This document discusses healthcare and screening for domestic violence. It notes that domestic violence affects millions of women each year and often presents physically, with symptoms like headaches, abdominal pain, and depression. Screening questions are suggested to help identify abuse. The role of healthcare providers is to routinely screen female patients, report abuse if requested, refer patients to support services, and document findings. Mandatory reporting is required for suspected child or elder abuse. The goal is to recognize abuse early and help victims access support.

1. “Healthcare and Screening
for Domestic Violence”
Raising Awareness; Inspiring Action
Families and Communities Empowered for Safety
(918) 519-3698 :: faces.sherry@gmail.com :: www.faces.tulsa.org

2. Rhianna with her abuser,
Chris Brown

3. Definition of IPV
• A pattern of assaultive and coercive
behaviors used in the context of dating or
intimate relationships
• May take the form of physical, sexual,
and/or psychological abuse, is generally
repeated, and often escalates within
relationships
• May be occurring despite end of intimate
relationship
Ganley A: Family Violence Prevention Fund 1995

4. Domestic violence is about…
Physical Social & physical
abuse isolation
POWER AND CONTROL
Sexual Emotional &
abuse Economic verbal abuse
abuse

5. 2006 Data
on Homicides
• Oklahoma ranks fourth (2008)
highest in the nation in homicides
of women per 100,000 population
• 92% of the victims knew their killer and of
these 60% were wives or intimate partners
of the perpetrator

6. U.S. Statistics
• 1 to 3 million women abused per year
• 1 in 4 (25%) lifetime prevalence in primary care
study
• 1 in 7 women (15%) seen
in GIM clinics
• 1 in 9 women seen in ED
• 1 in 2 (54%) lifetime prevalence
in women seen in ED
Bachman R: US Dept. of Justice, 1998
Freund KM: JGIM 1996
Gin NE: JGIM 1991
Abbott J: JAMA 1995

7. The Reality of Abuse

9. This is Often What We See
 Sleep and appetite  Abdominal and GI
disturbances complaints
 Fatigue  Irritable bowel
syndrome
 Sexual dysfunction
 Dyspepsia
 Headaches
 Depression
 Chronic pelvic pain
 Anxiety disorders
 Atypical chest pain
 Suicide attempts
 Somatization

10. Physical Health Consequences of
Physical and Psychological IPV
• 1152 women screened from 2 FP clinics
• Used 2 screening tools to assess both types of IPV (ISA-
P and WEB scale)
• 54% had experienced IPV of any kind
• 40% physical violence hx
• 14% psychological without physical
– More likely to report physical and mental health as
―poor‖
– Increased disabilities, chronic neck or back pain,
arthritis, migraines, STDs, pelvic pain, PUD, and IBS
• Psychologic IPV hx as strongly related to poor
health outcomes as physical IPV
Coker et al Arch Fam Med 2000

11. Physiologic Responses to IPV
• Spanish study tested physically and
psychologically abused women compared
to controls
• Saliva sampled at 8am and 8pm
• IPV victims had higher levels of evening
cortisol and morning and evening DHEA
• Differences remained after controlling for
age, smoking, medications and lifetime
history of victimization
Pico-Alfonso et al. Biol Psychiatry 2004

12. Stress-related
Chronic Illness
» Stress of living in abusive situation
may cause or worsen physical
symptoms:
• ―Thick Chart Syndrome‖ — frequent visits,
comprehensive exams with extensive testing, no
known physical cause for complaints
• ―Medically Unexplained Symptoms‖ – MUS
common in victims of violence

13. Post-traumatic Stress Disorder (PTSD)
• Exposure of traumatic event(s)
• Re-experiencing the traumatic event
• Persistent avoidance of stimuli and
numbing of responsiveness
• Persistent symptoms of increased arousal
• Symptoms > 1 month
• Symptoms cause significant distress or
impairment
DSM-IV 1994

14. PTSD
• Many but not all victims will develop PTSD
• More likely in victims of sexual assault
• Requires mental health professional for diagnosis and
treatment
• Commonly associated with patients with multiple somatic
complaints
• Relationships and exams can be difficult
Violence Against Women, Liebschutz, Frayne and Saxe, Eds., ACP 2003

15. Effects of
Childhood Abuse in Adults
• Adverse Childhood Experiences (ACE)
Study
• Questionnaire returned by 9500 HMO
patients
• Adjusted for demographic factors
• Graded relationship between no. of ACE
and adult risk behaviors and diseases,
such as CAD, cancer, chronic lung
disease and liver disease
Felitti et al Am J Prev Med 1998

16. Effects of Abuse on Children
• Of the 2-4 million women battered each year , one half
live with children under 12
• 62% of children living in a home
with domestic violence are also
abused
• Boys who witness violence against
their mothers are ten times more
likely to abuse their female
partners as adults
• 63% of boys aged 11-20 arrested
for murder were arrested for
murdering the man assaulting their
mother

17. Health Care Utilization
in IPV Victims
• History of DV predictor
of hospitalizations,
general clinic use,
mental health services
and out-of-plans
referrals
• Net costs $1775 more annually*
• Being IPV victim associated with 1.6 to 2.3-fold
increase in total health care utilization and
costs** *Wisner et al J Fam Pract 1999
**Ulrich et al Am J Prev Med 2003

18. Costs of IPV in US
• Exceeds $5.8 billion per year
– $4.1 billion in direct medical and mental
health care costs
• $900 million from lost productivity from
paid work and household chores
• $900 million from lifetime earnings lost by
victims of IPV homicide
Costs of Intimate Partner Violence
Against Women in the United States, CDC report, 2003

19. Why Don’t Victims Tell?
Could be:
• Fear of Retribution
• Shame and
humiliation
• Protecting their
relationship with:
– Partner
– Friend or parent
– Church
• Lack of trust in others

20. Why Don’t Victims Leave?
• Fear
• Children
• Finances (no job and /or few
skills)
• Denial
• Shame and embarrassment
• Guilt and low self-esteem
• Lack of resources
• Sex-role conditioning
• Religious beliefs & values
• Love
• Hope

21. Circle of Violence

22. The Physician’s Role

23. The Role of the Healthcare Provider

24. How Are We Doing
on Screening?
• Recent survey of clients at Family Safety
Center*
– Of 38 women, 27 had seen a physician in last
year
– 9 stated physician asked about personal
safety in relationships
– 4 were referred to DV advocacy organization
– 5 were given information on where to receive
services
*Ann Patterson Dooley Family Safety Center 2008

25. Interviewing the Patient
Recommendations from
American Medical Association
1. Physicians should routinely screen all
women
patients
2. Interview patient
alone, without
partner

26. Is This ―Our‖ Job?
• JCAHO standards:
– PE.1.9: ―Possible victims of
abuse are identified using
criteria developed by the
hospital.‖
– PE.8: ―Patients who are possible
victims of alleged or suspected
abuse have special needs
relative to the assessment process.‖

27. Physician Barriers to Screening
• Lack of education and experience
• Fear of offending patients
• Lack of effective interventions
• Limited time
• Not appropriate in health
care setting
• Patient will not make
changes
• Blaming the victim
• “Pandora’s Box” ?

28. Patient Barriers to Identification
• Fear that revelation will jeopardize safety
• Shame and humiliation
• Thinking she deserved the abuse
• Protection of partner
• Lack of awareness that physical
symptoms are caused by stress of
living in an abusive relationship
• Belief that injuries not severe enough to
mention

29. Screening Questions
Examples
1. ―Because violence is so common in women’s
lives, I’ve begun to ask about it routinely.‖
2. ―Do you ever feel afraid of your partner?‖
3. ―We all disagree at home. What happens when
you and your partner disagree?‖
4. ―Are you in a relationship in which you have
been physically hurt or threatened by your
partner?‖

30. Examples When Abuse Suspected
• ―Often when I see a person with this kind of
problem, it is because someone has hurt them.
Has this happened to you?‖
• ―Many women who have
physical problems like yours
have suffered from violence in
their homes. Could this have
happened to you?‖

31. Screening question
on new pt. Hx form:
Have you ever
experienced violence
or abuse from a
family member or
partner?

32. Safety Planning
• Don’t say: ―You need to leave now!‖
• Options should be given
• If victim has no safe place to go, leaving may
increase chance of severe injury or death
• 70% of severe injuries and deaths occur when
the victim is trying to leave
• Ask about weapons in home, threats of
murder, thoughts of suicide, strangulation

33. How You Can Help
• Don’t tell her what to do
• Be careful about saying
―I know just how you
feel…‖
• Help her explore her
options
• Reinforce her reasons
for leaving
• Encourage calling DVIS, getting counseling and
financial help
• Tell her you will be available no matter what she
decides to do

34. What to Say to a DV Victim
1. I fear for your safety.
2. I fear for the safety of
your children.
3. It will likely get worse.
4. I support you and I am
here for you.
5. You deserve better.
6. There is considerable help available.
7. Nothing you did (or didn’t do) makes you deserve
this.
8. I am sorry this has happened to you.
9. I believe what you are telling me.

35. Reporting Domestic Abuse for
Health Care Professionals
• Current Oklahoma law
• Old law was confusing and required
mandatory reporting, now considered risky
for the victim
• Old law did not provide sufficient guidance
to doctors on how to comply and how to
avoid liability
Rules are different for suspected abuse of
children, incapacitated and elderly

36. Reporting Domestic Abuse 1-2-3
1. Report DV and criminally injurious conduct to a non-incapacitated
adult victim only when the victim makes the request for you to
do so; at that time, a report to county law enforcement must be
made.
2. You must clearly and legibly document the incident and injuries
observed and treated, whether or not a report is made.
Document your actions in the patient’s record:
assess, report, and refer.
3. In all cases whether reported or not, you must give the victim a
referral to a DV violence service program and the 24-hour
Oklahoma statewide help line number:
1-800-522-SAFE.
Local DV victim advocacy services can be found on the
Oklahoma Coalition Against Domestic Violence & Sexual Abuse
website under “help”: www.ocadvsa.org.

37. Domestic Abuse Screening
1. Screen female patients for domestic violence.
2. Report when patient makes the request for you to do
so.
3. Refer patient to Oklahoma state hotline:
1-800-522-SAFE. Refer patient to local domestic
violence victim advocacy agency: www.ocadvsa.org
4. Legibly document findings and actions in patient’s
chart.

38. When Reporting is Mandatory
1. Any case of suspected child abuse – victim under the
age of 18
2. When a victim of domestic violence, age 18 and older
requests a medical practitioner to make a report to
local law enforcement.
3. Abuse of a vulnerable adult, a person age 18 or above
who has physical or mental conditions which cause the
need for a guardian as defined by law, or whose
impairments are less disabling but still prevent the
adult from independently managing all of his or her
own affairs or protecting him or herself from
maltreatment by others
4. Any case of elder abuse, 62 years or over.

39. Elder Abuse
• Elder abuse is a term referring
to any knowing, intentional, or
negligent act by a caregiver or
any other person that causes
harm to a vulnerable adult.
• Elder abuse can consist of
physical abuse, financial
exploitation, emotional abuse,
neglect and domestic violence.
• Elder abuse frequently consists of self-neglect, rather than abuse
by a second party.
• The definition of self-neglect excludes a situation in which a
mentally competent older person, who understands the
consequences of his/her decisions, makes a conscious and
voluntary decision to engage in acts that threaten his/her health or
safety as a matter of personal choice. (NCEA)

40. Elder Abuse and Neglect
Tulsa Lifespan Abuse Information
• FY 05- 1850 DHS Adult Protective Services confirmed cases in Tulsa
• Tulsa -- 8.6% of all state referrals (16,804)
• 38% increase of elder abuse by adult children
since 2005
• 116% increase over past 10 years
(Source: Adult Protective Services (APS) w/ the Oklahoma Department of Human
Services, 2005)
To compare
• In FY 04, Tulsa’s child abuse case investigations--1,228 confirmed
cases of 16,000 state calls
(Source: S. Arnold de Berges. Prioritization of System Issues, Child Protection
System of Tulsa County Report, 2005 )

41. Reporting Elder Abuse
1. In the case of abuse
of a vulnerable adult,
or elder abuse the
health care provider
must report to either
DHS-local office or
1-800-522-3511, or to
local law enforcement.
2. Suspected child abuse
must be reported to
DHS at local office
or 1-800-522-3511.

42. Reporting Abuse
• You must provide copies
of medical records
relating to abuse if
requested by law
enforcement invest-
igating reports.
• If you treat a victim of
abuse, you have statutory immunity from any liability,
civil or criminal, if you report or don’t report in good faith
as well as exercise due care.

43. To schedule a
presentation or for more
information, contact:
Sherry Clark at f.a.c.e.s.
faces.sherry@gmail.com
or (918)519-3609
Raising Awareness; Inspiring Action