Clinical Review

Your age-based guide to comprehensive well-woman care

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References

A concern at any age

Domestic violence

Domestic violence is common; approximately 5% of women report one episode during the past year and 25% report at least one lifetime episode.22 Domestic violence involves two people: a perpetrator and a victim. In some relationships, a recurrent cycle of violence and reconciliation is observed. Routine, confidential, and private screening is required to detect most cases of domestic violence.

Ask the right question(s). The single question, "At any time, has a partner hit, kicked, or otherwise hurt or threatened you?" can increase the rate of detection. Alternatively, a set of three questions can be used to screen for domestic violence:

  1. "Within the past year, have you been hit, slapped, kicked or otherwise physically hurt by someone?"
  2. "Within the past year, has anyone forced you to have sexual activity?"
  3. In pregnancy: "Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?"

Follow-up and refer. If a woman reports that she has suffered or is at risk for domestic violence, document the finding in her medical record. Then try to assess her safety by asking: "Are there guns in the home?", "Have there been threats of suicide or homicide?", "Has there been violence toward children?" Choking, specifically, could be a sign of future escalated violence—as many perpetrators choke their victims prior to further, escalated violence occurring—and should be taken as a threat of homicide. Refer women who report domestic violence to a specialist; often, the best trained and most available experts are experienced social workers.

Sexual assault

About 25% of women report at least one lifetime sexual assault. Most women who report being raped initially receive care in a hospital-based emergency department from nurses who are credentialed in Sexual Assault Nurse Evaluation (SANE) skills.

The initial evaluation includes rapid access to treatment by a specialized clinical team, assessment and treatment of bodily injuries with a focus on genital trauma, psychological assessment and support, pregnancy assessment and prevention, preventive treatment of STDs, and collection of forensic data, including toxicology testing for the presence of date-rape drugs.

When sexual assault is reported, treat for an STD. The Centers for Disease Control and Prevention (CDC) recommends the following approach to prevent and treat STDs in victims of sexual assault23:

  • ceftriaxone 125 mg IM to prevent gonorrhea
  • azithromycin 1 g orally as a single dose or doxycycline 100 mg twice daily for 7 days to prevent chlamydia
  • metronidazole 2 g orally as a single dose to prevent trichomoniasis
  • hepatitis B vaccination, for women not previously vaccinated. (The CDC recommends against the use of hepatitis B immune globulin as the costs are believed to outweigh the benefits.)
  • HIV postexposure prophylaxis for 3 to 7 days, with a follow-up visit to consider pros and cons of continued prophylaxis. (The risk of HIV infection following a sexual assault is low.)
  • postcoital contraception (for example, levonorgestrel 1.5 mg orally as a single dose).

An antiemetic also should be offered to reduce the risk that the multiple prescribed medications will cause vomiting and nullify prophylaxis efforts. Approximately 2 weeks after the sexual assault the patient should have a pregnancy test and be assessed for ongoing mental health needs. If she did not adhere to the medications or if she shows relevant symptoms, perform follow-up STD testing. Follow-up HIV and syphilis testing can be performed at 12 and 24 weeks following the assault.

Sexual dysfunction

Sexuality is an important part of the human experience. Sexual dysfunction is the inability to participate as desired in a sexual relationship. Problems of sexual dysfunction are best approached from a biopsychosocial framework that recognizes the important contributions of biological, psychological, and social-cultural factors in sexual health. Masters and Johnson posited four stages of sexual response: excitement, plateau, orgasm, and resolution. Building on this linear model, investigators later divided the excitement phase into desire and arousal.

Recent models of sexual response have emphasized a circular model, in which sequential responses overlap and build on previous stimuli. These models also emphasize the importance of emotional intimacy and the quality of the relationship in achieving optimal sexual health.

Approximately 40% of women and 30% of men report sexual dysfunction.24 Common sexual problems reported by heterosexual women include:

  • lack of interest in sex
  • inability to achieve orgasm
  • pain caused by sexual intercourse
  • lack of pleasure with sex
  • trouble lubricating.

The majority of men and women will not voluntarily report sexual dysfunction to their clinician. To elicit the presence of sexual concerns, you must initiate the conversation.25 You can begin the sexual history by asking, "Do you have any concerns about your sex life?" Additional helpful, open-ended questions include: "Are you having sexual relations currently? With men or women or both?", "If you are not having sex, when did you last have intercourse?", "Are you satisfied with the frequency and quality of your sexual experiences?", "What is the emotional quality and intimacy of your relationship with your sex partner?"

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