Domestic Violence in Healthcare

Statistics

One study showed that 37% of all women who sought care in hospital emergency rooms presented with violence-related injuries from a current or former spouse, boyfriend, or girlfriend.

Another study that surveyed patients in 24 different Emergency Departments and Primary Care Clinics determined that 58.1% of patients were physically abused in their lifetime, and 20.4% were currently physically abused. 67.7% of patients experienced lifetime emotional abuse, while 37.8% were currently experiencing emotional abuse.

Families in which domestic violence occurs visit doctors eight times more, visit emergency rooms six times more often, and use prescription drugs six times more than the general population.

In addition to acute physical injuries sustained by women during a physical episode, abuse is linked to a number of adverse medical effects:

  • Chronic neck or back pain
  • Migraines
  • Sexually Transmitted Diseases
  • Chronic Pelvic Pain
  • Peptic Ulcers
  • Irritable Bowel Syndrome
  • Frequent Indigestion
  • Constipation
  • Diarrhea


Optimal management of chronic illnesses such as diabetes, HIV/AIDs, hypertension, and gastrointestinal disorders can be problematic in women who are abused. Often times the perpetrator controls the victim’s access and compliance with health treatment.

Mental Health

Women who are victims of battering often suffer from several mental health conditions:

  • 37% of battered women have symptoms of depression
  • 46% have symptoms of anxiety disorder
  • 29% of all women who attempt suicide were battered


Battering In Pregnancy

0-70% of women abused before pregnancy are abused during pregnancy

There are many consequences of pregnancy-related violence. Women who are battered during pregnancy are more likely to delay prenatal care , deliver low birth weight babies, have premature labor, and experience fetal trauma

Pregnant women who are victims of domestic violence are more likely to suffer from depression and suicide, as well as engage in tobacco, alcohol and drug use during pregnancy.

Costs of Healthcare

The health related cost of domestic violence, rape, stalking and homicide exceed $5.8 billion a year. Nearly $4.1 billion are spent on direct medical care and mental health care services, and $900 million are indirect costs of lost productivity and wages of victims.

When a domestic violence screening and referral model was implemented in a managed care setting in California, the number of victim identification increased 260%. Assessing for domestic violence increased patient satisfaction with the physicians’ efforts to address domestic violence and offering themselves as a resource for domestic violence assistance.

Surveys show that 89% of patients would disclose abuse to their physicians, but 46% would only disclose abuse if specifically asked about it.

Patient’s Requests for Assessment

70-81% of survivors of abuse reported that they wanted their healthcare provider to privately ask them about domestic abuse during their appointment.

Another study found that 83% of women patients surveyed thought it was a good idea to screen for DV.

When asked about factors that would enable patients to more easily disclose abuse to their doctors, patients identified physicians asking directly about abuse as the number one factor.

Lack of Current Assessment

Physician Barriers to Assessment

  • Lack of training
  • Confusion about the boundaries between which normal conflict becomes abuse
  • Overlook patients that do not look like DV victims
  • Might be offensive to patient
  • Management takes too much time
  • Fear of retaliation from patient’s partner.


Patient’s Barriers to Disclosure

  • Fear
  • Ignorance that they could confide in their doctor
  • Thought abuse was controllable
  • Did not go to the doctor
  • Partner preventing them from being alone with doctor or preventing them from receiving medical care
  • Shame and denial
  • Fear of consequences to children
  • Not ready to change relationship.


Setting the Stage for Assessment

Always make sure patient is alone and not accompanied by abuser, family members, or children.

If the patient does not speak your language, provide that a professional interpreter is used. Do not ask questions when the patient’s partner/family members/children are interpreting.

When taking about domestic violence, trust is an important factor in the decision to disclose abuse. Show caring and concern for the patient’s well being. Use eye contact and nonjudgmental facial expressions. Do not seem rushed, impatient, or frustrated. Patients can perceive impatience and judgment in speech and looks.

It is important to ensure the privacy of the patient when assessing for domestic violence. You may have to think of some creative tactics, such as telling a accompanying partner that it is your policy to see patients alone, in order to get the patient by themselves for the assessment.

Framing Question

The goal is to normalize the issue, which is the same tactic used when asking patients about other sensitive issues, such as drugs/alcohol and sexual orientation.

Examples

  • “Violence can be a problem in many people’s lives, so I now ask every patient I see about Domestic Violence”
  • “I don’t know if this is a problem for you, but many of the women I see as patients are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I’ve started asking about it routinely”.

After the Stage is Set with a Framing Question, Follow with Direct Questions about Domestic Violence

These questions have been found very successful in determining whether abuse is present in the relationship:

  • “Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?”
  • “Do you feel safe in your current relationship?”
  • “Is there a partner from a previous relationship who is making you feel unsafe? How?”

If abuse is disclosed, use follow up questions to determine the pattern and severity of the abuse.

Current Episode - Examples:

  • “How were you hurt?”
  •  “Was a weapon involved?”

Prior Episodes/Abuse History

  • Ask about the first time, the worst time, and the most recent time.

Examples:

  • “Do you recall when the abuse began?
  • Can you tell me about the worst time?
  • Can you tell me about the most recent time?” child

Children’s Issues

Patient must understand before questioning the physician’s role of a mandated reporter. This will be discussed in the children section of training.

Example Questions:

  • “Have the children ever seen or heard your abuse?”
  • “Have the children ever been threatened or hurt?”

Questions to Avoid:

Victim blaming statements

  • “Why don’t you leave?”
  • “What did you do to cause him to hit you?”
  • “How did you make him mad?”

These statements place blame on the victim instead of the perpetrator. If the patient denies abuse, but you believe she may be at risk, discuss the specific risk factors of abuse and offer resources and information about domestic violence. Sometimes, in cases in which abuse is highly suspected, further questioning may open the door to disclosure.

Example:

  • “When I see injuries like this, it really makes me concerned about domestic violence.”

If a patient does not choose to disclose abuse, the provider’s inquiry can often communicate support and increase the likelihood of future discussion of the issue.

For a patient that does not disclose DV, a physical exam could also be a gateway into uncovering Domestic Violence.

Be on the lookout for Suspicious Findings that could be violence-related:

  • Injury to face, torso, breasts, or genitals
  • Bilateral or multiple injuries
  • Delay between injury and care
  • Explanation by patient inconsistent with injury
  • Multiple injuries in various stages of healing
  • Chronic pain without apparent etiology
  • Psychological Distress
  • Evidence of rape
  • Pregnant women with any injury
  • Partner’s demeanor and attitude.

Document

Reasons to Document

Medical records are a good source of evidence for court cases. They can help prosecute perpetrators of violence and keep victims and their children safe. A well-written documentation can also keep the physician from having to testify in court.

A provider or institution can also be held accountable for failure to diagnose and record abuse and for not delivering necessary care. Proper documentation can protect providers against liability.

Written Descriptions

Document the current and history of abuse. Include who, what, where, how and when in the patient’s own words. Set off the patient’s words in quotation marks or use phrases such as “Patient states”. A statement about an injury in which the patient is documented as the direct source of information is more likely to be accepted as evidence in court.

Record the person who hurt the victim. Record the time of day the patient was seen and indicate the amount of time that has elapsed since the incident occurred.

Describe the patient’s demeanor, for example, whether she is crying, angry, scared, shaking, etc.

Document any weapons used, and the patient’s account of any threats made or other psychological abuse.

Body Map of Injuries

A “body map” is a drawing of the human figure used by physicians. In domestic violence protocols, body maps can document the locations, size, and age of injuries observed during a medical examination.

Photographs

  • Photograph all injuries.
  • Use a ruler in the picture to show the size of the wound/bruise.
  • Take photos before medical treatment is given.
  • Include the patient’s face in at least one photograph.
  • Mark photos with name of patient, date, and location of injury.
  • Schedule a follow up appointment with the patient to take more photographs. Some injuries, such as bruises, may not be apparent immediately after a physical assault.


Special Considerations

When documenting abuse, keep record in a place that perpetrator cannot access it. For example, do not keep a medical chart at the foot of the bed or in the room of a patient.

Never give the chart to the victim to carry to outpatient services (ex. X-rays) if accompanied by abuser.

 

It is important to realize that the patient knows her situation the best. Only she knows when it is safe for her and her children to leave, if she decides to do so. Medical intervention is used not only to provide information and resources to the patient about domestic violence, but to develop a plan to protect her safety and improve her health. It is ultimately her choice, however, on how she wishes to utilize this information.

Medical Treatment
The first priority is to provide the necessary medical treatment that the patient needs.

Communicate Concern

  • Provide Validating Messages
    • There is no excuse for abuse
    • You are not to blame
    • No one deserves to be abused
    • You are not alone in figuring this out
    • There may be some options
    • I will support your choices
    • I am concerned for your safety

Empower the victim by letting her know that she has the potential to make sensible choices about her well being and safety.

Provide Information About Domestic Violence

  • DV is common
  • DV often increases in frequency and severity over time
  • Children can be affected by being part of the abuse or by witnessing the abuse
  • You deserve to be free from violence
  • Convey that abuse is wrong, unacceptable and against the law

Past Abuse
For a patient who discloses past but not current abuse, communicate concern about her past experiences and the effects it has had on her health. woman

Examples:

  • “What happened to you may be related to health problems now.
  • How do you feel about this now?
  • Is there anything I can do for you?

If the patient feels that the abuse if still negatively affecting them, offer to make referrals to a mental health professional, DV advocate, or socia; worker depending on her needs.

Risk Assessment
Determine the immediate safety needs of the victim.

Question(s) to Consider:

  • Is the domestic violence victim in immediate danger? Where is the perpetrator now? Does the patient want or need security/police to be notified immediately?

Assess the patient’s risk of significant harm/injury. Ask about perpetrator’s use of tactics:

  • Use of weapons
  • Escalation in frequency or severity of abuse
  • Employment status
  • Stalking
  • Homicide or suicide threats
  • Use of alcohol or drugs
  • Attempts of strangulation or suffocation

If the patient’s safety is in question, recommend that the patient stays somewhere that will be safe for herself and her children. Remind the patient that the perpetrator may know where to find the victim if she stays at a friend’s or family member’s house, and this may not be the safest option for her.

Discuss resources that are available
A study showed that 84% of patients identified as DV victims agreed to see a crisis advocate. 54% of the patients who saw the advocate linked with at least one community agency for further assistance. Never refer a DV victim to couples counseling. Couples counseling is used for marital problems. Battering, however, is a crime, not a marital problem. The perpetrator is solely responsible for his behavior, and only he alone is capable of changing it.

Depending on the community, several resources may be available, including:

  • Shelter
  • Legal Help
  • Children Services
  • Counseling
  • Social Welfare Services

Safety Planning
Whether the victim decides to leave her abuser or stay, a safety plan can be a life-saving intervention. Take a moment to brainstorm some ideas that might be included in a patients safety plan.

Safety plans include:

  • How to keep safe during a violent episode.
  • Places the victim can go in case they need to leave their residence.
  • What the victim should prepare when planning to leave (important documents, extra clothes, money, etc).
  • How to keep safe in the home if the perpetrator is removed.
  • How to keep safe at work or in public places. How to keep their children safe during violent episode.

An example of a safety plan that can be used with patients can be printed from the "additional materials".

Schedule future appointments.

Ensure that the patient has a connection to a primary health provider.

At follow up visits, review medical records about past episodes of domestic violence in order to communicate a concern for patients and a willingness to address this health issue openly. This is also an opportunity to review and modify the patient’s safety plan.

Realize that it often takes several attempts for women to leave their batterer. Women may return for several appointments and be in the same situation. Continue to offer your support and availability as a resource if and when she decides it is safe to leave.