Domestic Violence: The Primary Care Physicians Role

1. Domestic Violence: The Primary Care Physician's Role Anika A. H. Alvanzo, MD February 27, 2001

2. Overview Definition Incidence/Prevalence Victim Presentation Barriers to Screening Screening Risk Assessment Safety Planning Documentation Mandatory Reporting Resources

3. Definition of Domestic Violence A pattern of intentionally coercive and violent behavior toward an individual with whom there is or has been an intimate relationship Includes physical injury, verbal abuse, and economic abuse

4. Incidence/Prevalence US Dept of Justice- National Crime Victimization Survey -1 million violent crimes against victims committed by current or former spouses or boyfriend/girlfriend in 1998 22% of violent crimes against women between 1993-1998 1,830 murders in 1998 (11% of all murders nationwide) Of above murders 72% of the victims were women Women were 5x more likely to be victims of abuse as compared to men Homicide data obtained from FBI Uniform Crime Reporting Program Conducted interview between 1993-1998 of approx 300,000 households and 600,000 people age 12 and overHomicide data obtained from FBI Uniform Crime Reporting Program Conducted interview between 1993-1998 of approx 300,000 households and 600,000 people age 12 and over

5. Incidence/Prevalence Abbot et al (Jama 1995) 12% of women with current partners reported domestic violence within the previous year 6% of women without current partners reported domestic violence within the previous 30 days 54% of women reported a lifetime prevalence of domestic violence 2 teaching hospital EDs, 1 private ED, 2 hospital walk-in clinics all in Denver, CO 30 randomly selected 4hr time blocks btwn April-May 93; 833 women seen; 648 participants Self administered 34 item questionnaire 2 teaching hospital EDs, 1 private ED, 2 hospital walk-in clinics all in Denver, CO 30 randomly selected 4hr time blocks btwn April-May 93; 833 women seen; 648 participants Self administered 34 item questionnaire

6. Incidence/Prevalence McCauley et al (Annals 1995) 5.5% reported domestic violence within the previous year 21.4% reported history of domestic violence ever in adult life 22% reported history of domestic violence prior to 18yo 4 PC clinics in Baltimore, MD associated with Hopkins Bayview between Feb-Jul �93 85 question self administered survey (Abuse Assessment Screen, CAGE, Symptom checklist) 3203 women total (283 not eligible, 528 not asked); 1,952 women completed the questionnaire 4 PC clinics in Baltimore, MD associated with Hopkins Bayview between Feb-Jul �93 85 question self administered survey (Abuse Assessment Screen, CAGE, Symptom checklist) 3203 women total (283 not eligible, 528 not asked); 1,952 women completed the questionnaire

7. Incidence/Prevalence Geary and Wingate (AM J of OB/GYN 1999) 40.1% of women gave history of abuse Of these women, 76.2% were currently in an abusive relationship Most common injuries reported were fractures Grady Memorial OB/GYN emergency clinics April 1991 452 respondents Voluntary self-administered questionnaire given to pt by triage nurseGrady Memorial OB/GYN emergency clinics April 1991 452 respondents Voluntary self-administered questionnaire given to pt by triage nurse

8. Presentation: History History inconclusive with type of injury Delay between injury and presentation Accident prone history Repeated STD�s Repeated failure of compliance with medical care

9. Failure to get prenatal care Psychosomatic complaints with negative organic workup (i.e. chronic HA�s, abd pain, or pelvic pain) Mental illness (depression, anxiety, PTSD) Suicide attempts Substance abuse Presentation: History

10. Central pattern of abuse (face, neck, chest, breasts, abd, genitalia) Multiple injuries in various stages of healing Bruises on inner aspect of arms/legs Injuries suggestive of a defensive posture (i.e. ulnar aspect of forearms) Presentation: Physical

11. Barriers to Screening Suggs and Inui (JAMA 1992), Suggs et al (Arch Fam Med 1999) Time constraints Opening Pandora�s Box �It�s a Private Matter� Physician Bias Fear of offending the patient Powerlessness Lack of Training Safety Concerns 1992 JAMA (Suggs and Inui) interviewed 38 physicians in an Urban HMO (34FPs�, 4 Int Med) between Aug 90-Feb 91 1999 interviewed 206 (71 physicians, 13 PAs, 6 NPs, 58 RNs, 25 LPNs, 33 Mas Comparison: 55% in 1992 felt fear of offending pt 65% in 1999 were not concerned re offending pt (85% felt it was not an invasion of privacy) 1999: 15% believed that victim�s personality caused them to be abuse 25% believed abused persons passive-dependent personality led to abuse 19% believed victim stayed b/c they were getting something out of the relationship 39% were confident in asking about DV 26.5% felt workplace was not secure enough to discuss DV with pts only 23% felt they had strategies to assist victims 1992 JAMA (Suggs and Inui) interviewed 38 physicians in an Urban HMO (34FPs�, 4 Int Med) between Aug 90-Feb 91 1999 interviewed 206 (71 physicians, 13 PAs, 6 NPs, 58 RNs, 25 LPNs, 33 Mas Comparison: 55% in 1992 felt fear of offending pt 65% in 1999 were not concerned re offending pt (85% felt it was not an invasion of privacy) 1999: 15% believed that victim�s personality caused them to be abuse 25% believed abused persons passive-dependent personality led to abuse 19% believed victim stayed b/c they were getting something out of the relationship 39% were confident in asking about DV 26.5% felt workplace was not secure enough to discuss DV with pts only 23% felt they had strategies to assist victims

12. Screening Conflict Tactics Scale Index of Spouse Abuse Abuse Assessment Screen CTS- 20 questions which measure 3 tactics: 1)Reasoning Scale- use of rational discussion, argument and reasoning (intellectual approach), 2)Verbal Aggression Scale- use of verbal and nonverbal acts which symbolically hurt, or the use of threats, 3)Violence scale- use of physical force as a means of resolving conflict Scoring: percentage of total score ISA: 30 item questionnaire which measures physical (ISA-P) and nonphysical abuse (ISA-NP) scoring: ranges btwn 0-100 for both AAS: 5 question screen CTS- 20 questions which measure 3 tactics: 1)Reasoning Scale- use of rational discussion, argument and reasoning (intellectual approach), 2)Verbal Aggression Scale- use of verbal and nonverbal acts which symbolically hurt, or the use of threats, 3)Violence scale- use of physical force as a means of resolving conflict Scoring: percentage of total score ISA: 30 item questionnaire which measures physical (ISA-P) and nonphysical abuse (ISA-NP) scoring: ranges btwn 0-100 for both AAS: 5 question screen

13. Risk Assessment Does perpetrator have access to you? Does partner abuse drugs or alcohol? Is partner violent with other people outside the home? Does partner abuse your children or other family members?

14. Risk Assessment Has violence increased in frequency and/or severity? Have you been choked? Are there weapons available? Has a weapon been used to scare or hurt you? Has partner ever threatened suicide?

15. Safety Planning Commit important phone numbers to memory Keep change for pay phone on your person at all times Make copies of all important documents (i.e. marriage license, birth certificates, social security card, passports, lease/mortgages, insurance papers)

16. Safety Planning Leave copies of documents, extra set of clothes, extra set of keys, and extra money with trusted friend or relative Rehearse and commit escape plan to memory

17. Documentation Record description of encounter as told to you by patient (use quotes if possible) If patient names her perpetrator, write name down in the medical record (i.e. Pt states that she was struck by her husband, John Brown.) Record all pertinent physical exam findings (use body map)

18. Documentation Offer to photograph visible injuries Preserve all physical evidence (i.e. bloodstained clothing) Record suspicions even if patient denies history of domestic violence (i.e. in cases where mechanism of injury is not consistent with exam) Write legibly Important because medical records can be subpoenaed, even if victims decline to press charges. Particularly important for civil cases like divorce and child custody.Important because medical records can be subpoenaed, even if victims decline to press charges. Particularly important for civil cases like divorce and child custody.

19. Mandatory Reporting Majority of states mandate reporting of injuries that occur as a result of a gun, knife, or other deadly weapon Some states require reporting of injuries resulting from crimes or nonaccidental acts As of 1995, 5 states had laws specifically addressing cases where domestic violence was suspected (CA, KY, NH, NM, RI)

20. Resources National Domestic Violence Hotline (800-799-SAFE) Virginians Against Domestic Violence (800-838-VADV) Health Resource Center on Domestic Violence (800-313-1310) YWCA (804-643-6761) 24hr hotline Richmond 643-0888, Chesterfield 796-3066

21. References El-Bayoumi G, Borum M, Haywood Y: Domestic violence in women. Medl Clin of North America 82:2, 1998 Haywood Y, Haile-Mariam T: Violence against women. Emerg Med Clin of North America 17:3, 1999 Rennison C, Welchana S. Intimate partner violence. BJS report, NCJ 178247, May 2000 Abbot J, Johnson R, Koioi-McLain J, et al. Domestic violence against women. JAMA 273:22, 1995 McCauley J, Kern D, Kolonder K, et al. The �Battering Syndrome�: prevalence and clinical characteristics of domestic violence in primary care Internal Medicine practices. Annals of Int Med 123:10, 1995 Geary J, Wingate C. Domestic violence and physical abuse of women: The Grady Memorial Hospital experience. AM J of Obstetrics and Gyn 181:1, 1999 Sugg NK, Inui T. Primary care physicians� response to domestic violence. JAMA 267:23, 1992

22. References Sugg NK, Thompson RS, Thompson DC, et al. Domestic violence and primary care. Arch Fam Med. 8, 1999 Straus M. Measuring intrafamily conflict and violence: the conflict tactics scales. J Marriage Fam. 41, 1979 Urdy JR. Marital alternatives and marital disruption. J Marriage Fam. 43, 1981 McFarlane J, Parker B, Soeken K, et al. Assessing for abuse during pregnancy. JAMA 267:23, 1992 Salber P and Taliaferro E: The physician�s guide to domestic violence. California, Volcano Press, 1995 Hyman A, Shcillinger D, Lo B. Laws mandating reporting of domestic violence: Do they promote patient well-being? JAMA 273:22, 1995