4 – 5 pm Domestic Violence: Update for Primary Care Providers

SPEAKER Panagiota Caralis, MD, JD, FACP

Presenter Disclosure Information The following relationships exist related to this presentation: ► Panagiota Caralis, MD, JD, FACP: No financial relationships to disclose.

Off-Label/Investigational Discussion ► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

Objectives

Domestic Violence Update-A Global View P.V. Caralis MD,JD, FACP Professor of Medicine Miller school of Medicine ,U. of Miami Miami Veterans Health System

Family Violence Intimate Partner Abuse Definitions Prevalence Costs Cross-cultural issues Responses

Discuss demographics of interpersonal trauma Review screening and diagnosis strategies Describe optimal management Emphasize a patient-centered approach

Intimate Partner Abuse CDC Definition:  Physical and/or sexual violence or threat of such violence; or psychological/emotional abuse and/or coercive tactics when there has been prior physical and/or sexual violence; between persons who are spouses or non marital partners or former spouses (Saltzman et al. 1999)

Overall Prevalence IPV 20-30% of American women will be physically abused by a partner at least once in their lifetimes. Tjaden, &

IMPACT OF IPV

Thoennes, 2000.



1.3 million women and 834,732 men are physically assaulted by an intimate partner annually; 52% injured. Walton-Moss, 2004

503,485 women and 185,496 men are stalked by an intimate partner annually;201,394 women are forcibly raped by an intimate partner annually. Tjaden, & Thoennes, 2000. 11% of women in homosexual relationships and 23% of men in homosexual relationships report being raped, physically assaulted, and/or stalked by an intimate partner. Greenwood,2003

50% of men who assaulted their female partners also assaulted their children; 3.3 million children witness domestic violence each year. Fischbach, R.L. & Herbert, B. 1997 20-35% of victims seek medical care or are hospitalized for abuse; 85% in health care system for “something”; 42% of femicide victims. Campbell 2000

Economic Cost of Violence Against Women

Health Care Costs of Intimate Partner Violence o Women with IPV had 19% higher annual total health costs compared to women with no history.

2003 CDC estimate that the costs of IPV in US exceeded $5.8 billion per year;

o 17% more primary care visits, 14% more specialists, 27% more prescriptions.

$4.1 billion for direct medical and health care services;

o Costs remain 20% higher even 5 years after abuse has stopped.

$1.8 billion for loss of productivity.

Since 1998 DV rates in Fl. have been declining. FDLE Report , 2014 2014, there were 106,882; DV offenses. 21% involved spouses; 29% cohabitants; 11% of the victims were parents of offenders.

DV accounted for 20% of the state’s murders; total of 205 victims, a 6% decrease compared to 2011.

Cumulative Rates of Domestic Violence by Setting Study

Year

Appleton Goldberg & Tomlanovich

1980 1984

Abbott, et. al. Gin, et. al. Murdoch & Nichol Caralis , et al.

1995 1991 1994 1997

Hilliard McFarlane Parker

1985 1992 1993

Setting % Emergency Depts 35 22 Primary Care Clinics 54 34 28 42 Obstetrical Clinics 11 17 18

Trauma Can Manifest in Multiple Ways Trauma Direct Injury

Physiologic Adaptation to Stress

Health Impact

Health Outcomes in Women with Physical and Sexual IPV 2876 women interviewed: Health scores were self-assessed 5 points lower for women with IPV. Prevalence ratios for depressive and severe depressive symptoms were higher. Bonomi, J Womens Health 2007

 2730 women, mean age 30.5 yrs, 18% were exposed to physical and sexual violence and self-reported 6 somatic symptoms and 1.5 diseases, significantly higher compared to non-exposed women. Eberhard-Gran, J Gen Intern Med 2007

Lets Be Clear-

VIOLENCE IS A PUBLIC HEALTH PROBLEM

Physicians Failure to Diagnose and Treat Family Violence  ER physicians fail to identify battered women

1 in 3 diagnosed versus 1 in 4 documented.  1 in 5 women sought medical care an average of

11 times previously.  8% of documented records include this as discharge diagnosis.  Battered women identify health care professionals as the

LEAST helpful (less than police, clergy, lawyers).

It is not the violence of the few that scares me. But the silence of the many. Dr. Martin Luther King, Jr.

Barriers to Diagnosing and Treating DV: Removing the Myths  Abuse occurs in “normal” families - Abusers are indistinguishable - Abusers accompany victim  Cuts across racial and socioeconomic classes - Afr. Americans more likely to report abuse; Latinas and immigrants are less likely.  Don’t blame the victim - She can’t “just leave” - Respect their choices

In the US - Cultural Barriers Internal  Misunderstanding about what defines DV  Stigma associated with DV  Responsibility to maintain family regardless of cost  Community loyalty  Traditional male-female roles

Patients’ Self Experience with Abuse Caralis et. al,1997.

% Total Patients (N-406) 

Have experienced emotional or physical abuse by partner

42

Are currently in abusive relationships

7



Hit by partner in last year

7



Within past year had forced sex

3







Have been asked by doctor and or nurse about abuse Could tell their doctor they were victims of abuse

Treatment Plan

S creen T reat illness Educate and empower P lan for safety Support services & community referral

12

Cultural Barriers External barriers Unaware of services Culturally sensitive services Lack of economic self-sufficiency Mistrust of legal system and health care Immigration issues Language barriers

Comparing Partner and Nonpartner Violence Against Women A common perception is that women are more at risk of violence from strangers than from men they know. In the majority of all countries, over 75% of women physically or sexually abused by any perpetrator ,since the age of 15 years, reported abuse by a partner.

68

Practice Trauma-Informed Care Like universal precautions… we don’t always know who has had an exposure Disrobing, invasive exams can be especially difficult for trauma-exposed women Veterans Be prepared to let the patient direct the exam, and to stop if evidence of distress or dissociation Be attentive to privacy needs, personnel in the room

IPV Screening US Preventive Services Task Force Level B Recommendation:

Where

to ask about IPV?

comfortable & private setting

Screen women of childbearing age and provide or refer women who screen positive to intervention services

• No family, friends, or children over age 3 present • Invite partner to “sit in the waiting room where it is more comfortable”

AHRQ pub no. 12-05167-EF-2; Nelson et al, 2012; Tjaden & Thoennes, 2000.

HOW to

Introduce/normalize questions

ask about IPV?

Because violence is so common in the lives of women, we have begun asking all patients about it

Consider both current and past IPV

Be aware that feelings of isolation, coercion, or fear may signify emotional IPV

Women with multiple presenting  problems may have abuse histories… • Greater abuse severity along with varied forms of abuse → more physical symptoms • Ongoing abuse may → more somatic symptoms over time • ALWAYS validate her physical symptoms and pain Nicolaidis et al., 2004; Gerber et al., 2008.

I’m sorry that you have to experience that. We would like to help. The abuse is not your fault. It’s wrong for one person to hurt another person.

You didn’t do anything to deserve to be treated this way. I’m glad you told me.

I’m worried about your safety.

Unfortunately, you are not alone. Many of our patients have experienced abuse.

“First Responses”

Interpersonal Trauma Affects Physical Health Headaches

Abdominal and pelvic pain

Chest pain and palpitations

Irritable bowel syndrome or GI problems

Sexually transmitted infections

Fibromyalgia or chronic pain syndromes

Medically unexplained symptoms

She may be having a trauma-related reaction…

Interpersonal Trauma Affects Mental Health

• Anxious, agitated, jumpy or withdrawn, quiet, frozen • Tearful with no obvious cause; strong emotional reactions • Difficulty concentrating, distractible, disoriented

PostTraumatic Stress Disorder (PTSD)

Depression

Anxiety

Substance abuse

Suicidality

• Experiences flashbacks, dissociates • Minimizes symptoms that require intimate exams • Refuses care/cancels appointments

IPV is associated with depression, smoking, and heavy/binge drinking among women Veterans

Interpersonal Trauma Affects Reproductive Health In women, increased prevalence of…

30% 25% 20% 15% 10% 5% 0%

IPV No IPV

Pelvic inflammatory disease

Irregular menses, premenstrual symptoms

Perinatal and neonatal issues

Miscarriage

Data: Dichter et al., 2011.

Reproductive health and g pregnancy p g y violence during  Ever-abused women were significantly more likely to report at least one induced abortion and more miscarriages.  In 11 of 15 settings, more than 5% of the women had experienced physical abuse during pregnancy.

How Can You Help?

It is not your role to “fix it” Document encounter

Treat health problems and injuries

Assess safety

Offer support

Provide education and resources

Coordinate follow-up

 25-50% were kicked/punched over the abdomen.  Majority had been beaten before and reported that the violence got worse during the pregnancy.  50% of women in Brazil city and Serbia were beaten for the first time during pregnancy.  WHO Multicountry Study on Violence against Women and Health www.who.int/gender/violence/who multicountry study/en/index.html

44-47% of women killed were seen in health care setting before being killed. Sharps, Campbell 2002

2001 study of femicides… • 41% had health care provider contact prior to death • Yet only 3% accessed advocacy or shelter programs It’s common for women not to seek medical assistance after an injury from IPV Sharps et al., 2001; National Coalition Against Domestic Violence Report 2001.

Risk Factors for Intimate Partner Femicide  Funded study by NIDA/NIMH,DCD,NIJ  10 cities: Baltimore, Chicago, Houston, Kansas City, Wichita, LA, NY, Portland, Seattle, Tampa /St Pete.

 Socio-demographic comparisons of abused/killed and abused :  Being Latina neither raised or lowered risk of death; while being African American increased mortality risk and being NH White was protective.  Unemployment and Lower education of abusers increased risk.

Risk Assessment

Danger increases if:

She may not realize she’s in imminent danger

Abuser has access to weapons Abuser uses substances Abuser unemployed Recent abuse escalation History of severe abuse History of stalking Attempted strangulation

 Immigrant woman independent risk of IP femicide.  Walton-Moss,Campell et al 2005; Wilt & Frye, 2006

Campbell et al., 2002; Johns Hopkins School of Nursing, www.dangerassessment.org

FLORIDA LETHALITY INDICATORS  Prior history of domestic violence-19% had criminal “no contact”orders,10% had final civil injunctions  Estrangement / separation  Obsessive-possessive behavior - ownership / centrality of victim to perpetrator - hunting / tracking / stalking of victim - sadistic / terrorist acts / harming pets

Tailor to her specific situation Identify ways to stay safe Back-up plan for escalating violence Pack a bag, keep in a secure place Copy documents Code word for others to call police

 Suicidal ideation  Depression / sleep disturbances  Employment/Monetary Problems

National Coalition Against Domestic Violence Safety Plan

 Substance abuse  Prior threats to kill

FDLE, Report 2014

http://www.ncadv.org/protectyourself/SafetyPlan_130.html

Suggested Documentation 1. IPV assessment in social history

National Domestic Violence Hotline 1-800-799-SAFE

1. Specify details of IPV incident (user’s name, actions, date and time) 2. Document physical exam findings, injuries, health effects 3. Code for resulting condition (ex. contusion, laceration)

Good documentation can help in court, with child custody, or with state victims’ compensation

She may not leave the situation…

View as a chronic disease; work on it slowly over frequent visits

Understand the barriers to this behavior change

She may have lost her sense of free will and autonomy

Exiting Violent Relationships • Women who are separated from a violent partner are 25x more likely to be assaulted by that partner • Women are most likely to be killed while leaving • Up to a third who leave will continue to be harmed by their partner.

Help her regain selfesteem; validate her actions while being honest about your safety concerns Respect her timetable; never tell her what to do!

Reporting IPV • Some states have mandatory reporting. Most do not. Know your state reporting laws. • Women fear children will be placed in protective custody. • Ask: “Are there children in the home?” If yes: May need to enter a consult for social services

This is a time of risk. Be supportive and help connect her to resources.

Mandated Reporting  Child Abuse  Elder Abuse  Abuse of Disabled

Victims Use of Police and Court ( )Marin 1991 (n=750) %

AA

73

 Signed police

Latina US

Latina For. NHW

56

54*

66

complaint

64

 Got Protective order

60

62

84 *

Effectiveness of Batterers’ Intervention Programs Study

# Batterers

Hamberger

% Refrained

F/U(yrs)

1990

106

70

1

Duluth Program 1992

500

60

5

Domestic Abuse Project Minnesota 1989

1,500

66

4

Edleson

1,500

1989

84%-54%

1

Human Trafficking • 600,000 – 800,000 adults/children worldwide estimated • Sex trafficking • Labor trafficking • Debt bondage • Forced labor • Indentured servitude

Statistics rank Miami as 9th in Nation and Florida - 3rd highest destination for sex trafficking in the country. Florida legislature passed two bills to addressed the problem in 2012. Two shelters in Miami Dade.

• Child soldiers

Victim Recognition

Interventions for Trafficking

• Indirect questioning best

• From where, how and why in US?

• May or may not speak English, but someone speaks for her/him

• Type of work, set hours, pay, how paid?

• Vague replies to spending $, housing, job; story does not fit

• Threatened with violence?

• No ID or travel papers

• Permission needed to eat, sleep, use bathroom, talk with others?

• Signs of abuse, neglect, poor health

• Forced to do this? • Live where and with whom? • Locks on doors and windows?