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First, Ask the Question

By Laura Wexler
One in four women in the United States experiences intimate partner violence in her lifetime. Long after her wounds have healed, that violence can cause serious chronic health problems. That’s why Johns Hopkins nurse researchers say health care providers should ask every female patient about their experience with violence—past and present.

In 2006, when Jill Crank was in her final year of nurse practitioner training at Johns Hopkins School of Nursing, she entered a room where a female patient in her 30s was waiting and asked her a series of questions: Are you sleeping? Do you drink caffeine? Do you eat gluten? Do you have nausea or vomiting? The patient was having bad headaches. Crank was trying to get to the source of them.

“The woman gave me vague answers. She wouldn’t look me in the eye,” says Crank, now a nurse practitioner at Johns Hopkins Community Physicians– Remington. “We got to a roadblock, and I couldn’t get any further.”

That’s when the woman—who was actually a patient re-enactor hired to help train the budding nurse practitioners—“ broke character” and told Crank directly what she had been portraying: “The reason I’m having headaches,” she said, “is because I’m experiencing domestic violence.”

“I thought, ‘Oh my God, how could I have missed that?’” Crank says. “It didn’t occur to me to ask.”

Crank isn’t alone, not by a long shot. Domestic violence—known more widely in the medical field as intimate partner violence—is widespread, affecting nearly one in four women, according to the Centers for Disease Control and Prevention. And yet studies show most primary care providers don’t consistently screen female patients for IPV unless they present with a visible injury: a black eye, a concussion, a broken arm or jaw.

That, say researchers at the Johns Hopkins School of Nursing and elsewhere, denies two key truths of intimate partner violence: It’s rarely a one-time occurrence. And rarely is the visible injury the only—or the most serious— consequence for a woman’s health. Long after a woman is no longer experiencing violence, the physical and mental effects of IPV can cause serious chronic health problems. When health providers fail to ask about her present and past experience with violence, they’re missing key information that could help diagnose and treat her—even save her life.

Most primary care providers don’t consistently screen female patients for IPV unless they present with a visible injury: a black eye, a concussion, a broken arm or jaw.

Ann Bracken also had headaches. Bracken is an actual patient—not a re-enactor—and one day in 1993, she returned home from lunch with her husband with the beginnings of what would become a migraine. When the migraine didn’t go away, Bracken went to see her primary care doctor, then a number of different psychiatrists, then a headache specialist. “I told the doctors I thought the headache was emotional pain masquerading as physical pain,” says Bracken, 66, who lives in Howard County. “I told them my marriage was difficult. I couldn’t get anyone to listen to me.”

For the next seven years, Bracken suffered a daily migraine in addition to a major depression, despite being prescribed an increasing number of narcotic painkillers and anti-anxiety and depression medicines—at one point she was taking eight medications daily. Then, in 2000, after two car accidents Bracken believes were related to being overdrugged, she sought treatment from an energy healer who asked her to talk about her “difficult marriage.” For the first time, Bracken learned that what she was experiencing in her relationship had a name: emotional and psychological abuse. Within four months of seeing the healer, she was headache-free and no longer taking pain medication. She filed for divorce and has not had another migraine or major depression since.

“I don’t think most women understand that long after the violence is over, their health could be being affected. They think when the injuries are fixed, that everything is OK.”

Bracken knew there was a connection between her abuse and her health problems, but many women do not. In 1999, Nancy Glass, a professor at the Johns Hopkins School of Nursing and associate director of Johns Hopkins Center for Global Health, interviewed 76 women who had sought treatment for injuries from physical or sexual violence within the preceding five years. Glass talked with women who’d been shot, strangled, and stabbed by their boyfriends or husbands— and, unforgettably, one woman whose partner had thrown her from a highway overpass. When she asked this woman questions on a screening tool for post-traumatic stress disorder—Do you get angry easily? Are you hypervigilant?— the woman was shocked. “How do you know exactly how I feel?” she asked.

Glass told her that what she was experiencing could be connected to the trauma of being violently hurt by her partner. “She asked me if I really thought it was related, and I said, ‘Yeah, I do,’” Glass says. “She didn’t make the connection. She just thought she was crazy.”

The woman is not an outlier, says Phyllis Sharps, a professor and associate dean for community programs and initiatives at the Johns Hopkins School of Nursing, who also worked as a nurse at the House of Ruth Maryland, a local domestic violence crisis center. “I don’t think most women understand that long after the violence is over, their health could be being affected. They think when the injuries are fixed, that everything is OK.”

Yet often everything is not OK. In terms of mental health, women who have experienced IPV (defined as physical violence, sexual violence, or stalking and psychological aggression by a current or former intimate partner) have a three to five times greater likelihood of depression, and a four times greater likelihood of suicidal ideation. And 30 percent to 80 percent of women who experience IPV have multiple symptoms of PTSD. It’s one of the most prevalent health consequences of IPV, though its incidence is mainly known from research since abused women seldom go to a psychologist to receive a formal diagnosis.

“One of the things I’ve found to be very empowering is for women to know that what they’re experiencing isn’t a vague ‘it’s all in your head’ thing— it’s connected to the abuse.”

“For a long time, providers told women that what they were experiencing— depression, inability to sleep, nightmares, for example—was psychosomatic,” says Jacquelyn Campbell, a professor in the Johns Hopkins School of Nursing and a national leader in IPV research and advocacy. “One of the things I’ve found to be very empowering is for women to know that what they’re experiencing isn’t a vague ‘it’s all in your head’ thing— it’s connected to the abuse.”

Once a woman understands the connection between the abuse and her health, she can potentially manage her health more effectively. “Let’s say someone comes in with uncontrolled asthma,” says Carmen Alvarez, an assistant professor in the Johns Hopkins School of Nursing. “Anxiety is often a trigger of asthma symptoms. If I know a patient has experienced violence and trauma and I can help her identify her triggers, she can be more mindful of them, undertake self-coaching, and be better able to manage her asthma.”

But it’s not just patients who need to understand the connection—it’s providers as well, Campbell says. “If a woman’s abuse contributes to factors such as smoking, poor nutrition, substance abuse, and stress, interventions aimed at those problems will not succeed without addressing intimate partner violence,” Campbell says. “For many abused women, PTSD is driving their depression. The standard treatment for depression—antidepressants—won’t work because it doesn’t address trauma.”

Sometimes providers assume a woman is noncompliant, when in fact trauma could be driving her decisions. “When we see someone who isn’t taking care of their health—drinking, not eating right, not making good decisions—we look for personal responsibility reasons when it could be the trauma,” says Janice Miller, director of programs and clinical services at the House of Ruth. “People do not understand that trauma is hidden and not written out there like losing a limb.”

To uncover the hidden trauma, the nurse researchers are calling for health care providers to screen all female patients for past and present experience with IPV. The Affordable Care Act allows for routine IPV screening and counseling as part of preventive care, and the U.S. Preventive Services Task Force, a board of national experts in disease prevention and evidence-based medicine, recommends routine screening for women of childbearing age.

Yet screening and counseling rates for IPV remain low in the United States. Studies from the early 2000s show that less than 2 percent of women were asked about IPV in a family practice setting, and less than 10 percent in an OB/GYN setting. Though that percentage has risen since the ACA, screening is still far from standard or consistent. An ongoing study, led by Glass, of 15 urban and rural primary care clinics in four diverse states has found screening for IPV ranging from 11 percent to 50 percent.

The nurse researchers understand the challenges primary care providers face in screening for IPV—short patient visits, lack of training, lack of systemic support, lack of a clear course of action should there be a positive response—but they insist these limitations shouldn’t keep providers from asking.

“If you’re a provider and you knew one in four women was coming in with diabetes—can you imagine not asking?” Glass says.

In 2017, Alvarez authored a study that reported on interviews with 17 health care workers serving primarily lowincome Latina populations. The study showed that because none of the clinical sites had a protocol to guide IPV screening or response, many providers were left feeling unprepared. One confessed to the study authors, “If a woman was in front of me right now, saying, ‘My partner is beating the crap out of me,’ all I can say is, ‘Here’s the number to [the shelter], or here’s the number to this hotline. You can give them a call, and they can help you.’ I’m not prepared to walk her through the next steps at all. I cringe every time I go over their questionnaire [the clinic screening tool], like, please don’t be a ‘current yes,’ please don’t be a ‘current yes.’

In March 2018, Jill Crank saw a new patient at JHCP-Remington who was a “current yes.” The patient, a woman in her late 30s whose identifying details have been changed to protect her privacy, completed a new patient intake form asking for information on her surgical history, vaccines, allergies, medications, family history, and an answer to this question: Have you ever been a victim of abuse—physical, sexual, or emotional? She circled yes next to “physical abuse.” Had she not circled that, it’s likely she would not have been asked about her experience with IPV.

When Crank went in to see the patient, she broached the subject of abuse. “She was pretty forthcoming,” Crank says. “It didn’t take a lot of questioning to get her to talk about it.” Crank informed the woman about local support resources and recommended she see a mental health practitioner. The patient was already aware of the resources and already seeing a therapist.

Two months later, Crank was working in clinic when a colleague came to tell her a patient had called with an urgent question. It was the woman who had circled “physical abuse.” “She was calling me from home. She said her boyfriend had hit her and her ears were ringing. She was nauseated and dizzy, had a headache, and had trouble hearing. She wanted to know if she should come see me or go to an ER.” Crank urged the woman to go to the emergency room and get a CT scan.

By the time the woman came for her ER follow-up a week later, she had changed her living situation, though she hadn’t broken off contact with her boyfriend, with whom she shared a mortgage. She was still having dizziness and mild headaches, symptoms of a mild concussion that can last for weeks to months. Crank told the patient the CT scan showed no evidence of brain damage, then scheduled a follow-up.

Crank worried about the patient for weeks, frustrated by both the complexity of the woman’s situation and what felt like her own limited power to address it. “In any other health condition, I usually have at least a little bit of power to steer the situation,” she says. “For this, I feel helpless. I can’t go sequester her. I can’t do all the things I want to do for her health.”

And yet the fact that Crank is aware of the patient’s experience with violence is a step toward helping her understand the role of trauma in her health, Alvarez says. Alvarez, who sees patients a few hours a week at a health center in Maryland, says that at least once each week she encounters a patient “whose past trauma comes to light through a health problem.” She just completed a study of predominantly immigrant Latina women in East Baltimore, some of whom have experienced IPV or abuse as children, and the data show they have a lower confidence in managing their everyday stress. “Being able to manage your stress is a huge part of the equation for better mental and physical health,” she says. “We need to ask what potential history the person has and use that to help them find better stress management strategies.” Maybe it’s suggesting meditation. Maybe it’s giving her apps for her phone or online support.

“Helping women get to safety, although incredibly important, is only one aspect of helping them marshal their resilience against IPV,” Glass says. “We have to support them in dealing with all the impacts of the violence on their health. If we don’t, we can’t keep kidding ourselves. We’re not providing good care.”

“What could be more stressful than being hit by the person who is supposed to love you?”

For centuries it was thought that stress and trauma primarily affected emotional health, but in the past two decades, researchers have discovered it actually changes the body. In 1998, the landmark Kaiser/CDC study of adverse childhood experiences, or ACEs, offered statistical proof that experiencing stress in childhood—whether from direct abuse, witnessing abuse, neglect, or living in a home where substance abuse and mental illness were present—makes adults more vulnerable to diseases of nearly every organ system. That’s led to investigations of the connection between stress and the immune system, a connection that is strikingly pertinent to women who have experienced IPV. As Campbell says, “What could be more stressful than being hit by the person who is supposed to love you?”

Chronic psychological stress affects the immune system by creating chronic inflammation that harms tissues and by suppressing immune cells needed to fight infection. Inflammation is one likely explanation why women who have experienced IPV are at greater risk for asthma, diabetes, bladder and kidney infections, cardiovascular disease, fibromyalgia, irritable bowel syndrome, chronic pain syndromes, gastrointestinal disorders, and joint disease—all conditions related to inflammation. The immunosuppressant effects of IPV also put women at greater risk for both contracting HIV and having poorer outcomes with it.

In 2002, Campbell published a landmark study in The Lancet showing that abused women have a roughly 60 percent higher rate of health problems than nonabused women, exhibiting significantly more chronic pain, gynecological problems, gastrointestinal problems, and neurological issues. In the article, Campbell cites a study showing that abused women generate about 92 percent more health care costs per year than nonabused women—even after they’re no longer experiencing violence.

To understand how psychological stress impacts the immune system of women experiencing IPV, researchers draw insights from a seemingly unlikely population: male soldiers returning from deployment in war zones. “These are two cohorts of people fearing for their lives on a daily basis,” says Jessica Gill, a Lasker Clinical Research Scholar at the National Institutes of Health. While pursuing her master’s degree in psychiatric nursing at Oregon Health & Science University in 2002, she worked in a PTSD research group at a Veterans Affairs hospital and volunteered at a domestic abuse shelter. “I was compelled by the impact of stress, trauma, and violence on the lives of people in both groups. They had nightmares. They were jumpy. They were disregulated. I thought, ‘There’s got to be something else to help them.’”

Abused women generate about 92 percent more health costs per year than nonabused women—even after they’re no longer experiencing violence.

At the time, Gill says, the research on PTSD was focused on the mind, not the body. “That was back when things were more segmented,” she says. “But whenever I see a problem, I think about what’s happening biologically. I started to think about the immune system. How are the immune system and neuroendocrine system affected by this chronic stress?”

While at Hopkins for her dissertation, Gill interviewed low-income women about their trauma history, assessed them for PTSD, and tested their blood for levels of interleukin-6, a protein known as a cytokine that regulates the body’s immune response. “Women with a history of trauma and PTSD had higher levels of IL-6 than normal in their blood, which means their immune system was out of balance and producing higher levels of inflammation,” Gill says. “The balance of the immune system is crucial to health. We think the higher levels of IL-6 could be a link between chronic stress and medical morbidity.”

The good news is that it’s possible to reduce the level of IL-6—to bring the immune system into balance—by, for example, teaching patients to reduce their stress. “Exercise, mindfulness meditation, interventions that are not necessarily medically based, can help,” Gill says. “There’s just so much complexity. It’s not just one thing.”

“You think about how much force it takes to break a woman’s jaw. It’s not only your jaw that’s broken. Your brain is shaken.”

“It’s not just one thing” is something Campbell repeats again and again in her advocacy work. Often these days, she’s referring to what she believes is an underexamined consequence of IPV: traumatic brain injury. Because many symptoms of TBI correlate with those of PTSD—trouble concentrating, trouble sleeping, trouble with executive function, for example—women who have been hit, shaken, suffocated, or strangled may be diagnosed with PTSD when in fact they also have a TBI, Campbell says. According to her research, the incidence of TBI in women who have experienced IPV could range from 30 percent to 74 percent.

“Think about it. We know what happens to boxers’ brains. We know what happens to football players,” she says. “You think about how much force it takes to break a woman’s jaw. It’s not only your jaw that’s broken. Your brain is shaken.”

Part of the reason TBIs may be missed, Campbell says, is because it’s not standard to perform a full neurological workup on a woman who comes into an ER with injuries from IPV. “A kid comes in with a concussion, we do an MRI,” she says. “A woman comes in with a black eye and we say, Put ice on it.”

But it’s also true that researchers understand far less about brain injury in women than in men because TBI and PTSD research has focused largely on male war veterans and athletes. In recent years, for example, researchers have studied the brains of deceased boxers and football players to understand chronic traumatic encephalopathy. CTE is a degenerative brain disease found in those with a history of repetitive brain trauma. Campbell wonders how many women with a history of abuse could be suffering from the disease. In 2013, a man contacted her regarding his mother, a lifelong victim of IPV who kept a journal of her abuse and her many hospital visits. The man believes his mother’s dementia is due to CTE, and he asked Campbell for help. “We got her referred to a good neurologist, but they seem to think the damage to her brain is irreversible at this point,” Campbell says. The son plans to donate his mother’s brain to a brain bank after her death so that researchers have female brain tissue to study. That’s important for the future, Campbell says. But, she says, “I am focused on what we can do for women now, so they don’t get to that point. Let’s take all this information we’re learning from the veterans about how to prevent and repair neurological damage and apply it to women.”

The first step toward providing quality care for women who have experienced IPV means treating them with compassionate curiosity.

But providers won’t know to do that unless they are familiar with a woman’s history of violence. And so Campbell once again returns to something fundamental: questions. “When a woman comes in with a black eye, we need to ask first, Who did this to you? (since a black eye is usually caused by being hit and falling is less common). And then, How many times have you been hit in the face or head over the course of your life? How many times have you been choked or strangled? How many times have you suffered a concussion?” Campbell says. “If there have been multiple episodes, repeated head injuries, it means her symptoms may last longer. You’d want to check on things like balance and sleep disorders and neurological symptoms that continue or get triggered. If she is having problems with her memory or concentration, a cognitive appraisal could be done. We know the brain can be at least partially repaired with the right therapies. But we have to ask.”

Campbell and her colleagues say the first step toward providing quality care for women who have experienced IPV—who numbered 29 million in 2015, according to CDC statistics—means treating them with compassionate curiosity. It means viewing an injury as the beginning of a conversation, not the end. It means asking questions that uncover the often-hidden link between violence, trauma, and health—so that a woman’s past doesn’t have to be her future.

woman at a dresser
Cali Sales

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