Sexual Assault and

Domestic Violence
Department of Emergency Medicine
Johns Hopkins University
Center for International Emergency
Disaster and Refugee Studies
Objectives
 Definition
 Challenge
 Myths
 Presentation
 Clinical findings
 Physical exam
 Treatment
 Disposition

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Definition
 Non-consensual sexual contact
 Forced or coerced
 Legal diagnosis; not medical
 Perpetrators
 Family members, spouse, acquaintances, strangers
 Vulnerable target populations
 Children, adolescents, elders, developmentally
delayed or impairments, persons under the influence
of drugs or alcohol

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Challenge
 Psychological Harm
 History
 Perceptions
 Clinician’s Role
 Patient advocate
 Agent of the state

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Myths
 Myth: Rape is uncontrolled sex.
 Rape is an act of POWER and CONTROL
 Myth: The victim must have “asked for it” by
being seductive, careless, or drunk.
 Most rapes are planned. No one “asks” to be abused,
injured, or humiliated
 Myth: Most rapists are strangers to victims
 Most rapes are committed by someone the victim
knows. Strangers account for 1 in 5 rapes

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Myths
 Myth: Women lie about sexual assault to save
their reputation or to get attention.
 Sexual assault is an underreported. More likely to lie
about not being assaulted out of shame or fear
 Myth: Drinking by victim is why victim is raped.
 Alcohol is used as a tool for rapists to control and
render victims helpless

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Myths
 Myth: No fight or struggle = no rape.
 Sexual assault defined by action of perpetrator not
victim
 Myth: Men cannot be sexually assaulted

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Presentation
 Anyone can be a victim: young, old, female,
male, married, unmarried.
 All racial/ethnic groups at risk
 Male victim sexual assault: > underreported
 High degree of suspicion
 Wide spectrum of physical injuries
 Wide spectrum of emotional reactions
 Lapsed time in presentation varies
 Accompanied friend, family, or police

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Clinical situation
 Assess/treat life threatening injuries
 Provide safe environment
 Enlist social worker/rape victim advocate
 Preservation of potential evidence
 Do not change clothes, wash hands or bodies,
urinate, defecate, and, if oral penetration has
occurred, not to eat or drink
 Obtain consent

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Clinical situation
 Key:
 Good history
 Brief general history
 gynecologic history
 circumstances of sexual assault

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Physical exam
 Thorough physical exam
 Directed by history
 Forensic evidence
 Often dictated by a “sexual assault kit”
 Unclothe and keep clothes as evidence
 Head to toe
 Obtain samples: hair, skin, nails, secretions, etc
 Genitourinary exam
 Complete exam, obtain cultures, samples
 Document well
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Treatment
 Stabilize life threatening injuries
 Psychological: counseling
 Physical
 Prophylaxis
 Pregnancy
 Post-coital contraception within 72 hours of presentation
 STI’s
 Most common:Trichomoniasis, bacterial vaginosis,
chlamydia, and gonorrhea
 HIV and Hepatitis B
 Antiretroviral therapy and immunoglobulin/vaccine

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Disposition
 Admission
 Injuries requiring hospital care
 Severe psychological sequelae
 Follow up
 Counseling:
 Posttraumatic stress reactions and disorders
 Physical injuries
 Test/culture results:
 STI’s
 Unwanted pregnancy

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Overview-Domestic Violence
 Definition
 Importance of diagnosis
 Cycle of violence
 Characteristics of abusive relationships
 Treatment and disposition

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Definition
 Abuse of any type that occurs between people of
a past or present intimate/romantic relationship
 Spouse abuse
 Battering
 Adult intimate abuse
 Partner abuse
 Wife beating

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Definition
 Other meanings
 Family violence
 Child abuse
 Sibling abuse
 Elder abuse
 Sexual assault
 Domestic violence includes physical abuse, but
includes many other forms of abuse.

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Components of abuse
 Physical abuse
 Sexual assault
 Emotional abuse
 Verbal
 Intimidation
 Degradation
 Isolation
 Control
 Of money, transportation, resources
 Prohibiting access to health care

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Importance of diagnosis
 End cycle of violence
 Treating immediate physical complaints does not
solve/address the true problem
 Further alienation, isolation, feelings of hopelessness
 Prevent improper treatment
 Crosses all boundaries
 Gender, race, socioeconomic class, geography,
education
 Difficult diagnosis

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 Cycle of violence
criticism, yelling, physical and
sexual attacks,
swearing, using threats, in other
angry gestures, words any form
coercion, threats of abuse

Keep cycle in motion

apologies, blaming, promises to
change, gifts; “honeymoon” phase
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Characteristics of abusive
relationships
 Love…
 for partner, the relationship has its good points, it's
not all bad
 Hope…
 that it will change, relationship didn't begin like this
 Fear…
 that threats to kill you or your family will become true
 Dependence
 Learned helplessness
 become passive and unable to protect self

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Presentation
 Susceptible populations
 Pregnant women
 Psychiatric patients
 Disabled, Elderly
 Protean, nonspecific, nebulous complaints
 Physical findings
 Head and neck injuries
 Other body parts secondary to nature of injury
 Scratches, rope burns, cigarette burns
 Accompanied by abuser
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Treatment and disposition
 Provide safe and private environment
 Comfort
 Treat immediate injuries
 Assess safety
 Consider:
 Social worker, psychiatric referral,
 Notify law enforcement WITH consent
 Discharge after safety ensured

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Case
 A 21-year-old woman is brought to the casualty
department by two friends. Her friends say that
she told them that an acquaintance of their’s
forced her to have sex with him.
 They do not know the exact details of the sexual
assault, but say that it happened sometime
earlier that evening.
 The victim appears very upset and scared. She
is crying and is having a difficult time speaking in
order to answer initial questions.

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