Intimate Partner violence

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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


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