Domestic Violence by ZM95ea0


									Domestic Violence

  Cathleen Ligman, MD FACS
         May 21, 2010
• No Disclosures
• A pattern of coercive control consisting of
  physical, sexual, and/or psychological assault
  against a former or current intimate partner.
  – Includes male and female victims

  – Includes homosexual and heterosexual relationship

  – Majority of cases - female is victim and male is
• Domestic violence of adults is a separate
  category from child or elder abuse
  – Based on beneficence and nonmaleficence because
    children are unable to make informed decisions and
    elders may be incapacitated or disabled

  – Battered women generally have intact decision
    making capabilities
• Domestic violence is usually a chronic
        repetitive phenomenon
• Associated with psychological abuse and
             verbal intimidation
                   Characterized by:
    • A man who seeks to dominate his partner both
                physically and emotionally
• By a woman who is afraid to leave the relationship
  because of psychological and/or financial dependency
• The more extreme forms of domestic violence, including
    homicide, are usually the endpoints of long abusive

• 44% of domestic violence homicide victims presented to
  the ER in the year before their death

• 93% with an injury-related complaint

  Wadman, et al., 1996
• Estimated to be the
  leading cause of
  serious injury and the
  second leading cause
  of injury and death of
  women of child-bearing

         Grisso, et al., 1991
• 1 of every 4 women (27%) using
  emergency departments has a history
  of physical or nonphysical partner
  violence in the previous year. (Feldhaus,
   et al., 1997)

• Prevalence varies 8-27% in studies
  due to population differences and the
  definition of domestic violence. (Sisley,
   et al., 1999)

• Rates of domestic violence are
  highest in the 16-24 year old age
  group and for couples younger than
  30 years
• ED visits are highest among women
  age 25-34
• Extends across racial and social
                          Index year of assault
                          -Victims increased PCP visits by 15% and
                             by 31% in the subsequent year
                             compared with previctimized levels.
                          Koss, et al.,1991

12 month period after the incidence of
domestic violence
-Victims use the health care system
twice as frequently as nonabused
-Sustain health care costs 2.5 times
higher than nonabused women

Richardson, et al.,1996
Dutton, et al., 1996
• Increased somatic
  –   Headaches
  –   Ulcers
  –   Hypertension
  –   Pelvic pain
  –   Psychological
       • Major depression
       • Increased suicide rates
       • Substance abuse
   Pregnancy and Domestic Violence
• 1 in 12 women were physically battered during
  pregnancy when surveyed in a metropolitan hospital.
   – More common than pre-eclampsia or placenta previa

• Among those:
   – 87% were abused before pregnancy
   – 29% reported increased abuse after becoming pregnant
• Abused women have higher rates of:
   – miscarriage
   – low maternal weight gain
   – low birth-weight infants

                                              McFarlane, 1989
• Often ignored is the impact of exposure to
  domestic violence on children
  – 85% of assaults were directly witnessed by
     • None were referred for any form of intervention

                                             Brookoff, et al., 1997
• Abusive men were more likely to witness
  parental violence than nonabusive men.

• Women who witnessed parental violence are
  more likely to become a victim of domestic

                                    Hoteling, et al., 1986.
        Identifying Victims - History

• Delay in seeking care for an injury
• Injury and history are inconsistent
• History of multiple ED visits for injuries, vague
  complaints, headaches, depression or anxiey
• Pregnancy – late or no prenatal care
• Suicide attempt or gesture
      Identifying Victims - Behaviors

• Afraid to speak in front of partner
• Embarrassed, evasive
• Highly anxious, inappropriate emotional
• Listless, passive, flat affect
• Withdraws quickly to physical contact
 Identifying Victims – Partner Behavior

• Overly attentive, will not leave patient alone
• Speaks for the patient
• Anger or indifference toward patient
• Intimidating to staff
  Injuries Suspicious for Battering
• Soft tissue injuries
  – Head and neck, orbit
  – Lips/oral cavity
  – Forearms – defensive
  – Trunk, breasts, buttocks
  – Genital/rectal area

• Fracture/dislocations of
  face or extremities
   Injuries Suspicious for Battering
• Bruises
   – Multiple areas
   – Different stages of healing
   – Pattern reflecting hand,
     finger marks, belt, shoe,
• Blunt abdominal trauma
   – Vomiting, pain,
     tenderness, hematuria,
   – If pregnant – premature
     labor, vaginal bleeding,
     abruption, fetal demise.
Injuries Suspicious for Battering
• Choking
  – 50% have symptoms
    without physical signs
  – Ligature or finger marks on
  – Petechiae above markings,
  – Hoarseness, difficulty
    swallowing, dyspnea,
  – Unexpected stroke in a
    young patient
       Diagnosis of Domestic Violence

• Difficult
   –   No consistent domestic profile
   –   Battered women rarely offer information
   –   No distinctive pattern of injury
   –   Obvious signs are usually absent

• Explicit questioning increases its detection
“due to the prevalence and medical
  consequences of domestic violence,
  physicians should routinely inquire about
  abuse as part of the medical history.”
                The Council on Ethical and Judicial Affairs
                of the American Medical Association
• JAHCO Guidelines and California law require
  routine screening for victims of domestic
• All women seeking care in emergency
  departments should be asked directly about
  partner violence, regardless of marital status or
  current relationships.
• Ask about acute as well as past exposure to
  partner violence.
 How to Ask About and Respond to
        an Abused Patient
• Asking:
  – Does a partner or anyone at home hurt, hit or
    threaten you?
  – “Sometimes when I see an injury like this it was
    caused by someone else. Did someone do this to
  – Start with a “framing” statement:
    “I don’t know if this is a problem for you, but….”
    “Since this can affect health, we routinely ask all our
 How to Ask About and Respond to
        an Abused Patient
• Responding:
  – Be supportive and nonjudgemental
  – “I’m very sorry to hear this is happening.”
  – “This isn’t your fault.”
  – “No one deserves to be treated this way.”
  – “You are not alone – help is available.”
•   3 questions will detect 65-70% of domestic
    violence victims when asked in a
    nonjudgemental manner with the patient’s
    partner not present:
    1) Have you been hit, kicked, punched, or otherwise
       hurt by someone within the past year? If so, by
    2) Do you feel safe in your current relationship?
    3) Is there a partner from a previous relationship who is
        making you feel unsafe now?
                                    Feldhaus, et al., JAMA 1997
   Reasons patients fail to disclose
• Shame, embarrassment
• Belief the batterer can change
• Intense cultural, family, religious pressure to “make it
• Economic, immigration issues
• Fear of “outing” in same sex relationships
• Isolation by abuser, thinks no one cares
• Depression, anxiety, PTSD
• Threats of harm to patient’s pets, friends, or self
• Threats of harm to or abduction of children
• Lack of trust that the legal system can protect them
• Patients with a positive screen:
  – Document this history in the medical record
  – Treat the acute problem
  – Reassure the victim
     • That the behavior is unacceptable
     • That the problem is recognized
  – Determine whether there is immediate threat
  – Offered support, counseling
  – Offered referrals to safe shelters and assist with an
    action plan to ensure their future safety
• If immediate safety is a concern:
  – Involve hospital security
  – Admit under an alias if necessary
  – Document carefully
     • Use body maps
  – Involve social work or referrals
              Mandatory Reporting

• California law requires mandatory reporting for ages 18-
  64 if physical injuries are present from assaultive or
  abusive conduct
   – Any healthcare practitioner providing medical services for
     a physical condition
• Controversial
   – May fail to protect and create ethical dilemmas when
     patient does not want their case reported
   – Risk of retaliaton – studies show that batterers escalate
     violence if the partner seeks help or makes plans to leave
   – Takes away autonomy
• JAHCO (Joint Commission of Accreditation of
  Health Care Organization) requires EDs to have
  formal policies, procedures, and education in
  place specifically aimed at domestic violence.
   – In-hospital services
   – Referral lists
     •   Battered women’s shelters
     •   Criminal justice agencies
     •   Mental health agencies
     •   Providers of legal services
     •   General social services
• Healthcare workers often fail to identify or
  respond to domestic violence
• In a study of domestic violence in ED patients:
  – 40% of cases of known domestic violence, physicians
    made no response to the issue
  – In 92% of the cases, physicians made no referral for
    the abuse

• Results of a survey of 1,000 abused women
  showed they ranked healthcare professionals
  lowest in effectiveness in assisting them after
  battered women’s shelters, social service
  workers, clergy, police and lawyers.

  Bowker, et al., 1987
             Barriers to Identification

• A study of California EDs:
  – 23% provided an educational session on
    domestic violence for staff
  – 6% provided education for residents
  – 20% of Psychiatry residents received training
    in domestic violence

   McLoughlin, et al., 1993
            Barriers to Identification

• Lack of education of practicing physicians
  impedes identification and referral of victims.
  (Sisley, et al., 1999)

• Medical students with no ATLS training
  demonstrated better initial knowledge about
  domestic violence than groups of surgeons and
  ER physicians with previous ATLS training. (Davis,
  et al., 2000)
      Other Barriers to Identification

• Physician frustration over victims perceived
  unwillingness to leave the abusive partner
  – Lack of education regarding appropriate time course
• Lack of confidence in successful intervention
• Lack of resources
  – Fragmentation of community services
  – Overcrowded or underfunded shelters
Increasing Awareness and Detection of
          Domestic Violence
• Develop a curriculum for medical students,
  residents and physicians already in practice
  –   Epidemiology
  –   How to recognize behaviors
  –   Universal screening
  –   Appropriate documentation
  –   How to make referrals to hospital and community
Increasing Awareness and Detection of
          Domestic Violence
• Institute and support a policy of universal screening
   – Incorporate into standard H&P
• Promote the development of hospital based DV programs
• Advocate for increasing the number of beds or the funding for
• Develop interventions programs for children who witness
  domestic violence
• Promote the development of treatment programs for the
• Support the development of a national database for compiling
  domestic violence data
                             Referral and Educational Resources:
Family Abuse Prevention Council at Stanford: (for forms, reporting protocols, screening tools, etc.)
Hotlines (24/7):
Asian Women’s Home; 408-975-2739
California Youth Crisis Line: 800-843-5200
LGBT Partner Abuse/ Hate Crimes Hotline: 415-333-4357
Mid-Peninsula YWCA Rape:
              North County: 650-493-7273
              Central: 408-287-3000
              South County: 408-779-2115
National Domestic Violence Hotline: 800-799-7233 (140 languages available)
National Teen Dating Abuse Hotline: 866-331-9474
Next Door Solutions to DV (24 Hour Hotline): 408-279-2962 (English & Spanish)
Rape Crisis Hotline: local: 650-493-7273; national: 800-656-HOPE (4673)
Suicide & Crisis Hotline: 408-279-3312
Support Network for Battered Women: 800-572-2782

IPV Services & Referrals:
Catholic Charities: 408-944-0469
Community Solutions: 408-683-4118
Family Violence Center: 408-277-3700
Next Door Solutions to DV: 408-501-7550;
Support Network for Battered Women: 408-541-6100

Santa Clara County Agencies:
SC County Police Dept: 408-277-3700
Victim Witness Assistance: 408-295-2656
Victim Notification System (info on inmate’s release): 800-464-3568

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