Intimate - Partner Violence test 4

Health Consequences of Sexual Assault

Behavioral reactions to sexual assault: may later engage in risky sexual behaviors. Sexual dysfunction: common and sometimes chronic problem after sexual assault. Substance abuse: alcohol and drugs makes women more vulnerable. Sexual assault can result in substance abuse. Many women experience negative psychological impacts.

Management

Examiner: disclose and explain nature of physical trauma with sexual assault. Treat prophylactically for STIs. Provide information about risk of HIV, testing procedures, prevention, safe-sex options. PEP initiated within 72 hours of sexual assault to be effective. Inform of risk of conception; availability of emergency contraception (EC).

Heise's Framework of Violence

Personal history Microsystem Exosystem Macrosystem

Walker Cycle of Violence Theory

Tension-building phase Acute-battering incident Calm or loving phase

Victims

Victims may be illegal immigrants, legal immigrants or citizens Minors - "hello" Homeless Substance abuse users Mentally challenged Minimal education level Cultural background Experiences with legal system Believe that any debts are their obligation to repay - some may sign contracts; View their situation as temporary, surviving on the hope that once their debt is paid off or a certain amount of time has passed, they shall be free!

Children living in violent homes may have witnessed:

verbal threats objects thrown threats with weapons sexual assaults suicide attempts and murder

Effects

100% completed rape, 39% attempted rape result in injuries to victims 61% underestimated injuries 33% injuries are bruises and/or chipped teeth Only 36% receive medical care

Statistics continued

1:6 women have the potential to be the victim of attempted or completed rape in her lifetime. 9 out of 10 are women 1:33 men have the potential to be the victim of attempted or completed rape in his lifetime.

Statistics

2009 12.3 Million estimated in Forced Labor and Forced Prostitution around the world 99% are not rescued Leading source of profit for organized criem together w/ drugs and weapons 9.5 BILLION Most are women and children Average victim forced to have sex up to 20x a day Most victims are under 18 yrs of age 4,166 successful trafficking prosecutions 2,208 in Europe 49,105 Victims identified 14,650 in Europe

Epidemiology

25% of women said intimate partner had assaulted them at some time in their lives. 23% of women reported physical assault by intimate partner since age 18; 14% sexual assault by someone they knew. Abuse during pregnancy from 18.1% to 37.6%. 40% to 45% of all women experiencing IPV forced to have sex by their male partners Globally sexual violence effects 1/3 of women 44% of assaults occur to women under the age of 18 Risk of violence varies among ethnic groups 17% are white, 18.8% African American, 31% American Indian/Alaskan native, 24.4% bi-racial

Epidemiology

25% of women said intimate partner had assaulted them at some time in their lives. 23% of women reported physical assault by intimate partner since age 18; 14% sexual assault by someone they knew. Abuse during pregnancy from 18.1% to 37.6%. 40% to 45% of all women experiencing IPV forced to have sex by their male partners.

Special Considerations

Age of victim: very young and very elderly may both have difficulty describing incident and relating symptoms. Lesbian, gay, bisexual, transgender: many LGBT individuals who are sexually assaulted do not report assault; fear of judgment by police and rejection by gay community.

Fear of Rape

Between 33% and 54% of U.S. women report feeling unsafe when alone at night Recent survey suggests that women take many precautions to avoid being raped by a stranger However, women take fewer precautions to avoid being raped by an acquaintance, even though they know this is more common

Management

Clinician's role encompasses addressing all aspects of biopsychosocial needs of patients. Provide emotional support, crisis intervention, work as member of team. Treating injuries alone not sufficient. Trained staff provide specialized care for victims of sexual assault. Sexual assault nurse examiner (SANE).

Physical Examination

Conducted like any other physical assessment of adult female. Careful attention to signs of injury, past and present, with exact measurement taken of most insignificant-looking bruises. Most injuries: face, chest, breasts, abdomen. Sexual violence: pelvic examination included.

C O E R C I O N

Debt bondage Threats of serious harm to victim/victim's friends and/or family Trafficker/pimp controls all of victim's family/friends outside brothel Threatening to use photos against victim Withholding documents Punishment of others Quotas Verbal or psychological abuse

Documentation/Management

Document all findings in patient's record using correct medical forensic terms. IPV histories thorough and objective. Principles: Empowerment Childbearing cycle-stage specificity Abuse-stage specificity Cultural competence Use mnemonic EMPOWER.

Intimate-Partner Violence - Emotional

Emotional: humiliating a woman, controlling what she can and cannot do, isolating her from friends and family, disregarding what she wants.

Types of abuse - emotional

Emotional: humiliating a woman, controlling what she can and cannot do, isolating her from friends and family, disregarding what she wants.

Statistics

FBI 2011 crime statistics reports aggravated assault is 62.4% of all crimes reported Rape Crisis Center reports every 2 minutes someone in the US is sexually assaulted 54% of sexual assaults are not reported 97% rapists never spend a day in jail Approximately 2/3 of rapists are known to the victim.

Health Consequences of Sexual Assault

Genital trauma: posterior fourchette and labia minora most common injuries Sexually transmitted infections Pregnancy: victims of assault are often afraid of becoming pregnant.

Rape "Myths"

Going to a man's apartment implies a willingness to have sex. Any healthy woman can successfully resist a rapist if she really wants to. Women who dress provocatively are "asking for it." Many women have an unconscious wish to be raped. "No" means "yes"

Health Effects

Gynecologic problems: consistent, long-lasting, widespread physical health problems experienced by women who are battered. Pelvic inflammatory disease (PID) Sexually transmitted infections (STIs) Unexplained vaginal bleeding, fibroids, pelvic pain, urinary tract infections Painful intercourse; decreased sexual desire Genital irritation

Intimate-Partner Violence - Definitions

IPV: escalating pattern of abuse in which one partner controls the other through force, intimidation, threat of violence. IPV categories: physical violence, sexual violence, threat of physical or sexual violence, and psychological/emotional abuse. Physical: hitting, slapping, kicking, punching, shoving, strangulation, injuries from weapons

Physical Examination

If assault recent, forensic evidentiary examination warranted. Offer patients with visible injuries photographic documentation in medical record. Use body maps and diagrams; description of injury included with each drawing

Assessment

If mandated to report, important to let patient know; explain process and clinician responsibilities to her and her family. Detailed history of assault must be obtained. Carefully document details. Evidentiary examination: physical examination to collect evidence of crime; cannot be conducted without patient's consent.

Special Considerations

Individuals with physical, mental, communication disabilities: limited cognition or be unable to explain what happened. Reporting of sexual abuse of disabled persons is mandated in every state.

Force

Kidnapping/recapturing of an escaped victim Beatings and Torture (Rape, sexual abuse, harassment Forced pregnancy/abortion Confinement/kept under guard/surveillance Use of restraints Denial of food/ water/ medical care/ contraceptives/ condoms Removal of children Concealment of whereabouts to friends/family

Human TraffickingThe Industries - Trends

LABOR EXPLOITATION Labor Leasing Companies Elder Care Facilities Homes Begging/peddling rings Cattle and Sheep Herding Criminal Acts- shoplifting Magazine crews Asian Restaurants COMMERCIAL SEX Drug Mules Cantinas/Bars Brothel Rings

Definitions - labor trafficking

Labor Trafficking Force, Coercion

Assessment

Maintain chain of custody of evidence collected. Signed consent to complete medical legal examination, collect evidence, take pictures, release evidence to law enforcement. Violence Against Women Department of Justice Reauthorization Act of 2005.

Domestic Violence

Nationwide, there are more Domestic Violence calls made to 911 than any other type of emergency

What is Force or Lack of Consent

Physical force. Threat of physical force, but not other types of threats (i.e., divorce). Incapacitation due to intoxication, mental illness, physical or intellectual disabilities

Health Effects

Post-traumatic stress disorder (PTSD) Experiencing traumatic event Reexperiencing traumatic event Numbness and avoidance Hypervigilance May use drugs and alcohol as coping mechanisms. Prone to developing depression.

Special Populations

Pregnant women: pregnancy can be time of escalating violence in troubled relationship. Adolescents: one every eight adolescents will be involved in some form of dating violence. Older women: 500,000 to 1.5 million elders subjected to abuse and neglect each year. Influences of culture: assess woman's cultural values, beliefs, practices.

Screening

Primary care settings during periodic examinations; all visits for new concern. Most battered women do not come to healthcare facilities with obvious trauma or injuries. Obtain focused history; perform systematic physical examination. Woman who has been abused not always forthcoming about abuse.

History

Question in sympathetic, nonjudgmental manner. Violence not acceptable, no matter what she has been told by batterer. Privacy and confidentiality must be guaranteed. IPV screening in front of children raises safety concerns. Be sensitive to unique privacy, safety, protection issues of mothers who are survivors of IPV.

Culture and Rape

Rape is more common in cultures characterized by male dominance and violence. Within a culture, persons with more traditional or sexist gender role attitudes are more tolerant of rape than are people with more nontraditional or egalitarian attitudes.

Legal definition of rape

Rape: Sexual assault: Unwanted contact of sexual organs (or sexual areas) of tone person by another person, regardless of age, relationship or gender WITHOUT the individual's consent, obtained by force or threat of physical harm, or when a victim is incapable of giving consent . Related, broader term: sexual assault Sexual touching and other unwanted forms of sexual contact Accompanied by psychological pressure or physical threat

Assessment

Reporting issues addressed first; what clinician does determined by woman's decision about reporting. Any forced sexual contact is reportable crime. Provide emotional support. Be familiar with local state-mandated reporting laws and statutory rape laws. Statutory rape: sexual contact between minor and adult.

Definitions - sex trafficking

Sex Trafficking Adults: Force, Fraud, Coercion Minors: No Proof of Force, Fraud, or Coercion Required

Reporting

Sexual assault is the most under reported crime 39% reported Don't report 23.3% personal matter 16.3% reprisal 5.8% police biased

Intimate- Partner Violence - Sexual

Sexual: using physical force to make a woman engage in sexual act against her will and abusive sexual contact.

Types of abuse - sexual

Sexual: using physical force to make a woman engage in sexual act against her will and abusive sexual contact.

Screening Tools

Standard of care; failure to screen and document findings grounds for litigation. Abuse Assessment Screen (AAS). Danger Assessment (DA). Harassment in Abusive Relationships: A Self-Report Scale (HARASS) All items on screening instruments have been linked to increased risk of domestic homicide.

Sexual Assault Nurse Examination

What Happens During the SANE Examination The nurse can take the survivor's history, check for injuries, perform a pregnancy test and provide medication to prevent infection and pregnancy. All treatment options are completely voluntary. The survivor may stop the exam at any time. The exam The training The experts Chain of custody Evidence The Rape Crisis Center Advocate will provide emotional support and information to the survivor and any friends and/or family accompanying them. Following the exam, the survivor can shower in a private bathroom. A change of clothing can be provided. Information about filing a police report will be provided if the survivor is interested in pursuing this option.

Management

Women in ongoing abusive relationships may choose to return to abusive home. IPV hotline and shelter information. Minimum safety planning by clinician. Patients encouraged to call police and to use 24-hour health setting as safety net.