Abuse: Physical and Sexual

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Chapter 8 Abuse: Physical and Sexual

INTRODUCTION

Description: Abuse is a pattern of physical trauma that occurs within a continuing relationship. Although the definition of abuse requires only one episode of physical abuse, a pattern of escalating violence is more typical. (In at least one fourth of cases, there have been three or more episodes of violence in the 6 months preceding the report of abuse.) In the United States, women are at greater risk of injury or death at the hands of a domestic partner than from an unrelated attacker. Sexual abuse is a specific form of physical abuse that relates to trauma of a sexual nature or a pattern of coercive sexual activities. Sexual abuse includes, but is not limited to, disrobing, exposure, photography or posing, oral–genital contact, insertion of foreign bodies, and vaginal or rectal intercourse.
Prevalence: More than 1.5 million cases of domestic violence occur each year. It is estimated that between 5% and 25% of women treated for injuries in emergency rooms receive these injuries as a result of domestic violence. Of adults, 20% to 40% report abuse or sexual victimization before age 18 years, and 10% to 25% of wives report one or more episodes of sexual abuse.
Predominant Age: Any, most common teens to 30s.
Genetics: Women are the primary victims of domestic violence, accounting for almost 95% of incidents.

ETIOLOGY AND PATHOGENESIS

Causes: Multiple factors. Alcohol or drugs are often involved, although they are not causative factors.
Risk Factors: Such abuse occurs at a slightly higher rate among those of lower educational or socioeconomic status.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Physical abuse—Signs and symptoms are highly variable. (In almost 85% of reported cases, the injuries sustained are sufficient to require medical treatment. Between 5% and 25% of women treated for injuries in emergency rooms receive these injuries as a result of domestic violence. The correct diagnosis is rendered in less than 5% of women. The most frequent locations for injuries are the head, neck, chest, abdomen, and breasts. Upper-extremity injuries result from defensive efforts.)
• Sexual abuse—Signs and symptoms are nonspecific.

DIAGNOSTIC APPROACH

Differential Diagnosis

• Depression (may mimic the vague complaints that should raise the suspicion of abuse)
• Coagulopathy (leading to bruising)

Associated Conditions: More than one half of men who abuse their wives abuse their children as well. Between one third and one half of all murders of women occur at the hands of a male partner.

Workup and Evaluation

Laboratory: No evaluation is indicated.
Imaging: No imaging is indicated unless fracture or other injury is suspected.
Special Tests: The five-question Abuse Assessment Screen increases the likelihood of detecting abuse. The longer it has been since an assault or when abuse is ongoing, the more likely it is for the presenting complaints to be unrelated to the underlying acute concerns generated by the attack. Somatic complaints and subtle behavioral changes may suggest the possibility of domestic violence or abuse.
Diagnostic Procedures: History and suspicion. Because one of the pivotal aspects of sexual assault is the loss of control, every effort should be made to allow the patient control over even the most trivial aspects of the physical examination.

Pathologic Findings

In the typical battering relationship three phases are usually present: a tension-building phase that gradually escalates; the battering incident, which may be triggered by almost any event; and a period of contrition during which the batterer apologizes and asks for forgiveness. This cycle tends to repeat and escalate with greater physical harm and risk and less remorse.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Offer support, contact with social agencies, and assistance with developing means for independence (e.g., money, transportation, destination, child care) should escape become necessary.
Specific Measures: Assess and manage any injuries present. The patient should be given the telephone number of and directions to a shelter or safe house.
Diet: No specific dietary changes are indicated.
Activity: No restriction.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP083 (The Abused Woman).

Drug(s) of Choice

None indicated. Great care must be used with any antidepressants or other mood-altering drugs given in these situations.

FOLLOW-UP

Patient Monitoring: In many locations, suspected sexual assault must be reported to law enforcement authorities. In all locations, suspected abuse, sexual or otherwise, occurring to a minor must be reported.
Prevention/Avoidance: None. Patients must be told they are not at fault and that their efforts to change the abuser are unlikely to have an effect in reducing the number of future episodes.
Possible Complications: Escalating violence with an increasing risk of severe injury or death.

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Expected Outcome: The pattern of physical or sexual abuse is ongoing. Acute management of trauma is only a part of the larger problem and interpersonal dysfunction. If the abuser receives counseling and treatment, the outcome can be good; without it there is great risk of continued or worsening abuse. Abuse is associated with poorer general and sexual health for the victim. In one study, more than half of women who were abused had experienced common physical complaints during the previous 12 months compared with one third of the nonabused.

MISCELLANEOUS

Pregnancy Considerations: Of pregnant women, 10% to 20% report physical abuse during pregnancy. For these women, injuries to the breast and abdomen are more frequent.
ICD-9-CM Codes: 995.81, 995.85 (Multiple forms).

REFERENCES

Level II

Elliott L, Nerney M, Jones T, Friedmann PD. Barriers to screening for domestic violence. J Gen Intern Med. 2002;17:112.

Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005;67:906.

Rodriquez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA. 1999;282:468.

Ulla Pikarinen U, Saisto T, Schei B, et al. Experiences of physical and sexual abuse and their implications for current health. Obstet Gynecol. 2007;109:1116.

Level III

AMA Council on Scientific Affairs. Violence against women: relevance for medical practitioners. JAMA. 1992;267:3184.

American College of Obstetricians and Gynecologists. Health care for homeless women. ACOG Committee Opinion 312. Washington, DC: ACOG, 2005.

American College of Obstetricians and Gynecologists. Psychosocial risk factors: perinatal screening and intervention. ACOG Committee Opinion 343. Washington, DC: ACOG, 2006.

American Medical Association. Diagnostic and Treatment Guidelines on Domestic Violence. Chicago: American Medical Association, 1992.

Chez RA. Woman battering. Am J Obstet Gynecol. 1988;158:1.

Chrisler JC, Ferguson S. Violence against women as a public health issue. Ann N Y Acad Sci. 2006;1087:235.

Council on Scientific Affairs Diagnosis and management of family violence 2005 American Medical Association Chicago Available at http://www.ama-assn.org/ama/pub/category/15248.html Accessed May 11, 2007.

Gerber GL, Cherneski L. Sexual aggression toward women: reducing the prevalence. Ann N Y Acad Sci. 2006;1087:35.

Hillard PJ. Physical abuse in pregnancy. Obstet Gynecol. 1985;66:185.

Lentz GM. Rape, incest, and domestic violence. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:203.

U.S. Preventive Services Task Force Screening for family and intimate partner violence: Recommendation statement March 2004 Agency for Healthcare Research and Quality Rockville, MD Available at http://www.ahrq.gov/clinic/3rduspstf/famviolence/famviolrs.htm Accessed May 11, 2007.

Wathen CN, MacMillan HL. Prevention of violence against women: Recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ. 2003;169:582.

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