GP Education June 2021 Dr Melanie Johns Joint Clinical Lead
What we will cover…….. • • • • • • • • • •
What is sexual assault? Consent Screening and dealing with disclosures What is SAATS and who is MEDSAC? Tautoko Mai medical services How to refer to Tautoko Mai Forensic examinations Non-fatal strangulation ACC sensitive claims Trauma informed care
What is sexual assault? • Sexual contact that occurs without consent – fondling to penetration • Legal definitions of sexual violation in Aotearoa New Zealand: • Rape = penetration of genitalia (between the labia) by a penis • Unlawful sexual connection = physical touching with mouth or tongue of genitals or anus OR the penetration of genitalia or anus by a body part or object controlled by another person. • The contact was intentional and done without consent.
Don’t guess the yes • Lack of consent is the basis of sexual assault • Allowing sexual activity does not always imply consent • • • • • •
Force/threat/intimidation Intoxication with drugs/alcohol Being asleep/unconscious Intellectual/mental/physical impairment meaning can not consent or refuse Mistaken identity/deception Mistaken about nature of sexual activity (including stealthing)
Statistics • MoJ 2015: 24% of women and 6% of men in NZ report being sexually assaulted in their lifetime • Of 100 sexual assaults in NZ
• 10 will report to police • 3 will go to court • 1 will result in a guilty verdict
• So it’s very important that our medical care is awesome, because the medicolegal aspect is not
Screening for sexual assault • Screening opportunities: • • • •
ECP - some local pharmacies now have cards that they put in the packs STI screening Unusually distressed patient Patient with suspicious physical injuries
• • • • •
When taking a sexual health history Cx smear As part of your family violence screen Chronic pain Significant mental health / behavioural / D&A issues
• Ask (if it’s appropriate) – “Is there something from your past that is affecting how things are for you now?” • Reassure details are not required • Be clear about the boundaries of confidentiality
Dealing with a disclosure • Listen – be respectful and quiet – they will be hypervigilant and will remember your comments for many years – “I’m so sorry this has happened to you” • Validate their experience – “It is NOT OK that this happened to you” • Be empathic, do not blame/judge • Don’t ask if they said no/what were they wearing/how much had they had to drink • Be aware that freezing/dissociation is a normal response to overwhelming threat and can generate feelings of guilt/shame
• Don’t dig for details/ask leading questions
• Risk of retraumatising • Risk of affecting memory prior to evidential interview
• Assess safety of the person in front of you and of any children who may be affected • Do ROC if any children affected including witness to violence • Do they wish to involve Police?
• Consider sharing info anonymously if a public danger eg stranger attack
Documentation • Electronic medical records are permanent and are duplicated every time the patient changes practice – record what is needed to provide ongoing care by yourself/others in the future, not unnecessary details • Medical insurance companies request entire copies of medical records and will look for eg mental health diagnoses that weren’t disclosed on application form • Remember the Privacy Commissioner Privacy Principles: • Only collect the information you need • Only use it for the reason it was collected • Only share it if you have a good reason
• If you want to share info with us but not document it in your PMS: use our website referral form or phone
Myths • • • • •
Sexual assault is caused by the victim If it’s not rape (penile-vaginal penetration) it’s minor Men abused by women are lucky All male victims become perpetrators Sexual arousal during assault implies it was enjoyed and wasn’t abuse
• Examination can confirm whether or not someone is a virgin
• Hymens are not fragile structures that are broken with first vaginal penetration, they are a stretchy collar of tissue at the vaginal entrance
• Examination can tell whether sexual contact has occurred or not • Examination can tell whether or not sexual contact was consensual • At the end of the examination we will know if we have found the offender’s DNA
What is SAATS? • SAATS = sexual assault assessment and treatment services • Every DHB area of the country has a provider • Tautoko Mai is unique in that we hold SAATS, MSD and ACC contracts, enabling us to provide multiple services via one referral
• Funding is through ACC/Police/MoH • Training/accreditation/ongoing education is provided by MEDSAC (previously DSAC)
Our Tautoko Mai clinical/SAATS team • Clinical leader: Sandy Waller (Tauranga office) • Joint clinical lead: Melanie Johns (in Tauranga office on Tuesdays) • Office nurses: • Bridie (Tauranga) and Jenni (Whakatane)
• On call team • Doctors
• Melanie, Claire, Diana, Jen, Val, Lara (Tauranga) • Vasanthi, Marijke, Chame, Ruth (Whakatane) • Paediatricians: Viv, Kendall, Tracy, David, Jo, Sarah (Tauranga); Vasanthi sees paediatric cases in Whakatane
• Nurses
• Robyn, Beth, Bridie, Belinda, Laura, Lucy, Sarah (Tauranga) • Jenni, Lois, Julie (Whakatane)
• Clinic doctors
• Melanie, Jen (Tauranga) • Vasanthi, Marijke (Whakatane) • Paediatricians: Viv, David, Kendall, Jo (Tauranga)
Tautoko Mai Medical Services • Forensic examinations (within 7 days of assault) • All age groups • 0-13 years are seen by paediatric examiners
• Forensic sites in Whakatane and Tauranga • Site of exam depends on on-call team
• Can be “just in case” which allows 6 months for decision making re Police • The on call team have day jobs so it can be several hours until they are available • Average time taken for the examination is 3 hours • More on this later….
• Nurse clinics • Whakatane and Tauranga • Initial meetings • comprehensive triage process including HEADS and family violence screening • these are also done by our crisis social workers and counsellors
• STI and pregnancy screening/treatment after sexual assault • Forensic examination follow up • Medical management using standing orders
• Medical clinics • • • • • • •
Run by MEDSAC trained sexual assault clinicians All age groups Hour long appointments Paediatric clinics approx. monthly, adolescents/adults weekly Whakatane and Tauranga sites Triage process involves initial meeting and case discussion at MDT We work alongside the other services within Tautoko Mai (counselling/SW)
• Who to refer: • Those who would benefit from specialist clinician genital exam • Those with complex issues relating to their sexual assault including contraception, sexual health, pain etc
• Who not to refer: • Those who require specialist mental health assessment/intervention • Those who haven’t disclosed sexual assault – if high suspicion in young children we can discuss at MDT with paediatrician
• We have good working relationships with external services including ACC specialist pain and pelvic physiotherapists
How to refer to • OK to call for advice • <7 days since assault: phone to discuss ?forensic examination • 0800 2 B SAFE or 07 577 0512
• >7 days:
• eReferrals are now available – secure way to share medical info from your PMS • www.tautokomai.co.nz • “Contact us” -> “CLICK HERE for Agency/Professional Referral” • also secure but does not self-populate
• admin@tautokomai.co.nz
• Be aware that emails can be hacked moving between servers
• Advise the patient they will be contacted within 1-2 working days
• You can advise patient to phone us but many patients do not do so
Who else you can refer to: • Crisis team • Safe to Talk 0800 044 334 / Txt 4334 / on line chat • Police
• During working day there are dedicated adult sexual assault and child protection teams • Have a Family Harm team that meets regularly • Excellent information for sexual assault victims on their website
• • • •
Oranga Tamariki Women’s Refuge / Shakti Living Without Violence ACC counselling
Forensic examinations • Medical care takes priority over forensic examination • If medical care is provided please give patient copy of notes especially medications given • Give ECP prior to forensic examination if indicated and patient consents
• Exam includes therapeutic care • • • • •
Emergency contraception STI screening and prophylaxis, Safety assessment Medical certification Referral for counselling etc etc
• Purpose of the forensic examination:
• Document physical findings • Take samples, including for trace DNA, that might be useful for a Police investigation
• Most court cases do not rely solely on DNA evidence from the forensic exam
• The Police decide whether or not the Medical Examination Kit gets analysed by ESR • We do not get sent the results
• We are aware that the collection of some samples can be culturally sensitive
• All samples are taken with consent and we have plenty of time to discuss and explain • It is absolutely OK for a patient to decline any part of the examination or sample collection
Information required for forensic exam triage • Is the patient able to consent?
• Eg acute intoxication/serious incapacity due to mental illness or delirium • Consider deferring until can consent
• Are police involved or is the referral for a “just in case” exam • Relationship with alleged offender • • • •
partner/ex acquaintance/just-met stranger don’t know (no memory)
• The nature of sexual contact and activities since
• Eg if contact was touch/kissing skin and patient has showered several times vs • Penile-vaginal penetration with ejaculation in the last few hours, no shower
• ?strangulation/choking (more info later)
• If the assault was recent please help DNA conservation:
• No washing hands/showering • No eating/drinking (unless long delay expected and if so discuss with triage nurse) • Keep clothing/tampon etc
• If potential drug-facilitated sexual assault within last four days, and a delay to forensic: obtain a urine sample
• If potential offender DNA on genitals, provide clean gauze (sterile if possible) and ask patient to wipe with gauze prior passing urine • Place this in a paper envelope, seal, sign over seal, write date/time/legal name of patient and your own name • Collect urine in clean container and label as above • Give samples to Police or to patient to bring to forensic examination • If this is potentially critical evidence it needs a chain of custody process, keep in your sight until police collect it and you’ve signed the handover form
Strangulation is a red flag
• Strangulation itself is a red flag for future serious abuse • It is associated with a 7x risk of future homicide • Repeated strangulation/choking episodes causes head injury much like repeated concussion
Send to ED if strangulation has caused: • Loss of consciousness during the event • Recall may be vague
• Decreased LOC • confusion/excessive sleepiness
• Seizure during/since event • Poor balance • Persistent visual problems
• Difficulty breathing • Difficulty swallowing/talking • Swelling of tongue • Significant pain or visible injuries head/neck • Pregnant and PV bleeding • Vomited more than twice
Forensic examination statistics Total forensic exams Age: • 0-9 • 10-13 • 14-15 • 16-19 • 20-24 • 25-29 • 30-39 • 40-49 • 50-59 • 60+
2019 48 0 4 2 11 8 4 11 5 3 0
2020 (lockdown year) 35 1 1 2 6 13 4 3 4 0 1
2021 (Jan to May only) 25 1 0 2 3 8 2 2 3 1 3
• Just in case exams
2019 (48)
2020 (35)
2021 (25)
11
8
3
18 3 0 9 1 1 3 0
7 1 1 12 2 0 2 0
Ethnicity (self-identified on MER) – no easily retrieved stats for 2019 • Maori/NZ Maori/Maori+Euro • Maori+PI • Pacifica • Pakeha/European/“Nzer” • African/S African • Australian • Indian • Asian (excl Indian)
2020 (35)
2021 (25)
Residence (obtained from Medtech in 2020; homelessness not specifically recorded until 2021) • Tauranga/Mt M/Omokoroa 19 14 • Te Puke 2 0 • Whakatane 4 4 • Opotiki 0 2 • Other BOP 6 2 • Out of DHB area 2 2 • No address 2 0 • Homeless 1
• Associated strangulation • ?Drug-facilitated
2020 (35) 5 6
2021 (25) 6 5
ACC Sensitive Claims • ACC45 read code to use for all sensitive claims is SN571 (sexual abuse)
• This is because data extraction at ACC level has been challenging due to wide variety of codes being used –> likely under-reporting by ACC
• Do NOT put on a mental health diagnosis code • There is no longer a sensitive claim unit
• These claims are managed by Recovery Partners in the local offices • OK to put physical injuries on same ACC45
• The ACC45 can be useful as a nationally lodged document so if in several years time the client wants to engage in counselling it can be reopened and they won’t need to remember all the details
• If the patient requires time off work, do the ACC45 as an off work certificate but be aware that there may be no off work payment until the claim is accepted many months later • Consider concurrent WINZ form if they meet criteria
• “Declined” is a legal term used by ACC when a claim is not being actively managed • eg a person who is not ready for ACC counselling will have their claim “Declined” but that actually means it can be re-opened when they are ready to engage • In theory, ACC is now handling these conversations better but good to prepare your patient • It is OK to write on the form that the patient does not want to be contacted
Events covered by ACC Sensitive Claims •
Indecent communication with young person under 16
•
Sexual violation/Attempted sexual violation
•
Assault with intent to commit sexual violation
•
Inducing sexual connection by threat
•
Inducing indecent act by threat
•
Incest
•
Sexual connection/Attempted sexual connection/Indecent act with dependent family member
•
Meeting young person following sexual grooming
•
Sexual connection/Attempted sexual connection/Indecent act with child under 16
•
Indecent assault
•
Exploitative sexual connection/Attempted exploitive sexual connection/Exploitive indecent act with person with significant impairment
•
Compelling indecent act with animal
•
Assault on a child (specific section relates to female assaulting a child under 14)
•
Infecting with disease
•
Female genital mutilation
Trauma informed care • This acknowledges the impact of trauma, especially childhood trauma, on people’s lives. • Trauma in this sense is a deeply distressing or disturbing experience, interpreted as an overwhelming threat. The traumatised person was not able to control the situation. • It is not the event itself, but the individual’s experience of the event, and the meaning they make of it, that causes the trauma. • Complex trauma is repetitive and cumulative and generated by interpersonal interactions, often with someone from whom protection would be expected (eg living with a violent parent or being in an abusive relationship).
ACE scores • We are increasingly aware that childhood trauma has enormous impact on future physical and mental wellbeing • If you haven’t seen Nadine Burke-Harris’s TED talk on ACE scores I highly recommend that you watch it • ACE = Adverse Childhood Experience • Score of 1+ increases the likelihood of depression, drug/alcohol misuse and 50+ sexual partners. • Score of 2+ increases likelihood of smoking and obesity • Score of 4+ increases risk of stroke, IHD and cancer
• TIC requires a style of practice that GPs already understand and use. It is based in respect, trust and safety. • avoids inadvertent retraumatisation
• Be mindful of power and control dynamics that can mimic abusive relationships • Collaboration and shared decision making is crucial
• Viewing “difficult” clients as injured rather than flawed • “What’s happened to you?” rather than “What’s wrong with you?”
• Using strength based approaches • Being sensitive to how life experiences relate to health status, health behaviours and ability to communicate effectively…
• Crisis reactions are wide-ranging – there is no “normal” response • • • •
Dissociation is common/avoidance/denial Anger/confusion/despair Self-destructive behaviours Humour/laughter
• “Maladaptive behaviours”
Using drugs/alcohol used to managed stress Under or over eating as comfort, to change appearance, or be in control Anxiety/agitation due to constant hyperarousal Tendency to aggression due to inability to self-soothe/control emotions (fight/flight response) • Withdrawing/shutting down due to hypoarousal (freeze response) • • • •
• These initiated because they protect in some way against adversity • In the long term they may have significant impact on well-being • We need to be forgiving and empathetic
Ways to deal with toxic stress – for your patient and for you • Sleep • Exercise • Nutrition • Mindfulness • Healthy relationships
• Taha wairua
• Spiritual wellbeing
• Taha hinengaro
• Emotional/mental wellbeing
• Taha tinana
• Physical wellbeing
• Taha whanau
• Family wellbeing
• Whanaungatanga
• Family relationships
Look after yourself • Debrief safely • Ka Hono mentoring through Waikato Faculty RNZCGP • Psychology/professional supervision funded by MPS • EAP • Professional supervision