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Domestic Violence
Rhonda A. Faulkner, PhD
Luis T. Garcia, MD
image BASICS
DESCRIPTION
  • Domestic violence (DV) is the behavior in any relationship that is used to gain or maintain power and control over an intimate partner.
  • May include physical, sexual, and/or emotional abuse; economic or psychological actions; or threats of actions that influence another person
  • Although women are at greater risk of experiencing DV, it occurs among patients of any race, age, sexual orientation, religion, gender, socioeconomic background, and education level.
  • Synonym(s): intimate partner violence (IPV); spousal abuse; family violence
EPIDEMIOLOGY
Incidence
8% in the United States; women are more likely to report partner violence than men.
Prevalence
  • DV occurs in 1 of 4 American families. Nearly 5.3 million incidents of DV occur each year among U.S. women aged ≥18 and 3.2 million incidents among men.
  • DV results in nearly 2 million injuries and up to 4,000 deaths annually in the United States.
  • 30% of women and 22% of men have experienced physical, sexual, or psychological IPV during their lifetime in the United States.
  • 14-35% of adult female patients in emergency departments report experiencing DV within the past year.
  • Costs of DV are estimated to exceed $5.8 billion annually, of which $4.1 billion are for direct medical and mental health services.
  • DV survivors have a 1.6- to 2.3-fold increase in health care use compared with the nonabused population.
Geriatric Considerations
  • 4-6% of elderly are abused, with ˜2 million elderly persons experiencing abuse and/or neglect each year. In 90% of cases, the perpetrator is a family member.
  • Elder abuse is any form of mistreatment that results in harm or loss to an older person; may include physical, sexual, emotional, financial abuse, and/or neglect.
Pediatric Considerations
  • >3 million children aged 3 to 17 years are at risk of witnessing acts of DV.
  • ˜1 million abused children are identified in the United States each year.
  • Children living in violent homes are at increased risk of physical, sexual, and/or emotional abuse; anxiety and depression; decreased self-esteem; emotional, behavioral, social, and/or physical disturbances; and lifelong poor health.
Pregnancy Considerations
DV occurs during 7-20% of pregnancies. Women with unintended pregnancy are at 3 times greater risk of DV. 25% of abused women report exacerbation of abuse during pregnancy. There is a positive correlation between DV and postpartum depression.
RISK FACTORS
  • Patient/victim risk factors
    • Substance abuse
    • Poverty/financial stressors/unemployment
    • Recent loss of social support
    • Family disruption and life cycle changes
    • History of abusive relationships or witness to abuse as child
    • Mental or physical disability in family
    • Social isolation
    • Pregnancy
    • Attempting to leave the relationship
  • Abuser risk factors
    • Substance abuse (e.g., PCP, cocaine, amphetamines, alcohol)
    • Young age
    • Unemployment
    • Low academic achievement
    • Witnessing or experiencing violence as child
    • Depression
    • Personality disorders
    • Threatening to self or others
    • Violence to children or violence outside the home
  • Relational risk factors
    • Marital conflict
    • Marital instability
    • Economic stress
    • Traditional gender role norms
    • Poor family functioning
    • Obsessive, controlling relationship
Geriatric Considerations
Factors associated with the abuse of older adults include increasing age, nonwhite race, low-income status, functional impairment, cognitive disability, substance use, poor emotional state, low self-esteem, cohabitation, and lack of social support.
Pediatric Considerations
Factors associated with child abuse or neglect include low-income status, low maternal education, nonwhite race, large family size, young maternal age, single-parent household, parental psychiatric disturbances, and presence of a stepfather.
image DIAGNOSIS
  • DV is often underdiagnosed, with only 10-12% of physicians conducting routine screening.
  • Although prevalence of DV in primary care settings is 7-50%, <15% are screened.
  • Pregnancy increases risk.
  • Barriers to screening: time constraints, discomfort with the subject, fear of offending the patient, and lack of perceived skills and resources to manage DV
  • Abused patients may refuse to disclose abuse for many reasons, which includes the following:
    • Not feeling emotionally ready to admit the reality of the situation
    • Shame and self-blame
    • Feelings of failure if abuse is admitted
    • Fear of rejection by the physician
    • Fear of retribution from abuser
    • Belief that abuse will not happen again
    • Belief that no alternatives or available resources exist
PHYSICAL EXAM
  • Clinical presentation/psychological signs and symptoms
    • Delay in seeking treatment
    • Inconsistent explanation of injuries
    • Reluctance to undress
    • Signs of battered woman syndrome and/or posttraumatic stress disorder (PTSD) (flat affect/avoidance of eye contact, evasiveness, heightened startle response, sleep disturbance, traumatic flashbacks)
    • Depression, anxiety, chronic fatigue, substance abuse
    • Suspicious partner accompaniment at appointment; overly solicitous partner and/or refusal to leave exam room
  • Physical signs and symptoms
    • Tympanic membrane rupture
    • Rectal or genital injury (centrally located injuries with bathing-suit pattern of distribution— concealable by clothing)
    • P.309

    • Head and neck injuries (site of 50% of abusive injuries)
    • Facial scrapes, loose or broken tooth, bruises, cuts, or fractures to face or body
    • Knife wounds, cigarette burns, bite marks, welts with outline of weapon (such as belt buckle)
    • Broken bones
    • Defensive posture injuries
    • Injuries inconsistent with the explanation given
    • Injuries in various stages of healing
DIAGNOSTIC TESTS & INTERPRETATION
  • The U.S. Preventive Services Task Force (USPSTF) in 2013 issued guidelines recommending that clinicians screen all women of childbearing age (14 to 46 years old) for DV and provide or refer women to intervention services when appropriate (1)[B].
  • Other recommendations
    • American College of Physicians (ACP) recommends routine screening for DV for all women in primary care settings at periodic intervals and when women present for emergency care with traumatic injuries.
    • The American Medical Association (AMA) recommends that all patients be routinely screened for DV with inquiry into history of family violence.
    • The World Health Organization (WHO) recommends against DV screening or routine inquiry about exposure to DV; however, they recommend asking about exposure to DV when assessing conditions that may be caused or complicated by abuse (2)[B].
    • U.S. Surgeon General and American Association of Family Practitioners recommend that physicians consider the possibility of DV as a cause of illness and injury.
    • The Partner Violence Screen is a 3-question screening tool with a high specificity.
    • There is no evidence of harm in screening for DV.
Pediatric Considerations
American Academy of Pediatrics (AAP) and AMA recommend that physicians remain alert for signs and symptoms of child physical and sexual abuse in the routine exam.
Pregnancy Considerations
American Congress of Obstetrics and Gynecologists (ACOG) and AMA guidelines on DV recommend that physicians routinely assess all pregnant women for DV. ACOG recommends periodic screening throughout obstetric care (at the first prenatal visit, at least once per trimester, at the postpartum checkup).
Initial Tests (lab, imaging)
Liver function tests (LFTs), amylase, lipase if abdominal trauma is suspected
image TREATMENT
  • Treatment includes initial diagnosis; ongoing medical care; emotional support, counseling, and patient education regarding the DV cycle; referrals to community and supportive services as needed.
  • On diagnosis, use the SOS-DoC intervention:
  • S: Offer Support and assess Safety
    • Support: “You are not to blame. I am sorry this is happening to you. There is no excuse for DV.”
    • Remind patient of your commitment to confidential communication.
    • Safety: Listen and respond to safety issues for the patient: “Do you feel safe going home?”; “Are your children safe?”
  • O: Discuss Options, including safety planning and follow-up.
    • Provide information about DV and help when needed. Make referrals to local resources:
      • “Do you need or want to access a safety shelter or DV service agency?”
      • “Do you want police intervention and if so, would you like me to call the police so they can make a report with you?”
      • Offer numbers to local resources and National DV Hotline: 1-800-799-SAFE (open 24/7; can provide physicians in every state with information on local resources).
  • S: Validate patient's Strengths:
    • “It took courage for you to talk with me today. You have shown great strength in very difficult circumstances.”
  • Do: Document observations, assessment, and plans:
    • Use patient's own words regarding injury and abuse.
    • Legibly document injuries: Use a body map.
    • If possible, take instant photographs of patient's injuries if given patient consent.
    • Make patient safety plan. Prepare patient to get away in an emergency:
      • Encourage patient to keep the following items in a safe place: keys (house and car); important papers (Social Security card, birth certificates, photo ID/driver's license, passport, green card); cash, food stamps, credit cards; medication for self and children; children's immunization records; important phone numbers/addresses (friends, family, local shelters); personal care items (e.g., extra glasses)
      • Encourage patient to arrange a signal with someone to let that person know when she or he needs help.
  • C: Offer Continuity:
    • Offer a follow-up appointment and assess barriers to access.
GENERAL MEASURES
  • Reporting child and elder abuse to protective services is mandatory in most states. Several states have laws requiring mandatory reporting of IPV.
  • Contact the local DV program to find out about laws and community resources before they are needed.
  • Display resource materials (National DV Hotline: 1-800-799-SAFE) in the office, all exam rooms, and restrooms.
ADDITIONAL THERAPIES
  • National DV Hotline: 1-800-799-SAFE (7233)
  • Post in all exam rooms posters in both English and Spanish; available at http://www.thehotline.org/resources/download-materials/
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Schedule prompt follow-up appointment.
  • Inquire about what has happened since last visit.
  • Review medical records and ask about past episodes to convey concern for the patient and a willingness to address this health issue openly.
  • DV often requires multiple interventions over time before it is resolved.
PATIENT EDUCATION
  • Counsel patients about nonviolent ways to resolve conflict.
  • Educate patients about the cycle of violence.
  • Counsel parents about developmentally appropriate ways to discipline their children.
  • Educate parents about the negative consequences of arguments on children and each other.
  • National Coalition Against Domestic Violence: http://www.ncadv.org/
  • CDC: http://www.cdc.gov/violenceprevention/
PROGNOSIS
Most DV perpetrators do not voluntarily seek therapy unless pressured by partners or upon legal mandate. Current evidence is insufficient on effectiveness of therapy for perpetrators.
REFERENCES
1. U.S. Preventive Services Task Force. Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Rockville, MD: Agency for Healthcare Research and Quality; 2013.
2. Feder G, Wathen CN, MacMillan HL. An evidence-based response to intimate partner violence: WHO guidelines. JAMA. 2013;310(5):479-480.
Additional Reading
&NA;
  • Cronholm PF, Fogarty CT, Ambuel B, et al. Intimate partner violence. Am Fam Physician. 2011;83(10): 1165-1172.
  • Hegarty K, O'Doherty L, Taft A, et al. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet. 2013;382(9888):249-258.
  • Wu Q, Chen HL, Xu XJ. Violence as a risk factor for postpartum depression in mothers: a meta-analysis. Arch Womens Ment Health. 2012;15(2):107-114.
Codes
&NA;
ICD10
  • T74.91XA Unspecified adult maltreatment, confirmed, initial encounter
  • T74.11XA Adult physical abuse, confirmed, initial encounter
  • T74.31XA Adult psychological abuse, confirmed, initial encounter
Clinical Pearls
&NA;
  • Display resource materials in the office (e.g., posting abuse awareness posters/National DV Hotline, 1-800-799-SAFE, in both English and Spanish, in all exam rooms and restrooms).
  • Given the high prevalence of DV and the lack of harm and potential benefits of screening, routine screening is recommended.
  • For those who screened positive, offer resources, reassure confidentiality, and provide close follow-up.