Screening for Intimate Partner Violence in Military Health Care Settings

1. Screening for Intimate Partner Violence in Military Health Care Settings “When we try to pick out anything by itself, we find it hitched to everything else in the universe” --John Muir LTC Claudia Mackie, Ph.D. Chief, Community Mental Health US Military Academy LTC Mark Chapin, Ph.D. Assistant Professor Uniformed Services University

2. US Preventive Services Task Force • Evidence Based Recommendations: “I” • I = “Insufficient Evidence” to recommend for or against Intimate Partner Violence screening • Canadian Task Force on Preventive Services (CTFPS) also reached the same conclusion. • Caveats: • Evidence “Insufficient” because studies have not been done, not because there have been contradictory findings

3. Family Violence Prevention Fund • Criticized USPSTF evaluation parameters: • criterion outcome measures are “death or disability” • not meaningful outcomes for IPV interventions • Recommended “psychosocial assessment” for IPV instead of a medical screening test, • Evidence can be evaluated by established standards for psychometric instruments and behavioral outcomes • Examples: recidivism rates or marital stability

4. AMA AAFP ACOG • All recommend routine screening for IPV • quick • non-invasive • cost-free • “right thing to do” • Most primary care physicians don’t routinely screen their patients for domestic violence.

5. Health Issues Related to IPV • Injuries, chronic pain (neck, back, pelvic migraines) peptic ulcers, irritable bowel syndrome, STI’s (including HIV/AIDS), insomnia, vaginal and urinary tract infections, multiple pregnancies, miscarriages and abortions • Substance abuse by the patient: (such as tobacco, alcohol, or others) • Ability to manage other illnesses (such as hypertension, diabetes, asthma, HIV/AIDS) • Mental health problems: depression, PTSD, anxiety, stress, suicide risk • Pregnancy complications such as miscarriages, low weight gain, anemia, infections, first and second trimester bleeding, and low birth weight babies • Gynecological problems including STI’s, anal/vaginal tearing, sexual dysfunction, safe sex practices and contraception • Choking/head injury or patient unconscious: neurological findings • Particularly for teens: exposure to dating violence or forced use of drugs • such as Rohypnol (RH) “rophies”, GHB (Gama Hydroxybutyric acid) etc. • Preventive health behaviors: regular mammography, pap smears, early pre-natal care

6. Recent Military Studies • Military women support routine screening for domestic violence • Strong co-morbidity of IPV with alcohol abuse and mental health issues • Interaction effects with childhood abuse history and alcohol abuse • Deployments increase risk of child maltreatment and neglect

7. Military Women’s Policy Preferences on Screening for Intimate Partner Violence • Gielen et al (Military Medicine 2006): • “Domestic Violence in the Military: Women’s Policy Preferences and Beliefs Concerning Routine Screening and Mandatory Reporting” (August 2006) • 57% of military women support routine screening for intimate partner violence • 87% believed the military’s policy on mandatory reporting should be maintained. • Supported despite significant concerns about increased risk for further abuse and harm to military career.

8. IPV Co-Morbidity • Study of violent couples enrolled in the Ft. Bragg Family Advocacy Program: • 55% met screening criteria for alcohol abuse, • 81% met screening criteria for mental health concerns • 45% met screening criteria for both alcohol and mental health concerns in addition to the Domestic Violence referral. • Less than 10% of these couples actually had only domestic violence as a presenting problem • other 90% had some overlap of domestic violence, alcohol abuse and mental health problems

9. MAST Diagnosis in Sample of FAP Clients

10. Overlap of Abuse, Alcohol Abuse,and Axis II Findings N = 84 Abuse + Personality Factor = 68 Abuse + Alcohol Factor = 46 All Factors = 38 Physical Abuse Abusive Not Alcoholic No Axis II n = 8 Abusive Axis II Traits Abusive Not Alcoholic Probably Alcoholic Abusive n =20 No Axis II n = 1 Probable Alcoholic Axis II Traits Axis II Diagnosis Abusive n =10 Not Alcoholic Alcoholic Abusive Axis II Diagnosis Abusive n = 10 No Axis II Alcoholic Probably Alcoholic n = 7 Axis II Traits Abusive n = 4 ALL n= 16 Alcohol Abuse Axis II Features Abusive Alcoholic Axis II Diagnosis n = 8

11. Interaction Effects: Childhood Abuse History and Alcohol Use • Mackie (2004) study of violent couples at Ft. Bragg • Examined predictors of IPV severity • Main effects for depression, alcohol, and childhood abuse were not significant • Strong interaction effect between childhood abuse and alcohol use

12. Stresses of Military Deployment • Rate ratio of child maltreatment by wives during soldiers’ deployments was 3.34 (95% CI, 2.96-6.68) more than while not deployed • Rate ratio for child neglect incidents during soldier deployments was 3.87, (95% CI, 3.40-4.34) compared to non-deployed periods (Gibbs et al) • Military assignments located far from extended family reduces psychosocial and logistical supports

13. “Restricted Reporting” Option • Recent revisions to the mandatory reporting policy recommended by the Defense Task Force on Domestic Violence • Victims now have a “restricted reporting” option • Allows victims to receive services through the Family Advocacy program without the involvement of command or legal investigation • Allows military physicians to maintain patient confidentiality while connecting victims to local services. • Victims can still opt for “unrestricted reporting” which includes reports to the military member’s commander and military police

14. IPV Assessment Tools • Framing questions: • “Because violence is so common in many people’s lives, I’ve begun to ask all my patients about it” • “I am concerned that your symptoms may have been caused by someone hurting you” • “I don’t know if this is (or ever has been) a problem for you, but many of the patients I see are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I’ve started asking about it routinely”

15. IPV Assessment Tools • Direct verbal questions: • “Are you in a relationship with a person who physically hurts or threatens you?” • “Did someone cause these injuries? Was it your partner/husband?” • “Has your partner or ex-partner ever hit you or physically hurt you?” • “Do you (or did you ever) feel controlled or isolated by your partner?” • “Do you ever feel afraid of your partner? Do you feel you are in danger?” • “Is it safe for you to go home?” • “Has your partner ever forced you to have sex when you didn’t want to? Has your partner ever refused to practice safe sex?” • “Has any of this happened to you in previous relationships?”

16. Summary • Military physicians in primary care settings are urged to screen for domestic violence at all routine appointments • Positive screens likely to uncover other co-morbid mental health and substance use issues • Have available a multi-tiered system of responses to protect victims • Can intervene at a level matching the severity and risk in the family • Provide therapeutic options at an earlier stage of marital violence without involvement in the criminal justice system.

17. References • Gielen AC, Campbell J, Garza MA, O’Campo P, Dieneman J, Kub J, Snow-Jones A, Lloyd DW: Domestic violence in the military: Women’s policy preferences and beliefs concerning routine screening and mandatory reporting. Milit Med 2006; 171(8): 729-35. • United States Preventive Service Task Force. Recommendation statement: Screening for family and intimate partner violence. Ann Intern Med 2004; 140(5): 382-6. • Wathen CN, MacMillan HL. Prevention of violence against women: Recommendation statement from the Canadian Task Force on Preventive Health Care. Canadian Medical Association Journal 2003; 169(6): 582-4. • Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. San Francisco, CA, 2004. On line at http://endabuse.org/programs/healthcare/files/Consensus.pdf. • American Medical Association, Council on Scientific Affairs. Policy H-515.93: Diagnosis and Management of Family Violence 2005. • American College of Obstetricians and Gynecologists. Domestic Violence. Technical Bulletin No. 209. Washington, DC 1995. • American Academy of Family Physicians. Position Paper on Family Violence (2000); On line at http://www.aafp.org/online/en/home/policy/policies/v/violencepositionpaper.html. • Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999; 282: 468-74. • Chapin MG, Brannen, SJ. Overlap of alcohol abuse and axis II features in a clinical sample of couples involved in spousal violence. Paper presented at 7th International Conference on Family Violence; San Diego, California 2002. • Office of the Secretary of Defense. Policy Memo 17057-05: Restricted reporting policy for incidents of domestic abuse. 22 January 2006. • Mackie, CF. (2004). Risk factors and the level of physical violence: An analysis of spouse abusing Army husbands. Dissertation published by University Microfilms, Ann Arbor, MI. UMI #3124899.