Violence is the harmful, threatened or actual, use of force or power against oneself, another person, or against a group or community. Neglect and deprivation represent harmful misuses of power and, therefore, also constitute forms of violence. Violence takes many forms and the trauma it causes may result from material (e.g., financial) as well as physical and/or psychological harm. Violence is always potentially a crime, with the main codified forms being assault (any act of physical violence against another person with the intent to cause physical harm or any act that puts another person in fear of imminent physical harm) and harassment (the sustained and/or systematic unwanted and unwelcome actions that annoy, threaten, intimidate, or alarm another person). Physicians have an ethical and, often, legal obligation to report certain violent crimes, especially rape, child maltreatment (see “Overview” in “Child maltreatment”), and elder abuse. Any sexual act undertaken against another person without their consent constitutes sexual violence and is liable to criminal prosecution in the US. Sex crimes punishable by law include sexual harassment (a form of sexual discrimination in a social setting involving, e.g., unwanted advances that creates an abusive or hostile environment), unwanted sexual contact (nonconsensual touching of someone in a sexual manner), sexual assault (any nonconsensual nonpenetrative sexual act), child sexual abuse (see “Child sexual abuse”), and rape (nonconsensual penetration of another person's vagina, anus, or mouth with any body part or object). Incest between consenting individuals is also considered a crime under most jurisdictions. Sex crimes are among the most underreported crimes in the US, not least due to the associated stigma, fear, and perpetrators most often being close acquaintances (e.g., partner) and/or persons in a position of authority/power over the person experiencing the violence (e.g., guardians, teachers, religious officials). Individuals who have experienced sexual assault or rape typically present with signs of physical and mental trauma (bruises, lacerations, fear, intrusive thoughts, flashbacks, sleep disturbances, nightmares), often involving injuries to the genital, anal, and/or oral areas. Patients who have experienced sexual assault or rape should receive a comprehensive evaluation, conducted with great empathy and assurance of confidentiality to establish trust and prevent further traumatization and reluctance to report crimes. Psychological counseling with referral to sexual assault crisis programs and psychiatrists should also be provided. A trained professional (e.g., a sexual assault nurse examiner or sexual assault forensic examiners) should furthermore examine the patient using a sexual assault forensic evaluation kit (SAFE kit; colloquially referred to as “rape kit”) to gather and preserve physical evidence of the crime. Long-term complications of sexual violence include PTSD, depression, anxiety, sexual dysfunction, and substance use disorders. Elder abuse is any form of violence, including financial mistreatment, against elder individuals (i.e., > 60 years of age) by a trusted person or someone with responsibility for the patient (e.g., a caregiver). Domestic violence is any form of actual or threatened physical or psychological harm by one person in a household against another, often to maintain power over that person and regardless of the degree of intimacy between them. The term "intimate partner violence” is often used synonymously with “domestic violence” but more specifically refers to violence perpetrated by one partner in an intimate relationship against another. Presentation and treatment of elder abuse and domestic/intimate partner violence depend on the circumstances as well as the form, severity, and duration of violence experienced. Common features, however, include suspicious injuries (e.g., cigarette burns, bruises inconsistent with medical history) and signs of psychological trauma (e.g., PTSD, depression, anxiety). Patients who have experienced elder abuse or domestic/intimate partner violence should likewise receive a comprehensive evaluation, with great empathy and the assurance of confidentiality to establish trust and prevent further traumatization and reluctance to report crimes.
- Sustained and/or systematic unwanted and unwelcome actions that annoy, threaten, intimidate, or alarm another person
- Harassment is governed by state law in the US.
- See also “Sexual harassment” under “Sex crimes” below.
- A non-legal term referring to the physical and/or psychological mistreatment of another person
- Usually implies a close and/or long-term relationship between the perpetrator and the person experiencing the abuse
Individual who has experienced violence/survivor
- Preferred terms for persons who have experienced acts of violence, replacing the obsolete term “victim,” which implies a state of helplessness, perpetuating the stereotype of being unable to recover from the experience
- The term “survivor” has become very popular in recent years, but it is not unproblematic as it implies recovery from the experience as well as the threat of death, neither of which is necessarily given in all experiences of violence.
Sexual violence is the use of physical or psychological force during or as a means to obtain a sexual act from another individual. Although specific definitions of the types vary between jurisdictions, sexual violence is generally considered a crime if committed against nonconsenting individuals.
- Definition: voluntary and discernible approval by a legally or functionally competent individual to engage in a sexual activity proposed or initiated by another individual
- Age of consent: age at which an individual is legally permitted to engage in sexual activity
- Inability to consent: the inability to voluntarily and discernibly approve a sexual contact due to mental/physical disability or another illness, being asleep or unconscious, being too intoxicated (whether voluntarily or involuntarily so), or being below the age of consent
- Inability to refuse: the inability to express nonconsent due to physical violence, the threat of force, and other forms of coercion or intimidation (e.g., misuse of authority)
Sex crimes 
- Unwanted sexual contact
- Sexual harassment: a form of sexual discrimination in any social setting (e.g., workplace, school, church) that involves any type of unwanted sexual advances, the request of sexual favors, or any other type of sexual verbal and/or physical conduct that creates an abusive or hostile environment
- Any nonconsensual sexual act not involving penetration upon another person, including sexual acts upon persons lacking the capacity to give consent
- Definitions vary between jurisdictions but typically cover nonconsensual, nonpenetrative sexual acts involving:
- The use of force, the threat of force, coercion, or abuse of authority
- Touching, groping, and kissing
- Exposure to pornographic materials
- Individuals below the age of consent
- The use of drugs or alcohol for incapacitation or manipulation
- Rape: the nonconsensual penetration of another person's vagina, anus, or mouth with any body part or object.
- sexual assault, rape, incest, and exploitation (i.e., noncontact sexual activities, e.g., photoshoots) : any sexual act involving individuals under the age of consent, including
- Sex crimes are among the most unreported crimes in the US.
- Persons who have experienced an attempt or completed rape in their lifetime:
- Estimated 20% (1 in 5) of all women
- Estimated 3% (1 in 33) of all men
- Percentages of women who have experienced other types of sexual violence 
- Sexual coercion: 12.5%
- Unwanted sexual contact: 27.3%
- Noncontact unwanted sexual experiences: 32.1%
- Percentages of men who have experienced other types of sexual violence
- Made to penetrate another person: 6.7%
- Sexual coercion: 5.8%
- Unwanted sexual contact: 10.8%
- Noncontact unwanted sexual experiences: 13.3%
- The most commonly affected age group is 16–25 years.
- Sexual violence is most often perpetrated by men.
- Sexual violence is most often perpetrated by an intimate partner or acquaintance.
Warning signs and symptoms
- Injuries in the genital, anal, and/or oral areas (e.g., lacerations, bruising)
- Genital, pelvic, and/or abdominal pain
- Musculoskeletal injuries
- Acute stress reaction
- Signs and symptoms of sexually transmitted diseases
Approach to the evaluation of suspected physical sexual violence 
- Show empathy and willingness to provide continuous support.
- Assess the safety of the person who experienced sexual violence (consider, e.g., emergency plans, support network of friends and/or relatives, suitable shelters, crisis centers).
- Further assessment should be performed by trained professionals, such as sexual assault nurse examiners (SANEs) or sexual assault forensic examiners (SAFEs), whenever feasible.
- Patients must be informed and counseled about all aspects of the evaluation, documentation, the right to anonymity, and legal questions.
- Involves an integrated approach of providing medical care and performing a forensic exam
- Time, location, and setting of the assault (e.g., campus party, alcohol or drug use)
- Description of the perpetrator
- Details of the assault (e.g., type of sexual assault, extragenital acts, use of physical force or weapons, use of condoms)
- Details of the period after the assault (e.g., changing clothes, bathing, douching, brushing teeth, urination)
- Contraceptive use
- Time of last sexual intercourse before the assault
- Head-to-toe examination
- Signs of trauma (e.g., bruises, wounds, fractures)
- Detailed physical exam of the external genitals, vagina, cervix, anus
Diagnostic tests for STDs
- Vaginal and/or rectal smears and culture for Neisseria gonorrhoeae and Chlamydia trachomatis
- Saline wet mount of vaginal smear to test for Trichomonas vaginalis
- Serological testing
- Serum pregnancy test
- If applicable, blood alcohol levels
- Urine toxicology screen to detect substances that can be used to incapacitate a person (so-called date rape drugs) e.g., Rohypnol, GHB, and ketamine
Forensic exam 
- Involves a thorough assessment, documentation using standardized forms, and collection of evidence and should be performed without delay
- Sexual assault forensic evidence kits (SAFE) contain all required instructions, documents, and evidence collection equipment (e.g., bags for the patient's clothing, comb used to collect hair and fiber samples from the patient, materials for swabs and blood collection).
- The kits must be sealed and stored at the medical facility and the chain of custody of evidence material must be maintained.
- The kit is handed over to law enforcement if the patient wants to take legal measures against their abuser.
The following approach addresses the management of persons who have experienced sexual assault or rape. The specific treatment that is provided depends on the individual circumstances. Sexual assault that does not cause physical trauma can still cause severe psychological trauma with potentially severe consequences (e.g., risk of suicide) and should be managed accordingly.
- Treat injuries
- Empiric antibiotics
- Consider HIV postexposure prophylaxis
- Hepatitis B vaccination if the immunization status is unknown or negative
- HPV vaccination should be offered to all 9- to 26-year-old women and 9- to 21-year-old men.
- Provide oral
- Psychological support: Facilitate contact with sexual assault crisis programs for counseling.
- Timing: approx. 1–2 weeks after the event
- With the same physician or another appropriate provider
- Repeat STD screening (gonorrhea, chlamydia, trichomonas) in patients who declined empiric antibiotic treatment.
- Complete vaccination schedules.
- Repeat pregnancy test.
- Assess psychological status and how the patient is coping with the trauma.
- Provide referrals to a psychiatrist if needed.
- Mandatory reporting laws vary across states and jurisdictions, but physicians should be aware of their ethical obligation to report sex crimes and protect their patients.
- Physicians should familiarize themselves with the laws in their jurisdiction regarding mandatory reporting of suspected sex crimes.
- PTSD: sexual assault is one of the most common causes of PTSD in both men and women
- Anxiety disorders
- Chronic pelvic pain
- Sexual dysfunction
- Substance use disorders (e.g., sedatives, stimulants, analgesics)
- Any form of physical, sexual, psychological, financial mistreatment or neglect of an elderly person (> 60 years of age) at the hands of a caregiver or someone the individual trusts. 
- Vulnerable adult: a person who is or may be mistreated and who because of age and/or disability is unable to protect him or herself.
- Statistics: Approx. 3–10% of elders experience abuse at some point. 
Circumstances that may facilitate abuse
- Social isolation
- Lack of support
- Living in a shared living facility with a large number of household members
- Warning signs and symptoms 
- Detailed medical history
- Distinguish between intentional injuries and age-related conditions. (e.g., poor wound healing, osteoporosis, dementia, adverse effects of prescribed medication)
- Laboratory analysis
- Mandatory reporting laws vary across states and jurisdictions, but physicians should be aware of their ethical obligation to report elder abuse and protect their patients.
- Physicians should familiarize themselves with the laws in their jurisdiction regarding mandatory reporting of suspected elder abuse.
- Any form of actual or threatened physical or emotional harm committed by one member of a household against another, frequently used as an extension power
- Intimate partner violence (IPV): any form of physical, emotional, or sexual violence that is carried out by a cohabitating or noncohabitating intimate partner against the other 
- Statistics: Approx. 1:3 women and 1:10 men ≥18 years of age experience domestic violence. 
- Discord in the partnership; may be associated with a history of restraining orders and/or substance use
- Lower levels of education and socioeconomic status correlate with higher rates of domestic violence
- Perpetrator with history of abuse during childhood
- Rates of IPV are higher in women with a history of abuse and during pregnancy and the postpartum period
Warning signs and symptoms
- Multiple, unusual, and/or unexplained injuries (e.g., defensive wounds, injuries that appear inconsistent with history)
- Fearful, avoidant, hostile behavior (e.g., avoid eye contact)
- Signs suggesting hesitation to seek medical care (e.g., multiple injuries and bruises at varying stages of healing, injuries consistent with the timeline provided in history, history of missed appointments)
- History of frequent visits to the ER
- Evaluate for psychological trauma (e.g., signs of depression or substance use)
- Domineering partner: violent partners may insist on accompanying the patient and speaking on the patient's behalf.
- Document all evidence of abuse for potential legal action against the perpetrator.
- Physicians suspecting domestic violence should speak privately with the patient, inquire further, and offer assistance.
- Show empathy and willingness to provide continuous support.
- Treat injuries
- Physicians do not have a legal right to report domestic violence without patient consent.
- Facilitate contact to support services.
Preventing sexual violence
STOP SV strategy
- Definition: A technical package developed by the CDC to prevent sexual violence, mitigate its effects, address its social determinants, and facilitate access to services for individuals who have experienced violence
- S: promote social norms that inhibit violence (e.g., educating children and mobilizing men and boys to become allies against sexual violence)
- T: teach skills to prevent sexual violence (e.g., teaching safe dating and healthy intimate relationship skills, promoting healthy sexuality)
- O: provide opportunities to empower and support girls and women (e.g., strengthen economic support for families and facilitate leadership opportunities)
- P: create protective environments (e.g., monitoring in schools, addressing community-level risks, improving safety)
- SV: support victims/survivors to lessen harms (e.g., support centers, treatment of victims/survivors, and at-risk families)
Preventing intimate partner violence
- The U.S. Preventive Services Task Force (USPSTF) recommends screening all women of reproductive age for IPV.
- There is limited evidence for the effectiveness of screening for IPV in men, female individuals not of reproductive age, and elderly individuals.
- While there is no evidence for any appropriate screening interval, many sources still recommend routine annual screening. 
- However, screening is generally recommendable in vulnerable patients and such deserving of special protection (e.g., pregnant or disabled women) as well as in the presence of circumstances of risk (e.g., unstable household, history of abuse, substance use) or signs of violence (e.g., unexplained bruises, burns, or cuts).
- In all other patient groups, settings such as the first visit to a (new) family physician, gynecologist, or hospital admission may provide a beneficial opportunity for screening and education.
- Screening can help to address immediate threats and prevent long-term IPV-associated impacts (e.g., post-traumatic stress disorder).
- Screening for domestic violence and IPV should be conducted in an open, nonjudgemental, and nonstigmatizing setting.
- Broaching the topic may be facilitated by pointing out the routine nature of the assessment and politely asking if the patient is comfortable with discussing the topic (e.g., “I routinely screen all my patients for violence in their relationships, so I hope you don't mind me asking you a few questions regarding this topic?”).
- All of the following screening tests should be considered positive if the patient answers one or more questions with “yes.”
HARK screening tool: a four-question screening tool that assesses for different manifestations of IPV within the past year
- H: Has your partner humiliated or emotionally abused you?
- A: Are you sometimes afraid of your partner?
- R: Have you ever experienced rape or been forced to have any kind of sexual activity by your partner?
- K: Has your partner kicked, hit, slapped, or otherwise physically hurt you?
HITS screening tool: a four-question verbal or written screening tool used to assess how often an individual has been hurt by the intimate partner
- H: Does your partner physically hurt you?
- I: Does your partner insult you or talk down to you fairly often?
- T: Does your partner threaten you with harm?
- S: Does your partner scream or curse at you fairly often?
STaT questions: a three-question screening tool used to identify IPV
- S: Have you ever been in a relationship where your partner has pushed or slapped you?
- T: Have you ever been in a relationship where your partner threatened you with violence?
- T: Have you ever been in a relationship where your partner has thrown, broken, or punched things?
Partner Violence Screen tool (PVS): a three-question screening tool used to assess physical abuse and safety
- Is there a partner from a previous relationship who is making you feel unsafe now?
- Do you feel safe in your current relationship?
- Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
Woman Abuse Screening Tool (WAST): an eight-question screening tool used to assess IPV.
- Has your partner ever abused you sexually?
- Has your partner ever abused you emotionally?
- Has your partner ever abused you physically?
- Do you ever feel frightened by what your partner says or does?
- Do arguments ever result in hitting, kicking, or pushing?
- Do arguments ever result in you feeling down or bad about yourself? Often, sometimes, never?
- Do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty?
- In general, how would you describe your relationship? A lot of tension, some tension, no tension?
- Provide immediate and ongoing support (counseling and home visits)
- See “” above.
Preventing elder abuse
- The USPSTF has found no reliable, valid screening tools for primary care settings to identify abuse of elderly or vulnerable adults.
- There is still no evidence that screening of elder or vulnerable adults abuse reduces exposure to abuse, harm, or mortality in elderly or vulnerable adults.