Domestic Violence

Etiology

Reason Abusers Need to Control[8][9][10]

• Anger management issues
• Jealousy
• Low self-esteem
• Feeling inferior 
• Cultural beliefs they have the right to control their partner
• Personality disorder or psychological disorder
• Learned behavior from growing up in a family where domestic violence was accepted
• Alcohol and drugs, as an impaired individual may be less likely to control violent impulses

Risk Factors

Risk factors for domestic and family violence include individual, relationship, community, and societal issues. There is an inverse relationship between education and domestic violence. Lower education levels correlate with more likely domestic violence. Childhood abuse is commonly associated with becoming a perpetrator of domestic violence as an adult. Perpetrators of domestic violence commonly repeat acts of violence with new partners. Drug and alcohol abuse greatly increases the incidence of domestic violence.

Children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, gender roles can be reversed.

Domination may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.

Epidemiology

Domestic violence is a serious and challenging public health problem. Approximately 1 in 3 women and 1 in 10 men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1500 deaths in the United States.[11][12][13]

Domestic violence victims typically experience severe physical injuries requiring care at a hospital or clinic. The cost to individuals and society is significant. The national annual cost of medical and mental health care services related to acute domestic violence is estimated at over $8 billion. If the injury results in a long-term or chronic condition, the cost is considerably higher.

Financial hardship and unemployment are contributors to domestic violence. An economic downturn is associated with increased calls to the National Domestic Violence Hotline.

Fortunately, the national rate of nonfatal domestic violence is declining. This is thought to be due to a decline in the marriage rate, decreased domesticity, better access to domestic violence shelters, improvements in female economic status, and an increase in the average age of the population.

National

• Most perpetrators and victims do not seek help.
• Healthcare professionals are usually the first individuals with an opportunity to identify domestic violence.
• Nurses are usually the first healthcare providers victims encounter.
• Domestic violence may be perpetrated on women, men, parents, and children.
• Fifty percent of women seen in emergency departments report a history of abuse, and approximately 40% of those killed by their abuser sought help in the 2 years before death.
• Only one-third of police-identified victims of domestic violence are identified in the emergency department.
• Healthcare professionals who work in acute care need to maintain a high index of suspicion for domestic violence as supportive family members may, in fact, be abusers.

Child Abuse

Age, family income, and ethnicity are all risk factors for both sexual abuse and physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse.

Each year there are over 3 million referrals to child protective authorities. Despite often being the first to examine the victims, only about 10% of the referrals were from medical personnel. The fatality rate is approximately two deaths per 100,000 children. Women account for a little over half of the perpetrators.

Intimate Partner Violence

According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men experience some form of sexual violence during their lifetimes. Intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year.

One in 6 women and 1 in 19 men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about 6 in 10 female victims and 4 in 10 male victims.

At least 5 million acts of domestic violence occur annually to women aged 18 years and older, with over 3 million involving men. While most events are minor, for example grabbing, shoving, pushing, slapping, and hitting, serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults occur. About 1 in 5 women have experienced completed or attempted rape at some point in their lives. About 1% to 2% of men have experienced completed or attempted rape.

The incidence of intimate partner violence has declined by over 60%, from about ten victimizations per 1000 persons age 12 or older to approximately 4 per 1000.

Elderly

Due to underreporting and difficulty sampling, obtaining accurate incidence information on elder abuse and neglect is difficult. Elderly abuse is thought to occur in 3% to 10% of the population of elders.

Elderly patients may not report due to fear, guilt, ignorance, or shame. Clinicians underreport elder abuse due to poor recognition of the problem, lack of understanding of reporting methods and requirements, and concerns about physician-patient confidentiality.

Pathophysiology

There may be some pathologic findings in both the victims and perpetrators of domestic violence. Certain medical conditions and lifestyles make family and domestic violence more likely.[13][14][15]

Perpetrators

While the research is not definitive, a number of characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:

• Have a higher consumption of alcohol and illicit drugs and assessment should include questions that explore drinking habits and violence
• Be possessive, jealous, suspicious, and paranoid.
• Be controlling of everyday family activity, including control of finances and social activities.
• Suffer low self-esteem
• Have emotional dependence, which tends to occur in both partners, but more so in the abuser

Children

Domestic violence at home results in emotional damage, which exerts continued effects as the victim matures.

• Approximately 45 million children will be exposed to violence during childhood.
• Approximately 10% of children are exposed to domestic violence annually, and 25% are exposed to at least 1 event during their childhood.
• Ninety percent are direct eyewitnesses of violence.
• Males who batter their wives batter the children 30% to 60% of the time.
• Children who witness domestic violence are at increased risk of dating violence and have a more difficult time with partnerships and parenting.
• Children who witness domestic violence are at an increased risk for post-traumatic stress disorder, aggressive behavior, anxiety, impaired development, difficulty interacting with peers, academic problems, and they have a higher incidence of substance abuse.
• Children exposed to domestic violence often become victims of violence.
• Children who witness and experience domestic violence are at a greater risk for adverse psychosocial outcomes.
• Eighty to 90% of domestic violence victims abuse or neglect their children.
• Abused teens may not report abuse. Individuals 12 to 19 years of age report only about one-third of crimes against them, compared with one-half in older age groups

Pregnant and Females

The American College of Obstetricians and Gynecologists (ACOG) recommends all women be assessed for signs and symptoms of domestic violence during regular and prenatal visits. Providers should offer support and referral information.

• Domestic violence affects approximately 325,000 pregnant women each year.
• The average reported prevalence during pregnancy is approximately 30% emotional abuse, 15% physical abuse, and 8% sexual abuse.
• Domestic violence is more common among pregnant women than preeclampsia and gestational diabetes.
• Reproductive abuse may occur and includes impregnating against a partner's wishes by stopping a partner from using birth control.
• Since most pregnant women receive prenatal care, this is an excellent time to assess for domestic violence.

The danger of domestic violence is particularly acute as both mother and fetus are at risk. Healthcare professionals should be aware of the psychological consequences of domestic abuse during pregnancy. There is more stress, depression, and addiction to alcohol in abused pregnant women. These conditions may harm the fetus.

Gay, Lesbian, Bisexual, and Transgender

Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the rates are thought to be similar to a heterosexual woman, approximately 25%.

• There are more cases of domestic violence among males living with male partners than among males who live with female partners.
• Females living with female partners experience less domestic violence than females living with males.
• Transgender individuals have a higher risk of domestic violence. Transgender victims are approximately two times more likely to experience physical violence.

Gay, lesbian, bisexual, and transgender victims may be reticent to report domestic violence. Part of the challenge may be that support services such as shelters, support groups, and hotlines are not regularly available. This results in isolated and unsupported victims. Healthcare professionals should strive to be helpful when working with gay, lesbian, bisexual, and transgender patients.

Men

Usually, domestic violence is perpetrated by men against women; however, females may exhibit violent behavior against their male partners.

• Approximately 5% of males are killed by their intimate partners.
• Each year, approximately 500,000 women are physically assaulted or raped by an intimate partner compared to 100,000 men.
• Three out of 10 women at some point are stalked, physically assaulted, or raped by an intimate partner, compared to 1 out of every 10 men.
• Rape is primarily perpetrated by other men, while women engage in other forms of violence against men.

Although women are the most common victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.

Elderly

The elderly are often mistreated by their spouses, children, or relatives.

• Annually, approximately 2% of the elderly experience physical abuse, 1% sexual abuse, 5% neglect, 5% financial abuse, and 5% suffer emotional abuse.
• The annual incidence of elder abuse is estimated to be 2% to 10%, with only about 1 in 15 cases reported to the authorities.
• Approximately one-third of nursing homes disclosed at least 1 incident of physical abuse per year.
• Ten percent of nursing home staff self-report physical abuse against an elderly resident.

Elder domestic violence may be financial or physical. The elderly may be controlled financially. Elders are often hesitant to report this abuse if it is their only available caregiver. Victims are often dependent, infirm, isolated, or mentally impaired. Healthcare professionals should be aware of the high incidence of abuse in this population.

History and Physical

The history and physical exam should be tailored to the age of the victim.

Child Abuse

The most common injuries are fractures, contusions, bruises, and internal bleeding. Unexpected injuries to pre-walking infants should be investigated. The caregiver should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries should be investigated.

Children who are abused may be unkempt and/or malnourished. They may display inappropriate behavior such as aggression, or maybe shy, withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. School attendance is usually poor.

Intimate Partner Abuse

Approximately one-third of women and one-fifth of men will be victims of abuse. The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. One should be suspicious if the history is not consistent with the injury. Defensive injuries may be present on the forearms and hands. The patient may have psychological signs and symptoms such as anxiety, depression, and fatigue.

Medical complaints may be specific or vague such as headaches, palpitations, chest pain, painful intercourse, or chronic pain.

Intimate Partner Abuse: Pregnancy and Female

Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions. There are a number of historical and physical findings that may help the provider identify individuals at risk.

If the examiner encounters signs or symptoms, she should make every effort to examine the patient in private, explaining confidentiality to the patient. Be sure to ask caring, empathetic questions and listen politely without interruption to answers.

Intimate Partner Abuse: Same-Sex

Same-sex partner abuse is common and may be difficult to identify. Over 35% of heterosexual women, 40% of lesbians, 60% of bisexual women experience domestic violence. For men, the incidence is slightly lower. In addition to common findings of abuse, perpetrators may try to control their partners by threatening to make their sexual preferences public.

The provider should be aware there are fewer resources available to help victims; further, the perpetrator and victim may have the same friends or support groups.

Intimate Partner Abuse: Men

Men represent as much as 15% of all cases of domestic partner violence. Male victims are also less likely to seek medical care, so that the incidence may be underreported. These victims may have a history of child abuse.

Elderly Abuse

Health professionals should ask geriatric patients about abuse, even if signs are absent.

Risk Factors

• Dementia
• Pathologic characteristics of perpetrators including dementia, mental illness, and drug and alcohol abuse
• A shared living situation with the abuser
• Social isolation

Evaluation

Establishing that injuries are related to domestic abuse is a challenging task. Life and limb-threatening injuries are the priority. After stabilization and physical evaluation, laboratory tests, x-rays, CT, or MRI may be indicated. It is important that healthcare professionals first attend to the underlying issue that brought the victim to the emergency department.[1][16][17][18]

• The evaluation should start with a detailed history and physical examination. Clinicians should screen all females for domestic violence and refer females who screen positive. This includes females who do not have signs or symptoms of abuse. All healthcare facilities should have a plan in place that provides for assessing, screening, and referring patients for intimate partner violence. Protocols should include referral, documentation, and follow-up.
• Health professionals and administrators should be aware of challenges such as barriers to screening for domestic violence: lack of training, time constraints, the sensitive nature of issues, and a lack of privacy to address the issues.
• Although professional and public awareness has increased, many patients and providers are still hesitant to discuss abuse.
• Patients with signs and symptoms of domestic violence should be evaluated. The obvious cues are physical: bruises, bites, cuts, broken bones, concussions, burns, knife or gunshot wounds.
• Typical domestic injury patterns include contusions to the head, face, neck, breast, chest, abdomen, and musculoskeletal injuries. Accidental injuries more commonly involve the extremities of the body. Abuse victims tend to have multiple injuries in various stages of healing, from acute to chronic.
• Domestic violence victims may have emotional and psychological issues such as anxiety and depression. Complaints may include backaches, stomachaches, headaches, fatigue, restlessness, decreased appetite, and insomnia. Women are more likely to experience asthma, irritable bowel syndrome, and diabetes.

Assessment

Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.

• If there is no immediate danger, the assessment should focus on mental and physical health and establish the history of current or past abuse. These responses determine the appropriate intervention.
• During the initial assessment, a practitioner must be sensitive to the patient’s cultural beliefs. Incorporating a cultural sensitivity assessment with a history of being victims of domestic violence may allow more effective treatment.
• Patients that have suffered domestic violence may or may not want a referral. Many are fearful of their lives and financial well-being. They hence may be weighing the tradeoff in leaving the abuser leading to loss of support and perhaps the responsibility of caring for children alone. The healthcare provider needs to assure the patient that the decision is voluntary and that the provider will help regardless of the decision. The goal is to make resources accessible, safe, and enhance support.
• If the patient elects to leave their current situation, information for referral to a local domestic violence shelter to assist the victim should be given.
• If there is a risk to life or limb, or evidence of injury, the patient should be referred to local law enforcement officials.
• Counselors often include social workers, psychiatrists, and psychologists that specialize in the care of battered partners and children.

Testing

Children

A detailed history and careful physical exam should be performed. If head trauma is suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.

Laboratory

Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings similar to child abuse. As a consequence, they must be ruled out.

Urine

• A urine test may be used as a screen for sexually transmitted disease, bladder or kidney trauma, and toxicology screening. 

Hematology

If bruises or contusions are present, there is no need to evaluate for a bleeding disorder if the injuries are consistent with an abuse history. Some tests can be falsely elevated, so a child abuse-specialist pediatrician or hematologist should review or follow-up these tests.

Gastrointestinal and Chest Trauma

• Consider liver and pancreas screening tests such as AST, ALT, and lipase. If the AST or ALT is greater than 80 IU/L, or lipase greater than 100 IU/L, consider an abdomen and pelvis CT with intravenous contrast.
• The highest-risk are those with abusive head trauma, fractures, nausea, vomiting, or an abnormal Glasgow Coma Scale score of less than 15.

Imaging

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults, such as cranial sutures and incomplete bone growth. A fracture can be misinterpreted. If there is a concern for abuse, consider consulting a radiologist.

Imaging: Skeletal Survey

A skeletal survey is indicated in children younger than 2 years with suspected physical abuse. The incidence of occult fractures is as high as 1 in 4 in physically abused children younger than 2 years. The clinician should consider screening all siblings younger than 2 years.

The skeletal survey should include 2 views of each extremity; anteroposterior and lateral skull; and lateral chest, spine, abdomen, pelvis, hands, and feet. A radiologist should review the films for classic metaphyseal lesions and healing fractures, most often involving the posterior ribs. A “babygram” that includes only 1 film of the entire body is not an adequate skeletal survey.

Skeletal fractures will remodel at different rates, which are dependent on the age, location, and nutritional status of the patient.

Imaging: CT

If abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged six months or younger or children younger than 24 months if intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months.

CT of the abdomen and pelvis with intravenous contrast is indicated in unconscious children, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.

Special Documentation

Photographs should be taken before treatment of injuries.

Intimate Partner and Elder

Laboratory

Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, and malnutrition. 

Imaging

• X-rays of bruised of tender body parts to detect fractures
• Head CT scan to evaluate for intracranial bleeding as a result of abuse or the causes of altered mental status

Other

• Pelvic examination with evidence collection if sexual assault

Evidence Collection

Domestic and family violence commonly results in the legal prosecution of the perpetrator. Preferably, a team specializing in domestic violence is called in to assist with evidence collection.

Each health facility should have a written procedure for how to package and label specimens and maintain a chain of custody. Law enforcement personnel will often assist with evidence collection and provide specific kits.

It is important to avoid destroying evidence. Evidence includes tissue specimens, blood, urine, saliva, and vaginal and rectal specimens. Saliva from bites can be collected; the bite mark is swabbed with a water-moistened cotton-tipped swab.

Clothing stained with blood, saliva, semen, and vomit should be retained for forensic analysis.

Treatment / Management

The priority is the ABCs and appropriate treatment of the presenting complaints. However, once the patient is stabilized, emergency medical services personnel may identify problems associated with violence.[19][20][21]

Emergency Department and Office Care

Interventions to consider include:

• Make sure a safe environment is provided.
• Diagnose physical injuries and other medical or surgical problems.
• Treat acute physical or life-threatening injuries.
• Identify possible sources of domestic violence.
• Establish domestic violence as a diagnosis.
• Reassure the patient that he is not at fault.
• Evaluate the emotional status and treat.
• Document the history, physical, and interventions.
• Determine the risks to the victim and assess safety options.
• Counsel the patient that violence may escalate.
• Determine if legal intervention is needed and report abuse when appropriate or mandated.
• Develop a follow-up plan.
• Offer shelter options, legal services, counseling, and facilitate such referral.

Medical Record

The medical record is often evidence used to convict an abuser. A poorly document chart may result in an abuser going free and assaulting again.

Charting should include detailed documentation of evaluation, treatment, and referrals.

• Describe the abusive event and current complaints using the patient's own words.
• Include the behavior of the patient in the record.
• Include health problems related to the abuse.
• Include the alleged perpetrator's name, relationship, and address.
• The physical exam should include a description of the patient's injuries including location, color, size, amount, and degree of age bruises and contusions.
• Document injuries with anatomical diagrams and photographs.
• Include the name of the patient, medical record number, date, and time of the photograph, and witnesses on the back of each photograph.
• Torn and damaged clothing should also be photographed.
• Document injuries not shown clearly by photographs with line drawings.
• With sexual assault, follow protocols for physical examination and evidence collection.

Disposition

If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once the patient returns home.

• A referral should be made to primary care or another appropriate resource.
• Advise the patient to have a safety plan and provide examples.

Remember

• Forty percent of domestic violence victims never contact the police.
• Of female victims of domestic homicide, 44% had visited a hospital emergency department within 2 years of their murder.
• Health professionals provide an opportunity for victims of domestic violence to obtain help.

Differential Diagnosis

The differential diagnosis varies with the injury type of injury and age.

Child

Head Trauma

• Accidental injury
• Arteriovenous malformations
• Bacterial meningitis
• Birth trauma
• Cerebral sinovenous thrombosis
• Hemophilia
• Solid brain tumors

Bruises and Contusions

• Accidental bruises
• Birth trauma
• Bleeding disorder
• Coining
• Cupping
• Congenital dermal melanocytosis (Mongolian spots)
• Erythema multiforme
• Hemangioma
• Hemophilia

Burns

• Accidental burns
• Atopic dermatitis
• Contact dermatitis
• Impetigo
• Inflammatory skin conditions
• Sunburn

Fractures

• Accidental
• Birth trauma
• Congenital syphilis
• Malignancy
• Osteogenesis imperfecta
• Osteomyelitis
• Rickets
• Scurvy
• Toddler’s fracture

Prognosis

Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity.[3][22][23]

• Of those injured by domestic violence, over 75% continue to experience abuse.

• Over half of battered women who attempt suicide will try again; often they are successful with the second attempt.

In children, the potential for poor outcomes is particularly high as abuse inflicts lifelong effects. In addition to dealing with the sequelae of physical injury, the mental consequences may be catastrophic. Studies indicate a significant association between child sexual abuse and increased risk of psychiatric disorders in later life. The potential for the cycle of violence to continued from childhood is very high.

Children raised in families of sexual abuse may develop:

• Attention deficit hyperactivity disorder (ADHD)
• Conduct disorder
• Depression
• Bipolar disorder
• Panic disorder
• Sleep disorders
• Suicide attempts
• Post-traumatic stress disorder (PTSD)

Health Outcomes

There are multiple known and suspected negative health outcomes of family and domestic violence. There are long-term consequences to broken bones, traumatic brain injuries, and internal injuries.

Patients may also develop multiple comorbidities such as:

• Asthma
• Insomnia
• Fibromyalgia
• Headaches
• High blood pressure
• Chronic pain
• Gastrointestinal disorders
• Gynecologic disorders
• Depression
• Panic attacks
• PTSD