Domestic Violence

1. Domestic Violence A Health Care Epidemic Rachel E. Locker MD Warm Springs Health and Wellness Center

2. Alarming Statistics The American Medical Association estimates that over 4 million women are victims of severe assaults by boyfriends and husbands each year. � �Violence Against Women," CQ Researcher, Congressional Quarterly 1993 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42% 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42%

3. Alarming Statistics In the US a woman is more likely to be raped, injured, assaulted or murdered by a male partner than any other type of assailant. Resource Availability for Women at Risk�, American Society of Criminology 1987 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42% 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42%

4. The Facts Domestic Violence is the �leading cause of injury among women of reproductive age �the single most common trigger for female suicide �up to 60% of women who are murdered die as a result of a domestic dispute Webster 1995 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42% 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42%

5. In the Medical Scene... Murder is the leading cause of death related to pregnancy JAMA 2001 5.8 billion $ per year in health related cost due to DV in th U.S. CDC 4/03 In a study done in Maryland 25% of deaths in women that occurred during or in the year following pregnancy were murder. Put 2 and 2 together �� These are the ones we know aboutIn a study done in Maryland 25% of deaths in women that occurred during or in the year following pregnancy were murder. Put 2 and 2 together �� These are the ones we know about

6. Closer to Home At least 59 % of Women served in the Warm Springs Health and Wellness Center between 1990 and 2000 had a documented history of domestic violence Unpublished study 2001 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42% 54 %, I of murders in another estimate Victoria BC 1990 71% 1991 42%

7. Responding In order to respond to domestic violence effectively we need to have an understanding of � What is domestic violence? The causes The perpetrators The victims The impact on the victim, children and society

8. What is domestic violence? Relationship violence is an escalating pattern of abuse where one partner in an intimate relationship controls the other through force, intimidation or threat of violence. Look for confusion about the definition of domestic violence escalating control connection of physical force , intimidation, threats, pattern multiple episodes over time range of tactics Stress that control is the issue present both ws and jc legal definitionsLook for confusion about the definition of domestic violence escalating control connection of physical force , intimidation, threats, pattern multiple episodes over time range of tactics Stress that control is the issue present both ws and jc legal definitions

9. Abuse comes in many forms... Physical Kicking, punching, shoving, slapping, pushing, choking, burning and any other acts which may harm a body. Emotional/ Verbal Assaults against your self-esteem. �You are so stupid, no one else would want you.� Name-calling, threats, put-downs. �stupid, fat, whore� etc. Psychological Threats to victim, children, pets, property, stalking, yelling, controlling activities and access to resources. Use examples here take examples from participantsUse examples here take examples from participants

10. Abuse comes in many forms... Sexual Calling of vulgar names, criticizing body parts or sensuality, forced or pressured sexual acts, including rape. Destructive Acts Actual or threatened assault of your belongings or pets to scare you. Financial Controlling and manipulating you by threatening your economic status and basic needs. 

11. Abuse comes in many forms... Immigration Using your immigration status and fear of deportation to control you. Use of Children as hostages, physical and sexual abuse, using children as spies, custody fights, forcing children to engage in abuse of the victim Using �male privilege� -Master of the castle, treating partner like a servant

12. Why do they stay? Children- � He is the father of my children�, �I thought my children needed a father� Isolation- social, family, geographical Lowered Self Esteem- fear that she is � stupid�, that no one else would want to be with her. Religious beliefs/marriage vows- �till death do us part� Give examples of cases for isolation Examples for children Children used by the batterer to bring the victim backGive examples of cases for isolation Examples for children Children used by the batterer to bring the victim back

13. Why do they stay? Fear - threats of suicide, homicide, threats to family or children Blame- victims believes that she is at fault and the cause of the violence. Optimism- �I thought it would get better if he stopped drinking�, �He said he would never do it again� Give examples in of blame take examples from participantsGive examples in of blame take examples from participants

14. Special Issues For Teens in Violent Relationships Lack of Experience/Might think it�s normal May be involved with drugs and alcohol Peer Pressure/ Status Jealousy and Possessiveness = love Heavily influenced by the media/role models Stalking - on the campus

15. Causes of Domestic Violence Domestic Violence is not� genetically inherited caused by illness caused by alcohol or drugs the result of stress or anger due to �a bad temper� due to the behavior of the victim or children a �problem� in the relationship Stress that this is not caused by these things And is Reinforced by misconceptions from the public, police, medical, family, TV, religion what did you do to make him mad?Stress that this is not caused by these things And is Reinforced by misconceptions from the public, police, medical, family, TV, religion what did you do to make him mad?

16. Causes of Domestic Violence Domestic Violence is� a learned behavior. Look for confusion about DV as an anger management issue,out of control behavior, alcohol, victim blaming , drug use Studies of primates show violent behavior towards mates in order to maintain the harem, to control mating habits Don�t get to carried away hereLook for confusion about DV as an anger management issue,out of control behavior, alcohol, victim blaming , drug use Studies of primates show violent behavior towards mates in order to maintain the harem, to control mating habits Don�t get to carried away here

17. Why does this happen?  Abusive relationships are based on the belief that oneperson has the right tocontrol another.

18. Physical violence typically starts when the couple has become more seriously involved. �Going steady� Living together Engagement Marriage Pregnancy or birth of a child Controlling behaviors may also be seen to begin with significant events such as the birth of a child- head of the house now� Looking back most women can note behaviors that might be warning signs to violence that started laterControlling behaviors may also be seen to begin with significant events such as the birth of a child- head of the house now� Looking back most women can note behaviors that might be warning signs to violence that started later

19. Who are the perpetrators? Come from all races, religions, sexual orientations, education levels, and social groups. Can be male or female Can be adolescent to elderly Give examples DJ, batterer and victim Give examples of elderly murder age 80s, to teens Give examples DJ, batterer and victim Give examples of elderly murder age 80s, to teens

20. Who are the victims? From all races, religions, social groups, educational levels, and sexual orientations. Male or female Adolescent to elderly No specific personality traits Any level of physical ability Listen for victim blaming attitudes, dispel myths Note that violence is more prevalent in African American and more so in Native American No statistics to quote Listen for victim blaming attitudes, dispel myths Note that violence is more prevalent in African American and more so in Native American No statistics to quote

21. Effectson Victims Children Society Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

22. Medical Effects on the Victim Physical injuries Fractures Head injuries Genital trauma Abdominal trauma Delay in seeking medical care May exacerbate any injury Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

23. Medical Effects on the Victim Obstetric Late, sparse or no prenatal care Low birth weight Miscarriage Fetal Fracture Placental abruption Preterm labor Drug and Alcohol abuse Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

24. Medical Effects on the Victim Chronic pain syndromes Joints Pelvic Abdominal Headaches Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

25. Mental Health Concerns Decreased sense of �Well Being� Depression Anxiety disorders Sleeping disorders Point out that a large percentages of suicidal attempts. Suicides are related to domestic violencePoint out that a large percentages of suicidal attempts. Suicides are related to domestic violence

26. Mental Health Concerns Post Traumatic Stress Disorder Suicidal ideations Suicide attempts Point out that a large percentages of suicidal attempts. Suicides are related to domestic violencePoint out that a large percentages of suicidal attempts. Suicides are related to domestic violence

27. According to the AMA, Teen Girls Who Experience Physical and Sexual Abuse in Relationships Are: 2.5 times more likely to smoke heavily. 1.2 times more likely to drink and drive. 3.7 times more likely to use diet pills. 5.7 times more likely to consider suicide. 3.9 times more likely to become pregnant. 1.7 times more likely to binge drink. 3.4 times more likely to use cocaine.

28. Effects on the Victim Death Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

29. Children are the silent victims !

30. Child Abuse Children from homes where there is partner abuse are 15 times more likely to be abused than children from non-violent homes ! Stress this need to protect children Stress this need to protect children

31. Medical Effects on Children Physical injuries Abuse and Neglect Alcohol and Drug abuse/health consequences Sleeping disorders Psychosomatic complaints Point out examples of stress related illness that you shouldn�t see in children these should be triggersPoint out examples of stress related illness that you shouldn�t see in children these should be triggers

32. Mental Health Effects on Children Behavior problems Nightmares Difficulty forming relationships Depression PTSD Suicidal ideations Suicide attempts Discuss that suicidal ideations/ and attempts in children etc. need to be investigated furtherDiscuss that suicidal ideations/ and attempts in children etc. need to be investigated further

33. Domestic Violence and Children

34. Socioeconomic Impact Medical Expenses Victim & Child Protection Expenses Counseling services Lost time from work/school Police/Legal services Alcohol and Drug counseling/treatment Damage to property Poverty Homelessness/Runaways Homicide/imprisonment continues the cycle of violence

35. The Cycle Continues � A child�s exposure to the father abusing the mother is the strongest risk factor for transmitting violent behavior from one generation to the next. � Report of the American Psychological Association Presidential Task Force on Violence and the Family, APA, 1996 Stress this need to protect children Stress this need to protect children

36. Add It All Up... Physical and sexual violence against women is a public health problem that has reached epidemic proportions. American Medical Association Diagnostic and Treatment Guidelines on Domestic Violence, 1992 Good spot for a break!!!!Good spot for a break!!!!

37. What is Our Role in Health Care? Identify Assess Document Educate As a physician regardless of your practice type you will see victims of domestic violence ent -nasal fractures Pediatrics- children with behavioral concerns Surgeouns - truamatic and and chronic abdominca pain Pathologist- autopies ER injuries FP depression, anxiety, pain Ob pelvic pain, pregnancyAs a physician regardless of your practice type you will see victims of domestic violence ent -nasal fractures Pediatrics- children with behavioral concerns Surgeouns - truamatic and and chronic abdominca pain Pathologist- autopies ER injuries FP depression, anxiety, pain Ob pelvic pain, pregnancy

38. Identify When should I think domestic violence?

39. Suspicious Physical Findings Multiple injuries in various stages of healing

40. Presentation Delay between onset of injury and seeking care. Injury inconsistent with the explanation.

41. Suspicious Physical Findings Injuries centered around face Nasal/ facial bone fractures, Lacerations to the eyes, Rupture eardrum Dental injuries

42. Periortibal ecchymosisLacerations to the lips

44. Suspicious Physical Findings Injuries to the neck Ligature marks Rope burns, bruising petechiae

45. Suspicious Physical Findings Injuries Centered Around Sex Organs Injury during pregnancy Injuries to the torso and abdomen Rib Fractures

46. Suspicious Physical Findings Bilateral injuries Grip marks Pattern injuries Weapon patterns Bite marks Burns

47. Defensive injuries

48. Pattern injury- Hand print

49. Pattern injuries - linear

50. Pattern Injury Bite Mark Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

51. Mental Health Issues Eating disorders Alcohol or drug abuse Psychosocial distress depression suicidal anxiety sleep disorders

52. Partner Interactions... A partner who will not leave the exam room. A partner who does all the talking for the patient

53. Difficult Patients Vague psycho-somatic complaints Chronic pain syndromes

54. Labels �Borderline personality disorder� Manipulative �Crock� Hysterical Somatitization disorder Angry Demanding/Difficult Point out that a large percentages of suicidal attempts. Suicides are related to domestic violencePoint out that a large percentages of suicidal attempts. Suicides are related to domestic violence

55. Pediatric Clinical Signs Concerns of child abuse or neglect Depression Psychosomatic complaints Eating disorders Suicide attempts or gestures Behavior problems Nightmares Insomnia

56. We couldalso  Just Ask!

57. Medical Screening Patients don�t tell us they have it Cervical Cancer There is a high incidence in the population- HTN It may be contagious TB Give examples Patients don�t tell us they have TB, HTN, cervical cancer all things we screen for (TB skin test, BP, pap smear) Patients don�t routinely tell us about abuse in the home There is a high incidence of HTN, cervical cancer, TB in certain populations there is also a high incidence of DV TB is contagious as are the effects of Domestic violence Give examples Patients don�t tell us they have TB, HTN, cervical cancer all things we screen for (TB skin test, BP, pap smear) Patients don�t routinely tell us about abuse in the home There is a high incidence of HTN, cervical cancer, TB in certain populations there is also a high incidence of DV TB is contagious as are the effects of Domestic violence

58. Medical Screening It may cause other illnesses HTN It may cause an early death TB Early intervention makes a difference in outcome- Cervical Cancer HTN causes stokes , MI�s and heart failure TB, cervical cancer, and HTN can cause early death as can DV through homicide,and suicide Early intervention in HTN can prevent MI, CHF, cardiomegly and TB treatemnt can prevent active illness Education and intervention on DV can prevent early death, victim and children ilnesses a, homicid and suicideHTN causes stokes , MI�s and heart failure TB, cervical cancer, and HTN can cause early death as can DV through homicide,and suicide Early intervention in HTN can prevent MI, CHF, cardiomegly and TB treatemnt can prevent active illness Education and intervention on DV can prevent early death, victim and children ilnesses a, homicid and suicide

59. Why Should We Screen? Medical practitioners are often the first or the only professionals that individuals in abusive situations come in contact with.

60. Screening Tells a Woman� She is believed She is respected She is not alone You are familiar with DV You are willing to listen Abuse happens to a lot of women The issue is being taken seriously DV can affect her health She can get help

61. What if we don�t ask? Little or no disclosure Abused women remain isolated The problem will continue and personal and social cost will increase Opportunity to prevent illness, injury or death will be missed Treatment or advice may be inappropriate Professional Silence

62. Why Should We Screen? Domestic Violence and it�s medical and psychiatric sequelae are sufficiently prevalent to justify routine screening of all women patients in emergency, surgical, primary care pediatric, prenatal and mental health settings American Medical Association 1992

63. Who Should We Screen ? All Females over the age of 14 with or without signs or symptoms of domestic violence -on a routine basis Children - Screen female caregiver/parent or caregivers known to be in a same sex relationship who accompany their children Any patients who present with clinical findings that may indicate abuse

64. When Should We Screen ? In a perfect world� Every time you see them

65. When Should We Screen ? Good Choices Pregnancy � each trimester Women's health exams At least once per year At disclosure of a new intimate relationship On presentation with children for well child exams When woman or child presents with clinical signs or symptoms

66. How to Screen Screen in a safe and private environment. Separate any accompanying persons from the patient.

67. Frame the Question Use your own words in a non-threatening, non-judgmental way. �Domestic violence is so common that I ask all my female patients about abuse in the home� �It is hospital policy that we ask about abuse in the home��

68. Be Direct� �and easy to understand. �Do you feel safe in your current relationship?� �Have you or your children ever been threatened or abused by your partner?� �Is there a partner from a previous relationship who is making you feel unsafe?�

69. How to Screen Explain the confidentiality of these issues and the mandatory reporting of child abuse.

70. What do I do when she says yes?

71. Intervention Document Assess Danger Be supportive Educate Refer

72. Document� screening Document if your screening was �positive, negative, or suspicious� Document your findings or suspicions of abuse. Adult maltreatment syndrome 995.81

73. Educate/Support/Refer Let the patient know that there is no excuse for domestic violence. �No one deserves to be abused.� �There is no excuse for domestic violence. �The violence is not your fault this is the responsibility of the abuser.�

74. Educate/Support/Refer Let her know she has options and that help is available if she should find the need. �You are not alone, there are people you can talk to.� �It must be difficult for you to leave your situation, help is available when you are ready.� Offer to call a Victim's Advocate or other resources Review medical power and control wheel , empowerment /advocacy wheels Note that this may be where we can make the biggest impact. The patient needs to know that she can trust us and rely on us for help and confidentialtyReview medical power and control wheel , empowerment /advocacy wheels Note that this may be where we can make the biggest impact. The patient needs to know that she can trust us and rely on us for help and confidentialty

75. Educate/Support/Refer If she declines the need for an advocate� Give her/discuss with her information on safety planning. Give her info/discuss with her info on available resources

76. Assess Danger (lethality) Increase in the frequency or severity of violence . Increasing or new threats of homicide or suicide. Threats to children Using alcohol or drugs? Used a firearm or weapon in past threats Public Displays of violence? Hostage taking or stalking? Will she be in any immediate danger if she returns home?

77. Acute events Use the patients own words when ever possible. Record �excited utterances� and use descriptive terms in regards to emotions and appearances � He grabbed me by the hair and pulled me out of the car� �Patient appears extremely anxious and distraught.�

78. Acute events Photograph all injuries, (obtain written consent) Label with the date, time, patient name and your initials Use a standard scale to show size Use a standardized form so as not to leave out important issues Sexual Assault Exam if indicated

79. Use a size standard Point out that physical injury may be the most obvious but is not necesarrily the most harmful.Point out that physical injury may be the most obvious but is not necesarrily the most harmful.

80. Body Charts

81. Document� acute events Know your local reporting laws

82. Document� acute events Remember� Accurate documentation will help the patient�s legal case against the assailant.

83. Medical Power and Control Note that doing these things take the control of her life from her hNote that doing these things take the control of her life from her h

84. Medical Advocacy Note difference in how wecan be advocate of demonstrate power over the patent. Give examples Note difference in how wecan be advocate of demonstrate power over the patent. Give examples

85. Tips If you are suspicious of domestic violence but your patient denies, do not press the issue. Express your support and document your concerns. Don�t insist that she must leave the relationship. This must be her decision and in many cases it must be carefully planned. Most women who are killed in these situations are killed when they try to end the relationship. It takes an average of 12 times leaving for a woman to end an abusive relationship. Try not to get frustrated and don�t abandon her.