Medical Response to Domestic Violence Jane A Petro, MD Professor of Surgery New York Medical College

Medical Response to Domestic Medical Response to Domestic ViolenceViolence

Jane A Petro, MD

Professor of Surgery

New York Medical College

Domestic Violence Definition Domestic Violence Definition

A pattern of behavior used by one individual to exert power and control over other individuals within the context of an intimate relationship. Such behaviors include intimidation by force, emotional, and sexual, abuse, economic control, and neglect.

POWER AND CONTROL POWER AND CONTROL

INTIMIDATION ISOLATION EMOTIONAL ABUSE ECONOMIC CONTROL PHYSICAL THREATS HARM

Myths of Domestic ViolenceMyths of Domestic Violence

I never see it in my practice. It never happens to people like me. It doesn’t affect medical health. It is not common. It is better left to the family. I can’t do anything about it anyway.

Facts About Domestic Facts About Domestic ViolenceViolence

1 million women seek medical assistance for injuries caused by battering each year

A woman is beaten every 15 seconds

US dept HHS, 1991

Cultural Determinants of Cultural Determinants of AbuseAbuse

Historical tolerance of abuse. Belief that women should be subservient to

men. Belief that men should exercise

sovereignty. View that women are property. Men beat women because they can.


Battering is the major cause of injury to women, resulting in more injuries than auto accidents, muggings, and rapes by strangers combined.

50% of homeless women and children are fleeing domestic violence.


Women are 10 times more likely to be victimized by their intimate than men

75% of women seek care for injuries due to battering after they have separated

75% of police interventions are called after separation

In the US there are 1,500 shelters for battered women, 3,800 for animals


Medical expenses for DV total between $3 and $5 billion annually

Business costs of DV cost $100 million in lost wages, sick leave, absenteeism and non-productivity

The commonest cause of workplace death among women, is homicide by an intimate


25% or workplace problems, absenteeism, decreased productivity, turnover, and excessive use of medical benefits are due to family violence


40% of first assaults begin during pregnancy.

1 in 10 female high school students has been battered.

22% of female college students report being battered, equivalent to the reported rate for adults.

Co-factors in Domestic Co-factors in Domestic ViolenceViolence

Spouse and child and pets Drugs and Alcohol Social isolation Not economics, race, religion, education,

social class, national origin


More than twice as many women are murdered by an intimate partner than by a stranger

Among all female victims, 29% were slain by an intimate, 4% of males were slain by their wives or girlfriends (FBI, 1992)

Violence is the stated reason for middle class divorce in 22% of cases


The victim of domestic violence is a woman in 85% of all cases reported.

She is white in 64% of cases. She is an average age of 31.

Uniform crime reports, 1992.

Stated Reasons for Committing Stated Reasons for Committing HomicideHomicide

Men Possessiveness 82% Abuse 75% Arguments 63% Self defense 4%

Women Self defense 83%


Women charged with homicide of an intimate partner have the least extensive criminal record of any other crime category, and serve longer sentences than men who kill their spouse. Men who kill their spouse are less likely to be charged with first or second degree murder than are women.


90% of family violence defendants are never prosecuted

33% of the cases that would be considered felonies if committed by strangers, are filed as misdemeanors

Medical Consequences of DV Medical Consequences of DV

Separated or divorced women are 14 times more likely to report being a victim of a spouse, or ex-spouse.

Although only 10% of women are separated or divorced, they report 75 % of the spousal violence.

Women are far more likely to be killed after leaving, 41% within 2 months, 91% in 1 year.

Is DV a Medical Issue?Is DV a Medical Issue?

NEJM September 16,1999 JAMA annual issue 3200 articles listed in the peer reviewed

medical literature since 1969 All major specialties published articles in

the past year AMA diagnostic and treatment guidelines

Is there a duty to address DV?Is there a duty to address DV?

All clinicians examining children and adults should be alert to physical and behavioral signs and symptoms associated with abuse and neglect.

What are the duties?What are the duties?

Suspected cases of abuse should receive proper documentation of the incident and physical findings (e.g..., photographs, body maps)

Treatment of physical injuries; arrangements for counseling by a skilled mental health professional;

Telephone numbers of local crisis centers, shelters, and protective service agencies.


8% of women reported the abuse to their physician.

38% discussed it with a friend or co-worker.

More than 50% told no one. Abused women are more likely to seek help

from their physician than police or lawyers.

Medical Consequences of DVMedical Consequences of DV

Women at risk of injury and death Complications of pregnancy and childbirth Gynecologic problems, STD’s, HIV Chronic somatic disorders Non compliance with medical care

Medical Consequences of DVMedical Consequences of DV

Battered women are 15 times as likely to be alcoholic, and 9 times as likely to be drug abusers, than non-battered women.

This increased risk appears AFTER the first episode of domestic violence.

Mental Health ConsequencesMental Health Consequences

Chronic depression Anxiety disorders Suicide Eating disorders Alcoholism Substance abuse

Consequences to ChildrenConsequences to Children

50 % of the children of battered women are also abused

Adopt violent and aggressive behaviors Emotional trauma and behavioral problems Be incarcerated for assaulting the abuser Batterers are more likely to have witnessed

their mother being battered

Prevalence of DVPrevalence of DV

Emergency Room 25%-37% Obstetrics and Gynecology 15-25% Primary care 25 %, 15% Psychiatry 25% Pediatrics 50-70%, 15%

Batterers BehaviorsBatterers Behaviors

Aggressive Controlling or coercive Harassing Destructive Intimidating Isolating Threatening

Perpetrator or Victim?Perpetrator or Victim?

Remember, the batterer may have been injured during the battering.

Distinguishing them may not be a matter of who says what.

Clinicians RoleClinicians Role

Your have a right to be safe in your home No one has the right to do this to you This is a criminal act There are many ways that you can be

helped, when you are ready

Clinicians RoleClinicians Role

Believe the victim Validate the experience Recognize that truth is not concrete Respect decision making Be willing to be patient DO NOT REPORT, OR RECOMMEND

FAMILY COUNSELING

Failure to Screen for DVFailure to Screen for DV

Physician discomfort Time constraints in the clinical setting Failure to recognize the pervasive

occurrence of DV Lack of access to services Misunderstanding about the nature of

abuse, and of victims responses

Failure to Screen for DVFailure to Screen for DV

Believe the patient provoked the violence Believe that her drug use, alcoholism,

illness is more important, or makes the violence less relevant

Believe that she could just leave, if she wanted to

Believe that even medical help, won’t help

What Do the Victims Want?What Do the Victims Want?

To be asked To be believed

Why Don’t Patients Just Why Don’t Patients Just “Tell”?“Tell”?

Fear of retribution Shame and humiliation, isolation May believe that she does deserve it Wants to protect her partner May not understand the situation May not think the doctor cares, or that they

can’t help anyway

Why Stay in the Relationship?Why Stay in the Relationship?

Fear that the violence will escalate if she tries to leave

Lack of alternative living arrangements Believes that “family” is necessary for the

kids Economic fears Too traumatized to leave

Why Stay in the Relationship?Why Stay in the Relationship?

Cultural, religious or family values that place the needs of the “family” above those of the victim as an individual

Feels responsible for the violence Loves him, believes he will change Doesn’t know that anyone else cares

Comprehensive ReviewComprehensive Review

Physical. This includes physical hitting; extent of current and past injuries; if the patient has been beaten up, threatened, or attacked with a weapon.

Sexual. This includes forcing unwanted types of sex or refusing to use birth control.


Emotional. This includes humiliation, swearing, name calling, mental instability, alcohol, and other drug use, and obsession with partner.

Isolation. This includes controlling access to friends and family and limiting outside involvement.

Children. This includes threats to partner by threatening children.


Destroying. Destroying the patient's property or injuring patient's pets or children.

Economic. The abusive partner controls all money.

Threats. Threats of injuring patient or self, threats of reporting patient to immigration, stalking patient.

Past violence history. For example, arrests for violent acts or threats of using a weapon.


Short term plan. "Do you know what to do if you are afraid?" "Where could you go if you were in danger?"

Support. "Who can help you get safer?"

Strengths in patient and spouse. "Is there any hope that changes can be made?"

Clinical Indicators of AbuseClinical Indicators of Abuse

Physical findings General signs and symptoms Psychological symptoms Complications of pregnancy and childbirth Associated social and family problems

Clinical Clues to DV During Clinical Clues to DV During PregnancyPregnancy

Inconsistent injuries, bilateral injuries Central injuries, especially abdomen Pattern of injury, different stages of healing Delay between injury and attention Drugs, depression, STD’s, missed

appointments or no prenatal care Previous complications of pregnancy

Characteristics of DV InjuriesCharacteristics of DV Injuries

Central distribution Head and neck Defensive injuries of forearms Multiple sites, variable bruises Neurological symptoms, visual, auditory,

stroke, Sexual assault related

Physical Violence ScalePhysical Violence Scale

Throwing things, hitting the wall Throwing at the victim Slapping Punching Severe assault Threatening with weapons Using weapons

Medical Interventions for DVMedical Interventions for DV

Routinely ask about DV Assess safety Document the abuse Discuss the options and resources available Provide advocacy and referral Treat the medical and psychological issues Provide for follow-up care

How to Prepare to Ask About How to Prepare to Ask About AbuseAbuse

Learn the facts, lose the myths. Practice asking key questions on some of

your old patients. Talk to your staff about this. Put up posters, make palm cards available,

have information in the waiting room, and the women’s bathrooms.

Questions That Should Be Questions That Should Be Asked:Asked:

Is there abuse, now, ever, potential? Who is the perpetrator? What kind of

access does he have? How has the abuse affected health? Is it safe to go home? How is she feeling about the fact that you

are asking?

Questions That Should Be Questions That Should Be AskedAsked

How do your own feelings interfere with your ability to communicate with your patient?

What resources are available to help your patient?

What does the patient need to take the initial steps toward safety and freedom from abuse?

What Questions Should You What Questions Should You Ask?Ask?

First create a safe environment. Patient alone in the room. Literature about DV available.

Put the questions in context. Ask as part of your routing screening.

Use language that you are comfortable with.


Use direct questions: Have your ever been punched, hit or

kicked by someone you know? Are you safe at home? Is there someone close to you who is

hurting you now?


Your partner seemed reluctant to leave you alone. Is there something they are afraid you will tell me?

You seem afraid of your partner. Have your been threatened, or hurt? Have they ever threatened or harmed the children?

Do you have to ask permission from your partner to do things?


I see you have some bruises, did someone do this to you? Can you tell me how this happened?

Is there someone who is trying to keep you from taking your medication?, Or keeping you from doing things YOU want to do?

Are there guns or knives in your home? Who has access to them?

What Not to Ask Your Patient:What Not to Ask Your Patient:

Why don’t you just leave? Why would you stay with someone like

that? What did you do to aggravate him? What did you do to cause the violence? Are you a masochist? Why didn’t you diffuse the situation?

Does Asking Questions Work?Does Asking Questions Work?

Specificity 85% Sensitivity 71%

Do you ever feel unsafe at home? Has anyone at home hit you or tried to injure

you in any way?

JAMA 277:1357, 1997

Clinicians As AdvocatesClinicians As Advocates

Weight reduction Smoking cessation Cardiovascular fitness Tight control of diabetes Immunizations Flammable fabric, windshields, seat belts,

airbags, crib positioning

What Should You Say?What Should You Say?

You do not deserve this. You are not alone. You are not crazy. What happened to you is a crime. No one should be able to do this to you.

Screening QuestionsScreening Questions

Are you safe at home? Does (has)anyone you loved hit or hurt

you? Does anyone in your home harm your

children or your pets? Are there guns in the home?

Screening Parents of Screening Parents of NewbornsNewborns

How often do you have yelling or screaming fights?

Do you have pushing or shoving fights? Do you have guns, or other weapons in the

home? If yes, how are they stored? Where is the ammunition kept?

Screening Parents of ChildrenScreening Parents of Children

I am sure that you have heard about violence in the home and school. Do you have problems with fighting in your home?

Separate family members when doing follow thought questions.

Screening TeenagersScreening Teenagers

Sex, Drugs, Rock and Roll Has anyone forced you to have sex? How many pushing or shoving fights have

you had in the past year? Have you been injured? Do you carry a weapon for protection? How do you get out of a fight?

AdultsAdults

How do you disagree? How many pushing or shoving fights have

you had in the past year? Has anyone you loved hurt you this year? Do you have guns in your home?

Emergency RoomEmergency Room

Has anyone hurt or hit you recently? Did you come here today because someone

hurt you? This looks like it hurts. You don’t deserve

this? Do you feel safe in your home?

If the Answer Is Yes?If the Answer Is Yes?

Let her tell her story. Believe it, validate the experience. Document your history, and the physical

findings, include the name of the abuser, dates, nature of the injury, its mechanism, etc.

If you suspect it document it even if denied.


Discuss safety. Be sure she has the information she may

need. Information about calling the police, the

shelter, legal aid, your office. Be sure she knows that help is available,

even if she can’t afford it.


Make a follow-up appointment Validate the patient’s experience

concern for well-being and safety Consider whether suicide or homicide

should be discussed

If the Answer Is NO!If the Answer Is NO!

If you are suspicious, document it carefully. Make information available. Make a follow-up appointment, track it to

see if it is kept. Be sure to ask again at the subsequent visit. Be careful about messages left at the home.

Evidence Collection Evidence Collection GuidelinesGuidelines

Look, observe, assess, correlate Record your observations, using proper

medical terminology Photograph injuries if possible Preservation of evidence, clothing, rape kit Package, label, identify, store, chain of

evidence

Evidence Collection Evidence Collection GuidelinesGuidelines

Bite marks Instrument, tool marks Care for the patient, not just the legal

system

Referral ServicesReferral Services

Nat’l DV Hotline 1-800-799-SAFE Physicians for a Violence-free Society

(415)-821-8209 My Sisters’ Place 1-800-298-SAFE My Sisters’ Place office (914)-638-1333 NYS Office for the Prevention of DV

(518)-486-6262

Referral ServicesReferral Services

American College of OB-GYN (202) 638-5577 National Coalition Against DV (303) 838-1852 American Medical Association (312) 464-5000 National Resource Center on DV ( 800) 537-2238

What is Domestic Violence?What is Domestic Violence?

Power and Control Injuring, or trying to injure someone within

a relationship of love, or dating Isolating a partner from other forms of

social or family contact Preventing an adult from making

independent decisions (like and adult)

Comprehensive AssessmentComprehensive Assessment

Tell me about the last time you were hit? Can you tell me about the worst time you

have had? Are you afraid right now? Do you have a safe place to go to today?

Safety PlanSafety Plan

Where to go What to take

Documents Clothes Address book Medicine Keys

Safety PlanSafety Plan

Kids School Pets Resources Residence Work

ConversationConversation

"Are you safe now? Do you know what to do if you don't feel safe? This is terrible. You don't deserve this. If things stay the same, this will not get better. I am giving you a name and number of a counselor who can help you figure out how to be safer. Call this number when you can. If you are ever feeling that you or your children are in danger, come to the emergency room."

Where help is notWhere help is not

The legal system is not designed for healing or restoring relationships or individuals.

The legal system can sometimes make things worse. It models coercion as the best tool to solve the problem of violence.

Prosecutors and judges are interested in assessing blame, exacting revenge, punishing, following public opinion, and being sure they won't be blamed for further violence.

RememberRemember

Lying men and women can manipulate the criminal system more skillfully than naive or honest people.

Police almost always arrest the man of the household if anyone claims that a couple are beating each other.

But opportunists are using this law to increase female arrests