Medical Response to Domestic Violence

1
Medical Response to Domestic Violence

• Jane A Petro, MD
• Professor of Surgery
• New York Medical College

2
Domestic Violence Definition

• A pattern of behavior used by one individual to
  exert power and control over other individuals
  within the context of an intimate relationship.
  Such behaviors include intimidation by force,
  emotional, and sexual, abuse, economic control,
  and neglect.

3
POWER AND CONTROL

• INTIMIDATION
• ISOLATION
• EMOTIONAL ABUSE
• ECONOMIC CONTROL
• PHYSICAL THREATS
• HARM

4
Myths of Domestic Violence

• I never see it in my practice.
• It never happens to people like me.
• It doesnt affect medical health.
• It is not common.
• It is better left to the family.
• I cant do anything about it anyway.

5
Facts About Domestic Violence

• 1 million women seek medical assistance for
  injuries caused by battering each year
• A woman is beaten every 15 seconds
• US dept HHS, 1991

6
Cultural Determinants of Abuse

• Historical tolerance of abuse.
• Belief that women should be subservient to men.
• Belief that men should exercise sovereignty.
• View that women are property.
• Men beat women because they can.

7
Facts About Domestic Violence

• Battering is the major cause of injury to women,
  resulting in more injuries than auto accidents,
  muggings, and rapes by strangers combined.
• 50 of homeless women and children are fleeing
  domestic violence.

8
Facts About Domestic Violence

• Women are 10 times more likely to be victimized
  by their intimate than men
• 75 of women seek care for injuries due to
  battering after they have separated
• 75 of police interventions are called after
  separation
• In the US there are 1,500 shelters for battered
  women, 3,800 for animals

9
Facts About Domestic Violence

• Medical expenses for DV total between 3 and 5
  billion annually
• Business costs of DV cost 100 million in lost
  wages, sick leave, absenteeism and
  non-productivity
• The commonest cause of workplace death among
  women, is homicide by an intimate

10
Facts About Domestic Violence

• 25 or workplace problems, absenteeism, decreased
  productivity, turnover, and excessive use of
  medical benefits are due to family violence

11
Facts About Domestic Violence

• 40 of first assaults begin during pregnancy.
• 1 in 10 female high school students has been
  battered.
• 22 of female college students report being
  battered, equivalent to the reported rate for
  adults.

12
Co-factors in Domestic Violence

• Spouse and child and pets
• Drugs and Alcohol
• Social isolation
• Not economics, race, religion, education, social
  class, national origin

13
Facts About Domestic Violence

• More than twice as many women are murdered by an
  intimate partner than by a stranger
• Among all female victims, 29 were slain by an
  intimate, 4 of males were slain by their wives
  or girlfriends (FBI, 1992)
• Violence is the stated reason for middle class
  divorce in 22 of cases

14
Facts About Domestic Violence

• The victim of domestic violence is a woman in 85
  of all cases reported.
• She is white in 64 of cases.
• She is an average age of 31.
• Uniform crime reports, 1992.

15
Stated Reasons for Committing Homicide

• Men
• Possessiveness 82
• Abuse 75
• Arguments 63
• Self defense 4

• Women
• Self defense 83

16
Facts About Domestic Violence

• Women charged with homicide of an intimate
  partner have the least extensive criminal record
  of any other crime category, and serve longer
  sentences than men who kill their spouse. Men
  who kill their spouse are less likely to be
  charged with first or second degree murder than
  are women.

17
Facts About Domestic Violence

• 90 of family violence defendants are never
  prosecuted
• 33 of the cases that would be considered
  felonies if committed by strangers, are filed as
  misdemeanors

18
Medical Consequences of DV

• Separated or divorced women are 14 times more
  likely to report being a victim of a spouse, or
  ex-spouse.
• Although only 10 of women are separated or
  divorced, they report 75 of the spousal
  violence.
• Women are far more likely to be killed after
  leaving, 41 within 2 months, 91 in 1 year.

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Is DV a Medical Issue?

• NEJM September 16,1999
• JAMA annual issue
• 3200 articles listed in the peer reviewed medical
  literature since 1969
• All major specialties published articles in the
  past year
• AMA diagnostic and treatment guidelines

20
Is there a duty to address DV?

• All clinicians examining children and adults
  should be alert to physical and behavioral signs
  and symptoms associated with abuse and neglect.

21
What are the duties?

• Suspected cases of abuse should receive proper
  documentation of the incident and physical
  findings (e.g..., photographs, body maps)
• Treatment of physical injuries arrangements for
  counseling by a skilled mental health
  professional
• Telephone numbers of local crisis centers,
  shelters, and protective service agencies.

22
Facts About Domestic Violence

• 8 of women reported the abuse to their
  physician.
• 38 discussed it with a friend or co-worker.
• More than 50 told no one.
• Abused women are more likely to seek help from
  their physician than police or lawyers.

23
Medical Consequences of DV

• Women at risk of injury and death
• Complications of pregnancy and childbirth
• Gynecologic problems, STDs, HIV
• Chronic somatic disorders
• Non compliance with medical care

24
Medical Consequences of DV

• Battered women are 15 times as likely to be
  alcoholic, and 9 times as likely to be drug
  abusers, than non-battered women.
• This increased risk appears AFTER the first
  episode of domestic violence.

25
Mental Health Consequences

• Chronic depression
• Anxiety disorders
• Suicide
• Eating disorders
• Alcoholism
• Substance abuse

26
Consequences to Children

• 50 of the children of battered women are also
  abused
• Adopt violent and aggressive behaviors
• Emotional trauma and behavioral problems
• Be incarcerated for assaulting the abuser
• Batterers are more likely to have witnessed their
  mother being battered

27
Prevalence of DV

• Emergency Room 25-37
• Obstetrics and Gynecology 15-25
• Primary care 25 , 15
• Psychiatry 25
• Pediatrics 50-70, 15

28
Batterers Behaviors

• Aggressive
• Controlling or coercive
• Harassing
• Destructive
• Intimidating
• Isolating
• Threatening

29
Perpetrator or Victim?

• Remember, the batterer may have been injured
  during the battering.
• Distinguishing them may not be a matter of who
  says what.

30
Clinicians Role

• Your have a right to be safe in your home
• No one has the right to do this to you
• This is a criminal act
• There are many ways that you can be helped, when
  you are ready

31
Clinicians Role

• Believe the victim
• Validate the experience
• Recognize that truth is not concrete
• Respect decision making
• Be willing to be patient
• DO NOT REPORT, OR RECOMMEND FAMILY COUNSELING

32
Failure to Screen for DV

• Physician discomfort
• Time constraints in the clinical setting
• Failure to recognize the pervasive occurrence of
  DV
• Lack of access to services
• Misunderstanding about the nature of abuse, and
  of victims responses

33
Failure to Screen for DV

• Believe the patient provoked the violence
• Believe that her drug use, alcoholism, illness is
  more important, or makes the violence less
  relevant
• Believe that she could just leave, if she wanted
  to
• Believe that even medical help, wont help

34
What Do the Victims Want?

• To be asked
• To be believed

35
Why Dont Patients Just Tell?

• Fear of retribution
• Shame and humiliation, isolation
• May believe that she does deserve it
• Wants to protect her partner
• May not understand the situation
• May not think the doctor cares, or that they
  cant help anyway

36
Why Stay in the Relationship?

• Fear that the violence will escalate if she tries
  to leave
• Lack of alternative living arrangements
• Believes that family is necessary for the kids
• Economic fears
• Too traumatized to leave

37
Why Stay in the Relationship?

• Cultural, religious or family values that place
  the needs of the family above those of the
  victim as an individual
• Feels responsible for the violence
• Loves him, believes he will change
• Doesnt know that anyone else cares

38
Comprehensive Review

• Physical. This includes physical hitting extent
  of current and past injuries if the patient has
  been beaten up, threatened, or attacked with a
  weapon.
• Sexual. This includes forcing unwanted types of
  sex or refusing to use birth control.

39
Comprehensive Review

• Emotional. This includes humiliation, swearing,
  name calling, mental instability, alcohol, and
  other drug use, and obsession with partner.
• Isolation. This includes controlling access to
  friends and family and limiting outside
  involvement.
• Children. This includes threats to partner by
  threatening children.

40
Comprehensive Review

• Destroying. Destroying the patient's property or
  injuring patient's pets or children.
• Economic. The abusive partner controls all money.
  
• Threats. Threats of injuring patient or self,
  threats of reporting patient to immigration,
  stalking patient.
• Past violence history. For example, arrests for
  violent acts or threats of using a weapon.

41
Comprehensive Review

• Short term plan. "Do you know what to do if you
  are afraid?" "Where could you go if you were in
  danger?"
• Support. "Who can help you get safer?"
• Strengths in patient and spouse. "Is there any
  hope that changes can be made?"

42
Clinical Indicators of Abuse

• Physical findings
• General signs and symptoms
• Psychological symptoms
• Complications of pregnancy and childbirth
• Associated social and family problems

43
Clinical Clues to DV During Pregnancy

• Inconsistent injuries, bilateral injuries
• Central injuries, especially abdomen
• Pattern of injury, different stages of healing
• Delay between injury and attention
• Drugs, depression, STDs, missed appointments or
  no prenatal care
• Previous complications of pregnancy

44
Characteristics of DV Injuries

• Central distribution
• Head and neck
• Defensive injuries of forearms
• Multiple sites, variable bruises
• Neurological symptoms, visual, auditory, stroke,
• Sexual assault related

45
Physical Violence Scale

• Throwing things, hitting the wall
• Throwing at the victim
• Slapping
• Punching
• Severe assault
• Threatening with weapons
• Using weapons

46
Medical Interventions for DV

• Routinely ask about DV
• Assess safety
• Document the abuse
• Discuss the options and resources available
• Provide advocacy and referral
• Treat the medical and psychological issues
• Provide for follow-up care

47
How to Prepare to Ask About Abuse

• Learn the facts, lose the myths.
• Practice asking key questions on some of your old
  patients.
• Talk to your staff about this.
• Put up posters, make palm cards available, have
  information in the waiting room, and the womens
  bathrooms.

48
Questions That Should Be Asked

• Is there abuse, now, ever, potential?
• Who is the perpetrator? What kind of access does
  he have?
• How has the abuse affected health?
• Is it safe to go home?
• How is she feeling about the fact that you are
  asking?

49
Questions That Should Be Asked

• How do your own feelings interfere with your
  ability to communicate with your patient?
• What resources are available to help your
  patient?
• What does the patient need to take the initial
  steps toward safety and freedom from abuse?

50
What Questions Should You Ask?

• First create a safe environment.
• Patient alone in the room.
• Literature about DV available.
• Put the questions in context. Ask as part of
  your routing screening.
• Use language that you are comfortable with.

51
What Questions Should You Ask?

• Use direct questions
• Have your ever been punched, hit or kicked by
  someone you know?
• Are you safe at home?
• Is there someone close to you who is hurting you
  now?

52
What Questions Should You Ask?

• Your partner seemed reluctant to leave you alone.
  Is there something they are afraid you will tell
  me?
• You seem afraid of your partner. Have your been
  threatened, or hurt? Have they ever threatened
  or harmed the children?
• Do you have to ask permission from your partner
  to do things?

53
What Questions Should You Ask?

• I see you have some bruises, did someone do this
  to you? Can you tell me how this happened?
• Is there someone who is trying to keep you from
  taking your medication?, Or keeping you from
  doing things YOU want to do?
• Are there guns or knives in your home? Who has
  access to them?

54
What Not to Ask Your Patient

• Why dont you just leave?
• Why would you stay with someone like that?
• What did you do to aggravate him?
• What did you do to cause the violence?
• Are you a masochist?
• Why didnt you diffuse the situation?

55
Does Asking Questions Work?

• Specificity 85
• Sensitivity 71
• Do you ever feel unsafe at home?
• Has anyone at home hit you or tried to injure you
  in any way?
• JAMA 2771357, 1997

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Clinicians As Advocates

• Weight reduction
• Smoking cessation
• Cardiovascular fitness
• Tight control of diabetes
• Immunizations
• Flammable fabric, windshields, seat belts,
  airbags, crib positioning

57
What Should You Say?

• You do not deserve this.
• You are not alone.
• You are not crazy.
• What happened to you is a crime.
• No one should be able to do this to you.

58
Screening Questions

• Are you safe at home?
• Does (has)anyone you loved hit or hurt you?
• Does anyone in your home harm your children or
  your pets?
• Are there guns in the home?

59
Screening Parents of Newborns

• How often do you have yelling or screaming
  fights?
• Do you have pushing or shoving fights?
• Do you have guns, or other weapons in the home?
  If yes, how are they stored? Where is the
  ammunition kept?

60
Screening Parents of Children

• I am sure that you have heard about violence in
  the home and school. Do you have problems with
  fighting in your home?
• Separate family members when doing follow thought
  questions.

61
Screening Teenagers

• Sex, Drugs, Rock and Roll
• Has anyone forced you to have sex?
• How many pushing or shoving fights have you had
  in the past year?
• Have you been injured?
• Do you carry a weapon for protection?
• How do you get out of a fight?

62
Adults

• How do you disagree?
• How many pushing or shoving fights have you had
  in the past year?
• Has anyone you loved hurt you this year?
• Do you have guns in your home?

63
Emergency Room

• Has anyone hurt or hit you recently?
• Did you come here today because someone hurt you?
• This looks like it hurts. You dont deserve this?
• Do you feel safe in your home?

64
If the Answer Is Yes?

• Let her tell her story.
• Believe it, validate the experience.
• Document your history, and the physical findings,
  include the name of the abuser, dates, nature of
  the injury, its mechanism, etc.
• If you suspect it document it even if denied.

65
If the Answer Is Yes?

• Discuss safety.
• Be sure she has the information she may need.
• Information about calling the police, the
  shelter, legal aid, your office.
• Be sure she knows that help is available, even if
  she cant afford it.

66
If the Answer Is Yes?

• Make a follow-up appointment
• Validate the patients experience concern for
  well-being and safety
• Consider whether suicide or homicide should be
  discussed

67
If the Answer Is NO!

• If you are suspicious, document it carefully.
• Make information available.
• Make a follow-up appointment, track it to see if
  it is kept.
• Be sure to ask again at the subsequent visit.
• Be careful about messages left at the home.

68
Evidence Collection Guidelines

• Look, observe, assess, correlate
• Record your observations, using proper medical
  terminology
• Photograph injuries if possible
• Preservation of evidence, clothing, rape kit
• Package, label, identify, store, chain of evidence

69
Evidence Collection Guidelines

• Bite marks
• Instrument, tool marks
• Care for the patient, not just the legal system

70
Referral Services

• Natl DV Hotline [phone]-SAFE
• Physicians for a Violence-free Society
• (415)-821-8209
• My Sisters Place 1-800-298-SAFE
• My Sisters Place office (914)-638-1333
• NYS Office for the Prevention of DV
• (518)-486-6262

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Referral Services

• American College of OB-GYN
• [phone]
• National Coalition Against DV
• [phone]
• American Medical Association
• [phone]
• National Resource Center on DV
• ( 800) 537-2238

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What is Domestic Violence?

• Power and Control
• Injuring, or trying to injure someone within a
  relationship of love, or dating
• Isolating a partner from other forms of social or
  family contact
• Preventing an adult from making independent
  decisions (like and adult)

73
Comprehensive Assessment

• Tell me about the last time you were hit?
• Can you tell me about the worst time you have
  had?
• Are you afraid right now?
• Do you have a safe place to go to today?

74
Safety Plan

• Where to go
• What to take
• Documents
• Clothes
• Address book
• Medicine
• Keys

75
Safety Plan

• Kids
• School
• Pets
• Resources
• Residence
• Work

76
Conversation

• "Are you safe now? Do you know what to do if you
  don't feel safe? This is terrible. You don't
  deserve this. If things stay the same, this will
  not get better. I am giving you a name and number
  of a counselor who can help you figure out how to
  be safer. Call this number when you can. If you
  are ever feeling that you or your children are in
  danger, come to the emergency room."

77
Where help is not

• The legal system is not designed for healing or
  restoring relationships or individuals.
• The legal system can sometimes make things worse.
  It models coercion as the best tool to solve the
  problem of violence.
• Prosecutors and judges are interested in
  assessing blame, exacting revenge, punishing,
  following public opinion, and being sure they
  won't be blamed for further violence.

78
Remember

• Lying men and women can manipulate the criminal
  system more skillfully than naive or honest
  people.
• Police almost always arrest the man of the
  household if anyone claims that a couple are
  beating each other.
• But opportunists are using this law to increase
  female arrests