Domestic and Sexual Violence __________________________________________________________________
Just as the identification of a sexually transmissible infection in a child raises suspicion for prior sexual assault/abuse, so too does known or suspected childhood sexual assault/abuse warrant an assessment for STDs. The decision to perform a diagnostic evaluation and to collect vaginal or other specimens should be made on an individual case basis. Among factors to consider in the decision to screen a child for STDs are [37; 104]: • Child has experienced penetration or has evidence of recent or healed penetrative injury. • The perpetrator of the abuse is a stranger. • The perpetrator is known to have an STD or is at high risk for STDs. • Child has a relative or another person in the household with an STD. • Child has symptoms or signs of active infection (e.g., vaginal discharge or pain, genital itching or odor, genital lesions or ulcers). • Child or parent requests STD testing. The physical examination and collection of vaginal specimens is often frightening or uncomfortable for a child and should be conducted by an experienced clinician. The CDC and the American Society of Pediatrics provide updated guidance for healthcare providers involved in the evaluation of childhood sexual assault/abuse. LOW-INCOME POPULATIONS 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 [105; 106]. Greater economic dependence is associated with more severe abuse and homicide by an intimate partner [107]. Financial instability is also a potential adverse effect of inti- mate 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 [108]. 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 [109]. PEOPLE LIVING IN RURAL COMMUNITIES 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 [110]. There is some evidence that intimate partner homicide rates may be higher in rural areas than in urban or suburban locales [107; 111]. Substance use disorders and unemployment are more com- mon among IPV perpetrators in rural areas [111]. 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 [112]. Residents of rural areas are less likely to support government involvement in IPV prevention and intervention than urban residents [111]. 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 ser- vices for a greater geographic area than urban programs [113]. 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 [114]. 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) [115]. In rural areas, there may also be fewer sexual assault nurse examiners or the requirements for qualification and training may be absent or inconsistent [116]. IMMIGRANTS AND REFUGEES 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; undocu- mented 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 [117]. Recent immigrants are at increased risk for violence victimiza- tion. In one study of Chinese immigrants in the United States, acculturation and socioeconomic status were associated with severity, frequency, length, and type of abuse [118]. 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
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MDCT2026
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