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CHAPTER 294:  Intimate Partner Violenc e and Abuse      1971 Arrange follow-up appointments according to Centers for Disease Control and Prevention recommendations. Patients receiving postexposure prophylaxis should be seen within 1 week following initial assess ment, and all patients should be seen in 1 to 2 weeks. 31 This ensures the effectiveness of pregnancy prophylaxis and sexually transmitted infection treatment. Male sexual assault survivors should follow up with a urologist or proctologist. Special populations, such as children, should be referred to a pediatrician or a pediatric abuse clinic. SPECIAL POPULATIONS  ADOLESCENTS AND CHILDREN Consider sexual abuse in children if no definitive explanation for non sexual transmission of a sexually transmitted infection can be identified.31 For extensive discussion, see Chapter 150, “Child Abuse and Neglect. ” The most experienced examiner available should examine children to minimize pain or further trauma.  ELDERLY PATIENTS Most elder assaults take place at the patient’s home, and most assaults are by an unknown assailant. 52 In the case of an elderly assault survivor, the forensic interview and examination present unique challenges. The patient not only may resist the pelvic examination because of injury or pain, but the pelvic area may be difficult to visualize because of hip contractures or vaginal atrophy. It is also difficult to explain the examination to a patient with dementia or cognitive impairment. Further challenges include obtaining an accurate and reliable history of the details of the assault, the injuries sustained, and regions of pain or discomfort. 52,53 Special adjustments may be needed for the interview and sexual assault examination. 52,53  TRANSGENDER AND LESBIAN PATIENTS Until recently, information about sexual assault of lesbian and trans gendered women has mostly relied on data from informal surveys54 and anecdotal evidence. These data indicate that 47% of transgender women report being raped at least once in their life. 55 The Centers for Disease Control and Prevention’s 2018 report, National Intimate Partner and Sexual Violence Survey, 24 used more rigorous research methods and presents significant data about the lesbian, gay, bisexual, transgender, and queer community and sexual assault. FORGE (www.forge-forward .org) is a Wisconsin-based group for the support of the transgender population. The group has a website with printable handouts for lesbian and transgendered patients who are sexual assault survivors, survivor firstperson narratives, and resource links for both patients and providers.  MEN Male sexual assault is less common than sexual assault of women. 56 Assaults on males generally result in more severe injuries, 57,58 with 40% to 60% of males sustaining anogenital injuries, 58,59 and assaults on men are likely to involve multiple assailants.60 At least a third of males who are sexually assaulted have a history of psychiatric or cognitive disability. 59 One major factor that complicates the care of male survivors is the fact that physiologically, the stimulation of anal penetration can lead to involuntary erection and sometimes to ejaculation. Furthermore, many assailants manually stimulate their victims to cause ejaculation. Numerous cases of male sexual assault have been determined to be consensual by judges and defense attorneys who fail to understand the involuntary nature of this physiologic response.

o involuntary erection and sometimes to ejaculation. Furthermore, many assailants manually stimulate their victims to cause ejaculation. Numerous cases of male sexual assault have been determined to be consensual by judges and defense attorneys who fail to understand the involuntary nature of this physiologic response. 60 The survivors themselves can be confused and distressed by this response and may hesitate to offer this information. Use a short, simple explanation of the physiology using lay language to assist in history taking. Hospitals have male rape kits available, and the same guidelines should be followed for history, physical exam, collection of forensic evidence, and maintaining chain of custody as have already been described. SANEs and SAFEs are all trained in the sexual assault forensic examination of males. Resources for counseling may be more difficult to find for the male survivor, especially in small communities. The Rape, Abuse & Incest National Network does have special resources for men. Its victim hotline can be reached at 1-800-656-HOPE, and its website can be accessed at www.rainn.org. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Intimate Partner Violence and Abuse Cameron Crandall Sylvia Gonzalez Alden INTRODUCTION AND EPIDEMIOLOGY Intimate partner violence includes physical violence, sexual violence, threats of physical or sexual violence, stalking, progressive social isola tion, and psychological aggression perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent individual. These actions are aimed at establishing control by one partner over the other. 1-3 Intimate partner violence and abuse is the preferred alternative for previously used terms such as spousal abuse, wife battering, and domestic violence. This term more accurately reflects the fact that this type of abuse occurs not only in adult heterosexual married relationships but also in relationships between cohabiting, separated, gay and lesbian, bisexual, and transgender individuals as well as in adolescent dating relationships. Intimate partner violence and abuse occurs in every racial, ethnic, cultural, geographic, and religious group, and it affects individuals of all socioeconomic and educational backgrounds worldwide. Men are affected, but the overwhelming burden of victimization from intimate partner violence is borne by women. 1,4 Intimate partner violence occurs in both opposite sex and same sex relationships. 3 Risk factors for inti mate partner violence and abuse include female sex, age between 18 and 24 years, low income level of the household, black or multiracial race/ ethnicity, bisexual sexual orientation, and relationship status of sepa rated rather than divorced or married. 1 Presence of weapons in the home and threats of murder are associated with increased risk of homicide. Effects extend to family members, friends, coworkers, other witnesses, and the community at large. 1 In families in which either child maltreatment or spousal abuse is identified, it is likely that both forms of abuse exist. 5 Children exposed to violence in the home have higher rates of behavioral difficulties; mental and health problems including depression, anxiety, abusive behaviors, and drug abuse; and eating, sleeping, and pain problems. 5 Frequent exposure to violence in the home may normalize violence for children, resulting in higher rates of victimiza tion and perpetration later in life.1,5 Providers should ask about a history of intimate partner violence or abuse during healthcare encounters. Failure to recognize and intervene in situations of intimate partner violence may have serious conse quences for the survivor and family.

esulting in higher rates of victimiza tion and perpetration later in life.1,5 Providers should ask about a history of intimate partner violence or abuse during healthcare encounters. Failure to recognize and intervene in situations of intimate partner violence may have serious conse quences for the survivor and family. Such consequences may include continued violence, physical and behavioral health problems, and injury or even death. 1,6,7 CLINICAL FEATURES Intimate partner violence is often cyclical in nature. The cycle begins with a period of tension building, which may include arguing, blaming, or controlling behaviors or jealousy. The next phase is escalation CHAPTER Tintinalli_Sec25_p1967-1978.indd 1971 8/2/19 1:50 PM

and injury or even death. 1,6,7 CLINICAL FEATURES Intimate partner violence is often cyclical in nature. The cycle begins with a period of tension building, which may include arguing, blaming, or controlling behaviors or jealousy. The next phase is escalation CHAPTER Tintinalli_Sec25_p1967-1978.indd 1971 8/2/19 1:50 PM 1972 SECTION 25: Abuse and Assault and may include verbal threats, physical and sexual abuse, or assault. Weapons may be used at this point. Sometimes there may be a “honey moon” phase in which the perpetrator may apologize or make excuses for inappropriate behavior. Over time, the abusive behavior tends to increase in severity, and the intervals between abusive episodes become shorter. There are no “usual” features to help identify a victim of intimate partner violence. Health-related consequences of violence or abuse often lead to an ED visit (Table 294-1). 2,8,9 Signs suggestive of intimate partner violence and abuse are summarized in Table 294-2.1,8 Signs of abuse may be suspected by behavior of the partner. The abusive partner may be defensive, hostile, and aggressive, and might demonstrate controlling or overly solicitous behavior toward the patient. 9 The patient may appear frightened of the partner or refuse to answer questions and instead defer all responses to the partner. In situations raising concern, and if the patient agrees, hospital security can prevent the alleged perpetrator from visiting the patient in the ED and hospital. SCREENING AND ASSESSMENT Many experts, including the U.S. Preventive Services Task Force and the American College of Emergency Physicians, recommend routine screening for intimate partner violence for all adolescent and adult women who present to the ED and for mothers of children brought to the ED. Futures Without Violence has published national screening consensus guidelines. 9 Because of the known adverse long-term impacts of intimate personal violence on health, when time permits, consider screening for lifetime exposure. A protocol should be implemented that addresses identification of, and screening for, intimate partner violence; training of ED personnel; confidential interviewing; and appropriate interventions, including validation and referral. 2,9,11 TABLE 294-1 Health Consequences of Intimate Partner Violence Adults Adolescents Children Injuries Alcohol and substance abuse Sexually transmitted infections Human immunodeficiency virus infection Pelvic inflammatory disease Urinary tract infections Vaginal bleeding Unintended pregnancy Headaches Chronic pelvic pain Back pain Eating disorders GI disorders Depression Anxiety disorders Difficulty sleeping Posttraumatic stress disorder Substance abuse Homelessness Social isolation Suicide Death Same as for adults plus Victimization as an adult Fertility problems Poor school performance and school dropout Unwanted pregnancy and associated complications of pregnancy, frequent pregnancies Obesity Behavioral disorders Involvement with the legal system and courts Risky sexual behaviors Prostitution Alcohol and drug use Low birth weight Prematurity and associated complications Failure to thrive Parental neglect syndrome Speech disorders Bedwetting Headaches Cognitive functioning problems—lower verbal and quantitative skills Psychological and emotional problems— aggression, hostility, withdrawal, acting out Child abuse TABLE 294-2 Signs Suggestive of Intimate Partner Violence Findings Comments Injuries characteristic of violence Fingernail scratches, broken fingernails, bite marks, dental injuries, black eyes, broken bones, cigarette burns, bruises suggesting strangulation or restraint, and rope burns or ligature marks may be seen.

e TABLE 294-2 Signs Suggestive of Intimate Partner Violence Findings Comments Injuries characteristic of violence Fingernail scratches, broken fingernails, bite marks, dental injuries, black eyes, broken bones, cigarette burns, bruises suggesting strangulation or restraint, and rope burns or ligature marks may be seen. Injuries suggesting a defensive posture Forearm bruises or fractures may be sustained when individuals try to fend off blows to the face or chest. Injuries during pregnancy Up to 45% of women report abuse or assault during pregnancy.10 Preterm labor, placental abruption, direct fetal injury, and stillbirth can occur. Central pattern of injury Injuries to the head, neck, face, and thorax, abdominal and genital injuries. Extent or type of injury inconsistent with the patient’s explanation Multiple injuries at different anatomic sites inconsistent with the described mechanism of injury. The most common explanation of injury is a “fall.” Embarrassment, evasiveness, or lack of concern with the injuries may be noted. Multiple injuries in various stages of healing These may be reported as “accidents” or “clumsiness.” Delay between the time of injury and the presentation for treatment Victims may wait several days before seeking medical care for injuries. Victims may seek care for minor or resolving injuries. Visits for vague or minor complaints without evidence of physiologic abnormality Frequent ED visits for a variety of injuries or illnesses, including chronic pelvic pain and other chronic pain syndromes. Suicide attempts Women who attempt or commit suicide often have a history of intimate partner violence.10 Multicultural and multilingual information about intimate partner violence and effects on abused individuals and family members should be made available to the public and employees. This may consist of posters and/or brochures in areas of the hospital such as public areas, examination rooms, and restrooms. Community resources that provide services to victims should be a part of the shared information. Screening should be conducted by providers educated about the dynamics of intimate partner violence. Provide a safe and private envi ronment for the interview. Take into account cultural differences and expectations. If language interpreters are required, use individuals who have no connection to the patient. Document screening results, safety assessment, and any interventions, including referrals and required reporting. Screening guidelines for adolescent and adult patients are summarized in Table 294-3. 9 Sample verbal screening questions are listed in Table 294-4.9 The U.S. Preventive Services Task Force has published a review of a variety screening tools. 2 When conducting screening and assessment, be nonjudgmental, sensitive, and direct. Let the patient know that you take the situation seri ously. Assure victims of confidentiality. Communicate an understanding of the complexity of the situation and the difficulties of achieving a “quick fix. ” Reassure the victim that no one deserves abuse and victims are not at fault. It is the abuser whose behavior is unacceptable. Avoid pressuring, respect patient decisions, and work together to determine an appropriate course of action. 12 Ask abused individuals if they have suicidal or homicidal ideation. Such ideation, particularly if accom panied by a concrete plan of action, should trigger immediate consultation with a mental health provider. RISK ASSESSMENT AND DISPOSITION Ensuring the safety of the abused individual and children is the foremost goal. The most dangerous periods for abused individuals are during the time of abuse disclosure and during attempts to leave the relationship.

n, should trigger immediate consultation with a mental health provider. RISK ASSESSMENT AND DISPOSITION Ensuring the safety of the abused individual and children is the foremost goal. The most dangerous periods for abused individuals are during the time of abuse disclosure and during attempts to leave the relationship. Indicators of a high-risk and potentially lethal situation Tintinalli_Sec25_p1967-1978.indd 1972 8/2/19 1:50 PM

n, should trigger immediate consultation with a mental health provider. RISK ASSESSMENT AND DISPOSITION Ensuring the safety of the abused individual and children is the foremost goal. The most dangerous periods for abused individuals are during the time of abuse disclosure and during attempts to leave the relationship. Indicators of a high-risk and potentially lethal situation Tintinalli_Sec25_p1967-1978.indd 1972 8/2/19 1:50 PM CHAPTER 294:  Intimate Partner Violenc e and Abuse      1973 TABLE 294-3 Summary of National Consensus Guidelines for Screening for Intimate Partner Violence and Abuse in the ED 9 Screening Assessment Intervention Documentation Referral and Follow-Up Routinely screen at every visit. Screen for current abuse, and if time allows, screen for history of abuse. Screen privately (one on one) or with nonrelated trained interpreter. Ask: What happened? When did it happen? Where did it happen? Who did this? Respect patient decision to disclose or not. Discuss any required reporting. Include screening questions on intake forms. Assess immediate safety. Assess health impact of abuse. Assess pattern of abuse. Assess for danger and potential lethality. If the danger assessment findings are positive, assess potential for suicide and homicide. Listen carefully and provide support. “I’m concerned for your health and safety.” “You are not alone.” “Help is available.” “It is not your fault.” “You don’t deserve it.” “What happened to you can affect your health.” Provide information and materials. “What can I do for you?” Provide a safety plan. Offer services, including an advocate, social worker, police, shelter, etc. Legible, fluent; maintain confidentiality of records Abuse history: Subjective information: Patient’s own words Objective information: Detailed description of patient’s appearance, behavioral indicators, injuries, and health complaints Use of forensic evidence kits where appropriate Results of physical examination Use of body maps Photographs (with patient’s consent) Radiologic, laboratory findings, collection of forensic evidence: clothes, debris, etc. Any materials and referrals offered Results of health and safety assessments Refer to primary care physician, mental health provider, social worker, or intimate partner abuse advocate. Obtain permission to notify provider. Know current phone numbers for: Abuse and assault prevention programs Legal services Children’s programs Mental health services Law enforcement Substance abuse programs Transportation Local clergy or other community organizations TABLE 294-4 Sample of Intimate Partner Violence Screening Questions* The healthcare worker should explain the following in his or her own words: •   We are concerned about your health and safety, so we ask all patients the same questions about violence at home and personal life. •   Violence is very common, and we want to improve our response to individuals and families experiencing violence. The healthcare worker may ask the following questions of ALL patients: •   Are you ever afraid of your partner? •   In the last year, has your partner hit, kicked, punched, or otherwise hurt you? •   In the last year, has your partner put you down, humiliated you, or tried to control what you can do? •   In the last year, has your partner threatened to hurt you? If intimate partner violence has been identified in any of the above questions, ask if the individual would like assistance today. Be prepared to offer resources, assess for safety, and discuss a safety plan with the individual. *Additional screening tools are available.2,9 include escalation in the frequency or severity of violence; the threat or actual use of weapons; obsession with the abused individuals; hostage taking; stalking; strangulation; and homicide or suicide threats or attempts and evidence of violent behavior outside the home.

. *Additional screening tools are available.2,9 include escalation in the frequency or severity of violence; the threat or actual use of weapons; obsession with the abused individuals; hostage taking; stalking; strangulation; and homicide or suicide threats or attempts and evidence of violent behavior outside the home. Another risk factor for serious injury or death is substance abuse by the perpetrator, which can increase violent behaviors. 1,8 If lethality risk is high, consult with experts before ED discharge. 9 Hospital admission of the abused individual or children is an option in high-risk situations in which there is no other way to ensure safety. Use of a 24-hour safe room, a location established by some hospitals and communities to provide a safe place for the patient to stay while arrangements for safe disposition of the patient and family members are made, is another option. Use of an alias name on admission and screening of incoming phone calls may also be of benefit. Some individuals feel safer remaining in the violent relationship than leaving without adequate planning for a safe departure. 9 Placing the patient in a shelter or having the attacker arrested may not be congru ent with the individual’s goals. Ultimately, the abused individual must decide if it is safe to return home. By providing information about inti mate violence, risks, and options, the ED provider can help the patient TABLE 294-5 Resources for Healthcare Providers Futures Without Violence (formerly Family Violence Prevention Fund) http://www.futureswithoutviolence.org National Domestic Violence Hotline http://www.thehotline.org/ 800-799-SAFE (7233) National Coalition Against Domestic Violence http://www.ncadv.org decide what is best. The patient’s decision making may be very complex, because depression, lack of self-esteem, lack of support, social isolation, financial dependence on the perpetrator, and fear make it difficult to leave the relationship. Refer individuals to intimate violence experts, such as trained hospital social workers or community-based advocates, who can help the victim assess the situation, understand options, plan for safety, and arrange safe shelter. Community advocates are typically on call or available by telephone. If the patient can be safely discharged from the ED and personal contact with an advocate cannot be made before discharge, give the patient up-to-date information about available services in the community. Intimate personal violence advocates should not be asked to call the patient directly unless the patient agrees, because calls to the home could jeopardize the patient’s safety. Resources for healthcare providers to assist in preparing their prac tices for optimal response to victims of intimate personal violence are available from a number of organizations ( Table 294-5). Table 294-6 lists hotlines for patients.  ED RECORD DOCUMENTATION Voluntary descriptions of intimate personal violence should be quoted and described in the patient’s own words. Do not use the word alleged because it implies that the person recording the incident does not believe the complaint. 9 A complaint of “sexual assault” is no more alleged than is a complaint of “ear pain” or a “sore throat. ” Record past and current abuse, with details of date, time, location, witnesses, and specific injury. Describe the patient’s health complaints, injuries, appearance, and demeanor. Annotated body maps and photo graphs can supplement written notes. Tintinalli_Sec25_p1967-1978.indd 1973 8/2/19 1:50 PM