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Physical and Mental Health Effects of Intimate Partner Violence

Physical and Mental Health Effects of Intimate Partner Violence. Jacquelyn C. Campbell, PhD, RN, FAAN Anna D. Wolf Chair & Professor Program Director, RWJF Nurse Faculty Scholars Johns Hopkins University School of Nursing. Definitional Issues.

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Physical and Mental Health Effects of Intimate Partner Violence

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  1. Physical and Mental Health Effects of Intimate Partner Violence Jacquelyn C. Campbell, PhD, RN, FAAN Anna D. Wolf Chair & Professor Program Director, RWJF Nurse Faculty Scholars Johns Hopkins University School of Nursing

  2. Definitional Issues • CDC: Physical and/or sexual violence (use of physical force) or threat of such violence; or psychological/ emotional abuse and/or coercive tactics when there has been prior physical and/or sexual violence; between persons who are spouses or non marital partners (dating, boyfriend-girfriend) or former spouses or non marital partners (Saltzman et.al. ‘99) • Versus emotional abuse/controlling behavior a form of violence • Gender Symmetry – Archer ‘00; Straus; Dutton • Risk factor for health problems versus diagnosis

  3. MMRW ‘08 – BRFSS ‘05 – 4 questions – physical &/or sexual or threats; weighted; 16 states • 600,000 injuries to men: 1.2 ml injuries to women • Lifetime IPV – 11.5% for men; 23.6% for women • Significantly higher (p<0.05) among multiracial, non-Hispanic & American Indian/ Alaska Native women; & lower-income respondents. • Average of 1200 IP homicides per year of women – 400 for men (BJS ‘06)

  4. U.S. PREVALENCE • 35% lifetime IPV (4.4 Million) (Commonwealth Fund - Plichta, ‘02) • 10.8% physical &/or sexual assault - past 2 years (Walton-Moss et al ’04)– approx same prevalence in MSM (Greenwood, Relf et. al. ’03) – significantly less - female same sex partners (T&T ’01) • 3.2% severely abused past year • 52% injured (NCVS – ‘06) • 20 - 35% seek medical care or hospitalized • 85% in the health care system for something (42% of femicide victims - Campbell et. al. ‘00)

  5. Intimate partner sexual violence May include… • Forced sex - by force or threat of force • Including forced sexual initiation – • 12.5% of women in US – 15-44 - report first sexual experience is forced (Stockman ’09) • For those whose first sex <15 – 21.5% • Painful sex - clearly indicated as unwanted • Sex without protection

  6. Overlap between physical, sexual and emotional abuse (N = 889) (Campbell et. al. ’02 from Ellsberg ’00) Sexual (N = 243) 32 (3.6) 31 (3.5) 14 (1.6) 166 (18.7) 177 (19.9) 166 (18.7) Emotional (N = 677) 303 (34.0) Physical (N = 649)

  7. PHYSICAL HEALTH EFFECTS • Physical Injury (Facial, fractures, dental, neurological - soft tissue, internal, “falls”- Grisso ‘91) • (TBI & Strangulation – McClane ‘05) • Neurological Sx - Coker ’00 • Stroke or Sx consistent w/stroke (Black ‘08; Loxton ‘06) • Chronic Pain (Back, abdominal, chest, head) (Campbell ‘00; Coker ‘02) • Fibromyalgia (Alexander ‘99; Walker ‘00) • Chronic Irritable Bowel Syndrome (Drossman ‘98) • Hypertension (Schollenberger et al ’02; Coker ’00) • Smoking (30-34% victims; 13-15% controls) (Letourneau ’99; MMWR ’08)

  8. New Data from BRFSS (MMWR ‘08) • Women -lifetime IPV • High Cholesterol: AOR 1.3 ([CI] = 1.1--1.4) • Disability AOR = 1.7; activity limitations 2.1 • Arthritis AOR = 1.6 • Heart Attack; Heart Disease;Stroke :1.4; 1.7; 1.8 • Smoking AOR = 2.3 • Risk factors for HIV/STD’s 3.1 (CI = 2.4--4.0). • Men: disability equipment, arthritis, asthma, activity limitations, stroke, risk factors for HIV infection or STDs, smoking, and heavy or binge drinking. (AOR’s 1.4 (CI = 1.0--2.0) - stroke to 2.6 (CI = 2.0--3.6) – HIV/STD risk

  9. HEALTH EFFECTS OF FORCED RELATIONSHIP SEX 40-45% of physically abused women INCREASED RISK OF: • Unintended pregnancy (Pallito et al ‘04) • Adolescent Pregnancy (Renker ‘02) • Abortion (Evins & Chescheir ‘96) • Vaginal bleeding (Campbell et. al. ‘01) • Anal & vaginal tearing (Campbell & Alford) • Painful intercourse (Eby et. al., ‘95; Coker ‘00; Leserman ‘98)

  10. HEALTH EFFECTS OF FORCED RELATIONSHIP SEX Increased Risk of: • STD’s (Eby et. al. ‘95; Coker ’99; BRFSS ‘08) • HIV/AIDS (Gielen ‘94,‘00; Maman ’00, ‘02; Dunkle ‘04) • Pelvic pain, Pelvic Inflammatory Disease, Infertility (Eby et.al. ‘95; Leserman ‘98; Schei ‘90) • Urinary Tract Infections (Campbell &Alford ‘89; Coker ‘99; Campbell et. al. ‘00) • Risk of homicide, low self esteem (Campbell ‘89;’99; ‘03) • Cervical Cancer (Coker et. al. ‘00)

  11. New Face of HIV/AIDS – HIV/VAW interface official recognition by UN ‘04 • Around globe women are the fastest group contracting HIV & fastest group converting to AIDS • In US – poor African American women most affected (Levenson – The Secret Epidemic) • Africa – women dying most from AIDS – 3:1 ratios • South Africa – Direct link of IPV with HIV+ status Dunkle, Jewkes et. al. The Lancet 363:1415-21 ’04 • Fonck, Kidula – Nairobi, Kenya – AIDS & Behavior ’05 • Maman et al – Tanzania – ‘02 • Women at risk – heterosexual married women with few or no behavioral risk factors • Husbands having sex with other women without wives’ knowledge &/or forcing sex (WHO ’05)

  12. HIV/DV Connections – Etiology (Maman et. al. ’99; Outwater & Campbell ’05; Tietleman et al in ‘08) • Immune system depression with stress – decrease time from HIV+ to full AIDS (<250 CD4 count) • Trauma increasing HIV transmission; anal sex • Increased STD’s & untreated STD’s (Letourneau ‘99; Coker et.al. ’00; King et. al. ’00) • Impossible to negotiate safe sex if a battering relationship • Women accused of infidelity if want to use safe sex • Males have other partners unknown to women (WHO multicountry study ’04) • Fear of being beaten for being tested; notifying partner of positive status; delay in treatment • Substance abuse

  13. MENTAL HEALTH EFFECTS - Golding ‘99 • Depression 10 - 43 pop; 32 - 70% clinical (9.3% non abused) • Suicidality 14 - 40% (4.9% non abused) • Post Traumatic Stress Disorder 2 - 12% pop; 31 - 84% clinical (weighted X prevalence 64% - 5% non abused) • Alcohol Abuse 4 - 16% pop; 23 - 44% clinical • Drug Abuse 5 - 16% pop; 23 - 44% clinical (2% non abused) • Eating Disorders - bulimia (McCauley et.al.1995)

  14. Bio-Psycho-Immunologic Response to Trauma IPV Depression Comorbid PTSD HPA axis  cortisol HPA axis cortisol Th1 shift Th2 shift Immune Suppression IgE/IgA Response Pro-Inflammatory

  15. Pro Inflammatory Response • Associations with chronic pain – Woods et al ’05 (fibromyalgia) • Other inflammatory conditions – asthma – chronic fatigue syndrome, urinary tract infections • Implications for BMI, obesity • Implicated with cardiovascular disease • ACE study

  16. Co-Morbidity of PTSD & Depression in Battered Women • Far more comorbidity in battered women than in rape victims or Vietnam Vets – in fact recent research suggests that only depression IF PTSD (Woods ’05) • Predictors: childhood victimization, – importance of child abuse on physical health – ACE • Importance of severity of physical abuse • Lifetime trauma response? • Issues of ongoing trauma

  17. Abuse During Pregnancy • 8-22% of pregnant women (vs. 7% pre-eclampsia or hypertension during pregnancy) • Most significant risk factor - abuse before pg. • Pregnancy - protective period or risk period (1st pregnancy - jealousy); usually neither • Ethnic group comparison - significantly lower in Hispanic couples (Mexican American) -14% vs. 16% in African American and Anglo (McFarlane & Parker ‘92)

  18. Prevalence of Abuse Around Time of Pregnancy (Saltzman et. al. ’03)

  19. Abuse During Pregnancy • Maternal health correlates: depression, substance abuse, low social support, spontaneous abortion, smoking, risk of homicide (Gielen ‘94; Campbell ‘92) • Perinatal mortality (death btw 28 weeks gestation to 28 days after delivery): 5 of 8 studies - (Coker ‘04; Janssen ‘03; Leung ‘01; Lipsky ‘04; Pikarinen ‘07; Taft ‘08; Yost ‘05) • Infant outcomes: LBW – meta analysis (Murphy et al ‘01) especially in MC women (Bullock & McFarlane ‘89) & through connections w/ smoking, low weight gain & substance abuse (Curry et al ‘99)

  20. Gaps in literature / Future Directions • More comprehensive measurement of IPV (e.g. overlapping types, frequency, duration, age at first experience; lifetime trauma) to establish dose-response. • Cohort studies to establish temporal sequence. • Mediators & moderators of effects of IPV on health. (resiliency and risk) • Need biologic markers to determine physiological mechanisms on how IPV adversely affects health. e.g. immune functions, neuroendocrine response and measures of vascular response. • Validate health outcomes with medical records or biologic testing when possible. • Replication of studies particularly for chronic disease

  21. Interventions in Health Care system • Mixed reviews on routine inquiry • Sufficient prevalence and health consequences • Sufficient evidence of acceptance by women (e.g. Gielen, Campbell et al ’06; ‘00) • Sufficient evidence of methods of inquiry – questions & strategy & system (e.g Trautman et al ‘07; Campbell ‘92; Rabin et al AJPV ‘09) • But insufficient evidence of intervention efficacy – 2 trials completed & to be reported on ‘09 • Two trials in home visitation settings underway • More intervention development & trials needed – other settings - e.g. substance abuse Tx

  22. Challenges remain • IOM committees - reports ’98; ’02 – workshop ‘09 – global • recommendations for funding for research; centers on family violence; training for researchers – few recommendations followed through • Sporadic NIH RFA’s – CDC funding continuous but new calls yearly - insufficient for full clinical trials, sustained programs of research

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