1. By: Tanuja Sharma, MD

2.  Apply elements of the Illinois law for confidentiality  List the elements of interviewing and communicating a sexual assault case  Compare and contrast exam components of a pre- pubertal and post pubertal patient  List elements of the evidence rape kit  Recognize strategies to prevent breach of confidentiality  Retrieve resources available for sexually assaulted teens

3.  D.D is a 14 y/o female who presents with her mother and grandmother after being sexually assaulted (coerced into performing oral sex to a boy at school). Mother is requesting you to check if she is still a virgin.

4.  Cases can present in various clinical settings  85-95% suspected sexual abuse victims have no signs of significant injury  Need to rely on history/words (child, parent) and behaviors  Know your perpetrators - usually relatives or acquaintances  Resident and attending physicians do not receive formal training on interviewing, communicating and examining these patients

5.  ~50% are not at all-somewhat knowledgeable of Illinois confidentiality laws on minors  ~60% did not feel COMFORTABLE at all performing a sexually assault interview and exam  ~52% did not feel COMPETENT in performing sexual assault interview  ~70% did not feel COMPETENT performing sexual assault exam  ~70% were not knowledgeable of resources to provide victims and families

6.  Minor: < 18; IL requires a minor who seeks medical treatment to obtain consent from a parent/guardian EXCEPT  1) Mature Minor Exception: ◦ ‘Mature minor doctrine’-judge can determine that minor has judgment of an adult  2) Emancipation (attain legal adulthood) of Mature Minors Act: ◦ >/16 yrs may be emancipated – sound mind, capacity and maturity to manage own finances, best interest of minor and family 3) Emergency Care: hospital/physician may render emergency treatment (sole opinion of physician, hospital)

7.  4) Children of Adolescent Parents: ◦ Parent who is a minor may consent to perform upon his/her child of medical, surgical or dental procedure  5) General Medical Treatment including birth control  and abortion: ◦ Minor who is: Married, Pregnant, Parent  6) Testing for HIV: ◦ Yes; If + doctor should recommend that the minor notifies parent ◦ Doctor should notify minors parent if minor refuses, suspicion ◦ No duty/obligation that provider must notify parent/guardian 7) Rape Victims: Medical care, counseling, diagnosis and treatment of any disease/injury arising from the defense Sexual assault evidence collection kit may not be released by a hospital without the written consent from sexual assault victim

8.  8) Treatment for STDs ◦ >/12yrs medical care of counseling related to diagnosis or treatment ◦ All parties involved in treating minor should assist minor in accepting his/her families involvement  9) Mental Health Treatment: ◦ >/12 yrs may request counseling, psychotherapy services output with limits of 5 45min session total, until consent of a minors parent/guardian is obtained 10) Substance Abuse Treatment: >/12yrs medical care of counseling related to diagnosis or treatment All parties involved in treating minor should assist minor in accepting his/her families involvement

9. Illinois Consent & Confidentiality Laws Summary  Judge declares minor ‘Mature’ (Mature minor doctrine)  >16 have been emancipated  Emergency situations  Married, pregnant, parent – medical treatment, birth control, abortion  Testing for HIV  Rape victims  >12 mental health, substance abuse, STDs  Doctor should recommend parental involvement

10.  Balance confidentiality w/ need to care and protect  Know your state laws and institutional boundaries  Create a trusting environment so information is disclosed but also - discuss the limits of confidentiality – (police/child protective services report will alert their parents)  Discuss involvement benefit of a supportive parent/guardian even when the adolescents would prefer the parent not be informed Normalization (avoid appearing uncomfortable), avoid medial jargon Listen to responses and respect diversity and differences Avoid assumptions (treat all victims equally)

12. The Interview

13. History: Most imp, rely on pts words Specifics, who/what/where/when/how/contr aception/ejaculation Allergies, meds, HepB, Td, LMP Symptoms (anal, genital itching, pain, discharge, bleeding, dysuria, anxiety Open ended-questions to create child-friendly environment Recognize the links (parties w/alcohol, drugs, parents do not know)

14.  Child-friendly environment  Child should feel in control (choosing whether guardian is present and being allowed to stop exam)  School aged child should never be coerced to have an exam (may need assistance from parents for toddlers)  3 positions – supine labial separation, supine labial traction, knee-chest position  Use of speculum in an awake prepubertal child is never indicated (sedation)  Post-pubertal Exam: ◦ lithotomy position using stirrups; supine position may be used ◦ +/- speculum

15. Physical: Evidence Kit: swabs – oral, external genitalia, vagina/cervix Speculum NOT indicated for pre- pubertal Speculum avoided in pubertal teens (may sedate if needed) Rectal, pubic hair, fingernail, foreign debris, secretions, clothing in paper bag Grasp labia majora and apply outward and downward traction (hymenal edges separate) Yields most information Lithotomy position –post pubertal Journal of Child Sexual Abuse (see images at this website)

16. Indicated assault took place w/in 5 days. Requires consent Elements: Instructions and documentation forms Bags and sheets for evidence Swabs for collecting fluids from the lips, cheeks, thighs, vagina, anus, and buttocks Blood collection devices Comb used to collect hair and fiber from the victim’s body Labels Envelopes for preserving the victim’s clothes, head hair, pubic hair, and blood samples Nail pick for scraping debris from beneath the nails White sheets to catch physical evidence stripped from the body Post pubertal: STI testing, pregnancy, syphilis, hep B, C, HIV.

17. Medical Treatment: GC: Ceftriaxone 250 mg IM OR Cefixime 400mg PO CT: Azithromycin 1mg PO OR Doxy 100mg x 7 days Trich: Metronidazole 2gm PO BV: Metronidazole 500mg BID x 7d Post-pubertal: HIV prophylaxis Pregnancy prophylaxis 1.5mg Levonorgesterol (plan B) Hep B vaccine Td vaccine HSV treatment Support and Follow up

18. ◦ Depression and anxiety ◦ Eating disorders ◦ PTS ◦ Substance abuse ◦ Somatization and dissociative disorders ◦ Sexual dysfunction ◦ Interpersonal problems ◦ STIs ◦ Pregnancy ◦ Shame/Ridicule from family Child Advocacy Center Check in your area for regional center American Professional Society on the Abuse of Children (APSAC) www.apsac.org National Clearinghouse on Child Abuse and Neglect Information www.calib.com/nccanch 800-FYI-3366 (800-394-3366) Child help USA www.childhelpusa.org 800-4-A-CHILD Prevent Child Abuse America www.preventchildabuse.org 800-CHILDREN National Children’s Advocacy Center (NCAC) www.ncac-hsv.org 256-533-0531

19.  Parents and adolescents should be informed separately and together that information each of them share will be kept confidential  If this is not possible health care providers/staff should inform adolescents that parents have access to health records should be given the option for referral to a health care provider who is required to provide confidential care  Individual practices should develop an official confidentiality agreement for patient, parents, provider to sign after discussing policy  Northshore – parents do not have access to any minor >12 information unless minor signs for parental proxy  >/12 Northshore connect access becomes limited to parent (cant see avs, labs)  >18, Northshore popup that notifies pt to make him/her guarantor

20.  Be familiar with the Illinois laws for confidentiality in minors  Create a trusting environment, appear comfortable, listen, recommend parental involvement  Be familiar with the elements of the rape kit  3 positions – supine labial separation, supine labial traction, knee-chest position  Use of speculum in an awake pre-pubertal child is never indicated (sedation)  Lithotomy position using stirrups; supine position may be used (+/- speculum)  Know where to find resources for victims

21.  1) Low-Fidelity Hybrid Sexual Assault Simulation Training's Effect on the Comfort and Competency of Resident Physicians. http://www.ncbi.nlm.nih.gov/pubmed/25435474  2) Responding to sexual violence: critical issues for healthcare providers  3) Emergency contraception services for adolescents: a National Survey of Children's Hospital Emergency Department Directors  4) Should medical students be taught about rape?http://onlinelibrary.wiley.com/doi/10.1111/j.1471- 0528.2006.01205.x/full  5) Community medicine in action: an integrated, fourth-year urban continuity preceptorship  6) Educating physicians about women's health. Survey of Canadian family medicine residency programs.  7) Journal of Child Sexual Abuse  8) Up to Date