# Presentation: 485221

## Domestic Violence 

- An Individual’s Health Issue
- A Public Health Issue
- An Epidemic
- Rachel E. Locker MD

## Alarming Statistics

- The American Medical Association estimates that over 4 million women are victims of severe assaults by boyfriends and husbands each year.   		*“**Violence Against Women," *
*CQ Researcher, Congressional Quarterly 1993*

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## The Facts 

- Domestic Violence is the
- ...leading cause of injury among women of reproductive age
- ...the single most common trigger for female suicide
- ...up to 60% of women who are murdered  die as a result of a domestic dispute
- Webster 1995

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## Responding

- In order to respond to domestic violence  effectively  we need to have an understanding of ...
- What is domestic violence?
- The causes
- The perpetrators
- The victims
- The impact on the victim, children and society

## Domestic Violence is... 

- A systematic pattern of _intentional_ _intimidation_ through the use of threats and violence for the purpose of gaining _Power and Control_ over one’s partner in a *intimate relationship*

## Health Effects 

- Personal

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Physical Health 

- Physical injuries-
- We usually identify domestic violence with physical injuries
- Accidental injuries tend to be on the extremities
- Domestic Assaults  -on the torso and head

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Head injuries 

- 23 year old woman with subdural hematoma
- Reports “he kicked me over and over with his steel toed boot “

## Head injuries 

- Centered around face
- Nasal/ facial bone fractures
- Lacerations to the eyes
- Rupture eardrum
- Dental injuries

## Periortibal ecchymosedLacerations to the lips

## Fractures 

- Rib fractures- “he kicked me”
- “I told the other doctor I wrecked  on a
-  4- wheeler”
- Scapular Fracture – Thrown out of a car moving 35 mph
- Tib/Fib fracture- tried to run over me with the car

## Abdominal trauma

- Ruptured spleen – “ he punched me in the stomach over and over”
- Fractured Kidney – “He beat me with the blade end of a shovel “

## Genital Trauma

- 34 year old female , 2 years post hysterectomy for adenocarcinoma of the uterus.
- Presents with vagina hemorrhage
- Exam finds lacerations of vaginal cuff
- She reports sexual assault with screwdriver

- A delay in seeking medical care may exacerbate any injury
- Batterer may not let victim seek medical help
- Unconscious
- Afraid of what people would say
- Alcohol or drugs involved

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

- A delay in seeking medical care may exacerbate any injury
- Wound infections
- Poor healing without wound closure
- Open fractures
- Fractures healed misaligned
- Excessive bleeding

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Chronic Disease

- Uncontrolled_______________
- Not allowed to visit the Doctor for diabetes care
- Flushed medication for blood pressure down the toilet
- “Accuses me of sleeping around when I try to go exercise with my sister”

## Chronic Pain Syndromes

- Joints
- Pelvic
- Abdominal
- Headaches
- Psychologically based
- Some reflect actual physiologic changes

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Chronic Pain Syndromes

- Multiple factors contribute to a woman's response to physical violence
- Especially common in women who experience long term or repeated victimization
- Severity and duration are important factors

## Case History

- 53 year old female
- Chronic back pain
- 2 hospitalizations  related to incapacitating pain
- Extensive evaluation- negative

- Difficult to control
- Escalating doses of narcotics
- Unable to adhere to pain management contract
- Admits to taking more than prescribed when she feels stressed

- Extensive history of marital rape
- Infidelity- brings partners in the home
- Physical abuse
- Emotional abuse

## Self-medication   

- Alcohol
- illicit drugs
- Nicotine
- prescription drugs
- “a pill to calm me down”

- to calm
- to cope with the negative feelings
- to “make it all go away”
- “To shut my mind off”

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Substance  Abuse

- Cause or Effect ?
- May be used to self medicate
- Use may make more vulnerable
- Batterer as supplier may be barrier to leaving

## Substance Abuse 

-   Alcohol and drug use increase after a new assault. Even when there is  no prior history of prior substance use
- Kilpatrick J Consult Clin psycholgy.1997

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Substance Abuse and Relationship Violence 

- 90% of women with a history of drug or  alcohol abuse  have experienced  sexual and/or physical violence
-                              VS
- 18.5 % of women who have been assaulted  have abused alcohol.

## Post Traumatic Stress Disorder

- Also called Battered Woman Syndrome or Rape Trauma syndrome
- Interpersonal violence carries highest risk for PTSD
- May persist for many years

## PTSD Symptom Criteria

- Re-experiencing trauma (1)
- Night mares
- Flash backs
- Intense distress at reminders
- Heightened emotional arousal (2)
- Hypervigilance
- Exaggerated startle response
- Irritability and outbursts of anger
- Difficulty falling or staying asleep
- Difficulty concentration

## PTSD Symptom Criteria

- Avoidance and numbing(3)
- Avoid thoughts or conversation of the trauma
- Avoid activities of persons that arouse thoughts of the trauma
- Inability to recall an important  aspect of the trauma
- Restricted affect
- Sense of fore-shortened future

## Mental Health Concerns

- Anxiety disorders
- Sleeping disorders
- Depression
- Suicidal ideations, attempts
- Suicide

**Notes:**
Point out that a large percentages of suicidal attempts.  Suicides are related to domestic violence

## Teen Girls Who Experience Physical and Sexual Abuse in Relationships Are:

- more likely to...
-  drink and drive
- binge drink.
- smoke heavily
- use illicit drugs
- use diet pills
- become pregnant
- consider suicide

## Abuse in Pregnancy

- Violence is more  likely in an unintended pregnancy
- Abuse may often begin or escalate during pregnancy
- Is likely to continue postpartum

## Substance Abuse and Pregnancy 

- In Pregnant women receiving treatment for substance abuse the vast majority have experienced sexual or physical assault
- Liebschutzualt, Violence Against Women

- Increased c-section rate
- Particularly in sexual assault  or child sexual abuse
- Labor can mimic loss of control of body experienced with sexual assault
- Decreased breast feeding
- Partner may prohiibt
- Avoidance of sexal assault recall
- Increased risk for post partum depression

## Pregnancy Complications

- Stress Related
- Late, sparse or no prenatal care
- Low birth weight
- Miscarriage
- Preterm labor
- Drug and Alcohol abuse

**Notes:**
Point out that physical injury may be the most obvious but is not  necesarrily the most harmful.

## Pregnancy  Complications 

- Trauma related
- Miscarriage
- Fetal Fracture
- Placental abruption
- Preterm labor
- Uterine rupture
- Fetal death
- Maternal Death

**Notes:**
Point out that physical injury may be the most obvious but is not  necesarrily the most harmful.

- Murder is the leading cause of death related to pregnancy
- JAMA 2001

**Notes:**
In a study done in Maryland  25% of deaths in women that occurred during or in the year following pregnancy were murder.
Put 2 and 2 together ......

These are the ones we know about

-        Death

**Notes:**
Point out that physical injury may be the most obvious but is not  necessarily the most harmful.

## Oregon Statistics

- 1997-2001 Review of Intimate Partner homicides
- 151 women murdered
- 50%  (n=75) murdered by an intimate partner
- 387 men murdered
- 4% (n=17) murdered by an intimate partner
- 29 % (n=5 )of those killed in self defense

**Notes:**

54 %, I of murders in another  estimate
Victoria BC 1990 71% 
	       1991 42%

## What about the Kids ?

- 61 children involved (37% of cases)
-  21 (34%) children witnessed homicide
- 5 children also murdered

## Effects on Children

- Parents usually think children do not know what is happening
- Children witness between 60-80% of assaults
- When children live with domestic violence it is very likely that child is witness to some of the physical violence

**Notes:**
Point out examples of stress related illness  that you shouldn’t see in children these should be triggers

## Children's health 

- Physical  injuries
- Caught in the crossfire
- Trying to intervene
- Abuse and Neglect
- May come at the hands of either parent
- “Pecking order “

**Notes:**
Point out examples of stress related illness  that you shouldn’t see in children these should be triggers

## Child Abuse

- 15 times more likely to be abused than children from
-    non-violent homes !

**Notes:**
Stress this need to protect children 

## Case History 

- 6 year old male
- Frequent “stomach aches”
- “Zantac 75 helps”
- Work up negative for organic etiology

- Father is verbally abusive to her and children
- Throws things “near my head” and yells a lot, but never hits
- Stomach aches do occur after incidents
- Brothers being treated for headaches and insomnia

## Medical Effects on Children

- Sleeping disorders
- Difficulty falling asleep,
- Wake frequently
- Refuse to sleep in their own bed
- Night mares
- Anxiety
- Worry about parents
- Worry about self

**Notes:**
Point out examples of stress related illness  that you shouldn’t see in children these should be triggers

## Mental health 

- Increased aggression/ anxiety
- Become more aggressive
- Misunderstand intentions of other children
- Depression
- Suicidal ideations and attempts

**Notes:**
Point out examples of stress related illness  that you shouldn’t see in children these should be triggers

## Children who witness Domestic Violence are at increased risk for developing PTSD

- 85% of child witnesses interviewed had moderate to severe symptoms of PTSD
- _None _of the control group had symptoms
- Kilpatrick 1997

- Developmental regression –
- baby talk
- bed wetting
- Increase distractibility
- Repetitive talk or play about the event
- Withdrawal/apathy

**Notes:**
Point out examples of stress related illness  that you shouldn’t see in children these should be triggers

## As Adults 

- Decreased sense of “Well Being”
- Depression
- Feelings of hopelessness  and powerlessness
- Low self esteem

**Notes:**
Point out that a large percentages of suicidal attempts.  Suicides are related to domestic violence

## More adverse experiences more disease as an adult 

- True for
- IV drug abuse
- Depression
- Obesity
- Smoking

## Public Health

## Medical Economics 

- Medical Expenses
- 5.8 billion $ in the US in 2002
- CDC  2003
- A victim of domestic violence  uses
- 8 x more physician visits
- 6x more prescription drug use
- 6 x more ER visits
- $1775 more health care costs per year

## Tax payer  Impact

**Legal Expenses- Tennessee study**
**49,928,000 per year  in Tennessee**
**-includes**
**Protection orders**
**Divorce costs**
**Custody fillings**
**Probation over site for offences**
**Pretrial cost for arrested**
**Prison cost for DV murderers**

## Socioeconomic  Impact

**Other considerations**** **
**Counseling services**
**Alcohol and Drug counseling/treatment**
**Damage to property**
**Poverty**
**Homelessness/Runaways**

## Economic  Impact

- Lost time from work- nationally
- Tardy, harassment  absent, leave early , poor concentration, lost productivity, higher health care insurance, increased work place security
- Total **35,000,000,000** annually
- Yes  that is ***billion ***

## Jan and Bob  

- Jan is a 23 year old woman with subdural hematoma.
- Reports “Bob  kicked me over and over with his steel toed boot.”
- Continues to control and manipulate her, even from jail.

## The epidemic spreads   

- Jan leaves
- Bob meets new partner in jail- Sue
- All is “wonderful” until the first child is born and physical abuse begins.

## About Bob

- Bobs father was very abusive to mother and the children
- Bob’s sister reports-
- ”our dad was very violent – all us kids have been either the abused or the abuser in our  intimate relationships ”

## The Cycle Continues ...

-    A child’s exposure to the father abusing the mother is the strongest risk factor for transmitting violent behavior from one generation to the next. *– **Report of the American Psychological Association Presidential Task Force on Violence and the Family, APA, 1996*

**Notes:**
Stress this need to protect children 

## About Sue 

- Sue’s father physically abusive to children and mother
- Several brothers committed suicide.
- First partner and father of older set of children very abusive
- Alcohol abuse in both Sue and partner.

## About Sue 

- Older set of children
- children jail time in early teens,
- alcohol and drug treatment at age 14-16
- multiple school expulsions
- daughter  is a mother at 16- no parenting skills
- boys involved in gang activity
- son suspect for murder at age 18

## Sue and Bobs kids 

- Physical Violence begins soon after birth of the first son
- Sons ages 2 and 4 witness assaults
- Visit to clinic with mom after physical assault
- Uncontrollable out bursts
- Hit, spit, bite, scream at any attempted interaction
- 4 year old grunts and screams – uses no words

- what does the future hold ?