There’s NO excuse for DOMESTIC VIOLENCE

1. There’s NO excuse for DOMESTIC VIOLENCE Jennifer E. Guss, MD

2. Domestic Violence • No graphic photos/graphic stories • Lecture of statistics to convey the far reaching and universal nature of domestic violence • Underscore importance of screening for this very common physical and psychiatric health issue

3. Domestic Violence: Definition • Part of the spectrum of family violence *child maltreatment *elder mistreatment *adult intimate-partner violence • Adult intimate-partner violence= domestic violence=battering=spousal abuse

4. Domestic Violence:Definition • Physical • Sexual • Psychological • Economic • Just because someone is not being hit does not mean that they are not abused

5. Definition • Sexual-pressuring for sex, physically forcing or harming sexually, forced abortion, forced prostitution, forced pornography, marital rape • Economic-witholding funds, spending family funds, cutting off access to money

6. Definition • Psychological: violent acts against children, threats of violence, attacks against others/pets, yelling, stalking, preventing access to essential care and personal needs, controlling schedule • Note NEJM’s 9/99 article classifies as aggressive, controlling, harassing, destructive, intimidating, isolating, threatenting

7. Understanding IPV • Having a verbally abusive partner is the variable most predictive of a woman being victimized by that partner in the future. • This fact supports the theory that IPV is part of a systematic pattern of dominance and control, not an “accident” or “act of passion”

8. Understanding IPV • explains why a first violent act by an intimate partner is predictive of future and escalating violence, not an isolated incident

9. Misconceptions and Truths • Misconceptions undermine our ability as a community and as physicians to identify and help victims

10. Misconception #1 • Domestic violence is prevalent in lower class families • Domestic violence occurs among all levels of society without regard to age, race, ethnicity, cultural status, sexual orientation, education, or religion

11. Misconception #2 • Abused women can end the violence by leaving or divorcing the abuser • According to the US Dept. of Justice, 75% of all spousal attacks occur between people who are separated or divorced

12. Misconception #3 • Alcohol, stress, financial problems, and mental illness are major causes of physical and verbal abuse • These may be present, but none are the cause of violence, rather they are used as an excuse. Abuse is known to be a learned behavior, not an uncontrollable reaction

13. Misconception #4 • Victims can learn to stop provoking violence • Abuser needs no provocation to become violent. Using the violence is the choice of the abuser and not the victim

14. Prevalence: CDC 2/2000 • Occurs in 1/4 american families • 3/100 men severely assaulted their partner in the past year • 4 million women per year are victims • 50% of women murdered each year are killed by current or former partner • 1994-1,370 women killed by current partners

15. Prevalence-US • Affects people of all races, socioeconomic groups, religions • >90% victims are women • >90% abusers are men • Same sex relationships • According to the CDC 2/2000 A WOMAN IS BATTERED ONCE EVERY 9 SECONDS

16. Prevalence-US • more than 3 women are murdered daily by their husbands or boyfriends(US Dept of Justice May 2000)

17. Prevalence US-cultural differences • 1/3 of AA women will be victims of IPV in their lifetime • 1/4 of all caucasian women will be victims of IPV in their lifetime • American Indian/alaskan natives are more likely to report IPV • Asian and Pacific Islander americans least likely to report IPV

18. Prevalence US-cultural differences • much less disparity when sociodemographic and relationship variables are controlled • e.g. Nebraska-far more caucasian victims than African Americans

19. Prevalence-sexual orientation • Women living with female intimate partners experience signif less IPV than women living with male intimate partners • Men living with male intimate partners experience signif more IPV than men living with female intimate partners

20. Prevalence/Gender • 23% Men in intimate relationships with men report being raped, phys assaulted, stalked by male cohabitants(1-7.5% men in intimate relationships with women) • This statistic is part of the reason that prevention plans are directed at male abusers

21. Prevalence-Texas 2001 • DV incidents: 180,385 • Women killed by male IP :113 • majority of batterers were 20-24 yo • majority of victims were 20-24 yo • most common weapon used was physical force through hands, feet, fists(77%) • currently 85% of all men in TX prisons grew up in violent homes

22. Prevalence-Texas • of all women killed in TX in 1997, 35% murdered by intimate male partners(higher than National avg of 28% (FBI) • victims of IPV sheltered by public services • 12,589 adults in 2001 • 16,838 children in 2001 • adults denied shelter due to lack space 16% • hotline calls answered 156,518

23. Prevalence:health care setting • OB-GYN:1/6 pregnant women is physically abused during her pregnancy JAMA 1996 • (more common than gest diab, placenta previa, preeclampsia)

24. Prevalence:health care setting • Pediatrics: 50-70% of mothers of abused children are also being abused • 3.3 million children each year in the US witness parental abuse • Primary care:one in four women has been abused at some point in her life, one in seven women reports having been abused in the past year

25. Prevalence:health care setting • Psychiatry-25% of women who attempt suicide are victims of abuse, 25% of women treated for psychiatric illnesses have been battered • ER-37% of women treated for violent injuries have been injured by their partners, 33% of women treated for trauma have been injured by their partners

26. DV-impact on children • In home where mother is being abused, 60% children also being (Dept of Justice) • child’s exposure to father abusing mother is strongest risk factor for transmitting violent behavior from one generation to next

27. DV-impact on children • When children are killed during a domestic dispute, 90% under 10yo, 56% under 2yo • of children who witness mothers abused by fathers, 40% suffer anxiety, 48% suffer depression, 53% have behavioral issues • 40% teenage girls ages 14-17 report knowing someone their age who has been beaten by a boyfriend

28. Impact on Children • “Children worry that their mothers will get seriously hurt or their fathers will go to jail. These thoughts weigh most heavily on a child’s mind during school hours...this constant anxiety does not allow them to pay attention to their studies...the children feel guilty for having fun. Many children do not want to leave their battered mother alone. If intervention does not occur, these children’s feelings of anxiety, accountability, guilt, grief and embarrassment will being to take command of their lives.” -Understanding Children of Domestic Violence by Karen McGuckin

29. IPV-dating stats • one in five adolescent girls will be physically and/or sexually abused in a dating relationship • physical and sexual abuse against girls in dating relationships increases the likelihood that the girl will abuse drugs and/or EtOH, develop eating d/o, consider/attempt suicide, engage in risky behavior, become pregnant

30. IPV and workplace • husbands and boyfriends commit 13,000 acts of violence against women in the workplace every year • majority of welfare recipients have experienced domestic abuse in their adult lives and a high percentage are currently abused

31. Role of MD in Domestic Violence • Recognize different forms of IPV clinical presentation • Screen for Domestic Violence • Document well • Refer, Advise, Support

32. Role of MD in Domestic Abuse • recognize potential clinical indicators of abuse • NEJM 1999-dental trauma, injuries, chronic abd/pelvic/chest pain, IBS, chronic gyn symptoms, STD’s, exac of chronic dz such as DM, asthma, CAD, noncompl with meds, psych d/o

33. Role of MD in Domestic Abuse • recognize common injuries caused by domestic violence NEJM 1999 • central distrib of injuries, injuries to head, neck, mouth, defensive forearm injuries, inconsistent story to explain, injuries to multiple areas in various healing stages, neuro sxs like hearing loss, visual loss, HA, numbness, tingling, unexplained stroke in young woman, any type of injury caused by sexual assault

34. Role of MD • SCREEN

35. Screening:AMA and ACOG recs • All women once a year • All pregnant women once a trimester • All men with risk factors • *NEJM 9/99 has list of clinical indicators of abuse--many problems we see should prompt us to screen our patients!

36. Screening: DO IT! • Screening is 71% sensitive, 85% specific(JAMA, 1997) • Studies show that most victims won’t volunteer info, but are hoping to be asked about abuse(J. of Emergency Medicine, 1997)

37. Screening:what to say • “Do you ever feel unsafe at home? Has anyone at home hit you or tried to injure you in any way?” JAMA, 1997

38. MD Role-Document • DOCUMENT!!! Medical record is a legal document! • Use pt’s own words, include dates,times, previous assaults, injuries. Use a body map

39. Documentation • VERY IMPORTANT TO HAVE A HIGH INDEX OF SUSPICIAN FOR STRANGULATION AND SEXUAL ASSAULT BECAUSE THESE INJURIES ARE LINKED TO ESCALATING VIOLENCE AND MURDER OF THE VICTIM • document strangulation with specific wording-considered a felony and carries higher penalty than other types of abuse which are considered misdemeanors

40. Refer, Advise, Support • Refer to social work • Give hotline numbers • Try to understand the victims feelings of what is possible for her and support her-limitations include fear, love, children, money, embarrassment, religion • Not all women will be ready to seek assistance at the time of your referral • Safety tips for a victim returning to her abuser

41. Safety Tips • educate about warning signs of escalating violence: partner extreme jealousy, controlling behavior, verbal threats, hx of violent tendencies or abusing others, and verbal or emotional abuse • obtain checking account, credit card, keep cash on hand, keep gas tank of car filled • identify a safe house ie friend or relative who will agree to not allow abuser in

42. Safety Tips • keep shoes by the door • keep purse packed with keys/wallet by the door • keep hotline numbers in wallet • National Domestic Violence Hotline (800)799-SAFE • The Noah Project 1-800-444-3551 • Texas Council on Family Violence www.tcfv.org • internet safety-be aware that abuser can see surfing history-use public internet services/cafes/libraries/friend

43. RADAR • Remember to ask routine screening questions • Ask and ask again about violence • Document your findings • Assess your patient’s safety • Review options with your patient

44. Advocate for those who can not advocate for themselves