Domestic Violence and Sexual Assault: Is There a Connection?

Nurses in a variety of settings may specialize in working with domestic violence victims. Other nurses are specially trained as sexual assault nurse examiners (SANES). Nurses who know colleagues practicing in these areas but who are not themselves involved may not be aware of the commonalities in these two types of forensic nursing practice. Both are concerned with assessing and treating the current physical and mental status of the victim, both document and gather evidence for possible future use in courts of law, both help clients identify courses of action appropriate to their particular situations, and both provide referrals to community resources for assistance. Perhaps a less noticeable common factor is that the victim of one type of violence frequently is also the victim of another. There is research to indicate that clinical services focused on one type of problem may not "note" the presence of other problems.

Many health professionals as well as lay persons limit their understanding of domestic violence to physical abuse: black eyes, multiple bruises, fractures, concussions and such. Others appreciate that abuse is inherent in threats, financial control, restriction of activities or social interaction, and continuous chipping away at self-esteem. But many still do not think of sexual abuse as a frequent part of that cycle of violence. In fact, in terms of sexual abuse between married partners, it is only in the last twenty years that the courts have begun to recognize that there was any such thing as spousal rape. Prior to that time, it was presumed in law that marital rape could not occur; the woman had "given consent" through marriage vows, which could only be rescinded by divorce. Sexually abusive behavior may include forcing intercourse against the woman's wishes or following an episode of physical abuse, physical abuse directed toward an ongoing pregnancy, performing sex acts in a painful or shame-producing manner, requiring unwanted pornographic viewings or acts, refusing to allow protection against pregnancy or STD/HIV transmission, and/or withholding desired sexual activity or affection as a control mechanism. Jacqueline Campbell, a prominent nurse researcher and author on the topic of domestic violence, studied women who were physically and emotionally abused in current or past intimate relationships and found that 40% of them were forced into sexual activity by their male partner. If one looks at family violence as opposed to strictly domestic (intimate partner) violence, a history of sexual abuse or exploitation has been found to occur in 2-40% of children, the range dependent on the particular researcher's definition of the term. One-third to one-half of initiators of pediatric sexual intercourse are family members. Elder abuse has also included sexual assault. Its prevalence is unknown, in part because elders are infrequently assessed for sexual abuse, perhaps illustrating health care providers views of senior sexuality.

Approaching the commonalities from the other perspective, the Massachusetts SANE protocols for gathering evidence from and providing crisis services to victims of sexual assault have recently been modified to place greater emphasis on assailant identification as a current or former intimate and on safety planning for the client. This is necessary not only for referrals to the justice system for protection from the actual assailant(s), but also to determine factors in the home and family that can contribute to or jeopardize the client's future safety and well-being. Education of family members regarding the "normal" physical and psychological aftermath of sexual assault and instruction in appropriate responses and support to the victim can improve client outcomes. Conversely, negative or inappropriate reaction or family disbelief that a close relative or friend could be the perpetrator of a sexual assault can lead to continue assailant access to the victim and/or much delayed psychological healing processes. In some cultures, physical punishment, ostracism, or even death may follow a reported sexual assault to "cleanse the honor" of the family. In addition, concurrent domestic and sexual assaults tend to result in more severe trauma. Studies have shown that the percentage of sexual assaults that result in major physical trauma is up to ten times higher (50% vs 5%) in patients whose assailants are current or past intimate partners. Even when a specific sexual assault is not directly related to domestic abuse, SANEs have noted that a history of domestic violence is frequently elicited. Finally, on a purely practical note, additional funding sources to enhance sexual assault services may be accessed when the specific relationship of sexual assailant to victim can also be placed under the umbrella of domestic violence.

Throughout the country, there are a few clinical programs in which nurses provide a full range of forensic examination services. They evaluate, document, photograph, and gather evidence in circumstances of adult and pediatric sexual assault, physical assault, domestic abuse, and elder neglect from victims and suspects alike. While Massachusetts does not appear to be moving in this direction, nurses dealing with clients in any one of these circumstances should be aware of the opportunities for identifying these frequently overlapping problems and referring them to appropriate resources.