INTIMATE PARTNER VIOLENCE CLINICAL CARE GUIDE FOR PRIMARY CARE PROVIDERS
The 4 S's
Recognize Signs & Symptoms, Initiate Screening and Assess Safety
1 and 2) Look out for Signs & Symptoms:
- visible recurrent or suspicious injuries to head, face, torso
- recurrent fractures, with unclear precipitant
- bruises and burns varying in appearance and recurrent episodes
- recurrent sexual/reproductive health visits, unwanted pregnancies
- mental health concerns, suicidal ideation, self harm
- frequent ER visits, missed appointments
- partners that seem "overprotective"
3) Screen:
Remember, be supportive but be direct. Understand that you may not get a disclosure the first time.
- "I am noticing this bruising/fracture and am worried about you. Do you feel safe? Is someone harming you?"
- "I see that you are here for STI testing/Emergency contraception. Are you worried about a specific incident? Did you give permission to engage in the sexual act?"
- “Is there anyone putting you in danger at home?”
- If you are on a virtual call and unable to ask questions safely try to screen for the "Signal for Help."
“Signal for Help” is a simple one-handed sign someone can use on a video call. It can help a person silently show they need help and want someone to check in with them in a safe way. Look out for this as a primary care provider during your virtual video visits! The Signal for Help was developed by the Canadian Women’s Foundation in response to COVID-19.
4a) Safety/ Reporting Obligations to disclose:
Discuss your obligations to report up front, this often can help clarify fears patients have about repercussions of disclosing to a healthcare provider and clarify what your role can be.
- "My primary concern is your safety. I am here to support you."
- "I want to clarify that the conversation you have with me will remain private and confidential and the information you provide would only be shared within your circle of healthcare, reasons I would need to share information outside of this circle are very specific."
Report to CAS
if you are a minor under age 16 and
-have been sexually assaulted by someone in a relationship of trust, authority or dependency
-you are being abused at home
if you are an adult with violence in the home and
-there are children under age 16 living in the home where the violence took place
Report to Police
NO mandatory reporting of sexual assault to police for adults. No mandatory charging even if the police do become involved.
NO mandatory reporting of domestic violence to police for adults. But, if the police are called following a domestic incident there IS mandatory charging. Requires police to make an arrest if they believe on reasonable and probable grounds that violence occurred.
4b) Safety/ Risk Assessment
Identify risk factors for death due to abuse:
• Increasing severity and frequency of
violence
• Weapons used or available
• Threats to kill
• Forced or threatened sexual acts
• Life transition (pregnancy, separation,
divorce)
• History of violence
• History of suicide attempts
*Most important- disclose directly and clearly that presence of these risk factors increase chance of death of the victim due to violence and highlight the importance of safety planning and leaving if the victim is ready. But do not pressure the victim to leave*
For first line support apply this adapted version of the "LIVES" strategy developed by the World Health Organization.
Listen to survivors without judgement
- be culturally sensitive
- treat the individual with dignity and respect
Inquire about and respond to their needs
- give the individual control over their disclosure
Do NOT blame the victim.
“Why didn’t you call police?”
Do NOT ask irrelevant/inappropriate questions.
Why would you stay in this relationship?
Do NOT force victims to leave their abuser if they are not ready. Be aware that staying with abuser can sometimes be easier than leaving. Victims of IPV face the highest fatality risk upon leaving the abuser. Survivors also may not be able to leave due to, financial dependence, immigration status, child custody, among other reasons.
Create a safe environment for conversation.
- "Do you know what your options are and what you would like to do next?"
- " How can I best support you right now?"
Validate survivors by believing them
- provide emotional support "it is NOT your fault, abuse is NEVER okay
Enhance their safety- go over a safety plan together, start with the basics first and add on later at future visits
Be aware of dangerous areas in home (kitchen, stairs) to avoid during violence.
Know your exits, and areas to hide if you cannot get out of the home.
Re-iterate importance of calling 911, having a safe contact on speed dial, and establishing a code word to indicate need for help with trusted support person
Make an emergency bag and keep it somewhere easy to access and not accessible to the abuser; either at home or a trusted friend or family member's home.
It should contain:
photocopies of important documents like custody orders, restraining orders, health insurance papers, immigration papers, identification
medications, extra set of keys, change of clothes
valuables, cash, credit cards, cheque books
Deactivate GPS on phone and in car if leaving abuser
If not living with abuser, change your routes to work and school and let people know you should be notified of new visitors, and calls should be screened, provide photo of abuser to increase awareness if possible
Support survivors in the way they choose and connect them to resources for their specific needs.
DIRECT PATIENT TO LOCAL SEXUAL ASSAULT & DOMESTIC VIOLENCE CENTRE https://www.sadvtreatmentcentres.ca/
Beware of giving a laundry list of resources that can lead to dead ends especially during this pandemic during which resources are very scarce. See our Resources section for details on safety planning, legal aid, shelter, acute care and follow up centers.
Check out the power and control wheel below developed by “Domestic Abuse Intervention Programs”. This wheel can be a very powerful tool in counselling patients and understanding the nature of intimate partner violence.
References
1. WHO, Pan American Health Organization (PAHO), (2012). Understanding and addressing violence against. women. https://www.who.int/reproductivehealth/topics/violence/vaw_series/en/
2. O’Reilly, R., Peters, K. Opportunistic domestic violence screening for pregnant and post-partum women by community based health care providers.BMC Women's Health18,128 (2018).
https://doi.org/10.1186/s12905-018-0620-2
3. Ontario Network of Sexual Assault and Domestic Violence Treatment Centres. https://www.sadvtreatmentcentres.ca/
4. Faculty of Medicine COVID-19 Wellness Series: Intimate Partner Violence (IPV) and COVID-19: Considerations for Health Care Workers.
5. Centers for Disease Control and Prevention- Intimate Partner Violence.
https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html
6. The Canadian Women’s Foundation Signal for Help in response to COVID-19.
https://canadianwomen.org/signal-for-help/
7. Dicola D, Spaar E. Intimate Partner Violence. Am Fam Physician. 2016;94(8):646‐651.
https://www.aafp.org/afp/2016/1015/p646.html
8. Bhandari M, Dosanjh S, Tornetta P III, et al.; Violence Against Women Health Research Collaborative. Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma 2006;61:1473‐9.
https://pubmed.ncbi.nlm.nih.gov/17159694/
9. Jeffrey, N., Fairbairn, J., Campbell, M., Dawson, M., Jaffe, P. & Straatman, A‐L. (November 2018). Canadian Domestic Homicide Prevention Initiative with Vulnerable Populations (CDHPIVP) Literature Review on Risk Assessment, Risk Management and Safety Planning. London, ON: Canadian Domestic
Homicide Prevention Initiative. ISBN: 978‐1‐988412‐27‐6
http://www.cdhpi.ca/literature-review-report