Update on Domestic Violence

1. Update on Domestic Violence Laurel Romer, M.D. Primary Care Conference May 26, 2004

2. Financial Disclosure • This talk has not been sponsored by any organization.

3. Learning Objectives • Understand current screening and intervention recommendations for intimate partner violence • Feel competent to assess patients for intimate partner violence • Know what resources to offer a patient who is a victim of intimate partner violence

4. Case Presentation • A 40 year-old white female presents to an internal medicine clinic with complaints of syncope. Past medical history is notable for asthma, headaches, abdominal complaints and chest pain. Further workup reveals a resting pulse rate of 42 and the patient has a witnessed syncopal episode in the office. She is diagnosed with symptomatic bradycardia and a pacemaker is placed. The patient presents for follow-up after pacemaker placement and she makes poor eye contact, appears depressed and is vague in her answers.

5. Case Presentation • After further directed questioning, she admits that she has been physically and sexually abused by her husband for 12 years. • What is your response to this revelation? • What resources do you offer the patient? • What is the plan for follow-up?

6. Intimate Partner Violence (IPV) - Definition • AMA definition: • “a pattern of coercive behaviors that can include battering and injury, sexual assault, social isolation, deprivation, and intimidation perpetrated by someone who was or is intimate with the victim”

7. Intimate Partner Violence - Scope • 1 to 4 million women are physically, sexually or emotionally abused by their intimate partners each year • 4000 deaths annually • 31% of all women report abuse at some point in their lifetimes • Women are 7 to 14 times more likely than men to suffer severe physical injury from assault by an intimate partner • In primary care settings, 14 to 28% of female patients are victims of IPV Ann Intern Med. 2004; 140:382-386. Kripke EN. JGIM. 1998; 13(12):839-841.

8. Victim Characteristics • Age less than 35 • Low income status • Pregnancy • Mental health problems • Alcohol or substance abuse • Separated or divorced status • Recently obtained a restraining order • History of childhood physical/sexual abuse Ann Intern Med. 2004; 140:382-386.

9. Common Presenting Problems of Victims • Headache • Musculoskeletal pain • Gastrointestinal complaints • Premenstrual symptoms • Dyspareunia • Depression • Alcohol abuse • Sexual dysfunction Freund KM, et al. JGIM. 1996; 11(1): 44-46.

10. Perpetrator Characteristics • Characteristics associated with increased risk of inflicting abuse: • Alcohol abuse • Drug abuse • Intermittent employment • Recent unemployment • Less than a high school education • Former/estranged husband or boyfriend Kyriacou DN, et al. NEJM. 1999; 341(25): 1892-1898.

11. Barriers to Screening for IPV • 5 minute mail survey sent to 600 each of IM, FP, OB-GYN, ER physicians • 88% of respondents knew patients in their practice who had experienced IPV • Respondents screened a median of only 10% of female patients for IPV • 80% reported to have had training on issues of IPV Elliott et al. JGIM. 2002;17(2):112-116.

12. Barriers to Screening for IPV • Results: • Lack of confidence in ability to recognize victims • Inadequate resources to help identified victims • Did not want to offend or anger patients • Forgot to routinely ask about IPV • Lack of time Elliott et al. JGIM. 2002;17(2):112-116.

13. Barriers to Screening for IPV • Training issues gleaned from this study: • Remind physicians that patients do not mind being asked • Remind physicians that it is RARE for a woman to voluntarily admit a history of violence • Chart reminders/check-off boxes on history forms Elliott et al. JGIM. 2002;17(2):112-116.

14. Does screening identify victims? • Comparison of addition of a single question about IPV on the health history form to discretionary inquiry alone • At any time has a partner ever hit you, kicked you, or otherwise physically hurt you? Freund KM et al. JGIM. 1996;11(1):44-46.

15. Does screening identify victims? • Results: • IPV identification rose from 0% in the control group (discretionary inquiry) to 11.6% in screening group Freund KM et al. JGIM. 1996;11(1):44-46.

16. Screening Questions • SAFE • Stress/safety: Do you feel safe in your relationship? • Afraid/Abused: Have you ever been in a relationship where you were threatened, hurt or afraid? • Friends/Family: Are your friends/family aware that you have been hurt? Could you tell them, and would they be able to give you support? • Emergency Plan: Do you have a safe place to go and resources you need in an emergency? Barrier PA. Mayo Clin Proc. 1998;73:271-274.

17. Screening Questions • At any time, has a partner hit, kicked or otherwise hurt or threatened you?

18. USPSTF Recommendations • No direct evidence that screening for IPV leads to decreased disability or premature death • No existing studies that determine the accuracy of screening tools for identifying IPV • Limited evidence as to whether interventions reduce harm to women • No existing studies to determine the harms of screening and interventions for IPV Ann Intern Med. 2004; 140:382-386.

19. Recommendations of Other Groups • ACOG: physicians should routinely ask women direct, specific questions about abuse • AMA: physicians should inquire routinely about domestic violence history and refer, when appropriate, to medical/community-based services • AAFP: physicians be alert for the presence of family violence in virtually every patient encounter Ann Intern Med. 2004; 140:382-386.

20. Physicians With Expertise in IPV • Focus groups conducted of ER, OB/GYN, IM and FP physicians identified as having expertise in IPV Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

21. Physicians With Expertise in IPV • 5 themes identified • How physicians frame screening questions to reduce patient discomfort • Patient signs that cause physicians to suspect abuse • Direct and indirect approaches to identifying victims • Rarity of direct patient disclosure • How physicians redefined successful outcomes of universal screening Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

22. Physicians With Expertise in IPV • How physicians frame screening questions to reduce patient discomfort • Many do not conduct universal screening • “Normalizing” IPV in health history by including it with other safety questions • Telling patients they routinely ask all of their patients about IPV Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

23. Physicians With Expertise in IPV • Patient signs that cause physicians to suspect abuse • Depression, anxiety, chronic headaches, pelvic pain, vague stomach pains that do not improve over time with treatment • Story of injury does not fit presentation of injury • Chronic injuries that fit a pattern • Known history of abuse Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

24. Physicians With Expertise in IPV • Direct and indirect approaches to identifying victims • The more time they had with patients, the more indirectly they approached the topic • Developing a trusting relationship over time enhances the chance of future disclosure and decreases patient dropout • Acute injuries obviously related to abuse, more easy to go after directly Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

25. Physicians With Expertise in IPV • Rarity of direct patient disclosure • Seems to occur only with an acute injury or in an emergent situation • Screening questions rarely produces direct disclosure • Watch for patient cues: body language, tone or hesitation Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

26. Physicians With Expertise in IPV • How physicians redefined successful outcomes of universal screening • Compassionate asking = success • Success does not depend on knowing for sure that the cause of the presenting problem is abuse • Make sure the patient knows they don’t deserve abuse and there are resources available to help Gerbert B, et al. Ann Intern Med.1999; 131(8): 578-584.

27. Physician Factors That Facilitate Trust • Semistructured open-ended interviews with 27 IPV survivors yielded 5 dimensions of provider behavior that facilitate trust • Provider willing to openly discuss abuse (89%) • Professional competency • Provider accessible, respected confidentiality, shared decision making • Caring/compassion (89%) • Emotional equality (67%) Battaglia TA et al. JGIM. 2003;18(8):617-623.

28. Interventions • Once you have identified a victim of IPV, what should you do? • Ask about concurrent child abuse • Assess patient for immediate safety • Ask about guns/weapons in home • Tell patient you believe her and that she doesn’t deserve abuse • Assess patient for depression/suicidality • Make follow-up appointment with patient within 1 month

29. Interventions • Offer resources to patient: • National Domestic Violence Hotline: • 1-800-799-SAFE

30. Interventions

31. Interventions

32. Interventions • Other resources to consider: • Religious counseling services (Lutheran family social services…) • Counseling through patient’s insurance plan • Social worker to help with family issues • Supportive family members/friends • Consider a permanent restraining order

33. Teaching Medical Students About IPV • One model: 3 day interclerkship • Stories of IPV survivors • Role play • Reflect on own experiences • Resulted in sustainable improvements in attitude and skills for violence screening and intervention Jonassen JA, et al. Acad Med. 1999;74:821-828.

34. Resident Competency in IPV • Standardized patient-based Clinical Skills Assessment • 56% correctly identified IPV as the underlying problem in a patient presenting with chronic headaches • Of these residents, 75% would have referred the patient for IPV counseling • Among all residents, 68% made 1 or more incorrect recommendations Varjavand N et al. JGIM. 2002;17(6):465-468.