CLUES TO THE PRESENCE OF

VIOLENCE
• Clues to the presence of violence in the lives of women are both
behavioral and physical. 
•  Behavioral clues that should increase the index of suspicion for
violence include missed appointments, repetitive psychosomatic
symptoms, depression (including suicide attempts), being accident
prone, substance abuse, poor reproductive history, vague and
inconsistent descriptions of injuries, delay in seeking attention for
injuries, partner's demeanor and behavior in the medical setting, and
the patient's direct report of abuse. 
• The demeanor of the woman during the history and physical
examination can include a flat or sad affect, embarrassment on the
discovery of injuries, hesitance in discussing issues, apprehension
about discussing her injuries, evasiveness, and even anger. All of these
responses to a life of violence are acceptable, because there is no one
set way in which abused women will respond when asked about
injuries acquired as part of domestic abuse. Her response may be
colored by past experiences with professionals, where she is within
the cycle of violence, and the lethality of her particular circumstance.
• The physical examination can further aid in the identification of
women who have been abused. The injuries in women who have
experienced IPV(Intimate partner violence) tend to occur in a pattern
that is generally not visible when the woman is clothed (bathing
suit appearance) or in the head and neck region. Injuries are usually
multiple and out of phase, and the explanation given for their
presence does not fit with either the injury itself or the age of the
injury . During the examination, the woman's partner may stand and
watch the examination, answer all questions directed to the woman,
and appear overly solicitous; he may even refuse to leave the
examination room. 
• This is of particular importance if the partner is the primary translator
for a woman who does not speak English. The abuser may also test
the limits of the medical visit, exhibiting hostile and surly behavior
toward the staff. These clues should alert the physician to the
possibility of IPV.
Common injuries :
Bruises
Cuts
Black eyes
Concussions
Broken bones
Miscarriage
Joint damage
Loss of hearing/vision
Scars from bites, knife wounds, burns
• It is the obligation of the physician to recognize injuries that may be
secondary to abuse. Typically, these injuries appear on portions of the
patient's body that are usually clothed; therefore, they are hidden from
friends, family, and neighbors. Bruises are usually of varying ages, and
other injuries are in various stages of healing. The examining physician
must question the presence of these injuries but must also ensure that
acute injuries receive specific trauma care, if necessary.
• Documentation of all injuries must be part of the confidential medical
record.19 Both the physical injuries and the emotional injuries must be
addressed . Often, outpatient therapy is sufficient. However, if injuries
are severe or the situation is deemed to be lethal, then inpatient
therapy is justified. The safety of the woman must be the first
consideration under these circumstances.
• Specific gynecologic indications of DV include sexually transmitted
disease, pregnancies, chronic pelvic pain, sexual dysfunction,
recurrent vaginal infections, and premenstrual syndrome. When the
obstetrician/gynecologist is faced with these problems without any
physiologic confirmation (especially if symptoms are repetitive), DV
must be considered.
Reasons women stay in abusive relationships

Psychosocial
Economic
Cultural
Financial
Lack of education
Children
No place to go
Religion
Low self-esteem
• Immediate care by the obstetrician/gynecologist should also focus on emotional
support of the patient, including assurance that no one deserves to be battered
and that the woman is not alone. Information regarding options and
community resources should be given to the patient when IPV is discovered.
The long-term goals of these interactions are to validate the woman's
experience and to explore and advocate safe options while respecting her right
to make her own decision about the next step. Finally, a follow-up plan should
be devised when the obstetrician/gynecologist identifies or suspects IPV. This
should include firm plans for a future visit as well as follow-up communication
with the woman that is documented in the patient record. The follow-up plan
serves to maintain open lines of communication for the patient while assuring
that she and her children remain safe.
PREGNANCY

• IPV during pregnancy is not rare. It is estimated that up to 20% of pregnant women
are victims of IPV and as many as 25–45% of battered women are battered during
their pregnancies.2, 22 The more severe the abuse is before pregnancy, the more likely
it is that abuse will continue and/or escalate during pregnancy. 3 Indeed, 29% of
battered women report an increase in abuse during pregnancy. One third of these
women seek medical attention related to their injuries during pregnancy.
• The National Family Violence Survey, which evaluated more than 6000 women,
reported that there were 154 acts of violence per 1000 women during the first 4
months of pregnancy and 170 acts per 1000 women during months 5 through 9. 7
 These data also suggest that a pregnant woman's risk of abusive violence is more
than 60% higher than that for a nonpregnant woman. 12 Fifty-five percent of women
abused during the last year prior to pregnancy experienced abuse during pregnancy.
10
• It is well known, however, that abuse during pregnancy poses
significant risks for both mother and fetus. The adverse effects of
abuse during pregnancy result from either direct or indirect causes.
Direct causes of adverse perinatal effects include abruptio placentae;
fetal fractures; rupture of the maternal uterus, liver, or spleen;
maternal pelvic fractures; and antepartum hemorrhage (Fig. 3).13
 Indirect effects include maternal stress, isolation of the mother and
inadequate health care, behavioral risks such as substance use, and
inadequate maternal nutrition (either secondary to emotional factors
or as part of the abuse cycle).
 For the practicing obstetrician/gynecologist, pregnancy presents a
unique opportunity to form a partnership with a woman for the
identification and assessment of IPV. Pregnancy may motivate women
to seek help from abusive relationships. It may also be the only time
that a woman seeks medical attention. The fetal consequences of the
abuse may be the factor that motivates the woman to take steps to
remove herself from the abusive situation.
MEDICOLEGAL CONSIDERATIONS

• All physicians are required to keep comprehensive medical records for

all patients, and these records must document the woman's report of
abuse.23 The records should contain the patient's statement about the
abuse, the medical findings, and the physician's opinion regarding the
physical findings.19 Photographs can be used; however, they must be
handled properly. In most circumstances they should be handled by
law enforcement specialists. They must also be kept in a sealed
envelope so that they can be admissible for courtroom use at a later
date, if necessary. Finally, under certain circumstances, a report must
be filed with the police
• Any cases in which children are involved in the abuse must be
reported by medical personnel. Other cases that must be reported
include attempted murder, assault with a deadly weapon, and other
potentially lethal incidents. US laws regarding the reporting of these
events vary from state to state and within municipalities. It is the
physician's responsibility to be aware of the particular reporting
requirements in his or her state of practice and/or community.