Nyaya Health Program for Victims of Intimate Partner/Domestic Violence
For questions, contact sanjay@nyayahealth.org or jhumka.gupta@yale.edu
A note about our use of gender specific language: Because the vast majority of victims of adult domestic violence are women who are abused by their male partners, the content of the protocol refers to victims as female and abusers as male. However, the majority of the content in this protocol will apply to all victims regardless of their gender or the gender of their partner.
Introduction
Domestic violence is a health care problem of pandemic proportion with far reaching implications. Recorded data on the number of victims does not reflect the visits made for numerous chronic health problems exacerbated by domestic violence such as depression, substance abuse and hypertension.
Many patients are discharged with only the presenting symptoms or injuries having been treated, leaving the underlying cause of the problem, domestic violence, unaddressed. Failing to identify domestic violence can result in incorrect diagnosis, costly unnecessary testing, and increased utilization of health care services and hospitalizations.
Definitions
Domestic violence is a pattern of coercive tactics that can include physical, psychological, sexual, economic and emotional abuse perpetrated by one person against an adult intimate partner, with the goal of establishing and maintaining power and control over the victim.
Domestic violence occurs in all ethnic, religious, socio-economic, sexual preference and age groups.
Domestic Violence Myths
The following are often blamed as a “cause” for domestic violence:
− Alcohol/substance abuse
− Stress
− Socio-economic factors
− Anger/loss of control
− Another person’s behavior
While these factors may be contributing, they are not causal. Many people experience the above factors and do not abuse their partners.
Tactics & Clinical Cues
Tactics of control may manifest in the following ways:
Tactics
• Biting
• Grabbing
• Punching
• Shoving
• Kicking
• Slapping
• Shooting
• Stabbing, etc.
• Withholding medication, medical care, medical equipment, nutrition
• Forcing use of alcohol or other drugs
Psychological Abuse
• Instilling, or attempting to instill fear through ridiculing or humiliating the victim
• Destroying property
• Threatening to harm self or victim
• Blaming abuse on victim
• Injuring, killing, or threatening to injure or kill animals
• Coercing, or attempting to coerce any sexual activity without consent
− Rape, sodomy, attacks on sexual parts of the body
− Unprotected sex
− Sex with others
− Prostitution
− Degrading, sexually explicit behavior toward victim
− Taking/showing sexually explicit film or photos and using them against the victim
• Attempts to undermine a person’s sexuality
− Treating partner in a sexually derogatory manner
− Criticizing sexual performance and desirability
− Accusations of infidelity
− Withholding sex
Economic Abuse
• Making, or attempting to make a person financially dependent
Emotional Abuse
• Undermining, or attempting to undermine, a person’s self-worth
− Constant criticism
− Put downs
− Insults
− Name calling
− Silent treatment
− Manipulating feelings/emotions
− Repeatedly making and breaking promises
− Subverting partner’s parenting and/or relationship with children
− Threatening to harm, kill or abduct children
Health Care Manifestations
• Ecchymosis (bruises)
• Lacerations, often to arms & face
• Headaches
• Anxiety
• Hyperventilation
• Hypertension
• Chest pains
• Chronic pain
• During pregnancy
− Injury to abdomen, breasts, genitalia
− Hemorrhaging, including placental separation
− Uterine rupture
− Miscarriage/stillbirth
− Pre-term labor
− Premature rupture of membranes
• Delay in seeking prenatal care
• Frequently missed appointments
• Lack of attendance to prenatal
education
• Poor nutrition
• Continued use of cigarettes, drugs and/or alcohol during pregnancy
• Chronic muscle tension
• Psychosomatic illness
• Suicidal ideation
• Homicidal ideation
• Substance abuse
• Multiple pregnancies
• Spontaneous abortion
• Sexual assault injuries
Identification
To achieve early identification of domestic violence, private routine screening is recommended for all female patients over the age of 16. In addition, men and women in gay and lesbian relationships are also at risk for domestic violence and should be routinely screened.
Patients receiving care in the OPD should be informed that “Because intimate partner violence and abuse are so common, we screen for it routinely.” This gender-neutral statement communicates to the patient that the physician is knowledgeable about domestic violence and does not assume that everyone is heterosexual.
If the patient does not disclose abuse, consider domestic violence if any of the following is observed:
• Injuries to face, neck, throat, chest, abdomen or genitals
• Evidence of sexual assault; vaginal/anal injuries
• Bilateral or patterned injuries
• Injuries during pregnancy
• Delay between injury and treatment
• Multiple injuries in various stages of healing
• Injury inconsistent with patient’s explanation
• Frequent use of emergency department services
• History of trauma related injury
• Chronic pain symptoms with no apparent etiology
• Repeated psychosomatic or emotional complaints
• Suicidal ideation or attempts
• An overly attentive or aggressive partner accompanying the patient
• Patient appears fearful of partner
Management
The following guidelines are designed to assist medical personnel in treating victims of domestic violence.
1. Interview the patient in private. Ask any accompanying spouse, friend or family member to leave the treatment area. Questioning the patient about domestic violence in the presence of the abuser, suspected abuser or other family members may put the patient in extreme danger.
2. Convey an attitude of concern and respect for the patient and assure the confidentiality of any information provided.
3. Inform the patient of routine domestic violence screening policy and ask the patient directly if the injuries or complaints are the result of abuse by someone they know.
4. If domestic violence is disclosed, communicate to the victim that they are not alone, they are not to blame for the abuse, and that help is available.
5. Take the patient’s history and conduct a thorough medical examination, with appropriate laboratory tests and x-rays. If the extent or type of injury is not consistent with the explanation the patient gives, note this in the medical record. A question to elicit information about site and cause of injury that might indicate domestic violence should be asked. Ask for specifics and document using the patient’s own words.
“He threw a brick at me” is better than “We
were arguing and things got out of hand.”
“Patient states that her husband hit
her with his belt” is better than “Patient has been
abused.”
All OPD logs should include a code for domestic violence.
6. Preserve physical evidence. Bag torn or blood stained clothing and/or weapon. Mark bag with patient’s name, date and name of person who collected evidence. Keep evidence under lock until it is turned over to the police, prosecutor or patient’s lawyer. Refer to your facility’s sexual assault protocol for evidence collection information.
7. Help the victim assess their immediate safety and safety of the children. Respect and accept the victim’s evaluation of the situation. If appropriate, offer to call the police. Tell the patient that battering is a crime and help is available. Support the patient’s decision.
8. Offer to photograph the patient’s injuries.
9. Make safety the primary goal of all interventions. Victims are likely to be the best judge of what is safe for them. If it is necessary to follow-up with medical appointments, laboratory tests or prescriptions, ask directly if the victim can safely do so, or what could be done to make it possible for her to meet follow-up care needs
Assessments
Let your patients know that you ask everyone about domestic violence.
• “Because intimate partner violence and abuse are so common, we screen for it routinely.”
Questions:
Avoid asking patients questions using the term “domestic violence.” Most victims do not initially identify with the term, and their understanding of the term varies greatly.
Tailor the following questions to your practice:
Questions that tell victims they are not alone:
• Many patients tell me their partners have hurt them. Is this happening to you?
Questions based on observation:
• You seemed frightened of your partner. Has he ever hurt you?
• Your partner seemed not to want to let me speak with you alone. I’m concerned that he might want to control what you tell me. Do you think that is happening?
• I noticed you check with your partner before you answer any questions. Are you afraid you might get hurt if you say the “wrong” thing?
Questions about physical abuse:
• Are you in a relationship where you get hit, punched, kicked or hurt in any way?
• Do arguments ever end in your partner pushing, shoving or slapping you?
• Has your partner ever used a fist or weapon to hurt or threaten you?
Questions about sexual abuse:
• Does your partner force you to engage in sex that makes you uncomfortable?
• Does your partner ignore your decisions regarding safe sex or contraceptives?
Questions about emotional abuse, threats or intimidation:
• Does your partner ever call you names or put you down?
• When your partner gets angry, does he throw things? Hurt your pet?
• Does your partner accuse you of having affairs? Check up on you?
• Do you have to ask your partner’s permission to do things you want to do?
Avoid the following:
Labeling questions:
• Are you a victim of domestic violence?
• Are you battered?…abused?
Blaming questions:
• Why didn’t you come to the hospital sooner?
• Why didn’t you leave the first time he hit you?
• Why didn’t you call the police?
Be cautious about giving advice (go to a shelter, leave your partner). Your advice may have safety implications of which you are unaware, while providing information about available resources may be helpful.
References
Domestic violence international resources
WHO Multi-country Study on Women's Health and Domestic Violence against Women
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