If you treat women, whether in private practice or a hospital setting, you are almost certainly treating some patients who are victims of domestic violence.

The following decision tree is designed to help you assess a patient’s risk of domestic violence and offer appropriate help to those in need of it.

You may want to offer a statement such as: “Because violence is so common in many women’s lives, I’ve begun to ask about it routinely.” Then you can ask a direct question, such as: “At any time, has your partner hit, kicked, or otherwise hurt or frightened you?”

If the patient answers yes, the following steps are suggested:

1. Encourage her to talk about it:

   “Would you like to talk about what has happened to you?”
   “How do you feel about it?”
   “What would you like to do about this?”
   

2. Listen nonjudgmentally.

   This serves both to begin the healing process for the woman and to give you an idea of what kind of referrals she needs.

3. Validate.

   Victims of domestic violence are frequently not believed, and the fear they report is minimized. The physician can express support through simple statements such as:

   • You are not alone.
     
   • You don’t deserve to be treated this way.
     
   • You are not to blame.
     
   • You are not crazy.
     
   • What happened to you is a crime.
     
   • Help is available for you.
     

4. Document.

   • The patient’s complaints and symptoms as well as the results of the observation and assessment. (Complaints should be described in the patient’s own words whenever possible.)
   • The patient’s complete medical and trauma history and relevant social history.
   • A detailed description of the injuries, including type, number, size, location, resolution, possible causes, and explanation given.
   • An opinion on whether the injuries were inconsistent with the patient’s explanation.
   • Results of all pertinent laboratory and other diagnostic procedures.
   • Color photographs and imaging studies, if applicable.
   • If the police are called, the name of the investigating officer and any action taken (the police should be called only if patient requests this or exhibits a reportable injury).
   • Child abuse and neglect is a reportable offense. If you suspect that children in the patient’s home are also being abused, you are mandated to report the situation to the NYS Department of Social Services at 1-800-342-3720.

5. Assess the danger to your patient:

   Assess your patient’s safety before she leaves the medical setting. The most important determinants of risk are the woman’s level of fear and her appraisal of her immediate and future safety. Discussing the following indicators with the patient can help you determine if she is in escalating danger:

   • an increase in the frequency or severity of the assaults
   • increasing or new threats of homicide or suicide by the partner
   • threats to her children
   • the presence or availability of a firearm

6. Provide appropriate treatment referral and support:

   • Treat the patient’s injuries as indicated. In prescribing medication, keep in mind that medications which hinder the patient’s ability to protect herself or to flee from a violent partner may endanger he life.

   • If your patient is in imminent danger, determine if she has friends or family with whom she can stay. If this is not an option, ask if she wants immediate access to a shelter for battered women. If none is available, can she be admitted to the hospital?

   • If she doesn’t need immediate access to a shelter, offer written information about shelters and other community resources. Remember that it may be dangerous for the woman to have these in her possession. Don’t insist that she take them if she is reluctant to do so.

   Give your patient the telephone number of the local domestic violence hotline or the toll-free NYS Domestic Violence hotline (1-800-942-6906; 1-800-942-6908 for Spanish- speaking callers). It may be safest for your patient if you write the number on a prescription blank or an appointment card. You may wish to give her the opportunity to call from a private phone in your office.

   
   

If the patient answers no, or will not discuss the topic:

1. Be aware of clinical findings that may indicate abuse:

   • Injury to the head, neck, torso, breasts, abdomen, or genitals
   • bilateral or multiple injuries
   • delay between onset of injury and seeking treatment
   • explanation by the patient which is inconsistent with the type of injury
   • any injury during pregnancy, especially to the abdomen or breasts
   • prior history of trauma
   • chronic pain symptoms for which no etiology is apparent
   • psychological distress, such as depression, suicidal ideation, anxiety, and/or sleep disorders
   • a partner who seems overly protective or who will not leave the woman’s side

2. If any of the above clinical signs are present, it is appropriate to ask more specific questions. Be sure that the patient’s partner is not present. Some examples of questions that may elicit more information about the patient’s situation are:

   • It looks as though someone may have hurt you. Could you tell me how it happened?
   • Sometimes when people come for health care with physical symptoms like yours, we find that there may be trouble at home. We are concerned that someone is hurting or abusing you. Is this happening?
   • Sometimes when people feel the way you do, it’s because they may have been hurt or abused at home. Is this happening to you?

   If patient answers YES:
   

   See the suggestions for assessment and treatment above.

   If patient answers NO:

   If the patient denies abuse, but you strongly suspect that it is taking place, you can let her know that your office can provide referrals to local programs, should she choose to pursue such options in the future.

   You may want to write the New York State Domestic Violence hotline number (1-800-942-6906 English; 1-800-942-6908 Spanish) on a prescription blank or on an appointment card.

   Don’t judge the success of the intervention by the patient’s action. A woman is most at risk of serious injury or even homicide when she attempts to leave an abusive partner, and it may take her a long time before she can finally do so. It is frustrating for the physician when a patient stays in an abusive situation. Be reassured that if you have acknowledged and validated her situation and offered appropriate referrals, you have done what you can to help her.