**Transcript of Cyberseminar**

**Spotlight on Women's Health**

**Intimate Partner Violence and VHA Medical Care**

**Presenter: Megan Gerber, MD, MPH**

**November 27, 2012**

**Intimate Partner Violence and VHA Medical Care**

**November 27, 2012**

Moderator:  And we are at the top of the hour so I’d like to introduce our speaker.  Presenting for us today, we have Dr. Megan Gerber; she is the medical director for women’s health at VA Boston Healthcare Center.  So at this time I’d like to turn it over to Meagan.  Meagan, you’re going to see a popup that says show my screen. Click that button and we should be set to go. 

Dr. Gerber:  Great, thank you Molly.  Am I coming through loud and clear?

Moderator:  You’re not.  Do you have the handset picked up?

Dr. Gerber:  I do.  

Moderator:  OK, I guess – if you could increase the volume on the actual telephone that would be great, and then also please project your voice. 

Dr. Gerber:  OK.  How’s that?

Moderator:  Better, thank you.

Dr. Gerber:  OK.  [long pause] OK.  Good morning everybody.  I’m going to be speaking with you today about intimate partner violence and VA medical care, and I’m guessing that a number of people on the line have heard me speak before and I have updated this presentation to incorporate some of the new thinking and changes that we’re moving towards in the community of researchers and clinicians who focus on intimate partner violence in the VA.  So I do completely welcome comments and any questions you have at the end.  Anything I can’t answer, I will get back to you within 24 hours.  I just want to – whoops my slides aren’t changing, sorry about that.  

Moderator:  If you click anywhere on the side, it should advance.  

Dr. Gerber:  OK.  I just want to acknowledge the women veterans whom we’ve had the honor to serve.  Many of us have learned a lot about strength, resilience, and recovery from our patients.  I also want to take a minute to acknowledge that there are very likely, in the audience, men and women who have survived situations of intimate partner violence.  We support you and hope that this kind of presentation is helpful or useful, and that if it is difficult in any way, that you’re able to reach out to colleagues, to clinicians you’re already seeing, or perhaps even the EAP program.  And again, I welcome any comments at the end of our talk.  I want to also acknowledge a number of VA staff who’ve contributed meaningfully to the content of this presentation.  We have a really wonderful kind of researcher clinician advocate community here in the VA that’s been a real pleasure to work with.  

So today, the goals and objectives – and this is really, you know, going to be a 45 minute presentation and this topic is so complex and so huge that we really could fill several hours, but we won’t today.  So we’re going to try to focus really on the basic epidemiology of what I’ll call IPV.  I want to really also talk about women veterans – this is a women’s health cyber series – women veterans and IPV, and really understand what are the challenges and opportunities that we have to deliver care in the VA.  We’ll go over some basic approaches to responding to intimate partner violence in primary care, and I’d also like you to consider ways in which PACT and PACT providers, as well as health services researchers, can contribute to improving the care of veterans impacted by IPV.  So as you go – as we go through this, think about places where there’s an opportunity to do interventions, to study, to improve care and especially, to improve patient-centered care.  So we’re going to go to poll number one. 

Moderator:  Thank you Dr. Gerber.  I have launched the first poll, and the question is “what is your role within the VA – primary care provider, other medical care provider, emergency specialty, et cetera, nursing staff, researcher or I believe this is social worker slash women veterans program manager ?”

Dr. Gerber:  Yeah.

Moderator:  – and all the attendees, please go ahead and click the circle that best applies to your role within the VA, and it looks like we have had about 60% of our audience vote so we will leave that open for a few more minutes – I’m sorry, for a few more seconds and wait for everyone else to vote.  

Dr. Gerber:  [Laughs].

Moderator:  Looks like we’re up to about almost 80%.  We’ll give our audience about 10 more seconds.  Alrighty, we’re going to go ahead and close the poll now and share the results and – Dr. Gerber, can you see those results?  Oh I’m sorry, let me get back to where I was.  OK, I will go ahead and read the results.  It looks like we have 3% primary care provider, we have 22% other medical provider, we have 14% nursing staff, we have 27% researcher, and we have about 1/3 of our audience – social worker or women veterans program manager.  And at this time, I’ll turn it back to you Dr. Gerber.

Dr. Gerber:  Well that’s really interesting and I appreciate folks letting me know who’s in the audience, and that is really going to be –

Moderator:  I’m sorry to interrupt.  We’re not actually seeing your slides right now.  Let me try turning it over to you one more time.  Oops.  Sorry about the delay.  OK, you should see a popup that says show my screen – go ahead and click on that.  There we go.

Dr. Gerber:  Yep.  OK.  So, anyway, this is very helpful to me and I will be speaking to all of you I think in this presentation and again, welcome comments at the end.  So, going briefly through some definitions and background which may be familiar to many of you, the CDC has a very comprehensive definition that defines IPV as physical, sexual, or psychological harm by a current or former partner or spouse.  The CDC is a real leader in terms of both prevention and intervention, and most of us working at the VA do adhere to the CDC definition.  I just want to remind you that IPV can occur basically in any intimate relationship and does not require sexual intimacy, nor does it require that partners be domiciled together.  

I will briefly just touch on the different types of IPV.  Physical violence is what we most commonly think of when we talk about intimate partner violence.  Basically, the intentional use of any physical force and these include activities such as hitting, pushing a person against a blunt object, strangulation, choking, sexual violence is unwanted sexual activity; emotional violence, a little more difficult to measure, is trauma to the victim caused by acts or threats of acts or coercion, and then stalking.  The definition is here.  

So, what do we know at this point about IPV?  The most recent population based study is the National Intimate Partner and Sexual Violence Survey that was sponsored by the CDC.  When sexual assault is included – that’s sexual assault by an intimate – when sexual assault is included in the prevalence of IPV, among women, the lifetime prevalence of IPV is 35.6%.  The annual rate, the past 12 month rate is 5.9%.  So, seven million women experience intimate partner violence annually.  I want to mention that same sex couples are understudied and I’m pleased that 20% – 27% of our audience is researchers because there’s some really important opportunities here.  Some who’ve been studying this population suggest that rates may be up to two times higher in same sex couples.  Now the National Violence Against Women Survey, which is an older population based study, a secondary data analysis of that by Messinger in 2011 found that 21.5% of men in same sex relationships and 35.4% of women reported lifetime IPV.  Advocacy programs such as the NCAVP, which is funded by Verizon, are also reporting steady increases in reported violence in same sex couples; a lot of that may be due to reporting bias.  

So what are the risk factors for intimate partner violence?  We know that younger age is a risk factor and actually aging is protective.  Income – again, variable across studies, depends on how the study is designed; but even across all three major ethnic groups, lower income seems to be a risk factor, especially for more severe forms of IPV.  Unemployment, in a number of studies – black people have had higher rates than Hispanics and whites.  Again, that can vary based on how the study is done and what population is being looked at.  And then I’m just – put in gender preference as a bulleted point because this – we may find when study design incorporates same sex couples more than it does now, that gender preference may be a risk factor.  We just don’t know; but again, an important research opportunity.  Some other risk factors include antecedent intimate partner violence, intimate partner violence in the family of origin, an experience of child abuse, and alcohol or drug use.  Some studies show a greater effect for alcohol than for recreational drugs but again, that varies by study.  Though, if a person is abusing alcohol and recreational drugs, the risk is compounded.  And then depression seems to be a risk factor and PTSD.  

So what is the scope of problems – the problems for veterans?  We’re really just starting to understand the true impact of IPV on the veteran population.  This is a new field.  Veterans face a unique set of challenges.  Women veterans in particular often join the military – enlisted women join the military to escape difficult families of origin.  They have not had a good, trusting childhood.  Many of them – military life, of course, has all sorts of extra stressors on relationships and individuals, and then veterans have higher rates of co-morbid PTSD, substance abuse, and TBI.  I won’t have time today to talk much about TBI but I do want to mention that this is an important emerging area because violence is not only a cause of TBI but a consequence of TBI.  And we do know that TBI increases aggressive behaviors and it can also decrease safety behaviors, so this is a very important area going forward.  I also want to mention that HSR&D has funded two very exciting career developing awards.  Dr. Dichter in Philadelphia and Dr. Iverson here in Boston are both doing very important work, and very soon, these slides will be full of more data on women veterans.  VA official guidance about addressing intimate partner violence in practice settings is forthcoming.  I do want to mention that nothing that I’m presenting today is official VA policy.  You know, IPV is very complex.  The terms victimization and perpetration are easy to use, but they infer mutually exclusive states.  Since the dynamics of an abusive relationship – it’s very complex, those of you who’ve worked directly with these patients know bidirectional violence is very common and the intimate partner violence itself may range from very low level to very severe.  So we’re moving towards adopting the term “veteran who experiences violence” rather than victim.  This is a veteran who’s the recipient of violent behavior.  We’re also moving towards the use of the term of “veteran who uses violence”, rather than saying batterer, abuser or perpetrator.  Looking at this is really a difficult state for the person who is using violence as well as the person who is experiencing violence.  So this is language that avoids blame and works towards identifying behavior, which can be intervened upon.  So we’re going to get to poll number two now.  

Moderator:  Thank you.  I’ll go ahead and launch the second poll.  This applies to the clinicians among our audience.  So, please go ahead and answer the question.  Among clinicians attending today’s call, please indicate the percent of your patient panel comprised of women veterans.  This is zero percent, 5-10%, 10-30%, or greater than 30%.  And it looks like the answers are still streaming in so we’ll go ahead and give people a few more seconds to answer.  OK.  And the votes have stopped streaming in, so I’m going to go ahead and close it and share the answers.  Looks like 7% say zero percent, 44% say 5-10% of their patient panel is comprised of women veterans.  Nineteen percent say 10-30% and 30% say greater than 30%.  So, thank you, and we’re back on your slides, Dr. Gerber.

Dr. Gerber:  Thanks.  So, that is interesting.  And I’m glad that we’re not talking today simply with a – not to put down women’s health providers, I’m one of them, but it’s good to know that we’re speaking to a diverse group.  So gender issues, these always come up; this is a women’s health webinar.  I am a women’s health provider.  I do see male veterans when I’m on service here at VA Boston.  And, just basically, women are more likely to sustain physical and psychological consequences from IPV.  So for this reason alone, we’re seeing that IPV may disproportionately affect women’s health.  Now current research, which is definitely limited in veterans and also limited in looking at male IPV, really does identify women who experience IPV as the highest risk group.  We’re talking about morbidity, mortality – so, when women do use IPV, it tends to be on the lower end of the severity scale and there are research tools, many of you know, to measure severity of IPV.  So women are almost as likely to perpetrate IPV as males, but the end result of the IPV is different.  

Now that being said, it can be very difficult for men to disclose receipt of IPV.  The NISDS lifetime experience of physical IPV is 32.9% for women and 28.5% for men, so I’m in no way arguing this is not a significant problem for male patients.  Older studies have shown lower rates in males, but I think newer studies are really trying to focus on female perpetration quote, unquote, and looking more at males’ experience of physical partner violence and sexual assault.  

So, I also want to point out that using IPV has health consequences.  Being a user of IPV, inflicting violence on another person alone has health consequences.  And we as healthcare organizations have a responsibility to pay attention to that.  Now in – IPV and military personnel – rates have been estimated to range from 13.5% to 58%.  Active duty personnel are at much higher risk of being perpetrators of IPV.  The incidence of PTSD – high rates of PTSD correlate with higher risk of IPV perpetration.  Among women, there are higher rates of child abuse and pre-military trauma.  Up to 1/3 report IPV during active duty.  In mental health settings – this is currently unpublished data – 70% of women report a lifetime rate of IPV upon intake to a women’s stress disorders treatment team setting and in primary care, currently unpublished data, about 50% of women in a women’s health setting reported current or past IPV, and this is notable in the OEF/OIF population as well.  Looking at BRFSS data, which is something Dr. Dichter has done, more veterans experience lifetime IPV than non-veterans.  So when we look at non-VA data, we can see that veterans are a more affected population.  And then IPV is associated with increased odds of heart health risks in women and heart disease in women has become a huge focus.  The VA has recently partnered with the American Heart Association.

Now what do we know about OEF and OIF veterans?  Not as much as we’d like, and I guess the answer really is stay tuned because there is some very exciting research going on as we speak.  Data is very limited; Sayers in Philadelphia did the study looking at recently returned veterans screened in primary care who had recently separated from the military, and not surprising to anybody on the call, 75% had family readjustment issues, 60% reported IPV; however, the researchers used a very generous definition.  Now, it’s not surprising that 25% of this cohort had guns in the home; many veterans do own guns, this is an important safety issue that we’ll get into a little bit later.  

So, talking more about the health impact of IPV.  How does IPV look in medical practice?  Well, in primary care, and these are non-VA studies, the annual rate can range up to 14% and lifetime rate can range up to 60%.  Again, it depends on how the study was done and what population was studied.  I’ll note that the 60% lifetime rate comes from a study in an urban hospital, generally a large group of poor patients.  In OBGYN, 12 month prevalence has been measured at 15%, lifetime at 35%.  And then during pregnancy, as many as 1/5 of pregnant woman will experience intimate partner violence.  In the emergency department, rates can run a little higher.  It’s not surprising.  Twelve month rates have been estimated as high as 19%, lifetime at 54%.  So, I suspect – we don’t have a large number of primary care physicians on the call, we do have – about 1/5 of our audience are other physicians or medical providers.  I think that you may already agree that IPV is a medical issue.  I often speak to audiences who do not.  The study that Jackie Campbell ran a number of years ago was a multi-city study of homicides.  They interviewed last contacts of women who’ve been murdered by intimate partners and tried to recreate what these women were doing, who they were seeing in the 12 months before their deaths, and 41% of the women had been in contact with a healthcare provider but only 3% of the murdered women had accessed an advocacy or shelter program.  

So, we really are in routine contact with these patients.  We’re seeing them every day.  If you just look at the prevalence rates, there’s no way that these patients are not in and out of our VA facilities daily.  Now, half of women who experience physical IPV report being injured, so we did say that women tend to be more likely to experience sequelae or injury, but only about 20% of those seek medical care for their injuries.  So it’s – we’re not – we’re maybe seeing the tip of the iceberg in our clinical settings.  The physical health effects are well known and I suspect folks on the call are already familiar with increased histories of headache, pelvic pain, abdominal pain, GI issues, especially IBS, fibromyalgia, chronic pain, and medically unexplained symptoms.  We often see, especially in women’s health patients with long lists, these patients may have a history of experiencing violence, either in an intimate relationship or as a child.  They may be survivors of other forms of violence as well.  

Reproductive health impact has received more and more attention over the last few years; women who’ve been abused have more STIs, more PID, more recurrent genital urinary infections, unwanted pregnancy, adverse pregnancy outcomes, and interestingly in this Yost study, emotional abuse alone was linked to adverse pregnancy outcomes.  More data on IPV and pregnancy: women are certainly at higher risk of experiencing IPV, the type of IPV may change from emotional to physical abuse.  IPV right now is a leading cause of maternal mortality in the US.  And, I just want to mention that there’ve been a number of papers, they’re small n’s, but they’ve come out in the last few years, there’s a paper – this Helmuth paper came out this year, really looking at women’s use of IPV during pregnancy.  So women do use IPV perhaps more during pregnancy.  

Mental health sequelae are well known: PTSD, depression, anxiety, substance abuse and suicide.  IPV has been linked to adverse health behaviors.  Interestingly, it’s long been argued that alcohol and substance misuse increase IPV risk and that’s true, and there are a number of models that have been advanced to explain how that works.  But, when this phenomenon is studied prospectively, alcohol and substance use have been shown to increase from a baseline level.  So, it’s definitely an interwoven problem that’s difficult to tease out.  The predicted probability of IPV – so looking at a probability model, if you are sitting with a patient who uses alcohol, what is the probability that she’s been – experienced violence in the last 12 months or in the lifetime.  That is even higher when the patient is both a smoker and a drinker.  So we all have patients who smoke and drink and have never had experienced IPV but this can be a useful marker in a clinical setting.  The long term health effects are well known.  Interestingly, there is a dose response relationship between the severity of abuse and the degree of physical health problems experienced.  And again, probably from chronic stress, women who have experienced psychological abuse or very low level physical abuse still report increased physical health symptoms.  

Now, talking about abusive relationship dynamics, and I know that a number – I know Dr. Iverson gave one of these webinars not too long ago on mental health care and interventions for intimate partner violence survivors.  And again, I’m not going to get too much into mental health sequelae or interventions; but, I do want to make sure that everybody on the call is acquainted with some of the unique features of abusive relationship dynamics.  So, a woman and a man can experience IPV in the absence of physical violence.  A lot of times, the threat of violence has the same effect as low level violence.  Persons experiencing IPV are frequently isolated.  And we’ve definitely seen that here in our women’s health center.  Partners can interfere with receipt of healthcare; we’ve seen that as well, and I’m sure that all of you are familiar with situations in which partners are a source of diversion of opioids, or keep their partners from speaking to clinicians.  Somebody who looks poorly compliant may actually be in an abusive situation.  And then, a controlling partner who refuses to leave the room when you ask him or her is a red flag.  And we do recommend that most facilities have a policy or a protocol for interviewing patients alone.  So I mentioned to you earlier that patients with a list may have abuse histories; these are very difficult patients to manage.  Woman who are in situations where there is ongoing IPV do report more somatic symptoms over time and, they can be very challenging patients – we’re all pressed for time and it’s very difficult to address these issues.  So what should our response be?  Let’s go to poll number three first.

Moderator:  Thank you.  And I’m going to go ahead and launch poll number three.  So the question is how comfortable do you feel addressing IPV in your VA role? – very uncomfortable, uncomfortable, I can do it if I have to, comfortable, and very comfortable.  Looks like almost half of our audience has voted so we’ll give people some more time to get their submissions in.  OK. Looks like the votes have stopped coming in, so I’m going to go ahead and close the poll and share the results. Four percent feel very uncomfortable, 2% feel uncomfortable, 23% report I can do it if I have to; 52%, just over half, say they feel comfortable, and 18% feel very comfortable.  So thank you for those responses.  And we’re back to you Megan.

Dr. Gerber:  Thank you.  So, those are very interesting results.  Those results suggest that the majority of you are very comfortable or comfortable with dealing with this issue and I personally don’t find that surprising.  I think that those of us – all of us who work at the VA are used to very complicated, multi-factorial messy issues that involve a big psychosocial component and our system, I think, is very well equipped to deal with these situations and to really, really help our patients.  So, the Patient Aligned Care Team, I think is an ideal place to start.  I think because IPV is a complicated issue that no single provider can manage or fix, it’s a wonderful opportunity for a team to really focus on helping affected patients.  Similarly, in Patient Aligned Care, the patient’s preferences and needs of the family are critical.  Patient Aligned Care requires knowledge of community and VA resources.  And then to remind you, patients experiencing IPV are often isolated from social networks; they’re often ashamed of the abuse, they’re in poor health, and they’re in need of a team approach.  

Now, a couple of years ago I gave a Grand Rounds in VISN 1 and PACT was just – kind of getting off the ground in our VISN and I decided to ask some of the patients in my practice what they thought providers needed to know.  And I told them I was going to give this presentation and I want to know what you would like to ask of providers or suggest that they learn.  And I found some very interesting things, and I want to share this excerpt from one of my patients, WT.  She came to Boston with children to escape an abusive partner down south. He didn’t know where she was, she was living in a shelter, involved with HUD-VASH and wanted to start a new life up here in New England.  She’s diabetic, recently started on insulin and when she came to see me, had no insulin.  So I said you know, what do you think I should be telling the audience later this week.  And this is what she told me.  You’re looking at me now.  Your body is turned towards me; I feel safe with you.  She went on to tell me that nobody at her previous VA did anything like that.  The fact that I talked about her experience, I talked about what it must feel like to be starting somewhere completely new with her kids, I asked her what she needed.  I did actually very little.  I might argue that me giving her insulin would be way more important than any of the talking I did.  

But for this patient, this minor intervention was very important and I will share that a couple of months later I saw her again and she asked me how the Grand Rounds went and I showed her her slide and she was very proud and excited.  So, these are the kinds of things that patients really need from us.  So, Gene Fedder, who’s a very well known researcher in the UK, did a meta-analysis of studies looking at women’s expectations of clinicians and found similarly that women want clinicians to be non-judgmental and individualized.  So, you’re not going to pass judgment on this patient who’s remained in a very bad situation for 20 plus years because she loves this guy who sounds creepy to you.  Patients do not want to be pressured to talk about abuse or pressured to leave the situation.  They also do not want to be pressured to prosecute the person abusing them.  

So the women in the study, in the meta-analysis really wanted us to understand the complexity of a violent relationship and to meet them where they are in the continuum of deciding what to do.  So what does that sound like – it sounds a lot like what we do when we’re trying to help patients stop smoking, when we’re trying to help patients stop drinking.  We’re trying to meet them where they are.  Now the difference is that intimate partner violence could be immediately dangerous in the way that smoking isn’t, so can we truly help?  Well there have been many qualitative studies that demonstrate that abused women want providers to ask them about IPV.  Studies also show that women who experience IPV believe we can help.  I will just suggest to you that asking, in and of itself, is an intervention.  I frame intimate partner balance as part of a social history, I have it in a template that I use for social history, and I think of it as an adverse health exposure.

So what are some of the common barriers and the, you know – I think that many of you could have written this slide.  The fear is the classic fear of opening Pandora’s box – time constraints.  I’ll tell you honestly that when I get a disclosure, all the other reminders go out the window.  I just focus on that, and unless they’re acute medical issues, we don’t always know what to do if we get a disclosure.  We don’t have anybody right in our office, especially those of us at little CBOC’s.  We don’t have somebody who can come in and help.  We’re not like a big hospital with a full time advocate with a beeper.  You can feel very helpless when a patient starts telling you about this problem, especially patients in the VA who are beset by multiple social problems, housing problems, substance abuse; then you hear that this is happening.  But remember that there is no quick fix for this.  Even if you were out in private practice and you were seeing very well heeled patients who were experiencing abuse, there would still be no quick fix.  The poverty and other challenges are not necessarily insurmountable, especially with an organization that has the resources that the VA does.  And then of course, IPV doesn’t follow a traditional biomedical model, but again, the VA care models allow for complex issues.  So addressing some of these barriers, don’t think about fixing it.  What you can do is provide support, validation, offer education, resources, address safety, and document and treat injuries.  Adopt a patient-centered team approach.  Use existing VA resources and let your health tech, your LPN, your social worker help you. 

What are some of the benefits of routine inquiry?  Well, this communicates to your patient that you believe this is a health issue.  You’re really bringing it into the exam room and for a lot of these patients, men and women, this is a shameful, private thing, hard to talk about, and many of them don’t have the best feeling about themselves to begin with.  So make it a medical issue.  Over time, those of you who are not comfortable, and that really is the minority of you, and some of you are neutral, the more you talk about it, the easier it gets.  I mean, remember the first time you asked somebody about suicidality or code status.  You know, if you were to die, would you want us sticking a tube into your lungs to breathe?  That is not a question that rolled off my tongue.  So hopefully, if a patient comes to trust you, he or she may disclose experience of violence if it’s there.  

So, how can you identify intimate partner violence?  Ask directly.  There are many people who will not disclose abuse.  If you see a suspicious injury, ask how it happened.  Many patients are more willing to discuss intimate partner violence when they’re asked directly.  And I mentioned that I view asking as an intervention and it begins a process.  Disclosure could take place over weeks, months, years.  It occurs on the patient’s timeline.  Assessment of course validates IPV as a legitimate healthcare issue and I mentioned PACT. 

So, screening.  Screening has been controversial and there are folks who still don’t like that term and prefer the term inquiry.  But currently, the US Preventative Services Task Force recommends that clinicians screen women of childbearing age for intimate partner violence and provide or refer women who screen positive to intervention services, and that was published this year.  Reasons to screen, especially women, in the VA setting, include high prevalence.  Remember, those of you who have done some EPI know that the more prevalent an issue is, the higher the positive predictive value of the test.  So, we think that the prevalence of IPV is high in this population.  I think when you ask, you decrease stigma, ‘cause like, you smoke, you drink, is this happening to you.  Do you – are you taking your statins.  There’s potential to moderately reduce exposure to abuse – physical and emotional injury and mortality and again, we don’t have time to go into detail about the findings of the report, but there are some promising interventions.  VA guidelines again are forthcoming.  

So, what are some best practices for asking about IPV?  You should develop your own routine for asking that makes it comfortable for you and the researchers on the call may want to kind of get an idea of how current clinicians are asking – there’s a lot of work to be done.  You know, use an introduction or a stem, you know, because violence in relationships is so common, I’m asking all my patients about it.  You know, make it clear that you’re not singling this person out.  Consider assessing for both current and lifetime.  I’ll tell you honestly, when I ask about IPV, I often get a lifetime disclosure, not now, but I’ve been through that.  You want to affirm that.  Now, short validated screens do exist, but at this point I’m just talking about incorporating this question into your usual interview.  I won’t read these out loud but you can see the examples of questions; some of these are very behaviorally specific.  You know, have you been hit, kicked, punched, or choked, and then others get more at the emotional abuse.  Do you feel controlled or isolated; do you feel frightened?  Again, what you really want is to have a rapport with patients.

So what are the best settings and timings for inquiry?  A private setting.  A partner should not be present and, you know, that includes many situations where a partner is staying in to translate, interpret – we have some CHAMPVA women in our practice who don’t speak English.  There are lots of excuses that partners will give for remaining in the room and I would just argue that even a brief period of time – I saw a patient a couple of weeks ago at our Brockton practice who’s hemiplegic and wheelchair bound and her spouse is there all the time to help her.  And, you know, we did get him out of the room and we did screen her for IPV and he did leave willingly.  But there should be a time in which you can talk to your patient alone.  Family, friends, children over age 3 should not be present, and I would just get into a routine – I’d combine it with social history.  And then of course, signs and symptoms raising concern or red flags – this really is a process of case finding.  This is when your clinical suspicion is raised and you maybe think something else is going on here and it’s fine to use that strategy.  And then, I would argue the – ACOG has set times during pregnancy that they recommend that providers screen for intimate partner violence. Because we at the VA often don’t see our patients throughout pregnancy, I would recommend that when you do catch a glimpse of your patient during pregnancy that you consider asking her about intimate partner violence.  Because you’re not going to be – most of us, there are a few places that do, but most of us are not providing routine prenatal care.

So I talked earlier about risk factors for IPV.  What are some potential clinical markers?  So these are some potential clinical markers, and again, I won’t read the slide.  I’m watching the time but you know, discomfort when asked about intimate relationships, unexplained injuries, unexplained symptoms, high utilization, tobacco and alcohol use.  All of these may be clues.  And again, I mentioned earlier, targeted inquiry or case finding.  You know, there are going to be patients where your suspicion is high.  So what if somebody does say yes to you?  Stop what you’re doing.  You know, maybe hit the flag and the L and lock your keyboard.  Turn away from the computer, turn your body away; remember what WT said, I turned away from the computer, nobody had I guess done that before.  Make eye contact.  Respond with empathy and compassion.  You know, this is what we would hope everybody’s doing when an MST screen is positive or a suicide or depression screen is positive and validate.  Some examples of first responses, you know I’m sorry that you’ve gone through that, this is not your fault, you know, supportive, supportive language.  

What should happen next, what’s your role?  You know, you just heard this disclosure.  You want to be non-judgmental.  So, I saw a patient a few years ago who told me that she went to see an ENT surgeon after her boyfriend had kind of forcefully cupped her head on both sides with his hands and ruptured her eardrums and the ENT surgeon said, “Someone must not have liked you very much.”  I mean maybe that provider was trying to make a joke, but she was really wounded by that.  And of course treat the injury.  You can provide education; we hope and we know that many local VAs right now have little palm cards that are provided by state domestic violence agencies.  We hope that all of you will consider using something like that, it can be tucked into a wallet, and then you want to evaluate whether your patient is in immediate danger.  The difference between this and tobacco use is of course smoking will kill you after many years but IPV could kill you in an hour.  So this is where you really want to use your team.  

You will probably make referrals within the VA and for services in the community.  Dr. Campbell has created something called the danger assessment tool, it’s online.  The idea being that women do not always realize that they’re in imminent danger – this is probably true of males with PTSD as well – danger can increase if the abuser has access to weapons, if there’s substance abuse, if there’s a past history of severe, escalating abuse, control of daily activities, stalking.  So, again, PCPs are busy; this may occur after a warm handoff to a social worker or to a women veteran’s program manager.  And again, that would be another interesting research question, what’s happening with risk assessment?  What’s happening with referrals within the VA?  You always want to document your assessment.  I would be as specific as possible, even if you’re not in a mandatory reporting state.  There are states that have victim compensation funds; I would include the name of the person using violence towards your patient whenever possible.  She may – she or he may not want to tell you.  Always document injuries and physical findings.  Right now, we don’t have any method for using a body map in CPRS, but certainly one could be scanned in.  And then of course, complying with state mandated reporting laws is really important.

So I just want to remind you that patients will not always leave these relationships.  Patients love their partners.  It can be hard to leave a relationship, there can be economic concerns.  Patients will often stay for the kids.  But your providing information or kind words may help down the line.  You really haven’t failed if your patient shows up to the next visit and is still with the abusive spouse.  You know, you have still done your job as a provider and just remember that survivors of IPV, especially veterans, have lost their sense of agency and autonomy. Military service – military medical care is not always supportive of patients’ choices.  And never tell a patient what to do.  So I think I’d stress that you need to be supportive, you need to respect the victim’s timetable – I’m sorry, I’m using victim – respect the patient’s timetable.  Help the person experiencing IPV by gaining self-esteem. Help her gain – or help him gain self-esteem.  That really is something that you as a provider can do.  It’s also important that you be honest about your concern for safety.  And we do that as clinicians all the time.  You know, I understand that you’re afraid to take a statin for your high cholesterol but I really think your risk of stroke and heart attack is high.  So you’re validating the patient’s afraid of the medication.

So what next?  If there’s no immediate danger, if the patient’s not ready to leave, you’re going to provide local resources.  All states have domestic violence hotlines.  They can be found from this national number.  VA social work is very well trained.  I’ve been very impressed with VA social work.  Our women’s veterans program managers are wonderful advocates for our patients.  I am the sole provider in one of our women’s health centers on Friday and I’ve never had trouble finding somebody to help, even if it’s over the phone.

Now what about kids?  This question always comes up.  Of course the VA doesn’t have authority to treat children.  Some states have mandatory reporting for IPV; most states have mandatory reporting for child abuse.  So many women do fear that their children will be placed in protective custody.  So I would just suggest that if there are children in the home, they are witnessing IPV, I would involve social work earlier.  Because again, these situations are complicated.  I don’t have time to go into safety planning and I think that many of you will use your practice partners or PACT team to help with this, but just think of safety planning as a harm reduction strategy, similar to what we often use in substance abuse.  It really provides a backup plan for any escalation of violence.  We have patients be ready to exit if they need to, to keep important copies of their documents, their financial records, even the DD 214.  And there are very well recognized obtainable safety plans online and again, use your team.  If a patient endorses past IPV, validate, offer referrals, inquire about current mental health symptoms.  

Now, I’m going to try to close with helping veterans who use violence.  This comes up all the time; the majority of our patients are male.  There is currently no good evidence for screening for use of IPV, that’s in males and females.  Targeted inquiry is warranted when the patient is showing signs of chronic pain, mental health issues, or substance abuse.  The Jager 2008 study in the Journal of General Internal Medicine really showed low rates of disclosure with direct inquiry by primary care physicians.  Interventions for use of violence or perpetration alone lack evidence of efficacy and here I’m talking about things like state mandated batterers programs.  And there may be reasons for that.  Much more hopeful have been programs that have found treatment of co-morbid PTSD or substance abuse to be effective at reducing use of violence.  And again, I mentioned that TBI can be associated with aggressive behavior and this is another really important research possibility, just to really look at what proportion of perpetrating veterans who are using IPV have a TBI.  So veterans with PTSD are 2-3 times more likely to perpetrate or to use violence, and interventions for this group show reductions in partner violence.  Substance abuse, alcohol programs that just treat alcohol dependence have been shown to reduce intimate partner violence, even without a partner violence treatment component.  So treating the comorbidity can reduce the violence.

Now, self-identified perpetrators – and certainly when I took care of men in the past, I would have patients self-identify. Respond in a non-judgmental manner.  These are not nefarious people who are necessarily choosing to hurt people they love.  You can’t think victim good, perpetrator bad anymore.  And try to refer to an expert in dealing with perpetrators because again, treating the comorbidity is useful.  We know that advocacy is helpful.  There are some qualitative and RCT data that I don’t have time to cover today, but there really is some good evidence that what we’re doing is helping. 

And then I’ll just close with showing you national resources – the National Center for PTSD has some excellent content, and summarizing IPV is prevalent, we know it’s a significant issue for veterans, we need to know more about it, I’m glad that there are folks doing research on the call today, we clinicians need your help.  Some of your most vexing, difficult patients could be experiencing or even using violence.  There’s no question that we’re in regular contact with these patients, and use your team.  Use existing VA resources.  The VA is – the VA does complicated very well and I’ve only been here for four years, so I can really vouch for that.  I mean, the more you do this, the more routine and easy it becomes.  So, I know that you have questions.  I’ll stop and ask what questions do you have.  I’m sorry I went a little over.

Moderator:  Not a problem.  Thank you very much for that information, and we do have several questions pending, so we’ll just get right into those.  The first one: in my experience with women veterans who are not using VA either due to ineligibility or choice, some have experienced IPV, particularly those who become homeless, particularly from Vietnam, Desert Storm or peacetime eras.  How is VA reaching out to these women veterans to screen since the emphasis is on OEF/OIF?

Dr. Gerber:  That’s a great question and I actually – I don’t want to say that that isn’t true because those of us in the field know that often what we experience in the field is different than what policymakers think is happening.  But, certainly, the majority of our women patients are in that middle age group.  And, while we have a large number of young women entering VA care, certainly at record numbers, I don’t think the focus of any partner violence intervention officially will be on any one era of women veterans.  There is definitely an acknowledgment that this is an issue for everyone.  It may be that the homeless program may have to focus more on combining a component that addresses intimate partner violence.  I know that in our women veteran’s homeless program here in Boston, the team does go out to shelters and they do provide information and support and they do try to enroll women.  So, this is hopefully something that will happen more and more as more – I know there are more interventions coming down the pike for homeless women, so I hope I answered your question.

Moderator:  Thank you for that response.  We do have one person who has a comment:  I’m also a female veteran and a researcher outside the VA system; I’m grateful to be allowed to participate in this session and learn.  Thank you and we do welcome people outside the VA.

Dr. Gerber:  Thank you also for your service and for joining us.

Moderator:  Excellent.  The next person says: excellent presentation but I do have one question.  I believe you said IPV was highest among the active duty population.  Many Reserve and National Guard units do not have a full time medical – do not have full time medical resources.  Is there any data on how prevalent IPV is in the Reserve and Guard community?

Dr. Gerber:  I actually don’t know and that’s an excellent question and I will see if I can get an answer for you and send that out through Molly.  I will also just flag any of the researchers on the call.  Perhaps some of you are aware of some pilot data that hasn’t been published; I haven’t seen anything recently, but that’s a great question and I think another important issue with the guard and the reserve population is they’re together when they’re drilling and mobing and when they’re deployed, but the rest of the time, they’re back out in the world.  So they’re exposed to many of the stressors that active duty military are, but without the sort of constant support.  And, I know that National Guard has access – I’m pulling up a slide, I don’t know if you can still see the slides.  These are military DoD resources.  So this family advocacy program is a wonderful program and there definitely is a family advocacy program of the National Guard as well.  So hopefully, these resources will be disseminated.  Does that still show, Molly, if I –

Moderator:  Yeah, you can go ahead – oh perfect, that’ll be great.

Dr. Gerber:  Yeah, sorry about that.  There we go.  

Moderator:  Not a problem.

Dr. Gerber:  And these lead to additional resources.  OK.

Moderator:  Excellent.  Just a quick announcement, for those of you who joined us after the top of the hour, if you want to submit a comment or question, just use the question section of the go to webinar dashboard on the right hand side of your screen and we’ll get to it in the order that it’s received.  Next question: do you screen for the perpetrators of IPV as well?

Dr. Gerber:  So, that’s a complicated question.  I have not, in my own practice. I have not been screening for perpetration.  I can tell you that I have patients – I have a large panel of women veterans – I have patients who perpetrate IPV, absolutely.  It’s not something that I have been routinely screening for.  I know that there are programs in the VA, certainly PTSD and substance abuse treatment programs are routinely screening for perpetration but evidence for screening for perpetration in primary care settings is very limited.  The other problem is that when you screen for a condition, an illness, a disease, part of what’s implicit in screening is that you have a treatment or an intervention to offer.  So we would not really be doing mammography if we didn’t have any way of treating the breast cancer that we might find.  So one of the problems is just a lack of good knowledge about how to treat persons who use violence.  And at this point, what the best – the best evidence we have, and it’s very effective, is that we are understanding that treating PTSD, treating substance abuse, does reduce IPV.  So, it may be fair to ask your patients who are known substance abusers or afflicted with PTSD whether they’re using violence in their relationships.  Because we know that treating PTSD and treating that substance abuse can be helpful.

Moderator:  Thank you for that response.  The general guidelines for couples therapy is that it is contraindicated when violence is recent and ongoing.  What guidelines are you aware of for determining when it is safe to begin couples therapy?

Dr. Gerber:  That’s a great question.  So, I would always – and, as a PCP, as a primary care provider, I would never refer a couple to couple’s therapy.  I would have the individuals assessed by a psychologist or another licensed professional well versed in this area.  And basically, the VA has developed a couples treatment program for intimate partner violence and the patients who seem to safely benefit from that are those who are engaging in very low level violence.  So there are – there is a subset of patients who are appropriate for couple’s therapy.  Some of you are familiar with the CALM program that does something similar with – excuse me, substance abusing patients.  So, the patients have to be carefully selected, the violence has to be low level, but there is evidence of effectiveness.  Patients engaging in what’s called intimate terrorism or high severity violence would not be candidates for couples therapy.  PCPs again are not going to be the ones to make this judgment but definitely access your mental health colleagues.

Moderator:  Thank you for that reply.  This next question does touch on a subject that I believe you’ve already spoken about, but maybe, well – when current IPV is identified, do you refer any children to child abuse services?

Dr. Gerber:  Well, that’s always really hard.  Now, many of the PCPs in the VA system are family practice certified clinicians.  Internists like myself have not been trained to treat the family.  Have I ever filed a child abuse report?  Definitely.  The problem is, that in situations of intimate partner violence, it’s very complicated.  And, if there’s a child witnessing violence, we know that witnessing violence is almost as harmful as experiencing violence for later mental health, physical health as well.  Removing that child from that family unit or from that one parent is not necessarily healthy or safe for the child.  So I would always, always, always – if there’s a child involved, I would get an immediate social work consult before doing any kind of reporting, because I think – and it also varies by state.  There’s some states that are more sophisticated about assessing the risk to the child in partner violence situations.  So I would not hesitate to involve a social worker and if you’re at a little CBOC, in a very rural area, I would definitely give a call to even the social work executive at our parent facility just to get some consultation before I contacted child services.  Obviously, it’s a very severe situation, and you feel you must report the child that’s acutely injured, that’s a different situation.

Moderator:  Thank you for that reply.  The next question we have – a couple of people are asking for the slides – the reminder email that you used to access today’s presentation – if you scroll down, there’s a hyperlink leading directly to today’s slides, so thank you for that request.  Next question: for sexual assault, we have the DD 2911; why do we not have a templated chart for IPV in the absence of sexual assault?  This would make the data history collection easier and encourage clinicians to ask about IPV.  

Dr. Gerber:  I agree.  I think it’s a great idea.  

Moderator:  Thank you.  How do you feel about male therapists working with female victims?  Do you think male therapists can create a positive impact on their lives?

Dr. Gerber:  Well, I think that’s patient dependent.  I think we have a very large women’s stress disorders treatment team here and I know that there are not that many around the country, and the Women’s Health Sciences Division of the National Center for PTSD, and we have several male therapists; again, this is not evidence based, this is me telling you anecdotally what I know.  I’m not sure that this has been officially studied, another interesting area of study, but some women can create very effective alliances with male therapists.  And there are situations in which working with a male therapist can be helpful but the patient should always be given the choice and the person who does the intake for your mental health services should be very sensitive about gender.  I would say probably the majority of the trauma exposed women that we see in Boston do not want to see male therapists, but we have several who have worked very, very effectively with male therapists.

Moderator:  Thank you for that reply.  When will the VA guidance on IPV be coming out?

Dr. Gerber:  Most likely sometime next year.

Moderator:  Thank you.  Next question:  Indiana has a state regulated batterer intervention program.  I’m sure other states do as well.  This is an excellent program for treating batterers and is designed as a victim advocacy program to further protect victims from further abuse.

Dr. Gerber:  That’s wonderful.  And I think there’s a lot of variability in programs that are available to persons who use violence.  The VA has several programs that right now are kind of in the study phase, or in small, you know, available to small numbers of patients that have excellent outcomes.  So, I think that this is a very promising area and I think the VA probably is in a great position to be a leader.  

Moderator:  Thank you for that reply.  A couple more questions.  This person came a little late but maybe you can briefly review.  Please comment on any differences in IPV in the same sex versus heterosexual couples.

Dr. Gerber:  Well, I don’t know that it’s – there’s been several studies recently that have had reasonably good study design.  But in general, the data is very limited; but what we’re really seeing when we review this literature is that intimate partner violence is at least if not more common among same sex couples.  Some psychologists talk about something called minority stress.  I’ll also mention that it can be harder to disclose when you’re in a same sex relationship and lastly, that there have been more and more reports, even in the last two years, of same sex – individuals involved in same sex relationships being turned away from shelters.  So resources for intimate partner violence tend to be designed for heterosexual women.  And, we all understand that, but that kind of leaves out transgendered individuals, it leaves out men, it leaves out gays and lesbians.  So, the field is definitely starting to look at this more and try to develop services.  It’s a really important problem. 

Moderator:  Thank you for that reply.  We have a comment in response to that.  It is important to note that IPV among people who identify as LGBT or who are in same sex relationships may be lifetime individuals, may have experienced IPV from an opposite sex partner prior to a same sex relationship.

Dr. Gerber:  Right.  And actually that’s one of the difficulties with the secondary data analysis from the NVAWS, the National Violence Against Women Survey, which is that large population survey that we mentioned earlier, and it was not designed to measure intimate partner violence in same sex relationships.  So, it’s flawed in the sense that it’s measuring violence among folks who’ve reported being in a same sex relationship at some point.  But what’s really needed is really good population based data that’s designed to examine this problem and certainly, just a call to the researchers on the line and certainly, we need to look more closely at LGBT populations in the VA and the don’t ask, don’t tell is probably a really important component of all of this.  Who knows how much partner violence could be related to issues like disclosure or military life?  It’s really an area where we need to know a lot more.  

Moderator:  Thank you for that reply.  Just a couple more questions and comments.  We have men who have had sexual trauma be more receptive to a female therapist; have you found the same?

Dr. Gerber:  I think it varies and again, I’m – I don’t work as a therapist so I would probably defer that discussion to somebody who’s a psychologist or another LIP in that field.  But certainly, anecdotally, in primary care, I’ve had male patients before I came to the VA who wanted to see me because they’d been sexually assaulted.  I had one patient who had been sexually assaulted in prison, some survivors of child abuse; so it can happen.  And we can’t forget the prevalence of trauma in men.  

Moderator:  Thank you for that reply.  We have a comment that came in.  Course of control in a domestic violence relationship can include both low and high levels of physical violence and thus the dangerousness is not just about physical injury.  The calculus of harm has to be redefined to include the loss of agency and autonomy, which you mentioned in your slide.  Screening questions about the levels of control and the individual’s independence and ability to move around in society also need to be asked in the interviews to help get a clear picture of the types of harm the individual is suffering.  

Dr. Gerber:  Absolutely.  I couldn’t agree more and actually, I have a patient, and I’ll just tell you very quickly, who was in the CALM program, the violence escalated, she was no longer in the CALM program.  But prior to that, her husband had been stalking her by using her cell phone to find her.  Because she had been in a substance abuse treatment program and you can imagine substance abuse treatment in the VA, mostly males, she made friends with fellow patients and was hanging out with them for support and, you know, he was really trying to control her.  He was calling her and asking her who she was with and one day she came in with a broken rib and an orbital fracture and told us that she had fallen.  So really, I think more detailed assessment of his sort of plotting and controlling might have predicted that later extreme  physical violence.  She needed eye surgery.  So we do see that and we need better ways of measuring it.  I agree. 

Moderator:  Thank you for that reply.  At this time, I’d like to ask you to give any concluding comments you’d like to.

Dr. Gerber:  Well I just want to thank everybody for your attention.  I know this is a hard time of day because it’s kind of right before lunch and I think that there’s a lot of strengths and a lot of interest in the VA for really approaching this problem systematically.  We believe that the VA can help and we hope to have more official guidance available soon.  And I should have actually made a slide, there are – and people can email me if you’re interested in getting more involved in a research group that’s run by Ruth Klap and HSR&D Intimate Partner Violence Workgroup.  There have been many – I know Dr. Rachel Lada will be giving a presentation I think on December 3rd that goes more in depth into mental health issues.  So there’s really a lot going on, and the other thing I want to mention is that the references on these slides are not completely comprehensive.  So if I did say something and it isn’t referenced, please feel free to email me and I’ll get you the reference.

Moderator:  Thanks.  Great.  Thank you Dr. Gerber for sharing your expertise with the field today and thank you to all of our attendees for joining us.  A quick reminder as you exit today’s session, please wait just a moment while a feedback survey populates on your screen.  We do try and take your comments and criticisms into account to better the program and it also gives you the opportunity to bring up more subjects that you’d like to see an HSR&D cyber seminar on.  So thank you once again to everyone for joining us and enjoy the rest of your day.

**[End of Recording]**

1 of 16

16 of 16