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Physical and Sexual Abuse of Adults - A Comprehensive Answer

DEFINITIONS AND OVERVIEW

Physical abuse refers to the use of physical force against a person that results in bodily injury, physical pain, or impairment. This encompasses hitting, slapping, pushing, kicking, burning, choking, striking with objects, and the improper use of physical restraints or medications. In the context of intimate partner violence (IPV), physical abuse ranges from "high-severity" forms (threats with or use of a weapon, burning, choking, resulting in broken bones, head or internal injuries) to "low-severity" forms (slapping, kicking without injury, bruising, minor cuts, sprains).

Sexual abuse/assault is a crime of violence, conquest, control, and aggression - not passion. It encompasses a continuum of sexual activity ranging from coercion to contact abuse (unwanted kissing, touching, fondling) to forcible rape. The revised FBI definition recognises that survivors and perpetrators may be of any gender and that oral and anal penetration with an object or body part constitutes rape. Physical force is no longer a legal requirement, thereby encompassing individuals who are intoxicated, unconscious, mentally or physically incapable of demonstrating consent, or otherwise vulnerable.

Rape is legally defined by three elements:

Use of physical force, deception, intimidation, or the threat of bodily harm
Lack of consent or inability to give consent (due to age, alcohol/drug impairment, unconsciousness, or mental/physical impairment)
Oral, vaginal, or rectal penetration with a penis, finger, or object

Subtypes include: acquaintance rape, date rape, statutory rape, marital rape, and incest.

Berek & Novak's Gynecology, p. 1016-1017
Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7941

EPIDEMIOLOGY AND PREVALENCE

Nearly 30% of women and 10% of men in the United States have experienced some form of physical or sexual abuse from an intimate partner (National Intimate Partner and Sexual Violence Survey, NISVS 2011).
The NISVS found 27.3% of women and 11.5% of men experienced sexual violence, physical violence, or stalking by an intimate partner during their lifetimes.
The NCVS reported over 521,870 domestic violence incidents in 2019, including 310,320 cases of IPV.
Approximately 18% of women have been raped during their lifetimes; 8.8% by an intimate partner.
Among female rape survivors: 51% reported a current/former intimate partner, 41% an acquaintance, and 13% a family member - only 14% reported a stranger.
78.7% of female rape victims were first raped before age 25; 40.4% before age 18.
Only 26% of rape survivors seek medical attention after an assault.
Sexual assault is the fastest growing, most frequently committed, and most underreported crime.
Rape-related pregnancy rate: approximately 5% among girls and women aged 12-45.
Berek & Novak's Gynecology, p. 1016-1017
Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7942

RISK FACTORS

For Physical Abuse / IPV Perpetration

Individual factors: younger age of victim, pregnancy, low income, substance use, prior exposure to violence in childhood, low educational level, borderline or antisocial personality traits.

Relationship factors: marital discord and instability, economic stressors, male with multiple partners, male dominance in the family.

Community/Societal factors: poverty, overcrowding, social acceptance of IPV, lack of sanctions against it, traditional or rigid gender roles.

For Sexual Violence Perpetration (CDC factors)

Individual: prior sexual victimization or perpetration, substance use, impaired empathy, aggressiveness, acceptance of violence, early sexual initiation, coercive sexual fantasies, hostility toward women.

Relationship/Environmental: family environments characterised by physical violence, emotionally unsupportive families, associating with sexually aggressive peers, poor parent-child relations.

Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7941-7942

PERPETRATOR PROFILE

Perpetrators of domestic violence span all races, cultures, ethnicities, genders, religions, educational levels, and socioeconomic strata. Two broad typologies are recognised:

Emotionally dependent type: High jealousy, interpersonal dependency, anger, low self-esteem. Interprets partner's behaviour as betrayal; anger explodes into violence. More emotionally reactive.
Antisocial/narcissistic type: Low empathy, hostile attitudes toward women. Becomes less physiologically aroused as violence escalates. Highest rates of alcohol dependence.

Observable traits include verbal abuse, projecting blame onto victims, objectifying victims, isolating them from social support, and presenting as charming/manipulative in public while being hostile in private.

Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7942-7943

CLINICAL PRESENTATION / SIGNS AND SYMPTOMS

Physical Signs of Ongoing Abuse

Frequent or serious bruises (particularly in non-accidental locations - torso, face, neck)
Fractures, sprains, or serious cuts
Burns or bite marks
Strangulation signs (petechiae, neck bruising, hoarseness, dysphagia)
Pelvic or genital pain
Vaginal discharge or bleeding
Abdominal pain, breast pain, chest pain
Fainting, shortness of breath

Behavioural/Psychological Signs

Loss of appetite, eating disturbances (binges, self-induced vomiting)
Nightmares, problems sleeping
Diarrhoea or constipation (somatic symptoms)
Difficulty passing urine
Frequent or severe headaches
Partner who is controlling, speaks for the victim, refuses to leave the room

Pattern Recognition

Injuries inconsistent with the history provided
Delay in seeking treatment
Partner reluctant to allow private interview with patient
Injuries at different stages of healing
Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7944-7945

SEQUELAE OF ABUSE

Physical Sequelae

Chronic pelvic pain, sexual dysfunction
Chronic pain syndromes, functional gastrointestinal disorders
Headaches, multiple somatic symptoms
STDs, HIV/AIDS, unintended pregnancy
Reproductive health complications

Psychological Sequelae

Post-Sexual Assault: The most common sequelae are PTSD, affective (depressive) disorders, substance misuse, disordered eating, and sexual disorders. Perceived life threat and physical injury further increase PTSD risk.

Rape Trauma Syndrome is a constellation of physical and psychological symptoms that unfolds in two phases:

Acute/Disorganisation Phase (days to weeks): Fear, helplessness, disbelief, shock, guilt, humiliation, embarrassment, anger, self-blame. Intrusive memories, emotional blunting, hypersensitivity to stimuli, insomnia, nightmares, somatic symptoms, fear of retaliation.
Integration/Resolution Phase (weeks to months): Apparent return to routine but repression of anger, fear, guilt. Gradual acceptance. Over the long term: difficulty with work and family relationships, disruption of existing relationships, job loss (nearly half lose or quit jobs in the year following rape).

Domestic Violence Sequelae: Depression, anxiety, low self-esteem, substance abuse (both risk factor and consequence), sexual dysfunction, multiple somatic symptoms. Research shows a dose-effect: escalating violence correlates with increasing physical complaints. Suicide attempts are significantly more frequent than in non-abused populations.

Risk of subsequent psychiatric disorders: PTSD, major depression, agoraphobia, OCD, social phobia, simple phobia. The childhood abuse-adult abuse link is complex - childhood abuse as a risk factor worsens all sequelae of adult abuse.

Protective factor: Social support is the most important protective factor in ameliorating trauma-related symptoms. Its absence or perceived social marginalisation significantly worsens outcomes.

Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7944-7945
Berek & Novak's Gynecology, p. 1017-1018

APPROACH TO THE VICTIM

1. Triage and Immediate Priorities

Sexual assault patients should be triaged as high priority per Department of Justice recommendations. Place the patient in a private room (ideally dedicated to sexual assault care). Notify the Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE) on call. Instruct the patient not to undress, wash, eat, drink, or rinse the mouth - all clothing must be stored as forensic evidence.

2. Establishing the Therapeutic Environment

Begin with introductions and an expression of regret about the assault. Maintain a professional, non-judgmental, caring attitude. Key principles:

A physician's shock or outrage increases the patient's concern or feelings of marginalisation
Questions perceived as critical or judgmental generate guilt and shame, interfering with history-taking
Allow the patient to direct the pace and content of the interview - the crime may have been a time of powerlessness, and recapitulating that dynamic can trigger traumatic responses
Remain attuned to nonverbal cues of discomfort
This early therapeutic contact may positively influence long-term prognosis

3. History Taking

Open-ended questions should be used. Obtain:

Detailed assault description (type of assault, weapons used, orifices involved, condom use, patient's activities since assault - bathing, changing, urinating)
Past medical and gynaecological history (LMP, contraception, prior STDs, baseline injuries)
Whether injuries occurred and their location
Any drug or alcohol ingestion (important for drug-facilitated assault)

Critical time point: Forensic evidence collection is viable within 72 hours (some states allow up to 96 hours). However, medical treatment (STI prophylaxis, emergency contraception, injury management) should be provided regardless of forensic examination consent.

4. Consent

Obtain written informed consent for:

Forensic examination
Evidence collection
Photography
Transfer of evidence to law enforcement

Patients have the right to refuse any component of the examination. Medical care is provided irrespective of consent to forensic examination or police reporting.

5. Physical Examination - Systematic Approach

General Examination:

Full vital signs and mental status assessment
Head-to-toe inspection after properly removing and storing clothing
Focus on defensive injury areas (extremities) and common injury sites: oral cavity, neck (strangulation signs), breasts, thighs, buttocks
Document all injuries using a body diagram/clock face reference (in lithotomy position: pubic bone = 12 o'clock, left hip = 3 o'clock, right hip = 9 o'clock)
Describe location, size, shape of each injury; photograph if possible

Genital Examination:

Comb pubic hair and collect samples (including hair root)
Examine genital and rectal areas for injuries, discharge, abrasions, lacerations
Toluidine blue dye can be applied to the external vulva (not mucous membranes) to highlight microtrauma - it has affinity for DNA/RNA and highlights areas where the superficial non-nuclear layer has been removed by injury. Use before speculum examination to avoid confusion with iatrogenic abrasions.
Colposcopy detects injuries not visible to the naked eye (one study: 34% visible naked eye; 49% with colposcopy; 52% with toluidine blue)
If anal penetration is reported, examine anus and rectum for abrasions or lacerations
Wood's lamp examination in a darkened room to detect traces of semen; swab all areas of oral contact and fluorescent areas

Chain of Custody: All collected evidence must be maintained under strict chain of custody. Do not leave the rape kit unattended. Each handover must be signed, dated, and timed. Store in a locked, refrigerated cabinet if police are unavailable.

Tintinalli's Emergency Medicine, p. 2009-2012

6. Laboratory Investigations

STI testing: NAAT for gonorrhoea and chlamydia (cervical, pharyngeal, rectal as appropriate), wet preparation for bacterial vaginosis and trichomonas, syphilis serology
Pregnancy test (urine or serum hCG)
HIV baseline serology
Hepatitis B status
Drug-facilitated assault: special urine toxicology for ketamine, flunitrazepam (Rohypnol - detectable up to 72 hours), gamma-hydroxybutyric acid/GHB (detectable only up to 12 hours) - these are NOT detected on routine ED toxicology screens; specific send-out tests are required
Tintinalli's Emergency Medicine, p. 2012

7. Prophylaxis and Medical Treatment

Emergency Contraception:

Levonorgestrel (Plan B) within 72 hours (up to 120 hours with reduced efficacy)
Ulipristal acetate within 120 hours
Copper IUD within 5 days (most effective option)

STI Prophylaxis:

Ceftriaxone 500mg IM (or 1g if weight >150kg) for gonorrhoea
Doxycycline 100mg BD x 7 days or azithromycin 1g single dose for chlamydia
Metronidazole 2g single dose or 500mg BD x 7 days for BV/trichomonas
Hepatitis B vaccination if non-immune
HIV post-exposure prophylaxis (PEP): Should be offered when there is significant exposure risk; initiated within 72 hours, continued for 28 days (e.g., tenofovir/emtricitabine + raltegravir or dolutegravir)

Injury management: Treat acute injuries as clinically indicated. Refer surgical injuries appropriately.

8. Safety Assessment

After any assault (physical or sexual), conduct a formal safety assessment:

Assess for suicidal and homicidal ideation directly related to the assault
Assess safety from further assault (particularly if perpetrator is an intimate partner or known acquaintance)
Screen for severe psychological symptoms: acute mood deterioration, affective instability, self-destructive behaviours, dissociation, psychosis
Develop a safety plan: safe place to sleep, eat, recuperate; plan for absence from home/work

Indications for Hospitalisation:

Severe medical injuries requiring inpatient care
Active suicidality or homicidality
Dissociative or psychotic symptoms
Mood instability or affective dysregulation
Self-destructive behaviours
Continued serious threat to patient's life or wellbeing

An individualised, multidisciplinary treatment plan must be developed if admitted.

Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7946

9. Legal and Mandatory Reporting

Mandatory reporting requirements vary by jurisdiction
Child, elder, and developmentally disabled abuse requires mandatory reporting in all 50 US states
Domestic violence between adults does not universally require mandatory reporting, but serious injuries from criminal violence often do (de facto mandatory reporting)
Document all findings thoroughly in the medical record for future legal purposes
Chain of custody for forensic evidence must be maintained rigorously
The forensic examination aims to document history and physical findings and collect evidentiary material - it does not determine whether rape occurred; final documentation should avoid legally conclusive language
Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7946

10. Psychological Interventions

Acute Phase:

Psychological first aid: validation, normalisation of responses, emotional support
Avoid victim-blaming language or attitudes
Crisis intervention techniques

Post-Assault Psychotherapy:

Cognitive Behavioural Therapy (CBT) is the most well-researched intervention with demonstrated efficacy
Trauma-focused CBT (TF-CBT): Accelerates recovery in acute PTSD
Exposure therapy (a CBT variant): Helps victims emotionally process the assault by reducing fear of assault-related memories/cues; decreases avoidance
Eye Movement Desensitisation and Reprocessing (EMDR): Evidence-based for trauma processing
Pharmacotherapy: SSRIs (e.g., sertraline, paroxetine) are first-line for PTSD; address comorbid depression, anxiety, insomnia as indicated
Address substance abuse if present

Ongoing Support:

Referral to rape crisis centres, support groups
RAINN (Rape, Abuse & Incest National Network): 800-656-HOPE - national resource
Ensuring continuity from inpatient to outpatient care
Follow-up appointments at 1 week (for those on PEP/STI treatment) and 1-2 weeks for all patients
Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7947-7948
Tintinalli's Emergency Medicine, p. 2012

SPECIAL POPULATIONS

Elder Abuse

Physical, sexual, emotional, financial, or neglect
Most elder sexual assaults occur at the patient's home
Forensic examination is challenging due to: hip contractures, vaginal atrophy, cognitive impairment/dementia (difficulty obtaining accurate history)
ACOG recommends routine assessment of all patients >60 years for signs of elder abuse, including "Do you feel safe at home?"
May be reportable to Adult Protection Services depending on state law

Male Victims of Sexual Assault

Less commonly reported; resources for counselling are more limited, especially in smaller communities
SANE/SAFE examiners are trained in forensic examination of males
Rectal/anal examination is important
Follow-up with urology or proctology recommended
RAINN provides resources for male survivors

Transgender and Lesbian Patients

47% of transgender women report being raped at least once in their lifetime
Cultural competence and affirming care are essential
Tailor examination and history-taking to the individual's anatomy and identity

Drug-Facilitated Sexual Assault

"Date rape drugs": Rohypnol (flunitrazepam), GHB (gamma-hydroxybutyric acid), ketamine
These are NOT detected on routine toxicology screens
Must order specific send-out urine tests within the detection window
GHB is only detectable for 12 hours; Rohypnol for up to 72 hours
Tintinalli's Emergency Medicine, p. 2011-2014
Berek & Novak's Gynecology, p. 1017

SCREENING AND PREVENTION

ACOG recommends routine screening for sexual abuse history in all female patients ("Has anyone ever forced you to have sexual relations?")
Domestic violence screening tools (e.g., HITS, AAS) should be incorporated into routine primary care and emergency encounters
Trauma-informed care principles should be applied across all settings
All patients should be screened privately (without partner present)
When domestic violence is disclosed, it must be documented in the chart for follow-up and potential future legal documentation

SUMMARY TABLE

Feature	Physical Abuse	Sexual Abuse/Assault
Definition	Use of force causing bodily injury/pain	Non-consensual sexual contact/penetration
Commonest perpetrator	Intimate partner	Intimate partner/acquaintance
Immediate injury	Bruises, fractures, burns	Genital lacerations, contusions
Investigation	Clinical + photographic documentation	Rape kit, forensic swabs, STI/pregnancy testing
Forensic window	Variable	Within 72-96 hours
Emergency Rx	Injury management, safety planning	EC, STI prophylaxis, HIV PEP, counselling
Psychiatric complication	PTSD, depression, substance use	Rape trauma syndrome, PTSD, depression
Mandatory reporting	Depends on jurisdiction	Evidence to police (patient consent needed)

Key Sources:

Kaplan & Sadock's Comprehensive Textbook of Psychiatry (Domestic Violence, IPV, and Sequelae sections)
Berek & Novak's Gynecology (Sexual Assault and Rape chapter)
Tintinalli's Emergency Medicine, 8th Ed. (Sexual Assault Evaluation chapter)
ROSEN's Emergency Medicine (Male and Older Adult Sexual Assault sections)

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