Sexual Assault. What is Rape? What is Consent? Legally Speaking.. Victim Reporting Practices. Prevalence. History

Transcription

1 What is Rape? Sexual Assault J.R. Realing, MD Chief Resident Department of Emergency Medicine University of Nebraska Medical Center History Latin rapere -to take by force 2000 BC- Code of Hammurabi English Common Law the unlawful carnal knowledge of a woman by force and against her will 1970s anti-rape movement Exposure of the 2 nd rape Legally Speaking.. Any person who subjects another person to sexual penetration (a) without consent of the victim, or (b) who knew that the victim was mentally or physically incapable of resisting or appraising the nature of his or her conduct, or (c) when the actor is 19 years of age or older and the victim is less than 16 years is guilty of sexual assault Section , NE Revised Code What is Consent? protection of physical safety protection of freedom of choice age restrictions impairment incompetence submission vs. consent violence or the perceived threat of violence Prevalence Victim Reporting Practices 442 eligible ED pts 360 participants (81%) 39% (n=139) lifetime prevalence rate 70% older than 15 yrs 52% acquaintance, family member, friend 30% stranger 18% partner Feldhaus K, et al. Lifetime sexual assault prevalence rates and reporting practices in an emergency department population. Ann Emerg Med. 2000;36(1) % reported to police 43% sought medical care 25% contacted social services Stranger vs. Partner. Police 79% vs. 18%. Medical 70% vs.29%. Soc Services 30% vs. 24%. Feldhaus K, et al. Lifetime sexual assault prevalence rates and reporting practices in an emergency department population. Ann Emerg Med. 2000;36(1)

2 Your Legal Responsibility Assault History Every person engaged in the practice of medicine shall report every case in which he treats a wound or injury of violence which occurs in the commission of a criminal offense Section , NE Revised Code Who? known vs unknown, single vs multiple What happened? description of type of assault, use of force/weapon, threats of force/weapon, restraints guides PE When? corroborates PD Hx, guides PE/evidence collection Where? corroborating evidence, collection of forensic evidence Specific Acts Committed Potential Evidence Problem: detailed and thorough vs. too much info difficult subject matter (descriptions of any touching, penetration, etc.) Solution 1: Standardized H&P form with response to each question: yes, no, attempted, or unsure Solution 2: Accurate, directed H&P w/ focus on medical care Condom use/sexual dysfunction No spermatozoa may be seen s/p vasectomy Location of ejaculation Body cavity Body surface Elsewhere Use of lubrication Lower probability of injury Potential Evidence Evidence Lost Saliva transfer Biting, licking, kissing, etc. Establishes contact DNA Bitemarks? Post assault activities/hygiene that may impact evidence collection Vomiting/oral hygiene Douching/tampon use Urination/defecation Bathing Clothing change 2

3 Gynecologic History Medical History Use of birth control before the attack Last normal menstrual period Last voluntary intercourse Gravidity and parity? Recent gynecologic surgery Illnesses Current medications Allergies Tetanus immunization status Recent injury/trauma Look at the patient General description Demeanor Affect Ability to relate history to examiner/consent to sexual contact Look at the skin Neck, back, thighs, breasts, wrists, ankles Palpation Bite marks Evidence (DNA, scene-related) Semen/Wood s lamp assisted exam Fingernail scrapings Look in the mouth Facial trauma Traumatic intraoral finding Gingival contusions Frenulum trauma May be subtle Semen evaluation STD cultures Look at the genitals Anatomy and its terminology are important Perineum Foreign materials, secretions, stains/wood s lamp exam Pubic hair clippings/combings Pubic hair plucking? Traumatic physical findings 3

4 Variations in Hymens annular crescentric cribiform Look at the genitals External genitalia Foreign material, secretions, stains, etc. Traumatic physical findings Hymen Colposcopy photos/video 1% toluidine blue Look at the genitals Speculum exam Water moistened speculum, avoid gel Foreign objects Traumatic physical findings Colposcopy Sometimes There, Sometimes Not Look at the rectum and anus Traumatic physical findings Clinical evaluation for severe injury (especially if foreign body used) anoscopy if indicated swabs/slides STD culture 311 female SA victims, 75 female controls following consensual sexual intercourse SA: 63% (n=213) anogenital trauma 76% multiple sites (mean=3.1) most common sites: post fourchette, labia minora, hymen 70% posterior fourchette injuries- usually tears Slaughter L, et al. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol 1997;176:

5 Consensual Intercourse Colposcopy Control group following consensual sexual intercourse 11% (n=8) genital trauma limited to one site most commonly posterior fourchette Slaughter L, et al. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol 1997;176: adult women presenting for SA examination Colposcope 9/17 Gross visualization 1/17 Lenahan L, et al. Colposcopy in evaluation of the adult sexual assault victim. Am J Emerg Med 1998;16(2): Forensic Evaluation: Three Goals Include or exclude potential suspects Quantitate intoxication that may have invalidated lawful consent Confirm a recent sexual contact The officer is still waiting See any sperm? Basics Chain of evidence Systematic, protocol-driven Evidence Potential Suspects Removal of clothing After photos taken Place in paper bag Trace evidence from suspect/crime scene Suspect DNA from semen/blood stains Hair analysis? Bite marks? DNA profiling Fingernail scrapings Saliva Hair Blood/semen 5

6 Finding the DNA Identification of Semen Semen-specific spermatozoa p30 antigen prostate specific glycoprotein High-concentration in semen Acid phosphatase Identify semen for DNA testing Confirming Recent Sexual Contact Sperm survivability Sperm motility- average of two to three hours Presence of non-motile sperm- 24 hours in the vagina/rectum, several days in the cervical mucus DNA Profiling Ability to Give Consent? Procedure Semen/blood stains DNA extraction PCR Electrophoresis Accuracy Probability that a different individual matches same profile using nine loci: one in quintillionseptillion Quantitate intoxication that may have invalidated lawful consent EtOH Flunitrazepam (Rohypnol) Roofies, Roaches, R2s, Forget pill Gamma-hydroxybutyrate (GHB) Georgia home boy, Grievous bodily harm, Easy Lay Ketamine Special K, Super acid Flunitrazepam GHB Fast-acting benzodiazepine producing amnesia 10x more potent than diazepam Time to onset min Lasts 8-12 hours Detection urine or serum sample refrigerated or frozen Hoffman-La Roche no longer offers free screening program CNS depressant Time to onset min Dx: marked agitation with stimulation, despite deep sedation/prolonged apnea Detection Urine and serum tests available undetectable in urine after 8-12 hrs 6

7 Ketamine SA Treatment Pregnancy Chemically related to PCP Time to onset min Dx: Dissociative anesthesia Detection Serum risk of pregnancy 2-4% (multiple references) Post-coital interception Exclude pre-existing pregnancy Inhibit/disrupt ovulation Inhibit fertilization Inhibit implantation 72 hour window Sexual Assault-related Pregnancy SA Treatment Yuzpe regimen: 100ug ethinyl estradiol/1mg norgestrel vs Plan B 0.75 mg levonorgestrel po q 12 hrs x 2 Pregnancy rate 1.1% Emergency oral contraception. Amer College of Obstetricians and Gynecologists Practice Patterns 1996;2:1-8. STDs Gonnorhea Chlamydia Syphilis Trichomonas BV HIV Hepatitis B Sexually-transmitted Diseases in SA Victims 204 SA victims evaluated within 72 hrs, calculated risk of acquiring STD N gonnorheae 4.2% C. trachomatis 1.5% Trichomonas vaginallis 12.3% No cases of HIV, hep B Jenny C, et al. Sexually transmitted diseases in victims of rape. N Engl J Med 1990;322: STD Prophylaxis GC ceftriaxone 125 mg IM (B) ciprofloxacin/cefixime/ofloxacin (C) Chlamydia azithromycin 1 gm po (B) doxycycline (D) Trichomonas/BV metronidazole 2 gm po (B) trimester dependent clindamycin (B) Hepatitis B Hep B vaccine (immunoglobin not normally recommended) Sexually Transmitted Treatment Guidelines CDC 7

8 HIV? Assess probability High Unprotected anal receptive intercourse w/ HIV+/high risk assailant Moderate Unprotected vaginal intercourse w/ HIV+/high risk assailant Low Unprotected vag/anal intercourse w/ unknown HIV status from low risk population assailant HIV PEP High recommend PEP Inform patient that expected benefits outweigh risk & PEP is advisable Moderate consider PEP Inform patient and tailor decision to clinical situation and patient desires Low inform patient of PEP Inform patient of risks/benefits & advise that risks of toxicity > expected benefits HIV PEP SA Treatment Most effective within 2 hours Recommended up to 72 hrs Two or Three drug regimen Zidovudine (AZT) & Lamivudine (3TC) or (Combivir (AZT + 3TC)) +/- Indinavir or enfavirenz or abacavir Follow-up visits Detect new infection Serologic tests HIV at 6,12, and 24 weeks Recheck GC/Chlamydia Complete counseling and treatment of other STDs Hepatitis B 1-2 mos & 4-6 mos Assessment/Documentation Correlates w/ Prosecution Appropriate Findings of recent trauma Findings of recent sexual contact Consistency between history and physical findings Inappropriate Whether a rape has occurred Judgements about the use of force Judgements about consent Successful prosecution Younger victims Evidence of trauma Weapon used Charges filed Known assailant Multiple assailants Evidence of trauma Forensic evidence collected 8

9 SANE/SART Conclusions Dedicated individuals/teams High-quality patient care/evidence collection Resolves following inherent problems: Needs of the SA victim vs. constraints of ED practice Physicians performing small numbers of SA exams deficiencies in exam/evidence collection skills Patient-centered approach Directed, systematic H&P Meticulous evidence collection Clear, concise, consistent documentation Utilize SANE/SART if available 9