Specialty Specific Issues Regarding Domestic Violence
For The Healthcare Professional

Diana Quinlan, CRNA, MA

 
Introduction

Many studies reveal that physicians do not adequately screen for intimate partner violence. Ironically, physicians cite personal (provider) discomfort with delving into the topic of intimate partner violence as a major barrier against screening. Physicians have suggested that patients would be too uncomfortable with screening, whereas patients report that they want to be screened. In 4 different studies of survivors of abuse, 70% to 81% of the patients studied reported that they would like their healthcare providers to ask them privately about intimate partner violence. The American Medical Association (AMA) commissioned a survey of Americans' attitudes about intimate partner violence and found that over 85% of those surveyed believe that physician screening for intimate partner violence is a good idea.


Recommended Screening Policy

As 5% to 25% of women presenting to primary care settings are currently in abusive relationships and 25% to 66% of women presenting to primary care have been victims of intimate partner violence in the past, this type of completely hidden misunderstanding occurs with regularity in primary care settings in which screening for intimate partner violence is not done. So, while there is inadequate data on the health outcomes related to intimate partner violence screening and intervention, the converse option of "not screening" is not acceptable. Therefore, it is recommended that all women and adolescent girls in primary care (internal medicine, family practice, obstetrics/gynecology, and pediatrics) be screened for past and present intimate partner violence. This recommendation is consistent with the recommendations of the AMA, the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Emergency Physicians (ACEP), the US Preventive Services Task Force, the American Academy of Pediatrics (AAP), the American Nurses Association (ANA) and the Family Violence Prevention Fund. The American Academy of Pediatrics states, "The abuse of women is a pediatric issue" and recommends that pediatricians screen for "exposure to violence in the home (domestic violence and child abuse)."

The significant finding that women and girls respond positively to very direct questions about abuse in the healthcare setting cannot be underestimated. One must ask direct questions about abuse using behavioral terms rather than words like "abuse" or "rape." Many victims and survivors will presume these terms do not apply to them if the perpetrator is an intimate partner. Direct questions about forced and unwanted sexual activity are necessary (even for the marital partner), as forced sexual activity is so common in abusive relationships but so distressing to victims/survivors that they most often do not volunteer unsolicited information about this.

Physicians may gain clues from observing a battered patient and their partner. The patient may seem evasive, embarrassed or inappropriately unconcerned with their injuries while the partner may be overly solicitous and answer questions for the patient. Or the partner may be openly hostile, defensive, or aggressive, setting up communication barriers between doctor and patient. It is extremely important that when battering is suspected that the patient be isolated from their partner for questioning to avoid placing them at further risk.


Direct Questions suitable for a questionnaire:

  • Does your partner ever hit you, hurt you, or threaten you in any way?
  • Has your partner ever forced you to have sex when you didn't want to?
  • Are you ever frightened of your partner?
  • Has anyone ever hit you, hurt you, or threatened you in the past?

Phrased as interviewing questions:

  • I ask all my patients about violence in their relationships; does your partner ever hit you, hurt you, or threaten you?
  • I want to make sure that each of my patients is safe in her/his relationships. Does anyone you know ever hit you, hurt you, or threaten you?
  • Feeling that a person close to you does not respect you or treat you well can be so difficult. How do your partner/family members treat you?

In some settings, the primary provider may have responsibility of screening. In others, a nurse, social worker, or mental healthcare provider may do intimate partner violence screening. As long as patients are screened in a private, confidential, compassionate, and culturally competent manner, and the patient's responses are shared with the primary healthcare providers caring for the patient to ensure coordination of care, there is no evidence to support any particular type of provider doing screening rather than another.

Primary Care

Primary care practice provides an ideal opportunity for the discussion of the remarkably prevalent yet often hidden problem of intimate partner violence. Patients report that screening of intimate partner violence is acceptable, yet most providers do not discuss intimate partner violence with their patients.

Male Domestic Violence: Whereas abuse of women and girls by a male intimate partner or ex-partner is of epidemic proportions, a far smaller proportion of men experience violence in their intimate relationships. In the NIJ/CDC study, 7.8% of men reported physical assault and/or rape by an intimate partner during their lifetime (0.9 % during the past 12 months). Men experience extremely high levels of violence in US society, yet this violence is far less likely to occur in the context of an intimate relationship. Of the men who report being raped and/or physically assaulted as adults, 82% are assaulted by someone other than an intimate partner. In intimate heterosexual relationships, when men are the victims of violence they are much less likely to be severely injured than women in violent relationships. Men in violent heterosexual relationships, also, are unlikely to be victims of a "battering syndrome" in which a female partner exerts power and control over her male partner. Violence against men is largely perpetrated by other men; 86% of men raped and/or physically assaulted were assaulted by male strangers or acquaintances.

Homosexual men, also, are at risk of abuse by their male partners. Again, there is a dearth of studies done in homosexual male populations. The little data that exist suggest that the prevalence of abuse in male homosexual relationships may be at least equivalent to the prevalence of abuse in women and girls by men in heterosexual relationships.

Obstetrics And Gynecology

Intimate partner violence affects approximately 1.5 million women annually and may even be more common than conditions for which pregnant women are routinely screened. This escalating violence during pregnancy may possibly be associated with unintended pregnancy, delayed prenatal care, smoking and substance abuse according to the American College of Obstetricians and Gynecologists. In studies of pregnant women, estimates of prevalence of abuse during pregnancy range from 0.9% to 20.1% (with most studies finding 4% to 8%), this equates to approximately 324,000 pregnant women each year.

The study that reported the highest prevalence was one in which trained nurses asked patients in public health prenatal clinics about intimate partner violence at every prenatal visit. In this study, pregnant teens were at even higher risk than adult women for interpersonal violence: 21.7% had been physically or sexually abused during the pregnancy, as compared with 15.9% of adult pregnant women attending the same clinic; 68% of the physical and/or sexual abuse of these pregnant teens was reported as being perpetrated by an intimate partner. Pregnant adolescents are also at risk of physical and sexual assault by other family members, acquaintances, and strangers.

Obstetricians have a unique window of opportunity during pregnancy to identify intimate partner violence since 96% of pregnant women do receive prenatal care. Patients average 12-13 prenatal visits and this is a time where trust can be developed in the healthcare provider. Additionally the victim may be motivated by the desire to be a good parent, the desire to prevent child abuse and the opportunity to think about the future.

In the presence of intimate partner violence direct effects on the fetus can include spontaneous abortion, fetal injury or death from maternal trauma. Indirect effects may be caused by maternal stress, smoking or substance abuse.

Routine screening for obstetrical patients should include not only the first prenatal visit but also at least once each trimester, at postpartum checkup and during routine ob-gyn visits or preconception visits. The components of screening should include a review of the medical history (including notations of chronic pelvic pain, headaches, vaginitis, irritable bowel syndrome, depression, insomnia) observing and recording the presentation and the behaviors of the patient and partner. When the patient is isolated, ask direct questions and then document the patient's response. All of the questions referenced in the first part of this article may be utilized but with the additional phrase, "Since you've been pregnant…have you been hit, slapped"…etc. Keep in mind that a NO response is an answer that should be documented. The patient may be ashamed, fearful, untrusting of alternative support systems and feel compelled to cover up. However merely asking the questions may help those in fear move closer to possible disclosure in the future. It also demonstrates the professional's willingness to discuss the issue. With repeated screening, the patient may eventually disclose and accept the resources toward help. It is wise to have materials readily available in the dressing area and bathrooms so that patient's may help themselves to resources even if they refuse to disclose.

For more information and office materials from ACOG call (202) 638-5577, or www.acog.org/goto/noviolence .

Reproductive Health

The study of the effects of intimate partner violence on reproductive health is far from complete. The relationships of contraceptive use and abortion to intimate partner violence have hardly been studied. Unintended pregnancy does seem related to intimate partner violence, but studies of the effects of intimate partner violence on pregnancy outcomes are inconclusive. Gynecologic problems (sexually transmitted diseases [STDs], menstrual problems, and urinary tract infections) have been found, in a cross-sectional study, to be associated with intimate partner violence in young maternal age and adolescence.

Geriatrics

The Adult Protective Services Act in Florida Statutes §415.102 ("Chapter 415") covers several types of elder abuse (neglect, abuse, and exploitation), but specifically defines "abuse" as:

"The non-accidental infliction of physical or psychological injury or sexual abuse upon a disabled adult or an elderly person by a relative, caregiver, or household member..."

"Or an action by any of those persons which could reasonably be expected to result in the physical or psychological injury, or sexual abuse of a disabled adult or any elderly person by any person."

"The active encouragement of any person by a relative, caregiver, or household member to commit an act that inflicts or could reasonably be expected to result in physical or psychological injury to a disabled adult or elderly person."

At first glance, it may appear that all older persons who have been abused warrant protection under this law. Chapter 415 is more narrow in its scope, however, by virtue of its definition of "elderly person" as:

"a person 60 years of age or older who is suffering from the infirmities of aging as manifested by organic brain damage, advanced age, or other physical, mental, or emotional dysfunctioning to the extent that the person is impaired in his [or her] ability to adequately provide for the person's own care or protection is impaired."

This means that some persons who have experienced abuse and are aged 60 and over may not be covered under the Adult Protective Services Act. For example, an abused 62 year old woman who is not physically, mentally, or emotionally impaired to the extent that she cannot provide for her own care, does not meet the definition of "elderly person" under F.S. Chapter 415.

Turning again to the Florida Statutes (§741.28), we find "domestic violence" defined as:

"any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, or any criminal offense resulting in physical injury or death, of one family or household member by another family or household member; where household member means spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family or who have resided together in the past as if a family, and persons who have a child in common regardless of whether they have been married or have resided together at any time."

Elder maltreatment that involves physical abuse by a family member often fits the definition of domestic violence. Therefore, some instances of elder abuse are domestic violence; and in turn, some cases of domestic violence constitute elder abuse. Abuse can happen over the entire course of a relationship, sporadically, or first start in midlife or old age, and divorce is rare among older couples. In addition, older women may experience physical violence at the hands of other more powerful family members such as sons, and the dynamics are quite similar to partner abuse. Abuse may escalate when an elderly parent is physically or financially dependent on an adult child, especially if the parent has diminished capacity.

In the past, the response to elder maltreatment has been more akin to child abuse than spouse abuse, and interventions were organized within the context of health care institutions. As in the case of child abuse, state legislation has been enacted to address the reporting and investigation of elder abuse. Mandatory reporting acts in this area were modeled after the child abuse reporting statutes. The assumption here is that being of a young or advanced age is equivalent to being vulnerable and dependent.

Abused elders have been offered an array of services that include case management, homemaker, home health and personal care, transportation, meals, counseling, adult day care, legal assistance, and nursing home placement. Abused elders who are believed to be incompetent have also been referred for guardianship services. These services involve petitioning the court in order to appoint a guardian or conservator to handle the elder's personal and/or financial affairs.

In Florida, a Governor's Task Force on Domestic Violence convened and issued a report in January 1994 that highlighted, in part, the particular problem of domestic violence against older women. This report made the following recommendations:

  1. The Department of Health and Rehabilitative Services should require Adult Protective Services staff to be trained in the dynamics of domestic violence, investigation skills, effective intervention and advocacy strategies, safety issues for victims and workers, legal remedies, and prevention measures. In-service training should be provided on a continuing basis.
  2. The Department of Health and Rehabilitative Services, including Adult Protective Services staff, should cooperate with local domestic violence centers to serve as liaisons to the courts and community service agencies in order to protect, and provide follow-up services to, elder victims of domestic violence.
  3. The Department of Health and Rehabilitative Services should provide funding for sheltering elder victims of domestic violence.  This can be accomplished through funding domestic violence centers to address the special needs of elders in shelter or through creating other safe places that specifically address the needs of the elder victim of domestic violence.
  4. The Department of Health and Rehabilitative Services should collect accurate data on the relationship of the abuser to elder victims. This data should be regularly disseminated to the public and to professionals responsible for responding to domestic violence victims.
  5. The Department of Elder Affairs should work with local domestic violence centers and distribute information about domestic violence to nursing homes, health care facilities, intermediate health care facilities and rehabilitation centers.
  6. The Department of Elder Affairs should work with local domestic violence centers and ensure that information about domestic violence is available at senior centers throughout the state; and is provided in a variety of media.
  7. The Department of Elder Affairs should provide training on domestic violence to the staff of the "Elder Helpful Information and Referral Service" in each county, including referrals to the local domestic violence center.
  8. The Department of Elder Affairs should periodically include information on domestic violence in Elder Update, a monthly newsletter that is distributed free to elders.
  9. The Department of Elder Affairs should include information about local domestic violence centers in its statewide-computerized information and referral resource directory.

Some of the resources available today in Florida are the result of these recommendations, along with the work of the Aging Network and Florida Coalition Against Domestic Violence.

Child characteristics

  • The child was born prematurely   
  • The child has disabilities or abnormalities   
  • The child exhibits certain behaviors of infancy and childhood, such as persistent crying.

Family characteristics

  • There is other violence in the home (in particular, the father abuses the mother or siblings abuse one another)   
  • Substance abuse, including alcohol abuse, by the parents or caretakers   
  • The parents or caretakers lack the necessary maturity to care for the child.
  • Parental expectations are inconsistent with the child's developmental abilities   
  • The caretaker is socially isolated (i.e., has no external support systems)   
  • The family is experiencing high levels of stress from events such as loss of a job, increased financial burdens, serious illness, death in the family, separation or divorce   
  • Adult members of the family have themselves been abused as children, either physically or sexually

These risk factors are not necessary antecedents to abuse, however, and physicians must consider abuse or neglect whenever physical or behavioral signs are suggestive, regardless of the presence or absence of the foregoing risk factors. Otherwise, instances of abuse may not be identified.

Children living in violent homes react to violence by feeling responsible for the abuse. This creates a state of grief, constant anxiety, guilt for not being able to stop the violence and fear of abandonment. As a result they may have an excessive need for adult attention, harm themselves physically and constantly worry about the future. This often leads to coping behaviors that put them in even greater peril.

The causes of child abuse and neglect are complex and varied. Child maltreatment can be inflicted by anyone responsible for caring for children, and it occurs in all types of families and settings. Children of all ages may be physically abused. Although infants and young children are more likely to receive serious or life-threatening injuries, adolescent abuse also occurs and often is unrecognized.

Pediatrics

A study on what pediatricians perceive to be barriers to screening for family violence in the pediatric setting found that 64% were not aware of the AAP recommendation to screen routinely, 74% never received family violence training and 58% estimated the incidence to be less than 5% of their practice. Education, office protocol, time and staff support were cited as prime barriers to effective screening. Greater efforts need to be expended to change this approach, especially since the study also revealed that only 8.5% of pediatricians are screening routinely despite the Academy recommendation. (Erickson, Pediatrics)

In another study, Parkinson found that almost 83% of mothers supported pediatricians asking about maternal domestic violence in the pediatric setting. While AAP advises screening routinely, only 17% of mothers recalled being asked. Approval of screening by pediatricians did NOT vary between women who did or did not have a history of domestic violence. The authors estimate that screening for violence took approximately five minutes and did not require additional support staff, therefore time restrictions and maternal approval should not be seen as barriers to routine screening. (Parkinson, Pediatrics)

Approximately 2 million children in the U.S. are seriously abused by their parents, guardians or others each year; and more than 1,000 of these die as a result of their injuries. Studies suggest that approximately 20% of children will be sexually abused by someone they know before reaching adulthood. (American College of Emergency Physicians, 1998)

Child abuse may be classified according to the four common categories: sexual abuse, physical abuse, neglect, and Munchausen by proxy. Medical, mental health, social, and legal issues are interwoven in diagnosis and treatment of child abuse. Physicians must always remain alert to the possibility that child abuse may be occurring, even when the child says nothing or says that she or he has never been hurt because children frequently do not complain about the abuse they are receiving. The following child and family characteristics may be risk factors for child abuse and/or neglect:

In situations where the physician provides care for all members of the family, knowledge of the medical and social histories of the child's parents or caretakers will help ensure that fewer cases of child abuse elude detection. Different forms of abuse can and do coexist in families. Moreover, abusive behavior often occurs in successive generations of families, a phenomenon known as the "cycle of violence."

In sexual abuse cases, an allegation as related by the child is the key element in making a diagnosis and care must be taken to insure an interview by a trained professional. Interviewing sexually abused children on multiple occasions by multiple interviewers often leads to recantation of the disclosure and may destroy the effectiveness of the forensic interview. Fabricated reporting by children is very rare. The physical examination is often normal in children who are seriously sexually abused.

A child with extensive free-form bruises and no history of trauma needs bleeding and clotting studies before abuse is a serious consideration. If a delay in assessment is unavoidable, photographs of the initial lesions may be helpful in both the medical and forensic evaluation.

Reporting: All child abuse reports to the Department of Children and Families are received by a central hotline which utilizes a fixed matrix to decide whether to take a report and to assign the urgency of response. Reports made by physicians are treated differently from other reports. If a report is taken it is referred to the local Department of Children and Families for investigation. The investigator may or may not elect to involve the local Child Protection Team. The physician may not delegate the responsibility to report, but if he desires the participation of the team, he may call the team directly in addition to making the report. The team or a team examiner can be consulted directly for advice about reporting or for medical or psychosocial assistance. If the assessment by the Children and Families worker suggests that a crime has been committed, law enforcement is involved in the investigation. Law enforcement is always involved in investigation of allegations of sexual abuse.

The Child Protection Team and the Child Sexual Abuse Program can provide specialized interviews with videotaping by highly trained social workers or nurses, psychosocial assessment of the family, coordination of services, medical forensic evaluations, psychological evaluation and testing, legal consultation, and both short-term and long-term treatment of victims and families. Routine screening for other domestic violence is done with all cases and appropriate referrals are made. Cases are assessed in a multidisciplinary format and case plans are developed as consensus decisions among case managers and consultants. There are statutory limitations relating to services that can be provided without a report being made. Medical consultation is always available to assist in all decisions and individual questions can always be addressed in the consultation format. These statutory rules are often confusing in individual cases, but can always be discussed with the team on a case-by-case basis.

When reporting a case it is reasonable to first call the abuse hotline at 800 96-ABUSE. If a referral to law enforcement is more appropriate, the hotline will direct you or you may call 630-0500. If there is any confusion, call the team at (904) 549-4603.


(Section on "Reporting" excerpted from Jacksonville Medicine article by J.M. Whitworth, M.D. is Executive Medical Director, Children's Crisis Center, Inc. and Professor of Pediatrics, University of Florida Health Sciences Center / Jacksonville)

Adolescent girls are a distinct population within the pediatric community that are at increased risk if they witness or experience family violence. (Berenson, Archives of Pediatrics & Adolescent Medicine) They found that girls who witnessed violence were 2-3 times more likely to report using tobacco and marijuana, drinking alcohol or using drugs before sex and having intercourse with a risky partner. Girls who experienced, but did not also witness it, were at increased risk of these same behaviors and were 2-4 times more likely to report early initiation of additional health-risk behaviors such as intercourse with strangers and drug abuse. Adolescent girls who witnessed and experienced violence demonstrated 3-6 times greater risk of suicidal ideation or attempts, self-injury, use of drugs during intercourse. This study points to the need to screen for both family violence and teen dating violence in adolescent girls.

Acute Care/Emergency Department

Emergency physicians treat more than 1.3 million people each year for injuries caused by violent attacks, a dramatic 250% increase over past years (US Justice Department, ACEP). Women are victims of 4.5 million violent crimes each year including about 500,000 rapes or other sexual assaults with 30% being committed by current or former partners.

The American College of Emergency Physicians (ACEP) encourages emergency personnel to screen patients for domestic violence and appropriately refer those patients who indicate domestic violence may be a problem in their lives. (ACEP, 1999). The ACEP opposes mandatory reporting of domestic violence to the criminal justice system. Instead, ACEP encourages reporting to local social services, victim's services, the criminal justice system, or any other appropriate resource agency to provide confidential counseling and assistance, in accordance with the patient's wishes. (ACEP, 2001).

Additionally, ACEP has stated that they believe domestic violence is a serious public health problem that EMS personnel will encounter and that on the scene the potential for harm to the health care provider is present and therefore special documentation and communication may be required. They believe that special training in the recognition, evaluation and management of victims and their injuries, patterns of abuse, scene safety and preservation of evidence are all essential components of this training.

Some physicians may not be familiar with the emotional, psychological, and social issues that can predispose someone to accept abuse. Emergency physicians are trained to rapidly recognize and stabilize medical emergencies and therefore may place less emphasis on psychosocial factors. They may also be unfamiliar with the clinical presentation of domestic violence or may have prejudices or misunderstandings that prevent them from considering this possibility. They may be concerned about intruding into the family unit.

Situations that may indicate abuse and trigger suspicion would include: repeated visits to the ER, arriving in ER after suicide attempt or rape, substantial delay between injury and seeking treatment, evidence of substance abuse, and injuries during pregnancy. Always document findings in the patient's chart, in the patient's own words, with a body map and photographs (with written consent) and with specific details. Assess the patient's safety before releasing them. Safety plans are available online and through shelters and should be part of the materials kept in the emergency department or available through an advocate.

Ask four basic questions before release from the ER:

  1. Are you or your children in danger if your return home?
  2. Has violence escalated recently?
  3. Are there weapons in the home?
  4. Do you have a safety plan?

If any of the above indicate risk upon return:

  1. Formulate a safety plan before returning
  2. Remove abuser through arrest or protective order.
  3. Leave the relationship temporarily or permanently.
  4. Refer to the appropriate resources for immediate assistance.

Battering is a crime and in Florida mandatory reporting is required for abused children, the elderly and where lethality (weapons, chemicals, poison) was indicated in the injury. Every emergency department should have written material with names and phone numbers of local shelters, advocacy groups and legal assistance to give to patients if they feel safe to take the information.

Surgery/Anesthesia

Most anesthesia providers are well aware of the profound honesty that patients have when sharing their history just prior to surgery or an anesthetic. Information is revealed that no other practitioners have been privy to including information on illicit drug use, risky behaviors, pregnancy, and other situations that may place them at risk for anesthesia. So it is important to utilize this advantage during the assessment stage as a final filter to uncover an undisclosed victim of domestic violence (or elder abuse). As anesthesia providers there are several key areas to examine in reviewing the battered or victimized patient. A thorough history and physical assessment for anesthesia should include a cadre of considerations during both the history and physical assessment.

History - The patient history may give the practitioner a window into a life-style that won't be detected on physical exam. It is important to inquire about prior hospitalizations or surgeries noting carefully for the frequency of visits, vague complaints, and undiagnosed or chronic injuries. Previous injuries requiring only doctor's office visits, especially for "accidents", minor cuts or suturing should not be overlooked. A medication history (past and present) should include inquiries about tranquilizers and anti-depressants. Prior alcohol or drug abuse by the patient or their family of origin if adopted, plus a history of disturbed sleep pattern like insomnia or nightmares, are important to document. As battering often escalates during pregnancy it is important to allow a few moments to ask about late or sporadic prenatal care, premature labor or abortions.

Physical - Anesthesia providers should not depend on someone else doing a thorough physical exam. Merely listening to heart and lungs can miss the often overlooked telltale signs of abuse. Inquire about broken bones (past and present) and examine old X-rays if available. The batterer may grab and twist his victim in an altercation leaving choke marks and finger impressions about the neck, arms and wrists as well as obvious bruises and black eyes about the face. Occasionally the perpetrator gets more devious and hits only on the torso where clothing easily camouflages the bruising. This torso bruising is called the "swim suit pattern" and the surgical staff are often the only providers who recognize this during the prepping and draping of the patient. Skin burns from cigarettes or being drug across a rough surface and weapon patterns from knives are other indicators should raise suspicion. Lastly, the general condition and nutrition of the patient including observations about poor dentition or missing teeth may be significant to note.

Psychosocial (Adult) - The adult victim often suffers from depression, anxiety disorder or panic attack as a result of not being sure what to do regarding the ongoing abuse. Red flags would be: if the victim is reluctant to speak in front of their partner, withdrawn, defensive or poor eye contact during the interview, or if the partner dominates by answering the questions for the suspected victim. Victims have little control over their own life; they are often scared and unsure how to change or make choices to take control, therefore they may flee from any attempt or assistance that likewise, is overwhelming. Therefore, victims frequently fail appointments and are non-compliant with follow up and treatment.

Psychosocial (Pediatric) - The child from a violent home may have social responses that should trigger further investigation. Children learn what they see in their home. Children living in homes characterized by domestic violence often become polarized by learning to identify with either the "victim" or the "offender" parent, or they may learn both in different circumstances. On one end the child may have extreme difficulty separating from the parent, have a morbid fear of bodily harm or disfigurement, fear being touched, reluctant to talk or share feelings, being alone. On the other end they may become aggressive, challenging, fight, and show threatening behavior towards their caregiver. These children frequently do not learn to develop healthy boundaries as boundaries in the home are frequently violated. Likewise, the children do not know how to respond appropriately to the caregiver's approach or touch as approach and touch may be associated with hurt, fear, and pain.

A positive screen for any of the above indicators should warrant further screening and assessment by the appropriate provider who will be a referral source. (Quinlan, 2000)

Terminology in Screening For Domestic Violence

Substance abuse providers, domestic violence support staff, mental health providers, medical providers each may use different terms such as intake, screening, or interview to describe the screening process. Regardless, the screening process focuses on level of risk, safety planning, and intervention strategies. After a person is referred to a domestic violence intervention program they will undergo a more detail assessment.

The following mental health section is offered by way of information to the medical provider to bridge the understanding between medical care and mental healthcare of the domestic violence victim.

Mental Health (General)

Cross-sectional studies have found associations between intimate partner violence and an increased prevalence of overall worsened mental health status, depression, anxiety, somatization, and posttraumatic stress disorder. Most studies do not address the distinct contributions of childhood abuse and adulthood abuse or the effect of the "cumulative dose" or severity of abuse on health outcomes as there are too many variables and it does not alter what needs to take place in the present.

One study examined the contributions of both childhood and adulthood victimization and found that past childhood abuse and current adulthood abuse were equivalently associated with more physical symptoms, higher scores for depression, anxiety, somatization, low self-esteem, and higher rates of attempted suicide and substance abuse. Women who had experienced childhood abuse and who were also experiencing current adulthood abuse had the highest levels of these poor health outcomes. (AMA, Addressing Intimate Partner Violence in Primary Care) Perhaps an underlying and unaddressed issue resulting from past, current, or accumulative abuse is the patients' inability to provide them with beneficial self-care. Violence and abuse often strips away a victim's sense of self-value, and the ability to know how to care for themselves; but these can be learned.

Screening for domestic violence in the mental healthcare setting is undertaken to identify both survivors and batterers. Domestic violence assessment should include the usual screening questions with the addition of the following:

Emotional Abuse: "Does your partner (former partner) ever humiliate you? Shame you? Put you down in public? Keep you from seeing friends or from doing the things you want to do?"

Child Abuse: "Within the last year, has someone made you worry about the safety of your child? If yes, who?"

Avoid the following questions, as they are counter-productive: "Why don't you just leave? What did you do to make him/her so angry? Why do you go back?" What you can say is: "This is NOT your fault. No one deserves to be treated this way. I'm sorry you've been hurt. Do you want to talk about it? I am concerned for your safety and your children. Help is available to you."

Mental Health (Substance Abuse)

Screening for domestic violence in substance abuse treatment settings, like general mental health treatment, is undertaken to identify both survivors and batterers. Keeping in mind that substance use is often a coping mechanism used in dealing with life and relationship stresses, it is not the cause of the violence. Once it is determined that a client is a victim of domestic violence, a substance abuse provider needs to refer the victim and offender to domestic violence related services such as medical care, legal, and to advocates who specifically assess and treat the issues and behaviors of domestic violence for both parties. Substance abuse treatment needs to occur prior to treatment or the intervention of domestic violence. This progression of treatment issues increases the level of safety, physical and psychological, for the victim and offender alike. A word of caution: There is a tendency to think of residential treatment as a safety zone for both batterers and survivors with substance abuse problems. Domestic violence experts, however, note that batterers in treatment frequently continue to harass their partners by circumventing program rules and threatening them by phone, by mail, and through contacts with other approved visitors. Telephone and other communication and visitation privileges should be carefully monitored for identified batterers and survivors in residential programs.

Clues for the Substance Abuse Treatment Provider

The most obvious indicator of domestic violence is the presence of physical injuries, especially patterns of untreated injuries to the face, neck, throat and breasts. Many survivors of domestic violence may be reluctant to seek medical treatment because they are afraid that documentation of violence in the household will result in their children being removed or because they are afraid of further violence as a result of the disclosure. These victims may get their injuries treated at a number of different clinics or emergency rooms in order to avoid documentation of recurrent injuries.

Other indicators may include a history of relapse or noncompliance with substance abuse treatment plans; inconsistent explanations for injuries and evasive answers when questioned about them; complications in pregnancy (including miscarriage, premature birth, and infant illness or birth defects); stress-related illnesses and conditions (such as headache, backache, chronic pain, gastrointestinal distress, sleep disorders, eating disorders, and fatigue); anxiety-related conditions (such as heart palpitations, hyperventilation, and panic attacks); sad, depressed affect; or talk of suicide. Many batterers intensify their physical attacks when they learn their partner is pregnant.

Another clue is documented or reported child abuse perpetrated by the partner of a client. Evidence suggests that a father who abuses his children often abuses his wife. Providers should be alert to the possibility that the mother of a child who has been or is being abused by her partner is
also being abused herself.

The provider can also glean information from a victim's description of their partner's treatment of them. Behaviors that suggest abuse include:

  • Isolating, keeping victim away from family, friends, and others who are supportive of recovery from substance abuse)
  • Forcing victim to sell drugs or prostitute themselves for drugs
  • Preventing attendance of treatment or 12-Step meetings
  • Threatening to harm victim, self, or others
  • Engaging in reckless behavior that endangers batterer or others
  • Damaging property or belongings
  • Harming other family members or pets
  • Threatening abandonment or taking the children

During an initial interview, many survivors will deny that they have been battered. Therefore, treatment staff must be alert to indicators of possible domestic violence and must continue to pursue them, with sensitivity and tact, over the course of treatment.

  • "Do you feel safe at home?"
  • "Has anyone in your family ever physically hurt you?"
  • "Has anyone in your family made you do sexual things you didn't want to do?"
  • "Have you ever hurt anyone in your family physically or sexually?"

At this point, the interviewer can ask more specific questions regarding the nature and circumstances of specific incidents. Three questions have been cited as key to identifying victims of domestic 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 a partner from a previous relationship who is making you feel unsafe now?"

Barriers to an accurate screen - the biggest barrier to accurate screening is the physician or provider not understanding the dynamics of domestic violence, victimization, and battering. It is common for a survivor of domestic violence to evade the issue or deny when asked about her abusive experiences. Survivors' reasons for denying they are being abused varies but regardless the denial is indicative that it is too hard to face the reality of how bad things really are because they too often are powerless to do anything about it. Denial is a survival technique when faced with problems that seem overwhelming and insurmountable. The truth of the reality a victim lives is often incongruent; therefore victims learn to mis-read and mis-label what is truth. If speaking the truth causes them to be hit or kicked then they learn not to speak the truth if they speak at all. Many blame themselves for the violence as the batter often tells them that it is their fault. They often make excuses for the batterer's erratic or destructive behavior as they often depend on them as their sole source of livelihood. Victims learn to mistrust as those they've trusted have proved to be untrustworthy and frequently turn things back on the victim while they avoid responsibility. Therefore, victims are tentative and unsure how the screening information about violence and battering will be used. They would prefer to remain silent therefore, and not divulge anything.

As with substance abuse, the full dimensions of a domestic violence problem are seldom immediately clear and may emerge unexpectedly at a later stage in treatment. If this happens, questions posed during screening can be asked again, and a referral to a violence support or batterers' intervention program can be initiated. (SAMHSA, TIP 25, 1997)

Conclusion

Whether or not there is a history of rape, childhood neglect, physical or sexual abuse, ADD/ADHD, being handicapped, drug/alcohol use if the victim is currently being injured, abused, or battered this IS a crime. It is the present victimization of domestic violence on which medical and mental health providers should focus their time and attention in order to create and maintain a safe intervention. It would be unfortunate for physicians to focus on the victim's history, regardless of positive or negative experiences, as the "history" neither causes, explains, nor predicts the current domestic violence. The focus needs to remain on the present situation, safety issues, and on the patient's level of current life coping skills. Only after being safe will a patient be able to learn new and more effective life coping skills that could then lead a person toward facing and responsibly resolving current, and perhaps past issues.

Becoming educated about this growing public health issue will enable caregivers the ability to effectively intervene while providing patient health care rather than overlook this increasing national health crisis. A woman is battered every 9 seconds in the U.S. In the time it takes most reader to complete this lesson, an additional 300 victims may be traumatized by domestic violence; and this figure does not include the children or the elderly.

Physicians and other healthcare professionals are in a unique position to intervene on behalf of domestic violence victims by identifying, treating and referring their patients to appropriate resources. Physicians are the first line of defense for the domestic violence victim. Thorough routine screening is the patient's best chance of getting the help they so desperately need.

References

  1. American College of Emergency Physicians, Domestic Violence (Health Information), January 1998, www.acep.org/1,391,0.html
  2. American College of Emergency Physicians, Board of Directors, Position Statement, October 1999
  3. American College of Emergency Physicians, Board of Directors, Position Statement (reaffirmed), October 2001
  4. American Medical Association, Addressing Intimate Partner Violence in Primary Care, www.ama-assoc.org
  5. Berenson AB, Wiemann CM, McCombs S, Archives of Pediatrics & Adolescent Medicine, Vol. 155
  6. Erickson MJ, Hill TD, Siegel RM, Pediatrics, Volume 108, No.1
  7. Parkinson GW, Adams RC, Emerling FG, Pediatrics, Volume 108, No.3
  8. Quinlan DS, Domestic Violence: What the Anesthesia Provider Should Know, Current Reviews for Clinical Anesthesia, 2000
  9. Substance Abuse and Mental Health Services Administration (SAMHSA), TIP 25, Screening and Referral of Survivors and Batterers in Substance Abuse Treatment Programs, 1997, pp.37-49
  10. Whitworth JM, Child Abuse and Domestic Violence: Decisions for the Medical Professional, Jacksonville Medicine, May 1999, Volume 50, No.5, pp.205-208
Jacksonville Medicine / May, 2002

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