Bixby Lecture Debbie Lee, Senior Vice President Health Futures Without Violence

1. 1
Debbie Lee
Senior Vice President, Health
Futures Without Violence
dlee@futureswithoutviolence.org
February 16, 2016
Creating Futures
Without Domestic Violence:
Policy Change, Men and Clinicians
The Factor Program in Violence Prevention
and UCLA Bixby Center

2. 2
Your Role
• Because Intimate Partner Violence is so
prevalent, assume that there are survivors
among us
• Public Health professionals, clinicians, health
lawyers, employers, policy experts
• Partner with DV & SA
organizations in your
communities.
• As a friends, sister/brother,
mother/father

3. 3
Futures Without Violence

4. 4
My Agenda Today
The problem
Clinical and public health response to DV/SA
Men and Boys
Audrie and Daisy
Evolving strategies and our lessons learned
Training, policy and public education.

5. 5
Abuse is a pattern of behaviors to gain power
over an intimate partner
Including:
• Using extreme and controlling jealousy
• Isolation
• Physical Abuse
• Threats
• Sexual Assault/ Coercion
• Emotional/Mental (psychological)
Abuse
• Digital Abuse
Abuse is not the same as conflict in
relationships

6. 6
Who are victims/survivors?
 Cuts across all lines of race,
socioeconomic status, gender,
sexuality, ethnicity, age etc.
 Survivors develop various
coping skills to live with abuse
 May love the abusive partner
and not want to leave the
relationship
 Know the abusive partner’s
potential for violence and
abuse better than anyone else

7. 7
Who are abusive partners?
 Cuts across all lines of race,
socioeconomic status, gender,
sexuality, ethnicity, age etc.
 Often very jealous and
controlling partners
 Do not take responsibility for
their actions
 May be upstanding community
members
 Can be loving partners at times
 May or may not be violent in
other areas of their lives
 Many times, blame the survivor
for the abuse

8. 8
Prevalence of Intimate Partner Violence
1 in 4 (25%)
U.S. women
report ever
experiencing
physical and/or
sexual IPV.
(Source: 2010 CDC National Intimate
Partner and SexualViolence Survey)

9. 9
Intimate Partner Sexual Assault
1 in 5 women in U.S. has been
raped at some time in their lives
and half of them
reported being
raped by an
intimate partner.
(Source: 2010 CDC National Intimate
Partner and SexualViolence Survey)

10. 10
Male Victims
• 1 in 59 men have been
raped in their lifetime.
• 1 in 7 men have been
the victim of severe
physical violence by an
intimate partner
(Source: 2010 CDC National Intimate Partner and SexualViolence Survey)

11. 11
LGBTQ Communities
61% of bisexual women and 37% of bisexual
men experienced rape, physical violence,
and/or stalking by an intimate partner in their
lifetime.
44% of lesbian women and 26% of gay men
experienced rape, physical violence, and/or
stalking by an intimate partner in their lifetime.
Of transgender individuals, 34.6% reported
lifetime physical abuse by a partner and 64%
reported experiencing sexual assault.
11
(Breiding et al, 2011; Landers & Gilsanz, 2009)

12. 12
Marginalized Communities
Marginalized communities can be particularly vulnerable to D/SV
Consider….
• Lack of culturally competent support services
• Less access to housing, health services, jobs, etc.
• Possibly unsafe to report violence to the police or use the courts
• Leaving and other common safety planning options might mean
a loss of small community
•Threat of deportation for immigrants

13. 13
Long-term health impact of violence
13
(CDC, 2010)

14. 14
IPV and impact on chronic health conditions
• Heart disease
• Overweight/Obese
• Stroke
• Depressed immune
function
• Irritable bowel syndrome
• Poor perinatal health
outcomes
• Arthritis
• Asthma
• Headaches and migraines
• Back pain
• Chronic pain syndromes
• Genitourinary problems
• High cholesterol
(Black & Breiding,2008; Campbell et al, 2002; Coker et al, 2000; Constantino et al, 2000; Follingstad, 1991; Kendall-Tackett et al,
2003; Letourneau et al, 1999;Wagner et al, 1995; Coker et al, 2000; Drossman et al, 1995; Lesserman et al, 2007; Kernic et al,
2000;Talley et al, 1994; Black & Breiding, 2008; Bailey, 2012)

15. 15
Behavioral Health Co-Morbidities
• Anxiety/Panic Attacks
• Sleep problems
• Memory loss
• Post-traumatic stress disorder (PTSD)
• Depression, poor self-esteem
• Insomnia
• Suicide ideation/actions
• Alcohol, drug, tobacco use
(Bergman & Brismar, 1991; Coker et al, 2002; Dienemann et al,
2000; Elsberg et al, 2008; Kernic et al, 2000; Stark & Flitcraft,
1995; Sato-DiLorenzo & Sharps, 2007; Lemon et al, 2002;
Ackard et al, 2003; Weinsheimer et al, 2005; Kaysen et al, 2007;
Miller et al, 1989; Plichta, 1992)

16. 16
Young victims of physical and sexual violence
are more likely to:
Report sadness or hopelessness
Report disordered eating
Over 50% of youth reporting both physical and
sexual violence in their relationship also reported
attempting suicide.
(Kim-Godwin YS, et al 2009;Howard DE,et al ,2008; ,Brossard RM,
et al ,2008,Bossarte et al, 2008; Ackard & Neumark-Sztainer , 2002)

17. 17
Reproductive and Sexual health
• Increased risk for unintended and
rapid repeat pregnancy
• Increased incidence of low birth
weight babies, preterm birth and
miscarriages
• Abuse is more common than
gestational diabetes or
preeclampsia -- conditions for which
pregnant women are routinely
screened.
(Miller, 2010; Sarkar, 2008, Goodwin et
al, 2000; Hathaway, 2000)

18. 18
Supporting Survivors
• Regardless of gender, it can sometimes be difficult to
understand if the patient sitting in front of you is surviving
violence or using violence to hurt their partner, especially
if there is limited time.
• Providers (clinicians, social workers and other care
providers) have a unique opportunity to help break the
cycle of abuse by working with families and within their
communities to prevent abuse.
• In working on this issue we have come to this newer
strategy…

19. 19
Universal Education and Response for Intimate
Partner Violence in all Health Settings
“Is your relationship affecting your health?”

20. 20
Video: We Always See Patients Alone
The following video clip
introduces strategy for
ensuring that providers
are able to have
confidential
conversations with their
patients.

21. 21
Why Universal Education?
 Screening w/o response is ineffective
 (Feder et al. 2014)
 Survivors often chose not to disclose
 Not ready, distrust of formal systems, limited
resources, fear of retaliation, CPS
 Universal education provides an opportunity
for primary, secondary and tertiary prevention

22. 22
Universal Education and Intervention
Primary Prevention:
For clients who are not experiencing
abuse, universal education affirms that
IPV is an important health care issue
and provides an opportunity to talk
about healthy relationships and the
warning signs of an abusive
relationship as well as showing the
patient how they should be treating
their partners.
PRIMARY
PREVENTION

23. 23
Universal Education and Intervention
Secondary Prevention:
In the early stages of an abusive
relationship, early identification and
intervention can prevent serious
injuries and chronic illnesses as the
violence escalates and the
entrapment increases.
PRIMARY
PREVENTION
SECONDARY
PREVENTION

24. 24
SECONDARY
PREVENTION
Universal Education and Intervention
Tertiary Prevention:
In relationships with escalating
violence, direct assessment provides
the opportunity for disclosure in a
safe and confidential environment.
Even if clients do not feel safe
disclosing their abuse, giving
supportive messages can end their
isolation and let them know that they
have options.
PRIMARY
PREVENTION
TERTIARY
PREVENTION

25. 25
Clinical Preventive Services for Women
2011 Institute of Medicine released
Clinical Preventive Services for Women:
Closing the Gap
• IPV screening is one of eight
preventive services that would ensure
women’s health and well being

26. 26
Affordable Care Act
As of January 2014:
Insurance companies are prohibited from
denying coverage to victims of domestic
violence as a pre-existing condition.
As of August 2012:
Health plans must cover screening and counseling for lifetime
exposure to domestic and interpersonal violence as a core
women’s preventive health benefit.

27. 27
How can universal education compliment
screening and education about IPV?

28. 28
C: Confidentiality: Disclose limits of confidentiality & see patient alone
UE: Universal Education:
Normalize activity: "I've started giving info on D/SV to all of my
patients”
Make the connection: Open the card and do a quick review: "It
talks about healthy and safe relationships…and how relationships
affect your health“
S: Support:
• Warm referral
• Follow up at next appointment.
CUES Universal Education approach

29. 29
Universal Education
You might
be the first
person to talk
to your
patient about
what is going
on in their
relationship

30. 30
You might be
the first one
to talk with
your patient
about what
they don't
deserve in
their
relationship.
UE: Universal education on unhealthy relationships

31. 31
Patient-centered approach to DV assessment
• Patients want providers to talk to
them about DV
• Empower patients with information,
regardless of disclosure
• Patients may not disclose due to
concerns of how information will be
used
 Disclosure is NOT the goal

32. 32
S: Support: Important reminder
32
Disclosure
is not the goal
AND
Disclosures do
happen!

33. 33
S – Support: Positive Disclosure: What now?
• Your initial response is important!
• Thank patient for sharing
• Convey empathy for the patient who has
experienced fear, anxiety, and shame
• Validate that IPV is a health issue that you
can help with
• Ask patient if they have immediate safety
concerns and discuss options.
• Refer to a D/SV advocate for safety
planning and additional support.
• Follow up at next visit.

34. 34
S: Positive disclosure: One line scripts
• “I am so sorry this is happening. It is not okay, but it
is common. You are not alone.”
• “This is not your fault. Nothing you did caused this.
Someone else made a choice to hurt you.”
• “What you’re telling me makes me worried about
your safety and health”
• “Would you like me to explain options and
resources that survivors are often interested in
hearing about?”
• “Some survivors find talking to an advocate or
counselor to be helpful”
• “What else can I do to be helpful? Is there another
way I can be helpful?”
34

35. 35
Setting/visit-specific resources
Reproductive Health
Adolescent Health
Pediatrics
Behavioral Health

36. 36
FUTURES YouTube channel
https://www.youtube.com/user/FutureswoutViolence
Educational Videos for Health Professionals and
Advocates
(29 video vignettes, most 2-3
minutes)

37. 37
Futures Without Violence

38. 38
Coaching Boys into Men is born …
In 2000, we spearheaded an innovative prevention strategy to end
violence against women and girls … invite – don’t indict – men
to be part of the solution
• But, many said they didn’t know how to help AND others said simply that no
one had ever asked them to get involved.
• National poll showed a willingness to do something:
 Talk to children and youth about healthy relationships (#1)
 Contribute money
 Call your legislator
Resulted in a public awareness campaign that set out to:
• Appeal to the “good guy” in men to be role models to young people and
teach them the importance of healthy, nonviolent relationships.

39. 39
“Wrong Way Around” - PSA

40. 40
The CBIM Coaches Kit
The CBIM Playbook – Introduction to issue
• Developed to take advantage of
“Teachable Moments”
The CBIM CARD SERIES
• Messages delivered in 15 minute
discussions once a week
• From personal responsibility & digital
disrespect to modeling respectful
behavior to build leadership
References & Resources
• Assists coaches during
implementation
• Includes CBIM Overview, professional
referral information

41. 41
CBIM’s evidence
Three-year CDC study* of 16 high schools in Sacramento working
with approximately 2,000 athletes and 150 coaches.
Results:
• Athletes in the program are more likely to report doing
something when they witness disrespectful and harmful
behavior (e.g., telling their coach or another adult).
• Greater knowledge of abusive behaviors (e.g., language,
pressure, control).
• Trend toward directly reducing damaging behaviors (i.e.,
emotional and verbal abuse).
* Evaluation conducted by a research team at Children’s Hospital of Pittsburgh/University of Pittsburgh Medical Center.
Special thanks to Dr. Elizabeth Miller, MD, PhD and Maria Catrina Virata, MPH.

42. 42
Policy Advocacy
What is Policy Advocacy: Attempt to influence,
policies, regulations, laws, funding sources,
actions of key government/ policymakers
What Are the Key Elements:
 Direct lobbying/education of officials
 Media/communications
 Grassroots Organizing
 Lawsuits
 Research (not traditional element but can help set
agenda for policymakers)
Why Do it: It works and the other side is doing it

43. 43
What makes for good advocacy
• Need to hone in on specific ask
• Assess the environment
• And targeted to person(s)/entity that has the
power to fix it
• Need to organize your allies, key influencers
or large groups – know your audience
• Need to have the evidence about the problem
but also about the solution
• Need the stories to make it real

44. 44
Introducing Audrie & Daisy
a new documentary about high school sexual assault

45. 45
Audrie & Daisy
Audrie
& Daisy
Programs
Partnerships
Policy

46. 47
Create Curriculum for Targeted Audiences:
Creating Safer High school environments
Audrie
& Daisy
Programs
Parents
Students/Frien
ds
Survivors
Educators
School Nurses
Policy Makers
Administrators
Physicians
Coaches
Employers
Community members
Law enforcement
Judges
Religious leaders

47. 49
Audrie & Daisy: Questions/Discussion
Where do you see the greatest opportunities for impacting
positive change?
Is what we are presenting as a solution resonating with you?
What are we missing?

48. 50
National Health Resource Center
on Domestic Violence
National Workplace Violence
Resource Center
Sexual Assault on College
Campuses
Teach Early and Coaching
Boy’s into Men
Defending Childhood Initiative
For free technical assistance and tools
from FUTURES’

49. 51
THANK YOU!
By asking about IPV you
can help change lives.
YoYou
Debbie Lee
dlee@futureswithoutviolence.org