Asking about intimate partner violence advice from female survivors to health care providers
The adverse health consequences associated with domestic violence often bring patients who are abused in contact with health care professionals. Patients who use violence against their partners are also likely to seek health services. Patients may seek health care services for problems, such as physical injuries, anxiety, depression, and post-traumatic stress that are triggered by domestic violence. Facial injuries caused by domestic violence can be identified in dental settings. Primary care, reproductive health, and child health care providers are also positioned to identify and prevent domestic violence.
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Intimate Partner Violence
The identification of women who are victims of IPV must be incorporated into the routine care performed by obstetricians and gynecologists. Practitioners often cite multiple reasons to rationalize their exclusion of this discussion as a routine part of patient care Table 1. Also responsible are personal biases that all practitioners bring along to the practice of medicine.
Foremost among these myths are the following: 1 IPV is rare. Knowledge of the prevalence of IPV in the United States as well as in the practitioner's own community helps the practitioner realize that violence may be a part of the lives of patients and therefore must be addressed as a routine part of comprehensive health care; 2 IPV does not occur in normal relationships.
In fact, the health care provider may know and like the abuser, as has been demonstrated by celebrity cases highlighted in the media. IPV is not relegated just to women of specific ethnic or socioeconomic groups. In addition, most health care providers use a very narrow definition of what constitutes IPV. Physical violence is easier to see, but abuse also consists of sexual, emotional, economic, and verbal assaults. There is no real difference between these forms of abuse because all result in significant damage to the woman and her children; 3 women are responsible.
After all, medical personnel deal with issues far less immediately life-threatening to patients, such as diet, exercise, and smoking cessation, and have less success with these than they do with assisting a woman involved in a violent relationship. IPV, as with many other problems, may require frequent, repeated messages from physicians to convince battered women to stop their involvement with their abusive domestic partner; 4 IPV is a private matter.
Knowledge regarding the cycle of violence clearly demonstrates that abuse will escalate. In addition, keeping IPV a private matter further serves to stigmatize the issue, thereby preventing interventions that could be life-saving.
It is important for the practitioners to understand the cycle of violence so that they can appreciate the fact that violence escalates and that women may seek care only during certain periods of the cycle Fig. Table 1. Reasons physicians do not screen for IPV. The cycle of violence adapted from JAMA 9, Clues to the presence of violence in the lives of women are both behavioral and physical.
Behavioral clues that should increase the index of suspicion for violence include missed appointments, repetitive psychosomatic symptoms, depression including suicide attempts , being accident prone , substance abuse, poor reproductive history, vague and inconsistent descriptions of injuries, delay in seeking attention for injuries, partner's demeanor and behavior in the medical setting, and the patient's direct report of abuse.
The demeanor of the woman during the history and physical examination can include a flat or sad affect, embarrassment on the discovery of injuries, hesitance in discussing issues, apprehension about discussing her injuries, evasiveness, and even anger. All of these responses to a life of violence are acceptable, because there is no one set way in which abused women will respond when asked about injuries acquired as part of domestic abuse.
Her response may be colored by past experiences with professionals, where she is within the cycle of violence, and the lethality of her particular circumstance. The physical examination can further aid in the identification of women who have been abused. The injuries in women who have experienced IPV tend to occur in a pattern that is generally not visible when the woman is clothed bathing suit appearance or in the head and neck region. Injuries are usually multiple and out of phase, and the explanation given for their presence does not fit with either the injury itself or the age of the injury Table 3.
During the examination, the woman's partner may stand and watch the examination, answer all questions directed to the woman, and appear overly solicitous; he may even refuse to leave the examination room.
This is of particular importance if the partner is the primary translator for a woman who does not speak English. The abuser may also test the limits of the medical visit, exhibiting hostile and surly behavior toward the staff. These clues should alert the physician to the possibility of IPV. Specific gynecologic indications of IPV include sexually transmitted disease, pregnancies, chronic pelvic pain, sexual dysfunction, recurrent vaginal infections, and premenstrual syndrome.
In addition to recognizing the problem, physicians must provide a secure environment in which the woman can feel comfortable talking, can validate her experience as a serious problem, and can record the occurrence and the effects of the violence. Asking about violence in a direct fashion communicates to the patient that the physician is willing to help and is aware of the patient's problem. Victimized women are more likely to disclose the circumstances of their victimization to other women and to personnel who offer protection and are sympathetic to the plight of battered women.
Educating staff members about the signs and symptoms of IPV may prove to be an invaluable step in the identification of women suffering spousal abuse. In addition to asking the question on a routine basis, having posters and pamphlets clearly visible in patient areas also communicates that this is a safe haven where the issues of IPV are understood.
The bathroom in the medical office is one of the few places where the woman will be unaccompanied; strategically placing posters and cards with hotline numbers or the numbers of local agencies can be invaluable here.
Not only can the woman receive the message that this is a place of support for her plight but also can she take steps toward leaving the abusive relationship in her own time frame. After a disclosure about IPV to a physician, nurse, or social worker, the woman should be seen as quickly as possible by an advocate or social service representative who can provide her with information about her legal rights and, when needed, shelter.
When women are asked about violence directly and routinely, in a way that is not threatening, they will discuss their abuse, particularly if they believe that the health care provider really wants to know.
When physicians do not diagnose abuse, the abuse will most likely continue and will often escalate. The interview approach should include directly and gently questioning all women about the presence of violence in their lives. Is that happening to you? Are you afraid of anyone at home? Did someone cause these injuries? Do you know where you could go or who could help you if you were being abused?
Perhaps even more disturbing for physicians is a "No" answer when all clinical indicators suggest that the woman is a victim of IPV. Understanding the reasons women cannot leave is helpful to the practitioner in accepting this response Table 4.
The inability of women to leave abusive relationships must be compared with attempts to stop smoking and other less complex life changes. The practitioner should not expect that a single question about what is obviously long-standing violence in the woman's life is going to miraculously cure the situation. The difficulties encountered by women leaving these situations are often overwhelming. What the practitioner can do is provide the woman with guidance regarding a safety plan for when and if she does choose to leave.
The patient's confidentiality must be respected during all questions about abuse. Any queries regarding the home situation must be asked with the patient alone, away from the abuser. In addition, any reporting with the exception of child abuse reports must be performed with the patient's expressed consent unless the physician is required by law to report a particular event.
The opportunity to evaluate for the presence of injuries is more likely to occur during an obstetric or gynecologic physical examination, because of the nature of this examination, than it is during other primary care physician visits e. Therefore, it is the obligation of the physician to recognize injuries that may be secondary to abuse. Typically, these injuries appear on portions of the patient's body that are usually clothed; therefore, they are hidden from friends, family, and neighbors.
Bruises are usually of varying ages, and other injuries are in various stages of healing. The examining physician must question the presence of these injuries but must also ensure that acute injuries receive specific trauma care, if necessary.
Documentation of all injuries must be part of the confidential medical record. Often, outpatient therapy is sufficient. However, if injuries are severe or the situation is deemed to be lethal, then inpatient therapy is justified.
The safety of the woman must be the first consideration under these circumstances. Information regarding options and community resources should be given to the patient when IPV is discovered. The long-term goals of these interactions are to validate the woman's experience and to explore and advocate safe options while respecting her right to make her own decision about the next step.
This should include firm plans for a future visit as well as follow-up communication with the woman that is documented in the patient record. The follow-up plan serves to maintain open lines of communication for the patient while assuring that she and her children remain safe. The assessment of lethality is the most important consideration when a women is identified as living with IPV.
It is well known that the cycle of violence escalates over time and that the risk of life-threatening injury and homicide increases. Therefore, assessing the safety of the woman and her children is of primary importance. Queries regarding the presence of firearms, a previous history of threats to harm with firearms, or previous injuries with potentially lethal weapons should alert the physician to the lethal risk of this situation.
Questions regarding safety must be posed to the woman at the time that IPV is identified. Models for assessing lethality in pregnancy Abuse Assessment Screen and in other clinical circumstances SAFE questions are available to practitioners.
They add very little time to the clinical interview and demonstrate the practitioner's desire to know about abuse and the safety of the woman. After she is assessed for lethality, the woman must be assisted in developing a plan of action to secure her safety and that of her children. The safety plan must include transportation, a place to go, necessary items for survival, and important documents Table 5.
IPV during pregnancy is not rare. There are a lack of data on frequency, timing, and severity of injuries during pregnancy as well as a lack of stratified data on ethnic and other demographic variables. It is well known, however, that abuse during pregnancy poses significant risks for both mother and fetus. The adverse effects of abuse during pregnancy result from either direct or indirect causes. Direct causes of adverse perinatal effects include abruptio placentae; fetal fractures; rupture of the maternal uterus, liver, or spleen; maternal pelvic fractures; and antepartum hemorrhage Fig.
Pregnancy may motivate women to seek help from abusive relationships. It may also be the only time that a woman seeks medical attention. The fetal consequences of the abuse may be the factor that motivates the woman to take steps to remove herself from the abusive situation. Fractured fetal femur secondary to IPV. Data suggest that IPV determines the trimester during which women will seek care during pregnancy. In fact, the abuser may force the woman not to seek earlier care by denying transportation, nutrition, and access to medications antibiotics, vitamins.
Because injuries around the head and neck are publicly visible, evidence of the abuse may contribute to missed appointments. Women who begin prenatal care late may have only one opportunity to obtain information on abuse and be given options for maternal and fetal safety. All physicians are required to keep comprehensive medical records for all patients, and these records must document the woman's report of abuse.
In most circumstances they should be handled by law enforcement specialists. They must also be kept in a sealed envelope so that they can be admissible for courtroom use at a later date, if necessary. Finally, under certain circumstances, a report must be filed with the police. Other cases that must be reported include attempted murder, assault with a deadly weapon, and other potentially lethal incidents. US laws regarding the reporting of these events vary from state to state and within municipalities.
Part of the development of safety plans for women who are victims of IPV is to identify what resources are available within the health care provider's community. The principles of this community relationship include ensuring the safety of the woman and her children, respecting the woman's integrity and authority, holding the perpetrator responsible for abuse, providing advocacy for women and children, and improving the response of the health care system.
Resources that should be available in every community include emergency housing, psychological counseling, legal counsel, and other support.
IPV Screening and Counseling Toolkit
Her visit was expected. The patients tend to come in gripping their stomachs or complaining of earaches, but the nurses and doctors look out for bruises or cuts on their bodies that suggest a different story. Rijal, suspecting something was off, asked the woman what happened.
We'd like to understand how you use our websites in order to improve them. Register your interest. Routine IPV screening is a controversial topic and there is no evidence to suggest that it improves the health outcomes of women. Consequently, understanding the socio-cultural dimensions, becomes essential to ensure that victims receive appropriate and local support.
Asking about intimate partner violence: Advice from female survivors to health care providers
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: Our study objective was to identify what advice women who had experienced IPV would give health providers regarding how to ask about and discuss the issue of IPV. View on PubMed. Alternate Sources. Save to Library. Create Alert. Launch Research Feed.
Asking about intimate partner violence: advice from female survivors to health care providers.
Female patients aged 16—29 completed after-visit surveys. Chi-square tests were used to compare groups that received training and historical controls. Overall, in this exploratory study, both communication-skills and standard training improved frequency of IPV communication when compared to historical controls but with few differences when compared to each other. IPV and RC are associated with a variety of negative health consequences such as unwanted pregnancies, sexually transmitted infections, smaller birthweight babies, chronic pain and gastrointestinal disorders and mental health disorders such as depression and substance abuse [ 8—13 ].
Intimate partner violence IPV , defined as sexual violence, stalking, physical violence, and psychological aggression perpetrated by an intimate partner, affects nearly a third of all Americans at some point in their lives. Although IPV affects men and women of all ages, women, particularly young women and women of color experience IPV at higher rates. An estimated 6. People who are victimized by their partners are more likely to experience health problems and both the Centers for Disease Control CDC and U.
Patient information : See related handout on intimate partner violence. Intimate partner violence IPV is a prevalent worldwide health problem, affecting women more commonly than men. IPV is underreported and underrecognized by health care professionals. Even when IPV is recognized, it remains an underaddressed issue.
Puzzled by all the details in new health care laws that benefit millions of women and girls? In February of , the U. With this and other new coverage requirements for screening and response, addressing DV in the health setting is becoming the standard of care. This toolkit offers health care providers and advocates for victims the tools to prepare a clinical practice to address domestic and sexual violence, including screening instruments, sample scripts for providers, patient and provider education resources. It also offers strategies for forging partnerships between health care and domestic and sexual violence programs. In that time, we have created resources to help providers identify and support women and girls experiencing intimate partner violence IPV.
Read terms. This information should not be construed as dictating an exclusive course of treatment or procedure to be followed. ABSTRACT: Intimate partner violence IPV is a significant yet preventable public health problem that affects millions of women regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational background. Individuals who are subjected to IPV may have lifelong consequences, including emotional trauma, lasting physical impairment, chronic health problems, and even death. Although women of all ages may experience IPV, it is most prevalent among women of reproductive age and contributes to gynecologic disorders, pregnancy complications, unintended pregnancy, and sexually transmitted infections, including human immunodeficiency virus HIV.
A more recent article on the intimate partner violence is available. Patient information: See related handout on partner violence , written by the authors of this article. Intimate partner violence is a common source of physical, psychological, and emotional morbidity. In the United States, approximately 1.
Judy C. Chang, Michele R. Decker , Kathryn E. Moracco, Sandra L.