Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Domestic Violence
Domestic Violence - Key Features
1. In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (e.g., periodic annual exam, visits for anxiety/depression, ER visits).
2. In a patient in a suspected or confirmed situation of domestic violence:
a. Assess the level of risk and the safety of children (i.e., the need for youth protection).
b. Advise about the escalating nature of domestic violence.
3. In a situation of suspected or confirmed domestic violence, develop, in collaboration with the patient, an appropriate emergency plan to ensure the safety of the patient and other household members.
4. In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (e.g., helplessness, guilt), and its impact on children.
DEFINITION: intentional controlling or violent behaviour by a person the victim is/was intimately related. Controlling behaviour may include physical, emotional, sexual, or economic. Includes elder abuse.
Primary pattern of domestic violence is episodic, unpredictable outbursts. They tend to start as emotional and verbal, but eventually lead to physical. Victims live in constant state of fear. Violence frequently escalates.
15% prevalence, only pick-up < 5% so we need to screen in high risk groups.
- - Female trauma victims
- - Women with chronic headaches and abdominal pain
- - Pregnant women (especially with injuries)
- - Women with STIs
- - Women with a history of childhood abuse
- - Elders with signs of neglect or with injuries
- - Elders with increasing chronic pain, depression and the number of health conditions
- - Don’t forget about men (15% of abuse victims)
Pregnancy: classic medical teaching is that domestic violence starts (or escalates) in pregnancy and in the post-partum period (so watch for it on the exam).
- - 20% prevalence (higher than pre-eclampsia and gestational diabetes)
- - Higher in unintended pregnancy
- - Higher in those who seek late prenatal care
- - Higher incidence of low birth weight, pyelonephritis, preterm labour
When to suspect domestic violence:
- - Inconsistent explanation of injuries
- - Delay in seeking treatment for injuries
- - Increased somatic complaints such as headaches, abdo pain, fatigue, chronic pelvic pain
- - Strange injures: breasts, abdomen, genitals, head and neck, forearms
- - Many bruises at different stages of healing
Consequences of abuse:
- - Social isolation, economic dependence
- - Anxiety, depression, somatization
How to screen: 1 question method
“At any time, has your partner hit, kicked or otherwise hurt or threatened you?”
S.A.F.E. questionnaire method (outline for the entire encounter)
- - “Do you feel safe in your relationship?”
- - “Have you ever felt threatened or afraid?”
- - “Is your family aware you have been hurt? Could you go to the for support?”
- - “Do you have a safe place to go in an emergency?”
Treatment:
- 1) Assess level of violence
- - Has the violence increased in severity or frequency over the past year?
- - Has your partner threatened to kill you, your children, or himself?
- - Are there weapons in the house?
- - Does your partner know you are planning to leave?
- 2) If previous murder threats, or guns in the house (or you just feel it is VERY unsafe):
- - Suggest immediate referral to mental health, social work, women’s shelter
- 2b) Lower risk domestic violence:
- - Most victims not ready to leave abuser because of fear of retaliation, economic dependence, hopes that violence might stop
- - Involve counseling, social workers: improves a victim’s self worth, assess the degree of danger, help to develop safety plan
- 3) Safety plan:
- - Safe place to go, how to get there, having money, clothes, keys, medications, important documents, taking the children
- - Define where they will go: relative, emergency department, calling domestic violence hotline (give number)
- - See patient frequently in follow-up
- - Re-visit idea of counseling/support if there is resistance
- 4) Documentation:
- - State the diagnosis of domestic violence, use specifics in notes
- - Injuries should be described and photographed
- - Mandatory reporting for abuse of minors (<18 years old) and those in imminent danger
- - Domestic violence not reportable without women’s permission