Module 2: Indicators of domestic violence

Identification of violence
Indicators
Domestic violence: Frequent radiological findings
Identification of victims of domestic violence in dentistry
Witnesses of domestic violence

Introduction to the topic

Victims who are exposed to domestic violence often originally seek medical attention because of the psychological or physical injuries they suffer. However, they do not often talk about the violence out of shame, fear of being judged or fear of their partner. In order to support the patient, it is important that victims are identified at an early stage and that the violence is disclosed as early as possible.

Learning objectives

The learning objectives of this module are to become familiar with the various indicators of domestic violence as well as their related risks and to be sensitised to them.


Case study: Disclosure of domestic violence in medical practice

We are in a family practice and a 25-year-old patient comes to a consultation.

Physician: “Good morning Mrs. Schmidt, what can I do for you today?”

Patient: “I feel totally overworked at the moment and wanted to ask if you could put me on sick leave for two weeks?”

Physician: “Is there any particular reason why you feel that way and has this happened before?”

Patient: “I have never been on sick leave because of overload before. But I have just recently separated, and everything just gets too much for me at the moment.”

Physician: “Of course, I can put you on sick leave, but if you feel so overwhelmed by your situation, I would be happy to offer you further support. Perhaps you would like to talk to me about it?”

Patient: “Mmm, I actually feel very uncomfortable to talk about it. There were some problems in my previous relationship. My boyfriend was a control freak and constantly checked my cell phone. We were fighting whenever I wanted to meet with my friends or family. As a result, I became more and more isolated and the only company when leaving the house was my boyfriend. He read messages from my friends before I had a chance to read them. I finally broke up, but I don’t know if that was the right decision.”

Physician: “If your boyfriend controlled and bullied you so much, why do you think the breakup was a mistake?”

Patient: “He keeps calling me and sending me messages. He puts me under pressure by saying that he cannot live without me and will hurt himself if I don’t come back. I see his car in the parking lot all the time: while shopping, being at work or meeting my friends. I always have the feeling that he is around. Can that even be a coincidence? I have already met him twice because I felt so sorry for him, and I was afraid that he would really hurt himself.”


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Identification of violence

It is important for health service providers to be aware that a victim’s health problems may be caused or made worse by violence. Victims subjected to domestic violence in relationships seek health services for related emotional or physical conditions, including injuries. However, they often do not tell the provider about the violence due to shame or fear of being judged or fear of their partner. To tackle domestic abuse, it is essential that victims are identified and disclose their abuse as early as possible. People experiencing domestic abuse are more likely to come into contact with health services than other public services. As a health professional, you will be a first point of contact for many.

There is a whole range of indicators to warn health professionals that a patient may be experiencing domestic abuse. Some of these are quite subtle and it is important that professionals remain alert to the potential signs and respond appropriately. Some victims also drop hints in their interactions with health and care staff and their behaviour may also be telling. They rely on staff to listen, persist, and enquire about signs and cues. They need staff to follow up on conversations in private, record details of behaviours, feelings and injuries seen and reported, and support them to take action suitable for their organisation’s systems and local pathways.


Indicators

To improve diagnosis and the subsequent care of patients, health care professionals should always ask about domestic violence when taken the medical history.

Many health settings are busy places, with people passing in and out of cubicles and offices. This is not an appropriate environment to be asking about domestic violence or talking about feelings.


Indicators of domestic violence in adults

The following are indicators associated with victims of domestic violence. Please note that none or all of these might be present and be indicators of other issues. Some victims also give hints in conversations, and their behaviour can also be revealing. Victims are therefore dependent on being listened to, on someone being persistent and asking for signs and clues. Using these indicators as a guide can complement the practice of asking directly.

Physical indicators
  • Unexplained bruising and other injuries
    • Especially head, neck, and facial injuries
    • Bruises of various ages
    • Injuries sustained do not fit the history given
    • Bite marks, unusual burns
    • Injuries on parts of the body hidden from view (including breasts, abdomen and/or genitals), especially if pregnant
    • Chapped lips
    • Teeth knocked out
  • Miscarriages and other pregnancy complications
  • Chronic conditions including headaches, pain and aches in muscles, joints and back
  • Sexually transmitted infection and other gynaecological problems
Psychological indicators
  • Emotional distress, e.g., anxiety, indecisiveness, confusion, and hostility
  • Sleeping and eating disorders
  • Anxiety/depression/pre-natal depression
  • Psychosomatic complaints
  • Self-harm or suicide attempts
  • Evasive or ashamed about injuries
  • Seeming anxious in the presence of their partner
  • Social isolation/no access to transport
  • Frequent absence from work or studies
  • Submissive behaviour/low self-esteem
  • Alcohol or drug abuse
  • Fear of physical contact
  • Nervous reactions to physical contact/quick and unexpected movements
Possible indicators of sexual violence
  • Injuries to the genitals, the inside of the thighs, the breasts, the anus
  • Irritations and redness in the genital area
  • Common infections in the genital area
  • Pain in the lower abdomen and/or pelvic area
  • Sexually transmitted diseases
  • Bleeding in the vaginal or rectal area
  • Pain when urinating or defecating
  • Pain when sitting or walking
  • Strong fears of examinations in the genital area; avoidance of examinations
  • Severe cramps in the vaginal area during gynaecological examinations
  • Sexual problems
  • Self-harming behaviour
  • Unwanted pregnancies/abortions
  • Complications during pregnancy
  • Miscarriages

Indicators of domestic violence in children

Physical indicators
  • Difficulty eating/sleeping
  • Slow weight gain (in infants)
  • Physical complaints
  • Eating disorders (including problems of breast feeding)
  • Fingertip injuries
Psychological indicators
  • Aggressive behaviour and language
  • Depression, anxiety, and/or suicide attempts
  • Appearing nervous and withdrawn
  • Difficulty adjusting to change
  • Regressive behaviour in toddlers
  • Delays or problems with language development
  • Psychosomatic illness
  • Restlessness and problems with concentration
  • Dependent, sad, or secretive behaviour
  • Bedwetting
  • ‘Acting out’, for example cruelty to animals
  • Noticeable decline in school performance
  • Fighting with peers
  • Overprotective or afraid to leave mother or father
  • Stealing and social isolation
  • Exhibiting sexually abusive behaviour
  • Feelings of worthlessness
  • Transience

Source: Hegarty (2011): Intimate partner violence – Identification and response in general practice



Domestic violence: Frequent radiological findings

The following description refers to domestic violence against adults in particular (e.g., partners). A special aspect in the broader context is child abuse – radiological findings may be decisive for its detection.

Reasons to contact a physician in cases of domestic violence
  • In many cases, victims do not report domestic violence as the cause of an injury or for hospitalisation.
  • Medical presentations that do not directly involve an injury can also provide indications of domestic violence.
  • Victims of domestic violence receive radiological examinations more often, especially for physical trauma.
Common injuries detectable with medical imaging
  • Injuries to the reproductive organs (also during pregnancy, e.g., chorionic hematoma)
  • Acute fractures (especially in the facial region, e.g., nasal bone fracture, orbital floor fracture; but also fractures of the extremities)
  • Subacute and temporally indeterminate fractures (especially face, extremities, and spine)
  • Soft tissue injuries (e.g., hematoma and laceration)
Evaluation of image findings and the role of radiology
  • Radiological findings and imaging data contribute to the documentation of the extent of physical injuries.
  • However, the injury patterns of adult victims of domestic violence are similar to those of other causes of injury.
  • The positive predictive value of a radiological examination alone for the possible presence of domestic violence is limited but can be better assessed and thus increased by considering the overall clinical context.
  • This can include injury patterns that do not match the medical history, the presentation of multiple injuries of different ages and frequent radiological examinations in the past.
  • The radiologist’s complementary view of the case and the often somewhat calmer situation when preparing and reporting the findings of the examinations (compared to the emergency room) can thus facilitate the detection of domestic violence.

Reference: E. George et al., Radiologic Findings in Intimate Partner Violence. Radiology 2019, 291:62-69

Further Reading: S. Matoori et al. (2020), Intimate partner violence crisis in the COVID-19 pandemic: how can radiologists make a difference? European Radiology



Identification of victims of domestic violence in dentistry

Identification of victims of domestic violence (DV) can also play an important role in the dental practice, as they see often dentists on a regular base for check-ups. It is important that dental professionals ask specific questions on DV, follow-up on cases they suspect DV being present and document findings and injuries which may be related to DV in a timely fashion and as such that it can be used in court later.

Recommendations for daily practice

To reduce hurdles for the potential victim to talk about the violence he or she has experienced, you should keep the following in mind:

  • Many victims come to your practice accompanied by their children or even their partners. Make sure that the patients are alone with you and can speak freely.
  • General questions can help you to address the topic: “How are things at home?”, “How do you get along with your partner?”. Direct questions can lead to the alleged victim opening up more in the course of the conversation: “Have you ever been verbally/physically/emotionally/sexually abused by your partner?”
  • Listen carefully when a victim discloses the presence of DV and confirm that talking about this was the right decision. Make clear that domestic violence, in any form, is not acceptable.
  • Avoid questions that put the blame on the victim such as “Why are you still living with your partner?” or “Could you have avoided the situation?”.

After disclosure, the next step follows, which should be seen as an ongoing process, assessing the risk for your patients:

  • Ask the victim about their partner’s behaviour in the past in order to draw possible conclusions about behaviour in the present and in the future.
  • Ask whether the victim and any children involved currently feel safe at home and work out an emergency plan together. Possible contact points and telephone numbers (police, women’s shelters, etc.) as well as possible accommodation and escape routes should be discussed and documented in writing.

If there is a legal case in the future, you as a dental professional may be questioned about the victim, so you should document everything well:

  • Document suspected cases very precisely – with date, body site, condition of the injury related to the suspected age and current appearance. This also applies to unconfirmed cases.
  • Conspicuous behaviour should also be described in detail. Furthermore, you can include special statements of the patient that support your suspicion as a quotation in the file.
  • If possible, take photos to support your documentation.

The violence is often directed against the unprotected neck and head. You may find bruises, contusions, puncture wounds and cuts in this area, but also burns and strangulation marks as well as injuries to teeth (loosening, chipping, breaking off, loss), jaws (contusions, luxations, fractures) and/or dentures (up to irreparable destruction). Immediate, careful, and unambiguous dental documentation of violence-related injuries (in words and pictures) is particularly important for possible later criminal prosecution, as the traces of violence in the human head and face area are usually only fully visible for a certain period of time. They often heal after a short time or are completely healed within a short period of time. In addition to written and photographic documentation, in some cases additional documentation by x-rays and/or impressions of the teeth and jaws is recommended.

For a court-proof photo documentation, it is necessary that you photograph the injury together with a yardstick. If no metric scale (ruler, folding rule, etc.) is available, you should use an everyday object that is also visible on the photo: This includes, for example, pencils or the like, which – using the rule of three – allow you to calculate the size of the injury. You should always take overview and detail photos: Location, size, colouring, configuration as well as other special features of the injuries should be documented in detail. As long as no official order exists, you should obtain written consent for photographic documentation (release from confidentiality) from the injured person or the legal guardians.

At subsequent appointments, you should always look after the well-being of the respective patient and ask about the current situation at home. Have information ready with which you can support them.

Sources:

https://www.zm-online.de/archiv/2022/20/praxis/wie-laeufts-denn-so-zu-hause/

https://www.zmk-aktuell.de/fachgebiete/allgemeine-zahnheilkunde/story/haeusliche-gewalt-was-koennen-zahnaerzte-erkennen-und-was-koennen-sie-tun__3832.html

Bregulla, J. L., Hanisch, M., & Pfleiderer, B. (2022). Dentists’ Competence and Knowledge on Domestic Violence and How to Improve It—A Review ([Electronic ed.].).


Witnesses of domestic violence

Caregivers and family members, but also neighbours or work colleagues can become potential witnesses of domestic violence. The victim’s cooperation and consent are the most important prerequisites for intervening as a witness. An intervention by a witness can include talking to the victim, helping to access help services, or supporting the reporting of domestic violence to the authorities.


Factors that may inhibit or encourage intervention by witnesses

  • Witnesses often have a strong desire to intervene, but not necessarily to report domestic violence to the police. The possibility to remain anonymous can encourage them to report domestic violence to the authorities.
  • Understanding domestic violence and knowing how to support victims can motivate witnesses to intervene. This underlines the importance of awareness-raising campaigns that promote understanding and help to identify the signals of domestic violence (especially non-physical violence). They should also provide guidance on how to support victims.
  • In the health and social sector, the obligation to report domestic violence is a crucial factor, as witnesses must report domestic violence to the authorities. However, these obligations vary from country to country and the existing conflict between reporting and confidentiality may prevent them from reporting.
  • As a rule, witnesses are more inclined to report domestic violence to the authorities if children are involved. If they do not report domestic violence in those cases, it may be because they are worried that the children will be separated from their parents or experience trauma as a result of a police investigation.
  • Other factors that may prevent witnesses from intervening are a negative picture of the police and justice system, fear for their own safety and the misunderstanding that domestic violence is a private matter.

Recommendations

  • There is a great need for measures that sensitise witnesses and encourage them to act. Further information is needed for professionals who are obliged to report domestic violence.
  • It is crucial that police and judicial authorities increase their efforts to deal with reports of domestic violence in a way that protects both, victims and witnesses.
  • Further research is needed to ensure that relevant measures to promote and facilitate witness intervention, such as awareness campaigns and helplines/hotlines, are monitored and evaluated to maximise their effectiveness.

More information on the decisive factors for witness intervention in domestic violence can be found here: https://eige.europa.eu/gender-based-violence/eiges-work-gender-based-violence/intimate-partner-violence-and-witness-intervention?lang=sl