Description #
This is an Obstetrics and Gynecology unit.
Learning Objectives #
The Students should be able to:
-Cite the prevalence and incidence of violence against women and children
-Assess the involvement of any patient in domestic violence situations and be familiar with rape trauma syndrome
-Counsel patients regarding local support agencies for long term management and resources
-Counsel patients requiring support services after incidents of battery and domestic violence
-Explain the medical, forensic, psychological evaluation, and treatment for sexual assault survivors
SEXUAL ASSAULT AND ABUSE INTRODUCTION
Dr. Ellen Wiebe
The following 4 sections of text accompanies the “Caring for Sexual Assault Survivors” Lecture on Demand.
I. Sexual Assault and Abuse is Common
The Sexual Assault Service at Vancouver General Hospital sees about 200 adolescent and adult sexual assault victims each year. The Children’s Hospital sees 400 cases of child sexual abuse each year. The Vancouver City Police investigate about 600 cases each year. Those are high numbers but the prevalence studies indicate that the rates are very much higher. One out of six women says that she has been sexually assaulted after puberty. One out of four girls has suffered some form of sexual abuse; one out of ten boys has suffered some form of sexual abuse. The large discrepancy between incidence and prevalence means that most woman and children do not report sexual abuse. In fact, only 10-15% will report sexual assault and sexual abuse.
In a study of American College men and women, Koss found that 15% of the women said that they had been raped, and over half of them said that they had been victims of some kind of sexual aggression. Five% of the men admitted to having raped, and 25% admitted to have victimized women.
Perpetrators of rape and abuse are usually ordinary men. They don’t fit into any diagnostic criteria of mental illness. Their victims range in age from babies to women in their nineties, and they cover all social strata and races. The act is mainly one of violence and power, rather then of sexual desire. 85% of the perpetrators are known by their victims. The male victims are fewer and are about half heterosexual and half homosexual. Even fewer men report and the ones who do are usually the ones with severe injuries. Almost all rapists are men but about 20% of child abusers are women. With the low rate of reporting and the low rate of conviction, one can expect that about 1% of rapists will be incarcerated for the crime.
II. Sexual Assault and Abuse is Devastating
The rape trauma syndrome was first described by Burgess and Holmstrom in the 1970’s when they followed women who had reported rape at the Boston Emergency. They described the acute phase of disorganization, followed by a second phase of reorganization. The symptoms include anxiety, fear, anger, depression, development of phobias, substance abuse and increased suicide attempts. These symptoms are often prolonged. In the adolescent follow up study, 50% still had their symptoms up to two and a half years after the assault. The severity of rape trauma syndrome is not related to whether the attacker was a stranger or whether violence was used, but only to preexisting mental state. Specific symptoms such as agoraphobia can be related to the type of attack.
The reaction of the husband or partner can have a major effect on the woman’s recovery. According to a study by Burgess and Holmstrom, half of the male partners reacted as if they were the victims, that it was their property that had been violated, rather than their partner’s.
In children, the reactions to sexual abuse vary with age. Preschoolers exhibit developmental regression, excessive fears, psychosomatic pains, and sexually precocious behavior. School age children may also have developmental regression, a drop in school performance, insomnia, depression, anxiety, phobias, and sexualization. Adolescents may act out in running away, having school difficulties, depression, suicide, low self esteem.
Roland Summit described the sexual abuse accommodation syndrome and explained some of the process by which the children show secrecy, helplessness, accommodation, and retraction. A large population survey by Burnham indicated that a history of sexual assault or abuse predicted major depression, substance abuse, and anxiety disorders, but had no relation to other mental illnesses.
III. Our Profession Can Make a Difference
Doctors have a tendency to want to appear objective and competent when dealing with sexual assault victims. It is important to recognize one’s own emotional response. Some of the mistakes that doctors make are to focus on the sexual aspect rather than the violence and power issues, to over-identify with the victim, avoid the topic, shun the victim, or to obsessively ask questions.
There are some important guidelines to remember. First of all the victim is a patient, and needs to be treated with consideration and respect. Her wishes come first, not the physician’s or the police. Informed consent must be obtained not just for medical legal reasons, but because this is the first therapeutic step in which the child or woman is given back the power over her own body. It is not the physician’s role to prove or disprove sexual assault or abuse. The physician must record accurately what he or she observes. Unlike other aspects of medicine, the history taking is usually left to other professionals. We need only to get a limited, directed history.
It is important that we as physicians know the signs of sexual abuse in children so that we are able to recognize them. To see an acutely molested child is unusual. In those situations one might expect contusions, abrasions, lacerations, and seminal products. Chronic molestation is more common, and many times there will be no signs, but if there are signs, one could expect hymenal tags, vaginal relaxation, perineal scars, anal relaxation with scars. With children we have an obligation to report if the child is Òin need of protectionÓ. With adults we do not. The important thing for physicians to remember is that their approach to the victim, from the first examination through subsequent medical care, can make a difference to how an adult or child heals.
IV. Physicians Sexual Abuse of Patients
Our profession is no better or worse than other people in our society. In 1992 the BC College of Physicians and Surgeons studied physician sexual misconduct and found that 3.5% of BC physicians admitted to having sex with patients. Because of our immense power over our patients, these situations usually constitute abuse. Other studies have indicated similar percentages, with about 10% of psychiatrists admitting to sexual activities with patients. Most of these are male doctors with female patients, although there have been a few cases of male/male, female/female, and female/male abuse. Clearly, although most physicians are ethical people, many of our respected colleagues have been guilty of this behavior.
The effects of abuse by a person in a position of trust and power produces all the same reactions as the rape trauma syndrome including depression, anxiety, and substance abuse. In addition, as Pope has written about the therapist patient abuse syndrome, there is a loss of trust, a loss of confidence in the patient’s own judgment, feelings of guilt, and difficulty establishing a relationship in any subsequent therapy.
Those of us physicians who do not sexually abuse our patients can help. We can be open to our patient’s disclosures and help the patient report the offending physician. We can teach our medical students and residents about the complexities of the physician-patient relationship.
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