Transcript IPV MST Assault 0131132

Violence Against Women:
Military Sexual Trauma, Intimate Partner Violence, and
Acute Sexual Assault
01/31/13
VETERANS HEALTH ADMINISTRATION
Objectives
By the end of this lecture, participants will be able to:
• Describe the frequency and impact of military sexual trauma
(MST) and intimate partner violence (IPV)
• Discuss how to adapt care for patients with these sensitive
issues
• Summarize VHA policies for MST and acute sexual assault
• Explain a trauma-informed patient-centered, team-based
approach to these complex and common issues
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Interpersonal Trauma
IPV
Sexual
Assault
MST
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Shared Mechanism
Trauma
Physiologic Adaptation
to Stress
Direct Injury
Health Impact
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Physical Health and Interpersonal Trauma
• Increased incidence of:
• Increased incidence of:
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– STIs
– Pelvic inflammatory disease
– Low birth weight and
perinatal/neonatal problems
– Irregular menses
– Premenstrual symptoms
– Miscarriage within past 6
months
Headaches
Pelvic pain
Abdominal pain
Chest pain/palpitations
Gastrointestinal
problems/IBS
– Chronic pain/fibromyalgia
– Medically unexplained
symptoms
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Mental Health and Interpersonal Trauma
Associated with:
• PTSD
• Depression
• Anxiety
• Substance abuse
• Suicidality
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Military Sexual Trauma (MST)
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What is MST?
• Sexual assault or repeated, threatening sexual
harassment that occurred during military service
• Can occur on or off base, while a Veteran was on or off
duty
• Identity of the perpetrator does not matter – could be
men or women, military personnel or civilians, superiors
or subordinates in the chain of command, strangers,
friends, or intimate partners
• Veterans from all eras of service have reported
experiencing MST
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MST Prevalence
• Difficult to quantify prevalence, as sexual trauma is
frequently underreported
• When screened as part of VHA’s universal screening
program, 1 in 5 women (20%) report having
experienced MST
• Positive screen indicates a need to evaluate whether
mental health care is warranted – not everyone needs
it
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VHA Policy
• VHA is mandated to provide treatment for conditions
related to MST, provide staff with training on MST, and
engage in outreach to Veterans about available services
• VHA has also established national policy that:
– All Veterans seen in VHA must be screened for MST
– All treatment (including medications) for physical and mental
conditions related to MST is free, with no limit on duration
– Every facility must have a designated MST Coordinator to
serve as a point person for MST issues at the facility
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How Can We Help?
As a representative of the VA, every staff member has the
power to help Veterans recover from MST
Key ways in which primary care can assist in Veterans’
recovery:
1. Screening to help to identify MST survivors and connect
them with appropriate care
2. Recognizing when care is MST–related and documenting this
appropriately
3. Adapting care when necessary
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Screening and Connecting to Care
• VHA policy: all Veterans must be screened for MST
using the one–time clinical reminder in CPRS
• Universal screening is also good clinical practice
– Many patients do not spontaneously disclose a trauma
history. Asking about MST can be the first step in getting
them help.
– Understanding that a patient has a history of MST may
provide context for his or her presenting problems.
– Knowing that a patient has experienced MST helps the
provider adapt care appropriately.
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MST Screen
• When you were in the military, did you receive uninvited
or unwanted sexual attention (i.e., touching, cornering,
pressure for sexual favors, or inappropriate verbal
remarks, etc.)?
• When you were in the military, did anyone ever use
force or the threat of force to have sex with you against
your will?
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Who Should Screen?
• Screening is a clinical procedure
– Should be done by licensed professional or someone with
appropriate clinical training
• LPNs who have been trained on how to screen and respond to
disclosure may screen and complete CPRS clinical reminder
– Primary care provider must always review Veteran's response and
initiate follow–up discussion if needed
• Generally not appropriate for health technicians to screen unless
they have been trained on how to screen and respond to disclosure
– When this is the case, their screening must be closely supervised and
reviewed by the primary care provider
• Not appropriate for clerks to screen
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How to Ask…
"Many of the Veterans I’ve worked with have had upsetting
experiences in their lives that may still bother them today. It can be
helpful for healthcare providers to know this, because these
experiences can have an impact on both physical and mental health
and sometimes can affect Veterans’ reactions to medical
procedures.
Because of this, I’d like to ask whether you received any unwanted
sexual attention such as touching, cornering, pressures for sexual
favors, or verbal remarks while you were in the military? Or, while
you were in the military, did someone ever use force or threats of
force or punishment to have sexual contact with you when you did
not want to?"
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What to do if she says “yes”…
You may be the first person she has ever told about her
experiences. An empathic, supportive response can be
tremendously healing.
• Provide validation and empathy: "I’m sorry this happened
to you while you were serving your country."
• Provide education and normalization: "Many Veterans have
had experiences like yours and for some, it can continue to
affect them even many years later. People can recover,
however."
• Assess current difficulties: "How much does this continue
to affect your daily life today? In what ways?“
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Adapting Care When Necessary
• Interactions with healthcare providers can be
complicated for Veterans who experienced MST because
the patient–provider relationship can resemble some
aspects of the victim–perpetrator relationship
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Power differential
Being in physical pain
Physical exposure and touching of intimate body parts
Feeling a lack of control over the situation
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Signs That a Veteran May Be Having an MST–
Related Reaction During an Appointment
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Appears highly anxious, agitated, or "jumpy"
Appears tearful during exams, with no obvious cause
Physically withdraws, or becomes very quiet or "frozen"
Has difficulty concentrating, is very distractible, or seems
disoriented
Minimizes symptoms that might require an intrusive exam
Cancels appointments or refuses needed care
Exhibits strong emotional reactions (e.g., crying, panic,
irritability, anger) to relatively benign interactions
Experiences flashbacks or dissociates during appointments
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Resources for MST
• Facility MST Coordinator
• VA Intranet MST Resource Homepage (accessible only to
VA staff)
– vaww.mst.va.gov
– Repository for staff training resources, Veteran education
materials, and training opportunities
– List of facility MST Coordinators
• VA Internet website (accessible to Veterans)
– http://www.mentalhealth.va.gov/msthome.asp
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Acute Sexual Assault
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VHA Policy
Assessment and Management of Veterans Who Have
Been Victims of Alleged Acute Sexual Assault
• Defined as sexual contact with an alleged perpetrator within the
last 72 hours
• VHA policy: emergency departments, urgent care clinics,
outpatient clinics, and all inpatient and residential settings must
have plans in place to appropriately manage the medical and
psychological assessment, treatment, and collection of evidence
from Veterans, male and female, who are victims of alleged acute
sexual assault
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Responsibilities
• When sexual assault is suspected or identified by primary
care provider, referral is made to Mental Health to assist
with assessment, treatment, referral, reporting, and
documentation
– Mental Health keeps list of private/public agencies that
provide or arrange for evaluation and care for victims
• For all victims referred to and seen in Emergency
Department, immediate support will be provided by mental
health, social work, or nursing staff with familiarity of
psychological needs of victims of acute sexual assault
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Patient Consent
• Informed consent for physical examination, evidence
collection, and treatment must be obtained by licensed
health care provider acting within the scope of his/her
practice
– Patient may need 2 types of services: 1) evaluation/treatment
of medical and mental health needs, 2) forensic exam to obtain
evidence. Consent must be obtained separately for each.
– Many facilities have contracts with Sexual Assault Nurse
Examiner (SANE) nurse programs via fee basis. Some provide
this service on site.
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Treatment and Support Services
• Providers must deliver emergency treatment for physical and emotional
trauma, address evidence collection to properly care for patient, and
maintain chain of evidence.
• Appropriate prophylaxis for STIs/pregnancy must be offered if indicated
• Referral for psychological counseling (including electronic consult to
Mental Health) must be offered immediately. Initial contact from mental
health provider must occur within 24 hours.
• Non-VA consult must be entered in CPRS to obtain authorization for
payment of services rendered at the outside facility
• Sending facility assumes full responsibility for patient during travel. If
appropriately trained VA staff is not available, arrangements will be
made with local Rape Crisis Center, SANE or other agencies for trained
staff to be available on demand.
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Examination Considerations
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Reducing Distress
Reduce the power differential between provider and
patient
• Whenever possible, have conversations while the patient is fully
dressed
• Sit at the same level as the patient, preferably without a desk in
between you. Make eye contact.
• Give the patient options and choices whenever possible.
• Be transparent. Explain your reasoning for choosing certain
courses of action.
• View the patient as an expert on her own body and functioning.
Attend carefully to her identified concerns.
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Managing Reactions to Exams and Procedures
• Anticipate and prepare
– Explain that it is not unusual for assault survivors to have
strong reactions to certain procedures
– Describe the procedure and ask her what she anticipates will
be the most difficult part
– Brainstorm with her about coping strategies
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Seeing the procedure suite in advance
Having a chaperone or family member present
Using sedation or pain medication, if appropriate
Employing distractions (e.g., headphones, music, focused
breathing, discussion of a pleasant event)
• Things that have worked in the past
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Managing Reactions to Exams and Procedures (cont.)
• Ensure she feels in control
– Ask permission before touching her
– Let her know you will stop if she asks
– Keep a running commentary of what you are doing/plan to do
• "Okay, as you can see I am picking up the blood pressure cuff. I
am going to move close to you and put it around your arm. It
won’t hurt. Is that okay?"
– Check periodically to ask how she is doing
• Respect her reactions
– Respect her subjective experience, even if it seems extreme
given the circumstances
– Never ignore/dismiss her request or her expression of distress
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Intimate Partner Violence
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CDC Definition
• Physical, sexual, or psychological actual or threatened
harm or stalking by a current or former partner or
spouse
• Occurs on a continuum of frequency and severity from
emotional abuse to death
• Can occur among heterosexual or same-sex couples
and does not require sexual intimacy
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General Population
• More than 1 in 3 women (36%) report IPV in their
lifetime
• Women are much more likely to be injured or killed by
an intimate partner
– On average, more than 3 women are murdered every day by
their intimate partner
– Women are victimized in 85% of nonfatal IPV-related injuries
• Younger women (18 to 24) experience the highest rates
of IPV
– May not hold true among Veteran population
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Health Effects of IPV: Physical and Mental Health
• Primary injuries
– Physical pain, stab wounds, broken bones, STIs, and TBI
• Secondary and long-term health consequences
– Chronic pain, headaches, reproductive health issues,
pregnancy complications, gastrointestinal disorders, central
nervous system disorders, and heart disease
• Mental health disorders
– Anxiety, depression, substance use (including tobacco use),
and PTSD
• Emotional well being
– Shame, guilt, low self-esteem, isolation, suicidality
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Health Effects of IPV: Adverse Health Behaviors
• Engaging in adverse health behaviors results in
increased prevalence and severity of chronic disease
• Adverse health behaviors include
– Smoking
– Over-eating
– Alcohol use
• Women who engage in smoking and alcohol use are at
increased risk for experiencing IPV
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IPV and the Military
• Veterans and active duty service members are at higher
risk for use and experience of violence
• Prevalence rates may not be representative
– Under-reporting, VA samples
• Rates of IPV use across male military populations range
from 13.5% to 58%
– Increase with co-occurring mental health issues, substance
use, and combat exposure
• Rates of victimization among female Veterans range
from 33% to 71%
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OEF/OIF/OND Veterans
• Data are currently limited
• May be at elevated risk for use of IPV
– High rates of PTSD, interpersonal aggression, and reported
family readjustment issues suggest they are at high risk for
use of IPV
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How Can We Help?
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Remember that IPV is not a mental health diagnosis
It’s not your role to “fix it”
Recognize the complexities women face
You can
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Provide education
Offer support and resources
Assess safety
Document
• IPV inquiry response, injuries, health effects
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Asking About IPV
• US Preventive Services Task Force (USPSTF) recommendation
– Screen all women of childbearing age and provide or refer
women who screen positive to intervention services (level B)
• VA guidelines are anticipated soon
• Reasons to inquire include:
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Women want to be asked
High prevalence
Decreases stigma by normalizing discussion of violence
Potential to moderately reduce exposure to abuse, physical and
emotional injury, and mortality (USPSTF)
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When to Ask About IPV
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Routinely, as part of the social history
When injuries don’t fit the story
Chronic pain, somatic issues
Depression, anxiety, PTSD
Alcohol or other drug abuse
Pregnancy
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How to Ask About IPV
• Must occur in private
– Partner, family, friends, or children should not be present
• Ask in a non-judgmental, validating manner
• Use direct, behaviorally-specific questions
• Improve your own comfort level
– Know referral sources
– Find language that works for you
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What to Ask About IPV
• Introduce the questions:
– “Because violence is so common in the lives of women, we
have begun asking all Veterans about it.”
• Assess for both current and lifetime IPV
– “Have you been hit, kicked, punched, choked or otherwise hurt
by an intimate partner in the past year (ever)?”
– “Have you been physically harmed or threatened by your
partner in the past year (ever)?"
– “Do you (or did you ever) feel controlled or isolated by your
partner?”
– “Do you feel frightened by what your partner says or does?”
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What to do if she says “yes”…
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Stop what you are doing
Make eye contact
Respond with empathy and compassion
Be non-judgmental, supportive, and concerned
Evaluate whether she is in immediate danger
– Use your team to make referrals within the VA and for
services in the community
Always be ready for a yes response; often it will be
a surprise, coming after recurrent denials.
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Examples of “First Responses”
• I’m sorry that you have to experience that. We would like to help.
• The abuse is not your fault. It’s wrong for one person to hurt
another person.
• You didn’t do anything to deserve to be treated this way.
• I’m worried about your safety.
• I’m glad you told me.
• Unfortunately, you are not alone. Many of our patients have
experienced abuse.
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Risk Assessment
• Woman Veteran
– Pregnancy or recent birth; fear of partner
• Partner
– Weapons; attempted or actual choking/strangulation; threats
of killing self, partner, children, or pets; stalking; sexual
assault; violation of restraining order; coercive behavior;
substance abuse disorder; obsessive, jealous behavior
• Relationship
– Escalation of violence, recent separation
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Safety Planning
• Increasing safety
• Consider different needs
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In the relationship
Preparing to leave the relationship
After leaving the relationship
Safety and technology
• Thoughtful about what is documented and where
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Other issues
• Some states have mandatory reporting for IPV. The
majority do not. Know what your state laws are.
• Many victims fear that their children will be placed in
protective custody
• What if there are children in the home?
– You may need to report
– A social work consult is advisable
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Next Steps
• Inform the provider
• Know steps necessary to connect patient with mental
health if warranted
• Provide written information on local resources
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Shelters
Hotlines
Support groups
Social work or mental health referral
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Your patient may not leave…
• Understand the barriers to her decision to leave the relationship
– Leaving is similar to making other types of behavior changes
• You haven’t failed if she doesn’t leave
– View this situation as a chronic disease. Work on it slowly at frequent visits.
• Victims have lost their sense of agency and autonomy
– Support her choices even if you don’t agree with them
• Respect her timetable. Never tell her what to do!
• Help her gain self-esteem
– Validate her actions, while being honest about your concern for her safety
• You may be the only person with whom she feels comfortable
talking about the violence
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https://www.myhealth.va.gov/mhv-portalweb/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=spotlightArchive&content
Page=spotlight/October 2011/spotlight_oct2011_domesticviolence.html
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Primary Authors:
Megan Gerber, MD, MPH
VA Boston Healthcare System
Margret Bell, PhD
National MST Support Team, Dept of Veterans Affairs
Contributors:
Linda Baier Manwell, MS
University of Wisconsin Center for Women’s Health Research
Susan McCutcheon, RN, EdD
Women’s Mental Health and Military Sexual Trauma
Office of Mental Health Services, Dept of Veterans Affairs
Sarina Schrager, MD, MS
University of Wisconsin Department of Family Medicine
WH Nurse Reviewers: Barbara Robinson, RN
Katrina Goldby, RN, BSN, JD
Susan Johnson-Molina, RN, BSN, MAOM
Connie LaRosa, RN, MSA, CPHQ
Barbara Polak, RN, MSN
Mary Ann Reale, MS, RN
Lisa Roybal, MSN, WHNP
Additional Reading
• Dichter et al. Intimate partner violence victimization among women veterans
and associated heart health risks. Womens Health Issues. 2011;21(4S):S190-4.
• Frayne et al. Medical profile of women veterans administration outpatients
who report a history of sexual assault occurring while in the military. J Womens
Health Gend Based Med. 1999;8:835–45.
• Gerber et al. Adverse health behaviors and the detection of partner violence by
clinicians. Arch Intern Med 2005;165:1016-21.
• Gerber et al. Intimate partner violence exposure and change in women's
physical symptoms over time. J Gen Intern Med 2008;23:64-9.
• Kimerling et al. Military-related sexual trauma among Veterans Health
Administration patients returning from Afghanistan and Iraq. Am J Public
Health. 2010;100(8):1409-12.
• Marshall et al. Intimate partner violence among military veterans and active
duty servicemen. Clin Psychology Rev 2005;25:862-76.
• McCloskey et al. Abused women disclose partner interference with health care:
an unrecognized form of battering. J Gen Intern Med 2007;22:1067-72
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Additional Reading
• Nelson et al. Screening Women for Intimate Partner Violence and Elderly and
Vulnerable Adults for Abuse: Systematic Review to Update the 2004 U.S.
Preventive Services Task Force Recommendation [Internet]. Rockville (MD):
Agency for Healthcare Research and Quality (US); 2012 May.
• O’Campo et al. Depression, PTSD and comorbidity related to intimate partner
violence in civilian and military women. Brief Treat Crisis Int 2006;6:99-110.
• Sadler et al. Life span and repeated violence against women during military
service. J Womens Health 2004;13:799-811.
• Sayers et al. Family problems among recently returned military veterans referred
for a mental health evaluation. J Clin Psychiatry 2009;70:163-70.
• Suris & Lind. Military sexual trauma: a review of prevalence and associated
health consequences in veterans. Trauma Violence Abuse 2008;9:250-69.
• Tjaden & Thoennes. Full Report of the Prevalence, Incidence, and Consequences
of Violence against Women. National Institute of Justice and CDC, 2000.
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