57610: Domestic Violence: The Florida Requirement for Dental Professionals

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Overview

Domestic violence continues to be a prevalent problem in the United States today. Because of the number of individuals affected, it is likely that most dental professionals will encounter patients in their practice who are victims. Accordingly, It is essential to recognize and accurately interpret behaviors associated with domestic violence. It is incumbent upon the dental professional to establish and implement protocols for early identification of domestic violence victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, dental professionals in all settings must take the initiative to properly assess all patients for abuse during each visit and, for those who are or may be victims, to offer education, counseling, and referral information.

Education Category: Ethics - Human Rights

Release Date: 08/01/2013

Expiration Date: 07/31/2016

Audience

This course is designed for all Florida dental professionals required to complete domestic violence education.

Accreditations & Approvals

CME Resource is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 10/01/2011 to 09/30/2015. Provider ID 217994. AGD Subject Code 156. CME Resource is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. CME Resource is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. CME Resource is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. CME Resource has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 1760 Old Meadow Road, Suite 500, McLean, VA 22102. In obtaining this approval, CME Resource has demonstrated that it complies with the ANSI/IACET Standard which is widely recognized as the Standard of good practice internationally. As a result of their Authorized Provider accreditation status, CME Resource is authorized to offer IACET CEUs for its programs that qualify under the ANSI/IACET 1-2013 Standard.

Designations of Credit

CME Resource designates this activity for 2 continuing education credits. This course meets the Dental Board of California's requirements for 2 unit(s) of continuing education. Dental Board of California course #02-3841-14135. CME Resource is authorized by IACET to offer 0.2 CEU(s) for this program.

Special Approvals

This course fulfills the Florida requirement for 2 hours of Domestic Violence education every third renewal period.

Course Objective

The purpose of this course is to enable dental professionals in all practice settings to define domestic violence and identify those who are affected by domestic violence in the United States. This course describes how a victim can be accurately recognized and identifies the community resources available in the state of Florida for domestic violence victims.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Define domestic violence.
  2. Cite the general prevalence of domestic violence on a national and state level and identify state laws pertaining to the issue.
  3. Describe how to screen and assess individuals who may be victims or perpetrators of domestic violence.
  4. Identify community resources presently available for domestic violence victims and their perpetrators throughout Florida.

Faculty

Marjorie Conner Allen, BSN, JD, received her Bachelor of Science in Nursing degree from the University of Florida, Gainesville, in 1984. She began her nursing career at Shands Teaching Hospital and Clinics at the University of Florida, Gainesville. While practicing nursing at Shands, she gave continuing education seminars regarding the nursing implications for dealing with adolescents with terminal illness. In 1988, Ms. Allen moved to Atlanta, Georgia where she worked at Egleston Children’s Hospital at Emory University in the bone marrow transplant unit. In the fall of 1989, she began law school at Florida State University. After graduating from law school in 1992, Ms. Allen took a two-year job as law clerk to the Honorable William Terrell Hodges, United States District Judge for the Middle District of Florida. After completing her clerkship, Ms. Allen began her employment with the law firm of Smith, Hulsey & Busey in Jacksonville, Florida where she has worked in the litigation department defending hospitals and nurses in medical malpractice actions. Ms. Allen resides in Jacksonville and is currently in-house counsel to the Mayo Clinic Jacksonville.

Faculty Disclosure

Contributing faculty, Marjorie Conner Allen, BSN, JD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

William E. Frey, DDS, MS, FICD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of CME Resource is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

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It is the policy of CME Resource not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

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57610: Domestic Violence: The Florida Requirement for Dental Professionals

INTRODUCTION

Domestic violence continues to be a prevalent problem in the United States today. Because of the number of individuals affected, it is likely that most dental professionals will encounter patients in their practice who are victims. Accordingly, it is essential that dental professionals are able to recognize and accurately interpret behaviors associated with domestic violence and to establish and implement protocols for early identification of victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, dental professionals in all settings must take the initiative to properly assess all patients for abuse during each visit and, for those who are or may be victims, to offer education, counseling, and referral information.

Victims of domestic violence suffer emotional, psychological, and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness, and injury. In some cases, the injuries sustained require abused victims to seek care from dental professionals immediately after their victimization, putting dental care providers in a critical position to identify domestic violence victims in a variety of clinical practice settings where victims receive care. Because dental prophylaxis appointments occur at a greater frequency than routine medical assessments, dental professionals may be the first healthcare contact for many victims.

DEFINING DOMESTIC VIOLENCE

Domestic violence, which is sometimes also referred to as spousal abuse, battering, or intimate partner violence (IPV), refers to the victimization of an individual with whom the abuser has or has had an intimate or romantic relationship. Researchers in the field of domestic violence have not agreed on a uniform definition of what constitutes violence or an abusive relationship. The Centers for Disease Control and Prevention (CDC) defines IPV as, "physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy" [1]. According to the Florida Department of Children and Families, domestic violence is "a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and control. It may include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner" [2]. Florida law defines domestic violence as "any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member" [3]. Family or household members, according to Florida definition, must "reside in the same single dwelling unit, with the exception of persons who have a child in common" [3]. Domestic violence knows no boundaries. It occurs in intimate relationships regardless of race, religion, culture, or socioeconomic status [2].

Whatever the definition, it is important for dental professionals to understand that domestic violence, in the form of emotional and psychological abuse, sexual abuse, and physical violence, is prevalent in our society. Because of the similar nature of the definitions, this course will use the terms "domestic violence" and "IPV" interchangeably.

NATIONAL AND STATE STATISTICS AND LEGISLATION

Domestic violence is one of the most serious public health problems in the United States [4]. More than 26% of women and 15.9% of men 18 years of age and older have a lifetime history of IPV [5]. Furthermore, in Florida, the weighted lifetime prevalence of IPV is 34.2% among women and 24.6% among men [4]. Although many of these incidents are relatively minor and consist of pushing, grabbing, shoving, slapping, and hitting, IPV resulted in 2,340 deaths in the United States in 2007, 214 of which were in Florida [6,7,8]. One of the difficulties in addressing the problem is that abuse is prevalent in all demographics, regardless of age, ethnicity, race, religious denomination, education, or socioeconomic status [2].

The health and economic consequences of domestic violence are significant. Statistics vary from report to report, and due to the lack of studies on the national cost of domestic violence, the U.S. Congress funded the CDC to conduct a study to determine the cost of domestic violence on the healthcare system [9]. The 2003 CDC report, which relied on data from the National Violence Against Women Survey conducted in 1995, estimated the costs of IPV by measuring how many female victims were nonfatally injured; how many women used medical and mental healthcare services; and how many women lost time from paid work and household chores. The estimated total annual cost of IPV against women in the 1995 survey was more than $5.8 billion [9]. When updated to 2003 dollars, the amount was more than $8.3 billion annually. The costs associated with IPV at this time would be considerably more [10]. It must be noted that the costs of any one victimization may continue for years; therefore, these statistics most likely underestimate the actual cost of IPV [9].

The national rate of nonfatal domestic violence against women declined between 1994 and 2010, dropping from 2.1 million violent crimes in 1994 to 907,000 in 2010 [11]. The rate of overall family violence also fell by more than half in this time period [12]. Studies reveal that several factors may have contributed to the reduction in violence, including a decline in the marriage rate and decrease of domesticity, better access to federally funded domestic violence shelters, improvements in women's economic status, and demographic trends, such as the aging of the population [13,14]. Of note, with the decline in the economy and stress associated with financial hardship and unemployment since 2008, there was a significant increase in the use of the National Domestic Violence Hotline in 2009, with more than half of victims reporting a change in household financial situation in the last year [15]. Furthermore, a 2012 press release from the Police Executive Research Forum reported a 56% increase in responding to domestic violence, which they partially attributed to the state of the economy [16].

FLORIDA

In 2012, the Florida Department of Law Enforcement (FDLE) reported 108,046 domestic violence offenses [24]. In general, domestic violence rates have been declining since 1998. Twenty percent of domestic violence incidents involved spouses and 29% involved cohabitants; 11% of the victims were parents of the offenders. Domestic violence offenses resulted in the death of 191 victims in Florida in 2012, a 6% increase compared to 2011 [24]. Domestic violence accounted for 19% of the state's murders in 2012 [24].

In their 2012 Annual Report, Fatality Review Teams summarized 64 cases of domestic violence that resulted in death or near death [21]. The most significant findings included the following observations [21]:

  • The perpetrators were predominantly male (83%) and had prior criminal histories, generally (60%) and for domestic violence specifically (48%).

  • 28% of perpetrators had a known "do not contact" order filed against them previously, of those with prior domestic violence criminal history 20% had been enrolled in a Batterers' Intervention Program (BIP).

  • The decedents (victims) were predominantly female (83%) and at some point lived with their abuser full time (67%). At the time of the incident, 30% of the decedents were separated from the perpetrator.

  • 63% of decedents had children and of those, 50% had a child from a different relationship.

  • 35% of the decedents had previously reported domestic violence to the police. In 29% of the cases, death threats made by the perpetrator were reported.

  • Substance abuse by the perpetrator was identified in 44% of the cases and mental health disorders in 28%.

  • Perpetrators committed or attempted to commit suicide in 59% of the cases.

  • In 25% of cases there was known contact between the Department of Children and Families (DCF) and the decedent or her/his family.

  • 16% of incidents included a collateral victim (i.e., a victim other than the decedent), excluding perpetrator suicides.

To obtain a copy of the 2012 Florida Domestic Violence Fatality Review Team Annual Report, please visit http://www.fcadv.org/sites/default/files/FACES%20OF%20FATALITY%20II.pdf. As of 2013, this was the most recent report available.

IDENTIFYING GROUPS AT RISK FOR DOMESTIC VIOLENCE

Dental professionals are in a critical position to identify domestic violence victims in a variety of clinical practice settings. They are often the first healthcare provider a victim of domestic violence will encounter and must therefore be prepared to provide care and support for these victims. Although women are most often the victims, domestic violence extends to others in the household as well. For example, domestic violence includes abused men, children abused by their parents or parents abused by their children, elder abuse, and abuse among siblings [3].

For every victim of abuse, there is also a perpetrator. Like their victims, perpetrators of domestic violence come from all socioeconomic backgrounds, races, religions, and walks of life [27]. Accordingly, dental professionals must likewise be aware that seemingly supportive family members may, in fact, be abusers.

PREGNANT WOMEN

According to the CDC, IPV affects as many as 324,000 pregnant women each year [25]. This represents approximately 8% of all pregnant women in the United States. As with all domestic violence statistics, this number is presumed to be lower than the actual incidence as a result of under-reporting and lack of data on women whose pregnancies ended in fetal or maternal death. This makes IPV more prevalent among pregnant women than some of the health conditions included in prenatal screenings, including pre-eclampsia and gestational diabetes [25]. Possible factors that may predispose pregnant women to IPV include young maternal age, unintended pregnancy, delayed prenatal care, lack of social support, and use of tobacco, alcohol, or illegal drugs [25].

The overarching problem of violence against pregnant women cannot be ignored, especially as both mother and fetus are at risk. At this particularly vulnerable time in a woman's life, an organized clinical construct leading to immediate diagnosis and medical intervention will ensure that therapeutic opportunities are available to the pregnant woman and will reduce the potential negative outcomes [29].

CHILDREN

Children exposed to family violence are at high risk for abuse and for emotional damage that may affect them as they grow older. The National Survey of Children's Exposure to Violence (NatSCEV), sponsored by the Office of Juvenile Justice and Delinquency Prevention and the CDC, included a nationally representative sample of 4,549 children and adolescents 17 years of age and younger and was designed to determine rates of exposure to family violence. Results of the NatSCEV indicated that more than 11% of children were exposed to IPV at home within the last year, and as many as 26% of children were exposed to at least one form of family violence during their lifetimes [31]. Of those children exposed to IPV, 90% were direct eyewitnesses of the violence; the remaining children were exposed by either hearing the violence or seeing or being told about injuries [31]. Of note, according to Florida criminal law, witnessing domestic violence is defined as "violence in the presence of a child if an offender is convicted of a primary offense of domestic violence, and that offense was committed in the presence of a child under age 16 who is a family or household member with the victim or perpetrator" [32].

A meta-analysis of 118 studies on the psychosocial outcomes of children exposed to domestic violence found that 63% of child witnesses exhibited more aggression, anxiety, difficulties with peers, and academic problems than the average child [33]. Children exposed to violence may also be more prone to dating violence (as a perpetrator or a victim) and the ability to effectively cope with partnerships and parenting later in life may be affected, continuing the cycle of violence into the next generation [34].

In addition to witnessing violence, various studies have shown that these children may also become direct victims of violence, as between 30% and 60% of husbands who batter their wives also batter their children [35]. Moreover, victims of abuse will often turn on their children; statistics demonstrate that 85% of domestic violence victims abuse or neglect their children. The 2012 Crime in Florida report found that more than 7% of domestic homicide victims were children killed by a parent [24]. Teenage children are also victimized. According to the U.S. Department of Justice, between 1980 and 2008, 17.5% of all homicides against female adolescents 12 to 17 years of age were committed by an intimate partner [36]. Among young women (18 to 24 years of age), the rate is 42.9%. However, abused teens often do not report the abuse. Individuals 12 to 19 years of age report only 35.7% of crimes against them as compared to 54% in older age groups [37].

Dentists are often the practitioners who have the most frequent interactions with children and therefore must be attentive to any signs of physical abuse, as abusive injuries involving the face, jaw, mouth, teeth, and tongue occur in more than half of child abuse cases [17]. During examination, injuries in various stages of healing and those that seem inappropriate for the child's developmental age should be noted. Dentists also have a legal and ethical responsibility to report suspected child abuse to the proper authorities. Accordingly, dental professionals who see young children and adolescents in their practice must have the tools necessary to detect these "silent victims" of domestic violence and to intervene quickly to protect young children and adolescents from further abuse. Without such critical intervention, the cycle of violence will never end.

ELDERLY

Abused and neglected elders, who may be mistreated by their spouses, partners, children, or other relatives, are among the most isolated of all victims of family violence. According to a Congressional report in 2011, 14% of noninstitutionalized older adults had experienced physical, psychological, or sexual abuse; neglect; or financial exploitation in the past year [38]. The number of elder abuse reports increased 200% between 1996 and 2004, and it is predicted to continue to increase as a result of the growing elderly population in the United States [39]. The prevalence rate of elder abuse in institutional settings is not clear. However, in one nonprobability study, 36% of nursing and aide staff disclosed to having witnessed at least one incident of physical abuse by other staff members in the preceding year. When asked whether they themselves perpetrated physical abuse against an elderly resident, 10% admitted they had [40].

As dental professionals in Florida, which leads the nation in percentage of older residents, it is important to understand that the needs of older Floridians will increase as will the numbers of elder victims of domestic violence. Because elder abuse can occur in family homes, nursing homes, board and care facilities, and even medical facilities, dental professionals must remain keenly aware of the potential for abuse. When abuse occurs between elder partners, it is primarily manifested either as a long-standing pattern of marital violence or as abuse originating in old age. In the latter case, abuse may be precipitated by issues related to advanced age, including the stress that accompanies disability and changing family relationships [41].

It is important to understand that the domestic violence dynamic involves not only a victim but a perpetrator as well. For example, an adult son or daughter who lives in the parents' home and depends on the parents for financial support may be in a position to inflict abuse. This abuse may not always manifest itself as violence, but can lead to an environment in which the elder parent is controlled and isolated. The elder may be hesitant to seek help because the abuser's absence from the home may leave the elder without a caregiver [41]. Because these elderly victims are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected. Dental professionals in all settings must remain aware of the potential for abuse and keep a watchful eye on this particularly vulnerable group.

MEN

Women are the predominant victims of IPV, and it is persuasively argued that the impact on the health of female victims of domestic violence is generally more severe than the impact on the health of male victims [18,42]. Approximately 7 million women are raped, stalked, and/or physically assaulted by an intimate partner each year, compared to 5.7 million men [4]. In addition, 3 out of every 10 women has been physically assaulted, raped, and/or stalked by an intimate partner in her lifetime, compared to 1 out of every 10 men [7].

However, there is evidence to suggest that individuals do exhibit violent behavior against their male partners [4]. Rape, non-contact unwanted sexual experiences, and stalking against men are primarily perpetrated by other men, while other forms of violence against men were perpetrated mostly by women [4]. Almost 5% of all male homicide victims in 2008 were killed by an intimate partner [36]. Of the 2,340 deaths attributed to IPV in 2007, 30% were of male victims [7]. Although women are more often victims of IPV, dental professionals must always keep in mind that men can also be victimized and assess accordingly.

SAME SEX COUPLES

Domestic violence exists in the gay and lesbian community, and the rates are thought to mirror those of heterosexual women, approximately 25% [30]. It is interesting to note, however, that women living with female intimate partners experience less intimate partner violence than women living with men [6]. Conversely, men living with male intimate partners experience more intimate partner violence than do men who live with female intimate partners [6]. This supports other statistics indicating that intimate partner violence is perpetrated primarily by men.

A form of abuse specific to the gay community is for an abuser to threaten or to proceed with "outing" a partner to others [30]. Because of the stigma of being gay, victims may be reticent to report abuse and afraid that their sexual orientation will be revealed. Many in this community feel that support services (e.g., shelters, support groups, crisis hotlines) are not available to them due to homophobia of the service providers. Unfortunately, this results in the victim feeling isolated and unsupported. Dental professionals should strive to be sensitive and supportive when working with homosexual patients.

CHARACTERISTICS OF PERPETRATORS OF DOMESTIC VIOLENCE

Abuser characteristics have been studied far less frequently than victim characteristics. Some studies suggest a correlation between the occurrence of abuse and the consumption of alcohol. A man who abuses alcohol is also likely to abuse his mate, although the abuser may not necessarily be inebriated at the time the abuse is inflicted [28]. Domestic violence assessment questionnaires should include questions that explore social drinking habits of both victims and their mates.

Other studies demonstrate that abusive mates are generally possessive and jealous, exhibiting signs of controlling behaviors and suspiciousness bordering on paranoia [27]. In addition, abusers often suffer from low self-esteem and their sense of self and identity is directly connected to their partner [27]. Extreme dependence is common both in abusers and those being abused. Due to low self-esteem and self-worth, emotional dependence often occurs in both partners, but even more so in the abuser. Emotional dependence in the victim stems from both physical and psychological abuse, which results in a negative self-image and lack of self-worth. Financial dependence is also very common, as the abuser often withholds or controls financial resources to maintain power over the victim [27].

SCREENING FOR DOMESTIC VIOLENCE AND ABUSE

There is no universal guideline for identifying and responding to domestic violence, but it is universally accepted that a plan for screening, assessing, and referring patients of suspected abuse should be in place at every dental facility. Guidelines should review appropriate interview techniques for a given setting and should also include the use of assessment tools. Furthermore, guidelines within each facility should include referral, documentation, and follow-up. The California Dental Association's Dental Professionals Against Violence Reference Manual includes the acronym RADAR to assist in the routine abuse screening of patients [19]:

  • Recognize signs and symptoms of abuse/neglect, routinely screen

  • Ask direct, non-judgmental questions with compassion

  • Document your findings

  • Assess patient safety

  • Review, refer, report

Several barriers to screening for domestic violence have been noted, including a lack of knowledge and training, time constraints, lack of privacy for asking appropriate questions, and the sensitive nature of the subject [35]. Although awareness and assessment for IPV has increased among dental providers, many are still hesitant to inquire about abuse [26]. At a minimum, those exhibiting signs of domestic violence should be screened.

Although victims of IPV may not display typical signs and symptoms of abuse, some common injuries are suggestive of abuse, and dental professionals should be vigilant in recognizing signs of abuse among their patients. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. Facial injuries are estimated to occur in 75% of intimate partner violence cases. Abuse victims are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen, particularly in combination with evidence of old injury, physical abuse should be suspected [28].

Again, dental visits may be a patient's only contact with healthcare professionals, making identification of abuse an important part of dental visits [19]. A history of intimidation, fear, isolation, and dependency is often present in victims of abuse, so it is especially important to determine the origin of orofacial injuries through the use of nonjudgmental questions.

In addition to physical signs and symptoms, domestic violence victims also exhibit psychological cues that resemble an agitated depression. As a result of prolonged stress, various psychosomatic symptoms that generally lack an organic basis often manifest. For example, complaints of backaches, headaches, and digestive problems are common. Often, there are reports of fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical.

The unique relationship dynamics of the abuser and abused are not easily detected under the best of circumstances. They may be especially difficult to uncover in circumstances in which the parties are suspicious and frightened, as might be expected when a victim presents to the emergency department. The key to detection, however, is to establish a proper assessment tool that can be utilized in the particular setting and to maintain a keen awareness for the cues described in this course.

ASSESSING DOMESTIC VIOLENCE AND ABUSE

Dental providers have reported that even if routine screening and inquiry results in a positive identification of IPV, the next steps of assessing and referring are often difficult, and many feel that they are not adequately prepared [26]. According to the FVPF, the goals of the assessment are to create a supportive environment, gather information about health problems associated with the abuse, and assess the immediate and long-term health and safety needs for the patient to develop an intervention [35].

Assessment of domestic violence victims should occur immediately after disclosure of abuse and at any follow-up appointments. Assessing immediate safety is priority. Having a list of questions readily available and well-practiced can help alleviate the uncertainty of how to begin the assessment (Table 1 and Table 2). If the patient is in immediate danger, referral to an advocate, support system, hotline, or shelter is indicated [35].

ASSESSMENT OF IMMEDIATE SAFETY FOR DOMESTIC VIOLENCE VICTIMS

Are you in immediate danger?
Is your partner at the health facility now?
Do you want to (or have to) go home with your partner?
Do you have somewhere safe to go?
Have there been threats or direct abuse of the children (if s/he has children)?
Are you afraid your life may be in danger?
Has the violence gotten worse or is it getting scarier? Is it happening more often?
Has your partner used weapons, alcohol or drugs?
Has your partner ever held you or your children against your will?
Does your partner ever watch you closely, follow you or stalk you?
Has your partner ever threatened to kill you, him/herself or your children?

STARTING THE DOMESTIC VIOLENCE CONVERSATION

Indirect Questioning

  • I am concerned that your symptoms/injuries may have been caused by someone hurting you.

  • I don't know if this is (or has ever been) a problem for you, but many of the patients I see are dealing with abuse/abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I have started asking about it routinely.

Direct Questioning

  • Did someone cause these injuries? Was it your parent/caretaker/partner/husband?

  • Are you in a relationship with (or do you live with) someone who physically hurts or threatens you?

  • Is it safe for you to go home?

If the patient is not in immediate danger, the assessment may continue with a focus on the impact of IPV on the patient's mental and physical health and the pattern of history and current abuse [35]. These responses will help formulate an appropriate intervention.

When working cross-culturally, it is helpful to learn the colloquialisms used to describe abuse. For example, in some Latino cultures "disrespected me" refers to intimate partner violence [19]. If abuse is suspected and there is a cultural disconnect, consider the assistance of a knowledgeable co-worker, who may be able to act as a cultural broker.

INTERVENTIONS FOR DOMESTIC VIOLENCE AND ABUSE

After the assessment is complete, the patient may or may not want immediate assistance or referral. It is important for dental providers to assure patients in a nonjudgmental manner that the decision of what they would like in terms of assistance is their choice and that the provider will help regardless of the decisions they are currently ready to make [35].

If the patient would like to immediately implement a plan of action, information for referral to a local domestic violence shelter to assist the victim and the victim's family should be readily available. The acute situation should be referred immediately to local law enforcement officials. Other resources in an acute situation include crisis hotlines and rape relief centers. After a victim is introduced into the system, counseling and follow-up are generally available by individual counselors who specialize in the care of battered women and their spouses and children. These may include social workers, psychologists, psychiatrists, other mental health workers, and community mental health services. The goals are to make the resources accessible and safe and to enhance support for those who are unsure of their options [35].

In Florida, a 24-hour domestic violence hotline is available for toll-free counseling and information. The number is 800-500-1119. The counselors answering the toll-free line may refer the victim to his or her local domestic violence center. A list of Florida certified domestic violence centers organized by county and city may also be found on the Florida Coalition Against Domestic Violence website at http://www.fcadv.org/centers. As of 2013, Florida had 42 certified domestic violence centers that provide information and referral services, counseling and case management services, a 24-hour hotline, temporary emergency shelter for more than 24 hours, educational services for community awareness relative to domestic violence, assessment and appropriate referral of resident children, and training for law enforcement personnel.

DOCUMENTATION AND FOLLOW-UP

It is imperative that dental professionals document all findings and recommendations regarding domestic violence in the victim's record, including a patient's denial of abuse, if applicable. If domestic violence is disclosed, documentation should include relevant history, results of the physical examination, findings of diagnostic procedures, and results of the assessment, intervention, and referral. The dental record can be an invaluable document in establishing the credibility of the victim's story when seeking legal aid [35].

Florida law mandates that dentists report any known or suspected cases of abuse against children and vulnerable adults, defined as the adult dependent on others for care (e.g., the elderly, those with developmental disabilities) [20,22,23]. Reports may be made to the Florida Department of Children and Family Service's central abuse hotline at 1-800-962-2873. Faxed reports may be submitted to 1-800-914-0004, and web reporting is available at http://reportabuse.dcf.state.fl.us.

Dental professionals should offer a follow-up appointment if disclosure of past or current abuse is present. Reassurance that assistance is available to the patient at any time is critical in helping to break the cycle of abuse [35].

CONCLUSION

Domestic violence will likely continue to be a significant problem in Florida. If abuse is to be prevented, dental professionals in all settings must educate themselves and assess all patients for abuse during each visit. For identified victims and perpetrators, prompt intervention and referral information are vital. Through these interventions, dental professionals can play a tremendous role in reducing and preventing domestic violence.

Complete for credit

Works Cited

1. Centers for Disease Control and Prevention. Intimate Partner Violence: Definitions. Available at http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/definitions.html. Last accessed May 22, 2013.

2. Florida Department of Children and Families. What Is Domestic Violence? Available at http://www.dcf.state.fl.us/domesticviolence/whatisdv.shtml. Last accessed May 22, 2013.

3. Florida Statutes. Section 741.28 (2011): Domestic Violence; Definitions.

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