Special Feature

Detecting Domestic Violence

By Frederic Kauffman, MD, FACEP

Case study: SW, a 25-year-old female, presents to triage with a complaint of being struck in the face by her husband. She denies other trauma, loss of consciousness, visual complaints, or prior history of physical abuse. Past medical history is positive only for an appendectomy at age 15, but she was in the emergency department twice this month with vague complaints of abdominal pain; no organic cause was found. SW has been married for three years, but, for the last year, she and her husband have had frequent arguments, often after her husband had been drinking. They have no children, and, though SW wants a family, she has had second thoughts lately due to her marriage difficulties. SW and her husband live in the suburbs and both work—she as a teacher and her husband as a lawyer.

What is domestic violence?

Domestic violence (DV) can be defined as a violent act(s) that one intimate adult inflicts upon another. Generally, child abuse is considered a special syndrome, but all too frequently it occurs in the setting of DV, as well (in as many as 50% of DV cases).1,2 The term DV implies that the violence takes place in the home setting but, often, it involves ex-partners, and, as such, the key aspect to DV really is the intimate relationship between the abuse and the abuser. It must be emphasized, however, that the abuse seen in DV is not limited to physical acts of trauma; rather, the issue is more one of power or control. As such, psychological, physical, and sexual abuse all fall under the definition of DV. Batterers may use a multitude of tactics to gain dominance over their partner, including verbal and emotional abuse, economic abuse, physical threats and acts, sexual assault, and physical isolation. The exact magnitude of the problem of DV in this country is hard to quantify, though estimates exist that up to 12 million women will be abused in their lifetime.1 Probably several thousand women are killed each year by their partners.

Who are the victims of DV?

Despite the fact that there is no "typical profile" for a victim of DV, it is important to be aware of certain characteristics frequently seen in these patients, and that, as health care providers, we frequently miss or fail to make the diagnosis of DV.

Most victims of DV are women and most batterers are men. When a woman assaults a man in this setting, more often than not it is after the man has initiated a violent act and the woman is acting in self defense. Despite the commonly held belief that DV is a problem of the socially and economically disenfranchised, it crosses all such boundaries, with greatest risk in the setting of social status difference between partners.1 DV can occur at any age. It most commonly occurs among those younger than age 30,1 but elder abuse by partners is an increasingly recognized problem as well. Unfortunately, battering is a common problem during pregnancy, regardless of age; estimates that up to 17% of all pregnancies are associated with battering are quite sobering.3 Abuse may begin, escalate, or change its pattern in the setting of pregnancy, placing both mother and fetus at significant risk. Alcohol and drug use within the relationship must be assessed, with the knowledge that their use may increase the risk of mortality in a violent relationship.

Recognition of DV

All patients are potential victims of DV. Historical clues include:

    1. The chief complaint and history of the incident are inconsistent with the nature of the injury.

    2. An inordinate time delay exists between the injury itself and the presentation for medical evaluation.

    3. The patient seems to be very accident-prone.

    4. A history is obtained of depression or suicide attempt, either in the past or at the time of presentation.

    5. The patient has repetitive presentations for complaints that elude diagnosis of an organic cause. Complaints are often vague and non-specific.

    6. A history of "stress" at home is elicited.

    7. Presentation of injury during pregnancy is especially worrisome.

    8. The patient is inappropriately unconcerned over the extent of circumstances of the injury, or minimizes its importance. On the other hand, a patient who is overly emotional about a minor problem also may be "asking for help" in a setting of DV.

    9. The partner appears overly-concerned, answers questions for the patient, or insists on staying with the patient at all times.

    10. Most importantly, do not be afraid to ask about DV in a direct, yet compassionate and private manner. The presentation of DV is so varied, and its diagnosis so overlooked, that a low threshold of suspicion must be maintained at all times.

Physical examination clues to the diagnosis of DV

Diagnosis of DV often requires a complete physical examination. Embarrassed or frightened patients may try to conceal old injuries, once again emphasizing the need for a private and compassionate approach to these patients. Clues to the diagnosis of DV include:

    1. Central pattern injuries of the trunk, face, neck, and genitals.
    2. Injuries "hidden" by sunglasses and clothing.
    3. Injuries in various stages of healing.
    4. Injuries that indicate self defense as a mechanism.
    5. Injuries that occur during pregnancy.

Why do patients fail to tell their physicians about DV?

It is not easy to simply walk away from an abusive relationship, and the factors that hold such relationships "together" are complicated and unique for each relationship. Listed below are some of the reasons why victims may be hesitant to admit to an abusive relationship as a cause of the clinical symptoms:

    1. Fear of retribution by the batterer. Batterers may threaten their partner with harm if the issue is discussed with anyone. The victim may be unable to discuss the situation with a health care provider without the batterer’s presence. Mandatory reporting laws or, in the very least, involvement of legal authorities, may provoke a lethal attack. Patient safety must always be in the forefront of the physician’s mind.

    2. Shame, humiliation, or a feeling of responsibility on the part of the victim. Victims of DV often feel trapped by their situation and may believe that they are alone in their predicament. In addition, especially in the setting of emotional abuse, the victim may believe that she caused the problem and, therefore, does not wish to disclose her plight to a doctor. She even may feel that she does not deserve help. Her partner may be her main source of financial and social support.

    3. Lack of knowledge or time on the part of the physician. DV carries a stigma in our society, and even in the medical community it has received little recognition as a viable problem to be addressed until relatively recently. Addressing the problem of DV with an individual patient takes time, a commodity that is becoming increasingly difficult to find in today’s health care climate. The stress at home that originates from DV does not require an anxiolytic; it requires time, compassion, counseling, and specific patient safety skills in order to be addressed completely.

Intervention

First and foremost, patient safety must be assured. This requires a careful assessment by the entire health care team. Compassion and understanding are essential elements in helping the patient assess her risk should she decide to return home. Table 1 lists some of the key red flags when assessing patient risk; their absence, however, does not indicate an absence of danger.

    Table 1 
    Domestic Violence Safety Risk Factors ______________________________________________
    • Physical violence has increased in frequency and severity.
    • Hospitalization has been necessary in the past due to DV incidents.
    • The batterer has threatened or used a weapon in the past, or has attempted strangulation of the victim.
    • The batterer frequently uses drugs and/or alcohol.
    • The victim is contemplating homicide or suicide.
    • The batterer is obsessed with the victim, unwilling to "let go" of the victim.
    • The batterer accuses the victim of promiscuity.
    • The batterer has a history of significant violence in the past, including violence against pets.
    • The batterer has a history of suicide attempts or is currently threatening suicide.
    _______________________________________________________________________________

Careful medical record documentation is critical, even if the victim decides to return home or not to leave the relationship. Future issues, such as child custody, divorce, or criminal charges may hinge on the current medical document. Table 2 lists the essentials of the medical document in cases of DV.

    Table 2
    Medical Record Documentation in DV ____________________________
    • Specific and detailed history of the abuse, including any details as to the batterer and specific events.
    • Clearly documented physical examination, with the use of body charts to localize specific injuries and physical examination findings.
    • With the patient’s written permission, place photographs in the chart that document specific injuries.
    • As with cases of sexual assault, document the chain of physical evidence when indicated, as with blood or semen-stained clothing.
    _____________________________________________________________

Once the patient’s immediate medical issues are cared for, and the above assessment and documentation take place, it is crucial to develop a safety plan in conjunction with the patient. If the patient believes that it is unsafe to return home, safe living conditions must be assured for the patient and her family. In developing a safety plan, certain questions often prove helpful in the ultimate disposition plan for the patient. These questions are listed in Table 3.

    Table 3
    Safety Plan Assessment_________________________________________
    • Does the patient feel safe to go home?
    • If she has children or other dependents, where are they? Are they safe?
    • Does she have friends or family with whom to stay? Can they assist with child or dependent care? Would she and/or her family be safe with her friends/family?
    • Does the patient desire immediate access to a safe shelter or other temporary living facility?
    • If alternative living arrangements are needed but not immediately available, what other alternatives exist via administrative/social service channels? (Such options might include hospital admission, temporary placement in the ED, or vouchers for local hotel services.)
    • Is there a need for immediate psychiatric crisis intervention? 
    • Upon returning home, does she have immediately available to her a definite follow-up appointment, information regarding community services, the telephone number for the local abuse hotline and police department, and a mechanism to return to the health care system (e.g., the ED) in the event of imminent danger?
    • Should rapid evacuation from home become necessary, does she have readily accessible emergency identification, important documents such as restraining orders, a supply of medically necessary medications, a set of car and house keys, and a list of family/friend phone numbers and addresses?
    _____________________________________________________________

Conclusion

Emergency medicine prides itself in being the ultimate safety net for the medical needs of our patients. Access to medical care is provided 24 hours per day, seven days per week. Unfortunately, DV is all too common and a diagnostic challenge. The consequences of missing the diagnosis, or just as bad, failing to properly address the needs of the victim, can be lethal. We must commit to preparing ourselves to improve our diagnostic and therapeutic skills. Our patients’ lives depend on it.

References

    1. Salber PR, Taliaferro E. The Physician’s Guide to Domestic Violence: How to Ask the Right Questions and Recognized Abuse . . . another way to save a life. Volcano, California: Volcano Press; 1995.

    2. Physicians for a Violence-Free Society. P.O. Box 35528, Dallas, Texas 75235-0528. Telephone: (214) 590-8807.

    3. Kilgore N. Every Eighteen Seconds: A Journey Through Domestic Violence. Volcano, California: Volcano Press; 1993.

Suggested Readings

    1. McLeer SV, Anwar RA. The role of the emergency physician in the prevention of domestic violence. Ann Emerg Med 1987;16:1155.

    2. Randall T. Tools available for health care providers whose patients are at risk for domestic violence. JAMA 1991;266:1179.

    3. Salber PS. Improving emergency department response to victims of domestic violence. West J Med 1993;159:599.

    4. Schiavone FM. Hitting close to home: Domestic violence and the EMS responder. J Emerg Med Services 1994;19:112.