Clinical Approach to Intimate Partner Violence and Sex Trafficking

Educational Objectives

The goal of this program is improve recognition of intimate partner violence (IPV) and sex trafficking (ST). After hearing and assimilating this program, the clinician will be better able to:

1. Recognize common indicators of IPV and ST to identify potential victims.
2. Create an environment conducive to disclosure of IPV or ST.

Summary

Intimate partner violence (IPV): a pattern of assaultive and coercive behaviors aiming to establish control over a current or former partner; includes physical violence, psychological aggression, sexual abuse or assault, reproductive coercion, stalking, social isolation, deprivation or neglect, intimidation, and threats; economic costs — estimated at $3.6 trillion (for IPV injuries, loss of productivity, and criminal justice); lifetime costs for a woman exceed $100,000

Sex trafficking (ST): exploitation of a person for a commercial sex act; induced by force, fraud, or coercion; for persons <18 yr of age, it is unnecessary to prove force, fraud, or coercion, per federal law

Statistics: IPV — in the United States (US), 1 in 4 women experience IPV, 1 in 5 are sexually assaulted in college, and >3 women per day are murdered by their male partners; women 20 to 24 yr of age are at highest risk for nonfatal IPV; globally, 1 in 3 women experience IPV in their lifetime; 11 million women report dating violence (at <18 yr of age) and are at high risk for pregnancy; ST — in 2019, 15,000 cases were reported in the US; 4.8 million persons were forced into ST globally, with women and children representing 99% of victims

Risk factors: IPV — female gender; prior history of domestic violence; witnessing violence as a child; low socioeconomic status; young age; disparities within a relationship; high-risk sexual behaviors; substance abuse; ST — generational trauma; historic oppression; discrimination (related to, eg, ethnicity, sexual orientation); unstable housing; history of domestic violence; history of childhood sexual abuse; having a caregiver with a substance abuse disorder; being a runaway; involvement with the juvenile justice or foster care system; being undocumented; low socioeconomic status; addiction; cognitive disability

Indicators of IPV: suspicious injuries — if history is inconsistent with the injury, ask more questions; evaluate for evidence of strangulation, burns, serious head injury, beatings (eg, facial fracture, loose or broken teeth), bite marks, and bruising on the inner thigh; multiple wounds in various stages of healing indicate ongoing events; review history for reports of frequent falls, sprains, and/or fractures; if any of these are found, examine for additional injuries; worrisome behaviors — refusal of a companion to leave the patient alone or to allow the patient to answer questions (frequently interrupts or corrects the patient); patient body language consistent with anxiety (eg, has downcast eyes, appears unduly subordinate, is hypervigilant); distress out-of-proportion to the medical concern; fear upon examination; delay in seeking care; vague complaints; overuse of medical care; poor adherence; reproductive health — sexually transmitted infections (may indicate “survival sex”); genital injury; unplanned pregnancy; multiple abortions; substance abuse during pregnancy; mental health — IPV is associated with high rates of postpartum depression, self-harm, posttraumatic stress disorder, anxiety, depression, disordered eating, and cognitive issues

Indicators of ST: branding (tattoos or tagging chips); high number of sex partners; inappropriate clothing; appearing younger than stated age; use of rough language or terms common to the sex industry; impact of adverse childhood experiences — affects neurodevelopment; adults often present with risky health behaviors as coping mechanisms, eg, substance abuse, disordered eating, self-harm; incidence of chronic disease and early death is elevated; patients may present with chronic pain syndromes, infertility, heart or lung disease, musculoskeletal disorders, or sleep disturbances; increased risk for incarceration and homelessness for women; economic dependence on the abuser; frequent moves; social isolation; poor academic or work performance and frequent absences

Promoting disclosure: recognize patient, provider, and cultural barriers to disclosure; victims are often in high-risk groups from marginalized populations and may be severely traumatized; limited time with the patient can inhibit formation of trusting relationships; gender privilege and economic challenges complicate the issue; basis of trauma-informed care — create a comfortable environment, emphasize confidentiality, ask permission, and provide support; provide rationales for questions (to normalize questions, explain the pervasiveness of trauma and abuse); be prepared to respond effectively, show empathy, provide aftercare with follow-up, and identify resources; listen to the patient with an open mind; avoid culturally-based assumptions; use an interpreter unconnected to the violence or abuse; do not interrupt

Approaching IPV and ST: begin with open-ended questions and follow with direct questions; ensure confidentiality and do not pressure disclosure; include abuse and neglect in the differential diagnosis; do not make assumptions based on culture or socioeconomic status; consider the victim's perspective (fear, shame, lack of trust, language barriers, lack of self-identification as a victim, and traumatic bonding may inhibit disclosure); be truthful about limits of confidentiality and reiterate the intent to maintain privacy; consider explaining laws before asking questions; explain when, where, and what will be reported; accept answers without challenge; develop a plan that places patient-identified needs first; perform a short safety assessment by asking whether the patient is afraid to go home or has ever been threatened with violence; provide links to social and legal services and resources; schedule follow-up; respect individual decisions

Reporting: documentation — include a detailed description of the disclosure, preferably with quotations, detailed description of the physical examination, and medical concerns; document a follow-up plan, including resources provided and the safety assessment; mandatory — for children, elders, and vulnerable adults; if abuse, neglect, or exploitation is suspected, no proof is needed; contact protective services, according to law; indicate whether ST is suspected (requires a different protocol); there is no reporting requirement for domestic violence in adults, except in cases of life-threatening injury

Readings

Ahmad I et al. Intimate partner violence screening in emergency department: a rapid review of the literature. J Clin Nurs. 2017;26:3271-3285; doi: 10.1111/jocn.13706; Dicola D, Spaar E. Intimate partner violence. Am Fam Physician. 2016;94:646-651; Leslie J. Human trafficking: Clinical assessment guideline. J Trauma Nurs. 2018;25:282-289; doi: 10.1097/JTN.0000000000000389; Lutgendorf MA. Intimate partner violence and women's health. Obstet Gynecol. 2019;134:470-480; doi: 10.1097/AOG.0000000000003326; Ogunsiji O, Clisdell E. Intimate partner violence prevention and reduction: A review of literature. Health Care Women Int. 2017;38:439-462; doi: 10.1080/07399332.2017.1289212; Oral R et al. Adverse childhood experiences and trauma informed care: the future of health care. Pediatr Res. 2016;79:227-233; doi: 10.1038/pr.2015.197; Prosman GJ et al. Healthcare utilization by abused women: a case control study. Eur J Gen Pract. 2012;18(2):107-113. doi:10.3109/13814788.2012.675503; Roberts SJ et al. A model for trauma-informed primary care. J Am Assoc Nurse Pract. 2019;31:139-144; doi: 10.1097/JXX.0000000000000116; Walker RM. Mandatory reporting of intimate partner violence: an ethical dilemma for forensic nurses. J Forensic Nurs. 2017;13(3):143-146. doi:10.1097/JFN.0000000000000159.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Harrison was recorded at the Health of Women 2021, held virtually on June 25 to August 13, 2021, and presented by the Virginia Commonwealth University Institute for Women’s Health. For future CME activities from this presenter, please visit Vcu.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the publication of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB682002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.