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Prevalence of Abuse
Almost 5 million women each year are violently victimized by men, especially by men who they know and with whom they have been intimate.Of the 3/100,000 female homicides in the United States in 1997, almost 30 percent were committed by husbands or boyfriends. Annually, 8/1000 women experience violent victimization by their current or former spouse or boyfriend and an estimated 1 million women are stalked.
These figures do not reveal the full effect of abuse primarily because of the limited scope of the types of abuse considered and lack of reporting. For example, in addition to physical violence, abuse of women includes emotional abuse, sexual harassment, prostitution, and pornography. Statistics most often cited include only completed acts of violence reported to authorities. However, fewer than 1 in 10 rapes are reported to the police and less than 1 percent are ultimately resolved by arrest and conviction of the perpetrator. Recurrent or threatened abuse may go unreported and abuse is highly underreported in certain vulnerable populations of women including adolescents, the homeless, ethnic minorities, women who are disabled, lesbians, and women in institutions.
Consequences of Abuse
Abuse has a devastating effect on the health of women. Thirty percent of women treated in emergency rooms are suffering from injuries or symptoms related to abuse. Even low level abuse is associated with increased physical and psychological symptoms and substance abuse? The long-term consequences of abuse include mental health problems, substance abuse, increased use of medical services, restricted activities and careers, and decreased self-efficacy of the victims. There are also ramifications for friends and family members, especially children, including stress, fear, and loss of support.
Recognition of Abuse
Public recognition of abuse of women in this country is less than three decades old. Historically women were considered men’s property and rape was considered the fault of the woman. Born of the women’s movement in the 1960s and 1970s, the first “speakout” on rape was in New York in 1971 and the First International Tribunal on Crimes against Women, which recognized the systematic rape of women in war for example, was held in Brussels in 1976.
United States Justice System
Although the legal system has historically failed to acknowledge the abuse of women, changes have occurred over the past two decades. California passed the first antistalking law in 1990, and in the last decade all states have recognized marital rape. Reforms in rape laws and in police investigation and enforcement have also taken place as summarized.
Mandatory reporting of domestic violence is controversial because it may put the victim at increased risk and make the victim less likely to present for help. Also although the use of restraining orders or mandated counseling have been helpful, enforcement is inadequate and women are at risk for murder despite the restraining order. For example, women are five times more likely to be murdered by their partner during a separation than before the separation or after divorce. Civil suits for abuse, although most common for sexual harassment, are increasingly an option for survivors of sexual assault and spouse abuse.
Clinicians have also frequently failed to recognize abuse of women. Even now, with domestic violence occurring as frequently as breast cancer and being potentially fatal, abuse is rarely inquired about as part of a routine medical examination. 1° Clinicians often have no training for this role and believe themselves powerless to effect change. The health provider’s discomfort may add to the survivor’s and provider’s denial of abuse. Routine screening questions have been used in emergency room settings with Some success. Potential confounders resulting from abuse such as mental health problems, substance abuse, multiple somatic complaints, and patient denial make it imperative that clinicians ask about abuse even when it is not obvious.
The single most important step that any health care professional can take is to ask every woman if she is being or has been abused or if she is afraid. Questioning communicates to the patient that the problem is not trivial, shameful, or irrelevant. It conveys to all women the clinician’s belief that it is important to talk about the problem of abuse.
Primary prevention of abuse against women will only be achieved by challenging the roles of violence and patriarchy in society. All individuals need to become aware of the destructive consequences of sexual stereotypes, rape myths, and pornography and to support and model nonviolent methods of conflict resolution.
Secondary prevention can be achieved by the interruption and elimination of intergenerational abuse of all kinds. Females need to be taught to recognize risk(e.g., distinguishing private parts of the body not to be touched by others, identifying dangerous situations) and practice self-defense (e.g., reporting inappropriate touching, avoiding dangerous situations, how to call for help). Especially important is the recognition of a partner exercising control-directing dress, restricting friends, demeaning women, using intimidation, or being jealous. Recognition of the dangers associated with drugs or alcohol is also critical.
Tertiary prevention can be achieved by identifying victims and their abusers and helping them. This includes the education and training of medical and law enforcement personnel; specifically, medical providers and educators need to address issues of sexual and student harassment. The Joint Commission on Accreditation of Healthcare Organizations requires policies for the identification and assessment of abuse victims and education of providers. Community resources such as rape crisis centers and battered women’s shelters are effective, but more are needed. Court-ordered programs for male batterers have had some success in the reduction of battery. Offenders need to be appropriately incarcerated.
The most easily recognized form of abuse of women is sexual assault and/or rape. Sexual assault is an act of violence described by three defining characteristics: (1) the use of threat, physical force, intimidation, or deception; (2) sexual relations-the legal definitions vary from fondling to vaginal penetration; and (3) nonconsent or the inability to give consent for a sexual encounter.
Thirteen to 25% of all women in the United States will experience a rape in their lifetime and the percentage is probably underestimated. The difficulty in defining the incidence and prevalence of abuse of women is illustrated by rape statistics; prevalence rates reported in the literature vary by over 10-fold. The FBI Uniform Crime Reports (UCR) include those rapes reported to the police-70/100,000 women. These tend to be underestimates for the following reasons. First, rapes are not reported because of the victim’s fear of reprisal for self or others, shame, fear of the justice system, or because she does not defme the act as rape (such as in marital rape). Second, there may not be sufficient evidence to support a woman’s report of rape. This is higher in rapes when the assailant is known to the victim, the victim has used alcohol or gone to the assailant’s home, or if there has been a delay in reporting. Finally the UCR list only the most serious crime, so if there is both a rape and murder it is recorded as a murder. The second most often cited rape statistics come from the National Crime Survey. This is an annual telephone interview of randomly selected households organized by the Bureau of Justice Statistics. Since 1995, the survey has asked specifically about rape and found approximately double the rate of sexual assaults compared to the UCR. A recent section of this, the National Women’s Study, focused on women older than 18 years and found that 84 percent of rape victims did not report the offense to the police.
Other population surveys reveal even higher prevalence rates. Koss, in a review of college student surveys, found that annually 10 percent described a rape, 17 percent an attempted rape, 26 percent unwanted sexual coercion, and 63 percent unwanted sexual contact. A survey by the Crime Victim Research and Treatment Center of the Medical University of South Carolina concluded that over 12 million adult women had been rape victims, 61 percent before age 18 and 29 percent before age 11 The most intensive survey was done by Diana Russell in which trained multilingual interviewers spoke with women older than 17 years in their homes. Even though in this survey the definition of rape was limited to vaginal penetration, 25 percent of women revealed a completed rape.
Adolescent sexual assault is frequently unrecognized even though this group is at high risk for sexual assault (most of which are “date rapes”). The majority of teens younger than 15 years who engage in vaginal intercourse do so involuntarily. Ten percent of undergraduate women report abuse in a dating relationship and 25 percent report attempted or completed date rapes. This underreporting may occur because adolescents lack experience with complex feelings or lack understanding about what is normal in a sexual relationship. Underreporting may also be exacerbated by less well-developed communication skills, reluctance to involve others as part of striving for autonomy, and having fewer resources such as money or transportation.
Five percent of victims of sexual assault have major nongenital injuries, 1 percent have genital injuries requiring surgery, and 0.1 percent have fatal injuries. However, the majority of sexual assault victims (60 to 80 percent) do not have severe physical injuries but rather suffer from psychological trauma.
Although every woman and situation differs, rape victims characteristically progress through stages described as the rape trauma syndrome. Initially there is acute disorganization that may last days to months. During this time, it is important for clinicians and counselors to educate the patient and her family about normal reactions to trauma, relieve guilt, and confirm and witness the survivor’s experience of trauma, allowing time for grieving. After the initial shock and disorganization, there may be denial, depression, psychosomatic complaints, and diffuse anger. Recovery is individual and characterized by such features as the ability to control memories.
Recognition of sexual assault depends primarily on the type of assault. Stranger and gang rapes are often the most easily recognized because the victim is likely to suffer physical injury, be seen in the emergency room, and report the assault. However, even among women presenting for care to the emergency room following a rape, 26 percent did not identify themselves as assault victims. In one study, 57 percent of women who were raped did not label their experience as rapeP In a study of adolescents, 71 percent of victims told only a friend. Spousal rape is the most prevalent and least commonly reported. Thus, all women should be asked about their exposure to violence.
Secondary prevention of sexual assault can be taught by reviewing the characteristics associated with assault. These are summarized. However, there are no controlled trials of the effectiveness of such educational programs.
Most survivors of sexual assault report that they thought they were going to be killed. A survivor may appear distraught or may be calm, although there is likely to be acute psychological disorientation with either presentation. She may be unable to give a complete history of the assault or the history may be disorganized. It is important that the clinician believe the victim, reassure her of her safety, and respect her autonomy by obtaining informed consent for the examination, procedures, or contact with others. With the victim’s permission, the clinician should contact a rape crisis worker. Police are automatically contacted in the setting of assault, but the survivor decides if she wants to file criminal charges. When there is undisclosed assault, reporting is discussed individually between the health care provider and patient. The most important feature facilitating recovery is contact and support within 72 h.
The emergency room treatment of the victim of sexual assault first and foremost involves assessment and management of the victim’s injuries and prevention of sexually transmitted diseases and pregnancy. Only secondarily, and with the patient’s permission, should the clinician gather the information and samples necessary to support a criminal investigation. Most emergency rooms have rape or sexual assault kits that contain instructions for gathering materials to support legal charges. Legal evidence collection must follow a “chain of evidence,” which means that all samples have to be labeled and those samples kept under supervision. Although it is the survivor’s decision to file charges, most clinicians attempt to gather evidence appropriately so this option remains open for the survivor.
summarizes the history necessary from a survivor of sexual assault. The history directs the physical examination, sample collection, and risk assessment. It also provides information that will be necessary should the survivor choose to file criminal charges. However, it is critical to remember that the history is frequently partial and disorganized.
The purpose of the physical examination is to assess injuries to the survivor, as directed but not limited by the history, knowing that it is often incomplete. It is critical not to retraumatize the survivor at this time. Examination should be com. plete, starting with a general assessment, and then proceeding to the areas of trauma unless there is an obvious injury necessitating an initial intervention, such as vaginal bleeding.
Laboratory Testing And Procedures
Cultures for sexually transmitted diseases (STDs) and serum testing should be obtained as noted. Vaginal colposcopic pictures may show lacerations. However, because laceration may also occur with volitional sexual activity, colposcopy is not always required evidence and the need for colposcopic investigation is controversial.
summarizes the risks and recommended treatments for STDs in the setting of sexual assault. The current recommendation is not only to offer STD and pregnancy prophylaxis but to include hepatitis Band HIV prophylaxis. Although the risk may be individualized by knowledge of the assailant’s HIV status, often this is unknown and the traumatic nature of the event, especially for those who experienced anal penetration, puts the victim at risk.
The office management of the victims of sexual assault is determined by the time at which the assault is recognized by the clinician. With, known sexual assault, Burgess and Holmstrom found that one-third of victims reported recovery within 1 year, another third stated that it took longer than 1 year, and one-quarter of women felt they had not recovered after 4 to 6 years. Recovery appears to be dependent on the individual, her life stage, and the characteristics and context’ the traumatic event. For example, stranger rape leaves the victim feeling like there is no way 10 prevent an attack, whereas acquaintance rape leaves the victim feeling like no one can be trusted. Victims of date or marital rape show the greatest long-term effects with more depression and social phobias. Individuals who have been previously victimized are especially vulnerable to a complex posttraumatic stress disorder. Finally, although women’s physical and psychological symptoms usually directly correlate with the severity of the violence experienced, even women exposed to low severity assaults (e.g., pushing, threats) experience an increase in physical and psychological health problems? Recognition of the duration of symptoms and the effects on physical and mental health as well as interpersonal relationships can help the clinician provide needed support. Education of the family and the patient about normal recovery and such things as anniversary reactions is also key.
A clinician may also be contacted by a patient after an assault before she goes to the emergency department. If the clinician has such a telephone contact with a victim, immediate safety and physical well-being should be assessed. She should be told not to brush her teeth, change her clothing, or shower, although in reality, many victims have already done so. Most clinicians would recommend that the patient go to an emergency room for assessment and treatment and also to gather legal evidence so that the option of filing criminal charges remains open to her.
Clinicians may also be contacted many days or weeks after an assault. Although evidence is unlikely to be obtained after several days, the victim needs to still be assessed and treatment given for STDs. Pregnancy prevention is only effective within 72 h. The patient may be offered 600 mg mifepristone followed by 400 ug misoprostol 2 days later if a pregnancy test is positive and it is within 50 days of the assault Clinicians may also see women without realizing that they have been victims of a sexual assault. These women may have posttraumatic stress disorder or other problems as described previously, but often they have difficulty with pelvic exams occasionally to the point of having a flashback. All women should be asked about any experience of violence and violation.
Domestic violence, an intimate partner’s physical, emotional, or sexual abuse, effects up to one-half of women in the United States at some time in their lives. Battery (an unlawful beating of another person or any threatening touch to her clothes or body) is the single greatest cause of injury to women. As many as 35 percent of women who visit emergency departments are battered, and studies in these settings reveal a lifetime prevalence of 11 to 54 percent, depending on the definition of abuse and the reporting method used.
One-third to one-half of women presenting to mental health centers have been battered. Up to one in five women are battered during pregnancy, and this may become more frequent in the postpartum period. Two surveys in family practice settings revealed current abuse in 25 percent to 48 percent of women, with a lifetime prevalence of percent. Annually, an estimated 10 million children witness wife battering.
Eight to 39 percent of battered women report receiving medical care and 10 percent require hospital treatment. Most women, however, present for routine not emergency medical care, and most injuries do not require hospitalization. Abused women have an increased rate of surgical procedures, pelvic pain, functional gastrointestinal problems, chronic headaches, and chronic pain problems in general. Women who experience serious assault average almost double the number of days in bed due to illness compared with other women. Fear of abuse has also limited partner notification of HIV status.
Abused women are twice as likely to delay seeking prenatal care, twice as likely to miscarry, and four times as likely to have a low birth weight infant. In addition, these infants are 40 percent more likely to die during the first year of life. After battery, victims have demonstrated a nine-fold increased risk for drug abuse, and the use of alcohol increased 16-fold. There is concurrent use of alcohol and drugs during 25 percent to 80 percent of the battering episodes, and the presence of one should precipitate questions about the other.
Batterers exercise control by using male privilege threats and coercion, intimidation, minimizing denying and blaming, isolating and emotional abusing the victim, using the children, and Controlling financial resources. These are enforced and reinforced by the threat or actuality of physical and sexual violence.
Survivors of chronic trauma universally experience depression, insomnia, nightmares, and psychosomatic complaints. The diagnoses of borderline personality disorder and substance abuse are particularly common among abused women, although in a family practice center study, depression was the strongest indicator of domestic violence. It is often these symptoms that are presented to clinicians. Judith Herman has proposed the diagnostic category of complex posttraumatic stress disorder to apply to this constellation of symptoms. The associated depression may be so severe that up to one in six victims of abuse attempts suicide and up to 50 percent of suicide attempts among African American women are associated with domestic violence.
Recognition of partner control is key to the avoidance of establishing a relationship in which abuse persists. Once domestic violence is established, trying to break the cycle of violence through victim education and the availability of community resources is likely to prevent further injury.
It is important for clinicians to remain non-judgmental and relaxed because abused women are extremely sensitive to nonverbal cues. The goal of history taking is not only to establish the presence of abuse but to assess the woman’s immediate danger. Clinicians may inadvertently cause additional emotional trauma by blaming her, diagnosing anxiety, depression, or substance abuse without realizing that these are a result of ongoing abuse. This oversight may result in both a delay in appropriate intervention or, if psychoactive drugs are given, increased risk of suicide. The quality of medical care that a battered woman receives often determines if she will follow through with referrals to legal, social service, and health care agencies.
The battering injuries are often bilateral and only in areas covered by clothing. There may be contusions, lacerations, abrasions, pain without obvious tissue injury, evidence of injuries of different ages, and evidence of rape.
The battered woman needs to develop a safe plan so she can escape quickly. It may save her life. A safe plan consists not only of consideration of where to flee but includes such things as a set of clothes packed for her and her children; an extra set of keys to home and car; evidence documenting the abuse, such as names and addresses of witnesses, pictures of injuries, and medical reports; cash, checkbook, and other valuables; legal documents such as birth certificates, social security cards, driver’s license, insurance policies, protection orders, prescriptions; something meaningful for each child (blanket, toy, book); and a list of important telephone numbers and places to stay. If the children are old enough, she should talk to them about safety-how to call for help and where to go to keep themselves safe.
Once recognized, the abuse also needs to be documented by the clinician. The abused woman needs to know that her records are confidential unless she decides to use them. The clinician’s documentation provides the history and evidence of abuse. Notes should be nonjudgmental, precise, and document the chronology. The chief complaint and a description of abusive events should be recorded in the patient’s own words. A complete description should be included of any injuries with body diagrams, describing the type, number, size, location, age of the injuries, and the explanation offered of any injuries. Photographs should be taken before medical treatment if possible and should include a reference object and the face of the woman in at least one. All photographs should be dated and kept with the consent form. The medical record should also include the results of diagnostic procedures, referrals, recommended follow-up, and a record of any contact with the abuser. Recording the badge number of the investigating officer, if the police are notified, is important.
If the victim says she is in immediate danger, the clinician should believe her and begin to explore safer options. Isolation, power imbalance and alternating abusive and kind behaviors predispose victims to the formation of strong emotional attachments to their abusers, explaining why battered women struggle to separate themselves emotionally from their abusers and Often return after leaving.
Regular follow-up for continued assessment of risk, documentation, and expanding options must be established. The battered woman may take civil actions, which include filing a protective order, injunction, or restraining order, or file criminal charges including prosecution for assault and battery, aggravated assault or battery, harassment, intimidation, or attempted murder. However, the legal response to domestic violence is less than optimal and the woman is likely to know whether the batterer will adhere to court orders.
Continued support, validation, risk assessment, and documentation comprise the clinician’s “treatment” of domestic violence. Scheduled follow-uP visits provide the victim with opportunities to acknowledge the validity of her experiences, the difficulties in her situation, and the chance to reassess her options. Clinicians need to review factors associated with increasing risk of violence, review and expand options, and focus on the process of empowerment rather than the outcome of leaving.
Recognizing The Cycle Of Violence
The cycle of violence, described by Walker, consists of violence followed by a honeymoon phase of perpetrator remorseand apology, then a tension-building phase during which the victim is controlled, isolated, and systematically stripped of resources. Tension culminates in the violent phase and the cycle repeats with increasing frequency and severity. In any captive setting, the methods of establishing control of another person are based on systematic repetitive psychological trauma. This includes terror, isolation, enforced dependency, and, most elaborately in domestic violence, intermittent reward. Victims disassociate, suppress thoughts, minimize, and deny to tolerate their reality. Ongoing ego battering erodes the victim’s self-image. She comes to believe that she is somehow to blame for the violence she suffers and that she is worthless, helpless, and incapable of survival without her abuser.
Separation from an abusive partner is an on going process. The abuser responds predictably when his partner leaves by first trying to locate her, apologizing, then threatening, then promising religion or counseling, and often embarrassing her in public or harassing her. If she does not comply, she is at risk for significant injury. Women are at the greatest risk of being brutally beaten or killed when they leave their abuser. Seventy-five percent of the calls to the police and 73 percent of the emergency room visits occur after separation.
Women report going through stages of “reclaiming self” as they separate from their abusive partners. They progress from initial denial, shame, humiliation, shock, and fear, through guilt, through staying in the relationship trying to minimize the abuse and hoping for improvement, to realization of the unavoidable abuse and the need to separate both emotionally and physically, to eventually establishing a safe and separate living situation and finally a new sense of themselves and their abuse history.
Effect On Children
The influence of domestic violence on children must also be considered. Parents often claim the children are unaware of the violence, but 40 to 80 percent of children have witnessed the violence and many others will hear the assault from another room or witness the results. Thirty to 40 percent of children are physically injured themselves. Many consider spousal abuse to be, in and of itself, child abuse. Conversely, in 45 to 60 percent of child abuse cases, there is concurrent domestic violence.
Treatment of domestic violence requires working in partnership with community agencies. Many communities and states operate toll-free 24-h domestic violence hotlines. Other resources include the Domestic Violence Hotline (1-800-799-SAFE).
Elder abuse encompasses the following: physical abuse including sexual abuse, is any act resulting in pain, injury, or disease; neglect can be either physical (such as the withholding of medical care) or psychological (such as forced isolation); psychological abuse includes acts that result in emotional distress such as harassment or intimidation; financial exploitation is the unauthorized use of funds, property, or resources; and the violation of rights is the failure to allow competent elders to make their own decisions or the denial of freedom of speech, personal property, and privacy.
Estimates of the prevalence of elder abuse range from 1 to 5 percent of elderly women, depending on the definition and method of detection. Similar to other forms of violence, underreporting makes it difficult to determine the extent of the problem.n One study estimated that only 1 in 14 elder mistreatment cases is reported to a public agency. Abuse of the elderly takes place in both the community and institutional settings. There are no reliable national data on the prevalence of abuse in institutional settings.
Elder abuse was originally described as “granny bashing.” Most of the victims of elder abuse are women; however, it can occur across genders, socioeconomic, racial, or ethnic groups. This reflects the fact that women make up the majority of the elderly, especially institutionalized elderly and also that women across all ages are more likely to be victims of abuse. The institutionalized elderly are often dependent or demented, resulting in a loss of agency-acting for oneself-and allowing people to be more easily objectified. The majority of caretakers of the elderly are also women. Feminists note that the societal assumption that females are naturally nurturing makes this abuse perhaps even more invisible.
Nearly 50 percent of incidents of elder abuse lead to physically apparent trauma. There is not only the societal costs of medical care, institutional care law enforcement, and adult protective services but there is the emotional pain and sometimes the perpetuation of intergenerational violence.
Elder abuse is rarely reported by either the victim or abuser; therefore, the key to the recognition of elder abuse is awareness and a high index of suspicion. Elder abuse may be missed because of lack of clinician recognition of the signs of abuse in the elderly, ageism such that the problems of the elderly are thought of as inevitable and unmanageable, irregular medical visits, or the patient’s inability to communicate. There may also be denial by the clinician, victim, or caretaker. As in domestic violence, clinicians may avoid the time-consuming nature of such an investigation, feeling that they have inadequate training, or because they are frustrated, feeling they cannot effect a resolution. It is important to ask patients directly about their living situation and relationships with others in the home and specifically about physical violence and neglect.
Primary prevention involves the social policies and cultural mores that prevent sexism and ageism. Secondary prevention such as identification of risk factors among the elderly and their caretakers may allow a clinician to intervene before abuse transpires. The most significant risk factor is a prior history of abuse. As the stress of the caregiver and the dependency of the elderly person rises, the risk of abuse increases. Tertiary prevention consists of the recognition and treatment of abuse to prevent ongoing trauma.
Up to one-third of victims specifically deny abuse. Victims may be unable or fearful about reporting abuse. They may excuse their caretakers, blame themselves, or be fearful of abandonment. The clinician should be alert to similar features as found in domestic violence-a story that does not fit the injury, delay in seeking treatment, evasiveness exhibited by either the patient or caretaker, lack of concern by the caretaker, the patient who looks to the caretaker before answering questions, or the caretaker who answers for the patient and will not leave the patient alone.
The clinician should interview the patient without the caretaker present and attempt to get a picture of the patient’s life. As much as possible, direct quotes should be used to document this history. As in the case of domestic violence, it is helpful to ask about relationships in general and any conflicts in particular. An inquiry into financial relationships may also be revealing. A history of abuse needs to include a description of the home environment; a detailed history of any trauma from both the victim and caretaker; inquiry into prior injuries, threats, emotional abuse; and any current or past denial or delay of food, shelter, clothing, or necessary services. Specific questions are found, but no studies have reported the specificity or sensitivity of these or other questions to reveal elder abuse. A positive response to any of these questions should be followed up to determine the specific details of incidents, including the perpetrator and outcome.
In the setting of acute trauma, the physical examination will obviously focus on any overt trauma such as fractures, hematomas, burns, welts, and lacerations; more subtle signs of abuse are listed. Presentation late in the stages of disease or repeated presentations for injury should also arouse a clinician’s suspicion. Somatic complaints, depression, withdrawal, agitation, or mental status changes may also indicate abuse. Part of the examination should also be the determination of competency.
Laboratory Testing and Procedures
Laboratory testing is directed by the history or physical examination. Simple tests including a complete blood count, electrolytes, albumin, renal function tests, and a urinalysis can document such things as dehydration or malnutrition. Serum levels of drugs may reveal either under or overdosing of medication. X-rays to reveal old and new fractures may be indicated.
The first concern is always safety, and any person at immediate risk should be removed from the setting if agreeable. Adult protective services may need to be contacted to accomplish this if the person is incompetent or institutionalized.
As in the care of victims of domestic violence, documentation is critical. This must be comprehensive including findings, interpretations, investigations, recommendations, and follow-up. Photographs may be used as documentation, although informed consent with an impaired adult may be problematic.
If the victim is able to make a decision, options must be discussed with her. However, regardless of her desires, mandatory reporting of suspected abuse may be required. Health care providers risk being found negligent for not reporting suspected elder abuse. The difficulty surrounding mandatory reporting is the same as for domestic violence. Clinicians are caught between respecting the confidentiality and agency of a competent adult and the dictates of the law when victims may elect to stay in an abusive setting. Also, there is wide variation in the state protective services, age of client eligibility, types and definitions of abuse, and reporting requirements. Adult protective services or the state ombudsperson will provide clinicians with specific state and county information.
If the patient is a resident in a long-term care facility or if the patient is not competent, reporting to adult protective services is necessary. There are also in most states, long-term care ombuds-person programs that can be contacted for institutionalized adults. Adult protective service organizations exist in every state to protect the rights of vulnerable adults. If the patient is competent, she must decide whether or not to accept voluntary agency help or file charges. The clinician must provide ongoing support in either case. If she is willing to explore the use of other services, such agencies often will provide financial management, homemaker services, and drug or alcohol rehabilitation.
The clinician’s role is to provide ongoing support at regularly scheduled visits, document incidents, educate the patient about the ongoing nature and tendency for increasing severity of abuse over time, and expand her options. Ongoing assessment should include safety, access to medical care and other services, competency, emotional status, health and functional status, and social and financial resources.
As in the care of victims of domestic violence, a safe plan should be developed. The patient should receive information about the multiple community agencies and resources from social service workers to adult protective services or senior advocacy groups that are available to her.
Information about support services may also be made available to the caretaker although that must be balanced with keeping patient information confidential. It has been estimated that 20 percent of the chronically ill community-living elderly in the United States require at least minimal assistance with activities of daily living (ADL). Family caregivers provide three times as much elder care as do all nursing homes, hospitals, and other institutions combined; 72 percent of all days of care are provided by families. In addition, 80 percent of caregivers provide this care every day of the week.
Sexual harassment is a form of sexual discrimi. nation forbidden by Title VII of the Civil Rights Act, 1964. The Equal Employment Opportunity Commission (EEOC) in 1980 issued specific guidelines on sexual harassment as follows:
Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment, (2) submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual, or (3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment,
The initial two parts of the definition are often referred to as quid pro quo harassment. Although the definition is clear and more easily identified by all parties, the hostile work environment is based on assessment by the victim, the severity and frequency of the behavior, and how it interferes with work performance.
Since the establishment of the EEOC guidelines, the following clarifications have emerged: (1) the victim as well as the harasser may be a woman or a man and the victim does not have to be of the opposite sex (1998 Supreme Court decision); (2) the harasser can be the victim’s supervisor, an agent of the employer, a supervisor in another area, a co-worker, or a nonemployee; (3) the victim does not have to be the person harassed but could be anyone affected by the offensive conduct; (4) unlawful sexual harassment may occur without economic injury to or discharge of the victim; (5) the harasser’s conduct must be unwelcome.
Stalking is a form of sexual harassment that is considered a type of sexual assault. Stalking is defined as a constellation of unwanted behaviors inflicted by one person (usually male) on another (usually female). Common behaviors include surveillance, multiple forms of communication, and specified or implied threats to the victim herself, her important others, or her property.
The prevalence of sexual harassment varies greatly based on the method of assessment and definition used. Surveys of sexual harassment reveal higher prevalence rates than formal reports. Surveys of female college students report a prevalence of 30 percent and for working women up to 70 percent The prevalence of sexual harassment of women during medical training varies from 7 to 60 percent, depending on the definition used in the study (e.g., sexual favors to sexual slurs). In the first comprehensive survey of federal employees in 1980, the U.S. Merit Systems Protection Board Survey of over 10,000 women revealed that 62 percent reported sexual harassment (such as sexual touching) and 20 percent reported actual or attempted rape. Forty-two percent had experienced sexual harassment within the past 2 years. A repeat survey in 1987 found similar results. MacKinnon estimates that 85 percent of women will experience sexual harassment at some time in their working lives.
Common responses to sexual harassment are a decrease in self-confidence and self-esteem, a sense of not being able to control one’s own environment, anger, and stress symptoms (such as anxiety, depression, fear, helplessness), Somatic symptoms most commonly include nausea, headaches, and chronic fatigue. In an investigation of the type of harassment and its effect on either negative feelings about work or psychological symptoms, researchers found that harassment from superiors, quid pro quo harassment, work groups dominated by men, and increasing duration of harassment caused more psychological trauma. Students experiencing harassment report trouble learning, become fearful and isolated, experience a loss of self-esteem, and more often drop out of school.
The most common symptoms experienced by stalking victims are nightmares, appetite disturbances, anxiety, and depressed mood. In a study of 100 stalking victims, Pathe and Mullen found that flashbacks were reported by 55 women, 24 admitted to suicidal ruminations, and 37 fulfilled the criteria for posttraumatic stress disorder.
Organizations experience lower productivity, lower employee moral, increased employee turnover, and diminished performance because of sexual harassment. The EEOC records indicate that charges of sexual harassment were filed in 1998. Of these, 87 percent were filed by women. Although only 20.9 percent required settlement (excluding litigation), this cost 43.3 million dollars.
Gender bias is differential treatment based on gender; it can be positive or negative. If negative, it is referred to as gender discrimination. Gender discrimination is a continuum of behavior that ranges from sexual remarks, jokes, teasing, questions; suggestive looks, gestures, and favoritism to pressure for dates, deliberate touching, leaning over, caressing, pressure for sexual favors, sexual letters, phone calls, written materials and pictures, and actual or attempted sexual assault. Some forms of gender discrimination, although objectionable, are not illegal. The more subtle forms of gender discrimination, referred to as microinequities, are not illegal. Examples of these include language that minimizes women, negative perceptions of women’s abilities, treating women as invisible, or the exclusion of women from informal networks.
There are gender differences in the perception of sexual harassment. Women note a high incidence, identify with the victim, and recognize effects. Men tend to identify with the perpetrator and the intent and more often blame the victim. Men in the work environment are more likely to report finding overtures from women flattering; women find overtures from men insulting. In general, a hostile work environment is less about sexual exploitation and more about exclusion and harassing behavior that undermines an individual’s competence. Behaviors such as these are only now being interpreted as harassment, because they function to exclude women from certain tasks or positions in the workplace.
Sexual harassment is rarely reported. Of those experiencing sexual harassment in one study, 11 percent reported to a higher authority and 2.5 percent initiated a formal complaint. The barriers to reporting are both operational and social. One-third of the federal employees who filed formal complaints reported that it made things worse. Often women just want the behavior to stop without further investigation or retribution.
Organizations need to establish educational programs and policies to deal with sexual harassment. The educational programs must clearly outline definitions of sexual harassment an review the organization’s policy. Policies need to establish mechanisms for both formal and informal reporting. The purpose of all informal report is often to solve the problem rather than establish the harasser’s guilt or innocence. It is confidential, future-focused, and resolved when the victim is satisfied. Adherence to any recommendations is voluntary.
The purpose of a formal report is to establish the guilt or innocence of an accused harasser. It is focused on past behavior, and resolution is usually mandated by an appointed board and carries binding consequences. In a formal report, a standard written format is proscribed and confidentiality may not be maintained. A grievance committee screens and reviews complaints, usually within 60 to 90 days. The individual may be referred for mediation or to a disciplinary committee. If an appeal is made, this usually requires notice and a hearing. A complaint to the EEOC may be made in the setting of either a formal or informal report.
Victims predictably go through stages of coping with harassment. Initially they question the offender’s true intention. Next they blame themselves for the offender’s behavior. Afterward they identify the behavior as abnormal and worry about whether they will be believed by others and whether there will be retaliation if they formally protest the behavior.
Individuals first need to identify a behavior as sexual harassment. Women often ignore the behavior, hoping it will go away. It is important not to blame oneself or delay documentation. The victim should keep a record (diary) of incident(s). This should be factual and include the behavior, the effect on the victim, what was done to end the harassment, and any reports made. The victim should keep any evidence such as notes, talk with trusted co-worker(s), and get information from the institution on their policy. The individual may contact the appropriate individual or office in the work environment or use outside resources such as a lawyer, the EEOC, or organizations such as the National Organization for Women.
The victim may decide to contact the harasser. It is always helpful to speak up at the time of the harassment but that may not be possible. Contact may also be made through a third party or by letter. If a letter is used it is important to include facts, dates and description of incidents, effect, and future desired behaviors. It is necessary to keep a copy of the letter and make sure the harasser receives itY The victim needs to be prepared for adverse consequences of reporting, such as denial and accusations of exaggeration or outright fabrication, being treated as a “whistle blower,” and having co-workers refuse to collaborate and blaming the victim.
Working With Survivors
Understanding Posttraumatic Stress Sequelae
Traumatic events such as sexual assault, domestic violence, elder abuse, or sexual harassment produce long-lasting changes in physiologic arousal, emotion, cognition, and memory. Initially victims of abuse are ovelWhelmed by symptoms of hyperarousal such as irritability, exaggerated startle, and sleep disorder. These will fade as safety is established. Intrusive symptoms including flashbacks during waking states and nightmares while sleeping then dominate. Eventual integration of these memories requires naming the event, verbalizing and connecting images, and finally linking these with emotion and feeling. As intrusive symptoms diminish, constrictive symptoms become evident. Constrictive symptoms not only include an “inability to feel” but an inability to actively plan and establish initiative. Clinicians can use a number of pharmacologic and nonpharmacologic aids, at different stages, to help the survivor. These are summarized.
Stages of Recovery
The stages of recovery from psychological trauma are (1) establishing safety, (2) reconstructin the trauma story, and (3) restoring a connection between survivors and their community. The initial stage of establishing safety is critical, especially in the case of domestic violence; an example being the establishment of a safe plan. However, equally important is the therapeutic alliance between the clinician and survivor to control self-destructive behaviors such as eating disorders, substance abuse, or suicidal risk. Reconstructing the trauma story involves the wit nessing by the clinician as the patient struggles to construct meaning from disorganized painful memories. Feelings of shame and doubt emerge; guilt is especially intense if the victim feels she has been complicit, and emotional control and the regulation of intimacy are fractured. The final stage of restoring connection is best established with the collective empowerment present in therapeutic groups. Initially structured, didactic, flexible groups focus on present self-care of survivors. In the second stage of recovery, homogeneous, closed, goal-directed, cohesive groups focus on remembering, mourning, and transforming traumatic memories so that they can be integrated into the survivor’s life. Finally, future oriented heterogeneous unstructured groups aid in the survivor’s full integration.
The Primary Care Clinician s Role
It is the role of the clinician to bear witness to a crime, support truth telling, and confront denial.Because the core experiences of psychological trauma are disempowerment and disconnection, recovery is based on empowerment and reconnection. Each survivor is the author of her own recovery. The clinician cannot direct this Process but must support autonomy, acting as the survivor assistant. Clinicians may be emotionally overwhelmed and want to either professionally distance or attempt to rescue the survivor. Clinicians may also experience a heightened sense of vulnerability, grief, rage, and doubt. In addition, feelings about personal experiences may be rekindled. Up to 38 percent of clinicians report a history of personal or family violence. Clinicians also need a support system and should be encouraged to consider co-management with a colleague or consultant.
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