The Faces of Domestic Violence In the office setting, domestic violence is hard to ascertain. More often than not the patient that is a victim of physical abuse is a woman.1,6,7 Interestingly though, a man is more often the victim of psychological abuse.7 There is evidence that heavy alcohol and substance use including prescription drug abuse, as well as, chronic and persistent mental illness, particularly depression and personality disorders, are contributing factors to the existence of domestic violence.1,7,10,11 Additionally, poor social skills, lower education, poverty, pregnancy, disabilities, conflict and anger, limited access to resources in the community, witnessing violence in the home, old age, and young age are all identified as significant risk factors to domestic violence.5,10,11,12 So although not exclusively, your patients who are experiencing domestic violence are often women and children. In 2009 the CDC fact sheet on Intimate Partner Violence (IPV) stated that close to 5 million women are sexually or physically assaulted each year. The incidence for men is in the range of 3 million.6 Male patients can become victims as well. This is especially true if they are elderly, disabled or otherwise identified as vulnerable.8 Unfortunately, we are often talking about your male patients as the perpetrators. A Department of Justice study reported in 2007 that only 3% of the individuals who experience IPV from 1976 through 2005 stated that the perpetrator was a woman.9 It is impossible to tell for certain who is going to commit domestic violence and who is not, but there are some signs to pay attention to. As indicated earlier, the numbers related to incidences of domestic violence are increasing in a parallel fashion to our declining economy. As anxiety related to money, jobs, mortgages and community resources grows, so do the physical and psychological concerns in our general population. Placed in this environment, a person who is unemployed, has reduced coping skills to handle stress, uses and/or abuses mood altering substances (including prescriptions and Over the Counter or OTC), has a belief in strict traditional gender roles, has witnessed violence in family of origin, and is domineering and desires control.10,11,12 Even this information has to be tempered with the fact that, like the victims, the perpetrators can be from any socioeconomic class, religion, race, location or walks of life.12
Health Impacts of Domestic Violence
Once you have an understanding of which of your patients might be victims, it can be challenging to identify how the manifestations and effects of long-term abuse influence patients’ health. From the clinical perspective, emotional and sexual abuse are by far the most devastating to a person and leave the deepest scars, but it is the physical symptoms that will most often get the attention of professionals. History of 4 Vol. 62, No. 2 2011
Northeast Florida Medicine
broken bones, internal injuries, “falls”, trouble sleeping, and anxiety are all red flags for domestic violence that professionals are accustomed to seeing. Recent studies have related domestic violence to a laundry list of chronic health conditions including irritable bowel syndrome, eating disorders, back pain, gynecological disorders, STDs and heart disease.7,10 On the psychological side, long-term effects can include Post Traumatic Stress Disorder (PTSD), panic attacks, anxiety, somatic concerns, depression, dysphoria, social isolation and suicide attempts.2,10,12 Taken all together, these symptoms can be evidence of “Battered Woman’s Syndrome” yet many times physicians misinterpret them as neuroses, irrationalities or exaggerations.12 Aside from the correlations with chronic and acute medical concerns that clearly affect how you develop your treatment protocol, there is the doctor-patient relationship that has to be considered. Persons in the medical field are trusted experts to their patients. Their patients “bare all”. It has been noted that patients experiencing domestic violence are likely to talk to their medical professional about what is happening if initiated by the professional, yet only 10% of primary physicians routinely ask about it.4 Additional reasons for medical personnel to get involved are the laws related to being a Mandatory Reporter for children and vulnerable adults with regard to abuse, neglect or exploitation. Florida statute 415.1034 outlines the law related to the responsibility of a large variety of professionals, including medical professionals, to report domestic violence.13
Domestic Violence Screening Tools Due to domestic violence being a recurring, chronic condition, routine screening is critical. By identifying patients experiencing domestic violence, interventions could improve a patient’s health and quality of life and, in some situations, it can save a life. Because of scheduling constraints in providing patient care, it is important to utilize time efficiently. Having effective tools that best identify victims of domestic violence and providing intervention and referrals where appropriate can be very helpful. Health issues resulting from domestic violence are too significant to overlook an underlying cause. Three quick and effective domestic violence screening tools are presented here that can be utilized in health care settings. These include RADAR, HITS, and WEB. RADAR is brief Intimate Partner Violence intervention model. It is available online as a pocket resource guide for physicians.14 Its elements include:
R = Remember to Ask A = Ask Directly D = Document findings A = Assess Safety R = Review options Insert