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Sexual Offence

HKCEM College Tutorial. Sexual Offence. aUTHOR Dr Wong Wai Yip August, 2013. History. A 17 year old woman attended AED with her friend in the morning Had party with friends last night Drank alcoholic beverages Woke in the the morning Complained of pain in the perineum

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Sexual Offence

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  1. HKCEM College Tutorial Sexual Offence aUTHOR Dr Wong Wai Yip August, 2013

  2. History • A 17 year old woman attended AED with her friend in the morning • Had party with friends last night • Drank alcoholic beverages • Woke in the the morning • Complained of pain in the perineum • Suspected sexual assault

  3. A MAN COMMITS RAPE IF HE HAS UNLAWFUL SEXUAL INTERCOURSE (I.E. PENETRATION OF WOMAN’S VAGINA BY THE MAN’S PENIS) WITH WOMAN WHO AT THE TIME OF THE INTERCOURSE DOSE NOT CONSENT TO IT; AND AT THAT TIME HE KNOWS THAT SHE DOES NOT CONSENT TO THE INTERCOURSE OR HE IS RECKLESS AS TO WHETHER SHE CONSENTS TO IT. RAPE CAN OCCUR WITHIN A MARRIAGE! What is rape?

  4. What are the other sexual offences? Rape Indecent assault Intercourse with girl under 16/13 Buggery

  5. Maximal penality • Rape: • life imprisonment • Indecent assault: • 10 years • Sexual intercourse with a girl between 13 and 16: • 5 years • Sexual intercourse with a girl < 13: • life imprisonment • Sexual intercourse with a mentally incapacitated person: • 10 years

  6. Would you report to police?

  7. Reporting to police • If >16 years • Should be encouraged to report the case to pollice • As evidence needs to be gathered as soon as possible • Reasons of not reporting should be sought, but avoid being pushy

  8. Reporting to Police • If the victim is a minor and not accompanied by parents, the parents should be notified. • The A&E doctor should ask for their consents to involve medical social workers and should persuade them to report to the Police.

  9. Reporting to Police • For minor patient, • If the sexual offence is a serious one, e.g. rape or sexual intercourse with a girl under 13, the A&E doctor can as a last resort report the case to the Police when all attempts at persuasion fail. • If the sexual offence is not a serious one, the A&E doctor does not have to report to the Police if the victim and the parents do not want to

  10. Reporting to Police • Mentally incapacitated Adults • “Notes on reporting to the Police for incident involving a MIP” of Procedural Guide for Social Workers on the Handling of Mentally Incapacitated Adults Arising from the New Provisions in Criminal Procedure (Amendment) Ordinance 1995 should apply. • Consent from legal guardian

  11. What would be your management? • Carry out initial assessment of the victim’s medical condition and provide immediate treatment • The perineum can still be examined by A&E doctor for life-threatening injuries • Otherwise, leave it to forensic pathologist The role of medical doctor is to examine and treat the victim. We are not detectives and should leave the collection of such evidence to the forensic experts.

  12. History taking • Be tactful and sensitive • Allow time for patient to tell the story • Embarrassing questions needed to be asked • Subsequent after-care measures usually based on history. • Presence of nurse coordinator

  13. What is important in the history? • The Events • O&G history: • parity, LMP, contraception, • sexual intercourse within 72 hr • drug history (substance of abuse, alcohol) • past medical history esp. recent surgery/injury around anogenital region

  14. Event • When • Number of assailants • Physical Environment • Restraint used • Acts committed • Penetration/Ejaculation/?Condom/oral/anal sex • Loss of Consciousness

  15. After the Event • Wiped and washed • bathed • Douched (French for “wash” or “soak”) • vomited • change clothes • brushed teeth • defecated Why do you concern about these details?

  16. Patient history • She was brought to a party by a recently known female friends • Had drunk some alcohol but did not take any drugs • Lost of memory afterwards • Woke up in friend’s home • mild discomfort over the external genitalia • had not changed clothes or bathed yet • past health good; deny habitual drug use; • LMP: 2 weeks ago, regular

  17. What would you look for in Physical Examination? • General appearance • estimate age of teenagers • Clothes • External injuries • e.g. face, lips, medial thigh, perineum • lacerations • bruises (color) • pattern of abrasions The name of the registered nurse present at the examination & the name of the policewoman if she was also present at the examination should be documented. Proper documentation is very important because these may become evidence in court proceedings

  18. Pelvic exam • Usually done by forensic pathologist or gynecologist except life threatening injuries • speculum should be lubricated with sterile water (not NS)

  19. Prevention of pregnancy How do you advise the patient? What ttherapiesare available? What Is thetime of essence?

  20. Emergency Contraception • Risk of pregnancy • 2-4% in general • 20% if mid cycle • Within 72 hours • Levonorgestrel (1.5mg single dose/750microgram q12hx2) • not 100% • Within 5 days • IUCD • failure rate < 1% Make sure patient is not pregnant first!

  21. Yuzpe method • Eugynon/Duoluton/Ovral tab 2 q12H x 2 • Lower efficacy and more side effects

  22. Prevention of venereal disease What kind of sexual transmitted diseases(STD) are more common? Do you suggest prophylactic treatment?

  23. Tests for STD • Cultures for:- • Gonococcus • Chlamydia • Trichomonas • Serum for:- • Hep B • HIV • Syphilis Day 1 and 2 week Day 1, 6 wk, 3 and 6 mth

  24. CDC 2010 • Regimen recommended by CDC • Guidelines for Treatment of Sexually Transmitted Disease (CDC MMWR 2010) • Ceftriaxone (Rocephin) 250 mg IMI; PLUS • Metronidazole 2 g orally in single dose; PLUS • Azithromycin(Zithromax) 1gm PO; OR Doxycycline (Vibramycin) 100mg PO BD for 7days http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm?s_cid=rr5912a1_w Remarks: oral cephalosporins no longer a recommended treatment for Gonococcal infection (CDC MMWR August 2012) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

  25. Patient advice • Patient should be advised to abstain from sex before prophylactic treatment is completed.

  26. Alternative approach • Alternatively, the patient can be followed up 1-2 week for examination and swabs and treated only if sexual transmitted diseases are identified. • Culture swab: • HVS, endocervical for Gonorrhea • HVS for Chlamydia (special transport medium) • HVS for Trichomonas

  27. Any worries apart from common STDs…?

  28. What is the chance of Hepatitis B tramsmission? • Semen and saliva titre of HBV 1000 to 10,000 lower than serum • Local prevalence of HBV carrier ~10.6% • Risk of transmission (3-30%) = 0.032% to 0.32% • Chance of hepatitis B virus transmitted in semen is considered to be low • If assailant is not available for test, prevention of hepatitis B transmission should be considered (needle stick protocol)

  29. What is the chance of HIV and AIDS transmission? • Estimated risk= 0.22% x 0.2% = 0.00044% Post-exposure Prophylaxis PEP What factors need to be considered?

  30. Factors to consider • The time lapsed • probably not effective when started later than 24-36 hours after exposure • optimal period to start for human not known • HIV status and risk-behaviour hx of source • Risk for HIV transmission during the incident • Risk events • (condom use, break in condom, receptive or insertive partner) • Factors that modify risks: • (vaginal or anal tears or bleeding, ulcers)

  31. Referral Centre 1) QEH Special Medical Service - Tel: 2958 6571, Urgent consultation, call 2958-8888 Pager 321; 2)  Therapeutic Prevention Clinic of Department of Health • (Integrated Treatment Centre, 8/F, Kowloon Bay Health Centre, 9 Kai Yan Street, Kowloon Bay. Tel: 2116 2929.) • A 24-hour hotline with recorded messages for health care worker is also available (2780 2211).

  32. What need to be considered on disposal? • Refer patients to crisis intervention centres • Family Planning Association • Rain Lily (Association concerning sexual violence against woman)http://www.rapecrisiscentre.org.hk/ • FU at 2wks, 6 wks • repeat physical • repeat psychological assessment • look out for STD e.g. venereal wart, herpes, trichomonas

  33. Counseling • Designated workers of Social Welfare Department (SWD) or the Crisis Centre • Clinical Psychological Service by SWD • NGOs like • The Association Concerning Sexual Violence Against Women關注婦女性暴力協會 (hotline 2375 5322) • The HK Federation of Women’s Centres香港婦女中心協會(2386 6255)

  34. Take home messages • Provide assessment and immediate treatment or hospital admission as other patient • Perineum examination for life threatening injuries should not be delayed by involvement of forensic pathologist • Professional communication with forensic pathologist when necessary • Prevention • Pregnancy, STD, HBsAg and HIV • Counseling and Support • Psychological and counseling support • Referral to Sexual violence clinic or SWD

  35. Thank You

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