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3 Physical and Sexual Abuse of Adults

SHANNON F. STROMBERG, M.D.
One of the biggest threats to public health in the United States is
interpersonal violence. It comes in many forms to include assault, rape,
domestic violence, torture, and homicide. Although there are a plethora of
types of violence, there is an unfortunate common denominator for them
all. Namely, that every act of violence must have a victim. These victims
span all races and genders. As an example, the leading cause of death in
male African Americans continues to be homicide. Women continue to be
at highest risk for lifetime sexual assault. Those in law enforcement may
face threats daily just by going to work. In fact, statistics show that the
majority of Americans will fall victim to a violent crime during their
lifetime.
The most egregious result of violence is undoubtedly death, but the
greater costs of violence may lie well beyond mortality. Morbidity for an
individual exposed to violence is seen in decreased productivity, medical
disability, and psychiatric sequelae. Morbidity from a societal standpoint
occurs when people let violence impact where they live, where they raise
and school their children, how late they stay out, or even where they walk
or drive.
This threat has not been ignored though as evidenced by increased
public health awareness. The last 20 years have seen an increase in
emphasis on education and prevention. Statistics show an overall decrease
in the total number of cases and the rates of violence in general during that
time. Identification of those who are at risk and of those who have been
victimized continues to improve. Finally, the treatment modalities available
to victims have expanded greatly and have led to decreased morbidity in
survivors. That being said, there exists a need to continue to treat and
attempt to prevent violence in all forms.
TYPES OF ASSAULT, PREVALENCE, AND RISK FACTORS
Assault can be viewed in the context of two variables. The first involves who
is being assaulted, and the second is where the assault occurs. With these
parameters, assault can be classified into several categories with some
overlap among them. Violent crime, rape, domestic violence, workplace
violence, and torture are the most commonly used categories to classify
assault. The prevalence of these different types of assaults is most often
reported via two different data collection systems. The first is the Federal
Bureau of Investigation’s Uniform Crime Report (UCR), which collects
reported crime information from local law enforcement agencies. The
second is the Bureau of Justice Statistics’ National Crime Victimization
Survey (NCVS). This survey generates estimates of the likelihood of
victimization from different types of assaults. For each type of assault,
there have also been attempts to develop risk factor assessments. Gender,
age, race, history of prior assault, past psychiatric history, substance abuse,
and income have been found to have some relevance to assault risk for
different categories of assault. The last component to each type of assault is
the makeup of the perpetrator. This varies widely both within and between
the different categories of assault.
VIOLENT CRIME (AGGRAVATED AND SIMPLE ASSAULTS, ROBBERY)
Violent crime is defined by the UCR as murder and nonnegligent
manslaughter, forcible rape, robbery, and aggravated assault. These
categories exclude simple assault, which in the UCR is defined as an assault
or attempted assault in which no weapon was used or no serious injury
occurred to the victim. Included within this definition are stalking,
intimidating, coercing, and hazing.
Prevalence
In 2013, an estimated 6,126,420 violent crimes occurred in the United
States excluding homicide. Aggravated assaults accounted for an estimated
994,220 of this total, simple assaults were estimated at 4,186,390, and
robberies were estimated to be 645,650. Ten-year trends show a decrease
of 29.2 and 5.6 percent since 2004 for the estimated number of aggravated
and simple assaults, respectively. Over the same 10 years, there was an
increase of 4.7 percent for the estimated number of robberies. The rates of
all types of violent crimes in 2013 were lower than the rates observed in
2004.
Risk Factors
Gender carries a small risk with males more likely to experience violent
crime than females. Age plays a larger role with those younger than 25
years being at highest risk. Racial and ethnic groups also appear to have
different rates of violent crime victimization. The groups most at risk for
experiencing violent crime are persons of two or more races, American
Indians, and Alaska Natives. African Americans and Hispanics have higher
rates than whites, while Asians have the lowest rate of any group. Another
risk factor is household income with lower income households being more
likely to be burglarized. Homelessness has also been shown to be a factor in
increased physical assaults. Finally, substance abuse has been shown in
multiple studies to increase the risk of victimization.
Perpetrators
Both the UCR and NCVS suffer from limitations with regard to reporting
on offender characteristics. One problem is the heavy reliance on arrest
data, which exclude any data from assaults and robbery not resulting in
arrest. Another problem is that data are largely generated on the basis of
the victim’s report of the incident. Although these incident data can be used
to define the victim’s characteristics, they cannot be used accurately to
define the offender. By way of example, the NCVS reports on victimization
as reported by the victims, but a tool as well developed as the NCVS does
not yet exist to collect information on offending as reported by the
offender. Furthermore, incident data for victims cannot control for a
situation in which one offender has assaulted multiple victims.
RAPE
The legal definition of rape varies from state to state. Some states strictly
define rape, whereas other states describe any sex crime as varying degrees
of sexual misconduct or sexual assault. The UCR defines rape as follows:
“Penetration, no matter how slight, of the vagina or anus with any body
part or object, or oral penetration by a sex organ of another person, without
the consent of the victim.” In this section, rape refers to forced oral,
vaginal, or anal penetration, and sexual assault refers to any forced sexual
contact.
Like other violent crimes, sexual assault is on the decrease; however,
every 107 seconds someone in the United States is sexually assaulted. The
stereotype of the perpetrator being a stranger has been proven inaccurate
by research, with nearly two-thirds of all sexual assaults being committed
by someone known to the victim.
Prevalence
Unfortunately, accurate statistics are difficult to obtain because of
underreporting and unacknowledgment. The Rape, Abuse and Incest
National Network (RAINN) and NCVS estimate that nearly 70 percent of
sexual assaults go unreported. Although in the United States rapes have
fallen in number since 1993, in 2013, there were more than 300,000
victims of rape, attempted rape, or sexual assault. RAINN estimates that
one in six US women and 1 in 33 US men are victims of sexual assault.
In addition to being underreported, there are many rapes that go
unacknowledged by the victim. They often refer to the assault in more
benign terms such as a misunderstanding, despite the fact that it meets the
legal definition of rape. Research has reported that this percentage is
substantial; more than 50 percent of sexual assaults may go
unacknowledged and, thus, unreported. Research has further revealed that
victims who fail to acknowledge having been raped usually believe that rape
involves two strangers and greater force, as opposed to the views of those
who acknowledge their having been sexually assaulted.
Risk Factors
Although females are usually the victim of rape and sexual assault, greater
than 10 percent of victims are estimated to be male. Furthermore, most
experts believe that males underreport more than females. Despite growing
awareness, research on the male sexual assault victim remains sparse.
Nevertheless, young females have four times the risk of any other group of
becoming a victim of sexual assault. Eighty percent of all rape victims are
younger than 30 years, and Bureau of Justice statistics indicates that
women 16 to 24 years of age are at the greatest risk for rape in the United
States. Having been a victim of childhood abuse or previous assault
increases the likelihood of further assault of all types. Many studies have
also showed substance use and abuse to be a risk factor for sexual assault.
Perpetrators
In general, rape is considered a crime of power and aggression, not one of
sexuality. However, some controversy remains about whether the sexual
predator’s motivation is anger, power, sexual gratification, or control. What
has been shown in multiple research studies is that the majority of
perpetrators are known by their victims. Approximately 73 percent of all
sexual assaults and 66 percent of rapes are being committed by
nonstrangers.
The Centers for Disease Control and Prevention (CDC) conducted a
review looking at the risk factors for perpetration and found a multitude of
individual and relationship components. Individual risk factors included
prior sexual victimization or perpetration, substance use, difficulty with
empathy, aggressiveness and acceptance of violence, different sexual issues
(early initiation, coercive fantasies, and impersonal sex), and hostility
toward females. Relationship risk factors for perpetration included family
environments characterized by physical violence or that were emotionally
unsupportive, association with sexually aggressive peers, and poor parent–
child relations.
DOMESTIC VIOLENCE AND INTIMATE PARTNER VIOLENCE
Domestic violence is defined as a pattern of abusive behavior in any
relationship with the intent to gain power or control. It can be in the form
of physical, sexual, emotional, economic, or psychological abuse. This
abuse can be directed toward children, elders, or partners. Domestic
violence directed at a partner by a current or former partner or spouse is
referred to as intimate partner violence (IPV). Domestic violence is often
broken down into two categories: “high-severity abuse,” which includes
being threatened or hurt with a weapon, burned, choked, hit or kicked, and
resulting in broken bones and head or internal injuries; and “low-severity
abuse,” which includes being slapped, hit, or kicked without injury, but
could also include bruising, minor cuts, and sprains. The CDC has defined
four subtypes of IPV: physical violence, sexual violence, stalking, and
psychological aggression.
Elder abuse is a variant of assault either when the abuser is an
unrelated caretaker or as a result of domestic violence. Elder abuse can
include physical, sexual, emotional, and/or financial abuse.
Prevalence
Estimates of the prevalence of domestic violence in the United States vary
widely, and many studies include psychological or emotional abuse. One of
the more consistent statistics is that nearly 30 percent of women in the
United States have experienced some form of physical or sexual abuse from
an intimate partner. The NCVS reported more than 1,116,090 incidents of
domestic violence in 2013 and 748,800 cases of IPV. The prevalence rates
for both are unchanged over the previous 10 years. The National Intimate
Partner and Sexual Violence Survey (NISVS) from 2011 found that 27.3
percent of women and 11.5 percent of men experienced sexual violence,
physical violence, or stalking by an intimate partner during their lifetimes.
Risk Factors
Studies have found that certain individual, relationship, community, and
societal risk factors are associated with domestic violence and IPV.
Individual risk factors may include younger age, low income, substance
use, exposure to violence and abuse as a child, low level of education, and
having traits of Borderline or Antisocial personality disorder. Relationship
risk factors include marital discord and instability, economic stressors, the
man having multiple partners, and male dominance in the family. Finally,
multiple studies have shown that community and societal risk factors such
as poverty, overcrowding, acceptance of IPV or lack of sanctions against it,
and traditional gender roles or norms play roles in increased rates of
domestic violence and IPV.
Perpetrators
The perpetrators of domestic violence come from all races, cultures, and
ethnicities. They also span all genders, religions, educational backgrounds,
and socioeconomic levels. Many studies have shown that having been a
victim of abuse or witnessing abuse in the home increases the risk of
someone becoming an abuser. Substance abuse is often a risk factor for
episodes of perpetration. Various authors have described typologies to
describe perpetrators of domestic violence. Generally, these can be loosely
grouped into two types of offenders. The first is described as being
“emotionally dependent,” with a high level of jealousy, a high level of
interpersonal dependency, a high level of anger, and low self-esteem. These
abusers are prone to interpret their partner’s behavior as betrayal, and
their anger can explode into violence. The second type is the
“antisocial/narcissistic” person, who tends to have hostile attitudes toward
women and low empathy. These abusers become less physiologically
aroused as violence escalates. They also have the highest rates of alcohol
dependence.
Several traits can be associated with domestic violence and IPV,
including exhibiting verbal abuse, projecting blame, objectifying the
victims, and isolating them from social support. Finally, abusers are noted
to be charming and have manipulative personalities in public while being
cruel and hostile to their intimates.
WORKPLACE VIOLENCE
Acts of violence at work are defined as simple assault, aggravated assault,
robbery, rape/sexual assault, and homicide.
Prevalence
Between the years of 2002 and 2009 in the United States, the rate of
nonfatal workplace violence declined by 33 percent according to the NCVS.
In 2009, nonfatal workplace violence accounted for about 15 percent of all
nonfatal violent crimes. During this same period of time, about 3,800
workplace homicides occurred of which 80 percent involved firearms. With
some variation, total violent crime in the workplace declined 35 percent
between the years 2002 and 2009. This correlates with a similar 37 percent
decrease in all violent crime (workplace and nonworkplace) during the
same period.
Risk Factors
Unlike other violent crimes, workplace crime rates are higher among
whites than other races. An important component of workplace violence is
the relationship between the risk of violence and the type of occupation.
The NCVS found that people working in law enforcement are at the highest
risk for victimization (47.7 per 1,000) and constituted 19 percent of all
workplace assaults. This included law enforcement officers, security
guards, and corrections officers. Other high-risk occupations include
bartenders (79.9 per 1,000), the mental health fields (20.5 per 1,000),
transportation fields (12.2 per 1,000), and high school teachers (13.5 per
1,000). Preschool and college/university teachers are at the lowest risk for
victimization (0.9 and 1.9 per 1,000, respectively).
Perpetrators
There are several distinct characteristics among offenders, of which gender
is the most pronounced. As reported by the victims, four-fifths of all violent
workplace crime are committed by men, and this is regardless of the
victim’s gender. The race of the offender is most often white (55 percent),
followed by African American (30 percent). Substance use in the offender is
reported more often by victims in the law enforcement and retail sales
occupations as opposed to the mental health and teaching fields. Unlike
domestic violence, workplace violence is more often perpetrated by
strangers (53 percent) than by well-known acquaintances (12 percent) or
known intimates (1 percent). Mental health and teaching are the only fields
in which attacks occur more often at the hands of a known perpetrator.
SEQUELAE OF VIOLENCE AND ASSAULT
Survivors of violence have varied reactions, but they are similar to those
exposed to other types of trauma. Furthermore, the severity of the sequelae
varies with the individual. However, multiple studies have shown that
many people who experience violence have decreased physical and mental
health, resulting in higher utilization of health care services.
The most common reported sequelae after sexual assault in women are
posttraumatic stress disorder (PTSD), mood disorders, substance abuse,
eating disorders, and sexual disorders. Although PTSD rates vary in the
literature depending on methodology and sample, one study in women
instituting legal proceedings found a PTSD rate of 95 percent versus a
control group of women who had experienced a life-threatening trauma
unrelated to any form of sexual abuse, who had a rate of PTSD of 47
percent. Perceived life threat and physical injury are also linked to a
diagnosis of PTSD. One of the most protective factors in ameliorating the
development of PTSD is social support. Furthermore, the lack of social
support and/or the perception of being treated differently can be quite
detrimental to the survivor, causing an increase in PTSD symptoms.
Domestic violence has been associated with depression, anxiety, low
self-esteem, substance abuse, sexual dysfunction, functional
gastrointestinal disorders, headaches, chronic pain, and multiple somatic
symptoms. Research has also shown a dose effect of escalating violence and
increasing physical complaints. Physical signs and symptoms associated
with current abuse include loss of appetite; frequent or serious bruises;
nightmares; vaginal discharge; eating binges or self-induced vomiting;
diarrhea; broken bones, sprains, or serious cuts; pain in the pelvic or
genital area; fainting; abdominal pain; breast pain; frequent or severe
headaches; difficulty in passing urine; chest pain; problems with sleeping;
shortness of breath; and constipation. Many studies have shown that
survivors of domestic violence attempt suicide more frequently than those
who have not experienced violence. Substance abuse appears to be a
significant factor for both the survivor and the batterer. It is both a risk
factor for abuse and a consequence of it.
The relationship between childhood abuse and adult abuse is complex.
Childhood abuse is a risk factor for abuse as an adult and it increases both
physical and mental health sequelae of adult abuse. As expected, survivors
of sexual assault or domestic violence who are older and without a history
of childhood abuse have fewer symptoms.
TREATMENT ISSUES
In the evaluation of assault victims, multiple treatment issues need to be
addressed. Assessing safety, treating acute psychiatric and medical issues,
and evaluating the need for hospitalization are primary foci of the initial
assault workup. Another important issue to be dealt with during the initial
evaluation is the mandatory reporting requirements for abuse victims.
After these treatment issues have been addressed, the clinician then needs
to assess whether the patient may benefit from psychotherapeutic and/or
pharmacological intervention.
Initial Evaluation
Many victims of assault initially present to a medical doctor for treatment
of their injuries. In emergency departments, patients may often be treated
for their injuries without the assault being recognized or addressed.
Consequently, it is important to consider any concerning injuries as being
potential stigmata of an assault. The patient may initially be avoidant when
asked about the cause of injuries that appear related to assault. This may be
further complicated by the need to complete specific tasks (rape kit, photo
documentation, reporting of legal concerns) that require the patient to
describe and relive the recent assault. Consequently, it is paramount to
build a rapport with the patient while continuing to complete a thorough
evaluation. To facilitate this process, it is important to reduce the victim’s
stress and anxiety regarding discussing the event. The initial evaluation
process should be explained to the patient before beginning. Allowing the
patient some say in dictating the pace and content of the interview is
preferable to having a patient feel a lack of control over the process. The
crime may represent a time when they lacked control, and similar feelings
in the initial interview can lead to a triggering of traumatic or anxious
responses. Finally, the physician should remain attuned to nonverbal
patient responses that signify discomfort and conduct the interview
accordingly. This early therapeutic contact with assault victims may help
influence their future prognosis positively. Furthermore, when a patient
discloses domestic violence, this should be documented in the chart for
future follow-up and possible future legal documentation.
Safety
After an assault, it is imperative that a safety assessment be performed on
the victim. The patient needs to be evaluated for suicidal and homicidal
ideation as it pertains to the recent assault. The patient’s safety from
further assault also needs to be addressed, especially in a setting in which
the perpetrator was an intimate partner or known acquaintance. Finally,
the patient needs to be screened for severe psychological symptoms that
would cause difficulty in self-care. These would include acute mood
deterioration or affective instability, self-destructive behaviors, dissociative
symptoms, and/or frank psychosis. If the evaluation shows that any of
these areas are inadequate to ensure patient safety, then a plan needs to be
developed. This plan should provide for the patient’s physical safety and
give the patient a place to sleep, recuperate, and eat.

Hospitalization
In the event that the patient’s safety cannot be guaranteed, hospitalization
of the assault victim may be necessary. Common indications for
hospitalization include (1) severe medical injuries, (2) suicidality and/or
homicidality, (3) dissociative or psychotic symptoms, (4) mood instability
or affective dysregulation, (5) self-destructive behaviors, and (6) a
continued serious threat to the patient’s life or well-being. If the victim is
admitted to the hospital, then an individualized multidisciplinary
treatment plan should be developed. Safety, milieu therapy, mood
stabilization, and medication evaluation are the primary treatment
modalities provided in the hospital and reflect the short-stay nature of
most psychiatric facilities. Because the assault victim will likely need longer
treatment than what can be provided in the hospital, it is important for
there to be a coordinated inpatient-to-outpatient transition. This, like the
treatment plan, should be a multidisciplinary transition, with psychiatric,
medical, and social work issues all being addressed prior to discharge.
Legal Issues
A physician evaluating an assault victim needs to adhere to mandatory
reporting requirements for the state in which he or she is practicing.
Mandated reporting of child abuse and abuse of developmentally disabled
children exists in all 50 states. Mandatory reporting laws also exist in all 50
states for confirmed elder abuse. In cases of assault secondary to domestic
violence, states do not usually require mandatory reporting. However,
many states do require physicians to report serious injuries due to acts of
criminal violence. Thus, in the setting of injury secondary to domestic
violence, this can sometimes be considered a de facto mandatory reporting
situation.
Continuing the Assessment
Initially, the victims of assault may report a variety of different psychiatric
symptoms and psychosocial issues. They may endorse feelings of
depression, anxiety, aggressiveness, guilt, shame, and low self-esteem.
Interpersonal relationships may suffer, and substance abuse may occur.
These symptoms and issues should be addressed early because of the risk
to the patient of future psychological sequelae. It is well documented that
victims of assault are at increased risk for PTSD, major depression,
agoraphobia, OCD, social phobia, and simple phobia. The likelihood of
developing these illnesses after an assault varies according to the type of
assault and risk factors related to being assaulted. Therefore, a treatment
plan must be developed that (1) assists the patient in dealing with
psychiatric symptoms that he or she is currently experiencing because of
the assault and (2) assists the patient with psychiatric symptoms that may
arise later.
Postassault Psychotherapy Treatment
After the patient’s safety has been ensured and the initial evaluation is
complete, there are a variety of psychological interventions that can be
initiated. Cognitive-behavioral approaches are the most researched
techniques demonstrating efficacy. Exposure therapy is a variant of CBT
that has been shown to help victims emotionally process the assault by
decreasing their fear to memories or cues of the event. Recent literature has
shown that brief trauma-focused CBT may accelerate recovery in victims
manifesting acute PTSD and is superior to supportive therapy. These
individual psychotherapies may be augmented with group psychotherapy,
art therapy, dance and movement therapy, music therapy, and
bodyoriented
approaches if these might prove beneficial to the patient.
Postassault Psychopharmacological Treatment
Although medications are not recommended in the acute treatment of all
assault victims, they may be beneficial in certain circumstances. The
clinician may decide to medicate patients with incapacitating anxiety,
extreme aggression toward themselves or others, and/or dissociation or
psychoses immediately after an assault. The patient’s safety and the safety
of those around the patient will help decide the need for pharmacological
intervention. Most medication treatment will be initiated much later after
the assault as the patient develops symptoms of PTSD, depression, anxiety,
OCD, and/or psychosis. Although medications may be useful in symptom
management, they should not be viewed as a replacement for
psychotherapy aimed at trauma symptom resolution.