Authors: Vanessa Mikhael, Rawane Ghabi, Abla Belahmer, Ryma Kadi, Natalie Guirguis, Andreas Gutzeit, Johannes M. Froehlich, Ema Ferreira, Tamsin Higgs, Marie-Michele Dufour, Valerie Theoret, Martine Hebert, Joane Turgeon, Marta Chadwick Balcom, Bharti Khurana, Simon Matoori
Categories: Research and Clinical
Source: Canadian Pharmacists Journal : CPJ
role
Intimate partner violence (IPV) is a serious public health issue and a violation of human rights. According to the World Health Organization, IPV is defined as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship.” These abusive acts include physical and sexual violence, psychological aggression such as controlling behaviour and stalking, and economic violence. IPV can lead to serious acute and chronic physical and mental health conditions, including physical injury, depression, posttraumatic stress disorder and death by violence or suicide.^1-4^
Data from the Centers for Disease Control and Prevention indicate that nearly 1 out of 4 women and 1 out of 9 men have experienced IPV throughout their lifetime in the United States.^ 5 ^ Among women in primary care or emergency departments (ED), the lifetime prevalence of IPV-related physical violence and/or unwanted sexual relations is about 37% to 50%, and 1% to 7% of female patients in the ED present with acute IPV-related physical injuries.^6-9^ It is important to note that IPV can affect persons of all gender identities.^10,11^ Indeed, the 2015 National Intimate Partner and Sexual Violence Survey, which included 10,081 participants, estimated that 5.4% of women and 5.1% of men experienced any past-year physical violence, sexual violence and/or stalking.^ 5 ^ In Canada, 12% of women and 11% of men reported experiencing IPV in the past 12 months in 2018, according to Statistics Canada.^ 12 ^ The economic burden of IPV is high, with per-victim lifetime cost of 23,414 for male IPV survivors in the United States.^ 13 ^
The COVID-19 pandemic has shaken many aspects of society, with long-lasting consequences.^3,14^ While stay-at-home orders were in place, many individuals in abusive relationships were forced to stay at home with their abuser.^3,14^ This crisis led to a drastic increase in IPV-related calls to the police and more severe injuries as IPV survivors delayed accessing health services due to the fear of COVID-19 infection.^3,14,15^ In addition, many women’s shelters had to turn away new survivors due to physical distancing measures and lack of space.^3,14^
IPV is underreported and underinvestigated because this type of abuse is often experienced in closed spaces, survivors are stigmatized and IPV is often not reported to the police. It has been shown that ED physicians, nurses, midwives and, more recently, radiologists can make a difference to IPV survivors.^3,6,14,16^ However, the role of the community pharmacist, a first-line health care worker, in identifying and supporting IPV survivors has been insufficiently explored. Easily accessible and knowledgeable, pharmacists may be able to identify IPV survivors, assess the immediate danger and refer a survivor appropriately. This is especially true if the pharmacist has already built a relationship of trust with the IPV survivor. Indeed, pharmacists have unique knowledge about IPV risk factors, including the medications of their patients, physical injuries, psychological state and patient characteristics. Furthermore, pharmacies are places where people can buy daily necessities (medication, food, cosmetics) and thus likely are accessible for IPV survivors who are being monitored by their abusers. Pharmacies also offer private and safe spaces for caring conversations and display options for actionable resources. Because of the unique accessibility of pharmacists, we have written guidelines for pharmacists to identify and provide actionable resources to support IPV survivors (Figure 1).
Figure 1 Guidelines for pharmacists to identify and support IPV survivors
IPV affects various segments of the population differently and leads to a variety of conditions, including physical injuries, neuropsychiatric diseases and gynecological disorders. Awareness of IPV-associated patient characteristics and injuries can help pharmacists to ask more specific questions to determine if IPV is occurring. The pharmacist’s role is to ask open-ended questions to find out more about the origin of the injuries and diseases. These questions can also provide important clues about the plausibility of the patient’s account of the origin of the injuries.
IPV can affect anyone, regardless of gender, religion, ethnicity and socioeconomic status. However, there are risk factors for IPV. Many reports show that IPV survivors are predominantly female,^17,18^ although IPV can affect persons of all gender identities.^10,11^ About 5.4% of IPV survivors identify as lesbian, gay, bisexual or transgender.^ 19 ^ According to one US study, approximately 37.3% of survivors are African American and 28.1% are of Hispanic origin.^ 19 ^ In Canada, lifetime prevalence of IPV survivorship is higher among Indigenous (First Nations, Métis, and Inuit) women (61%) and men (54%) than among their non-Indigenous counterparts (44% and 36%, respectively), and Indigenous women (17%) are more likely to have experienced IPV in the past 12 months compared with non-Indigenous women (12%).^ 12 ^ The median age of survivors is around 30 years; however, elderly persons are also affected.^10,17,20^ Populations with low levels of education, financial dependence, low socioeconomic status, drug or alcohol abuse, a history of childhood abuse, mental health issues, disabilities, homelessness, pregnant or perinatal women, single mothers and separating couples are at greater risk of experiencing IPV.^3,6,14,17^ Adolescents are also at risk of IPV, and experiencing this as an adolescent increases the risk of future IPV both as the victim and the perpetrator.^ 21 ^ As for abusers, they are often young, have a low income, have a low level of education, have a history of violence during their childhood, have personality disorders, have alcohol or drug abuse and are unemployed.^3,6,14,17^ However, it is important to note that any person can be an abuser.
According to a study in the United States that compared the characteristics of IPV between men and women, there are some differences in spousal violence toward males versus females. Compared with women, male survivors were older (36.1% vs 16.8% older than 60 years) and more likely to identify as Black (40.5% vs 28.8%).
The most common physical injuries are fractures, contusions/abrasions, lacerations, strains/sprains and internal organ injuries (Table 1).^ 19 ^ IPV survivors often present with multiple injuries to different parts of the body.^ 19 ^ A high frequency of injuries is also an indicator of IPV.^ 19 ^ Physical injuries are generally the most visible sign of IPV.^ 6 ^ When asked about the origin of these injuries, the stories IPV survivors tell are often inconsistent with their injuries.^ 6 ^
Facial injuries are the most common physical injuries among IPV survivors, as the head and face are easily accessible areas.^22,23^ In the ED, almost 90% of survivors of IPV-related assault present with facial injuries and about half of them have an associated facial fracture.^ 24 ^ More than half of the female patients with facial injury presenting to the ED have injuries secondary to IPV.^ 25 ^
Craniofacial fractures in IPV survivors are most commonly located in the middle third of the face and affect nasal bone and orbital fractures.^6,19^ Facial injuries are often on the left side because survivors can have a reflex to turn their face to the right during episodes of abuse.^6,19^ Punching and assault with a blunt household object (e.g., bottle) are most common.^22,26^
There are gender differences in the physical injuries of IPV survivors. Compared with women, male survivors in one study had more cut injuries (28.1% vs 3.5%), more lacerations (46.9% vs 13%), more upper extremity injuries (25.8% vs 14.1%) and fewer bruises/abrasions (30.1% vs 49.0%).^ 19 ^
Single and repeated head injuries can have consequences for the brain and cause head trauma such as contusions and intracranial hemorrhages.^ 27 ^ The resulting cognitive consequences are difficulties concentrating, hearing/vision problems and memory loss.^ 27 ^ Numerous mental health issues are also associated with IPV.^ 28 ^ In a Canadian study of female IPV survivors, participants reported chronic and acute depression (31%), anxiety disorders (13%), posttraumatic stress disorder (7%) and sleep disorders (7%).^ 29 ^ Other studies identified a high prevalence of depression, anxiety, emotional distress, low self-esteem, feelings of shame and guilt, and alcohol and substance abuse among IPV survivors.^8,28,30^
Women who experience IPV are likely to have repeated genital and urinary tract infections, repeated sexually transmitted infections, unwanted pregnancies, terminations of pregnancy, obstetrical and fetal complications and risky pregnancy behaviours such as smoking, drinking and drug use.^6,19,31^
Certain medication and adherence patterns are associated with IPV risk. Although taking these drugs does not necessarily mean that the patient is an IPV survivor, reviewing medical records offers important insights into the physical and mental well-being of the patient and may support a suspicion of IPV.
A challenge for pharmacists is that IPV-indicating over-the-counter (OTC) products are often not in the medical records. Indeed, to cope with the health consequences of physical and emotional abuse, IPV survivors often take various prescription and OTC drugs. A Canadian study showed that the rate of prescription medication use was 70% and OTC medication use 76% among IPV survivors.^ 29 ^ On average, IPV survivors took 3.2 prescription drugs and 1.7 OTC drugs.^ 29 ^ If IPV is suspected, assessing the patient’s medication can yield valuable information on their past and current mental and physical health status and IPV risk.
IPV survivors often require analgesics since physical injuries are highly prevalent in this population. According to a Canadian study of female IPV survivors, 15% of participants reported taking prescription painkillers such as analgesics and antipyretics, opioids and antimigraine medication (Table 2).^ 29 ^ In a Canadian study of female survivors of IPV with chronic pain, the average number of prescription medications increased with each pain grade, and participants with highly disabling chronic pain were more likely than those with low-disability chronic pain to take opioids, acetaminophen with codeine and prescription nonsteroidal anti-inflammatory drugs (NSAIDs).^ 32 ^
Prescriptions are not the only way a survivor can have access to pain medication. According to a Canadian study, many female survivors of IPV with chronic pain were taking OTC analgesic medication (42% acetaminophen and aspirin, 39% NSAIDs).^ 32 ^ The most common OTC medications taken by participants of another Canadian study were painkillers, with over a third taking OTC acetaminophen or ibuprofen.^ 29 ^ While this intake is high, it was still lower than that in a general population of Canadian women.^ 29 ^ This information is concerning with regard to the higher incidence of chronic pain in female IPV survivors.^ 32 ^ The authors speculated that affordability issues with OTC medication may explain these findings.^ 29 ^
As rates of mental health problems are high among IPV survivors, psychotropic drugs (antidepressants, anxiolytics, sedatives) are common in this patient population. Central nervous system depressants such as benzodiazepine anxiolytics/hypnotics and the Z-drugs zolpidem, zopiclone and zaleplon were frequently prescribed to female survivors of IPV.^ 33 ^ Female IPV survivors take more tranquilizers (11.3% vs 3.8%) and antidepressants (31.3 vs 9.5%) compared with Canadian women in the general population.^ 29 ^ Also, the rate of using medication for sleep, anxiety and depression was more than double among female IPV survivors with a disability than those without.^ 34 ^ The type of violence may influence drug the association between the use of hypnotics and psychotropic drugs was observed only with physical and/or sexual violence and not with psychological violence.^ 35 ^
IPV affects contraception use and the need for STI treatments. In a Canadian study, women with IPV were less likely than women in the general population to take oral contraceptives (5.8 vs 16.6%).^ 29 ^ One study found that IPV survivors were more likely to be forbidden to use contraception.^ 36 ^ According to a study from the United Kingdom, IPV survivors have more frequent consultations for emergency contraception.^ 37 ^ Several studies found that abusive men are less likely than men with no history of sexual aggression to use condoms and are more likely to remove condoms during sex.^ 36 ^ Indeed, the risk of unintended pregnancy was higher in the context of IPV among females ages 16 to 29 years in California.^ 31 ^ IPV survivors are also more likely to seek care for STIs.^ 38 ^
Female IPV survivors were less likely to take cough and cold medications compared with other Canadian women. Once again, a reason could be the affordability of these products.^ 29 ^ Female survivors also tend to engage in substance abuse, such as opioids or other drugs. A study showed that IPV survivors were 25% less likely to adhere to their treatment for substance use disorder.^ 39 ^ Reasons for this finding include negative effects of IPV on self-worth, controlling behaviour of the abuser and the need for illegal substances to cope with the abuse.^ 39 ^ Wound care products are often purchased by IPV survivors but may not come up in the medical history because they are OTC.^ 40 ^ Furthermore, IPV has a negative impact on medication adherence, even in continuing chemotherapy.^ 41 ^
To efficiently support IPV survivors, pharmacists need to be aware of the actionable resources for IPV survivors in their community. Multiple resources are available for survivors of IPV across various platforms, such as support organizations, women’s shelters and crisis hotlines. Information and communication technologies, such as mobile phones, smartphones and the Internet, have greatly facilitated access to these resources. According to a systematic review evaluating the effectiveness of information and communication technologies-based IPV interventions, 90% of participants who used these technologies to reach out for help left their abusive relationship within 1 year.^ 42 ^ It is therefore crucial that pharmacists are familiar with the IPV service providers in their community in order to advise IPV survivors of the care best suited to their needs.
The main mission of IPV support organizations is to empower IPV survivors by providing a wide range of individualized services such as education on identifying abuse, hotline-based crisis intervention, help to create a customized safety plan, and connecting survivors to service providers such as social workers, legal and economic advice.^ 43 ^ Additionally, such organizations offer resources to those who wish to support a person affected by IPV.
Community pharmacists can use such organizations as tools to better educate themselves on this health problem and to better advise IPV survivors and their concerned family members or friends. Furthermore, pharmacists can offer a safe environment for IPV survivors to access this type of platform through the pharmacy’s computer or telephone, as access could be monitored by the abusive partner at their home.
A women’s shelter is a place of protection and support for women escaping IPV.^ 44 ^ These government- and/or non-profit-funded facilities offer women safe temporary emergency accommodation, food, personal items and transportation. Some shelters offer additional services like a crisis hotline, child support and legal advice. ShelterSafe.ca, an initiative of Women’s Shelter Canada, is an online resource that guides women to locate a shelter near them according to the province in which they reside. Such websites are a useful resource for community pharmacists as well, helping them direct their patients to the closest shelter fitting their individual needs.
A crisis hotline is a phone number that connects callers to immediate emergency telephone counselling.^ 44 ^ This platform puts callers in contact with advocates who are trained to offer individualized support based on the callers’ needs. For IPV, crisis hotlines are available 24/7 free of charge for survivors, concerned friends/family members or abusive partners looking to change. A community pharmacist can call a crisis hotline to ask for guidance or advice about IPV in general or to put IPV survivors in the pharmacy in direct contact with a crisis hotline through the phone at the pharmacy.
There are many mobile applications for IPV survivors that can be downloaded free of charge and are often disguised as IPV-unrelated content.^45,46^ These apps assist IPV survivors in various steps of exiting their abusive relationship: from identifying abuse to creating a safety plan adapted to their situation and offering links to local resources. Additionally, many apps contain measures to ensure the safety of the a pin code is mandatory to access the account and the information provided is anonymous. Some applications are even tailored to appear as news applications or cooking sites to protect survivors from abusers who monitor their partner’s phone.
IPV brochures are paper documents that aim to educate individuals on IPV and to point to local resources that support IPV survivors.^ 44 ^ The pharmacist may offer brochures to potential IPV survivors unless the survivor is accompanied by the abuser or other individuals of unclear relationship to the abuser. As an alternative, the pharmacist can provide QR codes without any apparent information related to IPV. Displaying posters on IPV and local support organization in the community pharmacy is an effective way to raise awareness of this health issue. Pharmacies may also choose to take part in IPV fundraising campaigns (e.g., during domestic violence awareness month).
In addition to being aware of actionable local resources, pharmacists need to have effective communication skills to build trust and empower the IPV survivor to consider the proposed resources (Figure 2). Although pharmacists are not psychologists, their training and experience provides them with the tools to communicate with patients in psychological distress, offer moral support and guide them to specialized caregivers. For instance, pharmacists are trained to interact with depressed or suicidal patients. The infrastructure of pharmacies also offers the means for nonconfrontational indirect communication with IPV survivors.
Figure 2 Communication with IPV survivors
First, pharmacists need to understand that IPV survivors face different phases of abuse.^ 47 ^ Initially, tension builds between the partners that results in an acute episode of violence, which may then be followed by a so-called honeymoon phase, where the abuser justifies their actions and/or asks for forgiveness.^ 47 ^ Thus, a survivor’s thoughts, emotions, behaviours and needs often vary over time, which may affect the openness for disclosing IPV and considering IPV resources.
Second, pharmacists need to be aware of how difficult it is for IPV survivors, who are frequently stigmatized, to ask for help and to trust others. Open and caring communication is essential to maintain a good relationship with IPV survivors. It is imperative that pharmacists work on this bond of trust over the long term by creating and nurturing a therapeutic alliance, as they interact with patients for new prescriptions, renewals and advice about medications and health issues. When violence occurs, this trust can be used to increase the chance of IPV disclosure and acceptance of the provided resources.
A therapeutic alliance is a powerful tool for pharmacists to build relationships of trust with their patients.^ 48 ^ According to Edward Bordin’s definition of a therapeutic alliance, it is necessary to integrate both the nonspecific relational aspects (“the links”) and the technical relational aspects (“tasks and objectives”) in a single model.^ 48 ^ In practice, the therapeutic objective is mentioned by the patient and approved by the pharmacist. For example, for an IPV survivor who is also taking blood pressure medication regularly, the goal might be to lower the blood pressure value to <140/90 mm Hg within 4 weeks. Tasks are proposed actions to achieve what the pharmacists does for the patient and what the patient does. For example, the pharmacist dispenses antihypertensive drugs and a blood pressure monitor with instructions on its use, while the patient agrees to take the medication and measure their blood pressure daily. The link is the affective quality of the alliance and includes aspects like trust, concern and commitment. By tackling health issues as a team and achieving IPV-unrelated therapeutic goals, the pharmacist may create a bond of trust with patients that may enable them to disclose IPV and consider actionable resources.
Ensuring confidentiality, offering the patient the chance to talk in a private space, making eye contact and assuring the patient that the conversation is confidential will increase the level of comfort of IPV survivors, especially if they are new patients at the pharmacy.^ 3 ^ Throughout the consultation with a suspected or confirmed IPV survivor, the pharmacist preferably asks open questions, reflects the patient’s feelings and rephrases the IPV survivor’s words (active listening) to avoid misunderstandings or false interpretations (Table 3).^3,16,49^ It is important to show empathy to develop and strengthen the therapeutic alliance.
It is also important for pharmacists to convey that they believe and are concerned for IPV survivors without interrogating them.^3,16,49^ Suggestive questions, putting pressure on the survivor and asking judgmental “why” questions should be avoided. The key to good communication with an IPV survivor is to be a good listener, believe the survivor and express support.
The immediate safety of the patient, the pharmacist and pharmacy staff should be evaluated based on risk factors such as severity and frequency of violence, threats, drug or alcohol abuse and pregnancy. The pharmacist then communicates the actionable resources in the area, tailored to the patient’s needs. Validating the strengths of survivors further reinforces the bond and empowers them.^3,16,49^
It is important to conclude the consult by offering a follow-up and the pharmacy’s phone contact for further help. Finally, the pharmacist should document the interaction and advice given in the patient’s medical record.^ 44 ^ The pharmacist should be aware, however, that the patient’s medical record may be accessed by the abusive partner and therefore should ask the patient for consent before documenting.
In addition to providing opportunities for indirect communication with IPV survivors through posters and brochures, pharmacies can offer their infrastructure to enable the IPV survivor to access actionable resources in a safe for instance, for a call to an IPV support organization. Recently, a pharmacy chain in Canada started a campaign to support IPV survivors in collaboration with a local IPV support organization. The pharmacies offer a safe and confidential space to contact the support organization without the risk of the hotline appearing on the survivor’s phone or phone bill. The participating pharmacies can be found on a dedicated website and exhibit a special symbol. Furthermore, helping patients ask for privacy nonverbally can be a helpful tool for IPV survivors who are not visiting the pharmacy for instance, with a sticker with the letter P on the counter.
IPV is a serious health issue but remains a taboo in many societies, and IPV survivors often face stigma. It is essential for pharmacists to be aware of the scale of IPV, its consequences and their capability to identify and help IPV survivors. These guidelines provide pharmacists with the tools to identify IPV survivors, engage in caring conversations and offer actionable resources. Indeed, pharmacists are ideally suited to help IPV survivors, as community pharmacies are highly accessible spaces with safe and private sections. Pharmacists are trained to engage in difficult conversations, such as with depressed or suicidal patients. Pharmacists are patient-oriented health care providers who proactively engage with their patients and establish powerful therapeutic alliances and long-term relationships of trust and, thus, have the capacity to identify and effectively support IPV survivors. ■
The figures were created using biorender.
Vanessa Mikhael, Faculté de Pharmacie.
Rawane Ghabi, Faculté de Pharmacie.
Abla Belahmer, Faculté de Pharmacie.
Ryma Kadi, Faculté de Pharmacie.
Natalie Guirguis, Faculté de Pharmacie.
Andreas Gutzeit, Department of Health Sciences and Medicine, University of Lucerne, and the Institute of Radiology and Nuclear Medicine and Breast Center St. Anna.
Johannes M. Froehlich, Hirslanden Klinik St. Anna, Lucerne, Switzerland; the Clinical Research Group, Klus Lab Zurich, Zurich, Switzerland.
Ema Ferreira, Faculté de Pharmacie; Département de pharmacie, CHU Ste-Justine, Montreal, Quebec.
Tamsin Higgs, Département de psychologie.
Marie-Michele Dufour, École de psychoéducation
Valerie Theoret, Département de sexologie, Université du Québec à Montréal, Montréal, Quebec.
Martine Hebert, Département de sexologie, Université du Québec à Montréal, Montréal, Quebec.
Joane Turgeon, Faculté de l’éducation permanente, Université de Montréal, Montreal, Quebec.
Marta Chadwick Balcom, Community Health Intervention and Prevention Programs.
Bharti Khurana, Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts.
Simon Matoori, Faculté de Pharmacie.