Health Care Systems/Domestic Violence

Train the Trainer

Health Care Responding to Domestic Violence

Screening and Intervention

November 2, 2012

Domestic Violence and Health Care• Domestic violence is a health care

issue• The US Department of Justice reports

that 37% of all women who sought care in hospital emergency rooms for violence-related injuries were injured by a current or former spouse, partner, boyfriend or girlfriend.

• Futures Without Violence

DV and Health Care• Of women seeking care at hospital

emergency departments, about ¾ of them failed to be identified as victims of domestic violence.

• Journal of General Internal Medicine, March 15, 2011

• Fewer than 10% of primary care physicians routinely screen during regular office visits.

• Journal of the American Medical Association, 1999

DV and Health Care• Recently abused women have health

care costs that are more than twice those of never abused women and about $4500 higher than women who had not been abused in the past year.

• Nationally, the medical cost burden of IPV against women aged 18 and older within the first year of victimization ranges from $2.3 billion to $7 billion.

Domestic Violence Costs Lives

Why Understanding Domestic Violence MattersDomestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior perpetrated by an intimate partner against another. It is an epidemic affecting individuals in every community, regardless of age, economic status, race, religion, nationality or educational background. Violence against women is often accompanied by emotionally abusive and controlling behavior, and thus is part of a systematic pattern of dominance and control. Domestic violence results in physical injury, psychological trauma, and sometimes death. The consequences of domestic violence can cross generations and truly last a lifetime.

Domestic Violence is Characterized by Power and Control

Facts About Domestic Violence• One in every four women will experience

domestic violence in her lifetime. • Domestic violence can occur to anyone regardless of

race, culture, language, income, education, religion, sexual orientation and occurs across the lifespan.

• An estimated 3.9 million women are physically assaulted each year.

• 85% of domestic violence victims are women. Most often victimized by someone they know.

• DV is more prevalent among women than diabetes, cervical cancer and/or breast cancer.

• Females who are 20-24 years of age are at the greatest risk of nonfatal intimate partner violence.

• Most cases of domestic violence are never reported to the police.

Domestic Violence & Disabilities• Women with disabilities have a 40% greater risk

of violence than women without disabilities• Studies estimate 80% of women with disabilities

have been sexually assaulted• One study showed 47% of sexually abused

women with disabilities reported assaults10 occasions

• Studies estimate that between 70% and 85% of cases of abuse against disabled adults go unreported

• One study found that only 5% of reported crimes against people with disabilities were prosecuted compared to 70% for serious crimes against people with no disabilities

Abuse In Later Life• Every year, an estimated 2.1 million older

women are victims of physical, psychological and other forms of abuse and neglect

• Only 1 out of 14 cases of elder abuse is reported to the authorities

• A few Indicators that abuse occurred:o broken bones, fractures, sprains and

dislocationso Bruises, bilateral and “wrap around”

bruiseso Unexplained injuries or details that “don’t

fit”o Delay between onset of injuries and

seeking medical attention

Domestic Violence in Wisconsin• Each year, more than 40,000 women,

children and men are served in WI’s domestic violence programs.There is at least one program in each of WI’s 72 counties and within our 11 Tribes. To learn where WI’s domestic violence programs are: www.wcadv.org

• There are more than 25,000 arrests annually for DV-related offenses.

What Can I Do?

• Ask• Validate• Document• Refer

ASK Each Patient if They are Safe at Home• Believe that domestic violence exists

and is prevalent• Believe it exists for the patients you

serve• If you don’t ask, victims won’t tell

you on their own. They may not even realize that what they are experiencing is abuse.

• Health care is not a neutral encounter.

VALIDATE THE PATIENT • Name and acknowledge abuse as

common• Recognize that escaping abuse is

complex and that you understand that.• Your role is to break isolation;• You cannot save her but you can be

there with her;• You cannot prescribe safety!

• You can offer options and information.

DOCUMENT What You See and Hear• Document any visible signs of abuse

by noting injury type, size, degree of healing, etc.

• If a patient tells you about abuse, make general notes about what s/he says.

• Because so few victims report the abuse to police, the confidential records you note may be the only records of the abuse.

REFER to Services• If a patient reports abuse, or if you suspect

abuse, make sure you share a number of a local domestic violence programs. Assure her that she can call anonymously if she chooses, and that like her relationship with health care, communication with a domestic violence or sexual assault advocate in Wisconsin is privileged and confidential.

• To find a local program in your community, go to www.wcadv.org. For referrals to programs out of state, contact the National Domestic Violence Hotline at 1-800-799-SAFE (7233)

Screening Tips• Golden Rule: ALWAYS ALONE• Develop and build trust

• If it feels comfortable, try to create a dialogue with patient about stress in her life, what home-life is like, etc.

• You are trying to achieve the overall health of the patient

• Present questions as routine, common and normal• You are not singling out the patient, “Because

abuse in the home is common, I ask this question of all my patients.”

• Use an interpreter, if necessary• Discuss confidentiality

Screening Tips• LISTEN- respect the patient’s

language and vocabulary• Try to be both general and specific

with questions• Don’t argue or debate; be part of the

solution• Take your time…and give your time!

Sample Screening QuestionsStart your questions generally, asking more specific questions as you go.

• How are things going at home?• Do you always feel safe at home?• When you haven’t felt safe, what causes

you to feel that way?• Has anyone in your home ever threatened

you? Intimidated you? Harmed you?• Has a person ever pushed, shoved, hit,

strangled you?

When a Patient Says “No”Leave the door open. Express concern and provide resource information.-Domestic violence is common. Our concern here is

to reduce health risks and injuries. If you know of someone who needs support or services, or if you ever feel you might need support someday, here is a resource…

-I want you to know that this clinic is a safe place for you to come.

-Thanks for letting me talk to you about this. If you ever have questions for yourself or for a friend, I’m always available.

When a Patient Says Yes• Assess the severity – ask about frequency,

duration, and patterns of violence• Ask if the patient is safe to go home after

the visit• Document what you see and hear• Provide referral information to a local

domestic violence, sexual assault or elder abuse program (depending upon the information you receive).

Understand the Unique Barriers Each Patient Might Have to Disclosing • Impact of culture -some cultures reinforce

very strong family values• The impact of racism, homophobia,

ageism and ableism may cause some victims to fear they won’t be believed

• Undocumented victims may fear deportation or may have language barriers

• Some religious traditions may strongly reinforce family values

• Can you think of other reasons a victim may not disclose?

Standard of Care• Ask all patients routinely• Listen• Offer validating messages• Respond to immediate safety issues• Assess history of abuse• Offer local, confidential resources• Arrange for follow-up if it is safe to do so

Guiding Principles• Work to understand the uniqueness of

each patient, including anticipating the barriers they may face

• Respect the choices of the victim• Work to increase safety for victim and

children• Send validating messages…”abuse is not

your fault”• Be an advocate for victims and their

children• Make changes in your clinical practice to

improve health care’s responses to intimate partner violence.

What Is Trauma Informed Care (TIC)?Trauma Informed Care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role of trauma in their lives

Adverse Childhood Experience (ACE) Study• Ongoing research study from the Center

for Disease Control and the Kaiser Permanente

• Data results in proof of the health, social and economic risks that result from childhood trauma

Trauma Informed Care Services

• Focus on the context of a person’s life or their life experience.

• Recognizes the role of violence and victimization in a women’s life.

• Collaborate with non-traditional & expanded community supports (i.e. faith communities, friends & families)

• Hospitable and engaging to survivors.• Facilitates recovery• Facilitates growth, resilience and healing

Domestic Violence Resources• In Wisconsin, WCADV, www.wcadv.org to

find a local domestic violence or elder abuse program. 608-255-0539

• National Domestic Violence Hotline (24 Hour)1-800-799-SAFE (7233)1-800-787-3224 (TTY)

Health Care Resources: Futures Without Violence,

www.futureswithoutviolence.org