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Domestic Violence
Con~ise Review for Primary·Cafe,flhysicians>
Domestic Violence P ATRICIA A. B ARRI ER, M.D., M.P.H.
Domestic violence, defined as abuse involving intimate partners, is a growin g problem in the United States. Most victims are women in heterosexual relationships. Frequently, the violence is a combin ation of physical, sexual, and psychologic abuse that occurs in a cycllc and intensify. iog paUern that can ultimately result in serious assaults with weapon s or even death . The signs and symptoms may be obvious injuries or subtle chronic complaints that are
often related to stress. Increased awareness of dom estic violence and routine inclusion of some screening questions in the medic al history can facilit ate detection and preve nt furth er inj ur)' to a patient or her children, Prov iding nonjud gmental support and info rmation about legal and social services to the victim in a cunfid enti al manner are the keys to intervention, Maya Clin Proc 1998;73:271-274
I
n the United States, domestic violence is a grow ing problem. in prevalence as we ll as in recognition and reporting. In the broadest sense. domestic violence includes spouse or partner abuse. child abuse, elder and vulnerab le adult abuse, a nd sibling violence. In a more speci fic se nse , domes tic violence refers to abuse involving intimate adult partners. Ninety to 95% of domestic victence victims are women, and the perpe trators are men.':' Domestic violence occ urs in homose xual and heterose xual coup les. Twe nty-two to 46 % of perso ns in homosexual and lesbian re lationships expe rience so me violence from thei r partners.' Domestic vio lence is rooted in a dynamic of unequal powe r and control that escalates 10 physica l, sexual. or psychologic abuse. In hom osexual relationships, this dynami c is ofte n compounded by homoph obia and tilt: victim' s fear that sexual orientation will be exposed.' Health-care providers in both primary care and subspecialty care must be aware of the signs and symptoms of domestic vio lence , must develop skill in addressing this possibility in a sensitive and nonjudgmental fashion, and must be aware of available com munity resources for the victim.
are used sugge st that this num ber is subs tantially underestimated. This discrepancy between national and clini cal surveys is thought to occ ur beca use national surveys are often completed by both partners. Domestic violence is tbe second leading cause of injuries to all US women and is the leading cause of inju ries to US women in the 15- to 44 year-old age -grou p. Statistics from the Federal Bureau of Investigation indica te that eac b yea r 30 to 40 % of female murder victims are murdered by male partners or ex-partners and 4% of all male homicide victims are killed by spouses or girlfriends. US Departm ent of Justice statistics indicate that a woma n is more likely to be raped , assaulted , or murdered by a partner or ex-partner than by any other assailant. Approx imately 25 to 45% of abused wome n are beaten during pregnancy . 1-4 Of wo men who see k medical assistance at the emergency departm ent , 22 to 35% are there because of domestic abuse, but only 5% of these situations are co rrectly identified.' Partner abuse observes no ethnic, geog raphic, religious , or socioeconomic bo undaries.': Some studies suggest that an abuser probably ex perienced vio lence during childhood a nd pro babl y abuses alcoho l. I
EPIDEMIOLOGY An estimated 2 to 4 million US wo men experience domestic violence annually. National surveys indicate that about 2 mill ion women eac h year are seve rely beaten or assaulted w ith weapo ns by their male partners. Clinical surveys in whic h anonymo us questionnaire s or structured interviews
SIGNS AND SYMPTOMS
Dom esti c vio lence ma y be ph ysi cal. se xua l, o r psychologic . A victim experie ncing anyone type is very likely to expe rience all types to some exte nt. Usually, the violence is chronic and repetitive and intensifies in the relationship in a cyclic pattern . During the initial or tension-building phase, relational conflicts result in the perpetrator exe rting increasing control over the partner and household and engag ing in emotional abuse, mild physical abuse, and in tim id ati on , The perpetrator undermine s the partner's co nfidence and self-es teem and isolates her from fam ily and friends. For exa mple. the perpetrator may take
From the Division of Preventive and Occupational Medicine and Internal Medicine. Mayo Clinic Rochester. Rochester. Minnesota. Address reprint requests to Dr. P, A. Barrier. Division of Preventive andOccupational Medicine. MayoClinic Rochester. 200 First Street SW. Rochester. MN 55905 . M ayo Ctin Prot' 199 8;73:27 1·214
271
© / 998 Afayo Foundation for M edical Edu cation and Resea rch
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
272
Domestic vjotence
away a vehicle or may give the victim very limited discretionary funds per day or wee k. A ser ious physical assa ult may follow this buildup period. A period of remorse or " honeymoon" phase follows. during which the batterer prom ises not to abu se the partner again. At this stage. the perpe trator often buys gifts or arranges spec ial eve nts or trips. Th e cycle then repeats with the violent e pisodes increasing in frequency and intensity.' Th e signs and symptoms of dome stic violence can be obvious or subtle. Key findings are injuries inconsistent with the exp lanation that the patient provides. Inj uries to the head. neck. chest. brea sts. and abdomen; multiple sites or repea ted injuri es; and injurie s during pregnancy may all be signals. In a recent clinical study that used structured interviews of co nsecutive wome n visiting a primary-care cl inic, nonabused women were more likely to have co me for a routine physical examination. whereas abused women had specific and often stress-related complaints.' Frequent medical visits for multiple somatic co mplaints such as fatigue. sex ual dysfunction, chronic pelvi c pain. headaches, chest pain, gastrointestinal disturbances, and abdom inal pain may be linked to domestic abuse . Th ese commo n chronic co mplaints should at least raise the index of suspicion of both the primary-care provider and the specialist. Prim ary psychiatric dysfunction such as depression. anxiety. panic attacks . eating disorders. dissociative behavior. suicidal ideation or attempts, and substance abuse may also be associated with current or past domestic violence. ' The perpetrator often accompanies the victim to the emergency de partmen t or the health-care provider's office and is unwilling to leave the victim alone. The barterer may be overly attent ive to the victim and ofte n is the one who relates the chief complaints and also answe rs for the patient.'
BARRIERS TO IDENTIFICATION Patient and physicia n characteristics may block or dela y identification of domestic vio lence . Often, the victim has a sense o f shame. self-blame. and fear of j udgment that precl ude her from seeking help or discussing the abuse openly with others. includ ing health-care prov iders. The victim may feel very protective of the abusing partner because of his socia l or economic status. She may genuine ly believe him when he shows remorse and promises never to abuse her aga in. The victim may fear for her safety and thai o f her children beca use child abuse is frequently linked to partner abuse. Moreo ver. she may feel socia lly and eco nomically dependent on the partner and believe that she is unable to function witho ut him. Health -care provid ers may lack awareness of the magnitude of the prob lem or not believe that it is prevalent in
Ma)'o Clio Proc.l\larch 1998. Vol 73
their community or population. They ma y believe that they have ·insufficient time to address these issues adequately. Health-care providers may not regard these situations as medical. In addition. they may be uncomfortable addre ssing possible dom estic violence issues with patien ts. Furthc rmorc, health-care providers may think that. if the question is answered affirmatively, they are now responsible for "rescuing" Ihe patient bUI arc unaware of resources available 10 ass ist victims of dome stic violence.'-'
SCREENING Because of the prevalence and dire consequences , a recent position statement from the Cou ncil on Ethica l and Judicial Affairs of the Ame rican Medical Association indicated the need for physicians to screen routinely for do mestic violence ." Fe w victims wi1l voluntee r information about abuse but very likely will respond to question s. Failur e to scree n for this problem or to recogn ize potential signs and symptoms can lead 10 more injury through co ntinued deterioration of the victim's se lf-es teem. Questions from healthcare providers can help validate that domestic violence is a real problem for the victim. Healt h-care providers can improve their detection of domestic abuse by increasing their awareness and by asking questions about domestic abuse during their routine elucida tion of the patient ' s medica l history, just as they would ask abo ut smoking or alcohol co nsumption. Informing the person that this question is asked routinely of all patients may also increase the likelihood of an affirmat ive response. A screening question can be broad, such as " Have you ever bee n physica lly. sexually. or emot ionally abused?" and can be included on a printed history form completed by the patie nt. Questi ons suc h as "00 you feel safe in yo ur relationship?" or " What happens when you and your partner disagree ?" included in the review of sys tems may also yield impo rtant informalion . Of note . these questions must be asked only when the patient's partner is not present in order 10 avoid possible incre ased inju ry to the patie nt beca use of retaliation by the partner. If the patienr' s responses indicate some co ncern for safety or possib le abuse. the health-care provider must dete rm ine the type and level of abuse. the degree of social isolation . the presence of weapons in the hom e. and whether the patient has an escape plan for herself and her children (if needed ).'> A good mnemon ic for health -care providers to use when asking questions 10 asses s the situation further is " SA F g' (Ta ble I). SA FE question s address the followin g issues: stress and safety. a fmid or abused, f riend o r famil y awareness , and emergency escape plan. The answe rs to SAFE question s can help the provider characterize the intensity of the situation and determi ne the appropriate intervention strategy.v?
For personal use . Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, March 1998, Vol 73
Table 1.-Screening for Domestic Violence in Intimate Adult Relationships: Use of the "SAFE" Mnemonic Stress and saf ety Do you feel safe in your relationship? What happens when you and your partner disagree? Afraid or abu sed Have yo u or yo ur children ever been physically threatened or abused? Have yo u ever been forced to have sexual inter-
course? Friend or f amily awareness Arc your friends or fam ily aware of what is happening?
Would they support and help you? E mergency escape plan Arc you in danger now , and would yo u like to go to a shelter or
talk with someone? Do you have a place where you and your children could go in an eme rgency?
INTERVENTIONS After the health-care provider has treat ed any inju ries, the foll owing factors mu st be docum ent ed in the patient ' s medical record : injuries. any history of abuse reported by the patient, and supporting laboratory or roent genog raphic findin gs. The victim may use this infonnation as ev ide nce in a future legal action. Emphasizing that domestic violence is wro ng and that no person dese rves (0 be mis treated by an intimate partner in a physical , emotional, or sex ual mann er is c ritical to the provider 's support o f the victim . Giving the victim inform ation about legal and soc ial services , suc h as a battered wom en 's shelter and victim advoc acy groups, is essenti al. Providers sho uld becom e fam ilia r with the se resource s in their co mmunities but mu st be cautious abo ut giving the victim written material, such as pamphlets, that could be found on her per son by the perpetrator and cause her more injury.I.6.7 Many health-care providers become frustrated when a woman does not elect to leave the abusive situation or take legal action immediately. A ballered woman may have many reason s for this de lay, including blaming herself for the abuse, fear of retaliation against her self or her children, deni al. or lack of financi a l support. Of import ance, the
Domestic Violence
273
health -care provider should nut blame the pati ent for this relu ctance or inabi lity to leave but rath er schedule follow up appo intments and offe r ongo ing support. Intervention programs with perpetrators ha ve not been show n to be effec tive. Th e reporting requirem ents regarding domest ic violence vary in eac h state. Because most battered partn ers a re legally com petent adult s with a right to co nfidentiality. many states do not require the reporting of partn er abuse except in certain circum stances. such as when firearms are invol ved. SUMMARY Dom estic violence . a prevalent and serious problem in the United Slate s, results in pron ounced morbidity and mortality to intimate partne rs and their c hildre n. It can occ ur in any patient population and has no ethn ic, geog raphic, reli gious , or soc ioeco nom ic bo undar ies. A dynam ic of uneq ua l power and contro l between intima te partners can result in a pattern of cyclic and esc alating psych ologic, sex ual, and physical abuse. The signs and sym ptoms ca n be obvious injuries or subtle somatic co mplaints. Screening question s about dom estic violence mu st be an integral part of medi ca l interactions because few victims will volunteer this inform ation. A speci fic knowledge of the resou rces in one 's com munity is es se ntia l for providing the support that victims and their children need .
REFERENCES 1.
2. 3.
Baker NJ, Mersy DJ, 'r eteur JM, CIl,.. JM. Family VIOlence. Monograph 20 5. Home Study SeIf.Assessment Program. Kansas City (MO): American Academy of Family Physicians; 1996 Jun Elliott BA, Johnson MM . Domestic violence in a primary care setti ng: pattern s and prevalence. Arch Fam Moo 1995:4 :113-119 AAFP CommhuHon on Special Issues and Clinical Interests . Family violence: an AAFP white paper. Am Fam Physician 1994 :50 :1636-
1638;1640; 1644;1646
4.
Council on Ethical and Judk:lal AHal"', American Med ical Associ ation . Physicians and domestic violence : ethic al considerations. JAMA
5.
Counc il on Sclttnt tflc AHaI"', American Medical Association. Violence against women. lAMA 199 2;26 7:3184-31 8 9 "-hur ML Asking about domest ic violence: SAFE questions [letter], l AMA 19 93 :269 :2367 Neufeld B. SAFE questions : overcoming barriers to the detecti on of comestc violence. Am Fam Physician 199 6;53: 25 75-2580
1992;267:3190-3 193 6. 7.
Questions About Domestic Violence in Intimat e Adult Relati onsh ips
(See article, pages 27110 273)
I. Which Qllf. of the following is l!S11 an epidem iologic characteristic of dom estic viol en ce? a. Ninety to 95% of victims are women in heterosexual re lation ship s b. It affects 2 to 4 milli on US wom en annually
c. It rare ly occ urs during pregn ancy d . It is the leading ca use of inju ry tu US women in the 15- to 44 -year-old age-group e. About 4% o f male homi cide victims arc killed by spouses or girlfriends
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
274
Mayo Clio Pr oc, March 1998. Vol 73
Domes-tic Violence
2. Wh ich I2!1J:. of the following statements abo ut domestic violence is true? a. It usually invo lves only physical abuse b. It occ urs primarily in lower socioeconomic groups c. The tension-building phase rarely esca lates to an actual incident d. Th e remorse phase leads to true resolut ion of the violence if co uples receive co unseling c. It progresses to increasing violence in a cyclic fashion 3. Which I2!1J:. of the followi ng is not true regarding the signs and symptoms of domestic violence? a. Th e patient will often volunteer information about the abuse to the health -care provider b. Bruises on the breasts or abdomen are highly suggestive of abuse c. Injuries during pregnancy are com mon d. Repeated medical visits for chronic com plaints such as headac he. pelvic pa in, gastrointest inal distress, and fatigue should suggest the possibility of abuse e. Depression and suicidal ideation may be co mmon in abused women
4. Which I2!1J:. of the followi ng health-care provider interventions is /lot appropriate in domestic violence? a. Routin e screening of all patients whcn the provider review s the medica l history b. Immediate repo rting of any domestic violence to law enfo rcement personnel c. Offeri ng nunjudgmental follow-up and support d. Giving information on legal and socia l services in the com munity e. Caref ully doc umenting injuries 5. Which I2!1J:. of the followi ng is the lees: important factor to assess when a patient admits to a history of domestic abuse? a. b. c. d.
The type and intensity of the abuse The presence of weapons in the house The patient's degree of isolation The abuser's willingness to participate in family co unse ling e. The patient's esca pe plan
Correct answe rs: I. c, 2. e. 3. a, 4. b, 5. d
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Domestic Violence P ATRICIA A. B ARRI ER, M.D., M.P.H.
Domestic violence, defined as abuse involving intimate partners, is a growin g problem in the United States. Most victims are women in heterosexual relationships. Frequently, the violence is a combin ation of physical, sexual, and psychologic abuse that occurs in a cycllc and intensify. iog paUern that can ultimately result in serious assaults with weapon s or even death . The signs and symptoms may be obvious injuries or subtle chronic complaints that are
often related to stress. Increased awareness of dom estic violence and routine inclusion of some screening questions in the medic al history can facilit ate detection and preve nt furth er inj ur)' to a patient or her children, Prov iding nonjud gmental support and info rmation about legal and social services to the victim in a cunfid enti al manner are the keys to intervention, Maya Clin Proc 1998;73:271-274
I
n the United States, domestic violence is a grow ing problem. in prevalence as we ll as in recognition and reporting. In the broadest sense. domestic violence includes spouse or partner abuse. child abuse, elder and vulnerab le adult abuse, a nd sibling violence. In a more speci fic se nse , domes tic violence refers to abuse involving intimate adult partners. Ninety to 95% of domestic victence victims are women, and the perpe trators are men.':' Domestic violence occ urs in homose xual and heterose xual coup les. Twe nty-two to 46 % of perso ns in homosexual and lesbian re lationships expe rience so me violence from thei r partners.' Domestic vio lence is rooted in a dynamic of unequal powe r and control that escalates 10 physica l, sexual. or psychologic abuse. In hom osexual relationships, this dynami c is ofte n compounded by homoph obia and tilt: victim' s fear that sexual orientation will be exposed.' Health-care providers in both primary care and subspecialty care must be aware of the signs and symptoms of domestic vio lence , must develop skill in addressing this possibility in a sensitive and nonjudgmental fashion, and must be aware of available com munity resources for the victim.
are used sugge st that this num ber is subs tantially underestimated. This discrepancy between national and clini cal surveys is thought to occ ur beca use national surveys are often completed by both partners. Domestic violence is tbe second leading cause of injuries to all US women and is the leading cause of inju ries to US women in the 15- to 44 year-old age -grou p. Statistics from the Federal Bureau of Investigation indica te that eac b yea r 30 to 40 % of female murder victims are murdered by male partners or ex-partners and 4% of all male homicide victims are killed by spouses or girlfriends. US Departm ent of Justice statistics indicate that a woma n is more likely to be raped , assaulted , or murdered by a partner or ex-partner than by any other assailant. Approx imately 25 to 45% of abused wome n are beaten during pregnancy . 1-4 Of wo men who see k medical assistance at the emergency departm ent , 22 to 35% are there because of domestic abuse, but only 5% of these situations are co rrectly identified.' Partner abuse observes no ethnic, geog raphic, religious , or socioeconomic bo undaries.': Some studies suggest that an abuser probably ex perienced vio lence during childhood a nd pro babl y abuses alcoho l. I
EPIDEMIOLOGY An estimated 2 to 4 million US wo men experience domestic violence annually. National surveys indicate that about 2 mill ion women eac h year are seve rely beaten or assaulted w ith weapo ns by their male partners. Clinical surveys in whic h anonymo us questionnaire s or structured interviews
SIGNS AND SYMPTOMS
Dom esti c vio lence ma y be ph ysi cal. se xua l, o r psychologic . A victim experie ncing anyone type is very likely to expe rience all types to some exte nt. Usually, the violence is chronic and repetitive and intensifies in the relationship in a cyclic pattern . During the initial or tension-building phase, relational conflicts result in the perpetrator exe rting increasing control over the partner and household and engag ing in emotional abuse, mild physical abuse, and in tim id ati on , The perpetrator undermine s the partner's co nfidence and self-es teem and isolates her from fam ily and friends. For exa mple. the perpetrator may take
From the Division of Preventive and Occupational Medicine and Internal Medicine. Mayo Clinic Rochester. Rochester. Minnesota. Address reprint requests to Dr. P, A. Barrier. Division of Preventive andOccupational Medicine. MayoClinic Rochester. 200 First Street SW. Rochester. MN 55905 . M ayo Ctin Prot' 199 8;73:27 1·214
271
© / 998 Afayo Foundation for M edical Edu cation and Resea rch
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
272
Domestic vjotence
away a vehicle or may give the victim very limited discretionary funds per day or wee k. A ser ious physical assa ult may follow this buildup period. A period of remorse or " honeymoon" phase follows. during which the batterer prom ises not to abu se the partner again. At this stage. the perpe trator often buys gifts or arranges spec ial eve nts or trips. Th e cycle then repeats with the violent e pisodes increasing in frequency and intensity.' Th e signs and symptoms of dome stic violence can be obvious or subtle. Key findings are injuries inconsistent with the exp lanation that the patient provides. Inj uries to the head. neck. chest. brea sts. and abdomen; multiple sites or repea ted injuri es; and injurie s during pregnancy may all be signals. In a recent clinical study that used structured interviews of co nsecutive wome n visiting a primary-care cl inic, nonabused women were more likely to have co me for a routine physical examination. whereas abused women had specific and often stress-related complaints.' Frequent medical visits for multiple somatic co mplaints such as fatigue. sex ual dysfunction, chronic pelvi c pain. headaches, chest pain, gastrointestinal disturbances, and abdom inal pain may be linked to domestic abuse . Th ese commo n chronic co mplaints should at least raise the index of suspicion of both the primary-care provider and the specialist. Prim ary psychiatric dysfunction such as depression. anxiety. panic attacks . eating disorders. dissociative behavior. suicidal ideation or attempts, and substance abuse may also be associated with current or past domestic violence. ' The perpetrator often accompanies the victim to the emergency de partmen t or the health-care provider's office and is unwilling to leave the victim alone. The barterer may be overly attent ive to the victim and ofte n is the one who relates the chief complaints and also answe rs for the patient.'
BARRIERS TO IDENTIFICATION Patient and physicia n characteristics may block or dela y identification of domestic vio lence . Often, the victim has a sense o f shame. self-blame. and fear of j udgment that precl ude her from seeking help or discussing the abuse openly with others. includ ing health-care prov iders. The victim may feel very protective of the abusing partner because of his socia l or economic status. She may genuine ly believe him when he shows remorse and promises never to abuse her aga in. The victim may fear for her safety and thai o f her children beca use child abuse is frequently linked to partner abuse. Moreo ver. she may feel socia lly and eco nomically dependent on the partner and believe that she is unable to function witho ut him. Health -care provid ers may lack awareness of the magnitude of the prob lem or not believe that it is prevalent in
Ma)'o Clio Proc.l\larch 1998. Vol 73
their community or population. They ma y believe that they have ·insufficient time to address these issues adequately. Health-care providers may not regard these situations as medical. In addition. they may be uncomfortable addre ssing possible dom estic violence issues with patien ts. Furthc rmorc, health-care providers may think that. if the question is answered affirmatively, they are now responsible for "rescuing" Ihe patient bUI arc unaware of resources available 10 ass ist victims of dome stic violence.'-'
SCREENING Because of the prevalence and dire consequences , a recent position statement from the Cou ncil on Ethica l and Judicial Affairs of the Ame rican Medical Association indicated the need for physicians to screen routinely for do mestic violence ." Fe w victims wi1l voluntee r information about abuse but very likely will respond to question s. Failur e to scree n for this problem or to recogn ize potential signs and symptoms can lead 10 more injury through co ntinued deterioration of the victim's se lf-es teem. Questions from healthcare providers can help validate that domestic violence is a real problem for the victim. Healt h-care providers can improve their detection of domestic abuse by increasing their awareness and by asking questions about domestic abuse during their routine elucida tion of the patient ' s medica l history, just as they would ask abo ut smoking or alcohol co nsumption. Informing the person that this question is asked routinely of all patients may also increase the likelihood of an affirmat ive response. A screening question can be broad, such as " Have you ever bee n physica lly. sexually. or emot ionally abused?" and can be included on a printed history form completed by the patie nt. Questi ons suc h as "00 you feel safe in yo ur relationship?" or " What happens when you and your partner disagree ?" included in the review of sys tems may also yield impo rtant informalion . Of note . these questions must be asked only when the patient's partner is not present in order 10 avoid possible incre ased inju ry to the patie nt beca use of retaliation by the partner. If the patienr' s responses indicate some co ncern for safety or possib le abuse. the health-care provider must dete rm ine the type and level of abuse. the degree of social isolation . the presence of weapons in the hom e. and whether the patient has an escape plan for herself and her children (if needed ).'> A good mnemon ic for health -care providers to use when asking questions 10 asses s the situation further is " SA F g' (Ta ble I). SA FE question s address the followin g issues: stress and safety. a fmid or abused, f riend o r famil y awareness , and emergency escape plan. The answe rs to SAFE question s can help the provider characterize the intensity of the situation and determi ne the appropriate intervention strategy.v?
For personal use . Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, March 1998, Vol 73
Table 1.-Screening for Domestic Violence in Intimate Adult Relationships: Use of the "SAFE" Mnemonic Stress and saf ety Do you feel safe in your relationship? What happens when you and your partner disagree? Afraid or abu sed Have yo u or yo ur children ever been physically threatened or abused? Have yo u ever been forced to have sexual inter-
course? Friend or f amily awareness Arc your friends or fam ily aware of what is happening?
Would they support and help you? E mergency escape plan Arc you in danger now , and would yo u like to go to a shelter or
talk with someone? Do you have a place where you and your children could go in an eme rgency?
INTERVENTIONS After the health-care provider has treat ed any inju ries, the foll owing factors mu st be docum ent ed in the patient ' s medical record : injuries. any history of abuse reported by the patient, and supporting laboratory or roent genog raphic findin gs. The victim may use this infonnation as ev ide nce in a future legal action. Emphasizing that domestic violence is wro ng and that no person dese rves (0 be mis treated by an intimate partner in a physical , emotional, or sex ual mann er is c ritical to the provider 's support o f the victim . Giving the victim inform ation about legal and soc ial services , suc h as a battered wom en 's shelter and victim advoc acy groups, is essenti al. Providers sho uld becom e fam ilia r with the se resource s in their co mmunities but mu st be cautious abo ut giving the victim written material, such as pamphlets, that could be found on her per son by the perpetrator and cause her more injury.I.6.7 Many health-care providers become frustrated when a woman does not elect to leave the abusive situation or take legal action immediately. A ballered woman may have many reason s for this de lay, including blaming herself for the abuse, fear of retaliation against her self or her children, deni al. or lack of financi a l support. Of import ance, the
Domestic Violence
273
health -care provider should nut blame the pati ent for this relu ctance or inabi lity to leave but rath er schedule follow up appo intments and offe r ongo ing support. Intervention programs with perpetrators ha ve not been show n to be effec tive. Th e reporting requirem ents regarding domest ic violence vary in eac h state. Because most battered partn ers a re legally com petent adult s with a right to co nfidentiality. many states do not require the reporting of partn er abuse except in certain circum stances. such as when firearms are invol ved. SUMMARY Dom estic violence . a prevalent and serious problem in the United Slate s, results in pron ounced morbidity and mortality to intimate partne rs and their c hildre n. It can occ ur in any patient population and has no ethn ic, geog raphic, reli gious , or soc ioeco nom ic bo undar ies. A dynam ic of uneq ua l power and contro l between intima te partners can result in a pattern of cyclic and esc alating psych ologic, sex ual, and physical abuse. The signs and sym ptoms ca n be obvious injuries or subtle somatic co mplaints. Screening question s about dom estic violence mu st be an integral part of medi ca l interactions because few victims will volunteer this inform ation. A speci fic knowledge of the resou rces in one 's com munity is es se ntia l for providing the support that victims and their children need .
REFERENCES 1.
2. 3.
Baker NJ, Mersy DJ, 'r eteur JM, CIl,.. JM. Family VIOlence. Monograph 20 5. Home Study SeIf.Assessment Program. Kansas City (MO): American Academy of Family Physicians; 1996 Jun Elliott BA, Johnson MM . Domestic violence in a primary care setti ng: pattern s and prevalence. Arch Fam Moo 1995:4 :113-119 AAFP CommhuHon on Special Issues and Clinical Interests . Family violence: an AAFP white paper. Am Fam Physician 1994 :50 :1636-
1638;1640; 1644;1646
4.
Council on Ethical and Judk:lal AHal"', American Med ical Associ ation . Physicians and domestic violence : ethic al considerations. JAMA
5.
Counc il on Sclttnt tflc AHaI"', American Medical Association. Violence against women. lAMA 199 2;26 7:3184-31 8 9 "-hur ML Asking about domest ic violence: SAFE questions [letter], l AMA 19 93 :269 :2367 Neufeld B. SAFE questions : overcoming barriers to the detecti on of comestc violence. Am Fam Physician 199 6;53: 25 75-2580
1992;267:3190-3 193 6. 7.
Questions About Domestic Violence in Intimat e Adult Relati onsh ips
(See article, pages 27110 273)
I. Which Qllf. of the following is l!S11 an epidem iologic characteristic of dom estic viol en ce? a. Ninety to 95% of victims are women in heterosexual re lation ship s b. It affects 2 to 4 milli on US wom en annually
c. It rare ly occ urs during pregn ancy d . It is the leading ca use of inju ry tu US women in the 15- to 44 -year-old age-group e. About 4% o f male homi cide victims arc killed by spouses or girlfriends
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
274
Mayo Clio Pr oc, March 1998. Vol 73
Domes-tic Violence
2. Wh ich I2!1J:. of the following statements abo ut domestic violence is true? a. It usually invo lves only physical abuse b. It occ urs primarily in lower socioeconomic groups c. The tension-building phase rarely esca lates to an actual incident d. Th e remorse phase leads to true resolut ion of the violence if co uples receive co unseling c. It progresses to increasing violence in a cyclic fashion 3. Which I2!1J:. of the followi ng is not true regarding the signs and symptoms of domestic violence? a. Th e patient will often volunteer information about the abuse to the health -care provider b. Bruises on the breasts or abdomen are highly suggestive of abuse c. Injuries during pregnancy are com mon d. Repeated medical visits for chronic com plaints such as headac he. pelvic pa in, gastrointest inal distress, and fatigue should suggest the possibility of abuse e. Depression and suicidal ideation may be co mmon in abused women
4. Which I2!1J:. of the followi ng health-care provider interventions is /lot appropriate in domestic violence? a. Routin e screening of all patients whcn the provider review s the medica l history b. Immediate repo rting of any domestic violence to law enfo rcement personnel c. Offeri ng nunjudgmental follow-up and support d. Giving information on legal and socia l services in the com munity e. Caref ully doc umenting injuries 5. Which I2!1J:. of the followi ng is the lees: important factor to assess when a patient admits to a history of domestic abuse? a. b. c. d.
The type and intensity of the abuse The presence of weapons in the house The patient's degree of isolation The abuser's willingness to participate in family co unse ling e. The patient's esca pe plan
Correct answe rs: I. c, 2. e. 3. a, 4. b, 5. d
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