Health Care Professional’s Response
to Intimate Partner Violence
Sheryl Heron, MD, MPH, FACEP
Associate Professor/Associate Residency
Director
Assistant Dean – Clinical Education
Associate Director Education & Training, Center
for Injury Control
Emory University School of Medicine
October 2011
Disclosure Statement
I have no financial relationship in any
amount with a commercial interest
to disclose
Introductions
•
Who you are?
•
Why are you here?
Objectives
•
Review the Health Consequences of IPV
•
Describe Strategies to Improve the health
professional’s response
•
Demonstrate a Systemic Response to IPV
Intimate Partner Violence (IPV)
•
Physical, sexual, or psychological harm by a
current or former partner or spouse.
• heterosexual or same-sex couples
• does not require sexual intimacy
•
IPV can vary in frequency and severity
Centers for Disease Control & Prevention - 2000
Patient 1
20 yo female presents s/p GSW to the
head.
On presentation she is in traumatic arrest

US notes IUP at 3 months.
Patient 2
30 yo female presents to the ED, c/o “being
tired, recently unemployed”.
Her 2 kids are with her.
On exam, she is febrile at 38.2 and on
auscultation of her lungs, she has bruises to
her chest.
In the literature
By gender
•
Male and female perpetration of violence is
equalizing, but:
•
•
•
Women tend to report victimization more
Men tend to perpetrate more severe violence in
most surveys, incl. homicide
Women tend to sustain more injuries and 3x
more like to report more fear/ battering
Houry D: J Interpers Violence. 2008; 23(8):1041-55.
Medical settings
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•
•
•
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Obstetrics/gynecology- 12.7%
Pediatrics- 8.4%
Primary care- 8.6%
Addiction recovery- 36.2%
Emergency department- 16.5%
McCloskey: Acad Emerg Med. 2005;12(8):712-22
Pre-hospital
•
•
DV victims more likely to call 911 for
any reason (77% vs. 47%) (Datner 1999)
DV-positive patients more likely to
refuse EMS transport (23% vs. 7%)
(Husni 2000)
•
More DV patients presented during
the EMS night shift
Associations with IPV
•
•
•
•
•
•
•
•
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Young (mean age 32)
Female (62%)
Unemployed (60%)
Street drug use (29%)
Cigarette smoking (59%)
Depression (36%)
PTSD (21%)
Suicidal (10%)
Houry D Does Screening In The Emergency Department Hurt Or Help Victims Of Intimate Partner
Violence? Annals of Emergency Medicine 2008;51:433-42
Physical Morbidity
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Physical injuries
•
Disfigurement or disability
•
Chronic body pain (e.g., abdominal,
headache)
Physical Morbidity
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Miscarriage or abortion
•
Sleep and appetite disturbances
•
Recurrent vaginal infections (e.g., STDs)
•
Other complaints (gynecological, cardiac,
central nervous system)
Homicide
ED Use Prior To Death
139 homicide victims (5 years, 12 hospitals)
34 (25%) were IPV victims
15 (44%) presented to the ED < 2 years
14 had injuries
8 head lacerations; 2 perineal lacerations; 2
rapes; 1 suicide attempt
Medical records suggestive of abuse in 8
IPV documented in 2; no intervention
Arbuckle J et al: Ann Emerg Med. 1996 Feb;27(2):210-5.
What questions to ask?
HITS Scale
•
•
Hurt; insulted; threatened with harm; screamed at
you
Danger Assessment Scale
•
•
Increasing risk of lethal events with each “yes”
answer
Frequency/severity of violence, presence of
weapon, substance use, suicidal or homicidal
intent, violence towards children
What questions to ask?
SAFE
•
•
Safety; afraid/abuse; family/friends;
emergency plan
Abuse assessment screen/ Index of Spouse
Abuse/ Conflict Tactics Screen
•
•
Utilized in research
Labor intensive
What questions to ask?
Partner Violence Screen (Feldhaus 1997)
• Have you been hit, kicked, punched, or
otherwise hurt by someone in the past year? If
so, by whom?
• Do you feel safe in your current relationship?
• Is there a partner from a previous relationship
who is making you feel unsafe now?
Patient attitudes about screening
•
•
•
78% favored routine screening (Friedman
1992)
85% of patients feel it’s appropriate for health
providers to ask questions about violence
(Houry 1999)
36% of DV victims would tell a physician only
if asked directly (Hayden 1997)
So… what do you do with this
information?
How effective is screening for
and identifying victims?
Does it prevent or predict future
violence? Is it safe?
Why does screening matter?
Women who screened positive for IPV in the ED
• Re-interviewed 4 months later about violence in the
interim:
• 11.3 times more likely to experience physical
violence
• 7.3 times more likely to experience verbal
aggression
• All women who sought medical treatment for
injuries had screened positive for IPV
Houry D et al: J Interpers Violence. 2004 Sep;19(9):955-66
Is it safe?
2,134 screened for IPV
• 281 victims followed up at 1 week & 131 at 3 months
• No problems in the ED
• No problems from participating in the study at 1
week
• All were satisfied with the screening
•
1 “reminded her of the violence”
Houry D et al Annals of Emergency Medicine 2008; 51(4):433-42
Is it Enough?

Paucity of evidence for effective treatment and
services (MacMillan – JAMA 2009)

Lack of evidence that screening alone improves
health outcomes (Moracco – JAMA 2009)
Responses of Health Professionals
to IPV
•
•
•
•
•
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Identification
Evaluation
Treatment
Documentation
Safety Planning
Referral
Identify & Evaluate
•
First you have to get there!
•
If it doesn’t make sense………………
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THINK IPV or SEXUAL ASSAULT!!!
Presentations
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Traumatic injury
•
Suicidal/ depression
•
Vague complaints
Presentations
•
Abdominal pain (no determined etiology)
•
Chronic pain
•
Headaches
•
Multiple visits
Patterns of Injury
Injury patterns
•
Incompatible with history
•
Multiple injuries in various stages
of healing
•
Defensive injuries
•
“Central Pattern” of injury
Injury locations
9,057 women (280 acute IPV)
•
•
•
•
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Neck (OR 15.9)
Abdomen (OR 9.8)
Face (OR 8.9)
Thorax (OR 5.5)
Head (OR 4.9)
Muellemann et al: Annals of Emergency Medicine - 1996
Physical Examination
•
Physical Exam • Injury pattern: head, neck, torso, genitalia
• “Central Pattern of Injury”
• Look for bruises, throat injuries
• Wounds in various stages of healing
• Evaluate patient’s emotional state
• Pregnant Patients – FHT’s
Treatment – Medical Team
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Treat injuries
•
Treat other physical complaints
•
Create safety plan
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Secure legal advocacy
Documentation
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Medical records
•
Police reports
•
Protection orders
•
Witnesses
Safety
Planning/Advocates/Referral
•
•
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Ensure Patient Safety
Involve Advocates EARLY
Marshall support
•
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Spiritual
Family
Social Services
Benefits to Trained Medical Personnel
•
•
•
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Collaboration and involvement with
community leaders and resources
Relate medical needs of victims to community
members and groups
Advocacy
Learn about impact of violence on other
aspects of a patient’s life
Knowledge of community laws and responses
How does the community engage
the medical community?
•
•
•
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ASK!
Solicit Universities
Challenge your physician during visits
Note Authors of papers/ lecturers and
invite them to participate
How to involve “Medical
Professionals” with the task force
•
What’s in it for me??
•
•
•
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Your expertise
Medical aspect of IPV
Fatality reviews
Medical-legal issues (mandatory reporting)
Georgia statute (31-7-9)
•
Physicians, licensed registered nurses, and
other medical personnel “having cause to
believe that a patient has had physical injury
or injuries inflicted upon him other than by
accidental means” must report this to the
person in charge of the medical facility; this
person in turn shall notify local law
enforcement
Challenges for Medical Involvement
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•
•
•
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Lack of DV education
Lack of time
Lack of effective interventions
Powerlessness
Fear of offending the patient
Privacy concerns
Personal history of abuse
Other Challenges?
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•
•
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On-call emergencies
Night and weekend shifts
May not understand community or local
priorities
Time commitment
How do we Address these
Challenges?
•
Educate health professionals – go to Grand
rounds, lectures
•
Reiterate the seriousness of IPV
•
Understand the time constraints, give them
something to work with
How do we Address these
Challenges?
•
Reinforce it’s not a medical rather a societal
issue
•
Family/Friends are affected
•
It’s the right thing to do
Benefits To Medical Involvement
Medical Personnel:
•
Direct access to survivors of IPV
•
Bring a relevant perspective on the realities of
health and mental health issues facing
survivors
•
Potential financial strength to assist lobbying
efforts
Benefits To Medical Involvement
•
Medical Personnel:
•
Builds a scientific data base which can be used
to leverage funding (i.e. track injuries, etc.)
•
Strengthens the collaborative community
response
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Demonstrates Leadership
Patient Discussions
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Patient 1:
•
Patient 2:
Patient 1: IPV & Pregnancy
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Assessment
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Approach
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Documentation
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Referral
Patient 1
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IPV HOMICIDE/PREGNANCY
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http://www.ajc.com/news/no-bond-for-man-117116.html
•
Partners are responsible for >50% of homicides during
pregnancy in U.S.
•
Increased risk of miscarriage and LBW infants
•
HOW DO YOU APPLY THIS CASE TO OTHER
PATIENTS?
IPV in Adolescents (n= 570)*
–
Prospective study Adolescent girls
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IPV highest at 3 months post partum (21%), lowest
at 24 months (13%)
• Highest in African American & Mexican Amer.
–
78% at 3 mos post partum did not report IPV prior
to delivery.
•
High risk period, important to screen
Harrykissoon et al. Arch Pediatr Adolesc Med. 2002; 156: 325-330
Patient 2 – IPV & Children
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Assessment
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Approach
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Documentation
•
Referral
Violence & Children
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15.5 million Children live in families with IPV – (Whitfield
et al. Journal of Interpersonal Violence, 2003)
•
2/3rd of IPV of women occur at home where 38% of
children under 12 are witnessing
• (Catalono – 2007 US Dept of Justice)
•
16,458 were living in a domestic shelter (National Network
to End DV – 2009)
What Can You Do/Say?
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I am sorry
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This is not your fault
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You don’t deserve this
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I can offer you help
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Are you safe to go home?
Why diagnose it?
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Failure to diagnose/inquire sends a message
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Cycle will not stop
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Window of opportunity to intervene
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Legal responsibilities
A Coordinated Community
Response
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Health Care and Mental Health System
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Social Support Community
Educational System
Criminal Justice System
Shelter Community
Business Community
Faith Community
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Resources on Intimate Partner
Violence (National, State, Local)
National DV Hotline – 1-800-799-SAFE
Ga Shelter Hotline – 1-800-33-HAVEN
National Coalition Against Domestic Violence www.ncadv.org
Ga Commission on Family Violence –
404-657-3412, www.gcfv.org
GA Coalition Against Domestic Violence
404-209-0280, www.gcadv.org/
Conasauga Family Violence Alliance
Northwest Ga Family Crisis Center
Ga Commission Family
Violence
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Medical Protocol
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Revised 12/09
2 Primary Goals
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Incidence & Prevalence of IPV through enabling
hospitals, medical clinics and healthcare providers to
respond appropriately to IPV
•
Reduce the likelihood of violence developing into a
pattern of repeated assault and emotional suffering
http://gcfv.org/files/medical.pdf
Testimonial
Dear Dr. Heron,
I don't know if you remember me. I was working for Jezebel magazine last July
and came in to have stitches removed from my arm because I had put my arm
through a window. I was dating Ray from the "Cindy and Ray" show who was
being horrible to me (to put it mildly) and I hated my job because my boss was
making me feel like I was worthless. I was about to have a nervous breakdown
and you saved me. You were my guardian angel. You closed the door and
talked to me, told me I was better than all of this. I know that God sent you into
that room that day to send me a message. GET OUT AMY! And get out I did! I
quit my job, broke up with Ray and moved out of Atlanta and home to Palm
Beach. Now I am getting my MBA and happier (and healthier) than I have
ever been in my life! I run 3 miles a day and go to church ( or at least try to) as
much as I can! I pray a lot! Thank you so much Dr. Heron! If you hadn't been
there to wipe my tears that day and give me a hug I don't know what I
would've done. You were more than a doctor that day, you were my saving
grace and my friend. You said you couldn't wait until I emailed you about the
new man in my life and my three beautiful children. Well, I'm not there yet, but
there is time, thanks to you!
Thanks again, I owe you my life! You are a God send! You are a remarkable
doctor and person!
I am sorry it has taken so long to send this to you but just know that you are
always in my thoughts and prayers!
Warmest regards,
Amy Saleeby
Testimonial
Hi Dr. Heron!
I am so happy to hear back from you! Of course you can
share my email with the your students! I hope it will make
for more doctors like you! Thank you again for saving my
life! I don't know what I would've done if you hadn't been
there that day. I know God sent you in that room to talk
some sense into me. I will never understand how I put up
with such utter crap from that jerk of a boyfriend and a
boss. THANK YOU!!!!! My parents and friends thank you
too!! You definitely found your calling girl. I'm sending a
picture too!
Testimonial
Hi Dr. Heron!
I wanted to write an email while I remembered to wish you a very happy birthday on Friday! I
believe I may have missed last year's but you are always in my
thoughts as the person who gave me a second chance at life!
I have
been telling the story of how God sent you into my life when I was at my worst and how you
will always be my proof that living angels do exist!

Life is a little crazy, but all good. I'm dating the man of my dreams. He's an angel like
you! I'm pretty sure he's "the one." Wow is it crazy to write that! I have actually talked to Ray
(boyfriend on the radio who was not good to me) and everything there is good as well. I forgave
him and let go of all that crazy abusive past. I left Clear Channel a year ago and started my
own events and marketing company. This Halloween I am producing the biggest event of my
life and I'm a lot nervous! But I have faith that it will all go as it should. How are you? Are you
still in the ER at Emory? I hope are well as you deserve nothing but good things in life!

As I mentioned you have been on my mind a lot lately. I hope that means really good things
are happening for you! Have a HAPPY HAPPY BIRTHDAY! I hope you get everything you
wish for and more this year! It's going to be your best year yet. I can feel it! I hope to hear from
you but if I don't and life is just as crazy in your world, know that there is a gal in FL who will
never forget you. I always pray that good things come your way. :-)
Take care,
Amy Saleeby
Summary
•
Health Consequences of IPV
•
Strategies to Improve the health
professional’s response
•
Reviewed a Systemic Response to IPV
Take Home Points
•
IPV is the most common cause of assaultrelated injuries in women
•
Health professionals are vital
•
Resources are available to assist in your
efforts
Take Home Points
•
Your role involves recognition, treatment
of injuries, documentation, and referral
•
Success is defined by asking about abuse
Questions