Examination of patients presenting following sexual violence within an intimate partner violence relationship

Some of this article is reproduced with permission from The Royal Australian College of General Practitioners from Wells, D. Unit 578. Medico-legal. check – Independent learning program for GPs. East Melbourne, VIC: RACGP, 2020. Available at: https://gplearning.racgp.org.au/Content/2022/check/2020/Dec.pdf

Contributing authors: Marr R, Rowse J, Moller M

Data from the 2016 Australian Bureau of Statistics (ABS) Personal Safety Survey indicated that 17% of women and 4.3% of men aged >15 years had ever experienced sexual assault ¹.  Intimate partner sexual assault, child sexual abuse and sexual harassment are the most common forms of sexual violence ².

Intimate partner abuse (often known as domestic violence) is any behaviour within an intimate relationship that causes physical, emotional, sexual, economic and/or social harm to those in the relationship.  An intimate relationship may refer to a current or previous partner or living companion, including same-sex relationships.

It is estimated that a full-time GP sees five women each week who have experienced intimate partner abuse in the past year ². Many people may not identify sexual violence occurring within an intimate partner setting as being sexual violence, or voluntarily offer this info unless asked specifically. The GP’s role is to both respond to the immediate abuse and manage the long-term consequences of assault.

Patients who experience IPV and sexual violence may present with a wide range of non-.specific physical and psychological symptoms ². Such patients may not spontaneously disclose the abuse, so it is important that the possibility of abuse is addressed specifically.   It can be useful to normalise asking about IPV with an opening statement such as, ‘Violence is very common in the home. I ask a lot of my patients about abuse when I hear symptoms or see injuries like these’.

A non-judgemental approach to discussing IPV and sexual violence is required, and it is important that clinicians feel confident and comfortable discussing this. If a patient discloses, the clinician should respond in a non-judgemental way and address safety concerns. Even if there is no disclosure made, the patient may disclose a history of violence at a later date if they feel safe with you and have established rapport. This also highlights the importance of careful documentation of injuries even when no disclosure of violence is made. Victims of violence may attribute their injuries to alternative mechanisms but report a physical or sexual assault at a later date.

An examination after an alleged or suspected physical or sexual assault would ideally cover the entire body, though in the absence of reason to suspect sexual or physical assault to the breasts, genitals and/or buttocks, it would be reasonable not to examine them.  Particular attention should be paid to areas that do not commonly sustain accidental trauma, such as the inner upper arms, inner thighs, axillae and chest/abdomen.

Strangulation (or neck compression) is a common form of interpersonal violence and can result in serious adverse health outcomes, including death. The identification and attribution of injuries from non-fatal strangulation are complex, as there may be an absence of external signs of injury and their appearance may be delayed by many days. Patients who have experienced sexual violence may not attach the same level of importance to an episode of strangulation when disclosing sexual violence, so it is important that treating healthcare practitioners are comfortable specifically asking their patients.

While some victims of neck compression can provide an account of their assault, many are unable to because they may be affected by drugs or alcohol, distracted by other injuries or concerns, or have experienced a loss of consciousness that may have caused amnesia. There may be additional barriers to disclosure including fear of repercussions. Many will not know if they lost consciousness; it can take a very brief period of compression before a victim loses consciousness.

If the initial strangulation/neck compression is non-lethal and the injuries go unrecognised or untreated, delayed airway obstruction may occur as a consequence of late-onset swelling and bleeding. Life-threatening stroke via vessel dissection can also occur ⁴.

Strangulation is a form of violence that may occur in physical assault, sexual assault and IPV.

Symptoms may include ^4,5

• neck pain, difficulty swallowing, coughing, hoarse voice
• bladder and bowel incontinence
• light-headedness/headache/dizziness
• loss of consciousness, memory loss, visual changes, seizures
  
  

When present, signs of strangulation may include ⁴:

• subconjunctival haemorrhage (not specific to strangulation)
• petechiae  (usually on the face, around the eyes, oral mucosa and palate)
• bruising or abrasions to the neck
• red marks on the neck
• raspy or hoarse voice/loss of voice.
• noisy or difficult breathing and swallowing
• swelling of the neck, face or tongue.
  
  

The evaluation of neck compression is dependent on the history, symptoms and signs. It may include a period of observation, imaging studies such as a computed tomography angiogram, or ear, nose and throat review for laryngoscopy for evaluation of the vocal cords and trachea.

Healthcare practitioners must have an awareness of and sensitivity to the unique risks and impacts and understand the referral options.  Considerations include an awareness of privacy and confidentiality and a requirement to address these directly with patients.

Practitioners need to have a sense of self and be aware of their own sensitivities when managing patients who have experienced violence.  They need to be mindful of self-care and vicarious trauma and risks to themselves when supporting patients who have experienced sexual violence.  

Healthcare practitioners are uniquely placed to play an important role in awareness, prevention, intervention and treatment of intimate partner and sexual violence in the community. Professional networks can also strengthen the practitioners’ capacity to respond and refer and may be an important element in their own support and welfare.

There are national and local services, including 1800RESPECT that can provide information.

To register for free CPD-accredited training on Responding to Adult Patients who have experienced sexual violence go to:

https://www.monash.edu/medicine/sphpm/study/professional-education/responding-to-sexual-violence

This training is funded by the Department of Social Services under the Fourth Action Plan of the National Plan to Reduce Violence against Women and their Children 2010-2022 and there is no charge to participants.

Monash University, Dept. of Forensic Medicine
Contact: Jennifer Ryan, Manager Dept. of Forensic Medicine
Email: Jennifer.ryan@monash.edu
Mobile:  0438 090 005

References:

1. Australian Institute of Health and Welfare. Sexual assault in Australia. Canberra, ACT: AIHW, 2020. 
2. The Royal Australian College of General Practitioners. Abuse and violence – Working with our patients in general practice, 4th edn. East Melbourne, Vic: RACGP, 2014.
3. Kaspiew R, Carson R, Rhoades H. Elder abuse: Understanding issues, frameworks and responses. Research report no. 35. Melbourne, Vic: Australian Institute of Family Studies, 2016.
4. Bugeja, L., Rowse, J., Cunningham, N. et al. Non-fatal strangulation and COVID-19 common symptoms and signs: considerations for medical and forensic assessment. Forensic Sci Med Pathol 18, 165–169 (2022). https://doi.org/10.1007/s12024-022-00460-x
5. The Royal College of Pathologists of Australasia. Guideline: Clinical forensic assessment and management of non-fatal strangulation. Surry Hills, NSW: RCPA, 2018. Available at www.rcpa.edu.au/getattachment/59a67b0e-ca6b-4686-a81f- 14a1a15e70fe/Clinical-Forensic-Assessment-and-Management- of-Non.aspx [Accessed 3 September 2020].
6. De Boos J. Review article: Non-fatal strangulation: Hidden injuries, hidden risks. Emerg Med Australia 2019;31(3):302–08. doi: 10.1111/1742-6723.13243.