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Recognizing the signs of domestic violence

Abuse may cause many complaints—but few patients will volunteer their story

From the June ACP Observer, copyright 2006 by the American College of Physicians.

By Janet Colwell

A few months ago, Elaine J. Alpert, FACP, learned that a close friend of hers, a working mother of four, had been assaulted and admitted to the emergency room with two broken ribs, the likely result of domestic violence. Despite their long friendship, the woman had never told Dr. Alpert about her long history of abuse by her husband.


Elaine J. Alpert, FACP: Physicians can screen for abuse and still manage their time.



“I went to visit her and asked, ‘What’s happening? Help me to understand,’ and it all came out,” recalled Dr. Alpert who led an Annual Session program on domestic violence. “I was asking her what happened two nights ago and she started her story from 17 years before.”

Many victims of domestic violence, both male and female, are reluctant to reveal their abuse to friends and family, let alone their physician, said Dr. Alpert. Victims arrive in their internist’s office with a variety of physical and mental health complaints--but unless the physician asks directly about abuse, the real source of their problems is often left unsaid.

Some physicians worry that initiating such a conversation will prompt a long session and throw off their entire day’s schedule, she said. But that doesn’t have to be the case. Using a standard screening method, physicians can get victims the help and support they need while still managing their own professional time.

“Many patients who come in with abdominal pain, pelvic pain, headaches, fibromyalgia and other conditions are abused,” said Dr. Alpert, who is associate professor of public health and medicine at Boston University School of Public Health in Boston and an expert on sexual and domestic violence. “And if you ask, their stories will come out.”

Recognizing abuse

To best recognize and treat patients, physicians should be familiar with the three main categories of abusive relationships. Those include:

  • Intimate partner violence. This is a pattern of purposeful coercive behaviors used in the context of dating or intimate relationships. According to Dr. Alpert, intimate partner violence affects 1.5 million women and 835,000 men annually. Men are the main perpetrators while their victims are both male and female partners in both heterosexual and same-sex relationships.

    In these relationships, the abuser tends to view himself as the “ruler” and his partner as the “inferior adversary,” said Dr. Alpert. The abuse typically stems from the abuser’s belief that he must ensure obedience and control over the victim and the household.

    “Most abusers actually see their behavior as appropriate,” said Dr. Alpert. “They feel this is the way their lives should be.”

  • Elder abuse. This has many of the same characteristics of intimate partner abuse, she said. However, the abuser can be a caregiver, a partner or both.

    In some cases, it is “domestic violence grown old,” she explained, where the abuse has been going on for a while but is only discovered later in life. Sometimes, the victim is a widow or recently divorced, having very little experience with dating and assuming that abuse is “part of the modern world.”

    Abuse may also be late-onset, when a relationship becomes controlling or abusive as the couple ages and one partner becomes sick or disabled, for example. Another scenario, said Dr. Alpert, is the “comeuppance syndrome,” when a victim starts abusing her perpetrator after the latter becomes disabled.

    Elderly victims often have issues and fears unique to their situations, she added. For example, victims may be frail or disabled and be highly dependent on the abuser for basic needs such as transportation and housing. In addition, they may fear being institutionalized or losing access to health insurance or other benefits, or may be reluctant to seek help due to pride or religious and cultural beliefs about marriage.

  • Childhood abuse. While internists do not have children as patients, Dr. Alpert noted that they should know about the serious emotional and physical scars that abused children carry into adulthood.

    The most common type of childhood abuse is neglect, followed by physical, sexual and emotional abuse, said Dr. Alpert. Children who witness violence also suffer from seeing, hearing and experiencing the aftermath of violence against a parent or caregiver. Children often learn from these experiences that violence is an expected way to negotiate relationships and that it often goes unpunished. As a result, they enter their adult years feeling that the world is neither safe nor secure.

    To illustrate how such experiences carry over into adulthood, Dr. Alpert cited the now-famous Adverse Childhood Experiences (ACE) Study, conducted in the mid-1990s by Kaiser Permanente and the CDC.

    The ACE Study was launched to investigate the long-term relationship of childhood experiences to medical problems in adulthood. Researchers found that just over half of the 17,000 participants had at least one of seven exposures: physical, psychological or sexual violence; witnessing violence against their mother; substance abuse in the household; mental illness or suicidality in household; or a household member in prison. The more exposures patients had, the higher their risk of smoking, alcoholism, drug use, chronic depression and other problems in adulthood.

    “We should routinely seek a history of childhood experiences,” advised Dr. Alpert. “We will learn best if we ask them, ‘how has this affected your life and health?’ ”

A screening climate

To screen for abuse, Dr. Alpert suggested following the RADAR strategy, one she developed in 1992 for use in the first Massachusetts Medical Society "Campaign Against Domestic Violence":

  • Remember to ask
  • Ask directly
  • Document findings
  • Assess for safety
  • Review options and refer

To that mnemonic, she said she adds an "F"—for follow-up.

It’s important, she said, to create a “climate for inquiry.” Think of wearing a button, for example, that says "Ask Me" or "I’ve been trained about domestic violence." Display posters in the waiting room and include tear-off cards with numbers of hotlines and support services or include an item about support services in your practice newsletter.

In the exam room, think of screening for abuse in the same terms you would screen for angina, she suggested, starting with a general inquiry and proceeding based on the patient’s answers. “No one would ever say 'I’m not going to ask about angina just because someone might say yes and it would ruin my schedule.' ”

Physicians should frame the first question as a routine inquiry about whether the patient has ever been hit, hurt, threatened or made to feel fearful by a partner, Dr. Alpert said. “About 85% of the time, the patient will say ‘no’ and you’ve taken only a few seconds out of the visit.”

Sometimes a patient will answer the question indirectly by saying something like, ‘my husband loves me,’ or ‘things are usually OK,’ ” she said. “That’s a 'yes.' In that situation, let patients talk about their situation for a few minutes and then ask if they are in danger right now.” Most patients will say "no," she said, and you can end the visit by giving them some support numbers to call and setting up another visit to discuss the issue in more detail.

“Only once in a blue moon will you get a patient in a crisis,” she said. In that small percentage of cases, the physician must take extra time to place the patient in a separate room and call a domestic violence advocate and possibly the police, just as they would admit an unstable patient with angina to the hospital.

Exam and follow-up

Apart from the responses to screening, certain injuries or conditions should prompt suspicion of abuse, she said. Those include chronic pain symptoms without any apparent etiology, psychological distress, evidence of rape, injury during pregnancy, or a partner who is overly protective or refuses to leave during the visit.

During the physical exam, note any unexplained injuries, bilateral or multiple injuries, or a delay in seeking care for an injury, said Dr. Alpert. You should also suspect abuse if the patient’s explanation doesn’t fit the injury or if the patient has a history of using emergency services.

Once abuse is confirmed, make sure to document with photographs, written descriptions or diagrams, which may have to be used in court, she said.

The physician’s role is to communicate concern, provide information and options, protect the patient, and provide treatment. It’s important to validate and empathize with the patient, she said, letting them know that they have choices and that help is available.

Getting involved in domestic abuse cases can be emotionally draining for physicians, especially at first, Dr. Alpert conceded. Even when you do everything you can for patients, they still might opt to stay with their abuser for practical reasons, and “we have to accept their decision. ”Ultimately, she said, the patient has to determine their own course.

“We want to help them but also empower them,” she said. “We don’t want to become the next person that they are dependent upon.”

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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