The MEDICAL MANAGMENT of SEXUAL ABUSE

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CONTENTS

DOCTORS FOR SEXUAL ABUSE
FOREWORD
PREFACE
INTRODUCTION THE ROLE OF THE DOCTOR IN SEXUAL ABUSE
1. THERAPEUTIC:
2. FORENSIC:

SECTION 1: THERAPEUTIC ROLE of the DOCTOR
1.1 RECOGNITION AND TREATMENT OF SERIOUS INJURY IN VICTIMS
of SEXUAL ASSAULT
1.1.1 PHYSICAL INJURY:
11.1.2 PSYCHOLOGICAL TRAUMA
(a) The Rape Trauma Syndrome
(b) Crisis Intervention Theory
(c) Principles of Crisis Intervention
1.2 SUPPORTIVE APPROACH TO PATIENTS
1.2.1 EXAMINER'S APPROACH TO PATIENT
1.2.2 PATIENT SUPPORT PERSON
1.2.3 WHEN NO PATIENT SUPPORT PERSON IS AVAILABLE
1.3 DECIDING TO PURSUE A POLICE COMPLAINT
1.4 GENDER OF EXAMINING DOCTOR
1.5 REQUIREMENTS FOR PREMISES FOR MEDICAL EXAMINATIONS
1.6 SEXUAL ABUSE AND DIFFERENT CULTURAL PERSPECTIVES
1.7 SEXUAL ABUSE AND DISABILITY
1.8 SEXUAL ABUSE AND PSYCHIATRIC DISORDER
1.9 MALE VICTIMS OF SEXUAL ABUSE
1.10 PREVENTION OF PREGNANCY
1.10.1 LEGAL RESPONSIBILITY
1.10.2 TREATMENT REGIMEN
1.11 ADULT SURVIVORS OF CHILDHOOD OR PREVIOUSLY UNDISCLOSED SEXUAL ABUSE
1.12 COUNSELLING THROUGH TO RECOVERY
1.13 THE VULNERABLE VICTIM: FACTORS WHICH MAKE A PERSON MORE VULNERABLE TO RAPE
1.14 MEMORY AND SEXUAL ABUSE
SECTION 1 REFERENCES

SECTION 2: FORENSIC NOTES
2.1 THE FORENSIC ROLE OF THE DOCTOR
2.2 THE PATHOLOGY OF INJURIES
2.2.1 GENERAL PRINCIPLES -
A. Mechanical Forces
B. Factors Governing the Nature and Extent of Wounds
C. Practical application
D. Recognition of the type of injury and interpretation of the causation
E. Wounds examination
F. Type of lnjury
Abrasions
Bruises
Lacerated Wounds
Incised Wounds
Stab or puncture wounds
Gunshot wounds
The Age of a Wound in the Living
The Aging of Scars
2.22 SEXUAL VIOLENCE AND INJURIES
Oral intercourse
Bites
Intercrural intercourse
Genital Injury to the Female
Penile penetration of the vagina
Anal Intercourse
Signs of Restraint
Signs of Direct Violence
Asphyxia
Murder in the Course of Rape
Factitious Injury
Necrophilia
Bestiality
Sadism & Masochism
Self-Inflicted Sexual Injury
2.3 TIME LIMITS FOR THE DETECTION OF SPERMATOZOA AND SEMINAL FLUID
2.4 THE MEDICAL EXAMINATION KIT AND THE FORENSIC LABORATORY
2.4.1 PURPOSE OF KIT
2.4.2 MANUFACTURE AND SUPPLY
2.4.3 CONTENTS OF THE KIT
2.4.4 THE TOXICOLOGY KIT
2.4.5 CHARACTERISATION OF BODY FLUIDS AND TISSUES
The DNA Profiling Technique
Statistics
PCR and HLA DQA.1 Testing
REFERENCES
2.5 EQUIPMENT IN THE SEXUAL ASSAULT EXAMINATION ROOM
SECTION 3: FORENSIC MEDICAL EXAMINATION OF ADULT SEXUAL ASSAULT COMPLAINANT
3.1 INTRODUCTION
3.2 OBTAIN IDENTIFYING INFORMATION ABOUT THE PATIENT
3.3 OBTAIN CONSENT TO MEDICAL EXAMINATION:
3A HISTORY OF THE ASSAULT
3.5 CONDUCT A GENERAL PHYSICAL EXAMINATION AND RECORD FINDINGS COLLECT AND PRESERVE EVIDENCE FOR EVIDENTIAL EXAMINATION
3.6 ARRANGEMENTS FOR CONTINUING CARE
3.7 SAFETY OF THE PATIENT
3.8 CLAIM FOR MEDICAL EXPENSES
SECTION 4: CHILD SEXUAL ABUSE
4.1 ESSENTIAL INFORMATION
4.1.1 DEFINITION
4.12 CHILDHOOD SEXUALITY AND SEXUAL BEHAVIOUR
4.1.3 EPIDEMIOLOGY
4.1.4 NATURE OF THE PROBLEM
4.1.5 FORMS OF ABUSE
4.1.6 PERPETRATORS
4.1.7 THE VICTIMS
4.1.8 PSYCHOLOGICAL CONSEQUENCES
4.1.9 PROBLEMS AND PITFALLS
4.2 INDICATORS OF CHILD SEXUAL ABUSE
4.2.1 HISTORICAL INDICATORS
4.2.2 PHYSICAL INDICATORS
4.2.3 BEHAVIOURAL INDICATORS
4.3 VALIDATION: FUNDAMENTAL ISSUES
4.4 THE MEDICAL EXAMINATION:
4.4.1 AIMS OF THE EXAMINATION
4.4.2 SETTING
4.4.3 EXAMINER
4.4.4 TIMING
4.4.5 CONSENT
4.5 THE MEDICAL HISTORY
4.5.1 PURPOSE
4.5.2 THE CHILD'S NEEDS
4.5.3 TALKING ABOUT THE ABUSE
4.5.4 ISSUES FOR DIFFERENT AGES AND BOYS
4.5.5 THE NON-DISCLOSING CHILD
4.6 THE PHYSICAL EXAMINATION
4.6.1 ESSENTIAL POINTS
(1) Privacy and Support
(2) Consent, Participation and Control
(3) Context
(4) Examination under General Anaesthesia (E.U.A.)
(5) Extra-genital trauma
90
4.6.2. THE GENITAL AND ANAL EXAMINATION
A. POSITIONS
B. EQUIPMENT
C. ANAL INSPECTION
D. SAMPLE COLLECTION
DIAGRAM OF NORMAL GENITAL ANATOMY OF THE CHILD
4.6.3 FEMALE GENITALIA
A. TERMINOLOGY
B. DEVELOPMENTAL CHANGES
C. NORMAL ANATOMY
D. ABNORMAL FINDINGS
E DIFFERENTIAL DIAGNOSES
4.6.4 MALE GENITALIA
A. DEVELOPMENT
B. NORMAL ANATOMY
C. ABNORMAL FINDINGS
D. DIFFERENTIAL DIAGNOSES
4.6.5 ANUS
A. NORMAL ANATOMY
B. ABNORMAL FINDINGS
C. DIFFERENTIAL DIAGNOSES
4.7 THE MEDICAL RECORD
A. FORMAT
B. SUMMARY OF FINDINGS
C. CONCLUSION OF REPORT
D. DISTRIBUTION OF REPORT
4.8 CONCLUSION and FOLLOW-UP
4.9 PREVENTION
4.9.1 PROTECTION
4.9.2 PREVENTION
4.10 GUIDELINES FOR THE MANAGEMENT OF ADOLESCENT SEXUAL ABUSE
4.10.1 General Statement
4.10.2 GUIDELINES FOR SERVICE PROVISION
4.10.3 DISCUSSION
SECTION 4 REFERENCES:
 
SECTION 5: SEXUALLY TRANSMITTED DISEASES
5.1. INTRODUCTION
5.1.1 RELEVANCE OF SEXUALLY TRANSMITTED DISEASE IN MEDICAL MANAGEMENT OF SEXUAL ABUSE
5.1.2 CURRENT SITUATION IN NEW ZEALAND
5.1.3 INCIDENCE OF STDs IN SEXUALLY ABUSED PATIENTS
5.1.4 RISK OF ACQUIRING AN STD
5.1.5 FUTURE DEVELOPMENTS
5.2 COMMON SEXUALLY TRANSMITTED DISEASES
- organisms - diagnostic and forensic relevance - interpretation of results
A. GONORRHOEA
B. CHLAMYDIA TRACHOMATIS D-K
C. TRICHOMONAS INFECTIONS
D. SYPHILIS
E. HUMAN PAPILLOMA VIRUS INFECTIONS (Genital Warts)
F. VULVOVAGINAL CANDIDIASIS
G. BACTERIAL VAGINOSIS
H. GENITAL HERPES INFECTION
I. HUMAN IMMUNODEFICIENCY VIRUSES
J. GENITAL MYCOPLASMAS
K. MOLLUSCUM CONTAGIOSUM
L. PEDICULOSIS PUBIS
M. HEPATITIS B
N. HEPATITIS C VIRUS INFECTION
5.3 SEXUALLY TRANSMITTED DISEASE IN CHILDREN
5.3.1 Anatomy and Physiology
5.3.2 Evaluation of Vulvo-Vaginitis
5.3.3 STD Screening in Children
5.3.4 ST 154
5.3.5 TREATMENT OF STDs in CHILDREN
5.3.6 FOLLOW-UP CARE OF CHILDREN
5.4 SEXUALLY TRANSMITTED DISEASES IN ADULTS and ADOLESCENTS
5.4.1 STD SCREENING (following recent sexual assault)
5.4.2 PROPHYLAXIS AFTER ACUTE SEXUAL ASSAULT
5.4.3 FOLLOW-UP CARE
5.4.4 TREATMENT FOR COMMON STD's.
5.5 S.T.D. SCREENING OF ALLEGED OFFENDERS
5.6 NOTIFICATION REQUIREMENTS FOR STDS.
5.7 CONTACT TRACING ISSUES
5.8 PRACTICAL ASPECTS OF STD SAMPLING
COLLECTION AND HANDLING OF SPECIMENS
5.9 CHAIN OF EVIDENCE
5.10 ORGANISM TYPING
REFERENCES:
BIBLIOGRAPHY: CHILD SEXUAL ABUSE and SEXUALLY TRANSMITTED DISEASES

SECTION 6. LEGAL SECTION
6.1 INTRODUCTION
6.2 DOCTORS ARE EXPERT WITNESSES - WHAT DOES THAT MEAN?
6.3 ASPECTS OF INTERVIEW OR EXAMINATION
6.4 GENERAL COMMENTS ON COURTROOM PROCEDURE AND PROTOCOL
6.5 GIVING YOUR EVIDENCE - THE STATUS OF WRITTEN STATEMENTS - EVIDENCE-IN-CHIEF AND CROSS-EXAMINATION
6.6 COURTS INVOLVED
6.7 DIFFERENT EVIDENTIAL REQUIREMENTS
6.8 CHILDREN YOUNG PERSONS AND THEIR FAMILIES ACT 1989
6.9 EVIDENCE IN CHILD ABUSE CASES - MAJOR ISSUES:
1. Mode of Evidence
2. Nature of Evidence Given by Expert.
6.10 DISCLOSURE OF COMMUNICATIONS MADE TO A DOCTOR
6.11 CONSENT TO MEDICAL EXAMINATION
6.12 RELEVANT SECTIONS OF THE STATUTES:
1. Sexual Crimes
2. Children, Young Persons and their Families Act (1989)
SECTION 7: POLICE PERSPECTIVE
7.1.1 GENERAL OBSERVATIONS
7.12 ORGANISATION OF AN INVESTIGATION
7.1.3 LEGAL CONSIDERATIONS
7.1.4 SEXUAL CRIMES
7.1.5 MEDICAL ADVISERS
7.2 POLICE INVESTIGATION PROCESS
7.2.1 INITIAL COMPLAINT
7.2.2 MEDICAL EXAMINATION
7.3 POLICE - DOCTOR INTERFACE
7.3.1 IDENTIFY THE OFFICER IN CHARGE OF THE CASE
7.3.2 SUPPLY OF MEDICAL EXAMINATION KIT
7.3.3 BRIEFING BY POLICE
7.3.4 SPECIAL INSTRUCTIONS
7.3.5 INFORMATION ON THE OFFENDER
7.3.6 CONSENT
7.3.7 CLOTHING
7.3.8 PHOTOGRAPHS
7.3.9 CHAIN OF EVIDENCE
7.3.10 DE-BRIEFING
7.3.11 PAYMENT FOR MEDICAL EXAMINATION
7.4 COMPLAINANT INTERVIEW
7.4.1 GENERAL CONSIDERATIONS
7.4.2 INTERVIEWER
7.4.3 METHOD OF RECORDING COMPLAINANTS STATEMENTS
7.4.4 SIMULTANEOUS INQUIRIES
7.5 OFFENDER
7.6 CHILDREN AND YOUNG PERSONS
7.6.1 REPORTING THE ABUSE
7.6.2 INVESTIGATION OF THE ABUSE
7.6.3 CARE AND PROTECTION PROCESS
7.6.4 CARE AND PROTECTION RESOURCE PANEL
7.7 PROSECUTIONS AND MEDICAL EXPERT WITNESSES
7.7.1 Responsibility of Police for laying charges
7.7.2 Classification of Criminal Offences
7.7.3 Preliminary hearings, or "taking of depositions"
- Preparation of the Brief of evidence
7.7.5 Notification of requirement to attend at Jury Trial
7.7.6 Prosecutors.
7.7.7 Preparation for Court
7.7.8 Attendance at Court
7.7.9 Payment of Witness Expenses
SECTION 8: VICTIM COMPENSATION
SECTION 9: THE MEDICAL EXAMINER: PERSONAL ATTIUDES AND SELF CARE
9.1 EXAMINING PERSONAL ATTITUDES TO SEXUAL ABUSE
9.2 SELF CARE
SECTION 9 REFERENCES:

SECTION 10: OFFENDERS
10.1 SEXUAL ASSAULT SUSPECT EVIDENTIAL EXAMINATION
10.2 CHARACTERISTICS OF SEXUAL OFFENDERS
10.3 TREATMENT OF SEXUALLY ABUSIVE MEN
10.4 SEXUAL ABUSE OF PATIENTS BY DOCTORS
SECTION 10 REFERENCES:
APPENDICES
APPENDIX I TERMINOLOGY
APPENDIX 2 TANNER STAGES (Sex Maturity ratings)
APPENDIX 3 PATIENT HANDOUTS
(i. a) SAMPLE LETTER NOTIFYING GP of RECENT ACUTE SEXUAL ASSAULT
(i. b.) SAMPLE LETTER NOTIFYING GP OF SEXUAL ABUSE OF A CHILD/YP
(ii) SAMPLE PATIENT INSTRUCTIONS FOR STD PROPHYLAXIS
(iii) SAMPLE FOLLOW-UP TESTS AFTER A SEXUAL ASSAULT
(iv) MORNING AFTER CONTRACEPTION
APPENDIX 4 PAYMENT FOR SEXUAL ASSAULT MEDICAL EXAMINATIONS
APPENDIX 5 CHECK LIST FOR ADOLESCENT MEDICAL EXAMINATIONS APPENDIX 6 EVALUATION OF THE TRAINING MANUAL