# Presentation: 351046

## Intimate Partner Violence and Alcohol Use

- Carol R. Schermer MDDirector of Trauma and Critical CareUniversity of New Mexico

## Intimate Partner Violence(IPV)

- Lifetime prevalence of IPV 18-30%
- Annual incidence physical IPV : 1-13%
- Leading cause of serious injury for women 15-44
- 1/3 female homicide victims killed by intimate partner
- Up to 33% of ED visits by women for injury are due to IPV
- Subsequent Health problems well described
- 77% of women never screened for IPV
- Women go unrecognized by health care providers

**Notes:**
The severity and consequences of intimate partner violence are far reaching.

Over 1/3 of female homicide victims are killed by a current or former intimate partner.

Victims of abuse increase their health care utilization and  maintain higher levels of resource
utilization for 12 months after a single violent episode.  Women who are victims of
 IPV  have higher risks of depression and suicide 

Yet despite its significant prevalence, nearly 80% of women have never been screened for IPV
.

## Risk Factors for IPV

- IPV risk is multi-factorial
- Physical aggression is accepted or tolerated
- Poverty
- Unemployment
- Racial/ethnic differences
- Power and control
- Excessive alcohol consumption is considered controversial

## Magnitude of the problem

- In the general population
- alcohol problems are over-represented in partner-violent men
- Men in batterer intervention programs
- high rates of alcohol abuse and dependence
- Men seeking alcohol treatment
- High rates of partner violence
- 50-60% in year prior

## Views of Alcohol and IPV

- Broad agreement that
- Violent men are often heavy drinkers
- Heavy drinking often accompanies violence
- Disagreement whether alcohol plays a causal role
- Some argue “no credible evidence”
- Alcohol is an “excuse”
- Aggression does not stop with successful alcohol Tx
- Causal
- Resolution of drinking problems yields decreased IPV

## Association of Alcohol and IPV

- Extensive theoretical and empirical evidence linking substance abuse and male to female IPV
- Alcohol is the drug MOST commonly associated with IPV
- Paucity of good studies linking acute intoxication
- Female victims report partners had consumed alcohol prior 40-90% of time
- Can’t separate out from drinking in general
- Hard to tell if drinking and violence are related

## Magnitude of the Problem

- Evaluation of men recruited from DV intervention programs and men entering alcoholism treatment programs
- M to F IPV 8-10 times more likely to occur on a day the male partner drank compared to those he did not drink
- 17-20 times more likely to occur on a heavy drinking day compared to a non-drinking day
- (Fals-Stewart 2003)

## Alcohol and Aggression

- Studies of aggressive behavior show
- Alcohol makes subjects more aggressive
- Increases negative verbal behavior
- Old research shows no associations
- Newer research consistently shows associations of
- Acute intoxication and IPV
- Physical violence more prevalent than verbal
- Episodes where husband was drinking
- More acts of violence and
- More severe violence

## Alcohol and Violence Events

- Alcohol use more common in serious physical assault events
- Violence most likely to occur within 4 hours after drinking
- Men more likely to have had 6 or more drinks prior to the events
- Estimated Blood alcohol concentrations:
- 0.19 during violence episodes
- 0.11 during non-violent conflict episodes

## Alcohol and personality

- Alcohol appears to act synergistically with hostile motivations
- Except in those with very high hostile motivations
- Certain subsets of men are SO violent (ASPD)
- Violence episodes are not related to alcohol
- But alcohol worsens the severity of violence that occurs

## Interventions

- If there is evidence of causality between alcohol and violence: can intervene
- Addressing excessive drinking behavior in individuals who behave in a violent way while drinking
- Relative ineffectiveness of batterer intervention programs may be due to
- Different types of batterers
- One-size fits all treatment programs

## Data on Alcohol and IPV

- Case control and epidemiologic studies
- Consistent associations of heavy drinking and DV
- 2/3 of all IPV: alcohol is involved (DOJ 1996)
- Upper half of drinkers 2X risk of violence as lower half (Lipsey 1997, meta-analysis)
- Longitudinal studies report
- Drinking patterns are predictive of subsequent DV
- Controlling for prior DV

## Data on Alcohol and IPV

- Multivariate studies show drinking behavior associated with DV *independent *of
- Age
- Socio Economic Status
- Occupational status
- Race/ethnicity
- Hostility and anti-social behavior
- Normative views of aggression
- Drug problems

## Alcohol Treatment and IPV

- Recent reports show successful alcohol treatment reduces
- Verbal aggression
- IPV
- Decrease in drinking improves the relationship which improves the violence
- Couples alcohol treatment may work better than individual treatment
- Does not eliminate violence
- Makes it equal to those in non-alcoholic couples
- Alcoholics who relapse do not reduce their violence

## IPV and Female Problem Drinking

- Conflicting findings
- Women screening positive for IPV
- more likely to screen positive for problem drinking
- Little work has been done
- evaluate female problem drinking *while controlling* for partner drinking

## Study Objectives

- Identify women experiencing IPV
- Determine acceptability of screening
- Identify  a potentially treatable IPV risk factor
- problem drinking

## Hypotheses:

- Prevalence of IPV among female trauma center patients is greater than national samples
- Alcohol problems among abused women and their partners are greater than those among non-abused women
- Female problem drinking is an independent risk factor for IPV
- Female trauma patients endorse IPV screening

## Methods

- Women ages 18-80 admitted to Trauma Service
- Anonymous interview
- Eligible patients
- English speaking
- Excluded
- severe head injury
- major psychiatric disorder

## Measures

- IPV: Conflict Tactics Scales (CTS)
- Severe items: physical assault, sexual coercion, injury
- Not psychological items
- Lifetime and Past year IPV were evaluated
- Past year asked if partner >2 months
- Alcohol Use Disorders Identification Test (AUDIT)
- AUDIT _>_8 defined as problem drinkers

## Participant Demographics (n=95)

| Mean age | 39 years |
| --- | --- |
| Race/ethnicity
  Native American
  Hispanic-Latino
  White-non-Hispanic
  Black/African American  | 
28%
33%
38%
  1%  |
| Education 
 Less than high school  
 High school graduate/GED | 
25%
75%  |
| Household income
at or below poverty   
above poverty | 
31%
69%  |
| Alcohol use  
AUDIT > 8
AUDIT < 8   | 
26%
74%
 |

## Demographics (continued)

- Partners
- N=77
- Unemployed:  23%
- Problem Drinkers (AUDIT_>_ 8):  38%
- Missed subjects (10)
- Non-English speaking (5)
- Missed due to short hospital stay (5)
- No women declined interview

## Slide 22

| Type of Intimate Partner Violence (IPV)  | Lifetime 
(n=95)  | Past year 
(n=77)  |
| --- | --- | --- |
| Any Severe IPV  | 46%  | 26% |
| Any Severe Physical Assault

  Kicked, bit or hit me with a fist | 42%

36% | 21%

17% |
| Any Severe Injury due to partner

 Gave me a bloody lip or black eye  | 34%

27% | 16%

13% |
| Any Severe Sexual Coercion

  Used force to make me have sex | 16%

13% | 8%

5% |

## Association of drinking with past-year IPV

| Characteristic | + Past Year IPV | p-value |
| --- | --- | --- |
| Female problem drinker

Female non-problem drinker | 59%

13% | 
<0.001 |
| 
Partner problem drinker

Partner non-problem drinker | 
55%

                     8% | 

<0.001 |

## Risk Factors for past-year IPV

| Characteristic | + Past Year IPV
 | p-value |
| --- | --- | --- |
| Female Race
Native American/American Indian
Hispanic
White | 
43%
26%
14% | 
0.07 |
| Female age > 34 years
Female age < 34 years | 33%
20% | 0.17 |
| Less than high school graduate 
High school graduate or GED | 29%
26% | 0.75 |
| Partner < high school education
Partner high school grad or GED | 31%
23% | 0.44 |
| Household income 
at or below poverty 
above poverty  | 
33%
22% | 
0.29 |
| Unemployed partner
Employed partner | 40%
21% | 0.07 |

**Risk Factors for past-year IPV**

## F = Female

- P = Partner
- PD = problem drinker
- NPD = non-problem drinker
*χ*2 for trend = p<.001

## Multivariate Analysis of Risk Factors for IPV

- Logistic regression: female and partner alcohol use
- Both female problem drinking and partner problem drinking independently predict IPV
- Partner problem drinker OR 8.9
- Female problem drinker OR 5.8
- Individually added other factors
- Race/ethnicity, age, partner unemployment
- None were independently predictive of IPV
- None decreased the association of problem drinking and IPV

## Views on IPV Screening

| Items asked of all women
 (n=95) | Agree with statement |
| --- | --- |
| While hospitalized in a trauma center it is appropriate for somebody to ask me about partner abuse and violence | 91% |
| I would be offended if you asked me about partner abuse and violence | 10% |
| I would prefer to talk to a female rather than a male about partner abuse and violence | 52% |
| I would prefer to answer questions regarding partner abuse and violence on an intake questionnaire using paper and pencil instead of being asked in person | 26% |

## Views on IPV Screening Among IPV Victims

| Asked of IPV + women 
(n=44) | Agree with statement
 |
| --- | --- |
| It is important to talk with patients about partner abuse and violence while they are hospitalized for injury | 91% |
| If my HCP determines I am at risk from partner abuse and violence, he or she should report it to the police | 73% |
| If I talked to my doctor about abuse, it would increase my chances of further harm | 27% |
| If my trauma center HCP asked me about physical abuse I would respond truthfully | 98% |

## Logistic regression models of past year IPV (n=77)

| Factor | Model 1
OR (95%CI) | Model 2
OR (95%CI) | Model 3
OR (95%CI) | Model 4
OR (95%CI) |
| --- | --- | --- | --- | --- |
| Female AUDIT | 5.8 (1.6-21.1) | 5.7 (1.6-21.0) | 7.6 (1.9-31.1) | 5.8 (1.6-21.1) |
| Partner AUDIT | 8.9 (2.4-33.7) | 8.3 (2.2-33.1) | 8.5 (2.2-33.3) | 8.6 (1.9-37.7) |
| Partner Unemployment |  | 1.4 (0.4-5.6) |  |  |
| Female Age* |  |  | 3.2 (0.8-12.8) |  |
| Female Race/ethnicity
  NA/AI
  Hispanic/Latino |  |  |  | 0.9 (0.2-5.0)
0.9 (0.1-5.5) |

## Logistic Model of Correlates of Past-year Severe IPV

| Factor | Model 1
OR | Model 2
OR |
| --- | --- | --- |
| Drink-pairing
   F & P PD
   P PD
   R PD | 
164.9     (13.5-2013.2)
  39.9         (1.2-807.1)
  12.5         (1.1-143-4) | 
121.5       (8.7-1700.2)
  31.3       (1.5-645.4)
    9.8       (0.9-115.6) |
| 
P unemployment |  |    
    1.2        (0.2-7.6) |

## UNM Study Conclusions

- Female trauma patients
- High lifetime prevalence (46%)
- High past-year IPV (26% past year)
- Male and female alcohol use _*independently*_ associated with IPV
- Female trauma patients should be screened for IPV

## Study methodology and associations of alcohol and IPV

- Cross-sectional data do not establish causality
- Event based designs
- Stress may cause both drinking and violence
- Longitudinal Designs
- Assess temporal nature
- Experimental Studies may not translate out of the lab
- Treatment studies remove a putative causal factor
- Cause of the cure not necessarily the cause of the disorder

## Arguments for and against causality

- Alcohol is neither necessary or sufficient cause of violence
- Alcohol is not the primary determinant
- Alcohol’s influence on IPV is not uniform

- Alcohol contributes to violence in some people under certain circumstances
- Alcohol appears to act synergistically with hostile motivations

## Interventions

- Violence Intervention programs
- Relatively ineffective (USPSTF)
- Where should attention be focused?
- Can outcomes be improved?
- Meta-analysis of batterer intervention studies
- Effect size for batterer intervention programs very small
- Women 5% less likely to be re-assaulted if male had arrest and batterer treatment referral vs arrest alone
- Babcock, Green, and Robie 2004

## Interventions

- Majority of men arrested for partner violence drink alcohol hazardously
- Increased risk for violence recidivism after intervention more so than non-problem drinkers
- Frequency of husband drunkeness related to violence recidivism
- Probability of violence recidivism reduced by 30% to 40% if batterer obtains substance abuse treatment
- Integrate or use SA treatment as an adjunct
- Jones and Gondolf 2001

## Summary IPV and Alcohol Use

- Relationship between husband-to-wife IPV and male problem drinking
- well described
- Does excuse versus causality matter?
- Male alcohol treatment
- IPV decreases with cessation of male problem drinking
- Couples alcohol treatment
- Decreases IPV rates
- New Studies to evaluate efficacy of treating female problem drinking to decrease IPV

**Notes:**
Current data have clearly shown that a woman has a higher risk of IPV when her partner
is a problem drinker.  It remains unclear if the woman’s own alcohol use  puts her at risk for 
IPV.

The purpose of this study was to identify the prevalence of IPV among female trauma patients and 
to study the role of alcohol as a risk factor for this  violence.