HIV Determinants Webinar Series: Intimate Partner Violence and Sexual Abuse

1. HIV Determinants Webinar Series: Intimate Partner Violence and Sexual Abuse HIV Prevention Program HIV/AIDS and Hepatitis Section Florida Department of Health

2. Learning Objectives • Understand the intersection between intimate partner violence (IPV), sexual assault (SA) and HIV/AIDS • Describe the incidence of IPV and SA in Florida and among our target populations • Screening for clients who are risk of IPV and SA

3. Why are we talking about this? For us to be able to provide optimal support for people living with (or at risk for) HIV/AIDS, it is important to understand we will encounter individuals who are survivors of IPV and/or SA. Sex workers and victims of human trafficking are often victims of sexual assault.

4. The intersection of IPV, SA, and human trafficking/sex work • Elements of power and control • Victims are primarily women and children • Victims are traumatized • Abuse takes many forms (verbal, physical, emotional, sexual, economic)

5. The intersection of IPV, SA, and human trafficking/sex work continued • Mistrust of law enforcement and/or other agencies • Safety planning is critical • Risk of HIV/AIDS and other STDs

6. IPV, SA and HIV/AIDS services providers are all… • Accustomed to working with multiple systems • Understanding of empowerment-based, survivor/client-centered advocacy and case management • Savvy about issues of confidentiality • Crisis responders

7. Poll Question #1 • Do you know or suspect you have encountered someone who has experienced IPV, SA, or human trafficking?

8. Statistics

9. Florida’s DV Offenses (2012) Murder 191 Manslaughter 11 Forcible Rape 981 Forcible Sodomy 377 Forcible Fondling 931 Aggravated Assault 16,828 Aggravated Stalking 192 Simple Assault 85,929 Threat/Intimidation 2,209 Stalking 397 Total 108,046 Source: 2009 Florida Uniform Crime Report. Florida Department of Law Enforcement. Available at http://www.fdle.state.fl.us/Content/getdoc/05fbdbd3-1582-4f12-a73a-6f0c6cdc4e1c/dvoff_jur12.aspx Accessed December 9, 2013

10. Florida’s SA offenses (2012) • Rape by Force 4,960 • Attempted Rape 2,94 • Forcible Sodomy 1,375 • Forcible Fondling 3,516 • Total Forcible Sex Offenses 10,145 Source:Source: 2012 Florida Uniform Crime Report. Florida Department of Law Enforcement. Available at http://www.fdle.state.fl.us/Content/getdoc/f089698a-26f4-4899-9695-7c2dbc41f674/1971_fwd_sex_offenses.aspx Accessed December 10, 2013.

11. Florida’s human trafficking offenses (2010) • Of the 55 human trafficking victims served in Florida in 2010: • • 33 were male/22 were female • • 52 were adults/3 were children • • 50 were labor trafficking victims • • 5 were sex trafficking victims Source: Florida Human Trafficking Report. Florida Department of Children and Families. Available at http://www.dcf.state.fl.us/programs/humantrafficking/docs/ContinuedPresence.pdf Accessed December 10, 2013.

12. One in every three women and one in ten men will experience IPV or sexual assault in his/her lifetime. • Source: National Intimate Partner and Sexual Violence Survey – 2010 Summary Report,” National Center for Injury Prevention and Control Division of Violence Prevention (2010). Available at http://www.cdc.gov/violenceprevention/pdf/nisvs_executive_summary-a.pdf • Accessed December 10, 2013. • Sexual assault occurs in approximately 40-45% of relationships where IPV is present. • Source: Campbell, et al. “Assessing Risk Factors for Intimate Partner Homicide.” National Institute of Justice Journal. Washington, D.C. U.S. Department of Justice (2003) 14-19.

13. Abused women are more than three times as likely to contract HIV as women who are not in violent relationships. • Source: Sareen, et al. "Abusive Relationships Increase Women’s Risk Of HIV Infection." Center for Advancing Health. ScienceDaily 25 May 2009. Available at: http://www.sciencedaily.com/releases/2009/05/090521195702.htm. Accessed April 15, 2010

14. 23% of surveyed men who had lived with another man as a couple reported being raped, physically assaulted and/or stalked. • Source: Allen, et al. “Lesbian, Gay, Bisexual and Trans (LGBT) Communities and Domestic Violence: Information and Resources.” National Resource Center on Domestic Violence. (2007).Available at: http://new.vawnet.org/Assoc_Files_VAWnet/NRC_LGBTDV-Full.pdf. Accessed April 6, 2010.

15. A survey of transgender and intersex individuals found that 50% of respondents had been raped or assaulted by a romantic partner, though only 62% of these individuals (31% of the total) identified as survivors of IPV when asked. • Source: Fountain and Skolnik. “Lesbian, Gay, Bisexual and Transgender Domestic Violence in 2006: A report of the National Coalition of Anti-Violence Programs.” National Coalition of Anti-Violence Programs. Available at: www.ncavp.org. Accessed December 10, 2013.

16. Women who are trafficked for the purpose of sexual exploitation experience a tenfold risk for contracting HIV. • Source: Hynes and Raymond (2002) via National Coalition Against Domestic Violence • Available at http://www.ncadv.org/files/HumanTrafficking.pdf • Accessed December 10, 2013

17. Poll Question #2 A pattern of behavior that includes intimidation, violence, threatening, etc… within an intimate relationship are the major characteristics of?

18. Working Definition of IPV • The legal definition of IPV (domestic violence) is specific, the working definition refers to a much broader range of behaviors used by individuals to exert power and control over their partner.

19. Specifically… • IPV is a pattern of behavior used to establish power and control over another person through fear, intimidation, often including the threat or use of violence. • IPV happens when one person believes they are entitled to control another.

20. Specifically… continued • The violence occurs in the context of intimate relationships. • Occurs in homes regardless of age, income, race, ethnicity, religion, social background, or education level. • Results in physical injury, psychological trauma, and sometimes death.

21. Specifically… continued • Crosses generations and lasts a lifetime • Is a subset within a larger societal problem of violence against women including oppression, sexual assault, incest, prostitution, sexual harassment, human trafficking, etc.

22. Myth: Only women are victims of IPV. • Fact: Approximately 85% of those who experience IPV are women; however, in some cases, women are the abusers and their male partners the victims. IPV also occurs in same gender relationships. • Source: Bureau of Justice Statistics Crime Data Brief, Intimate Partner Violence, 1993-2001, February 2003.

23. Myth: Abuse is about a loss of self control • Fact: Abusers select their targets. They choose the circumstances of their violence, including the amount of injury inflicted by their acts.Abuse is about an attempt to control the behavior and/or emotional/intellectual life of the other person. They have learned that violence works to achieve this end.

24. Myth: Alcohol or drug use causes IPV. • Fact: Addictions are used as excuses to free the abuser from responsibility for the behavior. This myth does not explain why the abuser uses violence, why partners are targeted for abuse, or why s/he abuses when sober. The abuser will not necessarily stop abusing if s/he gains control over his addiction.

25. Myth: Victims of IPV should just leave. • Fact: The most dangerous time for someone who is being abused is when s/he tries to leave. There are times when it will be safer to stay.

26. IPV is… • A choice • A learned behavior • Tacitly supported by society • A behavior the survivor does not control • A crime

27. Power and Control Wheel • The power and control wheel was developed to illustrate the various tactics an abuser uses on his partner. • At the center of the wheel is the abuser’s need to get and keep power and control over the survivor’s life. • Each spoke contains a tactic used to control the victim. • Source: Domestic Abuse Intervention Programs, The Duluth Model. Power and Control Wheel. Available at: http://www.theduluthmodel.org/wheelgallery.php. Accessed April 2, 2010

29. Examples of Physical Violence • Pushing • Kicking • Harming pets • Stabbing • Strangulation • Shooting • Slapping • Scratching • Punching • Hair pulling • Biting • Twisting limbs

30. Examples of Sexual Violence • Forced exposure to pornography • Forced sex • Unwanted sexual acts, touching, advances • Forced prostitution • Forced pregnancy • Forced sex with others • Transmitting HIV or STDs

32. Continuum of Abuse… • Over time, the layering effect may adversely influence the survivor’s coping responses, confidence and self-esteem.

33. There is no “typical abuser” • Most abusers choose to abuse because the choice is there to make and they believe they have the right.

34. Poll Question #3 • Which of the following HIV risk factors are common for survivors of IPV, SA and Human Trafficking? • Choose one:

35. Risk of HIV/AIDS for Survivors of IPV • Unfaithful partners • Partners refuse to wear condoms • Sexual assault • Forced or coerced sex work • Self-medication/IDU • Lack of information & fear of seeking help

36. HIV/AIDS and IPV • Partners prevent access to health care and/or withhold necessary medications • Partners threaten to “out” survivor’s status • Partners make other threats related to status • Isolation from family, friends and the community

37. Risk of HIV for survivors of SA • Trauma is more likely (sexual, fight wounds, etc.) • Possible multiple assailants • Assailants refuse to use condoms • Assailant may have multiple partners/victims; increases risk of other STDs • Risk increases with multiple assaults • Shame, embarrassment, blaming self, self medicating/IDU, etc.

38. HIV/AIDS and SA • SA is grossly under reported - survivors don’t receive treatment • Emotional trauma can affect medication adherence • Isolation from family, friends and the community

39. Risk of HIV/AIDS for Survivors of Human Trafficking and/or Sex Workers • Sexual assault • Forced or coerced sex work, specifically acts that are associated with increased risk • No access to condoms • IDU • Lack of information & fear of seeking help

40. HIV/AIDS and sex work/human trafficking • Sex workers/human trafficking victims are seen as expendable • Less access to testing, health care, necessary medications, condoms, etc. • Isolation from family, friends and the community

41. Poll Question #4 • Which of the following are common characteristics of a survivor of sexual assault, IPV and human trafficking seeking health care? • Choose one:

42. What Do You Do Now?

43. Screen for indicators of IPV, sexual assualt and/or human trafficking • Safety Plan • Use an empowerment-based, survivor/client-centered approach • Educate yourself about potential remedies (domestic violence services providers, legal aid, local trafficking task force, etc.) • Provide linkage to community resources

44. Screening for Abuse • Common injury sites: head, face, neck, areas usually covered by clothing- chest, breast, abdomen, etc. • Common injury types: Contusions, abrasions, lacerations, fractures, sprains, eye or ear trauma, loose teeth

45. Screening for abuse continued • Injury to multiple sites • Injuries that don’t fit with provided explanations • Injuries in various stages of healing • Injuries during pregnancy

46. Screening for abuse continued • Miscarriages and spontaneous or multiple abortions • Pregnancy complications • Frequent vaginal and urinary tract infections, pelvic pain

47. Screening for abuse continued • Pain with no visible sign of injury • Chronic pain/headaches • Anxiety or PTSD • Substance abuse/self-medication

48. Screening for Abuse continued • Noncompliance with treatment regimens • Partner limits access to medical care • Missed appointments • Failure to use condoms/birth control

49. Screening for abuse continued • Reluctance to speak or disagree in front of partner • Minimalizing extent of injuries • Partner insists on attending appointments • Overt displays of possessiveness by partner

50. Screening for sex work/human trafficking • Only very rarely will someone self-identify • If your intuition tells you someone is trafficked, there are certain questions to ask • Gentleness and sensitivity must be exercised when seeking information