Domestic Violence, Sexual Assault and Child Abuse

Domestic Violence 

Pathophysiology: 

• Includes physical, sexual, and psychological abuse between intimate partners 

Patient Demographics: 

• Victim usually a woman 
• More than 1 in 3 women have experienced domestic violence in lifetime 

Clinical Presentation: 

• Physical injuries, psychological problems, social isolation 
• Loss of job, financial difficulties, potential death 
• Often begins or increases during pregnancy and postpartum period 

Characteristic Injuries: 

• Bilateral injuries, especially to extremities 
• Injuries at multiple sites 
• Fingernail scratches, cigarette burns, rope burns 
• Abrasions, minor lacerations, welts 
• Subconjunctival hemorrhage (suggests vigorous struggle) 

Elder Abuse

Elder abuse is widely under-reported. Several risk factors are recognized, such as female gender, physical dependency, cognitive impairment, lack of social support, difficult behaviour and history of psychiatric illness. 

Sexual Assault

Affect all ages and gender, most victims are woman

Diagnostic Studies: 

• Pregnancy testing indicated 
• Toluidine blue: detects vulvar tears 
• Wood lamp: detects semen stains 

Management: 

• Postexposure prophylaxis: Consider for HIV and hepatitis B only if perpetrator known to be infected 
• Standard treatment covers: gonorrhea, chlamydia, trichomoniasis 
• Vaccination: Start hepatitis B series if non-immunized 
• Emergency contraception considered 

Infections Diagnostic for Abuse in Prepubescent Population: 

• Syphilis, HIV, gonorrhea, chlamydia 

Clinical Findings Associated with Sexual Abuse 

Genital-rectal Complaints: 

• Genital, anal, or urethral trauma, bleeding, or itching 
• Chronic genital or anal pain 
• Genital infection or discharge 
• Vaginal or rectal foreign body 
• Vulvitis or vulvovaginitis 
• Anal inflammation 
• Sexually transmitted infection 
• Pregnancy 
• Dysuria 
• Recurrent urinary tract infection 

Behavioral Changes: 

• Clinging behavior 
• Temper tantrums, aggression, self-injury 
• Sleep disturbance, nightmares 
• Appetite disturbance 
• Neurotic or conduct disorders 
• Excessive fears, phobias 
• Depression, withdrawal, low self-esteem 
• Social problems with peers 
• School problems 
• Substance abuse 
• Suicidal ideation 
• Explicit description of sexual contact 
• Promiscuity, prostitution, sexual perpetration on others 
• Inappropriate knowledge of adult sexual behavior 
• Excessive sexual curiosity, sexual acting out 
• Compulsive masturbation 

Child Abuse 

Recognition Indicators: 

• Physical signs: Unexplained bruises, multiple bruises of varying ages, burns, fractures, spiral fractures in non-ambulatory children 
• Behavioral indicators: Fearfulness, inappropriate sexual knowledge, regression 
• Neglect signs: Poor hygiene, malnutrition, medical neglect