Sexual violence, domestic violence, and older adult abuse

Violence is the harmful, threatened or actual, use of force or power against oneself, another person, or against a group or community. Neglect and deprivation represent harmful misuses of power and, therefore, also constitute forms of violence. Violence takes many forms and the trauma it causes may result from material (e.g., financial) as well as physical and/or psychological harm. Violence is always potentially a crime, with the main codified forms being assault (any act of physical violence against another person with the intent to cause physical harm or any act that puts another person in fear of imminent physical harm) and harassment (the sustained and/or systematic unwanted and unwelcome actions that annoy, threaten, intimidate, or alarm another person). Physicians have an ethical and, often, legal obligation to report certain violent crimes, especially rape, child maltreatment (see “Overview” in “Child maltreatment”), and older adult abuse. Any sexual act undertaken against another person without their consent constitutes sexual violence and is liable to criminal prosecution in the US. Sex crimes punishable by law include sexual harassment (a form of sexual discrimination in a social setting involving, e.g., unwanted advances that creates an abusive or hostile environment), unwanted sexual contact (nonconsensual touching of someone in a sexual manner), sexual assault (any nonconsensual nonpenetrative sexual act), child sexual abuse (see “Child sexual abuse”), and rape (nonconsensual penetration of another person's vagina, anus, or mouth with any body part or object). Incest between consenting individuals is also considered a crime under most jurisdictions. Sex crimes are among the most underreported crimes in the US, not least due to the associated stigma, fear, and perpetrators most often being close acquaintances (e.g., partner) and/or persons in a position of authority/power over the person experiencing the violence (e.g., guardians, teachers, religious officials). Individuals who have experienced sexual assault or rape typically present with signs of physical and mental trauma (bruises, lacerations, fear, intrusive thoughts, flashbacks, sleep disturbances, nightmares), often involving injuries to the genital, anal, and/or oral areas. Patients who have experienced sexual assault or rape should receive a comprehensive evaluation, conducted with great empathy and assurance of confidentiality to establish trust and prevent further traumatization and reluctance to report crimes. Psychological counseling with referral to sexual assault crisis programs and psychiatrists should also be provided. A trained professional (e.g., a sexual assault nurse examiner or sexual assault forensic examiners) should furthermore examine the patient using a sexual assault forensic evaluation kit (SAFE kit; colloquially referred to as “rape kit”) to gather and preserve physical evidence of the crime. Long-term complications of sexual violence include PTSD, depression, anxiety, sexual dysfunction, and substance use disorders. Older adult abuse is any form of violence, including financial mistreatment, against older individuals (i.e., > 60 years of age) by a trusted person or someone with responsibility for the patient (e.g., a caregiver). Domestic violence is any form of actual or threatened physical or psychological harm by one person in a household against another, often to maintain power over that person and regardless of the degree of intimacy between them. The term "intimate partner violence” is often used synonymously with “domestic violence” but more specifically refers to violence perpetrated by one partner in an intimate relationship against another. Presentation and treatment of older adult abuse and domestic/intimate partner violence depend on the circumstances as well as the form, severity, and duration of violence experienced. Common features, however, include suspicious injuries (e.g., cigarette burns, bruises inconsistent with medical history) and signs of psychological trauma (e.g., PTSD, depression, anxiety). Patients who have experienced older adult abuse or domestic/intimate partner violence should likewise receive a comprehensive evaluation, with great empathy and the assurance of confidentiality to establish trust and prevent further traumatization and reluctance to report crimes.

• Assault
  • Any act of physical violence against another person with the intent to cause physical harm or any act that puts another person in fear of imminent physical harm
  • Assault is governed by state law in the US.
  • See also “Sexual assault” under “Sex crimes” below.
• Harassment
  • Sustained and/or systematic unwanted and unwelcome actions that annoy, threaten, intimidate, or alarm another person
  • Harassment is governed by state law in the US.
  • See also “Sexual harassment” under “Sex crimes” below.
• Abuse
  • A non-legal term referring to the physical and/or psychological mistreatment of another person
  • Usually implies a close and/or long-term relationship between the perpetrator and the person experiencing the abuse
• Maltreatment/mistreatment
  • A non-legal term sometimes used synonymously with “abuse”
  • Sometimes used in distinction to describe the quality of care (e.g., financial mistreatment or child maltreatment as a form of neglect) vs. the quality of injuries (child abuse as a form of physical and psychological violence)
• Individual who has experienced violence/survivor
  • Preferred terms for persons who have experienced acts of violence, replacing the obsolete term “victim,” which implies a state of helplessness, perpetuating the stereotype of being unable to recover from the experience
  • The term “survivor” has become very popular in recent years, but it is not unproblematic as it implies recovery from the experience as well as the threat of death, neither of which is necessarily given in all experiences of violence.

Sexual violence is the use of physical or psychological force during or as a means to obtain a sexual act from another individual. Although specific definitions of the types vary between jurisdictions, sexual violence is generally considered a crime if committed against nonconsenting individuals.

Sexual consent

• Definition: voluntary and discernible approval by a legally or functionally competent individual to engage in a sexual activity proposed or initiated by another individual
• Age of consent: age at which an individual is legally permitted to engage in sexual activity
• Inability to consent: the inability to voluntarily and discernibly approve a sexual contact due to mental/physical disability or another illness, being asleep or unconscious, being too intoxicated (whether voluntarily or involuntarily so), or being below the age of consent
• Inability to refuse: the inability to express nonconsent due to physical violence, the threat of force, and other forms of coercion or intimidation (e.g., misuse of authority)

Sex crimes ^[1]

• Unwanted sexual contact
  • The unwanted touching of a nonconsenting person or a person unable to consent/refuse in a sexual manner, esp. of the genitalia, anus, breasts, inner thigh, or buttocks
  • Unwanted sexual contact in a social setting may be considered sexual harassment.
• Sexual harassment: a form of sexual discrimination in any social setting (e.g., workplace, school, church) that involves any type of unwanted sexual advances, the request of sexual favors, or any other type of sexual verbal and/or physical conduct that creates an abusive or hostile environment
• Sexual assault
  • Any nonconsensual sexual act not involving penetration upon another person, including sexual acts upon persons lacking the capacity to give consent
  • Definitions vary between jurisdictions but typically cover nonconsensual, nonpenetrative sexual acts involving:
    • The use of force, the threat of force, coercion, or abuse of authority
    • Touching, groping, and kissing
    • Exhibitionism
    • Exposure to pornographic materials
    • Individuals below the age of consent
    • The use of drugs or alcohol for incapacitation or manipulation
• Rape: the nonconsensual penetration of another person's vagina, anus, or mouth with any body part or object.
  • Attempted rape: the clearly intended but unsuccessful attempt to penetrate another person's vagina, anus, or mouth with any body part or object without their consent
  • Statutory rape: sexual intercourse with a person below the age of consent, regardless of whether the act occurred against the person's will
• Child sexual abuse: any sexual act involving individuals under the age of consent, including sexual assault, rape, incest, and exploitation (i.e., noncontact sexual activities, e.g., photoshoots)
  • Child sexual abuse may be, but is not necessarily, motivated by pedophilic disorder.
  • See also “Child sexual abuse.”

• Sex crimes are among the most unreported crimes in the US.
• Persons who have experienced an attempt or completed rape in their lifetime:
  • Estimated 20% (1 in 5) of all women
  • Estimated 3% (1 in 33) of all men
• Percentages of women who have experienced other types of sexual violence ^[2]
  • Sexual coercion: 12.5%
  • Unwanted sexual contact: 27.3%
  • Noncontact unwanted sexual experiences: 32.1%
• Percentages of men who have experienced other types of sexual violence
  • Made to penetrate another person: 6.7%
  • Sexual coercion: 5.8%
  • Unwanted sexual contact: 10.8%
  • Noncontact unwanted sexual experiences: 13.3%
• The most commonly affected age group is 16–25 years.
• Sexual violence is most often perpetrated by men.
• Sexual violence is most often perpetrated by an intimate partner or acquaintance.

References:^[1][3][4]

• Injuries in the genital, anal, and/or oral areas (e.g., lacerations, bruising)
• Genital, pelvic, and/or abdominal pain
• Musculoskeletal injuries
• Acute stress reaction
  • Symptoms may persist for days to months.
  • Acute eating disturbances, anorexia
  • Fear, anger, anxiety, shame, guilt, embarrassment
  • Intrusive thoughts, flashbacks
  • Sleep disturbances, nightmares
• Signs and symptoms of sexually transmitted diseases

The treatment of recent sexual violence (i.e., within the past 72 hours) depends on the degree of physical/psychological trauma, patient age, and other individual circumstances. Sexual assault that does not cause physical trauma can still cause severe psychological trauma with potentially severe consequences (e.g., risk of suicide) and should be managed accordingly. ^[1][5][6]

Setting of care

• The most appropriate settings for the care of patients are the emergency room or a local rape crisis center, where professionals trained to care for these patients (e.g., sexual assault response teams) are present.
  • A primary survey for a life- or limb-threatening emergency should be performed and, if present, should be treated first.
  • As soon as the patient is deemed to be stable, offer to move the patient to a quiet room where they can be to themselves.
• If the patient presents to a health care provider in a setting other than the emergency room or local rape crisis center, the health care provider should:
  • Ask the patient to go immediately to the nearest emergency department or local rape crisis center and facilitate the transfer of care.
  • Advise the patient not to engage in any activity that can potentially destroy or alter evidence before they have been offered a forensic evaluation.
  • Such activities include: going to the bathroom, douching, changing tampons, cleaning the genital area or showering, brushing, smoking, eating, drinking, taking medications, changing clothes

Communication with the patient

• Health care providers must follow a trauma-informed approach to minimize retraumatization (see “Trauma-informed communication” in “Patient communication and counseling”).
• Informed consent should be obtained for every step in forensic evaluation and management.

Forensic evaluation

• Involves taking history related to the sexual assault, physical examination, collection of evidence, and thorough documentation
• Should be performed only by trained professionals such as sexual assault nurse examiners (SANEs) or sexual assault forensic examiners (SAFEs)
• Evidence should be collected with urgency (ideally within the first 72 hours).
• Patients should be informed of the following rights regarding a forensic evaluation:
  • Right to a forensic evaluation regardless of their decision to report the sexual assault (see “Reporting sexual assault”)
  • Right to refuse a forensic evaluation
• For patients who are unable to provide consent to a forensic evaluation (e.g., intoxicated or unconscious patients):
  • Postpone forensic evaluation if the patient is expected to recover within the window period for evidence collection.
  • If the patient is not expected to recover within the window period for evidence collection, examination and evidence collection can be completed without consent, but the sexual assault forensic evidence kit may not be released to the authorities without the patient's consent or until a court order is obtained.
• For patients unable to give or below the age of consent (e.g., minors, patients with dementia, coma patients), a surrogate decision-maker can provide consent granted that there is no suspicion regarding this person's involvement in the attack.

History taking

• Goal: gathering information about the attack and relevant medical and personal history
  • Attack
    • Time, location, and setting of the attack
    • Details of the assault (e.g., extragenital acts, use of physical force or weapons, use of condoms)
    • Obtain a description or, if possible, establish the identity of the perpetrator(s)
    • Patient's ability to consent to the sexual activity at the time of the attack and the details of any substance use beforehand
    • Details of the period after the assault (e.g., changing clothes, bathing, douching, brushing teeth, urination)
  • Relevant medical history
    • Time of last sexual intercourse
    • Immunization history and current medications
    • For women of child-bearing age: pregnancy status or last menstrual period
    • History of anogenital surgery
• Method
  • Use open-ended questions rather than yes-or-no/leading questions, e.g.:
    • “Can you tell me in your own words what happened?” rather than “Did the attack occur at night?”
    • “Can you describe the perpetrator?” rather than “Do you know the man who raped you?”
  • Avoid interrupting the patient and allow them to narrate the experience freely.
  • Document the patient's statements verbatim and avoid paraphrasing.

Evidence collection

• Method: use of sexual assault forensic evidence kits
  • Kits contain all required instructions, standardized forms for documentation of examination findings, and evidence collection equipment (e.g., bags for the patient's clothing, comb used to collect hair and fiber samples from the patient, materials for swabs).
  • Kits must be sealed and stored at the medical facility and the chain of custody of evidence material must be maintained.
  • Kits are only transferred to law enforcement if the patient wants to take legal action.
• Procedure
  • Avoid cross-contamination of evidence (e.g., by using gloves and changing gloves as needed).
  • Request the patient to undress over a clean hospital sheet and collection papers and to place each piece of clothing in separate paper bags.
  • Perform a thorough examination for the physical injuries (e.g., bite marks, strangulation marks) and collect biological samples that may help identify the perpetrator (e.g., semen, blood, saliva, fingernail scrapings, hairs).
    • Toluidine blue dye can be used to visualize injuries in the genital or anal region
    • The speculum used for vaginal examination should be lubricated with tap water, not gel-based lubricants.
    • Per speculum examination on prepubertal children should be performed under general anesthesia.
  • Document in writing and with photographs the examination findings, their exact location, and appearance.
  • Collect, seal, and label the biological specimens and foreign debris using equipment from the sexual assault forensic evidence kits
    • Moist specimens should be collected with a dry swab.
    • Dried-out samples should be rehydrated with a wet swab and then collected with a dry swab.
    • Debris should be scraped and collected in a paper bindle.
  • After the specimens and debris have been collected, photograph the areas from which they were collected.
  • If a substance-facilitated sexual assault is suspected:
    • Collect blood and urine specimens if the drug is suspected to have been ingested within the last 36 hours.
    • Collect urine specimens if the drug is suspected to have been ingested more than 36 hours ago.
    • Do not pack these blood and/or urine specimens together with the sexual assault forensic evidence kit.

Reporting sexual assault or rape

Laws for reporting sexual assault vary across states and jurisdictions. Physicians should be aware of their ethical obligation to protect their patients and familiarize themselves with the laws in their jurisdiction regarding mandatory reporting of suspected sex crimes.

• Adult patients
  • In most states, it is not mandatory for health care providers to report sexual assault of adults to law enforcement authorities without the patient's consent. In these states, adult patients should be asked if they would like to report the assault to law enforcement authorities.
  • Some states require mandatory reporting of all cases of sexual assault. In these states, the patient should be informed that the sexual assault will be disclosed to law enforcement authorities.
• Minors: in all states, sexual assault of minors must be reported by health care providers to law enforcement authorities or Child Protective Services

Additional management before the patient leaves the setting of care

• All patients should be offered testing for certain sexually transmitted infections.
  • Vaginal and/or rectal smears to test for Neisseria gonorrhoeae and Chlamydia trachomatis
  • Saline wet mount of vaginal smear to test for Trichomonas vaginalis
  • Serological testing for HIV, hepatitis B, and syphilis
  • Perform further testing based on individual risk factors
• Empirical prophylaxis against sexually transmitted infections
  • Adult and adolescent patients
    • Offer empirical prophylaxis against gonorrhea, chlamydia, and trichomoniasis with single-doses of:
      • Ceftriaxone (IM)
      • PLUS azithromycin (PO)
      • PLUS tinidazole (PO) OR metronidazole (PO)
    • Offer hepatitis B postexposure prophylaxis if the patient's immunization status is unknown or negative
    • Consider HIV postexposure prophylaxis based on individual risk factors and circumstances of the attack, including whether the patient knows the perpetrator, the type of sexual contact, the number of perpetrators involved, and the presence of mucosal lesions and/or bleeding.
  • Children: empirical prophylaxis is not recommended
• A female patient of reproductive age group should also be offered pregnancy testing and emergency contraception using hormonal methods.
• Offer psychological counseling, referral to a psychiatrist, and information on sexual assault crisis programs, rape crisis advocates, and social workers.

Follow-up care

• Timing: approx. 1–2 weeks after the event
• With the same physician or another appropriate provider
• Repeat STD screening (gonorrhea, chlamydia, trichomonas) in patients who declined empiric antibiotic treatment.
• Complete vaccination schedules.
• Repeat pregnancy test in women of the child-bearing age
• Assess psychological status and how the patient is coping with the trauma.
• Offer referral to a psychiatrist.

• PTSD: sexual assault is one of the most common causes of PTSD in both men and women
• Anxiety disorders
• Depression
• Chronic pelvic pain
• Sexual dysfunction
• Substance use disorders (e.g., sedatives, stimulants, analgesics)

Reference:^[1]

• Definition
  • Any form of physical, sexual, psychological, financial mistreatment or neglect of an older adult (> 60 years of age) at the hands of a caregiver or someone the individual trusts. ^[7]
  • Vulnerable adult: a person who is or may be mistreated and who because of age and/or disability is unable to protect him or herself.
• Statistics: 3–10% of older adults experience abuse at some point. ^[8][9]
• Circumstances that may facilitate abuse
  • Dementia
  • Social isolation
  • Lack of support
  • Living in an assisted living facility with a large number of household members
• Warning signs and common features ^[7]
  • Reports of theft or unusual loss of property/money
  • Unexplained soft tissue injury (e.g., cuts, bruises, pressure ulcers, burns)
  • Anogenital trauma, pelvic pain, or postmenopausal bleeding
  • Dehydration
  • Malnutrition
  • Unusual fractures
  • Depression/suicidality
  • Unusual, e.g., fearful, avoidant, or hostile behavior (e.g., avoiding eye contact) should raise suspicion, esp. if marking a change in behavior.
• Diagnosis ^[10]
  • Detailed medical history
  • Distinguish between intentional injuries and age-related conditions (e.g., poor wound healing, osteoporosis, dementia, adverse effects of prescribed medication).
  • Laboratory analysis
    • Rule out coagulopathies in unexplained or excessive bruising.
    • Measure prescribed drug levels to rule out medication withholding or overdosing.
• Management ^[11][12][13]
  • Physicians have a legal and ethical obligation to report older adult abuse and protect their patients.
  • If the patient is in immediate, life-threatening danger: inform law enforcement authorities.
  • If the patient is not in immediate, life-threatening danger:
    • Inform Adult Protective Services if the patient lives in the community.
    • Inform the Long-Term Care Ombudsman program if the patient lives in a facility (e.g., nursing home).
  • Mandatory reporting laws vary across states and jurisdictions, and physicians should familiarize themselves with the laws in their jurisdiction. ^[14]

In the United States, the Eldercare Locator Hotline (1-800-677-1116) and website (https://eldercare.acl.gov) can help to find the appropriate agency for reporting older adult abuse.

• Definition ^[15]
  • Any form of actual or threatened physical or emotional harm committed by one member of a household against another, frequently used as an extension power
  • Intimate partner violence (IPV): any form of physical, emotional, or sexual violence that is carried out by a cohabitating or noncohabitating intimate partner against the other ^[16]
• Statistics: Approx. 1:3 women and 1:10 men ≥18 years of age experience domestic violence. ^[8]
• Associated factors
  • Discord in the partnership; may be associated with a history of restraining orders and/or substance use
  • Lower levels of education and socioeconomic status correlate with higher rates of domestic violence
  • Perpetrator with history of abuse during childhood
  • Rates of IPV are higher in women with a history of abuse and during pregnancy and the postpartum period
• Warning signs and symptoms
  • Multiple, unusual, and/or unexplained injuries (e.g., defensive wounds, injuries that appear inconsistent with history)
  • Fearful, avoidant, hostile behavior (e.g., avoid eye contact)
  • Signs suggesting hesitation to seek medical care (e.g., multiple injuries and bruises at varying stages of healing, injuries inconsistent with the timeline provided in history, history of missed appointments)
  • History of frequent visits to the ER
• Diagnosis ^[17]
  • Evaluate for psychological trauma (e.g., signs of depression or substance use)
  • Domineering partner: violent partners may insist on accompanying the patient and speaking on the patient's behalf.
  • Document all evidence of abuse for potential legal action against the perpetrator.
• Management ^[15]
  • Physicians suspecting domestic violence should speak privately with the patient, inquire further, and offer assistance.
  • Assess the patient's safety and whether they have an emergency plan
  • Show empathy and willingness to provide continuous support.
  • Treat injuries
  • Physicians do not have a legal right to report domestic violence without patient consent.
  • Facilitate contact to support services.

Prevention of sexual violence

STOP SV strategy

• Definition: A technical package developed by the CDC to prevent sexual violence, mitigate its effects, address its social determinants, and facilitate access to services for individuals who have experienced violence
• Elements
  • S: promote social norms that inhibit violence (e.g., educating children and mobilizing men and boys to become allies against sexual violence)
  • T: teach skills to prevent sexual violence (e.g., teaching safe dating and healthy intimate relationship skills, promoting healthy sexuality)
  • O: provide opportunities to empower and support girls and women (e.g., strengthen economic support for families and facilitate leadership opportunities)
  • P: create protective environments (e.g., monitoring in schools, addressing community-level risks, improving safety)
  • SV: support patients who have experienced violence to reduce harm (e.g., support centers, medical treatment, and support for at-risk families)

Prevention of intimate partner violence

• The U.S. Preventive Services Task Force (USPSTF) recommends screening all women of reproductive age for IPV.
• There is limited evidence for the effectiveness of screening for IPV in men, female individuals not of reproductive age, and older individuals.
• While there is no evidence for any appropriate screening interval, many sources still recommend routine annual screening. ^[18][19][20]
• However, screening is generally recommendable in vulnerable patients and such deserving of special protection (e.g., pregnant or disabled women) as well as in the presence of circumstances of risk (e.g., unstable household, history of abuse, substance use) or signs of violence (e.g., unexplained bruises, burns, or cuts).
• In all other patient groups, settings such as the first visit to a (new) family physician, gynecologist, or hospital admission may provide a beneficial opportunity for screening and education.
• Screening can help to address immediate threats and prevent long-term IPV-associated impacts (e.g., post-traumatic stress disorder).

Screening tools

• Overview
  • Screening for domestic violence and IPV should be conducted in an open, nonjudgemental, and nonstigmatizing setting.
  • Broaching the topic may be facilitated by pointing out the routine nature of the assessment and politely asking if the patient is comfortable with discussing the topic (e.g., “I routinely screen all my patients for violence in their relationships, so I hope you don't mind me asking you a few questions regarding this topic?”).
  • All of the following screening tests should be considered positive if the patient answers one or more questions with “yes.”
• HARK screening tool: a four-question screening tool that assesses for different manifestations of IPV within the past year
  • H: Has your partner humiliated or emotionally abused you?
  • A: Are you sometimes afraid of your partner?
  • R: Have you ever experienced rape or been forced to have any kind of sexual activity by your partner?
  • K: Has your partner kicked, hit, slapped, or otherwise physically hurt you?
• HITS screening tool: a four-question verbal or written screening tool used to assess how often an individual has been hurt by the intimate partner
  • H: Does your partner physically hurt you?
  • I: Does your partner insult you or talk down to you fairly often?
  • T: Does your partner threaten you with harm?
  • S: Does your partner scream or curse at you fairly often?
• STaT questions: a three-question screening tool used to identify IPV
  • S: Have you ever been in a relationship where your partner has pushed or slapped you?
  • T: Have you ever been in a relationship where your partner threatened you with violence?
  • T: Have you ever been in a relationship where your partner has thrown, broken, or punched things?
• Partner Violence Screen tool (PVS): a three-question screening tool used to assess physical abuse and safety
  • Is there a partner from a previous relationship who is making you feel unsafe now?
  • Do you feel safe in your current relationship?
  • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
• Woman Abuse Screening Tool (WAST): an eight-question screening tool used to assess IPV.
  • Has your partner ever abused you sexually?
  • Has your partner ever abused you emotionally?
  • Has your partner ever abused you physically?
  • Do you ever feel frightened by what your partner says or does?
  • Do arguments ever result in hitting, kicking, or pushing?
  • Do arguments ever result in you feeling down or bad about yourself? Often, sometimes, never?
  • Do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty?
  • In general, how would you describe your relationship? A lot of tension, some tension, no tension?
• Management
  • Provide immediate and ongoing support (counseling and home visits)
  • See “Management” above.

Prevention of older adult abuse

• The USPSTF has found no reliable, valid screening tools for primary care settings to identify abuse of older or vulnerable adults.
• There is no evidence that screening for abuse in older or vulnerable adults reduces abuse in these populations.

References: ^[21]