Rape, Incest, Intimate Partner

Violence

LYLAH D. REYES MD FPOGS MSC

ASSOCIATE PROFESSOR C
DEPARTMENT OF PHARMACOLOGY

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

 LEARNING OBJECTIVES

u Discuss Rape, Incest and Domestic Violence( and their various

forms).
u Explain the Rape-Trauma syndrome.
u Discuss the physician’s responsibilities in the care of a rape victim.
u Discuss the appropriate physician’s approach when handling a
suspected case of incest.
u Recognize the signs of domestic and spousal abuse.
u Elaborate on the phases of battering.
u Discuss the doctor’s approach in cases of abuse.
u Explain the components of a sound exit plan for abuse victims.
Violence

“The intentional use of physical force or power, threatened or

actual, against oneself, another person, or against another
group or community, that either results in or has a high
likelihood of resulting in injury, death, psychological harm,
maldevelopment or deprivation.”

World Report on Violence and Health, WHO Geneva, 2002

Violence

ž OVERT - physical assault or threatening someone with a

weapon

ž COVERT - intimidation, threats, persecution, deception or other

forms of psychological or social pressure.

World Report on Violence and Health, WHO Geneva, 2002

 Gender-Based Violence (GBV)

v refers to violence directed against a person on

the basis of gender or sex

v the term gender expands the concept of

violence and serves as the key to developing
strategies for personal and social
transformation to end violence and to achieve
related development goals

United Nations International Research and Training Institute

for the Advancement of Women, Ending Mens Violence, 2004.
Forms of GBV

Violence Domestic
Against Violence
Women (DV)
(VAW)

GENDER-
Child abuse/ Sex
Maltreatment BASED Trafficking
VIOLENCE

Sexual Sexual
Abuse harassment

Training Module on Clinical Aspects of Violence Against Women and Children

Department of Health Center for Health Development
– Southern Mindanao Region Davao Medical Center – Women and Children Protection Unit
Form of GBV

Domestic Violence
– a pattern of assaultive and coercive behaviors
(physical, sexual and psychological attacks, and
economic coercion) that adults or adolescents
use against their intimate partners (Warshaw and
Gantley 1998:16)

– involves family members and persons not related

by blood and affinity, who LIVE IN THE SAME
DOMICILE OR CONSTITUTE A HOUSEHOLD
(Guerrero 1996:16)

Family violence
– a form of violence where the victim and
perpetrator are RELATED to each other BY
BLOOD OR AFFINITY WHO MAY NOT LIVE OR
BELONG TO THE SAME HOUSEHOLD (Guerrero 1996)
Form of GBV

Violence Against Women (VAW)

u any act of gender-based violence that

results in, or is likely to result in,
physical, sexual or psychological harm
or suffering to women, including
threats of such acts, coercion, or
arbitrary deprivation of liberty, whether
occurring in public or private life
(United Nations Declaration on the
Elimination of VAW, 1990)
Form of GBV
Sexual abuse
– of women: include DEMANDS FOR SEX USING COERCION
or the performance of certain acts, FORCING her TO HAVE
SEX WITH OTHER PEOPLE, TREATING her IN A SEXUAL
DEROGATORY MANNER and/or INSISTING ON UNSAFE
SEX
(Ending Violence Against Women, 1997)

Sexual Trafficking
– TRADING OF WOMEN FOR THE PURPOSE OF
PROSTITUTION; the key characteristics of trafficking are
exploitation, abuse, coercion, and violence
(Gender and Development Dictionary, 2001)
Sexual assault

u A crime of violence and aggression, and encompasses a

continuum of sexual activity that ranges from sexual coercion
to contact abuse (unwanted kissing, touching, or fondling) to
rape
u Any sexual act performed by one person on another:
u without consent - the victim's inability or refusal to give
consent.
u use of force, or the threat of force

Bates CK. Evaluation and

management of adult and
adolescent sexual assault
victims. April 2017
Sexual Violence

Any sexual act performed

by one person on another

without the latter’s consent

Sexual Violence
Unwanted
touching

Taking nude
photos Rape
without
consent
Sexual
Violence
Sexual
Peeping
harassment

Threates
Rape

Sexual assault of children,

women, and men
 u Homeless
u Mentally ill
Rape: u Very young
Susceptible u Very old
Persons u Physically handicapped

however…….
Rape

u Happens to people of all

ages, races, societal levels
Some Societal Misconceptions…

Victim “deserved” it

Indication of basic promiscuity of victim

Victim lied
Variants of rape

Marital Rape Date Rape Statutory Rape

• Forced coitus or • Woman may • Consent is

related acts voluntarily irrelevant
without consent participate in because the
but within the sexual play, but female is
marital coitus is defined by
relationship performed, statute as being
often forcibly, incapable of
without her consenting
consent
• Often not
reported
Rape-Trauma Syndrome: Two Phases

Acute or Immediate

Reorganization
Rape-Trauma Syndrome:
Acute or Immediate

Characterized by paralysis of
coping mechanisms

Reaction depends on several

factors:
• a. relationship of victim to attacker
• b. whether force was used
• c. length of time victim was held against
his/her will
Rape-Trauma Syndrome:
Acute or Immediate

Physical symptoms Behavior pattern

u Soreness u mood swings
u eating problems u Fear
u Headaches u Irritability
u sleep disturbances u Guilt
u Flashback of events u Anger
u Depression
u Difficulty in concentration
 u Characterized by:
u Continuation of flashbacks,
nightmares

u Development of phobias
Rape-Trauma
Syndrome:
Reorganization u Display of lifestyle changes
such as jobs, friends,
address, significant others

u Attempt to regain control of

his or her life
Physician’s responsiblity

Medical Medicolegal

Emotional
support
Physician’s responsiblity
MEDICAL treat injuries

diagnose and treat STDs

prevent pregnancy

Provide appropriate infectious

disease prophylaxis
 Note:
u size, shape, position and pattern of
lesions
u Associated features (e.g., tenderness
and swelling)
u Bruises, abrasions, and lacerations
u Neck
Assessment u Back
of physical u Buttocks

injury u Extremities
u Erythema, lacerations, and edema
u Vulva
u Rectum
u Bite marks
u Heat, chemical or electrical injury
Assessment of
physical injury
u Genital trauma occurs more commonly
in postmenopausal women and
adolescents

u Detectable trauma is more likely in

women with vaginal or anal penetration
and in virgins

u Common sites of genital injury: posterior

fourchette and the labia minora.

u Women who have had consensual sex,

when assaulted are more likely to have
genital lesions at sites other than the
posterior fourchette, and are more likely
to have multiple areas of trauma
Assessment for STI

Prevalence of STI among rape victims

• N. gonorrhea 0 to 26.3%
• C. trachomatis 3.9% to 17%
• T. pallidum 0 to 5.6%
• T. vaginalis 0 to 19%
• HPV 0.6 to 2.3%
• HIV 0.1 to 0.3%
Tests to perform

NAATs for Neisseria gonorrhoeae, Chlamydia

trachomatis, Trichomonas vaginalis
HIV—serology

Hepatitis B—screening serology

Syphilis—rapid plasma regain (RPR)

 Point-of-care Trichomonas—saline wet
testing mount preparation and culture
especially if
vaginal
discharge, Bacterial vaginosis—pH,
malodor or saline wet mount preparation
itching:
Candida—potassium
Tests to hydroxide wet mount
preparation
perform Other Herpes simplex—culture
consideratio lesion or serology
ns
Cytomegalovirus—serology

Condyloma virus—study
lesion
Acute Rape Management

Prophylactic Ceftriaxone 250 mg IM SD

Antibiotics

Plus
Azithromycin 1 g PO SD or
Doxycycline 100 mg PO BID x 7 days

Plus
Metronidazole 2 g PO SD or
Tinidazole 2g PO SD
Acute Rape Management

Pregnancy Menstrual history, birth

control regimen, and
pregnancy status should
be assessed

“morning after”
prophylaxis can be offered
as long as the pregnancy
test was negative
Sample
Algorithm
Sample
Algorithm
Physician’s responsibility

Medicolegal Obtain informed consent and have

chaperone.
Document history carefully

Examine patient thoroughly and

specifically note injuries
Consider drawing and photographs
of injuries
Obtain appropriate specimens for
STI testing
Physician’s responsibility
Medicolegal Collect articles of clothing

Collect vaginal (rectal and pharyngeal)

samples for sperm
Comb pubic hair for hair samples

Collect fingernail scrapings where appropriate

Collect saliva for secretion substance

Turn specimens over to forensic authorities

and receive receipts for chart
Survival Time of Sperm

Source Motile Sperm Sperm Acid Phosphatase

Vagina Up to 8 hours Up to 7-9 days Variable (up to 48 hrs)

Pharynx 6 hr Unknown 100 IU

Rectum Undetermined 20-24 hrs 100 IU

Cervix Up to 5 days Up to 17 days Similar to vagina

 MEDICOLEGAL
DOCUMENTATION
u Evidence for coitus present in
the vagina for as long as 48
hours after the attack, but in
other orifices the evidence may
last only up to 6 hours
Physician’s
responsibility u Vaginal wet mount is no longer
recommended for identifying
sperm as:
u it lacks reproducibility
u Manuactured evidence kits are
available.
Physician’s responsibility
Emotional Discuss degree of injury, probability of
infection, and possibility of pregnancy
support
Discuss the general course that can be
predicted

Consult with a rape-trauma counselor

Arrange a follow-up visit for a medical and

emotional evaluation in 1 to 4 weeks

Reassure as much as possible

Follow-up evaluation

u Conducted within 1 – 4 week after the initial post-assault examination

to provide an opportunity to

1) detect new infections acquired during or after the assault

2) complete hepatitis B and HPV vaccinations, if indicated;
3) complete counseling and treatment for other STDs
4) monitor side effects and adherence to post-exposure prophylactic
medication, if prescribed
5) Reevaluate for pregnancy
6) Reevaluate psychological status
Workowski KA, Bolan GA, CDC. Sexually transmitted
diseases treatment guidelines, 2015.
MMWR Recomm Rep 2015; 64:1
Comprehensive Gynecology 8th edition
 Follow-up evaluation

u If initial tests are negative and treatment was not provided, examination for
STDs can be repeated within 1–2 weeks of the assault

u A follow-up examination at 1–2 months should also be considered to

reevaluate for development of anogenital warts

u If initial test results were negative and infection in the assailant cannot be
ruled out
u serologic tests for syphilis (RPR) can be repeated at 4–6 weeks and 3 months
u HIV testing can be repeated at 6 weeks and at 3 and 6 months

Workowski KA, Bolan GA, Centers for

Disease Control and Prevention. STD
treatment guidelines, 2015.
Must stress

Patient is a victim
and is not
responsible for the
assault.
Incest

Sexual abuse (of children) in which the

perpetrator is a family member or family
friend
75% father-daughter
25% other forms
Incest

Chaotic relationships

Little outside contact

Associated problems (substance abuse,

mental illness)
Possible Effects on the Victim

Guilt feelings Fearful Shame

Poor interpersonal
Difficult
Weak ego and relationships and
relationships later
self-image chaotic families in
on
future

Abnormal
Psychiatric
psychological
symptoms
development
Gynecologist’s Approach

Start investigation ASAP

Appropriate questioning
Detailed and discrete inquiry
Reassurance
Appropriate referrals
Appropriate counseling
Somatic complaints

Physical
complaints Chronic pain and
bladder
involving several
problems
organ systems

Chronic fatigue
Intimate Partner Violence

Domestic violence
Partner abuse
Battered woman
Spouse abuse
Intimate Partner Violence
“pattern of coercive behaviors that may include repeated
battering and injury, psychological or emo- tional abuse,
sexual assault, progressive societal isolation, economic
deprivation, intimidation and stalking.” [American Medical
Association (AMA)]

Actual or threatened

Physical, Sexual, and /or Psychological

Battered Woman

A woman over age 16 with

evidence of physical abuse on at
least one occasion inflicted by
an intimate partner.
Battered Wife Syndrome

A symptom complex occurring as a result of

violence in which a woman has at any time
received deliberate, severe, or repeated (more
than three times) physical abuse from her
husband or significant male partner in which the
minimal injury is bruising.

Minimal injury: bruising

 Prenatal child abuse

Breast and abdomen

Physical
Escalation postpartum
Abuse in a
Pregnant
Significant correlates:
woman
• anxiety, depression
• housing problems
• inadequate prenatal care
• substance abuse
Range of Abuse

Verbal abuse, Throwing

Pushing Slapping
threats objects

Threatening
Kicking Hitting Beating or use of a
weapon

Mental abuse Intimidation

Common sites of Injury

Head Neck Chest

Upper
Abdomen Breast
extremities
Features/Signs of Abuse
 Risk factors in noninstitutionalized
adults
u Female
u ethnic/racial minority group
Intimate u With lower income
Partner u less educated
Violence u older

Strong relationship between

spouse battering and child abuse.
Typical profile of the abused wife

History of childhood abuse

Raised in single-parent household
Early/teenage marriage
Pregnancy before marriage
Common somatic complaints

Headaches
Insomnia
Choking sensation
Hyperventilation
Chest, back, pelvic pain
Other signs and symptoms

Shyness Fright Embarrassment Evasiveness

Often
Jumpiness Passivity Frequent crying accompanied by
male partner

Substance abuse
(e.g. alcohol, drug Injuries
overdose)
Phases of battering

First phase
Third phase
• Tension
• remorse building
escalation

Second phase
• actual
battering
Phases of Battering
Repeated first increases in
cycles: length and
phase intensity

becomes more
second severe
phase
decreases in
third duration and
phase intensity
 Batterer

Specific men who refuse to take responsibility for their behavior,

blaming their victims for their violent acts.
Profile
strong controlling personalities

do not tolerate autonomy in their partners

rigid expectations of marriage and sexual behavior and

consider their wives or partners as chattel

make unrealistic demands on their wives

show low tolerance for stress

charming and manipulative, especially in their

relationships outside the marriage.
 Physician’s Approach

Stress gravity of situation

Evaluate patient’s overall condition (e.g. physical injuries;

emotional status; psychological status -suicidal ideation,
anxiety, depression; signs of abuse of drugs)

Evaluate patient’s assessment of her situation and readiness

to take action
Appropriate referrals (e.g. mental health provider)

Assessment of community resources (e.g. police, crisis

centers, legal aid services)
The doctor’s job is to recognize the problem
and offer or get counseling for the victim so
that she understands her rights and
alternatives and learns to protect herself
and her children from future harm.
Health Outcomes of Violence

Heise, Ellsberg, and Gottemoeller 1999,

VIOLENCE AGAINST WOMEN: The Health Sector Responds, 2003
 Essential elements in the provision of appropriate
intervention for GBV cases

• Routinely screen patients about violence

• Assess the health impact of their victimization

• Document the occurrence of violence

• Conduct intervention by:

– Giving validating messages
– Providing information about violence
– Assisting in safety planning
– Referring to appropriate support and advocacy
services
– Conducting a follow up session
The Exit Plan

Change of clothes,other necessities in a suitcase left

with a trusted friend or relative
Cash, checkbook,bankbook left with a friend

ID and other important papers

Toy, book, favorite or special thing for each child

The Exit Plan

Available financial records

Where to go
Asks neighbors to call police
Remove weapons
Teach kids to call for help
Barriers to Physician Screening for
Intimate Partner Violence (IPV)

Belief that “someone else will take care of it”

Forgetfulness

Not a physician’s responsibility

IPV “should be private”

“Can not offer much”

Lack of scientific evidence that screening

improves outcome
Barriers to Physician Screening for
Intimate Partner Violence (IPV)

Cynicism: “nothing will happen”

Legal entanglement
Worry about offending patients
Time consuming
Insufficient training
Uncertain legal implications
Uncomfortable disccussion
Barriers to Physician Screening for
Intimate Partner Violence (IPV)

“Do not need to ask . The patient will volunteer information”

Beliefs about victims of spouse abuse

Fear of retaliation against patient

Frustration over lack of patient disclosure

Not scientific
Myth or Fact?
 u He wouldn’t beat her if she didn’t
love him so much

Myth or Fact
u Beating is not a sign of love. Love
means respect and kindness.
 u It’s their business. It’s not right to
interfere with the private affairs of a
couple.

Myth or Fact u Violence is not just a family matter.

It is a social and community health
problem.
Many women are killed or hurt.
 u Only certain types of women are
raped.
Myth or Fact
u Any woman could be a victim.
 u A woman who gets raped deserves
it, especially if she agreed to go to
the man’s house or ride in his car.
Myth or Fact
u No one deserves to be raped.
 u It’s best for the children if she stays
with him. He can still be a good
father to them.
Myth or Fact
u It is not good for the children to
witness violence in the household.
Rape, Incest, Intimate Partner
Violence

END OF LECTURE