Patient Barriers to Disclosure Patients may hesitate to disclose current or past abuse to a healthcare provider for a variety of reasons: 21 1. Fear of: • the healthcare provider confronting the perpetrator. • retribution if the perpetrator learns of the disclosure. • a breech in confidentiality if medical records are accessed by the perpetrator, child protective services, employers, police, or immigration authorities. 2. Shame and humiliation that abuse is taking place, or took place in the past, or not wanting to be perceived as a “victim”. 3. Belief that they deserved the abuse. 4. Protective feelings for the partner. 5. Inability to fully comprehend the situation. 6. Assumptions that: • the doctor and staff are not knowledgeable or do not care about IPV because IPV may not be viewed as a medical issue. • the doctor is too busy to spend time talking about IPV. • the doctor can’t help with this problem or that it is inappropriate to discuss it. • same-sex abuse is not recognized, screened for, or treated. 7. Language, culture, and religion: • language barriers when communicating with providers, and fear of losing confidentiality with the use of an interpreter. • religious customs pushing survivors to stay silent about abuse. • reluctance to “air dirty laundry” and cast a bad light on their community. 8. Immigration status being contingent on their current relationship, especially if they’re trafficked foreign nationals. 9. Sexual orientation and gender identity leading to fear of being “outed” or shamed. Additionally, perpetrators can control a patient’s ability to access healthcare. They may accompany the patient to healthcare visits and even dominate the encounter and speak for the patient. Perpetrators can also affect a patient’s ability to adhere to medical instructions. They may confiscate or discard medications or medical devices as a way to control the patient. The RADAR Model The United States Preventive Services Task Force (USPSTF) and the Affordable Care Act, along with many other organizations, support routine screening for IPV and IPV counseling as part of preventive services. Research clearly shows that identifying survivors can promote their safety and improve health outcomes. 22-24 The “RADAR” acronym developed by The Massachusetts Medical Society summarizes steps that healthcare providers can take to identify IPV and support victims:
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R outinely screen: ask about IPV in the course of routine care. A sk direct questions about violence such as, “At any time, has a partner or ex-partner hurt you, frightened you, isolated you, or made you feel unsafe?” Interview your patient in private whenever possible. D ocument in the patient’s chart any findings related to suspected IPV. A ssess for safety. Is the patient safe at home? Are firearms or other weapons kept in the house? Are children in danger? Is abuse or violence escalating? R eview options with your patient, and make appropriate community-based referrals (e.g., support groups, counseling, emergency shelter, legal advocacy).
• How badly have you been hurt in the past? • Have you needed to go to an emergency room for treatment? • Have you ever been threatened with a weapon, or has a weapon ever been used on you? • Have you ever tried to get a restraining order against a partner? • Have the children ever seen or heard you being threatened or hurt? • Have the children ever been threatened or hurt? • Do you know how you can get help for yourself if you were hurt or afraid? For adolescent patients, the following questions might be appropriate: • Have you begun to date? • Has your boyfriend/girlfriend ever threatened to hurt you? • Are you ever afraid of your boyfriend/ girlfriend? • Have you ever had a pushing or shoving fight with a boyfriend/girlfriend? • Have you ever gotten hurt from a fight with a boyfriend/ girlfriend? • 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 immediate 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 community 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. PLEASE COMPLETE CASE STUDY 1 ON THE NEXT PAGE.
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A single question, asked routinely and non- judgmentally in the course of the social history, can significantly increase the detection rate of IPV in office practice and can allow your patient to feel safe in disclosing a history of abuse. These sample questions can be adapted as needed to individual practices; all have been shown to be accurate assessment questions for IPV: 25 • “At any time, has a partner hit, kicked, choked, threatened or otherwise hurt or frightened you?” • “Have you ever been in a relationship in which you felt unsafe or felt you had to ‘walk on eggshells’ to keep the peace?” • “Do you feel safe in your relationship?” Screening Tools Several instruments can be used to screen women for IPV. Those with the highest levels of sensitivity and specificity for identifying IPV, according to research by the USPSTF, are: 1 1. Hurt, Insult, Threaten, Scream (HITS); self- or clinician-administered 4-item questionnaire assessing the frequency of IPV. 2. Extended Hurt, Insult, Threaten, Scream (E-HITS): includes an additional question on the frequency of sexual violence. 3. Humiliation, Afraid, Rape, Kick (HARK): self- administered 4-item questionnaire assessing physical and emotional IPV in the past year. 4. Partner Violence Screen (PVS): 3 item questionnaire assessing physical abuse and safety. 5. Woman Abuse Screen Tool (WAST): 8 item questionnaire assessing emotional and physical IPV. The USPSTF found no valid, reliable screening tools to specifically identify abuse of men or elderly or vulnerable adults in the primary care setting. 1 If your patient discloses that she or he has been abused, or if you suspect abuse without a disclosure, asking the following specific questions in a safe and confidential setting can help to determine the extent of abuse and the possible risk to your patient: • How were you hurt?
• Has this happened before? • When did it first happen?
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