Abuse is defined as any thing that is harmful, injurious, or offensive. Abuse also includes excessive and wrongful misuse of anything. There are several major types of abuse: physical and sexual abuse of a child or an adult, substance abuse, elderly abuse, and emotional abuse.
Physical abuse of a child is the infliction of injury by an other person. The injuries can include punching, kicking, biting, burning, beating, or pulling the victim's hair. The physical abuse inflicted on a child can result in bruises, burns, poisoning, broken bones, and internal hemorrhages. Physical assault against an adult primarily occurs with women, usually in the form of domestic violence. It is estimated that approximately three million children witness domestic violence every year.
Sexual abuse of a child refers to sexual behavior between an adult and child or between two children, one of whom is dominant or significantly older. The sexual behaviors can include touching breasts, genitals, and buttocks; either dressed or undressed. The behavior can also include exhibitionism, cunnilingus, fellatio, or penetration of the vagina or anus with sexual organs or objects.
Pornographic photography is also used in sexual abuse with children. Reported sex offenders are 97% male. Females are more often perpetrators in child-care settings, since children may confuse sexual abuse by a female with normal hygiene care. Sexual abuse by stepfathers is five times more common than with biological fathers. Sexual abuse of daughters by stepfathers or fathers is the most common form of incest.
Sexual abuse can also take the form of rape. The legal definition of rape includes only slight penile penetration in the victim's outer vulva area. Complete erection and ejaculation are not necessary. Rape is the perpetration of an act of sexual intercourse whether:
- will is overcome by force or fear (from threats or by use of drugs).
- mental impairment renders the victim incapable of rational judgment.
- if the victim is below the legal age established for consent.
- recurrent substance use resulting in failure to fulfill obligations at home, work, or school.
- using substance in situations that are physically dangerous (i.e., while driving).
- recurrent substance-related legal problems.
- continued usage despite recurrent social and interpersonal problems (i.e., arguments and fights with significant other).
Abuse in the elderly is common and occurs mostly as a result of caretaker burnout, due to the high level of dependency frail, elderly patients usually require. Abuse can be manifested by physical signs, fear, and delaying or not reporting the need for advanced medical care. Elderly patients may also exhibit financial abuse (money or possessions taken away) and abandonment.
Emotional abuse generally continues even after physical assaults have stopped. In most cases it is a personally tailored form of verbal or gesture abuse expressed to illicit a provoked response.
Causes and symptoms
Children who have been abused usually have a variety of symptoms that encompass behavioral, emotional, and psychosomatic problems. Children who have been physically abused tend to be more aggressive, angry, hostile, depressed, and have low self-esteem. Additionally, they exhibit fear, anxiety, and nightmares. Severe psychological problems may result in suicidal behavior or posttraumatic stress disorder. Physically abused children may complain of physical illness even in the absence of a cause. They may also suffer from eating disorders and encopresis. Children who are sexually abused may exhibit abnormal sexual behavior in the form of aggressiveness and hyperarousal. Adolescents may display promiscuity, sexual acting out, and—in some situations—homosexual contact.
Physical abuse directed towards adults can ultimately lead to death. Approximately 50% of women murdered in the United States were killed by a former or current male partner. Approximately one-third of emergency room consultations by women were prompted due to domestic violence. Female victims who are married also have a higher rate of internal injuries and unconsciousness than victims of stranger assault (mugging, robbery). Physical abuse or rape can also occur between married persons and persons of the same gender. Perpetrators usually sexually assault their victims to dominate, hurt, and debase them. It is common for physical and sexual violence to occur at the same time. A large percentage of sexually assaulted persons were also physically abused in the form of punching, beating, or threatening the victim with a weapon such as a gun or knife. Usually males who are hurt and humiliated tend to physical assault persons whom they are intimately involved with, such as spouses and/or children. Males who assault a female tend to have experienced or witnessed violence during childhood. They also tend to abuse alcohol, to be sexually assaultive, and are at increased risk for assaultive behavior directed against children. Jealous males tend to monitor the women's movements and whereabouts and to isolate other sources of protection and support. They interpret their behavior as betrayal of trust and this causes resentment and explosive anger outbursts during periods of losing control. Males may also use aggression against females in an effort to control and intimidate partners.
Abuse in the elderly usually occurs in the frail, elderly community. The caretaker is usually the perpetrator. Caretaker abuse can be suspected if there is evidence suggesting behavioral changes in the elderly person when the caretaker is present. Additionally, elderly abuse can be possible if there are delays between injuries and treatment, inconsistencies between injury and explanations, lack of hygiene or clothing, and prescriptions no being filled.
Children who are victims of domestic violence are frequently injured attempting to protect their mother from an abusive partner. Injuries are visible by inspection or self-report. Physical abuse of an adult may be also be evident by inspection with visible cuts and/or bruises or self report.
Sexual abuse of both a child and an adult can be diagnosed with a history from the victim. Victims can be assessed for ejaculatory evidence from the perpetrator. Ejaculatory specimens can be retrieved from the mouth, rectum, and clothing. Tests for sexually transmitted diseases may be performed.
Elderly abuse can be suspected if the elderly patient demonstrates a fear from the caretaker. Additionally, elderly abuse can be suspected if there are signs indicating intentional delay of required medical care or a change in medical status.
Substance abuse can be suspected in a person who continues to indulge in their drug of choice despite recurrent negative consequences. The diagnosis can be made after administration of a comprehensive bio-psychosocial exam and standardized chemical abuse assessments by a therapist.
Children who are victims of physical or sexual abuse typically require psychological support and medical attention. A complaint may be filed with the local family social services that will initiate investigations. The authorities will usually follow up the allegation or offense. Children may also be referred for psychological evaluation and/or treatment. The victim may be placed in foster care pending the investigation outcome. The police may also investigate physical and sexual abuse of an adult. The victim may require immediate medical care and long-term psychological treatment. It is common for children to be adversely affected by domestic violence situations and the local family services agency may be involved.
Substance abusers should elect treatment, either inpatient or outpatient, depending on severity of addiction. Long term treatment and/or medications may be utilized to assist in abstinence. The patient should be encouraged to participate in community centered support groups.
The prognosis depends on the diagnosis. Usually victims of physical and sexual abuse require therapy to deal with emotional distress associated with the incident. Perpetrators require further psychological evaluation and treatment. Victims of abuse may have a variety of emotional problems including depression, acts of suicide, or anxiety. Children of sexual abuse may as adults enter abusive relationships or have problems with intimacy. The substance abuser may experience relapses, since the cardinal feature of all addictive disorders is a tendency to return to symptoms. Elderly patients may suffer from further medical problems and/or anxiety, and in some cases neglect may precipitate death.
Prevention programs are geared to education and awareness. Detection of initial symptoms or characteristic behaviors may assist in some situations. In some cases treatment may be sought before incident. The professional treating the abused persons must develop a clear sense of the relationship dynamics and the chances for continued harm.
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National Clearinghouse on Child Abuse and Neglect Information. 330 C Street SW, Washington, DC 20447. (800) 392-3366.
Elder Abuse Prevention. <http://www.oaktrees.org/elder>.
National Institute on Drug Abuse. <http://www.nida.nih.gov>.
Laith Farid Gulli, M.D.
Bilal Nasser, M.Sc.
Encopresis—Abnormalities relating to bowel movements that can occur as a result of stress or fear.