CHAPTER 294: 1971
Arrange follow-up appointments according to Centers for Disease SANEs and SAFEs are all trained in the sexual assault forensic examina-
Control and Prevention recommendations. Patients receiving postexpo-
sure 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 con-
tractures 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 pop-
ulation. The group has a website with printable handouts for lesbian and
transgendered patients who are sexual assault survivors, survivor first-
person 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. Numer-
ous 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 evi-
dence, and maintaining chain of custody as have already been described.
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tion 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.
CHAPTER Intimate Partner Violence
and Abuse
294 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.3
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 wit-
nesses, 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 depres-
sion, 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. 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, blam-
ing, or controlling behaviors or jealousy. The next phase is escalation
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 1972 SECTION 25: Abuse and Assault
TABLE 294-1 Health Consequences of Intimate Partner Violence
Adults Adolescents Children
plus
abuse
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 vali-
dation and referral.2,9,11
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TABLE 294-2 Signs Suggestive of Intimate Partner Violence
Findings Comments
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 pub-
lished a review of a variety screening tools.2
When conducting screening and assessment, be nonjudgmental, sen-
sitive, 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 consul-
tation 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
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TABLE 294-3 Summary of National Consensus Guidelines for Screening for Intimate Partner Violence and Abuse in the ED9
Screening Assessment Intervention
include escalation in the frequency or severity of violence; the threat
or actual use of weapons; obsession with the abused individuals; hos-
tage 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 arrange-
ments 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 294-4 Sample of Intimate Partner Violence Screening Questions*
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CHAPTER 294: 1973
Documentation Referral and Follow-Up
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 hos-
pital 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 avail-
able 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.
TABLE 294-5 Resources for Healthcare Providers
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TABLE 294-6 Hotlines for Patients CHAPTER Abuse of the Elderly and
Impaired
295 Jonathan Glauser
Frederic M. Hustey

Obtain relevant forensic evidence, and follow the appropriate chain
of custody of evidence. If sexual assault has occurred, document ED
testing and treatment; arrange for a sexual assault nurse examiner exam,
if locally available. See Chapter 29 3, “Female and Male Sexual Assault,”
for detailed discussion.
Record safety assessment and planning. A safety assessment form or
referral notes from an expert are helpful adjuncts.
! LEGAL CONSIDERATIONS
Most states in the United States have laws that require healthcare provid-
ers to report specified injuries, wounds, or crimes. Intimate personal
violence is a crime in all 50 states.13 Four states have exceptions to manda-
tory reporting for injuries related to domestic violence. The specifics of
the reporting requirements vary from state to state, and the adequacy
of response by the police to reporting varies by jurisdiction. Inadequate or
inappropriate response to the reports (e.g., informing the perpetrator
of the report without providing for the safety of the abused individual)
can increase the risk of harm to the abused. Inform the victim if there is
an obligation to make a police report and explain possible ramifications.
SPECIAL POPULATIONS
! PREGNANCY
Prevalence of intimate partner violence during pregnancy ranges from
6% to 22%.4,8 Women who report intimate partner violence and abuse
during pregnancy are at increased risk of postnatal abuse. Women
assaulted during pregnancy are three times more likely to be admitted
to the hospital than nonpregnant women.8
! IMMIGRANT POPULATIONS
Overall, prevalence of intimate partner violence is lower in people born
outside of the United States. However, certain immigrant populations
have rates far higher than U.S. natives.1,14 Moreover, the burden of
intimate partner violence can be much higher in these populations as
victims may be socially and linguistically isolated and perpetrators can
use threats of deportation to restrain victims from seeking help.14 The
federal Violence Against Women Act establishes protection that may
protect undocumented persons from deportation if they have been a
victim of crime, including intimate partner violence.
INTRODUCTION
Elder abuse is an act or omission resulting in harm to the health or wel-
fare of an elderly person. Three key groups have published definitions of
elder abuse.1-3 Although the incidence of elder neglect and abuse is
unknown and widely felt to be underreported, the rate of different types
of abuse among the elderly has been estimated to be in the mid-single
digits up to 10% of persons age >65 years,4 or between 500,000 and
1 million U.S. adults.5,6 One meta-analysis identified the pooled preva-
lence of elder abuse overall in geographically diverse countries to be
15.7%.7 Alternatively, a clinician seeing between 20 and 40 adults over
age 60 per day could encounter more than one victim of elder mistreat-
ment on a daily basis.8 Table 295-1 summarizes the categories of elder
abuse.
CLINICAL FEATURES
! PHYSICAL ABUSE
Physical abuse is the most easily recognized form of elder abuse. It is
defined as the use of physical force that might result in bodily injury,
physical pain, or impairment. Pushing, slapping, burning, striking with
objects, and improper use of restraint are all examples of physical abuse.
Chemical restraint (such as intentional overmedication or administra-
tion of tranquilizers) is a more subtle form. Regardless of mechanism,
physical abuse is carried out with the intention of causing suffering,
pain, or other physical impairment to the abused person.
! CAREGIVER NEGLECT
Elder neglect is the most common form of elder maltreatment, account-
ing for more than half of all elder maltreatment cases reported to adult
protective services agencies annually.9 Elder neglect is defined as the
failure of a caregiver to meet basic needs for a person or to provide
goods and services necessary to prevent physical harm or emotional
TABLE 295-1 Categories of Elder Abuse
Categories of Abuse Example

! LGBTQ PERSONS
Intimate partner violence occurs in same sex relationships at rates gen-
erally similar to opposite sex relationships. Bisexual women and men,
however, report substantially higher rates of intimate partner physical
violence overall.1 Transgender women and gender nonconforming per-
sons also experience intimate partner violence at higher rates. Lesbian,
gay, bisexual, transgender, and queer persons may not report to police
or seek advocacy services for fear of discrimination.3
Acknowledgment: The authors gratefully acknowledge the contri-
butions of Mary Hancock, the author of this chapter in the previous
edition.

REFERENCES Source:
The National Elder Abuse Incidence Study
The complete reference list is available online at www.TintinalliEM.com.

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