1. Domestic Violence Screening in Adolescent Pregnancy Anisha Abraham, Maj, MD, MPH

2. Objectives To provide an overview of domestic violence as a public health issue To review key causes and risk factors of domestic violence during teen pregnancy To discuss the role of health care providers in domestic violence prevention

3. Domestic Violence and Women Domestic violence is the leading cause of injury to women between the ages of 15-44. (CDC, 1999) Every 21 days, a woman is killed by domestic violence. (U.S. Department of Justice, 1998) More than 5 million females experience some form of violence each year. Almost two of every three of these females are attacked by a relative or person known to them. (The Commonwealth Fund, 1998)

4. Domestic Violence and Women 34% of adults in the United States had witnessed a man beating his wife or girlfriend, and 14 % of women report that they have experienced violence from a husband or boyfriend. (U.S. Department of Justice's National Crime Victimization Survey, 1998) More than 1 million women seek medical assistance each year for injuries caused by battering. (U.S. Department of Justice's National Crime Victimization Survey, 1998)

5. Domestic Violence and Pregnancy The prevalence of violence during pregnancy (all ages) ranges from 4-8% (Gazamarian JA. Prevalence of violence against women.. JAMA 1996) Higher rates are identified when screening occurs more than once during the pregnancy (Macfarlane J. Assessing for abuse during pregnancy. JAMA. 1992.) The pattern of violence may escalate during pregnancy and may be more prevalent in the postpartum period (Helton AS. Battered and pregnant: a prevalence study. Am J Pub Health. 1987)

6. Violence and Teen Pregnancy Women < 18 yrs were twice as likely to have experienced violence during and after pregnancy then older women (Gessner BD. Experience of violence in teenage mothers. J Adolesc Health, 1999) 33.8% of births to unmarried teens younger than 16yrs resulted from statutory rape(Gessner BD, 1999) One-half of teens with rape histories resulting in pregnancy were raped more than once (Boyer D. Sexual abuse as a factor in teen pregnancy. Fam Plann Perspect.1992).

7. Violence and Teen Pregnancy The younger the partner the greater the partner gap. Over one-half of infants born to women younger than 18 yrs were fathered by adult men. 40% of 15 year -olds had partners aged 20 yrs or older. (Landry DJ. How old are US fathers? Fam Plann Perspect.1995) 74% girls who have had intercourse before 14yrs, reported having sex against their will (The Alan Guttmacher Institute,1994)

8. Violence and Teen Pregnancy Coercive sex is frequently perpetrated by boyfriends. 53% of nonfamilial perpetrators were adolescent girls’ boyfriends, dates,friends (Gershenon HP.The prevalence of coercive sex among teenage mothers. J Interpers Viol.1989. 51% of girls had their first coercive act between 13-16 yrs (Erickson PI. Unwanted sexual experiences among high school youth. J of Adol Health.1991.

9. Domestic Violence and Children Children are involved in 60 percent of domestic violence cases. More than three million children witness acts of domestic violence each year. Up to 50 percent of all homeless women and children in this country are fleeing domestic violence. More than 53 percent of male abusers beat their children

10. Domestic Violence and Children One in ten calls made to alert police of domestic violence is placed by a child in the home. One of every three abused children becomes an adult abuser or victim. Nearly 1/3 of children who witness the battering of their mothers demonstrate significant behavioral and emotional problems.

11. Definition- Domestic Violence/Abuse Domestic Violence-Injury to another within the context of family or intimate relationship Domestic Abuse- Forceful controlling behavior that coerces the victim to do what the abuser wants

12. Types of Abuse Physical-pushing, shoving Psychological-ignoring, controlling, criticizing Sexual-touching,calling with sexual names

13. Risks Factors for Violence during Adolescence Media Drugs/Alcohol Access to Firearms Lack of Self-Esteem Peer Group/School Influences Lack of Family Support

14. Risk Factors for Domestic Violence In Adolescence Commitment to relationship Fear of retaliation No place to go Fear of living alone Economic dependence Belief that they are responsible Hope that perpetrator will change

15. Signs/Symptoms of Abuse among Pregnant Teens Frequent somatic complaints (headaches, insomnia) Anxiety,irritability, crying Repeated visits to the ER Hx of being “accident prone” Injuries to breasts/abdomen Hesitancy to provide info on injuries (Often accompanied by partner who will prevent victim from answering directly) Anti-social behavior Foreshortened sense of future

16. Signs/Symptoms among Children (in abusive homes) Infants- FTT, developmental delays Toddlers- eating/development al disturbances, clinging School age- increased physical complaints, decreased attention, behavior disorders

17. Complications of Abuse during Pregnancy Poor maternal weight gain Infection Anemia Increased second and third- trimester bleeding Miscarriage/Abortion

18. Barriers to Screening Lack of provider recognition Provider discomfort Fear of offending patient Time constraints Feeling of powerlessness in the area of treatment

19. Importance of Screening 90% of female patients feel their provider can help! 78% favor universal inquiry about physical/sexual assault 1 out of 4 women using ER’s revealed a history of partner violence when questioned 10-40% of women disclose abuse when screened by primary care providers 31% of mothers disclosed partner violence when asked by their pediatrician (Mcnutt LA. Reproductive violence screening in primary care. J Am Med Womens Assoc.1999)

20. Setting the Stage Discuss confidentiality Use clear language, avoid medical terms Remain non-judgemental Avoid talking down Encourage discussion, use open-ended questions Listen to the patient!

21. Screening for Domestic Violence Risks Has anyone close to you ever threatened to hurt you? Has anyone ever hit, kicked, punched or hurt you physically? Has anyone, including your partner, ever forced to have sex against your will? Are you ever afraid of your partner?

22. Domestic Violence Counseling Implement universal screening Acknowledge trauma Assess immediate safety Help establish a safety plan Offer educational materials Document interaction (including photos) provide ongoing support Offer list of community resources Provide referrals

23. Summary Screen: Adolescent mothers for domestic violence risks (at prenatal visit, interval checkups, postpartum visit, and well-baby exams) Ask: Are you ever afraid of your partner? Has anyone close to you threatened you? Hit you ? Forced sex against your will? Discuss: Safety plan, legal implications,trauma Provide: Documentation, as well as, information and referrals for community resources