Transcript Sexual Assault and Domestic Violence UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series.

Sexual Assault and
Domestic Violence
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for SA and DV
 Identify patients at increased risk for sexual assault
 Describe the medical and psychosocial management of a
victim of sexual assault
 Cite prevalence and incidence of violence against
women, elder abuse, child abuse
 Demonstrate screening methods for domestic violence
 Communicate the available resources for victim of
domestic violence including short-term safety
Definitions
• Domestic violence refers to violence perpetrated
within the context of family or intimate relationships
– Family members include parents, siblings and other
blood-relatives as well as legal relatives such as
stepparents, in-laws and guardians
• Intimate partner violence refers to violence that
occurs between current or former partners in a
relationship
• Sexual assault is defined as any sexual act done by one
person on another without that person’s consent
Rationale
 Rationale: Individuals who are the victims of sexual
assault often have significant physical and emotional
sequelae.
 Domestic violence affects a significant proportion of
the U.S. population in all economic classes and walks of
life. All physicians should screen for the presence.
Facts about Sexual Assault
 In America
 A sexual assault occurs every two minutes.
 Sexual assault is down by ½ since 1993, yet there were
still 248,000 sexual assaults in 2001
 About 44% of rape victims are < age 18
 About 15% are < age 21
 One in six American women has been the victim of an
attempted or completed rape
Facts about Sexual Assault
 ~10% of sexual assault victims are men
 ~ 2/3 of sexual assaults are committed by someone who is
know to the victim
 4 of 10 assaults occur in the victim’s home
 Almost 2/3 occur between 6pm and 6am
 Less than 39% of sexual assaults are reported to law
enforcement
 More whites v. non-whites
 Stats do not include children 12 and younger
CHILDREN
Child Sexual Assault: Prevalence
 75% are victimized by family member or others within
their “circle of trust”.
 Child sexual abuse has been reported up to 80,000
times/year but true incidence is far greater but often
goes unreported due to fear, shame and threats of
harm.
 As many as 1:4 girls and 1:6 boys will experience some
form of sexual abuse before age of 18 (many of these
cases go unreported).
Child
Sexual Assault:
Prevalence
Prevalence:
Children
 In 2006, CPS reported the approximate rates of child
maltreatment victims:
 24.4 per 1,00 for 0 to 1 year-olds;
 14.2 per 1,000 for 1 to 3 year-olds;
 13.5 per 1,000 for 4 to 7 year-olds;
 10.8 per 1,000 for 12 to 15 year-olds; an
 6.3 per 1,000 for 16 to 17 year-olds.
 Non-CPS studies have reported higher rates of nonfatal child
maltreatment cases, ranging from 4,300 to 4,900 per
100,000 children.
Child Sexual Assault: Risk Factors
 Who is sexually abused?
 Children of all ages, races ethnicities and economic backgrounds
are vulnerable to sexual abuse.
 Affects both girls and boys in all kinds of neighborhoods and
communities and in countries around the worl
 In 2006, some children had higher rates of victimization:
 African-American (19.8 per 1,000 children).
 American Indian or Alaska Native (15.9 per 1,000 children).
 Multiracial (15.4 per 1,000 children)
 Overall girls (52%) were at slightly higher risk than boys (48%) for all
forms of child maltreatment.
Child Abuse: Risk Factors
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A history of mistreatment as a child
Depression
Anxiety
Marital conflict or single parenting
Domestic violence
Financial stress
Social isolation
Lower parental education
Alcoholism or other forms of substance abuse
A child in the family who was born prematurely or who is
developmentally or physically disabled
• Young children in the family, especially multiple children under age 5
History Intake
 Children suspected of being sexually abused require a
history that encompasses
 Behavior history
 Social history
 Gynecological history
 General medical history
Child Sexual Assault: History Components
 Behavior-phobias, aggression, depression, suicide, sleep
disorder
 Social substance abuse, domestic violence in home, runaway
behavior
 Gynecology- LMP, # of pregnancies, possible GYN
surgery/trauma to genitalia
 General PMH (somatic complaints- h/a, abd pain,
constipation, diarrhea, fatigue)
 Forensic Interview (performed by a trained law enforcement
official) – essential for case prosecution
Child Abuse: Physical Exam
 Complete PE in prepubertal children include examination of
external genitalia.
 PE may be done emergently, urgently or electively scheduled
by own physician
 Preparation of child/family should be part of every
examination of sexual abuse
 Info regarding needed for exam of external genitalia
 Prepubertal children do not need speculum or internal
examination
 Information on use of cotton-tipped swabs for infections
Child Abuse: Physical Exam
 Abnormal findings that are suspicious for sexual abuse
are rare
 Most cases of prepubertal girls have normal
examination
 Most cases of abuse does not leave physical evidence
(i.e. fondling)
 Normal crescent- shaped hymen is common in most
prepubertal girls
Child Abuse: Physical Exam
 Abnormal findings in prepubertal girls include
 Lacerations of genitalia (fresh lacs/tears w/o h/o accidental
trauma should be noted)
 Bleeding of genitalia
 Hymenal tearing
 Absence of all/part of hymen
 Other areas of inspection include
 Oral pharynx – bruising
 Grasp, rope/tie marks on extremities
Child Abuse: Management
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Repair of injuries
Treatment of STDs
Pregnancy prevention
Protection against further abuse
Psychologic support for patient and family
ADULTS
IPV: Prevalence
 IPV is underreported:
 Many victims do not report IPV to police, friends, or
family.
 Victims think others will not believe them and that the
police cannot help.
 Each year, women experience about 4.8 million intimate
partner related physical assaults and rapes. Men are the
victims of about 2.9 million intimate partner related physical
assaults.
 IPV resulted in 1544 deaths in 2004. Of these deaths 25%
were males and 75% were females.
IPV: Risk Factors
• Several factors can increase the risk that someone will hurt his
or her partner. However, having these risk factors does not
always mean that IPV will occur.
• Risk factors for perpetration (hurting a partner):
– Using drugs or alcohol, especially drinking heavily
– Seeing or being a victim of violence as a child
– Not having a job, which can cause feeling of stress
Adult Violence: History
 History
 Sexual
 Last consensual intercourse
 Sexual patterns
 Contraceptive use
 Alleged assault
 Penetration
 Condom use
 Weapons
Adult Violence: History
 Physical Exam
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General
Vital Signs
Emotional status
Body surface – contusions, lacerations, abrasions
Adult Violence: PE
 Physical
 General physical exam – skin, mouth, neurological
(trauma), breasts, extremities
 Genitalia – vulva, vagina
 Lacerations
 Abrasions
 Ecchymoses
 Hematomas
Adult Violence: PE
Forensic collection
 Describe trauma
 Take photographs
 Toxicology screening
Adult Violence: PE
Forensic collection
 Specimen collection
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Semen
Sperm
Acid phosphatase
Nail clippings
Pubic hair combings
Blood sample
Adult Violence: PE
Forensic collection
 Culture for gonorrhea, chlamydia
 Wet prep for motile sperm, trichomonads
 Collect clothing
 Offer RPR/VDRL, HIV and Hepatitis B & C testing
Adult Violence: Management
Medical treatment
 All injuries treated appropriately
 Tetanus toxoid
 Hepatitis B vaccine (without HBIG)
 Protects if exposed during assault
 Two follow-up doses needed
Adult Violence: Management
Medical treatment
 Antibiotic treatment
 Cefriaxone 125 mg IM – PLUS
 Metronidazole 2 gm PO – PLUS
 Erythromycin 1 gm PO – OR
 Doxycycline 100 mg PO BID x 7 days
Adult Violence: Management
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Medical treatment
HIV prophylaxis not recommended due to lack of data
Pregnancy prevention – emergency
Psychological management
 Acute phase adjustment
 Irritability
 Tension
 Anxiety
 Depression
 Fatigue Ruminations (persistent/Flashbacks)
Adult Violence: Management
 Monitor for behavior changes that need further
attention:
 Alcohol abuse
 Drug abuse
 Overeating
 Post-traumatic stress disorder
 Counsel or refer for evaluation and management
Adult Violence: Management
 Follow-up is needed
 Asses psychological status
 Repeat physical
 Repeat labs
 Further counseling and support
 Referral to long-term counseling program if needed
ELDERS
Elder Maltreatment:
Prevalence and Incidence
 1-2 million Americans ≥ have been injured, exploited, or
otherwise mistreated by someone on whom they depended
for care or protection.
 Data suggest that only 1 in 14 incidents, excluding incidents
of self-neglect, come to the attention of authorities.
 In 2000, states were asked to indicate the number of
elder/adult reports received in the most recent year for
which data were available - the total number of reports was
472,813.
Elder Maltreatment: Risk Factors
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Using drugs, alcohol
High levels of stress
Lack of social support
High emotional/financial dependence
Depression
Lack of training
SCREENING & COUNSELING
Screening
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Emotional abuse
Physical abuse
Forced sexual relations
Fear of partner, other person
Feel safe at home?
Screening
 Identify presence of domestic violence
 Hitting
 Slapping
 Kicking
 Choking
 Assault or threat with weapons
 Shaking
 Pushing
 Throwing
 Biting
 Pinching
Screening
Sexual
Emotional
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 Undermine self-worth
 Deprivation of sleep or
emotional support
 Unpredictability of response to
life situations
 Threats
 Destruction of personal
property
 Partner over controlling
 Limits victim’s contact with
others
 Inappropriately close
surveillance
 Restricts activities
Unwanted touching
Sexual name-calling
Unfaithfulness
False accusations
Forced sex
Hurtful sex
Counseling
 Offer safety – immediate safety or “escape” plan
 Is it safe to go home?
 Are your children safe?
 Can you stay with a friend or family?
 Do you need a shelter
 Provide advocacy and support
 Non-judgmental
 Victim may choose not to leave situation at that time
Counseling
 Local support agencies
 Police/rescue squad
 Domestic violence hotline
 Family Violence Prevention Fund – (800) 313-1310
 National Resource Center – (800) 537-2238
 Local referral agencies
 Shelters
Reporting
 Legal obligation to report
 Varies by state
 Spousal abuse reporting not required in most states
(may worsen the situation).
 Spousal abuse referral required in many states
 Elder, child abuse reportable – varies by state
Reminders for OB Providers
 High correlation between domestic violence and
sexual abuse: important to incorporate such
screening into New OB assessment, and again at
anytime during pregnancy that evidence warrants.
 Less than 3% ID’d by providers (Wilson, 96)
 According to Gazmararian et al (1996) more than
60% of OB providers do NOT screen for domestic
violence, even though it is more common than GD,
placenta previa, and pre-eclampsia
Reminders for OB Providers
 Up to 17% of pregnant women report physical or
sexual abuse during pregnancy
 Evidence highlights increased perinatal morbidity
among offspring of woman who were abused during
pregnancy
 Greatest risk factor for abuse is history of violence in
year before pregnancy (Campbell & Alford 1989,
Stewart 1994, Martin et al 2001)
 Violence in postpartum more common than during
pregnancy, especially if abused during pregnancy
Bottom Line Concepts
 Majority of child victimization is by close family or friends
 Look for signs of child abuse – clues in behaviors changes and somatic
complaints
 Prepubertal children do not need speculum or internal examination
 Adult IPV is underreported
 Exam should include evaluation of mental status and behaviors,
thorough skin inspection and genital exam
 Forensic collection is an important component of the exam – collect
specimens and cultures
 Medical treatment involves vaccinations, antibiotics and emergency
contraception
 Follow up is essential and MDs should monitor for psychological status
and behavior changes that may need further counseling and treatment
 Offer safety plan and information about available resources, and
respect patients’ decisions even if they choose to not leave an abusive
situation at home
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
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Educational Topic 38 (p80-81).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles
RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert,
Douglas W Laube, Roger P Smith. Chapter 29 (p269-276).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin
J Hobel. Chapter 25 (p298-303).
National Center on Elder Abuse. “Fact Sheet: Elder Abuse Prevalence and
Incidence”. 2005.
Rape, Abuse & Incest National Network. “Who are the victims?”. 2009.
Risenberg D. Treating a societal malignancy-rape, JAMA, 1987; 257: 726727
Smith MC, Nonconsensual sex on the college campus; a common
occurrence, Clinic Pract. Sexuality. 1989; 4(4):25-28.
Stovall TG, Muram D. Wilder M. Sexual abuse and assault: a
comprehensive program utilizing a centralized system. Adolesc Pediatr
Gynecol. 1988; 1:248-251
Clinical Cases
Sexual Assault
Objectives
At the conclusion of this exercise, the student
will be able to provide a preliminary
assessment and discuss management of
patients subjected to sexual assault.
Obstetrics and Gynecology
Case Presentation
A 24-year-old woman was seen in the emergency
department at 2:00am for alleged sexual assault. She
reported that she was on a “blind date” and began
heavy petting at about midnight. This continued for
quite some time, and the “date” would not stop his
advances. She stated that she had been held down
while her clothes were removed and then was
forced to “have sex.” She was very tearful,
distraught, agitated and admitted that she had been
drinking alcohol.
Obstetrics and Gynecology
Case Presentation
The emergency department staff was very busy
with a number of other patients. The
gynecologist finally arrived at 4:00am,
although the patient had arrived at 2:00am.
No female assistant or “stand-by” could be
found for another hour; so the examination
began around 5:30 am.
Obstetrics and Gynecology
Physical Exam
Minor abrasions on the patient’s back and several fresh
areas of ecchymoses were noted on her upper arms
and breasts. The sexual assault kit materials were
used, and specimens were obtained from the vagina,
urethra, rectum and oral cavity for analysis and
culture. Fingernail clippings hair brushings and acid
phosphatase swabs from the vaginal discharge were
obtained. The vaginal discharged was examined and
motile sperm were noted on a we preparation.
Laboratory: Cultures, swabs and blood work.
Obstetrics and Gynecology
Assessment & Plan
Assessment
Sexual assault
Plan
Careful history and physical exam
Specimen collection/sexual assault kit
Take photographs of any injuries
Fill out and sign sexual assault chain-of-custody form
Notify social services, the assault crisis center and the police
Arrange for proper follow-up
Obstetrics and Gynecology
Discussion
Rape has traditionally been defined by law as forcible vaginal
penetration without consent. However, this is changing in
many states. Many states have redefined rape so that both
men and women can be either victim or perpetrator. Some
states have degrees of rape, others limit admissibility of a
victim’s previous sexual conduct, and others have limited the
requirement that the victim’s testimony be corroborated by
other evidence. Reforms continue. This case exemplifies
“date rap: case in which consent for sexual intercourse
cannot be resumed without a clear expression of consent,
and because of mere acquiescence to sexual intercourse.
Obstetrics and Gynecology
Discussion
Rape is a crime that is seldom witnessed. Therefore, it is a very
important that the gathering of corroborating evidence
during the medical examination be done in such a way that
prosecution can be undertaken. The history and physical
examination should be conducted within a standardized
legal format. Most hospitals have sexual assault kits for this
purpose. The physician should use these instruments
precisely and should express no opinions. Conclusions or
diagnosis in the record. The record should describe the
physician’s findings and examination methods in detail.
Obstetrics and Gynecology
Documentation
Consents (2) – medical and forensic
Chain of custody forms
Treatment/referral/follow up forms
Medical history and assault info, including
Specific details of assault
Activities victim has engaged in post-assault
(eating, bathing, douching, etc.)
Pre-assault consensual sexual activity (****)
Diagrams – “traumagrams”
Discussion
All specimens should be collected in the
presence of a witness and taken directly to
the pathologist. Anyone participating in this
system of collection and transport must sign
a chain-of-custody statement to avoid
mistakes or exchanges of specimens. Any
break in the chain of custody makes it
impossible to prosecute the case.
Obstetrics and Gynecology
Discussion
It is important for physicians to be ready to testify in court if
prosecution is attempted. Hearsay rules may prevent
evidence alone from the examination to be admitted.,
although this is less common when evidence is properly
labeled. This can be the first contact with the legal system
for the obstetrician-gynecologist. In this setting, the
physician serves as a patient advocate and an expert witness
within the system, making it and ideal introduction to law.
Over time, proper legal management of a sexual assault
evaluation may be as therapeutic as appropriate medical
management, which could include long-term psychotherapy.
Obstetrics and Gynecology
Teaching Points
1.
2.
3.
In sexual assault case, the physician has two clear duties:
1) medical treatment of the patient; 2) collection and
preservation of evidence.
The evidence must be collected with care and
completeness, and chain-of-custody requirements must be
maintained or such evidence may be inadmissible in court.
Having available persons from social services who can
provide immediate counseling and emotions support in a
an emergency department setting is often helpful.
Obstetrics and Gynecology
References
 Flitcraft A. Violence, abuse, and assault over the life phases, in Wallis LA et
al. eds. Textbook of Women’s Health. Lippincott-Raven Publishers.
Philadelphia. PA , 1998:249-258
 Seaman B. A survivor’s view . In Wallis LA et al. eds. Text book of Wom’s
Health. Lippincott-Raven Publishers. Philadelphia. PA , 1998:259
 Severino SK Commentary: late luteal phase dysphoric disorder-disease or
did-ease? In God JH, Severino SK. Eds. Premenstrual dysphorias: myths
and realities. American Psychiatric Press, Inc., Washington. DC, 1994: 213230.
 Adapted from Association of Professors of Gynecolgy and Obstetrics
Medical Educational Objectives. 7th edition, copyright 1997
 www.cdc.gov/injury
Obstetrics and Gynecology
Patient presentation
 A.W. is a 25-year-old, G4P3 woman who makes an
appointment to consult you about her “PMS.: She
complains that she is “not herself” for several days
before her period and that she can’t stop crying. She
snaps irritably at her husband, who is a “good
provider for {her} and for the children.” She doesn’t
have her usual patience with the children, aged 3
years, 2 years and 8 months. She startles easily and
is clumsy. Just last month she accidentally broke a
favorite figurine her mother had given her.
Obstetrics and Gynecology
Patient presentation
She things she might have felt better when she took
birth control pills, but her husband doesn’t think she
should take drugs that “interfere with natural
functions”, especially with this PMS problem. He
doesn’t like IUDs diaphragms or condoms, either.
When you screen the patient for depressive
symptoms, she denies appetite disturbance. Her
sleep is somewhat fitful, but she has to keep an ear
cocked to hear the children so that they won’t
disturb her husband as “he has to get to work in the
morning.”
Obstetrics and Gynecology
Patient presentation
Her energy and sex drive are not great, but she
believes that’s pretty natural with three
children. She manages to keep up with them
and the housekeeping. She enjoys seeing
other people but doesn’t have much time for
socializing.
Obstetrics and Gynecology
Patient presentation
Her husband, who has accompanied her to the
appointment, confirms her account. He says she
“would be a great little wife and mother if it weren’t
for this damed PMS.” He remains in the examining
room throughout the interview and general physical
and pelvic exams., holding his wife’s hand and
patting her on the back from time to time. He tells
you that you shouldn’t worry about the cost of
treatment because he wants his wife to have
whatever she needs.
Obstetrics and Gynecology
Patient presentation
Physical Exam
All normal, except a small bruise on A.W.’s right
arm.
Laboratory
Hematocrit and TSH normal
Assessment
Possible depression, protective husband, bruise
on arm, possible domestic violence
Obstetrics and Gynecology
Plan
Careful history and physical exam
Rule out any possible underlying medical
problems, e.g. hypothyroidism
Review previous medical records
Counseling
Possible referral to therapist or social worker
Obstetrics and Gynecology
Discussion
A.W.’s symptoms do seem to occur in the
premenstrual phase. It is not clear whether
she meets criteria for major depression or
dysthymic disorder as well, but since the
treatment for PMS is selective serotonin
reuptake inhibitors (SSRIs), which are
antidepressants, you reason that you will
treat the depression. If it is present.
Discussion
After ordering a laboratory workup, you prescribe sertraline
50mg/day. You also arrange to have her previous medical
records sent to your office. Prior to A.W.’s return visit 2
weeks later, you review her records and notice that she has
made numerous visits to physicians with vague complaints
of headaches and abdominal pains over the years. She has
also been see in emergency department for a succession of
lacerations and broken bones. Bruises were noted on these
visits, but always explained by the patient.
Obstetrics and Gynecology
Discussion
When A.W. appears for her visit, again accompanied by her
husband, you ask the office nurse and clerk to engage him in
a lengthy discussion of insurance benefits. When he is not
present, you tell A.W. that you are glad to have the
opportunity to speak with her alone. She indicates that the
medication has not made much of a difference in her
symptoms. You tell her that people sometimes have
symptoms like hers when others in their home are hurting
them and that you have notice many injuries in her past
medical history. A.W. looks very frightened.
Obstetrics and Gynecology
Discussion
You assure her that you are there to help and that you will keep
her statements strictly confidential. A.W. breaks down in
tears and tells you that her husbands’ temper sometimes
gets the best of him, and she says, “He would kill me if he
knew I had told anyone.” You assure A.W. that no one has
the right to hurt anyone and discreetly provider her with
information about domestic violence. After several visits in
the company of her husband A.W. comes alone one day and
tells you, “It took me a while to face the fact that I was being
abused and to get up the nerve to leave, but one day my
husband hit our oldest daughter, and I realized I had to get
out. The kids and I are living with my mother, now and I am
going to school so that I can take care of us and make us a
new life.”
Obstetrics and Gynecology
Teaching points
1. An overly involved husband is often a sign of
domestic violence.
2. A history of domestic violence is seldom
volunteered, especially on the first visit, and it will
be necessary to interview the patient alone in
order to obtain the history.
3. Victims of domestic violence frequently present
with a succession of rather vague physical
complaints.
Obstetrics and Gynecology