8th Edition APGO Objectives for Medical Students Domestic Violence

8th Edition APGO Objectives for Medical Students

Domestic Violence

Rationale

Domestic violence affects a significant proportion of the U.S. population in all economic classes and walks of life. All physicians should screen for the presence of domestic violence.

ObjectivesThe student will be able to: Cite prevalence and incidence of violence against

women, elder abuse, child abuse Assess the involvement of any patient in domestic

violence situations Counsel patients for short-term safety Counsel patients regarding local support agencies for

long-term management and resources Counsel patients requiring resources for batterers and

perpetrators of domestic violence

Prevalence

Women 2-6 million women per year are assaulted

by spouses/partners 40% of wives are beaten 10% of wives are raped May be increased during pregnancy For every 200 assaults, only 28 reported

and only 3 arrests

Prevalence

Children6% are victims of violenceEstimated 500,000 cases per year

Prevalence

Elder abuseAlso increasingNo firm dataMost often by family member/caregiver

Assess involvement in domestic violence situation

Screen all women Emotional abuse Physical abuse Forced sexual relations Fear of partner, other person Feel safe at home?


Identify presence of domestic violence Physical abuse

Hitting Slapping Kicking Choking Assault or threat with weapons


Identify presence of domestic violence Sexual abuse

Unwanted touching Sexual name-calling Unfaithfulness False accusations Forced sex Hurtful sex

Assess involvement in domestic violence situation Identify presence of domestic violence Emotional/psychological abuse

Undermine self-worth Deprivation of sleep or emotional support Unpredictability of response to life situations Threats Destruction of personal property Partner overly controlling Limits victim’s contact with others Inappropriately close surveillance Restricts activities


Offer safety - immediate safety or “escape” plan

Provide advocacy and support Non-judgmental Victim may choose not to leave situation at

that time



Counsel patients for short-term safety Is it safe to go home? Are your children safe? Can you stay with a friend or family? Do you need a shelter?



Local support agencies Police/rescue squad Domestic violence hotline Family Violence Prevention Fund - (800) 313-1310 National Resource Center - (800) 537-2238 Local referral agencies Shelters



Resources for batterer and victim Goals - end violence Focus - victim’s safety Purpose of intervention

• Acceptance of responsibility for violence• Discontinue violent behavior • Develop non-violent attitudes and behaviors



Legal obligation to report - know state laws Varies by state Spousal abuse reporting not required in most

states (may worsen situation) Spousal abuse referral required in many states Elder, child abuse reportable - varies by state

References Flitcraft A. Violence, abuse, and assault over the life phases. in

Wallis LA, et al, eds. Textbook of Women’s Health, Lippincott-Raven Publishers, Philadelphia, PA, 1998:249-258.

Seaman B. A survivor’s view. in Wallis LA, et al, eds. Textbook of Women ﾕ s Health. Lippincott-Raven Publishers, Philadelphia, PA, 1998:259.

Severino SK. Commentary: late luteal phase dysphoric disorder - disease or did-ease? in God JH, Severino SK, eds. Premenstrual dysphorias: myths and realities. American Psychiatric Press, Inc., Washington, DC, 1994:213-230.

Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997

Clinical Case

Domestic Violence

Objectives

At the conclusion of this exercise, the student will be able to provide a preliminary assessment and discuss management options of patients subjected to domestic violence.

Patient presentation

A.W. is a 25-year-old G4P3 woman who makes an appointment to consult you about her “PMS.” She complains that she is “not herself” for several days before her period and that she can’t stop crying. She snaps irritably at her husband, who is a “good provider for [her] and for the children.” She doesn’t have her usual patience with the children, aged 3 years, 2 years, and 8 months. She startles easily and is clumsy. Just last month, she accidentally broke a favorite figurine her mother had given her.


She thinks she might have felt better when she took birth control pills, but her husband doesn’t think she should take drugs that “interfere with natural functions,” especially with this PMS problem. He doesn’t like IUDs, diaphragms or condoms, either. When you screen the patient for depressive symptoms, she denies appetite disturbance. Her sleep is somewhat fitful, but she has to keep an ear cocked to hear the children so that they won’t disturb her husband, as “he has to get to work in the morning.”


Her energy and sex drive are not great, but she believes that’s pretty natural with three children. She manages to keep up with them and the housekeeping. She enjoys seeing other people, but doesn’t have much time for socializing.


Her husband, who has accompanied her to the appointment, confirms her account. He says she “would be a great little wife and mother if it weren’t for this darned PMS.” He remains in the examining room throughout the interview and general physical and pelvic exams, holding his wife’s hand and patting her on the back from time to time. He tells you that you shouldn’t worry about the cost of treatment because he wants his wife to have whatever she needs.


Physical examAll normal, except a small bruise on A.W.’s

right arm.LaboratoryHematocrit and TSH normal.AssessmentPossible depression, protective husband,

bruise on arm, possible domestic violence

PlanCareful history and physical examRule out any possible underlying medical

problems, e.g. hypothyroidismReview previous medical recordsCounselingPossible referral to therapist or social

worker

Discussion

A.W.’s symptoms do seem to occur in the premenstrual phase. It is not clear whether she meets criteria for major depression or dysthymic disorder as well, but since the treatment for PMS is selective serotonin reuptake inhibitors (SSRIs), which are antidepressants, you reason that you will treat the depression, if it is present.

DiscussionAfter ordering a laboratory workup, you prescribe

sertraline 50 mg/day. You also arrange to have her previous medical records sent to your office. Prior to A.W.’s return visit 2 weeks later, you review her records and notice that she has made numerous visits to physicians with vague complaints of headaches and abdominal pains over the years. She has also been seen in the emergency department for a succession of lacerations and broken bones. Bruises were noted on these visits, but always explained by the patient.

DiscussionWhen A.W. appears for her visit, again accompanied by

her husband, you ask the office nurse and clerk to engage him in a lengthy discussion of insurance benefits. When he is not present, you tell A.W. that you are glad to have the opportunity to speak with her alone. She indicates that the medication has not made much of a difference in her symptoms. You tell her that people sometimes have symptoms like hers when others in their home are hurting them, and that you have noticed many injuries in her past medical history. A.W. looks very frightened.

DiscussionYou assure her that you are there to help and that you will keep

her statements strictly confidential. A.W. breaks down in tears and tells you that her husband’s temper sometimes gets the best of him, and she says, “He would kill me if he knew I had told anyone.” You assure A.W. that no one has the right to hurt anyone and discreetly provide her with information about domestic violence. After several visits in the company of her husband, A.W. comes alone one day and tells you, “It took me a while to face the fact that I was being abused and to get up the nerve to leave, but one day my husband hit our oldest daughter, and I realized I had to get out. The kids and I are living with my mother now, and I am going to school so that I can take care of us and make us a new life.”

Teaching points

1. An overly involved husband is often a sign of domestic violence.

2. A history of domestic violence is seldom volunteered, especially on the first visit, and it will be necessary to interview the patient alone in order to obtain the history.

3. Victims of domestic violence frequently present with a succession of rather vague physical complaints.

Documents

8th Edition APGO Objectives for Medical Students Domestic Violence