________________________________ Intimate Partner Violence: Compassionate Care, Effective Assessment
Questions: 1. What potential obstacles exist that would prevent the clinician from providing effective, compassionate care to Marcy? 2. If it is possible to safely separate the husband and wife, what screening options can be considered to determine if Marcy has a history of IPV? Discussion Providing care to a patient in Marcy’s situation can be complex. Since Marcy presents with her husband, who appears to be controlling the situation, it may be difficult to have a discussion with Marcy without potentially confronting the perpetrator of violence. In addition, it is unclear if there are any language barriers to communicating with Marcy, and religious or cul- tural customs may also be barriers to disclosure of violence. It is possible that Marcy’s immigration status may also be contingent on her relationship with her husband, presenting another potential barrier. If Marcy can be safely questioned alone, a single question can help the provider determine if abuse is occurring. A question as simple as ‘do you feel safe in your relationship?’ can show the patient that the provider is compassionate, show the patient that the provider is alert to the situation in front of them, and open the line of communication between the patient and pro- vider. If time allows and communication barriers are absent, screening tools such as HITS, HARK, or WAST can be utilized. CLINICAL PRESENTATIONS An abusive act is rarely an isolated event. Violent behavior usu- ally recurs and often increases in frequency and severity over time. Although abused individuals may sustain life-threatening physical injuries, they often can suffer less obvious effects that are just as debilitating. In addition to physical trauma, survivors may present with a variety of other medical problems [27]. While some patients exhibit such “red flag” indicators of current or prior abuse, many others show no obvious signs or symptoms of medical or psychiatric distress, underscoring the importance of routine inquiry by clinicians or others on a healthcare team. In both ambulatory and emergency settings, survivors may present with a wide range of signs and symptoms that may include [2]: • Physical trauma, particularly lacerations,
• Have you begun to have sex? • Has anyone ever forced you to have sex when you didn’t want to? • Have you been able to talk to anyone you trust about what is going on? SAFETY ASSESSMENT If a patient has disclosed being in a threatening or violent relationship, the clinician can help the patient assess the level of risk, initiate a discussion of the need for a safety plan, and make referrals to appropriate services. The most important determinants in assessing risk are the patient’s level of fear and their own appraisal of both immedi- ate and future safety needs. Since patients may minimize the danger of their situations, however, the following questions have been found to provide a more objective assessment of IPV risk and whether it has been escalating and therefore likelihood for lethality [26]: • Has the physical violence increased in frequency or severity over the past 6 months? • Has you ever been threatened with a weapon or actually had a weapon used against you? • Do you believe your abuser is capable of killing you? • Have you ever been beaten while you were pregnant? • Is the person abusing you violently and constantly jealous of you? If any three of the above risk indicators are present, the patient should be referred immediately to a domestic violence commu- nity agency and, if necessary, to appropriate law enforcement authorities. Since lethality is augmented by the presence of a weapon, screening for the presence of a firearm, either one owned by the patient or the abuser, is extremely important. CASE STUDY 1 Marcy is a 22-year-old immigrant from the Philippines who is present- ing with an older man for an annual primary care exam. The man introduces himself to the provider as Marcy’s husband and insists on sitting close to the patient with his arm around her shoulders or hips. Marcy’s husband has a purse over his shoulder, and they both wear religious jewelry. Her husband states that Marcy moved from the Philippines with him when they got married last March, and that she does not have family in town. During routine interviewing, Marcy’s husband consistently answers for her, although Marcy’s English appears adequate for expressing herself. A physical exam reveals bruises on the woman’s breasts and abdomen; her husband states these injuries occurred because of a stumble down the stairs. Marcy averts her eyes during his explanation of the injuries and appears uncomfortable.
contusions, dislocations, fractures, head injury, or findings consistent with attempted strangulation (e.g., facial petechiae, laryngeal edema). Note that visible signs of strangulation may be more difficult to detect in darker-skinned patients than in those with fairer skin coloration.
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MDFL0627
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