Intimate Partner Violence: Gender and Healthcare Response

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Intimate Partner ViolenceGender and Healthcare
Response

• Karin Rhodes, MD MS
• Academic Associates Program
• February 8, 2007

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Outline

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

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Goals

• Definitional Issues IPV
• Myths and Misconceptions
• Health Care Providers Response
• Types of IPV
• Gender
• Safety
• Womens Personal Needs Study (WPNS)

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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

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Additional data (not documented)

• Hovering, somewhat volatile boyfriend
• Pt initially complained to about boyfriends
  excessive jealousy but after the RN informed the
  boyfriend that she doesnt 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.

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Myths Realities true or false?
1. IPV happens only within low-income or poor families/couples
2. Alcohol and drug use is the major cause of domestic violence
3. A battered woman may have many legitimate reasons for staying with an abusive partner
4. A battered woman might leave her abusive partner many times
5. Abusers are violent because they cannot control their anger or frustration
6. Violent men are usually mentally ill or have psychopathic personalities
7. Women enjoy being abused
8. Survivors of IPV exaggerate the abuse
9. A victim is safe if she leaves her abusive partner
False
False
True
True
False
False
False
False
False
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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

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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

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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

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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

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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 Wome
n are more likely than men to be victims of
stalking
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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)

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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

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Womens violence Different from mens violence

• Gender differences in abusive behaviors and
  outcomes
• Context
• Meaning
• Motive
• Outcome

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Context Womens violenceagainst men

• Womens 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

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Men and womens motivations for using violence
differ

• Womens violence is more often motivated by
• Self-defense
• Fear
• Defense of children
• Mens violence is more often
• motivated by
• Control

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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.

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Types of violence women commit differ from mens
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

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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

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Womens 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

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Why doesnt 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?

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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

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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)

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Coping and Survival Strategies

• Calling police
• Seeking advice or help from others
• Fighting back / self-defense
• Leaving
• Hiding
• Denial
• Self-medicating

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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 theres mandatory reporting)
• Why healthcare providers dont screen dont know
  what to do if they get a positive, dont want to
  deal with it, dont 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

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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 200033(4)629-655.
Kringen vs. Boslough and St. Vincent Hospital
and Health Care Center, Inc. A Montana
Corporation.
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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 its not your fault not what
  did you do to provoke him? why didnt you just
  leave?)
• Provide resources, referrals (emergency numbers,
  social worker, literature)
• Encourage patient to see help

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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 (dont
  turn her off from help-seeking or put her in
  danger by telling her she has to leave)

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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

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Womens Personal Needs StudyAcademic 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 cant help if we dont know)
• Validation (someone asked, someone cares)
• Resources (give all women the emergency numbers!)
• Linking with services

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Womens Personal Needs Study Goals for Academic
Associates

• Watch out for patients safety (only interview
  her alone)
• Listen to patient and validate (if she says its
  not safe for her to answer questions, take
  papers, etc., dont 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

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Questions? Comments?