October is Domestic Violence Awareness month, but the problem of intimate partner abuse is something we should be aware of all year. Nurx senior medical advisor Dr. Beth Kaplan is an expert in intimate partner violence through her deep experience as an emergency department doctor. Early in her career she worked in the ER at a major San Francisco hospital and was startled to learn that the medical team there had no protocol in place for recognizing or intervening in domestic violence. So, she helped create one! In partnership with the nonprofit Futures Without Violence she created a program for helping patients who came to the ER with injuries and medical presentations related to domestic violence, and helped train providers in hospitals around the country and the world (she traveled as far as Siberia) in the best way to ask about domestic violence and connect victims with care and support.
Today when she’s not treating patients Beth teaches UCSF medical students about the health impacts of partner abuse. We sat down with her to get an expert perspective on the health impacts of domestic abuse, why it can take so long for victims to leave, and how you can help a friend — or yourself.
When you were in medical school did you learn about intimate partner violence?
I wasn’t taught about it in medical school, even though it affects more women than breast cancer or diabetes. But I did learn about it while I was attending med school because a friend called me one night because her husband had hit her and broken a bone in her face. I was shocked—I knew he was controlling and belittling but had no idea he could be physically violent. When I took her to the ER, the physician took the situation very seriously. He told her to get her locks changed and get a protective order, because domestic violence can be deadly. That was when I began to think about partner violence as a health issue.
Then when I did my residency in emergency medicine I had the luck to work at one of the few ER residencies where there was really an advocate for women’s health — my mentor, Barbara Herbert, MD. She was radical at the time (the late 80s) and taught us that partner violence is a health issue. Too often it’s seen as an interpersonal or legal issue, but it truly is a medical problem. In addition to traumatic and defensive injuries from physical abuse, partner violence results in worsening of chronic conditions, anxiety, pregnancy complications and unintended pregnancies, STIs, substance misuse, pain, and more health problems.
Are victims unwilling to tell healthcare providers that they’re being abused?
Victims often do not tell their provider without inquiry as they may feel shame or fear around disclosure. How the physician asks the patient is critical to whether the patient will choose to talk about it. If the physician handles it the right way and creates the environment for it, women feel more confident and supported to discuss the abuse history. The provider needs to create a private, confidential and safe environment, provide empathy and cultural sensitivity, and be prepared to offer resources. The patient wants to feel confident that you care about the issue and are concerned about their health and safety and that of their children and that you have something to offer. If you create the right environment, women often disclose.
What about patients who don’t have obvious physical injuries?
In 2018 the US Preventive Services Task Force updated their recommendation that all women of childbearing age be screened for intimate partner violence. The USPSTF is the organization that looks at all the research to make evidence-based recommendations for preventive care, and the evidence shows that screening for abuse is essential. The conversation can include questions like: Is your partner/ex scaring or hurting you? Do you feel safe at home? What happens when you get into an argument? Have you ever been hit, pushed or threatened by your partner? It’s important that providers ask this and offer resources.
How long does it take for a victim to leave an abuser? What are the steps that victims often take?
It’s important to understand that it’s a multi-stage process, and research shows that it’s typical for a victim to attempt to leave 7 times before ending the relationship for good.
These are the stages most victims go through before leaving for good:
- Not seeing your relationship as abusive
- Experiencing low self-esteem, wondering what you’re doing wrong, feeling embarrassed, and isolating yourself from your support system.
- Admitting to yourself and maybe others that there are abusive things happening.
- A grief process as you accept that your relationship is abusive, which can be very disappointing and hurtful. Once you realize that you may need to leave it’s likely you’ll really grieve that relationship.
- Then comes the planning stage. Ideally, this is when victims will seek help and put together a plan for their safety when they leave. It requires support and resources, as you may need a physical place to go, access to money, and legal advice, especially if there are children involved. This is even harder if the victim is undocumented, or a member of a sexual or gender minority—anybody who is marginalized in society faces extra barriers to exiting an abusive relationship.
- Taking action to leave, but then returning to the abuser (this can happen multiple times).
- Leaving for good
Why do victims return to an abuser?
Lots of reasons—they love the abusive partner, and the partner says they’ll change. They might have children and share a family and community. They may feel they can’t afford to live on their own. They believe it’s going to be better and they’re drawn back. Being able to leave successfully often takes a lot of planning. They need a place to go and access to financial resources. On top of that there’s often enormous fear—often the abuser has threatened to kill the victim or their children if the relationship ends. 70% of intimate partner homicides occur when the victim is about to leave or has left, so it’s a dangerous time.
What can I do if a friend or family member is in an abusive relationship?
Be supportive and don’t judge. Tell them that the situation is not their fault, they don’t deserve it, they have choices, and that you’ll support them during their process of change. Recognize that breaking free from abuse is a process that often takes time. Similar to somebody recognizing and dealing with alcohol or substance use, relapses are often part of the process and not a reason to give up.
What would you like to tell anybody reading this who is in an abusive relationship?
That you have choices. That planning and acting with support and separating from the abusive relationship is essential to your health, and that help is available. You can start getting help any time at the National Domestic Violence Hotline, which has confidential online chat as well as a phone line. They’ll connect you with local resources, such as safety planning, counseling, legal help, or addiction treatment. Find your local resource, reach out to friends and family who will keep it private and safe. Know that this isn’t forever, that you have choices, that you can’t do this alone. So reach out, get the support, and put together a plan. There are solutions, and you can break free, but you have to take the first step.
This blog provides information about telemedicine, health and related subjects. The blog content and any linked materials herein are not intended to be, and should not be construed as a substitute for, medical or healthcare advice, diagnosis or treatment. Any reader or person with a medical concern should consult with an appropriately-licensed physician or other healthcare provider. This blog is provided purely for informational purposes. The views expressed herein are not sponsored by and do not represent the opinions of Nurx™.