Tips to recognize—and respond to—domestic violence
Learning how to gently ask for information is the first step toward helping abused patients
From the March 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By Christine Kuehn Kelly
A mother of young children in Eugene, Ore., complained of worsening, recurring headaches. Prior blood work, a trial course of migraine therapy and a consult with a neurologist provided no answers. She had already taken so many sick days that she lost her job.
"I asked if she had ever been forced to do something sexual against her will," said Arlene Bradley, FACP, clinical director of women's health at the Veterans Affairs Roseburg Healthcare System in Oregon. The patient said she would rather not talk about it, but she admitted to nightmares, anxiety, abdominal pain, weight gain and dysmenorrhea. Dr. Bradley, who also is the College's representative to the AMA National Advisory Council on Family Violence, scheduled another appointment.
"At the next visit, I discussed her symptoms in a nonjudgmental way, explaining that she might be experiencing post-traumatic stress syndrome,” Dr. Bradley recalled. “I told her it is real--and treatable." The patient then admitted that her father had repeatedly abused her as a child, and that she now had to rely on him to care for her own children when she worked.
Dr. Bradley referred the patient for mental health therapy and suggested self-control activities such as keeping a headache diary. The patient eventually confronted her father, who moved out of town. The headaches abated and the patient was able to function normally again.
"The body keeps score," said Dr. Bradley. "Patients don't understand why they have headaches or gastrointestinal problems. It's up to us to find the source of the problem."
Domestic violence is widespread. Nearly 25% of women and about 7% of men in the United States say they have been raped and/or physically assaulted at some time in their lives, according to a 2000 report from the National Institute of Justice (NIJ) and the CDC. That same report also found that each year, an estimated two to four million American women are abused by an intimate partner. The National Center on Elder Abuse estimates that one to two million elderly persons, primarily women, experience abuse or neglect on an ongoing basis.
Domestic violence is not only physical. It can include psychological abuse and witnessing another family member being abused. Women in abusive relationships often say that psychological abuse affects them more adversely than physical abuse.
Abuse also cuts across all socioeconomic, racial, ethnic, geographic and age groups. But if you don't ask, your patients won't tell. Fewer than one in three abused patients discuss the trauma with a physician, according to a study published in the July-August 1997 issue of Journal of Emergency Medicine.
Primary care physicians can miss the diagnosis because patients usually do not present with signs of acute trauma. Instead, victims of abuse may present with vague aches and pains, depression, anxiety, substance abuse or a history of suicide attempts. Even women who experienced abuse in the past may present with similar symptoms. And women who are victims of "low-severity violence"—pushing, shoving and threats—also experience psychological and health problems.
"We recommend screening all women for domestic violence," said Jeanne McCauley, FACP, medical director for clinical research and outcomes at Johns Hopkins Medical Service Corporation and a co-author of several reports on domestic violence. Physicians cannot remove the trauma, but they can help reduce symptoms and enable patients to function better.
Several barriers, however, hurt physician willingness to deal with abuse. One is the belief that there are not adequate resources to help victims. Experts point out, however, that therapy and support are available from numerous public and private organizations.
Physicians also worry that talking about abuse will open a Pandora's box of emotions that will disrupt their practice. But according to Dr. Bradley, patients become extremely distraught only 1% to 2% of the time.
With those issues in mind, here are ways to help your patients who have been abused:
Ask nonjudgmental questions. When asking patients about abuse, your manner of questioning is key. Experts say that patients actually welcome nonjudgmental questioning and feel that it strengthens the doctor-patient bond. But like any other skill, it takes practice.
"Residents often use words like rape, incest or abuse,” said Susan Frayne, ACP-ASIM Member, a Boston internist who is working with Dr. Bradley on an upcoming College book on violence against women. (No release date has been set.)
Try using questions that are behaviorally based, such as "Has anyone ever forced you to have sexual contact against your will?" The idea is to normalize the conversation ("Abuse is very common, that's why I ask all my patients these questions"), validate the disclosure ("You've had a very difficult time") and show empathy ("I'm sorry that happened to you"). You also need to reassure patients that you will keep the conversation confidential.
Normalizing questions about sexual and physical abuse improves the likelihood that patients will respond. Experts suggest starting with statements such as, "Because abuse and violence are so common, I ask all my patients these questions," or "We know many women have had sexual experiences they didn't want. Has this ever happened to you?"
The American College of Obstetricians and Gynecologists recommends the following screening questions:
Within the past year—more recently, if you have been pregnant—have you been hit, slapped, kicked or otherwise physically hurt by someone?
Are you in a relationship with a person who threatens or physically hurts you?
Has anyone forced you to do sexual activities that made you uncomfortable?
Create a supportive environment. Surveys show that physicians who wear buttons with anti-abuse messages and generally display their support for victims of abuse have more conversations about family violence. Women who see domestic violence posters in a doctor’s office are also more likely to talk about their experiences. Patients respond well if you have a secure, discreet area to talk about referrals and other resources. Nurses and support staff also need preparation to better help victims of violence.
Make the physical exam less threatening. Women who have been abused may fear or be uncomfortable with physical contact with an authority figure. As a result, you should always ask permission before performing a physical examination or other procedure. Fully explain what you are doing and let the patient know she can stop any procedure or exam. Invite patients to bring a trusted family member or friend with them to medical appointments.
Prepare for disclosures. When you screen for abuse, it helps to plan your general responses before patients make any disclosures. Dr. McCauley noted that role-playing is effective in preparing for screening sessions and that the strategy takes only a few minutes of your time.
Sympathetic silence during disclosure is usually best, followed by acknowledgment of the patient’s pain ("I'm sorry this happened to you"). Keep in mind that consoling a patient too readily doesn't validate her experience.
Once the abuse is disclosed, "Tell your patient she doesn't need to provide you with the details, that you will refer her to people who are better equipped to help,” Dr. Bradley said. You’ll need a list of mental health professionals, legal and social services and support groups.
“Let her know you will continue to be there as her primary provider," Dr. Bradley said. Your ongoing attention and support can help empower traumatized patients and boost their self-esteem.
Don't get in the middle. Maintaining the abused patient’s confidentiality while getting help for her--and the abuser—can put you in a difficult position. Consult mental health professionals for the best way to handle each individual situation.
It’s important to realize that interventions really can help abusers as well as victims. Batterer-intervention programs with very specific inclusion criteria change behaviors about 30% to 45% of the time, said Dr. Bradley. "This may not sound like much to a medical provider,” she said, “but in mental health, it is excellent."
Recognize the ramifications of reporting. Although you are required to report abuse of children, the elderly and the disabled, few states require physicians to report abuse of patients outside of those categories. Remember that reporting may actually put victims at increased risk for future violence or make them reluctant to seek care.
"It's best for a patient to call support services herself," said Dr. McCauley. Patients face the greatest danger of being killed by an abuser shortly after they leave a bad domestic situation. If a patient is in immediate danger, Dr. McCauley said, point her to support groups that will provide a safe haven for her and any children involved.
Take care of yourself. Remember that trauma affects clinicians, too. Residents shouldn't feel they have to carry the whole burden and should talk to attendings for support, said Jane Liebschutz, FACP, assistant professor of medicine at Boston University, and co-editor of the College’s upcoming book about violence against women. Talking dilutes the power of the trauma, she said, and can help you accept the chronic nature of the patient's problems.
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
National Domestic Violence Hotline: 800-799-7233.
The Massachusetts Medical Society Seminar on Domestic Violence. This course curriculum includes CD-ROM, videotapes and slides. For information, contact the MMS Department of Public Health and Education at 800-322-2303, ext. 7373, or send an e-mail to firstname.lastname@example.org.
Researchers are increasingly recognizing abuse as a causal factor in multiple physical and psychological problems of female patients. Coping strategies used by some patients during abuse or later on to deal with bad memories may lead to physical, emotional and behavioral problems.
Abuse, for example, can lead to biophysical changes such as low pain thresholds. Arlene Bradley, FACP, clinical director of women's health at the VA Roseburg Healthcare System in Oregon, said that research suggests that repetitive traumatic experiences often correlate with chronic disruptions in the hypothalamic-pituitary-adrenal axis that, in turn, may contribute to the complex clinical picture. Measurable and sustained neuroendocrine dysregulation can be seen following trauma.
The following clinical presentations are frequently associated with trauma:
Physical: chronic pelvic pain, vaginismus, migraines, sleep disturbances, gastrointestinal disorders (nausea, vomiting, diarrhea, irritable bowel syndrome, spastic colon), temporomandibular joint syndrome, respiratory problems (asthma, shortness of breath), chronic back pain, fibromyalgia, sexual dysfunction.
Emotional: depression, anxiety, post-traumatic stress disorder, personality disorders, compulsivity.
Behavioral: self abuse or neglect, aggression, high risk behavior, suicide attempts, substance abuse, eating disorders, poor contraceptive compliance, poor adherence to medical recommendations.
Although violence cuts across socioeconomic, ethnic, racial and geographic lines, the following groups are more likely to be abused:
Women with current or estranged husbands or boyfriends who abuse alcohol, use drugs, are unemployed or intermittently employed, or have not graduated from high school.
Pregnant women, because physical abuse often begins during pregnancy.
Elderly women who are emotionally and financially dependent on their caregivers.
Women who are or have been in the military.
Women whose stories seem completely disconnected from the physical injury they present with. "A 35-year-old with bruises on multiple parts of her body who says she ran into a doorway is not believable," said Jane Liebschutz, FACP, assistant professor of medicine at Boston University. Also, look for symptoms that are out of proportion to what the work-up shows, particularly in their intensity.
Manipulative patients. "If you don't like a patient and can't identify an obvious reason, or feel you are being manipulated, there may be something going on," said Arlene Bradley, FACP, clinical director of women's health at the VA Roseburg Healthcare System in Oregon. Victims of abuse may be "doctor shoppers" who frequently alienate their caregivers, then change providers.
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