Healthcare and Domestic Violence in Arkansas

1. Healthcare and Domestic Violence in Arkansas Angela McGraw, CVAP-A The Arkansas Coalition Against Domestic Violence

3. ACADV Mission Statement The mission of the Arkansas Coalition Against Domestic Violence is to eliminate domestic violence and promote healthy families. 

4. Training Topics • Prevalence of Domestic Violence or IPV • Arkansas Law • Causes of Domestic Violence • Understanding Domestic Violence Perpetrators & Victims • Impact of IPV on Adults and Children • Implications for the Health Care Practice • Questions

5. Prevalence of Intimate Partner Violence (IPV) Family Violence is Very Common: • [1]4.8 million women experience IPV related physical assaults & rapes. • [2]Men are the victims of about 2.9 million IPV related physical assaults. • [3]Two-thirds of women have been raped, physically assaulted, or stalked by a current or former husband, cohabiting partner, boyfriend, or date.

6. Prevalence of Intimate Partner Violence (IPV) Family Violence is Very Common: • [4]Based on findings from the Bureau of Justice Statistics' National Crime Victimization Survey of 2003: 54 percent of violence against males was conducted by strangers, while 64 percent of violence against females was conducted by nonstrangers.

7. IPV victims turn to their health care system: 1. 1st attempt to get help is from health care providers. a. legal or battered women’s services b. individual or cultural issues 2. Community services assist victims in accessing health care providers.

8. Coordinated Community Response • Dynamics of IPV Include: • Nature of the problem & its impact on health • Causes • Perpetrators • Victims

9. Coordinated Community Response Cultural contexts of both domestic violence & health care. Misunderstanding of one or more of these issues decreases our effectiveness with our patients.

10. CASE STUDY

11. What is Domestic Violence? Domestic Violence is any abusive, violent, coercive, forceful, or threatening act of word inflicted by one member of a family of household on another.

12. Arkansas State Law Arkansas Code Title 9: Family Law: Chapter 15: Domestic Abuse: Subsection 103: Definitions. (9-15-103)"Domestic abuse" means: (A) Physical harm, bodily injury, assault, or the infliction of fear of imminent physical harm, bodily injury, or assault between family or household members; or (B) Any sexual conduct between family or household members, whether minors or adults, which constitutes a crime under the laws of this state;

13. Arkansas State Law (3) "Family or household members" means spouses, former spouses, parents and children, persons related by blood within the fourth degree of consanguinity, any children residing in the household, persons who presently or in the past have resided or cohabited together, persons who have or have had a child in common, and persons who are presently or in the past have been in a dating relationship together; and

14. Arkansas State Law 4)(A) "Dating relationship" means a romantic or intimate social relationship between two (2) individuals which shall be determined by examining the following factors: (i) The length of the relationship; (ii) The type of the relationship; and (iii) The frequency of interaction between the two (2) individuals involved in the relationship. (B) "Dating relationship" shall not include a casual relationship or ordinary fraternization between two (2) individuals in a business or social context.

15. Enhancement Penalties In the presence of children; means in the physical presence of child or knowing or having reason to know that child is present and may see or hear act. Offenses against pregnant women.

16. Definitions. (12-12-107) A health care provider may report to a law enforcement agency an injury to an adult that the health care provider has reason to believe is the result of a battery or other physically abusive conduct, including physical injuries resulting from domestic violence, if the • Injured adult agrees; or • Health care provider determines that the report is necessary to prevent serious harm to the injured adult. • A health care provider shall promptly inform the injured adult that the report has been or will be made.

17. Laws Affecting Children Act 944 (2003) An act to enhance the penalty for offenses of domestic violence committed on a pregnant woman. (A woman is considered pregnant 4 weeks after conception)

18. Abusive Behaviors List Physical Sexual Psychological Use of economics Use of children to control an adult victim

19. Effects of IPV Phase 1: Tension Building Batterer behavior • Picks fights • Acts jealous and possessive • Criticize or threaten • Drink and/or uses drugs • Moody and unpredictable Victim behavior • Feels like walking on eggshells • Tries to reason with batterer • Tries to calm batterer • Tries to appease batterer • Keeps silent and tries to keep children silent • Feels anxious or afraid Assault Honey-moon Tension

20. Tension Assault Honeymoon Effects of IPV Phase 2: Crisis/Assault Batterer behavior • Verbal and physical abuse • Sexual and emotional assault • Increased control over money and partner • Destroys property Victim behavior • Feels fear and shock • Protects self and children • Uses self-defense • Calls for help • Tries to leave • Prays for it to stop • Does what is necessary to survive

21. Effects of IPV Phase 3: Honeymoon Batterer behavior • Asks for forgiveness • Promises it won’t happen again • Stops drinking and using drugs • Goes to counseling • Affectionate • Minimizes or denies abuse Victim behavior • Forgives • Returns home • Arranges for counseling • Feels hopeful • Feels manipulated • Blames self • Minimizes or denies abuse

22. ACTIVITY

23. They have solved their problems in the past with violence They have effectively exerted control and power over others through violence No one has stopped them from being violent in the past Causes of IPV

24. Causes of IPV IPV is learned in the family, in communities, & in society. www.myspace.com/video/beatriz/children-imitate...parents/10715169

25. IPV is Not Caused by: Genetics Illness Alcohol and/or drugs Stress and/or Anger Out of control behavior Behavior of the victim or problems in the relationship

26. Understanding IPV Perpetrators & Victims • Individual experience with IPV • Experience with IPV • Sensitivity to stereotypes • Behavioral definition of IPV– how to use it in assessing IPV

27. ACTIVITY I will ask you a series of questions, which I want you to answer just by a show of hands.

28. ACTIVITY • Using the behavioral definition of IPV, answer the following questions. • How many of you, in your role as a health care provider, have talked with a victim of IPV about the abuse? • How many of you, as a health care provider, have talked with a IPV perpetrator about the abuse?

29. ACTIVITY • Using the behavioral definition again, answer these questions: • How many of you, in your nonwork interactions have talked with a victim of IPV about the abuse? • How many have talked in that nonwork world with a IPV perpetrator about the abuse?

30. ACTIVITY • This time I do not want you to raise your hand…do not raise your hands…sit on your hands…and just answer these questions for yourself: • Using the behavioral definition of IPV, how many of you are victims/survivors of IPV? • How many of you are perpetrators?

31. Understanding IPV Perpetrators & Victims • Influence of Prior Experience with IPV on Current Work with Patients

32. Perpetrators Perpetrators come from all groups Gender Minimizing, denying, or lying Coercive tactics by using the health care provider

33. Victims • The primary victim: The intimate partner • Gender • Demographics • Why they stay • Victims’ various presentation in health care settings (next slide) • Goal/Support

34. 50% to 70% increase in gynecological, central nervous system, and stress-related problems Campbell et al, 2002 Abused women experience a

35. IMPLICATIONS FOR WOMEN’S HEALTH • IPV is a hidden risk factor for many common women’s health problems • Screening provides an opportunity for women to make the connection between victimization, health problems, and risk behaviors

36. “I want to understand how violence affects me mentally and physically…so I can learn to avoid bad situations.” -woman at crisis center Wilson et al, 2007

37. IMPLICATIONS FOR WOMEN’S HEALTH Cancelled and missed appointments, interrupted care and noncompliance with treatment and follow-up may be related to victimization.

38. Victims • The primary victim: The intimate partner • Gender • Demographics • Why they stay • Victims’ various presentation in health care settings (next slide) • Goal/Support

39. Victims • The forgotten victims: The children • Victim’s may be accompanied by children or the patient may be the children. • Perpetrator’s use of children – physical, emotional, & behavioral effects

40. Victims Other victims: Those trying to help or innocent bystanders

41. Module 5 – Effects of Domestic Violence

42. Implications for the Health Care Practice • IPV can be lethal and is a major health issue. • Guiding principles for the health care response to IPV victims: • Safety for victims & their children • Respect the rights for self-determination • Holding perpetrators responsible for violence • Advocate on behalf of victims • Individual practice & health care system

43. Implications for the Health Care Practice • Elements of an improved health care response to domestic violence victims: • Screen • Assess • Intervention • giving validating messages • providing information • safety planning • referring • follow-up

44. Implications for the Health Care Practice • Elements of an improved health care response to IPV: • Document

45. REMINDER: Role of the Health Care Provider • R – Remember to ask routinely about violence • A - Ask Questions • D – Document Findings • A – Assess Patient’s Safety • R – Review Options

46. Failure to Identify IPV Results in: • Incorrect diagnosis • Costly & inappropriate tests • Ongoing morbidity and mortality

47. IPV Is A Health Concern [5]The national health care costs of IPV are high, with direct medical and mental health care services for victims amounting to nearly $4.1 billion. [6]Among women admitted to an emergency room for violence-related injuries, 37 percent were abused by an intimate partner.

48. IPV Is A Health Concern [7]In a study on the effects of violence, women who experienced any type of violence or abuse were significantly more likely to report being in “fair or poor” health, and were almost twice as likely to be coping with some form of depression.

49. IPV Is A Health Concern • [8]One study found that women who had experienced any type of personal violence (even when the last episode was 14 to 30 years ago) reported a greater number of chronic physical symptoms than those who had not been abused. The risk of suffering from six or more chronic physical symptoms increased with the number of forms of violence experienced. • [9]Although 96 percent of patients believe physicians should inquire about family conflict, two-thirds report that their physician has never asked them about intimate partner violence. Sixty-seven percent of those whose physician has inquired about family conflict reported that the same physician helped them receive assistance.

50. IPV Is A Health Concern • Homicide • Homicide was the second leading cause of death on the job for women in 2003, according to the Bureau of Labor Statistics. • Fifteen percent (15%) of the 119 workplace homicides of women in that year were attributed to a current or former husband or boyfriend. • [10]Spouses, boyfriends/girlfriends and ex-boyfriends/ex-girlfriends were responsible for the on-the-job deaths of 321 women and 38 men from 1997-2009, according to the U.S. Department of Labor, Bureau of Labor Statistics.