My patients are affected by intimate partner violence — and yours are, too!

By Kelly Thorstad, MD, Heather Bellino, and Cynthia Y. Herrera, JD

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One of the most unsettling feelings I have had as a physician is when my gut tells me a patient isn’t safe. Treating their physical injuries is one thing, but truly helping a victim of domestic violence goes well outside my medical training. Their injuries are not just medical, and the solutions I can offer must go beyond my daily routine. I cannot heal them alone.

I am grateful to have found community partners that offer legal services, shelter, and counseling to create a coordinated community response. This team-based approach has been an invaluable tool in improving health outcomes for my patients.

There are things we have to do when we suspect intimate partner violence, such as providing resource information to the survivor, as required by law, and mandatory reporting of abuse against children, elderly, and disabled patients. There are also things we should do, like partnering with community organizations to build healthier societies.

I work with Texas Advocacy Project, a statewide organization whose mission is to prevent domestic and dating violence, sexual assault, and stalking throughout Texas through free legal services, access to the justice system, and education. As a pediatrician, one of my favorite things about the Project is their commitment to teaching teens about healthy relationships. Perhaps this pay-it-forward mindset of empowering our youth is the only way we can tackle such a prevalent and horrible epidemic in our society. But for now, I will be comforted when I hear Texas Advocacy Project say, “We’ve got this.”

What is intimate partner violence?

Intimate partner violence, or IPV, is generally recognized as a pattern of behavior and tactics used to gain or maintain power and control over a current or former intimate partner that can include physical, sexual, emotional, economic, or psychological abuse or threats of abuse. The Centers for Disease Control and Prevention have adopted a uniform definition of intimate partner violence that includes physical violence, sexual violence, stalking, and psychological aggression, including coercive tactics.

The concept of intimate partner violence acknowledges that abuse can exist in any type of personal intimate relationship, regardless of sexual orientation, marital status, or gender. It’s important to stipulate at the outset that the term does not assign the roles of the abuser and victim to one gender, and that the term is often used interchangeably with “domestic violence” and “family violence.”

The legal definition of intimate partner violence in the state of Texas is more narrowly defined. Texas refers to intimate partner violence as “family violence” and includes only physical violence, sexual assault, or threat of either. Meanwhile, state law also encompasses a wider range of relationships to define an actor of family violence as any member of a family or household. That means that roommates and family members of blood relation who do not cohabitate with the victim are included.

The differences in these definitions are important when determining what legal remedies may be available to a patient affected by intimate partner violence. However, even if one of your patients is experiencing abuse outside of the state law definition, legal relief and advocacy may still be available. Partnering with local legal services organizations that specialize in intimate partner violence is important so that a legal expert can help make that determination for each individual patient and their unique circumstances.

Health consequence of intimate partner violence throughout the lifespan

We know a patient’s health is heavily influenced by his or her environment. The patient’s home, workplace, school, family, and income all play a role in health outcomes. These factors, sometimes referred to as “social determinants of health,” are the conditions in which people are born, grow, live, work, and age. What happens when intimate partner violence is added to the mix?

Intimate partner violence can cause severe and pervasive health consequences including physical injury, psychological trauma, and even death. One in three Texas women will experience domestic violence In 2017, 136 women were killed by their intimate partner. Physical injuries, unintended pregnancy, sexually transmitted infections, drug and alcohol use, and post-traumatic stress disorder are just some of the consequences that patients affected by intimate partner violence may suffer.

Pregnancy and intimate partner violence
Women are particularly vulnerable to intimate partner violence during and around pregnancy due to heightened relationship stress and the increased physical, social, emotional, and economic demands of pregnancy.6 Studies show that 25 to 45 percent of all women who are battered are battered during pregnancy.7 Intimate partner violence during pregnancy significantly impacts pregnancy outcomes and can lead to lower gestational weights, low birth weights, pre-term births, and higher rates of postpartum depression.

Pregnant patients may also experience a form of intimate partner violence that has led to an unintended pregnancy. Reproductive coercion includes overt force and direct interference with contraception such as limiting a woman’s access to contraception, destroying birth control pills, breaking condoms or diaphragms, and removing contraceptive rings or patches. Reproductive coercion is prevalent in 32 percent of pregnant survivors of intimate partner violence.

Childhood and intimate partner violence
An estimated 275 million children worldwide and 16.3 percent of U.S. children younger than 17 years of age witness physical assaults between their adult caretakers in their lifetime with children under the age of 5 years being more likely to witness adult violence. Children exposed to IPV are 2.6 times more likely to be physically abused and 9.6 times more likely to be psychologically abused than children without such exposure.6 The health consequences of exposure to IPV can be physical, ranging from poor weight gain and irritability to delayed milestones and under-immunization. Psychosocial effects also pose a risk of harm to children exposed to IPV. Internalized behaviors such as depression, eating disorders, and self-harm are commonly seen, as well as externalized behaviors like antisocial behaviors, aggression, and bullying. Additionally, children’s exposure to IPV is associated with victimization and perpetration of relationship abuse in adolescence.

Teens and intimate partner violence
One in three adolescents in the U.S. is a victim of physical, sexual, verbal, or emotional abuse from a dating partner. Teens often experience specific kinds of intimate partner violence, such as digital dating abuse and bullying. Digital dating abuse is defined as being verbally and emotionally abusive while using technologies such as texting and social networking to bully, harass, stalk, or intimidate a partner. In many of these cases, an abusive dating partner might demand or pressure your patient for sexually explicit materials, send unsolicited communication, or blackmail your patient with sexual content. One in four teens is harassed or abused in these ways through technology and 52 percent of teens who experience digital abuse are also physically abused.

The elderly and intimate partner violence
Intimate partner violence against the elderly takes various forms including physical harm, sexual assault, and murder. Caregiver stress, alcohol use, and the poor health of the victim, in general, have been cited as factors contributing to violence in later life. In general, elder abuse may go undetected. For every one case of elder abuse or neglect that is reported, five go unreported. At least one study has found that strangulation (as the cause of death) increases in frequency with the victim’s age. Suffocation homicide of elders is difficult for law enforcement to detect. Strangulation and suffocation, which also occur at a greater frequency in domestic violence relationships, may be fatal without external evidence of injury.

The physician’s response to intimate partner violence

Intimate partner violence is a preventable public health epidemic that adversely affects our patients. As physicians, we have the power to intervene, to mitigate, and even to prevent ongoing intimate partner violence and its effects on our patients.

Physicians are specially positioned to reduce incidents of IPV
As health care providers, we are in a unique position. We regularly interact with patients who may not otherwise engage community services. Our patients already trust us and are already telling us about their well-being and the challenges they face in life. For your patients, this may be the only place they feel safe to disclose abuse. We can save lives we may not even know are in danger by incorporating prevention and intervention strategies into our practices.

Create a safe place for disclosure and education
Making your practice a safe place for patients to disclose intimate partner violence is essential. Your office should communicate broadly with patients that it is a place where they can discuss and learn about options to address intimate partner violence, without fear of retribution or the risk of not being believed. Materials, such as signage and brochures, offering information about intimate partner violence and its impact on patient health and on the health of patients’ children should be prominently displayed. Many community organizations provide these types of materials free of charge for use in your practice.

Education on IPV in the health care setting is imperative. This invaluable information raises both the patient’s health literacy and their awareness of intimate partner violence. Even if at the time of a visit the patient is not involved in an abusive situation or is not ready to disclose, she or he will be more receptive to the next opportunity to receive information or to participate in a screening.

Effectively screen for intimate partner violence
The U.S. Preventive Services Task Force, American Congress of Obstetricians and Gynecologists, American Academy of Family Physicians, and the American Academy of Nursing recommend routinely screening all women of child-bearing age for domestic violence. We can detect or identify patients affected by IPV by being alert to warning signs of victimization or by screening patients for victimization. However, it is important for us to recognize and to understand that not all victims of intimate partner violence present outward signs of abuse. In fact, best practices suggest health care providers add information about domestic violence and screenings to routine visits (e.g., prenatal visits, post-partum depression screenings, and vaccinations). For most effective results, it is recommended that we invite IPV experts to join in the development of policies for screening or for the selection of a screening tool.

Recognition and validation of a patient’s experience with intimate partner violence is a critical first step in safety planning. It reduces isolation and shame and encourages the patient to believe that a better future is possible. Patients are four times more likely to use an intervention when they talk to their health care provider about abuse. And, women who talked to their health care provider about abuse have been shown to be 2.6 times more likely to exit the abusive relationship.

Things we must do

When your patient discloses intimate partner violence
As mentioned earlier, every health care provider is legally required to take certain steps when a patient discloses family violence or when we suspect injuries are caused by family violence. According to the law, any medical professional who treats a person for injuries that the medical professional has reason to believe were caused by family violence is required to (1) give notice to the person regarding the nearest family violence shelter center; (2) document, in the person’s medical file, that the notice was received and the reasons for the medical professional’s belief that the person’s injuries were caused by family violence; and (3) provide notice to the person that family violence is a crime that may be reported to law enforcement and that the person may seek a protective order from the court with certain types of relief. A well-documented medical record can help attorneys win court cases against the abuser.

Mandatory reporting
When the violence manifests as child abuse or neglect, we know we are all mandatory reporters. We should be reminded that we are also required to report abuse, neglect, self-neglect, and exploitation of the elderly or adults with disabilities. These reports should be made to the Texas Department of Family and Protective Services by calling (800) 252-5400 (anonymity can be maintained) or reporting online at the Texas Abuse Hotline website, www.txabusehotline.org.

Every health care entity should have a protocol for responding to disclosures of intimate partner violence. This protocol should include how to provide information to patients on how to access the nearest shelter, how to seek services through local community resources, such as Texas Advocacy Project, which can be called at (800) 374-HOPE, and how to report the crime to local law enforcement. Ultimately, connecting survivors to needed services and intervening to diminish the impacts of abuse are the keys to effectively addressing intimate partner violence.

Things we should do

Address health-harming legal needs with a medical-legal partnership
Traditionally, attorneys and doctors do not regularly work together. However, a medical-legal partnership, or MLP, turns that tradition on its head, encouraging the integration of attorneys in the health care setting. This innovative model provides patients with the wrap-around services they need to help them overcome those barriers to health that often hold them back from following through with the health plans we craft for them. An integrated health care system better addresses health-harming social needs by leveraging the unique expertise of attorneys into health care settings to help clinicians, case managers, and social workers address structural problems at the root of so many health inequities. Knowing and forming relationships with local community organizations that specialize in intimate partner violence services is a critical component in creating the coordinated community response your patients need.

An attorney can offer legal solutions for many issues that prevent patients from attaining optimal health outcomes. The following are examples of the legal relief for which a patient may be eligible, and that will make them healthier in the long term.

1. Safety – A patient experiencing intimate partner violence feels unsafe because of the presence of an abuser in the home. An attorney can help your patient apply for a protective order with the court. A protective order may prohibit the abuser from staying in the home or from coming near the applicant and from harassing or threatening the applicant. If violated, the police are required to arrest and charge the abuser for violation of a protective order for each incident, even if no other laws are broken. Protective orders have been shown to help keep applicants safer and to reduce incidents of intimate partner violence.
2. Privacy – Your teenage patient is having suicidal ideations because a nude photo may be circulated amongst her classmates if she breaks up with her abusive boyfriend. An attorney can help your patient seek an injunction to prevent revenge porn.
3. Employment – Your patient is affected by sexual harassment and is fired when she speaks out at work. She loses her health insurance coverage. An attorney can help your patient launch an investigation against the employer, based on gender discrimination, and get coverage restored as a term of conciliation.
4. Family law – Your patient discloses that she is pregnant as a result of a rape and she is concerned about the rapist’s access to the child. An attorney can help your patient terminate parental rights to sever any legal relationship between the child and the biological father.
5. Education – Your minor patient exhibits effects of bullying at school. An attorney can advocate that the school impose a stay-away agreement and any other accommodations needed, as required under Title IX.
6. Housing – Your patient discloses that she was raped in her home and no longer feels safe at her apartment complex. An attorney can help terminate her lease with no financial repercussions.
7. Financial – Your patient is struggling to pay her child’s medical bills because the non-custodial parent has failed to pay his half of uninsured health expenses. An attorney can help your patient seek an order to garnish the non-custodial parent’s wages to cover unpaid health expenses.

While it is important that we as physicians understand the breadth of legal relief an attorney can offer, it is not our job to act as an attorney. A medical-legal partnership is key because it allows each professional the opportunity and the ability to work at the top of their licenses. Attorneys focus on providing civil legal remedies while health care providers can focus solely upon delivering optimal health care in an environment where social determinants of health are adequately addressed and do not pose insurmountable barriers to desired health outcomes.

Be a health care champion!
Intimate partner violence is pervasive and may seem insurmountable. In reality it is a preventable public health epidemic. If we take the needed steps to integrate community services into our practices, we will save more lives and improve health outcomes for our patients in a way that we would never be able to do otherwise.

 

Texas Advocacy Project is a statewide non-profit organization providing legal solutions to victims of domestic violence and sexual assault. Visit their website at www.texasadvocacyproject.org.