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Home is Where the Hurt Is

Home is Where the Hurt Is. Aileen B. Pascual , MD 23 August 2009. Violence Against Women.

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Home is Where the Hurt Is

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  1. Home is Where the Hurt Is Aileen B. Pascual, MD 23 August 2009

  2. Violence Against Women • “An act of gender-based violence that results in physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty whether occurring in public or private life.” UN Declaration on Elimination of VAW

  3. Non-spousal violence Sexual harassment and intimidation Trafficking in women Forced prostitution Violence perpetrated or condoned by the state such as rape in war Spousal battering Sexual abuse of female children Dowry-related violence Rape, including marital rape Traditional practices harmful to women such as female genital mutilation Violence Against WomenUN Declaration on Elimination of VAW

  4. Philippine National Police Women and Children Protection Center (PNP-WCPC) Cases of Violence Against Women • 6,647 cases (2007) • 7,864 cases (2008) Cases Involving Violation of RA 9262 • 2,387 cases (2007) • 3,599 cases (2008)

  5. Philippine National Police Women and Children Protection Center (PNP-WCPC) Cases Perpetrated by PNP Personnel • 386 cases (2007) • 294 resolved • 70 referred to WCPC • 22 referred to pre-charge investigation

  6. Number of WEDC Served by DSWD,1998 to 2007accessed from http://www.nscb.gov.ph/headlines/StatsSpeak/2008/090808_rav_wedc.asp#2

  7. Number of WEDC Served by DSWD by Case Category, 1998-2007accessed from http://www.nscb.gov.ph/headlines/StatsSpeak/2008/090808_rav_wedc.asp#2

  8. Violence Against WomenUN Declaration on Elimination of VAW • Spousal battering • Sexual abuse of female children • Dowry-related violence • Rape, including marital rape • Traditional practices harmful to women such as female genital mutilation • Non-spousal violence • Sexual harassment and intimidation • Trafficking in women • Forced prostitution • Violence perpetrated or condoned by the state such as rape in war

  9. General Data • J.V. • 41/female, married • housewife from Pandacan • PGH-AMBU, 2nd time • April 11, 2003 • Chief Complaint: Chest Pain

  10. History of Present Illness 1 month PTC: Hypertension Unrecalled PRN medications 2 weeks PTC: nape pains, dizziness difficulty of breathing easy fatigability 2 hours PTC: chest pain difficulty in breathing Captopril Hypertension DM Suspect t/c CHF II prob 2nd to IHD Captopril, Aspirin OPD workup, follow-up

  11. Review of Systems (+) anorexia (+) sore throat x 1 wk (+) palpitations (+) easy fatigability (+) similar episodes of chest pain (+) occl. epigastricpain (+) weight loss of ~5% in 3 months (-) orthopnea (-) dyspnea (-) PND (-) edema (-) bloatedness (-) regurgitation

  12. Past Medical History • No history of diabetes mellitus, PTB, heart disease • No previous hospitalizations/surgeries • No known food/drug allergies

  13.  60  5 45 41 9 21 16 Family Medical History V. Family April 2003 No heart disease, premature cardiac deaths No bronchial asthma, cancer, goiter  - Hypertension  - Diabetes Mellitus

  14. Personal & Social History • Roman Catholic • high school graduate, former factory worker • married for the past 21 years to a businessman with three children ages 21, 16, and 9 • lives in a two-storey apartment in an urban community in Pandacan • nonsmoker, non-alcoholic beverage drinker • no history of OCP use or illicit drug use

  15. OB-GyneHistory • menarche at 18 y.o., RMI, lasting for about 7 days • with occasional dysmenorrhea • LMP = March 2003 PMP = February 2003 • G3P3 (3-1-0-3) all FT via SVD, with no complications

  16. Physical Examination awake, conscious, cooperative, not in cardiorespiratorydistress, agitated BP = 110/80 88 18 36.8C BMI = 22 pink palpebral conjunctivae, anictericsclerae, no neck vein engorgement (+) tonsillopharyngeal congestion (-) exudates equal chest expansion, clear breath sounds, no rales, no wheezes distinct heart sounds, normal rate and rhythm, AB=PMI at 5th ICS LMCL, no murmurs abdomen soft, normoactive bowel sounds, no masses, no tenderness pink nailbeds, full and equal pulses, no edema, no cyanosis

  17. Initial Assessment at the AMBU • r/o Acute Coronary Event • Hypertension • Acute Tonsillopharyngitis, probably bacterial

  18. Initial Intervention • 12-L ECG done • O2 inhalation at 2 LPM via nasal cannula • Complete resolution of symptoms even without intervention • Normal ECG

  19. Re-history • Marital problems at home • Physically hurt by her husband • Verbally abused by her husband

  20. Neurologic Examination awake, conscious, coherent, oriented to three spheres Cranial Nerves: Motor: 5/5 on all extremities I – can smell Sensory: 100 % intact II, III – 3 mm EBRTL DTRs: ++ on all tendons, no Babinski III, IV, VI – full EOMs Meningeals: supple neck V – good masseter tone Cerebellars: no nystagmus/dysmetria VII – no facial asymmetry no dysdiadokinesia VIII – gross hearing intact IX, X – good gag XI – good shoulder shrug XII – tongue midline on protrusion

  21. Mental Status Examination • oriented to time, place and person • appropriately dressed in shirt and shorts, well-kempt • appears anxious, initially hesitant to answer questions • no auditory/visual hallucinations, no delusions • intact remote, recent past memory, recent, immediate memory • good impulse control • good insight and judgment

  22. Discharge Diagnosis • Anxiety • Hypertension • Acute Tonsillopharyngitis, probably bacterial

  23. Problems Identified

  24. Responding to Disclosures of Violence Identifying Family Violence: A Resource Kit for General Practitioners in New South Wales • Listen Being listened to can be an empowering experience for a woman who has been abused • Communicate belief “That must have been very frightening for you” • Validate the decision to disclose “It must have been very difficult for you to talk about this” “I am glad that you very able to talk about this today.” • Emphasize the unacceptability of violence “You do not deserve to be treated this way”

  25. Potential Clinical Indicators of AbuseEisenstat and Bancroft. 1999. Domestic Violence. NEJM Vol. 341 No. 12 886-892 • PHYSICAL FINDINGS Dental trauma Any injury, especially to the head and neck (even with a seemingly good explanation), and any fatal injury

  26. Potential Clinical Indicators of AbuseEisenstat and Bancroft. 1999. Domestic Violence. NEJM Vol. 341 No. 12 886-892 • GENERAL FINDINGS Chronic abdominal, pelvic, or chest pain Somatic disorders Irritable bowel syndrome Chronic gynecologic symptoms Sexually transmitted diseases and exposure to human immunodeficiency virus through sexual coercion Exacerbation of symptoms of a chronic disease such as diabetes, asthma, or coronary artery disease Chronic joint or back pain, headaches, numbness, and tingling from injuries Noncompliance with medical regimen

  27. Potential Clinical Indicators of AbuseEisenstat and Bancroft. 1999. Domestic Violence. NEJM Vol. 341 No. 12 886-892 • PSYCHOLOGICAL SYMPTOMS Depression and suicidal ideation Anxiety symptoms and panic disorder Eating disorders Substance abuse Post-traumatic stress disorder

  28. Potential Clinical Indicators of AbuseEisenstat and Bancroft. 1999. Domestic Violence. NEJM Vol. 341 No. 12 886-892 • FINDINGS DURING PREGNANCY AND CHILDBIRTH Any of the above Unwanted pregnancy Complications such as miscarriage, low birth weight of infant, abruptioplacentae, premature rupture of membranes, and antepartum hemorrhage Lack of prenatal care

  29. Potential Clinical Indicators of AbuseEisenstat and Bancroft. 1999. Domestic Violence. NEJM Vol. 341 No. 12 886-892 • INCIDENTAL FINDINGS Delay in seeking treatment or inconsistent explanation of injuries Repeated visits to the emergency department or clinic Evasiveness of patient or jumpiness, fearfulness, or crying Overly attentive or verbally abusive partner Identifiable social isolation Abuse of child or elderly adult in a household

  30. Health and Safety AssessmentNational Consensus Guidelines on Identifying and Responding to Domestic Violence. Family Violence Prevention Fund 2004 • Assessment of Immediate Safety • Assess the impact of the violence (past or present) on the patient’s health • Assessment of the pattern and history of current abuse

  31. Interventions with Victims of Domestic ViolenceNational Consensus Guidelines on Identifying and Responding toDomestic Violence. Family Violence Prevention Fund 2004 • Provide validation • Provide information • Respond to safety issues • Make referrals to local sources • Reporting to law enforcement or social service agencies

  32. Short Term Goals • Address medical problems • Promote lifestyle changes for hypertension control • Keep patient coming up for follow up for continuous assessment and support

  33.  60  5 45 41 9 21 16 Family Genogram V. Family April 2003 No heart disease, premature cardiac deaths No bronchial asthma, cancer, goiter  - Hypertension  - Diabetes Mellitus

  34. Family Life Cycle • Unattached Young Adult • The Newly Married Couple • The Family with Young Children • The Family with Adolescents • Launching Family • Family in Later Years

  35. Exploring the Family SystemHamel, J (2006).Family Approaches to Domestic Violence: A Guide to Gender-Inclusive Treatment, Springer Publishing. • Family Structure • Differentiation and Organization • Boundaries and Hierarchies • Accessibility to Outside Influence • Adaptability

  36. Exploring the Family SystemHamel, J (2006).Family Approaches to Domestic Violence: A Guide to Gender-Inclusive Treatment, Springer Publishing. • Each individual’s ability to cope with anger, stress and conflict • Family beliefs about anger and violence • Relationship Dynamics • The function of each person’s behavior in the family context

  37. Children and Parenting Management of the Whole Family when Intimate Partner Violence is Present:Guidelines for Primary Care Physicians 2006. • Discuss any parenting concerns in the partner abuse context • Assess the risk to and adult perception of the impact on children • Consider the risk to and children’s perception of the impact on their lives. • Consider children’s access to significant supportive others

  38. Children and Parenting Management of the Whole Family when Intimate Partner Violence is Present:Guidelines for Primary Care Physicians 2006. • Other referral of children to therapeutic support services • Report children at risk to mandatory laws • Consider the patient’s level of fear about the children’s removal

  39. Lethality Assessment • Threats of Suicide or Murder • Availability of Weapons • Controlling and Jealous Behavior • Use of Drugs and Alcohol • Depression

  40. Lethality Assessment • Batterer’s Isolation • Escalation of Violence • End of the Relationship • Choking or Strangling

  41. Safety Planning • Maximize the safety of the woman and her children • May include a fair amount of disclosure about the abuse • Plan to leave the situation safely should be developed • Identify resources available (extended family, interpersonal skills, involvement in the community)

  42. Guiding Principles in Making a Safe and Effective ResponseFSU Institute for Family Violence Studies, 2001 • Regard the safety of the victim and her family as a priority. • Respect the autonomy of victims and their ability to make choices, such as whether or not to stay in the relationship for the time being. • Maintain an attitude that does threaten, blame or make judgments about the victim, the abuser or the choices that have been made • Never hold the victim responsible to staying in the abusive relationship.

  43. Guiding Principles in Making a Safe and Effective ResponseFSU Institute for Family Violence Studies, 2001 • Believe the victim and be willing to listen. • Provide choices, not interventions. • Be sure to let any potential victims (even those who deny abuse) know three things: • “It is not your fault” • “You are not alone – this happens to many people” • “There is help available”

  44. “ the goal of intervention may not be to cure or to solve the problem for the patient but to provide validation, support and information….”

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