Intimate Partner Violence and the Role of the Primary Care

Provider

Rebecca L. Cupp

Advisor:

Julie Gurwell, Ph.D

Intimate Partner Violence

• CDC Definition: Physical, sexual, or psychological harm by a current or former partner or spouse.

• Characteristics of IPV– Cycle of Violence

• Phase 1: Tension Building• Phase 2: Battering• Phase 3: Honeymoon Phase

– Power of Control Wheel

IPV: Prevalence• Primary Care Practitioners

will be exposed to IPV at some point in their practice, if not daily!

• In 2000, 1 out of 4 women in US and 7.6% men reported to have been physically assaulted or raped by current or former spouse, partner, or date in their lifetime.

• Women from Kentucky have higher risk: 37.4% lifetime prevalence. – 1 out of 9 adult women in KY

has been the victim of rape.

Impact on physical and mental health

• Many negative implications, including:– Immediate consequences:

• Unplanned/unwanted pregnancy• STIs• Trauma• Death

– Mental health: depression, PTSD– Chronic health problems:

• Headaches, Chronic pelvic pain, appetite loss, stomach ulcers

– Children exposed to IPV:• Traumatic, life-long impact• 4-6 fold increase of being

abused themselves as adults• Poor weight gain, sleep

disturbance, irritability

Barriers to Communication

• One study found only 13% of women had ever been asked about IPV by their healthcare provider.

• Significant Barriers to Communication– Provider Barriers:

• Lack of time, lack of education and experience on the topic, taboo of subject

– Patient Barriers:• Fearful to retaliation by partner, need to protect partner,

patient’s prior experiences with healthcare providers, judgmental attitudes of practitioners.

• May believe there is nothing that can be done to help them.– Unique concerns in rural areas:

• Social isolation, low economic status, geographic barriers

Risk Factors• Victim

– Young age, Low educational achievement, Marital Conflicts, “Traditional Gender Roles”, economic stress

– Pregnancy, especially in adolescence:

– 41% women aged 18 or younger who have children have reported being abused.

• Perpetrator– Victim or witness of abuse at young

age, alcohol use, low academic achievement, low self-esteem.

Role of the Health Care Provider

• Often PCPs are victim’s first contact

• Good opportunity for early detection, evaluation, and referral.

• PCP should be trained to identify patients who are victims of IPV, and those at high risk of being abused.

• Many models used in screening patients

RADAR Model• R: Routinely inquire about violence• A: Ask direct questions• D: Document Findings• A: Assess Safety• R: Review options and referrals

R: Routinely Ask QuestionsA: Ask Direct Questions

• Normalize questions• HITS:

– In the last year, how often has your partner…• Hurt you physically? Insult you or talk down to you? Threaten

you with physical harm?

• Conflict Tactics Scale:– Have you ever been hit, slapped, kicked, otherwise

physically hurt by your partner? Have you ever been forced to have sexual activiites?

• Written questionnaires available (American College of Obstetrics and Gynecology)

D: Document Findings

• Physical Exam: May/may not show evidence of IPV– Ask if patient has any injuries

• Characteristic Injury Patterns– Various stages of healing, defensive

wounds, multiple injuries, central injuries, injuries to head, neck, mouth.

– Check abdomen in women who are pregnant.

– May present with signs of depression, anxiety, etc…

• DOCUMENT!!!!! Pictures, drawings, details!

A: Assess Safety

• Assess patient’s risk of immediate danger.– Ask if afraid to go home, if there are guns and

knives in the house, if drugs and alcohol are involved, if there are children involved.

– Remind px to call 911 if in immediate danger!

• Develop a safety plan with the victim– ACOG Recommendation: leave bag at friends

house that includes cash, credit cards, extra clothes, important papers. Hide extra set of car and house keys.

R: Review Options and Referrals

• Know community resources!– Shelters, victim advocacy programs

• Services offered, have phone numbers available

– Challenge: Rural areas, limited resources

• Mandatory Reporting: – Know reporting mandates in practicing state:– KY: Mandatory to report IPV.– Anytime a child is involved, it is mandatory to

report abuse.

• US Preventative Services Task Force Recommendation - I: No direct evidence that screening for IPV leads to a decrease in disability or death.

• ACOG: Recommends routine questioning regarding abuse of all female patients. Screen women routinely at preconception visits, family planning visits, annual exams

IPV Commercial…..

• http://www.youtube.com/watch?v=AvBKlBhfgPc

SUMMARY

• Imperative that healthcare providers are educated to identify victims of IPV, health factors associated with abuse, screening tools, and how to respond when abuse is suspected or disclosed.

• Incorporating a brief screening protocol into practice could potentially save the life of your patient.

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• THE END