​Kembara Xtra - Medicine - Domestic Violence

​Kembara Xtra - Medicine - Domestic Violence 
Introduction
​Domestic violence (DV) is any conduct employed in a relationship to obtain or keep control over an intimate partner. It can take the form of physical, sexual, or emotional abuse as well as economic or psychological acts or threatening to take other people's actions.
Despite the fact that women are more likely to experience DV than males, it can happen to anybody, regardless of ethnicity, age, sexual orientation, religion, gender, or socioeconomic status. Synonym(s): intimate partner violence (IPV); spousal abuse; family violence


Occurrence and prevalence 
Prevalence
One in four American households experiences DV. For women in the US, lifetime estimates of DV range from 22 to 39%.
Both sexes are affected by DV, however women are more likely than males to become victims of and report partner abuse.
DV causes up to 4,000 deaths and approximately 2 million injuries per year in the US, with 5.3 million events occurring among women under the age of 18 and 3.2 million incidents among men.
DV is thought to cost more than $5.8 billion a year.
In the COVID-19 pandemic, lockdown limitations caused an 8.1% increase in DV incidences. DV survivors have a 1.6- to 2.3-fold increase in health care utilization.
Aspects of Geriatrics
Around 2 million old people experience abuse and/or neglect each year, making up 4-6% of the elderly population. 90% of the time, a family member is the offender.


Child Safety Considerations
Approximately 1 million abused children are found in the United States each year, and over 3 million children between the ages of 3 and 17 are at risk of witnessing DV. Children who grow up in hostile environments are more likely to experience physical, sexual, and/or emotional abuse, anxiety and despair, low self-esteem, emotional, behavioral, social, and/or physical disorders, as well as bad health for the rest of their lives.


pregnant women's issues
In 7–20% of pregnancies, DV occurs. Unintended pregnancy triples a woman's risk of developing DV.
25% of abused women indicate that their abuse got worse while they were pregnant. DV and postpartum depression have a positive link.

Risk factors include: Substance misuse (drugs or alcohol), high-risk sexual conduct, poverty, financial pressures, unemployment, and a lack of education, as well as recent social support loss, family upheaval, life cycle changes, and social isolation.
- Previous history of violent relationships or having been abused as a child - Family members having a mental or physical handicap - Pregnancy - Trying to end the relationship Risk factors for the perpetrator include substance abuse, depression, and personality disorders.
Young age, unemployment, recent job uncertainty, and poor academic performance
- Possessing weapons; threatening oneself or others; doing violence on children or others outside the family; witnessing or experiencing violence as a youngster
● Relationship risk factors include marital strife or instability, financial strain, traditional gender roles, dysfunctional families, and obsessive/controlling relationships.
Aspects of Geriatrics
Increasing age, non-white race, low income, functional impairment, cognitive disability, substance usage, poor emotional state, low self-esteem, cohabitation, and a lack of social support are all risk factors for geriatric abuse.
Child Safety Considerations
Low parental education, low maternal income, non-white race, big family size, young mother age, single-parent home, parental psychiatric disorders, and the presence of a stepfather are all risk factors for child abuse or neglect.

DV is frequently underdiagnosed, with only 10-12% of doctors performing routine screening. In 2013, the U.S. Preventive programs Task Force (USPSTF) released guidelines urging doctors to screen all women of reproductive age for DV and, where necessary, offer or refer them to intervention programs.

Other guidelines include the following: - The World Health Organization (WHO) advises against DV screening; nevertheless, they suggest inquiring about exposure to DV when evaluating conditions that may be aggravated or caused by abuse.
– There is no proof that DV screening is harmful.
pregnant women's issues
The American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) guidelines on DV advise doctors to routinely screen all pregnant patients for DV. Periodic screening is advised by ACOG during all phases of obstetric care (at the initial prenatal appointment, at least once each trimester, and at the postpartum exam).
Child Safety Considerations
The American Academy of Pediatrics (AAP) and American Medical Association (AMA) advise doctors to look out for indications of child sexual and physical abuse during routine exams.
Time restraints, discomfort with the subject, concern for upsetting the patient, and a lack of resources and skills viewed as necessary to treat DV are all obstacles to screening.
Patients who have been abused may choose not to disclose the abuse for a variety of reasons, such as the following:
- Not being emotionally prepared to acknowledge the problem, shame and self-blame, dread of the doctor's rejection, fear of abuse retaliation, confidence that the abuse would not recur, and conviction that there are no other options or alternatives.

Introducing History 

 Doctors should raise the topic of domestic violence in a generic fashion (e.g., "I routinely inquire about domestic violence with all patients. Have there ever been any relationships in which you felt fear?").
Without a partner or other people present, screen the patient alone.
Ask screening questions in the patient's primary language; do not rely on kids or other relatives to translate.

HITS inquiries: Each HITS question is graded on a 5-point scale (never, seldom, sometimes, fairly often, and frequently; sensitivity 30-100% and specificity 86-96%), with a score of >10 indicating potential victimization. How frequently does your partner: - Physically hurt you? insult or belittle you?
threatened to harm you? yell or swear at you?"
Partner Violence Scale (specificity: 80–94%; sensitivity: 35-71%)
- "Have you ever been struck, kicked, punched, or wounded in any other way during the last 12 months? If so, who, exactly?
"Do you feel safe in your current relationship?"
- "Is there a partner from a previous relationship who is making you feel unsafe right now?"
"Do you feel safe in your relationship?" is one of the SAFE questions for safety and stress.
- Threatened, injured, or terrified: "Have you ever been in a relationship where you felt threatened, afraid, or hurt?"
- Family/friends: "Are your family or friends aware that you have been hurt? Could you inform them, and could they support you in this?
- Emergency plan: "Do you have a place to go that is safe and the resources you'll need in an emergency?"
Assess pregnancy challenges include inadequate or delayed prenatal care, low birth weight kids, perinatal mortality, and repeat abortions (unplanned pregnancy may be caused by sexual assault or reproductive coercion).
Chronic abdominal and pelvic discomfort without visible pathology and gynecological diseases
Headaches, back pain, STIs, depression, suicidal thoughts, anxiety, exhaustion, eating disorders, and substance misuse are a some of the health issues that can affect people.
Excessive use of medical services and frequent trips to the ER
Failure to follow a treatment or drug regimen and/or missing appointments


Clinical evaluation Clinical manifestations and psychological symptoms
- Inconsistent explanations of injuries, refusal to undress, and delaying treatment - Symptoms of battered woman syndrome and/or posttraumatic stress disorder (PTSD) (low mood/avoiding eye contact, evasiveness, heightened startle reaction, disturbed sleep, traumatic flashbacks)
- Suspicious companion attendance at appointment; excessively pleading companion and/or refusal to leave examination room
Physical indications and signals
- A ruptured tympanic membrane
- A rectal or genital injury (distributed in the center and concealable by garments due to the distribution pattern of a bathing suit injury).
- Head and neck injuries (where 50% of violent injuries occur)
- Cuts, bruises, or fractures to the face or body - Burns from cigarettes or other objects, bite marks, or welts bearing the outline of a weapon (such as a belt buckle)
- Injuries caused by defensive posture - Injuries that are difficult to diagnose or that are still healing - Malnutrition or pressure ulcers in the elderly

Laboratory Results 

Initial examinations (lab, imaging)
Liver function tests (LFTs), amylase, and lipase if abdominal trauma is suspected, BUN and creatinine if malnutrition/dehydration is suspected, pregnancy testing and STD screening (HIV Ab/Ag, syphilis screen, gonorrhea and chlamydia NAAT, trichomonas) in cases of sexual abuse, x-ray if there is a fracture, and radiographic skeletal survey for

Management 
Initial diagnosis, continuing medical care, patient education about the DV cycle, emotional support, counseling, and referrals to supportive agencies are all components of treatment.
Use the SOS-DoC intervention after diagnosis:
- S: Provide Support and evaluate Safety:
 Encouragement: "You are not at fault. I'm sorry this is taking place to you. DV is never justified.
Remind the patient that you promise to keep all communications private.
• Safety Ask the patient whether they feel safe returning home and whether or not their children are safe.
Discuss options, taking into account follow-up and safety planning:
 Offer DV information and assistance as needed.
Make recommendations for nearby resources.
The question "Do you need or want to access a safety shelter or DV service agency?"
"Do you want police intervention, and if so, would you like me to call the police so they can make a report with you?"
 Provide phone numbers for neighborhood resources and the National DV Hotline: 1-800-799-SAFE (available 24/7; can give doctors in every state information on neighborhood resources).
Verify the patient's strengths.
"Talking with me today required a lot of guts from you. In extremely trying circumstances, you have exhibited amazing strength.
- Record observations, evaluations, and plans:
Use the patient's own words when describing abuse and damage.
Care should be taken when using language; "patient reports" is preferable to "patient denies/claims," which could imply the therapist does not trust the patient.
 Write down injuries clearly: Employ a body map.
 If the patient permits it, take pictures of their wounds. To be used as legal evidence, photographs must show the patient's face or other distinguishing characteristics alongside the damage.
Create a plan for patient safety. Educate the patient on how to flee in an emergency:
Encourage the patient to put together an emergency kit to store in a secure location: Cash, food stamps, credit cards, house and car keys, important documents (birth certificates, Social Security cards, photo IDs/driver's licenses, passports, green cards), medication for oneself and children, immunization records for children, crucial phone numbers/addresses (friends, family, local shelters), and personal care items (such as extra glasses), are just a few of the items that should be kept handy.
Encourage the patient to set up a signal with someone to let them know when they need assistance.
Offer Continuity (C)
 Provide a follow-up appointment and evaluate access difficulties.


Prevention 
In the majority of states, it is required to report elder and child abuse to protective services. There are laws requiring IPV reporting in certain states.
To learn about local laws and resources before you need them, get in touch with your area's domestic violence program.
Display informational materials (National DV Hotline: 1-800-799-SAFE) in the waiting room, office, and all exam rooms.


Take Action 

Make an immediate follow-up appointment. Find out what has changed since your last visit.
Before it is resolved, DV frequently necessitates a number of treatments over time.

Educate patients about the use of nonviolent conflict resolution techniques and the cycle of violence.
Educate parents on developmentally appropriate methods of discipline as well as the harmful effects of fighting on both children and one another.


Prognosis 
Most DV offenders avoid counseling out of choice unless forced to by partners or by a court order. The effectiveness of counseling for offenders is still understudied.

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