Medical Response to Domestic Violence Jane A Petro, MD Professor of Surgery New York Medical College
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 • INTIMIDATION • ISOLATION • EMOTIONAL ABUSE • ECONOMIC CONTROL • PHYSICAL THREATS • HARM
Myths 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 Violence • 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 Abuse • 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.
Facts About Domestic Violence • 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.
Facts About 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
Facts About Domestic Violence • 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
Facts About Domestic Violence • 25% or workplace problems, absenteeism, decreased productivity, turnover, and excessive use of medical benefits are due to family violence
Facts About Domestic 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 Violence • Spouse and child and pets • Drugs and Alcohol • Social isolation • Not economics, race, religion, education, social class, national origin
Facts About Domestic Violence • 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
Facts About Domestic Violence • 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.
Men Possessiveness 82% Abuse 75% Arguments 63% Self defense 4% Women Self defense 83% Stated Reasons for Committing Homicide
Facts About Domestic Violence • 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.
Facts About Domestic Violence • 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 • 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? • 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? • 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? • 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.
Facts About Domestic Violence • 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 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 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 Consequences • Chronic depression • Anxiety disorders • Suicide • Eating disorders • Alcoholism • Substance abuse
Consequences 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 DV • Emergency Room 25%-37% • Obstetrics and Gynecology 15-25% • Primary care 25 %, 15% • Psychiatry 25% • Pediatrics 50-70%, 15%
Batterers Behaviors • Aggressive • Controlling or coercive • Harassing • Destructive • Intimidating • Isolating • Threatening
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 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 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 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 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? • To be asked • To be believed
Why Don’t Patients Just “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? • 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? • 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 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.
Comprehensive Review • 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.
Comprehensive Review • 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.
Comprehensive Review • 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 Abuse • Physical findings • General signs and symptoms • Psychological symptoms • Complications of pregnancy and childbirth • Associated social and family problems
Clinical Clues to DV During Pregnancy • 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 Injuries • Central distribution • Head and neck • Defensive injuries of forearms • Multiple sites, variable bruises • Neurological symptoms, visual, auditory, stroke, • Sexual assault related
Physical Violence Scale • Throwing things, hitting the wall • Throwing at the victim • Slapping • Punching • Severe assault • Threatening with weapons • Using weapons
Medical 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 Abuse • 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 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 Asked • 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 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.