Tuesday, February 10, 2015

Vulnerable Populations – Violence Against Others

FLASHBACK SERIES: Blog posts written during my medical school days at Pacific Northwest University - College of Osteopathic Medicine

by Kim Ha Wadsworth, OMS I

Interpersonal violence occurs when an individual inflicts violence and coercive behavior—including economic control, isolation, and physical, emotional or sexual threats / actions—to gain power and control over another person. National statistics indicate that trauma accounts for 25% of health care visits by homeless patients, with 50% of this population having mental illness.1 Likewise, people with developmental disabilities have a lifetime sexual assault victim rate of 68% - 83% and a 4 - 10X increased risk of becoming a crime victim.2 In addition to abuse by family members or intimate partners, people with disabilities are at risk for abuse by attendants or health care providers. It is important to recognize that the survivor of the abuse is never to blame.

There are several common factors that cause a higher incidence of interpersonal violence in vulnerable populations, especially people with developmental disabilities or who are homeless and/or impoverished. [Note that victims of human trafficking and domestic violence often face homelessness.] Economic and/or emotional dependence, lack of self-advocacy skills, and unsafe living conditions are notable factors that contribute to this issue.

First of all, money is the biggest barrier for these marginalized individuals who are unemployed or earn below-living wage due to their developmental or other disability, education deficit, chemical dependency, trauma, among other causes. Some people with disabilities depend on caregivers for essential personal services. This can create a barrier to terminating an abusive situation. Similarly, victims of domestic violence and human trafficking are often financially dependent, believing that they have no place to go; when they do leave, they become homeless and often return to the abusive situation again and again. Inability to pay for services and access appropriate resources make it even more likely that trauma will continue. Those with intellectual disabilities may have additional confusion over how to access services as well as an inability to understand what is happening in abusive situations. Moreover, services within a community may be fragmented, hard-to-access (cultural barriers, societal discrimination, lack of transportation), or nonexistent.

Another characteristic of vulnerable populations is their lack of self-advocacy skills. The lack of access to social and medical services compounds this problem. These marginalized groups mistrust ‘authority’ figures, exhibit low self-esteem, and believe they do not have any choice. Oftentimes, victims blame themselves for the sexual assault and other interpersonal violence. They do not reach out for help, when all they experience is prejudice, discrimination and bigotry. Developmentally disabled individuals, in particular, have limited expressive and receptive language skills, thus relying on a third party—parent, guardian, or direct care provider—to communicate their needs.

Poor living conditions that are unhealthy and dangerous further prevent safety, privacy and healing from interpersonal violence in vulnerable populations. Drug-related violence and crime are prevalent in the poorest neighborhoods. Homeless individuals experience sexual assault and report being shot or hit at higher rates than the general population. Women are particularly vulnerable to multiple forms of interpersonal violence at the hands of strangers, acquaintances, pimps, sex traffickers, and intimate partners on the street, in shelters, or in precarious housing situations (“couch-surfing” – hidden homelessness). Emergency shelters and transitional housing in most cities are overcrowded—or nonexistent in rural areas—leaving many homeless without safe and sanitary alternatives.

However, it is difficult sometimes to determine cause and effect. To what extent does the experience of interpersonal violence contribute to homelessness, mental health issues, substance use disorders, or other issues? Do these issues make a person more vulnerable to interpersonal violence? Studies have documented the effects of early sexual abuse on later sexual victimization among female homeless and runaway youth. Most studies have found higher rates of family violence among homeless than among other poor families. Domestic and sexual violence can push victims into a cycle of poverty.

Regardless of the cause and effect, as a future physician, I will strive to protect these vulnerable populations from interpersonal violence in several ways:

1. Recognize, identify, and reach out to victims.
  • Recognize the red flags of abuse, observe body language, and never forget the importance of the history and physical exam.
  • Baseline, baseline, baseline.
  • Maintain communication and develop trust with patients.
  • Ask non-judgmental, non-blaming questions.
2. Know community resources to refer early.
  • Connect patients to advocates to support their safety, autonomy and justice.
  • Cooperate with other providers from a variety of disciplines in order to address the multiple, intersecting issues involved.
3. Identify the barriers to safety and keep the patient safe if there are signs of danger.

4. Provide OPTIONS to the patient (they are in control of their own decisions).

5. Increase self-esteem and self-awareness in patients.

6. Offer a message of hope to victims and help them feel connected.

7. Remind victims, “This is NOT your fault.”


1 Hepner, E. (2015, January). Poverty and Homelessness. Community DOctoring CLIN-506. Lecture conducted from Pacific Northwest University of Health Sciences, Yakima, WA.
2 Fiedler, T. (2015, February). Introduction to Intellectual Disabilities. Community DOctoring CLIN-506. Lecture conducted from Pacific Northwest University of Health Sciences, Yakima, WA.