Violence Flashcards
Use of force, coercion, or fraud to obtain some form of labor or commercial sex act
- “Modern day slavery;” Sexual exploitation, labor, organ - Labor thought to be more common, but less reported
- 3rd most profitable form of transnational crime
Human Trafficking
human trafficking is esp prevalent where?
large, multicultural cities
- NE - Washington DC, New York
- MW - Detroit, Chicago, St. Louis
- SE - Atlanta, Miami, Tampa, Orlando
- SW - Houston, Dallas, Fort Worth, Las Vegas
- West - San Diego, San Francisco, LA, Seattle, Denver
HOWEVER…can also be present in smaller communities!
what % of victims of human trafficking are female? are minors?
- 55-70% are female
- 50% are minors
Any age, race, gender, or nationality, including US citizens
Who Falls Victim to Trafficking?
People with little or no “safety net” are especially vulnerable to human trafficking!
- Economic hardship
- Violence in the home
- Unhoused individuals
- Natural disasters
- Political instability
- Undocumented immigrants
Traffickers use a variety of tactics to ensnare victims, including… (3)
- threats: Violence or threats toward the victim or his/her family members; Controlling individual’s identification documents; Threatening deportation or law enforcement action
- manipulation: False promises of love, companionship, a good job, a safe home, etc; Restricted social contact
- control: Limited freedom of movement; Garnishing the person’s salary to pay off “debts;” Depriving victim of basic necessities
warning signs of human trafficking
- Personal Behaviors: Social disconnect; Failure to attend school or work; Sudden or dramatic change in behavior
- Abuse/Neglect: Signs of mental or physical abuse; Signs of being denied basic necessities
- Living Situation: Living in unsuitable conditions; Lack of personal possessions; Unstable living situation
- Suspicious presentation: Accompanied by a controlling individual;“Coached” history
If you suspect Human Trafficking, what do you do?
- Contact federal law enforcement - 1-866-347-3423 or http://www.ice.gov/tips
- Provide patient with reporting information
- Take time to build rapport with patient
- If immediate, life-threatening situation, may need to contact local law enforcement
- Document, document, document
Roughly ?% of domestic violence (DV) victims are female
85%
- “Significant and sustained harm”
- Consider underreporting and repeat offenses
- Increasing numbers of male victims
How many men and women are victims of severe IPV in their lifetime?
1 in 7 men
1 in 4 women
How many men and women have been stalked?
1 in 19 men
1 in 6 women
How many men and women have been victims of rape/attempted rape?
1 in 33 men
1 in 6 women
How many men and women have experienced sexual violence victimization (other than rape) in their lifetime?
1 in 5 men
1 in 2 women
?% of women and ?% of men who experience sexual violence, stalking or other IPV report sequelae
PTSD, injury, IBS, and other poor mental or physical health
27%
12%
threatening, controlling, or harmful behavior imposed on a victim in a domestic or household setting without regards for the victim’s rights, feelings, body or health
Domestic Violence (DV)
Average length of victimization before presentation to health care providers or police?
4 years
Estimated at least ? of all American women will be physically assaulted by a partner or ex-partner during their lifetime
1/5
repeated pattern of harmful, threatening or controlling behavior as above
abuse
threats, harm, or controlling inflicted between intimate partners
Intimate Partner Violence (IPV)
Risk Factors for DV/IPV
- race - MC AA & Indigenous
- pregnancy - IPV is more frequent, more severe, and higher risk of homicide
- age - 16-24 y/o
- substance abuse
- prior exposure to violence
what is the leading cause of death among pregnant women
Homicide
Roughly 4-9% of pregnant women experience some form of IPV
s/s of DV
- Chronic Pelvic Pain
- Sexual Dysfunction - decreased libido or arousal, dyspareunia, anorgasmia
- Chronic or recurrent vaginitis
- Anxiety or tearfulness before or during pelvic or breast examination
- persistent multiple bodily complaints
- Psych - depression; PTSD; personality disorders; dissocative identity; substance use; anxiety
DV - Persistent multiple bodily complaints may mee the criteria for what disorder?
somatoform disorder
Domestic violence in ?% of pregnancies
MC than what other conditions in pregnancy? (3)
4-9%
MC than preeclampsia, gestational DM, placenta previa
DV/IPV leads to what consequences to pregnant women?
s/s of pregnancy
- Increased physical and psychological stress
- Inadequate prenatal care utilization
- Poor nutrition and weight gain
- Increased maternal behavioral risks - tobacco, alcohol, illicit drug use
result of physical trauma to pregnancy
- placental abruption
- preterm labor
- preterm premature ROM
- maternal and fetal injuries or death
As few as ? women experiencing DV are correctly identified by the practitioner to whom they turn for help
1 in 20
Barriers to Diagnosis DV
- Lack of practitioner knowledge or training
- Lack of practitioner recognition or awareness of prevalence
- Time constraints with office visit
- Fear of offending patient
- Feeling of powerlessness in area of treatment
- Many women will not voluntarily disclose abuse
The single most important thing a provider can do for a battered woman is?
ask about violence
screen for DV in who/when?
ALL patients for signs
- non-pregnant: at routine OB/GYN visits; at family planning visits; at preconception visits
-
pregnant: throughout pregnancy
- at first prenatal visit
- at least once per trimester
- at postpartum check-up
how to approach/screen DV?
- Give a statement establishing that screening is universal
- Direct questioning using behaviorally specific phrasing
- Disclosure rates are higher when:
- face-to-face rather than a questionnaire
- Behaviorally specific descriptions rather than terms like “abuse”, “domestic violence” or “rape” are used - Ask pts apart from intimate partner, family, friends, or children - Avoid using a friend or relative as interpreter
after dx DV, what are the next steps?
- Acknowledge trauma - Reinforce that the victim is not to blame
- Document trauma - Direct quotations of patient explanation; Photographs (with consent)
- Maintain confidentiality to avoid retaliation
- Assess immediate safety
- Assess lethality of violence
- Establish a safety plan
how to manage/prevent DV
- If pt is afraid for her safety or the safety of her children, she should be offered shelter
- Can get pocket cards with suggested safety/exit plan steps to give to patient or place in restrooms
- Provide educational materials: Provide lists of referral resources; Police departments, emergency departments; Battered women shelters and rape crisis centers; Counseling services; Self-help programs; Advocacy agencies
tx for DV
High rate of psychiatric symptomatology
- Referral for psychiatric screening and counseling
- Psychotherapy
- Psychiatric medication
- Detoxification and substance abuse treatment
- Patient advocacy groups
any sexual act performed by one person on another without the person’s consent
genital, oral, or anal penetration by a part of the attackers’ body or by an object
force, threat of force, or victim’s inability to give appropriate consent
Sexual assault
forced coitus or related sexual acts within a marital relationship without the consent of a partner
Marital rape
sexual assaults committed by someone known to the victim
Make up >75% of adolescent rapes
Acquaintance rape
rape by a family member, including step family and parental figures
incest
forced or unwanted sexual activity in the context of a dating relationship
Frequently associated with alcohol
May be associated with drugs
date rape
sexual intercourse with a female under an age specified by state law (14-18 yrs)
Mandated reporting laws vary by state
In general - greater age differential = greater penalties
Statutory rape
contact or interaction between a child and an adult when the child is being used for sexual stimulation of that adult or another person
Mandated reporting in all 50 states
child sexual abuse
Societal Misperceptions about Rape victims
- “Encourage” assault by their attire or actions
- Put themselves into a situation where it is “expected to happen”
- Act promiscuously, thereby “setting themselves up”
- Do not resist the assault enough
- May be falsifying events and pressing charges for ulterior motives
taught that rape is an ____ or _____ extension of normal sex drive
impulsive, aggressive
- Most sexual assault is motivated by a desire for degradation, terrorization, and humiliation of the victim
- Assault is a demonstration of power, anger, or sadism
clinical findings of rape
- Many do not openly admit to
- being sexually assaulted - Complaints of being “mugged;” Concerns over STDs or AIDS
- Psych - depression, anxiety, suicidal thoughts or actions
- Must obtain a sexual history or assault could go undiagnosed!
- 60-70% - no obvious injuries
- Vaginal irritation - >50% of victims
- Rectal pain and bleeding if anal penetration
- Risk for pregnancy and STIs
- MC nongenital injuries - bruises, cuts scratches, swelling; unconscious, internal injuries
acute phase of rape-trauma syndrome
Acute phase - hours to days
- Distortion or paralysis of coping mechanism
- Presentation ranges from complete loss of emotional control to an unnatural calm and detachment
- After first 2 wks - initial reactions of shock, numbness, withdrawal and denial usually abate
-
Somatic sx
- disturbed eating or sleeping patterns
- GI irritability
- MSK soreness, fatigue, tension headaches, startle reactions
delayed phase of rape-trauma syndrome
may be months-years after assault
- Chronic anxiety, feelings of vulnerability
- Loss of control and self-blame
- Depression
- Sexual dysfunction
- Psychologic distress - mistrust of others, phobias, depression
- 33-50% report suicidal ideation - Nearly 1 in 5 who do not seek tx will attempt suicide
- PTSD is a common long-term sequela - nightmares, flashbacks
- Risk of substance abuse
how to examine rape victim
- Physician has medical and legal responsibilities
- Consider use of sexual assault assessment kit
- Request assistance of personnel trained in collecting samples and information, if they are available - Sexual assault nurse examiners (SANE)
obtaining hx of rape victim
- Obtain informed consent prior to history
- H&P in presence of chaperone or victim advocate
- Ask patient to describe in her own words what happened and to identify or describe her attacker
- LMP, contraceptive use, pre-existing pregnancy and infection, date of last consensual intercourse
- Activities between assault and examination - Eating, drinking, bathing, douching, urination, defecation
how to perform PE of rape victim
- Careful PE of the entire body
- Document any injuries with photographs and/or drawings in medical record - “consistent with the use of force” rather than “rape” or “assault”
- Pelvic - note any injuries to vulva, hymen, vagina, urethra, rectum
- Inject 2 mL nml saline into vaginal vault; use non-absorbent swabs to sample fluid for tube and slides - pap, trich/gon/chl
- Evidence of coitus in vagina up to 48 hours after attack
- Offer baseline serology for hepatitis B, HIV, syphilis
rape victim PE - Sperm may persist in cervical mucus up to ?
17 days
what samples to obtain from rape victim
- Pubic hair combings
- Fingernail scrapings
- Skin washings and clothing - Wood’s lamp may be helpful
- Collect saliva (within a few hours)
- Properly process and label all specimens
- Must sign off to law enforcement that specimens have not been tampered with
tx of sexual assault
- Treat any physical injuries as appropriate
-
Emergency contraception can be offered - ulipristal, levonorgestrel, or IUD
- Serum pregnancy test beforehand - Empiric tx of STIs
- Ceftriaxone
- Metronidazole 500 mg - alt: 2 g of metronidazole or tinidazole x 1 dose
- Doxy
- HPV vaccination recommended
- Hep B vax or Ig - depends on pt’s risk
- ART for HIV prophylaxis - mixed recommendations - Not recommended if >72 hrs post-assault -
psych tx - Offer even if individual appears to be in control
- Do not release from facility until specific follow-up plans are made and agreed upon by patient, physician and counselor
No prophylaxis recommended for HSV or syphilis
copmonents of f/u for sexual assault
-
2 weeks after assault
- Repeat PE and collection of additional specimens
- Test for gonorrhea, chlamydia and trichomonas unless prophylactic abx given
- Discuss counselling again - Additional visits according to needs - Consider appt 12 wks after assault for hep B, syphilis and HIV serology
- Assess psychological needs at each visit
