CHAPTER 248

Violence Against Women

Violence against women is broadly defined as any act that is likely to cause physical, sexual, or psychologic harm or extreme suffering to a woman. Violence can occur in the home, workplace, or community. Two common forms of violence against women are domestic violence and rape.

Domestic Violence

Domestic violence includes physical, sexual, and psychologic abuse between intimate partners.

The victim is usually a woman.

Physical injuries, psychologic problems, social isolation, loss of a job, financial difficulties, and even death can result.

Keeping safe—for example, having a plan of escape— is the most important consideration.

Domestic violence includes physical, sexual, and psychologic abuse between people who live together, including intimate partners, parents and children, children and grandparents, and siblings. It occurs among people of all cultures, races, occupations, income levels, and ages. In the United States, as many as 30% of marriages are considered physically aggressive.

Women are more commonly victims of domestic violence than are men. About 95% of people who seek medical attention as a result of domestic violence are women, and perhaps 400,000 to 500,000 of women’s visits to the emergency department each year are for injuries related to domestic violence. Women are more likely to be severely assaulted or killed by a male partner than by anyone else. Each year in the United States, about 2 million women are severely beaten by their partner.

Physical abuse is the most obvious form of domestic violence. It may include hitting, slapping, kicking, punching, breaking bones, pulling hair, pushing, and twisting arms. The victim may be deprived of food or sleep. Weapons, such as a gun or knife, may be used to threaten or cause injury.

Sexual assault is also common: 33 to 50% of women who are physically assaulted by their partner are also sexually assaulted by their partner. Sexual assault involves the use of threats or force to coerce sexual contact and includes unwanted touching, grabbing, or kissing.

Psychologic abuse may be even more common than physical abuse and may precede it. Psychologic abuse involves any nonphysical behavior that undermines or belittles the victim or that enables the perpetrator to control the victim. Psychologic abuse can include abusive language, social isolation, and financial control. Usually, the perpetrator uses language to demean, degrade, humiliate, intimidate, or threaten the victim in private or in public. The perpetrator may make the victim think she is crazy or make her feel guilty or responsible, blaming her for the abusive relationship. The perpetrator may also humiliate the victim in terms of her sexual performance, physical appearance, or both.

The perpetrator may try to partly or completely isolate the victim by controlling the victim’s access to friends, relatives, and other people. Control may include forbidding direct, written, telephone, or e-mail contact with others. The perpetrator may use jealousy to justify his actions.

Often, the perpetrator withholds money to control the victim. The victim may depend on the perpetrator for most or all of her money. The perpetrator may maintain control by preventing the victim from getting a job, by keeping information about their finances from her, and by taking money from her.

After an incident of abuse, the perpetrator may beg for forgiveness and promise to change and stop the abusive behavior. However, typically, the abuse continues and often escalates.

Did You Know…

In the United States, about 2 million women are severely beaten by their partners each year.

The abusing partner may try to control the victim by limiting her access to other people, even by telephone or e-mail, and to money.

Effects

A victim of domestic violence may be physically injured. Physical injuries can include bruises, black eyes, cuts, scratches, broken bones, lost teeth, and burns. Injuries may prevent the victim from going to work regularly, causing her to lose her job. Injuries, as well as the abusive situation, may embarrass the victim, causing her to isolate herself from family and friends. The victim may also have to move often—a financial burden—to escape the perpetrator. Sometimes the perpetrator kills the victim.

As a result of domestic violence, many victims have psychologic problems. Such problems include posttraumatic stress disorder, substance abuse, anxiety, and depression. About 60% of battered women are depressed. Women who are more severely battered are more likely to develop psychologic problems. Even when physical abuse decreases, psychologic abuse often continues, reminding the woman that she can be physically abused at any time. Abused women may feel that psychologic abuse is more damaging than physical abuse. Psychologic abuse increases the risk of depression and substance abuse.

Management

In cases of domestic violence, the most important consideration is safety. During a violent incident, the victim should try to move away from areas in which she can be trapped or in which the perpetrator can obtain weapons, such as the kitchen. If she can, the victim should promptly call 911 or the police and leave the house. The victim should have any injuries treated and documented with photographs. She should teach her children not to get in the middle of a fight and when and how to call for help.

Children Who Witness Domestic Violence

Each year, at least 3.3 million children are estimated to witness physical or verbal abuse in their homes. These children may develop problems such as excessive anxiety or crying, fearfulness, difficulty sleeping, depression, social withdrawal, and difficulty in school. Also, children may blame themselves for the situation. Older children may run away from home. Boys who see their father abuse their mother may be more likely to become abusive adults. Girls who see their father abuse their mother may be more likely to tolerate abuse as adults. The perpetrator may also physically hurt the children. In homes where domestic violence is present, children are much more likely to be physically mistreated.

Developing a safety plan is important. It should include where to go for help, how to get away, and how to access money. The victim should also make and hide copies of official documents (such as children’s birth certificates, social security cards, insurance cards, and bank account numbers). She should keep an overnight bag packed in case she needs to leave quickly.

Sometimes the only solution is to leave the abusive relationship permanently, because domestic violence tends to continue, especially among very aggressive men. Also, even when physical abuse decreases, psychologic abuse may persist. The decision to leave is not simple. After the perpetrator knows the victim has decided to leave, the victim’s risk of serious harm and death may be greatest. At this time, the victim should take additional steps (such as obtaining a restraining or protection order) to protect herself and her children. Help is available through shelters for battered women, support groups, the courts, and a national hotline (1-800-799-SAFE or, for TTY, 1-800-787-3224).

Rape

Rape refers to unwanted penetration of the vagina, anus, or mouth.

Victims may have tears in the vagina, cuts and bruises, upsetting emotions, and difficulty sleeping.

Sexual transmitted diseases, including infection with the human immunodeficiency virus, and pregnancy are risks.

Women who are raped should be thoroughly evaluated in a center staffed by specially trained people (rape center).

Treatment of physical injuries, antibiotics to prevent infections, emergency contraception, and counseling or psychotherapy may be needed.

If possible, family members and close friends should meet with a member of the rape crisis team to discuss how to support a rape victim.

Rape is typically considered to be unwanted penetration of the victim’s vagina, anus, or mouth. In victims younger than the age of consent, such penetration— whether wanted or not—is considered rape (statutory rape). Sexual assault is a broader term, including the use of force and threats to coerce any sexual contact and unwanted touching, grabbing, or kissing. The reported percentage of women who have been raped during their lifetime varies widely: from 2% to almost 30%. The reported percentage of children who are sexually abused is similarly high (see page 1880). Reported percentages are probably lower than the actual percentages because rape and sexual abuse are less likely to be reported to the police than are other crimes.

Typically, rape is an expression of aggression, anger, or the need for power rather than sexually motivated. About half of women who are raped are physically injured.

Men are also raped. Men are more likely than women to be physically injured and less likely to report the rape.

Symptoms

Physical injuries resulting from a rape may include tears in the upper part of the vagina and injuries to other parts of the body, such as bruises, black eyes, cuts, and scratches.

The psychologic effects of a rape are often more devastating than the physical. Shortly after a rape occurs, almost all women have symptoms of post-traumatic stress disorder, (which can occur after any stressful event (see page 861). Women feel fearful, anxious, and irritable. They may feel angry, depressed, embarassed, ashamed, or guilty (wondering whether they may have done something to provoke the rape or could have done something to avoid it). They may have intrusive, upsetting thoughts about or mental images of the assault, and they may relive the rape. Or they may stifle thoughts and feelings about the rape. They may avoid situations that remind them of the rape. Difficulty sleeping and nightmares are common. These symptoms may last for months, interfering with social activities and work. However, for most women, symptoms lessen substantially over a period of months.

After a rape, there is a risk of infection with sexually transmitted diseases (such as gonorrhea, chlamydial infection, and syphilis) and hepatitis B and C. Infection with the human immunodeficiency virus (HIV) is a particular concern, even though the chances of acquiring it in a single encounter are low. Rarely, a woman becomes pregnant.

Did You Know…

Victims of domestic violence may develop depression, anxiety, or drug or alcohol abuse.

Women are in greatest danger of serious harm after their partner knows they have decided to leave.

Evaluation

Having a thorough medical evaluation after a rape is important. Whenever possible, women who have been raped or sexually assaulted are taken to a sexual assault center that is staffed by trained, concerned support personnel. The center may be a hospital emergency department or a separate facility.

After a rape, doctors are required by law to notify the police and to examine the victim. The examination provides evidence for prosecution of the rapist and is necessary before medical care of the victim can begin. The best evidence is obtained when the rape victim goes to the hospital as soon as possible, without showering or washing, without brushing the teeth, without changing clothes, and, if possible, without even urinating. The medical record resulting from this examination is sometimes admissible in court as evidence. However, the medical record cannot be released unless the victim gives her consent in writing or a subpoena is issued. The record may also help the victim recall details of the rape if her testimony is required later.

Immediately after a rape, a woman may be afraid of undergoing a physical examination. If possible, a female doctor examines the woman. If not, a female nurse or volunteer is present to help allay any anxiety the woman may be feeling. Before beginning the examination, the doctor should ask the woman’s permission to proceed. The woman should feel no pressure to consent, although consent is generally in her best interest. The woman can ask the doctor to explain what will happen during the examination so that she knows what to expect.

The doctor asks the woman to describe the events to help guide the examination and treatment. However, talking about the rape is often frightening for the woman. She may request to give a complete description later, after her immediate needs have been met. She may first need to be treated for injuries and to have some time for calming down.

To help determine the likelihood of pregnancy, the doctor asks the woman when her last menstrual period was and whether she uses a contraceptive. To help interpret the analysis of any sperm samples, the doctor asks the woman if she recently had sex before the rape and, if so, when.

The doctor notes physical injuries, such as cuts and scrapes, and may examine the vagina for injuries. Photographs of injuries are taken. Because some injuries such as bruises become apparent later, a second set of photographs may be taken later. A swab is used to take samples of semen and other body fluids for evidence. Other samples, such as samples of the perpetrator’s hair, blood, or skin (sometimes found under the woman’s nails), are collected. Sometimes DNA testing of the samples is done to identify the perpetrator. Some of the woman’s clothing may be kept for evidence.

If the woman consents, blood tests are done to check for infections, including HIV infection. If the initial test results for gonorrhea, chlamydial infection, syphilis, and hepatitis are negative, the woman is tested again at 6 weeks. If results for syphilis and hepatitis are still negative, tests are repeated at 6 months. Blood tests for HIV infection may be repeated after 90 and 120 days. A Papanicalaou (Pap) test is done to check for human papillomavirus infection after 6 weeks.

Usually, a pregnancy test to measure the level of human chorionic gonadotropin in the urine (see page 1616) is done during the initial examination to detect any preexisting pregnancy. If the results are negative, the test is repeated within 6 weeks to check for pregnancy that may have resulted from the rape.

Treatment

After the examination, the woman is offered facilities to wash, change clothing, use mouthwash, and urinate if needed.

Any physical injuries are treated. For preventing infections, the woman is given antibiotics, typically one dose of ceftriaxone injected into a muscle, one dose of metronidazole given by mouth, and doxycycline given by mouth for 7 days. If test results for HIV were positive, treatment for HIV is started immediately (see page 1261).

If there is no preexisting pregnancy, emergency contraception may be used. A high dose of an oral contraceptive is given immediately, then repeated 12 hours later (see page 1599). This treatment is 99% effective if given within 72 hours of the rape. Inserting an intrauterine device (IUD) within 10 days of the rape is even more effective. If pregnancy results from the rape, abortion can be considered.

Common psychologic reactions to the rape (such as excessive anxiety or fear) are explained to the woman. As soon as feasible, a person trained in rape crisis intervention meets with her. The woman is referred to a rape crisis team if one is located in the area. This team can provide helpful medical, psychologic, and legal support. For the woman, talking about the rape and her feelings about it can help her recover. If symptoms of posttraumatic stress disorder persist, psychotherapy or antidepressants can be effective (see page 862). If necessary, the woman can be referred to a psychologist, social worker, or psychiatrist.

Family members and friends may have some of the same feelings as the victim: anxiety, anger, or guilt. They may irrationally blame the victim. Thus, in addition to her own feelings, the rape victim may have to handle negative, sometimes judgmental or derisive reactions of family members and friends, as well as those of officials. These reactions can interfere with the victim’s recovery. Family members or close friends may benefit from meeting with a member of the rape crisis team or sexual assault evaluation unit to discuss their feelings and how they can help the victim. Usually, listening supportively to the victim and not expressing strong feelings about the rape are most helpful. Blaming or criticizing the victim may interfere with her recovery. A support network of health care practitioners, friends, and family members can be very helpful to the victim.