Resolve to Address Violence Against Women and Girls
Abigail L. Reese, CNM, MSN, is a fellow with the Robert Wood Johnson Foundation Nursing and Health Policy Collaborative at the University of New Mexico. She received her undergraduate degree from Princeton University and her master of science in nursing at the Yale School of Nursing. She has worked at a birth center on the U.S./Mexico border, and coordinated a federal women’s health grant in Vermont. This post is part of the “Health Care in 2014” series.
My resolution for the U.S. health care system in 2014 is to make strides in addressing one of the greatest health disparities affecting women and girls in this society and the world over: the experience of interpersonal and sexual violence. The Centers for Disease Control and Prevention (CDC) tells us that, in this country, one out of every five women has experienced rape or attempted rape. One in four has experienced “severe physical violence” at the hands of an intimate partner. Furthermore, the evidence tells us that victimization and its consequences begin early. Nearly half of all women who experience rape are assaulted before the age of 18, and 35 percent will be re-victimized during their lifetime.
Those of us who provide health care services to women are first-hand witnesses to the health-related consequences of interpersonal and sexual violence. These women are at greater risk for a range of potentially devastating health problems including: debilitating depression and anxiety, substance use disorders, sexually transmitted infections, unwanted pregnancies, and giving birth to preterm or low birth weight infants. They have higher reported rates of frequent headaches, chronic pain (including chronic pelvic pain), diabetes, asthma, and irritable bowel syndrome, among other conditions. Therefore, many of the symptoms and conditions that bring women into our care are related to their experiences of violence.
It is impossible to fully understand a woman’s health history or risk profile without knowing if physical or sexual trauma is a part of her story.
Evidence continues to emerge linking trauma and stress, including adverse childhood events, to chronic health conditions and poor health outcomes. The financial cost to society and our already-overburdened health care system is hard to pinpoint. However the most recent estimate available from the CDC exceeds $8.3 billion annually, excluding criminal justice costs (which are skyrocketing).
Health care providers have a privileged vantage point to assess the damage and, unfortunately, we share it with those in corrections and at state child welfare agencies. This is due to the fact that women who are involved with the criminal justice system (at rates rising exponentially due to non-violent, drug-related convictions) and those at risk to lose custody of their children are overwhelmingly survivors of abuse. Some studies cite rates as high as 82 percent or more. Therefore, women who experience physical and sexual trauma are at risk of losing more than their health and sense of personal safety; their experience puts them at risk of losing everything, including their freedom and their families. With the stakes so high for so many, there is a moral imperative for us to be engaged with efforts to eradicate the problem at its root.
There is much that the health care community must do to improve our response to violence against women and to assist with primary prevention efforts. Implementation of the Affordable Care Act (ACA) will expand our opportunities by making health insurance more accessible to women who have left abusive partners, or who previously may have been denied coverage due to intimate partner violence (IPV) as a pre-existing condition.
To begin, we must commit to universal screening for current and past abuse among the women we serve. There are many resources available to assist clinicians with individual competence and site-based screening implementation. Furthermore, the ACA includes screening and counseling for IPV among the essential health benefits that must be covered by all insurance plans. By asking, we communicate to our patients that we are interested and prepared to help—and by asking, we can resist the silence that perpetuates and normalizes abuse. Also, we now know from the evidence that it is impossible to fully understand a woman’s health history or risk profile without knowing if physical or sexual trauma is a part of her story.
Another essential part of our task is to reflect upon and address any ways in which our service delivery models may perpetuate or reinforce victimization experiences for women. This can take a variety of forms in which women may experience physical or emotional coercion while receiving care. Fragmented care is also implicated. The opportunity for system redesign prompted by the ACA and the unsustainability of our current system must incorporate comprehensive and trauma-informed models of care for women in all settings, especially for those who are involved with the criminal justice system.
Finally, those of us who provide health care for women must seek active participation in coalitions with other sectors of civil society to eradicate violence against women and girls. Until we live in a society where violence is not tolerated, our efforts to improve the health status of our communities will be have limited results. We owe it to those who entrust us with the most intimate, painful, and sometimes triumphant aspects of their lives.