Spousal abuse: The ‘silent illness’ driving women into homelessness

NEW YORK — There were little red flags that could have prevented Nina Sucre from spending New Year’s Eve in a New York City homeless shelter — an initial stay that was followed by months of 2014 spent in sleeping in trains, churches and a 24-hour McDonald’s.

A cut on the side of her middle finger (from being struck with a machete), bruises on her inner thighs and a burst eardrum were all warning signs that something wasn’t right, Sucre, a 41-year-old mother of two, later explained at a health care clinic for homeless and low-income families in the Bronx. Despite the signs of violence, not one medical practitioner inquired sufficiently into her domestic life to uncover the 15 years of spousal abuse she endured.

If one had, Sucre’s physical and mental abuse at the hands of her husband may have been picked up, and help could have been arranged.

Instead, it went unchecked and led to a spiral of events that ended with Sucre’s diagnosis of post-traumatic stress disorder and depression in January of last year by Debbian Fletcher-Blake, a nurse and the assistant executive director of Care for the Homeless, a nonprofit network that provides medical care at 25 clinics in New York.

“I never would have known Nina was in an abusive relationship had I not asked her, screened her,” Fletcher-Blake said. “Some women are crying out for help, and we don’t see it.”

Domestic violence is the leading cause of homelessness for women, according to John Lozier, the executive director at the National Health Care for the Homeless Council (NHCHC).

That link is nothing new. A study of 220 homeless families in sheltered accommodation that was published in The American Journal of Public Health in 1997 found that two-thirds of mothers have a history of domestic violence.

Yet medical practitioners don’t routinely screen for the abuse and aren’t trained to act on the symptoms, missing opportunities to rehabilitate women and help them stave off homelessness.

The NHCHC said it has seen the number of women seeking treatment for injuries or mental trauma related to domestic violence spike in recent years. “It’s a really important issue. It’s one that clinicians in the field recognize and understand that they are not yet terribly well equipped to deal with,” Lozier said.

The U.S. Preventive Services Task Force, an independent panel of experts, recommends screening all women of childbearing age for intimate partner violence across health specialties, but fewer than half of primary care clinicians — up to 41 percent, according to one study — reported routinely screening for abuse.

Since 2008, more women became homeless than men — 59,000 compared with 45,000 — and homeless female patient visits to federally funded clinics increased by nearly one-fifth, compared with just 11 percent for male patients, according to NHCHC statistics of homeless patients seen at health centers.

A U.S. economy reliant on low-wage workers, who are disproportionately female single mothers, is partly to blame for families’ vulnerability, Lozier said. Women, according to the National Women’s Law Center, make up two-thirds of the nearly 20 million low-wage workers.

This prevalence of insecure, low-wage work puts women at greater risk of having no place to stay if they are pushed out of their homes by domestic violence and left with the care of their children, he said.

Sucre’s experience backs up that assessment. “I knew when I left him I would have no support for the kids,” she said, “which I don’t have, up until now.”

After losing her job at a fast-food restaurant in Inglewood, Florida, Sucre tried to make ends meet by finding to a cheaper apartment and sending the kids to live with her sister. She moved to New York with a new partner to find work when imminent eviction threatened to force her out of her home. But rent in the city proved so expensive that she soon found herself homeless — sleeping first in a city shelter, then on the streets.

She eventually found a job at a supermarket in mid-2014, after which she was able to secure an apartment in the Bronx, where she currently lives with her family. “It’s good. I feel OK. I’m fine right now. I don’t have that stress of life plus that [abuse], because that is a very stressful feeling.”

Sucre’s abuse at the hands of her first husband went undetected for years. But women’s health experts said they hope that by providing training, improving compliance with official recommendations and connecting physicians with resources for survivors, the medical community might be able to deliver speedier help and protection to others.

There are various ways to conduct screenings; the American College of Obstetricians and Gynecologists (ACOG) recommends making a general statement about domestic violence and its prevalence while making it clear that support is available to anyone who requests it. They suggest this should be followed by three questions into a patient’s physical and sexual abuse history at every routine checkup and at least once per trimester during pregnancy:

Within the past year — or since you have been pregnant — have you been hit, slapped, kicked or otherwise physically hurt by someone?

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

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

While experts disagree on how best to intervene after a case of abuse is brought to their attention, the Preventive Services Task Force found that screening for intimate partner violence has moderate to substantial health benefits.

Research, however, indicates that screening levels across health care specialties is relatively low, with just 6 percent of clinicians always screening patients for domestic violence and 10 percent stating that they have never done so, according to a 2013 policy brief from the U.S. Department of Health and Human Services.

Sucre saw a doctor for medical checkups and issues such as urinary tract infections during her first marriage, she said, but a doctor never initiated a conversation that could have brought the violence to light.

“It never really came up to it, to be honest — not even when I was pregnant,” she said.

The ACOG has identified various obstacles to adequately screening women for domestic abuse, including “gaps in provider knowledge, clinical time constraints, confidentiality concerns and challenges and uncertainty regarding appropriate interventions once IPV [intimate partner violence] exposure is identified.”

To bridge those gaps, the ACOG has partnered with the Maryland Department of Health and Johns Hopkins University to train OB-GYN residents how to screen for domestic violence and identify available community resources, according to an emailed statement.

Fletcher-Blake said that practitioners have only recently started to address their fears to inquire into what is often described as an uncomfortable issue.

“Historically, intimate partner violence has been a silent illness,” Fletcher-Blake said. “Simply because, one, we didn’t know what to do with women and, two, we weren’t trained to screen for it.”

“People are afraid to talk about it,” she added. 

Of course, simply asking the question isn’t enough, experts say. Increasing awareness among women about available options and creating a trusted environment where they feel able to disclose incidents of spousal abuse are equally necessary to end the taboo.

“We have to provide education in such a sensitive way so that women understand that when they disclose [intimate partner violence] we’re not going to judge them,” Fletcher-Blake said. “We’re going to help them, but the decision is theirs on what action they want to take.”

Tanisha Dinkens, a resident of a Bronx family shelter, said she didn’t tell her doctor about the violence she suffered in her relationship, fearing her doctor would look down on her. Despite regular inquiries at semiannual checkups about bruises and cuts that scarred her arms, she “made up stuff” to avoid the embarrassment of appearing weak, she said.

“I felt uncomfortable with the woman doctor because I felt like she was going to judge me,” Dinkens said. “Does she think that I’m less of a woman than her because I choose to stay and get abused?”

According to health practitioners, cases like hers reveal a complex culture of silence that prevents patients from accessing the care they need before becoming homeless and possibly suffering additional traumas.

Homeless mothers are three times as likely to suffer from PTSD as women in the general population, according to a report by the National Center on Family Homelessness, a national research association.

“By not asking, it’s not going to go away. Silence is not going to take it away,” Fletcher-Blake said. “It’s a society problem. It’s not a women’s problem.”