by Jessica McCann
Introduction
Domestic violence (DV) is an important public health issue and includes child, intimate partner and elder abuse. Victims of domestic violence often first report their abuse to health care providers, including nurses, primary care physicians, emergency physicians and obstetricians/ gynecologists. Primary care providers, including those within community health centers, are often on the frontlines of domestic violence screening, reporting, and treatment, and offer unique interventions to diverse patient populations. Moreover, health center patients disproportionately experience risk factors for intimate partner violence (IPV), including low socioeconomic status, low educational attainment, and pre-existing behavioral health conditions. To recognize Domestic Violence Awareness Month and National Primary Care Week, we discuss domestic violence, the role of primary care providers in its treatment and prevention, and important next steps.
Domestic violence can include stalking, child sexual abuse or neglect, physical violence, and coercive control of a partner or family member. Most of this piece will focus on IPV, defined as “stalking, sexual and physical violence, and psychological aggression by a current or former partner.”
Impact
According to the U.S. Centers for Disease Control and Prevention (CDC), 41% of women and 26% of men have experienced IPV, which often co-occurs with negative medical outcomes such as physical and brain injuries, heart disease, chronic pain and headaches. Those who have experienced IPV are also likely to suffer from insomnia, depression, anxiety, and post-traumatic stress disorder. In total, the economic cost of IPV, which includes missed work and health and legal costs, is over $3.6 trillion.
There are many complicated and interrelated factors preventing IPV victims from actively seeking help, including fear, lack of resources, or being unaware of options. While the same underresourced populations likely to seek care in safety net settings are also likely to experience IPV risk factors, they are also less likely than non-health center patient populations to have the resources or knowledge to seek help. People of color, younger adults, pregnant individuals, immigrants, people with disabilities, and LGBTQ+ populations also experience unique barriers to reporting IPV. Therefore, screening and interventions in the primary care setting, particularly for the most vulnerable populations, are especially important.
The Role of Primary Care
Primary care and other health care providers are obligated by law in most states to report violence or abuse. Because obvious signs of abuse are often absent, groups like the American Academy of Family Physicians, the American Medical Association, and the American College of Obstetricians and Gynecologists recommend screening female patients of child bearing age for IPV. In the primary care setting, providers can use short screening tools such as Hurt, Insult, Threaten, Scream (HITS) or Slapped, Threatened, and Throw (STAT), which have been found to be just as effective as longer tools. Often these tools are integrated into a clinic’s electronic health record (EHR) system. If a patient reports abuse or screens positive for abuse, documenting the result of these reports or screenings in a patient’s health record is extremely important as these records are often used as court evidence.
Health centers and community organizations can access resources tailored to the populations they serve to help prevent, screen for, and assist patients experiencing IPV. The Protocol for Health Resources and Services Administration (HRSA)-supported Community Health Centers to Engage Patients through Universal Education Approaches on Exploitation (E), Human Trafficking (HT), Domestic Violence (DV) and Intimate Partner Violence (IPV) offers sample policies and procedures for handling IPV, patient and provider resources, and research-proven interventions, with the ultimate goal of educating and empowering patients. One successful clinic-based intervention, as outlined by the Kaiser Family Foundation, includes taking a systems approach with visible messaging for all patients, EHR-embedded screening tools, and on-call crisis response and legal support. Community Health Center, Inc. (CHC), a HRSA-supported health center based in Connecticut, went one step further when a local DV safe house was destroyed by an abuser. CHC raised funds to support a new shelter and now offers education, support groups, individual counseling, legal aid, and medical care to over 1,000 clients annually through New Horizons Domestic Violence Services.
Treatment and Recovery
Trauma-informed care for domestic violence survivors recognizes that patients’ past traumas may manifest in many ways, and providers focus on trauma survivors’ resilience, strengths, and their mental and physical safety–without re-traumatizing them. Primary care providers can offer trauma-informed care by establishing trust, seeking patient input on the visit (e.g., doors open or closed, asking before making physical contact), and being alert to patient distress. Primary care providers should be aware of local resources, including peer support networks, a tradition closely tied with trauma-informed care that connects women with IPV survivors with lived experience. These peer supporters offer emotional support, resource navigation, and self-advocacy skills.
Looking Ahead
Research on new screening and interventions is currently limited by funding constraints. Moreover, DV/IPV programs are often subject to budget cuts and limited funding. Policymakers and advocates should push for sufficient funding to prevent, screen for, and treat IPV to improve long term behavioral and physical health outcomes of those affected. Additionally, policies mandating firearm background checks, especially for IPV perpetrators, will better protect families. The recent Supreme Court ruling United States v. Rahimi banned people subject to restraining orders from owning firearms, a step in the right direction. The National Domestic Violence Hotline also stresses the importance of policies facilitating legal assistance; adequate reproductive health care access; culturally-specific, queer, and trans inclusive programs; and shifting the power back to those victimized by abusers. In honor of Domestic Violence Awareness Month, stakeholders and policymakers can recognize the role primary care providers play in helping patients recovering from abuse, and advocate for future research and support for patients.
If you or someone you know needs help, call 1-800-799-SAFE, text START to 88788, or visit https://www.thehotline.org/get-help/ to reach the National Domestic Violence Hotline.