Intimate Partner Violence / Domestic Violence A Public Health Issue

1. Intimate Partner Violence / Domestic ViolenceA Public Health Issue

2. Boston Public Health Commission (BPHC) • The Mission of the BPHC is “To protect, preserve, and promote the health and well-being of all Boston residents, particularly those who are most vulnerable.” • The Domestic Violence Program (DVP) is one of about 30 BPHC programs, and was created in 1992 to address domestic violence as a serious public health problem. Our mission is to raise awareness of DV as a health issue in the City of Boston, and to support community efforts to address the problem.

3. Why is Domestic Violence a Public Health Issue? • It is prevalent in our society • It is a leading cause of injury and death, and has a serious impact on health • It affects the health of individuals, families, and the whole community • Some groups are at higher risk and have less access to help due to language, cultural, economic, physical, and other barriers • IPV/DV and its health effects are preventable!!

4. What does it look like, sound like, feel like • Exercise

5. IPV/DV Defined A pattern of behaviors perpetrated in a private or family context intended to exert coercive control over another person, can include physical, sexual, psychological, and/or economic forms of abuse. in the context of a current or former intimate relationship.

6. Legal Definition: The Massachusetts Abuse Prevention Act, Chapter 209 A, defines abuse as: • Actual physical abuse and/or • An attempt to harm someone and/or • Placing someone in fear of serious physical harm and/or causing someone to engage in sexual relations by force, threat of force or duress. • Economic and emotional abuse

7. DV/IPV: The Data • Approximately 1.3 million women and 835,000 men are physically assaulted by an intimate partner annually in the US. Patricia Tjaden & Nancy Thoennes, U.S. Dep't of Just., NCJ 183781, Full Report of the Prevalence, Incidence, and Consequences of Intimate Partner Violence Against Women: Findings from the National Violence Against Women Survey, at iv (2000), available at http://www.ojp.usdoj.gov/nij/pubs-sum/183781.htm • 2.2 million women physically assaulted by partner/ex- every year. The Commonwealth Fund, 1999. • In a 1995-1996 study conducted in the 50 States and the District of Columbia, nearly 25% of women and 7.6% of men were raped and/or physically assaulted by a current or former spouse, cohabiting partner, or dating partner/acquaintance at some time in their lifetime Patricia Tjaden & Nancy Thoennes, U.S. Dep't of Just., NCJ 181867, Extent, Nature, and Consequences of Intimate Partner Violence, at iii (2000), available at http://www.ojp.usdoj.gov/nij/pubs-sum/181867.htm • Boston Police Dept served over 2000 restraining orders in 2009

8. IPV - Epidemiology • 25.5% lifetime prevalence (women) • 7.6% lifetime prevalence (men) • Women overall at significantly greater risk than men and more likely to sustain injuries. • Women are significantly more likely than men to be injured during an assault: 31.5% of female rape victims, compared with 16.1% of male rape victims, reported being injured during their most recent rape, and 39-42% percent of female physical assault victims, compared with 20-25% of male physical assault victims, reported being injured during their most recent physical assault. • Most IPV victimizations never reported to police, especially those committed against men

9. Commonwealth Homicides DV/IPV deaths tripled between 2005 & 2007 • 2005 there were 15 murders and 4 suicides related to ipv/dv • 2006, 28 murders and 3 suicides • 2007, 42 murders and 13 suicides • 2008, 28 murders, 1 suicide • 2009, 22 murders, 5 suicides • 2010, 32 murders, 12 suicides • 32 murders, 2 suicides in Massachusetts this year – 10/11 (Jane Doe, Inc.)

10. IPV/DV includes: • Physical violence that increases in severity and frequency; • Abusive behaviors that are followed by apologies and promises of change; • Increased danger when the victim tries to leave.

11. IPV/DV is the abuse of power in a relationship • Individuals use various types of power/authority to harm/control another: • Gender • Racial/ethnic identity • Socioeconomic status • Educational level • Class privilege • Sexual orientation

12. Verbal, Physical, Sexual, Emotional/Mental, Economic • Exercise DA

13. PHYSICAL ABUSE INCLUDES... slapping, punching, choking, pinching, biting, shoving, burning, kicking, beating, stabbing, shooting SEXUAL ABUSE INCLUDES... forcing you to have sex or perform sexual acts you don’t like, refusing to practice safe sex, preventing you from using birth control USING COERCION AND THREATS Threatening to hurt or kill you; Threatening to leave you; Threatening to commit suicide; Threatening to report you to welfare or immigration; Making you drop charges; Making you do illegal things USING INTIMIDATION Scaring you with looks, actions, or gestures; Smashing things, destroying your property, abusing pets; Displaying weapons; Using HIV status as a way to control you USING ECONOMIC ABUSE Preventing you from getting or keeping a job; Making you ask for money; Giving you an allowance; Taking your money; Not giving you access to family income USING EMOTIONAL ABUSE Putting you down; Making you feel bad about yourself; Calling you names; Making you think you’re crazy; Playing mind games; Humiliating you; Making you feel guilty POWER And CONTROL USING ENTITLEMENT Treating you as inferior because of your gender, race, education, religion, political views, sexual orientation, age, or physical characteristics; Not letting you make big decisions; Treating you like a servant USING ISOLATION Controlling what you do, who you see and talk to, where you go; Withholding medical/social services, limiting outside activities; Using jealousy to justify actions USING CHILDREN Making you feel guilty or responsible for children’s problems; Using children to relay messages or putting them in the middle of arguments; Threatening to take your children away, claim you are an unfit parent, or have you deported MINIMIZING, DENYING, AND BLAMING Making light of the abuse and not taking your concerns seriously; Saying the abuse didn’t happen; Blaming behavior on other things, like being drunk or under stress; Saying you caused the abuse Developed by: Domestic Abuse Intervention Project 202 East Superior Street, Duluth, MN 55802 218.722.4134

14. IPV - Dynamics • Abuser tends to view ‘partner’ as inferior adversary, not as equal • Abusive behavior to gain compliance from, or control over another • Abuser may seem ‘healthier’ than survivor • Many perpetrators do not see their behavior as wrong in any way

15. Wave of Abuse Abusive Incident Abusive Incident Remorse Carping Hearts & Flowers Same Old Stuff

16. Race, culture, community—intersections with ipv/dv • The ethnic/cultural background of the family may influence • The batterer’s tactics • The survivor’s coping strategies • Community response • Institutional response • The individual meaning of violence • The quality of the provider-client relationship • Shelter from the Storm, Child Witness to Violence Project, Boston Medical Center, 2000

17. Immigrant & refugee survivors’ fears • Deportation; • Worries, lack of knowledge, & misinformation about the legal system; • Kidnapping of children, loss of custody; • Finances; • Harm to family at home • Losing connections with family/community here & in home country

18. Working with immigrant & refugee survivors • Be clear about your role: what you can & will do, what you will not do (ie: contact INS); • Listen carefully; • Speak slowly, take your time; • Interview with the assistance of a bilingual, bicultural interpreter; • Do not use family members to translate.

19. Effects of domestic violence • Traumatic injury • Exacerbation of chronic complaints • Decreased attention to self-care, including difficulty maintaining medical and dietary regimens • Overall negative health effects, esp. with increased smoking, alcohol use.

20. Effects on victim • Fear for own safety & that of other family members • Anxiety/pain • Anger • Sense of shame & humiliation • Confusion • Depression • Eating & sleep disruptions/disorders • Suicidal thoughts /attempts • High risk behaviors • Hypervigilance

21. Health Effects of Abuse FATAL • Homicide • Suicide • Maternal mortality • AIDS related • Any death resulting from issues at right Source: Center for Health and Gender Equity NON-FATAL • Physical injury, disability • Chronic conditions • Mental Illness • Reproductive health problems • Negative health Behaviors

22. Trauma in the lives of battered women • “Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.” • The core of trauma is disconnection and disempowerment. • Herman J, 1990

23. Intimate Partner Violence during Pregnancy • Pregnancy can be an especially vulnerable time of life - Between 4% and 8% of women experience IPV during pregnancy, including women from all walks of life in every age, racial and ethnic group.  • Experiencing IPV during pregnancy has been associated with pregnancy complications, pre-term labor, prematurity, low birthweight infants, neonatal intensive care admissions and even neonatal death.  • Among pregnant women, IPV is linked to depression, post-partum depression, eating an unhealthy diet and engaging in unhealthy behaviors, such as alcohol or drug abuse.

24. Intimate Partner Violence during Pregnancy • Partners may become abusive (or more abusive) during pregnancy because they feel: • upset over an unplanned pregnancy • increased stress at the thought of supporting a new baby (or an additional child) • jealous that a partner's attention may shift to the new baby (or a new relationship)

25. Potential Pathways of Co-occurrence(Adapted from the Institute For Health and Recovery “Working with Women with DV, MH and SA Problems”) Physical, Financial, Mental Health Problems Victimization Trauma sequelae Poverty/Homelessness Low Self-esteem Dependence on abuser Self-Medication Unhealthy coping Perpetration, Illegal activity, Incarceration Addiction

26. IPV - Barriers to Disclosure • Fear • Perceptions of health care system • Language, culture and religion • Immigration status • Sexual orientation • Abuser threats and control

27. Mandatory Reporting Laws • State's mandatory reporting law & response to mandatory reports • If you suspect children are being neglected or harmed • Advocate on behalf of adult victim/survivor’s safety • If patient is over 65 or a dependent adult

28. The Conversation • Talking with clients is about dialogue, not simply screening • Only discuss domestic violence with client alone • Let the client know the limits of confidentiality • Discuss documentation

29. The Conversation • Use gender-neutral or gender-appropriate language • Prepare yourself for the client’s response • Recognize the client’s attachment to his/her partner

30. Ways to Respond • I believe you. • I’m concerned about your safety. • No matter what your partner says, you don’t deserve to be treated this way. • I would like to give you the name and number of an advocate who is quite knowledgeable about these issues. (Can you safely carry this information home?)

31. Safety Assessment • Are there any weapons (or access to weapons) in the home? • Is there or has there ever been domestic violence? • Is there or has there ever been a Restraining Order filed against the client? • Is anyone in the home at risk of harm? • Are there any other safety concerns?

32. Client Safety:Immediate safety needs • Are you in immediate danger? • Where is the perpetrator now? Is he/she at this facility now? • Is it safe for you to go home? • Do you want the police or security to be notified? • Is it safe to take this written information with you? • Will it be safe for you to meet with advocates in the community or would you like to meet with them in one of our offices?

33. Client Safety: Pattern & History of Abuse • What was the most serious thing he/she ever did to you? • Has your partner forced you to have sex? Hurt you sexually? Forced you into sexual acts that made you uncomfortable? • Does your partner control what you do? Whom you see?

34. Client Safety:Additional risks to consider • Partner risks • Risks related to sexual violence • Risks related to self harm

35. Client Safety • Assess current access to advocacy and support resources • Has the client used community resources? Why? Why not? • How helpful were they? • What else does client need?

36. Advocacy • Listening to the client’s story, their experience, including their efforts to resist, seek help, and cope • Support the client with their struggle in their feelings/attachment to her partner • Consider their context: i.e. cultural, socio-economic, religious • Discuss immediate safety, developing plan which will be considered and modified in ongoing way

37. Empowerment • Validate client’s experiences; • Explore options/advocate for safety • Build on client’s strengths/avoid victim-blaming • Respect client’s right to make own decisions

38. Defining Success Success is NOT “fixing” DV or telling survivors what to do… Success IS • providing them an opportunity to talk to a trusted provider, get information, reduce isolation and increase options • Ensuring access to highest quality health care possible

39. Criminal Justice Employers DV/SA Programs Health Care Faith Community Other community responses

40. 24-hr hotlines • Massachusetts SafeLink DV Hotline - 877.785.2020 • 877.521.2601 (TTY) • Boston Area Rape Crisis Center - 617.492.RAPE • 617.492.6434 (TTY) • National Domestic Violence Hotline: 1-800-799-SAFE (7233) • 800.787.3224 (TTY) • Domestic Abuse Helpline for Men & Women 1-888-7HELPLINE - spec. resources for men who are victims

41. IPV/DV Facts • DV occurs around the world, in all countries, cultures, religious groups, and classes. • Around the world and in the US, about one out of three women has been physically or sexually assaulted by someone close to her in her lifetime. • DV occurs in same-sex as well as opposite-sex relationships. • Women are assaulted more frequently and are more seriously injured by the assaults than are men DV is a pattern of coercive control involving physical, sexual, psychological, and/or economic abuse. • DV is perpetrated in the context of a current or former intimate relationship. • DV is a learned behavior, chosen by the abuser b/c it works. • Cultural differences exist in how violence is perpetrated, how/when services are sought, etc.

42. IPV/DV is NOT… • an isolated incident • a random act of violence • a loss of control • caused by alcohol, drugs or stress • the victim’s fault • genetic • limited to physical assaults

43. Defining Secondary Traumatic Stress • “…the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by another…the stress resulting from helping or wanting to help a traumatized or suffering person.” • Figley 1995

44. STAND UP