This chapter deals primarily with APGO Educational Topic Areas:
TOPIC 57 SEXUAL ASSAULT
TOPIC 58 DOMESTIC VIOLENCE
Students should be able to identify the risk factors for sexual assault and appropriately screen for domestic violence. They should appreciate the prevalence of violence against women and children. They should be able to outline the initial management of a victim of sexual assault, addressing both medical and psychosocial issues.
Clinical Case
A 20-year-old G1P1 college student presents for evaluation after being forced to have unprotected sexual intercourse by her date. Her last menstrual period was about 3 weeks ago; she has no medical problems and is taking no medication. She appears anxious and “nervous” and has trouble collecting her thoughts. Her urine pregnancy test is negative.
Sexual assault and domestic violence pose obvious immediate and often enduring long-term health and emotional risks. The compassionate and thoughtful care of victims and their families is an important goal of everyone involved in health care.
SEXUAL ASSAULT
Sexual assault is defined legally as involving any genital, oral, or anal penetration by a part of the accused’s body or by an object, using force or without consent. Criminal sexual assault, or rape, is often further characterized to include acquaintance rape, date rape, “statutory rape,” child sexual abuse, and incest. These terms generally relate to the age of the victim and her relationship to the abuser. Local law defines the details of each of these characterizations.
Each year, some 365,000 women in the United States experience sexual assault, rape, or attempted rape. An estimated one in six women have experienced sexual assault in their lifetimes. However, most do not file a complaint or report, and, therefore, its true prevalence is unknown. The 2009 U.S. National Crime Victimization Survey estimates that only 55% of rapes and sexual assaults were reported. When a male is raped, less than 10% are thought to be reported, and female–male and female–female rape are not included in this survey. Inconsistent definitions of rape, overreporting, underreporting, and false reporting create controversial statistical disparities and the concern that many rape statistics are unreliable or misleading. Because of the complex problems caused by sexual assault, treatment is best managed by a multidisciplinary team that fulfills the following roles:
• Care for the victim’s emotional needs, acute and (if possible within the constraints of the health care system) long-term
• Evaluation and treatment of medical needs, acute and follow-up
• Collection of forensic specimens and preparation of a record acceptable for health care and in the legal process
Definitions and Types of Sexual Assault
Sexual assault occurs in all age, racial, and socioeconomic groups; the very young, handicapped, and the very old are particularly vulnerable. Although the act may be committed by a stranger, in many cases it is committed by an acquaintance.
Some situations have been defined as variants of sexual assault. Marital rape is defined as forced coitus or related sexual acts within a marital relationship without the consent of a partner; it often occurs in conjunction with and as part of physical abuse in cases of domestic or intimate partner violence.
Date rape or acquaintance rape is another manifestation of intimate partner violence. In this situation, a woman may voluntarily participate in sexual play, but coitus occurs, often forcibly, without her consent. Date rape often goes unreported, because the woman may think that she contributed to the act by participating up to a point or that she will not be believed. Lack of consent may also occur in situations in which cognitive function is impaired by flunitrazepam, alcohol, or other drugs; sleep; injury with unconsciousness; or developmental delay.
All states have statutory rape statutes criminalizing sexual intercourse with a girl younger than a specific age, because she is defined, by statute, as being incapable of consenting. Many states also have laws addressing aggravated criminal sexual assault, which has the following attributes: weapons are used, lives are endangered, or physical violence is inflicted; the act is committed in relationship to another felony; or the woman is older than 60 years, physically handicapped, or mentally retarded.
Management
The medical and health consequences of sexual assault are both short and long term. All patients should be screened for a history of sexual assault. Most women with a history of sexual assault will not have reported it to a nonpsychiatric physician. Yet, women with a history of assault are more likely to present with chronic pelvic pain, dysmenorrhea, menstrual cycle disturbances, and sexual dysfunction than are women without such a history.
Clinicians evaluating women in the acute phase of a sexual assault have a number of responsibilities, both medical and legal (Box 36.1). Specific responsibilities are determined by the patient’s needs and by state law. Clinicians should be familiar with state rape and assault laws and comply with any legal requirements regarding reporting and the collection of evidence. They must also be aware that every state and the District of Columbia require physicians to report child abuse, including sexual assault. Additionally, physicians should be aware of local protocols regarding the use of specially trained sexual assault forensic examiners or sexual assault nurse examiners.
The clinician should provide medical and counseling services as well as inform the patient of both her medical and legal rights. Many jurisdictions and several clinics have developed a sexual assault assessment kit, which lists the steps necessary and the items to be obtained so that as much information as possible can be prepared for forensic purposes. Many health care facilities have nurses who are trained to collect needed samples and information. If these individuals are available, it is appropriate to request their assistance. Rape crisis counselors and centers can also provide valuable support. In addition, the clinician must assess and treat all injuries, perform sexually transmitted disease (STD) screening, and provide prophylaxis against infectious diseases and unintended pregnancy.
BOX 36.1 Physician’s Role in Evaluation of Sexual Assault Patients
Medical Issues
Ensure that informed consent is obtained from patient
Assess and treat physical injuries or triage and refer
Obtain pertinent past gynecologic history
Perform physical examination, including pelvic examination (with appropriate chaperone or support person present)
Obtain appropriate specimens for sexually transmitted disease testing
Obtain baseline serologic tests for hepatitis B virus, human immunodeficiency virus, and syphilis
Provide appropriate infectious disease prophylaxis as indicated
Provide or arrange for provision of emergency contraception as indicated
Provide counseling regarding findings, recommendations, and prognosis
Arrange follow-up medical care and referrals for psychosocial needs
Legal Issuesa
Provide accurate recording of events
Document injuries
Collect samples (pubic hair, fingernail scrapings, vaginal secretion and discharge samples, saliva, blood-stained clothing, or other personal articles) as indicated by local protocol or regulation
Identify the presence or absence of sperm in the vaginal fluids and make appropriate slides
Report to authorities as required Ensure security of chain of evidence
aMany jurisdictions have prepackaged “rape kits” for the initial forensic examination that provide specific containers and instructions for the collection of physical evidence and for written and pictorial documentation of the victim’s subjective and objective findings. Hospital emergency rooms or the police themselves may supply the kits when called to respond or when bringing a patient to the hospital. Most often the emergency physician or specially trained nurse response team will perform the examination, but all physicians should be familiar with the forensic examination procedure. If called to perform this examination and the physician has no or limited experience, it may be judicious to call for assistance because any break in the technique in collecting evidence, or break in the chain of custody of evidence, including improper handling of samples or mislabeling, will virtually eliminate any effort to prosecute in the future.
American College of Obstetricians and Gynecologists. Sexual Assault, Committee Opinion #499. Washington, DC: American College of Obstetricians and Gynecologists; August, 2011.
Initial Care
When a woman who has experienced sexual assault communicates with the physician’s office, emergency room, or clinic before presenting for evaluation, she should be encouraged to come immediately to a medical facility and be advised not to bathe, douche, urinate, defecate, wash out her mouth, clean her fingernails, smoke, eat, or drink.
In recent years, there has been a trend toward the implementation of hospital-based programs to provide acute medical and evidentiary examinations by sexual assault nurse examiners or sexual assault forensic examiners. Physicians play a role in the policy and procedure development and implementation of these programs and serve as sources for referral, consultation, and follow-up. In some parts of the country, however, obstetrician–gynecologists will still be the first point of contact for evaluation and care following a sexual assault.
Emergency Evaluation
In an optimal situation, the woman is able to seek care in a facility where there is a trained multidisciplinary team. A team member should remain with the patient to help provide a sense of safety and security and, thereby, begin the therapeutic process, including, specifically, assurance of the patient’s lack of guilt. The patient should be encouraged, in a supportive, nonjudgmental manner, to talk about the assault and her feelings. Treatment for life-threatening trauma needs to begin immediately. Such trauma is uncommon, although minor trauma is seen in one fourth of victims. Even in life-threatening situations, any sense of control that can be given the patient is helpful. Obtaining consent for treatment is not only a legal requirement but also an important aspect of the emotional care of the patient, by helping her regain control of her body and her circumstances.
Although patients are commonly reluctant, they should be encouraged to work with the police, because such cooperation is associated with improved emotional outcomes for victims. History taking about a sexual assault is necessary to gain medical and forensic information and is, as well, an important therapeutic activity. Recalling the details of the assault in the supportive environment of the health care setting allows the victim to begin to gain an understanding of what has happened and to start emotional healing (Box 36.2).
Physical Examination
Victims of sexual assault should be given a complete general physical examination, including a pelvic examination. Forensic specimens should be collected, and cultures or other tests for STDs should be obtained. When collecting forensic specimens, it is critical that the clinician follow the directions on the forensic specimen kit. These specimens are kept in a health professional’s possession or control until turned over to an appropriate legal representative. This ensures that the correct specimen reaches the forensic laboratory and is called the chain of evidence.
BOX 36.2 Documenting Patient History after Assault
Gynecologic History
• Menstrual history
• Method of contraception
• Date of last consensual sexual experience
• Obstetric history
• Gynecologic history, including infections
• Activities (e.g., bathing, douching, eating, and drinking since the assault) that could affect forensic evidence gathered
Details of Sexual Assault
• Location, timing, and nature of the sexual assault
• Use of force, weapons, or any substances that would impair the mental status of the victim
• Loss of consciousness
• Information about the assailant, including ejaculation and use of a condom, contraceptive, or lubricant
Initial laboratory tests should include cultures or other tests from the vagina, anus, and pharynx for STDs. Collection of serum for rapid plasma reagin (RPR) for syphilis, hepatitis antigens, and human immunodeficiency virus (HIV) is needed. Urinalysis, culture, and sensitivity, as well as a pregnancy test for menstrual age women (regardless of contraceptive status) are collected. Antibiotic prophylaxisshould be offered when indicated. Emergency contraception should be offered and is described in Chapter 26 (Table 36.1).
Posttreatment Evaluation
Within 24 to 48 hours of disclosure and initial treatment, victims should be contacted by phone or seen for a posttreatment evaluation. At this time, emotional or physical problems are managed and follow-up appointments arranged. Potentially serious problems, such as suicidal ideation, rectal bleeding, and evidence of pelvic infection, may go unrecognized by the victim during this time because of fear or continued cognitive dysfunction. Specific questions must be asked to ensure that such problems have not arisen.
Subsequent Care
At a 1-week follow-up visit, a general review of the patient’s progress is made and any specific new problems addressed. The next routine visit is at 6 weeks, when a complete evaluation, including physical examination, repeat tests for STDs, and a repeat RPR is performed. Another visit at 12 to 18 weeks may be indicated for repeat HIV titers, although the current understanding of HIV infection does not allow an estimate of the risk of exposure for sexual assault victims. Each victim should receive as much counseling and support as is necessary, with referral to a long-term counseling program if needed.
If the physician is not directly involved in the acute care of the victim, it is helpful for him or her to obtain records of the patient’s emergency evaluation. These enable the physician to be certain that all appropriate testing was performed and to provide the patient with full results. Patients may be disturbed to learn that the results of their forensic evaluation are usually not provided to their physician. In this situation, it is helpful to refer the patient to local legal or police authorities, who can also be helpful in answering patients’ questions.
Emotional Issues
A woman who is sexually assaulted loses control over her life during the period of the assault. Her integrity, and sometimes her life, is threatened. She may experience intense anxiety, anger, or fear.
Rape Trauma Syndrome
After the assault, a rape trauma syndrome commonly occurs, comprising an acute phase and a delayed phase. This rape trauma syndrome is similar to a grief reaction in many respects. As such, it can only be resolved when the victim has emotionally worked through the trauma and personal loss related to the event and replaced it with other life experiences. An inability to think clearly or remember things such as her past medical history, termed cognitive dysfunction, is a particularly distressing aspect of the syndrome. The involuntary loss of cognition may raise fears of “being crazy” or of being perceived as “crazy” by others. It is also frustrating for the health care team, unless it is recognized that this is an involuntary, temporary, and understandable reaction to the sexual assault and not a willful action.
Acute Phase (Immediate Response)
The acute phase of rape trauma syndrome may last for hours or days and is characterized by distortion or paralysis of the individual’s coping mechanisms. Outward responses vary from complete loss of emotional control to an apparently well-controlled behavior pattern. Signs may include generalized pain throughout the body; headache; eating and sleep disturbances; and emotional symptoms, such as depression, anxiety, and mood swings.
Delayed (or Organization) Phase
The delayed phase of rape trauma syndrome is characterized by flashbacks, nightmares, and phobias as well as somatic and gynecologic symptoms. Often occurring months or years after the event, it may involve major life adjustments.
Posttraumatic Stress Disorder
Those who have experienced physical and sexual assault are also at great risk for developing posttraumatic stress disorder. Clusters of symptoms may not appear for months or even years after a traumatic experience. These symptoms include the following:
• Reliving the event
• Experiencing flashbacks, recurring nightmares, and, more specifically, intrusive images that appear at any time
• Extreme emotional or physical reactions, including shaking, chills, palpitations, or panic reactions accompanying vivid recollections of the attack
Avoiding reminders of the event constitutes another symptom in posttraumatic stress disorder. These women become emotionally numb, withdrawing from friends and family and losing interest in everyday activities. There may be an even deeper reaction of denial of awareness that the event actually happened.
Symptoms such as easy startling, being hypervigilant, irritability, sleep disturbances, and lack of concentration are part of a third symptom cluster known as hyperarousal. These women often will have a number of co-occurring conditions, such as depression, dissociative disorders (losing conscious awareness of the present, or “zoning out”), addictive disorders, and many physical symptoms.
CHILD SEXUAL ASSAULT
Ninety percent (90%) of child victimization is by parents, family members, or family friends; “stranger rape” is relatively uncommon in children. It is extremely important to know who the perpetrator is and how the child sustained the injury, so that the child can be removed from an unsafe environment. Box 36.3 shows behavioral and physical signs and symptoms commonly associated with child sexual abuse.
Assessment/Examination
Because the assessment of a child for sexual abuse involves specific skills and has the potential for legal challenge, the individual who undertakes this evaluation should have significant experience in this area. This assessment is usually done by pediatricians and is beyond the skills of most general gynecologists. Awareness of and sensitivity to the issues, special needs, and circumstances of the child are important for obstetrician–gynecologists who are consulted to treat an injury to the pelvic floor. In many cities, a child abuse team consisting of trained experts including physicians, social workers, and counselors is available to perform the assessment.
The sexual abuse evaluation begins with an interview of the caretaker and the child. Unless the child refuses to leave the caretaker, the child should be interviewed privately to obtain specific details of the abuse. Questioning should be nondirective to elicit spontaneous responses such as time and location of the abuse, description of the scene, name and description of the perpetrator, and type of sexual acts. The child’s statements should be recorded verbatim; electronic interviews are helpful so that the child does not have to describe the abuse repeatedly. Good documentation of the interview is critical in the prosecution of sexual abuse cases because, in many instances, the patient’s statement is the only evidence that the abuse occurred. Documentation of the specific names the child uses for her genitalia is recommended to help others understand the context of her statements.
BOX 36.3 Signs of Child Sexual Assault
• Night terrors
• Changes in sleeping habits
• Clinging
• Sexual acting out
• Aggression
• Regression
• Eating disturbances
• Recurrent somatic complaints of abdominal pain
• Headaches
• Vaginal pain
• Dysuria
• Encopresis
• Enuresis
• Hematochezia
• Vaginal erythema
• Vaginal discharge or bleeding
The urgency of an evaluation of sexual abuse depends on how soon after the event the child is brought in for care. If the child presents within 72 hours of the last episode of abuse, the physician should immediately arrange for evaluation of the child and focus on collection of forensic evidence. However, fewer than 10% of child sexual abuse cases are reported within 72 hours. In cases that are reported after 72 hours, the patient should be referred to the nearest sexual abuse center, where more resources are available to conduct the evaluation.
Management
In the treatment of a child who is the victim of sexual abuse, management should focus (as applicable) on treatment of injuries, treatment of STDs, prevention of pregnancy, protection against further abuse, and psychological support for the patient and her family. Superficial injuries (e.g., bruises, edema, and local irritation) resolve within a few days and require only meticulous perineal hygiene. In some patients with extensive skin abrasions, broad-spectrum antibiotics may be given as prophylaxis. Small vulvar hematomas can usually be controlled by pressure or an ice pack, and even massive swelling of the vulva usually subsides promptly when cold packs and external pressure are applied. More extensive penetrative vaginal and anal injuries require thorough radiographic and anesthetic examination to rule out intra-abdominal penetration.
DOMESTIC VIOLENCE
Domestic violence is reported by over 25% of women at some time during their lives and is a significant source of illness and injury to women.
Definition
Domestic violence refers to the violence perpetrated within the context of family or intimate relationships. Family members include parents, siblings, and other blood relatives as well as legal relatives such as step-parents, in-laws, and guardians. Violence that occurs between current or former partners is referred to as intimate partner violence and includes male abuse by female partners and violence between partners in lesbian, gay, bisexual, and transgendered relationships.
Domestic violence may involve one or more of three presentations. Physical abuse, such as hitting, slapping, kicking, and choking, is the most obvious form of physical abuse. It should be suspected when there is evidence of trauma, especially to the head and neck or trunk associated with a history of violence, or when an explanation of the trauma does not seem appropriate (Table 36.2). Unfortunately, pregnancy appears to be a period of greater risk of inflicted trauma.Sexual abuse is another presentation of domestic violence. The third presentation is emotional, financial, or psychological abuse, neglect, or threat and is often traumatic and/ or long-standing. Examples include undermining of selfworth, deprivation of sleep or emotional support, repetitive unpredictability of response to life situations, threats, destruction of personal property or the killing of pets, lies, manipulation of friends, and interference in the workplace. Domestic violence is usually cyclic and repetitive, with periods of calm alternating with periods of rapidly increasing tensions or violence, the latter often increasing in severity with each iteration of the cycle.
Screening: Risk Factors
Recognition is the first, most important, and most often a missed issue. When domestic violence is suspected, compassionate and thoughtful discussion with the possible victim, as well as attention to any physical injury, is requisite. All patients should be asked about violence in their lives as part of the routine health history. Although all women are at risk for abuse, certain life experiences and circumstances may place some women at greater risk (Box 36.4).
The clinician’s role is 1) to know the signs and symptoms of intimate partner violence, 2) to ask all patients about the past or present exposure to violence, 3) to intervene and refer as appropriate, and 4) to assess the patient’s risk of danger (Box 36.5).
BOX 36.4 Identifying the Abused Woman
No true stereotype exists, but certain risk factors are found among victims:
• Younger women, especially those in long, difficult relationships
• History of violence or dysfunctional family of origin
• Dysfunctional past relationships
• Pregnancy, especially if unintended
• Relationships in transitions (i.e., separation and divorce)
• Any situation where the partner is overly attentive, especially if he repeatedly answers for her
• STDs
• Substance abuse
Clinical clues that the patient is or has been abused:
• Unexplained, multiple, and recurring injuries
• Elusive pain and other somatic complaints
• Specific problems in pregnancy
• Poor compliance, hostility, passivity, minimal response
• Psychologic changes, especially depression, anxiety, panic attacks, sleep, and eating disorders
• Compulsive sexual behaviors, seductive behavior with examiners (not sexual, but to gain attention)
• Self-destructive, high-risk behaviors (poor self-care, substance abuse, self-neglect and self-injury, and suicidal ideation)
• Increased use of prescription narcotics and tranquilizers
• Frequent visits and increased use of the health care system
• Extensive medical records documenting unresolved problems
• Unusual disclosure style (too detailed, not credible, cannot explain injuries in a satisfactory way, and cannot explain why instructions have not been followed)
• Difficulty in tolerating examination
• Difficulty in tolerating other medical situations that recreate traumatic experiences (isolation, injection of medications, restraints and immobilization, and surgery)
Counseling
If the patient will be returning to an unsafe home, safety planning should be conducted, and referrals to service agencies in the community should be provided. Women can be encouraged to call a woman’s shelter for more help with a safety plan and be assured that such calls would be anonymous. Box 36.6 details suggested steps for patients when they are ready to leave an abusive situation.
BOX 36.5 The RADAR Model of the Physician’s Approach to Domestic Violence
R: Remember to ask routinely about partner violence in your own practice
A: Ask directly about violence with such questions as, “At any time, has a partner hit, kicked, or otherwise hurt or frightened you?” Interview your patient in private at all times.
D: Document information about “suspected domestic violence” or “intimate partner violence” in the patient’s chart, and file reports when required by law
A: Assess your patient’s safety. Is it safe to return home? Find out if any weapons are kept in the house, if the children are in danger, and if the violence is escalating
R: Review options with your patients. Know about the types of referral options (e.g., shelters, support groups, and legal advocates)
Massachusetts Medical Society. Partner Violence: How to Recognize and Treat Victims of Abuse. 4th ed. Waltham, MA: Massachusetts Medical Society; 2004.
BOX 36.6 Making an Exit Plan to Leave an Abusive Relationship
• Pack a bag in advance and leave it at a neighbor’s or friend’s house. Include cash or credit cards and extra clothes for yourself and your children. Take each child’s favorite toy or plaything.
• Hide an extra set of car and house keys outside of the house in case you have to leave quickly.
• Take important papers, such as the following:
• Birth certificate (including children’s)
• Health insurance cards and medicine
• Deed or lease to the house or apartment
• Checkbook and extra checks
• Social security number or green card/work permit
• Court papers or orders
• Driver’s license or photo identification
• Pay stubs
American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care, 3rd ed, p. 280. Modified from Intimate partner violence. In: Special Issues in Women’s Health. Washington, DC: ACOG; 2005:169–188.
Clinical Follow-Up
A sense of emotional dysfunction is common in the immediate period following a sexual assault. The possibility that both the confusion and the sexual assault could be connected with a substance or substances ingested with or without the patient’s knowledge could be involved and should be explored when the prospect is seriously considered. A complete history and physical examination is needed, along with sexually transmitted disease testing, evidence collection, antibiotic prophylaxis, and emotional support.
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