CATEAU-CAMBRÉSIS — The emergency department (ED) at a hospital in northern France has implemented an enhanced protocol for managing victims of domestic violence. The protocol includes social measures, psychiatric care, and — since early 2020 — the dispatch of law enforcement officials to the hospital to enable victims to file reports more easily.

Medscape France spoke with Benjamin Paule, MD, a doctor in the ED at the Centre Hospitalier Cateau-Cambrésis, who is an expert on the subject of domestic violence and is responsible for the pilot program. 

Medscape: What is the sociodemographic background of the patients coming to the emergency department at your hospital?

Paule: First, it’s important to know that the hospital is located in a rural area, where the population is very disadvantaged and faces a lot of issues, particularly financial. The region also has problems with the availability of medical care. Primary care services are difficult to access, whereas the population can access the emergency room relatively easily. We see 50 to 60 patients a day in the department, both adults and children. Of these, approximately two per week are victims of domestic violence, which is six to 10 every month, which is a lot.

Medscape: How did you come up with the idea for this management protocol that you are piloting?

Paule: When I came to the department as a resident 3 years ago, there was no management protocol for victims of domestic violence. Generally speaking, people primarily came to have their injuries treated and to have them documented in order to file a report. We treated them, we drew up a certificate, and they left. Given the significant number of victims of domestic violence that we were seeing (who were mostly women; rarely men), I started to take an interest in this issue. At that time, it was also becoming a hot topic politically, with the debates on domestic violence, and in 2017, on the International Day for the Elimination of Violence against Women, French President Emmanuel Macron announced gender equality between men and women as the “national cause,” [an issue chosen by each president at the beginning of their 5-year term]. The French #MeToo movement also started that year and was frequently in the media. So as part of my thesis, I created a care pathway within the Cateau-Cambrésis hospital for the management of victims of domestic violence.

Medscape: What are the different components of the protocol?

Paule: We have developed several. When someone has been injured, or beaten, of course the priority is still to provide the necessary physical care, but we have added a social component. The hospital’s social workers come by routinely to speak with these patients to determine whether alternative housing is needed, whether any children are involved, what their financial resources are, etc. This is key, especially since the social workers are women, unlike the majority of the doctors in the emergency department, and female victims trust them more readily.

We also work with a local association, SOLVEIG, that assists and supports female victims of domestic violence, which means we can arrange follow-up for these women and not just provide medical care at a given time in the emergency room.

Medscape: What other types of assistance do you provide?

Paule: We routinely offer psychiatric support to women who are victims of violence. In order to do so, we had to find resources that didn’t previously exist in the department. We asked for support from the hospital’s addictions unit, which agreed to make itself available for these women, and we collaborated with the regional medical-psychological center via psychiatric liaison nurses. As domestic violence often has a devastating impact on mental health, we routinely carry out a suicide risk assessment and screen for signs of substance abuse, with assistance from the nurses in the addictions unit. The idea is to carry out an initial assessment in order to then put a care plan in place, if necessary.

Medscape: What processes are in place with respect to the legal aspects?

Paule: For the medicolegal side, I reworked the certificates for evidence of injuries, which previously were not fully compliant [with the law]. We have also organized training on how to draw up these certificates, and adopted a Total Incapacity for Work (ITT) scale (the one established by l’hôpital Raymond Poincaré de Garches).

Medscape: You were featured in the French media for having set up a process for filing reports at the hospital. What does that consist of?

Paule: Essentially, we put in place a simplified process for filing reports at the hospital. An agreement was reached between the prefecture and the courts for police officers to come to the hospital, right to the victim’s bedside, to talk to them and take the report. In these cases, we are the ones who call the officers with the patient’s agreement, or even without it; in certain situations defined by the criminal code, it is possible to break medical confidentiality (e.g., victims who are minors, victims who are pregnant, or victims controlled by a violent partner who are assumed to be in immediate danger).

Medscape: Have you already used this procedure? How quickly do the police officers respond?

Paule: We use it regularly — around 10 times a year. The rest of the time, often the women have already filed a report and come to the hospital to obtain a medical certificate for evidence of injuries, or they do not want to file a report. It is a group of specialized police officers from the Group Against Domestic Violence (GLVIF) that comes to the hospital to take the report. It’s a way of providing a rapid response, of making sure that the case will be investigated. It’s also a way of ensuring that women don’t change their minds on the way to the police station, especially if they need to go back another day, and that the woman’s partner is not present, as this could influence her decision.

Medscape: How could this procedure be improved?

Paule: In the future, we would like to implement a digital platform for filing reports by email, so that we can generate a preliminary report immediately from the hospital. The report would be fairly brief and would provide an overview of the events in a few sentences, along with the medical certificate of evidence of injuries, to be sent in real time to the court for the presiding magistrate. The idea is to be able to trigger an immediate legal response and initiate proceedings, even if the case is later retracted. This system should be implemented in the emergency room at the Cateau-Cambrésis hospital within the next few weeks.

Medscape: How has the implementation of this protocol changed your way of managing victims of domestic violence?

Paule: We have improved our screening and our detection. Since I took an interest in this topic, I no longer manage all patients in the same way. My practice and my manner have changed. I’m more proactive in looking for history of nonconsensual sex and sexual assault in victims of domestic violence, which I didn’t automatically do before. This is a small population base, so we often see patients again. Now that we are better trained, we sometimes spot domestic violence even when it is not reported by the women themselves, by asking simple questions, such as “How are things at home?” Our relationships with the court magistrates have also changed considerably. We call each other regularly, and we were invited to present our work. Overall, things flow more smoothly and communication has improved.

Medscape: What is still difficult in treating women who are victims of violence?

Paule: It is always very difficult having to file a report and intentionally breach medical confidentiality [when it is possible to do so, see above] because we believe a woman is being controlled, that her ability to make a judgement is impaired, and her health and safety are at stake, when the victim objects and asks us not to do so. It is also very complicated when we have to maintain confidentiality because a patient does not want to file a report, knowing that the chance of seeing her again in the ED for the same reason is high…. It feels as though I’m supporting her decision, and it’s very complicated to manage.

Medscape: Can we expect this type of protocol to be rolled out nationwide?

Paule: During a visit to our department last year, the Minister for Justice, Eric Dupont-Moretti, praised the strong collaboration we have fostered between medical professionals, magistrates, and law enforcement officials, and wanted these practices to be implemented nationwide. We hope to see this happen soon.

This article originally appeared in the French edition of Medscape.

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