Provided by the San Francisco Medical Society

Adapted primarily from the following sources:
San Francisco Domestic Violence Health Care Protocol, developed by the Family Violence Council's Health Care Committee in conjunction with the Family Violence Prevention Fund, 1996; Diagnostic and Treatment Guidelines of Domestic Violence, American Medical Association, 1992.

Edited by:
Steve Heilig, MPH, SFMS Director of Public Health; Michael Rodriguez, MD, MPH, San Francisco General Hospital; Sue Martin, Family Violence Prevention Fund; Dexter Louie, MD, President, SFMS.

Introduction

Domestic violence is a serious problem in the San Francisco Bay area. A 1996 review of San Francisco crime statistics found that women are more likely to be harmed or killed by a partner than via robbery, gangs, drugs, or any other form of crime. The American Medical Association estimates that nearly one quarter of American women will be abused by a partner at some time during their lives. Such reports and highly-visible cases such as the Nicole Brown Simpson tragedy have raised awareness about this issue. It is now well-recognized that clinical assessment of and intervention in domestic violence are important components of any effort to address the problem. The purpose of this brochure is to educate physicians and to provide useful guidelines for the screening, treatment, and prevention of domestic violence in various clinical settings.

Medical professionals have a unique opportunity to detect and intervene in domestic violence. We are often the first and perhaps the only professionals a woman will turn to for help, and many women would feel comfortable talking with their physician about this difficult issue. Even if a request for help is not explicit, the opportunity to help may be lost if domestic violence is not addressed. Women who are abused by their partners account for substantial percentages of women seeking care in emergency and primary care settings, including those seeking nontrauma, prenatal, or psychiatric care. Chronic health problems may result from domestic abuse, with associated increased utilization of health care services.

Although few physicians have been formally trained in this area, resulting in many missed opportunities to help our patients, it has been demonstrated that physicians and other clinicians can make a substantial positive impact with only a little heightened awareness and training. The high prevalence and severity of domestic abuse has led many to demand increased clinical attention to this problem, and in fact the Joint Commission on the Accreditation of Healthcare Organizations now requires that hospitals have policies for the identification, treatment, and referral of domestic violence victims. California law also requires continuing education for hospital staffs regarding routine screening and clinical aspects of domestic violence. The AMA issued diagnostic and treatment guidelines on this topic in 1992. Most recently, San Francisco's Family Violence Council in conjunction with the Family Violence Prevention Fund developed a detailed Domestic Violence Protocol, for use in various clinical settings. This brochure summarizes existing knowledge and guidelines; to order a complete Protocol with patient education and response materials, contact the Family Violence Prevention Fund at 415-252-8900.

Risks and Forms of Domestic Abuse

Domestic violence is defined as a pattern of coercive and abusive behaviors that is perpetrated by adults or adolescents against current or former intimate partners in order to control the partner. Such behavior may also include repeated psychological abu abuse or sexual assault, which typically progresses in severity, leads to increased social isolation and may result in death. The vast majority of assaults on current or former partners are committed against women, but victims can be men or same-sex partners. (For simplicity, the victims of abuse will herein be referred to as women.)

Domestic violence cuts across all ethnic, religious, educational, sexual orientation, and socioeconomic lines, but different backgrounds may influence how a woman responds to the abuse.

Physical abuse is most often recurrent and escalates in both frequency and severity. Forms of physical abuse may include pushing, slapping, punching, kicking or choking; assault with a weapon; holding or tying down; abandoning in dangerous places; or ref refusing to help when she is sick or injured. Sexual abuse is also common, including nonconsensual or painful sexual acts or sex acts unprotected against pregnancy or diseases. Such physical and sexual abuses may be accompanied by psychological abuse as a means of controlling through fear and degradation. Psychological abuse includes threats of physical harm, isolation both physically and socially, humiliation, false accusations and ridicule, and ignoring or dismissing her needs or complaints. These types of psychological abuse may also exist in the absence of actual physical abuse. The ultimate result of escalating domestic abuse can be murder or suicide.

Screening

Given the potentially severe consequences of domestic violence, routine screening of all female patients is needed in emergency, surgical, prenatal, primary care, pediatric, and mental health settings. The goal of screening is to identify the problem. This is most likely to be successfully accomplished if the patient is reassured that he or she will not be judged or endangered if the problem is disclosed to you and your help is sought. Simple, direct, nonjudgemental questions asked as part of a routine history and physical examination have been demonstrated to elicit previously unrecognized risks and histories of violence.

It is important that these questions be asked when alone with the patient. In order to see both adult and adolescent patients without others present, it may be necessary to emphasize confidentiality and a standard procedure of interviewing patients alone. Once alone with the patient, an opening statement may be used, such as: "Since violence and abuse are so common, I now ask my patients about it routinely." Once the subject has been raised, any of the following questions may be useful:

If the patient has an existing physical injury:
"Many people come in with injuries like yours, and often they are the result of a family member or partner hurting them. Is this what happened to you?"

For patients with no existing injury, the following questions might be used:
"Has your partner ever physically hurt or threatened you in any way?"
"Has your partner ever hurt or threatened your children?"
"Has your partner ever forced you into having sex at any time or in a way you did not want?"
"We all have conflicts at home from time to time. What happens when your partner and you disagree or fight about something?"
"Do you ever feel afraid of your partner for any reason?"
"If your partner uses alcohol or drugs, how does he act? Does he ever get verbally or physically abusive while drunk or high?"
"Has your partner ever prevented you from leaving the house or seeing your friends or family?"
"Do you have any guns in your home? Has your partner ever threatened to use them?"

Notes: If unable to converse fluently in the patient s primary language, use of a competent translator is recommended - but it is important that the translator not be a family member. Written forms may be used as well, but some verbal questioning is recommended for each patient.

The screening and results should be documented in the patient's chart (a sample screening/documentation form is available in the San Francisco Domestic Violence Protocol).

Finally, patients must be routinely informed of limits to confidentiality because of the mandatory reporting requirement of both domestic violence and child abuse.

Diagnosis and Clinical Findings

Once the history of the patient's present complaint is obtained and a domestic violence-related physical injury is identified or suspected, a physical examination with the patient disrobed is the next step. Further injuries or scars might be present and may be related to the present complaint. The following are indicators that might heighten suspicion that the patient is a victim of domestic violence:

Injuries

Common types of injuries include contusions, abrasions, and minor lacerations, as well as fractures or sprains. These may be to the head, neck, chest, breasts, and abdomen, to the wrists and arms, or at multiple sites. Injuries during pregnancy or any r repeated or chronic injuries may be indicative. Any implausible explanation for the injury or an unusual delay in seeking medical care should raise concerns about possible domestic violence.

Medical Findings

The stress of living in an ongoing abusive relationship may result in any of the following: chronic pain, psychogenic pain, or pain due to diffuse trauma without visible evidence. Physical symptoms related to stress, post-traumatic stress, anxiety, or depression may include sleep and appetite disturbances, fatigue, chronic headaches, abdominal or gastrointestinal complaints, palpitations, dizziness, paresthesias, dyspnea, or atypical chest pain. Gynecologic problems might include frequent vaginal and urinary tract infections, dyspareunia, and pelvic pain. Watch also for frequent use of prescribed minor tranquilizers or pain medications, frequent visits with vague complaints, or symptoms without evidence of physiologic abnormality. Finally, as sexual coercion or assault are common expressions of domestic violence, assessment for this should be conducted in the routine taking of a sexual history and in discussions of birth control and safer sexual practices.

Pregnancy

Violence often escalates during pregnancy. Presentations during pregnancy include injuries to the breasts, abdomen, and genital area; unexplained pain; substance abuse; poor nutrition; depression; late or sporadic accessing of prenatal care; and unexplained "spontaneous" abortion, miscarriages, and premature labor.

Mental Health/Psychiatric Symptoms

Symptoms include the following: feelings of isolation, suicide attempts or gestures, depression, panic attacks and other anxiety symptoms, alcohol or drug use, and post-traumatic stress reactions or disorder. A family history of drug and alcohol abuse, or drug and alcohol abuse by the patient's partner, is also an important risk factor.

Relationship Control Issues

The presence of the following should increase concern about the risk of abuse: Noncompliance with treatment regimens, missed appointments, not being allowed to obtain or take medications, lack of independent transportation or access to finances or teleph telephones, failure to use condoms or other suitable contraception.

Behavioral Signs

During patient encounters, the following are causes for concern: the partner accompanies the patient and insists upon staying close and answering questions for her; the patient is reluctant to speak or disagree with the partner; intense jealousy or posses possessiveness is expressed by partner or reported by patient; denial or minimization of injury by partner and/or patient; exaggerated self-blame on part of patient for partner's violence.

Further Assessment

For clinicians without the expertise, time, or confidence to conduct a full assessment of domestic violence, referral to other clinicians with such expertise is recommended. This may be done immediately or over multiple visits.

Interventions

If domestic abuse is revealed or suspected, the following three issues might be addressed prior to the patient s leaving. Answers to these questions will help to guide further intervention and follow-up:

Immediate risk:
"If you return home now, will you be in danger?"
State of mind:
"What type of help would you like? Are there any changes you would like to make in your situation? What steps might help you make those changes? How might we help?"
Suicide:
"Have you had any thoughts of harming or killing yourself?"

There are important issues to consider with each patient when domestic violence is identified. First is that her situation is taken seriously and compassionately by medical professionals. Second is you or others in the office should have a working knowledge of community resources that can provide treatment, safety, advocacy, and support. Referral to these resources is crucial to address whatever physical, substance abuse, and psychological problems are present. Third is that couples' counseling or other forms of family therapy, which otherwise might appear to be a reasonable option, is generally contraindicated in the presence of domestic violence. The immediate concern is for the safety of the woman and her children. The following need to be addressed when violence has been identified:

1. Primary Messages to Victims

"There is no excuse for domestic violence. Nobody deserves to be abused. Violence is not your fault. It must be very difficult for you to face leaving your situation. But you are not alone - there are people you can talk to for support, shelter, and legal advice."

2. Patient Education

Basic knowledge about domestic violence can be helpful for patients. Let her know that such violence occurs often in our society, that it continues over time and increases in frequency and severity, that it has long-term damaging effects on children who are hurt or who witness violence; that violence is a crime, and that there are resources available to her.

3. Patient Safety

As a coping strategy, many women tend to minimize the severity of violence and danger they face. Again, assessment and plans for the woman s safety need to take place before she leaves the clinical setting. Various options should be considered:

Does she have friends or family with whom she could stay?

Does she want immediate access to a shelter? If not, or if none is available, could she be admitted to a hospital or other clinical setting? If she does not want immediate access, offer her information about shelters and other resources, keeping in mind that written information may pose a danger to her at home.

Does she need immediate medical or psychiatric intervention?

Does she want immediate access to counseling to help her deal with the abuse?

Does she need referral to local domestic violence support organizations?

If the patient is returning home or to previous living arrangement, suggest that the patient gather important papers, (eg, birth certificates and other documents of identification), some money, clothing for her and children (if any), and an extra set of keys. Tell patient to keep these items in an accessible, hidden place or at a friend's home in case she has to leave home in a hurry.

4. Police Intervention

Given potential personal and legal ramifications, the decision to involve legal authorities is a serious one. Does the patient want police intervention? If so, assist her in asking the local police department to make an official police report. (Such a report is different from mandatory reporting of domestic violence by health care practitioners.)

If perpetrator is posing immediate danger, call 911.

If perpetrator is not posing immediate danger and patient wants police assistance, call police dispatch at 553-0123.

Health care personnel should remain with the patient during the police interview, if the patient so desires.

Ensure patient is in safe place while awaiting police. Suggest that the patient call the Family Violence Project at 552-7550 to help her or him navigate the criminal justice system.

Document in the medical record that a police report was made (include date, time, and officer name and badge number).

See the section on "Mandatory Reporting of Injury" regarding whether or not you are mandated to make report to the police, and if so, the appropriate procedures.

5. Referrals

Refer the patient to available community resources. Offer a written list of resources at each visit. (Call the Family Violence Prevention Fund at 415-252-8900 for a San Francisco resources list.)

When the patient is willing, assist her/him in calling a domestic violence hotline during the health care visit.

Tell the patient she/he can always call back for support or more information.

Continuity of Care

A. A history of domestic violence is linked with increased risk of recurring violence. For patients with known or suspected domestic violence, the following are recommended:

Ask about history of violence since last visit.

Ask about mental health.

Ask about coping strategies. Has the patient: sought counseling services? Called a hotline? Told any family or friends? Attempted to leave?

Ask about any abuse of children since last visit.

Give messages of support and concern.

Reiterate options to patient (Emergency Protective Order, Civil Restraining Order, friend's home, shelter, hotline, support groups).

B. For patients without a history of domestic violence in previous screenings, the following may indicate a necessity for recsreening:

When the patient starts intimate relationship with new partner;

When the patient presents with symptoms or signs of domestic violence;

Or, at periodic intervals (at provider's discretion).

Documentation

It is highly advisable to complete a legible medical record for each known or suspected victim of domestic violence. As much of the following as possible should be included in the medical record:

The patient's domestic violence history, including present complaints or injuries. Include date, time and location of domestic violence incidents. Whenever appropriate, use the patient's own words in quotation marks.

A description of patient's injuries, including type, location, size, color and age.

Alleged perpetrator's name, address, and relationship to patient (and children, if any).

A description of other health problems, physical or mental, which may be related to the abuse.

Whenever possible, and with patient's consent, take photographs of patient's injuries. Take Polaroid photographs of all injuries, including:
i. One full body shot (to link injuries with patient)
ii. One mid-range to show torso injuries with patient
iii. Close-ups of all wounds and bruises

Preserve any physical evidence (e.g., damaged clothing, jewelry, weapons, etc.) which can be used for prosecution.

In the case of rape / sexual assault, follow protocols on physical and forensic examinations and evidence collection, with the patient's consent. For more information, contact the Sexual Trauma Treatment Center at 415-821-3222.

Document details of intervention made and all actions taken.

Mandatory Report of Injury in San Francisco

Health Practitioners are required by California State Law (Penal Code Section 11160 et. seq.) to report certain cases of domestic violence to law enforcement. This is different from a patient's voluntary request for an official police report and/or request for police assistance.

Report to the local law enforcement agency when providing medical services for a physical condition to a patient you know or can reasonably suspect is suffering from a physical injury that is a result of a firearm or assaultive or abusive conduct.

Discuss with the patient your reporting requirements and what may occur as a result of reporting. Be aware of potential consequences for the patient and work to address patient needs. Patient consent, however, is not required. (See no. 7 for further discussion of this issue.)

Telephone report of domestic violence as soon as possible to the San Francisco Police Department by calling 415-553-9220 to leave a voice mail message. Document in the Medical Record that the call was made.

Complete the written REPORT OF INJURIES BY A FIREARM OR ASSAULTIVE OR ABUSIVE CONDUCT. Mail this form within two working days to:
San Francisco Police Department, Domestic Violence Unit, 850 Bryant Street, San Francisco, CA, 94103.
Forms are available from the SFPD Domestic Violence Unit at 415-553-9220.

Keep a copy of the report in a confidential locations; it cannot be accessed by friends, family, or other third parties without the patient's consent.

When two or more health care providers have knowledge of a known or suspected instance of violence required to be reported, the providers can agree to report as a team and only one person is required to submit the report. All health care provider providers involved are equally responsible to see that the report is made according to state requirements.

According to current police department practices, if you follow the procedures above, your report to the police will not result in police action. If you or the patient want police intervention or follow-up, you must call 911 for emergencies or 553-0123 for non-emergencies to ask that an official police report be made. Your mandatory report is not an official police report.

Child and elder and dependent adult abuse laws require different reporting procedures. Child and elder mandatory reports may result in investigation by Child Protective Services or Adult Protective Services.
For patients under the age of 18, call Child Protective Services at 415-558-2650 for reporting requirements and forms.
For patients age 65 and older and dependent adults, call Adult Protective Services at 415-557-5230 for reporting requirements and forms.

Note: Reporting is not a substitute for thorough documentation of the abuse in the medical records.