Intimate Partner Violence

Intimate Partner Violence

presented by

Laura A. Carter, RN, PHN

County of San Diego

Health and Human Services Agency East Region Public Health Nursing

Why talk about violence when we

talk about healthy pregnancy?

violence should not be a part of it. With nearly one in three women at risk for abuse in her lifetime, domestic violence is more common than pre-eclamplsia and hypertension -- both commonly addressed during pregnancy. Yet women are rarely asked about abuse or given information about the links between violence and their health.

• Violence agaisnt women is a costly and pervasive problem and women of reproductive age – in particular, those between 16-24 – are at greatest risk.

• Violence limits women’s ability to manage their reproductive

health. Abuse during pregnancy can have lasting harmful effects for a woman, the developing fetus and newborns.

“

DOMESTIC VIOLENCE”

cohabitant, or person with whom the suspect has had a child or is having or has had a dating or

engagement relationship. (PC 13700 9b0b)

This behavior is PURPOSEFUL and

DELIBERATE, and has the goal of establishing

IPV in San Diego

• In 2012, a total of 16,400 domestic violence incidents were

reported to law enforcement; an increase of 4 percent from 2011. (Source: SANDAG)

• _{In 2012, the San Diego County District Attorney’s Office filed a}

total of 2,324 domestic violence cases - 684 Felonies and 1,640

Misdemeanors. (Source: San Diego County District Attorney's Office)

• In 2012, 5,258 victims were served by local domestic

violence programs in California; there were 1,170 unmet

requests for services (shelter, legal, transportation, etc.), and 68% of these unmet requests were for housing.

(Source: National Network to End Domestic Violence, DV Counts Survey)

Types of IPV

• Physical abuse

• Verbal and emotional abuse

• Sexual Abuse, Marital

Rape, Partner Rape, Date Rape

• Stalking

This term is often used synonymously with

“domestic violence”, “wife beating”,

“husband battering”, “relationship violence”. “spousal abuse”, and “family violence”.

Myths and Misconceptions

• IPV is caused by mental illness, alcohol or drug use, out of control anger or stress.

• Children are too young to be affected.

• People who are abused ask for the abuse or get something out of it.

• Victims of IPV who stay are weak and have no willpower.

• IPV is a women’s issue.

This is the number one question most people

want to understand. The question, however,

should be "

Why does he batter?"

The

question why does she stay places the blame

on the victim. The reality is that the majority

of battered women make heroic efforts at

leaving, but because of the following reasons,

most are unsuccessful.

Why the victim stays

IDENTIFYING VICTIM’S MOTIVATION HELPS TO PROVIDE EFFECTIVE INTERVENTIONS.

• Sex-role conditioning • Religious beliefs and

values • Societal

acceptance/reinforcement of violence against

women/wives

A few processes DV victims

may encounter when involved

with child protection, civil and

criminal justice systems, and

the military response to

domestic violence

911 Call Squads Investigate Arrest No Arrest Arrest Report Non-Arrest Report Jail Arraignment Hearing No Contact Order Conditions of Release Pre-Trial/ Hearing

Trial Sentencing Monitoring/ Probation

DOMESTIC VIOLENCE/ ARREST INCIDENT

Initial Intervention Unit Contacted Child Protection Screening CP Investigation Child Welfare Assessment Child Maltreatment Assessment Law Enforcement Notified Risk Assessment Service Plan Safety Plan CP Case Mgmt CD Assessment Psych/Mental Health Parenting Education Visitation Individual/Family Therapy DV Classes Emergency Placement EPC Hearing Safety Assessment CHIPS COURT

Court Oversees and Sanctions Plan

Child Placement

CHILD PROTECTION MAP

Landlord/HRA Notified Warning Given Eviction Hearing Sheriff Evicts HOUSING MAP

Advocacy

Program Files OFP

Seeks Shelter Ex Parte Granted Sheriff Serves Respondent Ex Parte Denied Judge Reviews Civil Court Hearing OFP Granted OFP Denied Reliefs Granted OFP Filed

ORDER FOR PROTECTION – CIVIL COURT PROCESS

Supervised Exchange/

Visitation Praxis – Rural Technical Assistance on Violence Against Women

CUSTODY MAP Supervised Exchange/ Visitation Files for Divorce Family Court Hearing Final Divorce Hearing Custody Evaluation Interviews by Evaluator Custody Awarded Child Support Established Custody Hearing Temporary Custody

Advocacy Program Landlord/HRA Notified Warning Given Eviction Hearing Sheriff Evicts 911 Call Squads Investigate Arrest No Arrest Arrest Report Non-Arrest Report Jail Arraignment Hearing No Contact Order Conditions of Release Pre-Trial/ Hearing

Trial Sentencing Monitoring/

Probation Files OFP Seeks Shelter Ex Parte Granted Sheriff Serves Respondent Ex Parte Denied Judge Reviews Civil Court Hearing Initial Intervention Unit Contacted Child Protection Screening CP Investigation Child Welfare Assessment Child Maltreatment Assessment Law Enforcement Notified Risk Assessment Service Plan Safety Plan CP Case Mgmt CD Assessment Psych/Mental Health Parenting Education Visitation Individual/Family Therapy DV Classes Emergency Placement EPC Hearing Safety Assessment CHIPS COURT

Court Oversees and Sanctions Plan Child Placement OFP Granted OFP Denied Reliefs Granted OFP Filed Supervised Exchange/ Visitation Files for Divorce Family Court Hearing Final Divorce Hearing Custody Evaluation Interviews by Evaluator Custody Awarded Child Support Established Custody Hearing Temporary Custody

Report to Family Advocacy Program (FAP) Report from Medical Clinic Report to Military Law Enforcement Report to Civilian Law Enforcement Investigation Command Immediate safety actions, MPO, etc.

Civilian Criminal Prosecution Case Review Committee (CRC) -Substantiate abuse or Unsubstantiate abuse - And make treatment recommendations Spouse Abuse Assessment Command Decision -No Action -Disciplinary Action -Administrative Action -FAP treatment Military Investigation FAP Treatment

Military Domestic Violence Incident Response

IPV Related Fatalities

• The County of San Diego Domestic Violence Fatality Review Team (DVFRT) is a confidential multi-disciplinary team

(MDT) that conducts in-dept case reviews of IPV-Related homicides with their mission to prevent future deaths from IPV

• In 2011, there were 18 individuals allegedly murdered by a current or former intimate partner (spouse, dating partner, boyfriend/girlfriend, fiancée). There were an additional 7 victims* allegedly murdered as related to intimate partner violence incidents that same year, many of them children. • In 2012, there were 18 individuals allegedly murdered by a

current or former intimate partner and there were an

additional 8* victims allegedly murdered as related to intimate partner violence incidents, many of them youth and children.

*Does not include perpetrator deaths

Let’s Talk About the Kids

• Approximately 15.5 million children in the US are exposed to parental violence

• Reports by battered mothers show that 87% of children witness the abuse

• Nationally, one-third of law enforcement calls are for domestic violence situations. Of those calls,

Examples of How Children are

Exposed

• Hearing threats of physical harm

• Feeling tension building in the home prior to assault • Being hit/threatened while in parent’s arms

• Hearing/seeing assault on their parent

• Denied care because parent is injured or depressed • Forced to watch or participate in violence

• Seeing aftermath of violent incident

• Relationship with non-violent parent undermined • Experiencing loss of a parent due to murder/suicide

Effects of IPV on Children

• Excessive concern about parents

• Inability to trust adults to keep them safe

• Inability to learn

• Inadequate social and emotional development • Low self-esteem (could be

their fault, don’t feel valued) • Inability to be a child (busy

Understanding the Effects

A good way to

understand the

effects of

DV on children is to

look at their drawings

Effects of IPV on Infants

• Developmental delays • Attachment disorder • Failure to thrive

• Hyper arousal

• Infants may be caught in “cross-fire” and injured

IPV and Pregnancy

• At least 4 to 8% of pregnant women report

violence during pregnancy

• Affects as many as 324,000 pregnant women

each year

• May be more common than conditions for

which pregnant women are routinely screened,

such as gestational diabetes, preeclampsia and

neural tube defects

• Can be associated with unintended pregnancy,

delayed prenatal care, smoking, alcohol and drug

abuse

Effects of IPV During Pregnancy

• Higher risk of miscarriage fetal injury or death related to maternal trauma

• Less access to prenatal care

• Health risks to mother and fetus

- Increased cortisol in the amniotic fluid which can destroy synapses in the brain

- Uterine environment can affect all aspects of growth and

development of the fetus, even the development of

Effects of IPV During Pregnancy

• Studies show abuser’s attacks will generally focus on breasts, abdomen and genitals resulting in serious consequences for mother, fetus and newborn. Such attacks can cause:

– fetal fractures

– ruptures of woman’s uterus, liver or spleen – Uterine prolapse

– Hemorrhage

– Premature rupture of membranes – Abruptio placenta

– Increased first and second trimester bleeding – IBS or Chronic Pelvic Pain

Window of Opportunity

• 96% of pregnant women receive prenatal care

• Average of 12-13 prenatal care visits

• Opportunity to develop trust in health care

providers

• Desire to be a good parent

• Desire to prevent child abuse

Responsible Sexual Behavior

• Victims of abusive relationships are often

forced or coerced into unwanted sexual activity.

This can impact their ability to care for their

reproductive health. Studies indicate that women

with a history of relationship abuse are at high

risk for engaging in sexual activity that can lead

to unintended health outcomes such as STIs,

PID, cervical cancer and pregnancy

Birth Control Sabotage

• Tactics used by abusive partners include:

– Destroying or disposing of contraceptives

– Impeding condom use (threatening to leave her, poking holes in condom, condom “breaking”)

– Not allowing her to obtain or preventing her from using birth control, fear of condom use negotiation – Threatening physical harm if she uses contraceptives – Making explicit statements about wanting her to

“REPRODUCTIVE

COERCION”

Adverse Childhood Experiences

ACE Study

The ACE Study reveals a powerful relationship

between our emotional experiences as children and our physical and mental health as adults, as well as the

Adverse Childhood Experiences Influence To Adult Health Status

Early Death Disease & Disability Adoption of Health-Risk Behaviors Social, Emotional, and

Cognitive Impairment

Adverse Childhood Experiences

Felitti, Vincent J., MD & Anda, Robert F., MD, MS; ACE

Outcomes associated with Adverse

Childhood Experiences

• Heart disease

• Chronic lung disease • Liver disease

• Depression

• Suicide and suicide attempts • Injuries

• Alcohol abuse • Illicit drug use

• Fetal death

• Health-related quality of life • Risk for intimate partner

violence

• Multiple sexual partners • HIV and STDs

• Smoking

0 10 20 30 40 50 60 0 1 2 3 4 5 6 7 or More ACE Score

Adolescent Pregnancy

Facts on Health Care and IPV

• IPV is a health care problem of epidemic

proportions. In addition to immediate trauma

caused by abuse, IPV contributes to chronic

health problems including depression, substance

abuse, STIs, and limits the ability of a person to

manage other chronic illnesses

• Despite these facts, a critical gap remains in the

delivery of health care to victims of relationship

abuse, with many being discharged from care

with only treatment for presenting injuries,

leaving the underlying cause unaddressed

CONSEQUENCES OF LIFETIME

EXPOSURE TO VIOLENCE AND

ABUSE

• The COLEVA PROJECT is an effort to

demonstrate the impact that violence and abuse has

on the health and well-being of all people

• Medical researchers have uncovered links between

medical, emotional and psychological conditions

and exposure to violence or abuse

• Failing to understand this relationship affects the

overall quality of health care

The solution is not as complex as

the problem

• Your relationship with the victim may be the

greatest controllable predictor of her success

• Positive regard

• Non-judgmental

• Willingness to understand her perspective

Effective Interventions

• Identify her stage of change, start there • Join with her, even if you disagree

• DO NOT DEBATE

• Allow her to talk about the positive aspects of the relationship

• Establish a discrepancy between what she has and what she wants

• Give options, not directives

In the End

• You are a guide, not a savior

• She will make the best decision she sees fit at that moment in time

• You may be her most effective resource

• Just allowing her to talk may be the most valuable intervention

• The impact of your service will stay with her, no matter what decisions she makes

References

• Futures Without Violence

www.futureswithoutviolence.org • www.acestudy.org

• www.cdc.gov/nccdphp/ace/ace

• National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings

http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf

• Know More Say More

http://www.knowmoresaymore.org/wp-content/uploads/2008/07/Addressing-Intimate-Partner-Violence-and-Reproductive-Coersion1.pdf

• Reproductive Health Initiative

http://www.futureswithoutviolence.org/content/features/detail/788/