Chapter 60. Domestic Violence & Sexual Assault

For many victims of domestic violence and sexual assault, the first contact with the health care system is with the obstetrician-gynecologist or primary care doctor. Consequently, it is critical that these physicians be knowledgeable in the identification, evaluation, and treatment of such patients.

Essentials of Diagnosis

• Chronic pelvic pain
• Sexual dysfunctions, such as decreased interest or arousal, dyspareunia, or anorgasmia
• Chronic or recurrent vaginitis
• Anxiety or tears before or during the pelvic examination
• Persistent multiple bodily complaints, such as chronic headaches, palpitations, abdominal complaints, or sleep and appetite disturbances
• Eating disorders
• Somatoform disorder
• Depressed or suicidal
• Anxiety or sleep disorders
• May self-medicate with alcohol or other substances
• Posttraumatic stress disorder
• Personality disorders characterized by maladaptive character traits
• Multiple personality disorder

Although the home is often thought of as a safe haven, it is the site of the most common manifestations of violence in our society today. Domestic or intimate partner violence typically refers to violence perpetrated against adolescent and adult females within the context of family or intimate relationships. Although victims of domestic violence may be male or female, 90–95% of the victims are women. Domestic violence is characterized by a behavior pattern manifested in physical and sexual attacks, as well as psychologic and economic coercion.

The abuser uses the behavior in order to establish and maintain domination and control over the victim. Because abuse is usually accompanied by shame and guilt, the victim often does not report the abuse. As a result of significant underreporting, it is difficult to compile exact data on the incidence of domestic violence. Every year, approximately 4–5 million women are believed to be battered by their intimate partners. Violence by an intimate partner accounts for approximately 21% of all the violent crime experienced by women. More than 40% of all female murder victims are murdered by their husbands, boyfriends, or ex-partners. It is estimated that at least one-fifth of all American women will be physically assaulted by a partner or ex-partner during their lifetime.

Violent acts may include threats, throwing objects, pushing, kicking, hitting, beating, sexual assault, and threatening with or using a weapon. Domestic violence frequently includes verbal abuse, intimidation, progressive social isolation, and deprivation of things such as food, money, transportation, or access to health care. The violence typically occurs in a predictable, progressive cycle. The tension-building phase is characterized by arguing and blaming as anger intensifies. This leads to the battering phase that may involve verbal threats, sexual abuse, physical battering, and use of weapons. The battering phase is followed by a honeymoon phase during which the abuser may deny the violence, make excuses for battering, apologize, buy gifts, and promise never to do it again, until the next cycle begins. Although unemployment, poverty, and alcohol and substance abuse increase the likelihood of abuse, domestic violence cuts across all racial, ethnic, religious, educational, and socioeconomic lines. Domestic violence often occurs within a framework of family violence that can include child abuse, elder abuse, or abuse of adults who are disabled. It is estimated that child abuse occurs in 33–77% of families where adults are abused.

Prevention

If the violence has escalated to the point where the patient is afraid for her safety or that of her children, she should be offered shelter. An important step in addressing ongoing violence is to help the victim establish a safety plan. The American College of Obstetricians and Gynecologists (www.acog.org) distributes pocket cards with suggested steps for making an exit plan. These cards can be handed to the patient or left in patient restrooms where a woman can pick it up without concern of being seen by an accompanying partner.

Providing educational materials about domestic violence and its consequences can sometimes help victims take action toward ending the violence. These materials demonstrate to women that their physicians' offices are both a resource and a safe place should they decide to take action. A list of referral resources should be readily available in medical offices. The list should include telephone numbers for police departments, emergency departments, shelters for battered women, rape crisis centers, counseling services, self-help programs, and advocacy agencies that can provide legal, financial, and emotional support.

Clinical Findings

Survivors of domestic violence or sexual abuse may present to health care professionals in a variety of clinical settings. The prevalence of domestic violence among patients in ambulatory care settings is estimated to be between 20 and 30%.

Such patients commonly report chronic pelvic pain to their gynecologists. A history of sexual abuse is found in significantly more women with chronic pelvic pain as compared with other gynecologic conditions. Others may complain of sexual dysfunctions such as decreased interest or arousal, dyspareunia, or anorgasmia. Incest victims have a very high rate of sexual dysfunction and may avoid sex or seek it out compulsively. Still others may present with chronic or recurrent vaginitis. Some women may present for a routine gynecologic appointment but become anxious and tearful before or during the pelvic examination.

Some women present to their primary care physicians with persistent multiple bodily complaints, such as chronic headaches, palpitations, abdominal complaints, or sleep and appetite disturbances. Eating disorders may be more common among abuse victims. Others may have a somatoform disorder. This condition is characterized by physical symptoms suggesting a physical condition for which there are no demonstrable organic findings or physiologic mechanisms. In the face of a negative workup, there may be evidence of or a presumption that the symptoms are linked to psychologic factors or conflicts. Women who meet the criteria for somatoform disorder often have a history of abuse.

In a mental health setting, victims of domestic violence or sexual assault may note feeling depressed or suicidal. They may have anxiety or sleep disorders that they may self-medicate with alcohol or other substances. Most commonly, these women may have posttraumatic stress disorder (PTSD), which occurs in individuals who have experienced a psychologically distressing event that is outside the range of usual human experience. Symptoms of PTSD include re-experiencing the traumatic event through intrusive memories, dreams, flashbacks, or exposure to events symbolic of the trauma. Patients with PTSD also exhibit a “psychic numbing,” that is, they are detached from other people and have difficulty feeling emotions, especially those associated with intimacy or sexuality. Other clinical syndromes include personality disorders characterized by maladaptive character traits. In very extreme cases, patients may have multiple personality disorder, characterized by having ≥2 distinct personalities existing within them. This disorder is marked by a disturbance in the normally integrated functions of identity, memory, and consciousness as the result of dissociation from traumatic experiences.

The problem of domestic violence in pregnancy merits special mention because it is a threat to both the mother and her developing fetus. Estimates of prevalence of domestic violence in pregnancy are in the range of 1–20%, with most studies identifying rates between 4 and 8%. These estimates suggest that violence is a more common problem for pregnant women than preeclampsia, gestational diabetes, and placenta previa, conditions for which pregnant women are routinely screened and evaluated. Some evidence suggests that violence may escalate during pregnancy, especially in the postpartum period. Abuse is associated with increased physical and psychological stress, inadequate prenatal care utilization, poor nutrition and weight gain, and increased maternal behavioral risks (cigarette, alcohol, and substance abuse). These may lead to problems with fetal growth and development. Physical trauma can cause abruptio placentae, preterm labor, preterm premature rupture of membranes, and maternal and fetal injuries and demise.

Differential Diagnosis

Although battered women seek medical care frequently, as few as 1 in 20 are correctly identified by the practitioner to whom they turn for help. Barriers to diagnosis include the practitioner's lack of knowledge or training, lack of recognition of the widespread prevalence of the problem, time constraints, fear of offending the patient, and a feeling of powerlessness in the area of treatment. Research suggests that the use of abuse assessment questions on standard medical records may increase screening and documentation. In addition, because many women will not voluntarily disclose abuse, asking each patient directly about prior or ongoing victimization increases the likelihood of disclosure.

The screening assessment should be prefaced with a statement to establish that screening is universal, such as, “I would like to ask you a few questions about physical, sexual, and emotional trauma because we know that these are common and affect women's health.” Direct questioning using behaviorally specific phrasing should follow:

• Has anyone close to you ever threatened to hurt you?
• Has anyone ever hit, kicked, choked, or hurt you physically?
• Has anyone, including your partner, ever forced you to have sex?
• Are you ever afraid of your partner?

Disclosure rates will be higher when the questions are asked face to face by the health care provider rather than through a questionnaire and when behaviorally specific descriptions rather than the terms “abuse,” “domestic violence,” or “rape” are used. Abuse victims are often accompanied to health care appointments by the perpetrator, who may appear overprotective or overbearing, and may answer questions directed toward the woman. It is important to ask the patient questions in private, apart from the male partner. It is also important to ask the patient questions apart from children, family, or friends and to avoid using them as interpreters when asking questions about violence.

In the office setting, the most effective and efficient strategy for providing assistance to a woman who has disclosed abuse involves acknowledging and documenting the trauma, assessing immediate safety and establishing a safety plan, and providing patient education and referrals to community support services. An essential first step is to acknowledge the trauma. It is important to reinforce to the victim that she is not to blame, as many victims have trouble believing that they are not responsible for the abuse.

Documenting domestic violence is no different from documenting other patient interactions, but such documentation may provide important supportive evidence in the courtroom to put an end to the violence. Direct quotations of the patient's explanation of her injuries should be recorded. Photographs may be taken after consent is granted. Every effort should be made to maintain confidentiality to avoid retaliation by the perpetrators when they suspect disclosure of abuse. The physician or health care professional may be required by state law to report actual or suspected domestic violence.

Once domestic violence is acknowledged and documented, the next step is to assess immediate safety and to establish a safety plan. Lethality of the violence should be assessed by asking questions such as:

• Has your partner ever threatened to kill you or your children?
• Are there weapons in the house?
• Does your partner abuse alcohol or use drugs?
• Is it safe for you to go home?
• Are the children (or other dependents) safe?

Treatment

Given the high rate of psychiatric symptomatology in this population, referral for psychiatric screening and counseling can be useful. Patients who are experiencing posttraumatic stress disorder can benefit from psychotherapy and possibly medication as well. Those with depression, substance abuse, or anxiety, personality, or dissociative disorders will also require ongoing treatment. Psychiatrists or other mental health professionals can serve to coordinate a variety of treatment modalities for the victims: individual, couples, and family therapy; detoxification and substance abuse treatment; and advocacy groups.

Despite the best efforts of physicians and other health care professionals, some women may initially be unable to extirpate themselves from victimization. For such women, an encounter with a health care system that they experience as nonblaming, accessible, and supportive will help to maximize the chances of their making a positive life change at some future point.

Essentials of Diagnosis

• Complaints of having been mugged
• Concerns about acquired immune deficiency syndrome (AIDS) or other sexually transmitted diseases
• Psychiatric symptoms include depression, anxiety, or a suicide attempt
• PTSD
• Somatic symptoms include disturbed sleeping and eating patterns, gastrointestinal irritability (with nausea predominating), musculoskeletal soreness, fatigue, tension headaches, and intense startle reactions
• Symptoms of vaginal irritation occur in more than 50% of victims
• Rectal pain and bleeding are frequent in patients subjected to anal penetration
• Gynecologic trauma
• Escape through the use of alcohol and drugs

Sexual assault is any sexual act performed by one person on another without the person's consent. Sexual assault includes genital, oral, or anal penetration by a part of the accused's body or by an object. It may result from force, the threat of force either on the victim or another person, or the victim's inability to give appropriate consent. Many states have now adopted the gender-neutral legal term sexual assault in favor of rape, which traditionally referred to forced vaginal penetration of a woman by a male assailant.

An estimated 700,000 to 1,000,000 American women are sexually assaulted every year. These estimates are higher than official crime reports because the majority of cases go unreported. According to one estimate, only 30% of rapes are reported to the police, and 50% of rape victims tell no one. At least 20% of adult women, 15% of college-age women, and 12% of adolescent girls have experienced sexual abuse and assault during their lifetime. Sexual assault occurs in all age, racial-ethnic, and socioeconomic groups, but its incidence may be higher for African American women and for adolescent females. In several studies, approximately one-fourth to one-half of the victims of sexual assault were younger than the age of 18 years. The very young, the elderly, and the physically or developmentally disabled may be particularly vulnerable to sexual assault.

Several variants of sexual assault deserve special mention. Marital rape is defined as forced coitus or related sexual acts within a marital relationship without the consent of a partner. Acquaintance rape refers to those sexual assaults committed by someone known to the victim. More than 75% of adolescent rapes are committed by an acquaintance of the victim. When the acquaintance is a family member, including step-relatives and parental figures living in the home, the sexual assault is referred to as incest. When the forced or unwanted sexual activity occurs in the context of a dating relationship, it is referred to as date rape. In this situation, the woman may voluntarily participate in sexual play but coitus occurs, often forcibly, without her consent. Alcohol use is frequently associated with date rape. “Date rape drugs” such as flunitrazepam (Rohypnol) and gamma-hydroxybutyrate (GHB) have also been used to diminish a woman's ability to consent or to remember the assault.

Statutory rape refers to sexual intercourse with a female under an age specified by state law (ranging from 14–18 years of age); the consent of an adolescent younger than this age is legally irrelevant because she is defined as being incapable of consenting. Child sexual abuse is defined as contact or interaction between a child and an adult when the child is being used for the sexual stimulation of that adult or another person. All 50 states and the District of Columbia mandate reporting of child abuse, including child sexual abuse. Nearly half of the states also require physicians to report statutory rape. Physicians should be familiar with the laws in their states; failure to report sexual assault against children may subject the physicians to fines and incarceration for up to 1 year.

Our society has many misperceptions about sexual assault. The victims are often blamed for having encouraged the assault by their behavior or dress, for not sufficiently resisting the assault, for being promiscuous, or for having ulterior motives for pressing charges. This misplaced culpability is often internalized by the victims, which (in addition to fear of retribution) may explain their reluctance to report the violent crime to the authorities. Another common misperception is that rape is an impulsive or aggressive extension of normal sex drive on the part of the rapist. The motivation for most sexual assault, however, seems not to be sexual gratification but rather degradation, terrorization, and humiliation of the victim. The assault is often a demonstration of power (power rape), anger (anger rape), or sadism manifested in ritualized torture or mutilation of the victim (sadistic rape) on the part of the rapist.

Prevention

Much of this chapter addresses the role and responsibilities of the health care professional in caring for victims of domestic violence and sexual assault after they have occurred. One of the greatest challenges for health care and public health professionals working to improve women's health continues to be the epidemic of violence against women in our society and around the world. A great deal remains to be learned and done about the primary prevention of violence.

Clinical Findings

The majority of rape victims who come to emergency rooms do not openly admit to having been sexually assaulted. Instead, they may complain of having been mugged or may voice concerns about acquired immune deficiency syndrome (AIDS) or other sexually transmitted diseases. Others may present with psychiatric symptoms including depression, anxiety, or a suicide attempt. Unless the primary care physician, obstetrician-gynecologist, or psychiatrist obtains a sexual history, assault victims will remain unidentified as such and will be inadequately treated.

A “rape-trauma” syndrome often occurs after a sexual assault. The initial response (acute phase) may last for hours or days and is characterized by a distortion or paralysis of the individual's coping mechanisms. The initial outward responses vary from complete loss of emotional control (crying, uncontrolled anger) to an unnatural calm and detachment (although some physical signs such as shaking or lowered skin temperature are usually present). The latter behavior represents the victim's need to reestablish control over herself and her environment while simultaneously abandoning the defense mechanism of denial and allowing the renewed invasion of privacy represented by the questioning and examination. The initial reactions of shock, numbness, withdrawal, and denial typically abate after the first 2 weeks. However, studies suggest there is a period, occurring from 2 weeks to several months postassault, in which symptomatology returns and may intensify. It is at this time that the victim may begin to seek help for her symptoms, often without telling the health care provider of the sexual assault that precipitated these symptoms.

The next phase (delayed phase) may occur months or years after the sexual assault and is characterized by chronic anxiety, feelings of vulnerability, loss of control, and self-blame. Long-term reactions include anxiety, nightmares, flashbacks, catastrophic fantasies, feelings of alienation and isolation, sexual dysfunction, psychologic distress, mistrust of others, phobias, depression, hostility, and somatic symptoms. More than half of rape victims experience substantial difficulty in reestablishing sexual and emotional relationships with spouses or boyfriends. Thirty-three percent to 50% of victims report suicidal ideation; suicide attempts have been reported in nearly 1 in 5 rape victims who do not seek treatment.

PTSD is a common long-term sequela of sexual assault, characterized by psychic numbing, intrusive re-experiencing of the trauma, avoidance of stimuli associated with the trauma, and intense psychologic distress. Women with prior victimization histories often have more severe sequela. Women assaulted sexually by family members or dates experience as severe levels of distress as women assaulted by acquaintances or strangers.

Up to 40% of victims who are sexually assaulted sustain injuries. Although most injuries are minor, approximately 1% of the injuries require hospitalization and major operative repair, and 0.1% are fatal. Somatic symptoms are common during the acute phase and include disturbed sleeping and eating patterns, gastrointestinal irritability (with nausea predominating), musculoskeletal soreness, fatigue, tension headaches, and intense startle reactions. Symptoms of vaginal irritation occur in more than 50% of victims, and rectal pain and bleeding are frequent in patients subjected to anal penetration. Ongoing health concerns include gynecologic trauma, risk of pregnancy, and the potential for contracting infections or sexually transmitted diseases, including HIV. Victims may also seek to escape the pain of rape's effects through the use of alcohol and drugs.

Rape victims appear to be frequent users of medical services in the months and years after the assault. In one study, visits to physicians increased 18% in the year of the assault, 56% in the following year, and 31% in the year after, compared with previctimization levels. Reintegration of the self after sexual assault is a slow process that may take months to years as the victim works through the trauma and the loss of the event and replaces it with other life experiences. The prognosis for complete recovery is improved if health care professionals responsible for the victim's care have a supportive, nonjudgmental approach and a well-developed understanding and competent treatment of the emotional, as well as physical, consequences of sexual assault.

Differential Diagnosis

The physician evaluating the victim has both medical and legal responsibilities and should be aware of state statutory requirements. Such requirements may involve the use of sexual assault assessment kits, which list the steps necessary and the items to be obtained for forensic purposes. If personnel trained in collecting samples and information are available, it is appropriate to request their assistance.

Informed consent must be obtained before examining a sexual assault victim. A careful history and physical examination should be performed in the presence of a chaperon or victim advocate. The patient should be asked to state in her own words what happened and to identify or describe her attacker, if possible. The history should include inquiry about last menstrual period, contraceptive use, preexisting pregnancy and infection, and last consensual intercourse before the assault. The patient's activities in the interval between the assault and the examination—whether the patient has eaten, drunk, bathed, douched, voided, or defecated—might affect findings on physical examination; such activities must be recorded.

A careful physical examination of the entire body should be performed. The physician should search for bruises, abrasions, or lacerations about the neck, back, buttocks, and extremities. Bite marks should be noted, particularly about the genitalia and breasts. Injuries to the mouth and pharynx may result from oral penetration. Injuries should be documented with photographs or drawings in the medical record. Rape and physical assault are legal terms that should not be used in medical records. Instead, the physician should report findings as “consistent with the use of force.”

A pelvic examination should be performed. Injuries to the vulva, hymen, vagina, urethra, and rectum should be noted. Occasionally, foreign objects may be found in the orifices. The speculum must be moistened only with saline. Two milliliters of normal saline are injected into the vaginal vault. Nonabsorbent cotton swabs should be used to sample fluid from this vaginal pool and should then be placed in sterile glass tubes and refrigerated. Air-dried, nonfixed smears of this same fluid should be placed on glass slides. A Papanicolaou (Pap) test may also be obtained. Evidence of coitus will be present in the vagina for as long as 48 hours after the attack. Motile sperms may be noted in the vagina for up to 8 hours after intercourse, but may be present in the cervical mucous for as long as 2–3 days. Nonmotile sperm may be noted in the vagina for up to 24 hours and in the cervix for up to 17 days. Acid phosphatase is an enzyme found in high concentrations in the seminal fluid. Evidence of acid phosphatase should be sought by swabbing the vaginal secretions, even in the absence of sperm because the attacker may have had a vasectomy. DNA evaluation may also be performed from the vaginal swab. Nonmotile sperm may be found in the rectum for up to 24 hours after the assault, and acid phosphatase can also be detected in the rectum.

A wet mount or vaginal swab should be obtained to detect Trichomonas vaginalis. Testing for Neisseria gonorrhoeae and Chlamydia trachomatis should be performed from specimens from any sites of penetration or attempted penetration. A serum sample should be collected for subsequent serologic analysis if test results are positive. The risk of acquiring gonorrhea from sexual assault is estimated to be between 6 and 12%. Baseline serologic tests for hepatitis B virus, HIV, and syphilis should also be offered. The risk of acquiring syphilis from sexual assault is estimated to be 3%; the risk of acquiring HIV is undetermined.

An important part of the physician's legal responsibilities is to collect samples for forensic purposes. Pubic hair combings should be collected to look for pubic hair from the assailant. Fingernail scrapings should be obtained to look for skin or blood of the attacker. Skin washings and clothing should be investigated for the presence of blood or semen. A Wood light may be helpful because dried semen will fluoresce under its light. Saliva should be collected from the victim. Because seminal fluid is rapidly destroyed by salivary enzymes, identification of seminal fluid in the mouth after a few hours is difficult. Consequently, victims should be encouraged to come to a medical facility immediately after an assault, where they can be evaluated before they bathe, urinate, defecate, wash out their mouths, or clean their fingernails.

Proper processing and labeling of collected specimens is crucial. All collected specimens are placed in a larger sealed container and processed in a “chain of evidence” fashion. The person who collects the specimens verifies their completeness by signature on the sealed master container. The individual to whom they are transferred must verify by signature that all specimens were received in an untampered state. Thus each individual who has “custody” of the specimens during processing must verify that they were transmitted without alteration until they are turned over to the responsible law enforcement agency. The name of the law enforcement agent who receives the specimens should be noted in the medical record.

Treatment

Treatment of physical injuries sustained at the time of assault should be initiated immediately; prophylactic medical treatment may be indicated for prevention of sexually transmitted infections and pregnancy. For prophylaxis against sexually transmitted infections, empiric recommended antimicrobial therapy for chlamydial, gonococcal, and trichomonal infections may be given. One such regimen consists of the following:

• Ceftriaxone 125 mg intramuscularly in a single dose, plus
• Metronidazole 2 g orally in a single dose, plus
• Doxycycline 100 mg orally 2 times a day for 7 days

Alternative treatment may be given as recommended by the US Centers for Disease Control and Prevention. In addition, it is recommended that hepatitis B immunoglobulin be administered intramuscularly as soon as possible, but certainly within 14 days of exposure. It should be followed by the standard 3-dose active immunization series with hepatitis B vaccine at 0, 1, and 6 months, beginning at the time of passive immunization. Prophylaxis against HIV is controversial.

Emergency contraception can be offered as prophylaxis against pregnancy. The risk of pregnancy after sexual assault has been estimated to be 2–4% in victims who were not using some form of contraception at the time of the assault. A serum pregnancy test should be obtained before administration of emergency contraception to evaluate for preexisting pregnancy. Emergency contraception should be given within 72 hours of the assault, although it can still be effective up to 120 hours later. There are several different methods of emergency contraception. For many years, the most common method (Yuzpe method) involved the use of high-dose combined oral contraceptives within 72 hours of unprotected coitus, repeated 12 hours after the first dose. More recently, use of a progestin-only method has become popular. This method involves the use of levonorgestrel 0.75 mg, in 2 doses 12 hours apart, or a 1-time dose of 1.5 mg within 72 hours of unprotected coitus. A randomized study showed that this is more effective and better tolerated than the Yuzpe method. Levonorgestrel prevented 85% of pregnancies that would have occurred without treatment.

As most patients suffer significant psychologic trauma as a consequence of sexual assault, the physician must be prepared to provide access to counseling. It is preferable that follow-up psychologic counseling be provided by individuals who have extensive experience in the management of crisis response to rape. Even if the victim appears to be in control emotionally, she will probably experience aspects of rape-trauma syndrome at some time in the future. She should be made aware of the symptoms that she may experience and advised to seek help if and when these symptoms occur. No patient should be released from the facility until specific follow-up plans are made and agreed upon by the patient, physician, and counselor.

A follow-up visit should be scheduled approximately 2 weeks after the assault for repeat physical examination and collection of additional specimens. Testing for N gonorrhoeae, C trachomatis, and T vaginalis should be repeated unless prophylactic antimicrobials have been provided. Follow-up counseling should be discussed again at the second visit. Additional visits may be scheduled according to the victim's needs; an additional follow-up visit approximately 12 weeks after the sexual assault is advisable to collect sera for detection of antibodies against T pallidum, hepatitis B virus (unless vaccine was given), and HIV (repeat test at 6 months). During each of these visits, assessment of the patient's psychologic symptoms should be performed, and referrals for further counseling are made as indicated.