Three Hidden Signs of Physical Abuse

Healthcare professionals are on the frontlines of domestic abuse. They occupy a unique place where they may be able to spot signs of abuse even when a patient is frightened of sharing information about the violence they’ve suffered. Here are some little-known and often “hidden” signs someone is experiencing intimate partner violence that medical professionals should be aware of.

#1 - Minimally Displaced Ulna Fracture

Many victims of physical violence often raise their hands to their heads and faces to protect from being struck, including with objects. This results in a specific type of fracture to the ulna, the pinky-side forearm bone, concluded a recent study presented to the Radiological Society of North America. As many as one-third of adult women with this injury might be domestic violence victims, says the study.

The lead author of the study, orthopedic surgery resident at Boston Medical Center David Sing, MD, says, "The radiological characteristics we were looking at were the location of the fracture, the pattern of the fracture in terms of how it broke and the displacement of the fracture. Out of all those things, what we usually saw was a minimally displaced fracture, meaning the bone is broken all the way through but has not shifted significantly." 

Some patients in the study suspected of being victims of domestic violence claimed that their injury came from falling. However, a senior author of the study, Bharti Khurana, MD, director of emergency musculoskeletal radiology at Brigham and Women's Hospital in Boston, notes that it’s more likely to fracture the radius (the other forearm bone) in a fall.

Radiologists who see evidence of this injury can speak with the patient’s doctor, surgeon or emergency department staff to let them know it’s a possible sign of domestic abuse. Looking at past imaging results can validate these concerns and help victims document abuse.

#2 - Long-Term Effects of Strangulation and Suffocation

Breath deprivation is one of many ways an abuser exerts power and control over their victim. It’s a violent warning that the abuser is physically more powerful and could kill their victim at any time. Strangulation is a high indicator (along with other factors) of escalating violence that can lead to homicide. 

Visible signs of strangulation can present in a patient as bruising and lesions on the neck, but often manual strangulation does not leave obvious marks (though strangulation with an item like a rope or belt may leave abrasions). Other signs and symptoms of strangulation include difficulty swallowing, ear pain, vomiting blood, petechiae (red spots) on the face, eyes or scalp, swollen lips and tongue, lightheadedness, bloodshot eyes, changes in vision, slurred speech and raspy voice.  

However, strangulation and its similar sibling, suffocation, don’t always leave obvious or immediate evidence of trauma. These forms of violence can directly lead to traumatic brain injury (TBI). 

A study by The Ohio State University and the Ohio Domestic Violence Network (ODVN) looked at the prevalence and effects of traumatic brain injuries among domestic abuse survivors. Of the 49 study participants who reported having been physically abused by a partner, 83 percent said they’d been strangled at least once, more than half had been strangled “a few times” and one in five said they’d been strangled “too many times to remember.”

The New York State Office for the Prevention of Domestic Violence says side effects associated with TBI can include:

• Vision problems, insomnia, loss of coordination and seizures
• Cognitive difficulties, such as decreased ability to concentrate, pay attention and solve problems
• Difficulty communicating
• Executive function difficulty, such as making decisions, considering long-term consequences, taking initiative, feeling motivated, starting and finishing actions and impulsiveness
• Behavior changes like irritability, difficulty tolerating frustration, and emotional expression that doesn’t fit the situation

Other signs of strangulation and suffocation include changes in the voice, neck pain, difficulty swallowing or breathing, ear pain, vomiting blood, vision changes, tongue swelling, bloodshot eyes and lightheadedness. This violence can also cause miscarriage in pregnant victims. 

“In general, what we found is the survivors that we were speaking to didn’t realize the symptoms that they have could be attributed to a brain injury,” Julianna Nemeth, the lead researcher of the Ohio State University and ODVN study and an assistant professor of health behavior and health promotion at Ohio State University, told DomesticShelters.org. ODVN’s Center on Partner-Inflicted Brain Injury created the CHATS tool to help professionals assist suspected victims assess their injuries.

#3 - Sleep Deprivation and Chronic Fatigue

Sleep deprivation is another tool abusers use to control their victims. Lundy Bancroft, acclaimed speaker and consultant on domestic violence, addresses sleep deprivation in his book Why Does He Do That?, calling it “a serious form of physical abuse, though it is not often recognized.” Bancroft says the effects are cumulative; the longer you’re denied sleep, the greater the impact it can have.

Short-term effects of sleep deprivation present in patients with symptoms such as new or increased challenges handling stress, physical problems like headaches and abdominal pain, emotional distress, mood disorders and other mental health problems, cognition and memory issues, and behavior problems. Long-term effects present as obesity, diabetes, heart disease and hypertension, decreased immune system function, alcohol abuse and lowered life expectancy.

However, sleep deprivation might not just come from direct abuse. Researchers have found a strong link between domestic abuse and chronic fatigue syndrome (CFS), a complicated disorder characterized by extreme exhaustion that doesn’t get better with any amount of rest. Other symptoms of CFS include foggy thinking, sore throat, enlarged lymph nodes, unexplained muscle pain and unfamiliar feeling headaches. CFS is particularly prevalent in survivors of childhood abuse, with the CDC noting, “Childhood trauma […] affects the physical and mental well-being of humans from infancy throughout the lifespan. Markedly elevated levels of pain and fatigue have been reported in studies of survivors of childhood abuse.”

Exhaustion is a common symptom of many mental, physical and mood disorders and illnesses, however, in conjunction with other signs, it can be a strong indicator of past or present abuse. 

How Can Medical Professionals Help Domestic Violence Victims?

When a medical professional suspects their patient is a victim or survivor of domestic abuse, they have an obligation to help, according to the American Medical Association’s Code of Medical Ethics. The Code outlines ways medical professionals can intercede to help patients by becoming familiar with how to detect violence or abuse (including cultural variations in response to abuse); community and health resources available to abused or vulnerable persons; public health measures that are effective in preventing violence and abuse; and legal requirements for reporting violence or abuse.

The AMA also notes that it’s important doctors:

• Consider abuse as a possible factor in the presentation of medical complaints.
• Routinely inquire about physical, sexual and psychological abuse as part of the medical history.
• Not allow diagnosis or treatment to be influenced by misconceptions about abuse, including beliefs that abuse is rare, does not occur in “normal” families, is a private matter best resolved without outside interference, or is caused by victims’ own actions.
• Offer treatment for the immediate symptoms and sequelae of violence and abuse and provide ongoing care for patients to address long-term consequences that may arise from being exposed to violence and abuse.
• Discuss any suspicion of abuse sensitively with the patient, whether or not reporting is legally mandated, and direct the patient to appropriate community resources. (Though not noted specifically by the AMA, it’s key for medical professionals to hold these discussions when they’re alone with the patient and not in the presence of the patient’s partner.)
• Report suspected violence and abuse in keeping with applicable requirements.

Dr. Anita Ravi, MD co-founded PurpLE (Purpose: Listen & Engage) Health Foundation, a nonprofit organization that invests in the physical, mental and financial health of women and girls who have experienced gender-based violence. She says patients have shared that they’ve left medical settings because they felt they were being judged, so it’s important that medical professions are non-judgmental. 

Dr. Ravi also notes the importance of medical professionals to be aware of the mental health, housing, legal and social services available to abuse victims. She says that while a patient may not be open to discussing abuse during a first or even second visit, those interactions can lay the groundwork that the physician’s office or an emergency department is a safe place.