This interactive California Psychology Ebook contains 20 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Connecticut Continuing Medical Education
CONNECTICUT MEDICAL LICENSURE PROGRAM
MANDATORY CME REQUIRED FOR CONNECTICUT LICENSE RENEWALS TOPICS INCLUDE: • Domestic and Sexual Violence (Mandatory) • Frontotemporal Dementia (Mandatory) • HIV/AIDS (Mandatory)
• Opioid Prescribing (Mandatory) • Pain and Culture (Mandatory)
Need to complete the DEA’s new one-time MATE requirement? See inside for more details
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
COMPLETE ENCLOSED PROGRAM TO SATISFY ANY OR ALL OF THESE REQUIREMENTS
AVAILABLE ONLINE AT: CT.CME.EDU
CONNECTICUT PHYSICIAN
MANDATORY CONTINUING EDUCATION FOR CONNECTICUT PHYSICIANS
Dear Colleagues, Licensed physicians applying for renewal in Connecticut must earn a minimum of fifty (50) hours of qualifying continuing medical education (CME) within the preceding twenty-four (24) month period, unless exempt. Additionally, during the first applicable renewal period and not less than once every six (6) years thereafter, the CME must include at least one (1) credit hour in each of the following topics: infectious diseases, sexual assault, domestic violence, risk management, cultural competency and behavioral health. The InforMed Connecticut Medical Licensure Program is designed to fulfill these mandatory CME requirements for physicians (MD/DO) in the state of Connecticut. Completion of the program satisfies at least one (1) hour in each of the required topics mandated by Connecticut Gen Stat § 20-10b.
Thank you for choosing lnforMed as your CME provider. We strive to create a high-quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards, The lnforMed CME Team
InforMed has the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023 , renewing DEA-registered practitioners must complete 8 credit hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act. Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act?
Connecticut Medical Examining Board | 410 Capitol Avenue, MS #13PHO P. O. Box 340308 | Hartford, CT 06134-0308 | (860) 509-7603
We are a nationally accredited CME provider. For all board-related inquiries please contact:
BOOK.CME.EDU
BOOK CODE: MDCT2026
1-800-237-6999
i
What’s Inside
01
DOMESTIC AND SEXUAL VIOLENCE COURSE ONE | 5 CREDIT HOURS SATISFIES MANDATORY CME REQUIREMENTS IN DOMESTIC VIOLENCE AND SEXUAL ASSAULT Victims of domestic and sexual violence suffer emotional, psychological, and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims encounter and are in a critical position to identify victims in a variety of clinical practice settings where victims receive care. Accordingly, each healthcare professional should educate himself or herself to enhance awareness of the presence of abuse victims in his or her particular practice or clinical setting.
22
FRONTOTEMPORAL DEMENTIA COURSE TWO | 2 CREDIT HOURS SATISFIES MANDATORY CME REQUIREMENT IN BEHAVIORAL HEALTH/DEMENTIA
Frontotemporal dementia (FTD) is a group of degenerative brain disorders causing progressive deterioration in behavior, language, and/or movement. There are presently approximately 60,000 people with FTD in the United States. Onset generally occurs between 50 and 70 years of age, making FTD one of the most common presenile dementias. FTD affects the frontal and temporal lobes of the brain, which control emotions, judgment, personality, memory and language. The clinical diagnosis of FTD can be challenging, as some symptoms overlap with Alzheimer disease and other forms of dementia. FTD can be categorized based on its primary symptoms into three basic types: behavioral variant FTD, primary progressive aphasia, and progressive motor decline. Although most FTD does not appear to be inherited, genetics does play a role in a significant minority of cases. There is no effective treatment or cure for FTD, but there are strategies for management of symptoms. This course will discuss the possible causes and pathophysiology, diagnosis, and management strategies for FTD.
35
HIV/AIDS: AN UPDATE COURSE THREE | 5 CREDIT HOURS SATISFIES MANDATORY CME REQUIREMENT IN INFECTIOUS DISEASE
Since the discovery of HIV, scientists have made major inroads in understanding modes of transmission, infectivity, and pathogenicity. Knowledge about the characteristics and behavior of this human retrovirus and its complex mechanisms of immunopathogenesis has helped to develop targeted therapeutic interventions and vaccine strategies. Sophisticated techniques have been and are being developed to diagnose infection, to monitor immune decline, to monitor response to therapy and disease progression, and to accurately detect and diagnose opportunistic diseases. As the demographics of HIV infection evolve, both in the United States and around the world, it is clear that all healthcare professionals in all practice settings will be involved to some extent with HIV infection. To be effective and provide compassionate care, adequate and up-to-date information about transmission, prevention, diagnosis, treatment, and care of HIV-infected individuals should be obtained by all healthcare professionals.
ii
58
RESPONSIBLE AND EFFECTIVE OPIOID PRESCRIBING COURSE FOUR | 3 CREDIT HOURS SATISFIES MANDATORY CME REQUIREMENT IN RISK MANAGEMENT/OPIOIDS
Opioid analgesic medications can bring substantial relief to patients suffering from pain. However, the inappropriate use, abuse, and diversion of prescription drugs in America, particularly prescription opioids, has increased dramatically in recent years and has been identified as a national public health epidemic. A set of clinical tools, guidelines, and recommendations are now available for prescribers who treat pain patients with opioids. By implementing these tools, clinicians can effectively address issues related to the clinical management of opioid prescribing, opioid risk management, regulations surrounding the prescribing of opioids, and problematic opioid use by patients. In doing so, healthcare professionals are more likely to achieve a balance between the benefits and risks of opioid prescribing, optimize patient attainment of therapeutic goals, and avoid the risk to patient outcome, public health, and viability of their own practice imposed by deficits in knowledge.
76
THE INTERSECTION OF PAIN AND CULTURE COURSE FIVE | 5 CREDIT HOURS SATISFIES MANDATORY CME REQUIREMENT IN CULTURAL COMPETENCY
Pain is invisible, and diagnosis depends on patients’ reports. These factors contribute to the treatment of pain to be devalued and stigmatized. When issues of culture, race, and ethnicity come into play with pain experiences, it becomes even more complex. Assessing the interaction between how patients construct the meaning and subjective experiences of pain is necessary, rather than simply dealing with only the biomedical causes. Consequently, pain may be universal, but culture influences the creation of meanings, patient experiences, verbal expressions, and coping with pain.
98
FINAL EXAMINATION ANSWER SHEET REQUIRED TO RECEIVE CREDIT
iii
MOC/MIPS CREDIT INFORMATION
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS
American Board of Surgery’s Continuous Certification program
ABPath
American Board of Pathology’s Continuing Certification program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M 5 AMA PRA Category 1 Credits TM 2 AMA PRA Category 1 Credits TM 5 AMA PRA Category 1 Credits TM 3 AMA PRA Category 1 Credits TM 5 AMA PRA Category 1 Credits TM
Activity Title
ABA ABIM ABS
ABPath
ABP
5 Credits LL
5 Credits MK 2 Credits MK 5 Credits MK 3 Credits MK 5 Credits MK
5 Credits SA + AC 2 Credits SA + AC 5 Credits SA + AC 3 Credits SA + AC 5 Credits SA + AC
5 Credits LL 2 Credits LL 5 Credits LL 3 Credits LL 5 Credits LL
5 Credits LL
Domestic and Sexual Violence
Frontotemporal Dementia
5 Credits LL 3 Credits LL 5 Credits LL
5 Credits LL 3 Credits LL 5 Credits LL+SA
HIV/AIDS: An Update
Responsible and Effective Opioid Prescribing The Intersection of Pain and Culture
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow-up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
iv
How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDCT2026 in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MDCT2026
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options
Price
Option
Code
Credits
ENTIRE PROGRAM • Domestic and Sexual Violence • Frontotemporal Dementia • HIV/AIDS: An Update • Responsible and Effective Opioid Prescribing • The Intersection of Pain and Culture
$141
MDCT2026 20 Credit Hours
$35
Domestic and Sexual Violence
MDCT03SV 5 Credit Hours
$15
Frontotemporal Dementia
MDCT02FD 2 Credit Hours
$35
MDCT05HA 5 Credit Hours
HIV/AIDS: An Update
$21
Responsible and Effective Opioid Prescribing
MDCT03OP 3 Credit Hours
$35
The Intersection of Pain and Culture
MDCT05IP 5 Credit Hours
Note: Prices are subject to change
v
Domestic and Sexual Violence __________________________________________________________________
MDCT05SV — 5 CREDITS
R elease D ate : 06/01/25
E xpiration D ate : 05/31/28
Domestic and Sexual Violence
In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 5 ABIM MOC Points, 5 ABS MOC Points, 5 ABA MOCA Points, 5 ABP MOC Points, 5 ABPath CC Points.
Faculty Alice Yick Flanagan, PhD, MSW , received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correc- tional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families. Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon Uni- versity, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online cur- riculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities. John M. Leonard, MD , Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post- graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases. Faculty Disclosure Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Audience This course is designed for a wide range of healthcare and mental health professionals, including physicians, physician assistants, and nurses. Course Objective The purpose of this course is to provide healthcare profession- als with the skills and confidence necessary to identify victims of sexual or domestic violence and to intervene appropriately and effectively. Learning Objectives Upon completion of this course, you should be able to: 1. Identify common types of domestic and sexual violence. 2. Outline signs of abuse or victimization. 3. Describe the health effects and implications of domes- tic violence and/or sexual assault, including effects on pregnancy, developing fetuses, and child witnesses. 4. Evaluate the unique risk factors for and consequences of domestic and sexual violence in special populations. 5. Discuss traits of perpetrators of domestic and/or sexual violence. 6. Analyze screening and assessment methods to identify victims of abuse. 7. Describe appropriate responses to domestic and sexual violence, including best practices for follow-up care.
1
MDCT2026
_________________________________________________________________ Domestic and Sexual Violence
of Certification in Anesthesiology Program ® and MOCA ® are registered certification marks of the American Board of Anesthesiology ® . MOCA 2.0 ® is a trademark of the Ameri- can Board of Anesthesiology ® . Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 5 Lifelong Learning (Part II) credits for the American Board of Pathology Con- tinuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACC- ME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.
Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planner John V. Jurica, MD, MPH Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Designations of Credit NetCE designates this enduring material for a maximum of 5 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes participation in the evaluation component, enables the par- ticipant to earn up to 5 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equiva- lent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit par- ticipant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continu- ous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certi- fication in Anesthesiology Program ® (MOCA ® ), known as MOCA 2.0 ® . Please consult the ABA website, www.theABA. org, for a list of all MOCA 2.0 requirements. Maintenance
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included
so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
2
MDCT2026
Domestic and Sexual Violence __________________________________________________________________
Domestic violence can consist of any of many behaviors or combination of behaviors, falling under physical, psy- chological, verbal, sexual, and financial/economic abuse ( Table 1 ). It is important for healthcare professionals to understand that domestic violence, in the form of emotional and psychological abuse and physical violence, is prevalent in society. Unfortu- nately, domestic violence and abuse has become a fact of life for many Americans. This course will use the terms “domestic violence” and “IPV” interchangeably. DEFINING SEXUAL VIOLENCE According to the Massachusetts Coalition Against Sexual Assault and Domestic Violence, sexual violence is defined as “a multi-layered oppression that occurs at the societal and individual level and is connected to and influenced by other forms of oppression, in particular, sexism, racism, and het- erosexism…On an individual level, sexual violence is a wide range of sexual acts and behaviors that are unwanted, coerced, committed without consent, or forced either by physical means or through threats” [3]. The Association of American Universi- ties (AAU) defines it as “nonconsensual penetration or sexual touching by force or incapacitation” [4]. Whether out of impulse, compulsion, anger, or the assertion of power, sexual assault is a criminal act of violence imposed on the vulnerable and the innocent, causing immediate physical and emotional suffering and often having long-lasting adverse psychological effects. Rape is the legal term for a sexual assault during which there is penetration of a body orifice (vagina, anus, or mouth) involving force, the threat of force, or incapac- ity and nonconsent of the victim. It is important to consider that there is a wide range of sexual violence that can manifest in many different ways and set- tings/situations. For example, it can entail forced marriage and child marriage, forced lack of precautions to prevention sexually transmitted infections, and/or reproductive coer- cion (e.g., forced abortion, forced pregnancy) is considered a form of sexual violence [3; 5]. It is estimated that 35.6% of the global population have experienced sexual violence. It is important to note that men can be victims of sexual violence, although it is more challenging to obtain prevalence rates for this population [5]. CONTRACEPTIVE COERCION Control of reproductive or sexual health is also a recognized trend in IPV. This type of abuse includes trying to impregnate or become pregnant against a partner’s wishes, refusal to use birth control (e.g., condoms, oral contraceptives), manipulating a contraceptive so it becomes ineffective, preventing or forcing abortion, or stopping a partner from using birth control [6; 7]. It does not necessarily involve physical force, and it ultimately undermines the autonomy of the individual in regard to their reproductive health [7].
INTRODUCTION Domestic violence continues to be a prevalent problem in the United States today. Because of the number of individu- als affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims. Accord- ingly, it is essential that healthcare professionals are taught to recognize and accurately interpret behaviors associated with domestic violence. It is incumbent upon the healthcare profes- sional to establish and implement protocols for early identifica- tion of domestic violence victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, healthcare professionals in all settings should take the initiative to properly assess all patients for abuse during each visit and, for those who are or may be victims, to offer education, counseling, and referral information. Victims of domestic violence suffer emotional, psychological, and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims encounter and are in a critical position to identify domestic violence victims in a variety of clinical practice settings where victims receive care. Accordingly, each healthcare professional should educate himself or herself to enhance awareness of the presence of abuse victims in his or her particular practice or clinical setting. Specifically, healthcare professionals should be aware of the signs and symptoms associated with domestic violence. In addi- tion, when family violence cases are identified, there should be a plan of action that includes providing information on, and referral to, local community resources related to legal aid, sheltering, victim counseling, batterer counseling, advocacy groups, and child protection.
AN OVERVIEW OF THE ISSUE
DEFINING DOMESTIC VIOLENCE Domestic violence, termed spousal abuse, battering, or inti- mate partner violence (IPV), refers to the victimization of an individual with whom the abuser has or has had an intimate or romantic relationship. The Centers for Disease Control and Prevention (CDC) defines IPV as, “physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner)” [1]. The World Health Organization defines intimate partner violence as “behaviour by an intimate partner or ex- partner that causes physical, sexual, or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviours” [2].
3
MDCT2026
_________________________________________________________________ Domestic and Sexual Violence
DOMESTIC VIOLENCE BEHAVIORS
Physical Abuse
Psychologic/Verbal Abuse Sexual Abuse
Financial/Economic Abuse Withholding of money, refuse to allow victim to open bank account, all property is in the perpetrator’s name, victim is not allowed to work
Kicking, punching, biting, slapping, strangling, choking, abandoning in unsafe places, burning with cigarettes, throwing acid, throwing objects, refusing to help when sick, stabbing, shooting
Intimidation, humiliation, put-downs, ridiculing, control
Rape, forms of sexual assault (such as forced masturbation, fellatio, or oral coitus), sexual humiliation, unwanted touching, perpetrator refuses to use contraceptives, coerced abortion
of victim’s movement/ relationship/behaviors,
stalking, threats, threatening to hurt victim’s family and children, social isolation, ignoring needs or complaints
Source: Compiled by Author
Table 1
Research indicates that this form of violence is relatively common. A 2018 systematic review found that 5% to 16% of women had experienced reproductive coercion [7]. In another study of young women (16 to 29 years of age) present- ing to family planning clinics in California found that 53% of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion, and 15% reported birth control sabotage [8]. Of those who reported being victims of partner violence, 35% reported reproductive control. Research indicates that reproductive coercion is often one of multiple forms of interpersonal violence experienced by a victim [9]. Furthermore, studies suggest that reproductive control and unintended pregnancy may disproportionately affect women of color [10]. According to the American College of Obstetricians and Gyne- cologists (ACOG), interventions that focused on awareness of reproductive and sexual coercion and provided harm-reduction strategies reduced pregnancy coercion by 71% among women who experienced IPV [11]. The ACOG recommends the fol- lowing screening questions: • Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms? • Has your partner ever tried to get you pregnant when you did not want to be pregnant? • Are you worried your partner will hurt you if you do not do what he wants with the pregnancy? • Does your partner support your decision about when or if you want to become pregnant? Interventions targeted to protect victims of contraceptive coercion include helping conceal contraceptives, placement of an intrauterine device or other implanted birth control, and appropriate referrals [11].
SIGNS OF ABUSE/VICTIMIZATION
DOMESTIC VIOLENCE It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims. In a 2016 study of 288 healthcare facilities in Florida, 78% understood the importance of IPV screening and had some type of IPV screening policy institute in their setting [12]. However, many of the respondents did not know which screening tool was used or the types of screening questions asked. These guidelines should review appropriate interview techniques and should also include the utilization of screening tools, such as intake questionnaires. The following is a review of certain signs and symptoms that may indicate the presence of abuse. Although victims of domestic violence do not display typical signs and symptoms when they present to healthcare providers, there are certain cues that may be attributable to abuse. The obvious cues are the physical ones. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. In addition to physical signs and symptoms, domestic violence victims also exhibit psychological cues that resemble an agitated depression. If the perpetrator is present with the victim during an assessment, they may attempt to control the situation; this may manifest as an unwillingness to leave the victim alone or answering questions for the victim. Unfortunately, healthcare professionals may respond to these women by diagnosing the patient to be neurotic or irrational [13]. Healthcare professionals should cast aside these misper- ceptions of abused victims and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms. In addition, it is impor- tant to recognize that vulnerable populations, including lesbian, gay, bisexual, transgender, and other gender/sexual minority (LGBT+) individuals, those with human immunode- ficiency virus (HIV), individuals with disabilities, and veterans are also at risk and should be screened for IPV [14].
4
MDCT2026
Domestic and Sexual Violence __________________________________________________________________
SEXUAL VIOLENCE Although most cases of sexual violence are accompanied by physical force and/or active resistance, visible injuries are rare. Possible signs of sexual violence victimization include [15]: • Unwanted touching • Rape (i.e., actual or attempted unwanted vaginal, oral, or anal penetration by an object or body part) • Being forced or manipulated into doing unwanted, painful, or degrading acts during intercourse • Being taken advantage of while one is drunk or otherwise not likely to give consent • Being denied contraception or protection against sexually transmitted infections • Taking any kind of sexual pictures or film without consent • Being forced to perform sexual acts on film or in person for money • Threatening break up when sex is refused HEALTH EFFECTS AND IMPLICATIONS OF DOMESTIC VIOLENCE As is clear, victims of domestic violence experience a wide range of physical and psychological injuries. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen. These are often distinguishable from accidental injuries, which are more likely to involve the periphery of the body. In one hospital-based study, domestic violence victims were 13 times more likely to sustain injury to breast, chest, or abdomen than accident victims. Abuse victims are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen in a patient, particularly in combination with evidence of old injury, physi- cal abuse should be suspected [16]. As a result of prolonged stress, victims often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches/ migraines, and gastrointestinal problems. Often, they will complain of chronic pain, fatigue, restlessness, insomnia, or loss of appetite. Research indicates that women with a history of intimate partner violence are at greater risk of developing fibromyalgia and chronic fatigue syndrome [17]. Sleep distur- bances, including truncated sleep, nightmares, and restless sleep, are also common [18]. The likelihood of having some sort of stress-related sleep disturbance is 1.24 times greater for women affected by physical intimate partner violence and 3.44 times greater for victims of sexual abuse [18]. Great amounts of anxiety, guilt, and depression or dysphoria are also typical [16; 19]. In many women, this constellation of symptoms has been labeled “battered women’s syndrome.”
The long-term health implications should also be considered. In a study conducted by MORE magazine and the Verizon Foundation, 88% of women who have experienced sexual abuse and 81% of women who have experienced any form of domestic violence report having chronic health condi- tions (compared with 62% among women who experienced no domestic violence) [20]. In this study, the most common chronic health conditions among victims were low back pain (35%), headaches (32%), difficulty sleeping (30%), and depression/anxiety (30%). Victims of violence were also found to have increased incidences of diabetes, cervical pain, gastroesophageal reflux disease, irritable bowel syndrome, and post-traumatic stress disorder (PTSD). HEALTH EFFECTS AND IMPLICATIONS OF SEXUAL VIOLENCE Research indicates that victims of sexual violence experience a range of acute and long-term physical and psychological injuries as a result of the violence [21]. NON-GENITAL BODILY INJURY Non-genital bodily injury is seen in more than half of all rape victims presenting to emergency departments [22; 23]. 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% [24]. 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 [22]. GENITAL INJURY Signs of genital traumatic injury are not always found after sex- ual assault, and in such cases should not be taken as evidence that sexual assault did not occur [24]. When routine inspec- tion is combined with additional examination techniques, such as colposcopy and toluidine blue staining, the rate for identifying genital injury approaches 70% [25]. A 2021 study compared 834 women, half of whom reported nonconsensual intercourse. External genital tears were found more often in the nonconsensual group [26]. Similarly, anal penetration and tears were also more common in the nonconsensual intercourse group. As such, these may be indicators of lack of consent.
5
MDCT2026
_________________________________________________________________ Domestic and Sexual Violence
LONG-TERM PHYSICAL AND EMOTIONAL IMPACT OF SEXUAL ASSAULT
Chronic Somatic Disorders
Psychosocial Disorders
Pelvic pain, dyspareunia Functional gastrointestinal disorder Fibromyalgia Multisystem physical complaints Headaches Abdominal pains Source: [29; 30; 31; 33; 34; 35; 36]
Anxiety, depression, phobias Post-traumatic stress disorder
Sexual dysfunction Sleep disturbance Anorexia Work absenteeism
Table 2
The common types and location of genital injuries, and thus the areas to be examined most closely, are: • Bruises and abrasions to the labia, fossa navicularis, or perianal area • Ecchymoses, tears, or lacerations of the hymen • Abrasions and/or tears of the posterior fourchette • Tears/lacerations in the perianal area LONG-TERM PSYCHOSOCIAL IMPACT 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 [27]. 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 [28]. 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 experi- ence 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 [29; 30; 31]. The victim’s age and develop- mental stage can also affect help-seeking. Adolescents tend to delay seeking formal help more often than adult victims [32]. 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 [33]. In a cross-sectional, randomly selected study of 219 women fol- lowed 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 [34]. 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 [35]. 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) [36]. 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. SEXUALLY TRANSMITTED INFECTION The infections commonly reported in women after sexual assault are Chlamydia , gonorrhea, trichomoniasis, bacterial vagi- nitis, and pelvic inflammatory disease (PID) [37]. 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 [38]. The risk, however, does vary directly with the degree of genital trauma, associated bleeding (sustained by the
6
MDCT2026
Domestic and Sexual Violence __________________________________________________________________
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 papil- lomavirus (HPV), and HIV [37]. Follow-up within one to two weeks after the initial evalua- tion 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 infec- tion 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 [37]. IMPLICATIONS ON PREGNANCY AND PRENATAL CARE 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 [39; 40]. Because a gynecologist or obstetrician is frequently a woman’s primary care physician, these healthcare providers should be particularly sensitive to domestic violence issues [41]. According to the CDC, IPV affects as many as 324,000 pregnant women each year [39]. 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 [39]. Because 96% of pregnant women receive prenatal care, this is an optimal time to screen for domestic violence and develop trusting relation- ships with the women. Pregnant women indicate they find screening useful but also have concerns regarding confidential- ity and the sharing or information [42]. 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 incident had an eight-fold increased risk of fetal death [43]. 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 [16;
44]. Healthcare professionals should also be aware of the pos- sible psychological consequences of abuse during pregnancy. There is a higher risk of stress, depression, and addiction to alcohol and drugs in abused women, and victims are less likely to obtain prenatal care and to develop postpartum depression [43; 45; 46]. Low birth weight can result from either preterm birth or growth restriction in utero, both of which can be directly linked to stress. For example, pregnant women who experi- ence physical violence are five times more likely to give birth to preterm infants and six times more likely to have an infant with low birth weight [47]. Living in an abusive and danger- ous environment marked by chronic stress can therefore be an important risk factor for maternal health, as well as affecting birth weight [48]. The risk of becoming pregnant after vaginal rape is estimated to be 5%, although the risk may be higher for adolescent vic- tims [23; 49]. It is generally recommended that rape victims of childbearing age have a baseline urine or serum pregnancy test performed, in anticipation of offering prophylaxis against pregnancy if the result is negative. Postexposure emergency contraceptive treatment options are available for preventing pregnancy after unwanted intercourse [50]. The simplest and best-studied product is levonorgestrel (Plan B), an oral progestin-only medication developed for this purpose. The dosage regimen is 1.5 mg (two 0.75-mg tablets) administered as a single oral dose. It is considered to be most effective when administered within 12 hours of the assault. In one carefully conducted study, the success rate (prevention of pregnancy) exceeded 95% when administered up to 120 hours after unprotected intercourse [51]. This medication is safe and well tolerated, even if given to someone who is pregnant. Systemic side effects, such as headache, nausea, fatigue, and gastrointestinal/abdominal complaints, occur in less than 10% of patients. Transient vaginal bleeding in the days following treatment is more common (25% to 30%). HEALTH EFFECTS AND IMPLICATIONS OF CHILDREN EXPOSED TO DOMESTIC VIOLENCE Children may be victims of domestic violence either directly (if victims of the perpetrator) or indirectly (if witnessing the violence or suffering the fallout). Witnessing may also include overhearing threats or witnessing the consequences of domes- tic violence [52]. However, there is evidence that child abuse and intimate partner violence often occur within the same household and that exposure to violence in childhood may increase the risk of experiencing or perpetrating different forms of violence later in life [53].
7
MDCT2026
_________________________________________________________________ Domestic and Sexual Violence
Children exposed to family violence are at high risk for abuse and for emotional damage that may affect them as they grow older. The Department of Justice estimates that of the 76 mil- lion children in the United States, 46 million will be exposed to some type of violence during their childhood [19]. Results of the National Survey of Children’s Exposure to Violence indicated that 20% of children were exposed to IPV at home within the last year, and an estimated two-thirds of children were exposed to more than one form of family violence [54]. Of those children exposed to IPV, 90% were direct eyewitnesses of the violence; the remaining children were exposed by either hearing the violence or seeing or being told about injuries [54]. A number of studies indicate that child witnesses are at increased risk for post-traumatic stress disorder, impaired development, aggressive behavior, anxiety, difficulties with peers, substance abuse, and academic problems than the aver- age child [52; 55; 56; 57]. Men who are exposed to intimate partner violence are more likely to perpetrate violence in their lifetimes [58]. Children exposed to violence may also be more prone to dating violence (as a perpetrator or a victim), and the ability to effectively cope with partnerships and parenting later in life may be affected, continuing the cycle of violence into the next generation [59]. Overall, children who witness domestic violence appear to display neurological and functional changes, placing them at increased risk of developing hypertension, diabetes, and cardiovascular conditions later in life [52]. In addition to witnessing violence, various studies have shown that these children may also become direct victims of violence, and children who both witness and experience violence are at the greatest risk for adverse psychosocial outcomes [60]. Research indicates that between 30% and 60% of husbands who batter their wives also batter their children [61]. Moreover, victims of abuse will often turn on their children; statistics demonstrate that 85% of domestic violence victims abuse or neglect their children. According to the U.S. Department of Justice, between 1980 and 2008, 17.5% of all homicides against female adolescents 12 to 17 years of age were committed by an intimate partner [13]. 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 with 54% in older age groups [62]. Accordingly, healthcare professionals who see young children and adolescents in their practice (e.g., pediatricians, family physicians, school nurses, pediatric nurse practitioners, community health nurses) should 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. Without such critical intervention, the cycle of violence will never end.
DOMESTIC VIOLENCE AND SEXUAL VIOLENCE IN SPECIAL POPULATIONS
ELDERLY Abused and neglected elders, who may be mistreated by their spouses, partners, children, or other relatives, are among the most isolated of all victims of family violence. According to the CDC, 1 in 10 older adults who live at home experience abuse, including neglect and exploitation. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults and more than 19,000 homicides occurred [63]. According to one study, only 1 in 14 cases of elder abuse are reported to the authorities [64]. In the National Intimate Partner and Sexual Violence survey, 23% of persons 70 years of age and older disclosed having experienced abuse by an intimate partner [65]. In addition, 57% experienced abuse by a person other than an intimate partner [65]. The prevalence rate of elder abuse in institutional settings is not clear. In a 2019 systematic study of elder residents in institutional settings, the most commonly reported abuse expe- rienced in the previous 12 months was psychological (33.4%), followed by physical abuse (14.1%) and financial abuse (13.8%) [66]. In a nonprobability study, 36% of nursing and aide staff disclosed to having witnessed at least one incident of physical abuse by other staff members in the preceding year. When asked whether they themselves perpetrated physical abuse against an elderly resident, 10% admitted they had [67]. In a random sample survey, 24.3% of respondents reported at least one incident of elder physical abuse perpetrated by a nursing home staff member [68]. It is important to understand that the needs of older patients will increase, as will the numbers of elder victims of domestic violence. Because elder abuse can occur in family homes, nurs- ing homes, board and care facilities, and even medical facilities, healthcare professionals should 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 [69]. 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 [69]. Because these elderly victims are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected.
8
MDCT2026
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66 Page 67 Page 68 Page 69 Page 70 Page 71 Page 72 Page 73 Page 74 Page 75 Page 76 Page 77 Page 78 Page 79 Page 80 Page 81 Page 82 Page 83 Page 84 Page 85 Page 86 Page 87 Page 88 Page 89 Page 90 Page 91 Page 92 Page 93 Page 94 Page 95 Page 96 Page 97 Page 98 Page 99 Page 100 Page 101 Page 102 Page 103 Page 104 Page 105 Page 106Powered by FlippingBook