1. Intimate Partner Violence and MST Case Studies

2. VETERANS HEALTH ADMINISTRATION Case Study 1 Anita, a 26-year-old Caucasian female whom you have never met, presents with asthma exacerbation. While doing a lung exam, you notice ecchymoses on her upper arms and back. You order a nebulizer treatment. While she is getting her treatment, you review her chart. Anita is married with three young children. She has been seen multiple times in the ER and at the urgent care clinic for various orthopedic complaints including knee pain, ankle sprain, wrist pain, and also for a head injury. Multiple clinicians document that they screened her for IPV, but she denied it. She has also been seen multiple times by one of your partners for chronic abdominal pain. That work-up has been negative. 2 2

3. VETERANS HEALTH ADMINISTRATION Once the nebulizer treatment is over and her breathing is improved, you return to the room and tell Anita that you noticed the bruising on her arms and back. Case Study 1, continued 3

4. VETERANS HEALTH ADMINISTRATION Q1: What opening statements would you use? 4

5. VETERANS HEALTH ADMINISTRATION Discussion How did you get the bruises? How are things going at home? Others? 5

6. VETERANS HEALTH ADMINISTRATION Q2: How would you broach the subject of IPV? 6

7. VETERANS HEALTH ADMINISTRATION I’m concerned that someone caused these injuries. Was it your partner/husband? Do you ever feel afraid of him? Does he ever kick, hit, or slap you? Do you feel that you are in danger? Looking at your record, I see that you have been seen multiple times for injuries. In cases like yours, I get concerned that your symptoms (injuries) may have been caused by someone hurting you at home. Others? Discussion 7

8. VETERANS HEALTH ADMINISTRATION Q3: What else would you include in the history? 8

9. VETERANS HEALTH ADMINISTRATION Discussion Elements that might increase her danger, for example: − Partner unemployed? − Partner substance abusing? − Firearm in the home? − Pattern of physical assaults or controlling behavior escalating in frequency over the past year? Screen for depression/PTSD Screen for alcohol and other substance use Screen for childhood abuse, family history of violence 9

10. VETERANS HEALTH ADMINISTRATION You tell Anita that it is common for someone with her history (chronic pain, multiple injuries) to be a victim of violence. She starts to cry and admits that when her husband drinks, he gets angry if she has not cleaned up after the kids or doesn’t have dinner ready. Then he hits her. He is always very sorry afterwards and promises it will never happen again. She now thinks that he is not going to stop, because it always happens again. No matter how careful she is and how hard she works, he always finds something that makes him angry. The violence has escalated and is occurring more frequently. He lost his job and is home all the time and drinking much of the time. Case Study 1, continued 10

11. VETERANS HEALTH ADMINISTRATION Anita has thought about leaving, but she doesn’t have a job and has 3 children under the age of 5. She is afraid that if she leaves, she will not be able to support herself and her children. She doesn’t think that she has anywhere else to go. She has not told anyone about the violence before now. Anita is embarrassed to tell her family because they told her not to marry him in the first place. Her husband is in the waiting room, and she’s scared that he will find out that she told you about the violence. Case Study 1, continued 11

12. VETERANS HEALTH ADMINISTRATION Q4. What can you do to help Anita? 12

13. VETERANS HEALTH ADMINISTRATION Discussion Validate her story. Reassure her that it is not her fault. Perform a risk assessment. Help her develop a safety plan. Provide local resources − Is it is safe for her to take a handout home? If not, problem- solve how to get her the information. 13

14. VETERANS HEALTH ADMINISTRATION Engage in motivational interviewing – what does she see as the pros and cons of staying with her husband? Offer referral to behavioral/mental health providers; Contact your VA SW or WVPM. Inform her if you will need to report this incident to the police (dependent on state law). Discuss what this will mean for your relationship. Discussion 14

15. VETERANS HEALTH ADMINISTRATION Case Study 2 Monica, a 28-year-old female, G1P0A1, presents with a complaint of dysmenorrhea. She’s asking for “something stronger than Midol”. She states that her menstrual cycles are regular, occur about every 30 days, and last about 6 days. Her Paps have been normal, however she admits to not getting one in at least 3 years. She has never used birth control. Her responses are abrupt and she brushes off questions that she sees as unrelated to her cramps. 15

16. VETERANS HEALTH ADMINISTRATION Q1: What additional information would be useful? 16

17. VETERANS HEALTH ADMINISTRATION Discussion Has she tried any other medication or treatments for cramps? Other symptoms? Why did her pregnancy not go to term? What age was she when she became pregnant? Is she sexually active?; − If so, is she monogamous? Is her partner monogamous? − What precautions does she take to prevent STI’s? Social history − Smoking, drinking, drugs? 17

18. VETERANS HEALTH ADMINISTRATION Case Study 2 (continued) 18 Monica becomes teary when asked about her pregnancy. She’s reluctant to talk about it and curls up into a ball in the chair. Your gentle probing elicits the information that she was raped by a fellow soldier about 18 months ago while in the military and had an abortion for the resulting pregnancy. She’s been dating a co- worker on and off for several months, and states “so far I haven’t let him touch me”. She denies smoking and drugs, and drinks a couple of beers every night to help her sleep.

19. VETERANS HEALTH ADMINISTRATION Q3: What tests might you want to perform? 19

20. VETERANS HEALTH ADMINISTRATION Discussion 20 Pap smear with HPV reflex testing STI cultures including trichomonas, Chlamydia, gonorrhea, bacterial culture

21. VETERANS HEALTH ADMINISTRATION Case Study (continued) 21 You tell Monica that it is time for her exam. You hand her the gown and cover, asking her to undress from the waist down placing the cover over her legs. Monica becomes very anxious and keeps glancing at the door. When you return to the room, she is lying on the exam table in a fetal position, enclosed by the cover.

22. VETERANS HEALTH ADMINISTRATION Q5: What could you have done to prepare Monica for the exam? 22

23. VETERANS HEALTH ADMINISTRATION Discussion While Monica was still dressed and in the chair: Describe the exam and Pap procedures Ask Monica what she anticipates will be the most difficult part Brainstorm with her about coping strategies Let her know that you will stop if she asks Explain the role of the chaperone 23

24. VETERANS HEALTH ADMINISTRATION Q6: What can you do to make Monica more comfortable during the exam? 24

25. VETERANS HEALTH ADMINISTRATION Discussion Ask the chaperone to employ distractions during the examination Ensure that Monica feels in control by asking permission before touching her Continue to let her know that you will stop if she asks Keep a running commentary of what will be happening Check periodically to ask how she is doing 25

26. VETERANS HEALTH ADMINISTRATION Q8. What can you do before Monica leaves your office? 26

27. VETERANS HEALTH ADMINISTRATION Discussion Validate her story. Reassure her that it is not her fault. Perform a risk assessment. Help her develop a safety plan. Offer referral to behavioral/mental health providers; Contact your VA social worker or WVPM. Provide local resources 27

28. VETERANS HEALTH ADMINISTRATION Many women will deny being abused over and over to health professionals before they are finally ready to admit it. It is especially important to tell women that the abuse is not their fault, that they doesn’t deserve to be treated this way, and that there are people who can help them. Wrap-up 28