Megan R. Gerber

Abused Women Disclose Partner Interference with Health Care: An Unrecognized Form of Battering

BACKGROUNDSome providers observe that partners interfere with health care visits or treatment. There are no systematic investigations of the prevalence of or circumstances surrounding partner interference with health care and intimate partner violence (IPV).OBJECTIVETo determine whether abused women report partner interference with their health care and to describe the co-occurring risk factors and health impact of such interference.DESIGNA written survey of women attending health care clinics across 5 different medical departments (e.g., emergency, primary care, obstetrics–gynecology, pediatrics, addiction recovery) housed in 8 hospital and clinic sites in Metropolitan Boston.PARTICIPANTSWomen outpatients (N = 2,027) ranging in age, 59% White, 38% married, 22.6% born outside the U.S.MEASUREMENTQuestions from the Severity of Violence and Abuse Assessment Scale, the SF-36, and questions about demographics.RESULTSOne in 20 women outpatients (4.6%) reported that their partners prevented them from seeking or interfered with health care. Among women with past-year physical abuse (n = 276), 17% reported that a partner interfered with their health care in contrast to 2% of women without abuse (adjusted odds ratios [OR] = 7.5). Further adjusted risk markers for partner interference included having less than a high school education (OR = 3.2), being born outside the U.S. (OR = 2.0), and visiting the clinic with a man attending (OR = 1.9). Partner interference raised the odds of women having poor health (OR = 1.8).CONCLUSIONSPartner interference with health care is a significant problem for women who are in abusive relationships and poses an obstacle to health care. Health care providers should be alert to signs of patient noncompliance or missed appointments as stemming from abusive partner control tactics.

Assessing Intimate Partner Violence in Health Care Settings Leads to Women's Receipt of Interventions and Improved Health

Objective. This study investigated whether disclosure of violence to health care providers and the receipt of interventions relate to womens exit from an abusive relationship and to their improved health. Methods. A volunteer sample of 132 women outpatients who described intimate partner violence during the preceding year were recruited from multiple hospital departments and community agencies in suburban and urban metropolitan Boston. Through in-person interviews, women provided information on demographics, past year exposure to violence, past year receipt of interventions, and whether they disclosed partner violence to their health care provider. They also described their past month health status with the 12-Item Short-Form Health Survey and further questions. Results. Of the 132 women, 44% had exited the abusive relationship. Among those who were no longer with their partner, 55% received a domestic violence intervention (e.g. advocacy, shelter, restraining order), compared with 37% of those who remained with their partner. Talking to their health care provider about the abuse increased womens likelihood of using an intervention (odds ratio [OR]=3.9). Those who received interventions were more likely to subsequently exit (OR=2.6) and women no longer with the abuser reported better physical health based on SF-12 summary scores (p=0.05) than women who stayed. Conclusions. Health care providers may make positive contributions to womens access to intimate partner violence services. Intimate partner violence interventions relate to womens reduced exposure to violence and better health.

Extinction retention and the menstrual cycle: Different associations for women with posttraumatic stress disorder.

The propensity to acquire and retain conditioned fear responses may contribute to the risk of developing and maintaining posttraumatic stress disorder (PTSD) following a traumatic event. There is growing evidence that the gonadal hormones estrogen and progesterone are associated with how well women retain extinction of previously conditioned fear responses. Thus, sex steroid effects may contribute to the increased prevalence of PTSD in women. For the current study, 32 nonmedicated female trauma survivors with and without PTSD completed a differential fear conditioning task both during the early follicular phase of the menstrual cycle when estradiol and progesterone levels are low, and during the midluteal phase when estradiol and progesterone levels are high. Skin conductance served as the measure of conditioned fear. Women with PTSD, compared to those without, showed impaired retention of extinction learning in the midluteal phase of the menstrual cycle. Therefore, the impact of menstrual phase on extinction retention may differ between women with and without PTSD. These findings raise potential considerations regarding the coordination of psychopharmacologic and trauma exposure-based treatments for PTSD with specific phases of the menstrual cycle.

Women Veterans and Intimate Partner Violence: Current State of Knowledge and Future Directions

Intimate partner violence (IPV) is a serious public health concern for all; however, women who experience IPV are more likely to sustain injury and report adverse health consequences. An expanding body of research suggests that experience of IPV is common in women veterans (WV), particularly those who access Veterans Health Administration (VA) services. With unprecedented numbers of women serving in the military and subsequently becoming veterans, it is critical that clinicians and advocates caring for WV understand the impact of IPV on this population. WV have unique risk factors for experiencing IPV, including high rates of premilitary trauma, as well as military sexual trauma and posttraumatic stress disorder (PTSD). Correlates of IPV, traumatic brain injury (TBI) and homelessness, are common among this group. Although research on WV health and IPV is emergent, evidence suggests that IPV results in multiple health sequelae and increased healthcare utilization. In this context, we next discuss clinical and policy implications for VA. A number of targeted interventions and treatments are available for WV who experience IPV, including evidence-based mental health services. VA is well situated to implement screening programs for WV to facilitate referral to needed services and treatments available both within and outside its facilities. As the population of WV expands, future research will be needed to determine best practices; many avenues of inquiry exist. Finally, WV are strong and resilient; it is crucial that those who work with them recognize evidence of IPV and refer to needed services and evidence-based treatment to enable strength-based recovery.

The effect of a yoga intervention on alcohol and drug abuse risk in veteran and civilian women with posttraumatic stress disorder.

BACKGROUND Individuals with posttraumatic stress disorder (PTSD) often exhibit high-risk substance use behaviors. Complementary and alternative therapies are increasingly used for mental health disorders, although evidence is sparse. OBJECTIVES Investigate the effect of a yoga intervention on alcohol and drug abuse behaviors in women with PTSD. Secondary outcomes include changes in PTSD symptom perception and management and initiation of evidence-based therapies. MATERIALS AND METHODS The current investigation analyzed data from a pilot randomized controlled trial comparing a 12-session yoga intervention with an assessment control for women age 18 to 65 years with PTSD. The Alcohol Use Disorder Identification Test (AUDIT) and Drug Use Disorder Identification Test (DUDIT) were administered at baseline, after the intervention, and a 1-month follow-up. Linear mixed models were used to test the significance of the change in AUDIT and DUDIT scores over time. Treatment-seeking questions were compared by using Fisher exact tests. RESULTS The mean AUDIT and DUDIT scores decreased in the yoga group; in the control group, mean AUDIT score increased while mean DUDIT score remained stable. In the linear mixed models, the change in AUDIT and DUDIT scores over time did not differ significantly by group. Most yoga group participants reported a reduction in symptoms and improved symptom management. All participants expressed interest in psychotherapy for PTSD, although only two participants, both in the yoga group, initiated therapy. CONCLUSIONS Results from this pilot study suggest that a specialized yoga therapy may play a role in attenuating the symptoms of PTSD, reducing risk of alcohol and drug use, and promoting interest in evidence-based psychotherapy. Further research is needed to confirm and evaluate the strength of these effects.

Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension

The 4-item Hurt/Insult/Threaten/Scream (HITS) tool accurately detects past-year intimate partner violence (IPV) among female Veterans Health Administration (VHA) patients; however, it lacks a sexual IPV item. This study evaluated the accuracy of an extended HITS (E-HITS), which adds a sexual IPV item, in female VHA patients. A sample of 80 female U.S. veteran VHA patients in New England completed a mail survey (50.0% response rate) that included the 5-item E-HITS and the Revised Conflict Tactics Scales (CTS-2). Women were included if they were in an intimate relationship in the past year. The women averaged 49 years of age and 86.0% of the sample was White. Accuracy of the 4-item HITS was compared to the 5-item E-HITS, using the CTS-2 as the reference. There were 20 women (25.0%) who reported past-year IPV on the CTS-2. The receiver operator characteristic curves demonstrated that the HITS and E-HITS performed nearly identically at their optimal cutoff scores of 6 and 7, respectively. At these cutoff scores, the sensitivity of both tools was .75, 95% CI [.55, .95]. The specificities were similar; .83 for the HITS, 95% CI [.73, .92], and .82 for the E-HITS, 95% CI [.72, .90]. Including a sexual IPV item may be clinically beneficial; it also attains the same accuracy of case identification as the HITS.

Women veterans' preferences for intimate partner violence screening and response procedures within the Veterans Health Administration.

Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings.

VHA Primary Care Providers’ Perspectives on Screening Female Veterans for Intimate Partner Violence: A Preliminary Assessment

Female Veterans experience intimate partner violence (IPV) at alarming rates. The Veterans Health Administration (VHA) requires foundational research to guide the development of policy and programs to detect IPV among women Veterans and provide interventions. This pilot study reports findings from in-depth qualitative interviews conducted with 12 VHA primary care providers treating female Veterans in the New England region. Although most providers indicated that they were not currently routinely screening for IPV, they expressed positive attitudes and beliefs about screening in VHA primary care settings. Themes also included the importance of a comprehensive health care response to IPV, such as interdisciplinary coordination of care and team-based approaches to detection and intervention. Barriers to routine screening were identified, as well as recommendations for training programs and clinical tools to inform the successful implementation of a standardized IPV screening and response program in VHA. Although preliminary, these findings represent an initial step in an essential line of research.

Intimate Partner Violence and Current Mental Health Needs Among Female Veterans

Background: The Veterans Health Administration (VHA) recommends screening female patients for intimate partner violence (IPV), yet few studies inform IPV screening efforts among this population. This study examined the proportion of women who experienced IPV within the past year and the associations between IPV and depression, post-traumatic stress disorder (PTSD), alcohol dependence, mental health multimorbidity (ie, 2 or 3 of these conditions), and military sexual trauma (MST) among female veterans. Methods: A cross-sectional mail survey of 160 female VHA patients with an intimate partner within the past year was conducted in 2012 in New England. Self-reported IPV was assessed using the Hurt, Insult, Threaten, Scream screening tool. The survey also included validated screening measures of depression (Center for Epidemiologic Studies Depression Scale), PTSD (PTSD Checklist–Civilian), alcohol misuse (10-item Alcohol Use Disorders Identification Test), and MST. Results: Approximately 37% of women reported IPV within the past year on the Hurt, Insult, Threaten, Scream tool. Odds ratios for the associations between reporting IPV and mental health outcomes ranged between 2.75 and 3.67. With the exception of alcohol dependence, IPV remained strongly associated with mental health conditions when adjusting for MST. Conclusions: These findings can increase provider knowledge of the strong connection between past-year IPV and mental health conditions among female veterans. This may encourage IPV screening and facilitate appropriate referrals, treatment conceptualization, and planning within the VHA and other health care settings.

Eating disorders and associated mental health comorbidities in female veterans.

Eating disorders (EDs) remain understudied among veterans, possibly due to the perception that primarily male population does not suffer from EDs. However, previous research suggests that male and female veterans do experience EDs. The high rates of posttraumatic stress disorder (PTSD), depression, and obesity observed among veterans may make this group vulnerable to disordered eating. Retrospective chart review was used to obtain data from 492 female veterans who were presented to a womens primary care center at a large, urban VA medical center between 2007 and 2009. A total of 2.8% of this sample had been diagnosed with an ED. In bivariate analyses, presence of PTSD and depression were significantly associated with having an ED diagnosis. However, when these two disorders were included in a multivariate model controlling for age, only depression diagnosis and lower age were significantly related to ED status. In sum, the rate of EDs in this sample is comparable to prevalence estimates of EDs in the general population. Current findings underscore the importance of assessing for EDs among VA patients and the need for further research among veterans.