Shelley M. Guida, MS, LMFTDirector of Program Services

shelley@raccfm.com

Domestic Violence or Intimate Partner

ViolenceApplications to Medical Practice

As defined by the American Psychological Association (APA) DV is “a pattern of abusive behaviors including a wide range of physical, sexual, and psychological mistreatment used by one person in an intimate relationship with another to gain power unfairly or maintain that person’s misuse of power, control, and authority” (APA, 1996, p. 23)

Domestic Violence (DV) or Intimate Partner Violence (IPV)

Annually in U.S. 1 in 9 women experience domestic violence; 1 in 4 sometime throughout their life

Adolescents/young adults experience highest rates (16 victimizations per 1000 in women ages 16 to 24)

For women 15-55 domestic violence results in more injuries than car accidents, sexual assaults, and muggings combined

Domestic Violence-Prevalence

Majority (two-thirds) of incidents occur in the victim’s home

It is a family matter-focused usually on single individual (typically female partner) but affects all family members

Children are affected directly and indirectly In 2010, 15 women, 7 children, 4 family

members/friends, and 2 men died in MN from domestic violence

In 2009, 6 women and 3 children died in ND from domestic violence

Domestic Violence-Prevalence

Important to remember….domestic violence occurs in ALL groups of people…. regardless of race, ethnicity, religious affiliation, socioeconomic, educational status---NO TYPICAL VICTIM

Racial minorities tend to experience more intimate partner violence than white counterparts (economic and marginalized status creates higher risk….)

Cultural Considerations

FEAR of an escalation of the violenceFEAR of not being able to provide for

children, keeping children safe, loosing children,

LACK of real alternatives for living - housing, employment, financial support

BELIEVES she caused the violenceIMMOBILIZED by psychological and/or

physical trauma VALUES - Cultural, Religious, Family…keep

family unit together at all costs

Why do people stay in abusive relationships?

Center for Disease Control (2003) reports that domestic violence results in 5.8 billion dollars spent for medical care, mental health care, lost productivity and income

Medical and mental health care alone costs over 4 billion per year

Women who are involved in domestic violence make up 34%-46% of adult female patients in primary care practices (Burge, Schneider, Ivy & Catala, 2005)

Domestic Violence - a Major Public Health Care Concern

Families experiencing domestic violence visit physicians 8 times more often, visit the emergency room 6 times more often, and use six times the amount of prescription drugs as the general population (Mitchell, 1994).

Domestic Violence: a Public Health Issue

It is estimated that twenty-six percent of all suicide attempts in women are related to domestic violence

Domestic violence is associated to a multitude of health issues such as low-birth rates in pregnant women and alcohol abuse…

Alexander, B. & Elliott, E.V. (2000). Health care providers

response to domestic violence. East Lancing: Michigan State University.

Public Health Issues

Physical Mental

Broken Bones, Bruises, Cuts, Depression, Anxiety, Trauma (Post Traumatic Stress Disorder)

Concussions, Internal Injuries Substance Abuse

Chronic Pain, Neurological Disorders, Gastrointestinal Problems

Suicide

Migraines, Sexually Transmitted Diseases, Urinary Tract Infections

Children acting out, withdrawing, overachieving or underachieving

Children may experience hearing, speech problems, sleeping issues, appetite loss or increase, complaints of ongoing feeling sick, higher levels of hospitalization

Poor impulse control

Medical complications during pregnancy (pre-eclampsia, gestational diabetes, placenta previa)

Physical/Mental Health Effects

According to the Centers for Disease Control, each year 6% of pregnant women (240, 000) experience domestic violence

Complications for pregnancy include: low weight gain, anemia, infections, and higher levels of first and second trimester bleeding

Also associated with higher rates of maternal depression, suicide attempts, substance use and abuse

Effects of Domestic Violence on Pregnancy

Late and/or sporadic access to prenatal care Injuries to the breasts or abdomen Vaginal bleeding Low weight gain Frequent complaints for somatic complaints

(insomnia, hyperventilation) Poor nutrition Premature labor Recurrent pelvic infections

Indicators for Domestic Violence in Pregnant Women:

Self-induced or attempted abortion Increased substance abuse Short inter-pregnancy intervals Suicide ideation Evidence of noncompliance with treatment

or care

Indicators for Domestic Violence in Pregnant Women cont.

What role can medical professionals play in addressing this major health care issue?

Medical Practice and DomesticViolence

Screening, Identification, Referral, Education

Efforts have begun to encourage medicalpractitioners to learn about domestic violence and to screen patients. The American MedicalAssociation, American College of Emergency Physicians and Family Violence Prevention

Fund have published guidelines for identifying and assisting victims of domestic violence.

Role of Healthcare Professional:

A variety of models exist to screen for domestic violence in medical settings:

HITS (Hurt, Insult, Threaten, Scream)

WAST (Women Abuse Screening Tool), WAST (Short Form)

The Danger Assessment

Screening Models

The four questions in HITS stand for;◦ How often does your partner physically Hurt you? ◦ How often does your partner Insult or talk down to you? ◦ How often does your partner Threaten you with physical harm? ◦ How often does your partner Scream or curse at you?

Each question is answered on a five point scale ranging from 1 to 5 for never, rarely, sometimes, fairly often, and frequently, respectively.

The Score Ranges from a minimum of 4 to a maximum of 20. The patients who fall in the 11 to 20 range score are the ones who should be offered information regarding battered women's services including emergency shelter places and mental health services.

Source: Sherin, DK. (1998). HITS Brief Domestic Violence Screening Tool. Family Medicine (July/August).

HITS MODEL

1. In general, how would you describe your relationship? ◦ A lot of tension ◦ Some tension ◦ No tension

2. Do you and your partner work out arguments with: ◦ Great difficulty ◦ Some difficulty ◦ No difficulty

3. Do arguments ever result in you feeling down or bad about yourself? ◦ Often ◦ Sometimes ◦ Never

4. Do arguments ever result in hitting, kicking, or pushing? ◦ Often ◦ Sometimes ◦ Never

5. Do you ever feel frightened by what your partner says or does? ◦ Often ◦ Sometimes ◦ Never

6. Has your partner ever abused you physically? ◦ Often ◦ Sometimes ◦ Never

7. Has your partner ever abused you emotionally? ◦ Often ◦ Sometimes ◦ Never

Women Abuse Screening Tool (WAST)

The Danger Assessment (Campbell,1995) was developed in consultation with victims of domestic violence, law enforcement officials, shelter workers and other experts.

The aim of the DA is to assess for the risk of spousal homicide. The original items were obtained from retrospective studies that documented homicide or near fatal injury cases.

www.dangerassessment.org

The Danger AssessmentJacquelyn C. Campbell, PhD, RN, FAAN

Inconsistent training and screening in medical settings-10% of primary care physicians routinely screen for domestic violence…Elliot, L., Nearney, M., Jones, T., & Friedman, PD., (2002). Journal of General Internal Medicine, 17, 112-116.

Training in medical school varies, some increase in curriculum, but student’ self reported ability to deal with issue has not concurrently increased

Role of Physician-Current Status

Lack of knowledge about domestic violence (majority don’t feel prepared in training)

Fear of offending patients Perceived time pressures Perceived irrelevance of domestic violence

to practice Fear of loss of control of provider-patient

relationship Fear of involvement and danger in situation

Barriers to Addressing Domestic Violence for Health

Care Providers

Lack of trust Do not recognize the abuse Fear of retribution Threats of loss of children/pets Fear of loss of control Sense of hopelessness Embarrassment and humiliation

Barriers for the Patient

Develop Trust…..An interest in patients’ lives…know the signs, what to look for, what to ask, talk openly, ensure privacy

Care….Address the medical concerns within the context of the abuse situation, don’t blame the victim

Encouragement…Offer support, provide materials, resources and referrals

Advocate for addressing domestic violence in the medical community

Breaking Down Barriers

Center for Disease Control (2003) (http://www.cdc.gov/ncipc/factsheets/ivpfacts)

Coker, A. (2005). Opportunities for prevention: Addressing IPV in the health care setting. Family Violence and Health Practice, 01(www. Jfvphp.org)

Family Violence Prevention Fund (1999). Domestic violence healthcare protocols. San Francisco: CA: Health Resource Center on Domestic Violence.

Shornstein, S. (1997). Domestic violence and health care: What every professional needs to know. Sage Publications.

Resources

Hall, B.S. (2008). The Culture of Domestic Violence. In Essentials of Cultural Competence in Pharmacy Practice by Halbur, KV & Halbur, DA. Alexandria, VA: American Pharmacists Association.

Saber, P.R. & Taliaferro, MD (2006). The physician’s guide to intimate partner violence and abuse: A reference for all health care professionals. Volcano: CA: Volcano Press.

Resources

American Psychological Association. (1996). APA Presidential Taskforce. Washington: D.C.

Burge, S., Schneider, F.D., Ivy, L., & Catala, S. (2005). Patients advice to physicians about intervening in family conflict. Annals of Family Medicine, 3(3), 248-253.

Mitchell, A. (1994). Domestic dating violence resource handbook. King County, Seattle: Health Cooperative Group.

References