Emergency Medicine Specialty Reports

When Intimate Partner Violence Presents in the Emergency Department

Authors: Frederick M. Schiavone, MD, FACEP, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, State University of New York at Stony Brook; and Kerry A. Cronin, MD, Clinical Instructor, Department of Emergency Medicine, State University of New York at Stony Brook.

Peer Reviewer: Elizabeth deLahunta Edwardsen, MD, Associate Professor, Emergency Medicine, University of Rochester, NY.

Domestic violence has been characterized as a pattern of coercive behavior in which an individual establishes and maintains power and control over another with whom he or she has an intimate, romantic, or close relationship, by means of physical, sexual, or emotional violence. An adult male usually directs this violence toward an adult female.1,2 However, the term "domestic violence" is used to encompass various forms of violence, including the abuse of elders, children, siblings, and same-sex partners. Therefore, the Centers for Disease Control and Prevention (CDC) prefers to use the more specific term "intimate partner violence" to define intentional sexual, emotional, and/or physical abuse by a spouse, ex-spouse, boyfriend or girlfriend, ex-boyfriend or ex-girlfriend, or date.2 Intimate partner violence is the focus of this review.

Scope of the Problem

Intimate partner violence is the No. 1 public health problem that affects women in the United States.2,3 Although finding accurate, up-to-date data is difficult for many reasons, the statistics available are alarming. It is estimated that in the United States, 8-12 million women, or 1 in 4, are victims of intimate partner violence in their lifetimes.3,4 Two million women in the United States are severely assaulted by their partners each year, and approximately 26-28% of all female homicides are committed by an intimate partner.5-7

Intimate partner violence is a common problem in every practice setting. The truth is that physicians grossly underestimate the prevalence of violence in their practices.1,8 Only about 10% of physicians routinely screen patients for domestic violence.9 Most physicians do not feel comfortable dealing with victims of violence, nor do they properly document cases of domestic abuse in the medical record.1,8,10 Most physicians feel that they are not well trained to deal with domestic violence in general.9,10

Emergency medicine physicians are in a unique position in the health care system to screen, recognize, treat, and document violence against women. They are on the front line, treating large numbers of patients, of all demographic categories, in busy emergency departments (EDs) throughout the country. It is estimated that more than 50% of women who seek care in EDs nationwide have been involved in domestic violence of some type.11-13 Emergency medicine physicians must strive to raise awareness, improve screening and documentation, and educate all allied health care professionals.

Risk Factors

Intimate partner violence can affect those of all racial, ethnic, religious, educational, and socioeconomic groups. There is no single risk factor or group of risk factors that can identify a person in danger of abuse. Nevertheless, there have been numerous studies performed to help identify persons at risk for abuse, as well as to identify those at risk for perpetrating abuse. By recognizing the following documented risk factors for intimate partner violence, the ED physician can be more successful in screening and identifying victims of abuse.

Those at highest risk for enacting intimate partner abuse have been described in various research studies. Primary risk factors for perpetrating violence against a spouse or significant other are:

  • having committed violence against them previously;14
  • violence toward a previous spouse or partner;5
  • high levels of marital or relationship conflict; and
  • aggression on the part of the wife or partner.15,16

Other studies have shown that men with psychological problems—angry or hostile men, men who are depressed, men who suffer from posttraumatic stress disorder, those with borderline personality disorder, and those who abuse alcohol and drugs—are more prone to act violently toward their spouses.17-27 There is a strong relationship between firearm ownership and fatal intimate partner violence.28

There have been many studies that have demonstrated that both men who perform violent acts against their wives and women who are victims of violence often experienced violence as children.

Witnessing intimate partner violence as a child or adolescent and experiencing violence from a caregiver consistently have been identified with adult intimate partner violence.29-31

Women at greatest risk for injury from domestic violence include those:

  • whose male partners who abuse alcohol or drugs;
  • who are unemployed or intermittently employed;
  • who have less than a high-school education; and
  • who are of low socioeconomic status.17

Certain groups of women appear to be at the highest risk for abuse. These women include: those ages 17-28 years; those who abuse alcohol and/or drugs; women who are pregnant or postpartum; and women who are single, separated, divorced, or who recently have terminated a relationship.3,17,30,32 Some investigators have reported a high prevalence of depression, suicidal ideation, generalized anxiety disorder, and obsessive personality disorder among samples of battered women.33,34 Finally, women’s reports of past victimization and women’s own ratings of the likelihood of aggression on the part of their partners have been shown to be predictive markers for future abuse.35

Presentation to the ED

Intimate partner violence is an ongoing chronic process. It is not a distinct event or injury, but rather a pattern of perpetrator behaviors used against a victim over the course of a relationship.36

Physical abuse may include pushing, shoving, slapping, punching, kicking, choking, and physical restraint.3,36 Physical abuse also may consist of burning or assault with a weapon.3,28,36 It may involve refusal of assistance when an individual is sick or injured.3,36 Victims of physical abuse may present to the ED with a wide range of injuries, including contusions, sprains, lacerations, fractures to the chest, abdominal injuries, head injuries, gunshot wounds, and stab wounds.3,37 It is important for the emergency physician to closely observe for injuries when abuse is suspected; the most commonly injured areas are the head, face, and neck.3,37 Areas concealed by clothing are particularly important to examine, and include the chest, breasts, and abdomen.3,37 Physicians must be suspicious of injuries to multiple sites, injuries in various stages of healing, and injuries that do not fit the provided explanation.3,37,38

Sexual abuse is common in violent relationships. Sexual battering consists of a wide range of conduct that may include pressured sex when the victim does not want sex, coerced sex by manipulation or threat, physically forced sex, or sexual assault accompanied by violence.3,36 Victims may be forced to perform a kind of sexual act that they do not want (i.e, sex with third parties, physically painful sex, sexual activities they find offensive, use of objects or weapons intravaginally, verbal degradation during sex, or viewing sexually violent material), or at a time when they do not want it (i.e., when exhausted, when ill, in front of children, after a physical assault, when asleep).3,36

Emotional or psychological abuse usually accompanies physical and sexual abuse. It is a means of controlling a victim through fear and degradation. Types of psychological abuse include threats of violence and harm; attacks against property or pets; acts of intimidation; physical and social isolation; extreme jealousy; possessiveness; deprivation; degradation; and humiliation.3,36

The manifestations of abuse sometimes are less obvious upon presentation to the ED. Women with persistent headaches, or with chest, back, pelvic, or abdominal pain, may be victims of intimate partner violence.3,38,39 Commonly, women who are abused present with functional gastrointestinal complaints.40 Obstetrical manifestations of abuse include frequent vaginal and urinary tract infections, pelvic pain, miscarriage, spontaneous abortion, placental abruption, and pre-term labor.3,37,38 Intimate partner violence may lead to the exacerbation of chronic medical conditions such as diabetes, hypertension, and heart disease.37,41 Some women complain of physical symptoms related to stress, anxiety, and depression, including sleep and appetite disturbances, decreased energy, fatigue, difficulty concentrating, sexual dysfunction, palpitations, dizziness, and parasthesias.3,37 Psychiatric presentations are common, and include psychosis, anxiety, depression, and substance abuse.3,37,41

Screening for Domestic Violence

New guidelines have evolved to address intimate partner violence within the health care setting. Inquiring only when abuse is suspected or on the basis of risk factors is no longer considered adequate. Unless physicians ask routinely, regardless of the patient’s presentation, cases of intimate partner violence will be missed. The Joint Commission for the Accreditation of Healthcare Organizations’ (JCAHO) standards direct hospitals and clinics to institute protocols and training to help providers identify victims of abuse, assess their needs, provide interventions, and make referrals to community-based advocacy services.42 A major objective of the U.S. Public Health Service’s Healthy People 2000 program was to encourage universal screening and intervention for intimate partner violence in EDs nationwide.43 Despite these standards, we are doing poorly. It is estimated that 20-30% of all women seen in EDs are victims of domestic violence, yet fewer than 1 in 25 are identified.12

Physicians may be unsure about what to ask, how to ask, and what to say or do. Physicians may feel that patients are evasive and fail to disclose information.44 They report a lack of time and support resources, as well as a lack of education and training on the subject of intimate partner violence.44,45 Physicians fear that they will offend patients, and often are frustrated when trying to help victims whose failure to follow recommendations results in their situations remaining unchanged.8,44,45 Some physicians report that there is no scientific evidence to support the effectiveness of screening.46

Battered women identify medical providers as being among the least effective professional sources of help.47 In one study, half of abused women questioned reported having experienced negative treatment in the ED.48 Women reported feelings of humiliation; a sense of being blamed for their abuse; having their problem minimized; and most importantly, they felt that they were not identified as abused.48,49 Women report that disclosure is difficult; they fear retaliation by their partners; they deny the seriousness of the abuse; and they are concerned about confidentiality.50 Victims of intimate partner violence claim that hospital personnel are cold and uncaring, lack necessary training, and are uninformed about resources available to help.51 On the other hand, women are not offended by intimate partner violence screening.49,51,52 Abused women support routine screening and say they feel thankful that someone is taking an interest in their situation; they say they believe screening would make it easier for abused women to get help.52

The increased pressure for improved identification and management of intimate partner violence has resulted in protocol development and use in EDs throughout the country. There are various tools available to guide intimate partner violence screening.

The acronym RADAR was developed as a tool by the Massachusetts Medical Society to guide intimate partner violence screening and assessment:43

Routinely screen all patients.

Ask direct questions in private, and make questions simple and specific. Consider prefacing questions by stating that screening is part of standard protocol for all patients in the ED.

Document your findings. Document who the suspected abuser is and his or her relationship to the patient. Always use direct quotes, and steer clear of subjective language. Use a body map to document injuries. Photograph injuries.

Assess patient safety and that of any children in the household. Ask the victim if she is afraid to go home. Find out if there is anyone who can stay in the home with her; this will lessen the chance of another battering.

Review options and referrals. Help the victim outline or develop an emergency plan prior to leaving the ED. Prepare a list of referral information ahead of time to have available for women. Include crisis hotlines, police telephone numbers, and lists of shelters and advocacy agencies. Involve a social worker if one is available.

One group described intimate partner violence interventions used by physicians skilled and committed to providing care to battered women. After studying physicians’ intervention techniques and questioning women survivors of domestic violence, the authors provided a useful description of how physicians intervene with their battered patients:44

  • Give validating messages that the individual does not deserve abuse and is worth caring about;
  • Break through denial and plant seeds for change by labeling the abuse as wrong;
  • Listen and be nonjudgmental;
  • Let go of the idea that a physician can "fix it;"
  • Document all signs of abuse with specific quotes and photographs that include the victim’s face;
  • Offer referrals over time, and place business cards with domestic violence hotline numbers (i.e., local hotline numbers, shelter numbers, community resource numbers) in bathrooms or other private spaces;
  • Find ways to facilitate immediate and ongoing safety by staying aware and sensitive to the individual’s needs;
  • Foster a safe space for women to talk about their situation by putting relevant posters on the walls and conducting in-service training for staff;
  • Use a team approach, keeping roles flexible, and make domestic violence part of the whole staff’s educational process; and
  • Prioritize domestic violence and create a culture of caring so that intervening with victims is seen as important by all staff members.

ED Treatment Protocol

Physicians acting alone simply cannot care for intimate partner violence victims and their children. For this reason, ED protocols are being created nationwide to meet the needs of victims of violence. The optimal response requires a team coordinating the efforts of all members of the community, including health care providers, community-based domestic violence advocacy groups, child welfare and protective service agencies, and the civil and criminal justice systems. Table 1 summarizes many of the concepts discussed in this review and is a guideline for creating an ED protocol to treat intimate partner violence victims.

Table 1. ED Protocol for Dealing with Intimate Partner Violence
Coordinate Efforts
Build institutional support and involvement.
Create a multi-disciplinary team made up of an ED physician, nurse, social worker, administrator, and a domestic violence advocate from the local program in the community. Develop an action plan.
Assess resources within the institution and needs of the community.
Develop Interventions
Educate health care staff about intimate partner violence intervention.
Create a screening tool and conduct routine screening to detect battered patients; include sample questions and specify who is to do the screening.
Assess patient disposition. Assess patient safety and establish an emergency plan.
Learn the laws in your state for mandatory reporting.
Collect evidence and photographs. Clearly delineate what is to be included in the medical record.
Label photographs with patient name, medical record number, date, the photographer's name, and take two sets of photos.
Develop appropriate contacts and written resource materials for referral of violence victims and their children to domestic violence programs, legal advocacy programs, and other services, including counseling and support groups and shelters. Hang posters and stock waiting areas with brochures and pocket-sized cards with referral numbers of emergency and non-emergency domestic violence services.
Implementation
Determine site specific interventions: Decide who does what, when, and where regarding identification, assessment, documentation, referrals, and follow-up.
Make sure protocol is easily accessible, in a readable format, and visibly posted in clinical settings. Consider posters in clinical areas reminding clinicians what to ask and what to do, and/or pocket cards with protocols and referral numbers.
Sustaining the response
Provide periodic follow-up training for all clinicians and staff.
Identify obstacles to an effective response by conducting ongoing discussions with colleagues.
Provide feedback to staff from quality assurance reviews regarding changes in practices to maintain standards of care.
Hold violence prevention forums for the community.

Adapted from: Warshaw C, Ganley AL. Improving the health care response to domestic violence. San Francisco; The Family Violence Prevention Fund:1998.

Education

To improve screening, recognition, treatment, documentation, and prevention of intimate partner violence, we must incorporate education into medical school curriculum, resident education, and continuing medical education. The growing awareness of intimate partner violence has produced efforts to expand relevant curricula in medical schools throughout the country.53 While the number of medical schools requiring education on intimate partner violence increased by 18% during the last seven years, instruction primarily is given during the preclinical years, often is not enforced, and, therefore, is forgotten in the clinical years, when students interview and examine patients.54,55 The University of Massachusetts School of Medicine recently designed a third-year "inter-clerkship" in which students listen to the stories of domestic violence survivors, role-play how they might identify and give appropriate assistance to those at risk, and discuss and reflect on their own experiences with family violence.53 The MCP Hahnemann School of Medicine has developed a domestic violence educational intervention program which includes teaching cases illustrating signs and symptoms specific to domestic violence, written learning objectives on domestic violence in the health care setting, relevant resource material, and a training program conducted by an interdisciplinary team.56

Resident education on intimate partner violence is essential to increase the identification of abuse. A study published in Academic Medicine in 2000 showed that the brief education of residents during hospital orientation increased their knowledge and ability to diagnose intimate partner violence.57 Knowledge must be reinforced with additional programs throughout residency, and specific programs tailored for different specialties are appropriate.57 It is important to invest in the education of young physicians for them to become skilled at caring for victims of intimate partner violence.

Mandatory Reporting

Emergency physicians are concerned about how they can intervene and help victims. It is clear that physicians need to ask, assure patient safety, document appropriately on the medical record, listen non-judgmentally, and provide options and resources by contacting social services or developing coordinated community support systems to provide care to those victims who come to the ED. What is not clear is whether reporting domestic violence to law enforcement or criminal justice agencies without the specific consent of the patient is helpful or detrimental. Very little data exist within the medical literature as to the benefit or detriment to victims who are patients within the ED. Data from advocate agencies and studies within the legal community indicate that most communities throughout the United States do not have police agencies capable of protecting victims of domestic violence when it is reported. There is increasing activity by many state legislatures to create new laws and improve existing state statutes related to domestic violence. Some of these efforts focus on the role and value of mandatory reporting of patients identified by health providers to be victims of domestic violence.

The American College of Emergency Physicians opposes the mandatory reporting of domestic violence to the criminal justice system.58 There are laws in 45 states and the District of Columbia mandating health care workers to report injuries due to weapons, crimes, violence, intentional acts, or abuse.59 These laws are variable, and each requires reporting of violence to different extents. The majority of states require reporting of intimate partner violence only when a patient has an injury caused by a gun, knife, or other deadly weapon.59 At least seven states have laws which specifically address the issue of reporting when domestic violence or adult abuse is suspected.59 (See Table 2.)

Table 2. Laws Addressing Mandatory Reporting of Intimate Partner Violence
State Law Requirements

California Practitioners must report to police any patient suffering a physical condition caused by assaultive/abusive conduct.
Kentucky Reasonable cause to suspect an adult suffering abuse, neglect, exploitation must be reported to Cabinet for Human Resources. The Cabinet must notify police and make written recommendations.
New Hampshire Voluntary/mandatory reporting of criminal act, except if sexual assault or abuse; if victim is older than 18, objects to reports, and is not being treated for gunshot or other serious bodily injury.
New Mexico Any person who believes an adult is being abused, neglected, or exploited is required to report suspicions to police.
Mississippi A report may be made to the Department of Public Welfare by any person having any knowledge or suspicion of abuse.
Pennsylvania Initiatives in place to prevent insurance discrimination against domestic violence victims.
Rhode Island Reporting is for data collection purposes only.

The individual emergency physician must refer directly to his or her specific state laws about reporting of intimate partner violence. Information and specific state laws regarding mandatory reporting is easily accessible to practicing physicians via various web sites, including the Family Violence Prevention Fund (www.endabuse.org) and the U.S. Department of Justice (www.usdoj.gov).60

Those who advocate mandatory reporting of intimate partner violence believe that laws mandating the report of violence remove the burden of reporting from the victim.61 Mandatory reporting may seem to serve a benefit, such as mandating the health care response, holding the perpetrators accountable, and improving data collection. It is important for health care providers to realize why mandatory reporting may not achieve these goals. A law that mandates reporting of all patients, whether or not they consent, who have or may have injuries due to domestic violence invokes fundamental professional, ethical, and moral questions for the health practitioner, as well as significant health and safety risks for the patient.59,61 Mandatory reporting laws could deter women from seeking care.59,61 Female victims of abuse are apprehensive about policies mandating physician reporting, and prefer reporting abuse to the police to be the individual woman’s decision.62 Mandatory reporting may fail to protect survivors of domestic violence and can create ethical dilemmas for physicians when patients do not want their cases reported.59 Finally, mandatory reporting laws could decrease patient trust in the provider system and remove abused women’s remaining sense of control and autonomy.59,61

It is crucial to increase health providers’ awareness of the extent and impact of domestic violence on patients’ well-being and clinical presentation. However, mandatory reporting in and of itself will not impart understanding of the dynamics of domestic violence and will do nothing to ensure that practitioners provide the comprehensive, integrated care the patient needs. In fact, it may foster only the inappropriate belief that the health provider’s duty has been fulfilled once a report has been made and that nothing more is required. The way to enhance health care providers’ sensitivity and responsiveness to domestic violence is through professional education and the establishment of departmental policies and procedures regarding domestic violence identification, safety assessment, intervention, documentation, coordinated community response systems, and referrals.

Summary

Emergency medicine physicians are in a unique position to screen, recognize, treat, and document intimate partner violence. Although intimate partner violence is prevalent, it is grossly under-recognized by physicians across the country. To improve the care of victims of intimate partner violence, the ED physician may take steps that include: universal screening for intimate partner violence; creation of an ED protocol to provide and coordinate the care of these very difficult patients; a team approach with flexible roles; the development of a departmental educational process; and the preparation of a list of referral information to have easily available for victims, including crisis hotlines, police telephone numbers, shelters, and advocacy agencies. By improving the screening process and the response to intimate partner violence, the ED physician can be more successful in identifying and treating victims of abuse.

References

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2. National Center for Injury Prevention and Control, Domestic Violence, 2000. (www.cdc.gov/ncipc/factsheets/ipvfacts.htm. Accessed 2/13/2002.)

3. Flitcraft AH, Hadley SM, Hendrics-Matthews MK, et al. Diagnostic and treatment guidelines on domestic violence. Chicago; American Medical Association:1992.

4. U.S. Department of Justice, National Institute of Justice. Prevalence, Incidence, and Consequences of Violence against Women: Findings from the National Violence Against Women Survey. NCJ 172837. Washington, DC; Government Printing Office: November, 1998.

5. Riggs DS, Caulfield MB, Street AE. Risk for domestic violence: Factors associated with perpetration and victimization. J Clin Psychol 2000;56:1289-1316.

6. U.S. Department of Justice. Violence by inmates: Analysis of data on crimes by current or former spouses, boyfriends, or girlfriends. Washington, DC; Bureau of Justice Statistics:1998.

7. Bachman R, Saltzman LE. Violence against women: Estimates from the redesigned survey. Washington, DC; Bureau of Justice Statistics:1995.

8. Sugg NK, Thompson RS, Thompson DC, et al. Domestic violence in primary care. Arch Fam Med 1999:8:301-306.

9. Robinson SP. Domestic violence screening rate leaves much to be desired. Postgrad Med 2001;109:16.

10. Houry D, Feldhaus KM, Nyquist SR, et al. ED documentation in cases of intentional assault. Ann Emerg Med 1999;34:715-719.

11. Goldberg WG, Thomlanovich MD. Domestic violence in the ED: New findings. JAMA 1984;251:3529-3564.

12. Abbott J, Johnson R, Koziol-McLain J, et al. Domestic violence against women. JAMA 1995;273:1763-1767.

13. McLeer SV, Anwar R. A study of battered women presenting in an ED. Am J Public Health 1989;79:65-66.

14. O’ Leary KD, Barling J, Arias I, et al. Prevalence and stability of physical aggression between spouses: A longitudinal analysis. J Consult Clin Psychol 1989;57:263-268.

15. Feld SL, Straus MA. Escalation and desistance of wife assault in marriage. Criminology 1989;27:141-161.

16. Hotaling GT, Sugarman DB. A risk marker analysis of assaulted wives. J Fam Violence 1990:5:1-13.

17. Kyriacou DN, Anglin D, Taliaferro E, et al. Risk factors for injury to women from domestic violence. N Engl J Med 1999;341: 1892-1898.

18. Holtzworth-Munroe A. Social skill deficits in martially violent men: Interpreting the data using a social information processing model. Clin Psychol Rev 1992;12:605-617.

19. Holtzworth-Monroe A, Bates L, Smutzler N, et al. A brief review of the research on husband violence. Part 1: Martially violent vs non-violent men. Aggression and Violent Behavior 1996;2:65-99.

20. Pan HS, Neidig PH, O’ Leary KD. Predicting mild and severe husband to wife physical aggression. J Consult Clin Psychol 1994;62:975-981.

21. Jordan BK, Marmar CR, Fairbank JA, et al. Problems in families of male Vietnam veterans with post traumatic stress disorder. J Consult Clin Psychol 1992;60:916-926.

22. Hamberger KL, Hastings JE. Characteristics of male spouse abusers consistent with personality disorders. Hosp Community Psychiatry 1988;39:763-770.

23. Hamberger KL, Hastings JE. Personality correlates of men who abuse their partners: A cross-validation study. J Family Violence 1986;1:323-341.

24. Dutton DG, Starzomski A, Ryan L. Antecedents of abusive personality and abusive behavior in wife assaulters. J Family Violence 1996;11:113-132.

25. Tolman RM, Bennett LW. A review of quantitative research on men who batter. J Interpersonal Viol 1990;5:87-118.

26. Leonard KE, Blane HT. Alcohol and marital aggression in a nation sample of young men. J Interpersonal Violence 1992;7: 19-30.

27. O’Farrell TJ, Murphy CM. Marital violence before and after alcoholism treatment. J Consult Clin Psychol 1995;63:256-262.

28. Kellermann A, Heron S. Firearms and family violence. Emerg Med Clin North Am 1999;17:699-716.

29. Hotaling GT, Sugarman DB. An analysis of risk markers in husband to wife violence: The current state of knowledge. Violence Vict 1986;1:101-124.

30. Ernst AA, Weiss SJ, Nick TG, et al. Garza: Domestic violence in a university ED. South Med J 2000;93:176-181.

31. Aldarondo E, Sugarman DB. Risk marker analysis of the cessation and persistence of wife assault. J Consult Clin Psychol 1996; 64:1010-1019.

32. Hedin LW. Postpartum, also a risk period for domestic violence. European J Obstet Gynecol Reprod Biol 2000;89;41-45.

33. Cascardi MA, O’Leary KD. Depressive symptomatology, self-esteem, and self-blame in battered women. J Fam Violence 1992;7:249-259.

34. Gleason WJ. Mental disorders in battered women: An empirical study. Violence Vict 1993;8:53-68.

35. Weisz AN, Tolan RM, Saunders DG. Assessing the risk of severe domestic violence: The importance of survivors’ predictions. J Interpersonal Violence 2000;15:75-90.

36. Ganley A. Understanding domestic violence. Improving the health care response to violence: A resource manual for healthcare providers. San Francisco: Family Violence Prevention Fund;1998:15-45.

37. Warshaw, C. Identification, assessment, and intervention with victims of domestic violence. Improving the health care response to violence: A resource manual for healthcare providers. San Francisco: Family Violence Prevention Fund;1998:49-85.

38. Stark E, Flitcraft A, Frazier W. Medicine and patriarchal violence: The social construction of a "private" event. Int J Health Serv 1979;9:461-492.

39. Warshaw C. Limitations of the medical model in the care of battered women. Gender and Society 1989;3:506-517.

40. Drossman DA, Lesserman J, Rachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Int Med 1990;113:828-833.

41. Lamberg L. Domestic violence: What to ask, what to do. JAMA 2000;284:554-556.

42. Freund KM, Bak SM, Blackhall, L. Identifying domestic violence in primary care practice. J Gen Intern Med 1996;11:44-46.

43. Gerard M. Domestic violence: How to screen and intervene. RN 2000;63:52-56.

44. Gerbert B, Caspers N, Milliken N, et al. Interventions that help victims of domestic violence. A qualitative analysis of physicians’ experiences. J Fam Pract 2000;49:889-895.

45. Thompson RS, Rivara FP, Thompson DC, et al. Identification and management of domestic violence: A randomized trial. Am J Prevent Med 2000;19:253-263.

46. Cole T. Is domestic violence screening helpful? JAMA 2000; 284:551.

47. Rodriguez MA, Quiroga SS, Bauer HM. Breaking the silence. Battered women’s perspectives on medical care. Arch Fam Med 1996;5:153-158.

48. Campbell JC, et al. Battered women’s experiences in the ED. J Emerg Nurse 1994;20:280-288.

49. Warshaw C. Integrating routine inquiry about domestic violence into daily practice (editorial). Ann Intern Med 1999;131:619-620.

50. Gerbert B, Caspers N, Bronstone A, et al. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999;131:578-584.

51. Ellis JM. Barriers to effective screening for domestic violence by registered nurses in the ED. Crit Care Nurs Q 1999;22;27-41.

52. Gielen AC, O’Campo PJ, Campell JC, et al. Women’s opinions about domestic violence screening and mandatory reporting. Am J Prev Med 2000;19;279-285.

53. Phelps BP. Helping medical students help survivors of domestic violence. JAMA 2000;283:1199.

54. Alpert J, Tonkin AE, Seeherman AM, et al. Family violence curricula in U.S. medical schools. Am J Prev Med 1998;14: 273-282.

55. Warshaw C. Intimate partner abuse: Developing a framework for change in medical education. Acad Med 1997;72:S26-S37.

56. Weiss LB, Kripke EN, Coonse HL, et al. Integrating a domestic violence education into a medical school curriculum: Challenges and strategies. Teach Learn Med 2000;12:133-140.

57. Coonrod DV, Bay RC, Rowley BD, et al. A randomized, controlled study of brief interventions to teach residents about domestic violence. Acad Med 2000;75:55-57.

58. The American College of Emergency Physicians Policy. Mandatory reporting of domestic violence to law enforcement and criminal justice agencies (policy statement). Approved June 1997.

59. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: Do they promote patient well-being? JAMA 1995;273:1781-1787.

60. Goodman P. Domestic violence resources on the internet. JAMA 1998;280:477-478.

61. Houry D, Feldhaud K, Thorson AC, et al. Mandatory reporting laws do not deter patients from seeking medical care. Ann Emerg Med 1999;34:336-341.

62. Gielen AC, O’Campo PJ, Campbell JC, et al. Women’s opinions about domestic violence screening and mandatory reporting. Am J Prev Med 2000;19:279-85.

  

CME Objectives

After completing the program, participants will be able to:

- Understand and recognize the conditions/situations described, and their importance to the practice of emergency medicine;

- Be educated about how to identify patients suffering from HIV or who may be victims of domestic violence;

- Be educated about necessary diagnostic tests; how to take a meaningful patient history that will reveal the most important details about the particular medical problem discussed; and about the epidemiology, etiology, pathophysiology, and clinical features of the entity discussed, when applicable;

- Understand the role of medical ethics and risk management in the ED setting and the importance of those subjects both to physicians and patients;

- and provide patients with any necessary information.


Physician CME Questions

To earn CME credit for this issue of Emergency Medicine Specialty Reports, please refer to the enclosed Scantron form for directions on taking the test and submitting your answers.

1. What percentage of women who seek ED care in the United States are estimated to have been involved in domestic violence?

A. 10%

B. 25%

C. 50%

D. 75%


2. Which of the following is not a risk factor for perpetrating violence against a spouse or significant other?

A. Having committed violence against them previously

B. Race

C. Violence toward a previous partner

D. Aggression by the wife or partner


3. Women whose male partners abuse alcohol or drugs are not at greater risk for injury from domestic violence.

A. True

B. False


4. The most commonly injured area(s) on an abused woman’s body are:

A. Face

B. Head

C. Neck

D. All of the above


5. The acronym RADAR represents:

A. a guide for intimate partner violence screening and assessment.

B. a means of locating the perpetrator.

C. an algorithm for treating injuries of abuse.

D. a federal agency responsible for tracking domestic violence statistics.


6. Proponents of mandatory reporting generally believe that it:

A. removes the burden of reporting from the victim.

B. ensures that the abuse will stop.

C. reduces practitioners’ liability exposure.

D. avoids ethical dilemmas for physicians whose patients do not want their abuse reported.


7. Opponents of mandatory reporting assert that it:

A. protects the perpetrators.

B. hinders data collection.

C. might encourage false reports of abuse.

D. invokes fundamental professional, ethical, and moral questions for the practitioner, and health and safety risks for the patients.


8. Regarding dealing with victims of domestic violence, many physicians report that they:

A. feel they receive adequate training on the subject in medical school.

B. believe victims are forthcoming with information about abuse.

C. have a wealth of time and support resources to deal with victims of intimate partner violence.

D. feel unsure about what to ask, how to ask, and what to say or do.


9. A major objective of the U.S. Public Health Service’s Healthy People 2000 program was to discourage universal screening and intervention in the ED for intimate partner violence.

A. True

B. False


10. There is little data in the medical literature about whether mandatory reporting of intimate partner violence results in benefit or detriment to the victims.

A. True

B. False