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Walking a Tightrope For Too Long

South Carolina was ranked number one in the nation for the number of women killed by men in 2013. Through a number of domestic violence initiatives, MUSC’s College of Nursing is working to change that.

By Katharine H. Hendrix
Illustration by Ginny Canady

Complex problems require complex solutions. This is a frustrating truth and the primary reason we have yet to adequately address the ancient plagues of domestic violence and sexual assault. If this categorization seems overly dramatic, consider that the word plague is derived from the Latin plāga (blow or wound) and plangere (to strike or strike down). Unlike smallpox, polio, or measles, which have been largely eradicated, the twin scourges of domestic violence and sexual assault continue devastating the health of thousands of South Carolinians each year. In 2013, South Carolina was ranked number one in the nation by the Violence Policy Center in Washington, D.C., for the number of women killed by men. At 2.4 deaths per 100,000, our state’s rate of female homicides at the hands of men is more than double the national average.

The Disease Model

It is not that smallpox and polio are easier health problems to tackle but, in many ways, they are simpler. In biological diseases, teams of laboratory researchers work methodically to identify a pathogen and its transmission vectors. Vaccines and treatments are then developed and applied as uniformly as possible to improve health across large populations. In cases of domestic violence and sexual assault, the patient (ie, the victim) is often left on his/her own to identify the pathogen (ie, the perpetrator), find a support team (ie, health care, social, and legal services), and develop his/her own “vaccines” and “treatments.” To complicate matters, in cases of domestic violence and sexual assault, “vaccines” such as safety plans and “treatments” such as obtaining health care and safe housing often must be developed while having daily exposure to the “pathogen.”

Patients suffering biological diseases can usually describe their symptoms clearly, have particular signs or markers, and progress along a known trajectory. The potential benefits and harms of various interventions and possible long-term sequelae are generally well documented and predictable. By contrast, patients suffering from domestic violence or sexual assault can be difficult to identify, have few signs or markers, and progress along an unpredictable path. Despite their differences, both patient types face increased harm and possible death if healthcare providers fail to correctly identify the condition and offer adequate treatment.

The negative health effects of domestic violence and sexual assault are far-reaching and compelling. The most obvious are the most immediate, such as physical injury and death. However, the long-term sequelae are much more costly in both human and economic terms. These include sexually transmitted infections such as HIV/AIDS, pelvic inflammatory disease, and unintended pregnancy. In addition, assaults during pregnancy are associated with preterm birth, low birth weight, and decreased mean gestational age. Mental health effects include posttraumatic stress disorder, depression, anxiety, substance abuse, and suicide. Physical health effects of domestic violence and sexual assault include chronic pain, neurological disorders caused by injuries, gastrointestinal disorders such as irritable bowel syndrome, and migraine headaches. Finally, physical and sexual abuse during adolescence and young adulthood are highly associated with poor self-esteem, alcohol and drug abuse, eating disorders, obesity, risky sexual behaviors, teen pregnancy, depression, anxiety, and suicide.

The Health Provider’s Role

The National Violence Against Women Survey conducted by the U.S. Department of Justice in 2000 estimated that only 30% of women injured during a physical assault and 36% of women injured during rape receive medical attention. “The biggest challenge is that no one wants to talk about it,” says Kathy Gill-Hopple PhD, RN, AFN-BC, coordinator for MUSC’s Forensic Nurse Examiner Program. “These are difficult topics for both the provider and the patient. You can’t always see from the outside that someone is in an abusive situation or has been sexually assaulted–you have to ask the questions.”

But things are beginning to change. Until recently, it was not clear what the best screening questions were or how to ask them. In 2012, the U.S. Preventive Services Task Force (USPSTF) updated its recommendations to support domestic violence screening for “individuals in health care settings who do not have complaints or obvious signs of abuse, such as physical injuries.” The authors found that any of several brief screening tools could effectively identify victims and help prevent negative health consequences.

tightrope article imageCatherine Durham, DNP, an Instructor in MUSC’s College of Nursing, has spent much of her Navy active duty and Reserve career working on these issues and continues this in her clinical practice. Dr. Durham says, “One of the biggest myths I hear from fellow nurses and providers is that screening (for sexual assault or domestic violence) takes too much time during a short visit with the patient. In fact, one of the USPSTF-recommended screening tools is only four questions long. Some providers report avoiding screening due to concerns about getting a ‘yes’ answer, time constraints, and a lack of resources. They report feeling uncertain about how to approach the patient and to what depth... so it’s important that they know how to get in touch with local resources and are prepared to direct that person to the help they need.”

Health care providers also have an important role to play in de-stigmatizing domestic violence and sexual assault. This is especially true in light of the fact that one of the most common myths is that sexual assault cannot occur between two people who are married or in a romantic relationship. Routinely asking screening questions of all patients contributes to the community’s knowledge about these issues and helps domestic violence and sexual assault gain acceptance as general health concerns.

Deborah Williamson, DHA, MSN, RN, Associate Dean for Practice in MUSC’s College of Nursing, has designed a comprehensive website for healthcare professionals at http://www.dvguidelines.org. It includes definitions, guidelines, recommendations, patient resources in Spanish and English, and practical tips about how to discuss domestic violence and sexual assault with your patients. Dr. Williamson agrees with Dr. Durham, “Initially it does take time to educate your staff and to get familiar with local resources. You need to know where to send patients for help locally. But the hardest task is that you have to get comfortable actually asking the questions. And, how you ask the questions is really important. There is still a lot of stereotyping and bias about domestic violence and sexual assault. I’ve even heard people, health care professionals, say ‘I don’t want to get involved with their personal problems.’ Well, that just leaves patients on their own and what we know is that, without help, things will probably get worse.” One might even say that this attitude misses a central characteristic of health care–that, by its very nature, it is personal.

As Dr. Durham points out, “You often end up saving time with a patient and getting better outcomes in the long run if you identify a “social issue” such as domestic violence or sexual assault that may be impacting the patient’s ability to manage or address chronic health problems. Someone who has been sexually assaulted or is living in an abusive relationship may have difficulty keeping their other conditions under control due to isolation, anxiety, and depression.”

Solving the Rubik’s Cube

Domestic violence and sexual assault have persisted for centuries because they are complex problems that cannot be solved by health care interventions alone. Searching for solutions is more like turning the squares of a rubik’s cube than working out a mathematical equation. It is multidimensional and “real-world” rather than linear and theoretical. That said, health care providers are leading efforts to coordinate the resources that people living with these conditions need for recovery.

Patricia Warner in the MUSC Department of Psychiatry Crime Victim’s Center helped establish a Domestic Violence Coordinating Council (DVCC) for just this purpose. One goal of this group is to establish a uniform approach to helping victims of domestic violence and sexual assault. “What we see is that there is a wealth of services in the community but so often victims don’t get connected with them.” The purpose of the DVCC is to change this pattern by linking the many groups that work on these issues. “(The DVCC) has about 250 members from law enforcement, social services, the faith community, business owners, health care... anyone can be a member. We meet every other month and have a speaker and share our ideas and our challenges. It has been very educational and productive.”

This effort is also aligned with several other successful domestic violence initiatives around the country. There is now strong evidence to show that a coordinated community response that connects legal, medical, social, and community services can effectively reduce domestic violence. In fact, North Charleston has joined cities such as Baltimore and Boston in a national effort to pilot a Lethality Assessment Tool to help identify domestic violence and sexual assault victims who are at high risk for homicide. “This will be really valuable for helping police sort out who is at the greatest risk and, when extra steps are needed, to ensure that the victim and the perpetrator are kept apart,” Ms. Warner says.

Domestic Violence Questionnaire

This brief survey is validated and recommended for use with all adolescents and adults in healthcare and social work settings. Do not assume that anyone is immune. Domestic violence touches all types of people including those who are well-educated, wealthy, male, teenaged, or homosexual. If someone responds ‘yes’ to any question, conduct a full Abuse Assessment.


1. Have you ever been emotionally or physically abused by a partner?
Yes (If yes, by whom?)
No

2. Within the past year, have you been hit, slapped, or otherwise physically hurt?
Yes (If yes, by whom?)
No

3. Within the past year, have you been forced to have sex against your will?
Yes (If yes, by whom?)
No

4. Are you afraid of your partner?
Yes (If yes, who?)
No

(Source: http://www.dvguidelines.org/.)

What is Domestic Violence?

Domestic violence includes murder, negligent homicide, kidnapping, rape, forcible sodomy, sexual assault with an object, forcible fondling, robbery, aggravated assault, simple assault, or intimidation, where the victim-to-offender relationship is based on marriage, family ties, a romantic relationship, or a former marriage.1 It may also include psychological and economic abuse, isolation, and threats or violence against children and pets (Patricia Warner, personal communication, Feb. 5, 2014).

1 McManus, R. S.C. Department of Public Safety. Nowhere to Run, Nowhere to Hide: A Profile of Domestic Violence in South Carolina. 2006. Available at: http://dc.statelibrary.sc.gov/handle/10827/9362.