Rape and sexual assault

Child abuse and neglect

Sodomy
Domestic violence
Introduction
• Integrated and comprehensive multiagency service center
established in all Emergency and Trauma Departments (ETD) of the
Ministry Of Health for the management of survivors of domestic
violence, sexual assault, child abuse and neglect.
• The OSCC shall be suitably located to provide full privacy and
confidentiality.
Multidisciplinary
Emergency and Trauma Department Medical Social Services

 Obstetrics and Gynecology Department Counseling Unit

Pediatric Department Social Welfare Department

Surgical Department Royal Malaysian Police

Forensic Department Relevant Non-Governmental Organizations

(NGOs)

Psychiatric Department
Role of ED in OSCC case

• Emergency and Trauma Department

• Responsible for the initial management of OSCC cases. (triage, history taking,
general physical examination, clinical stabilization, treatment of injuries,
evidence collection other than that obtained from vaginal examination)
• Evidence obtained in the ED shall be managed and handed to the Police
Officer with preservation of chain of evidence.
• Coordinate management of OSCC cases including referrals to relevant teams
Note
• All alleged rape and sexual assault survivors shall be referred, managed and followed
up by the attending specialist from the Obstetrics and Gynecology (O&G)
Department.

• All alleged child abuse and neglect cases shall be referred, managed and followed up
by the Pediatric Department, and where available, to a Suspected Child Abuse
andNeglect (SCAN) team.

• All sodomy survivors shall be referred to the Surgical Department.

• Survivors shall be referred to a counselor, psychologist or psychiatrist when necessary.

Fresh case, cold case
• For alleged sodomy cases, acute(fresh) cases are defined as those up
to 120 hours from the time of incident (Willcort, 1982).
• All fresh cases shall be seen urgently in OSCC.
• Cases that present more than 120 hours from the last incident are
considered “cold” cases.
• For alleged rape and child sexual abuse, acute (fresh) cases are up to
72 hours from the time of incident. Cases that present more than 72
hours from the last incident are considered “cold” cases.
One Stop Crisis Centre
(OSCC)
Rape and sexual assault
 RAPE
Rape is dealt under section 375 of the Malaysian Penal Code. According to this section a man is said to commit
“rape” when he has sexual intercourse with a woman under the following circumstances:

1. Against her will. This means that the women is capable of giving her consent but consciously rejects sexual
intercourse and is forced into it.
2. Without her consent. Sexual intercourse may take place without the women’s consent because she is incapable of
giving her consent.
3. With her consent when consent has been obtained by threat to her or her family or persons.
4. With her consent through deception.
5. With her consent, when at the time of giving such consent, she is unable to understand the nature and
consequences of that to which she gives consent.
6. With or without her consent, when she is under sixteen years of age (statutory rape).
History taking
• Events preceding the assault
• Obs/gyn history
• Sexual history
• Medical / surgical history
• Social history
Examination
• The purpose of the examination is to assess and treat physical injuries, as well as
collect evidence submersible in court proceedings.
• Wounds, extra genital trauma (mouth, throat, wrists, arms, breasts and thighs)
• Genital examination

• Management
• Swabs (HVS, LVS)
• Blood ix
• Emergency contraception is medically warranted. (Levonorgestrel 1.5 mg stat / Copper
Intrauterine Device- insertion within 5 days from incident)
• Tetanus prophylaxis
• HIV prophylaxis
Cases requiring admission
• Survivors requiring medical management for acute physical and emotional
trauma.
• Concern for personal safety of survivor. Admit if case is seen after office
hours to be referred to the Medical Social Worker/Social Welfare
Department/NGOs for shelter and protection.
•  All suspected child sexual abuse after discussion with the SCAN
team/Pediatrician/Adolescent Pediatrician. All suspected intra-familial
child sexual abuse or those involving young children below 12 years of age
must be admitted for protection and more detailed history taking.
• Survivors who are pregnant and present with complications due to
pregnancy.
• Survivors requiring acute management of vaginal trauma requiring
examination under anesthesia (EUA).
FORENSIC ISSUES IN RAPE & SEXUAL ABUSE
❏ Forensic evidence is best obtained from physical examination as soon as possible after the incident, and
should not be delayed if it is still within 72 hours post incident.
❏ Each item of clothing worn during the incident to be packed in bags provided in OSCC. It has to be labeled
correctly by the attending OSCC nurse, with survivor’s name in the presence of the investigating Police Officer
and the attending doctor.
❏ Forensic swabs for DNA are to be taken before swabs for bacteriological examination.
❏ Forensic swabs should be thoroughly air dried before sealing in the kit.
❏ Police Officer should be available before examination of alleged rape cases and for transporting specimens
to the Chemistry Laboratory. Note: Specimens for confirmation of sexually transmitted disease, HIV or
Hepatitis will be sent to the Virology Laboratory. If chain of evidence is needed to be maintained, then the
Police Officer shall be responsible to send the specimens.
Forensic timescales (persistence of DNA)

➢ Vaginal penetration up to 7 days.

➢ Anal penetration up to 72 hours.

➢ Oral penetration up to 48 hours.

➢ Bite marks 48 hours or longer.

One Stop Crisis Centre
(OSCC)
Sodomy
 Definition
• Sodomy is defined as sexual intercourse between 2 persons by introduction of penis
into the anus of another person.

• The Malaysian Penal Code (Kanun Keseksaan) section 377(a) defined sodomy as “any
person who has sexual connection with another person by introduction of penis into
the anus or mouth of another person is said to commit carnal intercourse against the
order of nature”.

• In section 377 (c) when the above act committed without the consent or against the
will of another person, or by putting the other person in fear of death or hurt to the
person or any other person.

• In section 377 (CA) the above offences is committed by introduction any objects into
the vagina / anus of the other person without the other person’s consent.
Triage
• Acute cases should be seen within 90 minutes upon arrival at the
OSCC.
• By Malaysian definition, acute (fresh) cases are up to 120 hours from
the time of incident (Willcort, 1982).
• If more than 120 hours have passed since the assault, a complete
physical examination should still be conducted to examine for injuries
to the body and the genitalia, to offer treatment and to provide
information for support resources.
Examination
• A full evidentiary examination includes:
• Collecting clothing; samples from under the survivor’s nails; pubic and
scalp hair samples.
• Blood taking (e.g.: for DNA, alcohol, toxicology, VDRL, gonorrhea, HIV
etc) , urine sample
• Cotton swabs taken from the skin, sites of injury (bite marks), and bodily
orifices.
• Physical examination proceeds beyond the standard inspection of the
anus and the perianal area to include a careful examination of the distal
anus using an anoscope / proctoscope or flexible endoscope.
One Stop Crisis Centre
(OSCC)
Child abuse and neglect
Definition
• Child ( <18 years old)
• Constitutes all forms of physical abuse,
and/or emotional ill-treatment,
sexual abuse,
neglect or negligent treatment or
commercial or other exploitation,
• resulting in actual or potential harm, to the child’s health, survival,
development or dignity in the context of a relationship of
responsibility, trust or power.
The medical officer in the Emergency Department has to :-
• Treat any life-threatening condition
• Do an overall examination and stabilize the patient
• Take care so as not to tamper with any possible forensic evidence, such as cleaning up
the patient before the medical examination
• Examine the child together with the relevant doctor from the specialist team, e.g. from
pediatric, gynecology, surgery, forensic departments
• Document all examination findings in the patient’s notes
• Take the relevant specimens, ensure they are labeled correctly with the patient’s name
and other particulars and passed to the police
History taking (Red flags!)
● Inconsistent / vague history
● Injuries inconsistent with history
● Delay in seeking medical attention
● Child disclosing history of abuse
Non accidental injuries
Bruises
Burns
Fractures
Shaken baby syndrome
● Abrupt acceleration and deceleration with rapid head rotation.
● Child usually slammed or thrown down at the end.
● Occurs in less than 3yo, usually <1yo
● Symptoms may be non specific: Poor feeding, vomiting, irritability,
lethargy, FTT, hypotonia, pupils sluggish
● Some may only present when severe
● symptoms arise ( Seizures, apnea,coma)
Cases That Will Require Admission Are :-

■ Where the child requires medical treatment

■ Where safety is a concern (as in intra-familial abuse or other concerns
about physical safety or neglect or lack of supervision)
■ All cases of child sexual abuse
■ Presentation after office hours to enable review by the SCAN Team and to
ensure a satisfactory initial assessment and safe placement of child
JKM Notification
■ Doctors are mandated by law to report to JKM (use Borang 9).
This should be accompanied by a report giving reasons for suspicion or
diagnosis of child abuse. This may be followed up subsequently by a more
comprehensive medical report in complicated cases.
The health, welfare and protection of the child take precedence over other considerations. To do
this, health staff should ensure that :-
■ Competent evaluation takes place, including evidential history and careful expert medical
assessment with collection of objective forensic evidence
■ minimize trauma to the child from multiple questioning or examinations (especially of the
genitalia)
■ work with the other agencies to ensure that appropriate decisions are made concerning legal
action and protection measures
■ Assessment of psychological needs is made
■ There is provision of therapy and follow-up
■ The best possible relationship between child and non offending parent is maintained
One Stop Crisis Centre
(OSCC)
Domestic Violence
• Domestic violence (amendment) Act 2012 is the
commission of one or more of the following acts:

• Willfully or knowingly placing or attempting to place the victim in fear

of physical injury;
• Causing physical injury to the victim by such act which is known or
ought to have been known would result in physical injury;
• Compelling the victim by force or threat to engage in any conduct or
act, sexual or otherwise from which the victim has right to abstain;
• Confining or detaining the victim against the victim’s will;
• Causing mischief or destruction or damage to property with intent to
cause or knowing that it is likely to cause distress or annoyance to the
victim;
• Causing psychological abuse which includes emotional injury to the victim;
• Causing the victims to suffer delusions by using any intoxicating substance
or any other substance without the victim’s consent or if the consent is
given, the consent was unlawfully obtained; or
• In the case where the victim is a child, causing the victim to suffer
delusions by using any intoxicating substance or any other substance; and
• By a person whether by himself or a third party, against:
• his or her spouse
• his or her former spouse
• a child
• an incapacitated adult
• any other member of the family
 History taking
• The following indicators suggest the presence of domestic violence:

• Avoid confronting
• Injuries inconsistent with the stated history.
• Diminished self-image, depression, or suicide attempts.
• Self-abuse.
• Frequent Emergency and Trauma Department or doctor’s office visits.
• Symptoms suggestive of substance abuse.
• Self-blame for injuries.
• Partner insists on being present for interview and examination and
monopolizes discussion.
TAKE HOME MESSAGE
Every cases of OSCC has same workflow, need proper history taking and
documentation - medicolegal.
Physical examination should be done thoroughly by ETD doctors as we are
the first team to attend to patient/victim EXCEPT genital part
Victims are to be attended at only one isolated, closed place by all
agency/team to ensure security
Need further readings on CPG Malaysia for more understandings and to see
forms needed to fill up while attending OSCC cases - there’s a template for
history taking and physical examination.