Intimate partner violence and sexual assault: Clinical sciences

Intimate partner violence and sexual assault, also known as IPV and SA, are significant public health problems that affect millions of individuals regardless of age, gender, socioeconomic status, or sexual orientation. IPV and SA encompass a continuum of aggressive, coercive, and potentially violent behaviors. Specifically, IPV consists of a pattern of behaviors that includes physical injury, psychological abuse, sexual assault, isolation, intimidation, and reproductive coercion. On the other hand, SA includes acts ranging from sexual coercion to contact abuse to acts of penetration. So remember that IPV may include SA but SA may or may not be from an intimate partner.

Keep in mind that often patients do not disclose a history of IPV or SA, so it’s important to screen all patients for both. During obstetric care, screening should occur at the first prenatal visit, at least once per trimester, and at the postpartum checkup.

When a patient presents with signs and symptoms of intimate partner violence or sexual assault, first perform a CABCDE assessment to determine if the patient is unstable.

If the patient is unstable, control hemorrhage; stabilize airway, breathing, and circulation; obtain IV access, monitor vital signs, and manage severe injuries.

Severe injuries specific to IPV and SA include head injuries, strangulation, fractures, and wounds related to guns or knives, as well as penetrative trauma. In pregnant patients, consider fetal well-being, particularly if there is abdominal trauma. If the patient is stable, perform a focused history and physical examination.

A patient may report an incident of IPV or SA, but many actually won’t. However, they might reveal symptoms of anxiety or depression, disclose an inciting traumatic event, or report symptoms of chronic pain or illness such as chronic pelvic pain, dysmenorrhea, or sexual dysfunction.

When interacting with patients who have experienced trauma, a trauma-informed approach to care is necessary. Trauma-informed care can be described using the four “Rs”, which are to Realize the widespread effect of trauma on individuals and communities; Recognize the signs and symptoms of trauma, not only in patients but with everyone involved in their care; Respond with an understanding and knowledge about trauma, not only in policy but more importantly in practice; and to actively resist Retraumatization.

The key principles are ensuring emotional and physical safety, providing individual choice and control, empowering individuals, building trustworthiness, and encouraging peer support.

This means that, when obtaining the physical exam you need to emphasize privacy, choice and control for the patient. This might involve describing each part of the exam to them and asking for verbal consent as you go through it. Although it may be difficult, ask partners or caregivers to leave the room. Remember that these individuals might be a threat to the patient and might resist leaving.

Physical exam findings may include an abnormal mental status exam and unexplained bruising or injuries that might be inconsistent with the described mechanism, particularly to the head and neck, breasts, or abdomen. Injuries in the areas covered by clothing are more common. Screen these patients for IPV and SA with a partner violence screen, sexual assault screen, and depression or anxiety screen. Screening should be performed in a private, confidential setting.

Okay let’s start with SA. A positive screen includes acts ranging from sexual coercion, contact abuse such as kissing or touching, vaginal penetration, and forced oral sex, consistent with SA.

Next, assess the timeline of the events as well as their current safety. Here’s a clinical pearl! A safety plan encompasses acute and long term issues.

Acutely, it includes knowing which visitors may accompany the patient during a visit as well as offering the patient a chaperone or advocate during assessment and treatment.

Long term, it involves planning and resources for ongoing safety and housing including mental health services, crisis or domestic violence hotlines and agencies, shelters, legal aid, and police contact information.

Now, if a sexual assault occurred less than 7 days ago, medical considerations involve management of acute injuries such as head injuries, lacerations, or fractures. Discuss and offer testing for pregnancy and sexually transmitted infections, or STIs, including gonorrhea, chlamydia, trichomonas, HIV, hepatitis B, and syphilis.

Discuss options for emergency contraception, keeping in mind that the longest delay to start emergency contraception is 120 hours or 5 days after the event. In addition, discuss empiric treatment for gonorrhea, chlamydia, and trichomonas, as well as HIV postexposure prophylaxis or PEP for short; particularly if the assailant is unknown. Keep in mind that HIV PEP is only effective up to 72 hours or 3 days after the event.

Also, discuss recommendations for a sexual assault medical forensic exam, and recognize that they may not want to undergo this examination. Provide the patient with information about the exam itself and the rationale for performing it, but also empower the patient with the autonomy to consent or decline this or any other medical care. If a patient consents to a medical forensic exam, many hospitals have access to Sexual Assault Nurse Examiners or Sexual Assault Medical Forensic Examiners who have received specialized training to care for sexual assault patients and perform the exam. Also, provide the patient with emotional support and be sure to consult trained mental health providers for immediate counseling and follow-up.