# Presentation: 040228

## Domestic Violence 

- A Health Care Epidemic
- Rachel E. Locker MD
- Warm Springs Health and Wellness Center

## Alarming Statistics

- The American Medical Association estimates that over 4 million women are victims of severe assaults by boyfriends and husbands each year.   		*“**Violence Against Women," *
*CQ Researcher, Congressional Quarterly 1993*

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## Alarming Statistics

- In the US a woman is more likely to be raped, injured, assaulted or murdered by a male partner than any other type of assailant.
-  Resource Availability for Women at Risk..., American Society of Criminology 1987

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## The Facts

- Domestic Violence is the
- ...leading cause of injury among women of reproductive age
- ...the single most common trigger for female suicide
- ...up to 60% of women who are murdered  die as a result of a domestic dispute
- Webster 1995

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## In the Medical Scene...

- Murder is the leading cause of death related to pregnancy
- JAMA 2001
- 5.8 billion $ per year in health related cost due to DV in th U.S.
- CDC 4/03

**Notes:**
In a study done in Maryland  25% of deaths in women that occurred during or in the year following pregnancy were murder.
Put 2 and 2 together ......

These are the ones we know about

## Closer to Home

- At least 59 % of Women served in the Warm Springs Health and Wellness Center between 1990 and 2000 had a documented history of domestic violence
- Unpublished study 2001

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## Responding

- In order to respond to domestic violence  effectively  we need to have an understanding of ...
- What is domestic violence?
- The causes
- The perpetrators
- The victims
- The impact on the victim, children and society

## What is domestic violence?

- Relationship violence is an escalating
- pattern of abuse where one partner in
- an intimate relationship **controls** the
- other through force, intimidation or
-  threat of violence.

**Notes:**
Look for confusion about the definition of domestic violence
	escalating
	control
	connection of physical force , intimidation, threats, 
	pattern 
multiple episodes over time
	range of tactics

Stress  that control is the issue

present both ws and jc legal definitions

## Abuse comes in many forms...

- _Physical _   Kicking, punching, shoving, slapping, pushing, choking, burning and any other acts which may harm a body.
- _Emotional/ Verbal_ Assaults against your self-esteem.  “You are so stupid, no one else would want you.”  Name-calling, threats, put-downs. “stupid,  fat, whore” etc.
- _Psychological _ Threats to victim, children, pets, property, stalking, yelling, controlling activities and access to resources.

**Notes:**
Use examples here
take examples from participants

## Abuse comes in many forms...

- _Sexual _   Calling of vulgar names, criticizing body parts or sensuality, forced or pressured sexual acts, including rape.
- _Destructive Acts_ Actual or threatened assault of your belongings or pets to scare you.
- _Financial_ Controlling and manipulating you by threatening your economic status and basic needs.

## Abuse comes in many forms...

- _Immigration _   Using your immigration status and fear of deportation to control you.
- _Use of Children  _as hostages, physical and sexual abuse, using children as spies, custody fights, forcing children to engage in abuse of the victim
- _Using “male privilege” _-Master of the castle, treating partner like a servant

## Why do they stay?

**Children-** “ He is the father of my children”, “I thought my children needed a father”
**Isolation****-** social, family, geographical
**Lowered Self Esteem-**  fear that she is “ stupid”, that no one else would want to be with her.
**Religious beliefs/marriage vows- **“till death do us part”

**Notes:**
Give examples of cases for isolation 

Examples for children

Children used by the batterer to bring the victim back

## Why do they stay?

**Fear -** threats of suicide, homicide, threats to family or children
**Blame-** victims believes that she is at fault and the cause of the violence.
**Optimism-** “I thought it would get better if he stopped drinking”, “He said he would never do it again”

**Notes:**
Give examples  in of blame 
take examples from participants

## Special Issues For Teens in Violent Relationships

**Lack of Experience/Might think it’s normal **
**May be involved with drugs and alcohol**
**Peer Pressure/ Status**
**Jealousy and Possessiveness  = love**
**Heavily influenced by the media/role models**
**Stalking - on the campus**

## Causes of Domestic Violence

- Domestic Violence is _**not**_...
- genetically inherited
- caused by illness
- caused by alcohol or drugs
- the result of stress or anger
- due to “a bad temper”
- due to the behavior of the victim or children
- a “problem” in the relationship

**Notes:**
Stress that this is  not caused by these things
And is 
Reinforced by misconceptions from the public, police, medical, family, TV, religion

what did you do to make him mad?

## Causes of Domestic Violence

- Domestic Violence _**is...**_
-               a learned behavior.

**Notes:**
Look for confusion about DV as an anger management issue,out of control behavior, alcohol, victim blaming , drug use

Studies of primates show violent behavior towards mates in order to maintain the harem, to control mating habits
Don’t get to carried away here

## Why does this happen? 

**	**
**       ****Abusive relationships are based on the belief that one **
**person has the right to **
_***control***_** another.**** **
**	**

- Physical violence typically starts when the couple has become more seriously involved.
- “Going steady”
- Living together
- Engagement
- Marriage
- Pregnancy or birth of a child

**Notes:**
Controlling behaviors may also be seen to begin with significant events such as the birth of a child- head of the house now’

Looking back most women can note behaviors that might be warning signs to violence that started later

## Who are the perpetrators?

- Come from all races, religions, sexual orientations, education levels, and social groups.
- Can be male or female
- Can be adolescent to elderly

**Notes:**
Give examples

DJ, batterer and victim
Give examples of elderly murder age 80s, to teens

## Who are the victims?

- From all races, religions, social groups, educational levels, and sexual orientations.
- Male or female
- Adolescent to elderly
- No specific personality traits
- Any level of physical ability

**Notes:**
Listen for victim blaming attitudes, dispel myths

Note that violence is more prevalent  in African American  and more so in 
Native American  
No statistics to quote

## Effectson 

- Victims
- Children
- Society

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

## Medical Effects on the Victim

- Physical injuries
- Fractures
- Head injuries
- Genital trauma
- Abdominal trauma
- Delay in seeking medical care
- May exacerbate any injury

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

## Medical Effects on the Victim

- Obstetric
- Late, sparse or no prenatal care
- Low birth weight
- Miscarriage
- Fetal Fracture
- Placental abruption
- Preterm labor
- Drug and Alcohol abuse

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

## Medical Effects on the Victim

- Chronic pain syndromes
- Joints
- Pelvic
- Abdominal
- Headaches

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

## Mental Health Concerns

- Decreased sense of “Well Being”
- Depression
- Anxiety disorders
- Sleeping disorders

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

## Mental Health Concerns

- Post Traumatic Stress Disorder
- Suicidal ideations
- Suicide attempts

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

## According to the AMA, Teen Girls Who Experience Physical and Sexual Abuse in Relationships Are:

- 2.5 times more likely to smoke heavily.
- 1.2 times more likely to drink and drive.
- 3.7 times more likely to use diet pills.
- 5.7 times more likely to consider suicide.
- 3.9 times more likely to become pregnant.
- 1.7 times more likely to binge drink.
- 3.4 times more likely to use cocaine.

## Effects on the Victim

- Death

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

## Children are the silent victims !

## Child Abuse

-    Children from homes where there is partner abuse are 15 times more likely to be abused than children from non-violent homes !

**Notes:**
Stress this need to protect children 

## Medical Effects on Children

- Physical  injuries
- Abuse and Neglect
- Alcohol and Drug abuse/health consequences
- Sleeping disorders
- Psychosomatic complaints

**Notes:**
Point out examples of stress related illness  that you shouldn’t see in children these should be triggers

## Mental Health Effects on Children

- Behavior problems
- Nightmares
- Difficulty forming relationships
- Depression
- PTSD
- Suicidal ideations
- Suicide attempts

**Notes:**
Discuss that suicidal ideations/ and attempts in children etc. need to be investigated further

## Domestic Violence and Children

- Domestic Violence

- 63 % of boys arrested for homicide, ages 11-20 have killed their mothers assaulter

- 80% of runaways come from homes where domestic violence occurs.

- 70% of offenders in treatment for domestic violence witnessed it as a child.

-    **Witnessing violence always has an impact on children!**

- nightmares

- depression

- Behavior problems

- fear

- Difficulty forming relationships

- Eating disorders

- withdrawal

** ****suicidal thoughts**

- Problems at school

- Aggressive acting out

- Increased use and abuse of drugs and alcohol

- detachment

- Destructive rages

- increased assaults

## Socioeconomic  Impact

**Medical Expenses**
**Victim & Child Protection Expenses**
**Counseling services**
**Lost time from work/school**
**Police/Legal services**
**Alcohol and Drug counseling/treatment**
**Damage to property**
**Poverty**
**Homelessness/Runaways**
**Homicide/imprisonment**
- continues the cycle of violence

## The Cycle Continues ...

-    A child’s exposure to the father abusing the mother is the strongest risk factor for transmitting violent behavior from one generation to the next. *– **Report of the American Psychological Association Presidential Task Force on Violence and the Family, APA, 1996*

**Notes:**
Stress this need to protect children 

## Add It All Up...

- 	Physical and sexual violence against women is a public health problem that has reached epidemic proportions.
- 				American Medical Association
- 				Diagnostic and Treatment Guidelines on    			Domestic Violence, 1992

**Notes:**
Good spot for a break!!!!

## 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

## Identify

-    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
- Nasal/ facial bone fractures,
- Lacerations to the eyes,
- Rupture eardrum
- Dental injuries

## Periortibal ecchymosisLacerations to the lips

## Suspicious Physical Findings

- Injuries to the neck
- Ligature marks
- Rope burns,
- bruising
- petechiae

## Suspicious Physical Findings

- Injuries Centered Around Sex Organs
- Injury during pregnancy
- Injuries to the torso and abdomen
- Rib Fractures

## Suspicious Physical Findings

- Bilateral injuries
- Grip marks
- Pattern injuries
- Weapon patterns
- Bite marks
- Burns

## 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?

- 	Medical practitioners are often the _first or the only_ professionals  that individuals in abusive situations come in contact with.

## Screening Tells a Woman...

- She is believed
- She is respected
- She is not alone
- You are familiar with DV
- You are willing to listen

- Abuse happens to a lot of women
- The issue is being taken seriously
- DV can affect her health
- She can get help

## What if we don’t ask?

- Little or no disclosure
- Abused women remain isolated
- The problem will continue and  personal and social cost will increase

- Opportunity to prevent illness, injury or death will be missed
- Treatment or advice may be inappropriate
**Professional Silence**

## 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 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
- When woman or child presents with 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.

- What do I do when she says yes?

## Intervention

**Document**
**Assess Danger**
**Be supportive**
**Educate**
**Refer**

## Document... screening

- Document  if your screening was “positive, negative, or suspicious”
- Document your findings or suspicions of abuse.
- Adult maltreatment syndrome  995.81

## Educate/Support/Refer

- Let the patient know that there is no excuse for domestic violence.
- “No one deserves to be abused.”
- “There is no excuse for domestic violence.
- “The violence is not your fault this is the responsibility of the abuser.”

## Educate/Support/Refer

- Let her know she has options and that help is available if she should find the need.
- “You are not alone, there are people you can talk to.”
- “It must be difficult for you to leave your situation, help is available  when you are ready.”
- Offer to call a Victim's Advocate  or other resources

**Notes:**
Review medical power and control wheel , empowerment /advocacy wheels

Note that this may be where we can make the biggest impact.  The patient needs to know that she can trust us and rely on us for help and confidentialty

## Educate/Support/Refer

- If she declines  the  need for an advocate...
- Give her/discuss with her information on safety planning.
- Give her info/discuss with her info on available resources

## Assess Danger (lethality)

- Increase in the frequency or severity of violence .
- Increasing or new threats of homicide or suicide.
- Threats to children
- Using alcohol or drugs?

- Used a firearm or weapon in past threats
- Public Displays of violence?
- Hostage taking or stalking?
- Will she be in any immediate danger if she returns home?

## Acute events

- Use the patients own words when ever possible.
- Record “excited utterances” and use descriptive terms in regards to emotions and appearances
- “ He grabbed me by the hair and pulled me out of the car”
- “Patient appears extremely anxious and distraught.“

## Acute events

- Photograph all injuries,  (obtain written consent)
- Label with the date, time,  patient name  and your initials
- Use a standard scale to show size
- Use a standardized form so as not to leave out important issues
- Sexual Assault Exam if indicated

## Use a size standard

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

## Body Charts

## Document... acute events

- Know your local
-  reporting laws

## Document... acute events

- Remember...
- Accurate documentation
-  will help the patient’s legal case
- against the assailant.

##    Medical 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

##          Medical  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.