RECOGNIZING AND « T I N G VICTIMS
OF DOMESTIC VIOLENCE
J O H N D. M C D O W E L L , D .D .S .; D E N I S E K . K A S S E B A U M , D .D .S ., M .S .; S H E L L Y E. S T R O M B O E , D .D .S .
ABSTRACT
D o m estic v io le n c e can be d e fin ed as an y v io le n t b e h a v io r d ir e c te d a g a in st an in d iv id u a l w ith in the h om e or fam ily. It occu rs in all s e g m e n ts o f so cie ty and is n o t lim ite d to a s in g le e th n ic or s o c io e co n o m ic group. S in ce m o st in te n tio n a l in ju ries o c cu r in th e h e a d and n e c k area, th e d e n tist m ig h t b e th e fir st to trea t th e d o m estic v io le n c e v ictim .
44
JADA, Vol. 123, September 1992
^J^iolence th a t occurs in the home in all forms—child abuse, spouse abuse and elder abuse—is epidemic in W estern society. While m uch appears in the dental literatu re regarding child abuse, we have little inform ation about two other forms of intrafam ily violence—battered women and abuse of th e elderly. Although it is difficult to determ ine the exact incidence and prevalence of spouse and elder abuse, estim ates indicate th a t between 20 and 50 percent of U.S. homes have experienced some form of violence.1-3 Child abuse is well-recognized as a m ajor health problem, yet estim ates indicate th a t battered women are much more common th a n abused children. Abuse in the elderly popula tion is a t least as common as child abuse. Berrios and Grady4 have confirmed th a t, as w ith child abuse, m ost injuries in domestic violence are found in the head and neck area, clearly visible to the dental team . SPOUSE ABUSE
Spouse abuse is violent behavior occurring betw een p artn ers in an intim ate relationship, regardless of m arital sta tu s.5The battered woman syndrom e h as been defined as a symptom complex occurring as a resu lt of abusive actions directed against a woman by her m ale p a rtn e r in which the woman has a t any tim e received deliberate, severe and repeated (more th a n three tim es) physical abuse by her m ale partner, with the m inim al injury being severe bruising.” It h as been reported th a t some form of violence occurs in about 16 percent of relationships. In h alf of those violent relationships th e abuse takes the form of punching, kicking, biting or assau lt with a weapon.4,712 Most definitions of spouse abuse em phasize the physical abuse component because of the severe physical injuries. However, the health care provider should know th a t m ental abuse and intim idation are integral components of the abuse syndrom e.8 The sequelae of violence directed against women can be severe. It h as been reported th a t domestic disputes cause about one-third of all female homicides.9 The battered woman can place a
significant load on the hospital emergency room, approaching | 30 percent of all emergency d epartm ent visits by women w ith physical injuries.10,13 B attering episodes have been reported to lead to about 30 percent of all suicide attem pts am ong women.3,11 Although th is form of domestic violence is common in W estern society, it is frequently unrecognized by h ealth care providers responsible for the | im m ediate or delayed care of these victims. The lack of a clear demographic profile of the victim, combined w ith th e fact th a t victims rarely volunteer | th a t they have been abused, contributes to the low reporting rate for b attered women.10,12,13 Direct questioning by the health care provider about suspected intentionally inflicted injuries can elicit inform ation not otherwise volunteered. A suspected victim should be interview ed in a private setting as the abuser often tries to ! rem ain close to the victim, answ ering questions directed to th e victim. The health profes sional should be aw are th a t vague, repeated, subtle, non specific com plaints w ithout organic basis can indicate th a t {th e p atien t is a victim of domestic violence.14 ELDER ABUSE
Spouse abuse does not end abruptly a t age 65. Domestic violence among aged p a rtn e rs is not uncommon. Elder abuse victims are m ost likely to be victim s of physical violence received from those individuals i w ith whom they live, m ost commonly spouses.15 The U.S. aged population continues to increase. It is I estim ated th a t by the year 2000 46
JADA, Vol. 123, September 1992
nearly 20 percent of th e popula tion will be in th eir seventh decade and older. M any will live a quality of life unequaled in previous generations. Most people after age 70 will develop chronic diseases and disabilities th a t lim it th eir activities and ability to be self-sustaining. M any will become dependent on the care of others. U nfortunately, some elderly persons will be in the care of persons who are incapable, reluctant, unw illing or ill-
Figure 1. Facial injuries in female victim of intentional (non accidental) trauma. Note lip laceration and orbital injury.
prepared to deliver the care required. These living condi tions can lead to circum stances where the dependent individual can suffer abuse or neglect at the hands of the caregiver. The caregivers can be spouses, other family m em bers, employees in a nursing facility or persons employed in the elder’s home. Although uniform definitions and classifications of elder abuse and neglect are not found in the literatu re, m otivation
(intent) is frequently used to separate one form of m istre a t m ent from others. The concept th a t neglect is less severe th a n active abuse is not alw ays true. Active neglect (intentionally denying or w ithholding care) and passive neglect (uninten tionally failing to provide care) can be equally injurious. Failing to provide necessary support to a frail elderly person can lead to rapid deterioration and death. Neglect doesn’t alw ays occur because of the actions of individuals responsible for the elderly person. Self-neglect is the most frequent form of neglect. W hen com petent, the well-elderly person is respons ible for his or her own well being and may refuse care even if this refusal m ay lead to severe health risks.16 In suspected cases of self-neglect, the dentist should function as an educator, reviewing the possible unm et needs. The dentist can recognize financial abuse (often called m aterial abuse) of th e elderly person. U nreasonably tig h t control by the caretaker of the com petent elder’s finances can indicate financial abuse. S ta te m ents m ade by caregivers indicating th a t th e dependent elder does not need or deserve health care are often identified as indicators of financial abuse. As w ith battered women, there is no clear profile o f the abused elder. There are, how ever, characteristics th a t place elders a t risk for abuse. Abused elders are more likely to be in poor health and living w ith a person a t least partially responsible for th eir care.15,17 A recent study by Pillem er and Finkelhor reported th a t although there are alm ost equal num bers of abused elderly men
and women, women suffer more severe physical and m ental in juries.15 D E N T A L IM P L IC A T IO N S
Physical evidence of intentional tra u m a m ay be visible in m any ways. Intentional trau m a to oral/perioral structures includes lip trau m a, fractured or sub luxated teeth, fractures of the m andible or m axilla or severe bruising of the edentulous ridges.18 The dentist should exam ine the victim not only for acute tra u m a, b u t also for indicators of prior trau m a to the dental and orofacial structures, including fractures of the zygo m aticom axillary complex, eye | injuries, orbital fractures and ! bruising of the facial tissues. Sexual abuse is another form of physical abuse of the elderly. This m ay be so severe as to cause d eath in extrem e cases.19 O ral signs of sexually transm issible diseases can indicate sexual abuse. Im m ediate medical referral is indicated in th is instance. The suspected victim should be exam ined thoroughly by m edical personnel correlating the history and physical exam ination with the oral findings. Not all facial, mucosal/skin lesions or discolorations indicate abuse. The dentist should have a working knowledge of the aging process and concurrent health problems. Skin Dr. McDowell is
j assistant professor,
Department of Diag nostic and Develop mental Sciences, Division of Oral
j Diagnosis/Medicine/ j Radiology, UniverI sity of Colorado
| School of Dentistry» 4200 E. 9th Awe.,
| Denver, 80262.
| Address reprint | requests to Dr. McDowell.
48
JADA, Vol. 123, September 1992
Figure 2. Elderly male victim of intentional trauma. Patient suffered a mandibular fracture and a fracture of the orbital floor. Note human bitemark on upper right chest.
lesions th a t resem ble traum atic injuries can be caused by medicines, systemic or derm atologic diseases, fungal, bacter ial or viral diseases. D entists m ust perform an accurate and thorough exam ination to arrive a t a differential diagnosis. W hen lesions are identified as being traum atically induced, be aw are th a t injuries a t variance ( w ith history given, injuries a t various stages of healing and interpersonal difficulties are common to all forms of domestic ! violence.20'22. E X A M IN A T IO N A N D D O C U M E N T A T IO N
If the dentist suspects th a t the p atien t is a victim of intentional (non-accidental) traum a, take specific actions: *■* Have an office staff m em ber present throughout the exam ination by the dentist. ™ Interview and examine the patient in a private, quiet
environm ent where confiden tiality is assured. Use a sup portive, non-accusatory m anner. *■ D uring the exam ination of all female patients, include a woman fam iliar with the requirem ents of patient confidentiality. ™ Record all p atien t statem ents regarding the history of abuse in the patient’s own words. A statem ent th a t is inconsistent w ith the physical findings should also be documented in th e record. *■* Rem ember th a t sham e, em barrassm ent, self-blame, denial and downplaying the violent behavior are frequently seen in domestic violence victims. Be especially aw are of bruises of differing colors and bilateral injuries when evaluating the patien t for intentional traum a. Also record as an opinion th a t the physical findings are inconsistent w ith the history provided. *■ Keep a complete and accurate w ritten description of the physical injuries in the dental record in all trau m a cases. Documenting the injury p attern s is especially im portant in domestic violence cases. Photographic evidence th a t is a true and accurate represen tation of the injuries should be made and preserved as a p a rt of the patient record. Color photographs identifying the victim and orienting the injuries can be invaluable in possible prosecution of the abuser. Use scale photography for analyses in bitem ark cases. ™ W hen possible, place in the records a w ritten informed consent form statin g clearly the purpose of the photographs. Explain to the patient th a t
these photographs will become p a rt of the record and, when the victim is a competent adult, can only be released with the w rit ten perm ission of the victim. Radiographs, when indicated, are essential in the diagnosis and tre a tm e n t of maxillofacial traum a. Evidence of fractures a t various stages of healing can be evidence of repeated assaults. F ractures m ight be discovered th a t are inconsistent w ith the p atien t’s history. As in all forms of domestic violence, injuries a t variance w ith the history given should be consid ered strongly suggestive of intentional (non-accidental) traum a. IN T E R V E N T IO N
After recognizing and docu m enting the suspected domestic violence case, be prepared to take rem edial action on behalf of the victim. All health profes sionals should be fam iliar w ith their sta te ’s m echanism for reporting suspected domestic violence. D entists should be aw are th a t reporting laws for adult domestic violence victims are dictated by the individual states and are not presently m andated by federal law. State laws are following a trend to require health professionals to report
Dr. Stromboe is a general practice resident, Audie
Murphy Memorial
Veterans Hospital,
San Antonio, Texas.
50
JADA, Vol. 123, September 1992
suspected abuse.23'25 On th e basis of the health care provider’s responsibility regarding child abuse (dentists are m andatory reporters of suspected child abuse), the dentist could possibly be held respons ible for failing to intervene on behalf of an individual unable to escape the abusive environ m ent.26 Check w ith the respective state adult protective agencies regarding reporting mechanism s of th eir adult patients they suspect as being neglected or abused. ■ Dr. Kassebaum is
associate professor, Department of
Diagnostic and
Developmental
Sciences and chair, Division of Oral
Diagnosis/Medicine/
Radiology, University
of Colorado School of Dentistry.
1. G e lle s R J . V io le n c e i n t h e fa m ily : A re v ie w o f r e s e a r c h i n t h e s e v e n ti e s . J M a r r i a g e F a m 1 9 8 0 ;4 2 :8 7 3 -8 5 . 2 . S t r a u s s M A . W ife b e a t in g : H o w c o m m o n a n d w h y ? V ic tim o lo g y 1 9 7 7 -1 9 7 8 ;3 -4 :4 4 3 -5 8 . 3. H i l b e r m a n E . O v e rv ie w : T h e ‘w i f e - b e a t e r ’s w ife ’ r e c o n s i d e r e d . A m J P s y c h i a t r y 1 9 8 0 ;1 3 7 :1 3 3 6 -4 7 . 4. B e r r io s D C , G r a d y D . D o m e s t i c v io le n c e : R is k f a c t o r s a n d o u tc o m e s . W e s t J M e d 1 9 9 1 ;1 5 5 (8 ):1 3 3 -5 . 5 . P a r k e r B , S h u m a c h e r D N . T h e b a t t e r e d w ife s y n d r o m e a n d v io le n c e i n t h e n u c l e a r fa m i l y o f o rig in : a c o n tr o lle d p i l o t s t u d y . A m J P u b li c H e a l t h 1 9 7 7 ;6 7 :7 6 0 -1 . 6 . R o u s a n v i l le B , W e i s s m a n M M . B a t t e r e d w o m e n : A m e d ic a l p r o b le m r e q u i r i n g d e te c tio n . I n t J P s y c h i a t r y M e d 1 9 7 7 -1 9 7 8 ;8 :1 9 1 -2 0 2 . 7. S t r a u s M A , G e lle s R J . S o c i e t a l c h a n g e s a n d c h a n g e i n f a m i l y v io le n c e fr o m 1 9 7 5 t o 1 9 8 5 a s r e v e a l e d b y tw o n a t i o n a l s u r v e y s . J M a r r i a g e F a m 1 9 8 6 ;4 8 :4 6 5 -7 9 . 8. A m e r ic a n C o lle g e o f G y n e c o lo g is ts T e c h n ic a l B u ll e ti n . J a n u a r y 1 9 8 9 ;2 4 :1 -7 . 9 . S u r g e o n G e n e r a l ’s W o r k s h o p o n V io le n c e a n d P u b li c H e a l t h : R e p o r t. W a s h in g t o n , D .C .: G o v e r n m e n t P r i n t i n g O ffice, 1 9 8 6 . U .S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e rv ic e s ; P u b li c H e a l t h S e rv ic e ; H e a l t h R e s o u r c e s a n d S e r v ic e s A d m i n i s t r a t i o n .
D H H S P u b li c a t i o n N o . H R S -D -M C 8 6 -1 . 10. M c L e e r S , A n w a r R A H . T h e r o le o f t h e e m e r g e n c y p h y s i c i a n in t h e p r e v e n t i o n o f d o m e s tic v io le n c e . A n n E m e r g M e d 1 9 8 7 ;1 6 :1 1 5 5 -6 1 . 11. S t a r k E , F i l c r a f t A , F r a z i e r W . M e d ic in e a n d p a t r i a r c h a l v io le n c e : t h e s o c ia l c o n s t r u c t io n o f a “p r i v a t e e v e n t .” I n t J H e a l t h S ci 1 9 7 9 ;9 :4 6 2 -9 4 . 12. G o ld b e r g W G , T o m la n o v ic h M C . D o m e s tic v io le n c e , v i c t i m s a n d e m e r g e n c y d e p a r t m e n t s : N e w f in d in g s . J A M A 1 9 8 4 ;2 5 1 (2 4 ):3 2 5 9 -6 4 . 13. C h e z R A . W o m a n b a t t e r i n g . A m J O b s t e t G y n e c o l 1 9 8 8 ;1 5 8 :1 -4 . 14. G a y fo rd J J . W ife b a t t e r i n g : A p r e li m i n a r y s u r v e y o f 10 0 c a s e s . B r M e d J 1 9 7 5 ; 1:1 9 4 -7 . 15. P i l l e m e r K , F in k e l h o r D . T h e p r e v a l e n c e o f e l d e r a b u s e : A r a n d o m s a m p l e s u r v e y . G e r o n to lo g is t 1 9 8 8 ;2 8 :5 1 -7 . 16. G i l b e r t D A . T h e e t h i c s o f m a n d a t o r y e l d e r a b u s e r e p o r t i n g s t a t u t e s . A d v N u r s S c i 1 9 8 6 ;8 (2 ):5 1 62. 17. W o lf R , G o d k in M , P i l l e m e r K . M a l t r e a t m e n t o f t h e e ld e rly : A c o m p a r a t i v e a n a l y s i s . P r i d e I n s t J L o n g T e r m H o m e H e a l t h C a r e 1 9 8 6 ;5 :1 0 -1 7 . 18. M c D o w e ll J D . E l d e r a b u s e : T h e p r e s e n t i n g s i g n s a n d s y m p to m s i n t h e d e n t a l p r a c t i c e .T e x a s D e n t J 1 9 9 0 ;1 0 7 (2 ):2 9 -4 0 . 19. R e a y D , E i s e l e J . S e x u a l a b u s e a n d d e a t h o f a n e l d e r l y l a d y b y “f i s t i n g .” A m J F o r e n s i c M e d P a t h o l 1 9 8 3 ;4 (4 ):3 4 7 -9 . 20. B r a h a m R , F u r n is s K , H o ltz H . H o sp ita l t r a i n i n g i n d o m e s t i c v io le n c e . J e r s e y B a t t e r e d W o m a n S h e l t e r . M o r r is t o w n , N J ; 1 9 8 6 ; 1-34. 2 1 . C o u n c il r e p o r t . E l d e r a b u s e a n d n e g le c t. J A M A 1 9 8 7 ; 2 5 7 (7 ):9 6 6 -7 1 . 2 2 . F e l d e r R , H e lm A , K o e n ig V . E l d e r a b u s e . G e r o d o n tic s 1 9 8 6 ;2 :1 2 7 -3 0 . 23. T h o b a b e n M , A n d e rso n L. R e p o rtin g e ld e r a b u s e : I t ’s t h e la w . A m J N u r s 1 9 8 5 ;4 :3 7 1 -5 . 24. K irk la n d K. A s s e s s m e n t a n d tr e a tm e n t of fa m ily v io le n c e . J F a m P r a c t 1 9 8 2 ;1 4 (4 ):7 1 3 -1 8 . 2 5 . B lo o m J , A n s e ll P , B lo o m M . D e te c t i n g e l d e r a b u s e : A g u i d e fo r p h y s i c i a n s . G e r i a t r i c s 1 9 8 6 ;4 4 (6 ): 4 0 -5 . 2 6 . T a l e r G , A n s e llo E . E l d e r a b u s e . A m F a m P r a c t 1 9 8 5 ;3 (2 ): 1 0 7 -1 4 .
OF DOMESTIC VIOLENCE
J O H N D. M C D O W E L L , D .D .S .; D E N I S E K . K A S S E B A U M , D .D .S ., M .S .; S H E L L Y E. S T R O M B O E , D .D .S .
ABSTRACT
D o m estic v io le n c e can be d e fin ed as an y v io le n t b e h a v io r d ir e c te d a g a in st an in d iv id u a l w ith in the h om e or fam ily. It occu rs in all s e g m e n ts o f so cie ty and is n o t lim ite d to a s in g le e th n ic or s o c io e co n o m ic group. S in ce m o st in te n tio n a l in ju ries o c cu r in th e h e a d and n e c k area, th e d e n tist m ig h t b e th e fir st to trea t th e d o m estic v io le n c e v ictim .
44
JADA, Vol. 123, September 1992
^J^iolence th a t occurs in the home in all forms—child abuse, spouse abuse and elder abuse—is epidemic in W estern society. While m uch appears in the dental literatu re regarding child abuse, we have little inform ation about two other forms of intrafam ily violence—battered women and abuse of th e elderly. Although it is difficult to determ ine the exact incidence and prevalence of spouse and elder abuse, estim ates indicate th a t between 20 and 50 percent of U.S. homes have experienced some form of violence.1-3 Child abuse is well-recognized as a m ajor health problem, yet estim ates indicate th a t battered women are much more common th a n abused children. Abuse in the elderly popula tion is a t least as common as child abuse. Berrios and Grady4 have confirmed th a t, as w ith child abuse, m ost injuries in domestic violence are found in the head and neck area, clearly visible to the dental team . SPOUSE ABUSE
Spouse abuse is violent behavior occurring betw een p artn ers in an intim ate relationship, regardless of m arital sta tu s.5The battered woman syndrom e h as been defined as a symptom complex occurring as a resu lt of abusive actions directed against a woman by her m ale p a rtn e r in which the woman has a t any tim e received deliberate, severe and repeated (more th a n three tim es) physical abuse by her m ale partner, with the m inim al injury being severe bruising.” It h as been reported th a t some form of violence occurs in about 16 percent of relationships. In h alf of those violent relationships th e abuse takes the form of punching, kicking, biting or assau lt with a weapon.4,712 Most definitions of spouse abuse em phasize the physical abuse component because of the severe physical injuries. However, the health care provider should know th a t m ental abuse and intim idation are integral components of the abuse syndrom e.8 The sequelae of violence directed against women can be severe. It h as been reported th a t domestic disputes cause about one-third of all female homicides.9 The battered woman can place a
significant load on the hospital emergency room, approaching | 30 percent of all emergency d epartm ent visits by women w ith physical injuries.10,13 B attering episodes have been reported to lead to about 30 percent of all suicide attem pts am ong women.3,11 Although th is form of domestic violence is common in W estern society, it is frequently unrecognized by h ealth care providers responsible for the | im m ediate or delayed care of these victims. The lack of a clear demographic profile of the victim, combined w ith th e fact th a t victims rarely volunteer | th a t they have been abused, contributes to the low reporting rate for b attered women.10,12,13 Direct questioning by the health care provider about suspected intentionally inflicted injuries can elicit inform ation not otherwise volunteered. A suspected victim should be interview ed in a private setting as the abuser often tries to ! rem ain close to the victim, answ ering questions directed to th e victim. The health profes sional should be aw are th a t vague, repeated, subtle, non specific com plaints w ithout organic basis can indicate th a t {th e p atien t is a victim of domestic violence.14 ELDER ABUSE
Spouse abuse does not end abruptly a t age 65. Domestic violence among aged p a rtn e rs is not uncommon. Elder abuse victims are m ost likely to be victim s of physical violence received from those individuals i w ith whom they live, m ost commonly spouses.15 The U.S. aged population continues to increase. It is I estim ated th a t by the year 2000 46
JADA, Vol. 123, September 1992
nearly 20 percent of th e popula tion will be in th eir seventh decade and older. M any will live a quality of life unequaled in previous generations. Most people after age 70 will develop chronic diseases and disabilities th a t lim it th eir activities and ability to be self-sustaining. M any will become dependent on the care of others. U nfortunately, some elderly persons will be in the care of persons who are incapable, reluctant, unw illing or ill-
Figure 1. Facial injuries in female victim of intentional (non accidental) trauma. Note lip laceration and orbital injury.
prepared to deliver the care required. These living condi tions can lead to circum stances where the dependent individual can suffer abuse or neglect at the hands of the caregiver. The caregivers can be spouses, other family m em bers, employees in a nursing facility or persons employed in the elder’s home. Although uniform definitions and classifications of elder abuse and neglect are not found in the literatu re, m otivation
(intent) is frequently used to separate one form of m istre a t m ent from others. The concept th a t neglect is less severe th a n active abuse is not alw ays true. Active neglect (intentionally denying or w ithholding care) and passive neglect (uninten tionally failing to provide care) can be equally injurious. Failing to provide necessary support to a frail elderly person can lead to rapid deterioration and death. Neglect doesn’t alw ays occur because of the actions of individuals responsible for the elderly person. Self-neglect is the most frequent form of neglect. W hen com petent, the well-elderly person is respons ible for his or her own well being and may refuse care even if this refusal m ay lead to severe health risks.16 In suspected cases of self-neglect, the dentist should function as an educator, reviewing the possible unm et needs. The dentist can recognize financial abuse (often called m aterial abuse) of th e elderly person. U nreasonably tig h t control by the caretaker of the com petent elder’s finances can indicate financial abuse. S ta te m ents m ade by caregivers indicating th a t th e dependent elder does not need or deserve health care are often identified as indicators of financial abuse. As w ith battered women, there is no clear profile o f the abused elder. There are, how ever, characteristics th a t place elders a t risk for abuse. Abused elders are more likely to be in poor health and living w ith a person a t least partially responsible for th eir care.15,17 A recent study by Pillem er and Finkelhor reported th a t although there are alm ost equal num bers of abused elderly men
and women, women suffer more severe physical and m ental in juries.15 D E N T A L IM P L IC A T IO N S
Physical evidence of intentional tra u m a m ay be visible in m any ways. Intentional trau m a to oral/perioral structures includes lip trau m a, fractured or sub luxated teeth, fractures of the m andible or m axilla or severe bruising of the edentulous ridges.18 The dentist should exam ine the victim not only for acute tra u m a, b u t also for indicators of prior trau m a to the dental and orofacial structures, including fractures of the zygo m aticom axillary complex, eye | injuries, orbital fractures and ! bruising of the facial tissues. Sexual abuse is another form of physical abuse of the elderly. This m ay be so severe as to cause d eath in extrem e cases.19 O ral signs of sexually transm issible diseases can indicate sexual abuse. Im m ediate medical referral is indicated in th is instance. The suspected victim should be exam ined thoroughly by m edical personnel correlating the history and physical exam ination with the oral findings. Not all facial, mucosal/skin lesions or discolorations indicate abuse. The dentist should have a working knowledge of the aging process and concurrent health problems. Skin Dr. McDowell is
j assistant professor,
Department of Diag nostic and Develop mental Sciences, Division of Oral
j Diagnosis/Medicine/ j Radiology, UniverI sity of Colorado
| School of Dentistry» 4200 E. 9th Awe.,
| Denver, 80262.
| Address reprint | requests to Dr. McDowell.
48
JADA, Vol. 123, September 1992
Figure 2. Elderly male victim of intentional trauma. Patient suffered a mandibular fracture and a fracture of the orbital floor. Note human bitemark on upper right chest.
lesions th a t resem ble traum atic injuries can be caused by medicines, systemic or derm atologic diseases, fungal, bacter ial or viral diseases. D entists m ust perform an accurate and thorough exam ination to arrive a t a differential diagnosis. W hen lesions are identified as being traum atically induced, be aw are th a t injuries a t variance ( w ith history given, injuries a t various stages of healing and interpersonal difficulties are common to all forms of domestic ! violence.20'22. E X A M IN A T IO N A N D D O C U M E N T A T IO N
If the dentist suspects th a t the p atien t is a victim of intentional (non-accidental) traum a, take specific actions: *■* Have an office staff m em ber present throughout the exam ination by the dentist. ™ Interview and examine the patient in a private, quiet
environm ent where confiden tiality is assured. Use a sup portive, non-accusatory m anner. *■ D uring the exam ination of all female patients, include a woman fam iliar with the requirem ents of patient confidentiality. ™ Record all p atien t statem ents regarding the history of abuse in the patient’s own words. A statem ent th a t is inconsistent w ith the physical findings should also be documented in th e record. *■* Rem ember th a t sham e, em barrassm ent, self-blame, denial and downplaying the violent behavior are frequently seen in domestic violence victims. Be especially aw are of bruises of differing colors and bilateral injuries when evaluating the patien t for intentional traum a. Also record as an opinion th a t the physical findings are inconsistent w ith the history provided. *■ Keep a complete and accurate w ritten description of the physical injuries in the dental record in all trau m a cases. Documenting the injury p attern s is especially im portant in domestic violence cases. Photographic evidence th a t is a true and accurate represen tation of the injuries should be made and preserved as a p a rt of the patient record. Color photographs identifying the victim and orienting the injuries can be invaluable in possible prosecution of the abuser. Use scale photography for analyses in bitem ark cases. ™ W hen possible, place in the records a w ritten informed consent form statin g clearly the purpose of the photographs. Explain to the patient th a t
these photographs will become p a rt of the record and, when the victim is a competent adult, can only be released with the w rit ten perm ission of the victim. Radiographs, when indicated, are essential in the diagnosis and tre a tm e n t of maxillofacial traum a. Evidence of fractures a t various stages of healing can be evidence of repeated assaults. F ractures m ight be discovered th a t are inconsistent w ith the p atien t’s history. As in all forms of domestic violence, injuries a t variance w ith the history given should be consid ered strongly suggestive of intentional (non-accidental) traum a. IN T E R V E N T IO N
After recognizing and docu m enting the suspected domestic violence case, be prepared to take rem edial action on behalf of the victim. All health profes sionals should be fam iliar w ith their sta te ’s m echanism for reporting suspected domestic violence. D entists should be aw are th a t reporting laws for adult domestic violence victims are dictated by the individual states and are not presently m andated by federal law. State laws are following a trend to require health professionals to report
Dr. Stromboe is a general practice resident, Audie
Murphy Memorial
Veterans Hospital,
San Antonio, Texas.
50
JADA, Vol. 123, September 1992
suspected abuse.23'25 On th e basis of the health care provider’s responsibility regarding child abuse (dentists are m andatory reporters of suspected child abuse), the dentist could possibly be held respons ible for failing to intervene on behalf of an individual unable to escape the abusive environ m ent.26 Check w ith the respective state adult protective agencies regarding reporting mechanism s of th eir adult patients they suspect as being neglected or abused. ■ Dr. Kassebaum is
associate professor, Department of
Diagnostic and
Developmental
Sciences and chair, Division of Oral
Diagnosis/Medicine/
Radiology, University
of Colorado School of Dentistry.
1. G e lle s R J . V io le n c e i n t h e fa m ily : A re v ie w o f r e s e a r c h i n t h e s e v e n ti e s . J M a r r i a g e F a m 1 9 8 0 ;4 2 :8 7 3 -8 5 . 2 . S t r a u s s M A . W ife b e a t in g : H o w c o m m o n a n d w h y ? V ic tim o lo g y 1 9 7 7 -1 9 7 8 ;3 -4 :4 4 3 -5 8 . 3. H i l b e r m a n E . O v e rv ie w : T h e ‘w i f e - b e a t e r ’s w ife ’ r e c o n s i d e r e d . A m J P s y c h i a t r y 1 9 8 0 ;1 3 7 :1 3 3 6 -4 7 . 4. B e r r io s D C , G r a d y D . D o m e s t i c v io le n c e : R is k f a c t o r s a n d o u tc o m e s . W e s t J M e d 1 9 9 1 ;1 5 5 (8 ):1 3 3 -5 . 5 . P a r k e r B , S h u m a c h e r D N . T h e b a t t e r e d w ife s y n d r o m e a n d v io le n c e i n t h e n u c l e a r fa m i l y o f o rig in : a c o n tr o lle d p i l o t s t u d y . A m J P u b li c H e a l t h 1 9 7 7 ;6 7 :7 6 0 -1 . 6 . R o u s a n v i l le B , W e i s s m a n M M . B a t t e r e d w o m e n : A m e d ic a l p r o b le m r e q u i r i n g d e te c tio n . I n t J P s y c h i a t r y M e d 1 9 7 7 -1 9 7 8 ;8 :1 9 1 -2 0 2 . 7. S t r a u s M A , G e lle s R J . S o c i e t a l c h a n g e s a n d c h a n g e i n f a m i l y v io le n c e fr o m 1 9 7 5 t o 1 9 8 5 a s r e v e a l e d b y tw o n a t i o n a l s u r v e y s . J M a r r i a g e F a m 1 9 8 6 ;4 8 :4 6 5 -7 9 . 8. A m e r ic a n C o lle g e o f G y n e c o lo g is ts T e c h n ic a l B u ll e ti n . J a n u a r y 1 9 8 9 ;2 4 :1 -7 . 9 . S u r g e o n G e n e r a l ’s W o r k s h o p o n V io le n c e a n d P u b li c H e a l t h : R e p o r t. W a s h in g t o n , D .C .: G o v e r n m e n t P r i n t i n g O ffice, 1 9 8 6 . U .S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e rv ic e s ; P u b li c H e a l t h S e rv ic e ; H e a l t h R e s o u r c e s a n d S e r v ic e s A d m i n i s t r a t i o n .
D H H S P u b li c a t i o n N o . H R S -D -M C 8 6 -1 . 10. M c L e e r S , A n w a r R A H . T h e r o le o f t h e e m e r g e n c y p h y s i c i a n in t h e p r e v e n t i o n o f d o m e s tic v io le n c e . A n n E m e r g M e d 1 9 8 7 ;1 6 :1 1 5 5 -6 1 . 11. S t a r k E , F i l c r a f t A , F r a z i e r W . M e d ic in e a n d p a t r i a r c h a l v io le n c e : t h e s o c ia l c o n s t r u c t io n o f a “p r i v a t e e v e n t .” I n t J H e a l t h S ci 1 9 7 9 ;9 :4 6 2 -9 4 . 12. G o ld b e r g W G , T o m la n o v ic h M C . D o m e s tic v io le n c e , v i c t i m s a n d e m e r g e n c y d e p a r t m e n t s : N e w f in d in g s . J A M A 1 9 8 4 ;2 5 1 (2 4 ):3 2 5 9 -6 4 . 13. C h e z R A . W o m a n b a t t e r i n g . A m J O b s t e t G y n e c o l 1 9 8 8 ;1 5 8 :1 -4 . 14. G a y fo rd J J . W ife b a t t e r i n g : A p r e li m i n a r y s u r v e y o f 10 0 c a s e s . B r M e d J 1 9 7 5 ; 1:1 9 4 -7 . 15. P i l l e m e r K , F in k e l h o r D . T h e p r e v a l e n c e o f e l d e r a b u s e : A r a n d o m s a m p l e s u r v e y . G e r o n to lo g is t 1 9 8 8 ;2 8 :5 1 -7 . 16. G i l b e r t D A . T h e e t h i c s o f m a n d a t o r y e l d e r a b u s e r e p o r t i n g s t a t u t e s . A d v N u r s S c i 1 9 8 6 ;8 (2 ):5 1 62. 17. W o lf R , G o d k in M , P i l l e m e r K . M a l t r e a t m e n t o f t h e e ld e rly : A c o m p a r a t i v e a n a l y s i s . P r i d e I n s t J L o n g T e r m H o m e H e a l t h C a r e 1 9 8 6 ;5 :1 0 -1 7 . 18. M c D o w e ll J D . E l d e r a b u s e : T h e p r e s e n t i n g s i g n s a n d s y m p to m s i n t h e d e n t a l p r a c t i c e .T e x a s D e n t J 1 9 9 0 ;1 0 7 (2 ):2 9 -4 0 . 19. R e a y D , E i s e l e J . S e x u a l a b u s e a n d d e a t h o f a n e l d e r l y l a d y b y “f i s t i n g .” A m J F o r e n s i c M e d P a t h o l 1 9 8 3 ;4 (4 ):3 4 7 -9 . 20. B r a h a m R , F u r n is s K , H o ltz H . H o sp ita l t r a i n i n g i n d o m e s t i c v io le n c e . J e r s e y B a t t e r e d W o m a n S h e l t e r . M o r r is t o w n , N J ; 1 9 8 6 ; 1-34. 2 1 . C o u n c il r e p o r t . E l d e r a b u s e a n d n e g le c t. J A M A 1 9 8 7 ; 2 5 7 (7 ):9 6 6 -7 1 . 2 2 . F e l d e r R , H e lm A , K o e n ig V . E l d e r a b u s e . G e r o d o n tic s 1 9 8 6 ;2 :1 2 7 -3 0 . 23. T h o b a b e n M , A n d e rso n L. R e p o rtin g e ld e r a b u s e : I t ’s t h e la w . A m J N u r s 1 9 8 5 ;4 :3 7 1 -5 . 24. K irk la n d K. A s s e s s m e n t a n d tr e a tm e n t of fa m ily v io le n c e . J F a m P r a c t 1 9 8 2 ;1 4 (4 ):7 1 3 -1 8 . 2 5 . B lo o m J , A n s e ll P , B lo o m M . D e te c t i n g e l d e r a b u s e : A g u i d e fo r p h y s i c i a n s . G e r i a t r i c s 1 9 8 6 ;4 4 (6 ): 4 0 -5 . 2 6 . T a l e r G , A n s e llo E . E l d e r a b u s e . A m F a m P r a c t 1 9 8 5 ;3 (2 ): 1 0 7 -1 4 .
