Domestic Violence – SOGC 2005

Domestic Violence (Sexual, Physical, Psychological)

• Prevalence rates among pregnant and adolescent women appear to be greater
• All women, regardless of socioeconomic status, race, sexual orientation, age, ethnicity, health status, and presence or absence of current partner, are at risk

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1 In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (e.g., periodic annual exam, visits for anxiety/depression, ER visits).

• Queries about violence in
  • the behavioural health assessment of new patients,
  • at annual preventive visits,
  • as a part of prenatal care and
  • in response to symptoms or conditions associated with abuse
• Screen all pt, regardless of gender/sexual orientation – asking is the strongest predictor of disclosure
• Physicians should discuss IPV (intimate partner violence) and family violence with their patients in a routine, nonjudgmental manner.
• make clear, legible, and objective clinical notes, using the woman’s own words about abuse and adding diagrams and photographs when appropriate

Risk Factors

• Low SES 

• Disability

• Pregnancy

• Adolescent (18-24yo)

• Hx of abuse  

• Substance use

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 Identifying and Assessing Intimate Partner Violence

1. Identifying current violence
   • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?
   • Do you feel safe in your current relationship?
   • Is there anyone from a previous relationship who is making you feel unsafe now?
   • Is anyone forcing you to do something sexual that you do not want to do or following you or harassing you in the community?
2. Assessing history of violence
   • Have you ever been in a relationship in which your partner frightened you or hurt you?
   • When you were a child or adolescent, did anyone ever physically hurt you, force you to do something sexual you did not want to do, or hurt you psychologically (e.g., telling you that you were worthless or unwanted)?
   • As an adult, have you ever been physically hurt by anyone or forced to do something sexual you did not want to do?
3. Assessing general signs and symptoms of distress
   • Medical: fatigue, headache, gastrointestinal and cardiac symptoms, pelvic pain, sexual dysfunction,
   • ROS: chronic pain, description of frequent and vague symptoms,
   • Psych: substance abuse, anxiety or depression, PTSD, missed appointments, social isolation
   • In my experience, these types of signs and symptoms are sometimes caused or made worse by stress. Are there any sources of stress in your personal life, family life, or at work?
4. Assess specific causes of distress 
   • Use screening question(s) above to assess current and past violence
   • Assess depression, anxiety, alcohol or drug abuse, recent positive and negative life events, financial problems
   • Assessing specific signs and symptoms of violence
     • Injury:
       • reported mechanism inconsistent with findings;
       • multiple injury sites; repeated injury; contusions, abrasions, and minor lacerations to head, neck, torso, or abdominal, genital, or anal areas;
       • burns; fractures; sprains; injury during pregnancy; delay in seeking care
       • In my experience, this type of injury is sometimes caused by other people’s actions. Is anyone hurting you or frightening you?
     • Behavior:
       • patient describes partner as jealous, controlling, angry with patient or children;
       • partner attends appointments, controls discussion, cancels appointments, and/or shows angry, threatening, aggressive behavior
       • In my experience, this type of behavior sometimes suggests problems with safety in the home. Is anyone hurting you or frightening you?
5. Ask directly about current violence – If patient denies suspected abuse
   • Do not confront or challenge the patient, but express concern
   • Describe resources available to the patient, Offer follow-up and document findings

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2 In a patient in a suspected or confirmed situation of domestic violence:
a) Assess the level of risk and the safety of children (i.e., the need for youth protection).
b) Advise about the escalating nature of domestic violence.

3 In a situation of suspected or confirmed domestic violence, develop, in collaboration with the patient, an appropriate emergency plan to ensure the safety of the patient and other household members.

• Essential elements of health sector response include
  • document all info clearly for medico-legal purposes
  • risk assessment: determine immediate & long-term risk to pt and children (ask about weapons at home)
  • addressing the safety of children present in the home,
  • facilitation of a safety plan – make safe exit plan for all involved – safe place to go, essentials packed if needing a quick exit, provide emergency numbers to pt
  • effective referral and follow-up: involve shelter, social worker, counseling (marital counseling NOT appropriate while abuse occuring), domestic violence advocate
  • Reassure pt is not to blame & advice about escalating nature of domestic violence, especially during pregnancy!
• Providers should assess women disclosing violence for depression and suicide risk
• Women disclosing the presence of children at risk should be assisted by the reporting health professional in contacting their local child welfare agency
  • Marital violence is a criminal act, but is not reportable w/o victim’s consent unless there are children at risk (suspect or confirmed)

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 Helping a Target of Intimate Partner Violence: The SOS-DoC Intervention

• Support:
  • talk in private; make eye contact; assure that the discussion will be kept confidential unless the patient expresses plans to harm self or another person
  • “I’m sorry this has happened. You have a right to be safe and respected. The violence is not your fault.”
• Safety:
  • identify risk markers—
    • increasing severity and frequency of violence, weapons used or available, threats to kill, forced or threatened sexual acts,
    • life transitions (e.g., pregnancy, separation, divorce), drug and alcohol abuse, and history of violence and/or suicide attempts
  • Do you feel safe going home?
  • Are your children safe?
• O: discuss Options, including safety planning and follow-up
  • Provide information about legal tools (e.g., restraining orders, mandatory arrest, police/911) and community resources (e.g., women’s shelters, support groups, legal advocacy); promote safety planning and offer safety planning handout
  • If you decided to leave, where could you go?
  • Can you keep clothes, money, and copies of keys and important papers in a safe place?
  • Where could you go in an emergency? How would you get there?
  • Many women call a women’s shelter to learn more about it. Would you like to use our office phone?
• S: validate patient’s Strengths – Identify and validate patient’s strengths
  • You have shown great strength in very tough circumstances. I can see that you care deeply about your children. It took courage for you to talk with me today about the violence.
• Do: Document observations, assessment, and plans
  • Subjective observations: record what the patient said; use quotation marks to document exact words
  • Objective observations: describe the behavior and injuries you observed, use drawings and photographs describing location and type of injuries; for photographs, include a ruler for scale, and patient’s face, if possible, for identity
  • Assessment: your assessment of potential partner violence
  • Plans: describe safety planning and follow-up plans
• C: offer Continuity – Offer a follow-up appointment and assess barriers to access
  • Do you have transportation? Will your partner try to prevent you from returning?

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4 In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (e.g., helplessness, guilt), and its impact on children.

1. Increasing tension – ↓ communication, pt becomes fearful, but wants to appease abuser who becomes angrier – tension builds
2. Incident – verbal (humiliation, blame, threats), emotional (anger), physical abuse
3. Reconciliation – abuser apologize / minimize/deny abuse or promise it will not occur again, or blame pt
4. Honeymoon – no abuse and pt forget about the incident and hope no further abuse will occur

Cycle leads to helplessness, guilt, low self-esteem, feeling worthless, depression, SI, shame, substance abuse – affecting both pt and children

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Children living in households with IPV

• are at increased risk of maltreatment and lifelong poor health
• have ↑ behavioral and physical health problems, including
  • depression, anxiety, attempted suicide
  • violence toward peers, abuse of drugs and alcohol, running away from home
  • risky sexual behavior, and committing sexual assault
• have higher mortality rates and increased morbidity as adults

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References:

• http://sogc.org/wp-content/uploads/2013/01/157E-CPG-April2005.pdf
• TN2014
• http://www.aafp.org/afp/2011/0515/p1165.html