Remarks to IOM Committee on Preventive Services for Women
Esta Soler, President and Founder, Family Violence Prevention Fund
“Thank you for the opportunity to speak here today, and for your work on this important committee. I am Esta Soler, founder and president of the Family Violence Prevention Fund. I’m here to ask you to reconsider the evidence around assessment and counseling for intimate partner violence (IPV) and recognize it as the critical component of preventive health services for women that it is.
For more than 15 years, the Family Violence Prevention Fund has run the U.S. Department of Health and Human Services-designated National Health Resource Center on Domestic Violence. The National Health Resource Center is the nation’s clearinghouse for information on the health care response to domestic violence. We provide training and technical assistance to thousands of health providers each year.
In that and our other work, we have seen the long-lasting, sometimes devastating, health effects of violence and abuse. The research is clear. Domestic and sexual violence are one of the most significant social determinants of health for women and girls. Nearly one-third of women in the United States report being physically or sexually abused by a husband or boyfriend some time in their lives. In clinical studies, the percentage of patients who have been exposed to abuse can be as high as 50 percent of the patients seen.
Women who have experienced domestic violence are 80 percent more likely to have a stroke, 70 percent more likely to have heart disease, and 60 percent more likely to have asthma than women who have not experienced this violence.
Day to day, women who have been abused utilize the health system at much higher rates. Women who are victimized by violence have 17 percent more primary care doctor visits, 14 percent more specialist visits, and 27 percent more prescription refills than non-abused women.
As others speak today on the importance of women’s reproductive health, I want to highlight this issue in the context of violence. There is a clear link between sexual and domestic violence and a range of reproductive health problems including unintended pregnancies, transmission of sexually transmitted diseases including HIV, miscarriages and more. Abuse increases the likelihood of teen pregnancy; adolescent girls in abusive relationships are 3.5 times more likely to become pregnant than their non-abused peers. That’s no surprise, given the prevalence of rape and pregnancy pressure in abusive relationships.
Over time, we also have learned more about how witnessing and experiencing violence affects children’s health. According to the Centers for Disease Control and Prevention, children with adverse childhood experiences grow up to have significantly higher risk of smoking, alcoholism, substance abuse, depression, and suicide. The CDC also links childhood exposure to violence with chronic health conditions including obesity, asthma, arthritis, and stroke.
With 15.5 million children exposed to violence each year, these long-term health effects are likely to continue – unless we learn to stop the violence that pervades so many relationships and homes.
Health care providers can help do just that and, in doing so, help prevent the health problems that result – if they identify and assist women at risk. But most providers don’t do so now, because they haven’t been educated or encouraged to assess patients for abuse, and because our health system doesn’t support this essential intervention.
Most health professional organizations – including the American Medical Association, American Nurses Association, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Psychological Association, American Academy of Pediatrics, and the Joint Commission on the Accreditation of Health Care Organizations – endorse routine assessment for domestic violence. For good reason. This simple intervention – done separately or as part a bundled service visit (such as preconception or well-woman visit) – can protect patients from violence now, and mitigate its long term health consequences.
In 2004, when the US Preventive Service Task Force (USPSTF) concluded that there was insufficient evidence to recommend routine screening in health care settings for partner violence and child abuse, the outstanding question was about the effectiveness of screening. At that time, the Task Force treated family violence as a medical screen.
We ask the Committee to instead examine assessment and counseling for intimate partner violence as a behavioral health practice, using the same standards applied to other behavioral health recommendations. Assessment and brief counseling about abuse should be considered in the framework of other important health risks and behaviors such as substance use, unintended pregnancies and safety practices, for which the Task Force recommends clinician interventions. Here too, clinicians who assess are attempting to identify the undiagnosed patients who are experiencing domestic violence in order to offer harm reduction strategies and link them to resources.
Providers may not be able to influence abusers’ behaviors, but by identifying domestic violence and offering education and referrals, they can prevent future injuries and illness, and improve overall quality of care. This creates a significant public health benefit.
In addition to addressing our concerns that the Task Force reviewed family violence as a medical screen, we also encourage this Committee to review the new data that has been released on assessment and response to partner violence. Separate from my remarks today, we will present to this Committee a list of references. These studies confirm that we know how to do effective brief assessments for intimate partner violence and the questions to ask. We also know that computerized assessment works well to increase identification.[i]
Let’s be clear: Women want to be asked. There are multiple studies that demonstrate that women support assessment for abuse. In 2008, a new study that incorporated intimate partner violence into an integrated intervention among pregnant African American women found that the intervention could be implemented in a prenatal setting without significant disruption of services. The majority of referred African American women in the study expressed satisfaction with treatment sessions.[ii]
Most importantly, though, new research has found that assessments paired with brief interventions can improve health outcomes. And since 2004, there is new evidence that assessment – asking about abuse – does not harm patients.[iii]
One randomized control trial published in 2005 found that when assessment is coupled with education, harm reduction and referrals to services, intimate partner violence can be reduced AND the health status of women improved.[iv]
Another new randomized control trial published in Obstetrics and Gynecology this year found that brief intervention during pregnancy can decrease partner violence victimization and related poor pregnancy outcomes[v]. Yet another randomized control trial published this year in Contraception found that women who received a brief intervention reported fewer incidents of birth control interference and were more likely to leave relationships that were unhealthy and unsafe.[vi]
We need to continue assessment and brief counseling in health settings. We need to train health care providers so they know how to help if a patient discloses domestic violence. We need to train health care providers to connect abused patients to skilled service providers in their communities who can help.
Over the last 15 years, providers have told us time and again that lack of coverage and other system supports prevent them from doing this work. We need to change that.
The Justice Department reports that four to five women are murdered each day by current or former husbands or boyfriends. The Centers for Disease Control and Prevention report that women in this country suffer two million injuries from domestic violence each year. It’s time – past time – that we use every tool at our disposal to identify and help victims of partner violence.
I ask you to take a moment to think about what life is like for a woman experiencing domestic violence. Your home isn’t safe. You never know if the next moment will bring an assault. The violence is escalating, your confidence is gone, and your children are suffering. You’ve learned to hide the trauma and the terror, because you’ve had no choice. But you have a few moments, alone with a doctor or a nurse who is concerned about your health and well-being. Imagine the difference it can make if, in those few moments, your health provider asks about your safety, and knows how to help if you disclose abuse. And think about the lost opportunity – and the consequences – if that question is never asked.
I urge you to implement coverage for assessment, counseling and referrals without delay, to prevent the recurrence of abuse for women at risk of violence.
[i] Trautman, D. E., McCarthy, M. L., Miller, N., Campbell, J. C., & Kelen, G. D. (April 2007). Intimate Partner Violence and Emergency Department Screening: Computerized Screening Versus Usual Care. Annal of Emergency Medicine , 49 (4), 526.
[ii] Katz, K. S., Blake, S. M., Milligan, R. A., Sharps, P. W., White, D. B., Rodan, M. F., et al. (2008). The Design, implementation and acceptability ofan intergrated factors among pregnant African American Women. BMC Pregnancy and Childbrith , 1-22.
[iii] MacMillan, H., Wathen, N., Jamieson, E., et al. (2009). Screening for Intimate Partner Violence in Health Care Settings. JAMA, 493-501.
[iv] Tiwari, A., Leung, W., Leung, T., Humphreys, J., Parker, B., & Ho, P. (2005). A randomised controlled trial of empowerment training for Chinese abused pregnant women in Hong Kong. BJOG: an International Journal of Obstetrics and Gynaecology , 1-10.
[v] Kiely, M., El-Mohandes, A., El-Khorazaty, M., Gantz, M. (February 2010). An Integrated Intervention to Reduce Intimate Partner Violence in Pregnancy. Obstetrics and Gynecology, Vol 115, No. 2, Part 1.
[vi] Miller, E., Decker, M., McCauley, H. Tancredi, D., Levenson, R., Waldman, J., Schoenwalk, P., Silverman, J. (April 2010). Pregnancy Coercion, Intimate Partner Violence and Unintended Pregnancy. Contraception, Vol. 81, Issue 4, 316-322.