospective • Should have blinded the culposcopic reviewers • Definition of a valid complaint (what is denominator) • Control group numbers

38. Patterns of genital injury in female sexual assault victimsSlaughter et al. Am J Obstet Gynecol, 176 (3) 1997 • Very good study considering the topic, definitions of study population, difficult in getting controls • Excellent numbers • Can see why the study has not held up in court to date - “Easier to criticize then compliment” - as with all studies • Study is a good basis for more work

39. Domestic Violence • Serious and widespread problem • Lots of warning signs, not infrequently fatal • Historically poor at recognizing it • Managed inadequately

40. Domestic Violence • Of 50, 000 female homicides in 12 years 40% by spouse, intimate partner or family • Firearms puts you at increased risk • Most often killed in response to leaving a relationship

41. Domestic Violence • Spousal abuse as a cause of ED visits as high as 30%?? • 4-8% of women abused during pregnancy • We suckkkkkkkkkkkk

42. Patient Barriers • Their fault • Nowhere to go • Didn’t mean it • You can’t help

43. Physician Barriers • Afraid to offend • Can’t do anything • Won’t tell you • Takes time???????? - get a life

44. Domestic Violence - Signs and Symptoms • Head, neck, face, broken wrist or ankle - i.e., single black eye from a fall?????? • Abdo and chest - during pregnancy • Defensive posture injuries • Multiple states of healing • Multiple ortho, trauma visits

45. Domestic Violence - History and Physical • Screen for it • Non-judgemental/supportive • Private • Written screen

46. Domestic Violence Management • Assess safety - threats, drugs, firearms • 75% of domestic violence with “I’m leaving” • Document - photos, diagrams with specifics • Resources - know your local response • Patient knows best, what does she think?

47. Domestic Violence - Should We Have Mandatory Reporting? • 20% of women experience it • 5% are identified by physicians

48. Mandatory Reporting - Pro’s • Will offload blame • Increase prosecution • Increase identification and data collection • Beneficent and non-maleficent • Will force inquiry, documentation and the provision of resources

49. Mandatory Reporting - Con’s • Will increase violence • Will deter women from seeking care • Affects autonomy and confidentiality • Decreases identification • Is not beneficent and non-maleficent • Education and resources are not there

50. Mandatory Reporting of Domestic Violence Injuries to the PoliceWhat Do Emergency Patients Think?Rodriguez et al. JAMA, Aug 1 , 2001 - 286(5) • Method: Cross sectional study in 1996 • Patients:1218 females (72.8% response) • Clinical setting:12 ED’s in California and Pennsylvania • Outcome: Opposition to mandatory reporting