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Abuse Screening Kit
Violence Prevention
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The most dangerous period
for a woman in an abusive
relationship is the first
3 or 4 months following
separation.
[Peel Committee Against Women Abuse (PCAWA) Best Practice Guidelines, 2001]
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Introduction and Context Setting . . . . .Card 1
What to Look For [Signs/Symptoms] . .Card 2
Why and When to Screen . . . . . . . . . . . .Card 3
Creating a Safe Environment
for Disclosure . . . . . . . . . . . . . . . . . . . . . .Card 4
Identification and Screening
[How to Ask about Abuse] . . . . . . . . . . .Card 5
Sample Risk Assessment Questions . . . .Card 6
Safety Planning . . . . . . . . . . . . . . . . . . . . . . .Cards 7-8
Reporting and Confidentiality . . . . . . . .Card 9
Limitations Regarding Confidentiality . . .Card 10
Documenting Abuse
[What and How to Document] . . . . . . .Card 10
Injury Location Diagram . . . . . . . . . . . .Card 11
Community Referrals . . . . . . . . . . . . . . .Cards 12-13
TABLE OF CONTENTS
TABLE OF CONTENTS
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%
51
of Canadian women over the
age of 16 have experienced
at least one incident of physical
or sexual assault.
[Canadian Panel on Violence Against Women, 1993]
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PURPOSE OF THE ASK TOOL KIT
The ASK Tool Kit is a practical resource for health
professionals who provide services to women. The
information contained in this resource will help
you identify and respond to women who may be
experiencing abuse or violence in their relationships.
WOMAN ABUSE: A WORKING DEFINITION
Woman Abuse is the intentional and systematic use
of tactics to establish and maintain power and control
in a relationship. These tactics may include:
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Physical or sexual assault
Emotional or psychological abuse
Verbal abuse
Financial abuse
Environmental and social abuse
Religious or spiritual abuse
Stalking or criminal harassment
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INTRO & CONTEXT SETTING
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%
50
of women reporting physical
assault also experienced sexual
assault in the context of the
same relationship.
[Peel Committee Against Women Abuse (PCAWA) Best Practice Guidelines, 2001]
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WOMAN ABUSE: WHAT TO LOOK FOR
LOOK FOR:
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Unexplained injuries or an explanation that
does not match physical symptoms
Delay in seeking care, particularly if pregnant
Injuries when pregnant, particularly to breasts
and abdomen
Chronic illnesses that are unresponsive to
treatment
Frequently missed appointments
Overly solicitous partner who answers questions
on behalf of woman and is unwilling to allow
woman privacy
Family history of physical, sexual, or other abuse
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WHAT TO LOOK FOR
Woman abuse transcends age, race, culture, sexual
orientation and socio-economic status. The best
way to find out about abuse is to ask directly.
Women are excellent at hiding the effects of abuse.
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pregnant women are abused
during pregnancy.
[Middlesex – London Task Force Report, 2000]
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WHY SCREEN?
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1 in 4 Canadian women have experienced violence
in an intimate relationship.1
1 in 6 pregnant women are abused during pregnancy.2
40% of women who were abused during pregnancy,
reported abuse began when they were pregnant.3
WHEN TO SCREEN?
1
2
3
Type of Visit
How Often
New Patient
At first visit,
Yearly, during annual health exam, and/or
Whenever they disclose a new partner.
Prenatal
First prenatal visit,
At least once per trimester, and
Postpartum visit.
Emergency
At every visit.
Mental Health
At initial visit,
Yearly during annual health exam.
Other visits
Whenever there are physical or behavioural
signs of abuse, or
When client presents with chronic-somatic complaints.
Canadian Panel on Violence Against Women, 1993
Middlesex-London Health Unit, 2000
Canadian Panel on Violence Against Women, 1993
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WHY AND WHEN TO SECREEN FOR ABUSE
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%
95
of women abused during
the 1st trimester, reported
the violence escalated after
the baby was born.
[Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practice Guidelines:
Intimate Partner Violence Consensus Statement, No. 157, April 2005]
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CREATING A SAFE ENVIRONMENT FOR DISCLOSURE
TIPS FOR CREATING A SAFE ENVIRONMENT:
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Create a patient-friendly office with access to
community resources and up-to-date information
on woman abuse and violence.
Offer a private space for interviewing/examining
women. If husband is present, suggest reasons
why it is necessary to see the patient in private
(e.g., collection of a fresh urine specimen). Never
ask about abuse when the partner is present.
Ensure there is access to appropriate translators
(who are NOT family members, partners, children
or friends).
Use a non-threatening tone and body language
(e.g., sit at or below the woman’s level).
Be familiar with community supports and
services for women experiencing abuse or
violence [see cards 12 and 13].
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CREATING A SAFE ENVIRONMENT
Facilitating disclosure of abuse is partly dependant
on offering a safe and secure environment for
women to talk about the abuse.
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Young women under 25
are at greatest risk of
spousal homicide.
[Statistics Canada, 1999]
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IDENTIFICATION AND SCREENING
Routine Universal Comprehensive Screening
(RUCS) Protocol
ASKING ABOUT ABUSE:
To help me get to know my patients, I am asking
all my patients how things are at home or in their
relationships. I know that many women experience
some form of physical, emotional or sexual abuse
in their lives and that this directly affects their
health. I am wondering whether you have ever
experienced abuse or violence, either as a child,
an adolescent or as an adult?
For further tips on handling a “yes” or “no”
response, see Assessing Risk Questions, card 6.
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IIDENTIFICATION AND SCREENING
Asking women directly if they have been abused
remains the most important tool for identifying
abuse or violence. The following questions are a
GENERAL guide to help screen women for abuse.
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%
43
of women being abused require
medical attention.
[New England Journal of Medicine, Sept. 1999, Vol. 341, No. 12]
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ASSESSING RISK QUESTIONS
IF ANSWER IS YES
Assess Risk
Has the abuse occurred in the past 12 months?
Is the abuse still going on?
Do you still have contact with the abuser?
Do you feel safe now?
Are there children at risk of being abused?
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IF YES TO ANY OF THE ABOVE:
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Document details of abuse in patient’s own words.
Refer to social worker or community agency
[see cards 12 and 13].
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Address safety issues [see card 7].
IF ANSWER IS NO…
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Accept her response. She may not feel safe or
ready to disclose. No could also mean No.
Use as an opportunity to educate your patient
about woman abuse and it’s health effects.
Repeat that asking about abuse is now a routine
part of your health assessments and in about
one year you will “check in” again, as situations
can change.
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ASSESSING RISK QUESTIONS
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Women seek medical attention
in emergency departments
about 28 times before being
identified as abused.
[New England Journal of Medicine, Sept. 1999, Vol. 341, No. 12]
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SAFETY PLANNING
Safety of your patient and her children is the first
priority. If you, or your patient, feel that she is in
danger, collaborate with her to begin a safety plan.
SPECIFICALLY:
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Ask her directly what assistance she wants.
Warn her not to tell her abuser if she is planning
to leave the abusive relationship. Women are at
greater risk of violence or murder just after they
leave their husbands or partners.1
Inform her that the police can be asked to
accompany a woman returning home to retrieve
belongings. A referral to a shelter can be made
on behalf of the woman, provided she agrees.
Extend her support system by providing her with
information on community resources
[see cards 12 and 13].
Safety planning is not the expertise of most health
professionals, and it may be more appropriate to
refer her to a community agency specializing in
safety planning [see card 8].
Some women will decide that returning home is
their safest option. This decision MUST BE
respected and supported.
1
Statistics Canada, 2004
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SAFETY PLANNING
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Health care providers
identify only 3% of
abused women.
[New England Journal of Medicine, Sept. 1999, Vol. 341, No. 12]
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SAFETY PLANNING
A woman cannot control her abuser’s violence,
but it may be possible to increase her own and her
children’s safety.
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Provide emergency numbers, shelters and
resources (e.g., Peel Public Health’s Crisis
Numbers for Women and Children).
Suggest she:
Tell someone about the abuse.
Plan an escape route – where to go in an
emergency situation.
Ask a neighbour she can trust to call the
police if they hear a disturbance coming from
her home.
Collect essential documents and keep them in
a safe place (e.g., birth certificates, marriage
license, passports/immigration papers, bank
books, rent receipts).
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For additional information on Safety Plans, contact
your local shelter or visit www.shelternet.ca. The
booklet, Creating a Safety Plan, can be ordered by
calling the Peel Committee Against Woman Abuse
at 905-282-9792.
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SAFETY PLANNING
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In 39% of violent marriages
children have witnessed
an assault on their mother.
[Suderman & Jaffe, 1998]
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REPORTING & CONFIDENTIALITY
All alleged or suspected cases of child abuse must
be reported to Peel Children’s Aid Society [see card 12].
Among others, child abuse MUST be reported when:
REPORTING
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A woman discloses abuse and there are children
in the home
A woman discloses that her children are at risk
for abuse
An examination/interview with a child indicates
that he/she is being abused
An adolescent pregnant woman is being abused1
CONFIDENTIALITY
Protecting the confidentiality of an abused woman
is very important.
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Do not discuss or inform any person or authority
that your patient has disclosed abuse without
your client’s verbal or written informed consent
Do not pressure her to report/disclose her abuse
to the police or any other person or authority
Inform her of your professional obligation in
this regard
National Clearing House on Family Violence, 1999
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REPORTING AND CONFIDENTIALITY
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It is now suggested that
80 – 90% of children in
such homes are aware of
and affected by the abuse,
“whether it is seen, heard or
otherwise sensed”.
[Suderman & Jaffe, 1998]
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LIMITATIONS REGARDING CONFIDENTIALITY
Confidentiality cannot be guaranteed when:
The patient is actively suicidal or homicidal.
There are child welfare concerns (the Child and Family
Services Act supercedes the right to confidentiality).
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DOCUMENTING ABUSE
What to Document:
Description of the abuse, and how it occurred,
in the woman’s own words
Description of injuries (i.e., type, location, length, width,
shape, colour, depth, level of healing), including
notation if sexual assault has occurred or is suspected
Emotional status
Treatment required
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Any referral/consultations (written or verbal)
given to patient
Follow-up plans made
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How to Document:
Use an Injury Location Diagram [see card 11] to help
document the location of reported current or past abuse
Mark with an X the location of any bruises,
fractures, lacerations, burns, etc.
Attach any diagrams or photographs taken to
the medical records
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LIMITATIONS REGARDING CONFIDENTIALITY | DOCUMENTING ABUSE
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In a survey of 245 women
with disabilities, it was found
that 40% had experienced abuse
and 12% had been raped.
[Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practice Guidelines:
Intimate Partner Violence Consensus Statement, No. 157, April 2005]
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INJURY LOCATION DIAGRAM
Mark all injuries relevant to the assault, as well as areas of
tenderness and Woods light findings on the diagram. Describe colour,
appearance and size of injuries. Provide a brief history of injuries.
USE QUOTATION MARKS IF YOU ARE USING THE
EXACT WORDS OF THE VICTIM.
DESCRIPTION OF INJURIES
BODY - FRONT
BODY - BACK
INJURY LOCATION DIAGRAM
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Physician/Nurse Examiner’s Signature
Date
Time
[Trillium Health Centre Sexual Assault and Domestic Violence Services]
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Violence against women costs
more than 4.2 billion dollars
a year in social services/education,
health/medicine, criminal
justice and labour/employment.
[Greaves et al, 1995]
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COMMUNITY REFERRALS
Peel Regional Police . . . . . . . . . . . . . . .905-453-3311
Health Services
Credit Valley Hospital . . . . . . . . . . .905-813-4253
Trillium Health Centre
Sexual Assault and Domestic
Violence Services . . . . . . . . . . . . . . . .905-849-7600
Peel Public Health . . . . . . . . . . . . . .905-799-7700
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Shelters and 24-Hour Crisis Lines
Family Transition Place . . . . . . . . . .1-800-265-9178
Interim Place
Mississauga Site . . . . . . . . . . . . . . .905-403-0864
Malton Site . . . . . . . . . . . . . . . . . . .905-676-8515
Transitional Support Program . . .905-676-0257
Salvation Army Family Life
Resource Centre (Brampton)
Shelter . . . . . . . . . . . . . . . . . . . . . . .905-451-4115
Crisis Line . . . . . . . . . . . . . . . . . . .905-451-6108
Armagh . . . . . . . . . . . . . . . . . . . . . . .905-855-0299
(second stage housing up to 6 months)
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COMMUNITY REFERRALS
24-Hour Crisis Line Services
Assaulted Women’s Helpline . . . . . .1-866-863-0511
Family Transition Place . . . . . . . . . .1-800-265-9178
Victim Services of Peel . . . . . . . . . .905-568-1068
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women treated for trauma
in the ER has been injured
by an intimate partner.
[Middlesex-London Health Unit, 2000]
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COMMUNITY REFERRALS
Community Counselling and Support Services
Catholic Cross Cultural Services . . .905-457-7740
Catholic Family Services of
Peel-Dufferin . . . . . . . . . . . . . . . . . .905-450-1608
Family Services of Peel . . . . . . . . . . .905-270-2250
India Rainbow Community Services905-275-2369
Malton Neighbourhood Services . .905-677-6270
Muslim Community Services . . . . .905-790-1910
Salvation Army Women’s
Counseling Services . . . . . . . . . . . . .905-820-8984
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Legal Services
Victim Witness Assistance Program . .905-456-4797
Victim Services of Peel . . . . . . . . . . .905-568-8800
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Services for Children
Peel Children’s Aid Society . . . . . . .905-363-6131
Catholic Family Services of
Peel-Dufferin . . . . . . . . . . . . . . . . . .905-450-1608
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Elder Abuse
Elder Help Peel . . . . . . . . . . . . . . . . .905-457-6055
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COMMUNITY REFERRALS
Programs for Abusive Men
Catholic Family Services of Peel-Dufferin
(Man-to-Man Program) . . . . . . . . .905-450-1608
Merge Counselling and
Education Services . . . . . . . . . . . . .905-855-8028
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Is there anything you’d
like to talk about?
SOME WOMEN
ARE DYING TO
BE ASKED.
FamilyAbusePrevention.ca
Funding provided by the Government of Ontario. The views expressed
in this report are the views of the public health unit and do not
necessarily reflect those of the Government of Ontario.