Family Medicine Approach to the Management of Domestic Violence

Biodata

• Name: Mrs X.Y.
• Age: 28 years old
• Sex:
• Address: Ilorin
• Occupation: Hairdressing

Presenting Complaint/HPC

• Poor sleep ×6/12
• She noted she sleeps late and wakes up earlier than she used to.
• She sleeps between 12:30am and 3:00am unlike her usual pattern of 10pm to 5:30am.
• Associated band-like frontal headache that started at about the same time, graded 5/10 on numerical pain scale.
• Also associated intermittent palpitation and vague dull generalized chest pain that is not radiating, no cough, no dyspnea, no fever, no trauma to chest.
• Her room is well ventilated and the environment is quiet.

• This physical assault was said to have started about one year ago when she returned from her shop late.
• However, in the last 6/12, it became more frequent after his duties became more tedious with associated verbal and emotional abuse.
• It does not occur under the influence of alcohol or any other drug.
• He does not abuse his children and any other member of the family. He is the biological father of the children and he is a loving father to them, providing adequate financial and physical support.
• This abuse does not occur in the presence of the children or any other member of the family. He usually becomes remorseful after, begs her, and gets her a gift as a form of apology.
• She has not told any other person or family member because she believes every family has its problems and keeping the sanctity of the family is paramount.

Past Medical History: She is not a known diabetic, hypertensive, PUD, or asthmatic patient. Not known to have any mental health condition. Nil past history of surgeries, hospital admissions, or blood transfusion.

• Family and Social History
• She is married in a monogamous setting to a police officer
• Self-absolved introvert, neither drinks nor smokes
• They have two children.
• Relationship with husband is strained involving assaults.

FIFE

• Fear: Her fear concerning her condition is that it may get worse, which may be detrimental to her mental health, and that she may sustain a life-threatening injury or be killed.
• Ideas: She thinks her symptom started following physical assault by her husband.
• Functionality: She sometimes cannot go to work because of black eye and bruises sustained following repeated physical assault and sometimes wakes up in the morning not wanting to do anything.
• Expectation: She expects to get drugs to make her sleep well and help improve her total wellbeing.

SAFE

• S: She doesn’t feel safe.
• A: She’s afraid of being physically assaulted repeatedly.
• F: She has family and friends she can call and get support from but hasn’t informed any one of them.
• E: She, however, doesn’t have an emergency plan.

Examination Findings

• Young woman looking anxious, with poor eye contact.
• No bruises or other forms of body injuries noted.
• Afebrile, anicteric, not cyanosed, not dehydrated, no peripheral lymphadenopathy, no pedal edema.
• BP: 110/70, PR: 82 BPM, RR: 17 CPM.
• Abdomen full, moves with respiration, no tenderness, no organomegaly.
• Conscious and alert, pupils 2-3mm in diameter, reactive to light bilaterally.

Domestic violence is a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate/related partner.

The definition adds that domestic violence can happen to and can be perpetrated by anyone regardless of race, age, sexual orientation, religion, or gender, and can take many forms, including physical abuse, sexual abuse, emotional, economic, and psychological abuse.

Domestic violence encompasses domestic abuse, intimate partner violence, battering, family violence, and spousal abuse.

It is a pattern of abusive behaviors by one partner against another in an intimate relationship such as marriage or dating, in a family or cohabitation.

As a rule, domestic violence does not describe a single violent event, but rather a complex system of abuse that can include physical, economic, psychological, and sexual violence.

Forms of Domestic Violence

• Physical aggression or assault (hitting, kicking, biting, shoving, restraining, slapping, throwing objects)
• Sexual abuse
• Emotional abuse
• Controlling or domineering
• Intimidation
• Stalking
• Passive/covert abuse otherwise known as neglect
• Economic deprivation

(Reference: Seimeniuk, Krentz, Gish & Gill, 2010)

• Domestic violence is a social problem that, although well recognized, is still associated with uncertainty and taboos.
• Many men, women, and children, in their intimate relationships or immediate social environment, regardless of social status or ethnicity, experience psychological and/or physical violence, which becomes a serious health problem for them.
• Since the police are rarely notified in cases of domestic violence, the estimated number of unknown cases is high (most cases remain unreported/unrecorded) and reliable epidemiological data are scarce and may not truly reflect the actual state.
• The actual extent of violence can only be assumed, as it is not easy for the affected person to speak about their experiences or to ask for help in most cases.
• The reasons for this may be feelings of shame or guilt, fear, or perceptions based on traditional ideas of marriage and family and inherent customs of the people in the domiciled society.

• Anyone can be a victim.
• Globally, women are the major victims and also tend to experience more severe forms of violence.
• In some societies, domestic violence is justified and legally permitted, especially in cases of actual/suspected infidelity on the part of the woman.
• Research has established a direct and significant correlation between a country's level of gender equality and rates of domestic violence: less gender equality, higher rates of domestic violence.
• In the US each year, women experience 4.8 million intimate partner-related physical assaults and rapes. Men – 2.9 million.
• Up to 2.5 million older Americans suffer some form of elder mistreatment each year.
• Women are six times more likely to be assaulted by an intimate partner than men.

Domestic violence is among the most underreported crimes worldwide for both men and women.

Worldwide, domestic violence is considered as one of the most frequent forms of gender-based violence.

In various European countries, the lifetime prevalence of violence in intimate partnerships is reported to be between 10% and 36%.

One US study shows that among 3455 patients from 11 different emergency medicine providers, 37% have experienced physical and/or sexual violence from a current or former intimate partner at some point in their lives. Of these, 14.4% reported abuse within 12 months prior to the survey, and 2.2% were seeking medical care due to a current act of violence.

• In parts of the 3rd world – prevalent, justified, and condoned.
• 56% of Indian Women justified wife beating for various reasons.
• 25% of women in Dakar are subjected to physical violence from their partners, very few admit it. Law passed punishing Domestic Violence is poorly enforced due to religious and cultural resistance (IRIN, 2007).
• Many victims don’t know if they’ve been abused or not.
• Nigeria – 1/3rd of women have been subjected to physical, sexual, and psychological violence. (Afrol News, 2007)
• Beating of wives and children widely sanctioned as a form of discipline (UNICEF 2001).
• In Lagos - 66.4% and 50.4% of ever married and unmarried women respectively expressed consent for wife beating (Project alert, 2001).
• In SE Nigeria – 70% respondents reported abuse in their family (Obi and Ozumba, 2005).
• In a study conducted by Dr. B. A. Ayinmode and Prof. Mrs. M. F. Tunde-Ayinmode studies in UITH (2008):
  • 250 participants.
  • 69 (28%) reported cases.
  • 49 within 2 years of the study.

	Myths	Facts
1	Domestic violence only happens to women	While 1 in 3 women are affected by domestic violence, 1-4 men and 30-50% transgender will also experience intimate partner violence in their lifetime
2	Drugs, alcohol, stress, mental illness are the causes of domestic violence	While drugs, alcohol, stress, mental illness can be factors in an abuser's life and can make an abusive situation more complicated, these things do not cause domestic violence
3	Abusers are just out of control and need anger management	Abusers use many tactics to maintain power and control, these tactics may include aggression and violence but there are so many other ways
4	Domestic violence means physical abuse	While physical abuse can be one way of maintaining power and control it does not occur in every abusive relationship and is not the only form of abuse
5	If a victim doesn’t leave then it must not be that bad, they must be okay with how they are being treated	Leaving an abusive relationship can be extremely difficult, on the average a victim will attempt to leave 7 times before being successful. Modalities abusers use to ensure victims don't leave include financial dependence, children, threat of violence, court processes

Common Misconceptions

• Not a problem in my community
• Only happens to the poor
• Some people deserve it
• Personal problem between husband and wife

• Child abuse
• Intimate partner violence (IPV)
• Elder mistreatment

Child Abuse

At a minimum, any act or failure to act on the part of a parent or caregiver, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act that presents an imminent risk of serious harm (Child Abuse Prevention and Treatment Act).

4 forms of maltreatment:

• Emotional abuse
• Neglect (physical, emotional, educational)
• Physical abuse
• Sexual abuse

Intimate Partner Violence (IPV)

• Maladaptive behavioral pattern whereby an individual willfully harms their intimate as a means of gaining or preserving power and control within the relationship.
• Causes pain, distress and sometimes injury
• Married, heterosexual, gay or lesbian, living together, separated or dating
• Not an accident, doesn’t occur because of stress, drinking or use of drugs
• Not usually a one-time event

Elder Mistreatment

• An act or omission that results in harm or threatened harm to the health or welfare of an elderly person
• Physical, sexual, emotional abuse
• Caregiver neglect
• Material exploitation

Lenore Walker presented the model of a Cycle of violence which consists of three basic phases:

1. Tension Building Phase: Characterized by poor communication, tension, fear of causing outbursts. During this stage the victims try to calm the abuser down, to avoid any major violent confrontations.
2. Violent Episode: Characterized by outbursts of violent, abusive incidents. During this stage the abuser attempts to dominate his/her partner (victim).
3. Honeymoon Phase: Characterized by affection, apology, and apparent end of violence.

Reasons Victims Don't Leave

• FEAR
• LOW SELF ESTEEM
• ISOLATION
• LACK OF RESOURCES
• PROMISES TO CHANGE

SURVIVORS OF DOMESTIC VIOLENCE DO LEAVE! They leave when they are ready. They leave when it is safe to do so. We can support their process by providing an institutional response affirming battered victims and their decision-making ability.

• VICTIMS
• PERPETRATOR
• SOCIETY

Victims

• Age
• Sex
• Socioeconomic Status
• Sociocultural Beliefs
• Disabilities
• Prior Experience
• False sense of attachment
• Stockholm syndrome

Perpetrator

• Batterers cross all socio-economic, religious, racial, ethnic, age groups
• Sense of Entitlement
• Controlling
• Manipulative
• Frequently Charming
• Uninvolved parent
• Show contempt for others

Society

• Sociocultural Beliefs and Practices
• Gender inequality
• Conflicts
• Justice Approach

70% of abusive parents were abused as children themselves. BUT 70% of abused children do not become abusive parents.

Exposure to domestic violence may have emotional and physical consequences for victims depending on:

• Frequency, severity, chronicity, proximity to the violence
• Age and developmental stage at which exposure begins
• Multiple forms of violence (child abuse, community violence, exposure to DV)
• Presence or absence of loving and supportive adults
• Presence or absence of supportive community
• Victim's individual temperament
• Opportunities for healing and success

Such consequences include

• Aggression
• Delinquency
• Anti-social behavior
• Hyperactivity
• Conduct disorders
• Academic problems
• Attitudes supporting the use of violence
• Substance abuse
• Depression
• Anxiety
• Low self-esteem
• Social withdrawal
• Somatic complaints
• Trauma (some PTSD)
• Physical injuries

• Individualized management based on the victim
• Acute treatment for injuries and long-term management of sequelae requires a multidisciplinary approach, which may include:
• Physician
• Psychologist/Behavioral scientist
• Social workers
• Surgeons
• Pediatrician
• Gynecologist
• Nurses
• Patient-centered care management:
1. Explore both disease and illness experience (FIFE)
2. Understanding the whole person (family circle, family life cycle, ecomap)
3. Finding a common ground
4. Incorporating prevention and health promotion
5. Doctor-patient relationship
6. Be realistic

Entry into the health care represents an opportunity for detection of domestic violence and referral to appropriate community resources.

• Insist on interviewing the patient privately
• Biopsychosocial assessment of the patient (FIFE)

Proper interaction and identification of red flags of possibility of domestic violence is sacrosanct for all family physicians through excellent communication skills.

• Presence of co-morbid conditions (mood disorders, anxiety disorders, alcohol or other substance abuse, somatoform appearing presentation) can complicate assessment
• Physician must be especially sensitive to feelings of shame by the patient (avoidance of eye contact, cowering, low speech tone).

Key Actions for Healthcare Providers

• Ask about IPV directly
• Assess for suicidal or homicidal ideation, plan, or intent
• Incongruent injury with history
• Explore family and social history to identify safe havens
• Patient's autonomy
• Maintain rapport, adopt non-judgmental approach
• Unusual accounts of injuries and those that don't correspond to physical findings

Exploration of Family and Social History

• Identify safe havens that can be used for patient rescue
• Utilize counseling methods such as family conferencing, home visits, genograms, ecomap
• Incorporate spiritual influence and seek help from community/family elders

Affirmation of Patient's Autonomy

• Affirm patient's autonomy and right to control decision-making

Maintenance of Rapport

• Adopt a non-judgmental approach toward joint problem-solving

Screening Tools

• Patient Health Questionnaire (PHQ)
• SAFE
• Does she feel SAFE
• Does she feel AFRAID
• Can she access support of FAMILY and FRIENDS
• Does she have EMERGENCY PLAN

The single most important thing you can do is to communicate the message NO ONE DESERVES TO BE HURT LIKE THIS

Use supportive statements: “You don’t deserve this.” and, “Our concern is for your safety and your kids’ safety.”

Examination

• General Physical Examination
• Specific systemic examination starting with the system of interest
• Extensive documentation, map body injuries, take photos if necessary
• Possible evidences like clothing and samples should be stored with the consent of the victims for possible investigation and legal procedures

Investigation

• X-ray
• Ultrasound
• Rape kit
• Lentiviral screening
• Full blood count

Inexhaustive and individualized

Treatment

• Pharmacologic
• Pain killers
• Sedative
• Anteretroviral prophylaxis
• Anti-depressant
• Surgical intervention
• Counseling and Family conferencing and intervention if possible
• Referral for psychological and mental health issues
• Resources involvement e.g. human rights commission, social workers, legal aid, NGOs etc
• Development of an escape plan and follow up

Escape Plan and Safety Measures

• Develop an escape plan including emergency numbers and helplines
• Identify escape routes and alarm signs
• Plan for evacuation if necessary
• Avoid the presence of weapons
• Identify individuals who can intercede

Be aware that materials and referrals provided to a victim may place her in danger.

Actions for Family Physicians

• Make a follow-up appointment and possible home visit

For the patient in the case report:

• Patient was given pain killers and sedatives for complaints
• Patient believed work stress was the reason for the repeated assault and felt no need to involve legal and law enforcement agencies
• Patient accepted to involve her father-in-law in the process of conflict resolution
• A follow-up was booked for 2 weeks time

Reasons Why Physicians Do Not Ask Patients About Domestic Violence

1. Not enough time
2. Fear of offending the patient
3. Powerlessness to intervene
4. No control over patient behavior
5. Too close for comfort

The Family Physician

• The first physician contact
• The family physician must possess the necessary clinical skills to detect salient signs that may indicate domestic violence
• Advocates
• Community leaders
• Researchers

• Kurudu Center for Women and Children Victims of DV in FCT
• Mirabel Sexual Assault Resource Center in Lagos (LASUTH)
• Kwara State Ministry of Women Affairs
• Family Affairs Unit in Police Station
• The Project Alert on Violence on Women

• Household injuries are physical traumas that occur within the household via accident or deliberate harm by self or an assailant.
• They range from bruises, cuts to burns.
• They can be debilitating and life-threatening.
• Urgent interventions can go a long way in reducing morbidity and mortality.

Household Injuries Include:

• Burns
• Bruises
• Laceration and puncture wounds
• Blunt force trauma
• Falls
• Poisoning
• Electrocution

First Aid Measures

• Remove from danger
• Run injury under running water
• Use ice pack
• Use a clean towel to cover the wound site and secure hemostasis
• Don't remove object in puncture site
• Don't purge patient
• Don't give palm oil
• Don't pour water on patient
• Don't give glucose
• Take patient to the hospital