Intimate Partner Violence

Facilitator: Dr. Debbie Swiderski


INTIMATE PARTNER VIOLENCE

Clinical Considerations

 

 

What is IPV?

Actual or threatened psychological, physical or sexual harm by a current or former partner or spouse.

·      Does not require sexual intimacy

·      Is not gender-specific but majority of victims are women

·      Occurs in both heterosexual and same-sex couples

 

Epidemiology

·      Common but under-reported

·      A world-wide problem

·      Annually 1,200 deaths and 2 million injuries among women and nearly 600,000 injuries among men (MMWR 2008)

·      Lifetime occurrence estimates from 22 to 39% of all women

·      In one study of 1952 primary care patients,  5.5 %  had experienced IPV in the prior year and 21% in their adult lives

·      More common in ER patients

·      Often begins or escalates during pregnancy and post-partum period

 

Clinical Presentation

·      Chronic pain, particularly pelvic pain but also musculoskeletal pain, headache, irritable bowel syndrome, fatigue

·      Depression, anxiety, PTSD

·      STD’s

·      Inconsistent explanation of injuries

·      Frequent ER or urgent visits

 

Screening

·      Difficult/impossible to assess long term benefit of screening

·      Probably increases identification of IPV

·      Does not appear to cause harm

·      Multiple organizations endorse screening but with differing recommendations.  The majority suggest (and I concur):

o   All patients on initial primary care visit

o   All ER patients

o   On hospital admission

o   All Ob-Gyn patients, all pregnant patients

 

Screening strategies

1.     Initial screening questions

a.     Framing Questions (use to normalize the inquiry)

                                               i.     Violence can be a problem in many people’s lives so I ask every patient I see about their experience with it

                                             ii.     Every couple has conflict.  What happens when you and your partner have a disagreement? Does it ever get physical?

                                            iii.     I see patients who are being hurt or threatened by someone they love.  Has this ever happened to you?

b.     Direct questions about IPV

                                               i.     At any time has a partner ever hit, kicked, punched or otherwise hurt or frightened you?

                                             ii.     Have you ever felt threatened by your partner?

2.     Other potential entry points (keep your antennae up, communicate your interest in the patient))

a.     Family and social history (ask why previous relationships ended)

b.     Pregnancies (“Was FOB involved? How did pregnancy affect your relationship?”)

c.     Observation (partner present during visit, unwilling to leave, calls frequently)

3.     Do NOT use words like “victim”, “abused”, or “battered”, rather “hurt”, “frightened”, “treated badly”

 

Barriers to Screening

Patients

·      Fear of reprisal from abuser (“I’ll kill you if you tell anyone”)

·      Shame, worthlessness, hopelessness

·      Social isolation

·      Concern about economic consequences

·      Fear of ACS, immigration intervention

·      Ambivalence toward abuser, promises to change

·      Unresponsive support network

Physicians

·      Time pressures

·      Concern about inadequate knowledge base

·      Wish (conscious or unconscious) to avoid powerful negative emotions

 

What to do if you get a “Yes”

Physician Obligation   (E. Alpert)

1.     Communicate concern

2.     Provide medical treatment

3.     Review options, facilitate referral and/or follow-up

4.     Assure the generation of an individualized safety plan if threat is current

Strategies

1.     Remember that empathic listening has a powerful positive effect

2.     Open-ended questions are essential and will allow the patient to control the interview. (“Can you tell me what happened?” “How has this affected you?” “Have you told anyone else about this?”)

3.     Affirm the patient (“You do not deserve to be treated like this.” “Thank you for telling me about this.” “You are very strong to have gotten to this point.”)

4.     This is the appropriate time to ask the patient if she feels safe, if she has a safety plan, if there are weapons in the home, if children are involved/at risk.

5.     Do not jump to referral.  Let the patient be your guide. Patients will make a change when they feel ready. Remember that risk of injury/death increases when a woman decides to /tries to leave

6.     Explicitly reaffirm that your visit is confidential

7.     Explicitly reaffirm that the patient does not deserve to be threatened, controlled, or hurt.

8.     Explicitly affirm your ongoing support/advocacy, whatever choice the patient makes

 

Developing a Safety Plan

A safety plan should include the following elements:

1.     Preparing an emergency kit with important documents, keys, money, and other essential items, to be stored outside the home in case they need to escape urgently

2.     A place to go (friends, family, shelter)

3.     A signal to alert children or neighbors to call 911

4.     During times of escalating conflict avoiding rooms with potential weapons (kitchen) or risk for increased injury (hard bathroom surfaces)



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