Abuse

Intimate Partner Violence

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Intimate Partner Violence, Partner Violence, Partner Abuse, Spousal Abuse, Domestic Violence, Domestic Abuse, Interpersonal Violence, Battered Woman, Battered Women

  • Definitions
  1. Intimate Partner Violence
    1. Physical, sexual, emotional or economic abuse by a current or former intimate partner
  • Epidemiology
  1. Affects 12 Million people in U.S. each year
  2. Lifetime risks of physical Violence
    1. Women: 1 in 3
    2. Men: 1 in 7
  3. Incidence: 20-39% of women in primary care clinics
    1. 78% of women approve of Domestic Violence Screening
    2. Only 5% of women had been asked about Domestic Violence
    3. Bradley (2002) BMJ 324:271-4 [PubMed]
  4. Rates of Violence against men is increasing
    1. Women's injuries tend to be more severe
  • Risk Factors
  1. Age <35 years old
  2. Separated or divorced
  3. Pregnancy, peripartum or postpartum
  4. Disability
  5. Medical assistance or no insurance
  6. Higher depression or anxiety scores
  7. Drug or Alcohol Abuse
  8. Suicide attempts
  9. Broken bones, sprains, or serious cuts
  10. Substance Abuse by a partner
  • Screening
  1. Background
    1. Most Battered Women require 7 episodes on average to leave a relationship, due to many barriers
      1. Victims are at high risk of serious injury or death at times they leave perpetrator
      2. Fear and shame
      3. Children are threatened
      4. Perpetrator holds onto victims money, passport, identification
    2. Vigilent and systematic screening is key
      1. May result in providing patients the intervention at the right time to spare further injury or death
    3. Violence often involves others in the same household
      1. Child Abuse
      2. Elder Abuse
      3. Animal abuse
  2. See Intimate Partner Violence Screening
  3. SAFE Screen for Intimate Partner Violence
  4. HITS Screen for Intimate Partner Violence
  5. Women Abuse Screening Tool (WAST, WAST-SF)
  6. Partner Violence Screen
  7. Example scripts
    1. Excuse others in room
      1. "I have a few quick questions I ask all patients and then I will let you back into the room"
    2. With the patient alone
      1. "I have a few brief questions I ask everyone because Violence against women is common and serious."
    3. "The injuries you have do not seem to match the story. Can you tell me how this happened?"
    4. "Has anyone hit, kicked, choked or punched you in the last year?"
    5. "Forced or coerced you to have sex?"
    6. "Threatened you with a knife or gun to scare or hurt you?"
  • Signs
  1. Multiple injury sites in variable states of healing
  2. Injuries inconsistent with stated mechanism
  3. Delayed presentation for injuries
  4. Contusions, abrasions, burns or Lacerations (especially in areas hidden by clothes)
  5. Self-abuse or self-blame for injuries
  6. Tympanic Membrane Perforation
  7. Frequent emergency department or acute clinic appointment visits for seemingly minor complaints
  8. Trauma in Pregnancy
  9. Frequently missed appointments
  10. Partner present for appointment and controls visit (frequently speaks for the patient)
  11. Comorbid associated conditions, especially related to mental health (see below)
  12. Most common sites of injury in Battered Women
    1. Head, face and neck
    2. Chest
    3. Abdomen
    4. Muellman (1996) Ann Emerg Med 28(5):486-92 [PubMed]
  13. Strangulation Findings (see precautions below)
    1. Subconjunctival Hemorrhage
    2. Bruising or ligature marks at the neck
    3. Bruising behind the ears
    4. Facial Petechiae
    5. Dysphonia
    6. Dysphagia
    7. Neck Pain
    8. Drooling
    9. Dizziness
    10. Headache
  14. Other Injury patterns
    1. Defensive wounds at Forearms
    2. Ligature marks
    3. Linear or patterned markings from broom handle
    4. Shoe sole imprints
    5. Bite or burn injuries
    6. Fist or hand imprints (linear Bruises with central clearing)
  • Precautions
  • High risk situations for serious injury or lethality
  1. Recent escalation in Violence
  2. Available weapons
  3. Threats of serious harm or homicidality
  4. Chemical Dependency
  5. Significant fear on part of abused partner
  6. Strangulation Injury
    1. Consider CT angiography of carotid and Vertebral arteries (esp. for LOC, Dysphonia, Dysphagia)
    2. Predictor of death by Violence (10 fold increased risk)
  • Management
  • (Mnemonic: SOS-DoC Intervention)
  1. Approach
    1. Listen respectfully and demonstrate compassion
    2. Avoid condescending or judgemental language
    3. Keep questions open ended (as opposed to questions about specific experiences)
  2. Support and safety offered
    1. Talk in private offering good eye contact and emphasizing confidentiality
      1. "I'm sorry this has happened. This is not your fault. No person deserves to be abused..."
      2. Exceptions to confidentiality
        1. Suicidality or homicidality
        2. Mandatory reporting states (see below)
    2. Identify high risk for serious harm or lethality (see precautions above)
      1. "Are you and your children safe at home in the near future?"
  3. Options including safety planning and follow-up
    1. Discuss restraining orders, 911, shelters, resources
    2. Identify a safe point person of contact (e.g. relative, friend)
    3. "Do you have an emergency plan in case you need to leave?"
      1. Plan should include safe place, money, clothes, important papers
      2. Emergency bag (extra clothes, keys, money)
      3. Important papers: social security, birth certificate, driver's license, bank accounts, insurance, phone contacts
      4. Keep an adequate amount of money separate
      5. Notify a close friend
  4. Strength of patient is validated
    1. Strength to withstand circumstances and
    2. Courage to make the needed changes for patient and their children's safety
  5. Document observations, assessment and plan
    1. Careful documentation of history, exam, potential abuse, level of safety, and overall plan
  6. Continuity offered
    1. Involve social worker
    2. Discuss clinic and resource follow-up and eliminate barriers for access
    3. Assist with safety planning including safe places (as above)
    4. "Know that we'll always be available to talk to you"
  7. References
    1. Ambuel (1998) J Aggress Maltreat Trauma 1(2): 55-81 [PubMed]
    2. Cronholm (2011) Am Fam Physician 83(10): 1165-72 [PubMed]
  • Management
  • Mandatory Reporting
  1. Mandatory reporting varies by state in the U.S.
    1. http://www.acf.hhs.gov/sites/default/files/fysb/state_compendium.pdf
    2. In Minnesota, the state requires reporting abuse of minors and vulnerable adults
    3. In California, health care providers are mandated to report to police injuries due to Partner Violence
  2. Example script regarding mandatory reporting
    1. "I am going to do my best to ensure your safety and involve social work, "
    2. "I am also mandated by law to report this to the police"
  • Resources
  1. Futures without Violence
    1. https://www.futureswithoutviolence.org/
  2. National Coalition Against Domestic Violence (NCADV)
    1. http://www.ncadv.org/
  3. National Domestic Violence Hotline
    1. http://www.thehotline.org
    2. Phone: 1-800-799-7233 (1-800-799-SAFE)
  4. National Sexual Assault Online Hotline
    1. http://www.rainn.org/get-help/national-sexual-assault-hotline
    2. Phone: 1-800-656-4673 (1-800-656-HOPE)