Domestic Violence / Gender (and Sex) Specific Issues

Domestic Violence

1. In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (e.g., periodic annual exam, visits for anxiety/depression, ER visits).

2. In a patient in a suspected or confirmed situation of domestic violence:

   1. Assess the level of risk and the safety of children (i.e., the need for youth protection).

   2. Advise about the escalating nature of domestic violence.

3. In a situation of suspected or confirmed domestic violence, develop, in collaboration with the patient, an appropriate emergency plan to ensure the safety of the patient and other household members.

4. In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (e.g.,helplessness, guilt), and its impact on children.

Gender (and Sex) Specific Issues

1. In the assessment of clinical problems that might present differently in men and women, maintain an inclusive differential diagnosis that allows for these differences (e.g., women with coronary artery disease, depression in males).

2. As part of caring for women with health concerns, assess the possible contribution of domestic violence.

3. When men and women present with stress-related health concerns, assess the possible contribution of role-balancing issues (e.g., work-life balance or between partners).

4. Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (e.g., positioning for Pap, chaperones for genital/rectal exams).

5. Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (e.g., ASA use in women).

Intimate Partner (Domestic) Violence

Risk Factors for Victimization

• Young female (<24yo)

• Low SES

• Pregnancy

• Disability

Risk Factors for Both Victimization and Perpetration

• Unemployment

• Witnessing or experiencing violence as a child

• Substance abuse (alcohol/drug use)

• History of mental illness

Screening

• USPSTF recommends: All women of childbearing age should be screen for domestic violence

  • However, CTFPHC recommends against universal screening as only one study directly addressed the benefit of screening, and found no effect of screening on outcomes.

Woman Abuse Screening Tool (WAST), 90% sensitivity with first two questions

• In general, how would you describe your relationship? No tension, some tension, a lot of tension?

• Do you and your partner work out arguments with no difficulty, some difficulty, or great difficulty?

  • Do arguments ever result in you feeling down or bad about yourself?

  • Do arguments ever result in hitting, kicking, or pushing?

  • Do you ever feel frightened about what your partner says or does?

  • Does your partner ever abuse you physically?

  • Does your partner ever abuse you emotionally?

  • Does your partner ever abuse you sexually?

• Listen

• Acknowledge the injustice

  • "This is abuse"

  • "I am very sorry this is happening to you"

• Frame the violence due to perpetrator's behaviour and not the survivor's

  • "You do not deserve this, and it is not your fault"

• Respect autonomy and patient's decisions

  • "I want to help you through this in any way I can."

Assess for safety (high risk of harm)

• Consider 20-item Danger Assessment

  • Violent outside the home

  • Violent to children

  • Threatening to kill

  • Escalating threats

  • Drugs, alcohol

  • Abusive during pregnancy

  • Obsessive, controlling relationships

  • Serious prior injury

  • Owns weapons, especially handguns

  • Threatened others (family/friends)

Safety planning, resources, community services including local shelters

• Emergency kit with important documents, keys, money, essential items - stored outside the home

• Place to go (friend, family shelter)

• Signal to alert others (children/neighbours) to call 911

Document findings

• Quotes from patient

• Physical exam findings and photographs

• Labs/radiology

Mandatory reporting may be required in the following instances:

• Abuse involving children

  • Contact Youth Protection

• Abuse of elderly (in retirement home)

• Abuse of disabled persons

• Weapon use

Frequent follow-up

• Counsel on possible escalation/cycles of violence (tension build up, violent outburst, honeymoon phase)

• Update safety plan