IzBen C. Williams, MD, MPH
Instructor
Lecture # 19
AGGRESSION
AND
ABUSE
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
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:




frequently have moved and changed schools repeatedly
Have been physically and/or sexually abused
Mistreat animals, and
Cannot defer gratification
Their parents frequently display criminal behavior, and
abuse drugs or alcohol
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
Aggression
B. Biological determinants of Aggression
1. Hormones
a.
b.
c.
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
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
Estrogen, progesterone, and antiandrogens may be
useful in treating male sex offenders
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)
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)
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
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
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
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
Sexual Aggression:
Rape and Related Crimes
C. Characteristics of rapist and victim
1. The rapist
a.
b.
c.
d.
Rapists are usually younger than 25 years of age
They are usually the same race as the victim
They are usually known to the victim
They often use alcohol
The victim
2.
1.
2.
3.
Rape victims are typically between ages 16-24
Rape commonly occurs within the victim’s home
There may be no vaginal injuries
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
Sexual Aggression:
Rape and Related Crimes
E. The role of the physician in rape cases
1. Immediately after the rape the physician should
a.
b.
c.
d.
Take the patient’s history in a supportive manner and
not question the patients veracity or judgment
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)
Prescribe prophylactic antibiotics and take post coital
contraceptive measures (eg. diethylstilbestrol)
Encourage patient to notify the police. The doctor is not
required to notify the police if the woman is a competent
adult
Sexual Aggression:
Rape and Related Crimes
E. The role of the physician in rape cases
2. Up to six weeks after the rape
a.
b.
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
Do a pregnancy test and repeat other laboratory
tests if appropriate
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 or leaves him. In fact, there is a
greatly increased risk that he would.
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
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
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
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
Abuse and Neglect of Children
and the Elderly
B. Sequelae of child abuse
Children who are being abused often seem sad, show
personality changes and do poorly at school
Adults who were abused as children are more likely to
1.
2.
i.
ii.
iii.
iv.
Have dissociative disorders (eg. Dissociative identity
disorder ) and borderline personality disorder
Have PTSD and other anxiety disorders
Have depression and substance abuse disorders
Abuse their own children
Abuse and Neglect of Children
and the Elderly
C. Sexual abuse of children
1. Signs
a.
b.
c.
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
Genital or anal trauma, recurrent UTIs and excessive
initiation of sexual activity with friends are also
signs of sexual abuse
Young children have only a vague knowledge of
sexual activities. Specific knowledge about sexual
acts (eg fellatio) often indicates sexual abuse
Abuse and Neglect of Children
and the Elderly
C. Sexual abuse of children
2. Occurrence
a.
b.
c.
An estimated 500,000 children in the US are sexually
abused per year
Most sexually abused children are 8-13 years of age;
25% are younger than 8 years old
Approximately 20% of women and 5-10% 0f men
report sexual abuse at some time during their
childhood and adolescence
Abuse and Neglect of Children
and the Elderly
C. Sexual abuse of children
3. Characteristics of sexual abuser
a.
b.
c.
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
Alcohol and drugs are commonly used by the
abuser
The abuser typically has marital problems and no
appropriate alternative sexual partner;
occasionally he is a pedophile
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
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
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.
b.
c.
d.
e.
f.
Document the abuse
Ensure the safety of the abused person
Develop an emergency escape plan for the abused
Provide emotional support for the abused person
Refer abused person to an appropriate shelter or program
Encourage the abused person to make report to law enfor.