Domestic Violence:
A Primary Care Issue for Rural Women

by Linda Chamberlain, MPH, PhD. January/February, 2002, “The Network News,” National
Women’s Health Network, Washington, DC. http://www.womenshealthnetwork.org

From the remote islands of southeastern Alaska to rural counties in Georgia, rural women share a common risk: more than one-third will be victimized by an intimate partner.1,2 In rural communities especially, the risk of domestic violence is a reality that is easily hidden and forgotten. Many circumstances of rural living exacerbate the danger for women who experience abuse.

Geographic and social isolation, concerns about confidentiality in small communities, and limited service options entrap women in violent relationships. Firearms in the household are a fact of life in much of rural America. Law enforcement response times may range from hours to days in rural settings due to bad weather, difficulty of accessing the location and other factors. The closest women’s shelter or domestic violence program may be many miles away in a town or city unfamiliar to the victim. Accessing those services is all but impossible for women who don’t drive or must rely on their partner for transportation, as most rural communities have little in the way of public transportation.

Rural Reality

In Alaska, we often see abusive partners who have relocated their families to remote communities to isolate them from the support of their friends and family, and to more easily track and control their movements. Victims may be held hostage in their own homes with no winter clothing or means of escaping their extreme isolation. Deprivation and isolation become powerful tools to control victims.

One survivor, who shares her story to help others understand the dynamics of abuse in rural communities, described how her husband stranded her and their new baby at a remote fish camp for several weeks without enough food, medications and other essentials. Eventually, she was able to escape her abusive marriage and became a domestic violence outreach
worker to remote villages in the Arctic. Although she struggles with debilitating, long-term health problems secondary to the abuse, she survived. Her former husband murdered his next wife.

When domestic violence services are available in rural regions, they face additional challenges in maintaining security and accommodating rural lifestyles. In Alaska, none of the shelter locations are secret – the communities are too small to hide a facility. Maniilaq Family Crisis Center, a victims’ assistance program and shelter in northwestern Alaska, offers a safe
haven to victims and the animals that they are often unwilling to leave behind. The center uses a snowmobile to pick up clients and has a fenced yard where clients can keep their dog teams and other animals. Susan Jones, the center’s executive director, takes threats against victims’ pets seriously. The murder or mutilation of a pet by an abusive partner is another indicator of escalating domestic violence.


Making the Connection

A leading cause of injuries, homicide and emergency room visits for women in America, domestic violence takes a tremendous and relentless toll on women’s health. National standards require emergency departments to have written protocols on how to screen, identify, document and refer domestic violence victims to appropriate services. Unfortunately, the more subtle issue of the long-term health effects of living in an abusive relationship has received far less attention.

Women who experience domestic violence are more likely to experience a wide range of chronic health problems than other women. They suffer disproportionately from arthritis, irritable bowel syndrome, stomach ulcers, chronic pain syndrome, migraines and eating disorders.3,4 They are at higher risk for pelvic inflammatory disease, chronic pelvic pain and sexually transmitted disease.3,5 They have higher incidences of common physical and mental symptoms including chest pain, low back pain, stomach pain, breathing disorders and nervousness/anxiety. Long-term health problems, in turn, often limit their options,
especially during the later years of life. Chronic illnesses and physical disabilities, along with fear of losing health insurance, are major barriers to leaving an abusive relationship.

The mental health consequences of living in an abusive relationship can worsen this entrapment, particularly when combined with the social and geographic isolation of living in a rural community where there are few or no mental health services. Domestic violence increases a woman’s risk of experiencing insomnia, depression, post-traumatic stress disorder, panic disorder and substance abuse. The symptoms can persist for years after the abuse ends.6 Numerous studies have demonstrated a connection between a history of abuse and an elevated risk of suicide.6

Missed Opportunities

Primary health care providers can be a lifeline to rural women who experience domestic violence. By screening for domestic violence, being supportive and offering information on resources and safety planning, primary care providers acknowledge domestic violence as a women’s health issue while providing critical services. Most surveyed patients and battered women support routine screening for domestic violence in the primary care setting.7,8  Although the American Medical Association and the American College of Obstetricians and Gynecologists recommend screening all female patients for domestic violence, numerous studies have shown that providers rarely screen at primary care visits. Awareness among primary care physicians of the high prevalence of domestic violence is associated with an increased likelihood of screening for abuse.9

Asking a patient about domestic violence takes just a few minutes using a brief screening tool. In an enlightening study by Gerbert et al, physicians with expertise in domestic violence proposed that “compassionate asking” can have therapeutic value in and of itself.10 Time and time again, survivors have attested to the difference that a health care provider can make by asking questions and validating their experience. The time spent with patients who disclose abuse can help providers and patients understand the underlying issue of domestic violence and its impact on a patient’s health.

The Hidden Epidemic

Discussions of domestic violence must also address the hidden epidemic of sexual assault within relationships. Forced sex by an abusive partner is very common, but health care providers rarely ask about it.

Alaska is consistently ranked in the top five states for the highest sexual assault rate per capita. Given the barriers to reporting sexual assault in many of Alaska’s small, isolated communities, where everyone knows one another and service providers are often related to the perpetrator or victim, any statistic would grossly underestimate the actual number of cases. In some communities, health care providers, law enforcement officers and victim advocates have formed sexual assault response teams to coordinate care and prevent revictimization.

Still, many rural victims must travel significant distances to access health care, legal intervention and other services. Some have waited days to be evacuated due to bad weather in remote villages accessible only by small planes. Victims are advised not to shower or change their clothes before a sexual assault exam has been conducted. As days pass and victims remain weathered-in, they may find themselves torn between preserving forensic evidence and preserving their sanity.

Like domestic violence itself, the physical and mental health effects of sexual assault often last a lifetime and may not respond well to standard treatment. Primary care providers whohave built trusting relationships with their patients can provide the first opportunity for many sexual assault victims to discuss their experiences in a safe, supportive environment. But health care providers need to be prepared. In the words of one survivor, providers who ask about sexual assault may be overwhelmed by the number of women who suffered in silence until someone cared to ask. Specialized training on asking direct, non-judgmental
questions and assisting victims is available from state-based domestic violence and sexual assault coalitions and training projects.

Be an Advocate

As health care consumers in a competitive market that values client satisfaction, we can influence health care practices. Encourage your primary care provider to ask about domestic violence and sexual assault – let her or him know that you care about this women’s health issue. For victims, talking to someone who is safe and supportive is an initial step toward developing a safety plan and beginning the healing process. By advocating for domestic violence and sexual assault screening, you can help victims now and improve the quality of women’s health care.

Linda Chamberlain, Ph.D., MPH, is founding director of the Alaska Family Violence Prevention Project (see sidebar) and a board member of the Network.


SIDEBAR:
 

The Alaska Family Violence Prevention Project (AFVPP) provides domestic violence training for health care providers in rural communities. Using a train-the-trainer model, the project has worked closely with the Alaska Network on Domestic Violence and Sexual Assault to create and sustain training teams of health care providers and domestic violence advocates. Additionally, AFVPP is conducting an educational campaign on abuse during pregnancy, researching the screening of women for domestic violence in the pediatric setting, and publishing a book on rural women creating economic opportunities through self-employment. AFVPP training curricula and publications can be downloaded from its website at www.hss.state.ak.us/dph/mcfh/akfvpp

References

1State of Alaska, Department of Health and Social Services, Public Health Nursing.
Unpublished data, 1999.

2Wagner PJ, Morgan P, Hamrick D, Hendrick LK. “Experience of Abuse in Primary Care
Patients: Racial and Rural Differences.” Archives of Family Medicine 1995; 4:956-962.

3Coker AL, Smith PH, Bethea L, King MR, McKeown RE. “Physical Health Consequences
of Physical and Psychological Intimate Partner Violence.” Archives of Family Medicine 2000;
9:451-457.

4Talley NJ, Fett SL, Zinsmeister AR, Melton LJ. “Gastrointestinal Tract Symptoms and Self-
Reported Abuse: A Population-Based Study.” Gastroenterology 1994; 107:1040-1049.

5Schei B. “Physically Abusive Spouse—A Risk Factor for Pelvic Inflammatory Disease?”
Scandinavian Journal of Primary Health Care 1991; 9:41-45.

6Golding JM. “Intimate Partner Violence as a Risk Factor for Mental Disorders: A Meta-
Analysis.” Journal of Family Violence 1999; 14:99-132.

7Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P. “Inquiry about Victimization
Experiences. A survey of Patient Preferences and Physician Practices.” Archives of Internal
Medicine 1992; 152:1186-1190.

8McNutt LA, Carlson BE, Gagen D, Winterbauer N. “Reproductive Violence Screening in
Primary Care: Perspectives and Experiences of Patients and Battered Women.” Journal of the
American Medical Women’s Association 1999; 54(2):85-90.

9Chamberlain L, Perham-Hester KA. “The Impact of Perceived Barriers on Primary Care
Physicians’ Screening Practices for Female Partner Abuse.” Women & Health. In press.

10Gerbert B, Caspers N, Bronstone A, Moe J, Abercrombie P. A Qualitative Analysis of
How Physicians with Expertise in Domestic Violence Approach the Identification of
Victims. Annals of Internal Medicine 1999; 131:578-584.