UBC Objectives: Mental Health, UBC Objectives: Women's Health, UBC Objectives: Care of Men, Priority Topic: Domestic Violence, Priority Topic: Immigrants, & Priority Topic: Rape/Sexual Assault

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Screen, counsel, treat and/or refer patients for past or present domestic violence and abuse (physical, sexual, emotional or financial)
• Screen for abuse, neglect and domestic violence (child, adult and elder) and assess the level of risk for all members of the household, generating an emergency plan if needed
• Perform a history of an abused or neglected patient of any gender or age
  

Domestic Violence

Key Feature 1: In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (ex: periodic annual exam, visits for anxiety/depression, ER visits).
Skill: Patient Centered, Clinical Reasoning
Phase: History

Key Feature 2a: In a patient in a suspected or confirmed situation of domestic violence: Assess the level of risk and the safety of children (i.e., the need for youth protection).
Skill: Selectivity, Clinical Reasoning
Phase: History

Key Feature 2b: In a patient in a suspected or confirmed situation of domestic violence: Advise about the escalating nature of domestic violence.
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 3: In a situation of suspected or confirmed domestic violence, develop, in collaboration with the patient, an appropriate emergency plan to ensure the safety of the patient and other household members.
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 4: In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (ex: helplessness, guilt), and its impact on children.
Skill: Patient Centered, Communication
Phase: Treatment

Immigrants

Key Feature 2: As part of the ongoing care of immigrants, modify your approach (when possible) as required by their cultural context (ex: history given only by husband, may refuse examination by a male physician, language barriers).
Skill: Patient Centered, Communication
Phase: Treatment, History

Key Feature 3: When dealing with a language barrier, make an effort to obtain the history with the help of a medical interpreter and recognize the limitations of all interpreters (ex: different agendas, lack of medical knowledge, something to hide).
Skill: Communication
Phase: History

Rape/Sexual Assault

Key Feature 1: Provide comprehensive care to all patients who have been sexually assaulted, regardless of their decision to proceed with evidence collection or not.
Skill: Clinical Reasoning, Professionalism
Phase: Treatment

It is always important to have a high index of suspicion for abuse, but this may be easier said than done. There are many things in medicine that physicians should "always" be on alert for, which really isn't realistic. So, knowing the factors that raise a patient's risk for a given circumstance is useful to know when you should perk up and become suspicious for that circumstance. Factors that increase one's risk of being afflicted by domestic violence in particular are as follows:

1. Individual factors
   1. Female 
   2. Young age (<24) 
   3. Prior history of intimate partner violence
   4. At-risk alcohol use or drug use
   5. High-risk sexual behaviour
   6. Witnessing or experiencing violence as a child
   7. History of depression or chronic mental illness
   8. Being less educated 
   9. Unemployment or being below the poverty line 
2. Relationship factors
   1. Couples with income, educational, or job status disparities
   2. Dominance and control of the relationship by a male
   3. Excessive jealousy or possessive behaviour
3. Community and societal factors
   1. Poverty and associated factors (ex: overcrowding) 
   2. Lack of institutions or community norms that shape social interactions
   3. Weak community sanctions against IPV (ex: police unwilling to intervene)
   4. Traditional gender norms (ex: women should stay at home and not enter workforce, should be submissive)
   5. In some countries, notions of male/family honor and female chastity

It is also useful to know that domestic violence often begins or increases during pregnancy and the postpartum period. In fact, even in situations not involving a pregnant female, domestic violence tends to gradually escalate over time, at least without intervention. It is important to communicate this fact to any patients who are suspected or confirmed victims of domestic violence, to help them make more realistic choices as they decide how they want to navigate their often complex situations. Not all people are prepared to disclose that they have been impacted by domestic violence, just like many victims of sexual assault do not disclose this, and not all people who do disclose are prepared to take action to alter their circumstances or to charge a perpetrator. Regardless, the first step when interacting with a patient who is a possible victim of abuse is promoting an environment of safety and building rapport so that the person can feel safe to disclose and feel supported no matter what they choose. Depending on the region you live in, there may be a duty to report domestic violence or sexual assault to the police, but many regions do not mandate this. As is always important when practicing ethical medicine, it is best to support the patient as much as possible in keeping with their informed choices.

You may have noticed that many of the risk factors for domestic violence are also features more prevalent among patients who have migrated from abroad. This adds an extra layer of complexity, as cultural norms vary, and it can be particularly challenging to tease out when an issue is a violation of a person's human rights versus a true value/belief/desire from within the patient (ex: when a women prefers her husband to speak for her, does she really want this or is this being imposed on her). Language barriers and communicating through translators is only yet another factor that muddies the water. (ex: Often translators who speak the same language as the patient come from the same and often not-that-small community. Could there be things that the patient is not saying? Could the interpreter have their own interpretation of the message and is some of it lost in translation?) It is important to approach this situation with thoughtfulness around cultural safety and cultural awareness while taking extra steps to ensure such patients are not both presumed to be victims of domestic violence nor less at risk because the risk factors present are seen as simply part of their culture.

If I have identified a patient with suspected or confirmed ongoing risk of domestic violence, I use the Danger Assessment screening tool to help quantify just how worried I should be, regardless of whether or not a patient wants to report the perpetrator or stay silent. This screening tool includes a question to prompt assessment of the safety of any children who may be at risk as well. Beyond quantifying risk, the screening tool also helps the patient and care provider devise a safety plan that is tailored to the patient's unique circumstances. Some strategies that might be helpful include:

• Depending on availability, a hospital or community domestic violence advocate, hospital social worker, or local domestic violence hotline can provide advice about recommendations given particulars about the community where the patient lives. 
• Arranging to have a safe place to go (ex: friends, family). The patient may need access to a shelter.
• Preparing an emergency kit with important documents, keys, money, and other essential items, to be stored outside the home in case they need to escape urgently.
• Having a designated signal to alert children or neighbours to call 911.
• During times of escalating conflict, intentionally avoiding rooms with potential weapons (ex: kitchen) or where there might be increased risk for injury (ex: hard bathroom surfaces).

Beyond immediate safety, with rapport and good communication skills, motivational interviewing skills can be used to explore the impact of the patterns of domestic violence on everyone in the household. As well, it is important to continue to provide care for the patient who has experienced abuse in a comprehensive sense, not forgetting about the other aspects of the health care you provide as their primary care provider.