sexual violence in adolescents 2012 tadulako
TRANSCRIPT
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Sexual Violence in
AdolescentsYudha Nurhantari
2010
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• Tujuan
• Memahami pengertian kekerasan isik danseksual
• Memahami kepentingan medikolegal
• Memahami prosedur dan etikapemeriksaan
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!ntroduction
• Sexual "iolence is a glo#al pro#lem
• Majorit$% &omen men and children #oth
sexes• Negati"e impacts on health%
1' (eproducti"e and sexual health %
un&anted pregnanc$) ST!)*!V) adoption orisk$ sexual #eha"iors
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• 2' mental health serious+long lasting%
depression) su#stance a#use) post
traumatic stress disorder) suicide'
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Sexual "iolence
• a term co"ering a &ide range o acti"ities)
including rape,orced sex) indecent assault
and sexuall$ o#sessi"e #eha"iour
• a&are o the legal deinitions o sexual
"iolence &ithin their o&n jurisdiction the
age o consent and marriage'
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-einition ./e&kes et al)2002
• an$ sexual act) attempt to o#tain a
sexual act) un&anted sexual comments or
ad"ances) or acts to traic &omens
sexualit$) using coercion) threats o harm
or ph$sical orce) #$ an$ person
regardless o relationship to the "ictim3'
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4alse agreement to sexual
acti"it$%• threats o ph$sical "iolence)
+ threats o &ithholding #eneits .such as a
promotion at &ork or a good grade)+ ps$chological pressure or #lackmail
• una#le to gi"e consent% a mental disa#ilit$
incapacitated due to the eects o alcoholand,or drugs)
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Men as victims of sexual
violence
• Men most commonl$ experience sexual
"iolence in the orm o %
5 recepti"e anal intercourse65 orced mastur#ation o the perpetrator6
5 recepti"e oral sex6
5 orced mastur#ation o the "ictim'
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Sexual 7ences
• According to 89*:) coitus ma$ occur&ithin .2;;or non marital.2;ithin marital% injured or caused death to
the underage &ie• TheMedico legal purpose, e"idence %
1' signs o coitus
2' signs o "iolence ?' estimation o age
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Sign o coitus
@oitus is penis penetration .completel$or partiall$into "agina'The e"idence are depends on %
1' sie o the penis 2' degree o penetration ?' shape and elasticit$ o h$men
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Djaculate
• -etect the sperm the #est e"idence
• -etect the component % :?0) acidphosphatase en$me) kholin) spermin)
• The a#sence o ejaculate %
1' no coitus
2' coitus &ithout ejaculation
?' coitus using condom
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Time Dstimation
• Sperm % ound aging'
@omplete healing % =+10 da$s
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Signs o Violence
• Eite marks) hematoma) a#rasion
• Mouth) lips) neck) #reast) &riest) emur)and genitalia
• Need toxicological examination chemical "iolence
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Age estimation
• 89*: art' 2;< and 2;= under 12 orunder 1B $o
• ph$sical de"elopment) secondar$ sexual
signs) teeth) #one) cranial suture usion• Marrige competence
#iolog$% menarche
la& % 1C $'o'
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*omosexual
• a sexual oences under age .89*:2F2 or married histor$
• Dxamination
1' Male % age estimation) ejaculate) anus.unnel shape) m' sphincter ani relaxed'
2' 4emale % age) signs o genital
manipulation #$ hands or instrument
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Assessment and examination
• o#taining inormed consent
• A medical histor$
• a top+to+toe3 ph$sical examination• a detailed genito+anal examination
• recording and classi$ing injuries
• collection o indicated medical specimensor diagnostic purposes
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!normed consent
• is a central issue in medico+legal matters1'Dxamination) including examination o the genitalia andanus'
• 2' @ollection o specimens or medical in"estigations to
diagnose an$ medical pro#lems'• ?' @ollection o specimens or criminal in"estigation'
•
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medical histor$
• Relevant medical/surgical/psychiatric
history
• Relevant gynaecological history
• Allergies
• Medications/immunization status
• History of offence from patients andother parties
• Current symptoms
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descri#ing &ounds
• consider% site) sie) shape) surrounds)
colour) contours) course)contents) age)
#orders and depth'
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>ound classiication
• A#rasion% disruption o the outer la$er o theskin'
• Eruise% an area o haemorrhage #eneath theskin'• Gaceration% splitting or tearing o tissues
secondar$ to #lunt trauma'• !ncision% a cutting t$pe o injur$ &ith .usuall$
clear) regular margins'• Sta#% a &ound o greater depth than length)
produced #$ a sharp o#ject'
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Step 1
• patients general appearance and demeanour'
• Start &ith the patients hands6 this &ill reassure
the patient'
• Take the "ital signs)
• !nspect #oth sides o #oth hands or injuries'
7#ser"e the &rists or signs o ligature marks'
Trace e"idence ma$ need to #e collected .some jurisdictions reHuire ingernail scrapings'
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Step 2
• !nspect the orearms or deense injuries%
#ruising) a#rasions) lacerations or incised
&ounds'
• An$ intra"enous puncture sites should #e
noted'
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Step ?
• The inner suraces o the upper arms and
the armpit or axilla need to #e careull$
o#ser"ed or signs o #ruising'
• Victims &ho ha"e #een restrained #$
hands oten displa$ ingertip #ruising on
the upper arms '
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Step <
• !nspect the ace' Elack e$es and the signs o
#leeding nose
• The mouth should #e inspected careull$)
checking or #ruising) a#rasions and lacerationso #uccal mucosa'
• :etechiae on the hard,sot palate ma$ indicate
penetration'
• @heck or a torn renulum and #roken teeth'
• @ollect an oral s&a#) i indicated'
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Step B
• !nspect the ears and #ehind the ears) or
e"idence o shado& #ruising the ear has
#een struck onto the scalp'
• 9se an otoscope to inspect the eardrum'
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Step C
• Ientle palpation o the scalp ma$ re"ealtenderness and s&elling) suggesti"e ohaematomas'
• *air loss due to hair pulling during the assaultma$ cause large amounts o loose hair to #ecollected in the glo"ed hands o the examiner6alternati"el$) a gentle com#ing ma$ reco"er an$loose hair'
• Dlectrostatic orces can) ho&e"er) cause largeamounts o loose hair to #e retained in the headuntil the patient next takes a sho&er or #ath'
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Step =
• Eruising on the neck can indicate a lie+
threatening assault' !mprint #ruising ma$
#e seen rom necklaces and other items o
je&eller$ on the ears and on the neck'
• Suction+t$pe #ruising rom #ites should #e
noted and s&a##ed or sali"a #eore #eing
touched'
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Step ;
• The #reasts and trunk should #e examined &ith
as much dignit$ and pri"ac$ as can #e aorded'
• !n"estigate the presence injur$'
• Ereasts are reHuentl$ a target o assault andare oten #itten and so ma$ re"eal e"idence o
suction #ruises or #lunt trauma'
• ! the #reasts are not examined) the reasons ornot doing so should #e documented
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Step F
• The patient can then #e reclined or an
a#dominal examination)
• an inspection or #ruising) a#rasions)
lacerations and trace e"idence'
• A#dominal palpation should #e perormed
to exclude an$ internal trauma or to detect
pregnanc$'
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Step 10
• !nner thighs are oten the target o ingertip
#ruising or #lunt trauma .caused #$ knees'
• There ma$ #e a#rasions or lacerations to the
knee and the eet• !t is important to inspect the ankles .and &rists
"er$ closel$ or signs o restraint &ith ligatures'
• The soles o the eet should also #e examined'
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Step 11
• Dxamine the #uttocks and o the #ack o
the legs
• e"idence should #e collected &ith
moistened s&a#s .or semen) sali"a)
#lood or t&eeers .or hair) i#res) grass)
soil'
• -ocumented the presence o tattoo
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• The use o >oods lamps to detect semenon areas o skin &here this is suspected is
no longer recommended clinical practice do not luoresce semen as &ell aspre"iousl$ thought) and more relia#le
methods o detecting semen .e'g' s&a#sshould thereore #e used
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The genito-anal examination
• in the lithotom$ position
• make the patient eel as comorta#le and
as relaxed as possi#le
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Ienital examination
• The external areas o the genital region andanus should #e examined) !nspect the monspu#is'
• The "aginal "esti#ule should #e examinedpa$ing special attention to the la#ia majora) la#iaminora) clitoris) h$men or h$menal remnants)posterior ourchette and perineum'
• A s&a# o the external genitalia should #e taken#eore an$ digital exploration or speculumexamination is attempted
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Step 2
• ! an$ #right #lood is present) it should #e
gentl$ s&a##ed in order to esta#lish
• its origin) i'e' &hether it is "ul"al or rom
higher in the "agina'
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Supporting examination
• Seminal detection% :?0)
• Sperm detection
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• collection o orensic specimens
• la#eling) packaging and transporting oorensic specimens to maintain
• the chain o custod$ o the e"idence
• therapeutic opportunities
• arranging ollo&+up care
• storage o documentation
• pro"ision o a medico+legal report
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Ethical issues
• Autonomy 'The right o patients to makedecisions on their o&n #ehal' All steps taken inpro"iding ser"ices are #ased on the inormedconsent o the patient'
• Beneficence. The dut$ or o#ligation to act in the#est interests o the patient'
• Non-maleficence' The dut$ or o#ligation to a"oid
harm to the patient'• Justice or fairness' -oing and gi"ing &hat is
rightull$ due'
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Diagnostic tests specimen
collection and forensic issues
• The primar$ aim o a orensic examination
is to collect e"idence that ma$ help pro"e
or dispro"e a link #et&een indi"iduals
and,or #et&een indi"iduals and o#jects orplaces'
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• collect careull$) a"oiding contamination6
• collect specimens as earl$ as possi#le6 =2 hoursater the assault the "alue o e"identiar$ material
decreases dramaticall$6• la#el all specimens accuratel$6
• dr$ all &et specimens6
• ensure specimens are secure and tamper proo6
• maintain continuit$6
• document details o all collection and handlingprocedures'
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Ta!ing a "lind vaginal s#a"
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Ho# to perform a s#a" of the
mouth for spermatozoa
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• -ocumented all inding to the medical
record
• Visum et (epertum projustia) &ritten
e"idence
• Dxpert &itness explain in the court
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!nanticide
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Tujuan
• Memahami pengertian inanticide
• Memahami kepentingan medikolegal
• Memahami tujuan pemeriksaan
• Memahami memperkirakan maturitas)umur #a$i,inant
• Memahami perkiraan #a$i lahir mati atau
hidup'
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!nanticide
According to 89*: ?
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The role o orensic pathologist
• Assist in identi$ing the mother .i she isunkno&n
• Dstimate the maturit$ o the child
• Dsta#lish &hether the child &as ali"e atthe time o #irth
• To determine the cause o death natural
or unnatural
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Dstimation o maturit$
4ull term .
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• Testes are palpa#le in the scrotum6 "ul"alla#ia closes the "aginal opening
• The um#ilicus is mid&a$ #et&een
xiphisternum and pu#is• -ark meconium present in the large ints'
• *aase .@ro&n+heel and Streeter .@ro&n+
coccigeus rule
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Age (month) Haase Streeter1 1x1=1
2 2x2=4 0,23
3 3x3=9 6,10
4 4x4=16 11,60
5 5x5=25 6,40
6 6x5=30 20,80
7 7x5=35 24,70
8 8x5=40 28,30
9 9x5=45 32,10
10 10x5=50 36,20
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>as the child ali"e at #irth J
• *$drostatic test) loating the lungs in&ater' Sink still#orn ) loat #reathed
• @ollapsed al"eoli had not #reathed
• -etection o air in the stomach• :ro#lems% putreaction) resuscitation
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The cause o death
• Natural % diseases) atal a#normalities)pre+immature age
• 9nnatural death%
1'Suocation direct application to theace to close the nose and mouth
2'Strangulation
?'*ead injur$% thro&ing) dashing