CHAPTER 13 Domestic Violence, Health, and the Health System Response ❖ 345
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distribute or post, copy, not Do Copyright ©2017 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. 13 ❖ Domestic Violence, Health, and the Health distribute System Response or Chapter Overview Abused women use health care more than any otherpost, resource, including criminal justice. They may visit a doctor’s office, clinic, or hospital emergency department (ED). Their visit may involve injury, a secondary consequence of abuse such as depression or an unwanted pregnancy, or a problem with no apparent relation to abuse. In every encounter, the health professional can afford female patients the opportunity to identify abuse as a concern and, if identified, can open a window to the full spectrum of their experience, facilitate access to relevant information about their options, help plan for their immediate safety if needed, and incorporate an understanding of abuse into their ongoing care. Simply asking about abuse conveys its importance as a health issue. A successful strategy to manage or prevent abuse is inconceivable without an active role by the full range of medical, health, and mental health practitioners. copy, This chapter reviews evidence on the significance of domestic violence and coercive control for women’s health and on the health-care response. We identify the physical, mental, and behavioral health consequences of abuse, emphasizing its impact on reproductive health and populations with special needs. Next, we outline the response of the health systemnot to abuse and consider major challenges to reforming this response. These challenges include adapt- ing an all-inclusive definition of partner abuse; distinguishing new from ongoing cases; deciding how best to screen for abuse; understanding what “clinical violence intervention” implies for traditional approaches to patient care; learning to look beyond violence to coercive control; and appreciating the pros and cons of mandated reporting. MeetingDo these challenges entails complementing the medical paradigm with a public health perspective consistent with rooting the health response in a broader coordinated community response, an approach we term “complex social prevention.” 343 Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. 344 ❖ PART III THE SOCIETAL RESPONSE The Role of Health Service The criminal justice system in the United States is part of a state bureaucracy and so is accountable to centralized administrative and policy directives. By contrast, the health system in the United States consists of an amalgam of private, nonprofit, and federal institutions that operate in a competitive market. There is no constitutional right to health care in the United States as there is to justice resources. As a result, health services are provided and must be accessed by individuals largely through contractual relationships financed by an eclectic mixture of fee-for-service, work-based insurance, and government funds. What some observers describe as the “dis-organization” of U.S. health care has meant that the health care response to abuse has been much more varied and piecemeal than the response by the legal or criminal justice systems. Despite the sharp reduction in the uninsured population brought about the 2012 Affordable Care Act, significant financial, cultural, and demographic barriers continue to constrain victim access to quality health care, let alone to health services designed for abuse victims. An early glimpse at the significance of partner abuse for the health system was provided by two surveys in the early 1980s. A Kentucky Harris Poll showed that 17% of abused women had used emergency medical services because of violence and a Texas survey found that 385,595 women in that state had done so (Stark & Flitcraft, 1988; Teske & Parker, 1983). Meanwhile, the Yale Trauma Studies (YTS) conducted at Yale–New Haven Hospital demonstrated that domestic violence was the leading cause of injury for which adult women sought care and a major context for a range of other medical, behavioral, and mental health problems (Stark & Flitcraft, l988). Bydistribute 1992, the American Medical Association (AMA Council of Scientific Affairs, 1992) estimated that more than 1.5 million women nationwide sought medical treatment for injuries related to abuse annually. Subsequent research confirmed both the absolute and relative significance of abuse for women’s health, showing that victims of abuse makeor more visits to health-care providers over their lifetime than non-battered women, have more and longer hospitalizations, and are at greater risk for needing healthcare for a variety of problems than non-victims (Black, 2011). Estimates of the costs of providing health care to abused women have grown alongside the growing awareness of its significance, escalating from approximately $5.8 billion in 1995 to $8.3 billion in 2003 to more than $10 billion today. These estimates include both the direct costs for medical and mental health services and the indirect costs resulting from productivity lost due to abuse-relatedpost, morbidity and mortality (Centers for Disease Control and Prevention, 2003; Max, Rice, Finkelstein, Bardwell, & Leadbetter, 2004). One response to abuse-related health costs was that 8 of the 16 largest insurers in the country either denied coverage to battered women or charged them higher rates (Fromson & Durborow, 2001), a practice known as “pink lining.” This form of discrimination was outlawed by the Health Care Reform Act (HCRA) of 2010. copy,PINK LINING Discrimination risks are real. A woman from rural Minnesota was beaten severely by her ex-husband. After remarry- ing, she applied for health insurance and was told that she would not be covered for treatment relating to the abuse- related preexisting conditions of depression and neck injury. Studies by the Insurance Commissioners in Pennsylvania and Kansas revealednot that 24% of the responding companies used domestic violence as an underwriting criterion when issuing and renewing insurance (Fromson & Durborow, 2001). Do It may seem obvious why victims of violence would require health services in such large numbers. Media portray- als like the graphic video of NFL running back Ray Rice knocking out and then dragging his unconscious fiancée out of an elevator reinforce a widespread association of partner abuse with the types of injuries that would prompt any person to seek emergency care. But equating partner abuse with injurious violence captures only part of its significance for health—and not necessarily the most important part. Serious and even fatal injuries are all too common in abusive Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. CHAPTER 13 Domestic Violence, Health, and the Health System Response ❖ 345 relationships. In most cases of abuse, however, episodes of extreme violence are part of the larger pattern of coercion and control described in Chapter 4. The violence in this pattern is marked less by its severity than by its frequency, duration, sexual nature, and cumulative effects on a particular victim. As importantly from a health perspective, in a majority of cases, the effects of the violence are confounded by the consequences of the range of coercive and control- ling tactics that complement physical assault. As a result, most health visits by battered women are to primary care rather than emergency medical sites and involve medical, behavioral, mental health, and psychosocial problems sec- ondary to this pattern of coercive control. Indeed, clinicians or health systems that limit intervention to the ER or rely on injury to identify abuse miss the vast majority of battered women in their care and are likely only to identify victims after they have developed a complex clinical profile requiring extensive resources. Some of what we say about female victims of male partners applies to male victims of female partner violence as well as to transgender victims and victims coupled with persons who share their gender identity. Although we have extensive survey evidence of female-to-male partner violence, few studies have compared the abuse-related health profiles of male and female victims and fewer still have differentiated health outcomes by the sexual orientation of offenders or victims. Many of these studies find that the modal pattern of violence is bidirectional, though even in these cases there are significant differences in the dynamics and outcomes of the abuse by gender. Phelan, Hamberger, Hare, and Edwards (2000) compared men and women presenting complaints of injury at a level 1 trauma center for emergency medical services and who reported being indistribute a currently violent or abusive relationship. In this study, men reported significantly higher rates of violence initiation than women did. One hundred percent of the men reported they initiated violence between 50% and 100% of the time. In contrast, fewer than 1 woman in 10 reported initiating violence more than 20% of the time. Even in situations where violence was bidirectional, the women in these relationships were significantly more likelyor than the men to be injured by partner violence, to be injured more severely, to seek health care, and to experience a range of negative health