Family and Intimate Partner Violence, and Sexual Assault

EPIDEMIOLOGY

The prevalence and incidence of intimate partner violence is not known, but it is considerable. It has been estimated that as many as 2 million women are abused every year by someone they know. Any estimate of prevalence is likely to be understated owing to the likelihood that a significant number of victims are fearful of disclosing abuse against them. One study of the incidence of partner abuse found that of all women seeking care in an emergency room (ER), 54% said they had been threatened or injured at some time in their lives by a partner, and 24% said they had been injured by a current partner. One in three women presenting to an ER with injuries has symptoms related to partner violence. More than 20% of violent crimes against women and 30% of female murders are committed by intimate partners. Estimates of the number of pregnant women who are victims of partner abuse range from less than 1% to 20%.

Other forms of family violence are prevalent. The level of child abuse is epidemic, and it is estimated that nearly 500,000 elderly persons in domestic settings in the United States are abused or neglected. Seventy percent of cases of abuse of the elderly are perpetrated by a family member, including adult children.

In all cases of ongoing family or intimate partner abuse, the key enabling feature is some form of victim vulnerability, which the victim cannot or will not attempt to overcome.

ADVERSE EFFECTS OF INTIMATE PARTNER VIOLENCE

The impact of intimate partner abuse and violence includes significant health, social, and economic effects. Nearly one third of female intimate partner violence victims have physical injuries that require medical attention. Many victims develop posttraumatic stress disorder with all of its chronic symptoms and increased risk for suicide. Women who are “battered” and abused have lower overall health status and more depression and disability.

Social services for women who are victims of intimate partner abuse are inadequate. Nearly one third of battered women who request refuge are turned away because of a lack of space. Those turned away and their children often must return to a violent home. Many become homeless and involved in substance abuse as an escape mechanism or because they are forced into use and addiction by their partners.

The overall societal cost of intimate partner violence has been estimated to be in excess of $6 billion annually, and individual costs are increased because of higher insurance premiums paid by victims.

The abuser often provides for and is periodically in a caring and loving relationship with the victim, who may still love the abuser despite the abuse. Other obstacles to leaving the abuser include (1) fear of more abuse, (2) loss of economic support, (3) fear of social isolation, (4) feelings of failure, (5) promises of change, (6) previously unanswered calls for help, and in many cases (7) fear of loss of child custody. Figure 28-1 illustrates the cycle of violence that exists in these abnormal relationships.

FIGURE 28-1 Cycle of violence. Elements of the cycle occur on a repetitive, unpredictable, and frequent basis. Verbal and emotional abuse is the most common form of assault. An alternating kindness followed by abuse in an unpredictable manner contributes to the emotional distress and long-term psychological morbidity of victims.

(Reprinted from Obstetrics and Gynecology Clinics of North America, 34(3), Gunter J, Intimate Partner Violence, 367-388, Copyright 2007, with permission from Elsevier.)

ADDRESSING INTIMATE PARTNER AND FAMILY VIOLENCE

Healthcare providers may have difficulty bringing up the topic of possible intimate partner violence. Because of the alarming frequency of this problem, it is important to ask all women, when alone with them, if they feel safe in their own home. This should be a routine practice in taking a social history. Even without a suspicion of physical abuse, the woman should be asked directly if a partner has ever hit, kicked, hurt, or threatened her. If a positive response is obtained, it is important to document any physical findings. Pictures and drawings should be used.

It is helpful and reassuring to tell the victim that she is not alone, that help is available to her, and that her partner’s behavior is unacceptable. Nearly every victim will believe that she is the only person to suffer such abuse because of the isolating nature of abusive behavior. The perpetrator most likely will have convinced the victim that she is at fault and responsible for the abuse.

In addition to the need to comply with any reporting requirements (some states mandate reporting to appropriate authorities if there are acute injuries), social workers and other professionals should always be consulted when abuse is acknowledged, or even if it is just suspected. Box 28-2 lists the responsibilities that health-care providers have in addressing intimate partner and domestic violence.

MEDICAL CARE FOR SEXUAL ASSAULT

The medical consultation should proceed only after a supportive, caring relationship has been established. The adult or adolescent woman should be actively involved in the consultation so that she may regain a feeling of control over what has happened to her. The purposes of the consultation are threefold: (1) to provide her acute medical care, (2) to gather evidence, and (3) to transition her into the long-term care she will need for psychological recovery from the extreme loss of control and great fear of death that nearly every rape victim suffers. These objectives should be explained to her, and she should be allowed to dictate the pace of the questioning and the order of the examination.

During the interview and examination phases, a chaperone or patient advocate should be present. Careful attention must be paid to the rules governing the chain of evidence to maintain the legal integrity and utility of all the specimens, photos, and other materials collected. The woman should be asked about the detailed specifics of her assault in order to direct the collection of needed evidence and to address any risk for injury or infection. Information about her recent menstrual history, use of medications, recent immunizations, contraceptive use, and past medical and surgical history is important.

A thorough physical examination is needed to evaluate possible injuries because 40% of all women who are sexually assaulted sustain injuries. If possible, photographs or sketches should be obtained of the injured areas. The Centers for Disease Control and Prevention recommend routine testing for gonorrhea and chlamydia from specimens collected from any site of penetration or attempted penetration. Wet mount and culture for trichomonas are routine, and a microscopic evaluation for bacterial vaginosis and candidiasis is prudent in a woman with a vaginal discharge. Serum tests for human immunodeficiency virus (HIV), hepatitis B, and syphilis are needed for baseline evaluation. Positive HIV status can be another clue to identifying victims of abuse.

Prophylaxis is suggested as preventive therapy. This includes hepatitis B vaccination (if previously unvaccinated) and appropriate antibiotics for sexually transmitted infections (see Chapter 22). It is critical to provide any woman at risk for pregnancy with emergency contraception (see Chapter 26). If prophylaxis for HIV is considered necessary, consultation with an HIV specialist is recommended. Tetanus toxoid should be administered to an unprotected, injured woman.

PSYCHOLOGICAL SEQUELAE OF SEXUAL ASSAULT

Sexual assault is almost always associated with both immediate and long-term effects on victims. These effects have been termed the rape trauma syndrome and involve the following two phases:

The management of the sexual assault victim in the acute phase influences long-term adjustment. Many rape victims may manifest posttraumatic stress disorder. The likelihood of this disorder developing is high, owing to the abrupt nature of the crime, its violence, the passivity and helplessness imposed on the victim, and the high probability of receiving physical as well as psychological trauma. The lifetime prevalence of posttraumatic stress disorder in rape victims is about 50%.

In addition to attending to immediate physical and emotional needs, the initial evaluation provides an opportunity to prepare the victim for the long-term psychological impact of the experience. This preparation is intended to diminish the long-term consequences and to enable the woman to recognize the common psychosocial sequelae when they occur, thus enabling her to seek professional help at an early stage.

Longer-term reactions involve nightmares, phobic reactions, and sexual fears. Stimuli associated with the rape, such as a similar-looking man or similar surroundings, may be associated with flashbacks. Flashbacks may also occur during pelvic examinations. Reactions to the sexual assault may result in problems with sexual behavior and functioning. Loss of libido is a common response to stressful or traumatic circumstances of any kind. Other complaints include vaginismus, impaired vaginal lubrication, and loss of orgasmic capacity. These problems may be even more likely if the assault occurred at home while the woman was asleep. Preparing the woman for these eventualities can be extremely helpful in preventing sexual dysfunction from developing or persisting. Giving permission for a lower-than-usual sexual drive during the period following the assault may remove some performance anxiety. Explaining how anxiety and stress can inhibit sexual responsiveness and providing ways in which this can be overcome are also important.

AFTERCARE PLANNING

Careful follow-up must be arranged. If the patient used the prophylactic therapies, a return visit is needed in 1 week to review the initial laboratory results and to monitor her progress. Repeat testing is needed only if the woman is symptomatic. If she did not receive prophylaxis, repeat testing for gonorrhea, chlamydia, and trichomonas should be performed in 2 weeks and for syphilis in 6 weeks. Repeat serum tests for HIV should be performed 6, 12, and 24 weeks after the assault, regardless of whether prophylactic measures were taken.

Before discharging the patient, it is important to ensure that she has a safe place to go and a suitable means of transportation. She should also be given (in writing) the names, addresses, and phone numbers of resources available in the community to meet her medical, legal, and psychosocial needs related to the assault (Box 28-3).