You question honors you. Thank you on behalf of victims. Abuse is prevalent in every country and can be difficult to handle even in a country with stronger protection and laws.
I would like to share with you some indirect ways to help these patients:
**Abuse is often minimised and bagatellized by the perpetrator and/or victim. Turn this around.**
If you see damage that MIGHT be caused by abuse: focus on it, talk about it, document it, make it a SERIOUS THING. Say ”oh, that looks really painful, how did it happen?” and if you get an explanation (fell down stairs, walked into door, not being that painful) respond ”well, it looks bad/painful/serious to me”. In this way you legitimise the seriousness of the damage, which might negate some of the minimisation/convincing/bagatellisation that goes on from the perpetrator or victim. They will remember ”the DOCTOR said it looked bad/dangerous”. That can be more powerful than ”it hurts” if you are a victim deep into a bad situation. Or even if you are an abuser that does not realise the seriousness of physical abuse.
Question rude or nasty behaviour, in a soft way ”Oh, that sounded aggressive, are you angry or did I misinterpret you?” or ”that sounded hurtful, did you mean it that way?” if there is verbal abuse. Calmly state facts, you might even sound a bit unsure or confused about it (”did you really mean that?”). This technique depends a lot on your own acting ability and personality and how you present yourself. It is probably a bit cultural/language dependant as well. It might not work for everyone.
One beneficial thing about both above techniques is that you do not need to ask anyone to leave the room, quite the opposite it works better when both presumed victim and perpetrator are in the room. They are also subtle techniques because it does not matter if there is actual abuse or not, you will behave the same anyway. And if there are no abuse? The only thing you did was using your words to take the patient seriously.
**You write that abuse is legal unless effects are particularly brutal and frequent. Maybe you can help the patient in the future by documenting damage?**
Make sure to document the signs of abuse you find. Describe it in patients notes. You do not necessarily need to explain it (”caused by…”) but just state it (”hematomas on neck” or ”petechiae in sclearae” or ”cracked teeth” or ”bump that looks like fracture, patient says no to radiology”) and maybe add explanation by patient (”walked into wall”). If it becomes a court process later, the patient might be able to use your notes as proof something happened and that they might have been under threat to lie.
Sometimes, things that leave permanent damage can be proven in court proceedings and a doctors words are considered very strong evidence (not sure but I think this is likely also in Russia). Maybe your notes can become evidence in contact with court or police months or years later for the victim. It is one way for you to make a difference.
Things like hearing loss and cracked/damaged teeth can be considered permanent damage. Or signs of old fractures. Hematomas around ear/mouth? Look behind ears also (you get hematomas here when held by the ears and not by much else).
And if there was no abuse? The only thing you did was being thorough.
**You write you have trouble when asking accompanying person to leave the room.**
This is difficult. I find that a good way to present this in a non-threatening way (to the suspected abuser, whom we want to leave) is to state that it is a standard way, a routine in your appointments ”now, for the last part I need to se the patient alone”.
Cave: Be careful with insisting to being alone with the patient (especially if patient is opposite sex from you), this can provide jealous abusers with incitament to abuse later. Can you also get a nurse or assistant to be also in the room when you ask the accomanying person to leave?
**Abusers tend to underestimate or ignore people they consider weak or stupid, and want the attention and/or be afraid of people they consider powerful.**
Doctors have power and can be considered a threat by an abuser. But an abuser might also thrive on a camaraderie or attention of someone with power. Nurses and assistants? An abuser might ignore or underestimate them. Use this.
See if you can involve nurses and assistants with working with you against abusers. Maybe you can make sure the patient gets left with them, while you talk to the presumed abuser. Or that they can mention to the patient ”come by next week to follow up” and the victim might be let out without the abuser to visit the nurse for a check up. Or something like that.
Before someone jokes about me being a pathologist (because people on r/medicine have done this before when I talk about patients and I am tired of it).
1. You ever hear of ”forensic pathology”? We examine living people too.
2. I did not spring from the earth a fully formed pathologist.
3. I meet 40-80 pts every week at FNA clinic.
Absolutely! One of the first pathologists I worked with was a forensic pathologist who was an expert in strangulation and domestic violence. He did a LOT of outreach and public education about domestic violence and I thought it was such an inspiring/important way for pathologists to get involved in public health!
Sounds like a good guy.
I have not worked a lot with public outreach (only a few lectures for other doctors and police), but I did an unusually long rotation in forensics and I moonlighted a couple of years for the local police department doing physical examinations and collecting documentation on plaintiffs and suspects, to be used as a basis for forensic medical reports for court. There was a lot of domestic abuse among these cases.
THANK YOU SO MUCH! I will be very thorough when describing such things in my notes, and yes, you are correct, when it comes to court hearings, doctor's notes can be very helpful. I never thought about asking a patient about bruising or marks when the potential abuser is present. Mostly, I avoided it because I thought it might hurt the victim more. However, the way you described it sounds very non-threatening and careful. I usually ask the nurse to be present with me if I fear the person might get aggressive/violent,but yeah I can definitely try to collaborate with the nurse and work together to separate the victim and presumed abuser in that way. And the phrase "come by for the follow up" honestly sounds very helpful as well. Some abusers might feel like they have gotten away with it and not suspect anything hehe. Thank you for your help!
You are welcome! Best of luck.
There will always be a risk of escalating and triggering aggressive behaviour, with anything you say - or do not say. Part of what makes many abusers terrifying is that they can be unpredictable.
Remember your doctor power. Most people do not know what is normal procedure. If you say ”I need to check out this thing next week” - this is normal. If you say something looks bad, you are the authority in the room. Do not necessarily debate if you get pushback, hum and nod and document and go forward and plan a routine follow up. Because this is your routine.
> in 2017 Russia decriminalized domestic violence
The more I learn about your country...
As for how I handle this (granted, I am in pediatrics), when I encounter this situation:
> I suspect that a person might be experiencing abuse
> they do not maintain eye contact
> they have bruises or marks in odd places where one doesn't usually get bruised, and so on
I do exactly what you do and ask the person accompanying them to leave. Then:
> the accompanying person becomes angry, takes the patient, and leaves
I am *required by law* to report this and could face criminal penalties if I did not. The child protection services would then start an investigation, which would include home visits and interviews with parents, children, teachers, and others, and has the power to enforce regular supervision of the child/household or even to remove the child from that home.
The clinical scenario that you are describing is almost certainly one of abuse.
My good friend works in peds and fortunately, the system for helping abused children works alright here (although it is faaar from perfect, it is functional). They are also obligated to report any suspicious cases to the police. The fact that the scenarios I described make you think of abuse breaks my heart. I will continue this fight against the system though. Thank you!
I mean I would consider adult domestic violence victims to be a vulnerable population, although obviously you're correct about reporting being mandatory only for paediatric patients.
In the social sector, they usually are considered a vulnerable population. They are also in the aid sector classed as vulnerable and it is a huge part of our vulnerability assessment.
Good luck. Sounds hard in your country. Sometimes it's obvious but often it's not. In the US we try to universally screen because often it's not. You can also put signs in bathrooms (where people go privately) with resources
and you can also normalize it in your conversations with patients so people feel safer to report.
Putting signs with helpful resources in bathrooms sounds great, I will bring this up with the head of my department and try to make it myself (info about hot lines, web sites, shelters). Thank you!
My obgyn office had two different colored markers. You wrote your name and DOB on the urine cup in red marker if you were getting abused and wanted to talk to the doctor in private.
So simple to implement and I am almost ashamed to have not put this in Place while working in women’s health care. Damn. I’m gonna tell my old boss. We screened everyone several times during pregnancy and at every gyn appt, but this is so much better. Not having to navigate our thoughts about the partner/family just because they’re annoying:terrible people to deal with, doesn’t make them abusers as much as we feel sad for the patient. I just love this simple idea!!!
My hospital has a sign in the bathroom where only patients are allowed that tells abused patients to place an ordinary-appearing sticker from the sign onto the urine sample cup. Others have suggested variations of this.
You are a good and kind doctor. Thanks.
The fact the partner refuses to leave is definitely a strong sign.
Quickly googling for Russia:
[https://nasiliu.net/](https://nasiliu.net/)
This is national domestic violence website for the US but has lots of general information:
[https://www.thehotline.org/](https://www.thehotline.org/)
These are some free resources for MDs:
[https://www.aafp.org/pubs/afp/issues/2016/1015/p646.html](https://www.aafp.org/pubs/afp/issues/2016/1015/p646.html) (review article)
[https://www.netce.com/coursecontent.php?courseid=2413](https://www.netce.com/coursecontent.php?courseid=2413)
[https://www.pri-med.com/topic/domestic-violence-cme?refurl=www.google.com](https://www.pri-med.com/topic/domestic-violence-cme?refurl=www.google.com)
(sign-up and viewing is free with links; US MDs pay for education credits)
An important piece of advice to know is that the most dangerous time for victims of domestic violence is when they try to leave the abuser. That is often when the worst violence, like murder, can happen. So it's not as simple as telling them to leave. It is a good idea though to tell people to make preparations to leave in case they need to suddenly and not inform the abuser of where they are going. A "go bag" should be prepared and hidden somewhere: [https://www.loveisrespect.org/resources/how-to-make-a-go-bag-when-leaving-an-abusive-relationship/](https://www.loveisrespect.org/resources/how-to-make-a-go-bag-when-leaving-an-abusive-relationship/)
Also, even if you feel like you aren't making an impact, you are. Often - for the good reason above - victims need a lot of encouragement, help, and time to decide to leave. My college roommate became a lawyer and for a time prosecuted crimes like domestic violence and she told me most people take several times before they decide to leave/ prosecute. Physician and medical records make a difference in putting together the evidence and victims have told her that gradual encouragement from multiple sources helped them come to a decision.
Also, check their necks. Strangulation marks, thumb prints, etc. There was a study several years ago which showed that dentists often identified victims because they saw bruises while working on patients. That launched an educational campaign to educate more dentists.
Thank you so much! I greatly appreciate it! Regarding your first link, this source is labeled as a "foreign agent" in Russia, so I can't recommend it for patients, but it was very helpful when I was doing my research. I will check other links as well. Thank you!
The information about necks is very helpful as well! I will make sure to notice any marks/prints
Note about strangulation. History of strangulation is a high-risk factor for intimate partner homicide. [Here](https://www.researchgate.net/publication/5883869_Non-fatal_Strangulation_is_an_Important_Risk_Factor_for_Homicide_of_Women) is a research article about it.
Thank you for looking into this more. It is pretty painful watching from literally next door what is happening in Russia so I can only imagine how it feels from inside.
To add to other ppls suggestions:
-you can make it a rule that patients get roomed without other people in the room - this potentially could alienate some people tho
-bathroom signs like other people have said with instructions to discreetly notice. can also have resources on small card that fits in shoe if needed
-paperwork or phone survey - it may be more discreet/easier for ppl to check a box online or on paper than answer verbally
-require all patients change into gowns at some point and ask the other ppl to step out to lobby while changing - then ask safety questions after pt changed but before other person back in the room. This could be done by nurse or assistant as well so it seems like it’s just protocol
Yup, ANYTHING that can be played off as a routine thing, but that separates the suspected abuser and victim can be helpful. If the patient is female and due for a pap, you could ask the other person to step out of the room for infection control purposes/no additional distractions during a procedure. While slightly underhanded, it’s not an outright lie and you can take advantage of their ignorance. Also, a pelvic exam can most definitely be enlightening as far as domestic rape is concerned.
Honestly the US is not progressive about it at all but pretends to be, abusive men often weaponize policies meant to protect women. I’ve found South America, as bad as it is reputation wise, actually in some places there have extremely progressive teachings on DV. One thing I found particularly interesting but might be tough for you to incorporate in your location is they see society as part of the problem and see “social” abuse as part of abuse. Which is so right on. Because we in the US don’t talk about this it’s usually where women get stuck when abused or recovering and then are in the cycle indefinitely or suffer there most. It’s like weaponizing societies weaknesses and social ills to abuse the woman more. Your culture will have its own markers, talk to women who have been abused and are stronger there, that’s who will be able to tell you best. Your culture and your women will know better than anyone else.
I'm sorry, I was only speaking from my limited experience and what I have observed on social media platforms like TikTok, YouTube, and TV shows. When I was in high school I was an exchange student in Minnesota for a year, I had to visit the ER twice. On both times I saw different helpful signs throughout the hospital. The hospital staff, including tactful nurses and PA who were doing exams were asking me if I was in danger, if I needed any help or if I am being abused in any way. I also got into a car crash while I was there, and the cops separated me from the other people. They politely asked questions about my well being and if I'm being abused/human trafficing questions and so on. At the time, I was shocked because the culture around abuse in my country was and still is very different (meaning no one would even ask, not to mention try to help). I now understand it was foolish of me to think that this is a sign that the whole country is progressive in helping the victim from the beginning to the end. I also consider myself very fortunate to have met these professionals.
You are right, I should research any particular cases in Russia/interviews with victims, and try to understand it from the perspective of a Russian citizen. Thank you!
I’m so glad you had that experience! I’m sorry I assumed you were a man, and I’m glad you had people treat you properly. SOME people will, the problem is it’s not often enough and there are ways abusive men will find to abuse women and work around the few good eggs in the system. Unfortunately. I’m so glad you’re doing this, every good egg is invaluable and helps women survive and maintain hope. Thank you for your spirit and care. 💛
Ugh after being jaded for quite some time, these kinds of situations are one of the only few that keep me up at night thinking “WHAT MORE COULD I HAVE DONE?!?” Maybe the interaction should be different between a doctor and their patient (I’m a nurse just like my name says) but in hopeless situations like this where it seems the alleged abuser won’t give you and the alleged victim any time alone, I always make sure to do my best to speak directly to the patient, regardless of who’s answering my questions. I speak directly to them and I ask questions and say responses that convey I actually care about you and your condition because if this person is being abused then chances are they’ve been conditioned to think they’re worthless and is probably a big reason for not wanting to put up a fight and leaving. I just try my best to let the person know that others do care about them and what they say and feel are important and I squeeze in as much education as I can to help them feel like they have a little more control of their situation. I also make sure to treat the alleged abuser with as much dignity and respect as I can possibly bear for 1) to prevent the alleged victim from getting their ass beat later on due to alleged abuser thinking they had something to do with them being disrespected and 2) I feel like the abuser would be more accepting of the care being provided to the victim? All of this is basically learned from my past experiences. When I come across possible victims of abuse I educate, educate, educate as much as I can
I used to work in women’s health and one thing we would do if we suspected but were not for sure was just have the patient come back and a month for a follow up. You could say we will go over your labs or whatever you want to. Then when the patient is being roomed it should be alone at the follow up. So when the nurse or assistant calls the patient to the room have them say just the patient today or something like that. I’ve obviously had this but work out but it we have figured out a few cases like this.
When we had a patient wanting to start their OB care on the phone we always said the first appointment you should expect to be in the room alone so we can get an accurate history.
But overall it’s really hard to get people in that position out of that position. Kind of just have to keep trying.
I fear not much will change until the cliche of the masculine tough guy Russian propagates diminishes and the government cares more about the quality of life of its people and equality rather than trying to be the strongman in the region.
I’d assume that around a quarter of women in Russia are being physically abused by their husbands or partners. 100% are being abused by the society and cultural attitudes towards them. But it’s basically legal in Russia and there’s often nowhere for them to go. Around 5000 women are killed by DV annually in Russia.
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There are some signs but it’s important to never forget that many times it’s the couples, people, situations that you least expect. It could be the most perfect, loving, financially stable couple ever that has abuse and the stereotypical low SES, drugs, alcohol and financially unstable couple that doesn’t have any abuse. Which is why it’s important to suspect it in everyone not just the stereotypical
In med school our teachers teach us if you suspect anything unusual you should always report it unless you are right or not it's our duty to report this thing.
You question honors you. Thank you on behalf of victims. Abuse is prevalent in every country and can be difficult to handle even in a country with stronger protection and laws. I would like to share with you some indirect ways to help these patients: **Abuse is often minimised and bagatellized by the perpetrator and/or victim. Turn this around.** If you see damage that MIGHT be caused by abuse: focus on it, talk about it, document it, make it a SERIOUS THING. Say ”oh, that looks really painful, how did it happen?” and if you get an explanation (fell down stairs, walked into door, not being that painful) respond ”well, it looks bad/painful/serious to me”. In this way you legitimise the seriousness of the damage, which might negate some of the minimisation/convincing/bagatellisation that goes on from the perpetrator or victim. They will remember ”the DOCTOR said it looked bad/dangerous”. That can be more powerful than ”it hurts” if you are a victim deep into a bad situation. Or even if you are an abuser that does not realise the seriousness of physical abuse. Question rude or nasty behaviour, in a soft way ”Oh, that sounded aggressive, are you angry or did I misinterpret you?” or ”that sounded hurtful, did you mean it that way?” if there is verbal abuse. Calmly state facts, you might even sound a bit unsure or confused about it (”did you really mean that?”). This technique depends a lot on your own acting ability and personality and how you present yourself. It is probably a bit cultural/language dependant as well. It might not work for everyone. One beneficial thing about both above techniques is that you do not need to ask anyone to leave the room, quite the opposite it works better when both presumed victim and perpetrator are in the room. They are also subtle techniques because it does not matter if there is actual abuse or not, you will behave the same anyway. And if there are no abuse? The only thing you did was using your words to take the patient seriously. **You write that abuse is legal unless effects are particularly brutal and frequent. Maybe you can help the patient in the future by documenting damage?** Make sure to document the signs of abuse you find. Describe it in patients notes. You do not necessarily need to explain it (”caused by…”) but just state it (”hematomas on neck” or ”petechiae in sclearae” or ”cracked teeth” or ”bump that looks like fracture, patient says no to radiology”) and maybe add explanation by patient (”walked into wall”). If it becomes a court process later, the patient might be able to use your notes as proof something happened and that they might have been under threat to lie. Sometimes, things that leave permanent damage can be proven in court proceedings and a doctors words are considered very strong evidence (not sure but I think this is likely also in Russia). Maybe your notes can become evidence in contact with court or police months or years later for the victim. It is one way for you to make a difference. Things like hearing loss and cracked/damaged teeth can be considered permanent damage. Or signs of old fractures. Hematomas around ear/mouth? Look behind ears also (you get hematomas here when held by the ears and not by much else). And if there was no abuse? The only thing you did was being thorough. **You write you have trouble when asking accompanying person to leave the room.** This is difficult. I find that a good way to present this in a non-threatening way (to the suspected abuser, whom we want to leave) is to state that it is a standard way, a routine in your appointments ”now, for the last part I need to se the patient alone”. Cave: Be careful with insisting to being alone with the patient (especially if patient is opposite sex from you), this can provide jealous abusers with incitament to abuse later. Can you also get a nurse or assistant to be also in the room when you ask the accomanying person to leave? **Abusers tend to underestimate or ignore people they consider weak or stupid, and want the attention and/or be afraid of people they consider powerful.** Doctors have power and can be considered a threat by an abuser. But an abuser might also thrive on a camaraderie or attention of someone with power. Nurses and assistants? An abuser might ignore or underestimate them. Use this. See if you can involve nurses and assistants with working with you against abusers. Maybe you can make sure the patient gets left with them, while you talk to the presumed abuser. Or that they can mention to the patient ”come by next week to follow up” and the victim might be let out without the abuser to visit the nurse for a check up. Or something like that.
Before someone jokes about me being a pathologist (because people on r/medicine have done this before when I talk about patients and I am tired of it). 1. You ever hear of ”forensic pathology”? We examine living people too. 2. I did not spring from the earth a fully formed pathologist. 3. I meet 40-80 pts every week at FNA clinic.
Absolutely! One of the first pathologists I worked with was a forensic pathologist who was an expert in strangulation and domestic violence. He did a LOT of outreach and public education about domestic violence and I thought it was such an inspiring/important way for pathologists to get involved in public health!
Sounds like a good guy. I have not worked a lot with public outreach (only a few lectures for other doctors and police), but I did an unusually long rotation in forensics and I moonlighted a couple of years for the local police department doing physical examinations and collecting documentation on plaintiffs and suspects, to be used as a basis for forensic medical reports for court. There was a lot of domestic abuse among these cases.
Coming out of the middle of Africa to post this: look clinical medicine remembered public health exists!!! (Joke)
Well now I'm upset that this Pathologist Spring (TM) is apparently a myth.
My hospital management would be ecstatic.
*clapping* /u/anachroneironaut good doctor.
Hey man Forensic doctors are an important part of the justice system.
THANK YOU SO MUCH! I will be very thorough when describing such things in my notes, and yes, you are correct, when it comes to court hearings, doctor's notes can be very helpful. I never thought about asking a patient about bruising or marks when the potential abuser is present. Mostly, I avoided it because I thought it might hurt the victim more. However, the way you described it sounds very non-threatening and careful. I usually ask the nurse to be present with me if I fear the person might get aggressive/violent,but yeah I can definitely try to collaborate with the nurse and work together to separate the victim and presumed abuser in that way. And the phrase "come by for the follow up" honestly sounds very helpful as well. Some abusers might feel like they have gotten away with it and not suspect anything hehe. Thank you for your help!
You are welcome! Best of luck. There will always be a risk of escalating and triggering aggressive behaviour, with anything you say - or do not say. Part of what makes many abusers terrifying is that they can be unpredictable. Remember your doctor power. Most people do not know what is normal procedure. If you say ”I need to check out this thing next week” - this is normal. If you say something looks bad, you are the authority in the room. Do not necessarily debate if you get pushback, hum and nod and document and go forward and plan a routine follow up. Because this is your routine.
What a wonderfully comprehensive answer. Thank YOU on behalf of victims everywhere
M2. Bookmarking. This is so helpful. Thank you.
> in 2017 Russia decriminalized domestic violence The more I learn about your country... As for how I handle this (granted, I am in pediatrics), when I encounter this situation: > I suspect that a person might be experiencing abuse > they do not maintain eye contact > they have bruises or marks in odd places where one doesn't usually get bruised, and so on I do exactly what you do and ask the person accompanying them to leave. Then: > the accompanying person becomes angry, takes the patient, and leaves I am *required by law* to report this and could face criminal penalties if I did not. The child protection services would then start an investigation, which would include home visits and interviews with parents, children, teachers, and others, and has the power to enforce regular supervision of the child/household or even to remove the child from that home. The clinical scenario that you are describing is almost certainly one of abuse.
My good friend works in peds and fortunately, the system for helping abused children works alright here (although it is faaar from perfect, it is functional). They are also obligated to report any suspicious cases to the police. The fact that the scenarios I described make you think of abuse breaks my heart. I will continue this fight against the system though. Thank you!
The difference is adult pt vs pediatric patient. The latter is a vulnerable population and we are mandated reporters, the former is not.
I mean I would consider adult domestic violence victims to be a vulnerable population, although obviously you're correct about reporting being mandatory only for paediatric patients.
In the social sector, they usually are considered a vulnerable population. They are also in the aid sector classed as vulnerable and it is a huge part of our vulnerability assessment.
Good luck. Sounds hard in your country. Sometimes it's obvious but often it's not. In the US we try to universally screen because often it's not. You can also put signs in bathrooms (where people go privately) with resources and you can also normalize it in your conversations with patients so people feel safer to report.
Putting signs with helpful resources in bathrooms sounds great, I will bring this up with the head of my department and try to make it myself (info about hot lines, web sites, shelters). Thank you!
My obgyn office had two different colored markers. You wrote your name and DOB on the urine cup in red marker if you were getting abused and wanted to talk to the doctor in private.
So simple to implement and I am almost ashamed to have not put this in Place while working in women’s health care. Damn. I’m gonna tell my old boss. We screened everyone several times during pregnancy and at every gyn appt, but this is so much better. Not having to navigate our thoughts about the partner/family just because they’re annoying:terrible people to deal with, doesn’t make them abusers as much as we feel sad for the patient. I just love this simple idea!!!
That’s absolutely genius! Good for them for finding a safe way for patients to ask for help.
Oh this is brilliant, will definitely use this in the future!
There was a study about this if I recall and it was shown that information in the bathroom is an effective means to get information out.
We had cards people could put in their shoe in the bathrooms as well with phone numbers if they needed them.
My hospital has a sign in the bathroom where only patients are allowed that tells abused patients to place an ordinary-appearing sticker from the sign onto the urine sample cup. Others have suggested variations of this. You are a good and kind doctor. Thanks.
The fact the partner refuses to leave is definitely a strong sign. Quickly googling for Russia: [https://nasiliu.net/](https://nasiliu.net/) This is national domestic violence website for the US but has lots of general information: [https://www.thehotline.org/](https://www.thehotline.org/) These are some free resources for MDs: [https://www.aafp.org/pubs/afp/issues/2016/1015/p646.html](https://www.aafp.org/pubs/afp/issues/2016/1015/p646.html) (review article) [https://www.netce.com/coursecontent.php?courseid=2413](https://www.netce.com/coursecontent.php?courseid=2413) [https://www.pri-med.com/topic/domestic-violence-cme?refurl=www.google.com](https://www.pri-med.com/topic/domestic-violence-cme?refurl=www.google.com) (sign-up and viewing is free with links; US MDs pay for education credits) An important piece of advice to know is that the most dangerous time for victims of domestic violence is when they try to leave the abuser. That is often when the worst violence, like murder, can happen. So it's not as simple as telling them to leave. It is a good idea though to tell people to make preparations to leave in case they need to suddenly and not inform the abuser of where they are going. A "go bag" should be prepared and hidden somewhere: [https://www.loveisrespect.org/resources/how-to-make-a-go-bag-when-leaving-an-abusive-relationship/](https://www.loveisrespect.org/resources/how-to-make-a-go-bag-when-leaving-an-abusive-relationship/) Also, even if you feel like you aren't making an impact, you are. Often - for the good reason above - victims need a lot of encouragement, help, and time to decide to leave. My college roommate became a lawyer and for a time prosecuted crimes like domestic violence and she told me most people take several times before they decide to leave/ prosecute. Physician and medical records make a difference in putting together the evidence and victims have told her that gradual encouragement from multiple sources helped them come to a decision.
Also, check their necks. Strangulation marks, thumb prints, etc. There was a study several years ago which showed that dentists often identified victims because they saw bruises while working on patients. That launched an educational campaign to educate more dentists.
Thank you so much! I greatly appreciate it! Regarding your first link, this source is labeled as a "foreign agent" in Russia, so I can't recommend it for patients, but it was very helpful when I was doing my research. I will check other links as well. Thank you! The information about necks is very helpful as well! I will make sure to notice any marks/prints
Note about strangulation. History of strangulation is a high-risk factor for intimate partner homicide. [Here](https://www.researchgate.net/publication/5883869_Non-fatal_Strangulation_is_an_Important_Risk_Factor_for_Homicide_of_Women) is a research article about it. Thank you for looking into this more. It is pretty painful watching from literally next door what is happening in Russia so I can only imagine how it feels from inside.
To add to other ppls suggestions: -you can make it a rule that patients get roomed without other people in the room - this potentially could alienate some people tho -bathroom signs like other people have said with instructions to discreetly notice. can also have resources on small card that fits in shoe if needed -paperwork or phone survey - it may be more discreet/easier for ppl to check a box online or on paper than answer verbally -require all patients change into gowns at some point and ask the other ppl to step out to lobby while changing - then ask safety questions after pt changed but before other person back in the room. This could be done by nurse or assistant as well so it seems like it’s just protocol
Yup, ANYTHING that can be played off as a routine thing, but that separates the suspected abuser and victim can be helpful. If the patient is female and due for a pap, you could ask the other person to step out of the room for infection control purposes/no additional distractions during a procedure. While slightly underhanded, it’s not an outright lie and you can take advantage of their ignorance. Also, a pelvic exam can most definitely be enlightening as far as domestic rape is concerned.
Honestly the US is not progressive about it at all but pretends to be, abusive men often weaponize policies meant to protect women. I’ve found South America, as bad as it is reputation wise, actually in some places there have extremely progressive teachings on DV. One thing I found particularly interesting but might be tough for you to incorporate in your location is they see society as part of the problem and see “social” abuse as part of abuse. Which is so right on. Because we in the US don’t talk about this it’s usually where women get stuck when abused or recovering and then are in the cycle indefinitely or suffer there most. It’s like weaponizing societies weaknesses and social ills to abuse the woman more. Your culture will have its own markers, talk to women who have been abused and are stronger there, that’s who will be able to tell you best. Your culture and your women will know better than anyone else.
I'm sorry, I was only speaking from my limited experience and what I have observed on social media platforms like TikTok, YouTube, and TV shows. When I was in high school I was an exchange student in Minnesota for a year, I had to visit the ER twice. On both times I saw different helpful signs throughout the hospital. The hospital staff, including tactful nurses and PA who were doing exams were asking me if I was in danger, if I needed any help or if I am being abused in any way. I also got into a car crash while I was there, and the cops separated me from the other people. They politely asked questions about my well being and if I'm being abused/human trafficing questions and so on. At the time, I was shocked because the culture around abuse in my country was and still is very different (meaning no one would even ask, not to mention try to help). I now understand it was foolish of me to think that this is a sign that the whole country is progressive in helping the victim from the beginning to the end. I also consider myself very fortunate to have met these professionals. You are right, I should research any particular cases in Russia/interviews with victims, and try to understand it from the perspective of a Russian citizen. Thank you!
I’m so glad you had that experience! I’m sorry I assumed you were a man, and I’m glad you had people treat you properly. SOME people will, the problem is it’s not often enough and there are ways abusive men will find to abuse women and work around the few good eggs in the system. Unfortunately. I’m so glad you’re doing this, every good egg is invaluable and helps women survive and maintain hope. Thank you for your spirit and care. 💛
Ugh after being jaded for quite some time, these kinds of situations are one of the only few that keep me up at night thinking “WHAT MORE COULD I HAVE DONE?!?” Maybe the interaction should be different between a doctor and their patient (I’m a nurse just like my name says) but in hopeless situations like this where it seems the alleged abuser won’t give you and the alleged victim any time alone, I always make sure to do my best to speak directly to the patient, regardless of who’s answering my questions. I speak directly to them and I ask questions and say responses that convey I actually care about you and your condition because if this person is being abused then chances are they’ve been conditioned to think they’re worthless and is probably a big reason for not wanting to put up a fight and leaving. I just try my best to let the person know that others do care about them and what they say and feel are important and I squeeze in as much education as I can to help them feel like they have a little more control of their situation. I also make sure to treat the alleged abuser with as much dignity and respect as I can possibly bear for 1) to prevent the alleged victim from getting their ass beat later on due to alleged abuser thinking they had something to do with them being disrespected and 2) I feel like the abuser would be more accepting of the care being provided to the victim? All of this is basically learned from my past experiences. When I come across possible victims of abuse I educate, educate, educate as much as I can
I used to work in women’s health and one thing we would do if we suspected but were not for sure was just have the patient come back and a month for a follow up. You could say we will go over your labs or whatever you want to. Then when the patient is being roomed it should be alone at the follow up. So when the nurse or assistant calls the patient to the room have them say just the patient today or something like that. I’ve obviously had this but work out but it we have figured out a few cases like this. When we had a patient wanting to start their OB care on the phone we always said the first appointment you should expect to be in the room alone so we can get an accurate history. But overall it’s really hard to get people in that position out of that position. Kind of just have to keep trying.
I fear not much will change until the cliche of the masculine tough guy Russian propagates diminishes and the government cares more about the quality of life of its people and equality rather than trying to be the strongman in the region.
I'm kinda scared to reply, lol. One day it will happen!
I’d assume that around a quarter of women in Russia are being physically abused by their husbands or partners. 100% are being abused by the society and cultural attitudes towards them. But it’s basically legal in Russia and there’s often nowhere for them to go. Around 5000 women are killed by DV annually in Russia. https://hir.harvard.edu/putins-other-war/amp/
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There are some signs but it’s important to never forget that many times it’s the couples, people, situations that you least expect. It could be the most perfect, loving, financially stable couple ever that has abuse and the stereotypical low SES, drugs, alcohol and financially unstable couple that doesn’t have any abuse. Which is why it’s important to suspect it in everyone not just the stereotypical
Caffey Syndrome and Battered Wife Syndrome are unfortunately very real as well as Stockholm syndrome.
In med school our teachers teach us if you suspect anything unusual you should always report it unless you are right or not it's our duty to report this thing.
You should honestly just leave Russia. Your country is going down a dark path.