Clinical Approach Partner Abuse

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Family violence is an abuse of power, in which a more-powerful person exerts control over a less-powerful person or persons. This abuse can take the form of physical violence (battery), sexual violence, intimidation, emotional and psychological abuse, economic control, and isolation from others. Although it is most common to think of this as a man abusing a woman, abuse can occur both in homosexual relationships and in heterosexual relationships with a male victim. It is estimated that more than 1 million women are abused annually in the United States and that approximately 1 in 3 women are abused at some time in their lives.

Abuse can occur in any relationship or in any socioeconomic class. Certain situations increase the likelihood, or escalate the occurrences, of abuse. These situations include changes in family life (such as pregnancy, illnesses, deaths), economic stresses, and substance abuse. Personal and family histories of abuse also increase the likelihood of family violence.

Numerous professional organizations, such as the American Medical Association and the American College of Obstetricians and Gynecologists, advocate for the routine screening of women for abuse by direct questioning. Numerous tools exist for screening, from simple questioning ("Do you feel safe in your home?") to more formal inventory tools. The United States Preventive Services Task Force (USPSTF) has found insufficient evidence to make a recommendation for or against screening for domestic violence because they did not find studies that directly looked at the impact of screening on reducing adverse outcomes. The USPSTF does recommend that all clinicians should be alert to physical and behavioral signs and symptoms associated with abuse and neglect.

Victims of abuse can present with varied symptoms and signs suggestive of the problem. Direct physical findings can include obvious traumatic injuries, such as contusions, fractures, "black eyes," concussions and internal bleeding. Genital, anal, or pharyngeal trauma, sexually transmitted diseases (STDs). and unintended pregnancy may be signs of sexual assault. Depression, anxiety, posttraumatic stress disorder, and suicide attempts can also result from abusive relationships.

Some signs and symptoms may be less obvious and may require numerous encounters until the finding of family violence is made. Victims of abuse may present to doctors frequently for health complaints or have physical symptoms that cannot otherwise be explained. Chronic pain, frequently abdominal or pelvic pain, is commonly a sign of a history of abuse. The development of substance abuse or eating disorders may prompt inquiry into family violence as well.

When abuse is identified, an initial priority is to assess the safety of the home situation. Direct questioning regarding the presence of weapons in the home, as well as the need for a plan for safety for the victim and others at home (children, elders), is critical. Resources, such as shelters, should be provided. It may be helpful to allow the patient to contact a shelter, law enforcement, family members or friends, while still in the doctor's office. Mullidisciplinary interventions, including family, medical, legal, mental health, and law enforcement, are often necessary.

The laws regarding clinician reporting partner violence varies from state to state. It is important to know the statutes in your locality. Many states do not require contacting legal authorities if the victim of the abuse is a competent adult.

Child Abuse

Approximately I million cases of child abuse, with more than 1()(K) deaths, are reported each year in the United States; the number of unreported cases makes the overall prevalence much higher. The situations that increase the risk of child abuse are similar to those that increase the likelihood of other family violence. Children who are chronically ill or who have physical or developmental disorders may be at even higher risk.

Certain history and physical examination findings raise the suspicion for child abuse. Injuries that are inconsistent with the stated history or a history that repeatedly changes with questioning should raise the suspicion of abuse. Children who are taken to numerous different physicians or emergency rooms, or who arc brought in repeatedly with traumatic injuries, may be victims. Delay in seeking medical care for an injury may also be a clue to abuse.

Neglect is also a form of child abuse. An injury or illness that occurred because of lack of appropriate supervision may be a sign of neglect. Failure to provide for basic nutritional, healthcare, or safety needs may be other forms of neglect.

Children frequently have bruises, fractures, and other injuries that occur accidentally and it can be difficult to distinguish with certainty whether an injury is accidental or intentional. However, certain types of in juries are uncommon as accidents (Table 36-1). The presence of these injuries is highly suggestive of child abuse.

When an injury suspicious for child abuse is identified, attention should initially focus on treatment and protection from further injury. A complete examination should be performed and all injuries documented with drawings or photographs. An x-ray skeletal survey can be performed to look for evidence of current or previous bony injuries. Ophthalmologic examination should be performed to look for retinal hemorrhages. The progress note should be documented carefully and legibly.

All 50 states require reporting of suspected child abuse to the appropriate authorities (refer to local laws to determine the appropriate authority). Parents should be informed that a report is going to be made and the process that is likely to occur after the report is made. Consideration must also be given to the possibility that there are other victims of abuse in the home (spouse, other children, elders). Any healthcare provider who makes a good-faith report of suspected abuse or neglect is immune from any legal action, even if the investigation reveals that no abuse occurred. Providers may be held liable for failure to report child abuse.

Table 36-1


• Stocking-and-glove burns of the extremities (immersion in scalding water)

• Burns of the buttock and groin that spare the intertriginous areas (immersion in scalding water)

• Centimeter-sized circular burns (cigarettes)

• Multiple bruises of differing ages

• Unexplained injury to buttocks, thighs, ears, neck

• Bruises in the shape of a hand, belt buckle, or loops of a cord

• Retinal hemorrhages ("shaken baby syndrome")

• Corner or "bucket-handle" fractures of metaphysis of long bones

• Spiral fracture of femur or humerus

• Posterior rib fractures

• Scapular fractures

• Spinous process fractures

• Sternal fractures

• Complex, bilateral, or wide skull fractures

• Injury to external genitalia

• Sexually transmitted diseases, genital warts

• Circumferential hematoma of anus (forced penetration)

Elder Abuse

Many types of elder abuse may occur, including physical, sexual, and psychological abuse, neglect, and financial exploitation. An estimated 2 million elders are abused in some form annually in the United Stales. Along with the other risks for domestic violence, several factors unique to the care of elders may play a role. Caregiver frustrations and burnout are commonly heard excuses for abuse. Persons who are older, more cognitively and physically debilitated, and have less access to resources are more likely to be abused or exploited.

A history of abuse may be difficult to obtain, as the patient may fear worsening of the abuse or may not have the cognitive ability to make an accurate report. If feasible, it is helpful to interview the patient without the presence of the caregiver. The physical examination, like in child abuse, should carefully document any injuries that are found. Suspicions of dehydration or malnutrition should be confirmed with appropriate laboratory testing and radiographs should be performed as necessary.

By law. elder abuse should be reported to the appropriate adult protective services, but the reporting requirements vary by state. A multidisciplinary approach, involving medical providers, social workers, legal authorities, and families is usually necessary to address the issues involved.

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