Sexual assault as it presents in the Emergency Department

Sexual assault as it presents in the Emergency Department

Mar 13, 2019 0
Emergency Medicine,onthepods,sexual health

Sarah Dalton chats to Mary Dobbie about sexual assault as it presents in the Emergency Department. We will go over an example case and give advice on how junior doctors can approach these patients. We will talk about:

  • what the definition and impacts are,
  • how common it is for these patients to present to ED and what happens when they do,
  • debunking common myths around rape and assault.

Summary Writer:  Jane McDonnell

Script Writer:  Mary Dobbie

Editor:  Mary Dobbie

Interviewee:  Mary Dobbie

About Dr Mary Dobbie

Dr Mary Dobbie graduated from the University of Sydney in 1986 and worked as a General Practitioner for many years with a special interest in women’s health. She has worked in the Sexual Assault Service at Royal Prince Alfred Hospital and Liverpool Hospitals, New South Wales since 2012. Mary has completed the Education Centre against Violence Graduate Certificate in Adult Sexual Assault and also works as a teacher and examiner for the NSW Health Education Centre Against Violence.

 

Sexual assault as it presents in the Emergency Department

With Dr Mary Dobbie, Visiting Medical Officer in Sexual Assault at Royal Price Alfred Hospital and Liverpool Hospital, Sydney, New South Wales, Australia

Introduction

The sexual assault service at Royal Prince Alfred Hospital (RPAH) is geared to provide a joint medical and counselling response for patients reporting a recent sexual assault. It sees patients over 14 years of age.

  • Any sexual act that is performed without consent
  • Consent must be freely given – i.e. free of coercion
  • A child cannot consent if they are under 16 years of age
  • Other factors may transiently confer an inability to consent e.g. intoxication / acutely affected by mental illness
  • Sexual assault is common
  • It is widely under-reported so it is hard to know exactly how common
  • The Australian Bureau of Statistics estimates 1 in 5 women experience some form of sexual assault (including indecent assault, stalking, interpersonal violence, rape)
  • Worldwide, 1 in 3 women have experienced physical or sexual violence in their lifetime
  • MYTH: Only certain types of people get assaulted and it is because of how they dress or drink
  • MYTH: It is usually a stranger who perpetrates an assault
  • MYTH: If there is no struggle or violence within the event, it is not assault
  • MYTH: When women say no, they might really mean yes
  • MYTH: Men don’t get raped
  • MYTH: If you’re in a marriage or working as a sex worker, you can’t be sexually assaulted
  • It is important to acknowledge these myths because they result in shame and blame for the victim
  • Sexual assault is a traumatic crime, violating personal boundaries profoundly
  • It has both short-term and long-term effects and causes both physical and mental health problems
  • In some settings, a victim may be at increased risk of acquiring an STI including HIV
  • Women exposed to sexual violence have double the rate of mental health disorders
  • History of sexual assault is associated with disability, poor quality of life and other disadvantages
  • Introduce yourself and explain everything slowly and step by step
  • Above all, believe the patient
  • Have a private area to discuss these issues
    • It is usually not helpful to have other people present
  • Validate the patient for seeking help and validate their concerns
  • Patients may present to the Emergency Department in in an ambulance, with police or self-present
  • The Sexual assault service is a free service, even without a Medicare card – these patients are victims of crime
    • Travellers are a particularly vulnerable group
  • An undisclosed history of sexual assault may lead to repeated presentations, with depression or anxiety, unexplained physical symptoms, substance abuse or PTSD
  • Patients require regular triage and assessment – Regular vital observations – Medical clearance is the #1 priority
  • Need medical clearance, before they get referred to the sexual assault service
    • There are ways of preserving evidence if medical management is going to delay the forensic assessment
    • E.g. If the patient is too intoxicated, a forensic evaluation will be delayed until they recover
  • Additional sexual assault triage questions usually include
    • When did the assault occur?
    • Further information from police / paramedics if present
    • Is the patient in pain or bleeding anywhere? If so, this needs early management
    • Any strangulation history or neck pain? (red flag)
    • Record of mental health problems
    • Any obvious signs of intoxication
  • Once primary survey (ABC..) has been performed, a dedicated intake counsellor coordinates the response
  • Counselling team has a short period of privileged time for private, confidential counselling
    • NB: Anything that goes in medical notes may be used in court

Case

A 19-year-old woman presents to the Emergency Department after she has had a lot of alcohol the night before. She tells you she has a very poor memory of events from the previous evening and has no specific recollection of a sexual assault. She reports her vagina and bottom are painful.

History

  • Introduce yourself. Assess and document fitness to consent to forensic review
  • Consider what has caused history of memory loss – don’t overlook medical causes
    • Intoxication is a possibility (check BAC), other medical causes: strangulation, head injury
  • If the patient doesn’t volunteer that an assault has occurred, may need to gently explore
    • “In this sort of presentation, we would usually consider the possibility of sexual assault.”
  • Start with general medical history including LMP, contraception, vaccination particularly against Hep B and tetanus, mental health history, medications
  • Ask the patient to describe what happened in their own words
  • For this particular patient, when was her last memory and then the next clear memory – try to get a timeframe of the memory loss and do not assume she was unconscious
  • Consider drink spiking – note, alcohol alone can cause memory loss / impaired memory
  • If the patient recalls the assault, they may give vivid details of events leading up to the assault and no details about the actual assault – in this setting, you must ask specific questions
    • Ask when (time and date) and where (bedroom, park) the assault took place
    • Number of assailants
    • Any threats made during the assault or weapons / force used
    • How clothing was removed
    • Anything specific the victim can recall the assailant saying during the assault
    • Ask specifically what areas were penetrated and by what body parts – this is important to know where to take swabs from for forensic purposes and because different time frames apply for DNA evidence (e.g. skin cells are only able to be collected for approximately 12 hours after the event)
    • Frequently check that the patient doesn’t feel too overwhelmed by the assessment

Examination

  • Examination should be performed in a forensically cleaned area if available
    • Police kits containing decontaminated equipment are available
    • In a rural setting, you might have access to a SAIK (sexual assault investigation kit)
    • If in a setting where there is no forensically prepared room, record what measures you have taken to reduce DNA contamination which could compromise legal evidence
      • E.g. opened fresh set of gloves, wiped down bed, clean sheet
  • Take note of the patient’s coherence
  • Aim to do a head to toe examination
  • Look for any injuries – that might not have been noticed by the person presenting
  • You need good lighting and a stress-free environment for the patient
  • Take your time and explain to the patient what will happen before each step
  • If the patient is not managing, consider options and offer a stream-lined examination
  • Be aware of the fact that this work will affect you
  • Be conscious of your own personal strategies to prevent burn out
  • Don’t drink a lot
  • Exercise a lot
  • Have uninterrupted home time – maintain work life boundaries and don’t check emails at home
  • Institutional support is important

Related Podcasts

Tags: #consent,#emergency,#emergency department,#indecent assault,#interpersonal violence,#rape,#sexual assault,#sexual health,#sexual violence,#stalking

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