Transcript Referral - New York Hospital Queens

Domestic Violence in Primary
Care
Nancy Sugg MD, MPH
University of Washington
[email protected]
November 23, 2010
Disclosure
Nancy Sugg MD, MPH
 With respect to the following
presentation, there has been no
relevant financial relationship between
the party listed above (and/or
spouse/partner) and any for-profit
company in the past 24 months which
could be considered a conflict of
interest.
Further Disclosure
 Gender issues
 Victim/perpetrator
 Evidenced based vs. best practice
 Crosses all socio-economic groups,
including physicians
Intimate Partner Violence (IPV)
Definition
 A pattern of assaultive and coercive
behaviors that may include inflicted
physical injury, psychological abuse,
sexual assault, progressive social
isolation, stalking, deprivation,
intimidation and threats.
Intimate Partner Violence (IPV)
Definition
 These behaviors are perpetrated by someone
who is, was, or wishes to be involved in an
intimate or dating relationship with an adult or
adolescent, and are aimed at
establishing control by one partner
over the other.
Family Violence Prevention Fund
Intimate Partner Violence
Prevalence
 20-30% of women have been physically
and /or sexually abused by an intimate
partner at some time in their adult life
 7.5% of men have been physically
and/or sexually abused by an intimate
partner at some time in their adult life
Intimate Partner Violence
National Crime Victimization
Survey (DOJ); 2008
Rates of Victimization:
 Women: 4.3 victimizations per 1,000 females;
552,000 women/year; 99% committed by
male offenders
 Men: 0.8 victimizations per 1,000 men;
101,000/year; 83% committed by female
offenders
Prevalence of Violence
CDC estimates 5 million women
per year experience intimate
partner violence (2003)
Intimate Partner Violence
Prevalence
 25-60% of adolescents experience some
form of dating violence
 Adolescents may accept physical and sexual
aggression as normative
 Abused adolescent females are:
– 2.5 times more likely to smoke
– 3.4 times more likely to use cocaine
– 3.7 times more likely to use laxatives or
vomiting to control weight
– 8.6 times more likely to attempt suicide
Silverman et al (20010) JAMA 286(5): 572
Prevalence
Primary Care/Internal Medicine
 5- 14% of female patient have
experienced IPV within the last year
 21-37% of patients have experienced
IPV in their lifetime
Prevalence
Primary Care
Ever (%)
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McCauley J (Urban)
21.4
Fairchild D (Native American)
Current (%)
5.5
13.5
Hamberger LK (medium-sized,
Midwest community)
38.8
22.7
Johnson M (rural and small
Community)
46.0
21.0
Gin N, (Urban, Southern
California)
28.0
14.0
Rath GD (SD, low-income)
45.6
Prevalence
Physical Abuse During Pregnancy
Range
Prevalence:
0.9-20.1%
6%
Prevalence of Violence
In Pregnancy
 Unintended pregnancies: 2.5 times
higher risk of physical abuse
 Unwanted pregnancies: 4.1 times
higher risk of physical abuse
 Women who are physically or sexually
abused have 41% higher risk of
unintended pregnancies
Pallitto C et al, Trauma Violence Abuse 2005 6: 217
Emergency Department
 11.7 – 14 % annual prevalence of
abuse among female patients being
seen in the Emergency Department
 2.2% of female patients are in the
Emergency Department due to trauma
related to IPV
Prevalence
Specialty Clinics
 Gastroenterology (Drossman, 1990)
 ENT (Zachariades 1990, Le 1999,
Perciaccante 1999)
 Pain Clinic (Haber 1985, Domino 1987)
 Rehabilitation (Young 1997)
 Ophthalmology (Beck 1995)
 Psychiatry (Jacobson 1987, Cascardi 1992,
Cascardi 1996)
Health Consequences of Intimate
Partner Violence
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Arthritis
Chronic neck and back pain
Migraine or other headache
STI (including HIV/AIDS)
Chronic pelvic pain
Peptic ulcers
Chronic irritable bowel
Indigestion, diarrhea or constipation
 Health consequences can continue for years
after the abuse has ended
Health Consequences
 Management of chronic disease
diseases such as asthma, hypertension,
diabetes may be difficult to control
– Stress exacerbates condition
– Perpetrator may control access to
care or medications
– Victims less likely to engage in
preventative care
Mental Health
Consequences
 Depression/ anxiety
 PTSD
 Postnatal depression
 Suicide attempts
 Alcohol/Substance abuse
Pregnancy Complications
 Low weight gain
 Intrauterine growth retardation
 Anemia
 Infections
 First and second trimester bleeding
Adverse Pregnancy Outcomes
 Baby not sent home with mother
 Low birth weight
 Preterm delivery
 Fetal death
Health Consequences
Injury
 Only 20% of victims injured by IPV seek
medical care for injuries
 3-4 % of male and female victims of IPV
experience serious injury
Injury Pattern
 Centrally located
 Multiple injuries
Non-fatal IPV for females
National Crime Victimization Survey
(DOJ)
 Marked decrease in simple assaults
Homicide
Nationally (DOJ) 2007
 45% of murdered women murdered by
current or former intimate partner
 5% of murdered men murdered by current or
former intimate partner
 In general, IPV homicides numbers have
decreased but for women the proportion of
women killed by IPV has risen.
 Larger percentage of murders in rural areas
are IPV compared to suburban and urban
This does not include the children, other family members or
friends killed by a woman’s current or former intimate partner
Homicide Data
FBI Uniform Crime Reporting Program
 All IPV homicides decreased, male
homicides by 75%
Assessing for IPV
U.S. Preventive Services Task
Force
I: Insufficient evidence to recommend for or against screening
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No studies met eligibility criteria that directly addressed the
effectiveness of screening in health care settings in reducing
harm and premature death and disability
No studies on the adverse effect of screening or intervention
Screening tools poor-good validity but no longitudinal studies
Intervention studies fair validity but limited to small populations
of pregnant women
RCT on Screening
MacMillan et al; JAMA, Aug 5, 2009; 302(5):493-501
 Does screening and provider awareness of a
positive screen reduce subsequent violence
and improve quality of life?
 Participants recruited from Primary Care
Clinics, ED, and OB/GYN in Canada
 WAST: 8 items measuring physical, sexual
and emotional abuse in past 12 months
RCT for Screening
 347 positive WAST and provider aware
 360 positive after visit, provider unaware
 Only 44% of pre-screened positive patients
discussed abuse with their provider
 40-45 % were lost to f/u over 18 month
period; less education, more likely to be
single; higher violence scores
RCT for Screening
 No significant in reduction of violence
between screened and non-screened
women
 No significant difference in quality of life
or depressive symptoms
 No harm associated with screening
based on Consequences of Screening
Tool (COST)
Assessment
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Assess Everyone: There is no “typical” battered woman.
Provide multiple means of assessment:
– Written
– Verbal
– Computerized
There are higher risk groups:
– Younger age
– Lower income
– Childhood experience of trauma
– Alcohol and substance abuse
– Unplanned or unwanted pregnancies
Create an environment of
asking
 Place questions on health screening
questionnaire
 Posters
 Brochures in bathroom
 Provide Privacy
Verbal Assessment
 Ask verbally
 Use non-judgmental language
 Ask directly: Have you ever had
problems with anyone hitting you or
hurting you or threatening you?
 Ask often
Partner Violence Screen
 Have you been hit, kicked, punched, or
otherwise hurt by someone in the past year?
If so by whom?
 Do you feel safe in your current relationship?
 Is there a partner from a previous relationship
who is making you feel unsafe now?
 Sensitivity 71%; Specificity 84 %
Feldhaus et al; JAMA. 1997;277: 1357-1361
HITS
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1.
2.
3.
4.
Since you were pregnant, has a partner or
ex-partner …
Physically hurts you?
Insulted you fairly often?
Threatened you?
Screamed at you fairly often?
1) Never; 2) Rarely; 3) Sometimes; 4) Fairly often;
5) Frequently: > 10.5 is positive
Sherin et al. Fam Med. 1998; 30: 508-512
Fear of reprisal
 Interview alone: not in front of children
 Do not give chart to patient
 Do not bill for IPV specifically
 Do not document IPV in child’s chart
 Assure confidentiality except for
mandatory reporting
Intervention
 Acknowledge the problem
 Assess Safety
 Refer
 Document
Acknowledge
Let the patient know that you consider intimate
partner violence to be a serious problem that
affects their health and well-being and the health
and well-being of their children.
 Affirm that they have done nothing to deserve
being beaten
 Emphasize that there are other people in their
situation and help is available
 Re-enforce that intimate partner violence is a
crime
 Explain the impact of IPV on their health
Safety
 Do you feel safe going home?
 Do you have a plan if the violence recurs?
– Escape routes
– Money
– Transportation
– Documents
– Prescriptions
 Has the batterer ever threatened to kill you
or him/herself?
Lethality Risk
1.
2.
3.
4.
5.
Weapons in the home
Partner abusing drugs or alcohol
Violence outside the home
Beaten during pregnancy
Abused family pets
Jacquelyn Campbell PhD, RN 1985, 1988
Lethality Risk
6. Violence escalating
7. Obsessive or extremely jealous
8. Threats to kill you, your children,
him/herself
9. Forced non-consensual sex
10. Has he tried to choke you
Jacquelyn Campbell PhD, RN 1985, 1988
Referral
Know your resources
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New York Coalition Bilingual Hotline (Violence
Intervention Program): (800) 664-5880
New York City DV Hotline: (800) 621-4673
Safe Horizon Hotline (212) 577-7777
National – 1-800-799-SAFE (7233)
www.acog.org
www.fvpf.org
Documentation
 Identify assailant and relationship to
patient
 Specify mechanism of injury
 Describe all injuries, old and new, use
body map
 Photograph injuries if patient permits
 Record that IPV discussed and
resources made available
Legal Mandates
 Mandatory arrest
 Prosecution without the victim
 Protection orders
 Mandatory reporting
Mandatory Reporting
 Child abuse (Under 18)
 Elder abuse (Over 65)
 Vulnerable Adults
Mandatory Reporting
New York City
To the police:
 All firearm injuries
 Knife wounds that may result in death
To Office of Fire Prevention and Control
 Burns over 5% of body or that may
result in death
Follow-up
Self-Determination
Cultural Competency
Every doctor-patient
interaction is a cross-cultural
exchange.
-Dr. Erika Goldstein
Cultural Competence
Every individual is multi-cultural:
Sexual Identity
Race
Occupation
Ethnicity
AGE
Religion
Cultural Competence
“Having a clear understanding of the individual’s
experiences and unique circumstances is
needed to fully engage in assessment and
planning….It is not simply about identifying a
cultural practice, but is also important to
understand how culture – as experienced by
the person – influences all that they do, think
and understand.”
Bent-Goodley T. Trauma, Violence & Abuse,
April 2007 Vol 8 (2): 90-104 citing Lee et al.
(2002)
Cultural Competence
 Private family matter
 Stigma, shame
 Religious prohibitions
 More trust in informal services: friends,
hairdressers, faith based communities
Cultural Competency
 “Some contend that violence is there
regardless of culture and to distinguish
cultural matters might allude to the notion that
survivors contribute to the violence, that
perpetrators are somehow less accountable
for committing acts of violence, or that culture
is at the root of abusive behavior.”
Bent-Goodley T. Trauma, Violence & Abuse,
April 2007 Vol 8 (2): 90-104
Why Do Women Not Tell?
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Fear of death
Fear of reprisal
Fear of loss of child custody
Fear of deportation
Protection of perpetrator: from arrest or deportation
Perceived lack of time and interest by medical provider
Most don’t tell because they have never been ASKED
Create a safe environment
Why Do Women Tell?
(Battaglia TA. J Gen Intern Med 2003;18:617-623)
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Communicate about abuse: Ask, Ask often
Professional competence
Practice style:
– Accessible
– Respected confidentiality
– Shared decision making
Caring
– Non-judgmental
– Compassionate
– Empowering
Emotional equality
– Shares feelings
– Provides personal touch