Intimate Partner Violence: Perceptions of an Emergency Medicine Professional Sheryl Heron, MD, MPH,...

transcript

Intimate Partner Violence: Intimate Partner Violence: Perceptions of an Perceptions of an

Emergency Medicine Emergency Medicine Professional Professional

Sheryl Heron, MD, MPH, FACEPSheryl Heron, MD, MPH, FACEPAssociate Professor/Associate Residency Associate Professor/Associate Residency

DirectorDirectorAssociate Director, Center for Injury ControlAssociate Director, Center for Injury Control

Emory University School of MedicineEmory University School of Medicinesheron@emory.edusheron@emory.eduOctober 21, 2011October 21, 2011

5th Annual Domestic Violence Conference – Conasauga Family Violence Alliance

EMORY UNIVERSITY SCHOOL OF MEDICINE

DEPARTMENT OF EMERGENCY MEDICINE

Disclosure StatementDisclosure Statement

There are no financial There are no financial relationship in any amount relationship in any amount with a commercial interest with a commercial interest to discloseto disclose

October is Domestic October is Domestic Violence Awareness Violence Awareness

MonthMonth

National Import

ObjectivesObjectives National & State TrendsNational & State Trends

Perceptions from an EM Perceptions from an EM PhysicianPhysician

What does the data tell usWhat does the data tell us

Gaps in ServicesGaps in Services

Our RoleOur Role

National TrendsNational Trends

• On average > 3 women/day are murdered by their husband/boyfriend in U.S.

• 2 million women experience injuries from IPV annually

• Costs $5.8 billion dollars for medical expenses and work productivity losses (CDC - 2003)

National Trends – Violence & National Trends – Violence & ChildrenChildren

• 15.5 million children in US live in families with partner violence – one occurrence each year

• Children < 12 y.o live in households with IPV in 38% of cases involving women

• In a single day >16,000 children live in a domestic violence shelter or transitional housing

National Trends – Emerging National Trends – Emerging TrendsTrends

• Technology used to stalk and harass victims

• > ¼ stalking victims reports cyber-stalking i.e. email/Text messaging

• >1/2 teen girls state pressure from a guy is a reason to send sexy messages or images.

State Trends - GeorgiaState Trends - GeorgiaGa Commission on Family Violence Ga Commission on Family Violence

Facts – 2011Facts – 2011Year 2003

DV Fatalities

137 110 127 106 118 111 123 131

Georgia was recently ranked 6th in the nation for its rate of men killing women.

In 43% of the cases studied, children were present during the domestic violence killing.

Firearms were the cause of death in 76% of the domestic violence fatalities in both 2009 and 2010.

State Trends - GeorgiaState Trends - GeorgiaGa Commission on Family Violence Ga Commission on Family Violence

Facts – 2011Facts – 2011

IPV in Dalton, GaIPV in Dalton, GaWhitfield CountyWhitfield County

Pop : 33, 604•Male – 51%•Female – 49%

County Fatality – 03-05 – 6 total

Emergency Medicine PhysicianEmergency Medicine Physician Associate Residency DirectorAssociate Residency Director Assistant DeanAssistant Dean Fellow Injury ControlFellow Injury Control BSC - NCIPCBSC - NCIPC Past Chair - NMAPast Chair - NMA Commissioner – GCFVCommissioner – GCFV Associate Director – ECICAssociate Director – ECIC

Emory & GradyEmory & Grady

Physician’s RolePhysician’s Role

Patient Care DeliveryPatient Care Delivery EducatorEducator Advocate for Public Health issuesAdvocate for Public Health issues Community EngagementCommunity Engagement Screen in the Emergency Screen in the Emergency

DepartmentDepartment Support violence prevention Support violence prevention

researchresearch

Patient 1Patient 1

A 20ish -year-old female presents to the ED with need to have her stitches removed in her forearm

The pt is alone is sullen and withdrawn. She is quiet, slow to answer questions, and

offers little detail.

PE: Well-Healed wound to left arm. No other acute trauma noted

Patient 2Patient 2

20 yo female presents s/p GSW to 20 yo female presents s/p GSW to the head.the head.

On presentation she is in traumatic On presentation she is in traumatic arrestarrest

US notes IUP at 3 months.US notes IUP at 3 months.

In the literatureIn the literature

Medical settings

• Obstetrics/gynecology- 12.7%• Pediatrics- 8.4%• Primary care- 8.6%• Addiction recovery- 36.2%• Emergency department- 16.5%

McCloskey: Acad Emerg Med. 2005;12(8):712-22

By genderBy gender

• Male and female perpetration of violence is Male and female perpetration of violence is equalizing, but:equalizing, but:• Women tend to report victimization moreWomen tend to report victimization more• Men tend to perpetrate more severe violence in Men tend to perpetrate more severe violence in

most surveys, incl. homicidemost surveys, incl. homicide• Women tend to sustain more injuries and 3x Women tend to sustain more injuries and 3x

more like to report more fear/ batteringmore like to report more fear/ battering

Houry D: J Interpers Violence. 2008; 23(8Houry D: J Interpers Violence. 2008; 23(8):):1041-55.1041-55.

By ethnicityBy ethnicity

• Varies by study/data sourceVaries by study/data source• NVAWS (2000):NVAWS (2000):

• Blacks: 26%; Hispanics: 21%; Whites: 22%Blacks: 26%; Hispanics: 21%; Whites: 22%• NLCS (1995):NLCS (1995):

• Blacks: 30.4%; Hispanics: 21.2%; Whites: Blacks: 30.4%; Hispanics: 21.2%; Whites: 15.5%*15.5%*

• Ethnic difference disappear when control for SESEthnic difference disappear when control for SES

By sexual orientationBy sexual orientation

NVAWS one of the few national surveysNVAWS one of the few national surveys

Lifetime prevalence for same sex couples was Lifetime prevalence for same sex couples was higherhigher Perpetrators are more likely to be malePerpetrators are more likely to be male Female same sex partners reported more prior abuse Female same sex partners reported more prior abuse

by a male partner than a female partner (30.4% vs. by a male partner than a female partner (30.4% vs. 11.4%)11.4%)

Male same sex partners reported more abuse by a male Male same sex partners reported more abuse by a male partner than a female partner (15.4% vs. 10.8%)partner than a female partner (15.4% vs. 10.8%)

Physical & Mental Health EffectsPhysical & Mental Health Effects

Men & Women:Men & Women:– Increased risk of poor healthIncreased risk of poor health– Depressive SymptomsDepressive Symptoms– Substance useSubstance use– Chronic diseaseChronic disease– Chronic Mental IllnessChronic Mental Illness– InjuryInjuryCoker et al. American Journal Preventive Health: 2002Coker et al. American Journal Preventive Health: 2002

Psychological MorbidityPsychological Morbidity• Cognitive distortionsCognitive distortions

• Low self-esteemLow self-esteem

• Hopelessness and helplessnessHopelessness and helplessness

• Suicidal behaviorSuicidal behavior

Associations with IPVAssociations with IPV• Young (mean age 32)Young (mean age 32)• Female (62%) Female (62%) • Unemployed (60%) Unemployed (60%) • Street drug use (29%) Street drug use (29%) • Cigarette smoking (59%)Cigarette smoking (59%)• Depression (36%)Depression (36%)• PTSD (21%)PTSD (21%)• Suicidal (10%) Suicidal (10%)

Houry D et al Annals of Emergency Medicine 2008; Houry D et al Annals of Emergency Medicine 2008; 51(4):433-4251(4):433-42

• Emergency Medicine PractitionerEmergency Medicine Practitioner• Associate Residency DirectorAssociate Residency Director• Assistant DeanAssistant Dean• Fellow Injury ControlFellow Injury Control• BSC - NCIPCBSC - NCIPC• Past Chair - NMAPast Chair - NMA• Commissioner – GCFVCommissioner – GCFV• Associate Director – ECICAssociate Director – ECIC

Georgia Commission on Georgia Commission on Family ViolenceFamily Violence

Member 2002 – 2010Member 2002 – 2010 Vice-Chair – 2009- 2010Vice-Chair – 2009- 2010

National & State Trends

Perceptions EM Physicia

Data Gaps in Services Our Role

Ga Commission Family Ga Commission Family ViolenceViolence

• Medical Protocol• Revised 12/09• 2 Primary Goals

• Incidence & Prevalence of IPV through enabling hospitals, medical clinics and healthcare providers to respond appropriately to IPV

• Reduce the likelihood of violence developing into a pattern of repeated assault and emotional suffering

http://gcfv.org/files/medical.pdfhttp://gcfv.org/files/medical.pdf

Emergency Medicine PractitionerEmergency Medicine Practitioner Associate Residency DirectorAssociate Residency Director Assistant DeanAssistant Dean Fellow Injury ControlFellow Injury Control BSC - NCIPCBSC - NCIPC Past Chair - NMAPast Chair - NMA Commissioner – GCFVCommissioner – GCFV Associate Director – ECICAssociate Director – ECIC

Emory Center for Injury Emory Center for Injury ControlControl

Associate Director for Associate Director for Education & TrainingEducation & TrainingNational

& State Trends

Perceptions EM Physicia

Data Gaps in Services Our Role

Connecting Science to Practice

The Emory Center for Injury Control The Emory Center for Injury Control (ECIC) Collaborative, multi-institution (ECIC) Collaborative, multi-institution research centerresearch center

Mission: to build the field of injury Mission: to build the field of injury prevention and reduce injuries in prevention and reduce injuries in Georgia by:Georgia by: facilitating collaborationsfacilitating collaborations supporting innovative researchsupporting innovative research training practitioners and researcherstraining practitioners and researchers strengthening the bridge between science strengthening the bridge between science

and practiceand practice

GapsGaps

Victim ServicesLaw EnforcementLegal ResponseDV in the WorkplaceDating Violence

GCFV: 2010 Georgia Domestic Fatality Review

GapsGapsVictim Services

•2636 victims (incl. children) turned away

•19% of fatalities reviewed connected with DV shelter

•Reframe the language

GapsGapsLaw Enforcement

•55-85% 911 calls DV related•24% of 49 firearm related deaths for US officers DV related•Specialized training rare•When Called

•Criminal charge, escalation

GapsGaps

Legal Response

•Survivors frustrate the system•Confused, uncooperative, afraid, not yet willing to leave

GapsGaps

DV in the Workplace

•DV occurs in and around work place

•Few employers have policies

2 Employees killed in 20072 Employees killed in 2007

35 people presented to Faculty 35 people presented to Faculty Staff Assistance ProgramStaff Assistance Program

AT EMORY

Intimate Partner Violence Working Group (IPVWG)Intimate Partner Violence Working Group (IPVWG) Incepted July 2007Incepted July 2007

Interdisciplinary and Community CollaborationInterdisciplinary and Community Collaboration Coordination of service providers, faculty and staff Coordination of service providers, faculty and staff

leaders, and experts in the field of IPV in Emory’s leaders, and experts in the field of IPV in Emory’s various schools and divisions and Emory various schools and divisions and Emory Healthcare.Healthcare.

Mission:Mission: Increase awareness and education of IPV on a Increase awareness and education of IPV on a

University levelUniversity level

University Initiative

GapsGaps

Dating Violence

•Teens receive little info on safe dating or DV resources at school

•If stalked, need adult to apply for Protective orders

Is there a role for us?Is there a role for us?

Absolutely!!!

What is our Role?What is our Role?

• Connecting Micro to MacroConnecting Micro to Macro• Collaborative EffortCollaborative Effort• Each one can make a Each one can make a

differencedifference• Consider the PossibilitiesConsider the Possibilities

Our RoleOur Role

Promote• Broadcast DV advocates expertise• Dating Violence initiatives• Workplace Initiatives• Faith Based Initiatives• Law Enforcement training• Expand Ga’s local fatality report team

Our RoleOur Role

Perpetrator Accountability

Community Accountability

Reframing the language

Maintaining vigilance

Patient 1: Removal of Patient 1: Removal of StitchesStitches

AssessmentAssessment

Approach Approach

DocumentationDocumentation ReferralReferral

Patient 2:Patient 2: IPV HOMICIDE/PREGNANCY http://www.ajc.com/news/no-bond-for-man-117116.html

Partners are responsible for >50% of Partners are responsible for >50% of homicides during pregnancy in U.S.homicides during pregnancy in U.S.

Increased risk of miscarriage and LBW Increased risk of miscarriage and LBW infantsinfants

The RealitiesThe Realities

Economy:Economy: harder to leave, more women harder to leave, more women

staying in abusive relationshipsstaying in abusive relationships Shelter funding cut:Shelter funding cut:

less outreach, fewer services less outreach, fewer services Firearms :Firearms :

laws are making it easier and easier laws are making it easier and easier to have a firearm = lethality factor.to have a firearm = lethality factor.

TestimonialTestimonialDear Dr. Heron, Dear Dr. Heron,

I don't know if you remember me. I was working for Jezebel I don't know if you remember me. I was working for Jezebel magazine last July and came in to have stitches removed from my magazine last July and came in to have stitches removed from my arm because I had put my arm through a window. I was dating Ray arm because I had put my arm through a window. I was dating Ray from the "Cindy and Ray" show who was being horrible to me (to put from the "Cindy and Ray" show who was being horrible to me (to put it mildly) and I hated my job because my boss was making me feel it mildly) and I hated my job because my boss was making me feel like I was worthless. like I was worthless. I was about to have a nervous breakdown and I was about to have a nervous breakdown and you saved me. You were my guardian angel. You closed the door and you saved me. You were my guardian angel. You closed the door and talked to me, told me I was better than all of thistalked to me, told me I was better than all of this. I know that God . I know that God sent you into that room that day to send me a message. GET OUT sent you into that room that day to send me a message. GET OUT AMY! And get out I did! I quit my job, broke up with Ray and moved AMY! And get out I did! I quit my job, broke up with Ray and moved out of Atlanta and home to Palm Beach. Now I am getting my MBA out of Atlanta and home to Palm Beach. Now I am getting my MBA and happier (and healthier) than I have ever been in my life! I run 3 and happier (and healthier) than I have ever been in my life! I run 3 miles a day and go to church ( or at least try to) as much as I can! I miles a day and go to church ( or at least try to) as much as I can! I pray a lot! Thank you so much Dr. Heron! If you hadn't been there pray a lot! Thank you so much Dr. Heron! If you hadn't been there to wipe my tears that day and give me a hug I don't know what I to wipe my tears that day and give me a hug I don't know what I would've done. You were more than a doctor that day, you were my would've done. You were more than a doctor that day, you were my saving grace and my friend. You said you couldn't wait until I saving grace and my friend. You said you couldn't wait until I emailed you about the new man in my life and my three beautiful emailed you about the new man in my life and my three beautiful children. Well, I'm not there yet, but there is time, thanks to you! children. Well, I'm not there yet, but there is time, thanks to you!

Thanks again, I owe you my Thanks again, I owe you my life!life!

You are a God send! You are a remarkable doctor and person! You are a God send! You are a remarkable doctor and person!

I am sorry it has taken so long to send this to you but just know that you are I am sorry it has taken so long to send this to you but just know that you are always in my thoughts and prayers! always in my thoughts and prayers!

Warmest regards, Warmest regards,

Amy Saleeby Amy Saleeby

TestimonialTestimonialHi Dr. Heron! Hi Dr. Heron!

I am so happy to hear back from you! Of course you I am so happy to hear back from you! Of course you can share my email with the your students! I hope can share my email with the your students! I hope it will make for more doctors like you! it will make for more doctors like you! Thank you Thank you again for saving my life! I don't know what I again for saving my life! I don't know what I would've done if you hadn't been there that would've done if you hadn't been there that dayday.. I know God sent you in that room to talk some I know God sent you in that room to talk some sense into me. I will never understand how I put up sense into me. I will never understand how I put up with such utter crap from that jerk of a boyfriend with such utter crap from that jerk of a boyfriend and a boss. THANK YOU!!!!! My parents and and a boss. THANK YOU!!!!! My parents and friends thank you too!! You definitely found your friends thank you too!! You definitely found your calling girl. I'm sending a picture too! calling girl. I'm sending a picture too!

ConclusionConclusionNational & State TrendsNational & State Trends

Perceptions from an EM PhysicianPerceptions from an EM Physician

What does the data tell usWhat does the data tell us

Gaps in ServicesGaps in Services

Our RoleOur Role

QuestionsQuestions

Intimate Partner Violence: Perceptions of an Emergency Medicine Professional Sheryl Heron, MD, MPH,...

Documents