I ABUSE ^xv ^223 ^347 ^392

Violence and abuse are important problems that affect women and ado­lescents, and they often have serious short-term and long-term health consequences. Abuse may be verbal, physical, or sexual and can manifest as intimate partner violence, child abuse, rape, sexual assault, elder abuse, or neglect.

Intimate Partner Violence and Domestic Violence

Although there is no single definition of intimate partner violence that satisfies all medical, social, and criminal justice purposes, the term typi­cally refers to violence perpetrated against adolescent and adult women within the context of past or current intimate relationships. Intimate part­ner violence encompass subjection of a partner to physical abuse, psycho­logic abuse, sexual violence, and reproductive and sexual coercion (see also “Sexual Assault or Rape” and “Reproductive and Sexual Coercion” later in this section). The term domestic violence also is used by many people to describe intimate partner violence. The term domestic violence, however, encompasses other forms of violence, including abuse of older individuals and children (see also “Elder Abuse” and “Child Abuse, Child Sexual Abuse, and the Adult Manifestations of Childhood Sexual Abuse” later in this section).

Domestic violence is a widespread social and public health problem that disproportionately affects women of all age, racial, educational, and socioeconomic groups and covers a broad spectrum of behaviors. It encompasses a pattern of actual or threatened physical, sexual, or psycho­logic abuse between family members or intimate partners and can range from intimidating behaviors to life-threatening actions. Although the true extent of intimate partner violence and domestic violence is difficult to ascertain, prevalence studies estimate that each year in the United States, 2 million women are abused by someone they know, and the prevalence of intimate partner violence goes up during pregnancy. According to the U.S. Department of Justice, violence by an intimate partner accounts for approximately 22% of all the violent crime experienced by women.

Patterns of Abuse

No one is immune from intimate partner or domestic violence, regardless of age, socioeconomic status, profession, religion, ethnicity, education, or sexual orientation. There is no typical victim, nor is there a typical abuser. Most frequently, the abuse is directed at a woman by a man. Often, perpe­trators are violent only with family members and have different public and private images. They minimize the seriousness of the violence and refuse to take responsibility for their behavior, accusing the victim of provoking them. The hallmark of their behavior is coercive control, including isola­tion of the victim.

Women with disabilities are vulnerable to physical, sexual, or emo­tional abuse, as well as neglect and exploitation. The abuse can include withholding necessary assistive devices, care, or treatment. Immigrant and refugee women are at risk of violence and abuse because of isolation and manipulation by their partners, language and cultural differences, and lack of awareness of their rights and legal and social resources.

Consequences

Research confirms that ongoing or past violence can lead to long-term physical and psychologic consequences.

Violence between intimate partners may be the most important risk factor for child abuse. Child abuse occurs at a rate 15 times higher in families with intimate partner violence than in families without violence. Witnessing or experiencing abuse in the home is associated with higher levels of behavioral and emotional problems, as well as poor social interac­tion and school performance. Adolescents are at risk of physical and sexual abuse by parents, family members, peers, and dating partners. Adolescent exposure to violence is associated with anger, depression, anxiety, and posttraumatic stress. Growing up in an abusive household increases a woman’s risk of abuse in adulthood.

Role of Health Care Providers

The clinician’s role is to know the signs and symptoms of intimate part­ner and domestic violence, ask all patients about past or present exposure to violence, assess the patient’s risk of danger, and intervene and refer as appropriate (Box 3-33).

Nonacute presentations of abuse include reports of chronic headaches, sleep and appetite disturbances, palpitations, chronic pelvic pain, uri­nary frequency or urgency, irritable bowel syndrome, sexual dysfunction, abdominal symptoms, and recurrent vaginal infections. These nonacute symptoms often represent clinical manifestations of internalized stress (ie, somatization). Diagnostic clues to intimate partner and domestic violence include nonspecific stress-related symptoms (eg, depression and chronic pain) or injuries in various stages of healing for which the explanation is inconsistent with the findings. There may be other evidence of abuse iden­tified from a reproductive history, including recurrent abortions. Although the results of most physical examinations of individuals affected by domes­tic violence or intimate partner violence are normal, the physical examina­tion may reveal bruises, burns, bite marks, and other injuries, particularly on the head, neck, breasts, abdomen, and groin.

There may be no pathognomonic signs or symptoms of intimate part­ner violence or domestic violence; hence, universal screening is warranted.

Box 3-33. 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 “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 (eg, shelters, support groups, legal advocates).

Reprinted with permission from Intimate Partner violence: how to recognize and treat victims of abuse. 4th ed, pg 25. Massachusetts Medical Society. Copyright 2004 Massachusetts Medical Society. All rights reserved.

Because of the prevalence of violence, all women should be screened for domestic violence at periodic intervals, such as annual examinations and new patient visits. Although patients may be reluctant to bring up their abuse, they often are responsive to direct inquiry. Questions must be asked in privacy and in a nonjudgmental manner. At the beginning of the assess­ment, offer a framing statement to show that screening is done universally and not because intimate partner violence is suspected. Also, inform patients of the confidentiality of the discussion and exactly what state law mandates that a physician must disclose. The following four questions are easily incorporated into a routine review of systems:

1.“Has anyone close to you ever threatened to hurt you?”

2. “Has anyone ever hit, slapped, kicked, or hurt you physically?”

3.

4. “Are you ever afraid of your partner or anyone at home?”

When there are injuries, it is appropriate to ask the direct question: “Did someone cause these injuries?” The patient’s answer will provide direction to pursue a series of questions relating to issues of safety for the woman and her children, the role of friends and family, and the range of available options.

When a patient confides that she has been abused, it is important to acknowledge the trauma and reinforce the fact that the patient is not to blame. The clinician should reinforce that the patient has done nothing to deserve the abuse and that intimate partner violence and domestic vio­lence are crimes. The physician must be prepared to discuss the abuse with the woman and establish a plan to deal with medical needs, psychosocial needs, and emergent issues. It is useful to have a protocol for physicians to follow that incorporates available resources.

Once intimate partner or domestic violence has been identified and acknowledged, the next step is to assess immediate safety. If the patient will be returning to an unsafe home, safety planning should be conducted. If she is afraid for her safety, she should be offered shelter immediately. With the patient’s consent, social-work services, women’s shelters, or community services for victims of violence should be imme­diately contacted. (See Box 3-34 for suggested steps for patients to take when they are ready to leave an abusive situation.) If the patient is not in need of immediate shelter or concerned that a sudden departure from her home environment may cause more threat of harm to herself or other family members, she should be advised that shelter is available if needed in the future. She should be provided with information on community resources and referred for continued assistance and support. Community resources include emergency housing (usually in shelters), peer group and individual counseling, and legal and social services advocacy.

Box 3-34. Making an Exit Plan to Leave an Abusive Relationship ^

Making a decision to leave an abusive relationship can be difficult. Clinicians can assist by providing concrete, practical guidance. 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. If the woman is ready to leave, the following tips may be helpful:

• 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 or work permit

— Court papers or orders

— Driver's license or photograph identification

— Pay stubs

Modified from American College of Obstetricians and Gynecologists. Leaving the violence. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/ Violence_Against_Women/Leaving_the_Violence. Retrieved September 27, 2013.

In particularly distressed women, an assessment of suicide risk may be indicated. Obviously, in acute crisis situations that involve serious risks to the life of the victim, her children, or others, crisis intervention resources should be used.

Psychologic and social assistance are best provided by services that are “trauma specific,” meaning that the practitioners are experienced in treat­ing victims of domestic violence or intimate partner abuse. Most agencies for battered women and rape crisis centers are expert in dealing with all forms of violence against women.

Perpetrators often retaliate when they suspect disclosure of abuse. Thus, every effort should be made to maintain confidentiality, especially regarding telephone calls, and to minimize paper materials, such as bills or brochures, given to the patient. The clinician and patient should discuss acceptable methods of communication and exchange of information. Office staff must be informed about the importance of confidentiality in any contact with the patient’s home.

Laws regarding reporting obligations vary widely among states; there­fore, familiarity with local laws and policies is critical. In all states, phy­sicians are required by law to report suspected child abuse. Mandatory reporting of intimate partner or domestic violence is required by some states, but it remains a controversial issue, especially with regard to issues of patient safety and confidentiality. Information regarding state reporting requirements is available through state medical associations, local violence prevention or service programs, or the state attorney general’s office. A summary of state laws can be found at www.futureswithoutviolence.org/ userfiles/file/HealthCare/MandReport2007FINALMMS.pdf.

Elder Abuse ^538

Elder abuse, or elder mistreatment, refers to intentional acts that result in harm or create a risk of harm or distress, and failure by a caregiver to satisfy the elder’s basic needs or protect the elder from harm. An estimated 1-2 million U.S. citizens aged 65 years or older have been injured, exploited, or mistreated by someone caring for them; and most elders who experience abuse are women. However, it is acknowledged that these findings repre­sent the most overt cases and that elder abuse is underreported.

The American College of Obstetricians and Gynecologists supports screening of patients older than 60 years to help identify victims of abuse and provide them with appropriate medical and psychosocial care and refer­rals. Evaluation should include a thorough social history to assess family structure, the stability of social supports, financial stressors, and substance abuse or mental health history. Health care providers should directly ques­tion their patients about present and past abuse (see Box 3-35). Multiple falls or fractures, multiple emergency department visits or hospitalizations,

Box 3-35. Performing an Elder Mistreatment Assessment ^

• Interview the patient separately and be aware that family members and caregivers may be abusers

• Start with general, open-ended questions and progress to more specific questions

• Note inconsistent or frequently changing stories

• Observe patient's reactions to accompanying family members or caregivers

• Remain empathic

Sample Screening Questions for Patients

• Do you feel safe in your home?

• Are you afraid of anyone in your home?

• Has anyone threatened you or verbally assaulted you?

• Has anyone touched you without your permission?

• Does anyone ever ask you to sign documents that you do not understand?

• Has anyone ever taken your things without your permission?

• Are you alone a lot?

• Has anyone ever failed to help you when you were unable to help yourself?

• Do you have anyone to share your worries with?

Data from Stanford School of Medicine. Elder abuse: how to screen. Available at http:// elderabuse.stanford.edu/screening/how_screen.html. Retrieved July 11, 2013.

or chronic poorly controlled medical problems should prompt clinicians to consider an unstable social situation and abuse. Signs of neglect also can be subtle, including poor hygiene and nail care, weight loss, unkempt appearance, missing assistive devices (eg, hearing aids, glasses, or den­tures), and inappropriate attire. Poor medication adherence or laboratory values reflecting dehydration, malnutrition, or abnormal medication levels also may suggest neglect.

When cases of abuse are confirmed, most states mandate that health care providers report the case to Adult Protective Services. Health care providers should become familiar with their individual state mandates regarding the reporting of abuse because it varies from state to state. A list of the most up-to-date reporting requirements can be found at www. ncea.aoa.gov/stop_abuse/get_help/state/index.aspx. Partnering or having a referral relationship with social workers, nurses, and psychiatrists for outpatient referrals is an important step for health care providers. A team approach to the problem is the best way to ensure that the multiple psy­chosocial, medical, and legal aspects of a case are addressed.

Child Abuse, Child Sexual Abuse, and the Adult Manifestations of Childhood Sexual Abuse ^538

Child abuse generally is categorized in four ways: 1) physical abuse, 2) emotional or psychologic abuse, 3) sexual abuse, and 4) neglect. In 2010, The U.S. Department of Health and Human Services estimated that about 1.25 million children were victims of abuse or neglect, a decrease from 1.55 million in 1996, which is nevertheless considered statistically mar­ginal. Every state and the District of Columbia require physicians to report suspected child abuse.

Most nonsexual physical abuse of children involves boys, whereas girls are sexually abused three times more often than boys. Young single mothers who were themselves abused are at risk of physically abusing and neglecting their children. Most perpetrators of child sexual assault are males, and it is estimated that the risk of a child being abused is 15 times greater in families that experience intimate partner violence.

Sexual assault that occurs in childhood, defined by most states as younger than 14 years, is considered child abuse. Childhood sexual abuse may be further defined as any exposure to sexual acts imposed on children, who inherently lack the emotional, maturational, and cognitive develop­ment to understand or to consent to such acts. These acts do not always involve sexual intercourse or physical force. Instead, they may involve manipulation and trickery.

The actual incidence of childhood sexual abuse in the United States is unknown, but the Department of Health and Human Services esti­mates that approximately 135,300 children are sexually abused each year. However, for some abusive actions, the National Incidence Study of Child Abuse and Neglect definitions count children as sexually abused only if they experienced moderate injury or harm (physical, emotional, or behav­ioral) from that maltreatment. Therefore, it can be assumed that the actual rate of childhood sexual abuse is higher.

Adult manifestations of childhood abuse may include depression; anxiety; posttraumatic stress symptoms; eating disorders; alcohol, drug, and tobacco use and abuse; suicide attempts or ideation; poor self-care; and somatic disorders (eg, chronic pelvic pain, migraine, and gastrointes­tinal disorders). Adolescents and adult women with such histories are at increased risk of sexually transmitted infections (STIs) (including human immunodeficiency virus [HIV] infection). These patients are less likely to have regular cervical cytology screening. Adult survivors of childhood sex­ual abuse also may have histories that include early, unplanned pregnancy; recurrent abortions; and little or no prenatal care (see Box 3-36).

With recognition of the extent of family violence, it is strongly recom­mended that all women be screened for a history of sexual abuse. Patients overwhelmingly favor universal inquiry about sexual assault because they report a reluctance to initiate a discussion of this subject. If the physician suspects abuse, but the patient does not disclose it, the obstetrician­gynecologist should remain open and reassuring. Patients may bring up the subject at a later visit if they have developed trust in the obstetrician­gynecologist. Not asking about sexual abuse may give tacit support to the survivor’s belief that abuse does not matter or does not have medical rel­evance and the opportunity for intervention is lost.

Once identified, there are a number of ways that the obstetrician­gynecologist can offer support to survivors of abuse. These include tech­niques to increase patient comfort during the gynecologic or obstetric visit and examination, the use of empowering messages, and the provision of counseling referrals.

• Visits and examinations. All procedures should be explained in advance, and whenever possible, the patient should be allowed to suggest ways to lessen her fear. It is important to ask permission to touch the patient. Techniques to increase the patient’s comfort include talking her through the steps, maintaining eye contact, allowing her to control the pace, allowing her to see more (eg, use of a mirror in

Box 3-36. Common Symptoms in Adult Survivors of Childhood Sexual Abuse ^

Physical Presentations

• Chronic and diffuse pain (especially abdominal or pelvic)

• Gynecologic problems (dyspareunia, vaginismus, and nonspecific vaginitis)

• Obesity, eating disorders

• Insomnia, sleep disorders

• Sexual dysfunction

• Addiction

• Low pain threshold

• Self-neglect

Psychologic and Behavioral Presentations

• Depression and anxiety

• Posttraumatic stress disorder symptoms

• Distorted self-perception

• Abuse of alcohol and illicit drugs

• Smoking

• Physically inactive

• Poor contraceptive practices

• Compulsive sexual behaviors

• Early adolescent or unintended pregnancy

• Prostitution

• Sexual dysfunction

• Somatizing disorders

• Eating disorders

• Poor adherence to medical recommendations

• Tendency to be victimized

Data from Adult manifestations of childhood sexual abuse. Committee Opinion No. 498. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:392-5. pelvic examinations), or having her assist during her examination (eg, putting her hand over the physician’s to guide the examination).

• Positive messages. Some positive and healing responses to the dis­closure of abuse include discussing with the patient that she is a survivor of abuse and is not to blame. She should be reassured that it took courage for her to disclose the abuse, and she has been heard and believed.

• Counseling referrals. Traumatized patients generally benefit from mental health care. The obstetrician-gynecologist can be a powerful ally in the patient’s healing by offering support and referral. Efforts should be made to refer survivors to professionals with significant experience in abuse-related issues. Physicians should compile a list of experts with experience in abuse and have a list of appropriate crisis hotlines that operate in their communities.

Reproductive and Sexual Coercion ^537

Reproductive and sexual coercion involve behavior intended to maintain power and control in a relationship related to reproductive health by some­one who is, was, or wishes to be involved in an intimate or dating relation­ship with an adult or adolescent. Many women who experience reproduc­tive and sexual coercion also experience physical or sexual violence.

Reproductive coercion is related to behavior that interferes with con­traception use and pregnancy. The most common forms of reproductive coercion include sabotage of contraceptive methods, pregnancy coercion, and pregnancy pressure. Birth control sabotage is active interference with a partner’s contraceptive methods in an attempt to promote pregnancy. Pregnancy pressure involves behavior intended to pressure a female part­ner to become pregnant when she does not wish to become pregnant. Pregnancy coercion involves coercive behavior, such as threats or acts of violence, if a partner does not comply with the perpetrator’s wishes regard­ing the decision to terminate or continue a pregnancy. Homicide is a lead­ing cause of pregnancy-associated mortality in the United States.

Sexual coercion includes a range of behavior that a partner may use related to sexual decision making to pressure or coerce a person to have sex without using physical force. This behavior includes repeatedly pres­suring a partner to have sex, threatening to end a relationship if the person does not have sex, forcing sex without a condom or not allowing other prophylaxis use, intentionally exposing a partner to an STI, including HIV, or threatening retaliation if notified of a positive STI infection test result.

Because evidence demonstrates that violence and poor reproductive health are strongly linked, health care providers should screen women and adolescent girls for reproductive and sexual coercion and intimate part­ner violence at periodic intervals, such as annual examinations and new patient visits. In contrast to most intimate partner violence interventions, which significantly depend on programs or resources outside the clinical setting, women’s health care providers can directly provide interventions that address reproductive and sexual coercion. Interventions include educa­tion on the effect of reproductive and sexual coercion and intimate partner violence on patients’ health and choices, counseling on harm-reduction strategies, and prevention of unintended pregnancies by offering long-act­ing methods of contraception that are less detectable to partners. (For more information on screening and interventions, see the “Family Planning” section earlier in Part 3.)

Sexual Assault or Rape ^537

Sexual assault is a crime of violence and aggression and encompasses a continuum of sexual activity that ranges from sexual coercion to con­tact abuse (unwanted kissing, touching, or fondling) to rape. Because definitions vary among states, the term sexual assault is sometimes used interchangeably with rape. The Federal Bureau of Investigation uses the following recently revised, more comprehensive definition of rape to track statistics for the annual Uniform Crime Report: “Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.” The Federal Bureau of Investigation’s change does not affect defini­tions under federal or state criminal laws; the new definition only applies for statistical purposes, so that crimes under existing state laws will now be counted by the federal government.

Data compiled from reports to law enforcement officials underestimate the incidence of sexual assault because of varying definitions of sexual assault and underreporting by victims. Although the true prevalence of rape or sexual assault is unknown, estimates based on the 2010 National Intimate Partner and Sexual Violence Survey reveal that approximately 1.3 million rape-related physical assaults occur against women annually. Approximately 18% of women surveyed reported that they had been vic­tims of a completed or attempted rape during their lifetime. Nearly 80% reported that they were first raped before age 25 years, and 42% before age 18 years. Among female victims, 51% reported that at least one perpetrator was a current or former intimate partner, 41% reported an acquaintance, 13% reported a family member, and 14% reported a stranger.

Health care providers should routinely screen all women for a history of sexual assault, paying particular attention to those who report pelvic pain, dysmenorrhea, or sexual dysfunction. Early identification of victims of sex­ual assault can lead to prevention of long-term and persistent physical and mental health consequences of abuse. Reproductive-aged victims of sexual assault are at risk of unintended pregnancy, sexually transmitted infections, and mental health conditions, including posttraumatic stress disorder.

Clinicians who evaluate a victim of sexual assault in the acute phase have a number of medical and legal responsibilities (see Box 3-37). Health care providers should offer victims emergency contraception and sexually transmitted infection prophylaxis. The health care provider who examines victims of sexual assault has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. Clinicians also may want to consider including a toxicology screen in the workup of victims of sexual violence, particularly adolescents and young adults. Other health personnel, particularly those trained to respond to rape-trauma victims, should be consulted to provide immediate interven­tion if necessary and to facilitate counseling and follow-up. Generally, a visit for clinical and psychologic follow-up should take place within 1-2 weeks, with additional encounters scheduled thereafter as indicated by results and assessments.

Box 3-37. Physician’s Role in Evaluation of Sexual Assault Victims <

Medical Issues

• Obtain informed consent.

• Assess and treat physical injuries.

• Obtain past gynecologic history.

• Perform physical examination, including pelvic examination, with appro­priate chaperone.

• Obtain appropriate specimens and serologic tests for sexually transmitted infection testing.

• Provide appropriate infectious disease prophylaxis as indicated.

• If the assailant’s human immunodeficiency virus status is unknown, evalu­ate the risks and benefits of nonoccupational postexposure prophylaxis.

• 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 Issues[‡‡‡‡]

• Provide accurate recording of events.

• Document injuries.

• Collect samples 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.

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