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The Gynecologist’s Role in Preventing Intimate Partner Violence 2/3

Part Two: How to Identify and Respond to Signs of IPV

male doctor talking to female patient

Trigger Warning: If you’ve encountered or experienced IPV in the past, please proceed with caution while reading this blog. Furthermore, if you don’t feel safe in your relationship you can take this quiz to determine if your relationship is abusive, call the Domestic Violence Support Hotline at (800) 799- SAFE or contact Catalyst Domestic Violence Services for resources if you’re in Chico, CA.

Last week we discussed the cycle of intimate partner violence (IPV.) This week we will be going over how to identify and respond to signs of IPV.

Signs of IPV

Out of all medical care practitioners, obstetricians and gynecologists are potentially the most well suited to identify and assist victims of IPV. This is because many women see their gynecologists regularly for annual exams, family planning, or gynecological symptoms, and they see their obstetrician regularly if they are pregnant for prenatal care. 

Indications of IPV can be both physical and behavioral. Behavioral indications that should cause concern include; the patient frequently missing appointments, psychosomatic symptoms like anxiety or depression, suicidal ideation, substance abuse, delay in seeking medical attention for injuries, and their partner’s behavior/demeanor. Victims of IPV may potentially have a flat or sad demeanor during appointments, hesitant in discussing their personal life, secretive, defensive, evasive, jumpy, or even come off as angry. All of these responses are normal reactions to being abused but there is no one set way in which victims of domestic violence act or respond to their circumstances.

Physical examinations can further assist medical professionals in identifying victims of IPV, especially considering IPV victims’ injuries tend to not be visible when the patient is fully clothed. Common injuries from IPV include bruises, cut, black eyes, concussions, broken bones, miscarriage, joint damage, loss of hearing/vision, scars, bites, knife wounds, and burns. Injuries are usually numerous and at different stages of healing. Furthermore, sometimes the patient’s explanation for the injuries won’t align with the placement nor the age of the injury.

The health care provider should not only question the existence of the injuries but ensure that any acute injuries are properly attended to. Furthermore, the health care provider needs to document all injuries that are potentially from abuse in the patient’s confidential medical record, regardless if the patient discloses they’ve been the victim of abuse.

The victim’s partner may want to supervise the examination or at least wait nearby in the waiting room, try to answer questions directed to the patient, and may appear overly attentive or domineering. The abuser may also come off abrasive, testing the limits by exhibiting hostile behavior towards the staff and/or demanding to be present with their partner at all times.

Particular gynecologic signs of IPV include sexually transmitted infections, multiple pregnancies, chronic pelvic pain, sexual dysfunction, recurring vaginal infections, and premenstrual syndrome. IPV must be considered if there is no physical explanation for these conditions (especially if signs are repetitive.)

How to Address the Issue

As well as identifying and acknowledging the signs of IPV, physicians must; provide a secure environment where the patient can be comfortable opening up, validate their experience, and document the incidence of violence. Addressing their concerns to the patient directly shows the patient that the physician is aware of the problem and is willing to help. 

Female victims are more likely to disclose their circumstances to other women and professionals who appear sympathetic that they feel are likely to help them. This is why all medical staff, especially those who work in gynecology or obstetrics, should be trained in the signs of IPV, and response plans should be integrated into the care of IPV victims. 

To create a safe environment for victims, medical providers should ask questions like, “Do you feel safe in your relationship?” or “Has your partner ever intentionally caused you physical or emotional harm?” In addition to routinely asking pertinent questions, having pamphlets and posters clearly visible in patient areas lets victims know that this is a safe place where they can reach out to help when they are ready. Considering the bathroom is a place where the patients are guaranteed to be alone, medical offices can strategically place posters in their restrooms with resources for IPV victims.

If a patient discloses IPV to any member of the medical staff, they should be seen as soon as possible by an advocate like a social service worker who can provide them with additional information and resources.

Obstetricians and gynecologists must consistently inquire/document abuse while ensuring the patient’s safety/privacy. It’s important to note that only 8% of victims will self-report abuse but 29% will report when prompted by a healthcare provider. Commonly self-identified routine interventions by primary care physicians consisted of; 91% of practitioners expressing concern for the patient’s safety, 89% documenting the abuse in the patient’s medical chart, 88% recommending counseling to their patient, and 79% referring their patients to domestic violence shelters.

How to Bring up IPV

Victims of IPV are more likely to open up if they are asked directly and routinely, in a way that is not threatening and if the inquirer has made them feel like they are safe to confide in. In the case of IPV, the medical ethical principle of beneficence requires medical professionals to intervene when they are made aware of instances of abuse. This is because when abuse continues without intervention, it is likely to persist and escalate.

It can be troubling when there are indications of IPV but the patient denies that anything is happening. It’s important to understand that there are psychosocial, economic, cultural, religious, psychological, and circumstantial reasons why victims stay in abusive relationships. Victims often feel overwhelmed and fearful when contemplating leaving their abuser. The best thing an ally can do is provide the victim with guidance creating a safety plan for if and when they do leave.

When medical professionals are treating patients who are potential victims of IPV, they must practice discretion and only ask questions about abuse when the patient is alone. Health care providers should also inform their patients that they are mandatory reporters and if a report is necessary, the victim should be informed of exactly what information is going to be shared, with whom, and what the next steps should be.

Victims of IPV must be evaluated and treated for physical injuries, as well as emotional injuries. Typically, outpatient therapy is sufficient to assist survivors in their emotional healing. Nevertheless, if the patient is at risk of hurting themselves, their safety must be prioritized and inpatient therapy is recommended.

Health care providers should concentrate on providing emotional support to the victim by reassuring them that they are not alone and no one deserves to be abused. When IPV is suspected or disclosed, the medical professional should provide the patient with local resources. While it’s vital to honor the patient’s right to make their own decision, it’s equally essential to validate their experience and provide them with options. 

A follow-up plan should also be put in place when a medical professional suspects or identifies IPV. This plan should include scheduling a follow-up visit and documenting the suspected IPV on the patient’s chart. The goal is to preserve an open line of communication between the provider and the patient so the provider can ensure the patient’s safety. 

Come back next week for the final part in this important series where we will be discussing developing a safety plan, community response, and other potential considerations. 

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