Intimate Partner Violence: Health Care Providers’ Role

Mark Masselli (00:04)
Intimate partner violence is more prevalent for women in the US than breast cancer and diabetes combined.
We're talking about the role of healthcare providers in identifying and preventing such violence.

Virginia Duplessis (00:17)
We also know that, you know, many people who are being hurt by their partners are prevented from seeing
providers on a regular basis. Sometimes that changes during pregnancy. They're actually allowed to go seek care
for their pregnancy and, you know, for the baby.

Margaret Flinter (00:35)
Our guest is Virginia De Pluses. She's the associate director at Futures Without Violence and the director of the
National Health Resource Center on Domestic Violence.

Virginia (00:45)
Unfortunately, I don't think that we are going to be put out of business anytime soon in terms of thinking about
an end to violence. And we're really leaning into, you know, what are new areas that we can think about, that
contribute to violence happening and, and violence being tolerated.

Margaret (01:05)
This is Conversations on Healthcare.

Mark (01:19)
Well, welcome Virginia to Conversations on Healthcare.

Virginia (01:20)
Thank you so much. Thanks for having me.

Mark (01:23)
Absolutely. You know, we always like to start with an overview and I'm wondering if you could tell our
listeners how Futures Without Violence works towards its goal, and maybe explain the role of the National
Health Resource Center on domestic violence as well.

Virginia (01:41)
Sure. So, futures Without Violence is a nonprofit. We have our, headquarters here in San Francisco where I'm
joining you from. We also have offices in Boston and in Washington DC and really our name says it all. We're
trying to work to create that future without violence. I'm on the health team, so we work specifically with the
healthcare sector, but we have teams that work with judges, with coaches, really just trying to impact all sectors
so they can do a better job of preventing and responding to violence through policy work, through training and
education. You know, I think that we have realized that violence is not an inevitable part of the human
experience, and we all have a unique and important role. So in terms of the National Health Resource Center,
our work, when I'm at a cocktail party and I, someone asks me what do I do day in and day out, and I say that
my job is to help healthcare providers and healthcare systems be able to talk about prevention so that violence
doesn't happen in the first place. And also to support people who have experienced violence. We also work very
closely with domestic violence programs. So people who are seeing survivors of violence to help, to help them
connect their clients with healthcare.

Margaret (03:07)
Well, your work is near and dear, to our heart because as part of our primary care system, we have both
healthcare and we also have had for more than 40 years, a 24-7, domestic violence shelter, an emergency
shelter, and then the full continuum of services. So we have so much to learn from you today and to share, with
our listeners. Really wanna thank you for being here. we are always, struck by the research that shows that
survivors are four times more likely to use an intervention like a domestic violence service after talking with a
healthcare provider about what they're experiencing in terms of abuse. But you've noted that you still see
reluctance among healthcare providers and bringing up the topic, even though screening for intimate partner
violence has been a considered a routine, if you will, expectation in primary care for many years now, how do
you overcome this reluctance?

Virginia (04:01)
I think really the big message to healthcare providers and health systems is that no one should be doing this
alone, right? So we don't expect healthcare providers to be experts in how to help, you know, the nitty gritty of

helping someone who's experienced violence. It's really important to partner with those local programs in your
community. So if you are having conversations with patients about relationship safety and relationship quality in
your back pocket, if someone does say, yeah, things are tricky in my relationship, I might wanna talk to
someone or, you know, I need some help to already have established a connection to that domestic violence
program to legal services. So I think that's really, once healthcare providers understand, aha, I don't have to do
all of this by myself, it helps. The other thing to just remember is it's not as if healthcare providers don't also
have their own experiences of violence, whether it's currently in their past, in their family of origin. And so we
really spend a lot of time also talking about how healthcare providers can take care of themselves and not have
that experience of, you know, vicarious trauma, because they're talking to patients about this. So we try to, from
the beginning, set providers up for success, both connecting them with resources for patients and clients, and
also doing that hard, you know, emotional work, of really grappling with, you know, if you have this in your
history as well, it can be harder.

Mark (05:40)
Margaret, one of the things I find fascinating about this group is that there, training tools are online. They're
very effective. Maybe tell us how you help providers spot violence when the victim may wanna cover it up. And
so many different examples we could give, but the woman who claims she fell off the ladder and was injured
and when really her husband beat her.

Virginia (06:03)
Okay. So this is actually one of the most exciting parts of our work. I think trying to catch someone before
they're pushed down the stairs and really having conversations about healthy and safe relationships before things
are escalating to that level of violence. So we're really encouraging healthcare providers to start with talking
about what it looks like to be treated with kindness and respect. And if things feel a little bit crunchy, not quite
right, how you can get help at that stage. And then having, not waiting for a red flag, but really talking with all
patients about this and being clear about that. Because if you're a survivor, you don't want to, that's only one part
of your identity, one part of your experience walking through the world. No one wants to think that they have
like domestic violence, right? Right. Plastered across their forehead. It's really important to sell every patient.
We know that this is so common. Lots of people experience domestic violence. It has a really big impact on
your health. So I think it's important to talk to everyone about this and then provide that information in a
nonjudgmental way. We know that success doesn't necessarily mean someone telling us what's happening at
home. We really measure our success by does the patient leave feeling supported, listened to, and have access to
information about what's available in the community if they choose to seek help. And that's a big difference,
right? Doctors, nurses, providers want to identify a problem, give someone a solution, and see that that is
followed through. And we know with an issue like this, it's not always that simple.

Margaret (07:57)
Well, I think the research is, very sobering because it makes it clear what I think everybody already knows. This
is a life and death issue. we try for prevention wherever we can, but particularly, in the area of pregnant women
and those who've recently given birth, those in the postpartum period. And this always, just astonishes me that,
those women are more likely to be murdered in the US than die from obstetrical causes such as hypertensive
disorders or sepsis or hemorrhage, which we hear so much about. And of course, the combination of gun
violence and domestic violence is lethal. What do you think that hospitals, OB-GYNs, nurse midwives can do to
try and change this?

Virginia (08:44)
So, I think there are solutions at every level. First of all, when we think about it from a systems-level research,
what kind of data gets collected? We need to be more intentional about acknowledging the role that intimate
partner violence, domestic violence has in maternal and infant mortality. As you mentioned, there's a, you know,
the, attention is really on those of obstetric causes, but, or, and IPV is also a huge driver of poor outcomes for
pregnant people and their babies. and then on that more of a individual level, I really think it is creating those
opportunities for providers to talk openly about relationship quality and safety. The beautiful thing about
pregnancy and postpartum is providers just have more touchpoints with patients. We know that sometimes what
it takes for someone to feel comfortable bringing this up, accepting referrals is that time together is building that
trust. So this is a really unique opportunity to have that impact. We also know that, you know, many people who
are being hurt by their partners are prevented from seeing providers on a regular basis. Sometimes that changes
during pregnancy. They're actually allowed to go seek care for their pregnancy and, you know, for the baby.
And so it could be that this is a person who has really been isolated and not had a chance to talk with a doctor or
nurse. and so we wanna make sure that we are taking advantage of that, one-on-one support that they're getting.

Mark (10:31)
You know, thinking about providers building trust, certainly that's sort of the foundational, foundation of the
community health center movement. and I know you're engaged, working with community health centers.
Maybe talk a little bit about what the national Training and support project is doing in helping them out as well.
And just as a reminder, I think most of our audience knows that 1600 health centers across the country, 10,000
locations, 31 plus million individuals served.

Virginia (11:03)
Yeah. So we also have a resource center that is specific to community health centers. And again, building that,
motivation and prioritizing talking about violence in that clinical setting and those really close partnerships with
the community organizations that serve survivors. So we do training and technical assistance. We have national
events. We have lots of resources that are available online. And one thing that's really unique is we have a series
of, communities of practice. So we have community health centers that come online and meet for, you know,
four sessions over a number of weeks. They also bring their domestic violence organization partners to really
work through, you know, what, what does it take for us to strengthen our partnerships? What are the different
strategies that we can adapt in our communities, really to do a better job of addressing this issue that we know,
unfortunately impacts so many people in our communities and for health sites, that are serving underserved
communities. You know, we see prevalence rates that are higher because these are folks who don't necessarily
have access to lots of other supports and resources. So I wanna make sure that we are reaching those who are
typically underserved.

Mark (12:33)
And you describe the structure of how people come together. Any best practices that you've identified and are
sharing with other health centers in terms of good examples of that intervention?

Virginia (12:48)
Sure. Definitely. So a couple of things. Some of them are topical, so, you know, how do we specifically reach
survivors who may be experiencing homelessness? What are the strategies that we've, created in community for
survivors who are struggling with substance use? And so it's really a lot of bi-directional learning here at
Futures. You know, we have many, many years of this national overview of what's happening in communities,
participating in research to identify those best practices. And we know we can learn from community. So I think
part of our cornerstone really is, as I talked about earlier, developing those partnerships between health settings
and social service settings. and then doing this universal education on healthy relationships and providing
information about where to get help if someone is experiencing violence. And that can be applied in a lot of
different ways.

Margaret (13:50)
Well, one place I'd love for you to, expand upon, is the, school setting and adolescents, right. Particularly
vulnerable group, hopefully more becoming more self-aware, able to both advocate for themselves, and protect
themselves. But you say the providers need to be prepared to talk to people of all ages. So tell us, particularly in
relationship to teens, they're transitioning sometimes with their pediatrician, sometimes they've moved on to
more of an adult provider. They may be in a school-based health center or Planned Parenthood or another
organization. What are you recommending for those providers in terms of training and activity?

Virginia (14:30)
I'm so glad you asked about adolescents. part of my career actually was in adolescent health, working for a
county public health department that did health education for teens. And then I did some work also in, a high
school, school-based health center. So this is a topic that is near and dear to me. And as you mentioned, it's a
time of incredible development, think growth for young people. They are practicing relationships, figuring out
what does it mean to be romantically involved with someone? Or maybe it's not romantic, maybe you're just
having sex, that's okay too. And so we have this period of time that we can have a lot of influence on those
beliefs and behaviors moving forward. So a lot of times we actually approach it more as, what would you do if a
friend were in this situation, right? Because we know there can be some reticence to that kind of direct inquiry
about what's happening in your life. It's more about being good friend a, you know, bystander intervention I
think is also another strategy that's really powerful in this age group because people want to feel that they're
making a difference in their community. Right? and we do see, unfortunately, you know, rates of teen dating
violence are high. we know that for fatal domestic violence, that age group, 15 to 24 is, is the highest age group
where we see intimate partner homicide. So I think it's really incumbent on us in those health settings to, to
make sure that we're talking about this at every visit, you know, and having the message in lots of different
ways, having your provider talk with you, having posters in your clinic, having those safety cards in your

bathroom. So really saturating those settings to make sure that young people know this is an important topic,
that is going to be covered, you know, in our, in our health settings. And, the opportunities to do some of the
conversations confidentially, you know, young people are just starting out negotiating how to communicate with
healthcare providers. and so this is an, an area that we can kind of build that health literacy muscle, right? And
help young people negotiate, those conversations on their own.

Mark (17:07)
Well, you said something dear to our heart. School-based health centers, we operate 160 of them across the state
and also are engaged with the, school-based Health Alliance. but talk a little bit about the, what you're doing
that's sort of a separate setting. Some, sometimes health centers have a school base, but sometimes many times
they're independent. are there any special interventions that you're doing with them? And, and I think you raised
the point earlier, getting them at a young age And, and setting them out in the right, direction is so important.
So, that seems to be a, a early, early intervention.

Virginia (17:47)
Early intervention in the health center. And we again, like to have kind of a saturated environment. So what else
is happening in the school that really supports young people entering into healthy and safe relationships,
speaking up if they see something that that's not quite right. So another arm of futures actually has a program
called Coaching Boys into Men, which helps young people, also navigate and talk about respectful relationships
in that athletic setting. I mean, we've seen successes where, you know, if we have multiple programs happening
in at one school site, just the impacts are even more powerful. and I, I think that all of the interventions that we
seem seeing, all of the strategies really hinge on harnessing the enthusiasm and energy of young people as they
are developing into adults, right? And creating, identifying their own values. Like if we can have a conversation
about what kind of person do you wanna be in this world? What kind of friend, what kind of partner that is
really powerful. Hmm. And I think in the adolescent health setting, especially, most providers are oriented
toward that, right? They're really excited to do this kind of anticipatory guidance. and they're not strangers to it.
So we are really just providing additional tools and supports, ideas for how to have these conversations. but
most of the time those providers are, you know, they've got the skills. They just need a couple more tools in
their toolbox in order to feel successful and effective.

Margaret (19:34)
That's right. That's so important. And if we learn anything in community health, that is, that it takes a village and
there's a continuum. it's never too late for prevention. It may be secondary, it may be after an initial event has
happened, but I wonder, and, don't know if this is within your scope, within futures, but certainly a critical
partner is law enforcement and the folks who respond to those 9-1-1 calls and make the assessments determine
the level of risk, and make the decision about arrests, not arrests, and then into the court system. And I think,
we've seen progress in funding along that whole continuum from primary prevention down to let us make sure
that we get through this situation without loss of life and don't have recurrence. Tell me what you're doing with
law enforcement around that kind of training and education about their role, prevention if we can, secondary
prevention if it has to be, but at all, at all costs, trying to protect life.

Virginia (20:33)
Yeah, so a couple things I'll mention. For all of our work in partnerships, we see the importance of bringing in
many community partners, right? So when we have coordinated community response teams, we encourage, you
know, who in law enforcement can you bring to the table? it is important to remember that the majority of
survivors do not engage with law enforcement, which is why, again, it's so important to make sure that other
helpers like healthcare providers are also, doing this prevention and response work. and we do, we have a long
history, especially working with judges, right? So that's a little bit further in, the criminal legal system, but I
think it does also send a really big message to make sure that we have law enforcement that is trauma informed,
right? That really understands some of the dynamics that go into intimate partner violence. And why is it that
someone might be reluctant to call the police or to say they wanna press charges? and kind of re by increasing
that understanding. we see the frustration, lower a lot because that is some of the feedback we've gotten is, you
know, police officers are like, I show up at this house many times, they never wanna press charges. Why do we
even come anymore? And just to help them understand how that is part of that trauma response, the empathy,
really increases, I think, which helps overall.

Margaret (22:13)
That's great.

Mark (22:14)
Yeah. And we, we see the importance in, in our own, work that we do, having people in the courts. we have two
full-time people who are in the courts working with the district attorney, working with the judges, and obviously
working with the police and so on their home territory, which is, which is very important in, in a place where,
women come in quite often. You know, I wanna shift topics a little and talk a little bit about human trafficking,
which affects nearly 28 million people worldwide, has similar devastating health impacts as intimate partner
violence. What more can the healthcare sector do about human trafficking? And is that an area that you are
focused in on?

Virginia (22:57)
Yes. So especially our community Health center project does have, particular resources and learning
communities that are focused on, trafficking and exploitation. We know that there's so much overlap on all these
issues, sexual assault, domestic violence, trafficking, exploitation, and helping providers, helping systems,
normalize conversations. I think especially for trafficking, it can feel overwhelming and scary to, to say, I'm
gonna address this. And just remembering, okay, what can we do from that prevention and early intervention
standpoint? And then of course, if things have escalated, you know, where can we send someone for help? What
are the resources that we can call in to help a victim or survivor? and again, when we think about young people
and adolescent health, that's also a really vulnerable time for young people, especially those from marginalized
communities, you know, being more at risk for being trafficked or exploited. And so, you know, we don't
wanna, we don't wanna scare people off, but we also wanna be realistic about this experience that is pretty
prevalent.

Margaret (24:18)
Well, we're always interested in learning from you, from others and what people are doing in other parts of the
country. So we've heard about the ACEs Aware Family Resilience Network in California. Very intriguing. Why
don't you share that with us and our listeners?

Virginia (24:31)
Sure. So here in California, we have really been investing in how do we reduce the number of childhood adverse
childhood experiences of Californians. And so the state has really made an investment in, grants to community
groups, and we're providing training and technical assistance to really test what works in communities, not just,
I think for some time we were kind of laser focused on those ACEs screenings and what is your number? How
many ACEs have you experienced in your life? And that is not a number we can change. So, okay, we've got,
we've identified, but really what can we do to help promote healing and thriving, right? If you, we do have folks
who've experienced ACEs and what can we do for prevention? And part of what I think is so beautiful about the
ACEs program is identifying things that help, that don't require a lot of additional resources are going to
appointments. That's like, how do you build strengths within yourself to help emotionally regulate, to reach out
for support in your community, identifying those cultural values and traditions that bring you strength and
happiness and really leaning into that. So I love that, that project. I think it's so important, even as we talk about
all of the negative impacts and devastation that all of these, different, you know, forms of violence bring, really
bringing it back to we have strength, personal strengths, community strengths that can help us heal and thrive.
And that's what we're leaning into.

Mark (26:23)
Oh, that's great. Virginia, I'd like to talk about Future's future. so maybe you could tell us what the state of your
finance financial model is right now. Has it been impacted by what's happening in Washington? And then
maybe just sort of programmatically what are you thinking about as you look out, on the horizon?

Virginia (26:43)
Yeah, so, you know, unfortunately, I don't think that we are going to be put out of business anytime soon in
terms of thinking about an end to violence. And we're really leaning into, you know, what are new areas that we
can think about, that contribute to violence happening and, and violence being tolerated. So how are ways that
we can change social norms, right? And so some of our work is around, the experience of manhood and
boyhood and how we can really bring a healthier masculinity, taking a look at things like economic security,
right? Because we know that is also a driver of, victimization and also perpetration actually. So, you know, what
can we do to increase the economic prosperity of all people as one way to address some of these drivers of
violence in terms of our financial outlook? you know, I think we're always open to, and looking for new and
different partnerships. we have a great mix of funding. Certainly, government funding is a part of our portfolio,
which we need to always be mindful of. But, you know, I think that there are so many people out in our

community who are committed to making sure that futures remains solvent and successful. So I have a positive
outlook there.

Mark (28:22)
What, what, how long have you been now, in existence?

Virginia (28:27)
40 years.

Mark (28:28)
Wow. Congratulations.

Margaret (28:29)
Perfect. Congratulations about as long as our domestic violence program within our organization.
Virginia, we want to thank you. We want to thank futures without violence for the very important work that you
do, both in intervention, but also in prevention and education. Thank you to our audience for being here. And
please remember to subscribe to our videos on YouTube, find us on Facebook and X, and also, please share
your thoughts and your comments about this program. Take care, and be well.

(29:00)
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