Domestic Violence Clinical Presentation

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

Training and support programs for clinicians and administrative staff have been shown to improve identification of women experiencing domestic violence and referral to advocacy services. ^[9] Use of a domestic violence advocate in the ED resulted in a higher incidence of detection of incidents of acute violence than the data reported in the literature. ^[10] 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. ^[11] 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). ^[12] 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: ^[13]

• 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

See the list below:

• 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

See the list below:

• 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

See the list below:

• 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

See the list below:

• 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

See the list below:

• 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

See the list below:

• 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

See the list below:

• 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

See the list below:

• 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?

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

See the list below:

• 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). ^[14] 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.

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 include a history of family violence, a current relationship involving abuse, and psychiatric history. Of those who report being abused as children, 50.4% also report adult abuse.

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.

HIV

In a study by Reed et al, 11.8 of new cases of HIV infection were directly attributed to recent intimate partner violence when one controls for socioeconomic factors and risky behaviors. ^[15] In another study by Sareen J et al, patients with a history of abuse were generally diagnosed earlier with HIV because of frequent hospital visits but were then more likely to miss appointments and delay initiating therapy. ^[16]