DOMESTIC VIOLENCE AKA INTIMATE PARTNER VIOLENCE

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DOMESTIC VIOLENCE AKAINTIMATE PARTNER VIOLENCE

• DR. H.M. DELGADO, DO, MBA-HCM
• DIPLOMATE AOBFP
• MEMBER AAFP
• FELLOW ABQUARP

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PRESENTATION OBJECTIVES

• DEFINITION
• TYPES OF IPV OR DOMESTIC VIOLENCE
• WHO IS AT RISK
• WHAT CAN WE DO AS HEALTH CARE PROVIDERS AND
  PATIENT ADVOCATES
• WHAT ARE THE PHYSICAL AND PSYCOLOGICAL ASPECTS
  OF THE ABUSE
• CLOSING REMARKS AND DISCUSSION

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CAN IT HAPPEN TO ANYONE ??????????
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WHO IS AT RISK
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DEFINITION

• THE INTENTIONAL USE OF PHYSICAL FORCE OR POWER,
  THREATENED OR ACTUAL , AGAINST ONESELF, ANOTHER
  PERSON, GROUP OR COMMUNITY RESULTING IN OR HAS A
  HIGH LIKELIHOOD OF RESULTING IN INJURY, DEATH,
  PSYCHOLOGICAL HARM, MALDEVELOPMENT OR
  DEPRIVATION.
• KRUG ET AL 2002)

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GENDER DIFFERENCES

• Estimates range from 960,000 incidents of
  violence against a current or former spouse,
  boyfriend, or girlfriend to 3 million women who
  are physically abused by their husband or
  boyfriend per year. (U.S. Department of Justice,
  Violence by Intimates Analysis of Data on Crimes
  by Current or Former Spouses, Boyfriends, and
  Girlfriends, March 1998. The Commonwealth Fund,
  Health Concerns Across a Womans Lifespan 1998
  Survey of Womens Health, 1999)

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GENDER DIFFERENCES

• One in four women (25) has experienced domestic
  violence in her lifetime.(The Centers for
  Disease Control and Prevention and The National
  Institute of Justice, Extent, Nature, and
  Consequences of Intimate Partner Violence, July  
    2000. The Commonwealth Fund, Health Concerns
  Across a Womans Lifespan 1998 Survey of Womens
  Health, 1999)
• Between 600,000 and 6 million women are victims
  of domestic violence each year, and between
  100,000 and 6 million men, depending on the type
  of survey used to obtain the data.(Rennison, C.
  (2003, Feb).  Intimate partner violence.  Us.
  Dpt. of Justice/Office of Justice Programs.  NXJ
  197838. Straus, M. Gelles, R. (1990). 
  Physical violence in American families.  New
  Brunswick, N.J. Transaction Publishers.Tjaden,
  P., Thoennes, N. (2000).  Extent, nature, and
  consequences of intimate partner violence. 
  National Institute of Justice, NCJ 181867.)

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THE MANY FACES OF IPV
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RISK BY OTHER STATS

• Separated and divorced males and females are at a
  greater risk of nonfatal intimate partner
  violence.(Bureau of Justice Statistics, Intimate
  Partner Violence in the U.S. 1993-2004, 2006.)
• Women of all races are about equally vulnerable
  to violence by an intimate partner.(Bureau of
  Justice Statistics, Violence Against Women
  Estimates from the Redesigned Survey, August
  1995)
• Average annual rates of intimate partner
  victimization between 1994 and 2004 are
  approximately the same for non-Hispanic and
  Hispanic females and males.(Bureau of Justice
  Statistics, Intimate Partner Violence in the U.S.
  1993-2004, 2006.)

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ECONOMIC STATISTICS

• Intimate partner violence affects people
  regardless of income. However, people with lower
  annual income (below 25K) are at a 3-times
  higher risk of intimate partner violence than
  people with higher annual income (over 50K).
  (Bureau of Justice Statistics, Intimate Partner
  Violence in the U.S. 1993-2004, 2006.)Please
  note that those with less resources are more
  likely to report incidents of violence
• On average between 1993 and 2004, residents of
  urban areas experienced highest level of nonfatal
  intimate partner violence. Residents in suburban
  and rural areas were equally likely to experience
  such violence, about 20 less than those in urban
  areas.(Bureau of Justice Statistics, Intimate
  Partner Violence in the U.S. 1993-2004, 2006.)

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• CONSEQUENCES
• CONSEQUENCES

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ARE YOU AWARE OF SOMEONE?

• Nearly three out of four (74) of Americans
  personally know someone who is or has been a
  victim of domestic violence. 30 of Americans say
  they know a woman who has been physically abused
  by her husband or boyfriend in the past
  year.(Allstate Foundation National Poll on
  Domestic Violence, 2006. Lieberman Research Inc.,
  Tracking Survey conducted for The Advertising
  Council and the Family Violence Prevention Fund,
  July October 1996)

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DEATH BY IPV

• On average, more than three women and one man are
  murdered by their intimate partners in this
  country every day. In 2000, 1,247 women were
  killed by an intimate partner. The same year, 440
  men were killed by an intimate partner. Intimate
  partner homicides accounted for 30 of the
  murders of women and 5 percent of the murders of
  men.(Bureau of Justice Statistics Crime Data
  Brief, Intimate Partner Violence, 1993-2001,
  February 2003. Bureau of Justice Statistics,
  Intimate Partner Violence in the U.S. 1993-2004,
  2006.)
• Most intimate partner homicides occur between
  spouses, though boyfriends/girlfriends have
  committed about the same number of homicides in
  recent years.(Bureau of Justice Statistics,
  Intimate Partner Violence in the U.S. 1993-2004,
  2006.)

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COSTS ASSOCIATED WITH IPV

• The health-related costs of intimate partner
  violence exceed 5.8 billion each year. Of that
  amount, nearly 4.1 billion are for direct
  medical and mental health care services, and
  nearly 1.8 billion are for the indirect costs of
  lost productivity or wages.(Centers for Disease
  Control and Prevention, Costs of Intimate Partner
  Violence Against Women in the United States,
  April 2003.)
• About half of all female victims of intimate
  violence report an injury of some type, and about
  20 percent of them seek medical
  assistance.(National Crime Victimization Survey,
  1992-96 Study of Injured Victims of Violence,
  1994)
• Thirty-seven percent of women who sought
  treatment in emergency rooms for violence-related
  injuries in 1994 were injured by a current or
  former spouse, boyfriend or girlfriend.(U.S.
  Department of Justice, Violence Related Injuries
  Treated in Hospital Emergency Departments, 1997)

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WHEEL OF LESS FORTUNE
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TYPES OF IPV

• 1.PHYSICAL VIOLENCE
• INTENTIONAL USE OF PHYSICAL FORCE WITH POTENTIAL
  TO DEATH,DISABILITY, INJURY OR HARM.
• Eg SCRATCHING,PUSHING, BITING, CHOKING,SLAPPING,
  BURNING ETC

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TYPES OF IPV

• 2.SEXUAL VIOLENCE
• 3 TYPES
• ABUSIVE SEX CONTACT
• USE OF PHYSICAL FORCE TO COMPLETE THE SEXUAL ACT
• UNABLE TO CONSENT DUE TO ILLNESS OR DRUGS TO
  COMPLETE SEX ACT

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TYPES OF IPV

• 3.THREAT OF PHYSICAL OR SEXUAL VIOLENCE
• USE OF WORDS GESTURES WEAPONS TO COMMUNICATETHE
  INTENT TO CAUSE DEATH, DISABILITY, INJURY OR
  PHYSICAL HARM.

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Rape / sexual assault

• Three in four women (76) who reported they had
  been raped and/or physically assaulted since age
  18 said that an intimate partner (current or
  former husband, cohabiting partner, or date)
  committed the assault.(U.S. Department of
  Justice, Prevalence, Incidence, and Consequences
  of Violence Against Women Findings from the
  National Violence Against Women Survey, November
  1998)
• One in five (21) women reported she had been
  raped or physically or sexually assaulted in her
  lifetime.(The Commonwealth Fund, Health Concerns
  Across a Womans Lifespan 1998 Survey of Womens
  Health, 1999)

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Dating violence

• Approximately one in five female high school
  students reports being physically and/or sexually
  abused by a dating partner.(Jay G. Silverman,
  PhD Anita Raj, PhD Lorelei A. Mucci, MPH and
  Jeanne E. Hathaway, MD, MPH, Dating Violence
  Against Adolescent Girls and Associated Substance
  Use, Unhealthy Weight Control, Sexual Risk
  Behavior, Pregnancy, and Suicidality, Journal of
  the American Medical Association, Vol. 286, No.
  5, 2001)
• Forty percent of girls age 14 to 17 report
  knowing someone their age who has been hit or
  beaten by a boyfriend.(Children Now/Kaiser
  Permanente poll, December 1995)
• One in five teens in a serious relationship
  reports having been hit, slapped, or pushed by a
  partner. 14 of teens report their boyfriend or
  girlfriend threatened to harm them or themselves
  to avoid a breakup.
• Many studies indicate that as a dating
  relationship becomes more serious, the potential
  for and nature of violent behavior also
  escalates.(Information provided by Oregon Law
  Center.)
• Date rape accounts for almost 70 of sexual
  assaults reported by adolescent and college age
  women 38 of those women are between 14 and 17
  years old. (Information provided by Oregon Law
  Center.)

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TYPES OF IPV

• 4 PHSYCHOLOGICAL/ EMOTIONAL ABUSE
• HUMILITIATING THE VICTIM,WITHHOLDING INFORMATION,
  CONTROLLIN VICTIM WHAT CAN AND CANOT DO,
  ISOLATING VICTIM FROM FRIENDS AND FAMILY.

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OTHER NEWER FORMS INCLUDE STALKING

• STALKING IS INCLUDED AMONG IPV TYPES.
• REPEATED BEHAVIORTHAT REQUIRESVICTIMS TO FEEL A
  HIGH
• LEVEL OF FEAR (tjaden andthoennes 2000a)

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Stalking

• Annually in the United States, 503,485 women are
  stalked by an intimate partner. (Patricia Tjaden
  and Nancy Thoennes, Extent, Nature, and
  Consequences of Intimate Partner Violence,
  National Institute of Justice, 2000)
• One in 12 women and one in 45 men will be stalked
  in their lifetime, for an average duration of
  almost two years(Tjaden and Thoennes, Stalking
  in America, Washington, DC National Institute
  of Justice, U.S. Department of Justice, 1998)
• Seventy-eight percent of stalking victims are
  women. Women are significantly more likely than
  men (60 percent and 30 percent, respectively) to
  be stalked by intimate partners.(Center for
  Policy Research, Stalking in America, July 1997)

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STALKING

• Victims may experience psychological trauma,
  financial hardship, and even death.(Mullen,
  Pathe, and Purcell, Stalkers and Their Victims,
  New York Cambridge University Press, 2000)
• Eighty percent of women who are stalked by former
  husbands are physically assaulted by that partner
  and 30 percent are sexually assaulted by that
  partner.(Center for Policy Research, Stalking in
  America, July 1997)
• Seventy-six percent of female homicide victims
  were stalked prior to their death.(MacFarlane et
  al., Stalking and Intimate Partner Femicide,
  Homicide Studies 3, no. 4 (1998) 300-16)
• Victim

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WHO CAN BE VICTIMS

• ANYONE
• AMONG HETEROSEXUAL PARTNERS
• AMONG HOMOSEXUAL PARTNERS
• DOES NOT REQUIRE INTIMACY
• COMMON TO BE IN FAMILY MEMBERS CLOSE AND NOT SO
  CLOSE
• ELDERLY PATIENTS ABUSED BY SPOUSE OR OTHER FAMILY
  MEMBER

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CONSEQUENCES

• PHYSICAL
• Victims may experience physical injury
  (lacerations, bruises, broken bones, head
  injuries, internal bleeding), chronic pelvic
  pain, abdominal and gastrointestinal complaints,
  frequent vaginal and urinary tract infections,
  sexually transmitted diseases, and HIV. (Jones
  Horan, 1997 and Bohn Holz, 1996).Victims may
  also experience pregnancy-related problems. Women
  who are battered during pregnancy are at higher
  risk for poor weight gain, pre-term labor,
  miscarriage, low infant birth weight, and injury
  to or death of the fetus.

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CONSEQUENCES

• PHYSICAL EFFECTS
• 60 WOMEN WITH HX IPV HAVE HIGHER HEALTH
  COMPLAINTS
• IPV VICTIMS HAVE A HIGHER INCIDENCE OF SEX
  TRANSMITTED DIS
• The physical health effects of domestic violence
  are varied,
• Battering is the single major cause of injury
  to women, more significant that auto accidents,
  rapes, or muggings. (O'Reilly, 1983).
• Many of the physical injuries sustained by women
  seem to cause medical difficulties as women grow
  older.
• Arthritis, hypertension and heart disease have
  been identified by battered women as directly
  caused by aggravated by domestic violence early
  in their adult lives.
• Medical disorders such as diabetes or
  hypertension may be aggravated in victims of
  domestic violence because the abuser may not
  allow them access to medications or adequate
  medical care. (Perrone, 1992).

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CONSEQUENCES

• PSYCHOLOGICAL
• ADOLESCENTS AND INVOLVED IPV TEND TO REPORT
  INCREASE DEPRESSION, SUBSTANCE ABUSE ANTISOCIAL
  BEHAVIOR
• ABUSED GIRLS AND WOMEN OFTEN REPORT ADVERSE
  MENTAL HEALTH CONDITIONS SUCH AS DEPRESSION
  ANXIETY AND LOW SELF ESTEEM

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CONSEQUENCES

• PSYCHOLOGICAL
• Depression remains the foremost response, with
  60 of battered women reporting depression
  (Barnett, 2000).
• In addition, battered women are at greater risk
  for suicide attempts, with 25 of suicide
  attempts by Caucasian women and 50 of suicide
  attempts by African American women preceded by
  abuse (Fischbach Herbert, 1997).

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CONSEQUENCES

• PSYCHOLOGICAL
• Along with depression, domestic violence victims
  may also experience Posttraumatic Stress Disorder
  (PTSD), which is characterized by symptoms such
  as flashbacks, intrusive imagery, nightmares,
  anxiety, emotional numbing, insomnia,
  hyper-vigilance, and avoidance of traumatic
  triggers. Several empirical studies have explored
  the relationship between experiencing domestic
  violence and developing PTSD.
• Vitanza, Vogel, and Marshall (1995) interviewed
  93 women reporting to be in long-term, stressful
  relationships. The researchers looked at the
  relationships among psychological abuse, severity
  of violence in the relationship, and PTSD. The
  results of the study showed a significant
  correlation between domestic violence and PTSD.
  In each group in the study (psychological abuse
  only, moderate violence, and severe violence),
  women scored in the significant range for PTSD.
  Overall, 55.9 of the sample met diagnostic
  criteria for PTSD.

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Domestic Violence and Children

• In a national survey of American families, 50 of
  the men who frequently assaulted their wives also
  frequently abused their children.(Strauss,
  Murray A, Gelles, Richard J., and Smith,
  Christine. 1990. Physical Violence in American
  Families Risk Factors and Adaptations to
  Violence in 8,145 Families. New Brunswick
  Transaction Publishers)
• On average between 1993 and 2004, children under
  age 12 were residents of households experiencing
  intimate partner violence in 43 of incidents
  involving female victims and 25 of incidents
  involving male victims.(Bureau of Justice
  Statistics, Intimate Partner Violence in the U.S.
  1993-2004, 2006.)
• Studies suggest that between 3.3 - 10 million
  children witness some form of domestic violence
  annually.(Carlson, Bonnie E. (1984). Childrens
  observations of interpersonal violence. Pp.
  147-167 in A.R. Roberts (Ed.) Battered women and
  their families (pp. 147-167). NY Springer.
  Straus, M.A. (1992). Children as witnesses to
  marital violence A risk factor for lifelong
  problems among a nationally representative sample
  of American men and women. Report of the
  Twenty-Third Ross Roundtable. Columbus, OH Ross
  Laboratories.)

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CONSEQUENCES FOR CHILDREN

• SOCIAL - CHILDREN
• CHILDREN WHO WITNESS IPV ARE AT GREATER RISK
  DEVELOP PROBLEMS AT SCHOOL AND SOCIAL
  DEVELOPMENT, LOW SELF ESTEEM AND VIOLENCE AGAINST
  OTHERS
• CHILDREN HIGHER RISK FOR ANXIETY DEPRESSION
• POOR SCHOOL PERFORMANCE AND DIFFICULTY IN
  RELATIONSHIPS WITH OTHERS
• Children may develop behavioral or emotional
  difficulties after experiencing physical abuse in
  the context of domestic violence or after
  witnessing parental abuse. Responses in children
  may vary from aggression to withdrawal to somatic
  complaints. In addition, children may develop
  symptoms of depression, anxiety, or PTSD (Harway
  Hansen, 1994).

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SPECIAL CASE OF ABUSE BY OTHER CHILDREN

• CHILDHOOD BULLYING
• SCREEN FOR IN CHILDREN
• CAN BE CAUSE OF NONSPECIFIC COMPLAINTS AS PRESENT
  BOTH FROM THE VICTIM AND THE PERPETRATOR
• MORE PREVALENT BOYS, OCCURS BOTH

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SPECIAL CASE

• CAN LEAD TO VIOLENCE IN THE SCHOOL
• CHILD CAN HAVE VAGUE COMPLAINTS HEADACHE, ABD
  PAIN,
• CAN LEAD PERPETRATORS TO FAIL IN LIFE, VIOLENCE
  AND CRIMINAL CONDUCT IN THE FUTURE
• CAN LEAD TO DEATH OF THE VICTIM VS PERPETRATOR

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CONSEQUENCES

• SOCIAL
• WOMEN INVOLVED IN IPV RESTRICT THEMSELVES IN HOW
  THEY GAIN ACCESS TO SERVICES, TAKE PART IN PUBLIC
  LIFE, AND RECEIVE EMOTIONAL SUPPORT FROM FRIENDS
  AND RELATIVES
• YOUNGER WOMEN MAY BE VICTIM OF DATE RAPE, LESS
  QUICK TO REPORT FEELS SHAME
• THIS BEHAVIOR MAY ACCOUNT WHY THEY DONT SEEK
  HELP EARLIER

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WHAT TO DO?

• BE AWARE THAT OCCURS AT ANY AGE AND SOCIAL CLASS
• WHEN INJURIES PRESENT THAT ARE NOT CONSISTENT
  WITH THE HISTORY EXPLORE DEEPER
• ROUTINELY DISCUSS WITH YOUR YOUNGER PATIENTS
  SOCIAL NORMS AND THAT NO MEANS NO

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WHAT TO DO

• Studies show that access to shelter services
  leads to a 60-70 reduction in incidence and
  severity of re-assault during the 3-12 months
  follow up period compared to women who did not
  access shelter. Shelter services led to greater
  reduction in severe re-assault than did seeking
  court or law enforcement protection, or moving to
  a new location.
• (Campbell, JC, PhD, RN, FAAN. Anna D. Wolf, Johns
  Hopkins University School of Nursing, Protective
  Action and Re-assault Findings from the RAVE
  study.)

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WHAT TO DO

• Once lethality and safety have been addressed,
  the longer-term goals of treatment for victims
  can be addressed.
• These goals include helping the victim identify
  the impact of abuse to their life and helping
  them to work toward empowerment (Hattendorf
  Tollerud, 1997).
• Victims can be empowered by regaining their
  independence and reconnecting with supports and
  resources that may have been cut off due to the
  isolation of domestic violence.
• In addition, the children may need their own
  treatment to address their responses to
  witnessing or experiencing abuse.

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WHAT TO DO

• For some victims, additional treatment may be
  needed to target symptoms of depression, PTSD,
  substance abuse, or other disorders found to
  occur in the presence of domestic violence.

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WHAT TO DO

• Batterers can also benefit from treatment,
  although it remains unclear exactly how effective
  treatment is in breaking the cycle of their
  violence. Batterers benefit most from batterer
  treatment programs, which in part focus on
  identifying what domestic violence is.
• These programs also focus on helping batterers
  develop a sense of personal responsibility for
  their actions and for stopping the violence
  (Harway Hansen, 1994). Batterers can also be
  treated in individual therapy, but the focus of
  treatment must be on the violence.
• While some batterers and victims may seek to
  engage in couples therapy to address the abuse in
  their relationship, such therapy is NOT
  recommended while violence is occurring in the
  relationship.
• In addition, it is recommended that each member
  of the couple complete their individual treatment
  first, before beginning any joint therapy (Harway
  Hansen, 1994).

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CONCLUSIONS

• IF PATIENT PRESENTS WITH LIFE THREATENING
  SITUATION, CALL THE POLICE, ELDER ABUSE, OR LOCAL
  SHELTER.
• IF NOT LIFE THREATENING, REFER HELP, COUNSELING,
• ROUTINELY REVIEW WITH DEPRESSED PATIENTS
• DRUGS AND ALCHOL MAY BE INVOLVED

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CLOSING REMARKS

• BE AWARE
• BE WILLING TO GET INVOLVED
• HELP YOUR PATIENT BE THEY
• CHILD
• YOUNG ADULT
• MEN AND WOMEN
• ELDERLY
• EACH HAVE DIFFERENT NEEDS
• SCHEDULE CLOSE FOLLOW UP APPT
• SCREEN AND TREAT FOR DEPRESSION
• SCREEN AND TREAT OR REFER FOR DRUG USE AND ABUSE