Domestic Sexual Violence: A Health Safety Issue

1. Domestic & Sexual Violence:A Health & Safety Issue -One Health Region�s Strategy to Reduce Risk Presenter: Linda McCracken RN Sexual Assault Nurse Examiner AHS-Domestic Violence Program Coordinator the medical side of DV and SA, what is seen, what the response is, where the gaps are the medical side of DV and SA, what is seen, what the response is, where the gaps are

2. The Essential Message Overview of associated adverse health conditions, & potentially lethal outcomes related to Domestic & Sexual Violence/Abuse that often go undetected when no one raises �the question� What denotes a medical emergency Opportunities do exist for primary prevention

3. What�s in it for you? After this presentation, you�ll have a better understanding of: Injury recognition & chronic illness in the context of abuse What to ask & or look for from a medical standpoint How collaboration can enhance response to this public health issue

4. Relevance *AB shelters find that the health effects of their clients: Are varied Often severe Have gone on for many years without resolution ACWS-Position Statement Responding to the Health Needs of Women & Children involved in Domestic Violence Plus: the Behavioural Health Effects: Self-abuse; low self-esteem, distorted body image Sleep disturbances Anxiety (hyperventilation), panic (palpitations) Hyper vigilance; dissociation Depression PTSD Suicidal ideation or attemptsPlus: the Behavioural Health Effects: Self-abuse; low self-esteem, distorted body image Sleep disturbances Anxiety (hyperventilation), panic (palpitations) Hyper vigilance; dissociation Depression PTSD Suicidal ideation or attempts

5. Issues from a medical perspective What are the most common health challenges experienced by clients you see? What concerns you the most? What about their children? Are there subcategories of need or population that you see i.e. specific health needs of pregnant women and unborn children, aboriginal women, seniors Such open discussion between disciplines is what makes the difference for the victimAre there subcategories of need or population that you see i.e. specific health needs of pregnant women and unborn children, aboriginal women, seniors Such open discussion between disciplines is what makes the difference for the victim

6. Long Term Effects of Stress Cardiovascular system Gastrointestinal system Cardiovascular System Long term effects of stress on the cardiovascular system can result in increased heart rate, damaged blood vessels, high blood pressure, and increase in serum cholesterol levels. All of which lead to an increased risk of cardiovascular disease. Stress causes the heart to beat more forcefully and to pump more blood. The blood pressure can rise and if the stress is chronic, hypertension can result. Stress causes blood vessels to constrict, reducing the amount of blood that can be circulated around the body tissues and organs. During the acute stage of stress - the "fight or flight" - blood thickens, coagulation increases and blood platelets build up along the fatty deposits in the arteries. Stress causes the release of cholesterol into the blood stream. If there is too much cholesterol it builds up on the walls of coronary arteries and restricts blood flow into the heart. If the arteries become blocked, the person has a heart attack. Gastrointestinal System Stress virtually shuts down the gastrointestinal system (GI). During the acute stage of stress, blood is diverted from the GI tract to muscles, where it is needed much more. Stomach peristalsis is reduced and sphincters are closed. The body reduces secretion of acid juices and digestion slows down. Stress affects the intestines as well. They undergo vasoconstriction (blood vessels in the intestines constrict) and peristalsis and tone of the intestines is decreased. When the stress is prolonged and the body does not return to homeostasis, this creates a variety of GI disturbances. Some people develop chronic constipation, problems with stomach acid, or ulcers. Cardiovascular System Long term effects of stress on the cardiovascular system can result in increased heart rate, damaged blood vessels, high blood pressure, and increase in serum cholesterol levels. All of which lead to an increased risk of cardiovascular disease. Stress causes the heart to beat more forcefully and to pump more blood. The blood pressure can rise and if the stress is chronic, hypertension can result. Stress causes blood vessels to constrict, reducing the amount of blood that can be circulated around the body tissues and organs. During the acute stage of stress - the "fight or flight" - blood thickens, coagulation increases and blood platelets build up along the fatty deposits in the arteries. Stress causes the release of cholesterol into the blood stream. If there is too much cholesterol it builds up on the walls of coronary arteries and restricts blood flow into the heart. If the arteries become blocked, the person has a heart attack. Gastrointestinal System Stress virtually shuts down the gastrointestinal system (GI). During the acute stage of stress, blood is diverted from the GI tract to muscles, where it is needed much more. Stomach peristalsis is reduced and sphincters are closed. The body reduces secretion of acid juices and digestion slows down. Stress affects the intestines as well. They undergo vasoconstriction (blood vessels in the intestines constrict) and peristalsis and tone of the intestines is decreased. When the stress is prolonged and the body does not return to homeostasis, this creates a variety of GI disturbances. Some people develop chronic constipation, problems with stomach acid, or ulcers.

7. The brain and the immune system are in constant communication, in a delicate balance that can be thrown off by chronic stress. The hypothalamus plays a key role in the stress response, releasing corticotropin-releasing hormone (CRH). CRH stimulates the pituitary gland beneath the hypothalamus to release another hormone, adrenocorticotropin hormone (ACTH), into the bloodstream. ACTH then causes the adrenal glands � located above the kidneys � to release the stress hormone cortisol. In addition to alerting the body to meet stressful situations, cortisol helps regulate the immune system. The hypothalamus uses both cortisol and signal molecules from the immune system called cytokines to monitor the situation in the body and ensure that there isn�t an immune system overreaction that harms healthy cells and tissues. Problems anywhere in this complicated communications system, whether caused either by extreme stress or by faulty genetics, can lead to disease Immune System The greatest long term effects of stress are seen with the immune system. Weather you are stressed or not, when you come across an organism, will largely determine weather you will develop an illness or not. How does stress affect the immune system? Your body naturally produces immune cells, called T lymphocytes, that fight bacteria, viral infections, fungi, and cancer cells. Elevated levels of adrenal hormones during stress suppresses the body's production of T lymphocytes, weakening your whole immune system. Not only stress worsens existing infections, you also become more susceptible to immune system related health problems. As you can see, the effects of stress on the body are very serious and can lead to many illnesses. An autoimmune disorder is a condition that occurs when the immune system mistakenly attacks and destroys healthy body tissue. There are more than 80 different types of autoimmune disorders. in patients with an autoimmune disorder, the immune system can't tell the difference between healthy body tissue and antigens. The result is an immune response that destroys normal body tissues. This response is a hypersensitivity reaction similar to the response in allergies. What causes the immune system to no longer tell the difference between healthy body tissues and antigens is unknown. One theory is that some microorganisms (such as bacteria) and drugs may trigger some of these changes, especially in people who have genes that make them more likely to get autoimmune disorders. The brain and the immune system are in constant communication, in a delicate balance that can be thrown off by chronic stress. The hypothalamus plays a key role in the stress response, releasing corticotropin-releasing hormone (CRH). CRH stimulates the pituitary gland beneath the hypothalamus to release another hormone, adrenocorticotropin hormone (ACTH), into the bloodstream. ACTH then causes the adrenal glands � located above the kidneys � to release the stress hormone cortisol. In addition to alerting the body to meet stressful situations, cortisol helps regulate the immune system. The hypothalamus uses both cortisol and signal molecules from the immune system called cytokines to monitor the situation in the body and ensure that there isn�t an immune system overreaction that harms healthy cells and tissues. Problems anywhere in this complicated communications system, whether caused either by extreme stress or by faulty genetics, can lead to disease Immune System The greatest long term effects of stress are seen with the immune system. Weather you are stressed or not, when you come across an organism, will largely determine weather you will develop an illness or not. How does stress affect the immune system? Your body naturally produces immune cells, called T lymphocytes, that fight bacteria, viral infections, fungi, and cancer cells. Elevated levels of adrenal hormones during stress suppresses the body's production of T lymphocytes, weakening your whole immune system. Not only stress worsens existing infections, you also become more susceptible to immune system related health problems. As you can see, the effects of stress on the body are very serious and can lead to many illnesses. An autoimmune disorder is a condition that occurs when the immune system mistakenly attacks and destroys healthy body tissue. There are more than 80 different types of autoimmune disorders. in patients with an autoimmune disorder, the immune system can't tell the difference between healthy body tissue and antigens. The result is an immune response that destroys normal body tissues. This response is a hypersensitivity reaction similar to the response in allergies. What causes the immune system to no longer tell the difference between healthy body tissues and antigens is unknown. One theory is that some microorganisms (such as bacteria) and drugs may trigger some of these changes, especially in people who have genes that make them more likely to get autoimmune disorders.

8. Consistent high level of Cortisol Is Toxic To Brain Development The stress response system in the brain is fully formed at birth but the cerebral cortex is not Babies can experience stress but are highly dependent on caregiver to manage stress Chronic stress can impair the developing brain Impacts areas that: Regulate stress (amygdala) Store memory (hippocampus) Are involved in planning and executing complex functions (prefrontal cortex) Are involved in language (broca�s area, wernicke�s area) The younger someone is the fewer defensive capabilities they have �the interplay between developmental trauma and brain development�the same event which occurs at age 15 may be much more traumatic at an early age. The intensity and frequency of the trauma determines how the brain will internalize the traumatic event Unresponsive, intrusive, frustrating or frightening caregiver behavior is an intolerable stress for the baby Impacts areas that: Regulate stress (amygdala) Store memory (hippocampus) Are involved in planning and executing complex functions (prefrontal cortex) Are involved in language (broca�s area, wernicke�s area) The younger someone is the fewer defensive capabilities they have �the interplay between developmental trauma and brain development�the same event which occurs at age 15 may be much more traumatic at an early age. The intensity and frequency of the trauma determines how the brain will internalize the traumatic event Unresponsive, intrusive, frustrating or frightening caregiver behavior is an intolerable stress for the baby

9. Genetic Risk Factors Emerging Earlier �and harder to control Like high blood pressure� We need to ask: *may be vital in creating an effective treatment plan. Like high blood pressure� We need to ask: *may be vital in creating an effective treatment plan.

10. The Mind/Body: Inseparable! Hx of sexual abuse: 2.8 times more likely to have a functional bowel disorder, chronic abdominal pain, Irritable Bowel Syndrome Talley, N.J., Helgeson S, insmeister AR. Are sexual & physical abuse linked to functional gastrointestinal disorders Gastroenterology 1992; 102:A52 IPV is common in patients seen in medical practices and can be a barrier to cancer screening. The Dx & Rx may lead to inability to work�issues of power esp. if the male partner is not working..increased risk of relationship strife�DV ������������������������������������������������������������ IPV is common in patients seen in medical practices and can be a barrier to cancer screening. The Dx & Rx may lead to inability to work�issues of power esp. if the male partner is not working..increased risk of relationship strife�DV ������������������������������������������������������������

11.  Chronic or recurrent headaches Temporomandibular disorder Musculoskeletal complaints Chronic back pains is pain that persists for long periods of time (usually >3 months). Failure to treat acute pain promptly and appropriately at the time of injury contributes to the development of chronic pain ...Chronic pain may be related to a number of different medical conditions including (but not limited to) diabetes, arthritis, migraine, fibromyalgia, cancer, shingles, sciatica, and previous trauma or injury. Chronic pain may worsen in response to environmental and/or psychological factors. WHES: Pain More than half of the women had experienced back pain, headaches, or general aches and pains in the past month, while 43.2% reported swollen, painful joints. Of the 309 women, as evaluated by the Chronic Pain Grade scale, 21% had severely limiting pain, losing an average of 90 days from usual activities (work, school, housework) in the past six months, while 14% had moderately limiting pain, and lost an average of 24 days. Only 5.5% of women were pain free. One third of the WHES experienced high disability pain, a rate that is significantly higher than the 18% of Canadian women reporting chronic pain in the CCHS. is pain that persists for long periods of time (usually >3 months). Failure to treat acute pain promptly and appropriately at the time of injury contributes to the development of chronic pain ...Chronic pain may be related to a number of different medical conditions including (but not limited to) diabetes, arthritis, migraine, fibromyalgia, cancer, shingles, sciatica, and previous trauma or injury. Chronic pain may worsen in response to environmental and/or psychological factors. WHES: Pain More than half of the women had experienced back pain, headaches, or general aches and pains in the past month, while 43.2% reported swollen, painful joints. Of the 309 women, as evaluated by the Chronic Pain Grade scale, 21% had severely limiting pain, losing an average of 90 days from usual activities (work, school, housework) in the past six months, while 14% had moderately limiting pain, and lost an average of 24 days. Only 5.5% of women were pain free. One third of the WHES experienced high disability pain, a rate that is significantly higher than the 18% of Canadian women reporting chronic pain in the CCHS.

12. Many injuries of physical abuse are focused on the head & face But some to avoid detection- strike to the back of the head Additionally, the mouth is often a target because this is where communication originates. Injuries from violence perpetrated in an attempt to cut off communication and keep the individual quiet often involve the teeth and oral structures Accidental bumps to the head usually occur on the forehead or upper occipital area- not on the sides or directly on top of the head The middle third of the face has been found to be the most at risk (Le et al, 2001) Women who were physically abused were more likely to sustain injuries to the head, face, neck, thorax, breasts, and abdomen when compared to women who were injured in other ways (Grisso et al, 1999) In a comparison study of maxillofacial fractures sustained from IPV and in motor vehicle accidents, mandibular fractures were more prevalent in IPV while mid-facial injuries were more common following MVAs (Lee et al, 2007) 33 percent of orbital fractures are due to IPV (Chrisler & Ferguson, 2006) The most frequent types of injuries among women reporting physical IPV in the past 12 months according to data from the Georgia Women�s Health Survey (Buehler et al, 1998): Swellings, cuts, scratches, bruises, strains, or sprains (92%) Black eyes (25%) Broken bones (16%) Knife wounds (12%) Broken teeth (8%) Burns or scaldings (6%) Bites (5%) Broken eardrums (4%) Ruptured tympanic membrane Injury Patterns Among Female Trauma Patients: Recognizing Intentional Injury Crandall ML, Nathens AB, Rivara FPJ Trauma. 2004;57:42-45 BACKGROUND: Intimate partner violence and interpersonal violence are a major source of morbidity and mortality among women. Our objective was to identify patterns of injury consistent with intentional injury in female trauma patients admitted to the hospital.METHODS: Subjects were women aged 16 to 65 years discharged from acute care hospitals in a single year with a primary diagnosis of injury. Data were collected from 14 states across the United States. Analysis was performed using multivariate logistic regression.RESULTS: Women who suffered blunt intentional trauma exhibited very different injury patterns than those hospitalized for motor vehicle collisions or falls. The risk of facial injury with blunt intentional trauma was much higher than for other mechanisms (odds ratio, 4.9; 95% confidence interval, 4.20-5.74). Head injury was also more common in these women (odds ratio, 1.4, 95% confidence interval, 1.15-1.70).CONCLUSION: Physicians can potentially improve identification of cases of intimate partner violence and interpersonal violence by understanding common injuries associated with interpersonal violence. But some to avoid detection- strike to the back of the head Additionally, the mouth is often a target because this is where communication originates. Injuries from violence perpetrated in an attempt to cut off communication and keep the individual quiet often involve the teeth and oral structures Accidental bumps to the head usually occur on the forehead or upper occipital area- not on the sides or directly on top of the head The middle third of the face has been found to be the most at risk (Le et al, 2001) Women who were physically abused were more likely to sustain injuries to the head, face, neck, thorax, breasts, and abdomen when compared to women who were injured in other ways (Grisso et al, 1999) In a comparison study of maxillofacial fractures sustained from IPV and in motor vehicle accidents, mandibular fractures were more prevalent in IPV while mid-facial injuries were more common following MVAs (Lee et al, 2007) 33 percent of orbital fractures are due to IPV (Chrisler & Ferguson, 2006) The most frequent types of injuries among women reporting physical IPV in the past 12 months according to data from the Georgia Women�s Health Survey (Buehler et al, 1998): Swellings, cuts, scratches, bruises, strains, or sprains (92%) Black eyes (25%) Broken bones (16%) Knife wounds (12%) Broken teeth (8%) Burns or scaldings (6%) Bites (5%) Broken eardrums (4%) Ruptured tympanic membrane Injury Patterns Among Female Trauma Patients: Recognizing Intentional Injury Crandall ML, Nathens AB, Rivara FPJ Trauma. 2004;57:42-45 BACKGROUND: Intimate partner violence and interpersonal violence are a major source of morbidity and mortality among women. Our objective was to identify patterns of injury consistent with intentional injury in female trauma patients admitted to the hospital.METHODS: Subjects were women aged 16 to 65 years discharged from acute care hospitals in a single year with a primary diagnosis of injury. Data were collected from 14 states across the United States. Analysis was performed using multivariate logistic regression.RESULTS: Women who suffered blunt intentional trauma exhibited very different injury patterns than those hospitalized for motor vehicle collisions or falls. The risk of facial injury with blunt intentional trauma was much higher than for other mechanisms (odds ratio, 4.9; 95% confidence interval, 4.20-5.74). Head injury was also more common in these women (odds ratio, 1.4, 95% confidence interval, 1.15-1.70).CONCLUSION: Physicians can potentially improve identification of cases of intimate partner violence and interpersonal violence by understanding common injuries associated with interpersonal violence.

13. Mild Traumatic Brain Injury*L.O.C. not required One of the most undiagnosed, prevalent, and serious consequences of IPV �Subtle Concussions�/ Soft Neuro Signs �chronic headaches� Second Impact Syndrome Risk Among women who visit the ER after IPV: 67% have symptoms of a head injury 30% have suffered loss of consciousness at least once Chrisler & Ferguson, 2006 Mild TBI should be considered in the differential diagnosis of IPV victims who present with chronic or vague complaints such as fatigue, dizziness, depression, or difficulties with concentration or judgment Women more likely to die from an assault-related head injury than men: ??why: theory evoking mech of injury, hormone-related gender differences in recovery of brain functions and gender differences in head-neck musculature and stabilization have been put forth Investigators examining IPV victims residing in & out of shelters found 74%-77% had symptoms consistent with TBI Rates of severe head injury were higher in sheltered women A hx of TBI is often undocumented in medical records of IPV victims�LOC may not be reported because of Posttraumatic Amnesia or a cognitive impairment associated with the brain injury Nondisclosure is consistent with the tendency to hide or minimize patterns of abuse when seeking emergency treatment *one study (Wadman & Muelleman) found that the most frequently documented injury prior to the victim�s IPV homicide was TBI Education of IPV victims after TBI should include discussion of the dangers of recurrent HI or Secondary Impact Syndrome -may occur days to weeks after the first injury�before symptoms associated with the first have fully resolved -following the first TBI- risk for a second is 3X greater�risk for a 3rd is 8X greater The diagnosis of Borderline Personality, PTSD or depression is frequently given to women with mild TBI or PCS (post concussion symptoms) Remember: estimated 22%-35% of women presenting to the ED for medical care are there because of IPV yet only 1% -6% are diagnosed with IPV related injuries or complaints �loss of consciousness,� is not required for an MTBI diagnosisAmong women who visit the ER after IPV: 67% have symptoms of a head injury 30% have suffered loss of consciousness at least once Chrisler & Ferguson, 2006 Mild TBI should be considered in the differential diagnosis of IPV victims who present with chronic or vague complaints such as fatigue, dizziness, depression, or difficulties with concentration or judgment Women more likely to die from an assault-related head injury than men: ??why: theory evoking mech of injury, hormone-related gender differences in recovery of brain functions and gender differences in head-neck musculature and stabilization have been put forth Investigators examining IPV victims residing in & out of shelters found 74%-77% had symptoms consistent with TBI Rates of severe head injury were higher in sheltered women A hx of TBI is often undocumented in medical records of IPV victims�LOC may not be reported because of Posttraumatic Amnesia or a cognitive impairment associated with the brain injury Nondisclosure is consistent with the tendency to hide or minimize patterns of abuse when seeking emergency treatment *one study (Wadman & Muelleman) found that the most frequently documented injury prior to the victim�s IPV homicide was TBI Education of IPV victims after TBI should include discussion of the dangers of recurrent HI or Secondary Impact Syndrome -may occur days to weeks after the first injury�before symptoms associated with the first have fully resolved -following the first TBI- risk for a second is 3X greater�risk for a 3rd is 8X greater The diagnosis of Borderline Personality, PTSD or depression is frequently given to women with mild TBI or PCS (post concussion symptoms) Remember: estimated 22%-35% of women presenting to the ED for medical care are there because of IPV yet only 1% -6% are diagnosed with IPV related injuries or complaints �loss of consciousness,� is not required for an MTBI diagnosis

14. Variations of �amnesia� or �seizures.� Despite an expectation that full recovery should occur within 12 weeks of the MTBI (Belanger et al., 2005) a sizable minority continue to experience persistent symptoms (Wood, 2004) and have difficulty with returning to work, school or play. (Bazarian, Blyth, Mookerjee, He, & McDermott, 2010). An accurate diagnosis, based on a systematic approach with appropriate follow-up, education and symptom management therapies, could most likely improve detection and limit prolonged symptoms. Our findings indicate that not all indicators for MTBI are frequently assessed and documented by our respondents. Specifically, the CDC criterion for MTBI requires that there be an acceleration/deceleration injury or blunt trauma to the head and one or more of the following any period of observed or self-reported transient confusion, disorientation, or impaired consciousness; (2) any period of observed or self-reported dysfunction of memory around the time of injury lasting 24 hr or less, (3) any period of observed or self-reported LOC lasting 30 min or less; or (4) acute seizure following the injury to the head. An accurate diagnosis, based on a systematic approach with appropriate follow-up, education and symptom management therapies, could most likely improve detection and limit prolonged symptoms. Our findings indicate that not all indicators for MTBI are frequently assessed and documented by our respondents. Specifically, the CDC criterion for MTBI requires that there be an acceleration/deceleration injury or blunt trauma to the head and one or more of the following any period of observed or self-reported transient confusion, disorientation, or impaired consciousness; (2) any period of observed or self-reported dysfunction of memory around the time of injury lasting 24 hr or less, (3) any period of observed or self-reported LOC lasting 30 min or less; or (4) acute seizure following the injury to the head.

15. Intimate Partner Sexual Violence common expression of domestic violence (esp. during reproductive yrs) likely to be raped may times physical violence also possible Reproductive Coercion One of the most widespread forms of sexual violence globally (WHO, 2002) Other definitions: . force or physical contact of a sexual nature intentionally applied to a person �fondling, touching or kissing without his or her consent��an act of aggression, power and violence�Burgess, Ann W. �Violence Through a Forensic Lens� Any unwanted intercourse or penetration (vaginal, oral, anal) obtained by force, threat of force, or when the partner is unable to consent Bergen, 1996; Pagelow, 1992; Russell, 1990 �No negotiation of condom use��Jacqueline Campbell Stats Canada 2005: 16% of women who had experienced DV identified SA as the most severe form Locally: over the last year only 10% were seen by SART�where the assault occurred within the last 72 hours (of the 290 patients seen by SART- 15 were sexually assaulted by their current partner & 14 by their former partner) Of interest: of the 290 SA�s�168 cases (57%) involved an assault from someone they knew�?dating relationship�( not defined)�= 67% of client�s seen Data from CONNECT Family & Sexual Abuse Network-CSART 2009 Women who are raped by their husbands are likely to be raped may times ( often 20 or more) before the are able to end the violence -more likely to experience oral & anal intercourse -physical violence also possible�75% of survivors of attempted domestic homicide reported being raped by their partner -Pregnancy appears to be a factor that places women at higher risk for both physical & sexual abuse -specifically sexual abuse�-GENTLY ASK IF THERE HAVE BEEN TIMES HER PARTNER HAS MADE HER DO SEXUAL THINGS THAT SHE DIDN�T WANT TO�don�t press her �denial either means that nothing has happened or she�s not comfortable talking about it right now�the seed has been planted HINTING: ��he gets angry when I don�t want to have sex��ask if there have been times she has been forced or coerced into having sex Naming can be painful..may believe she can�t be �raped� by her partner A Validating response could be��it�s not silly to call rape by its name�rape by a partner is as much a rape as that by a stranger��it�s a horrible betrayal and I�m sorry that it happened to you�but I�m glad you feel able to tell me� One of the most widespread forms of sexual violence globally (WHO, 2002) Other definitions: . force or physical contact of a sexual nature intentionally applied to a person �fondling, touching or kissing without his or her consent��an act of aggression, power and violence�Burgess, Ann W. �Violence Through a Forensic Lens� Any unwanted intercourse or penetration (vaginal, oral, anal) obtained by force, threat of force, or when the partner is unable to consent Bergen, 1996; Pagelow, 1992; Russell, 1990 �No negotiation of condom use��Jacqueline Campbell Stats Canada 2005: 16% of women who had experienced DV identified SA as the most severe form Locally: over the last year only 10% were seen by SART�where the assault occurred within the last 72 hours (of the 290 patients seen by SART- 15 were sexually assaulted by their current partner & 14 by their former partner) Of interest: of the 290 SA�s�168 cases (57%) involved an assault from someone they knew�?dating relationship�( not defined)�= 67% of client�s seen Data from CONNECT Family & Sexual Abuse Network-CSART 2009 Women who are raped by their husbands are likely to be raped may times ( often 20 or more) before the are able to end the violence -more likely to experience oral & anal intercourse -physical violence also possible�75% of survivors of attempted domestic homicide reported being raped by their partner -Pregnancy appears to be a factor that places women at higher risk for both physical & sexual abuse -specifically sexual abuse�-GENTLY ASK IF THERE HAVE BEEN TIMES HER PARTNER HAS MADE HER DO SEXUAL THINGS THAT SHE DIDN�T WANT TO�don�t press her �denial either means that nothing has happened or she�s not comfortable talking about it right now�the seed has been planted HINTING: ��he gets angry when I don�t want to have sex��ask if there have been times she has been forced or coerced into having sex Naming can be painful..may believe she can�t be �raped� by her partner A Validating response could be��it�s not silly to call rape by its name�rape by a partner is as much a rape as that by a stranger��it�s a horrible betrayal and I�m sorry that it happened to you�but I�m glad you feel able to tell me�

16. �In IPSV Genital injuries: vaginal stretching, lacerations (tears) Miscarriages, still births *Anal injuries Pelvic pain Frequent vaginal and urinary tract infections, painful intercourse Recurrent STI�s HIV/AIDS Hepatitis B Substance Abuse Also, sexually transmitted infections are significantly more common among women abused by male partners, and such infections are known to compromise health during pregnancy and fetal development.� Chronic illnesses can cause tension, stress and a range of other problems within a relationship but they do not cause domestic violence Abusive partners (or ex-partners) choose the weapons of abuse and control they use, and their or their partners� health can be used as one of these weapons In some abusive relationships the domestic violence began at or around the time that the illness was diagnosed. If the abusive partner does not have a chronic illness (eg is HIV negative) they may: Threaten to, or actually, disclose their partner�s health status to friends,family or colleagues. Withhold medication, treatments or access to other medical services. Threaten to cut off support or to leave. Verbally abuse their partner by saying they are �diseased, sick, unclean� or other inappropriate comments about their illness, or otherwise undermine their partner�s confidence. Hepatitis B virus (HBV):It is significantly more transmissible than HIV via blood-borne exposure, and some fluids that do not normally transmit HIV, such as saliva and sweat, contain infectious HBV but at much lower levels than blood. . The incubation period for HBV is 30 to 180 days (mean, 90 days), and acute infections may vary from asymptomatic or mild to severe jaundice and, rarely, fulminant hepatic failure. Fever, right upper-quadrant abdominal pain, headache, and malaise are common, as are elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Up to 20% of patients may develop arthralgias or arthritis. Symptoms resolve in 4 to 6 weeks, and 90% to 95% of non-HIV-infected patients develop HBsAb and are considered HBV-immune.2 However, the rate of HBsAb development in HIV-infected individuals is lower.9 Alcohol consumption accelerates liver fibrosis and decreases response to treatment Best Practice: it is essential that women being treated for substance abuse are screened for DV. Subst. abuse and battered women are a dangerous combination often unrecognized and under treated. Also, sexually transmitted infections are significantly more common among women abused by male partners, and such infections are known to compromise health during pregnancy and fetal development.� Chronic illnesses can cause tension, stress and a range of other problems within a relationship but they do not cause domestic violence Abusive partners (or ex-partners) choose the weapons of abuse and control they use, and their or their partners� health can be used as one of these weapons In some abusive relationships the domestic violence began at or around the time that the illness was diagnosed. If the abusive partner does not have a chronic illness (eg is HIV negative) they may: Threaten to, or actually, disclose their partner�s health status to friends,family or colleagues. Withhold medication, treatments or access to other medical services. Threaten to cut off support or to leave. Verbally abuse their partner by saying they are �diseased, sick, unclean� or other inappropriate comments about their illness, or otherwise undermine their partner�s confidence. Hepatitis B virus (HBV):It is significantly more transmissible than HIV via blood-borne exposure, and some fluids that do not normally transmit HIV, such as saliva and sweat, contain infectious HBV but at much lower levels than blood. . The incubation period for HBV is 30 to 180 days (mean, 90 days), and acute infections may vary from asymptomatic or mild to severe jaundice and, rarely, fulminant hepatic failure. Fever, right upper-quadrant abdominal pain, headache, and malaise are common, as are elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Up to 20% of patients may develop arthralgias or arthritis. Symptoms resolve in 4 to 6 weeks, and 90% to 95% of non-HIV-infected patients develop HBsAb and are considered HBV-immune.2 However, the rate of HBsAb development in HIV-infected individuals is lower.9 Alcohol consumption accelerates liver fibrosis and decreases response to treatment Best Practice: it is essential that women being treated for substance abuse are screened for DV. Subst. abuse and battered women are a dangerous combination often unrecognized and under treated.

17. What denotes medical urgency in the context of DV Airway Breathing Circulation �Disability� �Level of Consciousness Suicide Ideation Airway: Strangulation Breathing: aspiration; crush injury; rib fractures�risk of pneumonia Circulation: uncontrolled bleeding- vaginal bleeding Palpitations are usually not serious. However, it depends on whether or not the sensations represent an abnormal heart rhythm ( arrhythmia). The following conditions make you more likely to have an abnormal heart rhythm: Known heart disease at the time the palpitations begin Significant risk factors for heart disease An abnormal heart valve An electrolyte abnormality in your blood -- for example, a low potassium level Call 911 if: The client loses consciousness. -has shortness of breath, chest pain, unusual sweating, dizziness, or lightheadedness. Seek medical attention right away if: frequent extra heartbeats (more than 6 per minute or coming in groups of 3 or more). risk factors for heart disease, such as high cholesterol, diabetes, or high blood pressure. new or different heart palpitations. pulse is more than 100 beats per minute (without exercise, anxiety, or fever). Disability: from asphyxia, closed head injury, substance toxicityAirway: Strangulation Breathing: aspiration; crush injury; rib fractures�risk of pneumonia Circulation: uncontrolled bleeding- vaginal bleeding Palpitations are usually not serious. However, it depends on whether or not the sensations represent an abnormal heart rhythm ( arrhythmia). The following conditions make you more likely to have an abnormal heart rhythm: Known heart disease at the time the palpitations begin Significant risk factors for heart disease An abnormal heart valve An electrolyte abnormality in your blood -- for example, a low potassium level Call 911 if: The client loses consciousness. -has shortness of breath, chest pain, unusual sweating, dizziness, or lightheadedness. Seek medical attention right away if: frequent extra heartbeats (more than 6 per minute or coming in groups of 3 or more). risk factors for heart disease, such as high cholesterol, diabetes, or high blood pressure. new or different heart palpitations. pulse is more than 100 beats per minute (without exercise, anxiety, or fever). Disability: from asphyxia, closed head injury, substance toxicity

18. Strangulation-a Case of Medical Urgency Strangulation: is a form of asphyxia (lack of oxygen) characterized by closure of the blood vessels and/or air passages of the neck as a result of external pressure on the neck. Three forms: hanging, ligature, and manual. On a regular basis victims had reported being choked, and in many of those cases, there was very little visible injury or evidence to corroborate the �choking� incident. Further, lack of physical evidence caused the criminal justice system to treat many �choking� cases as minor incidents. We need to start by finding the right words to describe the incident: change your vocabulary�use words such as strangle, attempted strangulation and/or strangulation when victims report being �choked� Strangle means to obstruct seriously or fatally the normal breathing of a person while choke means having the windpipe blocked entirely or partly by some foreign object like food. ATTEMPTED STRANGULATION= AGGRAVATED ASSAULT ACC. TO CDN. LAW Strangulation: is a form of asphyxia (lack of oxygen) characterized by closure of the blood vessels and/or air passages of the neck as a result of external pressure on the neck. Three forms: hanging, ligature, and manual. On a regular basis victims had reported being choked, and in many of those cases, there was very little visible injury or evidence to corroborate the �choking� incident. Further, lack of physical evidence caused the criminal justice system to treat many �choking� cases as minor incidents. We need to start by finding the right words to describe the incident: change your vocabulary�use words such as strangle, attempted strangulation and/or strangulation when victims report being �choked� Strangle means to obstruct seriously or fatally the normal breathing of a person while choke means having the windpipe blocked entirely or partly by some foreign object like food. ATTEMPTED STRANGULATION= AGGRAVATED ASSAULT ACC. TO CDN. LAW

19. �It hurts to swallow� **Victims may have no visible injuries but underlying injuries may kill the victim up to 36 or more hrs later due to de-compensation of the injured structures

20. Injuries identified in non-fatal strangulation cases were similar to injuries found in fatal IPV strangulation assaults (Hawley et al, 2001) Women who survived more than one strangulation attack reported increased frequency of symptoms but only 39% had sought medical care (Smith et al, 2001). These findings emphasize the need for service providers to ask clients about strangulation and injuries. While strangulation, especially manual strangulation, is a frequent mechanism of injury for women experiencing IPV, there is little consistency in the medical terms used to describe the injuries associated with strangulation. The use of more standardized medical forensic terminology will increase the accuracy of this information and generalizability of findings (Sheridan & Nash, 2007) Sheridan article: Acute Injury Patterns of Intimate Partner Violence Victims Trauma Violence Abuse 2007; 8; 281 Injuries identified in non-fatal strangulation cases were similar to injuries found in fatal IPV strangulation assaults (Hawley et al, 2001) Women who survived more than one strangulation attack reported increased frequency of symptoms but only 39% had sought medical care (Smith et al, 2001). These findings emphasize the need for service providers to ask clients about strangulation and injuries. While strangulation, especially manual strangulation, is a frequent mechanism of injury for women experiencing IPV, there is little consistency in the medical terms used to describe the injuries associated with strangulation. The use of more standardized medical forensic terminology will increase the accuracy of this information and generalizability of findings (Sheridan & Nash, 2007) Sheridan article: Acute Injury Patterns of Intimate Partner Violence Victims Trauma Violence Abuse 2007; 8; 281

21. Vessels: arteries & veins HYOID BONE slides from: Investigating and Prosecuting Strangulation Cases Bridget Healy Ryan Violence Against Women Policy Advisor Cook County State�s Attorney�s Office Point to Consider: Exact Anatomic Location of Applied Force Quantity of Applied Force Surface Area Of Applied Force Duration of Applied Force Carotid artery occlusion � 11 pounds of pressure for 10 seconds Most common cause of strangulation Results in unconsciousness 8 pounds of pressure cuts off oxygen flow to brain (less pressure than used to pull trigger of handgun) Oxygen flow cut off for only 8 seconds can cause critical injury lack of oxygen from strangulation can render a victim combative at a crime scene Jugular vein occlusion � 4.4 pounds of pressure for 10 seconds Obstruction of Trachea 33 pounds of pressure completely obstructs Can cause tracheal fracture, death One third of manual strangulation victims have fractured hyoids Because the two halves of the hyoid do not fuse until age 30, the hyoid may not break in younger victims who die as the result of strangulation Brain death results if strangulation persists for 4-5 minutes slides from: Investigating and Prosecuting Strangulation Cases Bridget Healy Ryan Violence Against Women Policy Advisor Cook County State�s Attorney�s Office Point to Consider: Exact Anatomic Location of Applied Force Quantity of Applied Force Surface Area Of Applied Force Duration of Applied Force Carotid artery occlusion � 11 pounds of pressure for 10 seconds Most common cause of strangulation Results in unconsciousness 8 pounds of pressure cuts off oxygen flow to brain (less pressure than used to pull trigger of handgun) Oxygen flow cut off for only 8 seconds can cause critical injury lack of oxygen from strangulation can render a victim combative at a crime scene Jugular vein occlusion � 4.4 pounds of pressure for 10 seconds Obstruction of Trachea 33 pounds of pressure completely obstructs Can cause tracheal fracture, death One third of manual strangulation victims have fractured hyoids Because the two halves of the hyoid do not fuse until age 30, the hyoid may not break in younger victims who die as the result of strangulation Brain death results if strangulation persists for 4-5 minutes

22. If they don�t tell��Ask� Hoarseness or complete loss of voice Swallowing changes- pain, difficulty, drooling Breathing changes/difficulty, coughing Headache, weakness Passed out ?, loss of memory since assault Nausea or vomiting Mental changes, restlessness, and combativeness Urinary or bowel incontinence during event Voice changes occur in up to 50% of victims Mental changes- due to temporary brain anoxia and/or severe stress reaction The details that you put in your chart can often provide the evidence for the forensic expert to testify that in their medical interpretation, the symptoms are consistent with strangulation, Voice changes occur in up to 50% of victims Mental changes- due to temporary brain anoxia and/or severe stress reaction The details that you put in your chart can often provide the evidence for the forensic expert to testify that in their medical interpretation, the symptoms are consistent with strangulation,

23. Strategies to Reduce Risk Opportunities do exist to incorporate questions about Domestic Violence into routine patient encounters to determine points of intervention with the goal of preventing lethal outcomes Assisting the victim to be better engaged in risk assessment and safety planning and hold perpetrators responsible In a recent studies done by the Domestic Violence Death Review Committee in Ontario (�DVDRC�), information was collected to establish the context of the deaths, including the history, circumstances, and conduct of the abusers/perpetrators, the history and circumstances of the victims and their families, as well as community and systemic responses. The DVDRC found that many domestic homicides may have been prevented if the criminal justice system, doctors, clergy, counsellors, lawyers, co-workers, families, friends, and neighbours had better engaged the victim in risk assessment and safety planning and taken appropriate action when they recognized risk in a perpetrator�s behaviour. In the 2004 DVDRC report, it was determined that eight of the nine incidents of domestic violence were predictable and preventable with the benefit of hindsight and the analysis of well-known risk factors. In all homicides reviewed, seven or more risk factors were clearly identifiable in the history of the family circumstances. Assisting the victim to be better engaged in risk assessment and safety planning and hold perpetrators responsible In a recent studies done by the Domestic Violence Death Review Committee in Ontario (�DVDRC�), information was collected to establish the context of the deaths, including the history, circumstances, and conduct of the abusers/perpetrators, the history and circumstances of the victims and their families, as well as community and systemic responses. The DVDRC found that many domestic homicides may have been prevented if the criminal justice system, doctors, clergy, counsellors, lawyers, co-workers, families, friends, and neighbours had better engaged the victim in risk assessment and safety planning and taken appropriate action when they recognized risk in a perpetrator�s behaviour. In the 2004 DVDRC report, it was determined that eight of the nine incidents of domestic violence were predictable and preventable with the benefit of hindsight and the analysis of well-known risk factors. In all homicides reviewed, seven or more risk factors were clearly identifiable in the history of the family circumstances.

24.  Nearly one in three women who presented to emergency departments (34.8%) or academic clinics (31.4%) reported severe physical abuse or forced sexual activity in their lifetime One in seven (13.7%) women in the emergency departments reported severe physical abuse in the past year Women using health care settings in urban areas reported the highest levels of all forms of lifetime and past-year abuse. Reported rates of abuse by women completing the survey in rural sites were consistently higher than those reported in suburban settings for all forms of abuse with the exception of lifetime emotional abuse, which was slightly lower (57.6% rural vs. 60.8% suburban). Rates of lifetime emotional and sexual abuse did not vary by geographic location. One study reported that rural women are more likely than urban women to leave abusive partners but are also more likely to return Because women are at higher risk of spousal assault when attempting to leave the relationship and because previous assault is highly predictive of future victimization this suggests rural women may be at higher risk for repeated assault Dr Billie Thurston CMA- 2006 Prevalence of Violence against women reported in a rural health region Women using health care settings in urban areas reported the highest levels of all forms of lifetime and past-year abuse. Reported rates of abuse by women completing the survey in rural sites were consistently higher than those reported in suburban settings for all forms of abuse with the exception of lifetime emotional abuse, which was slightly lower (57.6% rural vs. 60.8% suburban). Rates of lifetime emotional and sexual abuse did not vary by geographic location. One study reported that rural women are more likely than urban women to leave abusive partners but are also more likely to return Because women are at higher risk of spousal assault when attempting to leave the relationship and because previous assault is highly predictive of future victimization this suggests rural women may be at higher risk for repeated assault Dr Billie Thurston CMA- 2006 Prevalence of Violence against women reported in a rural health region

25. Top 10 Diagnostic Codes with �+ disclosure� of DV when asked Plus shared with each site- specific How many times an abuse code has been captured on a patient the specific perpetrator of the abuse & discharge disposition Then reflected back to what exactly their compliance rate means�how many are they missing by not asking????Plus shared with each site- specific How many times an abuse code has been captured on a patient the specific perpetrator of the abuse & discharge disposition Then reflected back to what exactly their compliance rate means�how many are they missing by not asking????

26. Part of Assessment *at some point during their stay We know that violence and the threat of violence in the home is a concern for many people and can directly affect their health. Abuse can take many forms: physical, emotional, sexual, financial or neglect. We routinely ask all patients and parents about maltreatment or violence in their lives. Is this a concern for you or your child(ren) in any way? asking promotes health for them & their children The question is worded so as to: Raise awareness Prevent further abuse through early identification and intervention Assist victims to identify abusive behaviour Asking a clear and direct question about DV and abuse communicates that the interviewer is comfortable discussing abuse �the question is worded so that even the abuser has the opportunity to respond�and get resources to assist in learning he must take responsibility for the abuse We Know about Health�s Reluctance to �Ask� Discomfort with issue- complexity Difficulty identifying woman abuse within their patient population Believe that it�s up to the patient to raise the issue Not enough time; lack of privacy; the tool itself Nurse-patient relationship-fear of offending Unsure about requirements for legal reporting Vicarious trauma Or their own life experience asking promotes health for them & their children The question is worded so as to: Raise awareness Prevent further abuse through early identification and intervention Assist victims to identify abusive behaviour Asking a clear and direct question about DV and abuse communicates that the interviewer is comfortable discussing abuse �the question is worded so that even the abuser has the opportunity to respond�and get resources to assist in learning he must take responsibility for the abuse We Know about Health�s Reluctance to �Ask� Discomfort with issue- complexity Difficulty identifying woman abuse within their patient population Believe that it�s up to the patient to raise the issue Not enough time; lack of privacy; the tool itself Nurse-patient relationship-fear of offending Unsure about requirements for legal reporting Vicarious trauma Or their own life experience

27. Is it �Screening�? Different from most other health care screening interventions Not unaware Not asymptomatic Violence is not a mere risk factor awaiting identification �getting a �yes� or �no� is not our goal �Screening� refers to the use of a test in an asymptomatic population to identify persons with early disease, or risk factors for disease, with the aim of preventing morbidity and mortality. �Case-finding� refers to the practice, by physicians and nurses, of using the clinical encounter as an opportunity to test or screen patients for unrelated reasons. Both screening and case-finding are related, and both represent clinical prevention interventions. �Behavioural health assessment� can be part of either screening or case-finding. It can also be a part of an intake, periodic, or problem-specific history. It refers to the disclosure, by a patient or client to a provider, of behaviours that confer protection against or increased risk for health outcomes. When specific behaviours are identified, interventions, including counselling, referrals, testing, and follow-up, can be tailored to meet the needs of the individual. �Harm reduction� is another useful term for health providers. Harm reduction was first encountered in literature referring to substance abuse, but is now becoming more widely adopted to refer to interventions aimed at reducing risk when abstinence or avoidance is not possible or realistic. For individuals & their children unable or unwilling to leave abusive relationships, a harm reduction approach would include strategies to prevent injury, maximize safety, plan for escape, and promote health. Disclosure is a voluntary act. Adapted from: Intimate Partner Violence Consensus Statement Society of Obstetricians and Gynaecologists of Canada (SOGC) APRIL JOGC 2005 pgs. 365-388 Primary Prevention: Screening is a door to educate clients and communities about health relationships and the early signs of an unhealthy relationship Secondary Prevention: educates clients about the continuum of violence which typically escalates over time and the health implications; it is also an opportunity to strategize with clients to identify ways to prevent health effects of abuse such as: Family planning methods that are less likely to be sabotaged by an abusive partner Strategizing how to access preventive care in a way that will be safe for the client Discussing the risk of substance abuse as a coping mechanism which further compromises a victim�s safety and options Tertiary Prevention: in relationships with escalating violence, screening provides the opportunity for disclosure in a safe and confidential environment. Even if clients do not feel safe disclosing their abuse, giving supportive messages can end their isolation and let them know that they have options �Screening� refers to the use of a test in an asymptomatic population to identify persons with early disease, or risk factors for disease, with the aim of preventing morbidity and mortality. �Case-finding� refers to the practice, by physicians and nurses, of using the clinical encounter as an opportunity to test or screen patients for unrelated reasons. Both screening and case-finding are related, and both represent clinical prevention interventions. �Behavioural health assessment� can be part of either screening or case-finding. It can also be a part of an intake, periodic, or problem-specific history. It refers to the disclosure, by a patient or client to a provider, of behaviours that confer protection against or increased risk for health outcomes. When specific behaviours are identified, interventions, including counselling, referrals, testing, and follow-up, can be tailored to meet the needs of the individual. �Harm reduction� is another useful term for health providers. Harm reduction was first encountered in literature referring to substance abuse, but is now becoming more widely adopted to refer to interventions aimed at reducing risk when abstinence or avoidance is not possible or realistic. For individuals & their children unable or unwilling to leave abusive relationships, a harm reduction approach would include strategies to prevent injury, maximize safety, plan for escape, and promote health. Disclosure is a voluntary act. Adapted from: Intimate Partner Violence Consensus Statement Society of Obstetricians and Gynaecologists of Canada (SOGC) APRIL JOGC 2005 pgs. 365-388 Primary Prevention: Screening is a door to educate clients and communities about health relationships and the early signs of an unhealthy relationship Secondary Prevention: educates clients about the continuum of violence which typically escalates over time and the health implications; it is also an opportunity to strategize with clients to identify ways to prevent health effects of abuse such as: Family planning methods that are less likely to be sabotaged by an abusive partner Strategizing how to access preventive care in a way that will be safe for the client Discussing the risk of substance abuse as a coping mechanism which further compromises a victim�s safety and options Tertiary Prevention: in relationships with escalating violence, screening provides the opportunity for disclosure in a safe and confidential environment. Even if clients do not feel safe disclosing their abuse, giving supportive messages can end their isolation and let them know that they have options

28. �not our job to rescue� Supportive not curative Validate their experience Find out what they wish to do �Provide Options Try to ascertain their level of risk for serious harm �CONNECT� them with resources Disclosure in IPSV was Triggered by 3 factors: the violence approached the level of severity they associated with stranger rape The violence was abnormal They received help from an outsider ( who confirmed her definition of her experience) Bergen, R. �Wife Rape�:Understanding the response of survivors & service providers (1996) Potential Benefits of Universal Screening Increasing opportunities for women to disclose abuse Increasing opportunities for nurses to identify women who have been abused Linking health consequences to abuse, thereby positioning violence as a legitimate health concern Identifying the health impacts of abuse and providing early intervention Avoiding stigmatization by asking all women about abuse Reducing the sense of isolation abused women experience Affording opportunities to assist children of abused women Giving a strong message that abuse is wrong Informing women about violence against women services and other options that are available Fostering healthy communities The overall intended outcome is increased opportunity for disclosure, which will promote health, well-being, and safety for women. _Listening and affirmation are invaluable to victims ______________________________________________________________________________________________ Understanding the cycle gives direction to your intervention Contemplative Stage: this is where raising awareness & validation as the most important Be sensitive to the fact that victims of abuse are afraid and ashamed Remember they are the best judge of what is safest for them and their children It's not your job to rescue them Disclosure in IPSV was Triggered by 3 factors: the violence approached the level of severity they associated with stranger rape The violence was abnormal They received help from an outsider ( who confirmed her definition of her experience) Bergen, R. �Wife Rape�:Understanding the response of survivors & service providers (1996) Potential Benefits of Universal Screening Increasing opportunities for women to disclose abuse Increasing opportunities for nurses to identify women who have been abused Linking health consequences to abuse, thereby positioning violence as a legitimate health concern Identifying the health impacts of abuse and providing early intervention Avoiding stigmatization by asking all women about abuse Reducing the sense of isolation abused women experience Affording opportunities to assist children of abused women Giving a strong message that abuse is wrong Informing women about violence against women services and other options that are available Fostering healthy communities The overall intended outcome is increased opportunity for disclosure, which will promote health, well-being, and safety for women. _Listening and affirmation are invaluable to victims ______________________________________________________________________________________________ Understanding the cycle gives direction to your intervention Contemplative Stage: this is where raising awareness & validation as the most important Be sensitive to the fact that victims of abuse are afraid and ashamed Remember they are the best judge of what is safest for them and their children It's not your job to rescue them

29. *CONNECT www.connectnetwork.ca Family & Sexual Abuse Network Located within SMCHC Single access point for individuals & families affected by domestic violence & sexual assault -access to a wide range of services to meet their unique health, legal and social service needs Provides compassionate support, up-to date information and personal & confidential access to legal, police, medical and counselling services through one central locationFamily & Sexual Abuse Network Located within SMCHC Single access point for individuals & families affected by domestic violence & sexual assault -access to a wide range of services to meet their unique health, legal and social service needs Provides compassionate support, up-to date information and personal & confidential access to legal, police, medical and counselling services through one central location

30. Could this injury have been prevented? Don�t know�the patient in all of her previous visits, to the same ED by the way, was never asked about domestic violence (including raising awareness that DV can make her sick, has many forms and can impact the health & safety of her children as well) or how things were at home and if unsafe. As a result, she was never advised of her options Could this injury have been prevented? Don�t know�the patient in all of her previous visits, to the same ED by the way, was never asked about domestic violence (including raising awareness that DV can make her sick, has many forms and can impact the health & safety of her children as well) or how things were at home and if unsafe. As a result, she was never advised of her options

31. �some words of wisdom from a survivor �I really think that it�s the compassion, the asking of the question, the referral which can happen in a matter of minutes, which can be the hinge, the gateway to the way out� Excerpt from �The Voices of Survivor Documentary� �I know it saved my life� words of a patient seen in the Strathmore Emergency Department Domestic violence is life threatening but not terminalDomestic violence is life threatening but not terminal

32. Closing Comments for Reflection:Client-Centered Evolution of Response What additional resources would help your client address their medical needs in your community? Is there opportunity for a more collaborative response that involves all designations & disciplines? Do �turf issues� get in the way?