Domestic Violence

Domestic Violence / Intimate Partn= er Violence

Teresa Brya= n, M.D.

December 12, 2007

Definition= : Intentional controlling or violent behavior by a person who is or was in an intimate relationship with the victim. The controlling behavior may include physical abuse, sexual assault, emotional abuse, economic control, and/or social isolation of the victim.

Epidemiolo= gy: Frequently remains hidden and undiagnosed since patients often conceal that they are in abusive relationships. <= /span>

n&nb= sp; Over 1 million women are victims each year

n&nb= sp; 16% couples report violence previous year

n&nb= sp; Victims are women in 95% cases leading to criminal investigation

n&nb= sp; Health care costs 92% higher than non-batter= ed women

■ E= mergency Departments:

n&nb= sp; 2% women had acute trauma from abuse by an intimate partner

n&nb= sp; 14% had experienced abuse in the last year

n&nb= sp; 37% had history of abuse at some point in th= eir life time

n&nb= sp; Primary Care Clinics:

n&nb= sp; 5% women currently in abusive relationship

n&nb= sp; 20% revealed a history of past abuse

n&nb= sp; GI Clinics: 40-50% women had history = of abuse= .

n&nb= sp; Neurology Clinic: 66% of women with chronic headaches had abuse history

n&nb= sp; Pregnancy:

n&nb= sp; Physical abuse occurs during 7-20% pregnanci= es

n&nb= sp; Physical, sexual or emotional abuse associat= ed with low birth weight

Risk Facto= rs: Abuse occurs across all socioeconomic classes and ethnicities. However, prevalence higher with cert= ain risk factors:

n&nb= sp; Under age 35

n&nb= sp; Single, divorced or separated

n&nb= sp; Substance abuse by patient or partner

n&nb= sp; Pregnant

n&nb= sp; Lower socioeconomic group

n&nb= sp; Recently separated from abuser

n&nb= sp; Abusive childhood

Red Flags:=

n&nb= sp; Somatic complaints

n&nb= sp; Substance abuse, anxiety, depression and eat= ing disorders

n&nb= sp; GYN conditions: chronic pelvic pain, PMS, ST= Ds, unintended pregnancy

n&nb= sp; Noncompliance

n&nb= sp; Exam findings with inconsistent explanations=

n&nb= sp; Behavior of partner

n&nb= sp; Frequent ER visits

Screening = Questions:

n&nb= sp; Do you feel unsafe at home?

n&nb= sp; Has anyone ever hit you or tried to injure y= ou in any way?

n&nb= sp; Sensitivity 71%, Specificity 85% when compar= ed to other more extensive screens = ; (JAMA. 1997;277:1357-1361)

n S A F E

n&nb= sp; Stress/Safety: “Do you f= eel safe in your relationship?”

n&nb= sp; Afraid/Abused: “Have you ever been in a relationship where you were threatened, hurt or afraid?̶= 1;

n&nb= sp; Friends/Family: “Are fri= ends or family aware? Could you tell them? Do they support you?”

n Emergency Plan: “DO you have a plan if danger be= comes imminent? “

Screening Recommendations:

n&nb= sp; ACP: routine screening in PC and ER. =

n&nb= sp; ACOG and AMA: routine screening of pregnant women

n&nb= sp; USPSTF: insufficient evidence to recommend for or against

Who Should= We Screen? (efficacy not proven)

n&nb= sp; Chronic pain patients

n&nb= sp; Females with trauma or injuries

n&nb= sp; Women with STDs

n&nb= sp; ER patients

n&nb= sp; Pregnant women

Victims ma= y be in various stages:

n&nb= sp; Abuse unrecognized

n&nb= sp; Not ready to disclose abuse

n&nb= sp; Choosing to remain in relationship

n&nb= sp; Left relationship

Evaluation= :

n&nb= sp; Interview patient alone in private area

n&nb= sp; Introduce questions in a general way

n&nb= sp; Assure confidentiality

n&nb= sp; Non-judgmental attitude

n&nb= sp; Be supportive

n&nb= sp; Do not blame the victim

n&nb= sp; Tell them they do not deserve to be abused

n&nb= sp; Offer resources and referrals

n&nb= sp; Ultimate decision is the patient’s

Documentat= ion:

n&nb= sp; Medical Records may be submitted as evidence=

n&nb= sp; Be specific and detailed (time, date, place = and offender’s full name)

n&nb= sp; Set off patient’s words in quotation m= arks

n&nb= sp; Avoid phrases such as “patient claims” use “patient reports”

n&nb= sp; Do not include patient’s whereabouts

n&nb= sp; Describe patient’s demeanor

n&nb= sp; Photograph images of injuries

n&nb= sp; Body maps

n&nb= sp; Use medical terms and avoid legal terms (assault, perpetrator)

Assess Ris= k for Escalating Abuse:

n&nb= sp; “Has violence increased in frequency or severity over the past year?”

n&nb= sp; “Has your partner threatened to kill y= ou, your children or himself?”

n&nb= sp; “Are there weapons in the house?”= ;

n&nb= sp; “Does your partner know you are planni= ng to leave?”

Interventi= ons:

n&nb= sp; Refer abused women to intervention programs<= /p>

n&nb= sp; Advocacy Counseling: Assist women with devis= ing safety plans and accessing community resources (housing, employment, social support)

n&nb= sp; Resources for substance abuse: AA, NA, Alanon, Noranon.

Legal Obli= gation:

Mandatory reporting for:

n&nb= sp; Abuse or involvement of children

n&nb= sp; Abuse of disabled persons

n&nb= sp; Abuse of elderly (>60) or disabled

Resources:=

n&nb= sp; (800)799-SAFE is a National Domestic Violence hotline

n&nb= sp; (800)650-6522 is Alabama Domestic Violence Hotline

n&nb= sp; Resources at clinic (social worker, support groups, etc.)

n&nb= sp; Family Violence Center in Birmingham

n&nb= sp; For Jefferson, Blount, St. Clair counties

n&nb= sp; (205)322-4878 (crisis line)

n&nb= sp; (205)521-9646 (office)

n&nb= sp; Safehouse in Pel= ham

n&nb= sp; For Shelby,= Clay and Coosa counties

n&nb= sp; (205)664-4357 (crisis line)

Summary: <= o:p>

n&nb= sp; Intimate Partner Violence is a chronic probl= em

n&nb= sp; Consider screening particularly in high risk populations

n&nb= sp; Document appropriately

n&nb= sp; Keep referral sources available

n&nb= sp; Address substance abuse in perpetrators and victims

References= :

The Voices of Survivors Documentary. JGIM 2002;17:117-124

Intervention= s for Violence Against Women. JAMA 2003;289:589-600

UP To DATE. 2007.&nbs= p; Diagnosing, screening and counseling for domestic violence

US Department of Justice