Pocket ObGyn – Domestic Violence
See Abbreviations
Definitions
- Intentional controlling or violent behavior by someone in a relationship w/ the Includes physical, sexual, verbal, & emotional abuse as well as economic depriv.
- IPV: Victim is often intimately involved w/ her
- Common couple violence: Not connected to general control behavior, arises in a single argument where one/both partners are
- Intimate terrorism: General pattern of abuser control, emotional & psychological abuse, not mutual, more likely to escalate over time, more likely to involve serious
- Violent resistance: Self-defense, violence by victim against
- Phases of abuse: Tension-building: Poor communication, fear, victim tries to pacify the Acting-out: Outburst of violent, abusive behavior. Honeymoon: End of violence ® affection & apology.
Epidemiology
- Affects over 1 million each 54% of report an abusive relationship in the past.
- Higher prevalence if under age 35, single, divorced/separated, abuse EtOH or drugs, smoke, pregnant, lower socioeconomic class, h/o childhood
- Elder abuse: 10% of women over 65 report physical, sexual, or verbal abuse or Risks: Advanced age, AA, disability in self-care, dementia, depression, h/o hip fracture, h/o stroke, social isolation, low socioeconomic status, institutional staffing shortages.
- Preg: Domestic violence affects 7–20% of pregnancies, 3-fold higher risk if Preg is unintended, Preg can result from reproductive coercion (forced Preg by contraception sabotage).Victims more likely to deliver preterm & by cesarean 3-fold risk of attempted/completed homicide. Highest risk of IPV in 3rd trimester & postpartum.
- No typical abuser or victim, IPV affects all ages, races, & socioeconomic
Clinical Manifestations
- Inconsistent explan of injuries or delay in seeking Somatic complaints (HAs, abdominal/pelvic pain, fatigue). Depression, anxiety, eating disorders.
- Presenting late to prenatal Frequent ED visits. Noncompliance w/ rx. Skin tears, bruises, bone fractures, malnutrition, dehyd, & pressure ulcers common in victims of elder abuse.
- Most injuries on breasts, abd, & genitals, esp in Defensive wounds on hands, arms. Bruises of different ages.
Diagnostic Workup/Studies
- Screen routinely in all pregnant pts, for well-woman/preventive No strong evid that routine screening decreases harm (USPSTF).
- SAFE questions (JAMA 1993;269:2367)
“Do you feel safe in your relationship?”
“Have you ever been in a relationship where you have been threatened, hurt, or afraid?” “Are your family/friends aware that you have been hurt? Could you tell them and
would they be able to give you support?”
“Do you have a safe place to go and resources you need in an emergency?”
- Abuse assessment screen: Identifies physical or sexual abuse in Preg (JAMA 1992;267:3176)
“Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?”
“Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise phys- ically hurt by someone?”
“Within the last year, has anyone forced you to have sexual activities?”
- BASE & the CTS can be used to screen for elder abuse (JAGS 2004;52:297)
Treatment and Medications
- RADAR: Routinely screen, Ask direct questions, Document your findings, Assess safety, Review Provide supportive counseling & validation of a pt’s fear.
- Assess risk for escalation: Presence of weapons in the home, increasing violence frequency/severity, partner’s knowledge that victim is planning to leave, threats of
- Refer to social workers, safe houses, 1–800–799-SAFE provides information regarding local resources in every state.
- Specific, detailed, accurate, & nonjudgmental documentation is essential in case the victim seeks legal Mandatory reporting of child abuse in all states. Many states require elder abuse reporting. Some states require IPV reporting for adult women as well.