RAPE - a crime of violence and humiliation of the victim expressed through sexual means.

y y Is the perpetration of an act of sexual intercourse with a female against her will is overcome by force, fear of force, drugs or intoxicants. Refer to the insertion of the penis into the mouth, vagina, and anus of a victim.

RA 8353- Anti Rape Law TYPES OF RAPE 1. Attempted rape assault on a woman in which oral, vaginal or anal penetration is intended but does not occur 2. Statutory rape- act of sexual intercourse with a girl under age of consent. NOTE: sexual intercourse with a minor is rape, even with consent of the minor. 3. Incest- rape of a child by relatives MOTIVES FOR RAPE/SEXUAL ASSAULT 1. Anger rape- means of expressing range, hatred, and contempt toward the victim wronged him at some point of his life, means of retaliation. More of physical brutality, not sexually aroused 2. Power rape- attempt to prove manhood or masculinity. Finds little or no gratification and looks for another victim. 3. Sadistic rape- feels the need to inflict pain and torment on his victim to achieve sexual satisfaction. Sexual areas become the focus of injury. 4. Impulsive/opportunistic rape- occurs in conjunction with another antisocial act, such as during robbery. SUBCLASSIFICATION OF RAPE 1. 2. 3. 4. 5. 6. Blitz rape- unexpected surprise attack occurs in the absence of prior interaction with the victim. Confidence- offender and victim have had a prior interaction Marked victim rape- offender assaults a woman he has been acquainted with in some ways. Accessory to sex rape- inability of victims to give consent. Date rape- exploitation of an individual s friendliness during a date. Gang rape- group of assaulters taking turns raping the victim

RAPE TRAUMA SYMDROME (RTS) [refer to book] y Refers to signs and symptoms after rape

Physical effects: somatization, headache, fatigue, dizziness etc. Psychological effects: anxiety, fear, phobia, depression etc. 2 PHASES OF RTS 1. Acute Phase (0-2 weeks after rape) y Shock, numbness and disbelief y Anger, guilt, embarrassment, denial y Might appear calm, self-contained (means they know the rapist and have been threatened) y Might appear hysterical , restless y Might cry a lot, wish for revenge y Complains of disorganization in her life, somatic complaints. 2. Long Term Reorganization Phase (2 weeks or more) y Intrusive thought of the rape throughout the day and night y Flashback of the incident (re-experiencing the traumatic event) y Dreams with violent content y Insomnia, mood swings, crying spells, depression y Increased motor activity (moving new residence, taking trips, changing phone numbers, staying with friends). 1

Fear or phobia can develop 1- 6 phobias (indoors, outdoors, crowds, being alone, people around, sexual activity)

RAPE TRAUMA SYNDROME (RTS) Reaction- is a complex stress reaction to rape; victim usually unable to describe or discuss the rape. y y y y y y y Abrupt changes in relationship to men Unable to resolve feelings about sexual assault Nightmares; suicidal behaviour, somatization Increasing anxiety during interview, silence, blocking Marked change in sexual behaviour Sudden onset of phobic reactions No verbalization of the occurrence of rape

NURSING DIAGNOSIS y y y y y Ineffective individual coping Fear Anxiety Body image disturbances Disturbances in self-concept

PRIORITY CARE OF RAPE VICTIM y Preservation of EVIDENCE

NURSING INTERVENTIONS: 1. Follow hospital protocol y Don t shower, bathe, douche or change clothing 2. Provide privacy and comfort 3. Assist pelvic exam to collect evidence y Hair, semen, fingernails scraping, fibers, stains. Preserve any evidence. 4. Treat physical injuries y Nursing diagnosis: acute pain 5. Do not leave the person alone 6. Ensure confidentiality 7. Encourage the person to talk; listen empathically. 8. Emphasize that the person did the right thing to save her life 9. Encourage expression of negative emotions and feelings 10. Crisis intervention and short term counselling 11. Antianxiety, prophylactic antibiotics, pills 12. List of community and legal resources 13. Arrange for support follow-up: individual therapy, support groups SPOUSE/PARTNER ABUSE/BATTERED WIFE SYNDROME y y y Mistreatment or misuse of one person by another in the context of an intimate relationship Intimate Partner Violence (IPV) Cycle of violence characterized by wife beating of the husband, humiliation and other forms of aggression

BEHAVIOR OF DOMESTIC VIOLENCE 1. Intimidation- using looks, actions, gestures to instil fear in the victim 2. Threats- threatening to do something harmful to children, self, pet. 2

3. 4. 5. 6. 7. 8.

Sexual abuse- forcing unwanted sexual activity Isolation- controlling victim s contact, activities. Emotional abuse- put-downs, attacking victim s self confidence Use of children- using custody/visitation rights as a way to control or harass victim. Male privilege- expected to be waited on. Economic abuse- refusing to share money with or provide financial supports.

CYCLE OF ABUSE AND VIOLENCE y y y y Abuse is not constant nor it is random. There is ambivalence an imbalance of power in the relationship. Abuse occurs in cycle and has 3 phases that vary in time and intensity. The last stage is the one that convinces the woman to stay in the relationship.

1. TENSION BUILDING PHASE y Involves minor battering incidents- arguments, stony silences, and complaints from the husband. 2. ACUTE BATTERING PHASE y More serious form of battering- hitting, and serious physical injuries, loss control of behaviour due to blind rage 3. AFTERMATH/HONEYMOON PHASE y Abuser exhibits feelings of remorse, begs forgiveness, promise not to re- abuse, states that he cannot live without the partner; spouse believes him and thinks he will change. STARTS ALL OVER AGAIN Dangerous and victim often killed.

CHARACTERISTICS OF ABUSIVE HUSBAND y y y y Believes his wife belongs to him (like property), increasing violence if she shows sign of independencegetting a job. Strong feelings of inadequacy and low self esteem, poor problem solving and social skills. Emotionally immature, needy, irrationally jealous, and possessive. Jealous of his wife s attention to their children or may beat both his children and wife.

WHY WOMEN STAY AS LONG AS THEY DO y y y y y y y y y y y y Economic dependence Fear of emotional damage to children because of without a father Fear of greater physical danger to themselves and their children if they attempt to leave or have partner arrested Fear of losing custody to children Fear of retaliation from partner or partner s family Fear of involvement in court process Being in a state of denial and living a secret Believe that partner will change Ambivalence and fear over making formidable life changes and increased responsibility Believes the abuse is her fault Guilt about failures of marriage or relationship PLUS: She still loves him.

SEXUAL HARASSMENT y Unwelcome sexual advance or conduct on the job that creates an intimidating or offensive working environment. 3

STALKING y Pattern of unwanted communication such as harassing coupled with a threat to do harm (telephone calls, letters, e-mail, placing notices in the media, approach or follow the victim.

SEXUAL COERCION y Incidents in which one person dominates another by force to perform sexual act.

NURSING DIAGNOSIS y y y y y y y y y y y Ineffective individual coping Risk for injury Ineffective role performance Anxiety Fear Disabled family coping Powerlessness Disturbed body image Acute or chronic pain High risk for violence: self directed or directed at others Impaired social interaction

NURSING INTERVENTIONS y y y y y Be alert for signs of abuse Ask directly if abuse is occurring Identify the abusers behaviour as abusive: tell victim that they do not cause and deserve the abuse Acknowledge the seriousness of the abuse; convey message that you are willing to help and there are resources available Give the victim a list of resources; shelter, police, legal, financial help

ALLOW TO CHOOSE OWN OPTIONS y y y y y y y Tell the abuser to stop and get help Help the victim to develop an escape plan Do not disbelieve or blame the victim Do not get angry with the victim Do not refuse to help if victim is not ready to leave the abuser Do not align with the abuser against the victim Do not push the victim to leave the abuser before ready

 When the abused woman does leave her partner, the problems are not over. Prepare the woman about possible tactics that the man may employ to take advantage of her again- intimidation, apologies, gifts, promises, threats, entering counselling or religion, use other influential persons.  Decrease co-dependency behaviors  Resolve grief  Support groups: turning point and breaking free  ALERT: Obtain a restraining order- protection order that legally prohibits the abuser from approaching or contacting her.

Do s and Dont s of Working with Victims of Partner Abuse

Dont s
Don t disclose client communications without the client s consent.

Do s
Do ensure and confidentiality. maintain the client s

Don t preach, moralize or imply that you doubt the client.

Do listen, affirm, and say I am sorry

Don t recommend couple s counselling

Do recommend a support group or individual counselling

Don t direct the client to leave the relationship

Do identify community resources and encourage the client to develop a safety plan

Don t take charge and do everything for the client

Do offer to help the client contact a shelter, the police, or other resources

Don t minimize the impact of violence

Do express I m concerned for your safety

Don t express outrage with the perpetrator

Do tell the victim and respected

You have the right to be safe

Don t imply

CHILD ABUSE y Maltreatment, intentional, injury of a child (physical, emotional, sexual, neglect or exploitation of a child under the age of 18 years by a parent, caretaker or other person. Incidence: y y y y All socioeconomic levels Both genders All ages- youngest 6 months old Every geographic area

RA 9231- law that protects the child - Special protection against child abuse and exploitation and discrimination y y y y y Every racial, religious and educational background Over 1 million cases reported each year Majority of abused children are under 4 years old About 70-80% of abuse is by parents More common in nuclear families and blended/step families/ remarried families

CAUSES: y y y Familial factors- child abuser are people who themselves been abused as children (multigenerational pattern of child abuse, nuclear family structure) Individual factors- individuals with unmet needs, emotionally immature and have limited control of impulses. Societal factors- family violence is a reflection of a society that endorses violence as a means of dealing with frustrations and achieving goals (social influence that V-acceptable)

VULNERABLE CHILD y y y y Product of unwanted pregnancy, an older child who becomes too soon after marriage or an unplanned late child. Early prolonged parent-child-seperation premature birth, prolonged illness Low birth weight baby Difficult to care for child- sickly, hyperactive, colicky (palahibi) , deformed, retarded

CHARACTERISTICS OF ABUSIVE PARENTS y y y y y y y y y y Come from violent families Were also abused by their parents Have minimal parenting knowledge and skills- basic care or child development Emotionally immature, needy, and .. Views their children as property belonging to abusive parent Does not value the children as people with rights and feelings Feels the need to have children to displace his/her own faults and disappointing childhood Isolated- few support system or none Negative attitude towards the management of the abused They involve in crisis situation (unemployment) 6

y y y y y y y

History of drug or alcohol abuse They perceive child as bad or evil Parents with poor impulse control Family authoritarianism- raise children as they were raised by their own parents Violent temper outburst Poor coping skills Rigid, unrealistic expectations of child s behaviour

TYPES OF CHILD ABUSE 1. Physical abuse y Abuse in a form of inflicting pain- bodily abuse y Results from unreasonable severe corporal punishment y Intentional, deliberate assaults on children (shaken baby syndrome) Physical indicators y y y y y y y y y Pattern of bruises/ welts (red part that has been hit)- belt buckles, teeth marks (posterior side of the body, face) Burns (cigarette, scald, rope)- buttocks, palms of hands, soles of feet, ankle, wrists Unexplained fractures and dislocations (3 years and below- inconsistences or injury vs. explanation) Lesions resembling bites or fingernail marks Areas of baldness from hair pulling Injuries in various stages of healing Healing revealing old fractures Reports injury by parent Afraid to go home

MUNCHAUSEN S SYNDROME BY PROXY y Systematic fabricationor deliberate causes of illness or injury to the child to gain sympathy or attention for themselves. (e.g. giving lots of food then laxative to go to the hospital to say the child has diarrhea)

SHAKEN BABY SYNDROME y A form of child abuse that cause brain injury to infants as a result of adult s loss of control and violent shaking of a child who has been crying incessantly. Subdural hematoma, cerebral edema, blindness- retinal haemorrhage, cerebral palsy and cognitive impairment.

Behavioral indicators y y y y y y y Fear of parents, fear of physical contact with adults. Extreme behaviour- passivity/aggressiveness, crying very often/ very seldom Regressive behaviour- thumb sucking, enuresis Truancy from school or tardiness Excessive compliance to avoid confrontations Violence to other children or animals Demanding behaviour

Environmental indicators y Severe parental problems: drug addiction, alcoholism, mental illness, crisis, social isolation of family.

SEXUAL ABUSE y Sexual acts performed by an adult on a child younger than 18 years. 7

y y y

Include incest, rape, sodomy performed directly by the person or with an object. Oral- genital contact and acts of molestation: rubbing, fondling of child s genitals, or exposing the adult s genitals- exhibitionism. Commercial exploitation: making, promoting, selling pornography involving minors to participate in obscene acts.

Physical indicators y y y y y Fear of being touched Difficulty of walking or sitting Preoccupation with sexual organs of self or others Sexual promiscuity or prostitution Delinquency; truancy; running away; acting out

Terminology of Child Sexual Abuse 1. Sexual misuse of a child- sexual activity that is inappropriate because of the child s age, development, and role within the family unit, fondling, genitals, manipulation, voyeurism or exhibitionism 2. Rape- refers to actual penetration of an orifice of a child s body during sexual activity. Oral penetration most frequent type. 3. Incest- sexual intercourse, sexual behaviors that occur between family members who are so closely related as to be legally prohibited from marrying one another because of consanguity (blood relatives) y y y y Signs of Incest y y y Low self esteem, sexual acting out, mood changes, sudden low performance in school. Parent spends inordinate amount of time with child, especially in room late at night, very attentive to child Child is apprehensive/ fearing sexual act/ retaliation Often father- daughter relationship (biological/ stepfather) but can be father son as well as motherson. Child is made to feel special ( it is our special secret ); gifts given. Favouritism (becomes intimate friend/sex partner replacing mother/ or other parents) Serious boundary violations and no safe place for child (child s room used for bathing, dressing etc.)

NEGLECT y y y y Malicious or ignorant withholding of physical, emotional or educational necessities for the child s wellbeing. Lack of provision of those things which are necessary for the child s growth and development Most prevalent type of maltreatment Refusal to seek health care or delay doing so (financial constraint)

Physical indicators y Weight loss, inadequate nutrition or unkempt and lack of adequate clothing

Behavioural indicators y y y y y y Failure to thrive Learning difficulties- poor attention span, inability to concentrate or autistic behaviour Use of drug or alcohol Delinquency Sexual misconduct Living in poverty

Environmental indicators

y y y y y y y y y

living in poverty presence of a large family with marital conflict lack of material resources lack of positive parental attitude lack of adequate understanding of the development stages of childhood fail to recognize physical or emotional needs of children display lack of interest in childhood activities display poor parenting skills exhibit a lack of interest in personal hygiene

EMOTIONAL ABUSE y Psychological abuse consists of verbal assaults or threats that provoke fear; poor communication that may send double messages and blaming, confusing

EMOTIONAL NEGLECT y y y y y Ignoring child Providing minimal human contact Rebuffing child s attempt at establishing interactions that are meaningful Little to no positive reinforcement Failing to provide opportunities to foster growth and development

Behavioral indicators y y y y y y y y Stuttering- speech disorder Enuresis- encopresis Delinquency, truancy, or other disciplinary problems Hypochondriasis Autism or failure to thrive Hyperactive/ disruptive behaviour, childhood depression Presence of anxiety disorders, suicide attempts Failure to thrive- lags in physical development

Environmental indicators y y y y y Inadequate parenting skills Rejection or immature behaviour by parents or caretakers Continuous friction or conflict in the home Discriminatory treatment of the children in the family Abuse of drugs or alcohol by parents or caretakers

COMMON INDICATORS (SHADES) S- Serious injuries in various stages of healing H- Healthy hairs in various lengths A- Apathy, no reaction D- Depression E- Excessive knowledge of sex 9

S- Self esteem is low RA 7610- anti child abuse law requires reporting of suspected cases to authorities such as Brgy. Officials, DSWD personnel, police within 48 hours. Nursing Diagnosis y y y y y y y Risk for injury: trauma Impaired parenting Powerlessness related to interpersonal interactions Hopelessness Rape Trauma Syndrome- Silent reaction Social Isolation Risk for Suicide

Interventions y y y y y y y y y Ensure the child s safety and well- being remove child from home which is also can be traumatic Interview parent and child separately in privacy; ask in detail about symptoms Treat injuries Focus on helping parents with their own dependency needs- Group therapy, Home visiting, Foster grandparents Help parents learn to control frustrations through other outlets Educate parents about child s normal needs and development, new modes of discipline and realistic expectations Provide emotional support and therapy for the child such as play therapy or art therapy to reflect their ideas and feelings. Family therapy Foster care services

ELDER ABUSE y y y y y y Elder neglect/ abandonment- leaving unsupervised, failure to provide food, withholding aids, live in unsanitary place Psychological or emotional abuse- verbal assaults, insults, threats, intentional isolation Physical abuse- physical injury, pain, drugs, restraints Sexual abuse- non-consensual sex, rape, sodomy Financial abuse/ material exploitation- misuse of resources or property by children, stealing checks, credit cards Self-neglect- failure to take medications, eat adequate amounts of food

Typical victim: Female Etiology y y y y y Dependency on adult children or care taker- severe physical or mental disabilities Financial dependency on adult children or caretaker (caregiver role strain) Personality conflicts with adult children or caretaker Societal attitudes toward aging (burden) Frustrations on the part of the adult children or caretaker

Behavioral signs (Caretaker) y y Caregiver insistence on being present during entire appointment Answers for client 10

Express interference or anger

Behavioral signs (Elder) y y Hesitant to open, appearing fearful, poor eye contact, ashamed, baby talk Paranoia, anxiety, anger, low self esteem

Nursing Interventions y y y y y Assess for signs of abuse and neglect Report cases of abuse and neglect as mandated by law Initiate protective services Assess for dysfunctional family systems Promote family functioning and initiate contact with resources

Assessment Questions (Variety of therapeutic techniques to obtain answers) For all clients: 1. 2. 3. 4. 5. 6. 7. Tell me about what happened to you. Who takes care of you? (for children on dependent elderly) What happens when you do something wrong? (for children) How do you and your partner/ caregiver resolve disagreements? (for women and elderly) What do you do for fun? Who helps you with your children? (parents) What time do you have for yourself?

For spouse: 1. Have u been hit, kicked, or otherwise hurt by someone in the past years? By whom? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is making you feel unsafe now? For parents: 1. 2. 3. 4. What agreement do you make when you have to leave your alone? How do you discipline your child? When your infant cries for a long time, how do you get him or her to stop? (shaken baby) What about your child s behaviour bothers you the most?

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