Intimate Partner Violence as a Health Care Problem

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Intimate Partner Violence as a Health Care Problem


Kathryn Laughon, PhD, RN



OBJECTIVES


At the completion of this chapter, the reader will be able to:


• Describe the role of the sexual assault nurse examiner.


• Describe intimate partner violence and intimate partners.


• Discuss the health consequences of intimate partner violence.


• Discuss the mental health consequences of intimate partner violence.


• Identify opportunities to assess intimate partner violence in health care settings.


• Describe assessment tools and techniques to screen patients for intimate partner violence.


• Describe the steps to take after a positive screen for intimate partner violence.



PROFILE IN PRACTICE



Various forms of violence, including intimate partner and sexual violence, are experienced by men, women, and children around the world each day. After experiencing sexual violence or intimate partner violence, survivors may seek medical care either for documentation of the assault or for treatment of injuries. Sexual assault nurse examiners (SANEs) are specially trained forensic nurses that provide health evaluations, treatment, and evidence collection to victims of sexual and intimate partner violence.


My first experience working as a SANE was in a clinic where children, adolescents, and young adults who were victims of sexual abuse were referred for forensic services, including medical examinations, treatment, and evidence collection. My role at the clinic included conducting examinations to document any injuries, treating health needs, collecting evidence, and providing expert testimony in both civil and criminal cases. Later, I worked as a SANE in an emergency department in a university teaching hospital, providing forensic services for adults and children who had experienced either sexual violence or intimate partner violence. In both of these settings I found that combining concepts essential to nursing—compassion and caring—with the need for detailed evidence collection and forensic documentation resulted in a more positive experience for survivors.


I find working with survivors of violence in their hour of need to be personally rewarding. Looking into the eyes of rape survivors, holding their hands, letting them know they are in a safe place, and listening to their words are the reasons I became a nurse. I wanted to care for others when they needed help. SANEs help make an uncomfortable and often embarrassing examination more kind and humane while obtaining evidence that is crucial to prosecuting the crime. Perhaps there is no other time in a person’s life when he or she needs another person more than after surviving a violent attack.


In addition to the professional responsibilities of caring for survivors of sexual and physical violence, SANEs are also active in shaping the evolving practice. Much is still unknown about the best practices for evidence collection and physical injuries after sexual and physical assault. As a member of a SANE team and a nurse researcher, I have had opportunities to be active in research that will affect future practice and public policy for survivors of violence. As experts in the field, SANEs are essential to the growing science and debate over public policy that affects survivors of trauma.


The number of forensic nurses specializing in sexual and physical violence continues to grow. Nurses have successfully identified a wonderful way of using the nursing role to provide highly skilled and compassionate forensic care to survivors of trauma. As the specialty continues to grow, nurses may find themselves presented with an opportunity to work in forensic nursing. I encourage nurses to pursue interests working with survivors of violence. Although I found working with victims and survivors of sexual assault to be emotionally challenging, I believe working as a SANE allowed me to provide forensic service with the compassionate care that is at the heart of nursing.




imageIntroduction


Intimate partner violence (IPV) happens to approximately one fourth of women in their lifetimes (Tjaden & Thoennes, 2000). IPV is defined by the Centers for Disease Control (CDC) as “either physical or sexual violence, both physical and sexual violence, or threats of either. Psychological and emotional abuse is also counted when there have been prior violence or a threat of violence. Intimate partners are current and former husbands and wives, same-sex partners, boyfriends, and girlfriends” (Saltzman, Fanslow, McMahon, & Shelley, 1999, p. 12).


In a given year, approximately 1.5 million women—approximately 2% of the population—are physically or sexually assaulted by an intimate partner. The health consequences of IPV include a wide range of poor health outcomes beyond the obvious dangers of injuries and death related to the assault. This chapter describes the epidemiology of IPV and its health consequences, the nurse’s role in assessing for IPV, and guidelines for brief and more complete interventions. Also provided is a brief overview of the role of sexual assault nurse examiners (SANE) in addressing sexual assault and rape by intimate and nonintimate partners.



imageBackground


Rates of physical abuse of women by intimate partners during their lifetimes ranges from 25% to 33%, according to two large nationally representative studies (Plichta, 1997; Tjaden & Thoennes, 2000). Between 3% and 12% of women have been physically assaulted in the past year. More than 7% of women have been sexually assaulted by an intimate partner in their lifetimes (Tjaden & Thoennes, 2000). Most IPV is perpetrated by men against women; approximately 85% of the victims of serious IPV are women (Rennison & Welchens, 2000). Although women can abuse men, the pattern of repeated violence in a context of coercive, controlling behaviors is most commonly directed against women. Abuse can also occur within same-sex couples, although little research has specifically focused on violence in same-sex couples (Renzetti, 1998). One of the few population-based studies of IPV that included same-sex couples suggests that the prevalence of IPV in male homosexual couples was similar to that of heterosexual couples and was slightly lower for female homosexual couples (Tjaden & Thoennes, 2000).



imageConsequences of Intimate Partner Violence


PHYSICAL HEALTH CONSEQUENCES


IPV has serious health consequences. The most obvious physical consequence is injury. Approximately 40% of assaults result in injury, and roughly 20% of women seek health care services related to the assault. The most severe outcome, death, is addressed in detail below. Other physical health problems include headaches, fainting, chronic pain syndromes, increased rates of upper respiratory problems, urinary tract infections, pelvic pain, painful intercourse, increased rates of sexually transmitted infections, and irritable bowel syndrome.


The cause of these health problems is not fully understood. Some indications are that the chronic stress of living with IPV may adversely alter immune function (Woods, 2005). Forced sex may result in cervical and pelvic injuries that could partially explain chronic pelvic pain. Abusive partners may also refuse to use condoms or have multiple sexual partners, thus placing their female partners at greater risk for sexually transmitted infections (El-Bassel et al., 2001; Neighbors, O’Leary, & Labouvie, 1999; Wingood & DiClemente, 1997).



MENTAL HEALTH CONSEQUENCES


IPV has been consistently associated with depression and posttraumatic stress disorder (PTSD) in the literature. In one large population-based study, women experiencing abuse were three times more likely than nonabused women to have experienced depression in the prior month and more than twice as likely to have been anxious (Hathaway et al., 2000). Women who are depressed may be more likely to enter into and stay in abusive relationships, but there is evidence that in some cases the depression did not occur until after the abuse. A relationship between the severity of the abuse and the severity of the depression has also been shown (Campbell & Soeken, 1999; Silva, McFarlane, Soeken, Parker, & Reel, 1997).


PTSD and its related symptoms are also associated with experiencing IPV (Campbell, 2002). One study of inhabitants of a shelter for battered women found that increasing levels of dangerousness are associated with increased numbers of PTSD symptoms (Sato-DiLorenzo & Sharps, 2007). Symptoms of PTSD include reexperiencing the trauma through memories of the event that will not go away (intrusive thoughts) or recurring dreams; avoidance behaviors such as a general numbing of emotions or avoiding places, sights, smells, or sounds that might trigger memories of the event; increased arousal and difficulty falling asleep; exaggerated startle responses; and irritability and other persistent, unpleasant feelings. Formal diagnosis of PTSD requires exposure to a traumatic event that places a person in fear of bodily harm or death. Many battered women are exposed to psychological trauma that does not meet the requirements of the formal diagnosis, but studies show that these women have similar symptom profiles to women experiencing severe physical and sexual trauma (Kaysen, Resick, & Wise, 2003). Additionally, the diagnosis of PTSD requires that the clinician screen for exposure to a traumatic event.



FEMICIDE


Death is the most severe outcome of IPV. Femicide (or the homicide of a woman) is the seventh leading cause of premature death for women overall in the United States and the second leading cause of death among African American women ages 15 to 34 years (CDC, 2005). As many as half of murdered women are killed by a current or former intimate partner (Langford, Isaac, & Kabat, 1998). Although intimate partner homicides have declined since the 1970s, the decline has mostly occurred among male victims, with the rate holding nearly steady for women (Campbell, Glass, Sharps, Laughon, & Bloom, 2007). Among those women, as many as 70% of IPV murder victims were previously battered by their partner (Campbell et al., 2007). Nearly half of these murder victims used the health care system—and thus might have had access to help, had someone asked the women about violence—before their deaths (Sharps et al., 2001; Wadman & Muelleman, 1999).


An 11-city case-control study of risk factors for intimate partner femicide found that specific risk factors are associated with victims of completed and attempted femicide, as compared with women who had been abused by an intimate partner but had not experienced lethal or near-lethal violence (Campbell et al., 2003). Victims of femicide or attempted femicide were more likely to have a partner who was unemployed but not looking for work, have a partner who had access to a gun, have been threatened with a weapon, have a child who was not the biological child of the perpetrator in the home, and be estranged or separated from the perpetrator.



imagePregnancy and IPV


IPV rates during pregnancy appear to be about the same as IPV rates among all women (Sharps, Laughon, & Giangrande, 2007). Pregnancy is an important period for violence screening and intervention, however, and merits special attention. Almost all women seek health care during their pregnancies; thus pregnancy offers a unique opportunity for IPV screening. Experiencing IPV during pregnancy is associated with a number of poor pregnancy outcomes, including lower-birth-weight babies, more preterm labor, increased rates of smoking, and fetal trauma (Campbell et al., 2003; Silverman, Decker, Reed, & Raj, 2006). Pregnant women appear to have two to three times the risk for femicide compared with nonpregnant women (Krulewitch, Pierre-Louis, de Leon-Gomez, Guy, & Green, 2001; Krulewitch, Roberts, & Thompson, 2003; McFarlane, Campbell, Sharps, & Watson, 2002). Pregnant adolescents experiencing IPV are especially vulnerable to all these poor outcomes (Sharps et al., 2007).

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Oct 26, 2016 | Posted by in NURSING | Comments Off on Intimate Partner Violence as a Health Care Problem

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