Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 1
Marcy is a 22-year-old immigrant from the Philippines who is presenting 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.
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 cultural 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 provider. If time allows and communication barriers are absent, screening tools such as HITS, HARK, or WAST can be utilized.
• Gynecological problems (genital lacerations and contusions, sexually transmitted infections, including HIV/AIDS, rapid repeat pregnancies). • Medical signs and symptoms such as headache, chest pain, abdominal pain, pelvic pain, fatigue, eating disorders, or functional gastrointestinal disorders. • Localized or generalized neurological findings such as altered mental status, seizures, motor or sensory deficits, and memory problems. • Behavioral/psychiatric signs such as anxiety, depression, panic, suicidal ideation or attempt, substance abuse. • Social “red flags” such as frequent missed appointments, or non-adherence to prescriptions or medical instructions. • Partner “red flags” such as excessively attentive or jealous behavior on the part of a companion, a partner who insists on accompanying a patient during examinations, or a partner who speaks for the patient or displays dominant behaviors. • Delay between onset of injury and presentation for care. • New diagnoses of sexually transmitted infections may also result from sexual assault in an IPV relationship.
If any of these signs and symptoms are suspected to be the result of IPV, additional and more thorough questioning is warranted. 5 Behavioral Signs of IPV Even in the absence of disclosure, patients may appear frightened, ashamed, embarrassed, defiant, or even overtly angry. Basic questions on the medical history may be answered in a manner that appears ambiguous or evasive. Other behavioral clues may include: • Partner accompanies the patient to clinical visit, insists on staying close, and speaks for the patient, answering questions or monitoring/ controlling the patient’s responses. • The patient appears reluctant to speak independently or to disagree with partner. • Intense irrational jealousy or possessiveness expressed by partner or reported by patient. • Patient and/or partner deny, minimize, or divert questions about medical problems or injuries. • Patient displays an exaggerated sense of personal responsibility for the relationship, including self blame for partner’s violence or for staying in the relationship. • Explanations that are inconsistent with observed illness or injury pattern.
Clinical Presentations An abusive act is rarely an isolated event. Violent behavior usually 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, 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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