CHAPTER 20
Violence Against Women and Sexual Assault
KEY POINTS
1 Violence against women—particularly intimate partner and sexual violence—has
been characterized by the World Health Organization (WHO) as a major public
1103health problem and a violation of women’s human rights. Global estimates by WHO
indicate that approximately 35% of women worldwide have experienced either
intimate partner, or nonpartner, physical or sexual violence in their lifetime.
2 Childhood sexual abuse has a profound and potentially lifelong effect on the survivor.
Although most cases of childhood sexual abuse are not reported by the survivor or
her family, it is estimated that at least 20% of adult women were sexually abused as
children.
3 Women who were sexually abused as children or sexually assaulted as adults often
experience sequelae, including depression, anxiety, chronic pelvic pain,
dyspareunia, and vaginismus. These symptoms may be unrecognized by the
physician and patient.
4 All women should be screened for a history of sexual abuse or assault, and intimate
partner violence (IPV).
5 Nearly one in four adult women and approximately one in seven men in the United
States report having experienced severe physical violence from an intimate partner
in their lifetime.
6 The terms sexual abuse survivor and assault survivor are preferable to victim.
7 The National Intimate Partner and Sexual Violence Survey (NISVS) from the U.S.
Centers for Disease Control (CDC) found that approximately 18% of women have
been raped during their lifetimes. The lifetime prevalence of rape by an intimate
partner was 8.8% for women, with 0.8% reporting intimate partner rape in the last
year. Among female victims of completed rape, 78.7% were first raped before age
25 years, and 40.4% before age 18.
TERMINOLOGY
[1] Violence against women includes a number of different acts to which girls
and women may be subjected during their lifetimes. Violence against women
—particularly intimate partner and sexual violence—has been characterized
by the World Health Organization (WHO) as a major public health problem
and a violation of women’s human rights. Global estimates by WHO indicate
that approximately 35% of women worldwide have experienced either
intimate partner, or nonpartner, physical or sexual violence or sexual
violence from a nonpartner in their lifetime (1). Most violence that women
experience is perpetrated by intimate partners, and globally, as many as 38% of
murders of women are committed by a male intimate partner (1). This chapter
will address the topics of childhood sexual abuse, human trafficking, female
genital mutilation (FGM), sexual harassment, reproductive coercion, intimate
partner violence (IPV), sexual assault and rape, and elderly abuse. The term
trauma informed care has been used to refer to medical care (as well as social
services, education, and care in other settings) that acknowledges and takes into
1104account the wide-ranging and potentially profound impact that past traumatic
events can have on physical and mental health (2).
CHILDHOOD SEXUAL ABUSE
During childhood, the occurrence of adverse childhood experiences (ACE),
experienced either as a single event or sustained over time—defined in a
landmark 1998 study as including emotional abuse, physical abuse, sexual
abuse, emotional neglect, physical neglect, violent treatment of the mother,
household substance abuse, household mental illness, parental separation or
divorce, or an incarcerated household member—occur regularly for children
of all races, economic classes, and geographic regions, although those who
live in poverty have a much higher prevalence of ACEs (3). The experience of
these ACEs may become toxic when there is “strong, frequent, or prolonged
activation of the body’s stress response systems in the absence of a supportive,
adult relationship” (3,4). A number of common adult health conditions,
including obesity, heart disease, alcoholism, and other drug abuse have been
directly linked to ACEs. In addition, they pose an increased risk for early
initiation of sexual activity and adolescent pregnancy.
[2] Childhood sexual abuse has a profound and potentially lifelong effect on
the survivor. Although most cases of childhood sexual abuse are not reported
by the survivor or her family, it is estimated that at least 20% of adult
women were sexually abused as children (5). Child sexual abuse is defined as
any sexual activity with a child where consent is not or cannot be given, and
includes forceful sexual contact and noncontact activities (6). Younger
children are more often exposed to genital fondling or noncontact abuse
(exhibitionism, forced observation of masturbation, or posing in child
pornography), and children older than 10 years of age are more likely to be forced
to have intercourse or oral sex (7). As children age, they are more likely to
experience sexual abuse outside the home and more likely to be victimized by
strangers. As adolescents, women survivors of childhood sexual abuse are at
risk for early unplanned pregnancy, sexually transmitted diseases (STDs),
prostitution, further sexual abuse (revictimization), antisocial behavior,
running away from home, lying, stealing, eating disorders and obesity, and
multiple somatic symptoms (8). These women are more likely to engage in
health risk behaviors such as smoking, substance abuse, and early sexual activity
with multiple partners (9). They may be less likely to use contraception (10).
While the reported prevalence of child sexual abuse depends on varying
definitions and usually relies on adult retrospective reporting, one large
population study indicated that 10% of respondents reported experiencing contact
1105child sexual abuse before age 18, and about ¾ of the sample reporting abuse were
female (11). A meta-analysis of global prevalence studies reported a prevalence
of combined contact and noncontact child sexual abuse of 19.7% of females
(12,13). A history of childhood sexual abuse increases the risks of developing
posttraumatic stress disorder (PTSD), anxiety disorder, depression,
distortions of self-perception including self-blame, and hospitalization for
mental illness (13). Adult survivors of child sexual abuse are more likely to
become victims of IPV and sexual assault. Disorders that are frequently seen by
obstetrician/ gynecologists including chronic pelvic pain, eating disorders, sexual
effects (including disturbances of desire, arousal, and orgasm), dyspareunia,
vaginismus, unintended pregnancy, and prostitution are associated with a history
of sexual abuse (6). [3] Women who were sexually abused as children or
sexually assaulted as adults often experience sequelae, including depression,
anxiety, chronic pelvic pain, dyspareunia, and vaginismus. These symptoms
may be unrecognized by the physician and patient.
[4] The American College of Obstetricians and Gynecologists (ACOG)
strongly recommends that all women be screened for a history of sexual
abuse (6). Recommendations include routinely incorporating such screening,
normalizing the screening experience as occurring commonly, allowing
patient control over disclosure, asking whether this history has previously
been disclosed and whether she has experienced previous therapy, listening
attentively, and being willing to postpone sensitive examinations (6).
Survivors often avoid pelvic examinations and are less likely to have
Papanicolaou (Pap) tests because of the association between vaginal examinations
and pain (14). They may not be able to tolerate pelvic examinations and may
avoid seeking routine gynecologic care because these examinations may remind
them of the sexual abuse they experienced as children; dissociation and
flashbacks may occur during labor and birth (6,15). While data regarding adverse
pregnancy outcomes for women with histories of childhood sexual abuse are
inconsistent, pregnancy may be especially difficult, and the pain of labor and
delivery may trigger memories of abuse (6,15).
Obstetrician–gynecologists can assist their sexual assault survivor patients
by validating their feelings and concerns and giving them control over their
examination. It is important to ask the patient for permission to perform the
examination, give her the opportunity to have an advocate in the room with
her, and let her know that she has the right to stop the examination at any
time (6). Techniques to increase the patient’s comfort include talking her through
the steps of the examination, maintaining eye contact, allowing her to control the
pace, or guide the examination (6). Survivors may be unable to trust or establish
rapport with adults. Some women blame themselves for the abuse and come to
1106believe that they are not entitled to assistance from others. Thus, they risk
continuing to enter abusive relationships. Women survivors of childhood sexual
abuse often develop feelings of powerlessness and helplessness and may
become chronically depressed. They experience a high incidence of selfdestructive behavior, including suicide and deliberate self-harm, such as cutting
or burning themselves (14,16). The most extreme mental health symptoms in
assault survivors are associated with the onset of abuse at an early age, frequent
abuse over a long period, use of force, or abuse by a parent or other trusted
individual. Survivors are at risk for becoming victimized again later in life (17).
Of women who report being abused as children, 50% are abused again as adults.
Women who are sexually abused as children carry the effects of abuse into
adulthood. As adults, they have the same level of physical symptoms and
psychological distress as women who do not report childhood sexual abuse but
are currently experiencing sexual or physical abuse (18).
Women who were sexually abused as children or sexually assaulted as
adults often experience sexual dysfunction and difficulty with intimate
relationships and parenting (19). Chronic sexual concerns may incorporate fear
of intimate relationships, lack of sexual enjoyment, difficulty with desire and
arousal, and anorgasmia. Compared with women who were not sexually
assaulted, they are more likely to experience depression, suicide attempts, chronic
anxiety, anger, substance abuse problems, dissociative personality disorder,
borderline personality disorder, fatigue, low self-esteem, feelings of guilt and selfblame, and sleep disturbance (6,18,20,21). They often experience social isolation,
phobias, feelings of vulnerability, fear, humiliation, grief, and loss of control
(22,23). Survivors of sexual assault represent a disproportionate number of
patients with chronic headaches, fibromyalgia, and chronic pelvic pain (they
have a lower pain threshold) and are more likely to have somatic symptoms
that do not respond to routine medical treatment (6,24). Women with
common gynecologic symptoms, such as dysmenorrhea, menorrhagia, and
sexual dysfunction, are much more likely to have a history of sexual assault
(25). If they were forced to perform oral sex, they may have a dental phobia and
avoid preventive dental care.
Survivors may develop PTSD, in which characteristic symptoms are
exhibited following a psychologically traumatic event outside of normal
human experience. Symptoms of PTSD involve blunting of effect, denial of
symptoms, intrusive re-experiencing of the incident, avoidance of stimuli
associated with the assault, and intense psychological distress and agitation in
response to reminders of the event (26,27). Women affected by PTSD are more
likely to commit suicide. The cognitive sequelae incorporate flashbacks,
nightmares, disturbances in perception, memory loss, and dissociative
1107experiences (28). They are more likely to use the medical care system for
nongynecologic concerns (29). Women with PTSD are at greater risk for being
overweight and having gastrointestinal disturbances (9).
Referral for mental health care is frequently helpful if there are physical,
psychological, and behavioral symptoms potentially resulting from past
abuse. The manner in which this referral is done may be more easily received if
the statement indicates, “I think that a mental health professional could help
assess whether your past abuse is contributing to your current health problems,”
rather than suggesting that psychological problems are a cause of the symptoms
(6).
HUMAN TRAFFICKING
Trafficking of children for labor and sexual exploitation is a global health
issue and a violation of human rights. Child sex trafficking involves engaging
a person younger than 18 years in a commercial sex act (where there is an
exchange of money or something of value) (30). Activities that may be
contained in this category include exploitation of a child for prostitution (as a
buyer or a seller), mail-order bride trade and early forced marriage, the
production of child pornography, or online sexual abuse. An estimated one
million children, most of whom are girls, are being exploited yearly in the
global commercial sex trade (31). Children and adults may also be trafficked for
labor, although persons trafficked for labor tend to be adult females and foreign
nationals. Lesbian, gay, bisexual, transgender, or queer children and youth,
children with a history of abuse or neglect, or who are homeless, are among those
youth most likely to experience trafficking. In the United States, victims of sex
trafficking are likely to seek medical attention during their period of exploitation,
while those trafficked abroad may receive little or no medical care. The adverse
health effects of child trafficking for sex and labor consist of trauma from sexual
and physical assault, STDs, chronic untreated medical conditions, pregnancy,
chronic pain, substance abuse, and malnutrition (30). Mental health consequences
may involve depression and suicide attempts, self-harm, anxiety disorders, anger
control problems, and PTSD.
The American Academy of Pediatrics (AAP) has advocated that information on
human trafficking should be part of the medical education of health care
professionals, to facilitate the identification and care of victims of human
trafficking. ACOG’s Committee Opinion on Human Trafficking notes that signs
of sex victimization and trafficking may include: young age, multiple sexual
partners, multiple episodes of STDs, inappropriate attire for a health care
visit, tattoos or other branding for which there is only a vague explanation,
1108or evidence of sexual abuse or trauma (31). An unusual dynamic between the
patient and her partner can lead to a suspicion of abuse or trafficking. Other
possible indicators of trafficking among children or adults encompass: lack of
identification, vague answers to questions about their home situation, no eye
contact, inconsistencies in the medical or personal history, no control of their
money (someone else paying for the visit in cash), malnourishment, signs of
physical abuse (bruises, burns, cuts, broken bones, or teeth), signs of depression
or PTSD, or substance addiction (31). Clinicians are mandated reporters and
must contact Child Protective Services if abuse is suspected. Patients can be
given the National Human Trafficking Resource Center Hotline number (only
when the patient is alone): 1-888-373-7888. Clinicians who provide health care
for women and girls must be aware of the global issues of human trafficking, and
alert to detecting and assisting patients who are or have been victims of human
trafficking.
FEMALE GENITAL MUTILATION
FGM, also known as female genital cutting (FGC) or female circumcision, is
genital alteration performed on girls and young women for nontherapeutic
indications (32). The WHO estimates that approximately 200 million girls
and women worldwide have been cut in the 30 countries in Africa, the
Middle East, and Asia, the primary areas where FGM occurs (33). This
ancient tradition from at least 200 BC has cultural rather than religious origins
and is not restricted to any particular ethnic group or religious sect. FGM
typically is performed between infancy and age 15, and has been
characterized by the WHO as a violation of the human rights of girls and
women.
Increasing numbers of women who underwent FGM or FGC need gynecologic
care in Western counties. FGM has been classified into four types (33). Type I
FGM, often referred to as clitoridectomy, involves removing part or all of the
clitoris and prepuce. Type II, often referred to as excision, is removal of part
or all of the clitoris and the labia minora with or without excision of the labia
majora. Type III is known as infibulation and is the most extreme form,
involving narrowing the vaginal orifice and stitching the adjoining labia
minora and or labia majora with or without including the clitoris. There are
other “lesser” procedures often noted as Type IV, such as pricking, piercing,
incising, scraping, or cauterizing the female genitalia. Deinfibulation or
defibulation refers to the practice of cutting open the sealed vagina of a
woman who has been infibulated, which is necessary to allow intercourse or
facilitate delivery. Although some 85% of FGC are Types I and II and 15% are
1109Type III, recent immigration and refugee resettlement from countries where Type
III predominates, such as Somalia, resulted in many more women with Type III
FGC in North America and Europe. Immediate complications of FGM are severe
pain, hemorrhage, genital swelling, fever, and infections including tetanus, sepsis,
urinary problems, poor wound healing, injury to surrounding genital tissue, shock,
or even death. Long-term complications include painful urination, urinary tract
infections, urinary retention, vaginal infection, painful menstruation, scar and
keloid formation, sexual pain, increased risks of childbirth or hemorrhage, need
for later surgeries, and psychological problems including depression, anxiety,
PTSD, or low self-esteem (33).
Sound data are lacking on psychosexual outcome. The taboos against
discussing sexual displeasure or pain from FGC limit data collection. Despite this,
there is evidence that FGC may not completely destroy sexual function and
prevent enjoyment in all women (34). FGC invariably damages many neural
networks associated with the vulvar and perineal areas, potentially altering genital
sensation. Neuroplasticity within the brain and spinal cord is thought to account
for the fact that some women have sexual response, sometimes from genital
stimulation and other times from stimulation of breasts or other areas of the body.
Results of studies of dyspareunia are conflicting, some suggesting it is only
temporary after first intercourse during the initial period of marriage and after
reinfibulation (35). Some studies noted increased prevalence of dysmenorrhea,
vaginal dryness, lack of sexual desire, difficulty reaching orgasm, and an increase
of dyspareunia in comparison with noncircumcised women.
Surgery is recommended for women with Type III FGC complications
such as dysmenorrhea, a desire for vaginal birth that would not be possible
without surgery, apareunia, dyspareunia, or difficulty voiding. General
obstetricians and gynecologists should be familiar with the types of FGM and
their complications and should understand the surgical therapies for the excision
of cysts, revision of introital or urethral scarring, repair of fistulae, procedures for
correcting vaginal stenosis, and defibulation. Referral may be helpful to a
physician with special expertise in reconstructive surgery or a clinician practicing
in an area where FGC is prevalent. The surgical technique of defibulation has
been detailed and summarized (36).
It is apparent to people helping women who underwent FGC that culture
plays a very important role in their sexual health. It is imperative that the
specific needs of the individual woman with FGC are understood in order to help
her. Care should be given in a nonjudgmental manner that encourages trust and
open discussion. Her own cultural significance of the FGC should be explored
and often an interpreter is necessary to fully understand her situation.
The ACOG, WHO, AAP, American Medical Association (AMA),
1110International Federation of Gynecology and Obstetrics (FIGO), and a
number of other organizations oppose all forms of medically unnecessary
genital surgery and support the development and accumulation of evidence
related to eliminating FGC and caring for those who have experienced it.
SEXUAL HARASSMENT AND MISCONDUCT
Sexual harassment is unwelcome behavior of a sexual nature that includes
sexual advances, requests for sexual favors, bullying or coercion of a sexual
nature which may be tied to or a condition of employment, used as a basis for
employment decisions, unreasonably interferes with work performance, or
creates an intimidating, hostile, or offensive working environment (37). The
behaviors encompassed within the category of sexual harassment range from
unwanted sexual looks or gestures, unwanted sexual teasing or jokes, sexual
comments, unwanted touching, pressure for sexual favors, to actual or
attempted rape or sexual assault. As defined by the U.S. Equal Employment
Opportunity Commission (EEOC), sexual harassment is illegal, and constitutes a
violation of the Civil Rights Act of 1964. In the workplace, sexual harassment is
considered illegal when it creates a hostile or offensive work environment or
affects an employment decision. The concept of sexual harassment is culturally
based, but in its modern understanding, dates to the 1970s.
During the second decade of the 21st century, the “#me too” movement has
spread virally as a hashtag used in social media to bring awareness to the
widespread prevalence of sexual assault and harassment. It gained momentum
after multiple allegations of sexual misconduct against a prominent Hollywood
producer. Sexual misconduct in established organizations and institutions such as
the church, finance industry, politics and government, professional sports and the
Olympics, the music industry, the military, and the medical field have all been
cited as having ignored or tolerated sexual harassment (38). The movement has
highlighted the prevalence of sexual violence that has often gone unpunished.
Internationally, the movement has led to discussions of cultural norms and
differences between men’s and women’s perceptions of similar behaviors. While
the “#me too” movement initially focused on adults, sexual abuse is common
among children and adolescents.
An online survey of nearly 6,000 13- to 18-year-old internet users in the United
States found that sexual harassment was reported by 23% to 82% of youth, and
that the highest rates were reported by lesbian/queer girls (72%), bisexual girls
(66%), and gay/queer boys (66%) (39). When examined by gender identity,
transgender youth reported the highest rates of sexual harassment—81%
(39). In-person harassment was more common than online harassment in this
1111study. Besides the increased risk for harassment among sexual and genderminority individuals, there was an increased risk of sexual assault.
REPRODUCTIVE AND SEXUAL COERCION
Reproductive and sexual coercion consists of behaviors that are intended to
promote pregnancy and to maintain power or control over a woman’s
reproductive choices. This is accomplished through attempts to impregnate
her against her wishes, control the outcome of a pregnancy, coerce her to
have unprotected sex, or interfere with contraceptive methods. Reproductive
coercion (RC) has been reported by 11% of female veterans, 19% of highschool girls, and 8% of college women, with black women, younger women,
and single women more likely to experience reproductive coercion (40–42).
ACOG counsels that obstetrician-gynecologists are in a unique position to
screen for reproductive coercion and IPV that can be linked with
reproductive issues (43,44).
Unintended pregnancy has been found to occur more commonly in abusive
relationships that may contain forced sex, fears of violence if the woman refuses
sex, and difficulties negotiating contraception and condom use (45). Adolescent
relationship abuse, such as cyber-dating abuse, may manifest in ways that may be
less recognizable to clinicians (46). It has been suggested that reproductive health
care clinicians should be educated about and trained to detect reproductive
coercion. Tools such as safety cards and posters educating women about
reproductive coercion and provision of long-acting and hidden forms of
contraception are potential educational and treatment options for some patients.
Training in offering referrals to domestic violence hotlines and shelter resources
should be part of the preparation to deal with reproductive health issues (45).
Adolescents and young women can be engaged in a discussion of healthy versus
unhealthy relationships, as they may not identify themselves as being in a
coercive relationship. Reproductive coercion may be one aspect of young
women’s inconsistent use of contraception. Pilot projects have assessed familyplanning-clinic–based interventions that have been shown to reduce the odds of
pregnancy coercion and to increase the odds of clients ending an unhealthy or
unsafe relationship in which they were at risk for IPV (47). The co-occurrence of
IPV was found in approximately one-third of the 16% of women who experienced
reproductive coercion in a large urban obstetrics and gynecology clinic (48). A
clear temporal relationship has been shown between reproductive coercion and
unintended pregnancy. In a survey of young women 16 to 29 years of age seeking
care at family planning clinics in rural and urban settings, 5% reported
reproductive coercion in the previous 3 months, and overall 12% reported an
1112unintended pregnancy in the past year. Among those reporting recent
reproductive coercion, 21% reported an unintended pregnancy, with and without a
history of intimate partner physical and sexual violence (49). Globally,
reproductive coercion is a major issue, and associated with IPV, contributing to
adolescent and unintended pregnancies (50). Factors that will improve women’s
reproductive health related to IPV and reproductive coercion involve access to
female-controlled contraceptive methods, and the transformation of social norms
in which men feel entitled to control women’s and girls’ bodies and reproduction
(50).
INTIMATE PARTNER VIOLENCE
IPV is the term that is used to refer to assaultive and coercive behavior such
as physical abuse, psychological or emotional abuse, sexual assault,
progressive isolation, stalking, intimidation, and reproductive coercion by a
current or former intimate partner (43,51). IPV has previously been termed
wife/spouse abuse, domestic/family violence, or abuse or wife
beating/battering. IPV affects millions of individuals in the United States, and is
described by the U.S. Centers for Disease Control (CDC) as a preventable public
health problem that occurs across the lifespan (51). [5] Data from the National
Intimate Partner and Sexual Violence Survey (NISVS) indicate that nearly
one in four adult women (23%) and approximately one in seven men (14%)
in the United States report having experienced severe physical violence from
an intimate partner in their lifetime (51). Other estimates suggest that more
than one in three women in the United States has experienced rape, physical
violence, or stalking over a lifetime, although the true prevalence in not known, as
many individuals are afraid or ashamed to acknowledge their experiences of
violence (52). Severe physical violence can be throwing objects, pushing, kicking,
biting, slapping, strangling, hitting, beating, and threatening or using a weapon.
Psychological abuse erodes an individual’s sense of self-worth, and may consist
of harassment, verbal abuse, threats, stalking, and isolation from friends and
family. A range of sexual violence may occur, as may reproductive coercion. IPV
is most prevalent among women of reproductive age and it contributes to multiple
gynecologic problems, unintended pregnancy, pregnancy complications, and
sexually transmitted infections (STIs), such as human immunodeficiency virus
(HIV) (52).
Many racial/ethnic and sexual-minority groups are disproportionately
affected by IPV, as are people living with physical or mental health
impairments. The health and economic consequences of IPV include the costs of
physical injuries. Beyond injuries, about one in six murder victims is killed by an
1113intimate partner; 40% of female homicide victims in the United States is killed by
an intimate partner. Chronic health problems, such as mental health problems,
depression, and PTSD, are associated with IPV survivors (51).
The Institute of Medicine has recommended that IPV screening and
counselling should be a part of women’s health visits, and obstetriciangynecologists are in a uniquely important position to screen for and provide
care for women who have experienced IPV. ACOG provides recommendations
and examples of IPV screening questions, and patient education cards about IPV
and reproductive coercion, noting that even if a woman is not able to
acknowledge abuse initially, she may ultimately be able to do so in the right
setting. ACOG recommends that clinicians should routinely and universally
screen for IPV in a setting that is private, nonjudgmental, and safe where the
women is seen alone, without her partner, friends, family, or caretaker.
Printed resource materials addressing safety, with hotline numbers and referral
information should be placed in areas such as restrooms, and other educational
materials should be displayed in clinic settings (52).
SEXUAL ASSAULT AND RAPE
Sexual assault of children and adult women has reached epidemic
proportions in the United States and is the fastest growing, most frequently
committed, and most underreported crime (26,53,54). Sexual assault is a crime
of violence, conquest, control, and aggression, not passion, and encompasses a
continuum of sexual activity that ranges from sexual coercion to contact abuse
(unwanted kissing, touching, or fondling) and forcible rape. [6] The terms sexual
abuse survivor and assault survivor are preferable to victim.
The U.S. Federal Bureau of Investigation (FBI) has revised an old definition
that recognized forceful vaginal penetration of a woman by a man’s penis as rape
to a definition recognizes that rape survivors and perpetrators may be female or
male, and that oral and anal penetration with an object are defined as rape (54).
Physical force is no longer a requirement, thus encompassing vulnerable victims
and those who are intoxicated or otherwise mentally or physically incapable of
demonstrating consent. This change in definition affects national statistics, but
state and federal criminal laws vary; the term sexual assault is sometimes used
interchangeably with rape. Sexual assault and rape may be further characterized,
related to the age of the victim and the relationship to the abuser, such as
acquaintance rape, date rape, statutory rape, child sexual abuse, and incest.
Acquaintance rape and date rape refer to sexual assaults committed by an
individual known to the victim, and if the perpetrator is a family member, incest
is the term used. Statutory rape refers to consensual intercourse, variably defined
1114by states, related to the age at which an individual can give consent.
Rape
Although the legal definition of sexual assault may vary from state to state,
most definitions of rape contain the following elements:
1. The use of physical force, deception, intimidation, or the threat of bodily
harm
2. Lack of consent or inability to give consent because the survivor is very
young or very old, impaired by alcohol or drug use, unconsciousness, or
mentally or physically impaired
3. Oral, vaginal, or rectal penetration with a penis, finger, or object
The definitions of rape and sexual assault and methods of data collection are
generating underestimates. [7] The NISVS from the U.S. CDC is an ongoing
national survey (55). As reported in this survey, approximately 18% of
women have been raped during their lifetimes. The lifetime prevalence of
rape by an intimate partner was 8.8% for women, with 0.8% reporting
intimate partner rape in the last year (55). Among female victims of
completed rape, 78.7% were first raped before age 25 years, and 40.4%
before age 18. The highest incidence of acquaintance rape is among women
in the 12th grade of high school or in the first year of college (56).
Approximately one-half of female college students report that they were date
raped. Many of these women may have been unable to give consent because they
were impaired by alcohol or so-called date-rape drugs (Rohypnol or other
benzodiazepines, ketamine, or gamma-hydroxybutyrate [GHB]). Date rape may
have even greater psychological consequences than rape by a stranger because it
involves a violation of trust. There are many myths about rape. Perhaps the
most common myth is that women are raped by strangers. Most statistics
indicate that a minority of women are raped by someone they do not know;
in the NISVS, only 14% of women reported rape by someone they do not
know. Among female rape survivors, 51% reported that at least one
perpetrator was a current or former intimate partner, 41% reported an
acquaintance, and 13% reported a family member (53). Acquaintance rape
may seem to be less traumatic than stranger rape, but survivors of acquaintance
rape often take longer to recover. A common misconception about rape is that
most survivors sustain serious physical or life-threatening injury. Sixty percent of
rape survivors report some physical injury. General body injury is more than
twice as common as genital and anal injury (57). Serious injury is rare, although
many rape survivors report being fearful of serious injury or death during the
1115assault. The most common genital injuries from a sexual assault are vaginal
lacerations resulting in bleeding and pain. Intraperitoneal extension of a
vaginal laceration or damage to the anal mucosa is rare. Common nongenital
injuries in survivors include cuts, bruises, scratches, broken bones and teeth, and
knife or gunshot wounds (58). Sexual assaults rarely result in death (59).
Only 26% of rape survivors seek medical attention after an assault (60).
Women are more likely to immediately seek treatment after sexual assault if
weapons were involved, serious physical injury occurred, or physical coercion or
confinement was used in the assault (61). Many rape survivors do not inform their
physicians about the assault and may never volunteer information about the
assault unless they are directly asked. ACOG recommends that health care
providers should routinely inquire about a history of childhood sexual abuse
or adult sexual assault (54). These experiences are common and often have a
lasting and profound effect on a woman’s mental and sexual function and
her general health and well being. When obtaining a medical history,
physicians should routinely ask, “Has anyone ever forced you to have sexual
relations?”
Medical Consequences of Sexual Assault
After a sexual assault, women have many concerns, including pregnancy and
STDs (such as HIV infection). Rates of rape-related pregnancy among girls
and women aged 12 to 45 years have been estimated at 5% (62). Adolescents
may have particularly high rates of pregnancy because of low rates of
contraception, and the fact that they may be victimized in incestuous relationships
(6). Gynecologic problems such as chronic pelvic pain and sexual dysfunction are
more common among women with a history of sexual abuse or assault (25).
Mental Health Consequences of Sexual Assault
In the aftermath of a sexual assault, women worry about being blamed for
the assault, having their name made public, and having their family and
friends find out about the assault. The initial reactions to sexual assault may
be shock, numbness, withdrawal, and possibly denial. It is difficult to predict
how an assaulted individual will react. Despite their recent trauma, women
presenting for medical care may appear calm and detached (63).
The rape trauma syndrome is a constellation of physical and psychological
symptoms, including fear, helplessness, disbelief, shock, guilt, humiliation,
embarrassment, anger, and self-blame. The acute, or disorganization, phase of
the syndrome lasts from days to weeks. Survivors may experience intrusive
memories of the assault, blunting of effect, and hypersensitivity to environmental
1116stimuli. They are anxious, do not feel safe, have difficulty sleeping and eating,
and experience nightmares and a variety of somatic symptoms (60,64,65). They
may fear that their assailant will return to retaliate or rape them again.
In the weeks to months following the sexual assault, survivors often return
to normal activities and routines. They may appear to have dealt successfully
with the assault, but they may be repressing strong feelings of anger, fear,
guilt, and embarrassment. During this phase of integration and resolution, they
begin to accept the assault as part of their life experience, and somatic and
emotional symptoms may decrease progressively in severity. However, the
sequelae of rape often persist (27). Over the long term, survivors may have
difficulty with work and family relationships. Disruption of existing relationships
is not uncommon. Nearly half of the survivors lose their jobs or are forced to quit
in the year following the rape, and half change their place of residency (23).
Counseling can help a woman understand her own and common responses,
potentially mitigating the adverse symptoms (64).
Examination
Many health care facilities now have trained sexual assault nurse evaluators
(SANE) who provide acute medical examinations and who collect evidentiary
materials. National guidelines for sexual assault forensic examinations
describe the role of sexual assault forensic examiners as gathering
information for the medical forensic history, collecting and documenting
forensic evidence, and documenting pertinent physical finding from patients
(66). These examiners coordinate with advocates to ensure that patients are
offered crisis intervention and advocacy before, during, and after the examination
process; offer information, treatment, and referrals for STIs, and other nonacute
medical concerns; assess pregnancy risk and discuss treatment options with the
patient, including reproductive health services; and testify in court if needed (66).
Because of the legal constraints and ramifications, consent must be obtained
from the patient before obtaining the history, performing the physical
examination, and collecting forensic evidence. Documentation of the
handling of specimens is especially important, and the chain of evidence for
collected material must be carefully maintained. Everyone who handles the
evidence must sign for it and hand it directly to the next person in the chain.
The chain of evidence extends from the examiner, to the police detective, to
the crime laboratory, and finally to the courtroom. If an obstetriciangynecologist who has not had experience in evidentiary examinations is
called upon to perform an examination, they should consider seeking
assistance from someone who is familiar with the state and local
requirements for evidentiary evidence collection using a sexual assault
1117evidence kit (54). Coordinated community responses to sexual violence
include Sexual Assault Response Teams (SARTs).
The patient should be interviewed in a quiet and supportive environment
by an examiner who is objective and nonjudgmental. Support personnel and
patient advocates, such as family, friends, or a counselor from a rape crisis
service, should be encouraged to accompany the patient. It is important not
to leave the survivor alone and to give her as much control as possible over
the examination. To provide useful forensic information, the examination
should be performed as soon as possible after the incident occurred. It is
important to ascertain whether the survivor bathed, douched, used a tampon,
urinated, defecated, used an enema, brushed her teeth or used mouthwash, or
changed her clothes after the assault. If a woman communicates with her
physician about a sexual assault, she should be encouraged to go directly to an
emergency facility without changing, bathing, or otherwise cleaning herself, as
these activities can impair the collection of forensic evidence (54).
National guidelines for sexual assault examinations are based on a number of
principles, including: (1) providing a coordinated approach to the examination;
(2) focusing on victimcentered care; (3) assuring informed consent; (4) being
aware of the scope and limitations of confidentiality; (5) informing the victim of
the options related to reporting to law enforcement; and (6) informing victims of
funding that may be available for the forensic medical examination under the
Violence Against Women Act (VAWA) (66). Except in situations covered by
mandatory reporting laws, women may decide whether to report a sexual
assault to law enforcement. A respectful encouragement of forensic evidence
collection, even if the patient is undecided about whether to report, can facilitate
ultimate investigation and prosecution of the crime.
The national guidelines address sexual assault of adolescents and adults;
prepubertal children require a different type of evaluation. Providers in all
50 states are required to report all cases of suspected or known childhood
sexual abuse to appropriate authorities.
The forensic examination process addresses a number of considerations (66):
1. Initial contact: While some individuals who have been sexually assaulted
may present directly to a medical facility, typically the initial contact is with
law enforcement, emergency services, or advocacy agency. The response to
this initial contact should be standardized and victim centered.
2. Triage and intake: The initial response at the medical site includes
evaluation, stabilization, and treatment for serious and life-threatening injuries.
The safety of the patient and that of the staff should be considered. Forensic
examiners and victim advocates should be contacted.
11183. Documentation of findings by health care personnel: The examiner will
need to document examination findings, the medical forensic history, and
evidence collection in a medical forensic report.
4. Medical forensic history: The examiner will obtain a history to guide the
examination and evidence collection. An advocate should be able to provide
support and advocacy during the history taking, if the patient desires.
5. Photography: Documentation of injuries or other visible evidence will
supplement the history and written documentation. Patient comfort and
privacy should be considered and the processes explained.
6. Examination and evidence collection procedures: The examiner should
recognize the evidentiary purpose of the examination, and attempt to collect as
much evidence as possible, documenting evidence and injuries that may be
pertinent. The examination and evidence collection should be explained to the
patient. An understanding of the testing the evidence will receive will facilitate
the appropriate collection and minimize evidence contamination. The general
physical and anogenital examination should be thoroughly conducted and
findings documented on body diagram forms. Medical specimens should be
kept separately from evidentiary specimens.
7. Alcohol and drug-facilitated sexual assault: The possibility that drugs
and/or alcohol may have been used to facilitate an assault, particularly in
adolescents or young adults, should be kept in mind, and toxicology testing
may be appropriate (54,67). Routine testing is not recommended; voluntary
drug and/or alcohol use may be a factor. The evidence and its chain of custody
must be preserved and maintained.
8. STI evaluation and care: The need for STI testing should be considered on
an individual basis. Prophylaxis against STIs may be indicated, which
encompasses follow-up STI examinations, testing, immunizations, counseling,
and treatment. Laws in all 50 states limit the use of a survivor’s past sexual
history including evidence of previously acquired STIs as part of an effort to
undermine her credibility (68). Trichomoniasis, bacterial vaginosis,
gonorrhea, and chlamydial infection are the most commonly diagnosed
STIs among women who have been sexually assaulted. HBV infection can
be prevented through postexposure vaccination; HPV vaccination is
recommended for females through age 25 (68). Testing for STIs may include
Nucleic Acid Amplification (NAAT) testing for Chlamydia trachomatis and
Neisseria gonorrhoeae, and serum for evaluation of HIV, hepatitis B, and
syphilis. Because adherence to follow-up examination visits is poor among
survivors of sexual assault, presumptive treatment is recommended by the
U.S. CDC. This presumptive treatment involves antibiotics for chlamydia,
gonorrhea, trichomonas, postexposure hepatitis B vaccination if the
1119hepatitis status of the assailant is unknown and the survivor had not
previously been vaccinated, and HPV vaccination for ages 9 to 26 years
with follow-up vaccination series (68). HIV postexposure prophylaxis
(PEP) recommendations should be individualized according to the risk, if
the assailant’s HIV status is unknown (54,68). Consultation should be
obtained from local HIV specialists of the National Clinicians’ Consultation
Center Post-Exposure Prophylaxis Hotline (1-888-448-4911) (54,69). Followup examinations provide an opportunity to detect infections acquired at the
time of the assault, complete hepatitis B and HPV vaccinations if indicated,
counsel and treat other STDs, and monitor for medication side effects. The
timing of the follow-up examination is dependent on initial testing; repeat
testing for HIV can take place at 6 weeks, and at 3 and 6 months (68).
9. Pregnancy evaluation and care: All victims of sexual assault should be
offered prophylaxis for pregnancy with appropriate informed consent,
consistent with guidelines (70). ACOG states that emergency contraception
should be immediately available in hospitals and facilities where sexual
assault victims are treated (54).
10. Discharge and follow-up: Follow-up medical care to address follow up of
STD testing and prophylaxis, emergency contraception, and assess for
psychological issues should be planned and coordinated with advocates and
law enforcement representatives. Ongoing supportive counseling for the
patient should be arranged, and the patient should be referred to a sexual
assault center or a therapist who specializes in the treatment of sexual assault
survivors.
11. Examiner court appearances: Health care providers who conduct the
forensic examination should expect to be called on to testify in court as fact
and/or expert witnesses (66).
ELDERLY ABUSE
Elder abuse is defined as a single or repeated act, or lack of appropriate
actions, which causes harm, risk of harm, or distress to an individual 60
years or older (71). Elder abuse incorporates a number of issues, including
neglect, emotional or psychological abuse, physical abuse, sexual abuse, and
financial or material abuse and exploitation. Approximately two-thirds of elder
abuse victims are women. Major risk factors for elder abuse include cognitive
impairment, depression, anxiety, and having disabilities or being homebound with
its attendant social isolation. ACOG recommends assessing all patients older than
60 years for signs and symptoms of elder abuse, even asking whether they feel
safe at home (71). Screening questions for elder abuse can be found online.
1120Depending on state guidelines, elder abuse may be reportable to Adult Protection
Services (72).
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