1. Shelley M. Guida, MS, LMFT Director of Program Services shelley@raccfm.com

2. Applications to Medical Practice

3. As defined by the American Psychological Association (APA) DV is a pattern of abusive behaviors including a wide range of physical, sexual, and psychological mistreatment used by one person in an intimate relationship with another to gain power unfairly or maintain that persons misuse of power, control, and authority (APA, 1996, p. 23)

4. Annually in U.S. 1 in 9 women experience domestic violence; 1 in 4 sometime throughout their life Adolescents/young adults experience highest rates (16 victimizations per 1000 in women ages 16 to 24) For women 15-55 domestic violence results in more injuries than car accidents, sexual assaults, and muggings combined

5. Majority (two-thirds) of incidents occur in the victims home It is a family matter-focused usually on single individual (typically female partner) but affects all family members Children are affected directly and indirectly In 2010, 15 women, 7 children, 4 family members/friends, and 2 men died in MN from domestic violence In 2009, 6 women and 3 children died in ND from domestic violence

6. Important to remember….domestic violence occurs in ALL groups of people…. regardless of race, ethnicity, religious affiliation, socioeconomic, educational status---NO TYPICAL VICTIM Racial minorities tend to experience more intimate partner violence than white counterparts (economic and marginalized status creates higher risk….)

7. FEAR of an escalation of the violence FEAR of not being able to provide for children, keeping children safe, loosing children, LACK of real alternatives for living - housing, employment, financial support BELIEVES she caused the violence IMMOBILIZED by psychological and/or physical trauma VALUES - Cultural, Religious, Family…keep family unit together at all costs

8. Center for Disease Control (2003) reports that domestic violence results in 5.8 billion dollars spent for medical care, mental health care, lost productivity and income Medical and mental health care alone costs over 4 billion per year Women who are involved in domestic violence make up 34%-46% of adult female patients in primary care practices (Burge, Schneider, Ivy & Catala, 2005)

9. Families experiencing domestic violence visit physicians 8 times more often, visit the emergency room 6 times more often, and use six times the amount of prescription drugs as the general population (Mitchell, 1994).

10. It is estimated that twenty-six percent of all suicide attempts in women are related to domestic violence Domestic violence is associated to a multitude of health issues such as low-birth rates in pregnant women and alcohol abuse… Alexander, B. & Elliott, E.V. (2000). Health care providers response to domestic violence. East Lancing: Michigan State University.

11. PhysicalMental Broken Bones, Bruises, Cuts,Depression, Anxiety, Trauma (Post Traumatic Stress Disorder) Concussions, Internal InjuriesSubstance Abuse Chronic Pain, Neurological Disorders, Gastrointestinal Problems Suicide Migraines, Sexually Transmitted Diseases, Urinary Tract Infections Children acting out, withdrawing, overachieving or underachieving Children may experience hearing, speech problems, sleeping issues, appetite loss or increase, complaints of ongoing feeling sick, higher levels of hospitalization Poor impulse control Medical complications during pregnancy (pre-eclampsia, gestational diabetes, placenta previa)

12. According to the Centers for Disease Control, each year 6% of pregnant women (240, 000) experience domestic violence Complications for pregnancy include: low weight gain, anemia, infections, and higher levels of first and second trimester bleeding Also associated with higher rates of maternal depression, suicide attempts, substance use and abuse

13. Late and/or sporadic access to prenatal care Injuries to the breasts or abdomen Vaginal bleeding Low weight gain Frequent complaints for somatic complaints (insomnia, hyperventilation) Poor nutrition Premature labor Recurrent pelvic infections

14. Self-induced or attempted abortion Increased substance abuse Short inter-pregnancy intervals Suicide ideation Evidence of noncompliance with treatment or care

15. What role can medical professionals play in addressing this major health care issue?

16. Screening, Identification, Referral, Education Efforts have begun to encourage medical practitioners to learn about domestic violence and to screen patients. The American Medical Association, American College of Emergency Physicians and Family Violence Prevention Fund have published guidelines for identifying and assisting victims of domestic violence.

17. A variety of models exist to screen for domestic violence in medical settings: HITS (Hurt, Insult, Threaten, Scream) WAST (Women Abuse Screening Tool), WAST (Short Form) The Danger Assessment

18. The four questions in HITS stand for; How often does your partner physically Hurt you? How often does your partner Insult or talk down to you? How often does your partner Threaten you with physical harm? How often does your partner Scream or curse at you? Each question is answered on a five point scale ranging from 1 to 5 for never, rarely, sometimes, fairly often, and frequently, respectively. The Score Ranges from a minimum of 4 to a maximum of 20. The patients who fall in the 11 to 20 range score are the ones who should be offered information regarding battered women's services including emergency shelter places and mental health services. Source: Sherin, DK. (1998). HITS Brief Domestic Violence Screening Tool. Family Medicine (July/August).

19. 1. In general, how would you describe your relationship? A lot of tension Some tension No tension 2. Do you and your partner work out arguments with: Great difficulty Some difficulty No difficulty 3. Do arguments ever result in you feeling down or bad about yourself? Often Sometimes Never 4. Do arguments ever result in hitting, kicking, or pushing? Often Sometimes Never 5. Do you ever feel frightened by what your partner says or does? Often Sometimes Never 6. Has your partner ever abused you physically? Often Sometimes Never 7. Has your partner ever abused you emotionally? Often Sometimes Never

20. The Danger Assessment (Campbell,1995) was developed in consultation with victims of domestic violence, law enforcement officials, shelter workers and other experts. The aim of the DA is to assess for the risk of spousal homicide. The original items were obtained from retrospective studies that documented homicide or near fatal injury cases. www.dangerassessment.org

21. Inconsistent training and screening in medical settings-10% of primary care physicians routinely screen for domestic violence…Elliot, L., Nearney, M., Jones, T., & Friedman, PD., (2002). Journal of General Internal Medicine, 17, 112-116. Training in medical school varies, some increase in curriculum, but student self reported ability to deal with issue has not concurrently increased

22. Lack of knowledge about domestic violence (majority dont feel prepared in training) Fear of offending patients Perceived time pressures Perceived irrelevance of domestic violence to practice Fear of loss of control of provider-patient relationship Fear of involvement and danger in situation

23. Lack of trust Do not recognize the abuse Fear of retribution Threats of loss of children/pets Fear of loss of control Sense of hopelessness Embarrassment and humiliation

24. Develop Trust…..An interest in patients lives…know the signs, what to look for, what to ask, talk openly, ensure privacy Care….Address the medical concerns within the context of the abuse situation, dont blame the victim Encouragement…Offer support, provide materials, resources and referrals Advocate for addressing domestic violence in the medical community

25. Center for Disease Control (2003) (http://www.cdc.gov/ncipc/factsheets/ivpfacts)http://www.cdc.gov/ncipc/factsheets/ivpfacts Coker, A. (2005). Opportunities for prevention: Addressing IPV in the health care setting. Family Violence and Health Practice, 01(www. Jfvphp.org) Family Violence Prevention Fund (1999). Domestic violence healthcare protocols. San Francisco: CA: Health Resource Center on Domestic Violence. Shornstein, S. (1997). Domestic violence and health care: What every professional needs to know. Sage Publications.

26. Hall, B.S. (2008). The Culture of Domestic Violence. In Essentials of Cultural Competence in Pharmacy Practice by Halbur, KV & Halbur, DA. Alexandria, VA: American Pharmacists Association. Saber, P.R. & Taliaferro, MD (2006). The physicians guide to intimate partner violence and abuse: A reference for all health care professionals. Volcano: CA: Volcano Press.

27. American Psychological Association. (1996). APA Presidential Taskforce. Washington: D.C. Burge, S., Schneider, F.D., Ivy, L., & Catala, S. (2005). Patients advice to physicians about intervening in family conflict. Annals of Family Medicine, 3(3), 248-253. Mitchell, A. (1994). Domestic dating violence resource handbook. King County, Seattle: Health Cooperative Group.