Enhancing Dental Professionals’ Response to Intimate Partner Violence

Far from being a hidden stigma, intimate partner violence (IPV) is often quite visible, with 65% to 75% of the physical trauma sustained in these encounters resulting in injuries to the head, neck, and/or mouth.¹ While it would stand to reason that victims of IPV would avoid seeking care, one study reported that 70% to 81% of the patients studied said that they wanted their healthcare provider to ask them privately about IPV. However, the same study found that 87% of dentists do not screen for IPV even when injuries are present.² Because patients tend to trust their dentists and tend to keep dental appointments while avoiding other medical treatment, it is critical that dental professionals use their unique position to help those who have been victimized by an intimate partner or caregiver.

What is Intimate Partner Violence?

Intimate partner violence, or IPV as a social service agency would refer to it, is a pattern of assaultive and coercive behaviors that may include any of the following:

• Physical injury
• Psychological or emotional abuse
• Sexual assault
• Economic coercion
• Stalking

The abuser is someone who was, is, or wished to be involved in an intimate or dating relationship with either an adult or an adolescent, and can be either a man or a woman. The aim of the abuser is to establish power and control over the partner being abused.

How Common is Intimate Partner Violence?

According to the Centers for Disease Control, 35.6% of women and 28.5% of men in the United States report being physically or sexually abused and/or stalked by an intimate partner.³ Women are 5 to 8 times more likely than men to be victimized by an intimate partner; according to the Bureau of Justice Statistics, 84% of spousal abuse victims are female and 16% are men.⁴

According to the latest data from the National Coalition Against Domestic Violence (NCADV), an average of nearly 20 people per minute are physically abused by an intimate partner—more than 10 million men and women per year.⁵ The 2013 National Census of Domestic Violence Services, in which 1,649 local domestic violence programs in the United States and territories participated in a census about services provided during a 24-hour dedicated survey period, found that more than 20,000 phone calls were placed to local and state domestic violence hotlines in the United States and its territories, averaging 14 hotline calls every minute.⁶

In addition to the injuries sustained during a violent attack, physical and psychological abuse is linked to a number of physical health effects, such as:

• Frequent headaches
• Chronic pain
• Difficulty sleeping
• Poor mental health
• Asthma
• Arthritis
• Irritable bowel syndrome
• Stomach ulcers
• Diabetes
• Sexually transmitted infections

The annual costs of IPV exceed $5.8 billion, of which $4.1 billion is for direct medical and mental healthcare services.⁷ Emerging research indicates that hospital-based IPV interventions will reduce healthcare costs by at least 20%.⁸ However, only about 10% of primary care physicians currently screen for IPV during their standard new patient visit.⁹ Clearly, efforts to control the direct healthcare costs related to IPV should focus on early detection and prevention.

The Dynamics of the Intimate Partner Violence Relationship

Abusers and their victims come from all walks of life. From a demographic standpoint, there is no risk factor to which to point in terms of race/ethnicity, economic class, education level, occupation, age, physical ability, sexual orientation, or even personality traits. It is also not caused by genetic disposition, underlying illness, alcohol and/or drug use, anger or stress, the victim’s behavior, or any “problems” in the relationship. Rather, abusers learn their behavior through experience, interaction with, and observation of other abusers—in other words, abuse tends to be cyclical.¹⁰ The abuser makes a conscious decision to use power and control over the victim. His or her actions are systematic and deliberate (Figure 1). That is why education and intervention are both key to ending domestic violence.

Barriers to Leaving an Intimate Partner Violence Relationship

While it would seem intuitive for a victim to want to leave an IPV relationship, often it is not that easy. The victim is overwhelmed by the immediate physical and psychological trauma of the attack, and feelings of shame, denial, humiliation, guilt, low self-esteem, and helplessness often accompany a loss of trust in their own ability to make decisions and a loss of faith in other people. At the same time they may feel afraid of their partner, they may also feel protective of their partner as well, in hopes that the situation will improve, that the partner will change, because the partner is not abusive all the time. However, without intervention, not only do violent episodes tend to happen again, they also tend to escalate in intensity, and typically victims may leave seven to eight times before they perceive they are safe enough and establish enough resources to make the break.¹¹ If the victim has a disability of any kind, it can take twice as long to leave the abuser because of increased physical, economic, social, or psychological dependence on others, or because of fear of losing health insurance coverage, fear of institutionalization, being physically restrained when confined to a wheelchair, and/or having no access to a doctor, caregiver, and/or medication.¹² It is a well-known fact in the social services profession that the most dangerous time for a domestic abuse victim is when they decide to leave the relationship.¹³

Why Do Providers Not Ask Patients If They Suspect Intimate Partner Violence?

The reasons dental healthcare providers do not ask their patients about IPV, even when they suspect a patient may be a victim, are varied. In many cases the partner or the patient’s child is present with the patient during the examination, and opportunity does not present itself. Some providers fear that asking will take too much time, when the reality is that early intervention takes less time than addressing repeated and long-term consequences of unrecognized abuse. Some providers do not keep a list of local referral agencies in their practices.

But perhaps the most common—and easily rectified—reason dental healthcare providers do not ask their patients if they have been a victim of IPV is lack of education and awareness, which in turn leads to a lack of practice experience on how to intervene when IPV is discovered.

This is unfortunate, in light of a recent study that found that 44% of victims of IPV talked to someone about the abuse, and 37% of those women talk to their healthcare provider.¹⁴ Additionally, in four separate studies of abuse,^2,15-17 70% to 81% of the patients studied reported that they would like their healthcare providers to ask them privately about IPV.

The AVDR Approach to Identifying a Victim of Intimate Partner Violence

The AVDR approach is a four-step process that any healthcare provider can follow to identify and help a victim of IPV. These four steps are as follows:

• Ask about the abuse, sending the message that IPV is a healthcare issue.
• Validate that abuse is wrong, removing the blame from the victim and confirming the patient’s sense of worth.
• Document the presenting signs, symptoms, and disclosures in writing and with photographs to create a written record of the abuse.
• Refer victims to IPV specialists in the community.

The “Ask” Step

Communicate with victims in an empathetic, nonjudgmental manner. Research shows that asking in a caring manner takes the blame off the victim, lessens the victim’s fears and shame, and leaves openings for disclosure. Remember to use a nonjudgmental tone and language, talk in a private setting, and do not use the patient’s family members as interpreters. Some examples of questions to ask include, “Sometimes when I see injuries like these, the person is being hurt by someone. Is anyone hurting you?” or “It looks like you’ve been hurt by someone and I am concerned about you. How are things for you at home?”

The “Validate” Step

Provide validating messages that show compassion and take the blame off the victim. Research shows that validating statements help victims of IPV change their situation.¹⁸ Victims report that even when they do not disclose abuse, validating statements can make a difference. Examples of validating statements include, “Everyone deserves to feel safe at home,” “No one deserves to be hit or hurt,” and “You do not deserve the abuse, no matter what has happened.”

The “Document” Step

Dental professionals document the presenting signs and symptoms of abuse as well as any disclosures about the abuse by the victim. Remember to document all five indicators of abuse: location, size, duration, color, and shape of the injury or injuries.

The “Refer” Step

Have a list of local domestic violence resources to which you can refer your patients in need, and always offer those referrals in complete privacy. For emergency safety services, support, and shelter, call the state or national hotline and speak with an advocate to locate a program in your geographic area. Hotlines provide crisis intervention, information, referrals, and safety planning. All hotlines are toll-free, confidential, anonymous, and operate 24 hours a day, 365 days a year. The phone numbers for the national hotlines are as follows:

• National Domestic Violence Hotline: 800-799-SAFE (7233); 800-787-3224 (TTY); www.thehotline.org
• National Sexual Assault Hotline: 800-656-HOPE (4673); www.rainn.org
• National Sexual Violence Resource Center: 877-739-3895; www.nsvrc.org
• National Center for Victims of Crime, Stalking Resource Center: 800-394-2255; www.ncvc.org/src
• National Dating Abuse Helpline: 866-331-9474; www.loveisrespect.org

Knowing the Signs of Intimate Partner Violence

The entire dental team should be engaged and involved in identifying potential victims of IPV. (See Table 1 for the common signs of dental neglect that could be an indicator of IPV, and see Table 2 for the ways in which IPV can affect a patient’s continuum of care.) Educate every staff member on the following guidelines to become more aware of the signs of potential abuse:

• Observe patients walking into the office and how they behave in the waiting area.
• Is the patient in pain or discomfort as they walk? Or as they sit in the dental chair?
• Does the patient have any swelling or bruising around the face?
• Are there any bald spots on the scalp where the patient’s hair was traumatically removed or pulled?
• Look at the patient’s hands. Are there any cigarette burns, or burns from scalding water?
• Does the patient exhibit any oval-shaped abrasions or lacerations that might indicate bite marks?
• Is the patient overdressed for the current weather? Long sleeves and long pants may be covering up injuries to arms and legs.
• Does the patient appear dirty, disheveled, or malnourished?
• Was there an obvious delay in seeking treatment?

Intervention Basics

Privacy and Confidentiality

There are some basic guidelines to follow when deciding to intervene on a patient’s behalf when IPV is suspected.

First and most important is to speak to the patient privately, and provide a safe environment for disclosure. If the practice has open operatories, find a private office to bring the patient for a discussion.

The intervention itself need not last more than 5 to 10 minutes, just long enough to gather information to ascertain if next steps are needed in terms of getting the patient assistance from social services. Assure the patient that his or her privacy will be protected and confidentiality will be maintained. Listen to the patient carefully, and respond to his or her feelings in a supportive and nonjudgmental manner. It is very important that the patient feel safe and comfortable enough to confide in you as a healthcare provider, so be very careful the tone of voice and phrases you use.

It is critical to never ask a family member or a child to interpret for the victim, even if their native language is not English. There is no way to know what family member is the abuser, and children may also be victims themselves.

If the patient responds positively to screening questions (see below for examples), acknowledge that disclosing this information is scary for him or her, and then make appropriate referrals based on the patient’s needs and wants. Some possible ways to phrase screening questions include:

• “We are now asking all of our patients about violence at home because it has become so common. Are you in a relationship where you are threatened physically, emotionally, psychologically, or in which love and attention are withheld?”
• [If the patient answers yes] “I want to thank you for telling me. I want you to know that you are not to blame. You are not alone, and you do not deserve to be treated this way. We are here to help you. We can provide you with nearby resources to help you.”
• “Are you safe at home? Have you been threatened with a knife or gun? Do you have a safe place to go? Can I help you with police assistance?”

Office Environment and Phrasing

Consider making any changes to the physical environment of the practice that may make IPV patients more comfortable, and be sure to have literature available in languages other than English. During the reminder call, invite these patients to bring anything that might add to their comfort during the procedure (eg, music, an audiobook, a pillow or blanket, lavender oil for the bib, etc.).

When the patient arrives, greet him or her by name, and be sure to provide your and your staff’s relaxed, unhurried attention. Encourage the patient to ask the staff any questions about the current or upcoming procedures, and if necessary for comfort, allow him or her to keep the x-ray apron on or hold his or her hand while in the chair. Be flexible about having a support person, such as a friend or family member, in the operatory with the patient—as long as it can be established that the support person is also not the abuser. Talk over any concerns and explain the procedures thoroughly before beginning treatment, and validate any concerns the patient might have as understandable and normal. Give the patient as much control and choice as possible about what happens and when, and always ask for consent before proceeding to the next step.

It is very important to note that victims of sexual assault may feel anxious about lying back in a dental chair or having instruments in their mouth, so try to minimize this time. Be careful about how you phrase some statements, such as “Open wide,” “Relax, it will be over soon,” as these can also bring back memories of past assault. Remember that victims who have experienced forced oral penetration may be nervous about the use of instruments in their mouth.

If the operatory is outfitted with a television set, allow the patient to choose the channel. If the patient asks for sedatives, offer options and choices such as meditation techniques, non-narcotic medication, or a CD on visualization or meditation. If the patient was drugged or given alcohol as part of the assault or abuse, they may not want to take any medication that alters the way they feel or cause them to feel a loss of control.

Encourage the patient to ask questions. Ask the patient if he or she is worried about any aspect of the examination or procedure. If the practice has closed-door operatories, ask if the patient might feel safer with the door open, closed, or ajar. Be sure to ask if the patient is ready to begin, and make sure it is clear that he or she can pause or end the examination or procedure at any time. Make sure that any local anesthetic is taking effect before starting to work. Keep talking to the patient throughout the appointment and let him or her know what you are doing and why, and what you will be doing next, so as not to startle or scare the patient.

Before the patient leaves the office, provide him or her with options and resources. When a victim of IPV knows his or her options, they can decide their next course of action, which can include:

• Calling the police
• Talking with an advocate to discuss safety planning prior to leaving the abuser
• Looking into staying at an emergency shelter
• Taking related brochures, hotline phone numbers, and website addresses
• Doing nothing

Document as much information as possible in the patient’s chart, including any results from any intervention conversations that take place. Decide whether or not to file a report with law enforcement and social service agencies—but always remember the patient’s safety first. Make sure to schedule a follow-up visit before the patient is sent home.

After the appointment, the treating dentist should make a follow-up call to the patient to determine the immediate outcomes of the treatment, but always ask the patient if it is safe for him or her to receive this phone call at their current location.

IPV Intervention DON’Ts

Relationship violence is serious. Some may wish to lighten the mood during this uncomfortable conversation, but IPV or any other kind of abuse should never be joked about. Do not try to minimize the issue or try to change the subject, especially if the signs are extremely clear that the patient in front of you has been abused in any way.

Do not ever ask about or discuss your suspicions of abuse in front of the suspected perpetrator, or the victim’s children or other family members without the patient’s clearly expressed consent. Do not give advice or try to dictate what you believe to be an appropriate response; do not shame or blame the patient for his or her circumstances. Do not grill the patient for excessive details about the abuse; only the basic facts are sufficient for reporting and referral purposes.

Documentation of IPV Patients

The patient chart, including any records and reports relating to suspected or reported IPV, can become important court documents that will support a victim’s case in criminal, civil, and protective order hearings; therefore, it is critical that the patient chart and any other records are as clear and complete as possible. The contents of an IPV patient chart should follow these guidelines:

• The situation should be described objectively, including observations, descriptions, and information on incidents of trauma.
• Any reports made should be supplemented with narrative descriptions and statements.
• Any emergency examinations should be thoroughly detailed—history, oral examination, radiographs (periapicals, bitewings, panographs).
• Measurements, drawings, body map (ie, the head and neck area), and photographs will speak for themselves.
• The clinical diagnosis.
• The treatment indicated, including charting of soft and hard tissues of the head and neck.
• Documentation of referrals to other healthcare providers, domestic advocacy organizations, and other resources used (hotlines, websites, etc.).
• If possible, to illustrate pre- and post-trauma comparison, periapical radiographs of individual teeth and panoramic radiographs of the head; any plaster or stone study models if the patient had restorative or orthodontic treatment; intra- or extraoral photographs (if the trauma is inside the mouth, intraoral color photographs).

Ethical Considerations in the Reporting Process of IPV

Several professional associations¹⁹ have argued against mandated reporting for a variety of reasons. It circumvents doctor-patient confidentiality, which can prevent candid discussion and may be a deterrent to victims seeking care. The victim may misconstrue the obligation of the healthcare provider to report the abuse as a reduction of personal power when he or she already feel vulnerable, and it may not ultimately improve their situation; in many cases, it may actually escalate the violence for the victim and his or her children by putting them at risk for retaliation.

For the healthcare provider, whether dental or medical, mandated reporting compromises the integrity of the provider’s relationship with the patient by going against a principle tenet of all medicine—that of “informed consent.”

Furthermore, reporting a case of IPV to law enforcement does not guarantee an appropriate response that meets the survivor’s safety and survival needs. In some states, such as the author’s home state of Nevada, perpetrators may be released within 12 hours of their arrest.

IPV survivors are overwhelmingly against mandatory reporting. In one survey, all participants said their injuries would have to be life threatening before they would see a doctor due to the mandatory reporting law.²⁰

National Dental Resources for Victims of IPV

Association Programs

There are a number of resources in the dental profession aimed at helping oral healthcare providers respond to the needs of patients who are victims of IPV. The American Dental Association has written position statements on how to recognize and respond to IPV in a dental health setting, and the Prevent Abuse and Neglect through Dental Awareness program educates dentists about how to effectively intervene in cases of child and elder abuse/neglect and IPV. The American Academy of Cosmetic Dentistry provides free cosmetic dental care for survivors of IPV through its “Give Back a Smile” program. Launched in May 1999, the program consists of plastic surgeons, oral surgeons, and advocacy organizations as well as dental laboratories and manufacturers working in teams to provide care to IPV victims.

Dental Publications

A number of textbooks and journal articles have been published on this topic, and are recommended by the author for further reading:

• The Dental Assistant’s Role in Preventing Family Violence. By Lynn Douglas Mouden, DDS, MPH, FICD, FACD. Published in 2010.
• Instruction in Dental Curricula to Identify and Assist Domestic Violence Victims. By Joan Gibson-Howell, RDH, EdD, et al. Journal of Dental Education. Published in November 2008.
• Family Violence: An Intervention Model for Dental Professionals. By Kristin Little. U.S. Dept. of Justice OVC Bulletin. Published December 2004.
• Silence is Deadly: The Dentist’s Role in Domestic Violence Prevention. By Antwanette Newton. AGD Impact. Published June 2008.
• Dental Professional Response to Oral Conditions and Domestic Violence, Abuse, and Neglect. Margaret I. Scarlett, DMD.
• What Victims of Domestic Violence Need from the Dental Profession. Amy P. Nelms, et al. Journal of Dental Education. Published January 2009.
• Dental Students and Intimate Partner Violence: Measuring Knowledge and Experience to Institute Curricular Change. Pamela D. Connor, et al. Journal of Dental Education. Published 2011.
• AVDR Tutorial for Dentists. Free DVD developed by the UCSF School of Dentistry. To order, visit the Futures Without Violence website www.futureswithoutviolence.org and click their online store.

Conclusion

IPV is a serious problem that requires a serious response from all healthcare providers, including dental healthcare providers. When you commit your practice and your staff to creating a supportive environment for all of your patients, you create a safe space for any victim of IPV to be more easily identified and helped.

Begin by trying a routine assessment for IPV at your dental office or clinic for one week. Document the assessment using a rubber stamp on clinical records, or add the information to the patient’s chart. From there you and your staff can create an IPV protocol, or review and amend an existing protocol for the office or clinic setting.

Place victim “safety cards” in the restrooms, waiting room, and/or operatories for those who may need information but may not be ready to disclose their situations. These safety cards are small enough to fit in a cell phone case, and can be ordered through many of the hotlines.

Get everyone on the staff, including front desk and office support staff, involved by organizing trainings on IPV assessment and intervention. Invite a domestic violence advocate to speak at brown-bag lunch training.

Advocate to local and state legislators, asking them to take a close look at IPV as not just a social issue but a healthcare issue, and how it affects work, school, society, and the provision of medical and dental services. Advocate to dental schools to add IPV assessment and intervention to the curriculums, as well as offerings to continuing dental education. 

Finally, remember that the goal of the encounter with a patient who has been a victim of IPV is to enhance their safety and empower him or her with knowledge and resources so they can make their own choices and decisions and take the steps to break free from the violence in their lives.

References

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About the Author

Judy Henderson is with the Nevada Network Against Domestic Violence in Reno, Nevada.

Acknowledgment

The author would like to thank Julie A. Stage-Rosenberg, RDH, MPH, professor/educator at Truckee Meadows Community College, Reno, Nevada, for her assistance with the preparation of this manuscript.