Domestic Violence: Screening And Intervention
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
More than 25% of women living in the United States report a history of intimate partner violence (IPV), the occurrence of which is associated with adverse health consequences as well as increased health care use. Prior research has shown that obstetricians and gynecologists may selectively screen patients for IPV based on certain patient characteristics. We believe the use of standardized documentation form would result in higher screening rates. Certain patient characteristics such as younger age or history of mental illness might prompt health care providers to screen selectively for violence, and certain health care provider characteristics such as gender would be associated with increased violence screening. Domestic violence continues to be a prevalent problem in the United States. Because of the number of individuals affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims. Accordingly, it is essential that healthcare professionals are taught to recognize and accurately interpret behaviors associated with domestic violence. It is incumbent upon the healthcare professional to establish and implement protocols for early identification of domestic violence victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, healthcare professionals in all settings must take the initiative to properly assess all women for abuse during each visit and, for those women who are or may be victims, to offer education, counseling, and referral information. Victims of domestic violence suffer emotional, psychological and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, nurses are often the first healthcare providers that victims encounter and are in a critical position to identify domestic violence victims in a variety of clinical practice settings where victims receive care.
The purpose of this document is to enable healthcare professionals in all practice settings to define domestic violence and identify those who are affected by domestic violence. This chapter describes how a victim can be accurately diagnosed and identifies resources available for domestic violence victims. Accordingly, healthcare professionals must educate themselves to enhance awareness of the presence of battered women in each particular practice or clinical setting. Because women of all age groups, races, and socioeconomic backgrounds are at risk for intimate partner violence, Women's Health and Education Center (WHEC) recommends routine screening of adult women for partner abuse.
Defining Domestic Violence:
Domestic violence, which is sometimes also referred to as "spousal abuse," "battering," or "intimate partner violence," refers to the victimization of an individual with whom the abuser has or has had an intimate or romantic relationship. Researchers in the field of domestic violence have not agreed on a uniform definition of what constitutes violence or an abusive relationship. The prevailing perception about domestic violence is that assaults are "physical, frequent, and life-threatening". The Centers for Disease Control and Prevention (CDC), in their publication "Costs of Intimate Partner Violence Against Women in the United States," define intimate partner violence (IPV) as, "violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. It occurs among both heterosexual and same-sex couples and is often a repeated offense" (1)(2). Domestic violence can consist of any of many behaviors or combination of behaviors, falling under physical, psychological, verbal, sexual, and financial/economic abuse. Whatever the definition, it is important for healthcare professionals to understand that domestic violence, in the form of emotional and psychological abuse and physical violence, is prevalent in our society. Unfortunately, domestic violence and abuse has become a fact of life for many Americans (2). This chapter will use the terms "domestic violence" and "IPV" interchangeably.
Behaviors and Domestic Violence:
Sexual Abuse: Rape, forms of sexual assault such as forced masturbation, oral coitus, sexual humiliation, perpetrator refuses to use contraceptives, coerced abortions.
Financial/Economic Abuse: Withholding of money, refuse to allow victim to open bank account, all property is in the perpetrator's name, victim is not allowed to work.
Physical Abuse: Kicking, punching, biting, slapping, strangling, choking, abandoning in unsafe places, kicking, burning with cigarettes, throwing acid, beating with fists, throwing objects, refusing to help when sick, stabbing, shooting.
Psychological/Verbal Abuse: Intimidation, verbal abuse, humiliation, put-downs, ridiculing, control of victim's movement, stalking, threats, threatening to hurt victim's family and children, social isolation, ignoring needs or complaints.
Over the past two decades, domestic violence has emerged as one of the most serious public health problems facing women in this country. Nearly 5.3 million incidents of IPV occur each year among U.S. women 18 years of age and older, and 3.2 million occur among men. Although many of these incidents are relatively minor and consist of pushing, grabbing, shoving, slapping, and hitting, 2 million injuries and 1,300 deaths from IPV occur nationwide every year (2). One of the difficulties in addressing the problem is that the abuse of women cannot be predicted by any demographic feature related to age, ethnicity, race, religious denomination, education, socioeconomic status or class. Women who are abused often suffer severe physical injuries and will likely seek care at a hospital or clinic. The health and economic consequences of domestic violence are significant. Statistics vary from report to report and due to the lack of recent studies on the national cost of domestic violence, the U.S. Congress funded the CDC to conduct a study to determine the cost of domestic violence on the healthcare system (2). The CDC report, which relied on data from the National Violence Against Women Survey conducted in 1995, estimated the costs of IPV by measuring how many female victims were non-fatally injured; how many women used medical and mental health care services; and how many women lost time from paid work and household chores in 1995. The estimated total cost of IPV against women in 1995 was over 5.8 billion. It must be noted that the costs of any one victimization may continue for years, therefore the above number most likely underestimates the actual cost of IPV (2). The rate of domestic violence against women has declined from 1993 to 2001, dropping from 1.1 million violent crimes against women in 1993 to 588,490 in 2001. The rate of overall family violence also fell by more than one-half in this time period (3)(4). Studies reveal that several factors may be contributing to the reduction in violence, including a decline in the marriage rate and a decrease of domesticity, better access to federally-funded domestic violence shelters, improvements in women's economic status, and demographic trends, such as the aging of the population (3)(4).
Screening for Domestic Violence and Abuse:
A tremendous barrier to diagnosing and treating domestic violence is a lack of knowledge and training. Healthcare workers recognize and accurately interpret behaviors associated with domestic violence and abuse. However, healthcare professionals are hesitant to inquire about abuse (5). A Gallup poll initiated by the American College of Obstetricians and Gynecologists (ACOG) indicates that only 6% of its membership of over 46,000 physicians routinely asks their patients about abuse (14). Approximately 10% of primary care physicians routinely screen for intimate partner abuse during new patient visits, and 9% routinely screen during periodic checkups (6). A study by the CDC found that less than one-half of the physicians studied had recent training on intimate partner abuse, and only 17% routinely screened patients during their first prenatal visit (14). In addition, a 1999 survey of managed care organizations found that less than one-third of HMOs in the United States have policies, procedures, and guidelines for screening domestic violence victims (7).
It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims. These guidelines should review appropriate interview techniques, and should also include the utilization of screening tools, such as intake questionnaires. The following is a review (see below) of certain signs and symptoms that may indicate the presence of abuse. Although battered women do not display typical signs and symptoms when they present to healthcare providers, there are certain cues that we can attribute to abuse. The obvious cues are the physical ones. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen. These are often distinguishable from accidental injuries, which are more likely to involve the periphery of the body. In one hospital-based study, domestic violence victims were 13 times more likely to sustain injury to breast, chest, or abdomen than accident victims (8). Abused women are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen in a woman, particularly in combination with evidence of old injury, physical abuse should be suspected.
In addition to physical signs and symptoms, battered women also exhibit psychological cues that resemble an agitated depression. As a result of prolonged stress, these women often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches, and digestive problems. Often they will complain of fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical (9). In many women, this constellation of symptoms has been labeled "Battered Women's Syndrome." Unfortunately, physicians typically respond to these women by diagnosing the patient to be neurotic or irrational (10). Healthcare professionals must cast aside these misperceptions of abused victims and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms. For every victim of abuse, there is also a perpetrator. Like their victims, perpetrators of domestic violence come from all socioeconomic backgrounds, races, religions, and walks of life (10). Accordingly, healthcare professionals must likewise be aware that seemingly supportive family members may, in fact, be abusers. Perpetrators and their victims in lower socioeconomic groups are more likely to turn up in hospital emergency rooms and local community clinics. Conversely, people of higher socioeconomic status are more able to turn to the private clinician for assistance.
Abuser characteristics have been studied far less frequently than victim characteristics. Some studies suggest a correlation between the occurrence of abuse and the consumption of alcohol. A man who abuses alcohol is also likely to abuse his mate, although the abuser may not necessarily be inebriated at the time the abuse is inflicted (11). Screening questionnaires should include questions that explore social drinking habits of both the victim and his or her mate. Other studies demonstrate that abusive mates are generally possessive and jealous. Another characteristic related to the batterer's dependency and jealousy is extreme suspiciousness. This characteristic may be so extreme as to border on paranoia (12). In addition, battered women have frequently reported that abusers are extremely controlling of the everyday activities of the family. This domination is generally all encompassing. One battered woman gave the following examples of her controlling husband, "he insisted that no one (including guests and their toddler children) wear shoes in the house, that the furniture be in the same indentations in the carpet, that the vacuum marks in the carpet be parallel, and that any sand that spilled from the children's sandbox during their play be removed from the surrounding grass" (12). In addition, healthcare professionals should be on the lookout for men who have low self-esteem, are frequently angry and depressed and are "very dependent on their partners as the sole source of love, support, intimacy, and problem solving". Both batterers and battered partners are noted for being extremely dependent upon each other. It appears that each member of the couple believes that he or she will perish without the other, and that the survival of each can only occur if the conjugal relationship remains intact. This belief ostensibly arises from their negative self images, which cause the couple to doubt both their ability to live independently and to find other partners who will accept them. Both tend to deny or minimize the scope and severity of the violence in their relationship. This denial makes the conjugal relationship appear more viable and desirable to both.
The particular relationship dynamics reviewed above are not easily detected under the best of circumstances. They may be especially difficult to uncover in circumstances where the parties are suspicious and frightened, as might be expected when a victim presents to an emergency room. The key to detection, however, is to establish a proper screening tool that can be utilized in the particular setting, and to maintain a keen awareness for the cues described above. Screening should be carried out at the entry points of contact between victims and medical care (e.g., primary care, emergency services, obstetric and gynecologic services, psychiatric services, and pediatric care) (13). The key to an initial screening is to obtain an adequate history. Establishing that a patient's injuries are secondary to battering is the first task. Clearly there will be times when a victim is injured so severely that treatment of these injuries becomes the first priority (15). After such treatment is rendered, however, it is important that healthcare professionals not ignore the reasons that brought the victim to the emergency room.
Of female trauma patients, 16% to 30% will report that they have been battered when asked directly about how the injury occurred (14). Obviously, however, some women will not admit to a history of battering. Any trauma or burn that seems incompatible with a history of the injury is suggestive of battering and indicative of the need for gentle probing regarding how things are at home. Information must also be collected to facilitate a comprehensive assessment of the victim's needs, resources, and priorities in order to develop immediate and long-range plans designed to minimize and eliminate future abusive episodes. A structured interview that can be used to obtain the necessary information for treatment planning is outlined below (16):
Structured Interview for Treatment Planning and Standardized Documentation:
After the history is obtained and initial treatment is started, it is imperative that healthcare professionals document all findings and recommendations in the victim's medical record. The medical record can be an invaluable document in establishing the credibility of the battered woman's story when she seeks legal aid (17).
Culturally Sensitive Assessment:
During the assessment process, a practitioner must be open and sensitive to the client's/patient's worldview, cultural belief systems and how he/she views the illness (20). This may reduce the tendency to over-pathologize or minimize health concerns of ethnic minority patients. Pachter proposed a dynamic model that involves several tiers and transactions (17). The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. The professional must be willing to acknowledge that he/she does not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups he/she comes in contact with. Reading and becoming familiar with medical anthropology is a good first step.
The second component emphasizes the need for specifically tailored assessment (20). Pachter advocates the notion that there is tremendous diversity within groups. For example, one cannot automatically assume that a Cuban immigrant adheres to traditional beliefs. Often, there are many variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the client/patient and the professional (18). The negotiation consists of a dialogue that involves a genuine respect of beliefs. It is important to remember that these beliefs may affect symptoms or appropriate interventions in the case of domestic violence.
Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. These components are meant to provide an introduction to help practitioners recognize the range of dimensions, including physical, biological, social, and cultural factors that affect immigrants and ethnic minorities. By incorporating cultural sensitivity into the assessment of individuals with a history of being victims or perpetrators of domestic violence, it may be possible to intervene and offer treatment more effectively.
Interventions for Domestic Violence
All practitioners who deal with domestic violence should periodically review safety planning with victims. Homicide is of high risk for victims, thus safety planning is crucial. When advocating a safety plan, it is important to:
Although safety planning may be advocated, it does not necessarily mean victims will employ safety planning guidelines.
There are five states with mandatory reporting laws to address domestic violence (16). For example, California requires healthcare providers to report injuries resulting from firearm or assaultive violence, including injuries from intimate violence. However, there is a great amount of controversy among helping professionals about mandatory reporting laws. Those in favor of mandatory reporting for adult domestic violence maintain these laws improve the safety of the victim and will assist law enforcement to effectively intervene. Simultaneously, those who oppose the mandatory reporting laws also consider mandatory reporting creates a safety issue and may violate victims' rights of autonomy.
Domestic violence victims can obtain protective orders through a civil proceeding. Until the enactment of Pennsylvania's Protection of Abuse Act in 1976, only two states had protective order legislation. Protective orders now prohibit the abuser from communicating with the victim and/or other family members in a threatening manner. The order also prohibits the abuser from going to the home or place of employment of the victim or family members. Violations of protective orders can result in fines, imprisonment or a combination of both.
Support groups for crime victims can be beneficial. Often, victims think they are the only ones who have experienced the abuse. Victims may express shame and guilt, assume responsibility for the incident, and question what they did wrong to provoke the abuse. Support groups offer the opportunity for victims to meet others who are going through similar experiences and have similar feelings and concerns. Because batterers often utilize psychological tactics, such as isolation to keep the victim away from interacting and talking with family, friends, and other individuals, the victim's primary source of information, companionship, and support comes from the batterer (19). Support groups diminish victims' sense of isolation and provide education.
Shelters provide a haven for domestic violence victims and their children. They provide temporary emergency housing and a range of services to help victims "get back on their feet." Services vary but may include job training, support groups, skills development groups, and counseling.
Resources and Referrals:
After identifying victims and their abusers, healthcare professionals should immediately implement a plan of action that includes providing a referral to a local domestic violence shelter to assist the victim and the victim's family. The acute situation should be referred immediately to local law enforcement officials. Other resources in an acute situation include crisis hotlines and rape relief centers. Once a victim is introduced into the system, counseling and follow-up is generally available by individual counselors who specialize in the care of battered women and their spouses and children. These may include social workers, psychologists, psychiatrists, other mental health workers, and community mental health services. The goals are to make the resources accessible and safe, and to enhance support for women who are unsure of their options (19).
Integrated Intervention to Reduce Intimate Partner Violence during Pregnancy:
There is no agreement regarding what set of signs, symptoms, or illnesses are considered the standard International Classification of Diseases, 9th Revision, Clinical Modification constellation for a diagnosis of intimate partner violence (21). Exposure to intimate partner violence is associated with a range of negative psycho-behavioral risks and health, physical disability, psychological distress, mental illness, and heightened substance use including alcohol and illicit drugs. Sexual and physical intimate partner violence has been linked significantly with depression, suicidal tendency, and posttraumatic stress disorder. Abuse during pregnancy has been shown to be associated with significantly higher rates of depression and suicide attempts as well as use of tobacco, alcohol, and illicit drugs. Intimate partner violence among minority populations, already at higher risk for poor pregnancy outcomes, may be a significant contributor to the health disparities observed in reproductive outcomes among African-American women. There is evidence that even brief intervention for pregnant African-American women reduce intimate partner violence victimization during pregnancy and improved pregnancy outcome (22). We recommend healthcare providers and third party payers to go beyond screening for psychosocial and behavioral risks to providing services during prenatal care to address such risks. The potential cost savings associated with reduction of births within higher risk category may be substantial. Screening for intimate partner violence as well as other psychosocial and behavioral risks and incorporating similar interventions in prenatal care is strongly recommended.
Historically, identified barriers to screening for IPV have included inadequate health care provider training, time constraints, healthcare providers' feelings of powerlessness, and lack of resources for identified victims. Standardized documentation tools have offered as a means to overcome such barriers and increase detection of IPV. In a recent study (23) data suggest, embedding inquires about partner abuse in the medical record may improve IPV screening rates. The results of this study also imply that one of the strongest influences on a health care provider's screening behavior may be the tendency to perform comprehensive preventive health screening. Knowledge about IPV is a competency expected of all medical students completing their obstetric and gynecologic clerkships, and many residency programs (e.g., obstetrics and gynecology, internal medicine, family medicine, and psychiatry) are required to include training on partner abuse to receive accreditation by the Accreditation Council for Graduate Medical Education (24). Such efforts are undoubtedly aimed to advance the health care response to partner violence. Although many models of IPV curricula exist, our suggestions are that encouraging health care providers to address overall preventive health care may also improve screening for this important public health issue. Demarginalizing IPV training and incorporating it as part of preventive health education may positively influence physicians' internal framework for routine inquiry about partner abuse. Studies within the past two decades have shown that homicide is a leading cause of pregnancy-associated death, defined by the American College of Obstetricians and Gynecologists / Centers for Disease Control and Prevention Maternal Mortality Study Group as a death from any cause occurring during pregnancy or within 1 year of pregnancy delivery or pregnancy termination regardless of the site or duration of pregnancy (25). The majority of pregnancy-associated homicides are committed by current or former intimate partners, most commonly during the first 3 months of pregnancy. Efforts to protect women from partners optimally should begin before conception or very early in pregnancy
To lump all behavior in chaotic relationships under the category of violence can be misleading to the public. The common image of violence for the majority of people is physical harm, attack, and observable injury. Differentiating types of behavior in intimate relationships is necessary to define consequences related to outcome studies to form an evidence base for treatment. The formulation of accurate definitions is instrumental in designing methodology to compare differences. More accurate and sensitive instruments to measure the depth of the social problem are needed to reveal differences in gender initiated violence, show the accuracy of occurrences of mutual battering, and quantify post-effects of intimate violence on men, women, and children. The long-term focus on domestic violence is responsible for major reforms on multiple levels within various systemic functions related to criminal prosecution, legislative views and actions, and healthcare protocols. Given the pervasive nature of abuse in relationships, histories of partners including mental, psychological, and behavioral documentation is vital when determining the causes and effects of abuse. How historical and cultural belief systems are connected to domestic violence is essential in determining an accurate measurement of intimate violence.