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revised September 10, 2012

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Signs of Abuse

Some of the signs and/or behaviours that may suggest abuse is taking place include:

  • History of recurrent trauma or "accidents"
  • Explanation of injuries does not match the physical symptoms
  • Minimizing injuries or blaming herself for her injuries (i.e., “I’m so clumsy”)
  • Delay in seeking care, particularly if pregnant
  • Injuries when pregnant, particularly to breasts and abdomen
  • Chronic illnesses that are unresponsive to treatment
  • Frequently missed appointments
  • Partner who is overly solicitous, answers questions on behalf of woman, and/or is unwilling to allow woman privacy
  • Family history of physical, sexual, or other abuse

When to Screen

Type of Visit
How Often
New Patient
  • At first visit
  • Yearly, during annual health exam, and/or
  • Whenever they disclose a new partner
Prenatal
  • First prenatal visit,
  • At least once per trimester, and
  • Postpartum visit
Emergency
  • At every visit.
Mental Health
  • At initial visit,
  • Yearly during annual health exam
Other visits
  • Whenever there are physical or behavioural signs of abuse, or
  • When client presents with chronic-somatic complaints
Adapted from Family Violence Prevention Fund (2004). Identifying and Responding to Domestic Violence: Consensus Recommendations for Child and Adolescent Health.

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Creating a Safe Environment

Offering a safe and secure environment for women to talk about the abuse is an important part of facilitating her disclosure. The following offers practical ways to foster a safe environment in your practice:

  • Create a patient-friendly office with access to community resources and up-to-date information on woman abuse and violence.
  • Offer a private space for interviewing/examining women. If husband is present, suggest reasons why it is necessary to see the patient in private (e.g., collection of a fresh urine specimen). Never ask about abuse when the partner is present.
  • Ensure there is access to appropriate translators (who are NOT family members, partners, children or friends).
  • Use a non-threatening tone and body language (e.g., sit at or below the woman’s level).
  • Be familiar with community supports and services for women experiencing abuse or violence

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Screening Questions

Asking women directly if they have experienced abuse remains the most important tool for identifying abuse or violence. Screening questions broadly fall within the following categories:

Framing Statements

Framing statements will help to open the dialogue of woman abuse as a health issue and should remain neutral. Examples include:

  • “Women often experience abuse as children, adolescents or adults and we have begun to realize how seriously this abuse affects women’s health and the health of her children. For this reason, we are asking all of our female patients about any episodes of abuse or violence they may be experiencing currently or have experienced in the past.”
  • “To help me better get to know my patients, I am asking everyone about their relationships so I can understand them better and be available to discuss any problems they - or you - may be experiencing.”

Indirect Questions

Indirect questions enable health care providers to inquire more personally about episodes of abuse or violence Examples include:

  • “How is everything at home? How does your partner treat you?”
  • “Do you ever feel afraid at home?”
  • “Every couple has conflicts…what happens when you and your partner disagree? Has there ever been a situation when you have been afraid or hurt?”
  • “I often see patients who are being hurt or threatened by someone they love. Is this happening to you?”

Direct Questions

If signs of abuse are present and/or responses to indirect questions raise suspicion of abuse or violence, follow up with direct screening questions, as appropriate. Examples include:

  • “Is your partner or anyone else making you feel unsafe or frightened now?”
  • “Has your partner ever frightened you or threatened to hurt you or your children?”
  • (If presenting with either acute or chronic symptoms) “When I see a woman with a condition like yours, it is sometimes because someone has hurt her. Is someone hurting you?”
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Reporting and Confidentiality

Reporting

When a woman discloses abuse and there are children in the home, the case must be referred to Peel Children’s Aid Society. For a more complete list of reporting responsibilities, please consult Ontario’s Child and Family Services Act.

The Child and Family Services Act is not meant to offer specific legal advice. If you have any questions or concerns about a case, you should contact a Children’s Aid Society in your area.

Confidentiality

  • Do not discuss or inform any person or authority that your patient has disclosed abuse without your patient’s verbal or written informed consent.
  • Do not pressure her to report/disclose her abuse to the police or any other person or authority.
  • Inform her of your professional obligation in this regard.

Limitations to Confidentiality:

Confidentiality cannot be guaranteed when:

  • The patient is actively suicidal or homicidal
  • There are child welfare concerns. The Child and Family Services Act supersedes the right to confidentiality.

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Documentation

What to Document

  • Description of the abuse, and how it occurred, in the woman’s own words.
  • Description of injuries (type, location, length, width, shape, color, depth, level of healing), including notation if sexual assault has occurred or is suspected
  • Emotional status
  • Treatment required
  • Any referral/consultations (written or verbal) given to patient
  • Follow-up plans made

How to Document

Use an Injury Location Diagram (58 KB, PDF) to help document the location of reported current or past abuse.

  • Mark with an X the location of any bruises, fractures, lacerations, burns, etc. Describe color, appearance and size of injury
  • Attach any diagrams or photographs taken to medical records
  • Use quotation marks if you are using the exact words of the victim

Disclaimer

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