aileen b. pascual, md 23 august 2009. “an act of gender-based violence that results in physical,...

Home is Where the Hurt Is

Aileen B. Pascual, MD23 August 2009

“An act of gender-based violence that results in physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty whether occurring in public or private life.”

UN Declaration on Elimination of VAW

Violence Against Women

Non-spousal violence

Sexual harassment and intimidation

Trafficking in women Forced prostitution Violence perpetrated

or condoned by the state such as rape in war

Spousal battering Sexual abuse of

female children Dowry-related

violence Rape, including

marital rape Traditional practices

harmful to women such as female genital mutilation

Violence Against WomenUN Declaration on Elimination of VAW

Cases of Violence Against Women 6,647 cases (2007) 7,864 cases (2008)

Cases Involving Violation of RA 9262 2,387 cases (2007) 3,599 cases (2008)

Philippine National Police Women and Children Protection Center (PNP-WCPC)

Cases Perpetrated by PNP Personnel 386 cases (2007)

◦ 294 resolved◦ 70 referred to WCPC◦ 22 referred to pre-charge investigation

Philippine National Police Women and Children Protection Center (PNP-WCPC)

Number of WEDC Served by DSWD,1998 to 2007 accessed from http://www.nscb.gov.ph/headlines/StatsSpeak/2008/090808_rav_wedc.asp#2

Number of WEDC Served by DSWD by Case Category, 1998-2007 accessed from http://www.nscb.gov.ph/headlines/StatsSpeak/2008/090808_rav_wedc.asp#2

Violence Against WomenUN Declaration on Elimination of VAW

Spousal battering Sexual abuse of

female children Dowry-related violence Rape, including marital

rape Traditional practices

harmful to women such as female genital mutilation

Non-spousal violence

Sexual harassment and intimidation

Trafficking in women Forced prostitution Violence perpetrated

or condoned by the state such as rape in war

J.V. 41/female, married housewife from Pandacan PGH-AMBU, 2nd time April 11, 2003

Chief Complaint: Chest Pain

General Data

History of Present Illness

1 month PTC:Hypertension

Unrecalled PRN medications

HypertensionDM Suspect

t/c CHF II prob 2nd to IHDCaptopril, Aspirin

OPD workup, follow-up

2 hours PTC:chest paindifficulty in breathingCaptopril

2 weeks PTC:nape pains,

dizzinessdifficulty of breathing

easy fatigability

Review of Systems

(+) anorexia(+) sore throat x 1 wk(+) palpitations(+) easy fatigability(+) similar episodes of

chest pain (+) occl. epigastric pain

(+) weight loss of ~5% in 3 months

(-) orthopnea(-) dyspnea(-) PND(-) edema(-) bloatedness(-) regurgitation

No history of diabetes mellitus, PTB, heart disease

No previous hospitalizations/surgeries No known food/drug allergies

Past Medical History

Family Medical History

60

45 41

21 16 9

5

V. FamilyApril 2003

- Hypertension

- Diabetes Mellitus

No heart disease, premature cardiac deathsNo bronchial asthma, cancer, goiter

Roman Catholic high school graduate, former factory worker married for the past 21 years to a

businessman with three children ages 21, 16, and 9

lives in a two-storey apartment in an urban community in Pandacan

nonsmoker, non-alcoholic beverage drinker no history of OCP use or illicit drug use

Personal & Social History

menarche at 18 y.o., RMI, lasting for about 7 days

with occasional dysmenorrhea LMP = March 2003 PMP = February 2003 G3P3 (3-1-0-3) all FT via SVD, with no

complications

OB-Gyne History

awake, conscious, cooperative, not in cardiorespiratory distress, agitated

BP = 110/80 88 18 36.8C BMI = 22pink palpebral conjunctivae, anicteric sclerae, no neck

vein engorgement(+) tonsillopharyngeal congestion(-) exudatesequal chest expansion, clear breath sounds, no rales,

no wheezesdistinct heart sounds, normal rate and rhythm, AB=PMI

at 5th ICS LMCL, no murmursabdomen soft, normoactive bowel sounds, no masses,

no tendernesspink nailbeds, full and equal pulses, no edema, no

cyanosis

Physical Examination

r/o Acute Coronary Event Hypertension Acute Tonsillopharyngitis, probably bacterial

Initial Assessment at the AMBU

12-L ECG done O2 inhalation at 2 LPM via nasal cannula

Complete resolution of symptoms even without intervention

Normal ECG

Initial Intervention

Marital problems at home Physically hurt by her husband Verbally abused by her husband

Re-history

awake, conscious, coherent, oriented to three spheres

Cranial Nerves: Motor: 5/5 on all extremitiesI – can smell Sensory: 100 % intactII, III – 3 mm EBRTL DTRs: ++ on all tendons, no

BabinskiIII, IV, VI – full EOMs Meningeals: supple neck

V – good masseter tone Cerebellars: no nystagmus/dysmetria

VII – no facial asymmetry no dysdiadokinesiaVIII – gross hearing intactIX, X – good gagXI – good shoulder shrugXII – tongue midline on protrusion

Neurologic Examination

oriented to time, place and person appropriately dressed in shirt and shorts, well-

kempt appears anxious, initially hesitant to answer

questions no auditory/visual hallucinations, no delusions intact remote, recent past memory, recent,

immediate memory good impulse control good insight and judgment

Mental Status Examination

Anxiety Hypertension Acute Tonsillopharyngitis, probably bacterial

Discharge Diagnosis

Problem Identified Plan

Anxiety Initial counseling doneSlow breathing exercisesRefer to Counseling service on OPD basis

Domestic Violence Validated my patient’s experienceSuggested referral to Women’s Desk (but

patient refused)Advised to stay with her mother for the time

beingRefer to Counseling service on OPD basis

Hypertension Advised OPD work-upDiscontinued medications, lifestyle modificationWOF: chest pain, difficulty in breathing

Acute Tonsillopharyngitis

Amoxicillin 500 mg TID for 7 daysIncreased fluid intake, warm saline gargle

Problems Identified

ListenBeing listened to can be an empowering experience for a woman who has been abused

Communicate belief“That must have been very frightening for you”

Validate the decision to disclose“It must have been very difficult for you to talk about this”“I am glad that you very able to talk about this today.”

Emphasize the unacceptability of violence“You do not deserve to be treated this way”

Responding to Disclosures of Violence Identifying Family Violence: A Resource Kit for General Practitioners in New South Wales

PHYSICAL FINDINGS

Dental traumaAny injury, especially to the head and neck (even

with a seemingly good explanation), and any fatal injury

Potential Clinical Indicators of AbuseEisenstat and Bancroft. 1999. Domestic Violence. NEJM Vol. 341 No. 12 886-892

GENERAL FINDINGSChronic abdominal, pelvic, or chest painSomatic disordersIrritable bowel syndromeChronic gynecologic symptomsSexually transmitted diseases and exposure to

human immunodeficiency virus through sexual coercion

Exacerbation of symptoms of a chronic disease such as diabetes, asthma, or coronary artery disease

Chronic joint or back pain, headaches, numbness, and tingling from injuries

Noncompliance with medical regimen


PSYCHOLOGICAL SYMPTOMS

Depression and suicidal ideationAnxiety symptoms and panic disorderEating disordersSubstance abusePost-traumatic stress disorder


FINDINGS DURING PREGNANCY AND CHILDBIRTH

Any of the aboveUnwanted pregnancyComplications such as miscarriage, low birth

weight of infant, abruptio placentae, premature rupture of membranes, and antepartum hemorrhage

Lack of prenatal care


INCIDENTAL FINDINGS

Delay in seeking treatment or inconsistent explanation of injuries

Repeated visits to the emergency department or clinic

Evasiveness of patient or jumpiness, fearfulness, or crying

Overly attentive or verbally abusive partnerIdentifiable social isolationAbuse of child or elderly adult in a household


Assessment of Immediate Safety

Assess the impact of the violence (past or

present) on the patient’s health

Assessment of the pattern and history of

current abuse

Health and Safety AssessmentNational Consensus Guidelines on Identifying and Responding to Domestic Violence. Family Violence Prevention Fund 2004

Provide validation

Provide information

Respond to safety issues

Make referrals to local sources

Reporting to law enforcement or social service agencies

Interventions with Victims of Domestic ViolenceNational Consensus Guidelines on Identifying and Responding to Domestic Violence. Family Violence Prevention Fund 2004

1st consult April 2003

2nd consult May 2003

3rd consult June 2003

4th consult July 2003

5th consult Sept. 2003

SO

Chest painSore throatDisclosure of abuse

Chest painDysuria110-130/80-90N bld chem

AsymptomaticNo complaints90-130/70-90



SAFET

Y

Safe living with mother

Safe living with mother

? Safety, went back to husband



ABUSE

21 years married, 10 years physically and verbally abused

No abuse done to children

Allegedly stopped

Allegedly stopped

Allegedly stopped

A

AnxietyHypertension ATP, bact.

AnxietyHypertensionUTI

Hypertension, controlledUTI, resolved

Hypertension, controlled

Hypertension, controlled

1st consult 2nd consult 3rd consult 4th consult 5th consult

1

Domestic ViolenceP> Validation Information Address Safety





2

AnxietyA>AnxietyP> slow breathing exercisesRefer: counseling

AnxietyA>AnxietyP> slow breathing exercisesRefer: MHR & counseling

Allegedly no more symptoms of anxiety

3

HypertensionA> HypertensionP> workuplifestyle modification

HypertensionA> HypertensionP> workuplifestyle modification

HypertensionA> HypertensionP> lifestyle modification

HypertensionA>HypertensionP> lifestyle modification

HypertensionA>HypertensionP> lifestyle modification

4

ATPA> ATP, bactP> Amoxicillin OFI, warm saline gargle

This problem has resolved.

1st consult

2nd consult

3rd consult

4th consult

5th consult

5

DysuriaA> UTIP> Cotrimoxazole OFIPerineal Hygiene

This problem has resolved

Address medical problems

Promote lifestyle changes for hypertension control

Keep patient coming up for follow up for continuous assessment and support

Short Term Goals

Family Genogram

60

45 41

21 16 9

5

V. FamilyApril 2003

- Hypertension

- Diabetes Mellitus

No heart disease, premature cardiac deathsNo bronchial asthma, cancer, goiter

Unattached Young Adult The Newly Married Couple The Family with Young Children The Family with Adolescents Launching Family Family in Later Years

Family Life Cycle

Family Structure◦Differentiation and Organization◦Boundaries and Hierarchies◦Accessibility to Outside Influence◦Adaptability

Exploring the Family SystemHamel, J (2006). Family Approaches to Domestic Violence: A Guide to Gender-Inclusive Treatment, Springer Publishing.

Each individual’s ability to cope with anger, stress and conflict

Family beliefs about anger and violence

Relationship Dynamics

The function of each person’s behavior in the family context

Exploring the Family SystemHamel, J (2006). Family Approaches to Domestic Violence: A Guide to Gender-Inclusive Treatment, Springer Publishing.

Discuss any parenting concerns in the partner abuse context

Assess the risk to and adult perception of the impact on children

Consider the risk to and children’s perception of the impact on their lives.

Consider children’s access to significant supportive others

Children and Parenting Management of the Whole Family when Intimate Partner Violence is Present:Guidelines for Primary Care Physicians 2006.

Other referral of children to therapeutic support services

Report children at risk to mandatory laws

Consider the patient’s level of fear about the children’s removal

Children and Parenting Management of the Whole Family when Intimate Partner Violence is Present:Guidelines for Primary Care Physicians 2006.

Threats of Suicide or Murder

Availability of Weapons

Controlling and Jealous Behavior

Use of Drugs and Alcohol

Depression

Lethality Assessment

Batterer’s Isolation

Escalation of Violence

End of the Relationship

Choking or Strangling

Lethality Assessment

Maximize the safety of the woman and her children

May include a fair amount of disclosure about the abuse

Plan to leave the situation safely should be developed

Identify resources available (extended family, interpersonal skills, involvement in the community)

Safety Planning

Guiding Principles in Making a Safe and Effective ResponseFSU Institute for Family Violence Studies, 2001

Regard the safety of the victim and her family as a priority.

Respect the autonomy of victims and their ability to make choices, such as whether or not to stay in the relationship for the time being.

Maintain an attitude that does threaten, blame or make judgments about the victim, the abuser or the choices that have been made

Never hold the victim responsible to staying in the abusive relationship.

Believe the victim and be willing to listen. Provide choices, not interventions. Be sure to let any potential victims (even

those who deny abuse) know three things:◦ “It is not your fault”◦ “You are not alone – this happens to many people”◦ “There is help available”

Guiding Principles in Making a Safe and Effective ResponseFSU Institute for Family Violence Studies, 2001

“ the goal of intervention may not be to cure or to solve the problem for the patient but to provide validation, support and information….”

Bantay Bata 163◦ 163

Women’s Crisis Center◦ 926-7744◦ 924-9315

DSWD Hotline◦ 0918-9122893

Philippine National Police◦ 117

Helplines The Haven, Alabang

◦ 807-1586 PGH Women’s Desk

◦ 524-2990◦ 521-8450 loc 3072

Dial-A-Friend◦ 525-1743◦ 525-1881

aileen b. pascual, md 23 august 2009. “an act of gender-based violence that results in physical,...

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