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Intimate Partner Violence: Gender and Healthcare Response

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Title: Intimate Partner Violence: Gender and Healthcare Response


1
Intimate Partner ViolenceGender and Healthcare
Response
  • Karin Rhodes, MD MS
  • Academic Associates Program
  • February 8, 2007

2
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?

3
Goals
  • Definitional Issues IPV
  • Myths and Misconceptions
  • Health Care Providers Response
  • Types of IPV
  • Gender
  • Safety
  • Womens Personal Needs Study (WPNS)

4
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

5
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.

6
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
7
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

8
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

9
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

10
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

11
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
12
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)

13
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

14
Womens violence Different from mens violence
  • Gender differences in abusive behaviors and
    outcomes
  • Context
  • Meaning
  • Motive
  • Outcome

15
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

16
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

17
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.

18
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

19
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

20
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

21
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?

22
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

23
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)

24
Coping and Survival Strategies
  • Calling police
  • Seeking advice or help from others
  • Fighting back / self-defense
  • Leaving
  • Hiding
  • Denial
  • Self-medicating

25
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

26
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.
27
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

28
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)

29
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

30
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

31
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

32
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