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Training Course:Screening for IPV Angela Browne 1, Eleni Petridou 2,3 1 Department of Health Policy and ManagementHarvard School of Public Health, Boston,

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Presentation on theme: "Training Course:Screening for IPV Angela Browne 1, Eleni Petridou 2,3 1 Department of Health Policy and ManagementHarvard School of Public Health, Boston,"— Presentation transcript:

1 Training Course:Screening for IPV Angela Browne 1, Eleni Petridou 2,3 1 Department of Health Policy and ManagementHarvard School of Public Health, Boston, USA 2 Department of Epidemiology, University of Athens, School of Medicine, Athens, Greece 3 Department of Epidemiology, Harvard School of Public Health, Boston, USA Training Course:Screening for IPV Angela Browne 1, Eleni Petridou 2,3 1 Department of Health Policy and ManagementHarvard School of Public Health, Boston, USA 2 Department of Epidemiology, University of Athens, School of Medicine, Athens, Greece 3 Department of Epidemiology, Harvard School of Public Health, Boston, USA

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

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

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

5 Common Terms for IPV Domestic abuse Domestic abuse Spouse abuse Spouse abuse Domestic violence Domestic violence Courtship violence Courtship violence Battering Battering Marital rape Marital rape Date rape Date rape (US Centers for Disease Control & Prevention) (US Centers for Disease Control & Prevention)

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

7 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: 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 Having something thrown at you that could hurt you Being pushed, grabbed, or shoved Being pushed, grabbed, or shoved Having your hair pulled Having your hair pulled Being slapped or hit Being slapped or hit (Tjaden & Thoennes, 1998) (Tjaden & Thoennes, 1998)

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

9 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 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 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 Abusive sexual contact (US Centers for Disease Control & Prevention)

10 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. 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.

11 Lifetime prevalence of IPV

12 Mutuality of assaults (1) Both men and women can be verbally and physically aggressive Both men and women can be verbally and physically aggressive Men are the primary perpetrators of: Men are the primary perpetrators of: Physical aggression with the potential to cause physical harm Physical aggression with the potential to cause physical harm Sexual aggression Sexual aggression Forcible restraint Forcible restraint Partner homicide Partner homicide (Browne, 1992 & 1993)

13 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 Women are more likely than men to be killed by an intimate partner (Browne, 1992 & 1993) (Browne, 1992 & 1993)

14 Early Warning Signs (1) Intrusion: Constant desire to know a partners whereabouts and to restrict a womans contacts with others Intrusion: Constant desire to know a partners whereabouts and to restrict a womans contacts with others Isolation: Severe restrictions on contact with others Isolation: Severe restrictions on contact with others Possession: Belief that a partner belongs to the other; often used as justification for violence. 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!

15 Early Warning Signs (2) Jealousy: Often without cause, and with angry or violent reprisals. 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. 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 History of violence: Perpetrator has acted aggressively toward others in the past

16 Cycle Theory of Violence TENSIONS BUILDING PHASE TRIGGERING EVENT ABUSE REMORSE, FORGIVENESS (Walker, 1979) (Walker, 1979)

17 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 gradual buildup of intimidation, threats, anger, and minor physical aggression 2. Acute Battering Incident lack of control, lack of predictability lack of control, lack of predictability 3. Loving Contrition unusual period of calm unusual period of calm perpetrator may apologize, show kindness or remorse, ask for forgiveness, promise violence will not occur again. 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.

18 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. 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. However, episodes of violence do not necessarily occur when the abuser has been drinking or using drugs. (Fagan & Browne, 1994; Gleason, 1997)

19 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 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)

20 Physical Outcome of IPV Death Death Acute Injuries Acute Injuries Bruises, abrasions, lacerations Bruises, abrasions, lacerations Cuts and Stab Wounds Cuts and Stab Wounds Burns Burns Concussions Concussions Broken bones Broken bones Bites Bites Dislocations, sprains Dislocations, sprains Internal injuries Internal injuries Source: www.webshots.com

21 Long Term/ Chronic Outcomes of IPV Poor physical and mental health 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) 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 Exacerbation of chronic medical conditions Scars from burns, bites, and knife wounds Scars from burns, bites, and knife wounds Complications of pregnancy and birth, gynecologic problems, sexually transmitted diseases Complications of pregnancy and birth, gynecologic problems, sexually transmitted diseases Depression, anxiety, suicide Depression, anxiety, suicide Substance abuse Substance abuse Feelings of shame, isolation and entrapment Feelings of shame, isolation and entrapment (Coker et al., 2000, Hathaway et al., 2001)

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

23 Psychological Impact of IPV Depression Depression Suicide Ideation and Suicide Attempts Suicide Ideation and Suicide Attempts Substance Abuse Substance Abuse Post Traumatic Stress Disorder Post Traumatic Stress Disorder Trauma Reactions - shock, denial, withdrawal, confusion, psychological numbing, fear Trauma Reactions - shock, denial, withdrawal, confusion, psychological numbing, fear Anxiety Anxiety Sleep and Eating Disturbances Sleep and Eating Disturbances (Browne, 1992, Coker et. al, 2000 )

24 Importance of Screening Tool Development (1) Provides the opportunity for disclosure of IPV and allow victims to know there are resources available 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 Identification of domestic violence is the FIRST stage of intervention Asking about abuse helps break the isolation victims and other family members may experience Asking about abuse helps break the isolation victims and other family members may experience (Warshaw and, Ganley, 1998)

25 Importance of Screening Tool Development (2) Routine inquiry may allow for intervention before injury or illness occur and/or reduce further harm Routine inquiry may allow for intervention before injury or illness occur and/or reduce further harm Without intervention, violence usually continues Without intervention, violence usually continues (Warshaw C, Ganley, 1998)

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

27 Who Should Screen for IPV? Health Care Providers Health Care Providers Who have been educated about IPV issues 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 Who have been trained how to ask about abuse and how to intervene when identifying victims of abuse

28 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 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 Screening for IPV should be CONFIDENTIAL (Little 2000)

29 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 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 Ask about abuse in an nonjudgmental manner and in a direct and compassionate way Avoid doing paperwork during interview Avoid doing paperwork during interview (Hotch et al., 1995, Little 2000)

30 How to ask about family violence (2) Affirm clearly that you believe that violence in the home is a serious problem 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 Offer support in an empathetic, non- judgmental way that shows you respect the patient (Hotch et al., 1995)

31 Ways to Ask About Abuse in the ED or when there are not Obvious Injuries From my experience here in the A&E, I know that abuse and violence at home is a problem for many women/ families. Is it a problem for you in any way? From my experience here in the A&E, 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? 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? Have you ever felt unsafe or threatened in your own home? (Hotch et al., 1995)

32 Ways to Ask About Abuse when there are Physical Signs Has anyone hurt you? Has anyone hurt you? The injuries you have suggest to me that someone hit or hurt you. Is that possible? 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? 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? 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)

33 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)

34 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? 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? Who is the perpetrator? What kind of access does the perpetrator have to the patient/victim? How might the abuse affect the patients health? 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? 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)

35 Questions to Keep in Mind (2) Does she/he have a safety plan? Can you or someone else help her/him develop one? 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 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? What resources are available in the community that might help? How do you own feelings and responses affect your ability to provide appropriate care? How do you own feelings and responses affect your ability to provide appropriate care? (Hotch et al., 1995)

36 What to do if a Suspected Victim Denies Abuse Accept the patient response and right of self-determination Accept the patient response and right of self-determination Emphasize that such questions are asked routinely because of the prevalence of IPV 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 Let the patient know that they are resources available for someone who might be abused (Little 2000)

37 Services that are Helpful for IPV Cases Short-term and long-term counseling for women, men, and children Short-term and long-term counseling for women, men, and children Legal services for protection and prosecution Legal services for protection and prosecution Medical services Medical services Crisis services for safety and acute needs Crisis services for safety and acute needs Emergency shelters for family members at risk Emergency shelters for family members at risk Counseling for perpetrators of family violence Counseling for perpetrators of family violence

38 Services that are Helpful for IPV Cases in your Country To be completed by every collaborator for the respective country To be completed by every collaborator for the respective country

39 Summary (1) Although hidden behind the closed door of houses, the results of violence in homes affect all areas of society 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. 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. Health care professionals can be an important frontline for identification and intervention.

40 Summary (2) Recognition of the problem will allow society Recognition of the problem will allow society to develop resources for those who are in danger to develop resources for those who are in danger to establish policies so that all citizens can be safe in their own homes. to establish policies so that all citizens can be safe in their own homes.


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