Domestic & Sexual Violence: A Health & Safety Issue

Domestic & Sexual Violence:A Health & Safety Issue -One Health Region’s Strategy to Reduce Risk Presenter: Linda McCracken RN Sexual Assault Nurse Examiner AHS-Domestic Violence Program Coordinator

The Essential Message • Overview of associated adverse health conditions, & potentially lethal outcomes related to Domestic & Sexual Violence/Abuse that often go undetected when no one raises “the question” • What denotes a medical emergency • Opportunities do exist for primary prevention

What’s in it for you? After this presentation, you’ll have a better understanding of: Injury recognition & chronic illness in the context of abuse What to ask & or look for from a medical standpoint How collaboration can enhance response to this public health issue

Relevance *AB shelters find that the health effects of their clients: Are varied Often severe Have gone on for many years without resolution ACWS-Position Statement Responding to the Health Needs of Women & Children involved in Domestic Violence

Issues from a medical perspective What are the most common health challenges experienced by clients you see? What concerns you the most? What about their children?

Long TermEffects of Stress Cardiovascular system Gastrointestinal system

Stress & The Immune System Stress and Disease: New PerspectivesBy Harrison Wein, Ph.D.

Consistent high level of Cortisol Is Toxic To Brain Development The stress response system in the brain is fully formed at birth but the cerebral cortex is not Babies can experience stress but are highly dependent on caregiver to manage stress Chronic stress can impair the developing brain

Genetic Risk Factors Emerging Earlier …and harder to control Key message for Health: Many don’t associate their health problems with abuse and therefore, may not disclose abuse.

Hx of sexual abuse: 2.8 times more likely to have a functional bowel disorder, chronic abdominal pain, Irritable Bowel Syndrome Talley, N.J., Helgeson S, insmeister AR. Are sexual & physical abuse linked to functional gastrointestinal disorders Gastroenterology 1992; 102:A52 The Mind/Body: Inseparable! Vulnerable population + cultural beliefs Some believed that the stress in the relationship caused the cancer

…but is it always all ‘just in their head’? • Chronic or recurrent headaches • Temporomandibular disorder • Musculoskeletal complaints • Chronic back pains Or are they related to old injuries, most often recurrent and untreated

Injury Patterns Among Female Trauma Patients: Recognizing Intentional Injury Crandall ML, Nathens AB, Rivara FPJ Trauma. 2004;57:42-45 Many injuries of physical abuse are focused on the head & face • Evidence of pulled hair The “Shut-up” Blow Photos used with permission: Domestic Conflict Unit DV Presentation-CPS

Mild Traumatic Brain Injury*L.O.C. not required One of the most undiagnosed, prevalent, and serious consequences of IPV “Subtle Concussions”/ Soft Neuro Signs “chronic headaches” Second Impact Syndrome Risk

Variations of “amnesia” or “seizures.” Despite an expectation that full recovery should occur within 12 weeks of the MTBI (Belanger et al., 2005) a sizable minority continue to experience persistent symptoms (Wood, 2004) and have difficulty with returning to work, school or play. (Bazarian, Blyth, Mookerjee, He, & McDermott, 2010). Cognitive indicators of MTBI, such as, “feeling slowed down” or “mentally foggy” or “difficulty concentrating”

Intimate Partner Sexual Violence common expression of domestic violence (esp. during reproductive yrs) likely to be raped may times physical violence also possible Reproductive Coercion

Genital injuries: vaginal stretching, lacerations (tears) Miscarriages, still births *Anal injuries Pelvic pain Frequent vaginal and urinary tract infections, painful intercourse Recurrent STI’s HIV/AIDS Hepatitis B Substance Abuse …In IPSV Public Health Issues “No negotiation of condom use” Jacqueline Campbell

What denotes medical urgency in the context of DV Airway Breathing Circulation ‘Disability’ …Level of Consciousness Suicide Ideation

Strangulation-a Case of Medical Urgency Photo used with permission: Domestic Conflict Unit DV- CPS

“It hurts to swallow” **Victims may have no visible injuries but underlying injuries may kill the victim up to 36 or more hrs later due to de-compensation of the injured structures

More than two-thirds of victims are strangledat least once { the average is 5.3times per victim } Chrisler & Ferguson, 2006 • Injuries identified in non-fatal strangulation cases were similar to injuries found in fatal IPV strangulation assaults • (Hawley et al, 2001) • under-assessed & underappreciated by health care (Sheridan & Nash, 2007) 20

Vessels: arteries & veins • HYOID BONE CAROTID ARTERY THYROID CARTILAGE (with fracture shown) JUGULAR VEIN TRACHEAL RINGS

Hoarseness or complete loss of voice Swallowing changes- pain, difficulty, drooling Breathing changes/difficulty, coughing Headache, weakness Passed out ?, loss of memory since assault Nausea or vomiting Mental changes, restlessness, and combativeness Urinary or bowel incontinence during event If they don’t tell…“Ask” Seek Medical Attention Immediately !

Opportunities do exist to incorporate questions about Domestic Violence into routine patient encounters to determine points of intervention with the goal of preventing lethal outcomes Strategies to Reduce Risk

One study on “Prevalence” *Accessing Health Care Nearly one in three women who presented to emergency departments (34.8%) or academic clinics (31.4%) reported severe physical abuse or forced sexual activity in their lifetime One in seven (13.7%) women in the emergency departments reported severe physical abuse in the past year Alice Kramer, RN, MS* Darcy Lorenzon, MS and George Mueller, PhD Aurora Health Care, Milwaukee, Wisconsin Women’s Health Issues 14 (2004) 19–29

Source: Kelly Nelson, CHIM Health Information Analyst, Health Information Reporting Data Integration, Measurement & Reporting Alberta Health Services - Calgary Top 10 Diagnostic Codes with ‘+ disclosure’ of DV when asked

Part of Assessment *at some point during their stay • We know that violence and the threat of violence in the home is a concern for many people and can directly affect their health. • Abuse can take many forms: physical, emotional, sexual, financial or neglect. • We routinely ask all patients and parents about maltreatment or violence in their lives. • Is this a concern for you or your child(ren) in any way? Awareness/planting the seed Education-providing explanation Why we’re asking you Risks to kids when exposed to DV

Is it “Screening”? Different from most other health care screening interventions Not unaware Not asymptomatic Violence is not a mere risk factor awaiting identification …getting a ‘yes’ or ‘no’ is not our goal Taken from: Intimate partner Violence Consensus Statement Society of Obstetricians and Gynaecologists of Canada (SOGC) April JOGC 2005 pgs. 365-388

“not our job to rescue” • Supportive not curative • Validate their experience • Find out what they wish to do …Provide Options • Try to ascertain their level of risk for serious harm “CONNECT” them with resources

* Also Available for Consultation 24/7 *CONNECTwww.connectnetwork.ca Single Point Access Enhanced information and referral For victims, their families &/or the professionals that are concerned “ a shelter without walls” Deb Tomlinson, Project Manager CONNECT *Rural Referral Assistance Available

…some words of wisdom from a survivor “I really think that it’s the compassion, the asking of the question, the referral which can happen in a matter of minutes, which can be the hinge, the gateway to the way out” Excerpt from “The Voices of Survivor Documentary” “I know it saved my life” words of a patient seen in the Strathmore Emergency Department

Closing Comments for Reflection:Client-Centered Evolution of Response What additional resources would help your client address their medical needs in your community? Is there opportunity for a more collaborative response that involves all designations & disciplines? Do “turf issues” get in the way?

A Public Health Issue linda.mccracken@albertahealthservices.ca

Domestic & Sexual Violence: A Health & Safety Issue