Domestic Abuse Tied to Range of Health Issues
By Annette M. Boyle
BOSTON — Nearly 2 in 5 female veterans report experiencing intimate partner violence, as do up to 44% of active-duty women.
The high rates of domestic abuse have significant implications for federal healthcare: Women who have experienced intimate partner violence (IPV) have a 60% higher rate of health problems than those who have not. Common physical issues include cardiovascular disease, obesity, sexually-transmitted diseases, gynecological problems, stroke, asthma, ulcers, arthritis, headaches and chronic pain. IPV also increases the risk of depression, substance abuse, post-traumatic stress disorder, eating disorders and suicide.
With the number of women in the military increasing and the proportion of female veterans steadily rising, the VA has addressed the issue head-on with plans to introduce domestic violence and IPV coordinators and training at every VAMC.
In January, the VA hired Jennifer Broomfield, JD, domestic and intimate partner violence program manager, to coordinate training and services. Initially, a contact at each veterans’ integrated service network (VISN) will go through training on the signs and consequences of physical, sexual or severe psychological intimate partner violence. They will then train the IPV coordinators in the VAMCs in their regions. The coordinators will conduct ongoing trainings for clinicians in their medical centers and manage cases referred to them.
The training will build on research conducted by Katherine Iverson, PhD, of the women’s health sciences division of the national center for PTSD at the VA Boston Healthcare System. In research published in the Journal of General Internal Medicine, Iverson found that 29% of randomly surveyed women veterans currently in relationships reported experiencing intimate partner violence in the last year. Among women receiving care at women’s healthcare clinics in VHA facilities, 74% report some experience of IPV during their lifetime. 1, 2
With such high prevalence rates, enabling primary care providers to quickly and accurately identify women who have experienced IPV and then address the physical, social and mental health consequences of the abuse has significant benefit to the VA and women veterans.
Consequently, healthcare providers might be tipped off to screen a veteran for IPV if “they’ve had a lot of visits for different kinds of medical or mental health problems or a long list of issues that are not resolving,” Iverson said.
“Screening is critical because we know that women do not tend to spontaneously disclose IPV, but they are often willing to talk about it if asked. Screening gives women an opportunity to disclose, and it also sends a message that if IPV happens down the road, it’s important to discuss and there’s someone available to talk to,” Iverson added.
Iverson tested the Hurt/Insult/Threaten/Scream (HITS) screening tool for its sensitivity and specificity in identifying IPV in women veterans. The four-question HITS tool takes just minutes to administer and with a cutpoint of six provides comparable results to the more gold standard for IPV screening, the Conflict Tactics Scale-Revised (CTS-2).
HITS provides a screen that can be used in primary care settings or during emergency department visits or mental health assessments, Broomfield said. “The idea is to provide a ‘no wrong door’ approach. Wherever a veteran decides to talk about what’s going on, someone can help or get her to someone who can provide assistance.”
The first step is educating providers. “Training needs to be ongoing rather than one-time and in-person rather than online,” Iverson said. “The primary care providers who participated in my study stressed the importance of training programs to develop and hone skills, learn what questions to use, what body language to use. They want to know how to approach the topic in a way that is accurate and clinically sensitive and to have opportunities to roleplay with feedback on style.”
The results of the research conducted by Iverson and her colleagues on the perspectives of VA primary care providers on screening for IPV were published recently in the Journal of Family Violence. In keeping with recommendations made last year by the U.S. Preventive Services Task Force to screen all women of childbearing age, participants overwhelmingly supported routine screening of female veterans for IPV. 3
Hands-on training increases awareness and ease in asking about IPV, said Broomfield. “Years ago, providers weren’t comfortable asking about HIV. The more they practice, the better they get at it.” With IPV, as with many other sensitive topics, the more confident the provider is, the more comfortable the veteran will be in disclosing what’s happening at home.
Knowing what to do next is also part of the training. “It’s important that the provider validate the veterans’ willingness to discuss IPV and thank them for sharing. They need to be reassured that it’s not their fault and then connected with services,” Iverson noted. The provider would hand off to the IPV coordinator, who would help the veteran with safety planning, perhaps assist with finding new housing or getting to a shelter, refer to a social worker or connect her with other services in the community.
“IPV isn’t a diagnosis; it’s a social phenomenon,” Broomfield said. As such, it affects many aspects of veterans’ lives — their social health and social connections, where they live, how healthy they are. It can affect their children’s lives from performance in school to physical and mental health. Veterans who experience IPV may need legal help, and the domestic violence/IPV coordinator can put them in touch with the full range of services they need.
“Women in the study who reported that they experienced IPV in the last year also reported higher levels of PTSD than those that didn’t,” Iverson noted. “In the VA, we have evidence-based therapies available for these conditions. The domestic violence coordinator can link the veteran who has not sought out mental health treatment with those services.”
1Iverson KM, King MW, Resick PA, Gerber MR, Kimerling R, Vogt D. Clinical utility of an intimate partner violence screening tool for female VHA patients. JGen Intern Med. 2013 Oct;28(10):1288-93.
2Campbell R, Greeson MR, Bybee D, Raja S. The co-occurrence of childhood sexual abuse, adult sexual assault, intimate partner violence, and sexual harassment: a mediational model of posttraumatic stress disorder and physical health outcomes. J Consult Clin Psychol. 2008;76(2):194–207.
3 Iverson, K. et al (2013) VHA Primary Care Provider’s Perspectives on Screening Female Veterans for Intimate Partner Violence: A Preliminary Assessment. J Fam Viol. 2013;28:823-831.