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