DOMESTIC VIOLENCE
| WHAT INTERNISTS NEED TO KNOW ABOUT DOMESTIC VIOLENCE —Panagiota V. Caralis, MD, JD, Professor of Medicine, University of Miami Miller School of Medicine and Chief, Section of General Medicine, Miami Veterans Affairs Medical Center |
| Definition of domestic violence: actual or threatened physical injury; intimidation through insidious and repetitive process; sexual assault of any kind, even among spouses; psychologic abuse, eg, intimidation, threats, and withholding of privileges; economic control, eg, withholding of Social Security checks; progressive social isolation of victim; legal definition—physical injury and legally sanctioned relationship not requirements |
| Demographics: victims predominantly women, perpetrators predominantly men; 6 of 10 married couples meet definition of domestic violence; most common cause of traumatic injury; 37% of pregnant women have history of abuse, with 60% suffering recurrent abuse during subsequent pregnancies; 50% of female homicide victims killed by male partners; 12% of male homicide victims killed by female partners |
| Review of domestic violence deaths in Florida: 39% of deaths preceded by threat; 42% had no warning; location— 42% killed in residence; others include highway, workplace, businesses, and shopping malls; cohabitation—slight majority separated, with 75% having recently separated; serving of divorce or custody papers or initial separation represents vulnerable period; perpetrator characteristics—10% had received psychiatric treatment for depression; majority had recently lost job or business; relationship—intimate partner homicide most frequent; lethality indicators—history of domestic violence; obsessive and possessive behaviors; sadistic behavior (eg, killing pets); suicidal ideation; sleep disturbances; substance abuse increases likelihood of homicide by diminishing control over behavior; perpetrators usually communicate threat and tend to have police record |
| Prevalence: study—54% of patients attending primary care clinic had history of domestic violence; study—speaker conducted survey at Veterans Affairs hospital; 42% of women (patients and those accompanying patients) had history of domestic violence; 7% currently in physically abusive relationships; 3% had been raped or forced into sex; only 12% had been asked by physician or nurse about domestic violence; 68% of women asked willing to talk (other studies suggest 80% of women being abused willing to tell if asked) |
| Ineffective diagnosis: study—emergency department (ED) physicians diagnosed 1 in 35 women being abused, and 1 in 4 had abuse documented in medical record; only 8% of discharge diagnoses indicated abuse, despite being documented in medical record; 1 in 5 women sought medical attention for abuse injuries average of 11 times without receiving help |
| Barriers to physician recognition: tendency to label people presenting without exact diagnoses as “crocks,” having Munchausen syndrome, or having psychosomatic symptoms; no training in recognizing domestic violence; societal misconception that domestic violence rare; study by Connecticut Medical Society of physician members showed 8% of women and 4% of men had history of domestic violence; domestic violence occurs in normal relationships and in highly educated people, crosses socioeconomic groups, and not racial or ethnic problem (high prevalence in blacks likely due to cultural acceptance of reporting; low prevalence in Latinos likely due to reporting being culturally unacceptable); do not refer to marriage counseling because counselors treat people as equals, which can potentially increase violence; need to understand motivation of people willing to stay in abusive relationships, and to be aware of available resources |
| Perpetrator traits: often not angry or unintelligent people; many have low self-esteem; desire power and sense of control; exert control through emotion (eg, threatening to take children away), isolation (eg, confiscating credit card, car, or house keys), minimizing (eg, blaming victim), and economic abuse |
| Screening for domestic violence: American College of Physicians states that screening should be as routine as asking about medical history |
| Treatment: important to connect with patient same way as with any patient suffering chronic illness; educate patient that situation unacceptable and they have options; plan for safety, especially in adult abuse cases; record that patient counseled about safety issues and available options; be aware of and have easy access to support services |
| Recognizing signs and symptoms: only 4% of victims present with “black” eyes and broken bones; clues—injuries located in central portion of body, not periphery; multiple stages of healing; abdominal injuries in pregnant women; symmetric injuries, particularly in elderly; injury patterns (eg, of sticks) or wrist injuries indicating incarceration; repeated blows to head cause headaches, hearing problems, and sinus problems; chronic pain syndromes; chest and abdominal pain; case example—woman presented with acute pancreatitis; work-up revealed no cause; eventually diagnosed as blunt trauma pancreatitis when patient revealed husband was beating her on stomach with pillow; case example—woman presented with transient ischemic attacks and stroke; work-up revealed no cause; carotid artery damaged by ex-husband choking patient; mental health signs—alcohol abuse; licit and illicit drug abuse; depression and anxiety; increased rate of attempted suicide |
| How to screen: ask patient in simple, straightforward, confidential, and sensitive manner; studies show that women with no history of abuse not offended by questions; speaker asks all female patients |
| Safety assessment: once patient acknowledges abuse, important to do safety assessment and document in medical record; in adults, victim responsible for assessing danger level; provide patient with contact details of support services; important to advise patient on planning for sudden decision to leave, such as keeping suitcase somewhere safe containing identification, money, passport, and house and car keys; also plan for what to do with children; medical record—stands alone as evidence; documenting discussions with patient will not result in physician becoming part of legal dispute, provided information clear |
| Legal processes: physician required to report child abuse and should notify patient; also required to report abuse of elderly and disabled people but not adult abuse |
 | Temporary restraining order: obtained without court hearing; no fee; provides custody, residence, and payment; reviewed after 60 days, which requires court hearing |
| Mandatory intervention and treatment programs for batterers: group sessions lasting 26 wk; court-ordered attendance; patients required to successfully complete program; studies have shown 50% to 70% of patients abstain from perpetrating violence during 5-yr follow-up |
Elder Abuse | Reporting: mandatory; Florida hotline, 1-800-960-ABUSE; in 1998-99, of 171,000 calls reporting abuse, 17% involved elderly |
| Definition: includes willful and unintentional neglect by others, self-neglect, and monetary exploitation |
| Prevalence: 4% to 5% of elderly Americans abused (estimated 1 to 2 million victims per year); for every reported incident, 5 remain unreported |
| Types of abuse: 30% of cases involve physical and emotional abuse; sexual abuse less prevalent than in adult populations; 55% of cases involve neglect (in Florida, neglect by others more common than self-neglect) |
| Victim characteristics: Florida statistics—41% of cases involve older elderly (11% >90 yr of age); predominantly female, but more even than adult abuse; 82% of victims white (although frequent in black population); reporting— often reliant on neighbors, family, medical profession, and law enforcement; victim unlikely to tell; lack of health care—adult child may be unable to cope with parent and fail to provide appropriate medical care, eg, not giving insulin |
| Perpetrator characteristics: most commonly adult children; more frequently female; less frequently spouses; in many instances, perpetrator has mental illness, most commonly depression or stress; substance abuse common; low socioeconomic status; tend to be financially dependent on victim; combative elderly patient increases likelihood of violent conduct by caregiver; inadequate family leave in United States increases stress on caregiver |
| Barriers to self-reporting: victim may feel extreme shame and be fearful of exacerbating problem if he or she tells; may fear change of status, eg, entering nursing home; fear of not being believed and of navigating judicial system also deterrents |
| Signs and symptoms: variable healing signs; bruises on trunk; patterns of objects; bruises on throat; parallel, bilateral, and symmetric injuries; wounds that do not heal; spouse who insists on being present at all times, becoming belligerent when asked to leave; fear, denial, and social isolation |
| ELDER ABUSE —Hilda K. Grey, PhD, RN, Victim Advocate, Elder Abuse Unit, San Diego District Attorney’s Office |
| Financial abuse: rampant among family caregivers, other caregivers, and members of community |
| Legal definition of elderly: in California, elder defined as ≥65 yr of age; California law also protects dependent adults 18 to 64 yr of age; in most other states, elder defined as ≥60 yr of age |
| Neglect: usually occurs with caregivers, whether paid or unpaid; child who becomes caregiver for elderly parent responsible for any neglect; psychologic—terrorizing or threatening use of words or gestures, eg, telling patient they will be put into nursing home if they report abuse; yelling; denying food or privileges; self-neglect—forgetting to eat, often because they have no triggers telling them when to eat; dehydration also major problem; hygiene—dirty and badly maintained nails |
| Criminal definition: physical abuse or neglect considered felony if likely to cause great bodily harm or death, or misdemeanor if unlikely to cause great bodily harm or death; elder abuse parallels domestic violence model more than child abuse (abuse escalates if not dealt with, and victims often blame themselves) |
| Functional problems: difficulty managing money; symptoms of dementia often include inability to balance check book |
| Medication abuse: half-life of medication longer in elderly, so careful monitoring required; speaker believes dosing according to body weight more appropriate because of elderly patients’ reduced ability to metabolize medications; medication overuse—often involves sedatives; medication misuse—misuse by caregivers indicated by “doctor shopping”; giving wrong medication for wrong purpose; medication underuse—case example, male patient with Parkinson’s disease received only half of correct dose of medications because wife did not want to pay for refill; patient’s symptoms deteriorated significantly; complicated medication regimen—ask to see patient’s medication list and remove unnecessary ones; be aware that elders may be taking herbal remedies and of potential problems, eg, bleeding |
| Delirium: may be marker of abuse because of neglect, medication overuse, or delay in seeking care |
| Perpetrator profile: in speaker’s experience, commonly dependent son, 35 to 42 yr of age, who lives with elderly mother and has gambling, drug, or alcohol problem; abuses mother when she fails to provide money |
| Types of perpetrators: well-intentioned—speaker uses term “the new best friend”; blind patients and patients with macular degeneration particularly vulnerable; burden of being caregiver becomes stressful and overwhelming; not well-intentioned—abusive and sadistic |
| Signs and symptoms: patient becoming withdrawn or disheveled; argumentative and obstructive caregiver; implausible or vague explanations for injuries; falls may be due to medication overuse or abuse; inconsistent stories; change in behavior (pay attention to patient’s body language); clues on physical examination—sores; bruises; wounds; unkempt appearance; poor hygiene; malnutrition; dehydration; drug levels indicating medication overuse; x-rays and brain imaging also useful |
| Forensic documentation: create paper trail; ensure records clear and legible to avoid liability |
| Reporting abuse: in California, report to Adult Protective Services; different social services exist in other states, so be aware of contact details; physician’s responsibility to report abuse if there is reasonable suspicion, not to determine if abuse actually occurred |
Educational Objectives
| The goal of this activity is to provide information on domestic violence and elder abuse. After hearing and assimilating this program, the clinician will be better able to: |
| 1. Recognize signs and symptoms of domestic violence. |
| 2. Describe legal requirements for physicians reporting domestic violence. |
| 3. Discuss appropriate courses of action with victims of domestic violence. |
| 4. Recognize signs and symptoms of elder abuse. |
| 5. Report suspected cases of elder abuse. |
Suggested Reading
Bacskai E et al: Drinking and intimate partner violence in a changing society. Am J Public Health [Epub ahead of print], 2005; Berkowitz CD: Recognizing and responding to domestic violence. Pediatr Ann 34(5):395, 2005; Bond C: Education and a multi-agency approach are key to addressing elder abuse. Prof Nurse 20(4):39, 2004; Brown K et al: Effectively detect and manage elder abuse. Nurse Pract 29(8):22, 2004; Burge SK et al: Patients' advice to physicians about intervening in family conflict. Ann Fam Med 3(3):248, 2005; Caralis PV, Musialowski R: Women's experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J 90(11):1075, 1997; Dyer CB et al: Community approaches to elder abuse. Clin Geriatr Med 21(2):429, 2005; Feder G et al: Zero tolerance for domestic violence. Lancet 365(9454):120, 2005; Gerber MR et al: Adverse health behaviors and the detection of partner violence by clinicians. Arch Intern Med 165(9):1016, 2005; Hansberry MR et al: Dementia and elder abuse. Clin Geriatr Med 21(2):315, 2005; Lutz KF: Abused pregnant women's interactions with health care providers during the childbearing year. J Obstet Gynecol Neonatal Nurs 34(2):151, 2005; McIntire T: Elder abuse litigation and the duty to provide palliative care. Physician Exec 30(6):44, 2004; Nelson HD: Screening for domestic violence--bridging the evidence gaps. Lancet 364 Suppl 1:s22, 2004; Potter J: The importance of recognizing abuse of older people. Br J Community Nurs 10(4):185, 2005; Quinn K, Zielke H: Elder abuse, neglect, and exploitation: policy issues. Clin Geriatr Med 21(2):449, 2005; Reed K: When elders lose their cents: financial abuse of the elderly. Clin Geriatr Med 21(2):365, 2005; Thompson R: Intimate partner violence: a culturally sensitive approach. Adv Nurse Pract 13(5):57, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported nothing to disclose.
Dr. Caralis was recorded at Internal Medicine Update 2005, 40th Annual Postgraduate Course, presented January 30 to February 4, 2005, in Miami Beach, Florida, by the University of Miami Miller School of Medicine. Dr Grey was recorded at Topics and Advances in Internal Medicine, presented March 3-9, 2005, in San Diego by the University of California, San Diego, School of Medicine. The Audio-Digest Foundation thanks Drs. Caralis and Grey, the University of Miami Miller School of Medicine, and the University of California, San Diego, School of Medicine for their cooperation in the production of this program.
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