Domestic Violence

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[edit] Domestic Violence

Carole Warshaw

Kim Riordan

In response to the growing recognition of domestic violence as a major public health problem, new standards of care have evolved for addressing intimate partner abuse within the health care setting. The Joint Commission for the Accreditation of Health Care Organizations now requires that hospitals and clinics have protocols and training for identification, assessment, intervention, and referral for victims of abuse and violence. For many victims, the health care setting is the only place they will seek help, and health care providers play a critical role in creating a safe atmosphere for patients to discuss the abuse and violence they have experienced. Yet, many physicians still have difficulty integrating routine inquiry about domestic violence into their day-to-day practice.✢✢This chapter was adapted in part from Warshaw C: Identification, assessment and intervention with victims of domestic violence. In Warshaw C, Ganley A, Salber P: Improving the health care response to domestic violence: a resource manual for health care providers, San Francisco, 1998, The Family Violence Prevention Fund.

Because domestic violence is a complex social problem rather than a strictly biomedical one, addressing it requires more than adding new diagnostic categories to differential diagnoses or new technical skills to clinical repertoires. This complexity obliges physicians to step beyond traditional medical paradigms to confront the personal beliefs and feelings that shape their responses to patients, to consider larger social issues while treating symptoms, and to work in partnership with community groups committed to ending domestic violence. This chapter addresses the challenges faced by clinicians and patients in raising these issues and describes the identification, assessment, and intervention skills that primary care physicians need to respond effectively and sensitively to domestic violence.

[edit] BACKGROUND AND EPIDEMIOLOGY

The term domestic violence, although sometimes used more broadly, is generally considered synonymous with intimate partner abuse, a phenomenon that is largely directed toward adult women and adolescent girls.✢✢Male pronouns are generally used in referring to perpetrators of domestic violence, while feminine pronouns are generally used to reference victims. This is not meant to detract from those cases where the victims is male or the perpetrator is female. This pronoun use reflects the fact that the majority of domestic violence victims are female. Domestic violence is an ongoing pattern of domination and control perpetrated against a current or former intimate partner through a combination of actual or threatened physical violence, sexual assault, and psychologic abuse. This violence occurs in adult and adolescent dating, married, or separating relationships in gay, lesbian, and heterosexual couples. Random population surveys estimate that 10% to 12% of women experience physical or sexual assault at the hands of an intimate partner each year. Lifetime prevalence rates range from 21% to 34%.^[1][2][3]

While a small percentage of victims of partner abuse are male, the US Department of Justice estimates that women are up to eight times more likely than men to be victimized by an intimate partner.^[4] When women do assault male partners, it is more likely to be in self-defense and rarely as part of an ongoing pattern of coercion and control. Domestic violence is also a significant problem in same-sex relationships, and initial research indicates that prevalence rates may be similar to those found among heterosexual couples. Disabled women face additional risks for physical and sexual violation by caretakers and attendants and are likely to be trapped for longer periods of time. Elder abuse, too, may reflect longstanding domestic violence rather than more recent caregiver stress.

Physical violence is only one of many tactics batterers use to harm their victims, to undermine their autonomy and sense of self, and to keep them isolated and entrapped. Sexual violation is particularly degrading and often the most difficult to discuss. Whenever there is physical or sexual abuse, however, psychologic abuse is invariably present and may be quite severe. This often takes the form of verbal intimidation and threats, ridicule and humiliation, stalking and monitoring the victim's activities, isolating the victim from friends and family, and controlling their access to money, education, and jobs. Emotional withdrawal, threats of abandonment, and threats to harm or take away children are also powerful tactics of coercion and control.^[5] Abuse survivors describe this as the most devastating aspect of their experience.

[edit] Medical Consequences

Over the past 2 decades, research has begun to document the impact of abuse and violence on women's health. Prevalence studies indicate that approximately 5% to 27% of women seen in a range of clinical settings are currently being abused by their partners. Between 21.4% and 54.2% of women seen in emergency departments or primary care clinics have reported physical or emotional abuse by a partner in adulthood, and at least one in three have experienced some form of abuse during their lives.^[6][1][5] While, almost any type of injury can result from domestic violence, primary care providers often see the later consequences of these assaults. In addition to visible injuries and scars, physical abuse may present as chronic pain, complications of head and neck trauma (e.g., seizures, difficulties with performance and concentration), or deprivation of basic needs (e.g., food, water, shelter, medication, and sleep).

The majority of abused women, however, seek help for medical problems rather than physical injuries.^[7][8] Although acute injuries may be the most obvious manifestation of domestic violence, the long-term medical and psychologic consequences of living with ongoing abuse tend to be more debilitating over time. For example, there are significant differences in health status between abused and nonabused women, even when the abuse is emotional and not physical, and psychologic abuse is more predictive of low self-esteem, depression, and posttraumatic stress disorder (PTSD) than physical abuse. Health and mental health status are further diminished in women who were subjected to victimization in childhood as well.^[9]

Women who are being abused frequently present with exacerbations or poor control of chronic medical conditions, such as diabetes, hypertension, asthma, or angina, or develop sleep and appetite disturbances, fatigue, dizziness, weight change, and other physical symptoms associated with depression, anxiety, or posttraumatic stress. Other illnesses, such as gastrointestinal and autoimmune disorders, have also been associated with abuse.^[10][11] Sometimes, however, women seek help for problems that are seemingly unrelated to abuse—a blood pressure check, a routine physical, treatment of allergies, or an upper respiratory infection.

Complications of pregnancy, prolonged labor, preterm deliveries, low-birth-weight infants, and postpartum difficulties are also found at higher rates among women who are abused.^[12] Battered women, particularly when subject to sexual abuse, may experience dyspareunia, chronic pelvic pain, sexual dysfunction, and frequent vaginal and urinary tract infections. Sexual coercion increases women's risks for exposure to any of the complications of unprotected sex, such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), sexually transmitted diseases (STDs), and unplanned pregnancies, and must be addressed during safe sex counseling.

[edit] Mental Health Consequences of Abuse and Violence

At a time when primary care providers are encouraged to diagnose and treat common psychiatric disorders, it is important to recognize that many of these disorders are more prevalent among patients who have been abused. Studies of battered women indicate that 37% to 63% meet criteria for depression,^[13] 46% for anxiety disorders, and 33% to 58% for posttraumatic stress responses or PTSD.^[1][7] Somatoform disorders, eating disorders, sexual difficulties, and psychotic episodes have also been correlated with adult and childhood abuse. Partner abuse is a significant risk factor for suicide attempts as well.^[8]

Strong correlations also exist between battering and substance abuse among both victims and perpetrators. This relationship is a complex one. Alcohol consumption may contribute to violent behavior in already abusive men, but there is no evidence that substance abuse actually causes violence against women and children. Research also indicates that alcohol and drug use among abuse survivors is more likely to result from the victimization itself (e.g., self-medication or coercion into consuming alcohol and other drugs).^[14]

A diagnosis of PTSD is often used to describe the psychophysiologic sequelae that follow sexual assault, battering, and child sexual abuse.^[1] People who have been assaulted develop responses similar to victims of other types of trauma: shock, confusion, helplessness, and betrayal, as well as dissociation, intrusive recollections, increased reactivity to reminders of the trauma, avoidance of possible triggers, and continuing hypervigilance. Research on the neurobiology of trauma indicates that alterations in physiologic reactivity and stress hormone secretion contribute to these responses.^[11] However, when abuse is chronic and severe, involves betrayal by someone trusted and loved, and is deliberately intended to control and undermine the victim's sense of self, a more complex set of responses may ensue. In fact, the frequency of comorbidity associated with PTSD has led a number of authors to conceptualize comorbidity as a misnomer and to propose that a more complex form of PTSD may be found among those who experience longstanding abuse.^[15] Disorders of extreme stress not otherwise specified (DESNOS) incorporates a broader spectrum of the axis I and axis II sequelae of chronic abuse and is listed as an associated feature of PTSD.

Yet, even these diagnoses do not fully capture patients' psychologic responses to abuse, the perpetrator behaviors that generate them, or the larger contexts in which they emerge. For women who are still at risk, the “stress” is not “post,” the trauma is ongoing—symptoms may be an adaptive response to danger and entrapment, and heightened sensitivity can be a necessity for survival.^[8] Women often exhibit considerable strength and ingenuity, attempting to remedy their situations through talking, seeking help, fighting back, and trying to change the conditions either that they perceive or are told cause the abuse. When those attempts fail, however, they then may retreat into a mode that appears more passive and “compliant,” but which actually reflects how they have learned to reduce their immediate danger. Dissociation, denial, and avoidance may be used to protect against feelings that have become unbearable in the face of limited options for leaving or stopping the violence. For some women, substance abuse becomes another way of “coping” or “leaving.” When a person becomes increasingly isolated from outside resources, suicide or homicide may seem like the only way to end the abuse. These responses, while making it possible to survive intolerable conditions, may constrict a person's capacity to reach out for help. In addition, the ongoing trauma of social discrimination, lack of basic resources, and revictimizing experiences within systems a woman turns to for help not only affect her ability to psychically “heal” from the abuse but also to mobilize the resources necessary to build a safe, independent life.

Some patients present with PTSD initially, while others do not develop symptoms until years after they have left. Although avoidant responses may predominate at that time, treatment is still likely to be beneficial. In addition, avoidant posttraumatic stress responses may interfere with taking medication, having regular pap smears or mammograms, or agreeing to invasive medical procedures that may again evoke the experience of physical violation and loss of control.

[edit] IDENTIFICATION

[edit] Addressing Barriers

Despite the frequency with which battered women present to health practitioners, the abuse itself often goes unrecognized. Early studies indicate that only 6% of battered women were accurately identified in emergency departments.^[16] Health care providers give many reasons for not asking about domestic violence—lack of awareness, lack of time, thinking abuse is not that prevalent in their practice, not knowing what to do if abuse is identified, fear of being intrusive, and fear of being overwhelmed. Physicians may avoid asking because they find it difficult to tolerate the pain and helplessness they feel in hearing patients talk about abuse or having their own traumatic experiences evoked by listening to another's. In addition, when professional competence is tied to one's sense of mastery and control, it is harder to deal with situations that require an empathic presence rather than the ability to “fix” or cure. Clinician attitudes toward gender roles and family privacy may also prevent them from asking. Physicians, nonetheless, do overcome discomfort about other “private” matters, when they know it will improve clinical care. These barriers can largely be addressed through education, self-reflection, support from colleagues, and knowledge of community resources.^[17]

Patients also face numerous barriers to discussing abuse, accessing services, and leaving abusive partners. For example, threats of retaliation are common and abusers often try to prevent their partners from seeking help. In addition, patients may feel shame about the abuse and not want to risk being judged or blamed. Not trusting that a provider will understand their situation—loving a partner, hoping he'll change, wanting their children to grow up in an intact home, or not being able to survive financially on their own—can also prevent disclosure. Gay men and lesbians may be particularly reluctant to discuss abuse if they do not know how their provider feels about same-sex relationships. Immigrant women are frequently threatened with deportation and not aware of laws that can protect them. Cultural or religious constraints can also make it harder for a woman to discuss the abuse with someone outside her community, and she may face social isolation and ostracism if she leaves. A person's attitudes toward revealing personal information to outsiders and feelings of loyalty toward a partner, family, or community will play a role in how they feel about discussing the abuse and with whom they feel comfortable discussing it. Despite these concerns, studies consistently show that most women are relieved when a physician asks them about abuse.

[edit] Universal Screening

One of “the most important contributions physicians can make to ending abuse and protecting the health of its victims is to identify and acknowledge the abuse.”^[18] Because presentations of domestic violence are so varied, inquiring only when abuse is suspected is no longer considered adequate. Current guidelines for domestic violence recommend routine inquiry of all women patients and although less studied, men who may be at risk—men with disabilities, elderly men, and men in gay relationships.^[19] Because the field is new, interventions are only beginning to be evaluated. Recent studies, however, demonstrate that advocacy and counseling significantly reduce violence, increase quality of life, and help women expand their networks of support.^[20]

Before inquiring about domestic violence, it is essential to create an environment in which it is safe for patients to talk freely. Visibly displayed posters and brochures can help create this kind of atmosphere. A battered woman may be afraid to disclose information if she thinks the batterer will learn she has talked about the abuse or she may fear losing her children to protective services. Patients should be told that the information they give is confidential and within the confines of the law will not be revealed to the batterer or anyone else without their permission. For those physicians who practice in states with mandatory reporting laws, it is essential to inform the patient of this requirement in the beginning of the evaluation, preferably before she or he has discussed the abuse. It is also important to discuss reporting obligations before inquiring about child abuse.

All patients should be interviewed in private until abuse is ruled out, because any accompanying individual could be an abuser. This includes male or female friends, family, personal attendants, and nonprofessional translators who may be sympathetic to the perpetrator. Assailants may appear solicitous and concerned about the patient's well being, impersonate relatives, or insist on being present during the examination. It is helpful to inform accompanying parties that policy requires all patients to be seen alone. Self-report forms should not be mailed to the home before a visit or administered in waiting rooms where the batterer may be present. Strategies should be developed for safely separating patients from abusers should that become necessary. If there appears to be an immediate threat from the abuser, be prepared to notify the police or security, outlining any potential risk (e.g., husband is in waiting room intimidating staff).

Inquiring about domestic violence is the first stage of intervention. Asking about abuse helps to reduce the isolation abused patients experience and lets them know resources are available if and when they feel they can use them. Many women will readily talk about the violence if they feel safe and supported. All women patients seen in primary care settings should be asked at initial visits and at periodic intervals. Inquiry should also take place when a woman's relationship status changes, she is pregnant or contemplating pregnancy, her symptoms suggest abuse, or there are frequent unexplained appointment changes. Screening questions on domestic violence can be easily incorporated into the current and past medical history, social history, and review of systems.

Sometimes it feels awkward to suddenly introduce the subject of abuse, particularly if there are no obvious indications a patient is being abused. Clinicians can help decrease discomfort by framing questions in ways that let patients know that they are not alone and that the clinician is comfortable hearing about domestic violence. Possible questions include: “I don't know if this is happening to you, but many of the women I see as patients are involved with someone who threatens them or tries to control them. Some are too afraid or uncomfortable to bring it up themselves, so I've started asking about it routinely.” or “Many of the lesbians and gay men I see are being hurt by their partners. Has your partner ever threatened you or tried to hurt you?”

Because patients may not define themselves as battered, the medical practitioner should always ask direct, specific questions. For example, asking, “Has your partner ever punched or kicked you?” or “Are you ever afraid of your partner?” will be more effective than asking “Are you being battered?” Questions about emotional and sexual abuse should also be included in the assessment (Box 59-1). Sexual histories should always incorporate questions about abuse, for example, “Does your partner ever pressure you to engage in sexual activities that make you uncomfortable or force you to have sex against your will?”

If a patient denies abuse but the clinician is still concerned, he or she can gently voice those concerns, address potential fears about disclosure (e.g., deportation, child custody), and offer information about abuse. Sometimes, a woman will listen silently, without overtly acknowledging what is being said. Clinicians should provide the patient with a referral sheet or telephone numbers and encourage her to let them know if she has any problems in the future and to contact any of the resources provided. Concerns should be documented in the medical record.

[edit] ASSESSMENT

Although it usually takes less than a minute to ask initial questions about abuse, listening to the patient and providing adequate assessment and intervention can take somewhat longer. This time can be reduced when a domestic violence advocate or social worker is available to complete the evaluation. At a minimum, providers should let patients know they were glad to be told and address safety, document the abuse and its impact, and make referrals to community agencies.

In the primary care setting, a more detailed history of abuse is warranted. If a patient is being seen for an injury or other symptoms related to an acute battering event, ask in detail about what happened. Inquire specifically as to when the episode started, who inflicted the injuries, and whether there have been prior incidents. Patients should also be asked to describe both current and prior patterns of abuse and the relationship between abuse and the onset or exacerbation of symptoms. When time allows, a complete social history can be obtained, including any history of previous abuse in childhood or adulthood. The following issues are also important to discuss: how the abuse has affected the patient and her children, how she protects her children and herself, what she does to cope, her degree of isolation vs. support, what has she tried in the past, her assessment of the situation, what she would like to see happen, and what issues she faces in achieving those goals.

[edit] Safety Assessment

Many abused women are still in danger at the time they seek help and if they decide to leave, the danger may increase significantly. Anyone who is battered should be assessed for risk of serious injury or homicide before discharge. The process of inquiry itself can help clarify the danger the victim faces. Risk factors commonly associated with escalating danger include evidence of violence outside the home, threats of homicide or suicide, and imminent plans to leave (Box 59-2). If, after reviewing all her risk factors, the patient feels she is in danger of being seriously injured or killed, take this very seriously. If she says no, but there is reason to believe she is in danger, discuss this frankly. If she is at high risk and planning to leave the relationship, advise her to seriously consider leaving without telling her partner. Try to assist her in finding a safe place to go.

[edit] Mental Health Assessment

While it appears that many battered women do well without mental health intervention because symptoms resolve once they are safe, others need help in managing symptoms before they can mobilize the resources necessary for change. Psychiatric problems including major depression, panic disorder, PTSD, psychosis, suicidality, or substance abuse may hinder a battered woman's ability to assess her situation or take appropriate action. When serious psychiatric conditions are present, an appropriate plan includes psychiatric evaluation and treatment. On the other hand, emotional, behavioral, and cognitive responses to abuse can be misinterpreted as psychiatric in origin.

In either case, assessing and treating the psychiatric manifestations of domestic violence present a number of challenges. Once a woman is given a psychiatric diagnosis, she risks having it used against her in court by the abuser to gain custody of her children or to impugn her credibility. It can also reinforce the abuser's ability to make her feel that she is crazy. If a psychiatric diagnosis is made, discuss these issues with the patient and clearly document the abuse, its relationship to her psychiatric symptoms, and the efforts she has made to protect and care for herself and her children.

Treatment presents its own set of issues. In a busy primary care setting, prescribing medication can easily take the place of time spent with patients. Interventions that focus solely on the victim's symptoms without addressing the abuse itself, however, are not acceptable forms of care. Also, some medications can impair the ability to assess and respond to danger and should be prescribed with caution. If indicated, medication should be offered as a tool to help patients regain their sense of autonomy and control, as well as to manage their symptoms.

Women with psychotic disorders can also be victims of domestic violence. In fact, they are at even greater risk. Physicians must be cautious to take allegations of abuse seriously, even if the patient appears to be delusional. Women with serious mental illness are more vulnerable to repeat victimization, and symptoms may be aggravated by the abuse or by the abuser's control of her medications. Providers must take care not to assume that a partner's history is accurate and never ask him to confirm what a woman has said about the abuse.

Evaluating a woman's safety includes assessing for potential suicide or homicide. Victims of abuse should be asked about suicidal ideation. If there is significant risk, the patient should be kept safe at least until an emergency psychiatric evaluation can be obtained. Homicidal ideation also warrants emergency evaluation. In the majority of cases, women who kill their partners have been severely abused for long periods of time and see no other way out. They kill in self-defense or to prevent themselves or their children from being murdered or seriously injured. If homicide is a possible scenario, the patient should be asked directly if she has plans to kill or harm her partner. Psychiatric hospitalization can be initiated as a way to protect her and the potential victim until safe alternatives can be developed. However, providing her with safe alternatives may obviate this need.

[edit] Physical Examination and Preservation of Evidence

Physical examinations and medical procedures can be retraumatizing for patients who have been abused. Care must be taken to explain all procedures, obtain consent, maintain verbal and eye contact, ask what the patient needs to feel safer, and when possible, allow her to control the pace of the examination. Patients should be asked to disrobe and gown so hidden injuries can be seen. A thorough examination should be performed, including neurologic and mental status examinations when indicated.

Injuries should be described specifically (e.g., multiple bilateral contusions to the neck consistent with manual strangulation-like mechanism of injury will support allegations of attempted strangling). Include other details such as areas of tenderness, broken fingernails, smeared makeup, and disheveled or torn hair. If a patient indicates there has been a recent sexual assault, assess for evidence of forced sexual activity, including injuries to the genitalia and restraint marks on the skin. Also, assess the patient's emotional state and her risk for exposure to STDs, HIV, and pregnancy. Record nonbodily evidence of torn clothing and broken jewelry. Preserve as evidence bloodied clothing, foreign objects, or objects used as weapons. Obtain permission from the patient to preserve these items after explaining that evidence may be necessary for legal documentation now or in the future. Have her sign a release of information form and explain the conditions under which the evidence can be released. The clinician's opinion as to whether the injuries are consistent with the explanation given should also be noted.

In cases where there is concern that abuse may be occurring, but the woman does not acknowledge it, be sure to note in the chart whether the injuries are compatible with her explanation. This may provide documentation in the event that she decides to pursue legal action in the future. The names of all personnel who examined or talked with the patient about the abuse should be documented.

[edit] INTERVENTION

[edit] Validation and Empowerment

Intervention begins by letting a battered woman know that she is not alone, that she does not deserve to be abused, that assistance is available, and that this is a place she can continue to come for help whatever she decides to do (Box 59-3). Success should not be measured by whether or not a woman is able to leave an abusive partner. What women describe as most beneficial is being listened to and believed and taken seriously, rather than being judged or given advice they cannot use. Supporting a woman's choices despite fears for her safety is one of the most difficult tasks clinicians face. In addition, the time constraints under which most physicians practice can foster behavior that is controlling and directive—behavior that is particularly disempowering to victims of abuse. Compassionate interactions, however, need not take a lot of time. Respect and concern can be communicated through eye contact and tone of voice and by avoiding body language that conveys one is not interested in hearing about abuse.

[edit] Providing Information

It is important to discuss the patterns of abuse in violent relationships. Describing the typical controlling behaviors used by perpetrators and emphasizing that the perpetrator is solely responsibility for stopping the abuse—not the victim—can help patients gain perspective on their own situations. Most violence continues, and isolation, fear, entrapment, and lethality risk tend to increase over time. Many batterers enter counseling solely to keep their partners from leaving. If a woman is seeking help for her abusive partner, discuss what is known about perpetrator interventions. Perpetrators are likely to continue their controlling behaviors even if they stop the physical abuse and many are not willing to make the long-term commitment necessary to change. For a percentage of those who do, approved batterer intervention programs can be effective in reducing re-assault. In addition, women often want their children to grow up in intact homes, yet are deeply concerned for their children's safety. They may wish to stay if the children are not being abused and their partner appears to be a good father. Discussing the long-term traumatic effects of witnessing parental violence can help women weigh these painful alternatives. Finally, it is important to let a woman know that while she faces many difficult choices, there are options available should she decide to leave and that many women are able to find safety and rebuild their lives.

[edit] Safety Planning

Women currently in danger should be encouraged to develop safety and escape plans if they are staying with an abusive partner or he has access to them and to explore their options if leaving. Safety planning with a battered woman depends on her situation, her priorities, and the options she decides will work best for her. Many battered women choose to return home after an abusive incident. Sometimes they feel it is their safest option given the nature of the abuser's threats and the realities of the legal protection available to them. Others do not feel they can survive on their own or provide their children with the same resources if they leave. There are a number of things women can do in addition to calling the police or a crisis line or getting a protective order from the courts. If a domestic violence advocate or social worker is not available, clinicians should help patients develop safety plans that are practical and doable (Boxes 59-4 and 59-5). Other women do need to leave their homes and stay somewhere else temporarily, and physicians can explore possible alternatives with their patients. Establishing a working relationship with local domestic violence programs can make this process easier for clinicians. Women often decide to stay with family or friends, but if there are no other options, temporary hospitalization under an assumed name can provide immediate safety.

[edit] Contacting the Police

Patients identified as victims of domestic violence should be informed that battering is a crime and that help from the legal system is available. Physicians should ask patients if they want the police to be called and inform them about what to expect when that happens. Clinicians can offer to call themselves or assist the patient in doing so. Domestic violence programs can usually provide information about police and legal system responses within their communities. Patients should be asked if they want someone present during the police report, and if so, efforts should be made for that to happen. The name of the investigating officer and any actions taken should be documented in the patient's record. If the patient is unsure about filing a report, let her know that a paper trail may be beneficial for future court actions and about what protective orders can provide (e.g., eviction, prohibition of contact, financial support). Discuss the possible benefits and dangers of arrest and short-term detention of the abuser. It is important not to pressure patients into filing police reports that may increase their danger. They are usually in the best position to judge their own safety.

[edit] Referrals

Providers should maintain an updated list of local domestic violence agencies and other community resources to give to patients who are battered. Numbers can be written on the back of an appointment card or disguised in a list of other services. Many community organizations (e.g., serving lesbians and gay men, immigrant or indigenous communities, and people with disabilities) also have expertise in domestic violence. Domestic violence advocacy programs and shelters provide a wide range of services for battered women and their children, as well as public education and training for service providers (Box 59-6). Most of these services are confidential and either free or available for a nominal fee. While most women do not actually stay in shelters, they do utilize many of the other available services. In addition, domestic violence agencies generally are experienced in dealing with the legal system, the child protective service system, and immigration laws. Many programs also have informational materials that can be adapted for use in the health care setting. These should be made available for women to read during their visits and to take with them if it is safe.

Whenever possible, clinicians should refer to mental health providers who are knowledgeable and sensitive to abuse-related issues and their legal ramifications. Providers should emphasize that a referral does not mean the patient is crazy, but that symptoms are an understandable response to overwhelming trauma. Abuse survivors may benefit from trauma-focused support groups, individual and group psychotherapy, and medication. Although there is some support in the literature for couples counseling when the level of violence is low and the perpetrator has demonstrated a commitment to change, couples therapy is generally contraindicated in cases of domestic violence as it may actually increase the risk of harm to the victim.^[1] Many women report serious assaults during or after couples sessions when abuse was discussed. Only if the abuse has ceased for many months to years, the abuser has taken full responsibility for his behavior, and both partners want to rebuild the relationship should this modality be considered.^[1][7]

[edit] LEGAL OBLIGATIONS

[edit] Duty to Report

Because health care providers in some states are required by law to report injuries they suspect resulted from a battering incident, it is important to become familiar with state reporting laws. Statutory reporting mandates vary greatly from state to state based on who is required to report, what kind of injuries need to be reported, penalties for failure to report, and immunity from liability. Clinicians can potentially be held liable for subsequent injuries sustained by a patient who returns to an abusive situation if no inquiries about abuse were made when they initially presented.

While clinicians must be frank about the potential consequences of involving child protective services (inquiry, retaliation by the abuser, losing children to foster care), it is important to discuss the hazards of children continuing to live in a home where they are abused. Let women know there is help available for them and their children. If a woman feels that reporting will provoke immediate retaliation from her partner, help arrange a safe place for her and her children to go.

[edit] Duty to Warn

If a medical care provider is aware of a patient's intent to harm a third party, such as the patient's spouse or partner, the provider may have a legal duty to breach the patient's confidence and to warn the third party of the impending danger. In cases of domestic violence, one must intervene in a way that protects both the victim and batterer. The victim must be told of your intention and offered protective services. If commitment to a psychiatric facility is planned, the third party is thus protected and does not have to be warned.

[edit] DOCUMENTATION

[edit] Medical Record

Thorough, well-documented medical records can be essential for the prevention of further abuse. They provide concrete evidence of abuse and violence that can be crucial in any legal case. For example, if at trial the medical record and the abuser's testimony are in conflict, the record is usually considered more credible. Old records may also be helpful in uncovering and documenting past abuse.

Record the chief complaint and detail the specific descriptions of the abuse, including the identity of the perpetrator, his or her relationship and access to the patient, and the time, date, and location of abusive episodes. Use the victim's own words in quotes whenever possible. For example, “My husband hit me with a bat” is better than “Patient has been battered.” Use neutral language, such as “Mrs. Smith says …” rather than “the patient alleges.” Do not include information that is extraneous to medical facts, such as “It was my fault he hit me because …” or “I deserved to be hit because I was …” (Box 59-7). If a woman is concerned that documentation may jeopardize her safety, keep separate records in a safe place.

[edit] Photographs and Body Maps

Photographs are particularly valuable as evidence and should be offered to all patients with visible injuries. Even if they are not planning to file a case against the assailant at this time, photographs will be very helpful should they decide to do so in the future. Physicians should ask patients for permission and obtain written consent to take photographs. Explain that the photos will become part of the medical record and can only be released to the police or prosecutor with her written permission or by court order. At least one photo should contain the patient's face and something (e.g., coin or ruler) to measure the size of the injuries. Photos should be signed and dated by the patient, photographer, and a witness and placed in a sealed envelope in the patient's record.

A preprinted or hand-drawn body map can be very useful to document injuries that may not show up well in photographs. Each site on the body map should be labeled with the description of the patient's complaint, e.g., mark the area of the scalp and draw a line to a statement, such as, “My scalp hurts when you touch me because last night my husband kept slamming my head against the wall.”

[edit] Laboratory Tests, X-Rays, and Imaging

X-rays showing old injuries can support a past history of abuse. Laboratory abnormalities can also reflect abuse (e.g., blood sugar level is consistently elevated after episodes of abuse). Reports of computed tomography (CT) scans and other imaging procedures should be documented to provide additional concrete evidence of abuse-related trauma.

[edit] DISCHARGE

When discharging patients, providers should discuss what written material will be safe to take home. Try to avoid writing information about abuse on the discharge instructions if this will increase the likelihood of retaliation, and be sure the patient knows what is written on papers the abuser may see so that she can take precautions (Box 59-8).

[edit] CONTROVERSIAL ISSUES

Currently, much less is known about how to approach patients who may be batterers. Routine screening of male patients also remains controversial. Screening for perpetration can potentially increase a woman's danger and restrict her ability to return for care, particularly when the physician is treating both members of a couple. Confidentiality must be carefully preserved and physicians should not confront a perpetrator whose partner has revealed abuse. In addition, men who present as “victims” with injuries inflicted by a female partner often turn out to be perpetrators who were injured in self-defense or retaliation. Perpetrators tend to minimize, rationalize, or deny their abusive behavior and may be likeable and charming. Many clinicians find it difficult to knowingly care for an abuser without either colluding with his denial and rationalization or becoming critical and judgmental. Before providers consider asking about perpetration, they should be well grounded in understanding the dynamics of abuse and connected to established advocacy programs in their communities. If a patient does reveal that he engages in abusive behavior, it is important to let him know that persisting in this behavior compromises his own health and safety, as well as that of those he says he cares about. The physician should also make it clear that this behavior is both dangerous and unacceptable. Let the patient know that resources are available in most communities, and encourage him to accept and follow through with a referral to an approved batterers' intervention program. Individual treatment of batterers by physicians is unstudied and, given the current state of expertise in this area, should not be attempted.

[edit] SUMMARY

Providing quality health care involves integrating routine inquiry about domestic violence into ongoing clinical practice. This means asking all women patients, as well as others who may be at risk, about abuse in their lives. Whether or not a woman chooses to use services or leave her partner, intervention by health care providers is important. Some women return to violent partners numerous times before they feel safe enough to leave, feel they can survive on their own, or are able to mobilize the resources they will need to do so. When clinicians fail to ask about abuse, they further isolate patients who are living in great danger. Asking questions can build bridges, decrease isolation, and create hope. Providing a safe place for patients to talk about abuse and consider their options is supportive, fostering their ability to end the violence in their lives. Through their interventions, primary care providers can play a significant role in reducing and preventing domestic violence.

[edit] REFERENCES

[edit] ADDITIONAL RESOURCES

• National Domestic Violence Hotline, 800-799-7233.
• National Resource Center on Domestic Violence, 800-537-2238.