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ABUSE AND NEGLECT OF CHILDREN AND THE ELDERLY

A. Overview
1. Types of child and elder (persons aged 65 and over) abuse
include physical abuse, emotional or physical neglect, and
sexual abuse. The elderly may also be exploited for
monetary gain.
2. Abuse-related injuries must be differentiated from injuries
obtained during normal activity. Examples of accidental
(i.e., non-abuse) injuries in children include bruises and
scrapes on bony prominences (e.g., chin, forehead, knees,
elbows) or, in the elderly, bruising on extensor surfaces of
the limbs.
3. Occurrence of abuse and characteristics and signs that
indicate neglect and abuse are shown in Table 20-1.
B. Sequelae of child abuse
1. Children who are being abused often seem sad, show
behavioral changes (e.g., are no longer outgoing and
friendly), and do poorly in school.
2. Adults who were abused as children are more likely to

A. have dissociative disorders (e.g., dissociative identity


disorder) and borderline personality disorder (see
Chapter 14)
B. have posttraumatic stress disorder and other anxiety
disorders (see Chapter 13)
C. have depression and substance abuse disorders (see
Chapter 12 and Chapter 9, respectively)
D. abuse their own children
C. Sexual abuse of children:
1. Signs
A. Sexually transmitted diseases (STDs) in children are signs of
sexual abuse; children do not contract STDs through casual
contact with an infected person or with their bedclothes,
towels, or toilet seats.
B. Genital or anal trauma also are signs of sexual abuse.
C. Young children have only a vague knowledge about sexual
activities; specific knowledge about sexual acts (e.g., fellatio)
in a young child often indicates that the child has been
sexually abused.
D. Recurrent urinary tract infections and excessive initiation of
sexual activity with friends or with younger children, also are
signs of sexual abuse.
2. Occurrence

A. An estimated 500,000 American children are sexually


abused per year.

B. Most sexually abused children are 8 to 13 years of age,


and 25% are younger than 8 years old.

C. Approximately 20% of women and 5% to 10% of men


report sexual abuse at some time during their childhood
and adolescence.
3. Characteristics of the sexual abuser
A. Seventy percent to ninety percent of sexual abusers are
known to the child and 90% of these are men. About 50%
of these men are relatives (e.g., uncle, father, stepfather),
and 50% are family acquaintances (e.g., mother's
boyfriend, neighbor).
B. Alcohol and drugs are commonly used by the abuser.
C. The abuser typically has marital problems and no
appropriate alternate sexual partner; occasionally, he is a
pedophile (i.e., he prefers children to appropriate sexual
partners) (see Chapter 19).
PHYSICAL AND SEXUAL ABUSE OF DOMESTIC PARTNERS

A. Occurrence
1. Domestic abuse is a common reason women come to a
hospital emergency room. The abuse may be physical or
sexual and the abuser is almost always male.

2. The abused woman may not report to the police or leave


the abuser because she has nowhere to go and because he
has threatened to kill her if she reports or leaves him. (In
fact, she does have a greatly increased risk of being killed
by her abusive partner if she leaves.)
B. Evidence of domestic abuse
1. The victim commonly has bruises (e.g., blackened eyes)
and broken bones.
2. In pregnant women (who have a higher risk of being
abused), the injuries are often in the "baby zone" (i.e., the
breasts and abdomen).
3. An irrational explanation of how the injury occurred, delay
in seeking treatment, and appearance of sadness in the
victim are other indications of domestic abuse.
C. The cycle of abuse includes three phases
1. Buildup of tension in the abuser
2. Abusive behavior (battering)

3. Apologetic and loving behavior by the abuser toward


the victim
D. Characteristics of abusers and abused partners

1. Abusers often use alcohol or drugs, are impulsive, have


a low tolerance for frustration, and displace their angry
feelings onto their partner.

2. The abused partner is often emotionally or financially


dependent on the abuser, pregnant, and blames herself
for the abuse.

3. Both the abuser and the abused commonly have low


self-esteem.
The role of the physician in suspected child, elder,
and domestic partner abuse:
A. Child and elder abuse
1. According to the law in every state, physicians must
report suspected physical or sexual abuse of a child
or elderly person, or of an adult who appears to be
physically or mentally impaired, to the appropriate
family social service agency (e.g., state child
protective service or state adult-protective service)
before or in conjunction with treatment of the
patient.
2. The physician is not required to tell the suspected abuser of
the child or impaired elder that he or she suspects abuse.
3. The physician does not need family consent to hospitalize
the abused child or elderly person for protection or
treatment.
4. Even if there was no intention to injure, if a cultural remedy
such as "coining" (see Chapter 20) injures a child or elderly
person, such injury also must be reported to the appropriate
agency.
B. Domestic partner abuse

1. Direct reporting by the physician of domestic partner


abuse is not appropriate because the victim is usually a
competent adult between the ages of 18 and 64.

2. A physician who suspects domestic partner abuse should


A. Document the abuse.
B. Ensure the safety of the abused person.

C. Develop an emergency escape plan for the abused


person.

D. Provide emotional support to the abused person.

E. Refer the abused person to an appropriate shelter or


program.

F. Encourage the abused person to report the case to law-


enforcement officials
SEXUAL AGGRESSION: RAPE AND RELATED
CRIMES
A. Definitions.

Rape is a crime of violence, not of passion, and is known


legally as "sexual assault," or "aggravated sexual assault."
1. Rape involves sexual contact without consent.

2. Vaginal penetration by a penis, finger, or other object may


occur.
3. Erection and ejaculation do not have to occur.

4. Sodomy is defined as the insertion of the penis into the


oral or anal orifice. The victim may be male or female.
B. Legal considerations
1. Because rapists may use condoms to avoid contracting HIV
or to avoid DNA identification, or because they may have
difficulty with erection or ejaculation, semen may not be
present in the vagina of a rape victim.

2. A victim is not required to prove that she resisted the rapist


for him to be convicted. A rapist can be convicted even
though the victim asks him to use a condom or other form of
sexual protection.
3. Certain information about the victim (e.g., previous sexual activity,
"seductive" clothing worn at the time of the attack) is generally not
admissible as evidence in rape trials.

4. In almost every state, husbands can be prosecuted for raping their


wives. It is illegal to force anyone to engage in sexual activity. Even if
a woman consents to go on a date with a man and consents to sexual
activity not involving intercourse, a man can be prosecuted for rape
("date rape").

5. Consensual sex may be considered rape ("statutory rape") if the victim


is younger than 16 or 18 years old (depending on state law) or is
physically or mentally impaired.
C. Characteristics of the rapist and victim
1. The rapist
A. Rapists are usually younger than 25 years of age.
B. They are usually the same race as the victim.
C. They are usually known to the victim.
D. They often use alcohol.
2. The victim
A. Rape victims are most typically between 16–24 years
of age.
B. Rape most commonly occurs inside the victim's home.
C. Vaginal injuries may be absent, particularly in parous
women (those who have had children).
D. The sequelae of rape
1. For a variety of reasons, including shame, fear of
retaliation, and the difficulties involved in substantiating
rape charges, only 25% of all rapes are reported to the
police.
2. Others may commonly blame the victim in rape cases.

3. The length of the emotional recovery period after rape


varies, but is commonly at least 1 year. Posttraumatic
stress disorder sometimes occurs after rape (see Chapter
14).
4. The most effective type of counseling is group therapy
with other rape victims.
E. The role of the physician in rape cases
1. Immediately after the rape, the physician should

A. Take the patient's history in a supportive manner, and


not question the patient's veracity or judgment.
B. Perform a general physical examination and conduct
laboratory tests (e.g., cultures for sexually transmitted
diseases from the vagina, anus, and pharynx; test for
presence of semen).
C. Prescribe prophylactic antibiotics and postcoital
contraceptive measures (e.g., mifeprisone [RU-486]) if
appropriate.
D. Encourage the patient to notify the police. The doctor
is not required to notify the police if the woman is a
competent adult.
2. Up to 6 weeks after the rape

A. Discuss with the patient the emotional and physical


sequelae of the rape (e.g., suicidal thoughts, vaginal
bleeding) and, if needed, refer her for long-term
counseling or a support group.

B. Do a pregnancy test and repeat other laboratory tests if


appropriate.
EN
D

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