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Health // Doctor in the House
Rasa Fournier

Partner Violence Awareness Month

Dr. Alexa Sueda
Physician leader for Kaiser Permanente Hawaii’s Family Violence Prevention Program

Where did you receive your schooling/training?

I attended the University of Southern California Keck School of Medicine for medical school and then completed my residency here in Hawaii.

How did you become involved in the domestic violence program?

As an OB-GYN physician, I see violence against women frequently in my patients. When Kaiser Permanente was looking for a physician champion to advocate some of the intimate-partner violence programs that were rolled out on the Mainland, it seemed logical to have someone who worked with women’s health lead that. So I volunteered.

Are the signs of violence that you see in your patients physical signs?

Often, you don’t see anything physical, and they don’t even necessarily disclose that it’s going on. In women’s health, we’re encouraged to routinely ask about violence in a relationship. I found more and more that the women whom I didn’t expect, women who seemed to be happy and in a loving and supportive relationship, would eventually disclose that it wasn’t all that it seemed.

What is the Family Violence Prevention Program?

You can’t always tell who’s been battered or who’s in an abusive relationship just by how they look or by making assumptions. Recently, the U.S. Preventive Services Task Force recommended that all clinicians screen women of reproductive age at their medical facility. They view it as a medical health problem. In response, Kaiser Permanente has begun to formalize our approach to intimate-partner violence by following this recommendation.

We have a comprehensive program that incorporates routine screening and provides on-site services with behavioral health and social work. We try to provide a supportive environment with informational posters and displays about intimate-partner violence awareness, including elder abuse awareness. We also try to keep a good relationship with community organizations that support efforts in legal advocacy, shelters and safety planning.

What demographic is included in the term “intimate-partner violence”?

We moved away from the term domestic violence and moved toward intimate-partner violence because we recognize that violence in an intimate relationship can incorporate dating, where you might have a 14-year-old dating a 15-year-old and there’s incredible violence, including sexual violence, in that relationship, but you don’t think of them as domestic partners. The term intimate-partner violence also incorporates same-sex relationships and the elderly. There can be a lot of intimate partner violence among the elderly, especially as caregiver stress takes hold and the power dynamics change. Men can experience violence in their relationships as well.

Are people forthcoming about abuse in their relationships?

I don’t expect that I’m detecting everybody who is experiencing abuse. The statistics are that about 6 percent of women we see have experienced rape, physical violence or stalking by an intimate partner in the past year. That means that every other day I have a patient who is experiencing that type of situation, but I’m sure there are people who are not disclosing to me. Just by asking questions, giving it a name and bringing it out in the open plants a seed. For some women, it takes several visits and several times being asked before it comes out.

A 2010 National Intimate Partner and Sexual Violence survey found that overall in the United States, about 28.8 percent of women had experienced rape, physical violence or stalking by an intimate partner in their lifetime, and nearly 10 percent of men had experienced the same thing. In Hawaii, the statistics showed that about 36 percent of women at some point in their lifetime had experienced rape, physical violence or stalking by an intimate partner. It’s a common issue that we don’t talk about much until someone is killed, and then maybe on the news. For every woman who reaches that extreme, we forget about all the women out there who still are experiencing abuse.

The statistics on teen dating violence are horrible. A study found that 10 percent of adolescents in Hawaii have been hit by their partner in the past year. This includes men and women.

Most violence starts in the adolescent years and then escalates in the 20s. The incidence rate drops down a little bit from there. Parents often fail to recognize the problem because they don’t want to talk to their teenager about anything to do with their relationships. They’re afraid it’s going to lead to difficult discussions. What’s encouraging is that we’re having increased detection in this area.

What services do you offer to those who are experiencing a violent relationship?

We approach this as a health concern just as the Centers for Disease Control does, and consider this a public health problem. We don’t have the expertise to provide a restraining order, or to help with a divorce or with custody battles, but what we can do is give a name to the abuse. When we find someone who is experiencing abuse in their relationship, we find that emotional and verbal abuse are just as abusive as physical abuse. Or that sexual abuse is just as much a form of violence as physical abuse is. Then we talk to them about how it’s not their fault. We do a danger assessment to make sure they’re safe to go home that day.

We give referrals to either a community organization to provide shelter or help with a restraining order or to Behavioral Health Services to assist with emotional difficulties stemming from the abuse. Our social workers are trained to provide counseling and referrals.

How is intimate-partner violence a public health problem?

A lot of people, even in our own medical community, view this as why are we dealing with intimate-partner violence? Isn’t that more of a social or legal concern? But there is more and more evidence about the effects that violence has on one’s health, such as an increased risk of depression, PTSD and anxiety. There is also a higher risk of asthma, stroke and heart disease. People who experience violence are twice as likely to smoke.

One of the many physical effects is an area that is dear to my heart: reproductive choices. Evidence shows that in abusive relationships, authority over birth control or whether or not a woman has a baby is used as a tool of abuse, because abuse comes from the desire for power and control. These are all things that have an incredible impact on a person’s health. As a medical community, we have to address the issue, otherwise we’re overlooking the underlying cause of a lot of problems.

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