Domestic Violence / Gender (and Sex) Specific Issues
In a patient with new, obvious risks for domestic violence, take advantage of opportunities in pertinent encounters to screen for domestic violence (e.g., periodic annual exam, visits for anxiety/depression, ER visits).
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).
Advise about the escalating nature of domestic violence.
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.
In a patient living with domestic violence, counsel about the cycle of domestic violence and feelings associated with it (e.g.,helplessness, guilt), and its impact on children.
Gender (and Sex) Specific Issues
In the assessment of clinical problems that might present differently in men and women, maintain an inclusive differential diagnosis that allows for these differences (e.g., women with coronary artery disease, depression in males).
As part of caring for women with health concerns, assess the possible contribution of domestic violence.
When men and women present with stress-related health concerns, assess the possible contribution of role-balancing issues (e.g., work-life balance or between partners).
Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (e.g., positioning for Pap, chaperones for genital/rectal exams).
Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (e.g., ASA use in women).
Intimate Partner (Domestic) Violence
Risk Factors for Victimization
Young female (<24yo)
Risk Factors for Both Victimization and Perpetration
Witnessing or experiencing violence as a child
Substance abuse (alcohol/drug use)
History of mental illness
USPSTF recommends: All women of childbearing age should be screen for domestic violence
However, CTFPHC recommends against universal screening as only one study directly addressed the benefit of screening, and found no effect of screening on outcomes.
Woman Abuse Screening Tool (WAST), 90% sensitivity with first two questions
In general, how would you describe your relationship? No tension, some tension, a lot of tension?
Do you and your partner work out arguments with no difficulty, some difficulty, or great difficulty?
Do arguments ever result in you feeling down or bad about yourself?
Do arguments ever result in hitting, kicking, or pushing?
Do you ever feel frightened about what your partner says or does?
Does your partner ever abuse you physically?
Does your partner ever abuse you emotionally?
Does your partner ever abuse you sexually?
Acknowledge the injustice
"This is abuse"
"I am very sorry this is happening to you"
Frame the violence due to perpetrator's behaviour and not the survivor's
"You do not deserve this, and it is not your fault"
Respect autonomy and patient's decisions
"I want to help you through this in any way I can."
Assess for safety (high risk of harm)
Consider 20-item Danger Assessment
Violent outside the home
Violent to children
Threatening to kill
Abusive during pregnancy
Obsessive, controlling relationships
Serious prior injury
Owns weapons, especially handguns
Threatened others (family/friends)
Safety planning, resources, community services including local shelters
Emergency kit with important documents, keys, money, essential items - stored outside the home
Place to go (friend, family shelter)
Signal to alert others (children/neighbours) to call 911
Quotes from patient
Physical exam findings and photographs
Mandatory reporting may be required in the following instances:
Abuse involving children
Contact Youth Protection
Abuse of elderly (in retirement home)
Abuse of disabled persons
Counsel on possible escalation/cycles of violence (tension build up, violent outburst, honeymoon phase)
Update safety plan