1. Maltreatment, Neglect and Assault Sexual assault Child abuse Elder abuse Partner abuse

2. Sexual assault Definitions: Definitions: sexual assault: unwanted oral, genital, rectal or manual sexual contact rape: non-consensual sexual intercourse. Consent may not be given if the person is intoxicated, under age or if the perpetrator is in a position of trust, authority or power

3. Characteristics of victims Can be anyone Can be anyone Females under 18 Females under 18 Nearly 2/3 of all rapes and sexual assaults occur between 1800 – 0600 hours at the victims home or the home of a friend, relative or acquaintance Nearly 2/3 of all rapes and sexual assaults occur between 1800 – 0600 hours at the victims home or the home of a friend, relative or acquaintance

4. Characteristics of sexual assailants Can be from any background Can be from any background Many are under the influence of alcohol or drugs Many are under the influence of alcohol or drugs Many think domination is part of any relationship Many think domination is part of any relationship 30% of rapists use weapons 30% of rapists use weapons

5. Sexual assault with children Children raised in families where domestic violence occurs are 8 times more likely to be sexually molested within the family Children raised in families where domestic violence occurs are 8 times more likely to be sexually molested within the family Fear reprisal, may be confused about the situation, may fear that no one will believe them Fear reprisal, may be confused about the situation, may fear that no one will believe them Assailants may explore the child without intercourse or force the child to touch or fondle them Assailants may explore the child without intercourse or force the child to touch or fondle them

6. Symptoms of sexual abuse in children Nightmares Nightmares Restlessness Restlessness Withdrawal Withdrawal Phobias related to the offender Phobias related to the offender Regressive behaviour Regressive behaviour Truancy Truancy Promiscuity Promiscuity Drug and alcohol abuse Drug and alcohol abuse

7. Rape Victim may be physically injured – if multiple assailants there may be internal injuries Victim may be physically injured – if multiple assailants there may be internal injuries Can result in infections, STD and pregnancy Can result in infections, STD and pregnancy Psychological damage is often deep and long- lasting Psychological damage is often deep and long- lasting

8. Date rape Drug is Flunitrazepam (Rohypnol) Drug is Flunitrazepam (Rohypnol) Street names: ‘roofie’, ‘roche’, ‘rib’, ‘rope’ Street names: ‘roofie’, ‘roche’, ‘rib’, ‘rope’ Commonly causes drug-induced amnesia Commonly causes drug-induced amnesia

9. Intervention Protect the patient from further harm Protect the patient from further harm Provide a safe environment Provide a safe environment Ensure privacy Ensure privacy Be nonjudgmental Be nonjudgmental Avoid subjective comments Avoid subjective comments This is a crime scene – preserve evidence This is a crime scene – preserve evidence Carefully and objectively documents your findings Carefully and objectively documents your findings In case of rape – patients should not urinate, defecate, douche or bathe In case of rape – patients should not urinate, defecate, douche or bathe

10. Child abuse Characteristics of abused children Often the child is seen as “special” and different from others; may have physical and/or mental disabilities Often the child is seen as “special” and different from others; may have physical and/or mental disabilities Many abused children are under 5 years of age Many abused children are under 5 years of age Boys are abused more than girls Boys are abused more than girls

11. Characteristics of the abuser Often is a parent/step-parent or full time caregiver Often is a parent/step-parent or full time caregiver Many were abused as children Many were abused as children Can be from any geographic, religious, ethnic, racial, occupational, educational or socioeconomic background Can be from any geographic, religious, ethnic, racial, occupational, educational or socioeconomic background May be experiencing financial, marital or relationship stress, or physical illness or self or child May be experiencing financial, marital or relationship stress, or physical illness or self or child

12. Types of child abuse Psychological Psychological Physical Physical Sexual Sexual Neglect Neglect

13. Indicators of possible abuse Multiple injuries in various stages of healing Multiple injuries in various stages of healing Injuries scattered over many areas Injuries scattered over many areas Bruises or burns in distinctive patterns or outlines Bruises or burns in distinctive patterns or outlines Any injury that does not fit the description of the cause Any injury that does not fit the description of the cause Vague parental descriptions that change during the interview Vague parental descriptions that change during the interview Accusations that the child injured themselves intentionally Accusations that the child injured themselves intentionally

14. A delay in seeking help A delay in seeking help Revealing comments by bystanders such as siblings Revealing comments by bystanders such as siblings

15. Signs of neglect Malnutrition Malnutrition Longstanding skin infections Longstanding skin infections Extreme lack of cleanliness Extreme lack of cleanliness Untreated medical conditions Untreated medical conditions Verbal and social skills far below those you would expect for a child of similar age and background Verbal and social skills far below those you would expect for a child of similar age and background

16. Signs of emotional abuse One of the hardest to identify One of the hardest to identify May take one of the following forms: May take one of the following forms: 1. Parents or caregivers ignore the child, show indifference to the child’s needs and fail to provide stimulation 2. Parents or caregivers reject, humiliate or criticize the child 3. The child may be isolated and deprived of normal human contact or nurturing

17. 4. The child may be terrorized or bullied through verbal assaults, threats thus creating feelings of fear and anxiety 5. A parent or caregiver may encourage destructive or antisocial behaviour 6. The child may be over pressured by unrealistic expectations of success

18. Intervention Goal: to treat any injuries, to protect the child from further abuse, to notify authorities Goal: to treat any injuries, to protect the child from further abuse, to notify authorities Safety is a priority Safety is a priority Obtain as much information as possible in a nonjudgmental way. Try to have your partner present Obtain as much information as possible in a nonjudgmental way. Try to have your partner present Never leave transport to the alleged abuser Never leave transport to the alleged abuser Document all objective findings. Make no assumptions Document all objective findings. Make no assumptions

19. Report your suspicions when you reach the ER and notify the Children’s Aid Society Report your suspicions when you reach the ER and notify the Children’s Aid Society

20. Elder abuse Elder or geriatric abuse: a syndrome in which an elderly person is physically or psychologically injured Elder or geriatric abuse: a syndrome in which an elderly person is physically or psychologically injured Domestic elder abuse: physical or emotional violence or neglect when an elder is being cared for in a home-based setting Domestic elder abuse: physical or emotional violence or neglect when an elder is being cared for in a home-based setting Institutional elder abuse: physical or emotional violence or neglect when an elder is being cared for by a person paid to provide care Institutional elder abuse: physical or emotional violence or neglect when an elder is being cared for by a person paid to provide care

21. Theories of elder abuse Caregivers are distressed and overburdened Caregivers are distressed and overburdened Elders are in poor health physically and emotionally Elders are in poor health physically and emotionally Family history of violence Family history of violence Incidents increase with increased personal problems of the careegiver Incidents increase with increased personal problems of the careegiver

22. Characteristics of abused elders Most common is abused older women by their sons Most common is abused older women by their sons Most frequently among those dependent on others for their care Most frequently among those dependent on others for their care May live alone, may fear asking for help from relatives who have resisted providing care or have threatened putting them in a nursing home May live alone, may fear asking for help from relatives who have resisted providing care or have threatened putting them in a nursing home Fear retaliation, therefore they do not discuss the abuse Fear retaliation, therefore they do not discuss the abuse

23. Intervention Treat any injuries, medical conditions Treat any injuries, medical conditions Obtain a good patient and family history; pay attention to inconsistencies Obtain a good patient and family history; pay attention to inconsistencies Do not confront the family Do not confront the family Document objective information Document objective information Report your suspicions Report your suspicions If patient does not want to report the abuse to the police, give them the number for the Community Care Access Centre If patient does not want to report the abuse to the police, give them the number for the Community Care Access Centre

24. Partner abuse Physical or emotional violence by a person toward a domestic partner Physical or emotional violence by a person toward a domestic partner Abuse of women by men is the most widely seen Abuse of women by men is the most widely seen

25. Physical abuse Involves direct personal injury Involves direct personal injury May also include exacerbation of existing medical conditions May also include exacerbation of existing medical conditions

26. Verbal abuse Involves words chosen to control or harm a person Involves words chosen to control or harm a person May leave no physical marks but it damages a person’s self-esteem and can lead to depression, substance abuse or self destructive behaviour May leave no physical marks but it damages a person’s self-esteem and can lead to depression, substance abuse or self destructive behaviour

27. Sexual abuse Involves forced sexual contact Involves forced sexual contact Is a form of physical abuse Is a form of physical abuse Includes marital and date rape Includes marital and date rape

28. Characteristics of abusers May have increased stress May have increased stress History of family violence History of family violence May have overly aggressive personalities May have overly aggressive personalities May think they are ‘disciplining’ May think they are ‘disciplining’ Often feel insecure, jealous Often feel insecure, jealous Often involve alcohol and drug abuse Often involve alcohol and drug abuse

29. Characteristics of the abused 45% of women suffer some form of battery when pregnant 45% of women suffer some form of battery when pregnant Often involved with alcohol and drug abuse Often involved with alcohol and drug abuse Frequently exhibit depression, evasiveness, anxiety or suicidal behaviour Frequently exhibit depression, evasiveness, anxiety or suicidal behaviour May try to protect the attacker by providing alternative explanations for the injuries May try to protect the attacker by providing alternative explanations for the injuries

30. After the abuse Abusers – often feel remorse, shame Abusers – often feel remorse, shame - may promise to change or seek help - may promise to change or seek help - however, often the violence is repeated - however, often the violence is repeated The abused – may avoid eye contact, may be nervous and watching the abuser The abused – may avoid eye contact, may be nervous and watching the abuser - may provide verbal clues, “I seem to cause problems” - may provide verbal clues, “I seem to cause problems”

31. Assessment of the abused Ensure your safety Ensure your safety Approach calmly, introduce yourself Approach calmly, introduce yourself Treat any injuries or medical conditions Treat any injuries or medical conditions Avoid judgmental questions or statements Avoid judgmental questions or statements Don’t probe into the cause of the conflict Don’t probe into the cause of the conflict

32. Clues to watch for When asked “what happened?”, the abused may not explain; the abuser may do all the talking, including any questions directed at the abused When asked “what happened?”, the abused may not explain; the abuser may do all the talking, including any questions directed at the abused Evidence of a struggle Evidence of a struggle The abuser shows little or no concern for the abused The abuser shows little or no concern for the abused Explanations are inconsistent or illogical with the appearance of the injuries Explanations are inconsistent or illogical with the appearance of the injuries

33. Reasons why partner abuse is not reported Fear - of attack to themselves or their children Fear - of attack to themselves or their children Humiliation – feeling powerless to stop the abuse Humiliation – feeling powerless to stop the abuse Denial – claiming the situation is less serious than it is Denial – claiming the situation is less serious than it is Rationalizing – the abuse is justified Rationalizing – the abuse is justified Some believe that abuse is part of marriage Some believe that abuse is part of marriage May stay to preserve the family May stay to preserve the family

34. Reporting abuse is usually a last resort – many hope it will end on its own; the abuser often promises to change Reporting abuse is usually a last resort – many hope it will end on its own; the abuser often promises to change Lack of knowledge of resources available Lack of knowledge of resources available Lack of finances Lack of finances May not know who they can trust May not know who they can trust