Intimate partner violence and sexual assault: Clinical sciences

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Introduction0:00–1:17

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.

Unstable patient1:17–2:02

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.

Stable patient2:02–4:26

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.

Consistent with SA4:26–5:27

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.

SA occurred less than seven days ago5:27–8:37

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.
Other important considerations include agreeing upon a safety plan with the patient during the time that they are receiving acute care and after discharge.
Finally, inform patients of any mandatory reporting requirements, such as abuse of a minor, before reporting the assault to local authorities.Time for a clinical pearl!
If a patient desires a medical forensic examination, there are local guidelines for timing and collection of evidence. Many jurisdictions require the collection within 72 hours or 3 days of the assault, but others allow for up to 7 days.
If possible, the patient should avoid bathing, changing clothes, defecating, urinating, douching, washing out the mouth, cleaning the fingernails, smoking, eating, or drinking before the exam.
Many jurisdictions have sexual assault collection kits that are used to collect evidence and include checklists, materials for specimen collection, documents, and instructions.
If the sexual assault occurred more than 7 days ago, the medical considerations are a bit different. Offer pregnancy and STI testing as well as empiric treatment for gonorrhea, chlamydia, and trichomonas.

SA occurred more than seven days ago8:37–9:36

Emergency contraception and HIV PEP are not recommended, since they wouldn’t be effective at this point. Consult with trained mental health providers for counseling and follow-up, and be sure that there’s a safety plan in place.
For patients who have a more remote history of sexual assault, it’s important to assess for long term sequelae such as post traumatic stress disorder, anxiety, depression, substance use, and medical issues such as chronic pain or illness.
As before, inform patients of mandatory reporting requirements before reporting the assault to authorities per local mandates.
Now let’s discuss intimate partner violence. A positive screen for IPV might include physical injury, psychological abuse, sexual assault, isolation, stalking or deprivation, as well as reproductive coercion.

Consistent with IPV9:36–13:09

Remember that IPV can occur to anyone; regardless of gender, race, socioeconomic status, and sexual orientation. However, there are high-risk groups that deserve consideration and may have reduced access to screening and care, such as adolescents, immigrants, individuals with disabilities or housing insecurity, elderly, bisexual, and transgender individuals.
Medical considerations for patients experiencing IPV include the management of acute injuries and testing for pregnancy and STIs.
Consider emergency contraception if within the recommended time frame of 5 days, as well as empiric treatment for gonorrhea, chlamydia, and trichomonas.
Also, consider expedited partner therapy for sexually transmitted infections, but only if it doesn’t impact patient safety since this might cause partner anger or violence.
Consult mental health providers for immediate counseling and follow-up. Next, assess patients for post traumatic stress disorder, depression, anxiety, substance use, and medical conditions such as chronic pain.
Also, develop a safety plan and offer access to community resources and domestic violence agencies. Finally, discuss the mandatory reporting requirements before reporting intimate partner violence to authorities per local mandates, as this reporting could impact patient safety.
One last clinical pearl! Caring for patients who are survivors of intimate partner violence and sexual assault can be emotionally taxing for providers.
After these experiences, consider debriefing with other providers and practicing your own self-care, such as therapy, exercise, or meditation.
If you or someone you know are a victim of sexual assault, you can call the Rape, Abuse & Incest National Network, or RAINN, National Sexual Assault Telephone Hotline at 800.656.HOPE(4673) or visit rainn.org to be connected with a trained staff member from a sexual assault service provider in your area.In addition, you can call the U.S.
National Domestic Violence Hotline at 1-800-799-SAFE (7233) or text START to 88788 to be connected with a trained staff member for free and confidential support.
You can also go to thehotline.org/get/help to chat live with an assistance provider. In Canada, you can visit sheltersafe.ca or call Hope For Wellness 24/7 at 1-855-242-3310 for safety and support services.
Additional international support can be found at www.domesticshelters.org/resources.Alright, as a quick recap… All patients should be screened for Intimate partner violence and sexual assault and treated within the model of trauma-informed care.

Review13:09–13:48

Acute care involves medical management, testing and treatment for STIs and pregnancy, consideration of a forensic exam and reporting, counseling, and developing a safety plan.
Long term care addresses the sequelae of IPV and SA, including post traumatic stress disorder, anxiety, depression, substance abuse, and medical conditions such as chronic pain