The nurses noticed the behavior first — how he answered for her, his arms on her shoulders, and, on the day of discharge, his refusal to leave her room to retrieve her medications. The labor & delivery floor was already in full swing when her nurse came over.
“I am worried that she’s not safe to go home.”
We walked into her room and were immediately accosted by his voice: “We need to leave. Now. Why haven’t you discharged her yet?” The mother stood holding her baby, toes curling as if she was trying to grip the floor, steeling her body in place. The nurse and I shared a glance and stepped out of the room to discuss what was now dangerously evident.
Intimate partner violence (IPV) is a pattern of assaultive and coercive behavior aimed at asserting control over another individual, often rooted in community and social culture. More than one in three women in the United States have experienced IPV; in New Hampshire, the state where I train, that statistic worsens to one in two. Intimate partner violence is a significant health problem, yet it often evades the health care system. One study found that only 20% of victims of IPV ever seek treatment for injuries, chronic pain or somatic complaints, or sexually transmitted infections that occurred in the setting of an abusive relationship.
The effects of IPV are felt across generations. IPV is known to impact the pathogenesis of small-for-gestational age infants, obesity, and substance use through its multifaceted impact on health behaviors, health access, and hormonal balance, raising the question of how to best address this complex social disorder in a clinical setting. For women of color, like my patient, addressing IPV becomes further complicated by cultural, societal and social ramifications. Not only do we lack data on how IPV impact women of color, particularly those in rural areas like New Hampshire, but even fewer studies exist on how best address IPV for these minority communities.
In medicine, we are quick to discuss the lapses in medical care for complex sociocultural disorders like IPV by examining the issues in our current system. High clinical flow, procedure-focused reimbursement, and little training on the social determinants of health impede our ability to understand IPV as thoroughly as we understand pre-eclampsia or other physiological diseases. Providers, specifically OB/GYN residents, were found to be uncomfortable with using screening tools and asking intensely personal questions. For women of color, these systemic issues often combine with known structural racism and unconscious bias to further delay or prevent appropriate screening, discussion on options, and time to provide medical care.
While the system is flawed, it is a thin layer covering the deeper issue of the lack of diversity in our approach to treating and supporting women of color facing IPV. Many of the available solutions, such as shelters, acute access to hotlines and support staff, and legal action, focus on getting resources for a single person, and to “get them out” of a dangerous situation. Rarely do our solutions think of the context for why someone hesitates to leave. Magnussen et al. describes that homogenized solutions are not enough for a diverse community of women who are survivors of IPV, with “differences in cultural perspectives [leading to] barriers that prevent women from receiving effective care.” To develop diverse, culturally sensitive solutions, we need to start with the women who survive IPV and the stories they are willing to share.
After college, I spent a year traveling from one small village to another, exploring the connection between traditional dances and healing systems for women. I often found myself surrounded by women in tiny kitchens, where, after a few hours of work, stories were unleashed. There were women who talked about intimate partner violence of friends, or themselves, discussing the stark realities of leaving. It was not simple, and with children involved and the associated socioeconomic implications such as loss of income and ability to acquire a job, the women would click their tongues and shake their heads at the idea of walking away. Nothing would be worse than losing the respect of their society — their world — and being ostracized in a way that would truly impact their ability to survive.
Much like the web of intergenerational pathologies woven by IPV, it became evident that another web existed in which IPV was nestled among economic pressures, societal expectations, culture and religion. What struck me most in these kitchen discussions was the value they placed on both protecting and navigating the collective — the community and culture — in dealing with IPV, incorporating factors such as impact on children, societal reactions, and family protection into their decision.
In her TEDtalk Radical Women, Embracing Tradition, Kavita Ramdas of the Global Fund for Women touches upon the definitions of freedom and choice in such cultural spaces. She shares a story of Sakena, a feminist and activist, who explained how her religion in fact gave her the freedom to change the system for women. Like Sakena, the women chatting in the kitchen were smart, sarcastic and immensely proud. Like Sakena, they had a better grip on the reality surrounding them, what they could do to address IPV in their own homes, and how to maintain dignity while choosing freedom. Culture was not a barrier. It was their way of life, respected as highly as women respect their way of existing in Western cultures, with awareness of its flaws but celebration of its beauty. One woman shared that she would escape to her sister’s home to stay for medical care and support until she felt enough time had passed before returning home. Another shared how she would invite her husband’s friends over for a party whenever she sensed he was tending towards another “episode.” They acknowledged these were not ideal answers, but they remained clear in their reasoning — their vision was to protect their future and their families in their society.
As much as I wished I could give them permanent solutions, I knew that a part of my job was to support the patient’s — the woman’s — choice. Their solutions protected what they valued. To act against their wishes would be a violation of their freedom — ironically oppressing to “save” the oppressed. Kavita Ramdas ended her talk stating “As I smile and nod, [I realize that] I’m watching women and girls using their own religious traditions and practices, turning them into instruments of opposition and opportunity.” Could medical care for IPV be shaped by the patients of color and the futures they envision for themselves?
Too often in medicine, we standardize and formalize socially complex ideas to fit into a clinical encounter. Many of our solutions are based on Western notions of empowerment, and while this model may work for managing physiologic disease in our system, it is often inadequate for the social problems, like IPV, that reach far beyond the clinical realm. From the screening tools used to determine victims of IPV to the community health centers and shelters available for support, there is limited inclusion of cultural awareness and diversity. Worst of all, in case examples that attempt to teach cultural competency, stereotypes are implemented, leaving the nuances of individuals out of the purview of providers. Our solutions need to expand, from including behavioral or somatic cues for screening for IPV to addressing the reasons why women make certain choices. Is it social? Is it cultural? Is it economic? Can our solutions address these complex issues?
Addressing IPV requires intersectional awareness, long-term community engagement, and time to allow inherent empowerment to occur. The transformation of our current system into one able to address the intersection of sociocultural realities and clinical outcomes — destigmatizing and empowering survivors of IPV — is the future that I envision. Perhaps then, we can develop solutions that can build a violence-free future with better health outcomes for generations of mothers and babies to come. This process can begin as it did in the kitchens, with the radical and simple act of listening.
The nurse and I discussed what we could possibly do for our patient. Her partner stepped out for a moment to take a call and we sprang into action. We reentered the room and asked the patient what she needed. She requested discreet contraception. After discussing options, we agreed on and administered intradermal medroxyprogesterone. It was a powerful decision — a choice she made awaiting a future in which she makes many more, on her own terms.
Fellow Physician Contributing Writer
The University of North Carolina
Shilpa is a General Research Fellow in Obstetrics and Gynecology at the University of North Carolina and Creative Director of the Aseemkala Initiative, an organization that creates choreographies and conducts research on traditional arts to address health equity for women of color. Shilpa trained in Kuchipudi at the Academy of Kuchipudi Dance in Atlanta and at the Kalanidhi Dance school in Bethesda, MD. Shilpa served as AMWA National Artist-in-Residence in 2016, studied traditional dance as women’s medicine as a Thomas Watson Fellow in 2013, and studied art as a vehicle to teach cervical cancer awareness as a ASTMH Kean Fellow in 2018. She continues to perform medical narratives, conduct research, and run workshops exploring cultural humility and justice in healthcare through her work with the Aseemkala Initiative.