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Overview. DefinitionIncidence/PrevalenceVictim PresentationBarriers to ScreeningScreeningRisk AssessmentSafety PlanningDocumentationMandatory ReportingResources. Definition of Domestic Violence. A pattern of intentionally coercive and violent behavior toward an individual with whom there i
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1. Domestic Violence: The Primary Care Physician's Role Anika A. H. Alvanzo, MD
February 27, 2001
2. Overview Definition
Incidence/Prevalence
Victim Presentation
Barriers to Screening
Screening
Risk Assessment
Safety Planning
Documentation
Mandatory Reporting
Resources
3. Definition of Domestic Violence A pattern of intentionally coercive and violent behavior toward an individual with whom there is or has been an intimate relationship
Includes physical injury, verbal abuse, and economic abuse
4. Incidence/Prevalence US Dept of Justice- National Crime Victimization Survey
-1 million violent crimes against victims committed by current or former spouses or boyfriend/girlfriend in 1998
22% of violent crimes against women between 1993-1998
1,830 murders in 1998 (11% of all murders nationwide)
Of above murders 72% of the victims were women
Women were 5x more likely to be victims of abuse as compared to men
Homicide data obtained from FBI Uniform Crime Reporting Program
Conducted interview between 1993-1998 of approx 300,000 households and 600,000 people age 12 and overHomicide data obtained from FBI Uniform Crime Reporting Program
Conducted interview between 1993-1998 of approx 300,000 households and 600,000 people age 12 and over
5. Incidence/Prevalence Abbot et al (Jama 1995)
12% of women with current partners reported domestic violence within the previous year
6% of women without current partners reported domestic violence within the previous 30 days
54% of women reported a lifetime prevalence of domestic violence 2 teaching hospital EDs, 1 private ED, 2 hospital walk-in clinics all in Denver, CO
30 randomly selected 4hr time blocks btwn April-May 93; 833 women seen; 648 participants
Self administered 34 item questionnaire 2 teaching hospital EDs, 1 private ED, 2 hospital walk-in clinics all in Denver, CO
30 randomly selected 4hr time blocks btwn April-May 93; 833 women seen; 648 participants
Self administered 34 item questionnaire
6. Incidence/Prevalence McCauley et al (Annals 1995)
5.5% reported domestic violence within the previous year
21.4% reported history of domestic violence ever in adult life
22% reported history of domestic violence prior to 18yo
4 PC clinics in Baltimore, MD associated with Hopkins Bayview between Feb-Jul ’93
85 question self administered survey (Abuse Assessment Screen, CAGE, Symptom checklist)
3203 women total (283 not eligible, 528 not asked); 1,952 women completed the questionnaire
4 PC clinics in Baltimore, MD associated with Hopkins Bayview between Feb-Jul ’93
85 question self administered survey (Abuse Assessment Screen, CAGE, Symptom checklist)
3203 women total (283 not eligible, 528 not asked); 1,952 women completed the questionnaire
7. Incidence/Prevalence Geary and Wingate (AM J of OB/GYN 1999)
40.1% of women gave history of abuse
Of these women, 76.2% were currently in an abusive relationship
Most common injuries reported were fractures Grady Memorial OB/GYN emergency clinics April 1991
452 respondents
Voluntary self-administered questionnaire given to pt by triage nurseGrady Memorial OB/GYN emergency clinics April 1991
452 respondents
Voluntary self-administered questionnaire given to pt by triage nurse
8. Presentation: History History inconclusive with type of injury
Delay between injury and presentation
Accident prone history
Repeated STD’s
Repeated failure of compliance with medical care
9. Failure to get prenatal care
Psychosomatic complaints with negative organic workup (i.e. chronic HA’s, abd pain, or pelvic pain)
Mental illness (depression, anxiety, PTSD)
Suicide attempts
Substance abuse Presentation: History
10. Central pattern of abuse (face, neck, chest, breasts, abd, genitalia)
Multiple injuries in various stages of healing
Bruises on inner aspect of arms/legs
Injuries suggestive of a defensive posture (i.e. ulnar aspect of forearms)
Presentation: Physical
11. Barriers to Screening Suggs and Inui (JAMA 1992), Suggs et al (Arch Fam Med 1999)
Time constraints
Opening Pandora’s Box
“It’s a Private Matter”
Physician Bias
Fear of offending the patient
Powerlessness
Lack of Training
Safety Concerns 1992 JAMA (Suggs and Inui) interviewed 38 physicians in an Urban HMO (34FPs’, 4 Int Med) between Aug 90-Feb 91
1999 interviewed 206 (71 physicians, 13 PAs, 6 NPs, 58 RNs, 25 LPNs, 33 Mas
Comparison: 55% in 1992 felt fear of offending pt
65% in 1999 were not concerned re offending pt (85% felt it was not an invasion of privacy)
1999: 15% believed that victim’s personality caused them to be abuse
25% believed abused persons passive-dependent personality led to abuse
19% believed victim stayed b/c they were getting something out of the relationship
39% were confident in asking about DV
26.5% felt workplace was not secure enough to discuss DV with pts
only 23% felt they had strategies to assist victims 1992 JAMA (Suggs and Inui) interviewed 38 physicians in an Urban HMO (34FPs’, 4 Int Med) between Aug 90-Feb 91
1999 interviewed 206 (71 physicians, 13 PAs, 6 NPs, 58 RNs, 25 LPNs, 33 Mas
Comparison: 55% in 1992 felt fear of offending pt
65% in 1999 were not concerned re offending pt (85% felt it was not an invasion of privacy)
1999: 15% believed that victim’s personality caused them to be abuse
25% believed abused persons passive-dependent personality led to abuse
19% believed victim stayed b/c they were getting something out of the relationship
39% were confident in asking about DV
26.5% felt workplace was not secure enough to discuss DV with pts
only 23% felt they had strategies to assist victims
12. Screening Conflict Tactics Scale
Index of Spouse Abuse
Abuse Assessment Screen CTS- 20 questions which measure 3 tactics: 1)Reasoning Scale- use of rational discussion, argument and reasoning (intellectual approach), 2)Verbal Aggression Scale- use of verbal and nonverbal acts which symbolically hurt, or the use of threats, 3)Violence scale- use of physical force as a means of resolving conflict
Scoring: percentage of total score
ISA: 30 item questionnaire which measures physical (ISA-P) and nonphysical abuse (ISA-NP)
scoring: ranges btwn 0-100 for both
AAS: 5 question screen CTS- 20 questions which measure 3 tactics: 1)Reasoning Scale- use of rational discussion, argument and reasoning (intellectual approach), 2)Verbal Aggression Scale- use of verbal and nonverbal acts which symbolically hurt, or the use of threats, 3)Violence scale- use of physical force as a means of resolving conflict
Scoring: percentage of total score
ISA: 30 item questionnaire which measures physical (ISA-P) and nonphysical abuse (ISA-NP)
scoring: ranges btwn 0-100 for both
AAS: 5 question screen
13. Risk Assessment Does perpetrator have access to you?
Does partner abuse drugs or alcohol?
Is partner violent with other people outside the home?
Does partner abuse your children or other family members?
14. Risk Assessment Has violence increased in frequency and/or severity?
Have you been choked?
Are there weapons available?
Has a weapon been used to scare or hurt you?
Has partner ever threatened suicide?
15. Safety Planning Commit important phone numbers to memory
Keep change for pay phone on your person at all times
Make copies of all important documents (i.e. marriage license, birth certificates, social security card, passports, lease/mortgages, insurance papers)
16. Safety Planning Leave copies of documents, extra set of clothes, extra set of keys, and extra money with trusted friend or relative
Rehearse and commit escape plan to memory
17. Documentation Record description of encounter as told to you by patient (use quotes if possible)
If patient names her perpetrator, write name down in the medical record (i.e. Pt states that she was struck by her husband, John Brown.)
Record all pertinent physical exam findings (use body map)
18. Documentation Offer to photograph visible injuries
Preserve all physical evidence (i.e. bloodstained clothing)
Record suspicions even if patient denies history of domestic violence (i.e. in cases where mechanism of injury is not consistent with exam)
Write legibly Important because medical records can be subpoenaed, even if victims decline to press charges.
Particularly important for civil cases like divorce and child custody.Important because medical records can be subpoenaed, even if victims decline to press charges.
Particularly important for civil cases like divorce and child custody.
19. Mandatory Reporting Majority of states mandate reporting of injuries that occur as a result of a gun, knife, or other deadly weapon
Some states require reporting of injuries resulting from crimes or nonaccidental acts
As of 1995, 5 states had laws specifically addressing cases where domestic violence was suspected (CA, KY, NH, NM, RI)
20. Resources National Domestic Violence Hotline (800-799-SAFE)
Virginians Against Domestic Violence (800-838-VADV)
Health Resource Center on Domestic Violence (800-313-1310)
YWCA (804-643-6761) 24hr hotline Richmond 643-0888, Chesterfield 796-3066
21. References El-Bayoumi G, Borum M, Haywood Y: Domestic violence in women. Medl Clin of North America 82:2, 1998
Haywood Y, Haile-Mariam T: Violence against women. Emerg Med Clin of North America 17:3, 1999
Rennison C, Welchana S. Intimate partner violence. BJS report, NCJ 178247, May 2000
Abbot J, Johnson R, Koioi-McLain J, et al. Domestic violence against women. JAMA 273:22, 1995
McCauley J, Kern D, Kolonder K, et al. The “Battering Syndrome”: prevalence and clinical characteristics of domestic violence in primary care Internal Medicine practices. Annals of Int Med 123:10, 1995
Geary J, Wingate C. Domestic violence and physical abuse of women: The Grady Memorial Hospital experience. AM J of Obstetrics and Gyn 181:1, 1999
Sugg NK, Inui T. Primary care physicians’ response to domestic violence. JAMA 267:23, 1992
22. References Sugg NK, Thompson RS, Thompson DC, et al. Domestic violence and primary care. Arch Fam Med. 8, 1999
Straus M. Measuring intrafamily conflict and violence: the conflict tactics scales. J Marriage Fam. 41, 1979
Urdy JR. Marital alternatives and marital disruption. J Marriage Fam. 43, 1981
McFarlane J, Parker B, Soeken K, et al. Assessing for abuse during pregnancy. JAMA 267:23, 1992
Salber P and Taliaferro E: The physician’s guide to domestic violence. California, Volcano Press, 1995
Hyman A, Shcillinger D, Lo B. Laws mandating reporting of domestic violence: Do they promote patient well-being? JAMA 273:22, 1995