Download Sexual Assault

Sexual assault, Domestic violence and patient complaint handling
Sexual Assault
The Medical role
Medical care:
The primary function of the doctor who examines a person soon after a report of sexual assault is to satisfy the
medical needs of that person.
The main concerns of the victim may not be of forensic nature and the issues which will need to be addressed
include:
 Safety
 Pregnancy
 Sexually transmitted infections
In case of medical or psychiatric problem associated with the assault occurs, the treatment and stabilization of
this condition must take priority over the forensic examination.
Forensic examination:
 Not undertaken to prove or disprove whether a sexual assault has occurred
 Sexual assault is a legal finding and not a medical diagnosis
 Is an examination conducted principally to aid the investigation of a criminal/legal matter
In the setting of sexual assault, the forensic examination may provide corroborative evidence of:
 Sexual penetration
 Identity of assailant
 Place of assault
 Lack of consent – injuries to suggest same/struggle
During a forensic examination:
 Biological material may be collected to determine the potential identity of the assailant or support
alleged location/details of the assault
 Physical injuries and abnormalities are sought and documented in detail
 Association sought between the injuries and injury patterns present on the victim and the details of
the crime/assault described to the doctor.
The medical officer conducting the forensic examination:
 Should act as an independent and impartial observer
 Should perform the examination as soon as possible after the assault as occurred, usually within the
72-hr period
 Speculum (or anoscope) may not be routinely used and needs separate consenting
Victim’s needs:
The person may want:
 Information, advice or counseling only
 Medical attention and/or information without examination
o Emergency contraception/pregnancy concerns
o Issues around STIs and HIV
o Partner issues/ resuming sexual activity
 Medical examination – but not forensic examination
o Reassurance about absence of serious injuries
o Genital injury or pain
o Reassurance regarding genital health
o Management of minor injuries and medical necessities
 Medical and forensic examination
 Any of the combination of the above
 None of the above – presenting because suggested by friends/family to attend
The victim can choose to undergo the forensic examination and then decide at a later date whether and when
this information is given to the police.
Issues that may be affecting the victim include:
 Loss of control – allowing the person to regain control over herself, including the choice to undergo
certain or all or none of her investigations
 Fears and phobias – safety concerns, fear of being alone, flashbacks
 Relief – about surviving the assault
 Shame and guilt
 Physical repulsion – need to wash body and genitals repeatedly
 Depression
 Anger
 Anxiety
 Loss of sexual enjoyment
 Physical effects e.g. pain
 PTSD
To reduce psychological impact of incident:
The victim needs
 Information about options
 Restoration of control
 Belief/acceptance
The doctor should
 Provide information
 Be non-judgmental and non-directive in attitude
 Obtain consent for everything
 Avoid unnecessary physical contact
Role of counselors
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Coordinating the response to a crisis call
Obtaining basic history and determining individual needs of the person
Initiate contact with the doctor on call for medical advice, medical or forensic examination
Advocate for victim – provide information on roles of assault service, police, doctors and legal process
Longer term involvement in the ongoing well-being of the victim
Approach to medical assessment
Immediate, sensitive and comprehensive medical care, including treatment for psychological distress, can
alleviate the emotional and physical trauma of sexual assault.
Sensitive medical care can:
 Reduce acute psychological trauma and its after effects
 Support existing and emerging coping skills
 Facilitate resumption of normal functioning
Examiner’s approach
 Introduce yourself and explain your role
 Discuss options of medical care
 Inquire about need for friend, relative or counselor to be present
 Supportive and non-judgmental mannerism
 Provide privacy during all aspects of care
 Conduct examination in comfortable environment without delay
 Explain reasons for delay if any
 Explain needs for intimate and specific questioning
During examination
 Explain throughout of what is being done and why
 Inform patient of reassuring findings as the examination proceeds
 Use lay terms to describe parts of body or sexual acts
 Encourage victim to express feelings and acknowledge them
 Acknowledge the traumatic nature of assault
 Reassure that the victim is in control and examination will cease whenever he/she wishes it to.
After the examination
 Explain clearly the findings of the examination
 Check that follow-up care for injuries, STIs and pregnancy have been arranged and patient
understands instructions given
 Provide age-appropriate information regarding possible physical/psychological sequelae and
resources available to victim to tackle them.
Describing and interpreting injuries
Wounds may be defined as tissue damage caused by trauma.
Wound description:
The following features should be addressed in description of any wound: 4 S 4 C
 Site – recorded in relation to an anatomical landmark
 Size – measured
 Shape – use easily identifiable shapes
 Surrounds – features of surrounding tissues
 Colour – beware of lighting and skin colour
 Contours – reference to margins and edges
 Contents – presence of foreign debris
 Changes – presence of inflammation or healing
Classification of injuries
Bruise
Bruise is a contusion, hematoma, an area of hemorrhage beneath the skin’s surface. Issues relating to
appearances of bruises include:
 Distribution – gravity, tissue planes
 Medical conditions – bleeding disorders, alcoholism
 Medications – steroids, anticoagulants
 Age – infants and elderly more susceptible
 Site – skin thickness and vascularity
 Treatment – ice, drainage
 Ageing – development, colour
Colour changes in bruise are not a reliable indicator of age of bruise – only reliable finding is yellow
discolouration does not occur before 18hrs.
Abrasion
Abrasion involves disruption of the outer layers of the skin, “scratches and scrapes”.
Features include:
 Produced by combination of pressure and movement
 Represents site of contact with implement
 May identify the direction of injurious force
Types include:
 Scratch – linear e.g. fingernails
 Scrape – shearing of skin layers e.g. gravel rash
 Patterned – characteristic of implement used e.g. tyre tread
Laceration
Laceration involves splitting or tearing of the full thickness of skin layers produced by blunt force.
Features include:
 Ragged, abraded, inverted or bruised margins
 Profuse blood loss
 Foreign material within wound
 Fibrous bridging strands across the wound
Incisions (incised wounds)
Incised wounds involve wounds with regular edges, produce by sharp objects, usually longer than deep.
Features include:
 Often moderately deep structures involved
 Bleeding may be profuse
 Minimal damage to surrounding structures
Stab wounds
Stab wounds involve a wound whose depth is greater than its length, usually caused by a sharp object.
Features include:
 Site and depth dictate damage to deeper structures
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Visible bleeding often minimal
Appearances vary according to weapon
Missile wounds (including bullets)
Specialized injury requiring ballistic knowledge for description.
STI/ HIV prophylaxis following sexual assault
The risk of acquisition of a STI following a sexual assault will depend upon:
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The prevalence of STI/HIV in the community
The nature of sexual assault
Trauma and presence of other STIs – increases likelihood
Epidemiology of STIs/HIV in the community of the assailant
Risk behaviours undertaken by the assailant e.g. unsafe injecting, risk behavior for HIV/ hepatitis B
The information regarding the assailant may not be always available and medical assessment and decisions
regarding prophylaxis must be made with little information.
The following are suggested guidelines if STI prophylaxis is to be provided:
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Consider: chlamydia, gonorrhea, trichomonas and syphilis
Consider hepatitis B immunization
o Single dose of 1g Azithromycin orally covers chlamydia, gonorrhea and syphilis
o Adverse reactions – 30% nausea, 10-15% diarrhea and headache 1%, no teratogenic effects
known
o Reasonable to offer above if penetration has occurred.
Chlamydia Trachomatis
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Common STI – especially in younger population
Infects cervix, urethra, ano-rectal canal and pharyngeal infection possible.
Important long-term implications – PID, infertility and chronic abdominal pain
Rectal infection in gay men increasingly diagnosed
Usually asymptomatic – may present with vaginal/urethral discharge, dysuria, pelvic pain, bleeding or
pain during sex and inter-menstrual bleeding
Incubation period 10days
Diagnosis by first void urine specimen PCR, endocervical swab PCR and rectal swab PCR
o Treatment
 Uncomplicated – 1g Azithromycin
 PID – doxycycline 100mg BD and metronidazole 400mg BD for 10-14days
Neisseria Gonorrhoea
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Uncommon – more prevalent in northern Australia ATSI people and developing countries
Infects cervix, urethra, ano-rectal canal and pharynx – disseminated infection can occur
Important implications of PID and infertility
80% women asymptomatic – discharge, pelvic pain, bleeding and dyspareunia
Incubation 2-5 days
Treatment – IM ceftriaxone 250mg
Consider higher prevalence in gay men
Trichomonas vaginalis
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Uncommon – more prevalent among ATSI women, northern Australia and developing nations
Protozoal organism – infects urethra and vagina
May persist in women for long periods, while shorter in men
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Asymptomatic in women – discharge, offensive vaginal odor, vaginal or vulval inflammation and
irritation
Diagnosed by high vaginal swab – gram stain of wet swab or culture
PCR sometimes available
Treatment – 2g of tinidazole or metronidazole
Syphilis
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Systemic infection – painless ulcer-chancre
Incubation – 9-90days
Secondary stage represents systemic dissemination – asymptomatic, generalized rash, malaise or
lymphadenopathy
30% of untreated cases develop tertiary syphilis
Treatment – remains sensitive to penicillin and different regimen available
Hepatitis B immunization
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The first dose of hepatitis B immunization shortly after exposure is likely to give 90% protection
against infection. Giving immunoglobulin with vaccine adds another 5% more protection
Very safe and effective and no evidence of adverse effect on pregnancy
Should be given to patients with sexual assault if
o Not immunized and
o Consenting to same
Schedule for immunization
o 0- 1st dose
o 1 month – 2nd dose
o 6months – 3rd dose
o Double dose for immunosuppressed
o Repeat doses can be given if serology reveals inadequate protection (but not routinely
recommended)
Antibody level >10mIU/ml 4-8 weeks after course indicates seroconversion
About 5% of people do not respond to immunization. Increasing age, obesity and immunosuppression
increase this risk. Injection must be IM in deltoid region and not frozen for best efficacy
Patients with immunizations previously with negative antibody level can receive single dose and then
tested in 2 weeks for brisk anamnestic antibody response
High-risk patients who do not respond can get up to 3 courses and up to 50% of these will eventually
sero-convert, rest will need immunoglobulin in event of exposure
Hepatitis B
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Highly contagious, approximately 100times more infective than HIV
Frequently asymptomatic. 5-10% of adults and 90% infants will then become carriers
Chronic carriers eventually develop cirrhosis, liver failure and hepatocellular carcinoma
Incubation period 40-160days
About <0.5% prevalence in general Australian population. More prevalent in
o Homosexual/bisexual men
o International sex workers
o IVDU
o Male prisoners
o ATSI
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Institutionalized
Ethnic groups from endemic areas
 Asia and pacific islands
 Africa
 Latin America
 Middle east and
 Mediterranean
Victims from high prevalence groups should be first screened – anti-Hbc → is positive test for HbsAg
and anti-Hbs
Victims from non-prevalent groups should receive immunization as screening is not always cost
effective.
Hepatitis A immunization
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To be considered in oral-anal contact and twinrix (hep A and B) vaccine useful to cover both infections
HIV prophylaxis – Post exposure prophylaxis (PEP)
Anti-retroviral drugs are given for 4 weeks with the aim of preventing HIV infection following percutaneous or
mucosal contact with infected blood or body secretions. These drugs have potentially serious side effects
including hepatic toxicity.
Evidence for PEP
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Anti-retroviral drugs commenced within 24hrs may abort the infection by inhibiting local replication
of HIV and allowing the immune defense mechanisms to eradicate the infection
PEP has been effective following inadvertent blood transfusion of HIV positive blood
Animal studies have shown greater efficacy if treatment started within 24hrs
Health care workers occupationally exposed to HIV (698 HCW) treated with PEP showed 79%
reduction in risk of infection
Perinatal transmission has been reduced by 69% when AZT is given to pregnant women
Risk calculations
Seroprevalence for unknown heterosexual Australian source calculated at 1/1000 (0.1%), 1% for IVDU and 10%
for high prevalence country source (HPC).
Homosexual men exposure
Exposure
Receptive anal intercourse
Known + HIV source
1/120 x 1 = 1/120 – 3 drugs
recommended
1/1000 x 1 = 1/1000 – 3drugs
recommended
Not measurable – 2drugs
recommended if oral mucosa
injury
Unknown HIV + status
1/120 x local seroprevalence – 2 or
3 drugs recommended
1/1000 x local seroprevalence –
consider 2drugs or none
Not measurable – not
recommended
Exposure
Receptive anal intercourse
Known HIV + source
1/120 x 1 = 1/120 – 3drugs
recommended
Receptive vaginal, insertive anal
or insertive vaginal intercourse
1/1000 3drugs recommended
Receptive or insertive oral
intercourse
Not measurable risk – 2drugs
recommended if mucosal trauma
Unknown HIV + status
1/120 x 1/1000 = 1/120000 not
recommended
1/120 x 1/100 = 1/12000 (IVDU)
2drugs recommended
1/120 x 1/10 = 1/1200 (HPC)
3drugs recommended
1/1000 x 1/1000 = 1/1000000 not
recommended
1/1000 x 1/100 = 1/100000 not
recommended
1/1000 x 1/10 = 1/10000 2drugs
recommended
Not recommended
Insertive anal intercourse
Receptive or insertive oral
intercourse
Heterosexual exposure
If HIV prophylaxis is being considered urgent discussion with the on-call Infectious diseases consultant should
be sought.
HIV seroprevalence in Australian and overseas population
Community group
Homosexual men in Australia
Sydney
Melbourne
Brisbane
Perth
Injecting drug users
Homosexual
All others
HIV seroprevalence
14.2%
9.1%
6.0%
4.9%
17%
1%
Heterosexuals
Blood donors
STI clinic attendees
Commercial sex workers
Australian born
HIV seroprevalence in overseas regions
Carribean
Sub-saharan Africa
All others
<0.0005
<0.2
0.1
1.6%
7.2%
0.5 – 1.0%
Recommendation for PEP
Drug regimen
Recommend 3 drugs
Recommend 2 drugs
Consider 2 drugs
PEP not recommended
Risk calculation
>1/1000 risk
>1/10000 risk
>1/15000 risk
<1/15000 risk
Time to initiation
Patients presenting for NPEP should be triaged as a priority. Early initiation of NPEP is strongly urged. NPEP
should not be offered more than 72hrs after exposure.
Duration of treatment
28-day course of NPEP is recommended. Proactive approach to managing side effects will assist patients in
adhering with treatment.
Follow up
HIV antibody testing is conducted at baseline, at 4-6 weeks and 3 and 6 month after exposure.
Possible regimens
Two-drug regimen
 2 nucleoside reverse transcriptase inhibitors (NRTIs)
Three drug regimen
 2NRTIs + protease inhibitor or non-nucleoside reverse transcriptase inhibitor (NNRTI)
 2NRTIs + a nucleotide RTI
Drugs not to use for NPEP
 Nevirapine (NNRTI) contraindicated for use in NPEP
 Combination of d4T and ddi not recommended and c/I in pregnancy
 Efavirenz (NNRTI) C/I in pregnancy
Exposure and transmission risk/exposure
Type of exposure with known HIV + source
Receptive anal intercourse
Use of contaminated injecting equipment
Occupational needle stick injury
Receptive vaginal intercourse
Insertive anal or vaginal intercourse
All other sexual contacts
Community needle-stick injury
Estimated risk for HIV transmission
1/120
1/150
1/333
1/1000
1/1000
Not measurable
Not measurable
Emergency contraception following sexual assault
Emergency contraception should be offered to all women at risk of pregnancy following sexual assault, even if
the perceived risk is small.
In case the victim is unsure about pregnancy status at presentation, a urine β-HCG should be conducted. Urine
β-HCG is usually positive 10 days post conception. Emergency contraception has not been shown to disrupt or
be teratogenic to established pregnancy.
Oral emergency contraception
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Can be taken up to 5 days after unprotected sex – earlier it is prescribed, the greater likelihood of
preventing pregnancy.
Emergency contraception probably works by
o Inhibiting or disrupting ovulation
o Interfering with fertilization and/or embryo transport
o Inhibiting implantation in the endometrium
o It is not a abortifacient and thus does not disrupt implanted pregnancy
Most commonly prescribed regimen –
o Levonorgestrol 750µg orally two doses 12hrs apart PO or
o Single dose 1.5mg levonorgestrol PO
o Equally effective in both forms
o Nausea, vomiting and breast tenderness less likely with progesterone only preparations
WHO guidelines state there are no contraindications to emergency contraception use.
There are limitations to the emergency contraception and victim should undergo pregnancy test if
next menstrual period is delayed.
IUCD
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Emergency contraception IUCD can be inserted up to 5 days after unprotected intercourse.
Failure rate of approximately 1%.
IUCD can be left in place for ongoing contraception or removed after next menstrual period
Risks of complications including PID should be discussed with patient.
Domestic violence
ACEM defines DV as abuse of power between immediate and extended family members, both adult and
children, close relatives, de facto or separated spouses and people in same sex relationships.
DV involves such abuses between people who have been or are having an intimate relationship.
Abuse can be physical, verbal, psychological, economic or social and can include threats to the injured party,
those they love, pets or property.
 Physical abuse – causing pain and injury; denial of sleep, warmth or nutrition; denial of needed
medical care; sexual assault; violence to property or animals; disablement; and murder;
 Verbal abuse – in private or public, designed to humiliate, degrade, demean, intimidate, subjugate,
including threat of physical violence;
 Economic abuse – including deprivation of basic necessities, seizure of income or assets,
unreasonable denial of the means necessary for participation in social life;
 Social abuse – through isolation, control of all social activity, deprivation of liberty, or the deliberate
creation of unreasonable dependence.
Epidemiology of domestic violence
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Women eight times more likely to be victims than males
Third of all assaults on women are by partners
1.3% of women and 0.14% men admitted to ED are there as a result of partner-inflicted injury
Each year 20000 women in Australia seek shelter in women’s refuge and take out protection orders
I WA, 1.6/100000 homicides, 129.2/100000 hospital admissions, 183.5/100000 recorded crime and
248.1/100000 restraining orders.
19.3 – 25% of women have lifetime risk of DV
Presentations of DV in practice
Barriers to disclosure include:
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Fear
Denial and disbelief
Emotional bonds to their partner
Commitment to marriage
Hope for change
Staying for sake of children
‘normalisation of violence’
Social isolation
Depression, stress
Fear of not being believed
Potential clinical indicators of DV
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Psychological
o Insomnia
o Depression
o Suicidal ideation
o Anxiety symptoms and panic disorder
o Somatoform disorder
o PTSD
o Eating disorders
o Drug and alcohol abuse
Physical
o Obvious multiple injuries to head, neck or multiple areas
o Bruises in different stages of healing
o Sexual assault
o STIs
o Chronic pelvic or abdominal pain
o Chronic headaches
o Chronic back pain
o Numbness and tingling from injuries
o Lethargy
Pregnancy and childbirth
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Miscarriages
Unwanted pregnancy
APH
Lack of prenatal care
LBW infant
Role as a health professional
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Form a link not only in treatment of immediate symptoms, but also in arranging follow up support
and specialized counseling available from service providers outside the health system.
Referring women facing DV for support with accessing the family court system, accommodation and
financial support.
Enabling an effective referral system plays an important part in empowering those affected to break
the cycle of violence in their lives
Role for emergency departments
Some facts about DV that make the role of ED important include:
 Victims consult doctors and attend emergency services more often than consult any other group of
professionals
 Majority of victims seek medical assistance at least once
 Almost a quarter of injuries suffered by women presenting to hospitals are a result of DV.
Principles of healthcare role in FDV – suggested actions
 Detection
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Assessment
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Patients’ current and future safety regarded as paramount in cases of FDV
 FDV patients should not be discharged without written referral being made to
hospital social worker services
 Discharge plans to incorporate goals that promote future safety of patients
 Create guidelines for compulsory information to family and children services if there
are concerns about children’s safety.
Referrals
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Hospitals will undertake and coordinate supportive holistic assessment of patients suffering
FDV. Patient’s safety, dignity and privacy regarded as paramount
 Admission and triage to identify victims of FDV
 Clear guidelines to exclude perpetrators during examination of patients
 Provide private interview room for assessment
 Where relevant and practical, provide same-sex staff members for assessment
 Make relevant referrals to psychological assessment and other health professionals
 Develop and distribute checklist resources to nursing and medical staff
Patient safety
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Hospitals can play an important role in detecting and identifying victims of FDV
 Practical steps to ensure all staff are familiar with all the signs and symptoms of FDV
 In-depth screening of patients detected with warning signs
Promotion of multi-disciplinary intervention and appropriate inter-agency cooperation
enhances patient outcomes
 Develop multi-disciplinary approach to care of victims of FDV
 Provide patients with relevant information to access the services on offer
 Patients encouraged to receive follow-up support with social work after discharge
 Patients given contact details for DV hotline/helpline on discharge
 Hospitals to maintain local perpetrator programs for appropriate referral purposes
Confidentiality
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Patient’s privacy and confidentiality needs to be maintained. Their current and future safety
will be regarded as paramount, thus the duty of confidentiality will be balanced against the
notion of duty of care
 Access to patient information restricted to authorized staff
 Patients will be asked to sign consent prior to release of information
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Reporting to Police
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Hospital services to ensure that the identified admissions relating to FDV are accurately
reported in data collection systems
Professional development
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Recognize and respond to the diverse nature of the client population
 Knowledge of special populations at higher risk for FDV
 Aboriginal families
 Women from culturally and linguistically diverse backgrounds
 Pregnant women
 Rural women
 Elder abuse and protection issues
 People with disabilities
 People with mental illness
 Same sex relationships
 Children
Data collection
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Maintenance of records are essential for the long term reduction of risk of FDV
 Medical practitioners to record all information obtained during assessment
 Relevant photographic evidence, body maps/schematic drawings used where
relevant
Accessibility of services to a diverse population
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FDV is a crime. Police have an important role in reducing same.
 Patient consent will be obtained before reporting to police
 In case of life-threatening FDV
 Confer with senior medical staff
 Clarify with medical defense association
 Document patient’s refusal to sign consent
 Document attempted methods to persuade patient
 In case of consent received, medical staff will allow police services to take
necessary forensic evidence
 In case of inability to provide consent by patient, medical staff to make
considered decision
Patient records
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In life-threatening FDV, staff will make considered professional decision about
relevance of notifying police authorities
Patient will be informed about right to access medical records
Hospital management to support staff to gain necessary skills in identification and
intervention of FDV
Staff safety
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Hospital management to promote safe working environment for staff treating/assisting FDV
victims
 Debriefing and supervision support
 Risk management strategies e.g.
 Use of security guards
 Security screen alert systems
 Duress alarms
 Police role
 First name only on name badges
 Safe car parks and
 Safe commuting for shift workers
Patient complaint handling
GUIDELINES TO ASSIST YOU IN RESPONDING TO A COMPLAINT
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On receipt of complaint read it thoroughly
Isolate the issues that are relevant to you and your Unit, Department and / or ward
a)
b)
c)
Investigate the details and circumstances surrounding the occurrence of these events.
Talk with your staff involved
Receive action statements from those staff involved in the complaint.
WRITING A RESPONSE FOR THE PATIENT REPRESENTATIVE
First remember that your response is used to respond to the complainant. Only details that you have
submitted can be utilized, your comments need to reflect an understanding and empathy with the
perceptions of the complainant.
Apologise for the distress and pain as perceived by the complainant
An apology is always most powerful and can help in most situations
a)
Address and describe the circumstances of events contained in the complaint.
b)
Acknowledge areas that obviously need further assessment, improvement and/or change.
c)
Describe changes that have been made or will be made in the future to process that has been
complained about.
d)
Explain any ongoing service improvements that will be made for staff on an ongoing basis.
e)
Explain any disciplinary process that may take place with a staff member as a direct result of the
complaint.
f)
In some Departments and/or Units a joint reply between senior primary health managers may be
appropriate.