Domestic Violence

1
Domestic Violence

• An Individuals Health Issue
• A Public Health Issue
• An Epidemic
• Rachel E. Locker MD

2
Alarming Statistics

• The American Medical Association estimates that
  over 4 million women are victims of severe
  assaults by boyfriends and husbands each year.  
  Violence Against Women,"
• CQ Researcher, Congressional Quarterly 1993

3
The Facts

• Domestic Violence is the
• leading cause of injury among women of
  reproductive age
• the single most common trigger for female
  suicide
• up to 60 of women who are murdered die as a
  result of a domestic dispute
• Webster 1995

4
Responding

• In order to respond to domestic violence
  effectively we need to have an understanding of
  
• What is domestic violence?
• The causes
• The perpetrators
• The victims
• The impact on the victim, children and society

5
Domestic Violence is...

• A systematic pattern of intentional intimidation
  through the use of threats and violence for the
  purpose of gaining Power and Control over ones
  partner in a intimate relationship

6
Health Effects

• Personal

7
Physical Health

• Physical injuries-
• We usually identify domestic violence with
  physical injuries
• Accidental injuries tend to be on the extremities
  
• Domestic Assaults -on the torso and head

8
Head injuries

• 23 year old woman with subdural hematoma
• Reports he kicked me over and over with his
  steel toed boot

9
Head injuries

• Centered around face
• Nasal/ facial bone fractures
• Lacerations to the eyes
• Rupture eardrum
• Dental injuries

10
Periortibal ecchymosedLacerations to the lips
11
Fractures

• Rib fractures- he kicked me
• I told the other doctor I wrecked on a
• 4- wheeler
• Scapular Fracture Thrown out of a car moving 35
  mph
• Tib/Fib fracture- tried to run over me with the
  car

12
Abdominal trauma

• Ruptured spleen he punched me in the stomach
  over and over
• Fractured Kidney He beat me with the blade end
  of a shovel

13
Genital Trauma

• 34 year old female , 2 years post hysterectomy
  for adenocarcinoma of the uterus.
• Presents with vagina hemorrhage
• Exam finds lacerations of vaginal cuff
• She reports sexual assault with screwdriver

14

• A delay in seeking medical care may exacerbate
  any injury
• Batterer may not let victim seek medical help
• Unconscious
• Afraid of what people would say
• Alcohol or drugs involved

15

• A delay in seeking medical care may exacerbate
  any injury
• Wound infections
• Poor healing without wound closure
• Open fractures
• Fractures healed misaligned
• Excessive bleeding

16
Chronic Disease

• Uncontrolled_______________
• Not allowed to visit the Doctor for diabetes care
• Flushed medication for blood pressure down the
  toilet
• Accuses me of sleeping around when I try to go
  exercise with my sister

17
Chronic Pain Syndromes

• Joints
• Pelvic
• Abdominal
• Headaches
• Psychologically based
• Some reflect actual physiologic changes

18
Chronic Pain Syndromes

• Multiple factors contribute to a woman's response
  to physical violence
• Especially common in women who experience long
  term or repeated victimization
• Severity and duration are important factors

19
Case History

• 53 year old female
• Chronic back pain
• 2 hospitalizations related to incapacitating
  pain
• Extensive evaluation- negative

20

• Pain management
• Difficult to control
• Escalating doses of narcotics
• Unable to adhere to pain management contract
• Admits to taking more than prescribed when she
  feels stressed

21

• Married 30 years
• Extensive history of marital rape
• Infidelity- brings partners in the home
• Physical abuse
• Emotional abuse

22
Self-medication

• Alcohol
• illicit drugs
• Nicotine
• prescription drugs
• a pill to calm me down

• to calm
• to cope with the negative feelings
• to make it all go away
• To shut my mind off

23
Substance Abuse

• Cause or Effect ?
• May be used to self medicate
• Use may make more vulnerable
• Batterer as supplier may be barrier to leaving

24
Substance Abuse

• Alcohol and drug use increase after a new
  assault. Even when there is no prior history of
  prior substance use
• Kilpatrick J Consult Clin psycholgy.1997

25
Substance Abuse and Relationship Violence

• 90 of women with a history of drug or alcohol
  abuse have experienced sexual and/or physical
  violence
• VS
• 18.5 of women who have been assaulted have
  abused alcohol.

26
Post Traumatic Stress Disorder

• Also called Battered Woman Syndrome or Rape
  Trauma syndrome
• Interpersonal violence carries highest risk for
  PTSD
• May persist for many years

27
PTSD Symptom Criteria

• Re-experiencing trauma (1)
• Night mares
• Flash backs
• Intense distress at reminders
• Heightened emotional arousal (2)
• Hypervigilance
• Exaggerated startle response
• Irritability and outbursts of anger
• Difficulty falling or staying asleep
• Difficulty concentration

28
PTSD Symptom Criteria

• Avoidance and numbing(3)
• Avoid thoughts or conversation of the trauma
• Avoid activities of persons that arouse thoughts
  of the trauma
• Inability to recall an important aspect of the
  trauma
• Restricted affect
• Sense of fore-shortened future

29
Mental Health Concerns

• Anxiety disorders
• Sleeping disorders
• Depression
• Suicidal ideations, attempts
• Suicide

30
Teen Girls Who Experience Physical and Sexual
Abuse in Relationships Are

• more likely to
• drink and drive
• binge drink.
• smoke heavily
• use illicit drugs
• use diet pills
• become pregnant
• consider suicide

31
Abuse in Pregnancy

• Violence is more likely in an unintended
  pregnancy
• Abuse may often begin or escalate during
  pregnancy
• Is likely to continue postpartum

32
Substance Abuse and Pregnancy

• In Pregnant women receiving treatment for
  substance abuse the vast majority have
  experienced sexual or physical assault
• Liebschutzualt, Violence Against Women

33

• Increased c-section rate
• Particularly in sexual assault or child sexual
  abuse
• Labor can mimic loss of control of body
  experienced with sexual assault
• Decreased breast feeding
• Partner may prohiibt
• Avoidance of sexal assault recall
• Increased risk for post partum depression

34
Pregnancy Complications

• Stress Related
• Late, sparse or no prenatal care
• Low birth weight
• Miscarriage
• Preterm labor
• Drug and Alcohol abuse

35
Pregnancy Complications

• Trauma related
• Miscarriage
• Fetal Fracture
• Placental abruption
• Preterm labor
• Uterine rupture
• Fetal death
• Maternal Death

36

• Murder is the leading cause of death related to
  pregnancy
• JAMA 2001

37

• Death

38
Oregon Statistics

• 1997-2001 Review of Intimate Partner homicides
• 151 women murdered
• 50 (n75) murdered by an intimate partner
• 387 men murdered
• 4 (n17) murdered by an intimate partner
• 29 (n5 )of those killed in self defense

39
What about the Kids ?

• 61 children involved (37 of cases)
• 21 (34) children witnessed homicide
• 5 children also murdered

40
Effects on Children

• Parents usually think children do not know what
  is happening
• Children witness between 60-80 of assaults
• When children live with domestic violence it is
  very likely that child is witness to some of the
  physical violence

41
Children's health

• Physical injuries
• Caught in the crossfire
• Trying to intervene
• Abuse and Neglect
• May come at the hands of either parent
• Pecking order

42
Child Abuse

• 15 times more likely to be abused than children
  from
• non-violent homes !

43
Case History

• 6 year old male
• Frequent stomach aches
• Zantac 75 helps
• Work up negative for organic etiology

44

• Father is verbally abusive to her and children
• Throws things near my head and yells a lot, but
  never hits
• Stomach aches do occur after incidents
• Brothers being treated for headaches and insomnia

45
Medical Effects on Children

• Sleeping disorders
• Difficulty falling asleep,
• Wake frequently
• Refuse to sleep in their own bed
• Night mares
• Anxiety
• Worry about parents
• Worry about self

46
Mental health

• Increased aggression/ anxiety
• Become more aggressive
• Misunderstand intentions of other children
• Depression
• Suicidal ideations and attempts

47
Children who witness Domestic Violence are at
increased risk for developing PTSD

• 85 of child witnesses interviewed had moderate
  to severe symptoms of PTSD
• None of the control group had symptoms
• Kilpatrick 1997

48

• Developmental regression
• baby talk
• bed wetting
• Increase distractibility
• Repetitive talk or play about the event
• Withdrawal/apathy

49
As Adults

• Decreased sense of Well Being
• Depression
• Feelings of hopelessness and powerlessness
• Low self esteem

50
More adverse experiences more disease as an adult

• True for
• IV drug abuse
• Depression
• Obesity
• Smoking

51
Public Health
52
Medical Economics

• Medical Expenses
• 5.8 billion in the US in 2002
• CDC 2003
• A victim of domestic violence uses
• 8 x more physician visits
• 6x more prescription drug use
• 6 x more ER visits
• 1775 more health care costs per year

53
Tax payer Impact

• Legal Expenses- Tennessee study
• 49,928,000 per year in Tennessee
• -includes
• Protection orders
• Divorce costs
• Custody fillings
• Probation over site for offences
• Pretrial cost for arrested
• Prison cost for DV murderers

54
Socioeconomic Impact

• Other considerations
• Counseling services
• Alcohol and Drug counseling/treatment
• Damage to property
• Poverty
• Homelessness/Runaways

55
Economic Impact

• Lost time from work- nationally
• Tardy, harassment absent, leave early , poor
  concentration, lost productivity, higher health
  care insurance, increased work place security
• Total 35,000,000,000 annually
• Yes that is billion

56
A Public Health Epidemic
57
Jan and Bob

• Jan is a 23 year old woman with subdural
  hematoma.
• Reports Bob kicked me over and over with his
  steel toed boot.
• Continues to control and manipulate her, even
  from jail.

58
The epidemic spreads

• Jan leaves
• Bob meets new partner in jail- Sue
• All is wonderful until the first child is born
  and physical abuse begins.

59
About Bob

• Bobs father was very abusive to mother and the
  children
• Bobs sister reports-
• our dad was very violent all us kids have been
  either the abused or the abuser in our intimate
  relationships

60
The Cycle Continues

• A childs exposure to the father abusing the
  mother is the strongest risk factor for
  transmitting violent behavior from one generation
  to the next. Report of the American
  Psychological Association Presidential Task Force
  on Violence and the Family, APA, 1996

61
About Sue

• Sues father physically abusive to children and
  mother
• Several brothers committed suicide.
• First partner and father of older set of children
  very abusive
• Alcohol abuse in both Sue and partner.

62
About Sue

• Older set of children
• children jail time in early teens,
• alcohol and drug treatment at age 14-16
• multiple school expulsions
• daughter is a mother at 16- no parenting skills
• boys involved in gang activity
• son suspect for murder at age 18

63
Sue and Bobs kids

• Physical Violence begins soon after birth of the
  first son
• Sons ages 2 and 4 witness assaults
• Visit to clinic with mom after physical assault
• Uncontrollable out bursts
• Hit, spit, bite, scream at any attempted
  interaction
• 4 year old grunts and screams uses no words

64

• what does the future hold ?

65
(No Transcript)