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Addition Questions

Emotional Abuse:

"Does your partner (former partner) ever humiliate you? Shame you? Put you down in public? Keep you from seeing friends or from doing things you want to do?"

Child Abuse

"Within the last year, has someone made you worry about the safety of your child? (If yes, who?)"

Notes:

In conjunction with the Abuse Assessment Screen, there are other questions you might ask. The first asks the woman about emotional abuse. The second asks about child abuse. These questions might be added to the routine screening tool, especially if the woman is identified as having been physically abused. 

Remember to inform patients that cases of suspected or identified child abuse or neglect must be reported to authorities. Have a plan in place for handling such situations.

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Questions Not to Ask

• Why don't you just leave?
• What did you do to make him/her so angry?
• Why do you go back?

Notes:

It is important to be aware of questions not to ask. Examples include: 

(Read slide text) 

These types of questions insinuate that the woman is responsible for the violence, or they imply that it is easy to walk away. For many women, neither of these implications is true.

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Reasons for a "No" Response

• Embarrassment/shame
• Fear of retaliation by partner
• Lack of trust in others
• Economic dependence
• Desire to keep family together
• Unaware of alternatives
• Lack of support system

Notes:

Some women may answer “no” to abuse assessment screening questions even though there are strong indicators that they are experiencing violence. Embarrassment and shame have been cited by women as an important reason for not disclosing violence to clinicians. Women also report that fear of retaliation by the violent partner keeps them from disclosing abuse. Other reasons for nondisclosure may include lack of trust in others, economic dependence, desire to keep the family together, lack of awareness of alternatives, or lack of a support system.^21,22

To obtain accurate medical and violence histories, clinicians must actively create and maintain trusting relationships with patients. If the patient has no history of prior abuse or assault, routine screening establishes that the problem of intimate violence is something medically relevant. If the patient subsequently experiences some form of interpersonal violence, she may be more likely to see reproductive health care services as a potential resource for assistance.

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Responding to "No"

•  Always chart the women's response—even when she says "no."
• Your questions may help those experiencing abuse to move closer to discloser
• Your questions indicate you willingness to discuss the violence.
• your questions will let the women know you and other staff are always available as resources.
• Women will choose will to disclose.

Notes:

It is important always to chart the woman’s response, even when she says “no” and when you may suspect otherwise. Document your observations in the standard format.

When dealing with a clear case of violence—even if it is denied—let a patient know that you and other staff are always available as resources.

Even if she denies intimate partner violence, keep in mind that your questions about violence may help those experiencing violence move closer to disclosure. Your questions indicate your willingness to discuss the violence if she chooses to disclose it at a later time. 

Respecting a woman’s autonomy can be empowering for her. Also keep in mind that a woman experiencing violence is the best judge of her present situation and of her own safety. The woman will choose when—or whether—to disclose the violence or to leave an abusive relationship.

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Responding to "Yes"

Things you ca say:

• This is not your fault.
• No one deserves to be treated this way.
• I'm sorry you've been hurt.
• Do you want to talk about it?
• I am concerned about your safety (and that of your children).
• Help is available to you.

Notes:

When your patient confides that she is being abused, express support for her. Telling her that the abuse is not her fault and that no one deserves to be treated this way is a powerful, short intervention. Your comments may prompt a patient to consider changing her situation. Here are some examples of things you can say: 

(Read slide text)

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Document Your Feelings

• In the patient's chart
• In the patient's own words
• With a body map
• With photographs (get consent)
• With specific details

Notes:

Thorough documentation of your findings is essential. 

Document findings in the patient’s chart, using the patient’s own words to describe the violence whenever possible. Do not use words (such as “alleges”) that could undermine the woman’s credibility if the medical record is ever used in court.

Use a body map to describe locations of injuries. Ask her permission to take photographs of injuries. Document patient consent. Above all, be specific in documenting the information she gives you. Remember that documentation is one of our most important interventions for intimate partner violence. The medical record can be used by the woman to support charges of abuse if she chooses to pursue legal recourse some time in the future. 

Clinicians should be aware of any mandatory reporting statutes that may apply in your state.23

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Asses Patient's Safety

• Is either woman or her children in danger?
• Has violence escalated recently?
• Are there weapons in the home?
• If the patient is not safe, does she have a safety plan?

Notes:

After you have documented the abuse, the next step is to assess the safety of the woman and her children. 

Questions should focus on whether the violence or threat of violence has escalated recently and whether there are weapons in the home. It is important to assess for lethality. 

If guns are present, threats to kill have been made, or violence has intensified, this is an emergency that requires the formulation of a safety plan before the patient is discharged. 

A team approach to care is helpful to both the patient and you. For example, often it is efficient for a specially-trained nurse, social worker, or health care worker to take over formulating a safety plan with the patient. You then can be informed of any decisions or plans that have been made.

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Components of a Safety Plan

• Pack a bag in advance.
• Have personal documents ready.
• Hide extra sets of house and car keys.
• Establish a code with family and friends.
• Plan where to go.

Notes:

Here are some important components of a safety plan: 

• Pack a bag in advance—A woman should pack a bag in advance with cash, credit cards, and extra clothes for herself and for her children. It is often helpful to pack a child’s favorite toy or blanket. Leave the bag at a friend’s house. 
   
• Have personal documents ready—Important personal documents should be accessible and might include birth certificates, driver’s license, bank account information, important phone numbers, insurance information or cards, court papers or orders, and copies of utility bills. These are documents that will help her get started on her own. 
    
• Hide extra sets of house and car keys—She should hide an extra set of house and car keys in a safe spot outside the house or with neighbors.
    
• Establish a code word with family and friends—This will advise friends or family of her status once she leaves the relationship. 
    
• Identify a safe place to go—A simple referral is not sufficient in this situation. Take steps to make sure that other providers pick up where you leave off.

This is not a definitive list. You may wish to visit ACOG’s Web site * or contact local domestic violence advocates for more information.

Finally, each practice setting should establish a plan for following up on patients who decide to take action.

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Patient Options

1. Stay with abuse and formulate a safety plan
2. Remove abuser through arrest or protective orders
3. Leave the relationship temporarily or permanently

Notes:

Once a victim of violence has disclosed the abuse, discussing her options for the future is the next step. There are three primary options. She can:

 (Read slide text) 

When discussing options, remember that the clinician’s goal is not necessarily to get the woman to leave her current situation. Keep in mind that suggesting counseling for the abusive partner or for the couple is contraindicated. Couples counseling can be effective only when both individuals view their partners as equals. This is not the case in an abusive relationship. Moreover, suggesting to a woman that she ask her partner to enter counseling may place her at risk for a violent reaction.

You or your designated staff can help the woman think about each of these alternatives so she can choose the best one for her situation. Remember that the woman alone is in the best position to determine what she should do. It is helpful to know legal and social service options and local law enforcement arrest policies when reviewing options.

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Referrals

Keep a current list of local resources:

• Office and hospital personnel with special training
• Law enforcement (police, lawyers, advocates)
• Shelters (housing, support groups, advocates)
• Local hotlines
• Child protective services

Notes:

Your clinical staff should have available a current list of local resources with names of specially trained individuals. 

You can contact a local advocacy group or shelter to obtain such a referral list. Local numbers to have on hand would include: 

(Read slide and continue to next one) 

We are not—and don’t have to be—experts in all fields. It is better to refer to an expert than to try to handle it ourselves if we are not equipped to do so.

Local shelters can help you establish a referral network, and they are eager to assist you. Often the phone numbers can be found in your telephone directory. These local numbers will fit on small cards that can be placed in patient restrooms where women can read them discreetly.

Date last reviewed: 02/07/2012
Content source: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion