Training Course:Screening for IPV Angela Browne1, Eleni Petridou2,3 1 Department of Health Policy an

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Training CourseScreening for IPV
Angela Browne1, Eleni Petridou2,3 1 Department
of Health Policy and ManagementHarvard School of
Public Health, Boston, USA 2 Department of
Epidemiology, University of Athens, School of
Medicine, Athens, Greece3 Department of
Epidemiology, Harvard School of Public Health,
Boston, USA
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Objectives of the Training Course

• Have a working knowledge of
• Definition of Intimate Partner Violence (IPV)
• Overview of the IPV issue
• Patterns of abuse
• Risk factors for IPV
• Outcomes of IPV
• Screening for IPV
• Know how to respond appropriately when a victim
  discloses IPV

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Key Definitions

• Intimate Partner Violence (IPV) actual or
  threatened physical or sexual violence, or
  psychological/ emotional abuse by an intimate
  partner.
• Intimate Partner includes
• current spouses, current non-marital partners
  (dating partners, boyfriend/girlfriend-
  heterosexual or same-sex), former marital
  partners, former non-marital partners.
• (US Centers for Disease Control Prevention)

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Intimate Partner Violence

• Physical abuse
• Rape in intimate relationships and sexual
  violence
• Threat of Physical or Sexual Violence
• Psychological/ Emotional abuse

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Common Terms for IPV

• Domestic abuse
• Spouse abuse
• Domestic violence
• Courtship violence
• Battering
• Marital rape
• Date rape
• (US Centers for Disease Control
  Prevention)

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Intimate Partner Violence

• Social, cultural, legal, public health problem
• The main source of assault or injury
• Affects adults of all nationalities, races,
  socioeconomic levels
• Occurs in heterosexual, as well as same-sex
  relationships

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Physical Abuse

• Physical abuse in the context of IPV is defined
  as experiencing at least one of the following by
  a current or former intimate partner
• Having something thrown at you that could hurt
  you
• Being pushed, grabbed, or shoved
• Having your hair pulled
• Being slapped or hit
• (Tjaden
  Thoennes, 1998)

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Severe Physical Abuse

• Being kicked
• Being bitten
• Being choked or held underwater
• Being hit with an object that could hurt you
• Being beaten up
• Being threatened with a knife, gun, or other
  weapon, or
• Actually having a knife, gun, or other weapon
  used on you
• (Tjaden
  Thoennes, 1998)

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Sexual Assault

• Use of physical force to compel a person to
  engage in a sexual act against his or her will,
  whether or not the act is completed
• An attempted or completed sex act involving a
  person who is unable to understand the nature or
  condition of the act, to decline participation,
  or to communicate willingness to engage in the
  sexual act
• Abusive sexual contact
• (US Centers for Disease Control Prevention)

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Psychological/ Emotional Abuse

• Psychological or Emotional Abuse includes
  repeated verbal abuse, emotional intimidation,
  stalking, destruction of pets and property,
  harassment, confinement, deprivation of physical,
  financial, and personal resources.

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Lifetime prevalence of IPV
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Mutuality of assaults (1)

• Both men and women can be verbally and physically
  aggressive
• Men are the primary perpetrators of
• Physical aggression with the potential to cause
  physical harm
• Sexual aggression
• Forcible restraint
• Partner homicide
• (Browne, 1992 1993)

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Mutuality of assaults (2)

• Women are more likely than men to be physically
  injured during attacks by an intimate partner
• Women are more likely than men to be killed by an
  intimate partner
• (Browne, 1992 1993)

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Early Warning Signs (1)

• Intrusion Constant desire to know a partners
  whereabouts and to restrict a womans contacts
  with others
• Isolation Severe restrictions on contact with
  others
• Possession Belief that a partner belongs to
  the other often used as justification for
  violence.
• NOTE It is often difficult to separate early
  warning signs from more typical romantic or
  social interactions!

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Early Warning Signs (2)

• Jealousy Often without cause, and with angry or
  violent reprisals.
• Prone to anger Moods change rapidly to anger
  without warning level of anger out of scale with
  reason for anger.
• History of violence Perpetrator has acted
  aggressively toward others in the past

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Cycle Theory of Violence
TENSIONSBUILDING PHASE
REMORSE,FORGIVENESS
TRIGGERINGEVENT
ABUSE
(Walker, 1979)
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Cycle Theory of Violence
(Douglas, 1991 Frieze Browne, 1989
Walker, 1979)

• 1.Tension Building Phase
• gradual buildup of intimidation, threats, anger,
  and minor physical aggression
• 2. Acute Battering Incident
• lack of control, lack of predictability
• 3. Loving Contrition
• unusual period of calm
• perpetrator may apologize, show kindness or
  remorse, ask for forgiveness, promise violence
  will not occur again.
• !This phase may not occur in all relationships!
  Some relationships may have only a relief from
  violence and then a return to a Tension Building
  Phase.

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Substance Abuse and IPV

• Abusers with a substance abuse history are more
  likely to be aggressive or violent to others
  outside, as well as inside, the home compared to
  abusers without a history of substance abuse.
• However, episodes of violence do not necessarily
  occur when the abuser has been drinking or using
  drugs.
• (Fagan Browne, 1994 Gleason, 1997)

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Effects of Childhood Exposure to Violence at
Home

• Having suffered or witnessed physical/ sexual
  abuse during childhood is associated with
  physical/ sexual abuse in adulthood
• ( Oriel and Fleming, 1998 Diaz-Olavarrieta et
  al, 2001)

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Physical Outcome of IPV

• Death
• Acute Injuries
• Bruises, abrasions, lacerations
• Cuts and Stab Wounds
• Burns
• Concussions
• Broken bones
• Bites
• Dislocations, sprains
• Internal injuries

Source www.webshots.com
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Long Term/ Chronic Outcomes of IPV

• Poor physical and mental health
• Chronic somatic disorders (e.g. Chronic
  Gastro-Intestinal Pain/ Discomfort, Irritable
  Bowel Syndrome, Chronic back, neck or other
  muskuloskeletal pain, Chronic headaches,Stammering
  , Hypertension)
• Exacerbation of chronic medical conditions
• Scars from burns, bites, and knife wounds
• Complications of pregnancy and birth, gynecologic
  problems, sexually transmitted diseases
• Depression, anxiety, suicide
• Substance abuse
• Feelings of shame, isolation and entrapment
• (Coker et al., 2000, Hathaway et al., 2001)

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IPV and Pregnancy

• During pregnancy women are at higher risk for
  being abused by their intimates
• Assaults during pregnancy can lead to
• Placental separation, antepartum
• hemorrhage, fetal fractures
• Rupture of the uterus, liver, or spleen
• Kidney infection
• Premature labor
• Stillbirth
• (Browne, 1992 1993 Cokkinides et al, 1999)

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Psychological Impact of IPV

• Depression
• Suicide Ideation and Suicide Attempts
• Substance Abuse
• Post Traumatic Stress Disorder
• Trauma Reactions - shock, denial, withdrawal,
  confusion, psychological numbing, fear
• Anxiety
• Sleep and Eating Disturbances

(Browne, 1992, Coker et. al, 2000 )
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Importance of Screening Tool Development (1)

• Provides the opportunity for disclosure of IPV
  and allow victims to know there are resources
  available
• Identification of domestic violence is the FIRST
  stage of intervention
• Asking about abuse helps break the isolation
  victims and other family members may experience
• (Warshaw and, Ganley, 1998)

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Importance of Screening Tool Development (2)

• Routine inquiry may allow for intervention before
  injury or illness occur and/or reduce further
  harm
• Without intervention, violence usually continues
• (Warshaw C, Ganley, 1998)

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Three goals of Screening Tool Development

• Acquire a body of knowledge on intimate partner
  violence
• Master skills needed for identification,
  intervention, and prevention in cases of partner
  violence
• Develop relationships with local organizations
  that can assist victims of abuse
  
• (Osattin A, Short LM., 1998)

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Who Should Screen for IPV?

• Health Care Providers
• Who have been educated about IPV issues
• Who have been trained how to ask about abuse and
  how to intervene when identifying victims of
  abuse

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How Screening Should Occur?

• Screening for IPV should take place in a safe
  private setting, away from anyone who may have
  accompanied her, including sisters, daughters,
  friends, children or partner
• Screening for IPV should be CONFIDENTIAL
• (Little 2000)

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How to ask about Family Violence (1)

• Avoid an intimidating stance when asking patients
  about abuse sit at or below the patients level
  when asking about abuse
• Ask about abuse in an nonjudgmental manner and in
  a direct and compassionate way
• Avoid doing paperwork during interview
• (Hotch et al., 1995, Little 2000)

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How to ask about family violence (2)

• Affirm clearly that you believe that violence in
  the home is a serious problem
• Offer support in an empathetic, non-judgmental
  way that shows you respect the patient
• (Hotch et al., 1995)

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Ways to Ask About Abuse in the ED or when there
are not Obvious Injuries

• From my experience here in the AE, I know that
  abuse and violence at home is a problem for many
  women/ families. Is it a problem for you in any
  way?
• We know that abuse and violence in the home
  affect many people and that it directly affects
  their health! I wonder if you ever experience
  abuse or violence at home?
• Have you ever felt unsafe or threatened in your
  own home?
• (Hotch et al., 1995)

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Ways to Ask About Abuse when there are Physical
Signs

• Has anyone hurt you?
• The injuries you have suggest to me that someone
  hit or hurt you. Is that possible?
• In my experience, women often get these kinds of
  injuries when someone hits or hurts them in some
  way. Did someone hit you?
• It seems that the injuries you have have been
  caused by someone hurting or abusing you. Did
  someone hurt you? Can you tell me about what
  happened?
• (Hotch et al., 1995)

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Quick Reference

• DO
• ASK about abuse and violence
• IDENTIFY patients who have experienced abuse
• ACKNOWLEDGE the seriousness of family and partner
  violence as a health problem
• EXPRESS belief in the patient
• ASK about the patients immediate safety
• STRESS that no one deserves abuse
• GIVE the patient a list of resources in their
  community or nearby

• DONT
• BLAME OR SHAME the patient
• GIVE ADVICE, other than to explain resources
• IGNORE a disclosure of abuse
• PUT a patient at increased risk from an abuser!
• ASK Why dont you leave?
• (Hotch et al., 1995)

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Questions to Keep in Mind (1)

• Is the patient currently being abused? Has she/he
  been abused in the past? Is she/he still at risk?
• Who is the perpetrator? What kind of access does
  the perpetrator have to the patient/victim?
• How might the abuse affect the patients health?
• Is it safe for her/him to go home? How much
  danger is she/he in? Is she/he suicidal,
  homicidal, or otherwise in danger?
• (Warshaw C, Ganley A, 1998)

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Questions to Keep in Mind (2)

• Does she/he have a safety plan? Can you or
  someone else help her/him develop one?
• What does she/he need? Information, support
  services, mental health services? Can she manage
  this her/himself?
• What resources are available in the community
  that might help?
• How do you own feelings and responses affect your
  ability to provide appropriate care?
• (Hotch et al., 1995)

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What to do if a Suspected Victim Denies Abuse

• Accept the patient response and right of
  self-determination
• Emphasize that such questions are asked routinely
  because of the prevalence of IPV
• Let the patient know that they are resources
  available for someone who might be abused
• (Little 2000)

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Services that are Helpful for IPV Cases

• Short-term and long-term counseling for women,
  men, and children
• Legal services for protection and prosecution
• Medical services
• Crisis services for safety and acute needs
• Emergency shelters for family members at risk
• Counseling for perpetrators of family violence

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Services that are Helpful for IPV Cases in your
Country

• To be completed by every collaborator for the
  respective country

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Summary (1)

• Although hidden behind the closed door of houses,
  the results of violence in homes affect all areas
  of society
• Medical settings are particularly likely to see
  victims of violence in families, even if victims
  are afraid to disclose the cause of their
  injuries.
• Health care professionals can be an important
  frontline for identification and intervention.

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Summary (2)

• Recognition of the problem will allow society
• to develop resources for those who are in danger
• to establish policies so that all citizens can be
  safe in their own homes.