speranzaproject.

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WHITE PAPER 2022

DOMESTIC VIOLENCE
AND THE ROLE OF
HEALTHCARE
PROVIDERS
Promoting compassionate care
through education and awareness.

Authors Contributors
Lucinda Dass, MPH Christina Blackburn, MSc
John Crane Valentina Nikulina, PhD
INTRODUCTION
This white paper is meant for any person in health care that directly interacts with
patients and who may encounter domestic violence victims. We take you through the
statistics and current standing of domestic violence in the United States, illuminate some of
the recurrent issues in hospitals concerning re-victimizing victims, specifically in emergency
rooms, and propose some novel solutions. We also comment on the impact of the SARs-
CoV-2 pandemic.

Note: this is a working document. We will continue to update it as new information and
research emerge.

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TABLE OF CONTENTS
About Speranza........................................................................................................3

Case report..................................................................................................................3

Discussion of the Problem ...................................................................................5

Impact of SARS-CoV-2 on Domestic Violence...........................................8

Domestic Violence State Laws...........................................................................9

Speranza’s Approach............................................................................................10

Conclusion....................................................................................................................11

References...................................................................................................................12

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ABOUT SPERANZA
Speranza Human Compassion Project is a non-profit organization located in Philadelphia,
PA, dedicated to educating frontline workers and health care providers (HCPs) in
providing compassionate care and resources for victims of intimate partner violence (IPV).

VISION
​O ur vision is to educate and empower medical professionals and first responders through
comprehensive and targeted training programs, in order to reduce the incidence of
domestic violence and promote safe homes. ​

APPROACH
To conduct research and create knowledge-building tools, in partnership with academic
and medical institutions, for providers across all care settings; to offer effective strategies
that will empower victims and providers; and to be the subject matter experts.

CASE REPORT
Domestic violence (DV) usually occurs behind closed doors. When abuse escalates and is
observed publicly, immediate interventions are needed to protect victims. On August 12,
2021, Gabby Petito, a 22-year-old female blogger, and her fiancée, Brian Laundrie, were
involved in a physical domestic dispute during a cross-country road trip. The couple was
interviewed separately by Officer Daniel Robbins who reported, “I do not believe the
situation escalated to the level of a domestic assault as much as that of a mental health
crisis”, and encouraged them to separate for the night (Maxouris, 2022). No further action
was taken, and Ms. Petito was found dead on September 19, 2021. She died from “blunt-
force injuries to the head and neck, with manual strangulation”. Mr. Laundrie was the only
suspect identified, went missing, and was found dead later. Mr. Laundrie died of a self-
inflicted gunshot wound. Along with his remains was a notebook in which Mr. Laundrie
claimed responsibility for Ms. Petito’s death (Sampson, 2022). This incident highlights how
further research must be done to better identify first responders initial and ongoing
domestic violence training needs in the United States.

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Page 4
INTIMATE PARTNER VIOLENCE IN THE U.S.
IPV is abuse or aggression that occurs with a romantic partner (former or current) and
can include physical and sexual violence, stalking or psychological aggression. In each
situation, the abuser exerts a direct intention to hurt the victim, causing significant distress
and fear. The situation can be more complicated with the involvement of children and
considering the victims financial dependence on the abuser.

According to the CDC, about 1 in 5 women report having experienced physical violence
from an intimate partner in their lifetime. This alarming statistic is reflected here in New
York City, where in 2020, the NYC Police Department received 233,006 calls for
domestic violence complaints, 105,781 of which were specifically IPV related, making this
form of abuse a significant public health concern for the Big Apple (NYC Mayor’s Office
to End Domestic Violence and Gender-Based Violence, 2020). And these numbers are just
the tip of the domestic violence “iceberg.” According to this model, it is estimated that 25%
of the population is affected by domestic violence, however, only 2.5% to 15% are actually
reported (Garcia, 2004). Moreover, 1 in 5 victims will suffer the lethal consequence of
death from these senseless acts. For those who do survive and are able to remove
themselves from the situation, their physical and mental health takes a huge toll, such that
victims are at higher risk for chronic medical conditions involving the heart and nervous
system and mental health problems such as depression and posttraumatic stress disorder
(PTSD). Furthermore, they are at higher risk for engaging in risky behaviors such as
smoking, binge drinking, and sexual behaviors (CDC, 2020).

The problem is magnified when we consider the societal and economic impact. According
to a 2019 report from the American College of Obstetrics and Gynecology (ACOG),
hospital visits due to IPV are about 250,000 each year. This translates into a whopping
8.3 billion dollar cost ranging from both medical and mental health care services and loss
of productivity from paid work to pediatric-related problems associated with simultaneous
child abuse and alcoholism. Intangible or indirect costs are also of significant concern and
include lowered self-esteem, quality of life, destruction of family units and more.

DISCUSSION
About 80% of women suffering abuse will visit an emergency room (ER) at an average of
7 times within 4 years of the assault (Huecker, 2021). The high frequency visits makes the
ER a unique place to ensure that victims receive compassionate care and necessary
resources from front-line HCPs. However, many women do not feel comfortable disclosing
this information to their doctor, which may hinder them from receiving care. Their feelings

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of discomfort stem from a variety of concerns, including feeling embarrassed, fear of
safety, involvement of children, unease with the particular provider taking the history and
so on. For HCPs, it is pertinent to be aware of all these thoughts crossing the mind of the
patient, and use it carefully to guide responses and further questions.

Several barriers also exist on the side of healthcare professionals. According to a 2012
article in Women & Health Journal, the most frequently reported barriers to identification
of victims included personal discomfort, lack of knowledge, and time constraints (Sprague,
2012). Two other barriers identified by this review were resource limitations and
perceptions/attitudes of the issue. Recognition of these obstacles is the first step in enacting
change in ED protocols, guidelines, and screening methods for identifying victims of abuse.
Oftentimes, providers are simply grossly unaware of best practice guidelines and put
victims at risk of being revictimized. In a 1994 survey of Primary Care Physicians in the
Midwest, 51% of doctors felt that their medical education did not prepare them enough to
address DV (Reid et al., 1997). These findings are supported by another study of 44
primary care physicians who report feeling unprepared in identifying and managing IPV
within their practice (Zink et al., 2004). Similar results were observed in a qualitative
report from rural physicians of multiple specialties who reported barriers and lack of
comfort with IPV discussions and in a large study of nurses and physicians where only
32% of nurses and 42% of physicians reported routinely asking about IPV (Beynon et al.,
2012; Gutmanis et al., 2007; McCall-Hosenfeld et al., 2014). In the 2021 Speranza focus
group, we asked ten doctors to reflect on their experience with victims who enter the
emergency department. They overwhelmingly highlighted a lack of education and
guidelines for helping victims, rating their confidence level 2.44/5 in how to approach a
DV victim. All participants unanimously reported an interest in receiving more training.

Another concern to take into consideration is environmental factors and the way the
medical system is designed to care for patients. This includes anything and everything
from when a victim walks through the doors to when she leaves. She is first greeted by
triage nurses who, while innocently asking the question “What brings you in today?,” are
really asking the patient to relive her story. From here, she must wait, sometimes for
hours, to be seen by a physician who again asks her to retell the story and the trauma
that came with it; after this she is met with more waiting - this time for social workers and
other pertinent individuals to be notified. Victims can spend upwards to 12 hours in the ER
before receiving the information they need and are oftentimes discharged back into the
same situation. Moreover, victims may feel additional pressure or anxiety to leave the ER
as soon as possible such that abusers are not alerted to their prolonged absence. While
this process varies depending on hospital size, location, available resources, and training of
HCPs, there is always capacity to improve upon current processes for optimization of
compassionate patient care.

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Another worry physicians have is not knowing whether or not to use ICD coding for
diagnosing as this may contribute to labeling the patient as a victim and is forever in their
medical record. While this presents as a valid concern and may be difficult to decide on an
individual basis, this perspective can contribute to the significant underreporting of cases
across the country and this underreporting can minimize the importance of the issue,
further perpetuating the lack of societal funding for interventions.

While it seems that the system could use a lot of improvement, the clinicians did point out
a few good qualities of the process, notably working with the social workers. When it is
first recognized that a case of DV is present, the Sexual Assault Forensic Examiner
Program (SAFE) and Sexual Assault and Violence Intervention Program (SAVI) team at
Mount Sinai hospital get contacted immediately. Other solutions already in place include
the option of giving victims “paperless discharge papers” such that abusers won’t have
access to the medical history of victim; ensuring to make it standard procedure to always
interview victims alone if accompanied by abuser; and in the case of additional child
abuse, making sure that the child is the one to disclose the abuse instead of mom to avoid
further escalating the situation and avoids putting the blame on mom.

In terms of training of HCPs, medical students and residents are usually offered self-
training modules on topics such as this training to reinforce their existing knowledge base,
however one physician noted that these can be time consuming and students often skip
over them, noting that in-person training sessions would be a more effective option.
Another physician agreed with this, adding that "because it's such a sensitive topic, I don't
think I can go wrong by learning more.”

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IMPACT OF SARS-COV-2 ON DOMESTIC VIOLENCE
In 2019, the world was taken by storm. A
foreign invader by the name of SARS CoV-2,
also known as COVID-19, emerged and
ruthlessly spread around the planet, impacting
each and every soul. People were asked by
leaders to stay home and protect themselves
against the virus. They were asked to take
refuge in the comfort of their own homes. But
what if in seeking protection, some people
were met at home with fear and abuse
instead of hope and relief? What if there was
more danger being with the ones that were
supposed to love and protect us? For many
people experiencing DV, this was exactly the
case. According to the Journal of Emergency
Medicine, the incidence of domestic violence
increased by 25-33% globally in 2020
(Bhattaram, 2020). The pandemic only
exacerbated victims’ fears and anxieties,
adding a layer of complexity to their current
situation by intensifying the conditions that
lead to violence. Among these conditions are
financial instability, kids at home, food
insecurity, mental health aggravation, turning
to alcohol as a coping mechanism and so on.
And while the government worked to stabilize
the virus and put a focus on physical health
and well-being, victims were cast aside, their
screams unheard. But those numbers are too
strong to not take notice and take action

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DOMESTIC VIOLENCE STATE LAWS
Adapted from a Futures Without Violence Report

The majority of laws governing domestic violence are enacted by U.S. states, such as
protection orders, divorce, custody and crimes. However, there are some federal laws as
well which may be relevant to certain victims such as those about immigration, gun use
and military protective orders. In terms of healthcare, most U.S. states have enacted
mandatory reporting laws, which require the reporting of specified injuries and wounds,
and suspected abuse by HCPs. Fewer states specifically address reporting domestic
violence.

Laws vary by state, but generally fall into four categories:

1. states that require reporting of injuries caused by weapons
2. states that mandate reporting for injuries caused in violation of criminal laws, as a
result of violence, or through non-accidental means
3. states that specifically address reporting in domestic violence cases
4. states that have no general mandatory reporting laws

It is important to note that some visits in which women choose to disclose abuse may not
fall into some of these categories and thus, are not technically reportable by law. For
example, if a woman is seeing her primary care physician for an annual checkup and
reveals that she has been feeling emotionally abused by her husband for many years,
resulting in both mental and physical stress on her body, eventually leading to chronic
depression and anxiety. She feels pressured to stay with him because they have three
young kids and he is the sole provider of the family. Through the definition of domestic
violence, this case would clearly count, however, in states that do not legally define this
situation as reportable, this victim’s story may not need to be reported to law enforcement.
This leads to huge discrepancies in current statistics and actual prevalence.

Recognizing the rise in domestic violence prevalence, especially highlighted due to the
pandemic, New York State has recently taken action to hold hospitals accountable for
ensuring adequate screening of victims of abuse. On December 23th, 2021, the state’s
State Governor, Andrew Cuomo issued an amendment (new Section §2805-z) to the
state’s Public Health Law concerning Hospital Domestic Violence Policies and Procedures.
The new law (taken verbatim from the official release document) requires every general
hospital to:

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 1. develop, maintain, and disseminate written policies and procedures for the
identification, assessment, treatment and referral of confirmed or suspected cases of
domestic violence;
2. establish and implement a training program for all nursing, medical, social work and
other clinical personnel, and security personnel working in hospital service units on
these policies and procedures;
3. designate a staff member to contact the domestic violence or victim assistance
organization providing victim assistance to the geographic area served by the hospital
to establish the coordination of services provided to domestic violence victims; and
4. upon admittance or commencement of treatment of a confirmed or suspected domestic
violence victim, advise the victim of the availability of the services of a domestic
violence or victim assistance organization, and contact the appropriate organization
and request that a victim assistance advocate be provided if the domestic violence
victim requests one.

With our experience in already helping hospitals adhere to these protocols, Speranza is in
a unique position to guide NY hospitals in ensuring compliance, so as to avoid being in
violation of this law.

SPERANZA'S APPROACH
At Speranza, we pride ourselves on having a deep understanding of the lives of victims,
as well as expertise in medical systems and how healthcare professionals function within
them. With this combination of knowledge, we hope to bring forth positive change with
innovative solutions via education, awareness, hands-on training experiences, and more,
such that HCPs are providing compassionate care and discharging victims feeling more
empowered than when they came in. These include the creation of best practice guidelines,
standardizing screening processes, improving electronic medical record options to
adequately and safely report DV cases, implementing a live chat with crisis help for
physicians to use while waiting for social workers to get involved, building in-person
trainings for doctors to stay current with developing research and practice communication
skills, and lastly, ensuring that HCPs are appropriately managing their own mental health
and self-care.

We believe that healthcare as a whole can help victims by providing quality access to
treatment in a safe and respectful way, being knowledgeable about options and paths if
victims choose to escape their situation, and offering referrals to mental health counseling.

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CONCLUSION
Overall, our goal is to bring more awareness of this topic to HCPs, particularly those in
ERs who frequently encounter victims. Though it is mandated by law in many states for
HCPs to be trained in caring for DV victims, we know from this focus group that
physicians are just not aware of the laws or have not received the training to provide
adequate care, placing victims in an unsafe environment and placing the hospital at risk
for noncompliance.

We urge you to remember that a woman’s physical appearance does not necessarily
portray her abuse history, but to adequately screen each patient with compassionate care.
Create a safe space that fosters information sharing. Together, we can improve physical,
mental, social, and emotional health outcomes for our patients.

For more information, check out the Speranza and Mindful Care Global training platform
for resources and information.

Join us every month for the Mindful on Purpose podcast, a safe space where unexplored
topics on gender-based violence/intimate partner violence/child endangerment are
discussed with FIELD EXPERTS to increase awareness and improve care for vulnerable
women and children.

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