EMed

Domestic Violence

Definition

“…refers to the use of physical or emotional force or threat of physical force, including sexual violence in close adult relationships. This includes violence perpetuated by a spouse, partner, son, daughter or any other person who has a close or blood relationship with the victim. The term ‘domestic abuse’ goes beyond actual physical violence. It can also involve emotional abuse; the destruction of property; isolation from friends, family and other potential sources of support; threats to others including children; stalking; and control over access to money, personal items, food, transportation and the telephone”

Violence directed against women - Recognition and management in the ED (BAEM)

These guidelines focus on violence directed against women. This is because the incidence of victimisation and the resulting mortality, morbidity and socio-economic difficulties presently affect women very much more than men. It is recognised, however, that the number of male victims is increasing, and much of the following guidance is applicable to both genders.

The size of the problem

The legal position

Domestic violence is a crime like all other violent crimes. It should be prosecuted once reported in the same way as all other such crimes. The victim can be subpoenaed as a witness. Where the patient does not wish to report his/her assault to the Gardaí, this should be respected. Admission may buy time for discussion and reflection where the clinician feels that the risk of homicide or serious injury is great but the patient refuses Garda involvement. Where the patient is incapable of consent, the consultant in charge must be consulted whether to release information when a "serious arrestable offence" has occurred. The victim may also take action through the civil law, e.g. exclusion and non-molestation orders.

Legislation/Related Policies

Main legislation relevant to domestic abuse:

  • Domestic Violence Act 1996 and amendments in 2002 and 2011
  • Non Fatal Offences Against the Persons Act 1997
  • Civil Legal Aid Act 1995
  • Child Care Act 1991
  • Children First Guidelines 2011
  • Protections for Persons Reporting Abuse Act, 1998
  • HSE staff responsibility for the Protection and Welfare of Children
  • Policy and Procedures on the Management of Domestic Abuse by Medical Staff

Presentation

  • Domestic violence affects women (and men) of all classes & race
  • Types of violence are verbal, physical, sexual or neglect
  • Commonest pattern is that intermittent physical violence (which brings the patient to hospital) is done against a continual backdrop of verbal abuse
  • This often makes the victim say when she arrives that "she deserves it, she is useless"
    • Maintain a high level of suspicion
  • May commence at times of stress, e.g. recent unemployment
  • There is an association between beginning of violence and first pregnancy
  • It is important to understand this and re-empower the patient (often by asking a female nurse to talk with her for a while). A nurse chaperone should be present at all times for male doctors. It is so important to re-assure the victim that this is common and it is okay to talk about it. Nothing will shock us

Presenting complaints

  • Injury, often multiple
  • Suicide/para-suicide
  • Pelvic pain
  • Rape
  • Psychiatric illness/substance abuse
  • Multiple somatic complaints

Pattern of attendance

  • Patient attends late
  • Partner answers for patient
  • Patient may be pregnant
  • Over-vehement denial of abuse
  • May be frequent attender
  • Multiple prescribed drugs

Examination:

NB The presenting complaint is only part of the picture, enquire about, and with the patient's consent look for, other symptoms and signs of abuse. Body Maps, Assault Record

Indicators of abuse

Suspicions

  • Mismatch between what the patient says and any observed behaviour or signs e.g. Says arm is not sore but then winces at minor movement?
  • Delay in presentation to hospital?
  • Injuries inconsistent with the history of how they occurred?
  • Are there injuries to the face, head, neck, chest, breast, back, thighs or abdomen?
  • Evidence of multiple injuries at different stages of healing?
  • Evidence of sexual violence?
  • Patient minimises the extent of the injury or pain or conceals injuries?
  • Patient insist that they are solely responsible for the injury by being accident prone or clumsy etc
  • Patient is vague, anxious, fearful or distressed?
  • Patient reluctant to stay in the ED for a medical assessment?
  • Patient reluctant to make eye contact?
  • Patient appear overly anxious, passive (withdrawn) or fearful of their partner/spouse/other?
  • Partner insist on staying with the patient and speaking on their behalf?
  • Partner/spouse or other being seems over-dominant, controlling to their partner or to staff

Patient

  • Evasive / embarrassed / apologetic
  • Anxious / depressed / passive

Injuries

  • Affect areas normally clothed
  • At multiple sites, of differing ages
  • Inconsistent with mechanism
  • Symmetrically distributed

Characteristic injuries

  • facial injury
  • detached retina
  • genital injury
  • perforated eardrums
  • breast injury
  • bizarre injuries
  • burns/scalds/bruises
  • neck injury especially marks
  • abdominal injury when pregnant

Document

Document meticulously

Photograph injuries with patient's written consent. Sign and date all notes and photographs, and attach firmly to patient's medical record. Body Maps, Assault Record.

  • time, date, place of abuse
  • witnesses to incident
  • injury - size, pattern, age, location abuse
  • signs of sexual abuse (non-bodily evidence e.g. torn clothing)(SIVUH Sexual Assault Unit Referral Info and Form)
  • patient's explanation
  • your opinion regarding causation

Approach to the patient

Working with a migrant woman experiencing domestic violence, and for whom communicating in English is difficult?

The Language Line translation service can support your patient

  1. Staff or the woman can call the Women's Aid National Free-phone Helpline on 1800-341-900
  2. When a support worker answers the phone, state the language she wishes to communicate in
  3. Wait for a moment on hold while they connect to a translator
  4. The woman may then speak to the helpline worker about her situation, via the translator on the line

The service is available 10 a.m. to 10 p.m. Seven days per week. If you are concerned, admit the patient (alone) to CDU and we'll get a translator in the morning.

Exclude partner

  • Interview with privacy, stress confidentiality
  • Ask direct questions gently, stating that domestic violence is common and it is routine to enquire about home circumstances where there is a possibility of abuse on clinical grounds
  • Be non-judgemental and supportive, do not directly condemn partner, do not criticise patient for staying with him
  • Remember that the patient may have been told by her partner that "she deserves it, she is useless"
  • It is important to re-empower the patient (often by asking a female nurse to talk with her for a while)
  • A nurse chaperone should be present at all times for male doctors
  • It is so important to re-assure the victim that this is common and it is okay to talk about it. Nothing will shock us
  • Emphasise the appropriateness of the patient's attendance
  • Focus on informing the patient: stress that violence in the home is illegal, that expert help is available and legal intervention is possible. Supply contact details for support and organisations, e.g. Women's Aid
  • Discuss safely: How much at risk does the patient feel - of homicide? - of suicide? Are there weapons in the house? What has she tried before? What sources or support does she have? What possible safe havens? Are there children? Are they safe? Help her examine her options
  • Move at the patient's own pace. Nurture the patient's right to make her own decisions
  • Keep the patient is the Emergency Department for their own safety
  • Encourage the person to stay in the Emergency Dept to and to make a Garda statement
  • The decision to prosecute often needs to be nurtured and encouraged
  • All the time respecting the patients wishes if they still refuse
  • If the patient eventually decides to go ahead it is good practice to keep the patient in the environment in which they now feel comforted, to await the Gardaí

Treatment

  • Treat the physical illness of injury
  • Seek psychiatric help where depression is prominent or for para-suicide
  • Admit to hospital if there is no other safe option, or the patient is too emotionally exhausted to make her own decisions

What happens next?

  • If the patient is returning to her partner: give her contact numbers and written information (on legal grounds), help available etc., offer referral, help her plan an escape route for emergency, advise her to keep money and important financial and legal documents hidden in a safe place. If the children are at risk, consider referral to social services, preferably with patient's consent
  • If the patient does not wish to return and needs a place of safety: consider friends or relatives, try emergency housing (contact duty social worker), contact local refuge, the Gardaí may offer protected accommodation, hospitalise if all fails

Refer to

MUH Management Information

  • Patient information leaflet in drawer in triage
  • A to Z of domestic violence in "social worker" folder in back office
  • Please give advice leaflets and useful phone numbers card (blue credit card sized, kept in triage and at minors) to all
  • The "Breaking the Chain" leaflet (in triage) is particularly suitable for male victims of domestic violence
  • Emergency Social Works Dept (for e.g. Emergency accommodation / childcare needs)
  • Out of hours, the Gardaí may be contacted for further advice

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 22/10/22.