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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

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sexual abuse

Sexual Abuse

Muhammad Waseem, MD

Lincoln Hospital Bronx New York

sexual abuse2
Sexual Abuse
  • Medical and psychological emergency
  • Time consuming
  • Emotionally draining
  • Multi-disciplinary approach
sexual abuse3
Sexual Abuse
  • Medical issues
  • Social issues
  • Legal issues
sexual abuse4
Sexual Abuse
  • Both genders
  • All races
  • All ages
  • All socioeconomic levels
  • Legal definition varies from state to state
  • Nonconsensual sexual penetration
  • Need not involve intercourse
  • Invasion of the vulva, mouth or anus not necessarily vagina
  • Engagement of a child in sexual activities for which the child is unprepared for and can not give informed consent
  • Incest
    • Sexual assault perpetrated by a family member
  • 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
  • Statutory rape has occurred even in “consensual intercourse when one party is not of “legal age”
  • Actual incidence not known
  • Most underreported (10-15%)
    • Fear
    • Matter of privacy
    • Perceived negative social stigma
  • 90,000 substantiated reports in 1996
  • 700,000 females raped every year
  • Peaks 16-19 years
  • 61% rape victims are under 18 years
  • Perpetrator known to child (84%)
  • Relative (50%)
  • “date rape” (57%)
  • Male victims (5%)
sexual abuse13
Sexual Abuse
  • ED is not appropriate place for evaluation
    • Distracting environment
emergent evaluation
Emergent Evaluation
  • Inappropriate sexual contact within 72 hr
  • Acute vaginal or rectal bleeding
  • Psychological crisis
  • Inability to provide safe environment
urgent evaluation
Urgent Evaluation
  • Vaginal discharge/ suspicion of STD
  • Possibility of pregnancy
  • Possibility of foreign body (foul odor)
  • Exam requested by Child protection (CPS)
  • History - “disclosure”
  • Physical examination
  • Forensic evidence collection
  • STD
  • Pregnancy
  • To interview or not interview?
  • Be supportive
  • Disclosure (revelation of abusive episode) may occur long after the event
  • Children may “test the water” by making nonspecific comments
  • Interview the parent
  • Interview the child
interview the parent
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
Interview the child
  • Too young to provide meaningful history
  • Uncomfortable
  • Requiring children to repeat stories of sexual victimization is harmful
interview the child22
Interview the child
  • Children have their own language
  • Anatomically correct dolls
  • Draw a picture
interview the child23
Interview the child
  • Developmentally appropriate language
  • Non leading open-ended questions
  • Pointing to body parts may help the child understand
interview the child24
Interview the child
  • Asking the child to name her body parts to determine which ones are private
  • Good touch Vs bad touch
interview the child25
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 child26
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
  • Exact words
physical examination
Physical Examination
  • To provide reassurance
  • To determine treatable medical conditions
  • To collect forensic evidences
  • To assist in child protection
physical examination29
Physical Examination
  • Explain what you are doing
  • Give the child maximal control
  • Limit interruption
  • Consider sedation
  • Never conduct the examination alone
physical examination31
Physical Examination
  • General examination
  • Genital examination
  • Anal examination
  • Oral examination
general examination
General Examination
  • General appearance
    • non-genital injuries (5%)
  • Emotional state
  • Skin examination
genital 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 examination34
Genital Examination
  • Posterior fourchette (70%)
  • Labia minora (53%)
  • Hymen (29%)
  • Fossa navicularis (25%)
  • Becoming standard of care
  • Allows close focus & magnification
  • Detection of acute injuries improve by 87%
toluidine blue
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
Wood’s lamp
  • Capable of fluorescing
    • Semen stains
    • Clothing fibers
    • Subtle injuries (rope marks & contusions)
wood s lamp38
Wood’s lamp
  • Unreliable in the detection of semen
  • Not all that fluoresces is ejaculate
  • Not all ejaculate fluoresces
anal examination
Anal Examination
  • Anal laxity (first few hours  spasm)
    • “Anal wink”
  • Anal tear or fissure
  • Proctoscopy
anal examination40
Anal Examination
  • 12 o’ clock (most common site)
  • 10-1 o’ clock
oral examination
Oral Examination
  • Trismus
  • Oral petechiae
  • Torn frenulum
physical examination42
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 examination43
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
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 conclusions45
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
Evidence Collection
  • “Rape Kits” (within 72 hours)
  • Officially delivered & logged in laboratory
  • Chain of custody
evidence collection tips
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
Sure Signs
  • Semen, sperm &/or acid phosphatase
  • Pregnancy
  • Positive cultures
    • Neisseria gonorrhoeae
    • Syphilis
  • “…the suspect’s DNA profile matches that of the semen donor….”
  • Convicted offender Vs evidence sample
pregnancy prophylaxis
Pregnancy Prophylaxis
  • Risk for pregnancy (5%)
  • 60-90% effective within 72 hour
emergency contraception
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
  • Wouldn’t it be great to do whatever you do without having to write it down?
  • Watch your language
    • Alleged (Do you write alleged abdominal pain)
    • Claims?
    • Superficial or minor
    • External genitalia
    • NAD - “not actually done”
drug facilitated sexual assault55
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
“Date Rape” Drugs
  • GHB (Gamma hydroxybutyrate)
  • GBL (Gamma butyrolactone)
  • Rohypnol (Flunitrazepam)
  • Ketamine
  • Ecstacy (MDMA)
  • LSD
  • Alcohol
  • Gamma hydroxybutyrate
  • CNS depressant
  • Dissociative state
  • Enhanced by alcohol
  • Colorless & odorless liquid
  • 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
  • Gamma butyrolactone
  • GBL  GHB
  • Dissociative state
  • Sedation, muscle relaxation & memory impairment
  • Rapidly dissolved in liquid
    • Blue dye in new formulation
  • Dissociative anesthesia
  • CNS stimulant
  • Hyperthermia
  • Hyponatremia
  • Seizure
  • Not detected on routine toxicology screen
date rape drugs63
“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
  • You need not be correct in your suspicion in order to report
  • 2221
  • Obtain case ID #
sexual abuse myths
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
  • Medical, social & psychological implication
  • Know the elements of assessment
  • Be familiar with genital anatomy & STD
  • Collaborate with multiple disciplines