Bruce B. Ettinger, Joseph C. Gambone
Intimate Partner Violence and Family Violence
Family violence refers to abuse of children and older individuals in addition to violent behavior directed against a current or former intimate partner. Intimate partner violence (formerly known as domestic violence) is defined as intentionally abusive or controlling behavior by a person who is in an intimate or close relationship with the victim.
The focus of the first part of this chapter is on intimate partner violence because the obstetrician-gynecologist is most likely to deal with the effects of abusive behavior directed against an intimate domestic partner. Intimate partner violence can include verbal abuse, intimidation, social isolation, and physical assault, such as a punch, a kick, a threat, a severe beating, an act of sexual assault, or even murder. It occurs in every age group, in all ethnic groups, in every occupation, and in every socioeconomic group. Although the obstetrician-gynecologist may be called to see a patient with acute injuries from partner violence or sexual assault, he or she is more likely to have to deal with the nonacute clinical manifestations of abuse (Box 28-1). Although most often perpetrated by a man against a woman, the gender relationship may occasionally be reversed. Intimate partner violence can also occur between same-sex partners.
BOX 28-1 Clinical Manifestations of Possible Intimate Partner Violence∗
Data from American College of Obstetricians and Gynecologists (ACOG): Special Issues in Women’s Health-Intimate Partner and Domestic Violence. Washington, DC, ACOG, 2005.
• Inadequately explained injuries such as bruises and abrasions
• Unusual difficulty during a gynecologic examination, such as excessive distress, discomfort, or avoidance behaviors
• Chronic and unexplained pelvic pain, urinary symptoms, sexual dysfunction, or irritable bowel syndrome
• Persistent or recurrent vaginitis or sexually transmitted infections despite appropriate treatment
• Persistent vague complaints, such as headache, backache, palpitations, and digestive, sleep, or eating disorders
• Complaints or signs of depression, anxiety, phobias, panic attacks, feelings of shame or worthlessness
• Unintended pregnancy
• Suicidal ideation
∗ No single presentation can confirm intimate partner or family violence.
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.
BOX 28-2 Medical Professionals’ Responsibilities in Addressing Intimate Partner and Family Violence.
Data from American College of Obstetricians and Gynecologists (ACOG): Special Issues in Women’s Health-Intimate Partner and Domestic Violence. Washington, DC, ACOG, 2005.
• Implement a universal screening program
• Acknowledge any trauma
• Assess immediate safety of the patient and any children
• Help to establish a safety plan
• Review options
• Offer educational materials and toll-free hotline information (see Box 28-3)
• Provide referrals
• Document interactions
• Provide ongoing support at subsequent visits
• Inform authorities when appropriate (state medical societies can inform about legal requirements)
Sexual Assault and Rape
Sexual assault and rape have different technical or legal definitions depending on the state or country involved. However, any sexual act performed on a person without his or her consent is classified as sexual assault. Sexual assault includes any unwanted genital, anal, or oral penetration by a part of the attacker’s body or by any object. Rape, on the other hand, is generally a violent attack that may or may not stem from the perpetrator’s sexual desire. Very often, the perpetrator uses sex as a means of control over another person. Whatever the rapist’s intent, rape is definitely not a welcomed sexual experience for the victim. During any act of rape, the victim’s predominant feeling is one of fear for her life or fear of mutilation.
Women of all ages, ethnicities, and socioeconomic groups can be victims of sexual assault, although the very young, the mentally and physically disabled, and the elderly are more vulnerable. Nearly 75% of assaults are perpetrated by someone known to the victim, such as husbands (marital or partner rape), boyfriends (date rape), fathers (incest), mothers’ boyfriends, other relatives, or work associates. The American Medical Association reports that 20% of women younger than 21 years have been sexually assaulted. Other estimates are that 41% of women (of all ages) have been victims of actual or attempted sexual assault and that 50% of these have been victims more than once. Death occurs in about 1% of sexual assaults (including rapes), and serious injury occurs in 4%.
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 trichomonasare 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:
1. Acute and disorganization phase: This phase lasts days to weeks. Immediately after the experience, victims frequently appear calm, although preoccupied and inattentive. They are anxious, have difficulty sleeping, and commonly express shock, disbelief, fear, guilt, and shame. The psychological problems that may result are varied and can mimic those seen in the aftermath of other kinds of traumatic experiences. Among those expected in the acute phase of adjustment are irritability, tension, anxiety, depression, fatigue, and persistent ruminations. Somatic symptoms of a general nature may occur, such as headaches or irritable bowel syndrome, or symptoms may be more specific to the reproductive system, such as vaginal irritation or discharge. Behavioral problems, such as overeating and alcohol or substance abuse, may also surface, particularly when such problems have been evident in the past. Long-term sequelae include changes in lifestyle, the occurrence of disturbing dreams and nightmares, and the persistence of phobic reactions. Fear persists as the predominant feeling. These reactions often make it difficult for the victim to concentrate effectively on everyday activities and relationships.
2. Integration and resolution phase: During this phase, victims begin to accept the assault, but problems at work or with relationships may persist.
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.
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).
BOX 28-3 Key Telephone Numbers for Medical Professionals and Victims of Family Violence and Sexual Assault.
National Domestic Violence Hotline: 1-800-799-SAFE (7233 or 7234) TTY 1-800-787-3224 (hearing impaired)
RAINN (Rape, Abuse, Incest National Network) Hotline: 1-800-656-HOPE
National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453)
Elder Abuse Hotline: 1-800-922-2275
Disabled Person Abuse Hotline: 1-800-426-9009
American College of Obstetricians and Gynecologists (ACOG). Special Issues in Women’s Health: Intimate Partner and Domestic Violence. Washington DC: ACOG; 2005.
American College of Obstetricians and Gynecologists (ACOG). Special Issues in Women’s Health: Sexual Assault. Washington DC: ACOG; 2005.
Centers for Disease Control and Prevention: Intimate partner violence prevention. Retrieved April 12, 2008, from http://www.cdc.gov/ncipc/dvp/IPV/default.htm.
Ellsberg M., Jansen Ha, Heise L., et al. for the WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team: Intimate partner violence and women’s physical and mental health in the WHO Multi-country Study on Women’s Health and Domestic Violence: An observational study. Lancet. 2008;371:1165-1172.
Karch D.L., Lubell K.M., Friday J., et al. Centers for Disease Control and Prevention (CDC) surveillance for violent deaths. MMWR Surveill Summ. 2008;57(3):1-45.