#77832: Domestic Violence: The Kentucky Requirement

Because a gynecologist or obstetrician is frequently a woman's primary care physician, these healthcare providers should be particularly sensitive to domestic violence issues [15]. According to the CDC, IPV affects as many as 324,000 pregnant women each year [16]. This represents approximately 8% of all pregnant women in the United States. As with all domestic violence statistics, this number is presumed to be lower than the actual incidence as a result of under-reporting and lack of data on women whose pregnancies ended in fetal or maternal death. This makes IPV more prevalent among pregnant women than some of the health conditions included in prenatal screenings, including pre-eclampsia and gestational diabetes [16]. Because 96% of pregnant women receive prenatal care, this is an optimal time to screen for domestic violence and develop trusting relationships with the women. Possible factors that may predispose pregnant women to IPV include young maternal age, unintended pregnancy, delayed prenatal care, lack of social support, and use of tobacco, alcohol, or illegal drugs [16,17].

The overarching problem of violence against women cannot be ignored, especially as both mother and unborn child are at risk. One study found that pregnant women who had been treated at a hospital after a violent incidence had an eight-fold increased risk of fetal death [69]. At this particularly vulnerable time in a woman's life, an organized clinical construct leading to immediate diagnosis and medical intervention will ensure that therapeutic opportunities are available to the pregnant woman and will reduce the potential negative outcomes [18,19]. Healthcare professionals should also be aware of the possible psychologic consequences of abuse during pregnancy. There is a higher risk of stress, depression, and addiction to alcohol and drugs in abused women, and victims/survivors are less likely to obtain prenatal care and to develop postpartum depression [20,69,70].

The United States is becoming increasingly diverse in terms of ethnic composition. By 2044, the U.S. will become a majority-minority nation [71]. In 2021, 13.6% of the U.S. population was foreign-born, most of whom reside in the West [72]. It is inevitable, therefore, that race, culture, and ethnicity will have a profound effect on American culture. Consequently, health professionals must become more aware of, and sensitive to, the cultural norms, belief systems, and needs of culturally diverse patients in order to provide relevant services and interventions. Results from the National Violence Against Women Survey indicate that all racial minorities in the United States experience more IPV than white Americans, with the exception of Asian Americans [22]. It has been suggested that ethnic minority groups may be more vulnerable to violence as a result of environmental risk factors such as poverty, racism, oppression, and discrimination. For example, one study suggests that nearly one-third of African American women experience IPV in their lifetimes, compared with one-fourth of white American women [22]. Another study with 1,155 Mexican American women found that 10.7% of the sample reported physical abuse by a current partner. Researchers found that those born in the United States reported a rate of violence higher than those born in Mexico [23]. In a qualitative study of 10 Mexican women who experienced IPV, immigration status (specifically the fear of deportation) was the primary reason they did not leave the relationship or seek help [73].

In the Asian American community, the mistaken notion that Asian Americans have achieved success often cloaks the issue of domestic violence. In a telephone interview with 336 Asian American women in the San Francisco and Los Angeles areas, 27% experienced emotional abuse by an intimate partner, 16% reported being pressured to have sex without their consent, and 12% reported that an intimate partner had hurt or had attempted to hurt them by means of hitting, kicking, slapping, shoving, object throwing, or threatening their lives with a weapon [24]. Research indicates that perpetrators in these cases are overwhelmingly male [74]. Although this is a small study, it does indicate that domestic abuse is an issue for some Asian Americans.

Culture, race, and ethnicity also influence help-seeking patterns. Help-seeking behavior is in part influenced by an individual's definition and understanding of abuse, which is ultimately influenced by culture. For example, an ethnic minority woman who is being abused by her husband may not seek help if she does not label the event as a problem. Instead, she may believe the abuse is something to be persevered. Financial limitations, suspiciousness or wariness of health or mental health professionals, limited English proficiency, and inconvenience in locating and traveling to agencies are also hindrances specific to these populations [25].

Children who are raised in violent homes are also in danger. These children are at high risk for abuse and for emotional damage that may affect them as they grow older. Slightly more than half of female victims/survivors of domestic violence live in a household with at least one child younger than 12 years of age, and between 3.3 million and 10 million children witness domestic violence annually [24,26]. Studies demonstrate that children who witness domestic violence are more likely to grow into a perpetrator or victim of domestic violence than a child who was himself or herself abused, thereby creating a cycle of violence. For example, in one study, adolescent witnesses of abuse were also more likely to report having perpetrated abuse (42%) compared to non-witnesses (15%) [27]. Research regarding the psychosocial outcomes of children exposed to domestic violence has found that child witnesses exhibit more aggression, anxiety, difficulties with peers, and academic problems than the average child [26,28]. An estimated 47% of children who have witnessed IPV at home are younger than 6 years of age, and these preschool-age children are more likely to show evidence of internalizing behavior problems (e.g., anxiety, depression, somatic complaints) compared to older children, who show more signs of externalizing behavior problems (e.g., bullying, aggression, misconduct) [29]. In addition to witnessing violence, these children may also become direct victims/survivors of violence, as child maltreatment occurs in 30% to 60% of families in which IPV is reported [30]. Moreover, statistics demonstrate that 85% of domestic violence victims/survivors abuse or neglect their children.

Indirect exposure to violence may also have consequences. In one study, children whose mothers were victims/survivors of IPV exhibited externalizing problems regardless of whether they directly witnessed the violence [75]. The researchers concluded that the children may sense and internalize their mothers' psychologic distress [75].

Adolescents are also victimized. Between 7% and 17.5% of all homicides against girls 12 to 17 years of age are committed by an intimate partner [31,12]. Among young women 18 to 24 years of age, the rate is 42.9%. Abused teens often do not report the abuse. Individuals 12 to 19 years of age report only 35.7% of crimes against them, compared to 54% in older age groups [32]. Accordingly, healthcare professionals who see young children and adolescents in their practice must have the tools necessary to detect these "silent victims" of domestic violence and to intervene quickly to protect young children and adolescents from further abuse.

Adverse childhood experiences (including domestic violence) contribute to lifelong negative emotional, physical, and behavioral consequences. These adverse childhood experiences appear to be dose-related, in that the more traumatic the childhood experiences, the more severe the outcomes will be in later life [76]. In addition, if the stressors endure over a long period of time (referred to as "toxic stress"), it can lead to negative changes to the brain [76].

Abused and neglected elders, who may be mistreated by their spouses, partners, children, and other relatives, are among the most isolated of all victims/survivors of family violence. Among the elderly, it is estimated that 1 in 10 individuals will experience at least one form of abuse (e.g., physical, psychologic, financial, sexual, neglect) [34]. Those 65 years of age and older are projected to number 83.7 million in the United States by 2050, almost double the number in 2012, exponentially increasing the number of individuals experiencing elder abuse [34].

Because elder abuse can occur in family homes, nursing homes, board and care facilities, and even medical facilities, healthcare professionals must remain keenly aware of the potential for abuse. When abuse occurs between elder partners, it is primarily manifested in one of two ways, either as a long-standing pattern of marital violence, or as abuse originating in old age. In the latter case, abuse may be precipitated by issues related to advanced age, including the stress that accompanies disability and changing family relationships.

It is important to understand that the domestic violence dynamic involves not only a victim but a perpetrator as well. For example, an adult son or daughter who lives in the parents' home and depends on the parents for financial support may be in a position to inflict abuse. This abuse may not always manifest itself as violence, but can lead to an environment in which the elder parent is controlled and isolated. The elder may be hesitant to seek help because the abuser's absence from the home may leave the elder without a caregiver. Because these elderly victims/survivors are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected [77]. Healthcare professionals in all settings must remain aware of the potential for abuse and keep a watchful eye on this growing and particularly vulnerable group.

Statistics confirm that domestic violence is predominantly perpetrated by men against women; however, there is evidence to suggest that women also exhibit violent behavior against their male partners [35]. Studies demonstrate that approximately 5% of murdered men are killed by intimate partners [31]. It is persuasively argued that the impact on the health of female victims/survivors of domestic violence is generally much more severe than the impact on the health of male victims/survivors [36]. However, approximately 7% of men are raped and/or physically assaulted by an intimate partner in their lifetime [3,24]. In 2008, men experienced 101,000 nonfatal violent victimizations by an intimate partner [37]. Healthcare professionals should always keep in mind that men can also be victimized and experience mental health consequences of the abuse. Because IPV is perceived as a "woman's issue," men who are victims/survivors of IPV may perceive the experience as a threat to their manhood [78].

Domestic violence exists in the gay, lesbian, bisexual, transgender, and other gender and sexual minorities (LGBT+) community, with the 2010 National Intimate Partner and Sexual Violence Survey indicating that 43.8% of lesbian women, 61.1% of bisexual women, 26% of gay men, and 37.3% of bisexual men reporting ever having experienced rape, physical violence, and/or stalking by an intimate partner [38]. The lifetime prevalence rate of psychologic abuse was 59% for gay men and 53% for bisexual men [38]. Men living with male intimate partners experience significantly more IPV than men who live with female intimate partners [4]. This supports other statistics indicating that IPV is perpetrated primarily by men. Three dominant barriers to help-seeking by LGBT+ victims/survivors have been identified: lack of understanding of the problem, stigma, and systemic inequities [80]. In general, much of the IPV literature and knowledge base has focused on heterosexual women's experiences with IPV. Furthermore, because of the stigma of being gay, victims/survivors may be reticent to report abuse and afraid that their sexual orientation will be revealed. Many in this community feel that support services are not available to them due to prejudices of the service providers. Unfortunately, this results in the victim/survivor feeling isolated and unsupported. Healthcare professionals should strive to be sensitive and supportive when working with homosexual patients.

As with domestic violence in the civilian population, military victims/survivors face a host of barriers in disclosing abuse. In addition to shame and embarrassment, fear of reprisals, feelings of isolation, and lack of available services, many military victims/survivors found when they did report abuse, military personnel were not sensitive to their needs [39]. Given these barriers to disclosure, it is difficult to assess the prevalence of domestic violence among military families. According to the U.S. Department of Defense, there were a total of 18,208 reported incidents of domestic abuse in 2009 [40]. However, it should be noted that a 2010 report released by the U.S. General Accounting Office (GAO) indicated that the U.S. Department of Defense's use of multiple registries and inclusion of only those reports made to the Family Advocacy Program (excluding cases handled by civilian law enforcement, identified by nonmilitary medical staff, and reported to commanders) make calculating the actual number of domestic violence cases impossible [40]. Reports from the Congressional Research Service indicate that among the active-duty population, there were 16,912 reported incidents of spouse and intimate partner abuse in 2018 [33]. Among these, 8,039 reports (6,372 victims/survivors) met the Department of Defense definitions. Physical abuse accounted for the highest number of reports (73.7%), followed by emotional abuse (22.6%), sexual abuse (3.6%), and neglect (0.06%) [33].

The Family Advocacy Program is responsible for seeing that victims/survivors remain safe and have access to support and advocacy services and that offenders receive appropriate intervention services [41]. The Program works to prevent domestic abuse by educating service members and families about the issue; identifying families experiencing domestic abuse; providing support services to victims/survivors of abuse; and providing treatment for abusers.

Risk factors among this group are complex and multifaceted. Brewster conducted a study of 2,991 abusers who used physical domestic violence that received treatment at the Air Force Family Advocacy Program and agreed to participate in the study. As with the general population, the physical violence sustained was more severe when the offender was male. However, previously reported domestic violence cases were higher than the base rate for the general population—one in four had been reported for spouse abuse, and one in eight offenders had been substantiated for spouse abuse [42].

Presence of a psychiatric disorder can also increase the risk of domestic violence in military families. In one systematic review, 27.5% of male veterans with PTSD disclosed to perpetrating physical violence in the last year, and 91% reported using psychologic violence against their partner [81]. Male members of the military with depression had a 3.95 increased likelihood of perpetrating physical violence against their partner compared to men without a mental disorder [81].

It has also been speculated that deployment, exposure to the trauma of combat, and the development of post-traumatic stress symptoms provokes military veterans to be violent at home [43,44]. Furthermore, when these veterans do obtain treatment, either voluntarily or as mandated, many do not complete their treatment regimens.

The intersection of homelessness and domestic and/or sexual violence is bidirectional and complex. Studies indicate up to 92% of homeless women have experienced severe physical or sexual abuse at some point in their lives, and as many as 57% of all homeless women report domestic violence as the immediate cause of their homelessness [62,63,64]. Furthermore, victims of stranger-perpetrated violence are more likely to have been homeless on multiple occasions [146].

Homeless domestic violence victims face unique barriers to accessing help, including affordable housing, as a result of actions of their perpetrator. They may face housing discrimination, lack stable employment histories, and have poor credit as a result of their abuse histories [62]. In addition, a study published by the National Online Resource Center on Violence Against Women found that homeless women are "particularly vulnerable to multiple forms of interpersonal victimization, including sexual and physical assault at the hands of strangers, acquaintances, pimps, sex traffickers, and intimate partners on the street, in shelters, or in precarious housing situations" [63]. The sexual assault experiences of homeless women are more likely to be violent and include multiple sexual acts than women with housing [65].

Because homeless victims of violence face specific barriers to seeking and receiving services, interventions and assistance should be targeted to their specific needs. Homeless young adults who are sexually assaulted, for example, are reluctant to obtain a post-assault exam in part because they fear of getting involved in the legal system [147]. It is also important to remember that additional marginalizing factors (e.g., gender/sexual minority status, geographic isolation) compound the problems experienced by survivors.

Research indicates that disability predicts recent intimate partner violence victimization in both men and women [66]. National data indicate that women with a disability are significantly more likely to report experiencing every form of intimate partner violence, including rape, other sexual violence, physical violence, stalking, psychologic aggression, and control of reproductive or sexual health [66]. Stalking and psychologic aggression by an intimate partner are more likely in men with disabilities. Women with disabilities are 3.3 times more likely to be raped [133]. Most perpetrators are acquaintances of the victim [67].

The type of disability may also be an indicator or risk. In a national sample of victims of sexual assault who were disabled, the majority (60.5%) had a psychiatric disability and 25% had an intellectual/developmental disability; the smallest percentage (15.6%) had physical/sensory disabilities [67]. People with intellectual disabilities are sexually assaulted at a rate seven times higher than those without disabilities [68]. A survey study found that individuals with autism were more likely to have experienced physical and sexual violence when they were children, and they were not likely to have disclosed the incidence(s) [148].

Although persons with disabilities are more likely to be victimized, it can be difficult for them to seek and obtain help. Legal action was taken in only 13.6% of cases [67]. Differently able individuals may be less likely to be believed when they report abuse or may be unable to effectively communicate their experiences [69]. Police and prosecutors are often reluctant to take these cases because they are difficult to win in court [68]. In addition, there is a lack of coordinated community services and supports for disabled survivors of sexual assault [67].

Behavioral health problems, including substance use disorders, eating disorders, and compulsive behaviors, commonly co-occur with intimate partner violence and sexual violence. According to the American Society of Addiction Medicine, substance abuse co-occurs in 40% to 60% of IPV incidents, with several lines of evidence suggesting that substance use/abuse plays a facilitative role in IPV by precipitating or exacerbating violence [70]. Both victims and abusers are 11 times more likely to be involved in domestic violence incidents on days of heavy substance use [71]. Opioid misuse and intimate partner violence are correlated; women who have experienced IPV and sexual violence are more likely to use opioids [149].

It is unclear if substance abuse precedes the violence, or vice versa. However, victimization is considered a positive risk factor for substance use disorders, and women in abusive relationships have often reported being coerced into using alcohol and/or drugs by their partners [70].

Women with a history of eating disorders are also at increased risk for intimate partner violence [72]. In a study of undergraduate women, recent (i.e., last three months) sexual assault was associated with more severe eating disorder symptoms [73,74]. In another study, eating disorders were significantly correlated with lifetime intimate partner violence, PTSD, and depression among female participants [150].

Perpetrators of dating violence among young adults include witnessing interparental violence, experiencing child abuse, alcohol abuse, adherence to traditional gender roles, and relationship power dynamic issues [75]. Female perpetrators are more likely than men to display internalizing symptoms (e.g., depression), trait anger and hostility, and to be victims of past dating violence; young male perpetrators are more likely than women to report lower socioeconomic status and educational attainment, antisocial personality characteristics, and increased relationship length [75].

Cyberdating abuse or violence refers to abusive behaviors perpetrated using technology that occur in the dating context. In general, the control tactics are similar regardless of whether technology is involved [151]. Forms of sexual cyber abuse include sending unwanted sexual content, pressuring someone to send nude photos, and using technology to engage in sexual encounters [151]. Technologically mediated sexual violence can predict real-life violence. In fact, sexting has been identified as a unique risk factor for dating violence in young adulthood [76].

Young women are more likely than men to experience dating violence, as is the case among most subgroups. However, nonsexual violence in dating relationships is more likely to involve the reciprocal use of violence by both partners (mutual aggression) than adult abusive relationships [77]. Additional risk factors for dating violence include low self-esteem, substance use disorder, depression, isolation, pornography use, and hooking up for sex [144].

As with most sociodemographic risk factors for domestic and sexual violence, the correlation between lower socioeconomic status and violence is potentially bidirectional. Economic abuse (considered a form of intimate partner violence) may precede more severe forms of physical and sexual violence. Women who are financially dependent on their abusers are less able to leave and more likely to return to an abusive relationship, particularly if they are financially dependent on their abusers [79,152]. Greater economic dependence is associated with more severe abuse and homicide by an intimate partner [153].

Financial instability is also a potential adverse effect of intimate partner violence. Current or past exposure to violence has been found to negatively affect ability to sustain stable employment, and women in abusive relationships frequently lose their jobs, experience high job turnover, are forced to quit, or are fired [80].

Victims of sexual violence also experience short- and long-term economic consequences, and low-income individuals are more vulnerable. Victims exceed non-victims in the average number and cost of medical care visits. Beyond medical costs, there are productivity costs and other long-term costs to victims and their families such as pain and suffering, trauma, disability, and risk of death. Sexual violence and the trauma resulting from it can have an impact on the survivor's employment in terms of time off from work, diminished performance, job loss, or being unable to work. These impacts disrupt earning power and have a long-term effect on the economic well-being of survivors [81].

A large national study found that lifetime intimate partner violence victimization rates in rural areas (26.7% in women, 15.5% in men) are similar to the prevalence found among men and women in non-rural areas [82]. There is some evidence that intimate partner homicide rates may be higher in rural areas than in urban or suburban locales [83,153].

Substance use disorders and unemployment are more common among IPV perpetrators in rural areas [83]. It has been suggested that IPV in rural areas may be more chronic and severe and may result in worse psychosocial and physical health outcomes. Poverty in rural areas is also associated with an increased risk for IPV victimization and perpetration for both men and women [84]. Residents of rural areas are less likely to support government involvement in IPV prevention and intervention than urban residents [83].

Although the rates are similar, the risk factors, effects, and needs of rural victims are unique. For example, research indicates that rural women live three times further from their nearest IPV resource than urban women. In addition, domestic violence programs serving rural communities offer fewer services for a greater geographic area than urban programs [85].

Not only do rural women experience geographic isolation, they tend to be socially isolated as well. Because rural communities tend to be tight-knit, there can be more stigma and ostracism when residents reach out for assistance [154].

It is important to assess victims' proximity to available resources and to help in times of crisis. Rural victims may benefit from improved access to services, including technology-based outreach (e.g., videoconferencing, telehealth programs) [86]. In rural areas, there may also be fewer sexual assault nurse examiners or the requirements for qualification and training may be absent or inconsistent [155].

A variety of persons migrate to the United States, including legal immigrants granted the indefinite or time-limited right to live in the United States by immigration authorities; undocumented immigrants who have not been granted such a right; and refugees who are unable or unwilling to return to their country of origin due to fears of persecution based on their race or ethnicity, religion, nationality, political opinion, or gender identity or sexual orientation. For simplicity, all three groups are referred to as immigrants [87].

Recent immigrants are at increased risk for violence victimization. In one study of Chinese immigrants in the United States, acculturation and socioeconomic status were associated with severity, frequency, length, and type of abuse [88]. Persons who are displaced due to conflict in their home countries are also vulnerable to sexual violence. Studies indicate that approximately one in five refugees or displaced women in complex humanitarian settings have experienced sexual violence, but this is likely an underestimation [89]. Refugees may also experience torture and sexual violence prior to being displaced. Among male survivors, sexual torture is substantially under-reported, and estimates indicate that 5% to 15% of male survivors were sexually abused by threats of castration or rape, being raped or forced to perform sex in view of others, or receiving electric shock or mutilation to the genitals [90,91]. Fewer women than men are tortured in aggregate, but around 50% of female torture survivors report sexual torture, typically by rape and sometimes in front of family members [92,93,94]. Studies also show that sexual violence victimization is more likely while in transit to a host country [156]. Sexual and gender minority migrants may feel they need to conceal their identities for fear of sexual harassment and possible violence [156].

Immigrants tend to underuse health services, especially undocumented immigrants, who typically lack health insurance and may avoid seeking medical attention out of fear of being deported. Immigration status and the inability to understand domestic violence within given cultural norms are major barriers to help-seeking among recent immigrants [95]. They may also face language barriers, exacerbating an inability to seek help and lack of trust in health and social services. When migrants do seek help, access to interpreters may be limited [157]. The Violence Against Women Act puts some protections in place for noncitizen women, including the ability to self-petition for citizenship (instead of requiring a citizen sponsor) and immigration relief to victims of sexual/other violence or human trafficking [96]. Access to bilingual and culturally appropriate services is also a major concern.

In the United States, intimate partner violence disproportionately affects women of color [136]. Black and multiracial non-Hispanic women have significantly higher lifetime prevalence of rape, physical violence, or stalking by an intimate partner [137]. Black, American Indian or Alaska Native, and multiracial non-Hispanic men have a significantly higher lifetime prevalence of rape, physical violence, or stalking compared with white non-Hispanic men. These findings may be a reflection of the many stressors that racial and ethnic minority communities continue to experience. For example, a number of social determinants of mental and physical health, such as low income and limited access to education, community resources, and services, likely play important roles. These factors and medical mistrust, historical racism and trauma, perceived discrimination, and immigration status may affect help-seeking and the assessment of victims [136].

When race and ethnicity are considered, it is important to remember that there is great diversity within these groups. Certain factors may be generally applicable, but there may be unique contributions by ethnic sub-group [138].

Non-genital bodily injury is seen in more than half of all rape victims presenting to emergency departments [15,16]. In one study of 162 women examined between 2002 and 2006, signs of bodily injury were found in 61% of patients, with genital injury present in 39% [17]. Most common were bruises (56%) and abrasions (41%), followed by lacerations, penetrating injury, and bites. Evidence of injury was higher in the 137 cases examined within 72 hours of assault (66% vs. 33%) and in cases in which the assaults occurred outdoors (79% vs. 52%).

On examination, one should inspect carefully for evidence of blunt traumatic injury to the head, neck, arms, legs, and torso, looking for signs of penetrating injury, lacerations, and bite marks. Bruising may be evident on the neck (attempted strangulation), hands, arms, breasts, or thighs. Signs of bodily injury are more prevalent in women younger than 30 years of age. Other factors showing a strong positive association with bodily injury include alcohol consumption, history of prior assault, and assault by strangers [15].

Signs of genital traumatic injury are not always found after sexual assault, and in such cases should not be taken as evidence that sexual assault did not occur [17]. When routine inspection is combined with additional examination techniques, such as colposcopy and toluidine blue staining, the rate for identifying genital injury approaches 70% [18]. A 2021 study compared 834 women, half of whom reported nonconsensual intercourse. External genital tears were found more often in the nonconsensual group [131]. Similarly, anal penetration and tears were also more common in the nonconsensual intercourse group. As such, these may be indicators of lack of consent.

The common types and location of genital injuries, and thus the areas to be examined most closely, are:

The impact of sexual assault leads to immediate and long-term physical and mental health consequences. In addition to the potential risk for acquiring a sexually transmitted disease (STD), approximately 1% to 5% of rape victims become pregnant [20]. The National Violence Against Women Survey (NVAWS) found that 33% of women and 24% of men received counseling from a mental health professional as a direct result of their last assault; 28% and 10%, respectively, lost time from work [21]. Survivors of sexual assault are also at increased risk for re-victimization and experience higher rates of depression, post-traumatic stress disorder, substance abuse, and suicide.

In the aftermath of sexual assault, a variety of chronic somatic, cognitive, and emotional sequelae have been observed in sexual assault victims (Table 2). The individual's response and subsequent ability to cope with the trauma of the assault are influenced by a number of related factors. These include the nature and severity of the assault itself, age of the victim, relationship between the victim and assailant, prior history of abuse, and the person's own ambient life stress and coping mechanisms. For some, the impact of a sexual assault experience is severe and long-lasting, often resulting in difficulty with interpersonal relationships and tasks of daily living, sexual dysfunction, loss of work time, and increased utilization of healthcare resources [22,23,24]. The victim's age and developmental stage can also affect help-seeking. Adolescents tend to delay seeking formal help more often than adult victims [132]. This delay could exacerbate both physical and psychosocial consequences.

A meta-analysis of clinical studies published between 1980 and 2002 revealed a significant association between prior sexual assault and the lifetime diagnosis of fibromyalgia, chronic pelvic pain, and functional gastrointestinal disorders [25]. In a cross-sectional, randomly selected study of 219 women followed in a Veterans Administration (VA) primary care clinic, a history of prior sexual assault was found to be associated with a significant increase in somatization scores, multisystem physical complaints, anxiety, work absenteeism, and health care utilization [26]. Among another cohort of women receiving VA medical and mental health care, the prevalence of post-traumatic stress disorder was found to be seven to nine times higher in women who had experienced a prior sexual assault, compared with those having no assault history [27].

It is also vital to remember that some victims have experienced cumulative sexual violence over the course of their lifetime. This often results in continued fear and anxiety and chronic stress, which is associated with an increased risk for chronic health conditions (e.g., hypertension, disordered sleeping, chronic pain, asthma) [133].

To summarize, the priorities of acute care counseling are to provide emotional support, assure a plan for patient safety, and assess coping skills and strength of support system post-discharge. When possible, arrangements should be made for ongoing counseling through sexual assault crisis programs. In anticipation of the long-term adverse effects of sexual assault, arrangements should be made for primary care follow-up and patients and families should be offered information and access to mental health services.

The infections commonly reported in women after sexual assault are Chlamydia, gonorrhea, trichomoniasis, bacterial vaginitis, and pelvic inflammatory disease (PID) [28]. The possible exposure to hepatitis B virus and human immunodeficiency virus (HIV) is also an important consideration. In general, the risk of infection is relatively low; published estimates are 3% to 16% for chlamydia, 7% for trichomoniasis, and 11% for PID [29]. The risk, however, does vary directly with the degree of genital trauma, associated bleeding (sustained by the victim or assailant), and the number of assailants. The CDC has published guidelines for the assessment, counseling, and preventive treatment of infection following sexual assault, including common pelvic infections, hepatitis B, human papillomavirus (HPV), and HIV [28].

Follow-up within one to two weeks after the initial evaluation provides the opportunity to review previous test results, complete an assessment for STDs, and ensure safety and adherence to prescribed medication. CDC guidelines advise that a follow-up examination at one to two months should be considered to re-evaluate for development of anogenital warts, especially in patients who received a diagnosis of other STDs following the assault. If initial tests were negative and infection in the assailant could not be ruled out, serologic tests for syphilis can be repeated at four to six weeks and three months. To exclude acquisition of HIV, tests for acute infection should be repeated at six weeks, three months, and six months after the assault [28].

Kentucky law mandates the reporting of the abuse or neglect of children and elderly and/or vulnerable adults (i.e., those with a physical or mental disability) to the Cabinet for Health and Family Services, the state or local police, and/or the local prosecutor's office [58,60]. However, as of June 2017, Kentucky's law mandating reporting of suspected domestic or dating violence changed to a mandatory information and referral position [85].

According to the revised statute, if a professional has reasonable cause to believe that a person has experienced domestic violence or dating violence, the professional shall provide the individual with information about the regional domestic violence program or rape crisis center and information on how to access protective orders [86]. This is limited to persons with whom the professional has a professional interaction (as opposed to any contact whatsoever). In addition, a professional may report to a law enforcement agency at the request of a victim/survivor, but a report should not be made if the individual objects [86].

If a healthcare professional knowingly and willfully fails to report a case of suspected child or elder abuse as mandated by the law, then he or she can be subject to criminal penalties [58]. In fact, a healthcare professional who reports a suspected case of abuse in good faith in accordance with these laws is protected from civil and criminal liability [59].

During the assessment process, a practitioner must be open and sensitive to the client's/patient's worldview, cultural belief systems, and how he/she views the injury [61]. This may reduce the tendency to over-pathologize or minimize health concerns of ethnic minority patients. Pachter proposed a dynamic model that involves several tiers and transactions [62]. The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. Professionals must be willing to acknowledge that they do not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups they come in contact with. Reading and becoming familiar with medical anthropology is a good first step.

The second component emphasizes the need for specifically tailored assessment [62]. Pachter advocates the notion that there is tremendous diversity within groups. For example, one cannot automatically assume that a Chinese immigrant adheres to traditional beliefs. Often, there are many variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the client/patient and the professional [62]. The negotiation consists of a dialogue that involves a genuine respect of beliefs. It is important to remember that these beliefs may affect symptoms or appropriate interventions in the case of domestic violence.

Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. These components are meant to provide an introduction to help practitioners recognize the range of dimensions, including physical, biologic, social, and cultural factors, that affect immigrants and ethnic minorities. By incorporating cultural sensitivity into the assessment of individuals with a history of being victims/survivors or perpetrators of domestic violence, it may be possible to intervene and offer treatment more effectively.

All practitioners who deal with domestic violence should periodically review safety planning with victims/survivors. Homicide is of high risk for victims/survivors; therefore, safety planning is crucial. When advocating a safety plan, it is important to:

Although safety planning may be advocated, it does not necessarily mean victims/survivors will employ safety planning guidelines.

It is important to note that general safety planning does not take into account the specific needs of victims/survivors who fall into vulnerable populations or affected children [87]. Because these individuals are at higher risk of marginalization and oppression, they may feel powerless to execute a safety plan. It is important for practitioners to assess each IPV victim/survivor and his/her readiness to change, circumstances, resources, and needs in order to tailor a specific safety plan [88].

If a victim/survivor requires or requests legal assistance, local spousal abuse centers will be able to assist in making the appropriate referral. For the purposes of this course, it is important for healthcare professionals to know that domestic violence victims/survivors in Kentucky have legal remedies available to them. The first form of legal protection is an emergency protective order, which can be filed and heard by a judge without the batterer being informed of the filing or of the hearing. In cases of dating violence and stalking/sexual assault cases, a temporary interpersonal protective order can be filed [79]. Protective orders can be filed at the Office of Circuit Court Clerk in the county of residence (or temporary residence). Each county's contact information is available at https://courts.ky.gov/courts/clerks[79].

The batterer will not be present at the hearing, and the victim/survivor can present his or her evidence unopposed. This is referred to in the legal community as an ex parte hearing. The associated forms are relatively simple to file, and an attorney is not required. Having an attorney present, however, may result in obtaining a more thorough order. If the victim/survivor is not represented by an attorney, it is important that a battered woman's advocate, often called a legal advocate, be located to accompany the individual to court. To find an advocate trained in domestic violence issues, healthcare professionals may contact a local domestic violence center. The most ideal representation and assistance in these circumstances is usually a team approach that draws upon the expertise of an attorney and a domestic violence advocate/counselor [63].

Kentucky law provides that a judge can enter an emergency protective order or a domestic violence order that [64]:

The judge is not restricted to only these remedies, but can enter other orders he or she believes will be of assistance in eliminating future acts of domestic violence and abuse. The emergency protective order will be effective for a fixed period of time, as noted in the order, not to exceed 14 days. A copy of this order will be served upon the batterer, and if he or she violates any condition of the order, criminal penalties may be levied [65].

The court reviews petitions for protective orders on filing and schedules an evidentiary hearing within 14 days, at which the batterer is given notice of the hearing and is allowed to attend and present witnesses. If the court finds that a protective order is warranted, a domestic violence order will be followed to restrain the batterer from having contact with the victim/survivor [66]. In a domestic violence order, the protection is effective for up to three years, at which time it can be reissued. Batterers who violate the conditions of the protective order are subject to criminal penalties, including incarceration.

If a batterer violates the terms of the protective order, the police should be contacted immediately. When the police arrive, the victim/survivor should show the police the order or inform the officers of its existence. In Kentucky, a police officer who witnesses the batterer violating the terms of the protective order is required to arrest him or her [67]. If the batterer is no longer present when the police arrive, the victim/survivor should request that a report of the violation, and of any other crimes, be written. The victim/survivor can then follow-up on the violation by contacting the prosecutor's office and ask that an arrest warrant be issued based on the violation [63]. If the county has a Global Positioning System (GPS) monitoring service, the victim/survivor can request the court to order the batterer to wear a GPS device by filing a motion form, which will be evaluated by a judge [79].

If an arrest is made for a misdemeanor, such as violating a protection order, offenders may simply be given a citation and released. If a batterer is arrested and taken into custody, he or she may be released within a few hours. It is important, therefore, to advise victims/survivors to use this time to gather their children and personal belongings, to find a safe place to stay, to begin the process of obtaining a protection order if they do not have one, and/or to seek out a domestic violence program [63]. Victims/survivors should be fully informed about the criminal justice process, their role in it, and the possible outcomes of a criminal case so they can decide whether to turn to the criminal justice system for assistance.

If the prosecuting attorney decides to pursue a criminal complaint, there will be an arraignment. During the arraignment, the court informs the batterer of the charges and ensures that he or she has legal representation. Victims/survivors may be called to testify at an evidentiary hearing or at trial. If a victim/survivor does not want to testify, a court may issue a subpoena ordering him or her to testify; noncompliance with such a subpoena is a violation of law. Most cases are resolved before trial; if the case proceeds to trial, however, victims/survivors are again required to testify [63]. If the batterer is convicted, a judge will sentence him or her to one or any combination of the following: a fine; imprisonment; probation; victim/survivor restitution; mandatory counseling; mediation; substance-abuse treatment; or public service [63].