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Intimate Partner and Family Violence, Sexual Assault, and Rape


Clinical Keys for This Chapter

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    Intimate partner violence, formerly called domestic violence, is defined as intentionally abusive or controlling behavior by a person who is (or was) in an intimate or close relationship with the victim. The relationship may be heterosexual or between two people of the same sex. Most of the time a woman is the victim, but on occasion the abused person is a man.

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    Although exact numbers for domestic violence events are not known, intimate partner violence, along with other types of family violence, are common. The enabling feature of these events is feelings of vulnerability that the victim cannot or will not attempt to overcome.

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    Sexual assault includes sexual activity that ranges from sexual coercion to contact abuse, such as unwanted kissing or fondling, as well as rape.

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    A medical consultation for sexual assault and rape should involve providing acute medical care, gathering evidence for possible prosecution, and transitioning the victim into longer-term care.

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    The psychological consequences of intimate partner and family violence, as well as sexual assault, are significant, with lifelong problems reported. Providing social as well as psychological support and counseling are essential for adequate aftercare.

Domestic violence is now more commonly called intimate partner violence. The term family violence (covered only briefly in this chapter) also refers to abuse of other vulnerable persons such as the elderly, people with disabilities, or children. The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion on Intimate Partner Violence (Number 518, February 2012) addresses these issues.

Sexual assault and rape are the most violent manifestations of sexual abuse. ACOG issued a recent committee opinion on the topic of sexual assault (Number 592, April 2014).

The obstetrician-gynecologist is in a unique position to identify the crimes of intimate partner violence and sexual abuse and help women deal with them.

Intimate Partner Violence and Family Violence

The obstetrician-gynecologist is the health care provider most likely to deal with the effects of abusive behavior directed against an intimate domestic partner. Intimate partner violence can include verbal abuse, intimidation, social isolation, and physical assault, such as a punch, a kick, a threat, a severe beating, an act of sexual assault, or even murder. It occurs in every age group, in all ethnic groups, in every occupation, and in every socioeconomic group. Although the obstetrician-gynecologist may be called to see a patient with acute injuries that result from partner violence or sexual assault, she or he is more likely to have to deal with the nonacute clinical manifestations of abuse ( Box 29-1 ). Violence is most often perpetrated by a man against a woman; however, the gender relationship may occasionally be reversed. Intimate partner violence can also occur between same-sex partners.

Box 29-1
Modified from American College of Obstetricians and Gynecologists (ACOG): Special issues in women's health — intimate partner and domestic violence, Washington, DC, 2005, ACOG.
Clinical Manifestations of Possible Intimate Partner Violence *

* No single presentation can confirm intimate partner and/or family violence.

  • Inadequately explained injuries, such as bruises and abrasions

  • Unusual difficulty during a gynecologic examination, such as excessive distress, discomfort, or avoidance behaviors

  • Chronic and unexplained pelvic pain, urinary symptoms, sexual dysfunction, or irritable bowel syndrome

  • Persistent or recurrent vaginitis or sexually transmitted infections in spite of appropriate treatment

  • Persistent vague complaints, such as headache, backache, palpitations, digestive, sleep, or eating disorders

  • Complaints or signs of depression, anxiety, phobias, panic attacks, or feelings of shame or worthlessness

  • Unintended pregnancy

  • Suicidal ideation

Epidemiology

The prevalence and incidence of intimate partner violence are not known, but they are considerable. It has been estimated that as many as 2 million women are abused every year by someone they know. Any estimate of prevalence is likely to be understated, because of the likelihood that a significant number of victims are fearful of disclosing abuse. One study of the incidence of partner abuse found that of all women seeking care in an emergency room (ER), 54% said they had been threatened or injured at some time in their lives by a partner, and 24% said they had been injured by a current partner. One in three women presenting to an ER with injuries has symptoms related to partner violence. More than 20% of violent crimes against women and 30% of female murders are committed by intimate partners. Estimates of the number of pregnant woman who are victims of partner abuse range from less than 1% up to 20%.

Other forms of family violence are prevalent. The level of child abuse is epidemic, and it is estimated that nearly 500,000 elderly persons in domestic settings in the United States are abused or neglected. Seventy percent of cases of abuse of the elderly are perpetrated by a family member, including adult children.

In all cases of ongoing family and/or intimate partner abuse, the key enabling feature is some form of victim vulnerability that the victim cannot or will not attempt to overcome.

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