Last Updated: 17 September 2019
By Katherine Thompson, PA-C
CME Knowledge Gap: Interpersonal Violence
As medicine gets more siloed and specialists more specialized, fewer conditions than ever feel applicable to all specialties and practice settings. Unfortunately, this contributes to sub-optimal knowledge among clinicians at large about important patient presentations and their management. Some have gone as far to call this the bystander effect in medicine.
Interpersonal violence, including sexual assault, domestic violence, and other forms of physical abuse, fall into this category. Sure, you could argue that few conditions should be on the differential diagnosis of clinicians across specialty and practice setting, but interpersonal violence is one of them.
The unfortunate truth is that most clinical training does not adequately prepare healthcare professionals to care for patients acutely after they experience such a nightmare.
Some healthcare professionals may feel uncomfortable or start questioning their clinical decisions when faced with such a presentation. Many will miss it entirely. Meanwhile, others make it their life’s work to identify and help these patients.
Additionally, some legislators who have been educated on this knowledge gap agree that a solution is in order. That’s why certain states, like Florida and Connecticut, have mandated clinicians log ongoing education related to interpersonal violence. Finding relevant sexual assault CME, or other programs that meet this requirement can be challenging.
However, this CME can include a variety of topics on interpersonal violence, such as domestic violence, sexual assault, or human trafficking.
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State Required Sexual Assault CME
Regardless of your state CME requirements, you’ll be a better healthcare professional if you can recognize and appropriately care for patients who suffer from interpersonal violence.
Although, as a heads up, more and more states are mandating sexual assault CME as part of your license renewal.
That’s why we’re starting to run an occasional clinical series to help identify these areas of need in medical education. Today’s article, as you might have guessed, covers interpersonal violence. The following is a guest post written by Katherine Thompson, MCHS, PA-C, FE, over at Interpersonal Violence Educators.
Do you have an idea for a topic in this series? Let us know.
By Katherine Thompson, MCH, PA-C, FE
More than one-half of women (51 percent) will experience at least one attempted or completed sexual assault in their lifetime. One out of every eight men will experience rape or sexual assault. Fifty to eighty percent of these women know their attacker.
Sexual assault is not a crime of dark alleys and masked strangers, but one that is underrepresented in the public conscience and routinely minimized by the layperson and healthcare providers alike.
Statistics show a system skewed towards perpetrators; for every one hundred assaults that survivors report, seven will result in a prison sentence. However, this is also a heavily under reported crime. In fact, sexual assault is the most under reported violent crime in the United States; only about thirty four percent of sexual assaults are reported.
On average, twenty people every minute are abused by an intimate partner. One in every four women and one in every nine men experience severe interpersonal violence. This includes stalking and physical contact with injury, such as slapping, pushing, or non-fatal strangulation.
Additionally, one in ten women is raped by an intimate partner. While there are no related statistics available for men, that certainly does not mean it does not happen.
Experiencing interpersonal violence increases the risk of developing post-traumatic stress disorder (PTSD), anxiety disorders, depression, alcohol and drug dependencies, repeated assaults and sexual victimization, and psychosomatic pain syndromes.
This comes at a tremendous cost to the healthcare system and the victims, so it is important for healthcare providers to have an accurate, well-rounded, empathetic, and empowered perspective on sexual violence in the United States, as well as the possible sequelae, so that we can render sensitive, timely, and appropriate care to survivors from all backgrounds.
This article is intended as a general overview of interpersonal violence, a chance to improve your overall knowledge of the statistics and possible clinical presentations of these victims, and hopefully to whet your appetite for more knowledge, so that you can continue to support and advocate for survivors of interpersonal violence.
Acute rape and sexual assault are most commonly seen in the emergency room and urgent care settings, although this is a generalization and not the whole truth.
It is well-established that over fifty percent of survivors disclose to healthcare professionals first. Unfortunately, many of the reactions that they receive from disclosure are rated as negative experiences. The most commonly cited complaint on disclosure is that of controlling or authoritarian behavior from the healthcare provider, resulting in the victim continuing to feel helpless and powerless.
In the cases where disclosure is not made, the most common presenting complaints vary based on gender. With female victims, the most common complaints will be abdominal pain, vaginal pain, vaginal bleeding or discharge, or nausea and vomiting.
In men, disclosure is extremely uncommon, although physical injury rates are significantly higher in men than women. Therefore, the most common clinical presentations for men are anal pain or bleeding, or general complaints of physical violence, including facial injuries, lacerations, and abdominal or trunk injuries.
The most important fact to consider for treating patients who are potentially or confirmed survivors is the “ripple effect” that disclosure reactions can have.
Rape culture is prevalent in our society, and may lend certain implicit biases to the reactions that we have, no matter how sensitive and empathetic we are as providers. The more that we know and learn about this, the better we are able to serve our patients.
Domestic violence has a wide range of possible clinical presentations, and can also be overlaid with sexual violence. The media leads us to believe that domestic violence is only worth pursuing in the cases presented in which there is extreme physical injury.
Most commonly, there is little to no physical injury aside from bruises, mild swelling, scratches, etc. However, the greatest injury occurs within. The cycle of domestic violence is damaging for the individual’s mental state, and is often deeply exacerbated by societal attitudes that returning to the perpetrator means she is “bringing it upon herself.”
This is the most important point of awareness, that the cycle of leaving and returning is extremely complex emotionally and psychologically, and must be supported and understood by healthcare providers.
Clinical presentations vary widely for both domestic violence and sexual assault. However, clinicians should be acutely aware when they identify signs of non-fatal strangulation. Non-fatal strangulation is used to describe incidents of strangulation in which the victim was not killed.
Strangulation victims frequently have little to no external signs of violence, but may experience intense physical consequences, from increased risk of stroke, chronic migraine headaches, vocal cord damage, difficulty swallowing, or seizures.
Additionally, they are seven times more likely to become a victim of homicide in the future at the hands of the same partner.
A Solution to Interpersonal Violence CME Knowledge Gaps
Currently, many healthcare programs offer limited coverage of these areas of medicine. The most common excuse for not broadening the curriculum is the lack of time in the program, the “rarity” of treating these victims, and the emphasis on non-acute care (like family medicine based programs).
What healthcare professionals and the lay public often miss, however, is the large group of chronic survivors, either of childhood abuse or prior incidents of sexual violence as an adult.
These patients may present to clinics and family practice environments with a wide range of non-organic pain syndromes, difficulty with fertility or pregnancy, depression, anxiety, and post-traumatic stress disorder.
Trauma-informed care is crucially important and can not only save lives in the acute setting, but can allow you to provide the most holistic, healing, and empowered care possible to your patients.
IPV Educators has been established to help hospitals, corporations, and healthcare programs broaden their curriculum and educate current and future providers in how to provide this empowered care.
Fear is the most commonly cited reason for not addressing interpersonal violence in the care setting, and fear is directly related to lack of knowledge or confidence in the provider’s ability to handle whatever the victim presents with.
Education is the route away from that fear, so I encourage you, as a reader, to expand your knowledge as far as it will go, because whether you realize it or not, you are directly treating and interacting with survivors of interpersonal violence.
Where to Find Sexual Assault CME
Finding sexual assault CME (and interpersonal violence CME in general) is not easy. Here are a few places you can find online sexual assault CME.
A Clinicians Guide to Sexual Assault (2.0 Category 1 CME Hours)
Appropriate Screening and Documentation when Sexual Assault Is Suspected in the Adult Patient (1 Category 1 CME Hour)
About the Author
Get Statistics. National Sexual Violence Resource Center. https://www.nsvrc.org/node/4737.
Sexual Violence Research. Australian Institute of Family Studies. http://www.aifs.gov.au/acssa.
Stavert RR, Lott JP. The Bystander Effect in Medical Care. New England Journal of Medicine. 2013;368(1):8-9. doi:10.1056/nejmp1210501.