Domestic Violence Screening in Adolescent Pregnancy Anisha Abraham, Maj, MD, MPH

1. Domestic Violence Screening in Adolescent PregnancyAnisha Abraham, Maj, MD, MPH

2. Objectives • To provide an overview of domestic violence as a public health issue • To review key causes and risk factors of domestic violence during teen pregnancy • To discuss the role of health care providers in domestic violence prevention

3. Domestic Violence and Women • Domestic violence is the leading cause of injury to women between the ages of 15-44. (CDC, 1999) • Every 21 days, a woman is killed by domestic violence. (U.S. Department of Justice, 1998) • More than 5 million females experience some form of violence each year. Almost two of every three of these females are attacked by a relative or person known to them. (The Commonwealth Fund, 1998)

4. Domestic Violence and Women • 34% of adults in the United States had witnessed a man beating his wife or girlfriend, and 14 % of women report that they have experienced violence from a husband or boyfriend. (U.S. Department of Justice's National Crime Victimization Survey, 1998) • More than 1 million women seek medical assistance each year for injuries caused by battering. (U.S. Department of Justice's National Crime Victimization Survey, 1998)

5. Domestic Violence and Pregnancy • The prevalence of violence during pregnancy (all ages) ranges from 4-8% (Gazamarian JA. Prevalence of violence against women.. JAMA 1996) • Higher rates are identified when screening occurs more than once during the pregnancy (Macfarlane J. Assessing for abuse during pregnancy. JAMA. 1992.) • The pattern of violence may escalate during pregnancy and may be more prevalent in the postpartum period (Helton AS. Battered and pregnant: a prevalence study. Am J Pub Health. 1987)

6. Violence and Teen Pregnancy • Women < 18 yrs were twice as likely to have experienced violence during and after pregnancy then older women (Gessner BD. Experience of violence in teenage mothers. J Adolesc Health, 1999) • 33.8% of births to unmarried teens younger than 16yrs resulted from statutory rape(Gessner BD, 1999) • One-half of teens with rape histories resulting in pregnancy were raped more than once (Boyer D. Sexual abuse as a factor in teen pregnancy. Fam Plann Perspect.1992).

7. Violence and Teen Pregnancy • The younger the partner the greater the partner gap. Over one-half of infants born to women younger than 18 yrs were fathered by adult men . • 40% of 15 year -olds had partners aged 20 yrs or older. (Landry DJ. How old are US fathers? Fam Plann Perspect.1995) • 74% girls who have had intercourse before 14yrs, reported having sex against their will (The Alan Guttmacher Institute,1994)

8. Violence and Teen Pregnancy • Coercive sex is frequently perpetrated by boyfriends. 53% of nonfamilial perpetrators were adolescent girls’ boyfriends, dates,friends (Gershenon HP.The prevalence of coercive sex among teenage mothers. J Interpers Viol.1989. • 51% of girls had their first coercive act between 13-16 yrs (Erickson PI. Unwanted sexual experiences among high school youth. J of Adol Health.1991.

9. Domestic Violence and Children • Children are involved in 60 percent of domestic violence cases. More than three million children witness acts of domestic violence each year. • Up to 50 percent of all homeless women and children in this country are fleeing domestic violence. • More than 53 percent of male abusers beat their children

10. Domestic Violence and Children • One in ten calls made to alert police of domestic violence is placed by a child in the home. • One of every three abused children becomes an adult abuser or victim. • Nearly 1/3 of children who witness the battering of their mothers demonstrate significant behavioral and emotional problems.

11. Definition- Domestic Violence/Abuse • Domestic Violence-Injury to another within the context of family or intimate relationship • Domestic Abuse-Forceful controlling behavior that coerces the victim to do what the abuser wants

12. Types of Abuse • Physical-pushing, shoving • Psychological-ignoring, controlling, criticizing • Sexual-touching,calling with sexual names

13. Risks Factors for Violence during Adolescence • Media • Drugs/Alcohol • Access to Firearms • Lack of Self-Esteem • Peer Group/School Influences • Lack of Family Support

14. Risk Factors for Domestic Violence In Adolescence • Commitment to relationship • Fear of retaliation • No place to go • Fear of living alone • Economic dependence • Belief that they are responsible • Hope that perpetrator will change

15. Signs/Symptoms of Abuse among Pregnant Teens • Frequent somatic complaints (headaches, insomnia) • Anxiety,irritability,crying • Repeated visits to the ER • Hx of being “accident prone” • Injuries to breasts/abdomen • Hesitancy to provide info on injuries (Often accompanied by partner who will prevent victim from answering directly) • Anti-social behavior • Foreshortened sense of future

16. Signs/Symptoms among Children(in abusive homes) • Infants- FTT, developmental delays • Toddlers-eating/developmental disturbances, clinging • School age-increased physical complaints, decreased attention, behavior disorders

17. Complications of Abuse during Pregnancy • Poor maternal weight gain • Infection • Anemia • Increased second and third- trimester bleeding • Miscarriage/Abortion

18. Barriers to Screening • Lack of provider recognition • Provider discomfort • Fear of offending patient • Time constraints • Feeling of powerlessness in the area of treatment

19. Importance of Screening • 90% of female patients feel their provider can help! • 78% favor universal inquiry about physical/sexual assault • 1 out of 4 women using ER’s revealed a history of partner violence when questioned • 10-40% of women disclose abuse when screened by primary care providers • 31% of mothers disclosed partner violence when asked by their pediatrician (Mcnutt LA. Reproductive violence screening in primary care. J Am Med Womens Assoc.1999)

20. Setting the Stage • Discuss confidentiality • Use clear language, avoid medical terms • Remain non-judgemental • Avoid talking down • Encourage discussion, use open-ended questions • Listen to the patient!

21. Screening for Domestic Violence Risks • Has anyone close to you ever threatened to hurt you? • Has anyone ever hit, kicked, punched or hurt you physically? • Has anyone, including your partner, ever forced to have sex against your will? • Are you ever afraid of your partner?

22. Domestic Violence Counseling • Implement universal screening • Acknowledge trauma • Assess immediate safety • Help establish a safety plan • Offer educational materials • Document interaction (including photos) • provide ongoing support • Offer list of community resources • Provide referrals

23. Summary • Screen: Adolescent mothers for domestic violence risks (at prenatal visit, interval checkups, postpartum visit, and well-baby exams) • Ask: Are you ever afraid of your partner? Has anyone close to you threatened you? Hit you ? Forced sex against your will? • Discuss: Safety plan, legal implications,trauma • Provide: Documentation, as well as, information and referrals for community resources