Doc Talk: Domestic Violence the Silent Public Health Crisis

With October being National Domestic Violence Awareness Month, it is important to Women’s Health Connecticut (WHC) to shine a light on this public health crisis. Nationally, 1 in 4 women have experienced severe physical violence in their lifetime, and in Connecticut specifically, 12 to 14 women die every year from intimate partner violence (IPV). To provide advocacy and support for victims and survivors, WHC has partnered with the Connecticut Coalition Against Domestic Violence (CCADV) to receive training related to victim response to IPV and instituted a policy that all of our practices screen and connect patients in need with assistance. At WHC, our goal is to always keep our patients safe, healthy, and well.

To better understand how our IPV screening works and the resources available to our patients, we spoke with Dr. Tracy Brennan of Women’s Comprehensive Health Care and Ashley Starr Frechette the Director of Health Professional Outreach at CCADV. 

What is domestic violence?

Ashely Starr Frechette (ASF): Domestic violence is a pattern of abusive behavior in an intimate relationship where one partner tries to control and dominate the other. The behavior may be verbally, psychologically, physically, or sexually, financially, or technologically abusive with the victim left feeling scared, confused, dependent and insecure.

Dr. Tracy Brennan (TB): Domestic violence is also a public health crisis. It affects twice as many women as breast cancer (1 in 4 women is currently in a relationship with IPV or has been in the past).  Domestic violence has increased significantly during the pandemic, with our shelters in Connecticut operating at 145% capacity.

Why has there been a spike in domestic violence recently?

ASF: Unfortunately, domestic violence has always been there, but COVID-19 has really put a spotlight on the importance and need for increased IPV resources. Victims and survivors who are already more vulnerable to economic and health insecurity are facing additional challenges during the pandemic. With the increased stress and isolation associated with COVID-19, CCADV saw an increase in the number of individuals reaching out for IPV services. At the height of the pandemic, contacts to CT Safe Connect increased by more than 30% with more than a half of the contacts reaching out for the first time. With so many people confined to their homes the ability to reach out to usual support systems or even just to verbalize an issue have been greatly diminished.

How have CCADV and WHC worked together to help victims of domestic violence?

TB:  WHC has made a commitment to discuss IPV during every annual visit, during every trimester prenatally, during the routine postpartum visit, and whenever there is a concern regarding IPV raised by a physical finding on exam. WHC providers recognize the health concerns associated with IPV. We complete education yearly regarding IPV. We are determined to shatter the culture of shame and silence regarding IPV. Some of our staff members have completed extensive training and become advocates. They are available as a resource for providers, patients, and colleagues.

 ASF: For the past three years, WHC has created a policy whereby every practice must screen patients for IPV and make referrals to CT Safe Connect. WHC continues to have all staff educated by CCADV and trained to incorporate five IPV questions into the initial intake for every patient, at every appointment.

WHC also leads the way with patient security designed into the electronic medical record system.  This supports and ensure the safety of all victims and survivors. WHCT worked together with CCADV to add a separate, safe, and secure area of the online medical chart to document any positive disclosures of IPV.  This “Purple Ribbon” tab allows WHC health professionals to safely document IPV screening results without the fear that this information will be transferred to the patient’s at-home medical chart, which can be monitored by abusers, or printed out when records are requested.  The Purple Ribbon tab ensures that all IPV information is fully confidential and can only be accessed by the health professional working with the patient. This an incredibly helpful accommodation that serves to increase the safety of patients across the state.

What is IPV screenings, and how do our provider screen patients?

TB: There are a series of questions asked annually regarding IPV. These questions explore the issue of physical and sexual violence but also alert patients to the concept that IPV sometimes takes the form of social isolation and financial control without physical violence. These questions are asked on our intake form and then addressed by the provider during the exam.

ASF: WHC has a set of 5 questions and educational scripts to use with each patient. They also make sure to screen each patient alone and if there is a positive disclosure, they make a warm referral to their own onsite IPV advocates (if applicable) or directly to CT Safe Connect. This direct connection results in a much higher rate of patients seeking and following through with IPV resources.

Why is it important for women’s healthcare providers to do IPV screenings?

TB: Women's healthcare providers are involved in this issue because IPV is intimately connected to many other major health concerns: asthma, diabetes, hypertension, obesity, chronic pelvic pain, chronic depression, and maternal mortality. The number one cause of maternal mortality in the US is homicide and 50% of the time the homicide is committed at the hands of an intimate partner.

ASF: WHC health professionals have a unique opportunity to increase the safety of their patients by screening for, and educating on, IPV. IPV screens can assist patients who may have experienced violence in the past, who are currently experiencing violence, or may experience it in future relationships. Knowing that your health professional cares enough to ask about IPV sends a message to patients that this is an important health topic, and that they have someone to turn to if they need. There is a lot of silence and avoidance when it comes to talking about unhealthy relationships. Adding the screening and education that WHC has, for the past few years, breaks that silence and offers a safe place for patients to turn. Through implementation of this screen, WHC has been able to reach a population that might not otherwise known about the resources and supports available to them.  

What is the approach of a provider with a patient they think is a victim of IPV?

TB: I ask partners to leave the room when I do IPV screening.  I simply say, "I have some questions to ask your wife/girlfriend/partner and I'm going to ask you to step out for a moment.”  We also have a system in our office where a patient can place a colored sticker on their urine specimen which indicates that they are experiencing IPV or have some issue that needs to be discussed privately with the provider. The pandemic has been a unique opportunity to discuss IPV because partners have not been allowed in the office during visits.

There are many ways to start the conversation if you suspect a patient may be suffering IPV.  I have found that one of the simplest ways to address patients is to say: "I am worried about your safety, is everything ok at home?" When we approach this topic from a safety perspective it helps to remove some of the shame associated with disclosing, it implies: "this is not your fault!"

What happens after someone has disclosed they have experienced IPV?

TB: The first thing I say to a patient after they disclose to me is "I am so sorry you are going through this- I would like to help". I encourage patients to let me place a call to CT Safe Connect (1-888-774-2900) and connect them to an advocate. We have trained advocates in many of our offices and at WHC so we can connect patients easily to an advocate. I then let the patient speak privately to the advocate.

ASF: If someone discloses IPV, WHC staff are trained to listen, support, educate and make a warm referral to a certified IPV advocate. WHC is able to utilize their own staff, who are certified IPV advocates, to start that safety planning and resources for victims and survivors. This helps make a warm referral, starts the safety planning process, and increases the number of victims and survivors that follow up with resources and supports. Once connected with Safe Connect they are able to connect the victims/survivor with one of our 18 member organizations that serves the town that they reside in.

How as a community can we help end domestic violence?

TB: Perhaps the most important step is for all of us to know how to help women suffering from IPV. By not talking about this subject we have all been complicit in the culture of shame and silence. We should all have the CCADV.org website and CT Safe Connect (1-888-774-2900) number at our fingertips. I have asked all my patients to keep that information in their phones. If there is someone in our life who we suspect may be suffering from IPV, reach out, tell them you are worried about their safety-offer to help by connecting them to resources. Let them know you are willing to talk about it!

ASF: What we can do here in the state of Connecticut, is break the silence around IPV. We can start the conversation around what healthy relationships are, and where resources are available. The more people that are aware of what IPV is, how to get help, and who to turn to, the more we can help reduce IPV. Health professionals have a particularly unique opportunity to make IPV education a part of every patient interaction, just as WHC has done. Opening the conversation about what healthy relationships are and the resources available here in Connecticut can help break that silence and continue to spread the word.

Women’s Health Connecticut wants our patients to know that you are not alone. IPV affects everyone and crosses all socioeconomic, education and gender boundaries. Your appointment is a safe space that your provider will listen to your concerns and experiences without judgment or shame.

If you or anyone you know are experiencing IPV, you can reach a certified IPV advocate, 24/7, through the statewide hotline, CT Safe Connect. All services are free, confidential, safe and voluntary. CT Safe Connect is there to meet the individual where they are at and make a safety plan based from their specific needs and wants. They will then help connect to one of our 18 organizations across the state. Individuals do not even have to say their name if they are not comfortable. 

CT Safe Connect advocates can be reached by calling or texting 888-774-2900, or by live chat or email at www.ctsafeconnect.org