Transcript No Slide Title

Physical and Mental Health Effects
of Intimate Partner Violence
Jacquelyn C. Campbell, PhD, RN, FAAN
Anna D. Wolf Chair & Professor
Program Director, RWJF Nurse Faculty Scholars
Johns Hopkins University School of Nursing
Definitional Issues
 CDC: Physical and/or sexual violence (use of
physical force) or threat of such violence; or
psychological/ emotional abuse and/or coercive
tactics when there has been prior physical and/or
sexual violence; between persons who are spouses
or non marital partners (dating, boyfriend-girfriend)
or former spouses or non marital partners
(Saltzman et.al. ‘99)
Versus emotional abuse/controlling behavior a
form of violence
Gender Symmetry – Archer ‘00; Straus; Dutton
Risk factor for health problems versus diagnosis
MMRW ‘08 – BRFSS ‘05 – 4 questions –
physical &/or sexual or threats; weighted;
16 states
600,000 injuries to men: 1.2 ml injuries to
women
Lifetime IPV – 11.5% for men; 23.6% for
women
Significantly higher (p<0.05) among multiracial,
non-Hispanic & American Indian/ Alaska Native
women; & lower-income respondents.
Average of 1200 IP homicides per year of
women – 400 for men (BJS ‘06)
U.S. PREVALENCE
• 35% lifetime IPV (4.4 Million) (Commonwealth
•
•
•
•
•
Fund - Plichta, ‘02)
10.8% physical &/or sexual assault - past 2 years
(Walton-Moss et al ’04)– approx same prevalence in
MSM (Greenwood, Relf et. al. ’03) – significantly
less - female same sex partners (T&T ’01)
3.2% severely abused past year
52% injured (NCVS – ‘06)
20 - 35% seek medical care or hospitalized
85% in the health care system for something (42% of
femicide victims - Campbell et. al. ‘00)
Intimate partner sexual violence
May include…
Forced sex - by force or threat of force
Including forced sexual initiation –
12.5% of women in US – 15-44 - report first
sexual experience is forced (Stockman ’09)
For those whose first sex <15 – 21.5%
Painful sex - clearly indicated as
unwanted
Sex without protection
Overlap between physical, sexual and
emotional abuse (N = 889) (Campbell et. al. ’02
from Ellsberg ’00)
Sexual (N = 243)
32 (3.6)
31 (3.5)
14 (1.6)
166 (18.7)
177
(19.9)
166 (18.7)
Emotional (N = 677)
303 (34.0)
Physical (N = 649)
PHYSICAL HEALTH EFFECTS
• Physical Injury (Facial, fractures, dental,
•
•
neurological -
soft tissue, internal, “falls”- Grisso ‘91)
• (TBI & Strangulation – McClane ‘05)
Neurological Sx - Coker ’00
• Stroke or Sx consistent w/stroke (Black ‘08; Loxton ‘06)
Chronic Pain (Back, abdominal, chest, head) (Campbell
‘00; Coker ‘02)
• Fibromyalgia (Alexander ‘99; Walker ‘00)
• Chronic Irritable Bowel Syndrome (Drossman ‘98)
• Hypertension (Schollenberger et al ’02; Coker ’00)
• Smoking (30-34% victims; 13-15% controls) (Letourneau
’99; MMWR ’08)
New Data from BRFSS (MMWR ‘08)
Women -lifetime IPV
High Cholesterol: AOR 1.3 ([CI] = 1.1--1.4)
Disability AOR = 1.7; activity limitations 2.1
Arthritis AOR = 1.6
Heart Attack; Heart Disease;Stroke :1.4; 1.7; 1.8
Smoking AOR = 2.3
Risk factors for HIV/STD’s 3.1 (CI = 2.4--4.0).
Men: disability equipment, arthritis, asthma,
activity limitations, stroke, risk factors for HIV
infection or STDs, smoking, and heavy or binge
drinking. (AOR’s 1.4 (CI = 1.0--2.0) - stroke to
2.6 (CI = 2.0--3.6) – HIV/STD risk
HEALTH EFFECTS OF FORCED
RELATIONSHIP SEX
40-45% of physically abused women
INCREASED RISK OF:
Unintended pregnancy (Pallito et al ‘04)
Adolescent Pregnancy (Renker ‘02)
Abortion (Evins & Chescheir ‘96)
Vaginal bleeding (Campbell et. al. ‘01)
Anal & vaginal tearing (Campbell & Alford)
Painful intercourse (Eby et. al., ‘95; Coker
‘00; Leserman ‘98)
HEALTH EFFECTS OF FORCED
RELATIONSHIP SEX
Increased Risk of:
STD’s (Eby et. al. ‘95; Coker ’99; BRFSS ‘08)
HIV/AIDS (Gielen ‘94,‘00; Maman ’00, ‘02; Dunkle ‘04)
Pelvic pain, Pelvic Inflammatory Disease,
Infertility (Eby et.al. ‘95; Leserman ‘98; Schei ‘90)
Urinary Tract Infections (Campbell &Alford ‘89;
Coker ‘99; Campbell et. al. ‘00)
Risk of homicide, low self esteem (Campbell
‘89;’99; ‘03)
Cervical Cancer (Coker et. al. ‘00)
New Face of HIV/AIDS – HIV/VAW
interface official recognition by UN ‘04
Around globe women are the fastest group
contracting HIV & fastest group converting to AIDS
In US – poor African American women most
affected (Levenson – The Secret Epidemic)
Africa – women dying most from AIDS – 3:1 ratios
South Africa – Direct link of IPV with HIV+ status Dunkle,
Jewkes et. al. The Lancet 363:1415-21 ’04
Fonck, Kidula – Nairobi, Kenya – AIDS & Behavior ’05
Maman et al – Tanzania – ‘02
Women at risk – heterosexual married women with
few or no behavioral risk factors
Husbands having sex with other women without
wives’ knowledge &/or forcing sex (WHO ’05)
HIV/DV Connections – Etiology (Maman
et. al. ’99; Outwater & Campbell ’05; Tietleman et
al in ‘08)
Immune system depression with stress – decrease
time from HIV+ to full AIDS (<250 CD4 count)
Trauma increasing HIV transmission; anal sex
Increased STD’s & untreated STD’s (Letourneau
‘99; Coker et.al. ’00; King et. al. ’00)
Impossible to negotiate safe sex if a battering
relationship
Women accused of infidelity if want to use safe sex
Males have other partners unknown to women
(WHO multicountry study ’04)
Fear of being beaten for being tested; notifying
partner of positive status; delay in treatment
Substance abuse
MENTAL HEALTH
EFFECTS - Golding ‘99
• Depression 10 - 43 pop; 32 - 70% clinical (9.3% non
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•
abused)
Suicidality 14 - 40% (4.9% non abused)
Post Traumatic Stress Disorder 2 - 12% pop; 31 84% clinical (weighted X prevalence 64% - 5% non
abused)
Alcohol Abuse 4 - 16% pop; 23 - 44% clinical
Drug Abuse 5 - 16% pop; 23 - 44% clinical (2%
non abused)
Eating Disorders - bulimia (McCauley et.al.1995)
Bio-Psycho-Immunologic Response to
Trauma
IPV
Depression
Comorbid
PTSD
HPA axis
HPA axis
 cortisol
cortisol
Th2 shift
Immune Suppression
IgE/IgA Response
Th1 shift
Pro-Inflammatory
Pro Inflammatory Response
Associations with chronic pain – Woods et
al ’05 (fibromyalgia)
Other inflammatory conditions – asthma –
chronic fatigue syndrome, urinary tract
infections
Implications for BMI, obesity
Implicated with cardiovascular disease
ACE study
Co-Morbidity of PTSD & Depression
in Battered Women
Far more comorbidity in battered women
than in rape victims or Vietnam Vets – in
fact recent research suggests that only
depression IF PTSD (Woods ’05)
Predictors: childhood victimization, –
importance of child abuse on physical
health – ACE
Importance of severity of physical abuse
Lifetime trauma response?
Issues of ongoing trauma
Abuse During Pregnancy
8-22% of pregnant women (vs. 7% preeclampsia or hypertension during pregnancy)
Most significant risk factor - abuse before pg.
Pregnancy - protective period or risk period
(1st pregnancy - jealousy); usually neither
Ethnic group comparison - significantly lower
in Hispanic couples (Mexican American) 14% vs. 16% in African American and Anglo
(McFarlane & Parker ‘92)
Prevalence of Abuse Around Time of
Pregnancy (Saltzman et. al. ’03)
9
8
7
6
IPV
Other
>1
Total
5
4
3
2
1
0
Abuse Before Pg
Abuse During Pg
Abuse Around Pg
Abuse During Pregnancy
Maternal health correlates: depression, substance
abuse, low social support, spontaneous abortion,
smoking, risk of homicide (Gielen ‘94; Campbell ‘92)
Perinatal mortality (death btw 28 weeks gestation to
28 days after delivery): 5 of 8 studies - (Coker ‘04;
Janssen ‘03; Leung ‘01; Lipsky ‘04; Pikarinen ‘07;
Taft ‘08; Yost ‘05)
Infant outcomes: LBW – meta analysis (Murphy et
al ‘01) especially in MC women (Bullock &
McFarlane ‘89) & through connections w/ smoking,
low weight gain & substance abuse (Curry et al ‘99)
Gaps in literature / Future Directions
More comprehensive measurement of IPV (e.g.
overlapping types, frequency, duration, age at
first experience; lifetime trauma) to establish
dose-response.
Cohort studies to establish temporal sequence.
Mediators & moderators of effects of IPV on
health. (resiliency and risk)
Need biologic markers to determine physiological
mechanisms on how IPV adversely affects
health. e.g. immune functions, neuroendocrine
response and measures of vascular response.
Validate health outcomes with medical records or
biologic testing when possible.
Replication of studies particularly for chronic
disease
Interventions in Health Care system
Mixed reviews on routine inquiry
Sufficient prevalence and health consequences
Sufficient evidence of acceptance by women
(e.g. Gielen, Campbell et al ’06; ‘00)
Sufficient evidence of methods of inquiry –
questions & strategy & system (e.g Trautman et
al ‘07; Campbell ‘92; Rabin et al AJPV ‘09)
But insufficient evidence of intervention efficacy
– 2 trials completed & to be reported on ‘09
Two trials in home visitation settings underway
More intervention development & trials needed
– other settings - e.g. substance abuse Tx
Challenges remain
IOM committees - reports ’98; ’02 –
workshop ‘09 – global
recommendations for funding for research;
centers on family violence; training for
researchers – few recommendations
followed through
Sporadic NIH RFA’s – CDC funding
continuous but new calls yearly - insufficient
for full clinical trials, sustained programs of
research