When a Patient With a Black Eye Claims Everything Is Fine: Detecting Domestic Violence

Batya Swift Yasgur, MA, LMSW

Disclosures

January 28, 2015

In This Article

When Domestic Violence Appears in Your Office

It's a Monday morning, and you notice something unusual about a patient who comes to your office with flu-like symptoms. She has a black eye, which she says was caused by bumping into a closet. On the basis of past conversations, you're sure she was assaulted by her husband, and you know you have an ethical responsibility to report suspected intimate partner violence—and in many states, a legal obligation to do so—but what happens if the patient denies it?

That quandary is not uncommon. Medscape's 2014 Ethics Survey asked physicians, "Have you ever suspected domestic abuse of a patient but not reported it or investigated further?" Eleven percent of the more than 21,000 respondents said yes. Some elaborated:

"I have always made sure to ask the patient in private, but if they lied to me, there's nothing I can do."

"Often the suspicion is based on multiple chronic complaints, and not objective findings. If the patient does not endorse abuse, you have no grounds for instigating investigation."

"I suspected it, but the patient denied it. I observed closely but found no additional evidence, so I did not report it."

"The patient told me her boyfriend beat her up and that if I reported it, he would kill her three children, whom he was watching at the time of her ER visit. I had to promise this so that the patient would agree to be treated. Sad."

One expert says that in such cases, while you shouldn't give up and move on, at the same time you don't want to come across as overbearing.

"Do take 'no' for an answer," says Barbara Gerbert, PhD, professor emeritus, University of California at San Francisco, Division of Behavioral Science. "Your job isn't to badger the patient until she breaks down and admits it. Gently backing off is important, so that she feels safe. But keep asking, at every visit." It may take years before the woman acknowledges the abuse, and even longer before she's willing to leave the relationship. Keeping phone numbers and resources in the bathroom will give the patient the opportunity to peruse them in private. "I call this the 'planting seeds approach,'" Dr Gerbert says.

In states where it's mandatory to report suspicious injuries, such as California, some doctors are very open with patients about their legal obligation. "I've never had a patient clam up or shut down because of this. In fact, any time I've had to report, the woman has appreciated it," says Catherine Gutfreund, MD, of the Department of Family Medicine, and Domestic Violence Lead Physician, Kaiser Permanente, Santa Rosa, California.

In many cases, telling the woman that the injury must be reported can remove the denial and open up the discussion.

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