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Family violence, including domestic violence, child abuse, elder abuse, and intimate partner violence (IPV), is a highly prevalent, serious, and potentially life-threatening public health concern. Intimate partner violence has been defined as "the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another."1,2
IPV is described as physical, sexual, or psychological harm inflicted by a current or former partner or spouse, which may occur with varying degrees of frequency and severity. Physical violence is commonly accompanied by emotional abuse and controlling behavior, which may include intimidation, deprivation, threats, social isolation, economic coercion, and stalking, as well as other forms of emotional/psychological abuse.1,3-5
IPV affects people of every walk of life, regardless of their age, socioeconomic status, sexual orientation, gender, race, religion, or ethnicity.1,4 In 2020, an estimated 10 million adults in the United States experienced IPV.1 In fact, one in four women and one in ten men will experience some type of sexual or physical violence and/or stalking by an intimate partner during their lifetime.1 Many survivors of IPV experience repeated abuse. IPV can result in physical injury, psychological trauma, and even death. Ultimately, the consequences of IPV can span generations and cause lifelong problems for survivors.1
Psychological Consequences and Risk Factors of IPV
Individuals who experience IPV are essentially survivors of trauma. Trauma can cause profound and lasting psychological changes and can alter the survivor's belief systems and views of the world itself, frequently overwhelming the individual mentally, emotionally, and physically.3The psychological harm that the individual sustains diminishes their ability to trust, hinders their ability to make decisions for themselves, and decreases their sense of safety, which can result in intense and pervasive fear.3
The COVID-19 pandemic has exacerbated the risk factors for IPV. These include unemployment, financial pressures, substance use, social isolation, depression, anxiety, and increased overall stress. The majority of instances of IPV are not reported because those who are experiencing domestic abuse tend not to seek help, owing to social isolation and fear of further abuse. Compounding this, measures implemented to reduce the spread of COVID-19 infection, such as sheltering in place and work and school closures, have further isolated survivors from seeking help. As a result, the prevalence of partner and child abuse has increased since the start of the pandemic.6
Assessment and Interventions
Trauma-informed care (TIC) is a holistic approach used to engage patients with a history of trauma. As such, TIC recognizes the presence of symptoms of trauma and acknowledges the role that trauma has played in the patient's life.3 TIC moves the focus from "What is wrong with you?" (ie, "What symptoms are you having?") to "What has happened to you?" (ie, "What has happened in your life that has influenced your health?")5,7 TIC also involves the awareness of and avoidance of healthcare approaches and practices that may potentially retraumatize the patient. Certain interactions and practices in the dental office can essentially "retrigger" the experience or symptoms of trauma and create a sense of vulnerability and powerlessness in the patient; one such clinical practice is having the patient lie down tilted backwards in the dental chair and touching them with dental instruments intraorally.7Using a TIC approach, the clinician will recognize that many of the patient's behaviors, such as displaying fear of routine dental care or engaging in negative health habits, may be directly related to previous traumatic experiences.8,9Creating an environment of confidentiality, safety, and trust is essential when providing care to a survivor of IPV.3,5,7
Screening and Assessment
Dental providers can play a vital role in identifying and documenting signs of IPV and offering IPV survivors support, resources, and referrals to national and community resources.9-11Although many survivors of IPV avoid seeking medical care, they are more likely to keep routine and emergency dental appointments.10Also, on average, patients visit their dentist more frequently than their primary care physician and often see the same dentist over their entire lifetime, whereas IPV survivors may visit a variety of medical doctors.9,10,12
Because 65% to 75% of the physical injuries sustained by IPV survivors are located in or on the head, neck, and/or mouth region of the body,9,12assessing for IPV can be easily incorporated into the comprehensive intraoral and extraoral cancer examination. Clinical signs and symptoms of IPV detectable in the dental office are included in Table 1.10,13
Obtain thorough histories of the injury from the patient in a private room, noting the date, time, and place of the examination. Record and document all observable facts, including the location, size, color, and other information about the injury or injuries, using diagrams, when possible. Pay close attention to varying colors of bruising, which may indicate that the injuries were sustained at different times. Record the questions that are asked during the history-taking as well as a written narrative using direct quotes that provide the patient's own words. The use of intraoral or extraoral photography and periapical or panoramic radiographs are helpful for documenting injuries. Depending on state mandatory reporting requirements, if the healthcare provider is required by law to report suspected abuse, these images may be obtained and released without the patient's consent.14,15
At the time of the assessment, the provider should disclose that mandatory reporting requirements may affect the limits of patient-provider confidentiality. The provider may be required by law to share documentation related to suspicious injuries with authorities.15 If the patient's injuries were determined to be a result of IPV, the provider is required by law to make a report, especially in the case of an injury from a gun, knife, or other deadly weapon.15 This disclosure creates an ethical dilemma and may compromise the confidential nature of the provider-patient relationship and patient privacy, and may undermine openness and trust.15Many states impose penalties for failure to report, but also provide healthcare providers with civil and/or criminal immunity from liability that might occur as a result.15
Questions regarding IPV are sensitive in nature, and patients may feel unable to disclose information about domestic violence, especially if they are accompanied by the abusive partner at the dental visit. In multiple studies of survivors of abuse, an estimated 70% to 80% of the patients studied stated that they would like their healthcare providers to speak with them privately when discussing IPV.1,4,16Therefore, offering the patient privacy and remaining nonjudgmental when asking questions about and assessing for signs and symptoms of IPV is considered a best practice.3 Incorporating a couple of questions about IPV into the health history interview is one way to open a dialogue on this sensitive topic.17Examples of questions the dental provider might ask include:
· "Are you in a relationship in which you have been physically hurt or threatened?"
· "Do you feel safe in your home?"
Two models have been developed to help medical and dental professionals screen adults for IPV: the ADVR (Ask, Validate, Document, and Refer) model (Table 2) 9,14,17-19 and a more recent tool, the CUES (Confidentiality, Universal Education, and Support) model (Table 3).1,20,21CUES is an evidence-based intervention to address IPV violence in healthcare settings that has been shown to improve health and safety outcomes for survivors.1,5,21
Finally, every dental office should have a written protocol for the documentation and reporting of abuse and neglect.14
Interventions / Providing Referrals
If violence is suspected, even if the patient does not disclose it, ask the patient if they feel safe returning home. Assure the patient that their privacy will be protected and confidentiality will be maintained.1,18Ask if there is someone to call for help or if they have an alternate, safer place to stay after leaving your office, and ask if there are children who might also be at risk.
If a patient reveals that they have experienced IPV, the role of a dental professional is to provide the patient with helpful resources, if it is safe to do so, (eg, if the patient's partner is not present).18 Before the patient leaves the dental office, the provider should help the patient understand their options so that they can decide their next course of action, which may include18,19:
· Talking with an advocate to discuss safety planning prior to leaving the abusive partner
· Staying at an emergency shelter
· Accessing hotline phone numbers or resource website addresses
The dental provider should always schedule a follow-up dental visit. In addition, he or she should ask the patient if it is safe for them to receive a follow-up phone call at their current place of residence.18
It is essential that the dental professional provide the patient with specific information on available national and community resources, including 24-hour telephone hotlines that provide crisis counseling, as well as online resources (Table 4). The provider should learn who are the contacts (and their availability) for domestic and sexual violence survivor advocacy organizations, including local emergency shelters, crisis lines, and medical facilities, and keep the list updated regularly.
IPV survivors state that they want healthcare providers to be nonjudgmental, to listen, to offer information and support, and not to push for disclosure.4,9According to a survey of women who had a past or current history of IPV, one of the most helpful interventions is being provided with information on resource options while having their autonomy respected and preserved; the least preferred intervention was "health provider reporting IPV to the police."4 Reporting the abuse may in fact escalate the violence for the IPV survivor and their children by putting them at risk for retaliation. 1,10,14 Having an effective safety plan in place prior to making a report is essential.18 The primary goal of the dental provider is to provide ongoing, supportive care, such as referring the patient to local shelters or emergency crisis agencies, addressing safety issues, and guiding the patient through their available options.15
Reporting Requirements
Several states have laws mandating that healthcare professionals report IPV. Licensed dental professionals have the ethical and professional responsibility to know the legal requirements currently in effect in their community, the agency that they should contact to report documented information, and the steps that must be taken to ensure safety for the patient and themselves, as an increase in violence and retaliation by the abuser may result when the survivor seeks outside help or attempts to separate from the abuser.1,10,14
Conclusion
Because IPV is a highly prevalent, serious, and potentially life-threatening public health concern, healthcare providers, including dental professionals, should be aware of and knowledgeable about the signs and symptoms of IPV, and should know how to address suspected cases and to use trauma-informed care practices to respond to survivors of IPV, which include approaching the patient in a confidential and nonjudgmental manner. In the healthcare setting, recognizing signs of abuse, accurate documentation of IPV during the health history interview, provision of information on or referral to intervention services, and following proper protocol are necessary to promote both the health and safety of IPV survivors. Dental providers need to be familiar with their state's laws regarding the reporting of abuse and should know who the proper authorities are to contact to report IPV. In addition, dental professionals should keep current, up-to-date resources such as "safety cards" available in the waiting room, operatories, and/or restrooms of the dental office or clinic; this may prove especially helpful for those who may not be ready to disclose that they are experiencing IPV or are in an abusive relationship. These safety cards can be ordered through the Futures Without Violence online store (see Table 4). Ultimately, the goal of the dental provider in helping a survivor of IPV is to improve their safety and empower them with the knowledge and resources to make their own choices and, most importantly, to break free from the violence in their lives.
REFERENCES
1. National Coalition Against Domestic Violence. Domestic violence. https://assets.speakcdn.com/assets/2497/domestic_violence-2020080709350855.pdf?1596811079991. Published 2020. Accessed December 21, 2021.
2. Beatty CF. Community Oral Health Practice for the Dental Hygienist. 4th ed. St. Louis, MO: Elsevier; 2017: 237-238.
3. Ferenick SD, Ramirez-Hammond R. Trauma-informed care: best practices and protocols for Ohio's domestic violence programs. Ohio Domestic Violence Network, Ohio Department of Mental Health. National Center on Domestic and Sexual Violence website. www.ncdsv.org/images/ODVN_Trauma-InformedCareBestPracticesAndProtocols.pdf. Accessed October 11, 2021.
4. Chang JC, Cluss PA, Ranieri L, et al. Health care interventions for intimate partner violence: what women want. Women's Health Issues. 2005;15:(1):21-30.
5. Chang K. Protocol for HRSA-supported community health centers to engage patients through universal education approaches on exploitation, human trafficking, domestic violence and intimate partner violence, Health Partners on IPV & Exploitation, Futures without Violence. www.IPVhealthpartners.org.
6. Lynch KR, Logan T. Assessing challenges, needs, and innovations of gender-based violence services during the COVID-19 pandemic: results summary report. San Antonio, TX: University of Texas at San Antonio, College for Health, Community and Policy. https://hcap.utsa.edu/criminal-justice/research/research-reports/covid-gender-based-violence-final-report-2/. Published 2021. Accessed December 21, 2021.
7. Palmieri J, Valentine J. Using trauma-informed care to address sexual assault and intimate partner violence in primary care. J Nurse Pract.2021;17(1):44-48.
8. University of Nebraska-Lincoln, Center on Children, Families, and the Law. Setting the tone: understanding domestic violence and a trauma-informed approach. https://ccfl.unl.edu/community-services-management/2018_Setting_the_Tone.pdf. Published 2018. Accessed October 11, 2021.
9. Jones ML, Francisco E. Addressing intimate partner violence. Dimensions of Dental Hygiene.2014;12(10):63-66.
10. Family Violence Prevention Fund. Enhancing dental professionals' response to domestic violence. https://www.ihs.gov/doh/portal/feature/DomesticViolenceFeature_files/EnhancingDentalProfessionalsResponsetoDV.pdf. Accessed January 14, 2022.
11. Burke S. Domestic violence, intimate partner violence, and elder abuse: know the basics. Responsibilities and intervention techniques for dental professionals. www.dentalcare.com/en-us/professional-education/ce-courses/ce593. October 23, 2019. Accessed January 20, 2022.
12. Raja S, Hoersche M, Fajagopalan CF, Chang P. Treating patients with traumatic life experiences: providing trauma-informed care. J Am Dent Assoc.2014;145(3):238-245.
13. Bump SS, Bhaskar DJ, Prunia H, Singh V, Kadtane SS. Intimate partner violence (IPV): how a dentist can play a role for victims of IPV? TMU J Dent.2014; 1(1):13-16.
14. Boyd LD, Mallonee LF, Wiche CJ. Wilkins' Clinical Practice of the Dental Hygienist. 13th ed. Burlington, MA: Jones & Barlett Learning; 2021:219-224.
15. Hyman A. Mandatory Reporting Domestic Violence by Health Care Providers: A Policy Paper. https://www.futureswithoutviolence.org/userfiles/file/HealthCare/mandatory_policypaper.pdf. Published November 3, 1997. Accessed January 14, 2022.
16. Nelms AP, Gutmann ME, Solomon ES, DeWald JP, Campbell PR. What victims of domestic violence need from dental professionals. J Dent Educ.2009;73(4):490-498.
17. National Health Resource Center on Domestic Violence. Get help. Futures Without Violence website. www.futureswithoutviolence.org/resources-events/get-help. Published 2021. Accessed August 30, 2021.
18. Henderson J. Enhancing dental professionals' response to intimate partner violence. CDEWorld website. https://cdeworld.com/courses/20365-enhancing-dental-professionals-response-to-intimate-partner-violence. Published 2015. Accessed December 21, 2021.
19. Henderson J. Incorporating trauma-informed practices to enhance the dental professionals' response to intimate partner violence (IPV). PowerPoint Presentation. Accepted for presentation by the Nevada Coalition to END Domestic and Sexual Violence.
20. Adopt the evidence-based CUES intervention to support survivors and prevent violence. IPV health website. http://ipvhealth.org/health-professionals/educate-providers. Published 2018. Accessed December 20, 2021.
21. The Evidence Behind CUES: An intervention to address intimate partner violence in health settings. IPV Health website. January 28, 2021. http://ipvhealth.org/wp-content/uploads/2021/08/Evidence-for-CUES_1.28.21.pdf Accessed January 20, 2022.
