The Key Role of Plastic Surgeons in Intimate Partner Violence Screening

A woman steps into your exam room for a consult and immediately you notice that she recently sustained an orbital floor fracture. Her partner, sitting beside her, seems to answer every question you ask, and she glances his way before speaking for herself.

The patient may have merely taken a nasty fall, and her partner could simply be protective and concerned. Or could this be a sign of something more?

Intimate partner violence (IPV) is defined as abuse or aggression between former or current partners in a romantic relationship. It is believed to occur in one in four women and one in 10 men in the U.S.

Plastic surgeons are in the unique position to observe IPV victims as they handle consults in the management of craniofacial and hand trauma, where signs of intimate partner violence tend to be most evident.

Here are signs to look out for in your patients, how to give victims the resources and support they need, and how the COVID-19 pandemic is impacting the incidence of intimate partner violence.

Signs of Intimate Partner Violence

Patient Signs

According to practitioners, recognizing the signs of intimate partner violence is more than noticing a black eye.

“It’s not just physical abuse,” asserts Dr. Sean Figy, Assistant Professor and Program Director at the University of Nebraska Plastic and Reconstructive Surgery Residency Program, in the Enhance Your Practice podcast. “It’s a close, personal relationship being used as a weapon.”

He notes that plastic surgeons should be aware of patients that:

• • Have signs of orbital floor fractures
  • Have bruises in multiple places and in multiple stages of healing
  • Have had recent hand surgery
  • Have their financial means withheld and must ask their partner for their own money
  • Look to their partner before answering any of your questions, or the partner may do all the answering themselves.

Researchers classify IPV assaults as either “target” or “defensive,” each presenting with different injury types. The face is the most common target area while the upper extremity is the most common defensive area. In addition, head-and-neck trauma is the most common injury site overall. Patients who are admitted to the emergency department with head-and-neck trauma are nearly 12 times more likely to be victims of domestic violence.

Tips for Intimate Partner Violence Screening

To confirm any suspicions of IPV, practitioners note that it is important to separate the patient from the partner so they can speak freely. One way to do this is to tell the partner that there is a component of the exam that you need to complete in a different room, or that you need to take photos of the patient and need the partner to leave, says Dr. Figy.

Once the patient is alone, you can set the tone for a safe environment by:

• • Reassuring them that intimate partner violence screening is universal and you are not doing this because you necessarily suspect IPV, advises the American College of Obstetricians and Gynecologists.
    • To that end, consider incorporating intimate partner violence screening into routine medical intake forms so that all patients are screened regardless of whether abuse is suspected or not.
  • Using plain language when discussing IPV. Avoid using stigmatizing terms such as “abuse,” “rape,” “violence” etc.
  • Being cautious to not take an ambiguous or judgmental tone. Instead be caring and supportive, and allow your body language to reflect that as well, according to Dr. Figy.

Dr. Marie Crandall, a trauma surgeon and the Program Director for the General Surgery Residency at the University of Florida College of Medicine, notes that she uses the SAFE approach for screening patients by asking:

• • S – Do you feel safe at home?
  • A – We all get angry. Is there any grabbing, pushing, hitting, kicking or threats of violence when your partner gets angry?
  • F – Have you ever been forced to do sexual things that you don’t want to do?
  • E – Is you partner emotionally threatening or overly possessive?

In addition, some practitioners place take-home resources such as safety procedures and hotline numbers in privately accessible rooms such as bathrooms and exam rooms. This helps to normalize the conversation around IPV, and allows patients to get the information they need if they are not yet comfortable disclosing their situation to you, according to the American College of Obstetricians and Gynecologists.

COVID-19 and the Need for More IPV Screening

During the height of the COVID-19 pandemic, IPV became even more pronounced with lockdowns at home, less interaction with family and friends, increased financial stress and fear of contracting the virus. Such factors may have created an unescapable situation for some and the perfect environment for IPV to occur.

In fact, domestic violence incidents increased by over 8% after the U.S. imposed lockdown orders, according to a 2020 report by the Council on Criminal Justice. Some states such as Washington and Texas reported 21% and 35% increases in domestic violence calls at the peak of the pandemic.

What can plastic surgeons do to help?

In their 2021 report titled “The Plastic Surgeon’s Role in the COVID 19 Crisis: Regarding Domestic Violence,” Ford et al. noted that plastic surgeons can be the “second-line provider” to help identify signs of intimate partner violence during trauma consults in patients that had not been asked about it by their general physicians or the emergency department.