Suspicion of Abuse or Interpersonal Violence - Gynaecology

Suspicion of Abuse or Interpersonal Violence

·        It is common and victims are high users of health services

·        Epidemiology: 20% of women report sexual abuse before 16, full intercourse reported by 4%. Sexual abuse of boys is about 1/3 as common as for girls.

·        Adult women: 25% report sexual abuse, 12% rape

·        Men: 5% report sexual abuse, 3% rape (?under-reporting)

·        10 – 16 % of rapes reported to police

·        Effects: 

o  Acute and long term effects are related to age of victim, extent and duration of abuse, relationship with abuser and response of others

o  Acute effects: numbness, shock, disbelief, anxiety 

o  Long-term effects: feelings of helplessness, depression, sleep disturbances, nightmares, flashbacks, guilt, self-blame, shame. Measurable long-term psychiatric sequalae in 25%

·        What is patient‟s age: 

o  < 14: all suspected cases should be referred to CYPFS, or if older but abuser still has access to young people. 

o  14 – 17 don‟t make a decision about what to do on your own Þ need to put caveats on confidentiality 

·        History questions (but don‟t introduce it in a crisis situation) 

o  Suspect if physical injuries, chronic undiagnosed pelvic pain, heightened anxiety about an examination, STD‟s without being worried about health risks 

o  They will be reluctant to discuss it 

o  Physical: „have you ever been hit, slapped or shoved by a parent or partner. Ever had bruises or had to stay in bed… 

o  Sexual: Did anything sexually frightening happen to you as a child or young adult, have you ever been made to participate in sexual activity that made you feel uncomfortable. Was it your choice, or were you forced or coerced? 

o  Psychological: Does your partner ever ignore you, call you names, make fun of you, threaten to leave you, punish the children when he is angry with you, are you fearful of anyone at the moment?

·        Most helpful response is: being believed, being supported, not being blamed, being helped not to feel odd or alone

Rape/Non-Consensual Intercourse

·        Rape: = sexual contact without consent (including consent under threat) which involves oral, genital or anal penetration, otherwise unlawful sexual contact

·        Therapeutic role:

o   Recognise & treat physical injury

o   Attention to emotional trauma 

o   Prevention of pregnancy – offer ECP. Legal requirement under the Contraception, Sterilisation and Abortion Act. 

o   Check for infection (NB incubation of chlamydia is 21 days) and offer prophylaxis (but may interfere with ECP – do it after)

o   Referral to support services

o   If not sure about making a police complaint, bring in crisis counselling team

o   Victim compensation – inform re ACC entitlement

·        Forensic role:

o   When did it happen: If less than 7 days then may be forensic requirements. If very recent then nil-by-mouth and collect all urine and toilet paper until forensic examination. Ring forensic specialist (DSAC = Doctors for Sexual Abuse Care)

o   Keep detailed records at the time of examination

o   Forensic specialist will do genital exam, blood tests, urine (drug screen), colposcopy (for genital injury), finger nail scrapings, etc and appear as expert witness

·        Supportive role:

o   Communicate empathy: „that sounded really unpleasant for you‟

o   „You are safe now‟ (don‟t say if not true)

o   Reinforce „Its not your fault‟ – victims blame themselves

·        Follow-up at 1 week, 1 month and 3 months (pregnancy, HIV test, Hep B and C, Syphilis)