Health consequences of intimate partner violence and implications for health services Gene Feder

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Health consequences of intimate partner
violence and implications for health services
Gene Feder

• The Manchester
• Womens Conference
• 10th May 2007

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nature of intimate partner violence

• physical, sexual, emotional abuse perpetrated by
  a spouse or partner
• characterised by coercive control

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nature of intimate partner violence

• physical, sexual, emotional abuse perpetrated by
  a spouse or partner
• characterised by coercive control
• not confined to violence against women by men

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gender asymmetry

• comparable frequency of violent acts
• Best population study Canadian General Social
  Survey where 8 women and 7 of men living
  together in the past year experienced some form
  of family violence
• women sexually assaulted by partner 7X more often
  than men
• women more than 3x more likely to sustain serious
  injury (40 vs. 13 of all violent
  relationships)
• 38 of women and 7 of men in violent
  relationships feared for their lives
• violence against women was more frequent and more
  severe (beaten, choked or raped vs. slapped,
  kicked, bitten or hit)

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nature of intimate partner violence

• physical, sexual or emotional abuse perpetrated
  by a spouse or partner
• characterised by coercive control
• not confined to violence against women by men,
  but severity and consequences are more severe
  than violence perpetrated by women against men
• also manifests in gay and lesbian relationships

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same sex partner violence

• 11 of women living with a same sex partner
  report being ever raped, physically assaulted or
  stalked by a female co-habitant
• 15 of men living with a same sex partner report
  having experienced violence
• Tjaden and Thoennes 2000

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prevalence of violence perpetrated by men against
women

• depends on definition of violence, measurement
  tool, type of sample, and geography
• lifetime prevalence of physical violence
• 1/3 (10-40)
• physical violence in past year
• 1/10 (2-20)

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domestic violence population prevalence (British
Crime Survey 2001)
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sexual assault population prevalence(British
Crime Survey 2001)
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prevalence of lifetime physical and sexual
violence by an intimate partner among ever
partnered women
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east London cross-sectional study(clinical
population)

• 1027 women in 13 general practice waiting rooms
• 41 lifetime experience of violence (physical or
  sexual assault) ever from a partner
• 17 experienced violence from a partner in the
  past year
• Richardson et al 2001

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injuries and medical effects

• majority of women do not present with obvious
  trauma in health care settings, even in AE
  departments
• one of most common causes of injury in women
  (11-30)
• east London study lifetime injury rate (bruises
  or more serious injuries) 21
• effects persist after abuse has ceased
• range of other conditions (largely
  cross-sectional studies)
• chronic pain (eg. headaches, back pain)
• Increased minor infectious illnesses
• neurological symptoms (fainting and fits)
• GI symptoms and chronic IBS
• raised blood pressure and coronary artery disease

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gynaecological problems

• most consistent, longest lasting and largest
  health difference between women who have and have
  not experienced abuse
• 3X increased risk of gynaecological problems,
  with dose-response relationship and increased
  risk with combination of sexual and physical
  abuse
• STIs
• vaginal bleeding and infection
• dyspaerunia
• chronic pelvic pain
• recurrent UTIs

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mental health effects

• Meta-analysis by Golding (J Fam Violence 1999)
  of studies of populations of women who have
  experienced partner violence
• OR (95 c.i.)
• depression 18 studies 3.8 (3.2 to 4.6)
• PTSD 11 studies 3.74 (2.1 to 6.8)
• alcohol abuse 9 studies 5.6 (3 to 9)
• suicidality 13 studies 3.55 (2.7 to 4.6)

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percentage of ever-partnered women reporting
suicidal thoughts, according to their experience
of physical or sexual violence, or both, by an
intimate partner (WHO)
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violence during pregnancy

• probably not higher than in non-pregnant women
• inconsistent evidence of foetal distress,
  ante-partum haemorrhage and pre-eclampsia
• clear evidence of low birthweight (OR 1.4 in
  meta-analysis of 14 studies)
• co-morbidities STI, substance abuse, post-natal
  depression

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risks to children

• violence may involve other household members
• witnessing violence is a risk factor for
  psychological disorders in children and
  adolescents, educational problems and abusive
  relationships as an adult
• increased prevalence of long term mental health
  problems

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health service response

• until recently, negligible
• contrasts with criminal justice response

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health service response

• until recently, negligible
• majority of women who are experiencing abuse and
  its sequelae are not identified by physicians or
  other clinicians
• aetiological role of abuse in mental health
  problems not recognised

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Why should there be a specific health service
response beyond treating survivors?

• survivors of partner violence believe their
  doctor or nurse is one of the few people they can
  disclose violence to and want them to respond
  appropriately
• Feder et al 2006

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Why should there be a specific health service
response beyond treating the victims?

• survivors of partner violence believe their
  doctor or nurse is one of the few people they can
  disclose violence to and want them to respond
  appropriately.
• Feder et al 2006
• there is growing evidence of effective
  interventions post-disclosure
• Ramsay et al 2005

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http//www.dh.gov.uk/assetRoot/04/12/74/26/0412742
6.pdf
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evidence for effective interventions

• strongest for domestic violence advocacy
• most studies of women who have actively sought
  help or are in a refuge
• recent trials of women disclosing during
  ante-natal care
• psychological therapies, particularly CBT based,
  likely to be effective once a woman no long in
  abusive relationship

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What should clinicians do?

• domestic violence competent practice training
  and visible information materials
• ask about abuse
• non-judgmental support
• check immediate safety
• document
• suggest referral for domestic violence advocacy
• be available for further consultations

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When should we ask?

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Does partner violence fulfill the public health
criteria for a screening programme?

• valid, sensitive screening tool not really
• acceptability to women probably
• acceptability to health professionals no
• effectiveness of interventions for women who have
  been identified via screening no
• Ramsay et al 2002

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When should we ask?

• when women present with injuries
• when women present with symptoms of anxiety,
  depression, substance abuse
• when women present with sexually transmitted
  illnesses
• when women present repeatedly with non-specific
  symptoms or gynaecological problems
• in the course of ante/pre-natal care
• ? screening in the conventional sense
• routine enquiry?

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central role of the domestic violence advocate in
health service response

• in the UK, based largely in NGOs
• one-to-one work face to face and telephone
• safe and confidential environment
• non-directive and empowering, sensitive to the
  clients needs and pace
• assess risks and help develop a safety plan
• provide the client with information about their
  options (legal, housing, safety) and support them
  to make decisions
• liaise with other agencies on behalf of the
  client
• make referrals to other agencies, if requested

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training of clinicians

• needs to be integrated into curriculum and
  undergraduate clinical teaching
• minimum of one day in all training grades?
• needs reinforcement
• strengths and weaknesses of multi-agency/disciplin
  ary training
• integration with a community wide response,
  clarity about roles
• insufficient attention to specific training needs
  of clinicians

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conclusion

• prevalence and health sequelae of IPV mean that
  it is a major public health problem
• health service response needs to focus on
  training of clinicians so that consideration of
  IPV is part of every day practice
• referral link to expert domestic violence
  agencies is a prerequisite for an effective
  health service response
• debate over screening and routine enquiry is a
  distraction