How to Identify Sexual Assault and Intimate Partner Violence in Your ED

Sexual assault (SA) and intimate partner violence (IPV) are disturbingly common, with 1 in 3 women experiencing this kind of violence in their lifetime¹.  These patients are being seen in our EDs every day – a CDC study of an urban ED waiting room found 50% of people there had either SA or IPV as a contributing feature of their current visit²; while best estimates find that only 10% of violence survivors disclosed this to anyone within their healthcare visit^3,4.  There is still significant stigma associated with SA and IPV and disclosing this can be extremely difficult for a survivor.  So, who do we ask?  How do we ask?

We tend to have a picture in our mind of what a SA or IPV patient looks like – usually young, usually female, sometimes from particular backgrounds.  However, SA and IPV spans all age groups, all genders, all socioeconomic classes, all racial and ethnic backgrounds^5,6.  If we only ask those who fit our mold, we will miss a large segment of the survivor population.  To avoid this, we need to implement universal screening.  Universal screening is asking everyone about experiencing violence who is capable of replying.  It is beneficial to patients as it removes any source of bias (personal, systemic), and patients/survivors do not mind being asked – multiple studies have shown that this is encouraged.   We ask with two simple questions:

1. Do you feel safe at home?
2. Has someone hurt you?

These questions are quick, can be implemented in any ED setting, used by any member of the healthcare team, and have accessible language.  They also avoid the word “abuse” as many survivors of violence may not recognize/identify themselves as abused.

What does SA and IPV look like?

We tend to think of a person with head injuries, lacerations, and bruises, but it has significant overlap with these patient presentations:

1. Chronic pain, particularly pelvic/abdominal pain in women, where no underlying cause has been found despite multiple investigations.  The inciting violence event can often set up the chronic pain syndrome in patients.
2. Substance use – which makes people more vulnerable to abuse, as well as being used as a coping mechanism for the violence.
3. Mental health disorders – which also makes people more vulnerable to violence.  In particular, patients with significant anxiety disorders and post-traumatic stress disorder (PTSD) after a violent event are often labelled “difficult patients”, particularly when they are triggered/in crisis during their ED visit.
4. “Frequent flyers” – those patients who use our EDs very often, as violence survivors have on average 8 visits to healthcare institutions before the violence is identified.
5. Elderly or dependent patients for whom we are concerned for caregiver fatigue⁷.  Signs of neglect or progression of disease complications can represent unrecognized abuse.

A good framework to help you look for red flags for SA and IPV is to think of the signs of child abuse – which we all know very well.  Historical features like a story that changes over time, delays in seeking care, a story that does not match with the injuries seen.  Physical exam findings like injuries that do not match the story being told, injuries that are impossible given the physical capabilities of the patient, pattern injuries like bite marks or handprints, and multiple injuries in various stages of healing.  Always be wary of the person who laughs this off, stating that they are “so clumsy”.  This can be a cover for being abused and should prompt questioning as outlined above.

Identifying patients that are survivors of abuse is a vital first step in reducing their morbidity and mortality.  Violence survivors who were not identified in their healthcare visit have a 4-fold increase in mortality (usually by a current or former partner) within a year⁸.  Given that a woman is murdered in Canada every 36 hours⁹, we have a lot of room to improve our identification and care of these patients.  Asking about and having an empathetic response to a disclosure of violence has a 6-fold reduction in substance use and mental health concerns¹⁰, as well as reducing the mortality concerns.  You can literally save a life, not by a heroic procedure, but by being attuned to and asking about violence.

Additional Resources

International Association of Forensic Nurses

Ontario Network of Sexual Assault/ Domestic Violence Treatment Centres

References

1. Understanding and addressing violence against women [Fact sheet]. World Health Organization. Accessed March 15, 2022. http://apps.who.int/iris/bitstream/handle/10665/77432/WHO_RHR_12.36_eng.pdf?sequence=1
2. Violence Prevention – Intimate Partner Violence [Fast Facts]. Center for Disease Control and Prevention. Updated November 2, 2021. Accessed March 15, 2022. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html
3. Harland K, Peek-Asa C, Saftlas A. Intimate Partner Violence and Controlling Behaviors Experienced by Emergency Department Patients: Differences by Sexual Orientation and Gender Identification. Journal of interpersonal violence. 2021;36(11-12):6125-6143.
4. Ansara D, Hindin M. Formal and informal help-seeking associated with women’s and men’s experiences of intimate partner violence in Canada. Soc Sci Med. 2010;70(7):1011-1018. doi:doi:10.1016/j.socscimed.2009.12.009
5. General Social Survey: An Overview. Statistics Canada. 2022.
6. Ansara D, Hindin M. Exploring gender differences in the patterns of intimate partner violence in Canada: a latent class approach. J Epidemiol Community Heal. 2010;64(10):849-854. doi:doi:10.1136/jech.2009.095208
7. reiding M, Armour B. The association between disability and intimate partner violence in the United States. Ann Epidemiol. 2015;25(6):455-457. doi:10.1016/j.annepidem.2015.03.017
8. Campbell J, Webster D, Koziol-McLain J, al. e. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003;93(7):1089-1097. doi:10.2105/ajph.93.7.1089
9. Canadian Femicide Observatory, https://www.femicideincanada.ca/. Acceessed April 20, 2022.
10. Ansara D, Hindin M. Psychosocial consequences of intimate partner violence for women and men in Canada. 2011;26(8):1628-1645. doi:10.1177/0886260510370600