Domestic Violence

1. Domestic Violence Rajesh Kadam, MD Resident, IIIrd yr Med Psych

2. Case • 69 y/o Caucasian female residing with her niece is brought in for weight loss, abdominal pain and weakness. She is being w/u for possible malignancy. Niece at bedside during interview and controls the interview offering information as patient is very tearful and emotional “cries at the drop of a hat”. Niece reports that patient has been depressed for many yrs and has been treated with Xanax and various other antidepressants. She adds that patient isolates herself, does not do any household chores, sleeps all day, does not socialize, eats chocolates avoids regular food. • PPH: h/o depression, no inpatient stay • PMH: HTN, COPD, anemia • FH: father alcoholic, deceased: MI, Mother: depression, HTN, deceased. • Meds: Alprazolam, sertraline, lisinopril, inhalers, FeSO4, MV and Ca • Subs use: Smokes 1 ppd x 32 yrs, used to drink heavily as a teenager

3. Case: • Social: Lives with niece since 4 yrs. Niece manages her finances. Both parents deceased. Father was alcoholic, mother suffered from depression, Parents divorced when she was 3 yrs old, lived with mother, unhappy childhood. • Eloped at age 16, married had child at 17, divorced at age 22 ( could not get along), married thrice later all ending in divorces. 2 husbands alcoholic third cheated. Reports physical and emotional abuse in 3rd and 4th marriage. Has 3 children “they don’t respect me”. Psychological abuse by elder daughter. • Nurses report that the niece is very involved in care and fired the regular nurse. She wont let any doctor/ SW interview patient in her absence citing that all that patient would do is cry. She ordered that she be called should anybody wished to talk to the patient. After the interview when her niece had left the patient spoke with nurses and asked to speak with Psych. Patient talked in detail w/o breaking down once, about the emotional and physical abuse she was facing. She did not want disclosure fearing reprisal After talk with SW abuse hotline was called. Unfortunately niece became privy of the info and patient checked out AMA at 11.30 pm at night.

4. Objectives: • Diagnose DV • Screening for DV • Risk assessment • Interventions in DV • Documentation and referral • Legal ramifications

5. Topics of Discussion • Definition and Epidemiology • Victim and the Victimizer • Clinical presentations • Screening • Intervention • Management

6. Introduction: • Probably the most important contribution to ending abuse and protecting the health of its victims is to identify and acknowledge the abuse.Council on ethical and judicial affairs, AMA.

7. Definition • What? Pattern of assaultive, coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, deprivation, stalking, spiritual abuse, intimidation and threats. • Whom?By an abuser whois, was or desires to be involved in an intimate or dating relationship with an adult or adolescent victim. • Why ? To establish and maintain “Power and Control”.

8. AKA • Intimate partner violence and abuse: • The term "domestic violence" is now being replaced by intimate-partner violence • Spousal abuse • Wife battering • Wife beating • Man Beating,Husband battering • Domestic abuse • Relationship violence • Family violence

9. Pattern • Episodic with unpredictable outbursts. • Verbal and emotional initially. • Over time, tend to become physical. • Leaves victim in a state of constant fear.

10. Pattern: Cycle of violence • The tension-building phase: Increasing anger on the part of the abuser coupled with attempts by the woman to avoid violence. • The episode of acute abuse: includes various forms of abuse and may occur for an indefinite amount of time. • The honeymoon phase: follows the abuse Includes both excuses and expressions of love. Abuser may deny violence/ blame his actions on ETOH/ drugs. Abuser may promise that it will never happen again.

11. Types of abuse: • Physical: Punching, grabbing, beating, pulling hair, slapping, shoving, biting, kicking, using a weapon, choking. • Psychological: Threats to commit suicide, take away/ harm children, harm pets, limiting visitation. • Emotional: belittling, instilling guilt,, using male privilege, treating inferiorly, making major unilateral decisions

12. Types of abuse • Isolation: Limiting social interactions and mobility. • Sexual: Engaging in sexual acts against will or decline participation. • Economic: deprivation, controlling finances. • Spiritual: using partner’s religious or spiritual beliefs to manipulate them, preventing from practicing their religious or spiritual beliefs, ridiculing partners religious or spiritual beliefs.

14. Epidemiology • Victims and victimizers are of both sexes, all ages, socioeconomic classes, ethnicities, cultures, races, societies and religions. • Domestic violence is perpetrated by, and on, both men and women, and occurs in same-sex and opposite-sex relationships. • Reported frequency varies and depends on methodology and the definition of DV used.

15. Epidemiology • Survey of 50,000 households in 1992 and 1993 estimated that over 1 million women and 150,000 men are victims. • A US survey of family violence based upon interviews of 8,145 families in 1975 and 1985 found that 16 percent of couples reported episodes of physical violence in the previous year. • DV currently is leading cause of injuries to US women in 15- 45 yr age group • Its is estimated that approximately 2,000 women in the US die each year as a result of domestic violence.

16. Epidemiology: • A recent report of community hospital emergency departments found that 2 percent of women reported acute trauma from abuse by an intimate partner, 14 percent reported physical or sexual abuse in the last year, and 37 percent reported lifetime emotional or physical abuse. • In a study of primary care practices that defined domestic violence as physical or sexual abuse, 5 percent of the women patients were currently in an abusive relationship and 20 percent revealed a history of past abuse.

17. Epidemiology • Studies of women in two GI clinics reported that 40 to 50 percent of women had a history of childhood or adult sexual or physical abuse. The prevalence of abuse was 31 percent among patients with functional GI complaints such as dyspepsia, chronic abdominal pain, and irritable bowel syndrome. • A study of women in a neurology clinic found that 66 percent women with chronic headaches had a history of physical and/or sexual abuse.

18. Epidemiology: • Family studies show that women are far more likely than men to be the victims of chronic physical abuse.. • There are studies that claim that women perpetrate as much violence as men. • Women are the victims in 95 percent of cases of domestic violence that lead to criminal investigation. • Domestic violence in gay and lesbian relationships appears to be as common as in heterosexual relationships.

19. Epidemiology • Significant problem among the elderly. • Associated with an increase in reports of chronic pain, depression, number of health conditions, and an increased mortality. • Abuser is most commonly a relative (usually the spouse)

20. EpidemiologyPregnancy and DV: • Begins or increases during pregnancy and the PPP. . • A review of the OB literature found that physical abuse occurred during 7 to 20 percent of pregnancies. • Unintended pregnancy had a three-fold higher risk. • More likelihood of LBW babies. (odds ratio 1.4, 95% CI 1.1-1.8).

21. Epidemilogy • Pregnancy and DV: • More likely to deliver by cesarean and be hospitalized for maternal complications. • No increased risk for spontaneous abortion. • Three-fold higher risk of being victims of attempted/ completed homicide.

22. Victim profile • Mostly female, age less than 35. • Belongs to low income household. • Separated > single /divorced. • Has children less than 3 yrs of age. • Abuse alcohol or drugs. • Pregnant. • Has recently obtained a restraining order. • Has h/o Childhood physical and sexual abuse. • Poor self esteem

23. Abuser/ perpetrator profile • Of any age, ethnicity, or any SE background. • Tend to maintain different public and private images violent at home, but behaving normally at work. • Abuse drugs or alcohol. • Sense of entitlement • Objectify victim • Have witnessed DV ( learned behavior) • Typically deny or minimize their abusive actions.

24. Clinical presentations: • Patients who should be asked about domestic violence: • Female trauma victims. • Female emergency room patients. • Women with chronic abdominal pain. • Women with chronic headaches. • Pregnant women, especially with injuries. • Women with sexually transmitted diseases. • Elders with injuries.

25. Clues of abusive relationships • 1. Characteristic injuries. • 2. Central pattern of injury. • 3. Inconsistency in injury and explanation. • 4. Injuries in various stages of healing. • 5. Delayed presentations.

26. Clues of abusive relationships • 6. Visits for vague/ minor/ chronic complaints. • 7. Suicide attempts/ Substance abuse . • 8. OB/ GYN presentations: • 9. Patient appears anxious, terrified, upset, depressed. • 10. Partner’s behavior : overly solicitous, refuses to leave the examination room, extremely involved.

27. Consequences • Deeper impact than the immediate physical harm caused. • Psychological: PTSD, depression, multiple personality d/o, somatization, substance abuse and suicide. • Traumatic effect on children.

28. Screening and diagnosis • Routinely asking about DV significantly increases its detection in certain clinical situations. • In one study there was nearly a six fold increase in identifying domestic abuse after institution of a screening protocol in the ED. • 50 % Victims stated that they would discuss DV only if specifically asked.

29. Screening and diagnosis • The ACP recommends routine screening for domestic violence in primary care settings. • The United States Surgeon General and the AAFP recommend that physicians consider the possibility of domestic violence as a cause of illness and injury. • The JCAHO recommends that all emergency departments use protocols to increase the diagnosis of domestic violence.

30. Diagnosis • Victims should feel safe and comfortable. • Privacy and confidentiality of utmost importance. • At Brigham and Women's Hospital, detection of DV increased from 4 to 16 percent in the ED when the site for screening was moved to curtained, private patient care cubicles.

31. Questions recommended by AMA: • Are you in a relationship in which you have been physically hurt or threatened by your partner? Have you ever been in such a relationship? • Has your partner ever threatened or abused your children? • Has your partner ever forced you to have sex when you did not want to?

32. Questions recommended by AMA: • Are you in a relationship in which you feel you are treated badly? If yes in what ways? • 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?

33. SAFE questions. • Stress/Safety — "Do you feel safe in your relationship?" • Afraid/Abused — "Have you ever been in a relationship where you were threatened, hurt or afraid?" • Friends/Family — "Are your friends or family aware that you have been hurt? Could you tell them, and would they be able to give you support?" • Emergency Plan — "Do you have a safe place to go and the resources you need in an emergency?"

34. Questions: • The Massachusetts Medical Society Committee on Violence recommends one question to increase detection rate. • "At any time, has a partner hit, kicked, or otherwise hurt or threatened you?" • A 3 question Abuse Assessment Screen has been shown to be sensitive in identifying abuse in pregnancy. ·"Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone?" • ·"Since you've been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?" • ·"Within the last year, has anyone forced you to have sexual activities?"

35. Deterrents to diagnosis/ intervention Physicians factors: • Social factors, such as implicit and explicit social norms, societal tolerance of violence, and desensitization through exposure • Personal factors, such as sex bias, personal history of abuse, idealized concepts of family life, concerns over privacy, and perceived powerlessness

36. Deterrents to diagnosis/ intervention Physicians factors: • Professional factors: time, professional detachment. • Institutional and legal factors such as inadequate or unclear policies and fear of legal reprisal • Additional barriers: blaming the victim, disapproving of their decisions and circumstances.

37. Deterrents to diagnosis/ intervention Patient factors: • Love and hope • Dependence • Fear • Loss of children • Societal norms • Learned helplessness • A stress response syndrome

38. Assessment • Immediate safety • Health impact of abuse • Pattern of abuse ? escalating • Danger and lethality • Suicide or homicide

39. Intervention • Careful listening and support • Empathic validation • Counsel regarding DV • Referral to trained SW/ DV advocate, legal help • Provide a safety plan • Transport to shelter • Hospitalize if necessary

40. Intervention • “Your health and safety is concerning” • “You are not alone” • “Help is available” • “It’s not your fault” • “You don’t deserve it” • “Abuser’s behavior is unacceptable” • “ We will support you no matter what you decide to do”

41. Elements of a safety plan • Adapted from the San Diego city attorney's Personalized Safety Plan of April, 1990. • Avoid arguments in small rooms/ rooms with weapons. • Know which doors, windows, or fire escapes to use. • Tell a friend or neighbor to call the police in emergency. • Arrange use of a code word with children or friends • Teach children how to use the telephone to contact police

42. Elements of a safety plan • Hide identification documents, records, titles, papers, agreements licenses etc for easy retrieval. • Keep handy money, checkbook and credit card • Prescription medicines/ prescriptions. • Change the locks on doors and windows as soon as possible. • Install safety devices.

43. Documentation • Careful documentation if the patient seeks legal redress. • Very specific and detailed report of abuse. • Choose language carefully. It is helpful to say: "Patient reports( not denies) that she does not drink or use drugs." • The physician should state the diagnosis: "Domestic Violence."

44. Documentation • Injuries should be described and, photographed after obtaining the patient's signed consent. • If a camera is not available, the physician should make a sketch of the injuries. • Radiology and lab findings • Forensic evidence • Materials and referrals offered • Results of health and safety assessment

45. Mandatory reporting • To DCS it it involves a child under the age of 18 and the child is suffering as a result ; or the child has witnessed his/her parent being abused. • If an elder is being abused.

46. Mandatory reporting • California, Colorado, Kentucky, Mississippi, Ohio, and Rhode Island have mandatory DV reporting laws. Physicians have to report all injuries from DV. • A study of 1218 recently abused women presenting to emergency departments found that 44 percent did not support mandatory reporting of domestic violence to police.

47. Prognosis: • DV typically recurs and progressively escalates both in frequency and severity. • Of persons first injured by DV, 75% continue to experience abuse. • Half of battered women who attempt suicide try again. • The ultimate result of nonintervened DV may be death from suicide or homicide.

48. DV in popular culture • The Piano, 1993 • Once were warriors, 1990 • Sleeping with the enemy, 1991 • Fried green tomatoes, 1991 • The burning bed, 1984 • The color purple, 1984 • Gaslight, 1944 • The Joy luck club, 1993 • Diary of a Mad Black Woman,2005 • Men don’t tell, 1993

49. Resources and help: • ·National Domestic Violence Hotline • 800 799 SAFE • ·United States Department of Justice: Domestic Violence • ·National Coalition Against Domestic Violence

50. REFERENCES • 1. Rodriguez, MA, Bauer, HM, McLoughlin, E, Grumbach, K. Screening and intervention for intimate partner abuse. Practices and attitudes of primary care physicians. JAMA 1999; 282:468. • 2.Elliott, L, Nerney, M, Jones, T, Friedmann, PD. Barriers to screening for domestic violence. J Gen Intern Med 2002; 17:112. • 3.Bachman, R, Saltzman, LE. Violence against women: Estimates from the redesigned survey. Bureau of Justice Statistics special report, Publication no. NCJ-154348. U.S. Department of Justice, Washington, DC 1995. • 4.Straus, MA, Gelles, RJ, Steinmetz, SK. Behind closed doors: A survey of family violence in America. Doubleday, New York 1980. • 5.Straus, MA, Gelles, RJ. Physical violence in American families. Transaction Publishers, New Brunswick, NJ 1990. • 6.Abbott, J, Johnson, R, Koziol-McLain, J, Lowenstein, SR. Domestic violence against women: Incidence and prevalence in an emergency department population. JAMA 1995; 273:1763. • 7.Dearwater, SR, Coben, JH, Campbell, JC, et al. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA 1998; 280:433. • 8.McCauley, J, Kern, DE, Kolodner, K, et al. The "battering syndrome": Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123:737. • 9. Drossman, DA, Talley, NJ, Leserman, J, et al. Sexual and physical abuse and gastrointestinal illness: Review and recommendations. Ann Intern Med 1995; 123:782. • 10. Domino, JV, Haber, JD. Prior physical and sexual abuse in women with chronic headache: Clinical correlates. Headache 1987; 27:310.