Sexual Assault Max Brinsmead PhD FRANZCOG July 2011

This Talk Overview of the Problem Overview of the Problem –Definitions –Incidence –Potential Consequences –Principles of management of the victim of rape –The forensic examination will not be covered in detail Follow the protocol Follow the protocol Resources Resources –O’Connor and Kovacs “Obstetrics, Gynaecology and Women’s Health” 2003 –Miriam O’Connor’s material for PEmO Courses

Sexual Assault A universal problem A universal problem Most victims are women or girls and most perpetrators are men or adolescent males Most victims are women or girls and most perpetrators are men or adolescent males Encompasses a range of activities that includes... Encompasses a range of activities that includes... –Physical violence with a sexual component –Domestic abuse –Sexual harrassment –Paedophilia –Incest Each is defined under law Each is defined under law

Rape – Legal Definition Conviction requires 3 components: Conviction requires 3 components: Sexual Penetration Sexual Penetration Lack of Consent Lack of Consent Intent of the accused to penetrate without consent Intent of the accused to penetrate without consent Sexual Penetration: Sexual Penetration: Penile penetration of the vagina, anus or mouth Penile penetration of the vagina, anus or mouth Penetration of the vagina or anus by any object Penetration of the vagina or anus by any object Lack of Consent includes... Lack of Consent includes... Submission because of harm or threat Submission because of harm or threat Asleep, unconscious or affected by drugs Asleep, unconscious or affected by drugs Incapable of understanding Incapable of understanding Mistaken about the nature of the event or the identity of the person Mistaken about the nature of the event or the identity of the person

Rape – Incidence Difficult to measure because most is unreported Difficult to measure because most is unreported Official crime statistics just the tip of the iceberg Official crime statistics just the tip of the iceberg Up to 33% of women report a lifetime incidence of unwanted sexual penetration Up to 33% of women report a lifetime incidence of unwanted sexual penetration This means that most is perpetrated by partners, friends, acquaintances or family members This means that most is perpetrated by partners, friends, acquaintances or family members Vulnerable groups: Vulnerable groups: Minorities Minorities Adolescents Adolescents Sex workers Sex workers Intellectually or Psychiatrically impaired Intellectually or Psychiatrically impaired

Consequences of Sexual Assault Physical harm Physical harm May be minimal or life-threatening May be minimal or life-threatening STD or Pregnancy STD or Pregnancy Psychological harm Psychological harm Depression (guilt, anger and loss of self esteem) Depression (guilt, anger and loss of self esteem) Suicide Suicide Post traumatic stress disorder Post traumatic stress disorder Sexual dysfunction Sexual dysfunction Chronic Pelvic Pain Chronic Pelvic Pain Obstetric dysfunction Obstetric dysfunction

Your Responsibilities First and foremost is the physical and psychological care of your patient First and foremost is the physical and psychological care of your patient It is important to remain professional It is important to remain professional And not be judgemental or emotional And not be judgemental or emotional Secondary considerations include... Secondary considerations include... Assist the police in the identification and conviction of the perpetrator Assist the police in the identification and conviction of the perpetrator And protection of the community And protection of the community Assist the patient by explaining her options and then respecting her choices Assist the patient by explaining her options and then respecting her choices

Good Practice during a Forensic Evaluation Be kind, gentle, considerate & slow Be kind, gentle, considerate & slow Seek consent for every step of the process Seek consent for every step of the process Don’t forget that history precedes examination Don’t forget that history precedes examination Use support person as a chaperone Use support person as a chaperone But this also requires patient consent But this also requires patient consent Remember that lack of physical evidence for injury does not exclude the event Remember that lack of physical evidence for injury does not exclude the event You are not the judge and jury You are not the judge and jury

Tips for Competency during the Forensic Evaluation Make sure that you have enough time Make sure that you have enough time Triage other commitments Triage other commitments Get everything ready before you start Get everything ready before you start Read the protocol before you start Read the protocol before you start Needs meticulous records Needs meticulous records Observe legal protocols Observe legal protocols For example, the chain of custody For example, the chain of custody You may need You may need STD rapid testing and pregnancy tests STD rapid testing and pregnancy tests STD prophylaxis including that for HIV STD prophylaxis including that for HIV Emergency contraception Emergency contraception Some examinations require GA Some examinations require GA