Clinicians should reassure teens about the confidential and supportive nature of the doctor- patient relationship. Doctors should screen adolescents for abuse as described below, remembering that the abuser may be a parent, another family member, boyfriend, or girlfriend. The teen’s knowledge and behavior around violence, coercion, alcohol, drugs, and sexual activity needs to be assessed. An abused teen particularly needs to be told that the abuse is not their fault and that help is available (see the list of resources at the end of this document). IPV in GSM relationships appears to be as common, or possibly more common, than in heterosexual relationships. 37-39 Many GSM individuals do not feel comfortable disclosing their sexual orientation to healthcare providers, and are likely to be even more reluctant to disclose abuse. GSM individuals who do disclose their sexual orientation are still rarely asked about IPV. Barriers to inquiry include gender-related myths, for example, that men cannot be victims of abuse, or that same-sex relationships are inherently “equal” because parties are of the same gender. 37,40 Violence in Lesbian, Gay, Bisexual, Transgender, and other Gender and Sexual Minority (GSM) Relationships Additional obstacles specific to GSM survivors include homophobia and transphobia and resulting discrimination in society and among healthcare providers as well as social consequences of revealing one’s sexual orientation, such as loss of children and other family relationships, employment, or community standing. Shelter space and support services may not be available specifically for battered gay men, transgender, and gender nonconforming individuals. Lesbian and bisexual women have the option of going to more traditional domestic violence programs that accept women, but many of these programs may not be suitable for or sensitive to members of the GSM community. Transgender and gender-nonconforming individuals face particular barriers in getting help because providers, and the public in general, often understand even less about gender identity and expression than they do about sexual orientation. Healthcare providers should therefore approach screening, diagnosis, and treatment with special sensitivity to the difficult issues that abused GSM patients may face. Violence in Diverse Cultures and Immigrant Populations IPV is prevalent in every culture and segment of society. Immigrants and members of minority cultures, however, face extra hurdles as they attempt to access available services to protect themselves, their children, and other dependents. Patients of different cultures may hold belief systems and traditions that make it harder for them to perceive their own danger, understand their right to live in safety, know their legal rights and options, or even speak to anyone about their situation. Survivors whose native language is not English may find it difficult to communicate with healthcare providers,
advocacy services, and law enforcement personnel. They may also harbor legitimate fears of becoming homeless, losing their children, or deportation, if their abuse is revealed. These patients may not trust the health care system, and thus suffer in silence and be at risk. Healthcare providers who are sensitive to the potential barriers and problems that immigrants and members of diverse cultures face can better establish trusting relationships with their patients, which is critical for uncovering and dealing with IPV. Substance Abuse Substance abuse is often associated with violence. Perpetrators are more likely to use or abuse alcohol and other substances, and, in addition, patients who abuse alcohol and other drugs are more likely to become victims. Further, survivors of partner violence are more likely to abuse alcohol and to receive multiple prescriptions for tranquilizers, sedatives, and opioid analgesics to treat the pain or distress of present or past abuse. 9 With rising rates of opioid abuse, physicians should consider increasing screening of violence in their patient population. Although most abused individuals are neither dependent on alcohol nor involved with other drugs, those who are addicted are often doubly stigmatized. They may be labeled as sexually promiscuous, unfit as parents, unworthy as partners, have low self- control or willpower, or being just plain “crazy.” They are more likely to be blamed for the violence in their lives, further impeding efforts to resolve issues and regain health. Intervention goals for chemically dependent abused patients include sobriety as well as safety. For some, addiction treatment may be a necessary first step, but intervention for the violence should not be neglected. For others, achieving safety may be necessary before participating in an addiction recovery program. Becoming sober may threaten an abuser’s sense of control, and place the survivor at risk for increased violence. Ideally, both issues are treated together. Addiction or intoxication, although maladaptive, may serve as coping strategies for the victimized individual. Sobriety in the absence of safety and resiliency-oriented support may unmask previously undiagnosed mental health issues for marginally functioning abused patients. The success of safety planning can be compromised by ongoing drug use, and the success of addiction recovery can be impeded by continued violence. Therefore, healthcare providers should always carefully assess for IPV where there is evidence of substance abuse, and screen for substance abuse where there is evidence for IPV. In addition, providers should weigh carefully the risks and benefits of prescribing controlled substances for symptom relief in patients with chemical dependence, particularly opioid pain medications. 41 Sexual Assault and IPV According to the National Intimate Partner and Sexual Violence Survey (NISVS), the lifetime incidence of rape is 19.3% for women and 1.7% for men. 42
Patient responses to sexual assault can vary from visible distress to calm composure. Some survivors of recent rape have difficulty trusting hospital personnel and the evidence collection process. Thus, sensitivity and patience are critical when examining or referring a patient to the emergency department. Clinicians trained in empathetic evidence collection such as Sexual Assault Nurse Examiners can be invaluable collaborators. In addition to collecting physical evidence in cases of recent sexual assault, healthcare providers can offer validation, support, and appropriate referrals for sexual assault counseling. Clinicians should be mindful of asking questions that might sound victim-blaming or judgmental, such as “why were you wearing that?” or “why didn’t you report this to the police?” Instead encourage contact with a local rape crisis center and appropriate therapeutic and community services, even if an assault took place months or years ago. Supportive approaches such as these can be fundamental to the recovery and reintegration process for survivors of sexual assault. Strategies providers can use to assess patients for sexual violence are discussed further at the end Human trafficking is associated with significant physical and psychological harm including the risk for IPV. 43 The abuses suffered by people who are trafficked include many forms of physical violence or abuse (e.g., beating, burning, rape, confinement) as well as many psychologically damaging tactics such as threats to themselves or their family members, blackmail, extortion, lies about the person’s rights, and confiscation of vital identity documents. 43 Healthcare professionals are uniquely positioned to identify and intervene on behalf of trafficking victims. Outside of law enforcement, healthcare settings are among the few places where the lives of human trafficking victims may intersect with the rest of society, if only for brief periods. 44 In a study of 98 sex trafficking survivors, 88% had at least one encounter with a healthcare provider while they were being trafficked, with 63 percent of these encounters happening in an emergency department. 45 Some patients meet criteria for human trafficking, even if they don’t identify themselves as trafficking victims. Trafficked people, like IPV patients, often do not accurately perceive their status. They may view their situation, for example captivity, as a requirement for being brought into the country or an expectation they must obey. Adolescents are groomed by traffickers who may call themselves “boyfriends,” “daddies,” or romantic partners. Key tactics of manipulation and entrapment include seduction, gifts, and actions made to look like emotional support. Once the trafficker creates a romantic connection, the victim is coerced into engaging in commercial sex acts. Federal anti-trafficking laws exist and clinicians should be familiar with their general principles. 46 of this monograph. Human Trafficking
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