IPV and violence against woman Flashcards
Women who disclose any form of violence by an intimate partner (or other family member) or sexual assault by any perpetrator should be offered immediate support
a Health-care providers should, as a minimum, offer firstline support when women disclose violence
What are the first line supports according to the WHO ?
First-line support includes:
• being non-judgemental and supportive and validating what the woman is saying
• providing practical care and support that responds to her concerns, but does not intrude
• asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved)
• helping her access information about resources, including legal and other services that she might think helpful
• assisting her to increase safety for herself and her children, where needed
• providing or mobilizing social support
Providers should ensure:
• that the consultation is conducted in private
• confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting)
How do we identify woman with IPV?
“Universal screening” or “routine enquiry” (i.e. asking women in all health-care encounters) should not be implemented
Health-care providers should ask about exposure to intimate partner violence when assessing conditions that may be caused or complicated by intimate partner violence
Written information on intimate partner violence should be available in health-care settings in the form of posters, and pamphlets or leaflets made available in private areas such as women’s washrooms (with appropriate warnings about taking them home if an abusive partner is there).
What can be offered to help woman with IPV?
Women with a pre-existing diagnosed or partner violence-related mental disorder (such as depressive disorder or alcohol use disorder) who are experiencing intimate partner violence should receive mental health care for the disorder
Cognitive behavioural therapy (CBT) or eye movement desensitization and reprocessing (EMDR)c interventions, delivered by health-care professionals with a good understanding of violence against women, are recommended for women who are no longer experiencing violence but are suffering from posttraumatic stress disorder (PTSD).
Women who have spent at least one night in a shelter, refuge or safe house should be offered a structured programme of advocacy, support and/or empowerment.
Pregnant women who disclose intimate partner violence should be offered brief to medium-duration empowerment counselling (up to 12 sessions) and advocacy/support, including a safety component, offered by trained service providers where health-care systems can support this.
Where children are exposed to intimate partner violence at home, a psychotherapeutic intervention, including sessions where they are with, and sessions where they are without their mother, should be offered,
First line support within 5 days of the assault
- providing practical care and support, which responds to her concerns, but does not intrude on her autonomy
- listening without pressuring
- offering comfort
- offering information, and helping her to connect to services and social supports.
Take a complete history, recording events to determine what interventions are appropriate, and conduct a complete physical examination (head-to-toe including genitalia).
The history should include:
• the time since assault and type of assault
• risk of pregnancy
• risk of HIV and other sexually transmitted infections (STIs)
• mental health status.
Emergency contraception
Offer emergency contraception ASAP
Health-care providers should offer levonorgestrel, if available. A single dose of 1.5 mg is recommended, since it is as effective as two doses of 0.75 mg given 12–24 hours apart. If levonorgestrel is NOT available, the combined oestrogen–progestogen regimen may be offered, along with anti-emetics if available
CuIUD is feasible
If she presents after 5 days - or emergency contraception fails and she is pregnancy she should be offered a safe abortion
What should be done with HIV PEP
Consider offering HIV post-exposure prophylaxis (PEP) for women presenting within 72hours of a sexual assault. Use shared decision-makingc with the survivor, to determine whether HIV PEP is appropriate.
It depends on:
• HIV prevalence in the geographic area
• limitations of PEP
• the HIV status and characteristics of the perpetrator if known
• assault characteristics, including the number of perpetrators
• side-effects of the antiretroviral drugs used in the PEP regimen
• the likelihood of HIV transmission.
If used - start as soon as possible before 72 days
Provide HIV testing and counselling at the intiial consultation, ensure follow up at regular intervals, 2 drug regime it preferred, using drugs with fewer side effects
Adherence counselling
STI prophylaxis - what should be offered?
Women survivors of sexual assault should be offered prophylaxis for:
• chlamydia
• gonorrhoea
• trichomonas
• syphilis, depending on the prevalence. The choice of drug and regimens should follow national guidance.
What about hep B prophylaxis?
Hepatitis B vaccination without hepatitis B immune globulin should be offered as per national guidelines.
• Take blood for hepatitis B status prior to administering the first vaccine dose.
• If immune, no further course of vaccination is required
Psychological intervention
What should be offered
As above
Psychological debriefing should not be used
written information on coping strategies
Unless depression / drug use/ suicidal / self harming / not able to function use watchful waiting for 1-3 months after the event - make regular follow up appointments
If incapacitated use CBT or EMDR
after 3 months, if sx PTSD referred for CBT or EMDR
Mandatory reporting - according to the WHO
Manditory reporting is not recommended
Health care professionals should offer to report the incidence
Child maltreatment and life threatening incidence must be reported to relevant authorities by the health care provider
WHO says not to routinely screen everyone in early healthcare setting
Who should we screen
Antenatal
• symptoms of depression, anxiety, Ptsd, sleep disorders
• suicidality or self-harm
• Alcohol and other substance use
• unexplained chronic gastrointestinal symptoms
• unexplained reproductive symptoms, including pelvic pain, sexual dysfunction
• Adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations, delayed pregnancy care, adverse birth outcomes
• unexplained genitourinary symptoms, including frequent bladder or kidney infections or other
• Repeated vaginal bleeding and sexually transmitted infections
• Chronic pain (unexplained)
• traumatic injury, particularly if repeated and with vague or implausible explanations
• Problems with the central nervous system – headaches, cognitive problems, hearing loss
• Repeated health consultations with no clear diagnosis
• Intrusive partner or husband in consultation
6 step approach in exposure to FV
- Routine inquiry (identification)
- Validation and support
- Thank her for telling you
- Tell her you believe her
- Ask her what she would like you to do
- Health and risk assessment
- Safety planning
- Provide her with the option to talk to a community domestic violence agency - Referral and follow-up
- Documentation
What would the STI follow up be
At the time, one month and three months after.
Baseline screening is for chlamydia, gonorrhoea, hepatitis B, hepatitis C, HIV and syphilis. If a patient reports a penile-oral or penileanal assault, one should collect swabs from the
oropharynx or rectum. At the one-month follow up
we test for chlamydia and gonorrhoea
At three months - repeat serology
Forensic issues
The forensic assessment involves documentation of
any injuries and collection of specimens to detect
DNA and trace evidence.
The chance of finding DNA lessens as the time to examination increases so the first clinician to see the patient should collect an early evidence kit (EEK). EEKs are tailored to the type of assault, but may include an oral rinse, first void urine or a gauze wipe of the vulval, penile or peri-anal regions. EEKs are very effective, a SARC study demonstrating that spermatozoa were
detected in 35 per cent of EEKs versus 42 per cent
of full forensic examinations.
The clothes worn at the time of the assault should also be collected, with each item in a separate bag. Clothing should still be collected even if it has been washed because DNA may still be obtained. Blood and urine samples should be collected for toxicology assessment if drug facilitated sexual assault is suspected.
