eMedicine Specialties > Emergency Medicine > Psychosocial

Domestic Violence

Author: Lynn Barkley Burnett, EdD, MS, LLB(c), Medical Advisor, Fresno County Sheriff's Department; Attending Consultant-in-Chief and Chairman, Medical Ethics, Community Medical Centers; Adjunct Assistant Clinical Professor of Emergency Medicine & Forensic Pathology, Touro University College of Osteopathic Medicine--California; Adjunct Professor of Forensic Pathology, National University Master of Forensic Science Program; Adjunct Professor of Medical Law & Bioethics, Kaplan University
Coauthor(s): Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Contributor Information and Disclosures

Updated: Aug 18, 2009

Introduction

Background

The medical literature defines domestic violence in different ways. In this article, domestic violence refers to the victimization of a person with whom the abuser has or has had an intimate, romantic, or spousal relationship. Domestic violence encompasses violence against both men and women and includes violence in gay and lesbian relationships.

Domestic violence consists of a pattern of coercive behaviors used by a competent adult or adolescent to establish and maintain power and control over another competent adult or adolescent. These behaviors, which can occur alone or in combination, sporadically or continually, include physical violence, psychological abuse, stalking, and nonconsensual sexual behavior. Each incident builds upon previous episodes, thus setting the stage for future violence.

• Forms of physical violence include assault with weapons, pushing, shoving, slapping, punching, choking, kicking, holding, and binding. Two forms of physical violence have been posited: occasional outbursts of bidirectional violence (ie, mutual combat) and frank terrorism, of which the "patriarchal" form has been the most researched.
• Psychological abuse includes threats of physical harm to the victim or others, intimidation, coercion, degradation and humiliation, false accusations, and ridicule.
• Intimate partner stalking may occur during a relationship or after a relationship has ended. Of women who are stalked by an intimate partner, 81% are also physically assaulted. A new development is psychological abuse (generally threats) expressed through the Internet, so-called cyberstalking.
• Sexual abuse may include nonconsensual or painful sexual acts (often unprotected against pregnancy or disease).

Domestic violence may be associated with physical or social isolation (eg, denying communication with friends or relatives, or making it so difficult that the victim stops attempting communication) and deprivation (eg, abandonment in dangerous places, refusing help when sick or injured, prohibiting access to money or other basic necessities).

Domestic violence is not a new epidemic—it spans history and cultures. The Common Law of England permitted a man to beat his wife, provided the diameter of the stick so used was not wider than the diameter of his thumb, hence, the term "Rule of Thumb."

Domestic violence exacts a multitude of costs. Annual economic costs (in 2003 dollars) was estimated at $8.3 billion, including $6.2 billion for physical assault, $461 million for stalking, $460 million for rape, and $1.2 billion for lives lost. The Centers for Disease Control and Prevention (CDC) reports that victims of severe domestic violence annually miss 8 million days of paid work—the equivalent of 32,000 full-time jobs, and approximately 5.6 million days of household productivity.

The magnitude of the current problem may be further appreciated by examining the burden placed on law enforcement. Police in the United States spend approximately a third of their time responding to domestic violence calls. Of women presenting to the emergency department (ED), research suggests that between 4 and 15% are there because of problems related to domestic violence. Calls to the police and visits to the ED sometimes are used by victims of domestic violence to strategically manage the episode by de-escalating the violence.

When victims of domestic violence (male and female) were asked where they would go for assistance, they responded as follows:

• Would seek help from the police - 31.2%
• Did not know - 27.7%
• Would go to a hospital - 14.7%
• Would approach a family member - 10.7%
• Would go to a shelter - 10.7%
• Would forego assistance and simply retaliate - 3.1%

Women who are abused seek medical attention moreso than those who are not victimized. A study in the Northwest found that 95% of women with diagnosed domestic violence sought care 5 or more times per year and that 27% sought medical care more than 20 times per year. Often, these women go to the ED.

Victims of acute domestic violence are those patients in the ED whose complaints directly relate to an incident of abuse. Two to 4% of women who present for treatment of injuries, excluding those sustained in motor vehicle collisions (MVCs), are victims of domestic violence.

Of women in violent relationships, 77% who present to the ED do so for reasons other than trauma. The percentage of women with domestic violence–related symptoms who present to an ED with any complaint ranges from 22-35%, including patients requesting nontrauma, prenatal, or psychiatric care.

Abused patients who present for other medical problems resulting from a violent milieu are said to suffer from chronic domestic violence. This term applies to those patients who are victims of violence at the hands of a partner and who seek medical care for symptoms related, directly or indirectly, to the stress of the relationship.

Women report to the police only 20% of all rapes, 25% of all physical assaults, and 50% of all stalkings perpetrated by intimate partners. Even fewer men who are victims of such crimes at the hands of an intimate partner report them to law enforcement. Thus, the emergency clinician is often the first professional from whom an abused person seeks help. In fact, more than 85% of Americans indicated they could tell a physician if they had been a victim or perpetrator of family violence, slightly more than those who would tell their priest, pastor, or rabbi and considerably more than those who would tell a police officer.

Yet, if a request for help is not explicit, the opportunity to intervene in domestic violence often is not addressed. The following elements may deter interceding in domestic violence:

• Social factors, such as implicit and explicit social norms, societal tolerance of violence, and desensitization through exposure
• Personal factors, such as sex bias, personal history of abuse, idealized concepts of family life, concerns over privacy, and perceived powerlessness
• Professional factors, such as time constraints, inadequate skills, professional detachment, and professional relationships with abusers or victims
• Institutional and legal factors such as inadequate or unclear policies and fear of legal reprisal
• Additional barriers including blaming the victim, disapproving of her or his decisions and circumstances, questioning patients in an inappropriate manner, and failing to query middle-class or affluent patients in the mistaken belief that such individuals are not victims of domestic violence

If the emergency clinician is to recognize occult domestic violence and correctly interpret its associated behavior, a high index of suspicion is necessary, and battering must be entertained in the differential diagnosis of a wide variety of presenting complaints. In this regard, much improvement is needed. An accurate diagnosis of battering is estimated in less than 1 of 25 women. Data from another study documented that 23% of women presented 6-10 times and another 20% sought medical attention on 11 occasions before a diagnosis of abuse finally was made.

Why would domestic violence consistently be unrecognized over so many ED visits? The most significant reason for missing the diagnosis of domestic violence simply may be failure to ask. Limiting inquiry about domestic violence to patients with specific complaints fails to identify many victims of abuse.

The largest ED-based study to date (n = 4501) discovered that 6 diagnoses were more common in women in physically abusive relationships compared with women not in such relationships. However, the low sensitivity and positive predictive value of these diagnoses made the findings clinically useless in detecting most women in violent relationships—those who do not present with injuries resulting from acute battering.

The US Preventive Services Task Force states that it cannot, at this time, determine the balance between the benefits and the harms of screening for family and intimate partner violence among children, women, and older adults. However, given the substantial percentage of patients seeking care in the ED who are abused by their partners, considering a context of violence in assessing all types of ED patients would seem prudent. Patients may be males or females from any socioeconomic group, and their injuries may or may not be related to trauma. Moreover, the incidence and prevalence of domestic violence, coupled with its morbidity and potential mortality, strongly militate in favor of routinely screening most adult or adolescent emergent patients.

Recognition of domestic violence and employment of appropriate management strategies may well have even broader implications. Domestic violence fits within a spectrum of family violence that also includes elder abuse, child sexual abuse, and child abuse and neglect.

These forms of violence share many similar root causes, thus interventions directed at one may positively influence other forms of violence as well.

The practitioner in the emergency department is on the front line of interpersonal violence and is thus in a unique and vital position to initiate the process that may stop the cycle of violence in all of its familial expressions.

Pathophysiology

As with organic pathology, an archetypical abnormal behavioral function characterizes domestic violence. The term cycle of violence is descriptive of the pattern of abuse and consists of the following 3 components:

• Tension building
• Explosion, acute battering
• Absence of tension, also called loving respite, reconciliation, or the "honeymoon phase"

An appreciation of the cycle of violence is essential to understanding the nature of domestic violence, its clinical presentation, and appropriate intervention.

During the tension-building phase, the battering victim frequently tries to be particularly compliant and kind in an attempt to avoid violence. Irrespective of any special efforts, the abuser still becomes angry with increasing frequency and intensity. Paradoxically, the abused person may be so frightened during this tension-building phase that she or he attempts to precipitate abuse, just to be done with the episode. When battering does occur, it frequently is followed by a period of indefinite length during which the batterer is contrite and demonstrates loving behavior.

Friends and family of victims, as well as experts, frequently ask victims of domestic violence why they stay in such apparently horrible situations. A nonexhaustive list of reasons includes love, hope, dependence, fear, and learned helplessness.

• With reference to love, domestic violence often occurs in a relationship in which at least one partner loves the other. This partner wants things to be all right again and does not want to lose the other person's (perceived) love.
• Hope is an operative corollary to love. The abused partner wants to believe the batterer's promises made during the increasingly frequent honeymoon periods of ever-decreasing duration as the cycle of violence deepens.
• Dependence is an additional barrier to seeking help and most commonly is observed in women who may have a sense of emotional dependency with reluctance to expose batterers to punishment. In fact, few victims cooperate in the prosecution of arrested assailants. After only a few days, many victims even deny that they have been assaulted. Women are also more likely to rely on their partner for financial support. The abused person may feel there are no options but to stay and tolerate the violence, especially if children are involved.
• Fear is a powerful factor. Victims repeatedly emphasize that seeking care or assisting in prosecution of their assailants would escalate the violence, and their fears are based in fact. Batterers often escalate violence when their partners increase help-seeking measures or attempt separation. During prosecution, approximately half of batterers threaten retaliatory violence, and more than 30% actually commit assaults.
  • The most dangerous time for battered women is during attempts to leave relationships. Women who are separated from their husbands have a risk of violence about 3 times more than that of divorced women and approximately 25 times more than that of married women. Up to 75% of domestic assaults reported to law enforcement agencies occur after separation of the couple, with women most likely to be murdered when reporting abuse or attempting to leave an abusive relationship.
  • Another fear experienced by victims of domestic violence is loss of children; batterers often retaliate by abducting offspring, especially during the early period of separation.
• Finally, learned helplessness may be a factor. People exposed to unpredictable and inescapable negative stimuli may become passive and unable to protect their lives. A stress response syndrome has been described, which consists of self-blame, chronic anxiety, extreme passivity, denial of anger toward others while directing anger inwardly, and paralyzing terror at the first sign of danger.

Keeping the above factors in mind, attention now turns to the patient's willingness to accept help and take steps to extricate himself or herself from the environment of domestic violence. Recalling the cycle of violence previously addressed, the patient may be amenable to intervention during both the tension-building phase and the battering phase. During the reconciliation phase, the battered person typically is showered with expressions of love and apology and with assurances that the abuse will never happen again. Given the dynamics of this stage, the patient is much less willing to seek or receive help.

Insight into a further consideration of behavioral change is offered by the Transtheoretic Model of Change described by Proschaska and DiClemente. They posit a 5-stage dynamic model characterized by the following: Precontemplation, Contemplation, Preparation, Action, and Maintenance. Adapting this model to the setting of domestic violence, in Precontemplation, the patient may not recognize the abusive state (feeling he or she deserves such treatment or that such treatment is normal) and, therefore, has no thoughts of change; those unwilling or unable to make the requisite behavioral change are also placed in this stage.

Inquiry at this stage serves to raise awareness of the abnormal state.

In the Contemplation stage, which can last for years, the victim sees the problems created by the abuse and begins to think about the advantages and disadvantages of making a change. The Contemplation stage may begin with a nondisclosure phase, in which the patient is unwilling or unable to disclose the abusive relationship to others. This may be followed by a disclosure phase, when the patient is ready to discuss abuse with a clinician or other person. A study of patients who discussed abuse with a physician identified 4 expectations of significance: affirm the abuse is real, inform the patient about local resources for victims of domestic violence, educate patients about the effects of abuse on them and their children, and document injuries in the medical record.

The Preparation stage is marked by active planning for change, as manifested by telling family and friends of the abuse, calling hotlines, and making a plan for leaving. The Action stage speaks for itself and is frequently reached when violence is witnessed by or directed at children. This stage is reached when the victim makes the determination that the violence must end, and he or she assesses the presence of adequate support and resources. Maintenance involves solidifying the change and working to prevent relapse. Relapse is commonly seen as the patient moves through the stages of change and is most common in the action stage.

Frequency

United States

In 2001, domestic violence was causal in 20% of nonfatal violence directed against women and in 3% directed toward men. A 2002 study reports that 29% of women and 22% of men report having experienced physical, sexual, or psychological intimate partner violence during their lifetime.

Nearly 5.3 million incidents of domestic violence occur annually among US women aged 18 years and older, with 3.2 million occurring among men. Of these incidents, most are relatively minor, such as pushing, grabbing, shoving, slapping, and hitting. Serious consequences certainly do, however, result.

Every year approximately 1.5 million intimate partner rapes and physical assaults are perpetrated against women, and approximately 800,000 are committed against men. In the 2000 National Violence Against Women Survey of 8000 women and 8000 men, rape was reported by 7.7% of women and 0.3% of men. Physical assault affected 22.1% of women and 7.4% of men.¹

Victimization often occurs repeatedly. Data from the survey revealed that women averaged 6.9 physical assaults by the same partner, with men averaging 4.4 assaults.

Differing data have been published by the US Department of Justice. The Justice Department stated that, in 2002, women were the victims of an estimated 494,570 rapes, sexual assaults, aggravated assaults, and simple assaults, a decrease since 1993 when the estimate for such crimes was 1.1 million annually. For men, in 2002, an estimated 72,520 violent crimes were committed by an intimate partner, again down from the 1993 estimate of 160,000 such crimes.²

Stalking by an intimate partner is experienced by an estimated 1 million women and 317,000 men each year.

High-profile news reports may affect willingness to report domestic violence. Following the murders of Nicole Brown Simpson and Ronald Goldman, the Los Angeles County Sheriff's Department noted a significant increase in domestic violence dispatches.

Mortality/Morbidity

• Almost 2 million injuries occur each year as a result of domestic violence, of which approximately one third of patients will seek care in an ED. Reported injuries include 43,000 patients with gunshot wounds, stab wounds, fractures, internal injuries, and loss of consciousness; 53,000 injured as a result of intimate partner rape or sexual assault; and 390,000 with soft tissue trauma, such as contusions and cuts.
• Over the past 20 years, the number of intimate partner homicides has decreased by about 14% overall for men and women.
• In 2002, approximately 11% of homicide victims were killed by an intimate partner, accounting for 1,300 deaths.
• In the United States, most intimate partner murders are committed with firearms, as is the case for murder in general.
• Women were the victims in 76% of intimate partner murders in 2002. Of women murdered by an intimate partner, 44% had visited an ED within 2 years of the homicide, with 93% having had at least 1 visit for injury.
• Four to 8% of women are abused at least once during pregnancy. A study in Maryland found that homicide was the leading cause of death among pregnant women in that state, whereas for nonpregnant women of child-bearing age, murder ranked as the fifth cause of death.
• Nearly half of the estimated annual 4400 intrafamily murder victims are spouses. Fifty to 75% of the 1500 annual deaths resulting from murder-suicide occur in spousal or consortial relationships. More than 90% of such acts are perpetrated by the male partner, who often has a history of domestic violence. In these incidents, children and other family members may be murdered as well.
• A home in which anyone has been hit or hurt in a family fight is 4.4 times more likely to be the scene of a homicide than is a violence-free home.
• According to US Department of Justice data for 1998, women were the victims in 85% of nonlethal intimate violence.
• The literature is contradictory as to the proportion of males and females who sustain injuries as a result of domestic violence. While the conventional wisdom is that women are more likely to be injured than are men, some reports suggest that the frequencies of male and female victims of domestic violence are equal.
• In 1996, McCoy reported that, in mixed-sex domestic violence, the female is 13 times more likely to be injured than is the male.³ In 1995, Bachman and Saltzman indicated that, in violent incidents committed by intimates, women sustained injury in 52% of cases, with 41% of those patients requiring medical care.⁴
• Contrary findings come from a study of 516 patients presenting to an inner-city ED, in which high rates of domestic violence were nearly equal between men and women. Males and females had the following rates of domestic violence, respectively:
• Past nonphysical violence - 14% versus 22%
• Past physical violence - 28% versus 33%
• Present nonphysical violence - 11% versus 15%
• Present physical violence - 20% versus 19%
• In an ED study of 1003 patients reported by Sachs et al, no significant sex difference was noted in the rate of patients acutely injured by intimate partner violence. No such difference was found in patients reporting abuse within the past year, abuse with a weapon, or abuse with a weapon within the last year.⁵
• With reference to serious injury, in a small study (n = 37) reported by Vasquez and Falcone, victims of domestic violence admitted to one trauma center were just as likely to be male as female.⁶
• Males were more likely to be seriously injured than were females, with average Injury Severity Scores of 11.4 versus 6.9.
• While males were less likely than females to be victims of gunshot wounds (6% vs 21%) or to be injured in an assault (22% vs 53%), they were more likely to be stabbed (72% vs 26%).⁶

Race

• The National Violence Against Women Survey found that African American and American Indian and Alaskan Native women and men, and Hispanic women, report higher rates of domestic violence than do other minority groups; whereas Asian and Pacific Islander women and men tend to report lower rates of intimate partner violence than other minority groups. However, differences among minority groups diminish when other sociodemographic and relationship variables are controlled.
• In 1998, Salber and Taliaferro reported that the spousal homicide rate among African Americans is 8.4 times more than for whites; however, the US Department of Justice reports that between 1976 and 1998, a 74% reduction occurred in the number of black men murdered by intimates.
• The incidence of spousal homicide is 7.7 times higher in interracial marriages compared with intraracial marriages.

Sex

• Much of the data concerning domestic violence are based on involvement of the criminal justice system. When interpreting reports from law enforcement agencies, the following caveat should be noted: In 1997, Ernst and colleagues reported a significant difference in reports of past abuse to the police, with 19% of women having made such reports versus only 6% of men.⁷
• Females are more likely to be repeatedly attacked, injured, or raped by their male partners than by any other perpetrators. The US Department of Justice estimates that females are 6 times more likely than males to experience violence committed by an intimate (eg, spouse or ex-spouse, boyfriend or girlfriend, ex-boyfriend or ex-girlfriend). Of all violence against females that is committed by a lone offender, an intimate is the perpetrator in 29% of cases.
• Half of homeless women and children are fleeing domestic violence.
• Battered lesbians report high levels of sexual violence, in the range of 30-40%. Some experts believe that homosexual men also experience high levels of sexual violence, although little documentation can be found in the literature. Data from the National Coalition of Anti-Violence Programs report the rate of domestic violence in same-sex couples increased by 29% in 2000.
  • Approximately 11% of women living with female intimate partners report being raped, physically assaulted, or stalked by their cohabitant. (In comparison, 30.4% of women living with a male partner, reported such victimization by their male cohabitant.)
  • Approximately 15% of men living with male intimate partners report being raped, physically assaulted, or stalked by their cohabitant. (In comparison, 7.7% of men who have lived with a female partner experienced such problems.)

Age

• Women aged 16-24 years are more likely than other women to be victims of violence at the hands of an intimate. Twenty to 30% of university women report violence during a date.
• The rates of spousal homicide for all groups peak in the 15- to 24-year-old age category. Rates decline with age in African Americans but not in whites.
• As the age differential between husband and wife increases, so does the risk of spouse homicide.

Clinical

History

• The following is a list of some important points to remember when taking the patient's history
  • The batterer often accompanies the patient to the ED, may hover and refuse to leave the patient alone, and may insist on answering questions for the patient. These factors reinforce the necessity for taking the history in private.
  • Inform the patient of any limits to confidentiality imposed by mandatory reporting requirements for domestic violence and child abuse. If a translator is necessary, he or she should not be a member of the patient's or suspected abuser's family.
  • Simple questions asked in private may elicit previously unrecognized risks and histories of violence. Ask direct questions (eg, "Has your partner ever punched or kicked you?"), as opposed to asking if a person is battered or otherwise a victim of domestic violence. This is critical because the patient may not interpret what occurs as domestic violence.
  • If questioning the family, do so with care, always remembering that the batterer may be among those queried. Phrase questions in an open-ended manner such as "Betty seems upset. Do you have any idea why?"
  • When questioning an abuser who has been injured, use nonjudgmental language, such as "What happened after you threw your partner on the floor?" as opposed to "What did you do after you beat her?"
  • Abusers often blame the victim for their behavior; therefore, take care not to validate such assertions by saying "I can understand why that made you so mad you threw her down." The abuser should instead receive the message that "Hitting does not solve problems; it often destroys families."
• Historical findings associated with domestic violence
  • Presenting complaints relating to illness or stress predominate by a 2:1 ratio over injury.
  • Domestic violence may be causal in a large number of chronic health problems. Women who are battered are more likely to present with vague medical complaints (12% vs 3%), sexual problems (19% vs 3%), depression, or anxiety than are women who are not battered.
  • Presentations common to the ED include acute pain with no visible injuries, chronic pain (especially if evidence of tissue damage cannot be found), repetitive complaints inconsistent with organic disease, pain due to diffuse trauma without visible evidence, and symptoms without evidence of physiologic abnormality.
  • A history of multiple prior visits to the ED (traumatic and nontraumatic) suggests battering.
  • Medical recidivism for vague complaints without evidence of physical abnormality may result from psychosomatic complaints secondary to depression, the ultimate cause of which is domestic violence. Nonspecific complaints of ill or failing health may be voiced in the context of "I can't seem to do what I'm supposed to do."
  • A substantial delay between time of injury and presentation for treatment may stem from ambivalence about discovery of the true cause should the patient seek help. Such a delay also may result from the inability of the patient to leave the house or an absence of independent means of transportation.
  • Noncompliance with treatment regimens, missed appointments, and failure to obtain or take medications may be due to a lack of access to money or telephones and ultimately may indicate attempts to exercise control over the patient. The patient and/or partner may deny injury or minimize the incident(s).
  • The patient may feel isolated and may be kept socially isolated. The patient may provide a history of being restrained or locked in or out of shared domiciles. The patient also may feel threatened with violence, institutionalization, abandonment, or guardianship.
  • Reluctance by the patient to speak or disagree with the partner may be noted, as may exaggerated self-blame for the partner's violence. Intense jealousy or possessiveness may be reported by the patient or expressed by the partner.
• Depression and suicide
  • Patients with psychiatric complaints, especially suicide attempts, ideation, or gestures, always should be questioned about current or past domestic violence.
  • Domestic violence may be a factor in up to 25% of suicide attempts in women. Of pregnant women who are battered, 20% attempt suicide. When inquiring about the reason for the suicide attempt, clarify responses such as "fight with my husband" as to presence or absence of physicality.
  • Depression is a correlate of domestic violence. Patients (especially women) presenting with such complaints or with sleep or eating disturbances should be questioned about current or past abuse.
• Stress
  • Symptoms related to stress are common, including anxiety, panic attacks, other anxiety symptoms, and posttraumatic stress disorder (PTSD).
  • Fatigue and chronic headaches also may be noted.
• Abuse of alcohol and other drugs
  • Abuse of alcohol and other drugs is a correlate of domestic violence. Since substance abuse may develop or worsen as a result of domestic violence, it is appropriate to consider domestic violence when evaluating a patient for alcohol intoxication, drug toxicity, or drug overdose.
  • Be aware of frequent use of minor tranquilizers or pain medications.
  • A family history of alcohol and drug abuse or similar history in the patient's partner is also an important risk factor.
• Medical complaints
  • Palpitations, dyspnea, atypical chest pain, abdominal or other GI complaints, dizziness, and paresthesias, while common complaints, are noted frequently with domestic violence.
  • Current or past self-mutilation may be noted.
• The female patient
  • Gynecologic complaints include frequent vaginal or urinary tract infections, dyspareunia, and pelvic pain.
  • Failure to use condoms or other appropriate means of protection is frequent and is suggested by a history of sexually transmitted diseases, particularly if recurrent.
  • The pregnant patient may be homeless, may report no, sporadic, or late prenatal care, and may present with depression.
  • Other historical findings may include problem pregnancies, preterm bleeding and/or miscarriage, and self-induced abortion.
• Trauma
  • Some "accidents" (eg, falls) result from domestic violence. Patients presenting with non-MVC trauma, especially assault-related trauma, should prompt inquiry about the possibility of injury by a known partner.
  • Injuries sustained in a single-vehicle crash, either as driver or passenger, also raise suspicions for domestic violence.
• Asking about domestic violence
  • Several protocols for inquiring about domestic violence have been recommended and are easily adaptable to the ED.
  • The women-validated Partner Violence Screen (PVS) poses the following questions:
    • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom were you injured? (This question detected almost as many abused patients as the combined 3-question PVS, with better specificity.)
    • Do you feel safe in your current relationship?
    • Is a partner from a previous relationship making you feel unsafe now?
    • In addition, patients were asked, "Are you here today due to injuries from a partner? Are you here today because of illness or stress related to threats, violent behavior, or fears due to a partner?"
  • The mnemonic SAFE directs inquiry into domestic violence. Sebastian, in 1996, maintained that simply asking the SAFE questions alleviates the patient's alienation, offers him or her an opportunity to validate his or her worth, and provides a means to assess safety.⁸ When SAFE questions are made routine, clinicians become more comfortable in discussing domestic violence.
    • Stress/Safety: What stress do you experience in your relationships? Do you feel safe in your relationships (marriage)? Should I be concerned for your safety?
    • Afraid/Abused: What happens when you and your partner disagree? Do any situations exist in your relationships in which you have felt afraid? Has your partner ever threatened or abused you or your children? Have you been physically hurt by your partner? Has your partner forced you to have unwanted sexual relations?
    • Friends/Family (assessing degree of social support): If you have been hurt, are your friends or family aware of it? Do you think you could tell them if it did happen? Would they be able to give you support?
    • Emergency plan: Do you have a safe place to go and the resources you (and your children) need in an emergency? If you are in danger now, would you like help in locating a shelter? Do you have a plan for escape? Would you like to talk with a social worker, counselor, or health care professional to develop an emergency plan?
  • Other appropriate questions: Has you partner ever prevented you from leaving the house or seeing your friends or family? Has your partner ever destroyed things that you cared about?
  • Computer-assisted screening may be another option to detect risk for intimate partner violence. Ahmad et al assessed whether computer-assisted screening can improve detection of risk for intimate partner violence and control (IPVC).⁹ Their randomized study, in 282 women patients at a family practice clinic, used a computer-based multirisk assessment report generated from information provided by participants before the physician visit and attached to the medical chart. Analysis showed that the report increased opportunities to discuss IPVC (adjusted relative risk, 1.4) and increased detection of IPVC (adjusted relative risk, 2.0). The computer screening was acceptable to patients, despite some concerns about privacy and interference with physician interactions.
• The patient with known or suspected domestic violence
  • Concerns include the interval history appropriate to the domestic violence patient who frequents the ED, her or his capacity to cope with the violent situation, and assessment of the patient's legal needs, safety, and risk for serious injury or death.
  • Heilig and colleagues recommended that a patient with known or suspected domestic violence who regularly seeks help from the ED be asked about the following:¹⁰
    • Violence since the last visit
    • Abuse of children since last visit
    • Mental health
    • Coping strategies (eg, calls to hotlines, discussion with family or friends, attempts to leave)
  • Assessment of coping skills
    • Can the patient function at home and work?
    • What efforts has she or he made to cope with abuse? Who has been contacted and how often? What has been the response?
    • Has the behavior or mental status of the victim changed? Is she or he more or less aware of danger or harm? Is she or he reaching out or withdrawing? Does she or he seem in a fog or emotionally dulled?
  • Assessment of legal needs
    • Has the patient ever sought help to stop the abuse?
    • Is she or he familiar with protective laws and options they provide? Has she or he used them in the past? Was such use effective in decreasing contact with the batterer? If no, were police called to enforce the court order? Did the police provide adequate protection?
    • Has the patient filed a criminal complaint against the batterer? Has the case been heard? If yes, what was the outcome? If no, why? Did the victim drop the charges?
    • Does the patient want to pursue either criminal or civil legal action at this time? If yes, provide specific written instructions.
    • Give the patient the telephone number of a referral contact person or agency even if she or he does not request additional legal assistance.
• History of previous attacks
  • The frequency and severity of previous attacks indicate the degree of present danger. Threats are as important as any actual injury. The presence of weapons in the home is a risk factor.
  • In addition to threats and physical abuse, relationships with high risk for injury or death commonly feature exaggerated forms of coercion and manipulation to maintain the partner's dependence. This may result in the Stockholm syndrome.
  • A pattern may be discerned involving isolation of the victim, as follows:
    • Monopolization of the victim by the assailant (eg, does not allow demonstration of affection for children, family, pets)
    • Use of threats and public degradation
    • Nonviolent induction of disability (ie, assailant does not allow the victim to sleep or seek medical attention)
    • Expressions of omnipotence (eg, following the victim when she or he leaves the house, "I know what you are doing all the time")
    • Triviality (eg, obsessive attention to minor details about housekeeping or dress)
    • Use of indulgences to maintain the relationship (eg, buying gifts after episodes of abuse)
  • While the best indicator of danger is the patient's own assessment, the severity of violence and the danger faced by patients often are minimized as a coping strategy.
• The following instruments may be used to assess danger:
  • Physical Abuse Ranking Scale: Incidents ranking higher than 5 indicate a high likelihood of danger.
    • Throwing things, punching the wall
    • Pushing, shoving, grabbing, throwing things at the victim
    • Slapping with an open hand
    • Kicking, biting
    • Hitting with closed fists
    • Attempted strangulation
    • Beating up, pinning to wall or floor, repeated kicks and punches
    • Threatening with a weapon
    • Assault with a weapon
  • Lethality Checklist: The more items checked, the greater the danger. The perpetrator may exhibit the following behaviors and emotions:
    • Objectifies partner (eg, calls the partner names, body parts, animals)
    • Blames the victim for injuries
    • Is unwilling to release the victim
    • Is obsessed with victim
    • Is hostile, angry, or furious
    • Appears distraught
    • Is extremely jealous, blaming the victim for all types of promiscuous behavior
    • Has been involved in previous incidents of significant violence
    • Has killed pets
    • Has made threats
    • Has made previous suicide attempts
    • Is threatening suicide
    • Has access to the victim
    • Has access to guns
    • Uses alcohol
    • Uses amphetamines, cocaine, or other drugs
    • Has thoughts or desires of hurting partner
    • Has no desire to stop violence or control behavior
    • Has an extremely tense and volatile relationship with the victim
• In addition to a general history, assessment of immediate safety is critical as discussed by the following points:
  • Physical violence
    • What is the degree of physical violence?
    • Is your partner violent toward you or your children?
    • Has the amount of violence increased in frequency and/or severity over the past year?
    • How often does the batterer attack, hit, or threaten you?
    • Has your partner ever beaten you while you were pregnant?
    • Have you ever been hospitalized as a result of abuse?
    • Is your partner violent outside your home?
  • Threats of homicide
    • Has your partner ever threatened or tried to kill you?
    • Has your partner threatened to kill you with a weapon?
    • Has your partner ever used a weapon?
    • Does your partner have access to a gun?
    • Has the batterer ever tried to choke you?
    • Have you ever been afraid you might die while the batterer was attacking you?
  • Substance abuse
    • Are alcohol or other drugs involved?
    • Does your partner get drunk every day or almost every day?
    • Does your partner use uppers such as amphetamines (speed), angel dust (phencyclidine [PCP]), or cocaine (including crack)?
  • Control
    • How much control does your partner have over you?
    • Does your partner control your daily activities such as where you can go, who you can be with, or how much money you can have?
    • Is your partner violent and constantly jealous of you?
    • Has your partner ever said that if she or he cannot have you, no one else can?
    • Has your partner ever used threats or tried to commit suicide to get you to do what she or he wants?
  • Suicidal ideation
    • Are you thinking of suicide?
    • Have you ever considered or attempted to commit suicide because of problems in the relationship?
    • If so, do you have a plan?
    • Do you have access to a weapon or other means (eg, medications) chosen for suicide?
  • Homicidal ideation
    • Have you ever considered or attempted killing your batterer?
    • Are you considering this now?
    • Do you have a plan?
    • Do you have access to a weapon or other means chosen for homicide?

Physical

The partner may exhibit controlling behavior, or coercion may be reflected in the possessiveness and hovering of the intimate (male or female) partner who answers for the patient, seems overly aggressive or agitated, or isolates the patient while visiting. The absence of support in the ED also may indicate the possibility of domestic violence because of social isolation.

The patient may appear depressed. The patient may seem fearful of visitors and caregivers, including hospital staff. Eye contact may be poor. The consequences of emotional abuse may be observable (eg, reaction of the patient to a visitor who yells, threatens, or swears inappropriately). The patient may appear withdrawn.

Examine the whole patient, appreciating that the scalp may conceal signs of abuse. Patients may attempt to hide injuries under heavy makeup, turtleneck collars, wigs, or jewelry.

• Characteristic injuries
• Bilateral injuries, especially to the extremities
• Injuries at multiple sites
• Fingernail scratches, cigarette burns, rope burns
• Abrasions, minor lacerations, welts
• Subconjunctival hemorrhage suggests a vigorous struggle between victim and assailant.
• Fingernail markings: Three types of fingernail markings may occur, either singly or in combination as follows:
• Impression marks: These result from fingernails cutting into the skin. They may be shaped like commas or semicircles.
• Scratch marks: These are superficial and long and may be narrow or as wide as the fingernail. Scratches caused by the longer fingernails of women are frequently more severe than those from a male assailant.
• Claw marks: These occur when the skin is undermined, thus they appear to be more dramatic and vicious. While claw marks may be grouped parallel markings down the front of the neck, they often are randomly scattered.
• Pattern injuries: Pattern injuries suggest violence. Pattern injuries are marks, designs, or patterns stamped or imprinted on or immediately below the epithelium by weapons. Pattern injuries fall into blunt force, sharp force (incised and stabbed), and thermal categories.
• Blunt force trauma to the skin includes the most common injury, contusion, as well as abrasions and lacerations. Circular or linear contusions suggest abuse or battering. Parallel contusions with central clearing suggest assault from linear objects. Slap marks with delineation of the digits may be noted. Circular contusions 1-1.5 cm in diameter are consistent with fingertip pressure and may be seen with grabbing. Such marks are often present on the medial aspect of the upper arm, an area commonly overlooked in physical examination. Assaults with belts or cords may cause looped or flat contusions, and shoe soles or heels may cause contusions in patients who have been kicked or stomped on.
• Contusion caveats: Several factors determine development of a contusion, including the amount of blunt force applied to the skin, tissue density and vascularity, fragility of blood vessels, and amount of blood escaping into surrounding tissues. Bruises of identical age and cause on one person may not have the same color and may not change at the same rate in another person. Some basic guidelines as to the appearance of contusions are as follows:
• Red, blue, purple, or black colors may occur any time from 1 hour after the causal trauma to resolution of the contusion. The presence of red coloration, therefore, has no bearing on the age of the bruise.
• A bruise with any yellow coloration must be older than 18 hours.
• Although yellow, brown, or green bruises indicate an older injury, further specification of age is difficult.
• Bite marks: These are another type of pattern injury common in domestic violence. Some bite marks are difficult to recognize as such, appearing as nonspecific semicircular contusions, abrasions, or contused abrasions, while others are rich in identifiable features because of the anatomical location of the bite and the motion of teeth relative to skin.
• Strangulation: Thirty-three pounds of pressure per square inch is required to completely close the trachea, whereas the carotid arteries may be occluded with 5-6 pounds of pressure per square inch. Either results in strangulation, which accounts for 10% of all violent deaths in the United States annually. Hanging, ligature, or manual are the 3 forms of strangulation. The latter 2 may be associated with domestic violence.
• Ligature strangulation (garroting) is strangulation with a cordlike object such as a telephone cord or clothing items. Manual strangulation (throttling) is usually done with the hands; manual strangulation also may be accomplished with the forearms or by standing or kneeling on the patient's throat.
• Strack and McLane studied 100 women who reported being choked by their partners with bare hands, arms, or objects (eg, electrical cords, belts, ropes, bras, bathing suits).¹¹ Police officers reported no visible injuries in 62% of women, minor visible injury in 22%, and significant injury including red marks, bruises, or rope burns in the remaining 16%. Up to 50% of victims had symptomatic voice changes ranging from dysphonia to aphonia.
• Dysphagia, odynophagia, hyperventilation, dyspnea, and apnea may be reported or observed. Notably, reports indicate that some patients with an initial presentation considered "mild" have died up to 36 hours after strangulation, secondary to respiratory decompensation.
• Petechiae are most pronounced in manual strangulation. Conjunctival petechia may be observed, as well as petechia anywhere above the area of constriction, including the face and periorbital region.
• The neck may reveal scratches and abrasions from the victim's fingernails or a combination of lesions created by both victim and assailant. Location and extent varies with position of the assailant (front or back) and whether the victim or assailant uses one hand or two. In manual strangulation, the victim often lowers the chin to protect the neck, resulting in abrasions of the victim's chin and the attacker's hands.
• A single contusion or erythematous area is most commonly the assailant's thumb. Areas of contusions or erythema frequently run together, with clusters at the sides of the neck, along the mandible, up to the chin, and down to the supraclavicular area.
• Ligature marks may range from subtle to dramatic. They may mimic the natural folds of skin. Marks (eg, wavelike pattern of a telephone cord, braided pattern of a rope, or clothesline) may suggest the object with which the person was strangled. The nature and angle of a pattern may assist in differentiation of hanging from ligature strangulation. In ligature strangulation, the impression of the ligature is generally horizontal at the same level of the neck, and the ligature mark is generally below the thyroid cartilage; often, the hyoid bone is fractured. In hanging, the impression tends to be vertical and teardrop-shaped, above the thyroid cartilage, with a knot at the nape of the neck, under the chin, or directly in front of the ear. The hyoid bone usually is intact.
• Other complaints included loss of consciousness, defecation, uncontrollable shaking, nausea, and loss of memory.
• Central distribution of injury
• Injuries in domestic violence are usually central.
• Among the most common sites of injury are areas usually covered by clothing (eg, chest, breast, abdomen).
• The face, neck, throat, and genitals are also frequently the sites of injury.
• Up to 50% of injuries resulting from abuse are to the head and neck. To avoid obvious injury, male attackers may avoid striking the face, opting instead to hit the back of the head.
• Facial injuries are reported in 94% of victims of domestic violence.
• Maxillofacial trauma includes injuries to the eye and ear, soft tissue injuries, hearing loss, and fractures of the mandible, nasal bones, orbits, and zygomaticomaxillary complex.
• Injuries suggesting a defensive posture
• Fractures, dislocations, sprains, and/or contusions of the wrists or forearms may be sustained as a result of attempts to parry blows to the face or chest.
• Defensive injuries commonly are observed. These include injuries to the ulnar aspect of the arm, the palms (which may be used to block blows), and the soles (which may be used to kick away the assailant). Other common injuries include contusions to the back, legs, buttocks, and back of the head (which can result when the victim crouches on the ground for protection).
• Patient explanation inconsistent for extent or type of injuries: Multiple abrasions or contusions to different anatomical sites inconsistent with the history raises suspicions for domestic violence as would, for example, a blow-out fracture of the orbit that, per history, was sustained in falling from a chair. A body map may help document physical findings, especially with multiple injuries in various stages of healing.
• Violence during pregnancy
• Violence often increases during pregnancy.
• Injuries during pregnancy are commonly, but not exclusively, to the breast or abdomen.
• The patient also may present with trauma to the genitalia, unexplained pain, poor nutrition, unexplained spontaneous abortion, miscarriage, or premature labor.
• Sexual assault
• Sexual assault is reported by 33-46% of women who are physically battered.
• Examine the patient for evidence of sexual assault if indicated by clinical presentation.
• Any evidence of genital injury, such as labial or vaginal hematomas, small vaginal lacerations, or rectovaginal foreign bodies, should prompt assessment for domestic violence or sexual assault. Dried blood or semen may be noted.
• Sexually transmitted diseases, particularly if recurrent, raise suspicion of sexual assault.

Causes

• Both males and females with disabilities are at increased risk of abuse due to reliance on their caregiver.
• Many victims are pregnant.
• Women from families with annual incomes below $10,000 are at increased risk for intimate violence.
• Conversely, wives whose educational or occupational level is high relative to their husbands are at greater risk for abuse than those in marriages without such differences.
• The abuser is typically an underachiever who has obtained lower occupational status than expected, given the abuser's education.
• Other factors associated with domestic violence
  • History of family violence
  • Alcohol or drug use by the batterer, victim, or both
    • The use and abuse of alcohol is strongly associated with a higher probability that the drinker will be involved in violence as victim, perpetrator, or both.
    • Illicit use of drugs by household members increases a woman's risk of death at the hands of a spouse, lover, or close relative by a 28-fold factor.
    • Concomitant use of alcohol and illicit drugs is associated with a 16-times greater risk for suicide, a risk substantially higher than that observed for the use of either individual substance.
    • In a small study (n = 46) examining the relationship between selected socioeconomic risk factors and injury from domestic violence, alcohol abuse by the male partner, as reported by the female partner, was the strongest predictor for acute injury. Approximately half of the victims stated that their male partners were intoxicated at the time of the assault. Whether male partner intoxication is a direct causal factor, an indirect factor, or a factor that modifies the effect of a causal factor has not been determined.
    • On the day of the assault, 86% of assailants reportedly used alcohol, with 67% using the combination of alcohol and cocaine. The active metabolite of such a drug combination, cocaethylene, is more intoxicating, longer lived, and possibly more potent in its ability to kindle violent behavior than are the parent drugs.
  • A current relationship involving abuse
  • Psychiatric history
  • Of those who report being abused as children, 50.4% also report adult abuse.

• Search for CME/CE on This Topic »

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