Shelley M. Guida, MS, LMFT Director of Program Services shelley@raccfm.com

1. Shelley M. Guida, MS, LMFT Director of Program Services shelley@raccfm.com

2. Domestic Violence or Intimate Partner Violence Applications to Medical Practice

3. Domestic Violence (DV) or Intimate Partner Violence (IPV) • 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)

4. Domestic Violence-Prevalence • 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

5. 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

6. Cultural Considerations • 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….)

7. Why do people stay in abusive relationships? FEAR of an escalation of the violence FEAR 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 violence IMMOBILIZED by psychological and/or physical trauma VALUES - Cultural, Religious, Family…keep family unit together at all costs

8. Domestic Violence - a Major Public Health Care Concern • 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)

9. Domestic Violence: a Public Health Issue • 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).

10. Public Health Issues • 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.

11. Physical/Mental Health Effects

12. Effects of Domestic Violence on Pregnancy • 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

13. Indicators for Domestic Violence in Pregnant Women: • 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

14. Indicators for Domestic Violence in Pregnant Women cont. • Self-induced or attempted abortion • Increased substance abuse • Short inter-pregnancy intervals • Suicide ideation • Evidence of noncompliance with treatment or care

15. Medical Practice and DomesticViolence • What role can medical professionals play in addressing this major health care issue?

16. Role of Healthcare Professional: • Screening, Identification, Referral, Education Efforts have begun to encourage medical practitioners to learn about domestic violence and to screen patients. The American Medical Association, American College of Emergency Physicians and Family Violence Prevention Fund have published guidelines for identifying and assisting victims of domestic violence.

17. Screening Models 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

18. HITS MODEL 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).

19. Women Abuse Screening Tool (WAST) • 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

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

21. Role of Physician-Current Status • 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

22. Barriers to Addressing Domestic Violence for Health Care Providers • 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

23. Barriers for the Patient • 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

24. Breaking Down Barriers • 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

25. Resources • 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.

26. 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.

27. References • 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.