Domestic abuse paper

DOI: 10.1111/j.1744-4667.2012.00120.x

2012;14:197–202

The Obstetrician & Gynaecologist

Review

http://onlinetog.org

Domestic violence: a clinical guide for women’s healthcare providers Amy S Gottlieb

MD

a,b,

*

a

Associate Professor (Clinical), Departments of Medicine and Obstetrics & Gynecology, The Warren Alpert Medical School of Brown University, Rhode Island, USA b Director of Primary Care Curricula, Residency Program in Obstetrics & Gynecology, Women & Infants Hospital, 101 Dudley Street, Providence, RI 02905, USA *Correspondence: Amy S Gottlieb. Email: agottlieb@wihri.org

Key content

Domestic violence is common among obstetric and gynaecology patients and is a leading cause of maternal mortality.

Reproductive coercion involves male attempts to control female fertility; long-acting contraception should be considered in these cases.

Past domestic violence and late booking for antenatal care are associated with abuse during pregnancy.

Healthcare providers should ask women about domestic violence directly and in private, assess victims’ safety, offer referrals to community-based organisations and document abuse in the hospital or office record (not necessarily in the hand-held record).

Learning objectives

To know how to enquire routinely for domestic violence and offer assistance to victims.

Ethical issues

The highest standard of confidentiality is required to keep abused women safe; at times, this standard may conflict with complete information sharing.

Healthcare providers often feel frustrated and powerless when working with abused women. It is the woman’s decision when to leave her violent relationship and the clinician’s role to provide empathy and information about resources.

Keywords: abuse / pregnancy / reproductive coercion / safety

assessment / screening

To understand the prevalence of domestic violence, risk factors and the impact on women’s health.

Please cite this paper as: Gottlieb AS. Domestic violence: a clinical guide for women’s health care providers. The Obstetrician & Gynaecologist 2012;14:197–202.

Introduction Domestic violence is threatening behaviour, violence or abuse (psychological, physical, sexual, financial, emotional) between adults who are or have been intimate partners.1 The majority of victims are women; population studies2–4 estimate that at least one in four women worldwide will be abused by a partner during her lifetime. Clinical research5,6 in the UK demonstrates that 13–24% of women receiving antenatal or postnatal care and 21% of women receiving gynaecological services report a history of domestic violence.

In addition to acute trauma, exposure to domestic violence has wide-ranging effects on the health of women. Partner abuse has been associated with increased numbers of gynaecological, central nervous system, gastrointestinal, musculoskeletal and cardiac complaints and with a higher risk of depression, anxiety, post-traumatic stress disorder, suicidality and substance misuse.7–11 There is a dose– response relationship between the amount of symptoms reported and the number of violent episodes experienced, the

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number of types of abuse (e.g. physical, sexual, psychological) and the severity of the violence.9 When domestic violence continues, these health-related complaints increase over time.12 Compared with women without a history of partner violence, victims of domestic violence are more likely to access outpatient primary care and specialty care, visit accident and emergency departments, seek mental health and substance misuse services and obtain prescriptions from pharmacies.13 In the UK, the cost of care for domestic violence-related physical and mental health concerns has been estimated14 at almost ÂŁ2 billion pounds annually. It is likely that this figure under-represents the true cost of domestic violence by not capturing all medical services accessed by abused women.

The clinical setting Myths and stereotypes exist about abused women. Clinicians must be aware of their own biases and challenge any

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assumptions not based on fact. Although domestic violence involves controlling, coercive and even criminal behaviours perpetrated usually against women, it may be useful for healthcare providers to view domestic violence within the construct of a chronic illness. As such, it has well-studied risk factors, a natural history and commonly associated symptoms.

Risk factors Domestic violence occurs across all racial/ethnic groups and socioeconomic classes.3 The following risk factors have been associated with an increased likelihood of victimisation by an intimate partner: female gender,2,3 young age,2,8,15–17 unmarried status,3,8,16 low income,3,15,17 coverage by medical assistance or being uninsured16 and a history of childhood maltreatment.17 Pregnancy, particularly unintended pregnancy, may also be a risk factor for abuse.16,18–21

History In their study17 involving approximately 3500 women, Thompson and colleagues found that many experience more than one type of domestic violence and that the longer the abuse continues, the more likely it is that multiple forms will occur. Most abused women repeatedly seek outside help but lack the personal or economic resources to gain independence.22 Attempting to leave an abusive relationship can be a particularly dangerous time for a victim.23 Domestic violence is typically characterised by ongoing, repetitive acts of relatively minor physical assault accompanied by patterns of control, intimidation and isolation. An abuser may try to control access to money, transportation, modes of communication or even health care.

When assessing access to medical services across numerous specialties and practice settings, McCloskey and colleagues24 found that nearly 20% of women experiencing domestic violence within the previous year reported that their abuser had interfered with their health care. This finding is consistent with studies15,25,26 of pregnant women, which have revealed an association between domestic violence and delayed antenatal care.

Intimidation can range from a raised eyebrow to open threats and stalking and creates an unstable environment in which an abused woman may feel she could be assaulted for the most benign action. Isolation can take many forms and serve various purposes for the abuser; separation from friends, family and co-workers prevents detection of the violence, fosters dependence of the woman on her abuser and robs her of any potential means of escape.

Associated symptoms As mentioned above, domestic violence is associated with numerous health-related complaints, which tend to increase as the abuse continues over time. Various studies7–11 have shown

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that women exposed to partner violence are more likely to report: headache,7–9 dizziness, chest pain, palpitations,8,9 back pain,7–9 nausea and indigestion,8 stomach pain,7–9 diarrhoea and constipation,9 menstrual/pelvic pain, dyspareunia,7–9 insomnia,9 depression,7,8,10 anxiety,7 post-traumatic stress disorder10 and suicidal ideation.10,11 Not all individuals presenting with these concerns are being abused, but a consistent constellation of these complaints should be a red flag for healthcare providers to investigate the possibility of domestic violence.

Domestic violence and reproductive coercion Reproductive coercion can be defined as attempts by men to control their female partners’ pregnancies and pregnancy outcomes. In Miller’s landmark study27 of 1300 sexually active young women, one in five reported partner pregnancypromoting behaviours, such as intimidation, threats to leave the relationship if the woman did not become pregnant or actual violence, and one in seven experienced interference with contraception by intimate partners. Additionally, the overwhelming majority of these women reported a history of domestic violence.

As the largest assessment to date of reproductive coercion in the USA, Miller’s research corroborates earlier studies,28–31 describing the lengths to which male partners will go to assert power over reproduction, such as poking holes in condoms, pulling out NuvaRings and flushing oral contraceptive pills down the toilet. The findings also support the association between domestic violence and unintended pregnancy demonstrated previously16,21,27 and potentially explain the relationship between these two phenomena. In Miller’s study, approximately 35% of domestic violence victims reported birth control sabotage or forced pregnancy by their partners, with reproductive coercion in the setting of a partner abuse history doubling the risk of unintended pregnancy.

Reinforcing the concept that reproductive coercion is about fertility control and not a particular reproductive outcome, women in abusive relationships may be put under pressure to terminate their pregnancies despite partners’ refusals to use or allow contraception.28,30 Not only has current domestic violence been shown to be more prevalent among women seeking termination of pregnancy compared with women continuing their pregnancies,15,21,32,33 but male perpetrators of domestic violence report more involvement with decision making about termination than their nonabusive counterparts.34 Repeat termination has been associated with domestic violence, with increased risk for each additional termination.31,35 As research continues to demonstrate the prevalence of reproductive coercion, it is incumbent upon clinicians to assess for it. Reproductive health providers are well

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positioned to interrupt the cycle of birth control sabotage, male power over pregnancy resolution and unwanted births or terminations. By recognising that a woman who exhibits contraceptive non-compliance, multiple unplanned pregnancies or repeat terminations may, in fact, be unable to negotiate birth control adherence within her abusive relationship, a provider could redirect reproductive counselling efforts toward recommending hidden, longacting forms of contraception such as Depo-Provera® (medroxyprogesterone acetate) (Pfizer UK, Walton-on-theHill, Surrey, UK) injection or the intrauterine device.

Domestic violence in pregnancy Population-based research15,36 reveals that 4% of women with newborns report physical abuse by an intimate partner during pregnancy. Clinical studies37–39 demonstrate even higher rates: when asked about physical and sexual abuse in the previous year, up to 32% of pregnant women reported domestic violence, making abuse in pregnancy more common than pre-eclampsia or gestational diabetes.

Abuse may begin, cease or continue during pregnancy.18–20 Previous domestic violence is strongly associated with violence during pregnancy.18,39 Other risk factors include young age, single status and the following adverse factors: inadequate housing, finances or education; substance misuse; mental health problems; or trouble with the police.16,19,25,38–40 As noted above, unintended pregnancy and delayed entry into antenatal care are also associated with domestic violence.

After adjusting for confounding factors, studies have demonstrated an association between partner abuse during pregnancy and vaginal bleeding,19 kidney infections41 and preterm labor.25,41 Abuse during pregnancy is also a marker for risk of death from domestic violence, conferring a three-fold increase in homicide risk and making domestic homicide one of the leading causes of maternal mortality.42,43 Regarding the association between domestic violence and the poor obstetric outcome of low birthweight, research20,41,44,45 on this relationship yields conflicting results, perhaps reflecting differences in the domestic violence screening tools employed and the populations studied.

Enquiring about domestic violence In the USA, most major medical organisations recommend routinely asking adult women about domestic violence.46–49 Additionally, the Joint Commission on Accreditation of Healthcare Organizations,50 the entity which sets standards and accredits healthcare facilities in the USA, requires hospitals to have protocols in place to identify and assist victims of domestic violence in order to receive accreditation.

In the UK, the Department of Health recommends routine enquiry about partner abuse during maternity care only,

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while the British Medical Association endorses the guidance from the Royal College of Obstetrics and Gynaecologists to ask routinely about domestic violence during the course of all obstetric and gynaecological consultations.1,51 Because repeated enquiry may increase identification of abuse, USA-based guidelines52,53 typically encourage periodic screening beyond that performed at new-patient visits. For pregnant women in particular, the American Congress of Obstetricians and Gynecologists (ACOG) recommends enquiry about domestic violence at the booking appointment, at least once per trimester and at the postpartum visit.46 In addition to enquiry at routine obstetric and gynaecology appointments, ACOG recommends screening for domestic violence at family planning and preconception appointments.

Asking about domestic violence should be carried out in a safe, private setting. No adult known to the woman should be present and children should be excused from the room before initiating enquiry. Clinicians should be aware that language interpreters may come from the woman’s community and could, therefore, pose a potential threat to open communication. A general statement should be followed by direct, behaviourally specific enquiry. For example: ‘Because violence against women is so common in our society, I ask all my women patients about partner abuse. Is anyone close to you threatening or hurting you? Is anyone hitting, kicking, choking or hurting you physically? Is anyone forcing you to do something sexually that you do not want to do?’54 Family planning providers should also enquire about reproductive coercion by asking, for example, ‘Has your partner ever tampered with your birth control or tried to get you pregnant when you didn’t want to be?’55 It is critical to avoid vague questions like, ‘Are you being physically abused?’ and to specify the abuser, e.g. a boyfriend or ex-boyfriend.

Asking directly about specific forms of abuse is acceptable to women56 and has been shown to be more effective in domestic violence screening.57–59 Practitioners who suspect undisclosed abuse should leave the door open for future discussions by directly informing the woman in a gentle and non-judgmental manner, such as: ‘I’m concerned there may be something going on at home and would like to check in with you in a few months’. At subsequent visits the practitioner should address domestic violence as part of the woman’s ongoing problem list and should be aware that she may continue to withhold information about her abusive situation out of shame, denial, fear of repercussions or concerns about confidentiality.60

Aiding women who are being abused When a woman reveals that she is experiencing domestic violence, the healthcare provider should acknowledge her

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experience and tell her that she is not alone and that no one deserves to be abused. Qualitative research demonstrates that such brief statements of empathy and validation can be therapeutic in themselves.60

Safety assessment The clinician should then perform a brief safety assessment to establish the severity of the situation. The use of weapons and homicidal threats increase a woman’s risk of being murdered.23 Therefore, some important questions to ask are: Does your abuser have a weapon?

Has he made threats to kill you?

Do you feel safe to go home now?

To comprehend fully the nature of the abusive relationship and assess whether the violence is escalating, a provider who has identified a case of domestic violence should enquire about the first, most recent and most severe episodes, the specific types of abuse experienced and whether the woman has ever sought medical treatment. Lastly, it is important to ask whether she has ever attempted suicide and whether she has had any unintended pregnancies, terminations or partner interference with her contraception. Such an assessment can be done in a matter of minutes.

Safety planning After domestic violence has been disclosed, the woman’s experience acknowledged, her safety assessed and referrals made, the provider should schedule a follow-up appointment to discuss safety planning. Safety planning involves consideration of scenarios in which the woman must flee her situation immediately or decides to leave permanently.

Specifically, the clinician should encourage her to identify places she could go to if she were in imminent danger (e.g. friends, family, refuge accommodation) and to make copies of important personal and family documents such as her driving licence, passports, pay slips, birth certificates and immunisation records. If the woman has a bank account or credit cards, she should make a note of their numbers. These documents and numbers can be packed in a plastic bag together with a change of clothes for her and her family and, if possible, an extra set of car keys. This bag should be hidden outside the home, for example at a friend’s house or at work, to be used should she need to leave quickly.

Cultural sensitivity is important during every clinical encounter. There should be no cultural norm that ethically or legally permits violence against women, but there are women who live in communities where options for escaping such violence are severely limited. The clinician should take this into consideration when discussing safety planning.

Referrals As in the case of any newly diagnosed medical condition, a healthcare practitioner who has identified domestic violence should provide the woman with information about available resources such as helpline telephone numbers and addresses of websites with information about shelters, local support groups and legal aid services. In the UK, Women’s Aid is a national organisation which offers a 24-hour national helpline and an easy-to-use website with links to many resources for victims of partner abuse (see ‘Websites and further information’). Providers can also obtain informational materials such as posters and pamphlets from Women’s Aid. These materials can be displayed in waiting and examination rooms to serve as cues to women that the clinical environment is a safe place in which to discuss domestic violence.

When offering resource information, clinicians should make certain that women are able to use them; many materials are available in languages other than English and for women with low literacy. Take-home materials regarding domestic violence could pose a threat if discovered by an abuser and this possibility should be discussed. If there is concern about discovery, then information taken home must look innocuous. Simply writing down an unidentified telephone number on a small piece of paper may be all that is necessary. Additionally, a provider may contact services on behalf of an abuse victim if given permission to do so.

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Documentation The medical record is a legal document that could some day aid the victim of abuse in a court of law. It is, therefore, of utmost importance that clinicians report in the hospital or office record any suspicions of domestic violence and any discussions with the woman. (This documentation should not be included in the hand-held maternity notes if it could put the woman at risk.) In the event of injury, clinicians should clearly record a description of the abuse in the woman’s own words and all physical findings, using a body map and photographs if possible. In all cases, there should be special attention to stating the identity and relationship of the abuser (e.g. husband, exhusband) as recounted by the woman. Lastly, if a clinician suspects abuse but the woman does not disclose it, this should be included in the medical record.

Conclusion Domestic violence affects one in four women and has tremendous impact on the health and wellbeing of female patients. Women’s healthcare providers are in a unique position to lessen this impact, at the very least by alleviating the isolation that is often integral to such victimisation. In accordance with expert guidelines, clinicians should enquire routinely about partner abuse and offer support and information about available resources for women

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experiencing violence. As in many other chronic illnesses, the time frame for change is very likely to be prolonged; therefore, the goal should be to provide non-judgmental assistance so that these women can make informed, healthy choices.

Websites and further information Women’s Aid: telephone 0808 2000 247; website: www. womensaid.org.uk

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ª 2012 Royal College of Obstetricians and Gynaecologists