Domestic Violence

Domestic Violence: A Guide to Screening and Recognition

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October is National Domestic Violence Awareness Month. Learn how primary care clinicians play an important role in stopping violence at home.

A home and family should be a place of refuge and support, not cruelty and brutality. For millions of Americans, however, the safety of home and family is threatened by domestic violence. (For editorial purposes, the terms “violence” and “abuse” are used interchangeably.) Domestic violence is believed to occur in 1 in 4 families in the United States.[1] It can occur within families of any race, age, sexual orientation, education level, religion, or gender. A broad and overarching term, domestic violence is generally defined as a pattern of assaultive and coercive behavior used by one person to gain or maintain power over another within the confines of a family or intimate relationship. When power and control are aimed toward a partner or spouse, the practice is known as intimate partner violence (IPV). When the intended victims are children or elderly relatives, the practice is known as family violence.

The 2 most widely recognized forms of abusive and violent behavior are physical and sexual abuse. Three less-recognized types of abuse are emotional, psychological, or verbal abuse, which includes ridicule or intimidation; financial abuse, such as jeopardizing a partner’s employment or withholding financial resources; and spiritual abuse, whereby a partner’s religious beliefs may be ridiculed or dismissed. These patterns of abuse are particularly difficult to identify and document because they are much more subtle and “leave no marks.”

The Intended Victims

Intimate Partners
Every year, at least 1.5 million women and just over 800,000 men are victims of IPV,[2] which typically consists of a continuing pattern of behavior rather than a single abusive act.[3] It is estimated that more than 7 million episodes of intimate partner violence are reported each year in the United States and that nearly 25% of women have experienced some form of IPV in their lifetime.[2] Intimate partners need not be cohabiting nor is sexual activity necessarily involved,[4] and the abuse may occur between heterosexual or same sex partners. While most of the abuse perpetrated against women occurs in heterosexual relationships, abuse against men is overwhelmingly committed in same-sex relationships.[5] However, men and boys are less likely to report the abuse and seek services, due primarily to the stigma of being a male victim, the fear of not being believed, or a perceived lack of support from family members and friends.

In addition to the immediate physical and emotional needs of patients following an abusive episode, IPV is also associated with poor health outcomes; women with a history of IPV have a 60% higher rate of physical health problems[6] and are 4 to 6 times more likely to seek help for depression.[7]

Children
Child abuse consists of any act that endangers or impairs a child’s physical or emotional health and development. Child abuse is often represented by an injury or series of injuries that appear to be nonaccidental in nature (Table 1). In 2008, the child protective services received 3.3 million reports of child abuse or neglect on approximately 6 million children.[8] Aside from the physical and emotional trauma perpetrated on children by their abusers, child abuse has long-lasting sequelae that promote a cycle of ongoing abuse and destructive behavior. In fact, 14% of male and 31% of female prisoners in the United States were abused as children. In addition, abused children are 25% more likely to experience teen pregnancy, and more than one-third of abused and neglected children will eventually victimize their own children.[9]

Elders
According to a number of statistical sources, between 1 and 2 million older Americans experience mistreatment each year,[10] with only 2% of all cases being reported to the physicians.[11] Unfortunately, elders are less able to stand up to bullying and/or to fight back if attacked. They may not see, hear, or think as clearly as they used to, providing opportunities for victimization and abuse.

Elder abuse tends to take place where the senior lives with the abuser; most likely to be a spouse or partner, adult children, or grandchildren. Institutional settings can also be sources of elder abuse. Abuse of elders takes many different forms and can include intimidation or threats, verbal and physical abuse, neglect, or financial deception.

It can be difficult to recognize signs of elder abuse. Caregivers may explain them as symptoms of dementia or signs of frailty. In fact, many signs of elder abuse do overlap with symptoms of mental deterioration, and all findings should be confirmed with a complete physical and neurological exam. General warning signs of elder abuse include frequent arguments or tension between the caregiver and the elderly person and/or changes in personality or behavior in the elder. A more in-depth list of signs and symptoms is provided in Table 2.

Pets
Family violence is not limited to humans. Household pets are often the victims of abusive behavior so the abuser can demonstrate and confirm power and control over the family, eliminate competition for attention, or punish a human family member for trying to leave. While it may seem incongruous to associate animal abuse with human abuse, research suggests that the 2 forms of abuse are closely related.[12] Threatening, injuring, or killing animals can indicate the potential for increased violence, and more importantly, human victims may postpone leaving out of fear for their pets’ safety. Thus, animal cruelty within the family setting is an important signpost for domestic violence and should prompt an assessment for possible child or partner abuse.

Screening for Domestic Violence

Domestic violence is at least as prevalent as breast cancer, thyroid dysfunction, hypertension, or colon cancer,but is much more likely to be overlooked in a screening interview.[13] Early identification of patients involved in an abusive relationship is critically important when assessing their general health and mental health status. However, research indicates a high rate of missed opportunities for patient identification in clinical settings. On average, 50% of all physicians report screening for family violence, 10% to 50% report they never screen, and 6% to 16% report they screen routinely.[14-19] Even when screening is performed, it may not be done in a manner that promotes patient trust and full disclosure. Despite the burden of suffering caused by family violence and the strong advocacy among health professionals for identification and intervention, there is still no real consensus as to how best screen for domestic violence.

The Role of Primary Care
Family violence is likely to affect at least one-third of your patients, and should be formally addressed.[20] However, clinicians continue to cite barriers to providing these assessments, including patient evasiveness, lack of time and support resources, lack of experience in asking the right questions, fear of offending the patient, inability to “fix” the problem, and frustration with lack of change in the patient’s situation or the patient’s unresponsiveness to advice.[21,22] Physicians with expertise in domestic violence have proposed that “compassionate asking” can have therapeutic value in and of itself, and that a healthcare provider can make an enormous difference just by asking questions and validating the patient’s experience.[23]

Clinicians should routinely screen their patients for abuse even if there are no obvious signs or symptoms as part of their standard patient care according to the American Medical Association, American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the American College of Emergency Physicians.[24-28] Some interpretations of the US Preventive Services Task Force recommendation have been that of against screening; however, Task Force simply stated that they found no sufficient evidence showing that screening improves health outcomes. The statement does state “all clinicians examining children and adults should be alert to physical and behavioral signs and symptoms associated with abuse or neglect.”[29] You can easily incorporate a simple screening tool into a routine physical examination. One such validated tool uses the acronym AVDR[30]: asking patients about abuse; validating the message that battering is wrong and confirming the patient’s worth; documenting presenting signs, symptoms, and disclosures; and referring victims to domestic violence specialists. This approach allows clinicians to identify patients who may be in an abusive relationship and to then refer them to experts and resources who can provide individualized interventions.

Asking about abuse or violence at home can be included among a discussion of other safety issues, such as whether the patient wears a seatbelt, smokes, or practices safe sex. Incorporating the question in this manner can help reduce your discomfort at asking the question and to decrease the patient’s anxiety at having been asked. Try to ask the question in a private and confidential setting without a family member present. You can start with introductory questions and statements such as, “How are things at home?” or “Because violence is so common in many people’s lives, I think it’s important to ask all my patients whether they feel safe at home.” Two simple screening questions—“Do you ever feel unsafe at home?” and “Has anyone at home hit you or tried to injure you in any way?”—have a sensitivity of 71% and specificity of almost 85% in detecting violence.[13]

If they are asked in a sensitive and empathetic manner, many people in abusive relationships will talk openly about their experiences. Others may be reluctant to disclose their situations because of fear, embarrassment, or shame. There may be financial issues, concerns about immigration status, or a general lack of trust caused by the violation of trust in their intimate relationship. There are, however, some clues that can confirm your suspicions of violence at home, including—

  • Failure to keep medical appointments or comply with medical protocols
  • Secrecy or obvious discomfort when interviewed about relationships at home
  • The presence of a partner who comes into the examining room with the patient and controls or dominates the interview
  • Unexplained injuries or injuries inconsistent with the history given
  • Somatic complaints
  • Delay between time of  injury and seeking medical treatment
  • Injury to the head, neck, chest, breasts, abdomen, or genitals, especially during pregnancy
  • Bilateral or multiple injuries, especially if in different stages of healing
  • Chronic pain without apparent etiology
  • An unusual number of sexually transmitted infections, miscarriages, or abortions
  • Repeat vaginal or urinary tract infections[31]

Validation allows you to acknowledge that battering is always wrong. Statements such as “The abuse is not your fault” or “You deserve to be safe” help to remove the blame from an abused person and to reinforce a sense of self-worth. Validation can be a helpful tool even if the patient does not actively disclose the abuse. Abuse survivors have reported that validation can provide relief and comfort even if the abuse is not directly reported or acknowledged.[31] Therefore, if you suspect domestic violence, do not depend on direct disclosure from the patient. Instead, assume that the patient is being abused, acknowledge that abuse is wrong, and confirm your patient’s self-worth. This may be enough to provide reassurance and plant the seed that will motivate the patient to move forward. Do not judge patients negatively if they choose to return to abusive relationships—most women leave and return several times before finally leaving the relationship for good. It is important that you and your patient recognize that leaving an abusive relationship presents further risks to the patient; 75% of domestic assaults occur after the abused partner has tried to leave.[32]

Documentation should include all presenting signs and symptoms of abuse as well as all patient disclosures relative to abuse. Should an abused patient seek legal recourse against an abuser, the medical record will play an important role during the legal proceedings.[33] If possible, try to record specific names, locations, and witnesses. The patient’s direct words should be denoted with quotation marks, as these types of statements are admissible in court. Take a digital photo if possible, record the time of the medical interview, and indicate how much time has elapsed since the abuse occurred. Describe what you see on the physical examination, including the locations, shapes, colors, and size of bruises. Use a body map to record the extent and location of the injuries.

Referral is an important element in keeping your patients safe. If you work in a practice that has no social services on site, you can refer patients to an advocate for victims of domestic violence at a local agency, shelter, or hotline. If your work location is affiliated with a hospital, you should refer patients to social services. If the patient is employed, he or she may have access to an employee assistance program that can provide confidential services.

Be aware that you may be required to report certain subsets of patients to governmental or law enforcement authorities. All 50 states currently mandate that healthcare professionals report child abuse to state authorities, and 45 states require that elder abuse be reported to the state authority in which it occurs (exceptions are Colorado, New Jersey, New York, North Dakato, and South Dakota).[34] Civil codes in most states also mandate that medical personnel notify law enforcement when any patient presents with injuries due to a firearm or other deadly weapon. In many states the mandate extends to other severe injuries, sexual assaults, and injuries that result from a criminal act, including IPV.[35] Recent federal privacy regulations require providers to inform patients of health information use and disclosure practices in writing, and whenever a specific report has been made.

SIDEBAR: Making Your Practice Environment Accessible for Open Discussion[36]
Seed the idea that the topic of violence is important to you and your staff. Let your patients know that questions about safety at home are part of a routine visit to your office. You can

  • Put up posters and disseminate educational material. This lets patients know that you are aware of the possibility of violence in their homes and that you are open to discussing the topic.
  • Display material about abuse in public areas and in private places, such as the bathrooms, where a patient can read it without being seen.
  • Ask staff to wear buttons that say something about violence, such as, “We Talk About Family Violence Here.” This lets patients know that the staff are sensitized to this topic and want to know if their patients feel unsafe at home.
  • Have a binder with information about community safety resources readily accessible to all patients. The binder should be categorized by financial, language, cultural and transportation needs. Place a pencil and a pad of paper nearby so patients can write down this information for future reference. You should also provide a crisis hotline number in your office that patients can call if they are in immediate danger.

Resources

National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. The Family Violence Prevention Fund, 2004

National Coalition Against Domestic Violence

Domestic Violence Assessment Guide for Healthcare Practitioners

Family Violence Prevention Training Materials
Making the Connection: Intimate Partner Violence and Public Health, 2010

Screen to End Abuse Training Video

 

Published on October 12, 2010

A version of this article appeared in print in the 2008 Vol 10 No 5 Issue on page 2 of the Primary Issues newsletter.


References 

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