Intimate Partner violence
IPV is significantly associated with
> self-report of poor health
Screening
Create a safe and respectful environment where the patient may be comfortable discussing IPV Posters / flyers in office can be nonverbal signal that IPV is an important health issue Describe IPV assessment as part of standard assessment Use a generalized statement to start. "Because abuse happens to so many people, I ask all my patients if anyone is threatening or hurting them." Assure patient of confidentiality unless a child is in danger or abused. "Have you ever been in a relationship where you were threatened or hurt?"
IPV Clues: Partner's Behavior
Overly solicitous Answers questions for patient Refuses to leave exam room The Setting is important Safe, private Interview patient alone
Risk Factors: IPV Specific Factors
Past hx violence Marital discord/dissatisfaction Difficulty communicating w/partner Ability to resolve conflict Normative use of violence to resolve conflict Sexual Violence Factors Beliefs in family honor/sexual purity Ideology of male sexual entitlement Weak legal sanctions for sexual violence Ability to resolve conflict Normative use of violence to resolve conflict
IPV Health Consequences
Physical health: Chronic pain ( disability long after abuse) Gastrointestinal disorders Multiple physical symptoms Exacerbations of chronic disease > engaging in risky behaviors (e.g. smoking) Alcohol and substance abuse (may be coping tool) Mental Health: Depression, Anxiety, Hopelessness, PTSD, Suicide, Homicide, Unwanted pregnancy
Safety Concerns
Safety is primary concern. Support her right to choose what to do next: To return home To leave home Safety of children Danger increases when a woman leaves the relationship Visitation of children by perpetrator Suggest supervised visitation Assist with safety planning for victim Network with community partners
Patterns of IPV:
Situational couple violence Intimate terrorism Violent resistance Mutual violent control
Referral and Information
Social worker Law Enforcement Protective order Restraining order Domestic Violence Services Advocacy Shelter Support groups
what are some ways they can have Reproductive Control Choices:
manipulation or control of contraception, refusal to wear condom, failure to disclose STD, attempt to impregnate without partner's consent
what is the second phases of the cycle of violence and describe
2. Acute battering episode—When the tension peaks, the physical violence begins. It is usually triggered by the presence of an external event or by the abuser's emotional state—but not by the victim's behavior. This means the start of the battering episode is unpredictable and beyond the victim's control. However, some experts believe that in some cases victims may unconsciously provoke the abuse so they can release the tension, and move on to the honeymoon phase.
what is the third phases of the cycle of violence and describe
3. The honeymoon phase—First, the abuser is ashamed of his behavior. He expresses remorse, tries to minimize the abuse and might even blame it on the partner. He may then exhibit loving, kind behavior followed by apologies, generosity and helpfulness. He will genuinely attempt to convince the partner that the abuse will not happen again. This loving and contrite behavior strengthens the bond between the partners and will probably convince the victim, once again, that leaving the relationship is not necessary.
Psychological Aggression
: name calling, derogatory statements, use of intense anger. Threats of suicide, harming pets, property, death threats. Social isolation, control of finances, healthcare, meds, & food
Sexual Violence
: noncontact experience of coercion or forcing to participate in photo/video, unwanted kissing or fondling, lack of consent 2° drug/alcohol use & attempted/or completed rape
Why does someone stay in a violent situation
Believes promises of change Blames herself No money No place to go Fear No one intervenes Need resources for children
Mandatory Reporting in Connecticut
Child abuse: under age 18 Abuse of disabled persons Elder abuse: age 60 and over In 6 states: health care providers must report physical abuse caused by domestic violence Controversial: 44% abused women oppose mandatory reporting
Positive answers to the following = increased risk of IPV
Do you feel afraid to go home? Violence increased over year? Threats to kill patient, her children or himself? Weapons in house? Encourage patient to consider emergency safety plan ($$, car /house keys, documents, safe place, childrens' needs)
If She Says Yes to intimate partner violence
Express concern: "I'm concerned for you." "You deserve to be safe." "You are not alone." Ask about her needs: "How do you feel about what's happened?" "What would you like to do?" Offer local resources
IPV Clues: Red Flags in Patient History:Somatic complaints
Headaches, abdominal pain Depression PTSD Anxiety, panic attacks
What if she says "No" to IPV or getting help
Let her know that support is available Document your screening "Patient stated that abuse is not an issue." If you suspect abuse, ask at subsequent visits Asking has an impact Plant a seed for tomorrow
Risk Factors: IPV & Perpetrator Factors
Lower levels of education Exposure to child maltreatment Witness family violence Antisocial personality (perp only) Harmful use of etoh Having multiple partners or suspected of infidelity (perp only) Attitudes accepting of violence /gender inequality
Physical elder abuse:
Non-accidental use of force resulting in physical pain, injury, or impairment. Hitting, shoving, inappropriate use of drugs, restraints, or confinement.
IPV Clues: Red Flags in Patient History:Gynecologic clues
STDs Unintended pregnancy Chronic pelvic pain Sexual dysfunction Traumatic pelvic exam
IPV Impact on Adolescent Health
Students in high school are more likely to engage in health risk behaviors (etoh, drugs, use laxatives, diet pills, induce vomiting, early intercourse/multiple partners, have unprotected sex, suicidal ideation, and actual suicide attempts) 4x less likely to ask for condom use 11x more likely for fear refusing sex
Child Abuse Reporting in Connecticut
The Child Abuse and Neglect Careline operates 24 Reporters must report orally to the Department of Children and Families' (DCF) Careline or a law enforcement agency within 12 hours of suspecting that a child has been abused or neglected and must submit a written report (DCF-136 form) to DCF within 48 hours of making the oral report.
what is the first phases of the cycle of violence and describe
This cycle has three parts: 1.Tension building phase—Tension builds over common domestic issues like money, children or jobs. Verbal abuse begins. The victim tries to control the situation by pleasing the abuser, giving in or avoiding the abuse. None of these will stop the violence. Eventually, the tension reaches a boiling point and physical abuse begins.
National Organizations Support IPV Screening
USPSTF recommendation: screen women of childbearing age ACOG: all women AMA: ask about family violence, histories of all patients JC: identify possible victims of abuse and neglect IOM : Screen and counsel all women and adolescent girls domestic violence (2011)
RADAR
Use your RADAR to recognize and treat intimate partner violence R = Remember to ask A = Ask direct questions D = Document your findings A = Assess safety / danger risk R = Review the options
Emotional or psychological abuse:
Verbal: intimidation, humiliation, ridicule, habitual blaming Nonverbal: Ignoring, isolating from friends/activities, terrorizing acting in a menacing way
IPV Clues: The Physical Exam: Demeanor
avoiding eye contact fearful evasive flat affect
IPV Clues: The Physical Exam: Injury /locations
central part of body head and neck forearms Bruises of different ages
Healthcare fraud & abuse
charging for care not provided, overcharging or double-billing, kickbacks for referrals to other providers or for prescribing certain drugs, overmedicating or under medicating, recommending fraudulent remedies Medicaid fraud
Neglect or Abandonment:
failure to fulfill caretaking obligation; wandering, dehydration, poor hygiene
Abuse:Clues from the history
inconsistent explanation of injuries delay in seeking treatment frequent ED visits lack of prenatal care
Financial exploitation
misuse of funds, stealing money, forging signatures, identify theft, investment fraud
Document (IPV) - quote using the patient's words
quote using the patient's words Specific details Sketch or photograph of injuries Important if patient goes to court
Physical Violence
range from slapping, shoving, hitting with open/closed hand or object, burning, beating, choking, or use of weapon
Sexual abuse:
sexual contact without consent showing an pornographic material, forcing the person to watch sex acts, or forcing the elder to undress
Stalking
unwanted contact by phone, text, email; being followed, entering a home uninvited