# Presentation: 487375

## Domestic Violence 

- A Health Care Epidemic
- Don Clark MD, MPH
- Rachel E. Locker MD

## What is Our Role in Health Care?

- Identify
- Assess
- Document
- Educate

**Notes:**
As a physician regardless of your practice type you will see victims of domestic violence
	ent -nasal fractures
Pediatrics- children with behavioral concerns

Surgeouns - truamatic and and chronic abdominca pain

Pathologist- autopies

ER injuries

FP depression, anxiety, pain
Ob pelvic pain, pregnancy

-    When should
- I think
- domestic violence?

## Suspicious Physical Findings

- Multiple injuries in
- various stages of healing

## Presentation

- Delay between onset of injury and seeking care.
- Injury inconsistent with the explanation.

## Suspicious Physical Findings

- Injuries centered around face
- Injuries to the neck
- Pattern injuries

## Periortibal ecchymosisLacerations to the lips

## Suspicious Physical Findings

- Injuries Centered Around Sex organs
- Injury during pregnancy
- Injuries to the torso and abdomen

## Defensive injuries

## Pattern injury- Hand print

## Pattern injuries - linear

## Pattern Injury Bite Mark

**Notes:**
Point out that physical injury may be the most obvious but is not  necesarrily the most harmful.

## Mental Health Issues

- Eating disorders
- Alcohol or drug abuse
- Psychosocial distress
- depression
- suicidal
- anxiety
- sleep disorders

## Partner Interactions...

- A partner who will not leave the exam room.
- A partner who does all the talking for the patient

## “Difficult Patients”

- Vague psycho-somatic complaints
- Chronic pain syndromes

## Labels

- “Borderline personality disorder”
- Manipulative
- “Crock”
- Hysterical
- Somatitization disorder
- Angry
- Demanding/Difficult

**Notes:**
Point out that a large percentages of suicidal attempts.  Suicides are related to domestic violence

## Pediatric Clinical Signs

- Concerns of child abuse or neglect
- Depression
- Psychosomatic complaints
- Eating disorders

- Suicide attempts or gestures
- Behavior problems
- Nightmares
- Insomnia

## We couldalso  Just Ask!

## Medical Screening

- Patients don’t tell us they have it
- Cervical Cancer
- There is a high incidence in the population- HTN
- It may be contagious
- TB

**Notes:**
Give examples

Patients don’t tell us they have TB, HTN, cervical cancer  all things we screen for (TB skin test,  BP, pap smear)
				Patients don’t routinely tell us about abuse in the home 

There is a high incidence of HTN, cervical cancer, TB in certain populations  there is also a high incidence of DV

TB is contagious as are the effects of Domestic violence 

## Medical Screening

- It may cause other illnesses
- HTN
- It may cause an early death
- TB
- Early intervention makes a difference in outcome- Cervical Cancer

**Notes:**
HTN causes stokes , MI’s and heart failure

TB, cervical cancer, and HTN can cause early death as can DV through homicide,and suicide

Early intervention in HTN can prevent MI, CHF, cardiomegly and 
TB treatemnt  can prevent active illness
Education and intervention on DV can prevent early death, victim and children ilnesses a, homicid and suicide

## Why Should We Screen?

- Domestic Violence and it’s medical and psychiatric sequelae are sufficiently prevalent  to justify  routine  screening of all women patients in emergency, surgical, primary care pediatric, prenatal and mental health settings
- American Medical Association 1992

## Who Else ?

- American College of Physicians
- ACOG recommendations
- American Nurses Association resolutions and guidelines
- American medical Association
- American Academy of Pediatrics
- JCHO

## Who Should We Screen?

- All Females over the age of 14 with or without signs or symptoms of domestic violence -on a routine basis
- Children - Screen female caregiver/parent or caregivers known to be in a same sex relationship  who accompany their children
-  Any patients who present with clinical findings that may indicate abuse

## When Should We Screen?

-     In a perfect world...
-       Every time you see      		them

## When Should We Screen?

- Good Choices
- Pregnancy – each trimester
- Women's health exams
- At least once per year
- At disclosure of a new  intimate relationship
- On presentation with children for well child exams
- Clinical signs or symptoms

## How to Screen	

- Screen in a safe and private environment.
- Separate any accompanying persons from the patient.

## Frame the Question	

- Use your own words in a non-threatening, non-judgmental way.
- “Domestic violence is so common that I ask all my female patients about abuse in the home”
- “It is hospital policy that we ask about abuse in the home...”

## Be Direct...

- ...and easy to understand.
- “Do you feel safe in your current relationship?”
- “Have you or your children ever been threatened or abused by your partner?”
- “Is there a partner from a previous relationship who is making you feel unsafe?”

## How to Screen

- Explain the confidentiality of these issues and the mandatory reporting of child abuse.

##  Power and Control  

**Power and Control**

- Trivializing abuse

- Blaming the victim

- Not respecting her autonomy

- Ignoring the need for safety

- Failing to respond to her disclosure of abuse

- Violating Confidentiality

**Notes:**
Note that doing these things take the control of her life from her h

##                    Advocacy 

**Advocacy**

- Believe and validate her experiences

-  Acknowledge
- injustice

- Respect her autonomy

- Help her plan for future safety

- promote access to community services

- Respect Confidentiality

**Notes:**
Note difference in how wecan be advocate of  demonstrate power over the patent.

Give examples 

## Tips

- If you are suspicious of domestic violence but your patient denies, do not press the issue.  Express your support and document your concerns.
- Don’t insist that she must leave the relationship.  This must be her decision and in many cases it must be carefully planned. Most women who are killed in these situations are killed when they try to end the relationship.
- It takes an average of 12 times leaving for a woman to end an abusive relationship. Try not to get frustrated and don’t abandon her.