| Fall 2001;
Volume 2, Number 2|
Feature: Violence and Healthcare
Shaping California’s Health Policy for Victims of Intimate Partner ViolenceConnie Mitchell, MD
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Intimate partner violence (IPV), once thought of as a criminal and social justice issue, has been shaped over the last fifteen years as a public health issue. California is a leader in enacting new statutes and health policies that support womens health in general and intimate partner violence in particular.1 These policies have improved identification, documentation and surveillance, law enforcement affiliations, professional education, forensic examination, community prevention efforts and funding of services for victims of violence.
A Brief History of National IPV Health PolicyIn 1985, former United States Surgeon General C. Everett Koop brought national attention to domestic violence as a public health problem.2 National policies of major medical organizations such as the American Medical Association, the American Public Health Association, the College of Obstetricians and Gynecologists and the American Academy of Pediatrics have all strongly supported health care identification and intervention in family violence. The Joint Commission on Accreditation of Healthcare Organizations provided guidelines and standards for the improved recognition and initial intervention in domestic violence. The National Center for Injury Prevention and Control at the Centers for Disease Control (CDC) established the Family and Intimate Violence Prevention Team in 1993.3 In 1995, the Association of American Medical Colleges strengthened the curriculum on family violence.4 And in 1999, the CDC published guidelines for research that defined and promoted the phrase intimate partner violence that is now dominant in the medical literature but still used interchangeably with domestic violence elsewhere.5
Victim advocacy organizations worked throughout the 70s and 80s to strengthen the criminal justice response to perpetrators while providing support and safe havens for women and children victims of domestic violence. In the last ten years, these same organizations have promoted screening, safety planning, and patient education by health practitioners. Battered womens service providers have aligned with hospitals to provide on-site advocacy services and to increase the identification and documentation of IPV patient care.
The Health Impact of IPVIntimate partner violence is attracting the attention of the healthcare system as evidence mounts about the acute and long-term health impact of IPV on adults and children and the subsequent costs to the delivery system. Clinical studies indicate that 37-54% of women patients in the outpatient setting report a history of physical, sexual or emotional abuse in their lifetime.6,7 The long term and acute consequences of domestic violence include injuries, increased complications in pregnancy, reproductive health problems, stress related illnesses, somatization, depression, Post Traumatic Stress Disorder, suicide, and substance abuse.8-10 Increases in negative health behaviors such as smoking, alcohol and drug abuse, sexual risk-taking, and overeating have also been reported. The health impact of domestic violence on children includes direct physical abuse, caught in the crossfire injuries, neglect, and emotional trauma as witnesses to violence and abuse.11-13 Recent studies on the long-term health effects of adverse childhood events have associated childhood exposure to domestic violence with high-risk health behaviors as adults.14-18
Cost studies suggest this is an issue deserving of systemic and institutional attention. The cost of IPV to the healthcare system has been estimated at $857.3 million annually.19 When direct costs to the health care system are combined with indirect costs to society, total health care costs of IPV can escalate into the billions of dollars.20 Other studies have not only found that IPV patients generate significant healthcare costs, but also that the costs of their care may exceed the costs of care for a comparable non-IPV patient. 21,22
IPV Health Policy in CaliforniaIn 1996, the California Elected Womens Association for Education and Research published Violence Against Women in California, an outline of public policy options regarding violence against women. In 1997, the Office of Womens Health drafted a policy report titled Preventing Domestic Violence: A Blueprint for the 21st Century. This report identified six key goals for the state: 1) strengthen and expand domestic violence programs and resources, 2) protect children and youth from domestic violence, 3) ensure abuser accountability, 4) promote economic independence for domestic violence victims, 5) prevent domestic violence, and 6) improve state government operations relating to domestic violence.
Identification: In 1995, California enacted a screening law (Health and Professions Code §§1233.5, 1259.5) that required, as a condition of licensure, screening protocols and practices for Californias licensed clinics and hospitals. Compliance has been variable; some hospitals elect to have a chart prompted screen for every patient interaction, others have opted for chart prompted screens for select groups of at-risk patients, and others have fostered healthcare screening by providing more professional education or more streamlined access to IPV services. These policy changes have been enacted with evidence that patients and expert,s alike, believe verbal screening in a sensitive manner to be acceptable and helpful,23,24 but without evidence that such intervention leads to improved outcomes.
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