Intimate Partner Violence: Gender and Healthcare Response

1. Karin Rhodes, MD MS Academic Associates Program February 8, 2007 Intimate Partner Violence:Gender and Healthcare Response

2. Outline • Case scenario • What is IPV? Who does it affect and how? • What’s medicine got to do with it? • Healthcare provider responsibilities • How can you hurt? • How can you help?

3. Goals • Definitional Issues IPV • Myths and Misconceptions • Health Care Providers’ Response • Types of IPV • Gender • Safety • Women’s Personal Needs Study (WPNS)

4. Case Scenario • 23 y/o woman presents to ED for pelvic exam • HPI: Boyfriend wants her examined to verify that she had intercourse with another man. Patient denies having more than one partner or recent intercourse. No vaginal discharge or pelvic complaints. No hx of STD. • PE: Normal pelvic exam. Skin with some bruises on extremities. No other injury noted. • Lab: GC and Chlamydia cultures • A: Normal pelvic exam • P: Pain medication, discharge to F/U with PCP

5. Additional data (not documented): • Hovering, somewhat volatile boyfriend • Pt initially complained to about boyfriend’s excessive jealousy but after the RN informed the boyfriend that “she doesn’t want you in the room”, patient subsequently denied abuse. • There was a suspicion of IPV but no documentation or referral. • MD wrote a note – no signs of recent intercourse.

6. Myths & Realities – true or false?

7. Scope • Occurs across all SES, religious, racial, ethnic, groups • Nearly 5.3 million intimate partner victimizations occur each year among U.S. women ages 18 and older(CDC, National Center for Injury Prevention and Control) • More than 25% of women (7% of men) have been sexually or physically assaulted by an intimate partner at some point in their lives (U.S. Department of Justice) • Of individuals victimized by physical assaults from an intimate partner, more than 41% of women (19% of men) sustain injuries from these assaults(U.S. Department of Justice) • Less than 30% of female (14% of male) physical assault victims report such incidents to the police(U.S. Department of Justice) • Higher risk populations: immigrant women, women with fewer economic and social resources, pregnant women, women with disabilities

8. Negative Health Consequences • Physical and mental health problems • High rates of depression, anxiety, PTSD • Somatization disorders • Substance abuse • Increased health care utilization for medical problems • Injury • Sexually-transmitted infections

9. Not All Violence is Alike: Situational Couple Violence For instance, a distinct type of IPV is situational couple violence • Violence results from situational conflicts (argument that escalates) • Not a general pattern of coercive control • Men and women both equally likely to initiate this type of violence • Violence tends to be infrequent and not severe

10. Not All Violence is Alike: Intimate Terrorism Intimate terrorism is another distinct type of IPV • Characterized by a pattern of coercive control and severe violence • Primary abuser is almost always male • Comprises a small proportion of couples who use violence

11. Types of Aggression Physical:hitting, slapping, punching, kicking, shoving, beating… Men and women report using physical aggression against partners at equal rates Psychological:yelling, screaming, insulting, name-calling, isolating, destroying possessions Men and women report using psychological aggression against partners at equal rates Sexual:ranges from unwanted touching to forced sex Women are far more likely than men to be victims of sexual aggression Stalking Women are more likely than men to be victims of stalking

12. Coercive control • “A pattern of threats, intimidation, isolation, and emotional abuse; control over sexuality and social life, including relationships with family and friends, money, food, transportation; and [even] control over various facets of everyday life (coming/going, shopping, cleaning, etc.)” • Some believe that coercive control is at the heart of the pernicious effects of IPV • Coercive control may distinguish battering (intimate terrorism) from hitting (situational couple violence)

13. Overall Research Findings: Gender Differences in IPV • Men and women are equally likely to use • Physical abuse • Psychological aggression • Men use more • Sexual coercion • Stalking • Coercive control • Women are more likely to be injured

14. Women’s violence: Different from men’s violence Gender differences in abusive behaviors and outcomes • Context • Meaning • Motive • Outcome

15. Context: Women’s violenceagainst men • Women’s violence usually occurs in the context of violence against them by their partners • In four studies of women who have used violence against their partners, over 90% of the women were also victims of physical and/or sexual violence from their partners

16. Men and women’s motivations for using violence differ • Women’s violence is more often motivated by • Self-defense • Fear • Defense of children • Men’s violence is more often motivated by • Control

17. Types of Relationships in which Women Use Violence • Even in a sample of women selected based on their own use of violence, no “intimate terrorists” were identified. • Swan et al. found relationships in which women used the most violence • “Victims Fighting Back” • these women were victimized more than they perpetrated and clearly are not “batterers.”

18. Types of violence women commit differ from men’s violence • The two studies conducted by Swan & colleagues also found that women were as emotionally and physically abusive as their partners • But women were more often victims of coercive control, sexual abuse, stalking, and injury

19. Outcomes • Injury • Women are much more likely to be injured in domestic violence situations • In the National Survey of Families & Households, 73% of people who reported IPV injuries were female

20. Women’s MH in Relationships in which Women Use Violence • Women are likely to suffer adverse mental health consequences: • Depression • Posttraumatic stress disorder • Experiences of child abuse • Substance use

21. “Why doesn’t she leave?” • Assumes that leaving will end the violence • Assumes that leaving is feasible and safe • Instead, think about: • Why does he abuse? • What is the impact of his abuse on her? • What are the barriers to leaving? • Has she tried to leave or get help in the past? If so, what happened?

22. Barriers to Leaving • Love for partner • Commitment to wedding vows • Social or moral obligation to keep family together • Hope that partner will change • Lack of financial resources, housing, child care • Fear of retaliation • Children/parental kidnapping • Feeling trapped, ashamed, hopeless • Expectation of negative response from formal institutions • Survival strategy – maintaining access (to know his): location, mood, behaviors

23. Reasons for not Reporting • Fear of retaliation from batterer – assault, battering, CPS • Perceptions/anticipation of negative response from institutions – based on past experiences of self/others, or assumptions • Belief that she needs visible proof of physical abuse • Barriers to access – batterer-imposed, language, knowledge • Prior negative experiences • Arrest • Lack of (adequate) response • Escalation of violence or battering • Batterer bonding with/manipulating responder (law enforcement, medical)

24. Coping and Survival Strategies • Calling police • Seeking advice or help from others • Fighting back / self-defense • Leaving • Hiding • Denial • Self-medicating

25. Healthcare Provider Responsibilities • Routinely screen for IPV • Are you in a relationship where you have been hurt or threatened? Do you feel threatened by a current or former partner? • Women support universal screening by healthcare providers (unless there’s mandatory reporting) • Why healthcare providers don’t screen: don’t know what to do if they get a positive, don’t want to deal with it, don’t understand it • Recognize high risk situations • Stalking, choking, access to gun, suicide or homicide threats, times of leaving • Link patients with appropriate resources • Shelter, counseling, legal resources, advocacy • Document

26. Case Epilogue • Patient was discharged without any documentation or referral • Returned 1 hour later –with 62% 3rd degree burns, her boyfriend having thrown gasoline on her and lit her on fire – transferred to regional burn center • Survived, sued hospital and treating physician • Case was settled but is in the medical-legal literature* • Negligence: failure to diagnose a high risk situation, offer protection, counseling, link to DV services, failure to follow own protocol *Cranston.J Health Law 2000;33(4):629-655. Kringen vs. Boslough and St. Vincent Hospital and Health Care Center, Inc. A Montana Corporation.

27. What Can You Do? • Ask about experiences of IPV • Validate victims’ experience and avoid victim-blaming (I believe you; no one deserves to be hurt like that; it’s not your faultnotwhat did you do to provoke him? why didn’t you just leave?) • Provide resources, referrals (emergency numbers, social worker, literature) • Encourage patient to see help

28. Intervention & Response is Important, but remember… • Safety, safety, safety • Patient/victim/survivor probably knows her situation better than you do – listen to her and ask her what would work for her and about barriers • Leaving is not always feasible nor safe (don’t turn her off from help-seeking or put her in danger by telling her she has to leave)

29. Safety Measures • Do not disclose information to a current or former abusive partner • Abusers can be manipulative and threatening • Especially when you know a woman is hiding from her batterer, do not reveal any contact information or anything she has shared with you • Do not assume that: • Leaving is a good (or bad) option • Arrest, protection orders, or shelter services will keep every woman safe • Time frames will be the same for every woman • A job will keep a woman safe and independent

30. Women’s Personal Needs Study:Academic Associate Role Academic Associates play a crucial role in helping victims/survivors through the WPNS: • Can benefit victims/survivors in the long-run through contributions to science/knowledge • Can benefit victims/survivors in the immediate context • Screening (we can’t help if we don’t know) • Validation (someone asked, someone cares) • Resources (give all women the emergency numbers!) • Linking with services

31. Women’s Personal Needs Study:Goalsfor Academic Associates • Watch out for patient’s safety (only interview her alone) • Listen to patient and validate (if she says it’s not safe for her to answer questions, take papers, etc., don’t force it; you want her to feel safe and not judged) • Provide emergency numbers • Notify doctor of positive screens • Call Dr. Rhodes with any safety concerns • Call Melissa with any forms/procedures questions/concerns • Encourage and facilitate follow-up interviews w/ Melissa

32. Questions?Comments?