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Intimate partner violence, guns, and the ObGyn: Gun violence affects us all, let's not "stay in our lane".

On the afternoon of November 19, 2018, Dr. Tamara O'Neal was shot and killed by her ex-fiance outside Mercy Hospital and Medical Center in Chicago, Illinois. After killing Dr. O'Neal, the gunman ran into the hospital where he exchanged gunfire with police, killing a pharmacy resident and a police officer, before he was killed by officers. (1)

This horrific encounter between a woman and her former partner begs for a conversation about intimate partner violence (IPV). A data brief of The National Intimate Partner and Sexual Violence Survey was published in November 2018. According to this report, 30.6% of women experienced physical violence by an intimate partner in 2015, with 21.4% of women experiencing severe physical violence. In addition, 31.0% of men experienced physical violence by an intimate partner in 2015; 14.9% of men experienced severe physical violence. (2)

Intimate partner violence is "our lane"

The shooting at Mercy Hospital occurred amongst a backdrop of controversy between the National Rifle Association (NRA) and the medical community. On November 7, 2018, the NRA tweeted that doctors should "stay in their lane" with regard to gun control after a position paper from the American College of Physicians on reducing firearm deaths and injuries was published in the Annals of Internal Medicine, (3) Doctors from every field and from all over the country responded through social media by stating that treating bullet wounds and caring for those affected by gun violence was "their lane." (4)

It is time for us as a community to recognize that gun violence affects us all. The majority of mass shooters have a history of IPV and often target their current or prior partner during the shooting. (5) At this intersection of IPV and gun control, the physician has a unique role. We not only treat those affected by gun violence and advocate for better gun control but we also have a duty to screen our patients for IPV. Part of the sacred patient-physician relationship is being present for our patients when they need us most. The American College of Obstetricians and Gynecologists (ACOG) recommends that ObGyns screen patients for IPV at regular intervals and recognizes that it may take several conversations before a patient discloses her history of IPV. (6) Additionally, given the increased risk of gun injuries and death, it behooves us to also screen for gun safety in the home.

Ask patients about IPV, and ask again

The shooting at Mercy Hospital was a stark reminder that IPV can affect any of us. With nearly one-third of women and more than one-quarter of men experiencing IPV in their lifetime, action must be taken. The first step is to routinely screen patients for IPV, offering support and community resources (see "Screening for intimate partner violence" on page 26). The second step is to work to decrease the access perpetrators of IPV have to weapons with which to enact violence--through legislation, community engagement, and using our physician voices.

States that have passed legislation that prohibits persons with active restraining orders or a history of IPV or domestic violence from possessing firearms have seen a decrease in IPV firearm homicide rates. (7) These policies can make a profound impact on the safety of our patients. Women who are in violent relationships are 5 times more likely to die if their partner has access to a firearm. (5)

#BreakTheCycle

The 116th Congress convened in January. We have an opportunity to make real gun legislation reform and work to keep our communities and our patients at risk for IPV safer. Tweet your representatives with #BreakTheCycle, and be on the lookout for important legislation to enact real change.

To sign the open letter from American Healthcare Professionals to the NRA regarding their recent comments and our medical experiences with gun violence, visit https://affirmresearch.org/this-isour-lane-petition. Currently, there are more than 41,000 signatures.

Katherine Koniares, MD Resident, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, Massachusetts

Megan L. Evans, MD, MPH Assistant Professor, Tufts University School of Medicine; Associate Program Director, Department of Obstetrics and Gynecology, Tufts Medical Center

The authors report no financial relationships relevant to this article.

Screening for intimate partner violence

There are numerous verified screening tools available to assess for intimate partner violence (IPV) for both pregnant and nonpregnant patients. Many recommended tools are accessible on the Centers for Disease Control and Prevention (CDC) website: https://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf.

In our office, the tool most commonly used is a 3-part question assessing domestic violence and IPV. It is important to recognize IPV can affect everyone-all races and religions regardless of socioeconomic background, sexual orientation, and pregnancy status. All patients deserve screening for IPV, and it should never be assumed a patient is not at risk. During an annual gynecology visit for return and new patients or a new obstetric intake visit, we use the following script obtained from ACOG's Committee Opinion 518 on IPV (1):

Because violence is so common in many women's lives and because there is help available for women being abused, I now ask every patient about domestic violence:

1. Within the past year (or since you have become pregnant) have you been hit, slapped, kicked, or otherwise physically hurt by someone?

2. Are you in a relationship with a person who threatens or physically hurts you?

3. Has anyone forced you to have sexual activities that made you feel uncomfortable?

If a patient screens positive, we assess their immediate safety. If a social worker is readily available, we arrange an urgent meeting with the patient. If offices do not have immediate access to this service, online information can be provided to patients, including the National Resource Center on Domestic Violence (https://nnedv.org/) and a toll-free number to the National Domestic Violence Hotline: 1-800-799-7233.

Additionally, we ask patients about any history of verbal, physical, or sexual violence with prior partners, family members, acquaintances, coworkers, etc. Although the patient might not be at immediate risk, prior experiences with abuse can cause ' fear and anxiety around gynecologic and obstetric exams. Acknowledging this history can help the clinician adjust his or her physical exam and support the patient during, what may be, a triggering experience.

As an additional resource, Dr. Katherine Hicks-Courant, a resident at Tufts Medical Center, in Boston, Massachusetts, created a tool kit for providers working with pregnant patients with a history of sexual assault. It can be accessed without' login online under the Junior Fellow Initiative Toolkit section at http://www.acog.org.

Reference

(1.) American College of Obstetricians and Gynecologists. Committee Opinion No. 518: intimate partner violence. Obstet Gynecol. 2012;119:412-417.

References

(1.) Buckley M, Gorner J, Greene M. Chicago hospital shooting: Young cop, doctor, pharmacy resident and gunman die in Mercy Hospital attack. Chicago Tribune. Nov. 20,2018.

(2.) Smith SG, Zhang X, Basile KC, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 data brief--updated release. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; November 2018.

(3.) Butkus R, Doherty R, Bornstein SS; for the Health and Public Policy Committee of the American College of Physicians. Reducing firearm injuries and deaths in the United States: a position paper from the American College of Physicians. Ann Intern Med. 2018;169:704-707.

(4.) Papenfuss M. NRA Tweets Warning to Anti-Gun Doctors: 'Stay In Your Lane'. The Huffington Post. November 8, 2018.

(5.) Everytown for Gun Safety website. Mass Shootings in the United States: 2009-2016. Available at https://everytownresearch.org/reports/massshootings-analysis/. Accessed January 17, 2019.

(6.) The American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 518: intimate partner violence. Obstet Gynecol. 2012; 119(2 pt 1):412-417. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/ Committee-on-Health-Care-for-Underserved-Women/Intimate-PartnerViolence.

(7.) Zeoli AM, McCourt A, Buggs S, et al. Analysis of the strength of legal firearms restrictions for perpetrators of domestic violence and their associations with intimate partner homicide. Am J Epidemiol. 2018, 187:2365-2371.
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Title Annotation:COMMENTARY
Author:Koniares, Katherine; Evans, Megan L.
Publication:OBG Management
Date:Feb 1, 2019
Words:1332
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