Exclusives, Trauma

Caring for Survivors of Interpersonal Violence in Prehospital Environments

It’s believed that over half of women (51%) and one out of every eight men will experience at least one attempted or completed sexual assault in their lifetime. One out of every four women and 8% of men will experience intimate partner violence in their lifetime. Fifty to 80% of these survivors will know their attacker. Sexual assault isn’t a crime of dark alleys and masked strangers, but one that’s underrepresented in the public conscience and routinely minimized by the layperson and healthcare providers alike.1,2,3

Statistics show a system skewed towards perpetrators; for every 100 assaults that are reported, seven will result in a prison sentence. This is also a crime that’s heavily underreported; only 34% of sexual assaults are reported, making it the most underreported violent crime.

Experiencing sexual assault increases the risk of developing post-traumatic stress disorder (PTSD), anxiety disorders, depression, alcohol and drug dependencies, repeated assaults and sexual victimization, and psychosomatic pain syndromes. Research shows that the experience that survivors have with their first disclosure of the attack can dictate the general course for future encounters, as well as predict the likelihood and severity of PTSD, depression, and other physical and mental sequelae of assaults.

Sexual Assault

The terms “rape,” “sexual assault” and “sexual violence” are often used interchangeably, and it’s important to distinguish between them to improve your understanding of the crime at hand. Rape is a criminal definition that was first established in 1927, and while the U.S. attorney general approved a new, broader definition in 2012, it still doesn’t encompass the most comprehensive swath of sexual and coercive violence against both men and women.

For this article, we will be referring to the survivor with female pronouns (i.e., she, her, hers) and the perpetrator with male pronouns (i.e., he, him, his). It’s widely accepted that this gender binary does exclude a great number of sexually violent crimes with different profiles, but for the sake of a timely presentation of the material, we will work in traditional gender binary while solemnly acknowledging the great number of crimes that occur outside of these confines.

It’s widely acknowledged that survivors who interact in the acute setting with EMS or law enforcement tend to have experienced more physical violence in conjunction with sexual assault. These survivors are also more likely to have experienced sexual assault at the hands of someone they didn’t know well or at all (i.e., a stranger or acquaintance as opposed to a spouse or intimate partner).5

Despite this overall increase in physical violence, it’s also true that survivors frequently don’t display the “expected” emotional reactions. Although not always, this can set the stage for negative disclosure reactions, and thus increased rates of PTSD, depression and other sequelae. It’s an important reminder for prehospital personnel that acute stress reactions don’t have a template; survivors can be tearful, hysterical, calm, aggressive or anything in between.

Domestic Violence

Domestic violence, more recently called “intimate partner violence” or “interpersonal violence” (IPV) (as adopted by the Centers for Disease Control in 1999), encompasses a wide variety of crimes, including financial abuse, verbal abuse, emotional abuse, physical and sexual abuse. These can occur simultaneously, longitudinally or in any combination.6

As with sexual assault, prehospital care is often involved in cases with more physical injury present or a requirement for acute hospitalization. IPV is also important to have a holistic awareness of and education in, since it contributes enormously to the mortality rate—particularly of females particularly—in the U.S. Fifty percent of female homicide victims in the U.S. were related to IPV in one study, and up to 79% of female homicide victims were abused before their death in another study.7

In the case of physical injuries, bruising was often cited as the most common form of injury sustained, followed by lacerations or abrasions, and being pushed down.8 The most common form of aggression was slapping or punching, although male perpetrators were slightly more likely to resort to acts of severe violence (e.g., punching, choking or kicking). Although this is true, it’s also the case that prehospital care providers often see the more extreme ends of the spectrum, and are highly skilled at managing complications from interpersonal violence, such as head injury, which can also occur by mechanisms outside of domestic violence. What follows, therefore, is a brief overview of non-fatal strangulation as a component of injury for IPV that’s far more subtle and has a high mortality rate associated with it.

A perpetrator who strangles a victim as part of an incident of IPV is 800% more likely to kill that victim later.9 In strangulation, loss of consciousness only takes approximately 6.8 seconds. Death can occur in as little as two minutes.

Outward presenting signs and symptoms of strangulation can be very subtle or even nonexistent in the acute setting. Bruising and swelling of the throat can take up to 48 hours to appear, and outside of well-lit clinical environments, subtle petechiae and subconjunctival hemorrhage can be difficult to spot. Similarly, subtle voice changes or trouble swallowing may be masked by loud environments or adrenaline reactions, further confounding the severity of the patient’s condition.

Table 1 includes some questions that can help determine the violence or severity of the attack and also guide patient care. Non-fatal strangulation should always be taken with the greatest gravity, and these patients should particularly be encouraged to go to the hospital for complete evaluation.

Figure 1: Subconjunctival hemorrhage in non-fatal strangulation
Figure courtesy Gina D’Aquilla

Figure 2: Subconjunctival hemorrhage in non-fatal strangulation

Figure courtesy Gina D’Aquilla

Figure 3: Mucosal membrane petechiae in non-fatal strangulation

Figure courtesy Gina D’Aquilla

Figure 4: Post-auricular petechiae in non-fatal strangulation

Figure courtesy Gina D’Aquilla

Disclosure & Long-Term Sequelae

Up to 92% of survivors disclose the occurrence of an attack to at least one person over a variable period of time. It’s more common to disclose to medical professionals and/or law enforcement if there’s a higher level of violence as part of the assault or if the perpetrator is a stranger.10

Response to disclosure can be very important to the survivor, but it also holds larger implications for the survivor’s experience. Several studies have found that the initial reaction displayed by the primary recipient of disclosure can often set the tone for many subsequent interactions. One study found that survivors who experienced the most violent, stranger-perpetrated attacks often experienced the most negative reactions from mental health providers.3

There are generally two types of reaction to disclosure: positive and negative. These are explained in Table 2.

Controlling or infantilizing reactions were perceived as negative by 68% of survivors, and minimizing or blaming reactions were perceived as negative and not helpful by 100% of survivors.11

Some examples of positive reactions can be: telling the survivor directly that you believe them and their story, offering tangible support (i.e., emergency shelter or medical care), giving the survivor concrete resources and comfort, and distributing decision-making ability to the survivor.

Negative reactions can be patronizing the survivor, minimizing their experience, or implying that their reactions are out of context for the perceived severity of the insult.

The universal experience that survivors have after the incident and disclosure has been found to be very important to the survivor’s overall health, including the development of PTSD and the severity of the symptoms.

A 2014 study found that the lack of social support had a strong correlation with the development and severity of PTSD. Negative reactions to disclosure increased the chances of being placed on the severe end of the continuum for PTSD and remaining there for a longer period. The only protective factor against the development of PTSD was the presence of perceived control over one’s recovery.11

Evidence Collection

Sexual assault and IPV are unique crimes in the sense that their victims are generally living, breathing and walking crime scenes. Unlike other crimes where the crime scene remains static, the great bulk of evidence in sexual assault is collected off of the victim.

Without compromising patient care, it’s helpful for prehospital personnel to do what they can to preserve evidence for collection. This is nothing more than an awareness of how evidence collection proceeds and empowerment to take steps to ensure the protection of evidence wherever possible. (See Table 3.)

The largest change in evidence collection in the last 20 years has been the sensitivity of testing; it’s truly remarkable how little sample is required today to produce an adequate DNA match. Touch DNA has also become exquisitely sensitive, requiring a brief contact between the perpetrator and any part of the victim, including clothing items, to be able to isolate DNA, which can then be corroborated with the victim’s story.

For example, there was an attempted kidnapping case involving a young girl who was nearly pulled from her backyard by a neighborhood acquaintance. She was able to describe that he had grabbed her arm, and when swabs were obtained, his DNA was able to be matched, thus producing a conviction.13

Conclusion

Empowerment is the process of feeling galvanized or otherwise inspired and confident to complete an action or a task—and empowerment comes from education. Despite the presence of data that suggests the prevalence of sexual violence in our society and the lack of adequate follow up and resources, the U.S. continues to struggle with addressing these problems within our healthcare system.

The largest key to changing this trajectory is education. The more that we as healthcare providers are aware of the prevalence of these crimes and confident in our abilities to address them, the better we can serve survivors and potentially change their course through recovery, which benefits not only the survivor, but also the healthcare system as a whole.

Clinical “pearls” and practice reminders for survivors of sexual violence (PEA-TEBS)

1. Privacy: survivors often feel conspicuous and ashamed; allowing them privacy while waiting treatment can be enormously valuable.

2. Empowerment: of both yourself as the provider and the survivor! Empower yourself to care for the survivor in a holistic and empathetic way; empower the survivor to make choices that feel good and right for him/her.

3. Awareness: of these crimes and the fact that they may not present as the chief complaint. Be alert and responsive when dealing with all patients.

4. Time: allowing the survivor the time and space to process and make decisions without feeling rushed or forced.

5. Education: of survivor, staff and other providers.

6. Belief: the percentage of those who lie about these crimes is miniscule.

7. Support: both tangible and intangible. Support the survivor and find support for yourself. Never forget that these crimes may affect you in ways you do not expect, so it is important to care for yourself as a provider just as much as we care for others.

References

1. Luce H, Schrager S, Gilchrist V. Sexual assault of women. Am Fam Physician. 2010 Feb 15;81(4):489-495.

2. Deliramich AN, Gray MJ. Changes in women’s sexual behavior following sexual assault. Behav Modif. 2008;32(5):611–621.

3. Starzynski LL, Ullman SE. Correlates of perceived helpfulness of mental health professionals following disclosure of sexual assault. Violence Against Women. 2014;20(1):74–94.

4. Attorney general Eric Holder announces revisions to the uniform crime report’s definition of rape [news release]. Washington, D.C.: Office of the Attorney General; January 6, 2012. Retrieved March 23, 2019, from www.justice.gov/opa/pr/attorney-general-eric-holder-announces-revisions-uniform-crime-report-s-definition-rape.

5. Schei B, Sidenius K, Lundvall L, et al. Adult victims of sexual assault: Acute medical response and police reporting among women consulting a center for victims of sexual assault. Acta Obstet Gynecol Scand. 2003;82(8):750–755.

6. Thawley J. Definition—domestic violence. DomesticViolence.org. Retrieved April 1, 2019, from www.domesticviolence.org/definition/.

7. Campbell J, Snow Jones A, Dienemann J, et al. Intimate partner violence and physical health consequences. Arch Intern Med. 2002;162(10):1157–1163.

8. Karystianis G, Adily A, Schofield PW, et al. Automated analysis of domestic violence police reports to explore abuse types and victim injuries: Text mining study. J Med Internet Res. 2019;21(3):e13067.

9. Mcquown C, Frey J, Steer S, et al. Prevalence of strangulation in survivors of sexual assault and domestic violence. Am J Emerg Med. 2016;34(7):1281–1285.

10. Hunter BA, Robison E, Jason LA. Characteristics of sexual assault and disclosure among women in substance abuse recovery homes. J Interpers Violence. 2012;27(13):2627–2644.

11. Peter-Hagene LC, Ullman SE. Social reactions to sexual assault disclosure and problem drinking: mediating effects of perceived control and PTSD. J Interpers Violence. 2014;29(8):1418–1437.

12. Donnelly EA, Oehme K, Melvin R. What do EMS personnel think about domestic violence? An exploration of attitudes and experiences after participation in training. J Forensic Leg Med. 2016;38:64–69.

13. Santucci KA, Hsiao AL. Advances in clinical forensic medicine. Curr Opin Pediatr. 2003;15(3):304–308.

14. Capaldi DM, Shortt JW, Kim HK, et al. Official incidents of domestic violence: Types, injury, and associations with nonofficial couple aggression. Violence Vict. 2009;24(4):502–519.

15. Gilmore AK, Flanagan JC. Acute mental health symptoms among individuals receiving a sexual assault medical forensic exam: The role of previous intimate partner violence victimization. Arch Womens Ment Health. Feb. 14, 2019. [Epub ahead of print.]

16. Sawyer S, Coles J, Williams A, et al. Paramedics as a new resource for women experiencing intimate partner violence. J Interpers Viol. April 1, 2018. [Epub ahead of print.]