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.

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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
  assailants genitals

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Legal Definition of Sexual Assault

• Lack of consent
• Say No
• Minors
• Drugged
• Asleep
• Mentally incompetent
• Use of fear, force, threat of force, or fraud

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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.

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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

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Post Traumatic Stress Disorder

• Sleep disturbances
• Feelings of guilt
• Memory impairment
• Detachment from the world

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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/As - so ask about abuse

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Psychologic Support

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

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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?

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General Principles

• Provide medical treatment for the complications
  of the assault
• Wounds
• Psychologic support
• Pregnancy
• STDs
• Tetanus

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Legal Role

• Communicate with law enforcement
• Chain of evidence - dont 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

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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

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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

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Physical exam

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

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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

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Sexually Transmitted Disease

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

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Sexually Transmitted Disease

• Gonorrhea and chlamydia risk is 4-17
• Ann Emerg Med 19587-590, 1990
• Bacterial vaginosis 10
• Trichomoniasis 6
• HIV risk is less than 1
• Syphilis risk is less than 1

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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

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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?

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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

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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

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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

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Pediatric STDs

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

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Pediatric STDs

• Take swabs from the vagina not the cervix
• Swabs will be useless half the time(just dont
  grow) so take a urine and send for chlamydia
• Treat with the same antibiotics

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Pediatric Sexual Abuse Contacts

• gt72 hrs refer to Janice Heard Jennifer
  McPherson, they run a sexual abuse clinic every
  Wednesday
• lt72 hours call the Sexual Assault Team
• Always contact the CART, the Child Abuse Response
  Team (Police and social worker)
• Child protection services

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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)

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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

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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.

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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.

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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

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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

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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

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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

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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

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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

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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

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Domestic Violence

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

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Patient Barriers

• Their fault
• Nowhere to go
• Didnt mean it
• You cant help

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Physician Barriers

• Afraid to offend
• Cant do anything
• Wont tell you
• Takes time???????? - get a life

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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

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Domestic Violence Management

• Assess safety - threats, drugs, firearms
• 75 of domestic violence with Im 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

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Mandatory Reporting - Pros

• Will offload blame
• Increase prosecution
• Increase identification and data collection
• Beneficent and non-maleficent
• Will force inquiry, documentation and the
  provision of resources

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Mandatory Reporting - Cons

• 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

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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
• Patients1218 females (72.8 response)
• Clinical setting12 EDs in California and
  Pennsylvania
• Outcome Opposition to mandatory reporting

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Mandatory Reporting of Domestic Violence Injuries
to the PoliceWhat Do Emergency Patients
Think?Rodriguez et al. JAMA, Aug 1 , 2001 -
286(5)

• Results
• 12 reported physical or sexual abuse in last
  year by intimate partner
• Abused women 44.3 opposed mandatory reporting
• Unabused women 29.3 opposed mandatory reporting
• Non-english-speaking, abused within a year and
  women currently with partners were two times as
  likely to be opposed to mandatory reporting

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Mandatory Reporting of Domestic Violence Injuries
to the PoliceWhat Do Emergency Patients
Think?Rodriguez et al. JAMA, Aug 1 , 2001 -
286(5)

• Conclusions
• The efficacy of mandatory reporting needs to be
  further assessed.
• Consent should be included before wider
  implementation.

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Mandatory Reporting Laws Do Not Deter Patients
From Seeking Medical CareHoury et al., AEM 343
sept 1999

• Methods questionnaire in 3 stages
• Convenience sample,
• Prospective randomized,
• Targeted group at risk for domestic violence

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Mandatory Reporting laws Do Not Deter Patients
From Seeking Medical CareHoury et al., AEM 343
sept 1999

• Results
• Of 577 patients, 55 were aware of mandatory
  reporting
• 27 would be more likely to report violence if
  there was mandatory reporting
• 12 would be less likely
• There was no difference between targeted
  population and convenience sample in seeking
  medical care

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Mandatory Reporting laws Do Not Deter Patients
From Seeking Medical CareHoury et al., AEM 343
sept 1999

• Conclusion
• Only rarely did mandatory reporting laws
  adversely affect a patients decision to seek
  medical care.
• Mandatory reporting will deter a minority of
  patients