EXAM 3 Chapter 22 Sexual Violence

Perpetrator of Sexual Assault

*Biological factors* +Alterations in neurotransmitters (e.g., serotonin, dopamine, norepinephrine, acetylcholine, gamma-aminobutyric acid [GABA]) *Psychosocial factors* +Psychopathologic and personality disorders +Antisocial personality is one of the most prevalent. +Most perpetrators report a history of sexual assault as children. Other characteristics include: +Has impulsive and antisocial tendencies. +Is associated with sexually aggressive or delinquent peers. +Has a preference for impersonal sex. +Expresses a hostility toward women. +Has a childhood history of sexual and physical abuse or is a witness to family violence. +Is a member of a gang. +Belongs to a societal group that often turns its back on sexual assault.

Nursing Diagnosis

*Rape-trauma syndrome* +Variant of posttraumatic stress disorder (PTSD) and is a common sequela of psychologic trauma. *Rape-trauma syndrome: compound reaction* +Is also a likely diagnosis and includes both the acute phase of disorganization and the long-term recovery phase. * Acute Phase* +Typical reactions to a crisis often reflect cognitive, affective, and behavioral disruptions. The most common responses are shock, numbness, and disbelief. *Long-Term Phase* +*Teach the individual to know what to expect during this phase* to enable them to be prepared and not feel like they are going crazy or loosing their mind. Understanding that all assault survivors will deal with the event in their own manner is also important.

Interventions- psychotherapy

+*Crisis counseling*—Includes referrals to a family physician, community psychologist, and rape crisis line. +Group therapy can be beneficial. +If SART is unavailable, provide information on support groups and attorneys who work with survivors. +List of safe houses should also be available for those involved with intimate partner violence (IPV). +*Assess within 24 to 48 hours by telephone. - follow up, encourage ongoing therapy with this person*

Sexual Violence—Youth

+*High school:* 8% of high school students report being forced to have sex. +*Young adults:* 20% to 25% of college women will experience an attempted or completed rape by the end of their college years; 90% will know their attackers. -Majority of sexual assaults in young adults are date rapes. Young persons, ages 16 to 19 years, experience the highest rate of SV. Alcohol or other drugs are often involved. +Drugs and alcohol are often involved in gang rape.

Emergency Department: Collectionof Specimens—Forensic Evidence

+*Institutional protocol *is followed and "rape kits" are used for evidence collection. +*Body fluids and DNA are correctly preserved. * +If a date rape drug suspected, then a urine sample should be collected. +Individuals have the *right to refuse legal and medical examinations. * +*Consent forms must be signed *to collect evidence and to provide treatment. +"Chain of custody" is followed until the incident is turned over to authorities. NOTES: -Explain that even if the victim chooses not to press charges, the victim can still have a forensic exam without the rape being reported to the police Permission is necessary for collecting forensic data, performing pelvic exams, and taking photographs. Confidentiality is stressed.

Sexual Violence

+All individuals who have experienced SV suffer severe, deep, emotional scars. +In addition to physical trauma (e.g., STDs, pregnancy) psychologic consequences include depression, anxiety, difficulties with daily functioning, low self-esteem, eating disorders, self-destructive behaviors, substance abuse, and higher rates of suicide than in the general population, among others.

Assessment

+Asses and document the circumstances of the event (force, violence, sexual acts), locations of assault, and circumstances. Document pts own words if possible +Gather data that can be used as evidence +After consent forms have been signed forensic evidence should be obtained (fingernail scraping, head/pubic hair, smears for sperm) +Asses for evidence of physical trauma (bites, wounds) +Perform pelvis exam (anal for males and sodomized) +Perform Psychological assessment (crying, aggitation) mental status exam +Determine drug use by assailant/survivor (determine use of date rape drug) emphasize to pt that even if they were drinking they are not at fault) +Identify Victims support system

Prevalence and Co-Morbidity

+Both rape and child sexual molestation are among the most underreported crimes. +As little as 1% to 10% are ever disclosed. +Majority of perpetrators are men. +Gay men are victims of sexual assault more often than heterosexual men. +Prisons and the military have the greatest percentage of male rapes. +Culture of "blaming the victim" still persists. +More than 50% of gay men and lesbians have reported at least one incidence of coercion by a same-sex partner

Interventions- Emergency Department

+Care for physical injuries. +*Five percent of rapes result in pregnancy; offer emergency contraception.* +*Offer prophylactic treatment for STDs. * +Collect serum to test for human immunodeficiency virus (HIV), hepatitis B, and syphilis.

Therapy for Rapists

+Changing in thinking and behavior needs to be undertaken to effect change. +Unfortunately, most rapists do not acknowledge the need for change. +No single method or program of treatment has been found to be totally effective.

Vulnerable Individuals

+Gender: Women have a higher vulnerability. Both genders are more vulnerable if handicapped. +Age: Those 16 to 19 years of age have a higher rate of sexual victimization. Children are most vulnerable between ages 8 and 12 years. +Older adults: Domestic violence is most often perpetrated by relatives, caregivers, and health care providers. +Human trafficking victims & those involved in prostitution or sex work +History of sexual violence: Women raped before the age of 18 years are two to three times more likely be sexually assaulted as adults. +Drug and alcohol use: Increases the rates of victimization. +High-risk sexual behaviors: Vulnerability is often a consequence of childhood sexual abuse. +Poverty: May trade sex for basic needs. +Ethnicity or culture: Native Americans have a one-in-three chance of being raped. NOTES: Gender- both more vulnerable If handicapped, have cognitive problems, or mental disorders

Sexual assault first responders

+Info to help a recent victim of sexual violence in the aftermath of rape (either on phone or in person) 1. Go to a safe place immediately 2. Consider Reporting rape 3. You can report the assault and later choose not to pursue criminal proceedings 4. If you choice not to report the assault immediately you can do so at a later time Preserving the evidence: 1. Don't wash your hands or face 2. Do not shower or bath 3. Do not brush your teeth 4. Do not change your clothes or straighten up the area where the assault occurred

Rape

+Legal term versus medical diagnosis. +Legal definitions vary from state to state. +Date rape: -Is a form of acquaintance rape, but in the case of date rape, the "...victim agreed to spend time with the attacker..." -Date rape is still rape. +Rape should be considered a criminal act with long-term medical, psychologic, legal, and social problems. +Reporting crimes of sexual assault is not mandated unless it involves the abuse of a minor or older adult. +It is up to the survivors of assault to make the decision to report the crime. +It is up to health care workers to offer support, information on obtaining legal counsel, and, with the patient's permission, securing *forensic evidence* by a qualified person for future prosecution. NOTES: Rape is a legal term rather then a medical diagnosis

Children: Child Sexual Abuse or Incest

+One in three girls and one in six boys are sexually molested by 18 years of age. +Approximately 75% of molestation is perpetrated by family members. +Nearly 30% of reported child sexual assaults were children between 4 and 7 years of age. Child sexual assault and incest also includes: +Coercing children to touch the molester inappropriately. +Showing children pornographic photographs or videos. +Initiating inappropriate conversations involving sexual topics.

Date Rape

+Rapes related to date rape drugs are increasing. The exact numbers are unknown. +*Date rape Drugs: +Fϒ-hydroxybutyric acid (GHB)*: Affects the central nervous system (CNS). +Includes liquid ecstasy, salty water, scoop, homeboy. +*Rohypnol (flunitrazepam):* Is a potent benzodiazepine. +Is the "forget" drug +Also includes roofies, club drug, roachies, rophies, Mexican valium. *Ketamine*: Is an anesthetic frequently used in veterinary practice; is a hallucinogenic agent related to phencycidine (PCP), it induces a state referred to as "dissociative anesthesia". Difficult to move +Date rape drugs clear from body fairly quickly. +Detecting the drug in the emergency department (ED) is difficult. +Urine sample must be obtained within a certain period of time. +The most common drug used to facilitate the crime of rape is still alcohol. Fϒ-hydroxybutyric acid (GHB)- onset 10-20 mins durations 1-4 hours Rohypnol (flunitrazepam)- impact 10-30 minutes duration 2-12 hours Ketamine- onset 20 minutes duration only 30-60 minutes

Posttraumatic Stress Disorder Related to Sexual Assault

+Re-experiencing the trauma +Social withdrawal +Avoidance behaviors and actions +Increased psychologic arousal characteristics +Fears and phobias +Nightmares and difficulty sleeping: -Vivid nightmares of the event waking the individual -Feeling terror, disturbing sleep, and preventing sleep

Cultural Considerations

+SV happens in any socioeconomic group. +SV occurs across all ages. +Cultural and societal factors create attitudes. +Certain cultural and societal norms maintain women's inferiority through the support of male superiority and sexual entitlement. +Sexual assault on women in the military is the result of gender inequality or norms supporting male dominance.

Sexual Assault First Responders

+Sexual assault response teams (SART): Helps victims of SV and includes mental health agencies, rape crisis advocates, law enforcement, EDs, sexual assault nurse examiners, attorneys. +Sexual assault nurse examiners (SANE): Forensic nurses who work with the victims of SV: -Perform physical examination on the survivor. -Collect forensic evidence. -Provide expert testimony and forensic evidence. -Provide support re: the psychobiologic needs of survivor.

Sexual Assault and Sexual Violence

+Sexual violence (SV) and Sexual assault are acts of violence, power, hate, but not sex. +Are committed to demonstrate dominance. +SV can result in teen pregnancy, transmission of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). +Mental health issues are higher in people who have been sexually assaulted (e.g., anxiety, depression, suicide, use of alcohol, tobacco, drugs).

NOTES on sexual violence

+Survivor- someone who has experienced sexual assault, has addressed many of the issues, and is moving on with his or her life +Victim- a person who has experienced sexual assault and can become a survivor with time, intervention and or counseling +1- defined as contact between the penis and the vulva or the penis and the anus involving penetration, contact between the mouth and penis, vulva or anus, or penetration by the hand finger or another object 2.Attempt 3. Refers to inappropriate touching and foundling, either directly ot through clothing 4. Includes threatened sexual violence, exhibitionism, verbal or behavioral sexual harrassment, taking anothers nude photograph w/o consent or knowledge

Emergency Department: Documentation of Rape

+Treatment and documentation needs to be accurately and meticulously documented since documentation constitutes legal evidence: +Instead of alleged, use reported. +Instead of refused, use declined. +Instead of intercourse, use penetration. +Instead of in no acute distress, describe the behavior. NOTES: -all documentation is confidentially unless the case goes to court

Nursing Diagnosis NOTES

-Acute phase- at times pt may appear self-contained and calm: at other times cognitive function may be impaired

NOTES interventions

-to help alleviate anxiety, explanations of all interventions or procedures are provided to the patient before they are performed -Following sexual assault a forensic exam us conducted, the pt should be given medications to protect against STDs, evaluated for pregnancy, offered prophylaxis, and test for HIV and syphilis. If abrasions are noted a tetanus shot may be indicated in accordance to guidelines with CDC and ACOG Referrals can include- therapist, legal counsel, support groups

Sexual violence applies to all survivors who do not consent or who are unable to consent or unable to refuse to allow the act.

1. Completed nonconsensual sexual act 2. Attempted sexual act, but not completed 3. Abusive sexual contact 4. Noncontact sexual abuse

Sexual Assault and Sexual Violence—cont'd

Are umbrella terms encompassing: +Rape +Date rape +Acquaintance rape +Gang rape (two or more perpetrators) +Marital or partner rape +Sexual molestation +Incest +Statutory rape +Sexual assault of older adults

Emergency Department: Sexually Assaulted Individuals

Victim who arrives at the ED should: +Not be left alone. +Have privacy provided. +Be a priority in triage. +Receive psychologic support, medical care, documentation of pertinent history, and a thorough physical examination. NOTES: -care should be compassionate, comprehensive, and competent (this ideal is not always the case) --most have institutional protocols and use "rape kit" -if date rape drug suspected a urine sample should be collects