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|Domestic Violence/Intimate Partner Violence: Screening, Detection and Intervention|
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Northeast Florida Medicine, Vol. 69, No. 1, Spring 2018
Date of Release: March 1, 2018
Date Credit Expires: March 1, 2020
Estimated Completion Time: 2 hours
The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Domestic Violence/Intimate Partner Violence: Screening, Detection and Intervention” authored by Linda Edwards, MD, Francys Calle Martin, Esq., LHRM, Jeffrey Winder, DO, and Brittany Lyons, DO, which has been approved for 2 AMA PRA Category 1 credits.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.
Linda Edwards, MD is the Senior Associate Dean for Educational Affairs and Associate Professor for the Department of Medicine, University of Florida College of Medicine, Jacksonville, FL. Francys Calle Martin, Esq., LHRM is the Senior Loss Prevention Attorney for the Florida Board of Governors’ Healthcare Education Insurance Company. Jeffrey Winder, DO is Chief Resident, Department of Medicine, for the University of Florida College of Medicine, Jacksonville, FL. Brittany Lyons, DO is a Resident in the Department of Medicine, University of Florida College of Medicine, Jacksonville, FL.
Domestic Violence/intimate partner abuse is prevalent throughout the United States, as well as the rest of the world. It is important for healthcare providers to be aware of the prevalence of domestic violence and to become familiar with screening and referral tools in order to identify victims and provide resources. It is also critical for healthcare providers to be able to identify potential perpetrators of domestic violence.
1. Become familiar with the number of patients within a physician’s practice who are likely to be victims of domestic violence.
CME Credit Eligibility:
A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact the DCMS at 904-355-6561 or firstname.lastname@example.org.
Linda Edwards, MD, Jeffrey Winder, DO, Brittany Lyons, DO, and Francys Calle Martin, Esq., LHRM report no significant relations to disclose, financial or otherwise, with an commercial supporter or product manufacturer associated with this activity.
Disclosure of Conflicts of Interest:
St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.
Joint Sponsorship Accreditation Statement:
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 2 AMA PRA Category 1 credits.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.
Domestic Violence/intimate partner abuse is prevalent throughout the United States (U.S.), as well as the rest of the world. More than one in three women and one in four men report having experienced some form of rape, physical violence, or stalking by a partner in their lifetime.1 It is therefore important for healthcare providers to be aware of the prevalence of domestic violence and become familiar with appropriate screening and referral tools in order to identify victims and provide resources.
News feeds and newspapers seem to be filled with tragic stories of children and women who have lost their lives because of an abusive partner who then turns the gun on themselves. The media draws our attention to the issue of domestic violence/intimate partner violence (IPV), but it is not a recent societal phenomenon. In the U.S., assault did not become a legally recognized reason for divorce until the late 1800’s, and as late as the 1980’s many states carried an exception to the rape statute that exempted from prosecution a man who raped his legally married spouse. Today, every state holds a partner legally liable for marital rape. IPV has been identified and studied as a social problem with serious consequences to individual health and well-being. Healthcare providers should be aware of the issues of domestic violence, including elder abuse, and the risk of abuse to the children in homes where domestic violence occurs.
Definition of Domestic Violence or Intimate Partner Violence
Florida statutes (741.28-741.31) define domestic violence as any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one “family or household member” by another who is or was residing in the same single dwelling unit. A family or household member includes spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family, or who have a child in common regardless of whether they have been married or have resided together at any time. The American Medical Association defines domestic violence as the abuse of power or the domination and victimization of a physically less powerful person by a physically more powerful person.
Intimate partner violence is disturbingly prevalent throughout the United States and the world. More than one in three women (35.6 percent) and one in four men (28.5 percent) report having been the victim of rape, physical violence or stalking by a partner.1 Although both men and women can experience IPV, women are far more likely to experience severe sexual and physical violence from a partner or to be killed by one.2 According to the World Health Organization’s report on Violence by Intimate Partners, between 10 and 69 percent of women were physically assaulted by an intimate male partner at some point in their lives.3 Most assaults are minor and include pushing, grabbing, slapping, and hitting; however, intimate partner violence can lead to death. Sixty-four percent of women who experience domestic violence have an intimate relationship with the perpetrator; however, only 16.2 percent of men have an intimate relationship with their perpetrator.4 It is difficult to estimate the percentage of perpetrators because victims historically underreport given the consequences of admitting to such actions. These statistics are alarming since most acts of domestic violence are not reported, likely making the actual numbers much higher. In Florida alone in 2016, 105,640 incidents were reported.5,6 The majority of those, specifically 84,382 incidents, were simple assault, followed by aggravated assault, rape and threat/intimidation. There were 179 murders and 14 cases of manslaughter related to domestic violence.5 Researchers in one major metropolitan city examined murder/suicide by cop and found that 39 percent of incidents involved domestic violence.7
Intimate partner abuse often starts or escalates during pregnancy or the postpartum period.8 Physical abuse is estimated to occur in approximately 7 to 20 percent of pregnancies, making it more prevalent than preeclampsia or gestational diabetes. Pregnancy may lead the woman to focus her attention on her unborn child and thus less attention may be given to her partner. When the pregnancy is unintended the risk of domestic violence is three times greater.9 Even more alarming is that abused pregnant women have a threefold higher risk of becoming a victim of homicide or attempted homicide.10
Pathophysiology of IPV- Power and Control
To better understand the relationship between a victim and his or her abuser, it is important to understand the pathophysiology of IPV. Abusive relationships develop because one individual in the relationship exerts his or her power over the other. The Duluth Wheel of Power and Control exhibits the methods of abuse used by an abusive individual (Figure 1). The use of these methods of power and control by the abuser are unpredictable. A tension building phase may begin with threats, intimidation, fear and guilt (described in the wheel), followed by physical or sexual abuse.11 The abuser may blame their abusive behavior on the victim and the victim may ignore or deny the abuse until it recurs. Because the abusive behavior is unpredictable, women may feel as though they are “walking on eggshells.”12
Figure 1: The Duluth Wheel of Power and Control
The Affected Individuals
Elder abuse is included in domestic violence and is prevalent world-wide. Often overlooked, it does not receive the same prevention and screening awareness as intimate partner abuse. The prevalence of elder abuse ranges from 10 percent of cognitively-intact elders to 45-50 percent of those elders who suffer from dementia. Per the National Elder Abuse Incidence Study, 19 percent of the population in the U.S. is over the age of 80, and over half of all reports of abuse are within this age range.13 Elder abuse includes physical, mental, emotional/psychological and sexual abuse, neglect, abandonment, poor and improper medical care, and financial exploitation. Risk factors that can predispose an elderly individual to abuse include disability, depression, dementia, social isolation, poor socioeconomic status, external family stressors and substance abuse.
Elder abuse can occur in any setting. In the home, usually a daughter or son becomes progressively more frustrated “parenting their parent.” In a nursing home, it could be caused by burnout among the nursing or ancillary staff. A European study published in September 2017 looked at several hundred nursing staff employees, and analyzed three facets: emotional exhaustion, depersonalization, and personal accomplishment. Emotional exhaustion was observed in almost 50 percent of nurses, depersonalization in over 20 percent, and a feeling of low personal accomplishment in almost 40 percent.14 These numbers are a cause for concern, particularly if these numbers were to remain similar in larger scale studies. Recognition and prevention of burnout in both caregivers and nurses can reduce elder abuse.14
The American Medical Association and the American Academy of Neurology specifically advise screening individuals age 65 years and older for abuse. One approach is to utilize the Abbreviated Screening Method, which recommends asking your elderly patients three questions:
It is critical that elderly patients be screened alone to eliminate possible intimidation. If any of the above questions raise suspicion for elder abuse, one of the more detailed questionnaires should be performed such as the Brief Abuse Screen for the Elderly (BASE) or The Elder Assessment Instrument (EAI).15,16 Elder abuse or suspected abuse should be reported to the physician’s local elder abuse hotline.
Another approach used by law enforcement in field, the elder abuse suspicion index (EASI), is described in a recent publication in September 2017. Data was collected by officers in Connecticut to help better identify their perceptions and knowledge of elder abuse, barriers of detecting elder abuse in the field, characteristics officers deem most valuable as a detection tool, and the potential to use the EASI score in the field. Eighty percent of officers reported they will use the index score long term as it was shown to more easily and reliably help discern unknowing victims of elder abuse.17
II. Adult Victims
Anyone is a potential victim; however, victims of IPV are predominantly women less than 35 years of age, with many having had prior exposure to IPV.18 Additional risk factors for IPV can be found in Table 1.19-24
Certain groups have a higher prevalence of IPV including trauma victims, emergency room patients, patients with chronic abdominal pain, patients with chronic headaches, pregnant patients with injuries, patients with sexually transmitted diseases, and elderly individuals with injuries.25 Women living in non-industrialized countries have higher incidence of IPV than those living in industrialized countries.26
III. The Littlest Victims – Children
Nationwide, more than three million children are living in homes where IPV occurs. Among these children, studies estimate that the prevalence of child abuse may be as high as 60 percent.27,28 The U.S. Department of Health & Human Services reported that in 2013 alone 678,932 children were victims of child abuse and neglect, signifying that 9.1 in 1,000 children are affected.29
The long-term effects of a child witnessing or being a victim of domestic violence are numerous. They include increased risk for perpetuation of domestic violence in their future relationships along with psychological effects such as depression and vague somatic complaints.30,31 These children may also display increased rebellious behavior with an increased tendency for truancy, dropping out of school, drug and alcohol use and episodes of running away.
IV. The Batterer:
An abuser may lead what appears to be a “normal” life outside the home. The violent behavior may only occur behind closed doors. The abuser may have been a victim of abuse as a child. Men who lived in violent homes as children are more likely to be violent with their adult partners than men who were reared in non-violent homes.26 For the batterer, casting blame and guilt on the victim can elevate their own sense of worth. Batterers are often abusers of alcohol and drugs.
A patient experiencing intimate partner violence may present in a variety of manners. Often, they present with inconsistent injuries or vague explanations of injuries. Victims may also have poor follow- up, frequently miss appointments, be non-compliant with treatments or may be reluctant to comply with a physical examination. Their partner may be present and reluctant to leave the room during history or examination. It is estimated that between two and seven percent of acute emergency room visits are from IPV.32 Victims will seek care in the emergency department because they are likely to see different healthcare providers each time and there is less follow-up. The patient’s social history may include substance abuse disorders, tobacco abuse, anxiety and depression. Higher rates of previous abuse as a child and suicide attempts are also observed.32,33,34 According to Medical and Psychosocial Diagnoses in Women with a History of Intimate Partner Violence, published in 2009, several signs and symptoms are associated with intimate partner violence and are noted in Figure 2.35 Signs and symptoms with the highest relative risk include anxiety, substance abuse, tobacco abuse, depression, headache, sexually transmitted infections, contusions/abrasions, low back pain and lacerations (Figure 2).35
Persons suffering from IPV and/or sexual/physical abuse also have a 1.5 to 2 times greater risk of having functional gastrointestinal symptoms.32 Victims of intimate partner violence also reported worse physical and mental health and increased chronic pain and disability preventing employment or absence from work. Physical examination is often unremarkable. However, the physician may discover old fractures, cigarette burns or bites in areas that are not readily visible.
All healthcare providers should remain alert for the presence of IPV, even in asymptomatic patients. The United States Preventive Services Task Force states that screening asymptomatic females for IPV may provide benefits with minimal adverse effects.36 As of 2013, the U.S. Preventive Services Task Force had a grade B recommendation for the screening of IPV and current recommendations are being updated. The Affordable Care Act passed in August 2012 required insurance companies to cover IPV screening and counseling as part of eight essential health services for women at no additional cost to the patient.37 Based on this information, all primary care providers should screen females 12 years of age and older for IPV. Additional red flags that suggest screening is necessary include but are not limited to: trauma, chronic or recurrent sexually transmitted disease infections and injuries in the elderly. In a 2014 meta-analysis looking at screening for IPV in the healthcare setting, moderate evidence was found that screening led to an increase in identification of IPV, particularly in the antenatal setting; however, there was no evidence that identification led to more referrals to support services.38
Primary care providers can include screening questions in their initial assessment. Asking questions in a non-threatening and non-judgmental manner is imperative. Using phrases such as, ‘I ask all of my patients about violence in the home’ allows the provider to ask the necessary questions without singling out the patient.39 The healthcare provider should never ask the patient why they have allowed the abuse to happen or why they have not left the situation as this re-victimizes the patient. Raising questions about potential abuse should occur only if the patient is alone. If the questions are asked when the partner is present, the patient may deny that abuse occurs and the potential for escalation of violence at home is increased. Victims should be assured that information will be kept confidential unless there is a lethal weapon involved. Providing resources in restrooms or other private areas of the clinical setting allows women to obtain information without directly speaking to someone. Reasons cited for the lack of routine screening for IPV by healthcare providers include physician comfort levels, awareness of the various techniques, fear of offending the patient and perceived lack of effective interventions.40
Several effective screening tools for intimate partner violence have been developed. A widely utilized screening tool is the HITS (Hurt, Insult, Threaten, Scream) Screening Tool for Domestic Violence (Table 2).
HITS consists of four questions scored on a 5 point scale ranging from never to frequently.41 This test has a 30-100 percent sensitivity and 55-99 percent specificity. Physicians may also consider simply asking the patient if he/she is afraid of their partner or anyone else. A positive response can lead to further questioning.
Secondary and Tertiary Prevention: Four Steps to Take Once Intimate Partner Violence is Detected
Step 1: Be supportive. Physicians can best support their patients by acknowledging the patient’s admission of abuse and the difficulty the patient must have faced in disclosing this information. In addition, the physician can also ask the victim how they can best support them.
Step 2: Assess the patient’s safety. Clinicians should employ open-ended questions to ask victims of IPV about their concerns and fears.42 A validated 20-Item Danger Assessment Tool (Figure 3) is also available to predict the likelihood of lethality or near-lethality in a relationship afflicted by domestic violence.43
Figure 3: The Danger Assessment is an instrument that helps to determine the level of danger an abused woman has of being killed by her intimate partner.43
Reprinted with permission: Campbell, JC. (2004). Danger Assessment. Retreived May 29, 2008 from http://www.dangerassessment.org.
Although the majority of patients are not in imminent danger and are not planning to leave their current abusive relationship, clinicians should not lose sight of the fact that IPV can result in death. Physicians should work closely with the patient to formulate a safety plan. A Safety Packing List (Figure 4) highlights items that should be included in the safety plan. Essential items include a set of keys, important documents such as birth certificate(s), additional cash and clothes, as well as the emergency numbers and the number of someone that the victim trusts and can call in an emergency.44 Patients should be educated on the course of domestic violence and the potential for escalation of violence if the victim chooses to leave the relationship.
Figure 4: Safety Packing List by the U.S. Department of Health and Human Services, Office of Women's Health44
Step 3: Know onsite, local and national resources. The best resource for IPV victims is IPV advocacy services as they are well trained in IPV intervention and can most adequately assist the patient in dealing with IPV. Additionally, the National Domestic Violence Hotline is a valuable resource as are others listed in Table 3. Physicians and patients should ensure that any provided resources are hidden or concealed from the abuser. References can be small (thereby easily concealed in a shoe, etc.), obscure (hidden on the back of the physician’s card along with other useful numbers), or even technologically savvy. The ASPIRE News App appears to be a news website but actually offers a discrete way to call for help and can be downloaded onto a phone or other electronic device.45
Step 4: Determine whether or not Child Protective Services should be involved. If any child is thought to be unsafe in the home, it is mandatory for the clinician to report this. However, the IPV victim and parent of the child should be encouraged to report on his or her own as this may assist in custody decision making.
Careful documentation is imperative in cases of domestic violence, especially when the patient is contemplating pursuing legal intervention. Documentation should include direct quotes from the patient regarding time, nature and other details regarding the abuse; physical exam findings; photography or sketches of the sustained injuries (photographs to include the patients face in case of necessity for evidence); and comments on comorbidities and degree of disability.42,45 If necessary, rape kits should be obtained, completed and documented. Physicians should not use words such as “denies” or “claims” as this may suggest disbelief in the patient especially in a court of law. More appropriate language includes “patient reports” rather than “patient denies or claims.”
In the state of Florida, physicians are not required to report domestic abuse unless serious injury or gunshot wounds were inflicted. Similarly, Florida Statute § 877.155 requires any person who treats for second or third-degree burns affecting 10 percent or more of the body, to report such treatment to the authorities if they determine the burns were caused by a flammable substance and if they suspect the injury is a result of violence or other unlawful activity. Reporting of domestic abuse without the informed consent of the patient is illegal even if the patient admits to the violence.46
If there is a suspicion of child abuse or an admission of such, the child abuse must be reported to the Department of Children and Families.
As of 2012, only a minority of states had mandatory reporting of IPV which is largely due to the concern that mandatory reporting requirements threaten patient-physician confidentiality and may deter women from seeking needed medical attention or discussing abuse.47,48 In surveys of victims presenting to emergency departments, most victims do not support mandatory reporting.49 This is likely due to the fact that these women recognize that the reporting may lead to an escalation of the violence by their abuser. Nonetheless, it is important that healthcare providers be familiar with their state requirements for mandatory reporting of IPV.
Randomized control trials studying IPV are not feasible because of the nature of the “disease.” However, in recent years, many meta-analyses have been performed to further investigate the effectiveness of intervention in IPV. In 2013, the World Health Organization issued guidelines stating that, except for women who have spent one or more nights in a shelter or pregnant women, there was insufficient evidence that interventions for IPV improved health outcomes.50,51 Since that time, one large meta-analysis was published suggesting that women-centered advocacy and home-visitation programs reduce a woman’s risk of further violent abuse.52
The effectiveness of batterer’s intervention is also not completely understood. Therapy for batterers includes counseling and group therapy. The duration of treatment in the state of Florida is 26 weeks. In this setting, men with previous abusive behavior challenge other men about their unacceptable behavior. Many men are court ordered into these intervention programs and for those men who do complete at least a six-month program, there is some data to show that the recidivism rate is low.
Matters involving abuse and IPV fall under the jurisdiction of the Family Court within each legal jurisdiction in Florida. The Family Court has the authority to review those matters that deal with civil domestic, repeat violence, dating violence, stalking, and sexual violence injunctions. These same matters may also result in or stem from criminal actions which would be reviewed by the Criminal Court, usually within the same legal jurisdiction.
If the alleged IPV does not meet the requirements for mandatory reporting referenced above, the patient may also petition the court to provide a temporary injunction if there is an immediate and present danger of domestic violence. The petition for temporary injunction can be filed where the patient currently or temporarily resides, as well as where the abuser resides, or where the domestic violence occurred. The court may consider a number of factors when determining whether to grant the temporary injunction, including the abuser’s past history of violence against the patient and others.
These proceedings are usually first filed as an ex parte temporary injunction, meaning that the other party, or the abuser, is not present. If the ex parte temporary injunction is granted, it is effective for 15 days, and the court must set a full hearing to take place no later than the 15-day period to determine whether it will grant a permanent injunction. During this temporary injunction period, the court may restrain the abuser from contact with the patient, provide the patient exclusive occupancy of any shared dwelling, or specify places that the abuser must stay away from, like places of employment, children’s schools, or other family homes. The court may also order the abuser to surrender any firearms to the Sheriff’s Office, as well as any other relief the court believes is necessary.
At the hearing for final injunction, both the patient and the abuser are permitted to have advocates present from the State Attorney’s Office, law enforcement, or a domestic violence center. The court may also consider relevant evidence of abuse and violence from the patient’s medical records. If the court approves a final injunction, it may also order temporary support of any minor children, temporary alimony, and refer the patient to a domestic violence center. Though the patient cannot be ordered to attend counseling, the abuser can be ordered to undergo a substance abuse or mental health evaluation and any treatment that is recommended. The abuser may also be ordered to enroll in and complete a certified batterer intervention program. Any violations of these injunctions are treated as criminal matters, and the Florida Department of Law Enforcement maintains a Domestic, Dating, Sexual and Repeat Violence Injunction Statewide Verification System that will communicate these injunctions between state criminal agencies. Violation of a final injunction may result in arrest and charge of a first-degree misdemeanor for each violation with a maximum sentence of one year. The Domestic Violence Case Flow in Table 4 provides an example of the possible course of a case.53
Table 4: Domestic Violence Case Flow Chart created by the Florida Courts53
Domestic violence is prevalent and impacts the psychological and physical well-being of the victims, as well as the children in the homes where the abuse occurs. It is associated with financial and societal ramifications. Health care providers should pursue a better understanding of victims and their perpetrators, the clinical presentation, who and how to screen for IPV and the resources that are available to victims. Be your patient’s advocate!
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