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Domestic Violence . INTERNAL MEDICINE RESIDENTS University of Nevada School of Medicine July 21, 2008 Allan Ebbin, M.D. MPH Vice President, Healthcare Quality and Education Sierra Health Services, Las Vegas Emeritus Professor of Pediatrics and Family Medicine, USC 242-7731

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Domestic Violence


University of Nevada

School of Medicine

July 21, 2008

Allan Ebbin, M.D. MPH

Vice President, Healthcare Quality and Education

Sierra Health Services, Las Vegas

Emeritus Professor of Pediatrics and Family Medicine, USC


[email protected]

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Domestic Violence is a

major medical, social,

financial, legal & ethical


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Tell Tell Tell

  • Epidemiology

  • Medical-what do you look for?

  • Social

    • Whom to call

      a. Social workers

      b. Safe Nest (hotline #646-4981)

    • Restraining Order

    • Escape plans

    • Reporting

  • HPN’s response to DV

  • Legal & Ethical Considerations

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With Just One Question

You can save a life!

“Are you in a relationship in which you have been hurt or threatened?”

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3 Studies of medical students:

13-30% have experienced child physical or emotional abuse

13-23% have experienced partner abuse

7-10% have been sexually assaulted as an adult

Lifetime prevalence for any type of severe interpersonal violence ranged from 24-53%

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Domestic Violence - Definition

  • It is a pattern of assaultive and coercive behaviors

  • Including physical, sexual and psychological attacks as well as economic coercion

  • That adults or adolescents use against their intimate partners.

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Prevalence of DV

  • Nearly 25% of American women report being raped and/or physically assaulted by a current or former spouse, cohabitating partner or date.

  • Women are 7 to 14 times more likely than men to report suffering severe physical assaults from an intimate partner.

  • As many as 32,400 women each year experience intimate partner violence during their pregnancy.

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Domestic Homicide

  • On average, more than three women are murdered by their husbands or boyfriends in this country every day.

  • Pregnant and recently pregnant women are more likely to be victims of homicide than to die of any other cause.

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Health and Economic Impact of DV

  • The health-related costs of rape, physical assault, stalking and homicide committed by intimate partners exceed $5.8 billion each year.

  • Of that amount, $4.1 billion are for direct medical and mental health care services, and nearly $1.8 billion are for the indirect costs of lost productivity or wages.

  • Half of all female victims of intimate partner violence report an injury of some type, and 20% of them seek medical assistance.

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DV Rates in Nevada

  • Nevada ranks number five in the United States for domestic homicides, at a rate of 2.2 per 100,000 women murdered by men.

  • Each year, more than 40,000 Nevada women seek and receive DV services.

  • The Las Vegas Metropolitan Police Department handle more than 20,000 reports of DV each year.

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Physical Violence

  • Intentional use of force, such as:

    • slapping  scratching

    • pushing  choking

    • shaking  burning

    • biting  hitting

    • using a knife, gun, or other weapon

  • Coercing others to commit such acts

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Sexual Violence

  • Actual or threatened use of physical force to compel a person to engage in a sexual act against her/his will

  • Attempted or completed sex act with a person unable to

    • avoid participation

    • communicate unwillingness

    • understand the nature of the act

  • Abusive sexual contact

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Psychologic and Emotional Abuse

  • Humiliating, name-calling, using profanity

  • Embarrassing victim deliberately—especially in public

  • Controlling victim’s movement and activities

  • Isolating victim from friends or family

  • Controlling financial resources

  • Withholding information or resources

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Coercive Control and Intimidation

  • Acts perceived by recipient as violent or threatening

  • Recipient’s fear of attack or retaliation

  • Threats alternated with kindness

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Anyone can be a perpetrator or victim of domestic violence, regardless of their:

  • Race/ethnicity

  • Class

  • Education/occupation

  • Age

  • Physical ability

  • Sexual orientation

  • Personality traits

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Causes of Domestic Violence

Learned Behavior:

  • Through observation

  • Through experience and reinforcement

  • In culture

  • In family

  • In communities: schools, peer groups

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Causes of Domestic Violence

Domestic Violence is NOT caused by:

  • Illness

  • Genetics

  • Alcohol/drugs

  • Anger/stress

  • Out of control behavior

  • Behavior of the victim or problems in the relationship

    There is NO excuse for domestic violence.

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Window of Opportunity

  • 96% of pregnant women receive prenatal care

  • Average of 1213 prenatal care visits

  • Opportunity to developtrust in health care provider

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Window of Opportunity

  • During pregnancy, victims of DV may be motivated by the:

    • Desire to be a good parent

    • Desire to prevent child abuse

    • Opportunity to think about the future

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Violence and Pregnancy

Violence during pregnancy may be more common than:

  • Gestational diabetes

  • Neural tube defects

  • Preeclampsia

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Possible Demographic and Psychosocial Factors

  • Young maternal age/adolescence

  • Unintended pregnancy

  • Delayed prenatal care

  • Smoking

  • Alcohol and drug use

  • Lack of social supports


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Possible Effects on Fetus

  • Direct effects

    • spontaneous abortion

    • fetal injury or death from maternal trauma

  • Indirect effects

    • maternal stress

    • maternal smoking

    • alcohol or drug use or abuse

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Possible Risks for Children

  • Violence may involve other household members.

  • Witnessing violence is a risk factor for abusive relationships as an adult.

  • Child abuse is associated with depression, substance abuse, poor school performance, high-risk sexual activity.

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Routinely Screen Every Patient

  • At first prenatal visit

  • At least once per trimester

  • At postpartum checkup

  • At routine ob-gyn visits and preconception visits

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Components of Screening

  • Review medical history.

  • Observe and record presentations and behaviors of patient and partner.

  • Ask direct questions and listen actively.

  • Document patient’s response.

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Review Medical History

  • Warning signs of DV may include:

    • Previous medical visits for injuries

    • History of abuse or assault

    • Repeated visits

    • Chronic pelvic pain, headaches, vaginitis, irritable bowel syndrome

    • History of depression, substance use, suicide attempts, anxiety

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Observe Woman’s Behavior

  • Flat affect

  • Fright, depression, anxiety

  • Post-traumatic stress disorder (PTSD) symptoms:

    • dissociation

    • psychic numbing

    • startle responses

  • Overcompliance

  • Excessive distrust

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    Observe Partner’s Behavior

    • Being overly solicitous

    • Answering questions for the patient

    • Being hostile or demanding

    • Never leaving the patient’s side

    • Monitoring the woman’s responses to questions

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    Ask Directly

    • Ask questions in private.

      • apart from male partner

      • apart from family or friends

    • Explain issues of confidentiality.

    • Be aware of mandatory reporting laws in your state and inform the woman of them.

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    Open the Door

    • Find your own way of phrasing questions.

    • Be prepared to hear your patient’s answer.

    • Face-to-face talk is more effective than written patient questionnaires.

    • Caring, empathetic questions may open the door for later disclosure.

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    Why Don’t Physicians Screen for DV

    • Fear of asking the question

      • Analogous to “opening Pandora’s box”

    • Denial that abuse is a problem

    • Denial of problems that are too close for comfort

    • Frustration over ineffective treatment and intervention options

    • Lack of training

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    Elements of an ImprovedResponse to DV

    • Routine screening for DV victims

    • Assessment of DV

    • Documentation of the DV and any visible injuries

    • Intervention with patients who are DV victims

    • Intervention with perpetrators

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    Screening Tips

    • Present screening as routine after establishing a relationship

    • Use translator or certified interpreter if necessary (remember: never use family members as translators)

    • RADAR card (specifically developed to assist health care providers in screening for DV)

      • Copies available from NNADV (775) 828-1115

        or (800) 230-1955 or


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    Use Your “RADAR”

    • Routinely screen every patient

    • Ask directly, kindly, nonjudgmentally

    • Document your findings

    • Assess the patient’s safety

    • Review options and provide referrals

      (Massachusetts Medical Society, 1992)

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    Abuse Assessment Screen

    3. Within the last year has anyone made you do something sexual that you didn’t want to do? (If yes, who?)

    4. Are you afraid of your partner or anyone else?

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    Additional Questions

    Emotional Abuse:

    “Does your partner (former partner) ever humiliate you? Shame you? Put you down in public? Keep you from seeing friends or from doing things you want to do?”

    Child Abuse:

    “Within the last year, has someone made you worry about the safety of your child? Your pet? (If yes, who?)”

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    Reasons for a “No” Response

    • Embarrassment/shame

    • Fear of retaliation by partner

    • Lack of trust in others

    • Economic dependence

    • Desire to keep family together

    • Unaware of alternatives

    • Lack of support system

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    Responding to “No”

    • Always chart the woman’s response—even when she says “no.”

    • Your questions may help those experiencing abuse to move closer to disclosure.

    • Your questions indicate your willingness to discuss the violence.

    • Your questions will let the woman know you and other staff are always available as resources.

    • Women will choose when to disclose.

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    Responding to “Yes”

    Things you can say:

    • This is not your fault.

    • No one deserves to be treated this way.

    • I’m sorry you’ve been hurt.

    • Do you want to talk about it?

    • I am concerned about your safety (and that of your children).

    • Help is available to you.

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    Document Your Findings

    • In the patient’s chart

    • In the patient’s own words

    • With a body map

    • With photographs (get consent)

    • With specific details

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    Lethality Indicators

    • Frequency and severity of violence is escalating

    • Frequent drug/alcohol intoxication

    • Threats to kill spouse/threats to harm children

    • Weapons possession

    • Level of obsession and perceived ownership of partner

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    Lethality Indicators (cont.)

    • Separation

    • Indifference to public consequences

    • Previous criminal history

    • Expressed fantasies about homicide or suicide

    • Stalking behaviors

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    Lethality Assessment

    • Are you in immediate danger?

    • Are you afraid of your partner at times?

    • Has your partner’s behavior been getting worse or scarier?

    • Does your partner blame you and say it’s your fault or you caused it?

    • Does your partner own guns or weapons?

    • Has your partner ever been arrested for DV?

    • Does your partner accuse you of cheating?

    • Have alcohol/drugs been involved during any of the arguments?

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    Lethality Assessment (cont.)

    • Does your partner call you names?

    • Have you told your partner that you want to leave him?

    • Has your partner ever followed you? (to work, school, grocery store, friends house, etc.)

    • Has your partner ever threatened you?

    • Has your partner driven recklessly with you in the car?

    • Has your partner been physically abusive with you?

      • Grabbing, restraining, pushing

      • Hitting, slapping, punching

      • Kicking, strangling, threats with a gun or weapon

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    Safety Planning

    • Leaving your house safely

    • Extra copy of house and car keys

    • Pack a bag to give to a trusted someone

    • Develop a code word

    • Copy important documents

    • Use your instincts and judgement

    • Dial 911 in emergency

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    Sources of Help

    • Know your local programs

      (e.g., where victims of domestic violence can go for help):

      • Nevada Statewide Domestic Violence Hotline (800) 500-1556

      • Safe Nest 646-4981

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    Sources of Help

    • National resources for victims of domestic violence:

      • National Domestic Violence Hotline

        (800) 799-SAFE (7233) / (800) 787-3224 (TTY) (

      • National Coalition Against Domestic Violence

        (303) 839-1852 (

      • Face to Face (offers free plastic surgery to victims of domestic violence) (800) 842-4546

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    Sources of Help

    • National Resources for Health Care Professionals

      • National Health Resources Center on Domestic Violence

        (415) 252-8900 (

      • American Medical Association

      • American Bar Association

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    Other Resources

    Nevada Network Against Domestic Violence (NNADV) distributes, at no cost to agencies within Nevada, resources for health care providers including information packets and cards to aid in screening, as well as brochures for patients, posters (for waiting areas, bathrooms, etc.), and more.

    To obtain these materials, call NNADV at (775) 828-1115 in Reno, Sparks, and Carson City or 800-230-1955 for statewide providers.

    Some of these resources are also available for download on NNADV’s website at

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    Reporting Obligations &Confidentiality Concerns

    • You may be legally required to report the abuse to authorities, depending on which state you are practicing in.

    • Regardless of your legal obligation, you also have an ethical obligation to the patient.

    • The AMA recommends that spouses, partners, or other third parties, including the police, should not be notified of an abuse diagnosis without the consent of the patient.

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    Mandatory Reporting

    • Almost all states mandate reporting when patients have injuries caused by a knife, gun, or other deadly weapons.

    • Others require reporting when injuries are due to crime, acts of violence, or other non-accidental acts.

    • Five states require reporting when domestic violence or abuse is suspected (CA, CO, KY, NH, RI).11

    • Family Violence Prevention Fund. (2002). State Codes on Intimate Partner Violence Victimization Reporting Requirements for Health Care Providers. The National Health Resource Center on Domestic Violence. Retrieved April 6, 2007, from

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    AMA Council on Ethics and Judicial Affairs

    • Physicians should not report to state authorities without the consent of the patient. Physicians, however, do have an ethical obligation to intervene.

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    • The Health Care Provider’s Goal is to:

      • Increase victim safety

      • Support victims in protecting themselves and their children

    • Remember the importance of:

      • Communication that domestic violence is inexcusable

      • Your patient is not alone

      • You care about your patient’s health and safety

      • Networking with community resources

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    Collaborative Response





    Health Professionals



    Policy Makers

    Judges & Legal Professionals