1. IzBen C. Williams, MD, MPH Lecturer

2. Lecture # 14b AGGRESSION AND ABUSE

3. Aggression & Abuse DEFINITIONS 1. Aggression: hostile or violent behavior or attitudes toward another; readiness to attack or confront 2. Abuse: A repetitive pattern of behaviors to maintain power and control over another person

4. Aggression A. Social determinants of Aggression 1. Factors associated with increased aggression include poverty, frustration, physical pain, and exposure to aggression in the media 2. Children at risk for showing aggressive behavior in adulthood may have ……….  moved frequently and changed schools repeatedly  been physically and/or sexually abused  mistreated animals, and  Found it difficult to defer gratification Their parents frequently display criminal behavior, and abuse drugs or alcohol

5. Aggression A. Social determinants of Aggression 3. Homicides occur more often in low socioeconomic populations and its incidence is increasing. At least half of the homicides result from guns 4. The leading cause of death in African American males 15-24 years of age is homicide. It is the second leading cause of death (after accidents) in white males of this same age group

6. Aggression B. Biological determinants of Aggression 1. Hormones a. Androgens are closely associated with aggression; in most animal species and human societies, males are more aggressive than females; homicide involving strangers is committed almost exclusively by men b. Androgenic or anabolic steroids, often taken by body builders to increase their muscle mass, can result in high levels of aggression and even psychosis. Severe depression often occurs with withdrawal from these hormones c. Estrogen, progesterone, and anti-androgens may be useful in treating male sex offenders

7. Aggression B. Biological determinants of Aggression 1. Substances of abuse and aggression a. Low dose of alcohol and barbiturates inhibit aggression, while high dose facilitate it b. While intoxicated, heroin users show little aggression; increased aggression is associated with the use of cocaine, amphetamines, and phencyclidine (PCP)

8. Aggression B. Biological determinants of Aggression 3. Neural basis of aggression a. Serotonin and GABA inhibit aggression; dopamine and norepinephrine facilitate it; low levels of the serotonin metabolite 5-HIAA are associated with impulsive aggression. b. Drugs used to treat inappropriate aggressiveness include antidepressants, benzodiazepines, antipsychotics (particularly atypical agents) and mood stabilizers(eg lithium)

9. Aggression B. Biological determinants of Aggression 3. Neural basis of aggression c. Abnormalities of the brain (eg abnormal activity of the amygdala and preperiform area, and psychomotor and temporal lobe epilepsy) and lesions of the temporal lobes, frontal lobes, and hypothalamus are associated with increased aggression d. Violent people often have a history of head injury or show abnormal EEG readings

10. Sexual Aggression: Rape and Related Crimes A. Definitions: Rape is a crime of violence, not passion, and is known legally as “sexual assault” or “aggravated sexual assault” 1. Rape involves sexual contact without consent 2. Vaginal penetration by a penis, finger, or other object may occur 3. Erection and ejaculation do not have to occur 4. Sodomy, insertion of the penis into the anal orifice or oral cavity, may be committed against male or female

11. Sexual Aggression: Rape and Related Crimes B. Legal considerations 1. Semen may not be present in the vagina because rapist may use condoms in his own interest 2. A victim is not required to prove that she resisted the rapist for him to be convicted. A rapist can be convicted even though the victim asked him to use a condom or other form of sexual protection 3. Certain information about the victim (eg seductive clothing and sexual history)is generally not admissible as evidence in rape trials

12. Sexual Aggression: Rape and Related Crimes B. Legal considerations 4. It is illegal to force anyone to engage in sexual activity; hence husbands can be prosecuted for raping wives. A woman can consent to sexual activity not involving intercourse 5. Consensual sex may be considered rape (“statutory rape”). Age of consent 16-18; also, physically or mentally handicapped

13. Sexual Aggression: Rape and Related Crimes C. Characteristics of rapist and victim 1. The rapist a. Rapists are usually younger than 25 years of age b. They are usually the same race as the victim c. They are usually known to the victim d. They often use alcohol 2. The victim 1. Rape victims are typically between ages 16-24 2. Rape commonly occurs within the victim’s home 3. There may be no vaginal injuries

14. Sexual Aggression: Rape and Related Crimes D. The sequelae of rape 1. Only 25% of rape are reported to the police for reasons of shame, fear of retaliation, and difficulty of proof among others 2. The victim is frequently blamed 3. The length of the emotional recovery period after rape is commonly at least a year, but varies, and PTSD frequently occurs 4. The most effective type of counseling is group Tx with other rape victims

15. Sexual Aggression: Rape and Related Crimes E. The role of the physician in rape cases 1. Immediately after the rape the physician should a. Take the patient’s history in a supportive manner and not question the patients veracity or judgment b. Perform a general physical examination and conduct laboratory tests (cultures as necessary from vagina, anus, pharynx and test for presence of semen and loose hair) c. Prescribe prophylactic antibiotics and take post coital contraceptive measures (eg. diethylstilbestrol) d. Encourage patient to notify the police!?!?. The doctor is not required to notify the police if the woman is a competent adult

16. Sexual Aggression: Rape and Related Crimes E. The role of the physician in rape cases 2. Up to six weeks after the rape a. Discuss with patient the emotional and physical sequelae of the rape (eg. Suicidal thoughts, vaginal bleeding ) and whether there’s necessity for long-term counseling or a support group b. Do a pregnancy test and repeat this and other laboratory tests as necessary.

17. Physical and Sexual Abuse of Domestic Partners A. Occurrence 1. Domestic abuse is a common reason that women come to a hospital emergency room 2. The abused woman nay not report to the police or leave the abuser because he has threatened to kill her if she reports it or leaves him. There is, in fact, a greatly increased risk that he would.

18. Physical and Sexual Abuse of Domestic Partners B. Evidence of domestic abuse 1. The victim commonly has bruises and fractures 2. In pregnant women (who have a high risk of being abused), the injuries are often in the “baby zone” (ie. abdomen and breasts) 3. An irrational explanation of how the injury occurred, delay in seeking treatment, and appearance of sadness, are other indicators of domestic abuse

19. Physical and Sexual Abuse of Domestic Partners C. The cycle of abuse includes three phases 1. Buildup of tension in the abuser 2. Abusive behavior (battering) 3. Apologetic and loving behavior by the abuser toward the victim

20. Physical and Sexual Abuse of Domestic Partners D. Characteristics of abusers and abused partners 1. Abusers often use alcohol or drugs, are impulsive, have a low tolerance for frustration, and displace their angry feelings unto their partner 2. The abused partner is often emotionally or financially dependent on the abuser, pregnant, and blames herself for the abuse 3. Both the abuser and the abused commonly have low self-esteem

21. Abuse and Neglect of Children and the Elderly A. Overview 1. Types of child and elder abuse include physical abuse, emotional or physical neglect, and sexual abuse. The elderly may also be exploited for monetary gain 2. Abuse-related injuries must be differentiated from injuries obtained during normal activity

22. Abuse and Neglect of Children and the Elderly B. Sequelae of child abuse 1. Children who are being abused often seem sad, show personality changes and do poorly at school 2. Adults who were abused as children are more likely to i. Have dissociative disorders (eg. Dissociative identity disorder ) and borderline personality disorder ii. Have PTSD and other anxiety disorders iii. Have depression and substance abuse disorders iv. Abuse their own children

23. Abuse and Neglect of Children and the Elderly C. Sexual abuse of children 1. Signs a. Sexually transmitted diseases in children are signs of sexual abuse; children do not contract STDs through casual contact with an infected person or with their bedclothes, towels, or toilet seat b. Genital or anal trauma, recurrent UTIs and excessive initiation of sexual activity with friends are also signs of sexual abuse c. Young children have only a vague knowledge of sexual activities. Specific knowledge about sexual acts (eg fellatio) often indicates sexual abuse

24. Abuse and Neglect of Children and the Elderly C. Sexual abuse of children 2. Occurrence a. An estimated 500,000 children in the US are sexually abused per year b. Most sexually abused children are 8-13 years of age; 25% are younger than 8 years old c. Approximately 20% of women and 5-10% 0f men report sexual abuse at some time during their childhood and adolescence

25. Abuse and Neglect of Children and the Elderly C. Sexual abuse of children 3. Characteristics of sexual abuser a. 70-90% of sexual abusers are known to the child and 90% of these are men. About 50% of these men are relatives and 50% are family acquaintances b. Alcohol and drugs are commonly used by the abuser c. The abuser typically has marital problems and no appropriate alternative sexual partner; occasionally he is a pedophile

26. The Role of the Physician in Child, Elder, and Partner Abuse A. Child and elder abuse 1. In the US physicians must report suspected physical or sexual abuse of a child or elderly person (particularly if the elderly person appears to be physically or mentally impaired)to the appropriate family social service agency, before or in conjunction with treatment of the patient 2. The physician is not required to reveal that he is reporting to the authorities, to either the suspected abuser or to the abused

27. The Role of the Physician in Child, Elder, and Partner Abuse A. Child and elder abuse 3. The physician does not need family consent to hospitalize the abused child or elderly person for protection or treatment 4. Even if there is no intension to injure, if a cultural remedy such as “coining” injures a child or elderly person, such injury also must be reported to the appropriate authority

28. The Role of the Physician in Child, Elder, and Partner Abuse B. Domestic partner abuse 1. Direct reporting by the physician of domestic partner abuse is not appropriate because the victim is usually a competent adult. 2. The physician who suspects domestic partner abuse should a. Document the abuse b. Ensure the safety of the abused person c. Develop an emergency escape plan for the abused d. Provide emotional support for the abused person e. Refer abused person to an appropriate shelter or program f. Encourage the abused person to make report to law enfor.