Detecting domestic violence

Citation:
Director TD, Linden JA. Domestic violence: an approach to identification and intervention. Emerg Med Clin N AM 2004; 22: 1117-1132.

 

Domestic violence (DV), also known as intimate partner violence, includes a wide variety of behaviors that are aimed at coercing, controlling, intimidating, or demeaning someone else through physical abuse, social isolation, deprivation, and intimidation. Legal definitions vary but refer to acts of physical or sexual violence. Literature reports yearly incidence of DV ranging from 5 to 11.7% with lifetime prevalence of 21-54%; women were six times more likely to be the victims. Disturbingly, the National Violence against Women Survey found 25% of women and 7.6% of men report rape or physical assault in their lifetime. JCAHO now requires ED protocols to identify and treat DV victims.
Young, single women, as well as pregnant women are particularly at risk for DV. Victims are more likely to be depressed, have low self-esteem and increased stress. There is no consensus concerning if race or socioeconomic status places people at risk. Also, there are no specific universal characteristics of abusers. Substance abuse or exposure to violence as a child is prevalent in abusers according to some studies. Since it can be difficult to distinguish an abuser or a victim, it is very important that the EP screen for DV. Although 37% of female trauma victims presenting to the ED are caused by partner-related DV, studies have shown that EPs only identified 5% of DV victims and only 13% even ask about DV. This is particularly startling since victims of DV report that a question by a health care worker is the essential first step to identifying the problem.

The partner in violence screen has a sensitivity of 65-71% for DV while the StaT test has a sensitivity of 97% (see chart).

 

Other authors suggest open-ended questions, but since victims rarely volunteer information, attempting to perform some type of screening is more important than the types of questions asked.
Suspicion should be raised with any injury during pregnancy, recurrent injuries, or defensive injuries. Patients may present with vague, non-specific complaints as initially physical injury is less common. The patient may be evasive or fearful during the interview or delay seeking treatment or come in with an overly protective, hovering partner. DV victims present with a 60% higher rate of problems such as headache, back pain, GI problems, depression, substance abuse, eating disorders, and PTSD. Also chronic diseases can be exacerbated or be poorly controlled. Remember a high level of suspicion is important and you need to screen for suicidal ideation.

EPs need to understand the five stages of change in order to help their patient get out of an abusive relationship. In the precontemplation stage the patient may not know they are being abused and does not want to change the situation. In contemplation the victim can gather information but is not actively seeking change. In preparation the victim is planning change. This is followed by the action stage and the maintenance stage where the patient leaves/ends the violence and works to prevent relapse. Knowing the stages is important because making the patient aware of abusive behaviors and reassuring them that DV is not their fault is more effective in the first two phases while referrals, hotlines, and support groups are more effective in the later stages.

Documentation is very important as these records may be needed in a criminal trial. Direct quotes are very useful. Different states also have different laws concerning what must be reported. Also the physician must make sure it is safe before the patient leaves and can give them websites or phone numbers such as 1-800-799-SAFE (National Domestic Violence Hotline).

 

Other DV Sites:
www.ndvh.org
www.endabuse.org
www.ncadv.org
www.nnedv.org/who.html
www.ojp.usdoj.gov/vawo/state.htm