BREAKOUT SESSION
The Intersecting Roles of Violence, Gender, and Substance Use in the Emergency Department: A Research Agenda Esther K. Choo, MD, MPH, Madeline Benz, Megan Rybarczyk, MD, Kerry Broderick, MD, Judith Linden, MD, Edwin D. Boudreaux, PhD, and Megan L. Ranney, MD, MPH
Abstract The relationship between gender, violence, and substance use in the emergency department (ED) is complex. This article examines the role of gender in the intersection of substance use and three types of violence: peer violence, intimate partner violence, and firearm violence. Current approaches to treatment of substance abuse and violence are similar across both genders; however, as patterns of violence and substance abuse differ by gender, interventions may be more effective if they are designed with a specific gender focus. ACADEMIC EMERGENCY MEDICINE 2014;21:1447–1452 © 2014 by the Society for Academic Emergency Medicine
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he relationship between violence and substance use is influenced by gender. Men and women are differentially involved in types of violence, manifest different relationships between substance use and violence involvement, and face different challenges in seeking and receiving assistance for these problems.1–5 Identifying violence and substance use in the ED and providing appropriate interventions and referrals, therefore, may benefit from a gender-tailored approach. Given the complexity of the relationships between gender, substance use, and violence, this breakout session decided to dedicate a separate discussion and set of research questions specifically examining these interre-
lated topics, rather than integrating them with the other substance use and gender article.6 CONSENSUS PROCESS Through a consensus process, the authors sought to identify research questions that could improve our current knowledge of gender differences in violence and substance use relevant to the ED setting, focusing on the questions with highest potential to improve emergency care. As described in the executive summary,7 we used a modified nominal group technique to identify the highest priority questions in this area. After initial
From the Department of Emergency Medicine, Warren Alpert Medical School of Brown University (EKC, MLR), Providence, RI; the Department of Emergency Medicine, Boston University School of Medicine (MR, JL), Boston, MA; the Department of Emergency Medicine, Denver Health, University of Colorado School of Medicine (KB), Denver, CO; the Department of Emergency Medicine, University of Massachusetts Medical School (EDB), Worcester, MA; and Brown University School of Public Health (MB), Providence, RI. Received June 23, 2014; revision received September 10, 2014; accepted September 10, 2014. Substance abuse breakout group participants: Fuad Abujarad, Gavin Barr, Helen Barr, Gillian Beauchamp, Francesca Beaudoin, Steven L. Bernstein, Edwin D. Boudreaux, Kerry Broderick, Robert Cannon, Esther Choo, Gail D’Onofrio, Fiona Gallahue, Marna Greenberg, Kathryn Hawk, Gabrielle A. Jacquet, Bryan Kane, Anita Kurt, Judith Linden, Melanie Lippmann, Natalie Locci, Elizabeth Nestor, Jonathan Purtle, Megan L. Ranney, Karin V. Rhodes, Tyler Robin, Shaheen Shamji, Danica Stone, Susan Watts, Kevin Weaver, and Jessica Weiland. The consensus conference was supported by grant 1R13NS087861-01 from the National Institute of Neurological Disorders and Stroke and the Office of Research on Women’s Health at the National Institutes of Health. Additional funding was provided by several organizational, institutional, and individual donors. Non-CME events were supported by Janssen Pharmaceuticals and Besins Critical Care/BH Pharma. See the executive summary elsewhere in this issue for full funding information. The authors have no potential conflicts to disclose. Supervising Editor: James Miner, MD. Address for correspondence and reprints: Esther K. Choo, MD, MPH; e-mail: [email protected]. On November 25, 2014, after this article was published, the sixth author, Edwin L. Boudreaux, middle initial was change to “D.”
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12525
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development of a broad range of possible research questions, we refined and narrowed the list iteratively through discussion by the breakout group, online polling of conference participants before the event, in-person discussion on the day of the consensus conference, and online polling of conference participants after the event. This last step departs from the procedure for the gender and substance use disorders article, as there was not sufficient time for participants to vote for the violence subset in person.6 The final voting was on a scale of 1 (low priority), 2 (moderate priority), or 3 (high priority), and all questions with average scores greater than 2 were included. PEER VIOLENCE Peer violence, defined as violence between people who are not dating partners or family members, is more common among men than women. In 2012, an estimated 1,126,603 men were seen in U.S. emergency departments (EDs) for injuries from peer violence, compared to 695,305 women.8,9 Peer violence is the second leading cause of death for Americans aged 15 to 25 years,10–12 and the leading cause of death for black males aged 15 to 25 years.10,12 While these statistics suggest a gender difference in prevalence, it should be noted that accurate estimates for peer violence may be confounded by a number of gender-specific barriers to detection. Women may be proportionately more likely than men to seek medical attention for their peer violence-related injuries.13 On the other hand, of individuals who seek medical attention, men may be more likely than women to discuss the violence with their providers.14 Both male and female assault-injured youth make repeated visits to the ED for physical and mental health problems, suggesting that these visits may be an opportune time to intervene on these risky health behaviors and address related health outcomes.10 Substance use is strongly associated with peer violence for both males and females across the age spectrum.14–16 Harmful drinking (defined as drinking beyond the National Institute on Alcohol Abuse and Alcoholism–recommended gender-specific low-risk guidelines) increases the occurrence of intentional injuries,17 which seems especially true for injury from fights or assault in males.18 Although men more frequently drink alcohol and more often report heavy, episodic drinking before violent injuries,13 women who do drink heavily have a dramatically increased risk for violent injury—as much as five times greater—compared to women who do not.19 One U.S. study in particular found that heavy episodic drinking predicted violent injury only in women, not in men.13 Gender differences in substance use and violence involvement are theorized to be due to differences in aggression and social expectancies. Among men, alcohol use is often associated with perpetration of violence in pursuit of profit-based goals and social dominance and as a response to perceived threat.1 For men, externalization of negative emotions, as well as excessive alcohol use, is more socially acceptable; therefore, men may be more likely to use alcohol to disinhibit the expression of aggression.2,20 Conversely, many cultures
encourage females to internalize their emotions and to drink in moderation; together, this may make men more likely than women to demonstrate alcohol use leading to violence and to report alcohol use as a coping mechanism for negative emotions.20 What these differences mean for ED-based interventions for alcohol use is uncertain. For some men, involvement in violence following alcohol use may not be a motivator of change, as alcohol use is viewed positively among those with underlying dispositional aggression or aggression-related alcohol expectancies.21–23 There is some evidence that violence involvement and gender may alter the effectiveness of brief ED interventions for alcohol among men.18 For instance, one study in adults revealed that a brief alcohol intervention in the ED showed a positive effect in men without violence involvement, but not in women or men with violence involvement.18 The role of drug use among men and women involved in peer violence is less well defined.24 The heterogeneity of drug types and variable combination with alcohol confounds the relationship between drug use and violence and makes examining this relationship difficult. Many studies examine injury in general and are not powered to detect differences between sexes for drug subtypes and violence outcomes. Among youth, assault-injured patients in the ED are more likely to report substance use or misuse before a fight, compared to those without violence-related complaints.10 These associations persist after adjusting for a broad range of potential confounders.16,25 The majority of these studies, however, are based on self-administered questionnaires and self-reporting, most likely resulting in a bias that underestimates the association between substance use and youth violence. Gender does not appear to influence the effect of substance use on violence involvement among youth as starkly as among adults. In a longitudinal study of 1,600 male and female violence-involved teens, Pinchevsky et al.26 found that exposure to violence independently increased the frequency of subsequent alcohol use, binge drinking, and marijuana use among both males and females. The only difference found between males and females was that females who had been victimized tended to engage in binge drinking more frequently than victimized males. Studies based in the ED have described similarities between male and female adolescents presenting with assault-related injury in terms of past-year violent injury, alcohol use, reasons for aggression, and weapon carriage.10,11 Gender may play a role in the level of social support available for preventing future youth peer violence, as well as in the complexity of co-occurring disorders, both factors in outcomes and violence and ED recidivism. In comparison to males, female youth with assault-related injuries are less likely to report living with parents and more likely to report depressive symptoms and past-year dating aggression.27 As described in the consensus conference’s mental health breakout session paper, other risk factors for violence (including posttraumatic stress disorder and other mental health symptoms) may also differentially affect the role of substance abuse in violence.28
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The role of gender in interventions for violence is not well described. In one study, Walton et al.29 compared computer intervention, computer-assisted therapist intervention, and control (brochure only) condition for youth reporting past year aggression and alcohol. The computer program was gender-sensitive in that it allowed participants to choose male or female companion avatars, although the content was not otherwise gender-specific. Only the computer-assisted therapist group reduced peer aggression and peer victimization, but not alcohol-related outcomes. However, the main analysis did not include gender effects. Ultimately, substance use predicts peer violence involvement for both male and females presenting to the ED,9,14 and likely complicates interventions for either problem. There is a paucity of information about the genderspecific influence of substance use on immediate and long-term morbidity and mortality after peer violence. How best to intervene in coexisting problems during an ED visit and effectively address both substance use and coexisting violence also remains unclear. Research Questions for Peer Violence in the ED How does gender modify the relationship between specific substance use and peer violence, as shown by ED use, short-term and long-term morbidity (including mental health), and mortality? How can ED screening be improved to increase reporting of peer violence and substance use in injury-related visits, particularly among women? How can technology be used most effectively in designing interventions for youth and adults involved in peer violence with coexisting alcohol or drug use? What gender-specific content in alcohol and drug use interventions would be most likely to improve the effectiveness of interventions for both peer violence and substance use outcomes?
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GENDER, SUBSTANCE USE, AND INTIMATE PARTNER VIOLENCE Intimate partner violence (IPV) is defined as any pattern of assaultive and/or coercive behaviors perpetrated by someone who was or is in an intimate relationship with the victim.4 In 2005, IPV was the leading cause of serious injury among women between the ages of 15 and 44 years, and one-third to one-half of female homicides were committed by intimate companions.30 The prevalence of IPV is greater among women who present to the ED than in the general population, and alcohol in both female victims and their partners is associated with more severe IPV, including IPV that results in ED visits.18,30,31 Drug and alcohol use have been strongly linked with the perpetration of fatal and nonfatal IPV.32 The relationship between substance use and IPV is bidirectional in women: while substance use places individuals at increased risk of IPV,30 the reverse is also true, with women exposed to IPV being at higher risk for substance abuse.4,33 A wide range of drug use has been associated with IPV,34–36 but the relationship between alcohol use and IPV has been most closely studied.30 A 1996 U.S. Department of Justice report
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discovered that two-thirds of all cases of IPV involved alcohol use, by the victim or perpetrator.30 In a study conducted by Avegno et al.,37 over half of female victims reported substance use during events of IPV. In 2012, La Flair et al.11 showed that past-year IPV was associated with severe and moderate alcohol use. Female victims of partner abuse who misuse alcohol may have poor self-efficacy, may be more socially isolated, and may drink in response to negative (and unaddressed) psychological sequelae of violence.4,38 Studies have also revealed that positive alcohol and drug expectancies among women IPV victims, such as reduced stress or tension with use of these substances, is associated with more severe alcohol problems, posttraumatic stress symptoms, and severity of IPV.4,28 Perpetrator problem drinking is associated with an increase in partner abuse as well as homicide and attempted homicide,30 and as with peer violence, is thought to enable violence among those with aggressive tendencies.20 Among adolescents, past-year dating violence perpetration and victimization were each associated with a more risky drinking style, characterized by more frequent and heavier alcohol use, expectancies that alcohol increases aggressive behavior, drinking to cope with negative feeling, and beliefs that alcohol is disinhibiting and being drunk provides a time out from normal behavior expectations.39 In both sexes, the association between drinking style and dating violence reflects adolescents’ inclination for general problem behaviors.39 Loh et al.40 found that domestic violence victims of both sexes made more visits to the ED than non-victims. However, much of the current literature regarding IPV in the ED remains focused on female victims and male perpetrators. Assumptions that men are the aggressors and women the victims of IPV are not supported by epidemiologic evidence demonstrating that both sexes are involved in, and experience, negative health consequences of various types of violence.41–43 It is likely that male victims are underserved in the ED, as public dialogue often centers around violence against women, and provider education may also focus on screening and interventions for women. While these approaches may be justified, given the higher prevalence and greater severity of health outcomes in women, it is possible that they exacerbate feelings of shame among male victims, making report of abuse and seeking help even more difficult. Partner abuse is also not limited to heterosexual relationships, of course: the existing evidence within samesex relationships supports similar rates of violence. Prevalence estimates of IPV in males having sex with males (MSM) have a broad range, from 12% to 36%.44,45 Some studies have shown rates of IPV are greater in gay men than heterosexual men.44,46 Stevens et al.47 reported that the rates of IPV among heterosexual and lesbian women were no different. How alcohol and drug use intersects with MSM IPV is a large knowledge gap. While the U.S. Preventive Services Task Force recommends routine screening for IPV among reproductive age women in health care settings,48 this is a difficult standard to maintain.49 A broader awareness of the
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importance of screening women presenting with substance use problems, and screening for substance use problems among those who screen positive for IPV, may identify the highest risk patients and those who face significant challenges to addressing either problem.50 Whether IPV screening should be targeted at men with a history of substance use is yet to be determined. The ED visit is a great opportunity to identify and address coexisting IPV and substance use: there are particular barriers for women and men with IPV and drug/alcohol use once they leave the ED. For women with coexisting problems, domestic violence shelters often do not accommodate those with active drug or alcohol problems; substance use programs are often not prepared to address IPV and do not incorporate violence-specific content. For men, domestic violence shelters are scarce, and both ED and community-based counseling services may be primarily focused on women. For men or women with partner abuse, the controlling behaviors of an abusive partner may limit their ability to follow through with referrals to substance use programs and make accessing them potentially dangerous, as the abusive partner may oppose the victim’s attempt to make a positive change.51 It is important for providers to be aware of these barriers so they can offer patients follow-up plans that are relevant, feasible, and safe. Research Questions for IPV In what ways does co-occurring IPV victimization and substance use affect male patients in the ED differently than females? What is the relationship between gender and involvement in IPV and responsiveness to alcohol and drug interventions? What are the barriers faced by men and transgender, gender variant, and intersex patients who are IPV victims and substance users? How should gender-specific screening and intervention strategies for substance use incorporate consideration of IPV to maximize their effectiveness?
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GENDER, SUBSTANCE USE, AND FIREARM VIOLENCE Firearms were responsible for 85% of homicide-related deaths among adolescents in 2010 and for the majority of adult homicide deaths as well, particularly among victims of IPV.10 They are also the leading cause of death by suicide.28,52 Substance use increases the risk of firearm-related injuries and death for both sexes.40 The rate of ED visits for firearm-related injuries is nine times higher for males than for females.53 Male youth report easier access to handguns than females.40 Male firearm usage is heavily influenced by substance use and impulsivity.52 Male gender, binge drinking, drug use, violence involvement, and ED utilization are all independently associated with firearm access. However, firearm use is not entirely a “male” problem: although knives are the most frequently reported weapon of choice among female youth,34 female firearm use is on the rise.12 Firearm possession predicts
violence involvement for both sexes.13,15,34 In a study including adolescent females, Erickson and colleagues found higher rates of gun violence within the group using heavy alcohol.54 Both illicit and prescription drug use have been associated with increased firearm use among males and females.13,55 Interventions to prevent firearm violence are, as yet, poorly defined. Existing literature suggests that substance use, as a critical factor in firearm-related violence, should be addressed to mitigate risk of future injury. Whether gender-specific approaches may be more effective in addressing substance use and future firearm violence is not known. Research Agenda for Firearms Violence How do we incorporate a gender-specific assessment of firearm risk into substance use screening and interventions? Does a gender component increase effectiveness of interventions to increase firearm-related safety behaviors and reduce firearm injury among ED patients with a history of violence and substance use?
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LIMITATIONS Given the breadth and depth of topics included under the substance use breakout session group’s agenda, some important and relevant topics could not be included, for example, the relationship between sexual violence, gender, and substance use. Hopefully, the violence-related gender research agenda outlined here will serve as a starting point for further substance use research that is clinically relevant to the practice of EM. SUMMARY AND CONCLUSIONS Violence and alcohol and substance abuse frequently coexist in patients who present to the ED. Gender affects the experience of violence and the relationship between violence and substance use disorders, associated comorbidities, and barriers to accessing treatments for drug and alcohol use. The most effective way for ED staff to identify and address violence involvement in conjunction with substance use disorders is underexplored. Through a consensus process, we identified priority areas for future emergency medicine research that will enable us to approach violence using a gender-specific approach to optimize the relevance and effectiveness of drug and alcohol screening, brief interventions, and referrals to our patient population. The authors acknowledge Megan Greenberg, Shaheen Shamji, DO, and Jessica Weiland, MD, for their contributions to the breakout session.
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2. Borges G, Cherpitel CJ, Rosovsky H. Male drinking and violence-related injury in the emergency room. Addiction 1998;93:103–12. 3. Miller BA, Wilsnack SC, Cunradi CB. Family violence and victimization: treatment issues for women with alcohol problems. Alcohol Clin Exp Res 2000; 24:1287–97. 4. Peters EN, Khondkaryan E, Sullivan TP. Associations between expectancies of alcohol and drug use, severity of partner violence, and posttraumatic stress among women. J Interpers Violence 2012; 27:2108–27. 5. Stuart GL, Moore TM, Ramsey SE, Kahler CW. Hazardous drinking and relationship violence perpetration and victimization in women arrested for domestic violence. J Stud Alcohol 2004;65:46–53. 6. Choo EK, Beauchamp G, Beaudoin FL, et al. A research agenda for gender and substance use disorders in the emergency department. Acad Emerg Med 2014;21:1438–46. 7. Safdar B, Greenberg MR. Conference on genderspecific research in emergency care: an executive summary. Acad Emerg Med 2014;21:1307–17. 8. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System). Welcome to WISQARS. Available at: http://www.cdc.gov/injury/wisqars/. Accessed Sep 28, 2014. 9. Murray RL, Chermack ST, Walton MA, et al. Characteristics and treatment interests among indviduals with substance use disorders and a past six-month history of violence: findings from an emergency department study. Addict Behav 2014; 39:265–72. 10. Cunningham RM, Ranney M, Newton M, Woodhull W, Zimmerman M, Walton MA. Characteristics of youth seeking emergency care for assault injuries. Pediatrics 2014;133:e96–105. 11. La Flair LN, Bradshaw CP, Storr CL, Green KM, Alvanzo AAH, Crum RM. Intimate partner violence and patterns of alcohol abuse and dependence criteria among women: a latent class analysis. J Stud Alcohol Drugs 2012;73:351–60. 12. Carter PM, Walton MA, Newton MF, et al. Firearm possession among adolescents presenting to an urban emergency department for assault. Pediatrics 2013;132:213–21. 13. Wells S, Thompson JM, Cherpitel C, Macdonald S, Marais S, Borges G. Gender differences in the relationship between alcohol and violent injury: an analysis of cross-national emergency department data. J Stud Alcohol Drugs 2007;68:824–33. 14. Cunningham R, Walton MA, Maio RF, Blow FC, Weber JE, Mirel L. Violence and substance use among an injured emergency department population. Acad Emerg Med 2003;10:764–75. 15. Burke PJ, O’Sullivan J, Vaughan BL. Adolescent substance use: brief interventions by emergency care providers. Pediatr Emerg Care 2005;21:770–6. 16. Rossow I, Pape H, Wichstrøm L. Young, wet & wild? Associations between alcohol intoxication and violent behaviour in adolescence. Addiction 1999; 94:1017–31.
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17. Alderete E, Bianchini P. [Alcohol consumption in the emergency room] (in Spanish). Medicina (B Aires) 2008;68:31–6. 18. Choo EK, McGregor AJ, Mello MJ, Baird J. Gender, violence and brief interventions for alcohol in the emergency department. Drug Alcohol Depend 2013;127:115–21. 19. Schnitzer S, Bellis MA, Anderson Z, et al. Nightlife violence: a gender-specific view on risk factors for violence in nightlife settings: a cross-sectional study in nine European countries. J Interpers Violence 2010;25:1094–112. 20. Cooper ML, Russell M, Skinner JB, Frone MR, Mudar P. Stress and alcohol use: moderating effects of gender, coping, and alcohol expectancies. J Abnorm Psychol 1992;101:139–52. 21. Chermack S, Taylor S. Alcohol and human physical aggression: pharmacological versus expectancy effects. J Stud Alcohol 1995;56:449–56. 22. Giancola PR, Godlaski AJ, Parrott DJ. “So I can’t blame the booze?”: dispositional aggressivity negates the moderating effects of expectancies on alcohol-related aggression. J Stud Alcohol 2005;66:815–24. 23. Zhang L, Welte JW, Wieczorek WW. The role of aggression-related alcohol expectancies in explaining the link between alcohol and violent behavior. Subst Use Misuse 2002;37:457–71. 24. Korcha RA, Cherpitel CJ, Witbrodt J, et al. Violence-related injury and gender: the role of alcohol and alcohol combined with illicit drugs. Drug Alcohol Rev 2014;33:43–50. 25. Shepherd JP, Sutherland I, Newcombe RG. Relations between alcohol, violence and victimization in adolescence. J Adolesc 2006;29:539–53. 26. Pinchevsky GM, Wright EM, Fagan AA. Gender differences in the effects of exposure to violence on adolescent substance use. Violence Vict 2013; 28:122–44. 27. Ranney ML, Whiteside L, Walton MA, Chermack ST, Zimmerman MA, Cunningham RM. Sex differences in characteristics of adolescents presenting to the emergency department with acute assaultrelated injury. Acad Emerg Med 2011;18:1027–35. 28. Ranney ML, Locci N, Adams EJ, et al. Gender-specific research on mental illness in the emergency department: current knowledge and future directions. Acad Emerg Med 2014;21:1395–1402. 29. Walton MA, Chermack ST, Shope JT, et al. Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: a randomized controlled trial. JAMA 2010;304:527–35. 30. Weinsheimer RL, Schermer CR, Malcoe LH, Balduf LM, Bloomfield LA. Severe intimate partner violence and alcohol use among female trauma patients. J Trauma 2005;58:22–9. 31. Gilbert L, El-Bassel N, Chang M, Wu E, Roy L. Substance use and partner violence among urban women seeking emergency care. Psychol Addict Behav 2012;26:226–35. 32. Sharps PW, Campbell J, Campbell D, Gary F, Webster D. The role of alcohol use in intimate partner femicide. Am J Addict 2001;10:122–35.
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The Intersecting Roles of Violence, Gender, and Substance Use in the Emergency Department: A Research Agenda Esther K. Choo, MD, MPH, Madeline Benz, Megan Rybarczyk, MD, Kerry Broderick, MD, Judith Linden, MD, Edwin D. Boudreaux, PhD, and Megan L. Ranney, MD, MPH
Abstract The relationship between gender, violence, and substance use in the emergency department (ED) is complex. This article examines the role of gender in the intersection of substance use and three types of violence: peer violence, intimate partner violence, and firearm violence. Current approaches to treatment of substance abuse and violence are similar across both genders; however, as patterns of violence and substance abuse differ by gender, interventions may be more effective if they are designed with a specific gender focus. ACADEMIC EMERGENCY MEDICINE 2014;21:1447–1452 © 2014 by the Society for Academic Emergency Medicine
T
he relationship between violence and substance use is influenced by gender. Men and women are differentially involved in types of violence, manifest different relationships between substance use and violence involvement, and face different challenges in seeking and receiving assistance for these problems.1–5 Identifying violence and substance use in the ED and providing appropriate interventions and referrals, therefore, may benefit from a gender-tailored approach. Given the complexity of the relationships between gender, substance use, and violence, this breakout session decided to dedicate a separate discussion and set of research questions specifically examining these interre-
lated topics, rather than integrating them with the other substance use and gender article.6 CONSENSUS PROCESS Through a consensus process, the authors sought to identify research questions that could improve our current knowledge of gender differences in violence and substance use relevant to the ED setting, focusing on the questions with highest potential to improve emergency care. As described in the executive summary,7 we used a modified nominal group technique to identify the highest priority questions in this area. After initial
From the Department of Emergency Medicine, Warren Alpert Medical School of Brown University (EKC, MLR), Providence, RI; the Department of Emergency Medicine, Boston University School of Medicine (MR, JL), Boston, MA; the Department of Emergency Medicine, Denver Health, University of Colorado School of Medicine (KB), Denver, CO; the Department of Emergency Medicine, University of Massachusetts Medical School (EDB), Worcester, MA; and Brown University School of Public Health (MB), Providence, RI. Received June 23, 2014; revision received September 10, 2014; accepted September 10, 2014. Substance abuse breakout group participants: Fuad Abujarad, Gavin Barr, Helen Barr, Gillian Beauchamp, Francesca Beaudoin, Steven L. Bernstein, Edwin D. Boudreaux, Kerry Broderick, Robert Cannon, Esther Choo, Gail D’Onofrio, Fiona Gallahue, Marna Greenberg, Kathryn Hawk, Gabrielle A. Jacquet, Bryan Kane, Anita Kurt, Judith Linden, Melanie Lippmann, Natalie Locci, Elizabeth Nestor, Jonathan Purtle, Megan L. Ranney, Karin V. Rhodes, Tyler Robin, Shaheen Shamji, Danica Stone, Susan Watts, Kevin Weaver, and Jessica Weiland. The consensus conference was supported by grant 1R13NS087861-01 from the National Institute of Neurological Disorders and Stroke and the Office of Research on Women’s Health at the National Institutes of Health. Additional funding was provided by several organizational, institutional, and individual donors. Non-CME events were supported by Janssen Pharmaceuticals and Besins Critical Care/BH Pharma. See the executive summary elsewhere in this issue for full funding information. The authors have no potential conflicts to disclose. Supervising Editor: James Miner, MD. Address for correspondence and reprints: Esther K. Choo, MD, MPH; e-mail: [email protected]. On November 25, 2014, after this article was published, the sixth author, Edwin L. Boudreaux, middle initial was change to “D.”
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12525
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development of a broad range of possible research questions, we refined and narrowed the list iteratively through discussion by the breakout group, online polling of conference participants before the event, in-person discussion on the day of the consensus conference, and online polling of conference participants after the event. This last step departs from the procedure for the gender and substance use disorders article, as there was not sufficient time for participants to vote for the violence subset in person.6 The final voting was on a scale of 1 (low priority), 2 (moderate priority), or 3 (high priority), and all questions with average scores greater than 2 were included. PEER VIOLENCE Peer violence, defined as violence between people who are not dating partners or family members, is more common among men than women. In 2012, an estimated 1,126,603 men were seen in U.S. emergency departments (EDs) for injuries from peer violence, compared to 695,305 women.8,9 Peer violence is the second leading cause of death for Americans aged 15 to 25 years,10–12 and the leading cause of death for black males aged 15 to 25 years.10,12 While these statistics suggest a gender difference in prevalence, it should be noted that accurate estimates for peer violence may be confounded by a number of gender-specific barriers to detection. Women may be proportionately more likely than men to seek medical attention for their peer violence-related injuries.13 On the other hand, of individuals who seek medical attention, men may be more likely than women to discuss the violence with their providers.14 Both male and female assault-injured youth make repeated visits to the ED for physical and mental health problems, suggesting that these visits may be an opportune time to intervene on these risky health behaviors and address related health outcomes.10 Substance use is strongly associated with peer violence for both males and females across the age spectrum.14–16 Harmful drinking (defined as drinking beyond the National Institute on Alcohol Abuse and Alcoholism–recommended gender-specific low-risk guidelines) increases the occurrence of intentional injuries,17 which seems especially true for injury from fights or assault in males.18 Although men more frequently drink alcohol and more often report heavy, episodic drinking before violent injuries,13 women who do drink heavily have a dramatically increased risk for violent injury—as much as five times greater—compared to women who do not.19 One U.S. study in particular found that heavy episodic drinking predicted violent injury only in women, not in men.13 Gender differences in substance use and violence involvement are theorized to be due to differences in aggression and social expectancies. Among men, alcohol use is often associated with perpetration of violence in pursuit of profit-based goals and social dominance and as a response to perceived threat.1 For men, externalization of negative emotions, as well as excessive alcohol use, is more socially acceptable; therefore, men may be more likely to use alcohol to disinhibit the expression of aggression.2,20 Conversely, many cultures
encourage females to internalize their emotions and to drink in moderation; together, this may make men more likely than women to demonstrate alcohol use leading to violence and to report alcohol use as a coping mechanism for negative emotions.20 What these differences mean for ED-based interventions for alcohol use is uncertain. For some men, involvement in violence following alcohol use may not be a motivator of change, as alcohol use is viewed positively among those with underlying dispositional aggression or aggression-related alcohol expectancies.21–23 There is some evidence that violence involvement and gender may alter the effectiveness of brief ED interventions for alcohol among men.18 For instance, one study in adults revealed that a brief alcohol intervention in the ED showed a positive effect in men without violence involvement, but not in women or men with violence involvement.18 The role of drug use among men and women involved in peer violence is less well defined.24 The heterogeneity of drug types and variable combination with alcohol confounds the relationship between drug use and violence and makes examining this relationship difficult. Many studies examine injury in general and are not powered to detect differences between sexes for drug subtypes and violence outcomes. Among youth, assault-injured patients in the ED are more likely to report substance use or misuse before a fight, compared to those without violence-related complaints.10 These associations persist after adjusting for a broad range of potential confounders.16,25 The majority of these studies, however, are based on self-administered questionnaires and self-reporting, most likely resulting in a bias that underestimates the association between substance use and youth violence. Gender does not appear to influence the effect of substance use on violence involvement among youth as starkly as among adults. In a longitudinal study of 1,600 male and female violence-involved teens, Pinchevsky et al.26 found that exposure to violence independently increased the frequency of subsequent alcohol use, binge drinking, and marijuana use among both males and females. The only difference found between males and females was that females who had been victimized tended to engage in binge drinking more frequently than victimized males. Studies based in the ED have described similarities between male and female adolescents presenting with assault-related injury in terms of past-year violent injury, alcohol use, reasons for aggression, and weapon carriage.10,11 Gender may play a role in the level of social support available for preventing future youth peer violence, as well as in the complexity of co-occurring disorders, both factors in outcomes and violence and ED recidivism. In comparison to males, female youth with assault-related injuries are less likely to report living with parents and more likely to report depressive symptoms and past-year dating aggression.27 As described in the consensus conference’s mental health breakout session paper, other risk factors for violence (including posttraumatic stress disorder and other mental health symptoms) may also differentially affect the role of substance abuse in violence.28
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The role of gender in interventions for violence is not well described. In one study, Walton et al.29 compared computer intervention, computer-assisted therapist intervention, and control (brochure only) condition for youth reporting past year aggression and alcohol. The computer program was gender-sensitive in that it allowed participants to choose male or female companion avatars, although the content was not otherwise gender-specific. Only the computer-assisted therapist group reduced peer aggression and peer victimization, but not alcohol-related outcomes. However, the main analysis did not include gender effects. Ultimately, substance use predicts peer violence involvement for both male and females presenting to the ED,9,14 and likely complicates interventions for either problem. There is a paucity of information about the genderspecific influence of substance use on immediate and long-term morbidity and mortality after peer violence. How best to intervene in coexisting problems during an ED visit and effectively address both substance use and coexisting violence also remains unclear. Research Questions for Peer Violence in the ED How does gender modify the relationship between specific substance use and peer violence, as shown by ED use, short-term and long-term morbidity (including mental health), and mortality? How can ED screening be improved to increase reporting of peer violence and substance use in injury-related visits, particularly among women? How can technology be used most effectively in designing interventions for youth and adults involved in peer violence with coexisting alcohol or drug use? What gender-specific content in alcohol and drug use interventions would be most likely to improve the effectiveness of interventions for both peer violence and substance use outcomes?
• • • •
GENDER, SUBSTANCE USE, AND INTIMATE PARTNER VIOLENCE Intimate partner violence (IPV) is defined as any pattern of assaultive and/or coercive behaviors perpetrated by someone who was or is in an intimate relationship with the victim.4 In 2005, IPV was the leading cause of serious injury among women between the ages of 15 and 44 years, and one-third to one-half of female homicides were committed by intimate companions.30 The prevalence of IPV is greater among women who present to the ED than in the general population, and alcohol in both female victims and their partners is associated with more severe IPV, including IPV that results in ED visits.18,30,31 Drug and alcohol use have been strongly linked with the perpetration of fatal and nonfatal IPV.32 The relationship between substance use and IPV is bidirectional in women: while substance use places individuals at increased risk of IPV,30 the reverse is also true, with women exposed to IPV being at higher risk for substance abuse.4,33 A wide range of drug use has been associated with IPV,34–36 but the relationship between alcohol use and IPV has been most closely studied.30 A 1996 U.S. Department of Justice report
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discovered that two-thirds of all cases of IPV involved alcohol use, by the victim or perpetrator.30 In a study conducted by Avegno et al.,37 over half of female victims reported substance use during events of IPV. In 2012, La Flair et al.11 showed that past-year IPV was associated with severe and moderate alcohol use. Female victims of partner abuse who misuse alcohol may have poor self-efficacy, may be more socially isolated, and may drink in response to negative (and unaddressed) psychological sequelae of violence.4,38 Studies have also revealed that positive alcohol and drug expectancies among women IPV victims, such as reduced stress or tension with use of these substances, is associated with more severe alcohol problems, posttraumatic stress symptoms, and severity of IPV.4,28 Perpetrator problem drinking is associated with an increase in partner abuse as well as homicide and attempted homicide,30 and as with peer violence, is thought to enable violence among those with aggressive tendencies.20 Among adolescents, past-year dating violence perpetration and victimization were each associated with a more risky drinking style, characterized by more frequent and heavier alcohol use, expectancies that alcohol increases aggressive behavior, drinking to cope with negative feeling, and beliefs that alcohol is disinhibiting and being drunk provides a time out from normal behavior expectations.39 In both sexes, the association between drinking style and dating violence reflects adolescents’ inclination for general problem behaviors.39 Loh et al.40 found that domestic violence victims of both sexes made more visits to the ED than non-victims. However, much of the current literature regarding IPV in the ED remains focused on female victims and male perpetrators. Assumptions that men are the aggressors and women the victims of IPV are not supported by epidemiologic evidence demonstrating that both sexes are involved in, and experience, negative health consequences of various types of violence.41–43 It is likely that male victims are underserved in the ED, as public dialogue often centers around violence against women, and provider education may also focus on screening and interventions for women. While these approaches may be justified, given the higher prevalence and greater severity of health outcomes in women, it is possible that they exacerbate feelings of shame among male victims, making report of abuse and seeking help even more difficult. Partner abuse is also not limited to heterosexual relationships, of course: the existing evidence within samesex relationships supports similar rates of violence. Prevalence estimates of IPV in males having sex with males (MSM) have a broad range, from 12% to 36%.44,45 Some studies have shown rates of IPV are greater in gay men than heterosexual men.44,46 Stevens et al.47 reported that the rates of IPV among heterosexual and lesbian women were no different. How alcohol and drug use intersects with MSM IPV is a large knowledge gap. While the U.S. Preventive Services Task Force recommends routine screening for IPV among reproductive age women in health care settings,48 this is a difficult standard to maintain.49 A broader awareness of the
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importance of screening women presenting with substance use problems, and screening for substance use problems among those who screen positive for IPV, may identify the highest risk patients and those who face significant challenges to addressing either problem.50 Whether IPV screening should be targeted at men with a history of substance use is yet to be determined. The ED visit is a great opportunity to identify and address coexisting IPV and substance use: there are particular barriers for women and men with IPV and drug/alcohol use once they leave the ED. For women with coexisting problems, domestic violence shelters often do not accommodate those with active drug or alcohol problems; substance use programs are often not prepared to address IPV and do not incorporate violence-specific content. For men, domestic violence shelters are scarce, and both ED and community-based counseling services may be primarily focused on women. For men or women with partner abuse, the controlling behaviors of an abusive partner may limit their ability to follow through with referrals to substance use programs and make accessing them potentially dangerous, as the abusive partner may oppose the victim’s attempt to make a positive change.51 It is important for providers to be aware of these barriers so they can offer patients follow-up plans that are relevant, feasible, and safe. Research Questions for IPV In what ways does co-occurring IPV victimization and substance use affect male patients in the ED differently than females? What is the relationship between gender and involvement in IPV and responsiveness to alcohol and drug interventions? What are the barriers faced by men and transgender, gender variant, and intersex patients who are IPV victims and substance users? How should gender-specific screening and intervention strategies for substance use incorporate consideration of IPV to maximize their effectiveness?
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GENDER, SUBSTANCE USE, AND FIREARM VIOLENCE Firearms were responsible for 85% of homicide-related deaths among adolescents in 2010 and for the majority of adult homicide deaths as well, particularly among victims of IPV.10 They are also the leading cause of death by suicide.28,52 Substance use increases the risk of firearm-related injuries and death for both sexes.40 The rate of ED visits for firearm-related injuries is nine times higher for males than for females.53 Male youth report easier access to handguns than females.40 Male firearm usage is heavily influenced by substance use and impulsivity.52 Male gender, binge drinking, drug use, violence involvement, and ED utilization are all independently associated with firearm access. However, firearm use is not entirely a “male” problem: although knives are the most frequently reported weapon of choice among female youth,34 female firearm use is on the rise.12 Firearm possession predicts
violence involvement for both sexes.13,15,34 In a study including adolescent females, Erickson and colleagues found higher rates of gun violence within the group using heavy alcohol.54 Both illicit and prescription drug use have been associated with increased firearm use among males and females.13,55 Interventions to prevent firearm violence are, as yet, poorly defined. Existing literature suggests that substance use, as a critical factor in firearm-related violence, should be addressed to mitigate risk of future injury. Whether gender-specific approaches may be more effective in addressing substance use and future firearm violence is not known. Research Agenda for Firearms Violence How do we incorporate a gender-specific assessment of firearm risk into substance use screening and interventions? Does a gender component increase effectiveness of interventions to increase firearm-related safety behaviors and reduce firearm injury among ED patients with a history of violence and substance use?
• •
LIMITATIONS Given the breadth and depth of topics included under the substance use breakout session group’s agenda, some important and relevant topics could not be included, for example, the relationship between sexual violence, gender, and substance use. Hopefully, the violence-related gender research agenda outlined here will serve as a starting point for further substance use research that is clinically relevant to the practice of EM. SUMMARY AND CONCLUSIONS Violence and alcohol and substance abuse frequently coexist in patients who present to the ED. Gender affects the experience of violence and the relationship between violence and substance use disorders, associated comorbidities, and barriers to accessing treatments for drug and alcohol use. The most effective way for ED staff to identify and address violence involvement in conjunction with substance use disorders is underexplored. Through a consensus process, we identified priority areas for future emergency medicine research that will enable us to approach violence using a gender-specific approach to optimize the relevance and effectiveness of drug and alcohol screening, brief interventions, and referrals to our patient population. The authors acknowledge Megan Greenberg, Shaheen Shamji, DO, and Jessica Weiland, MD, for their contributions to the breakout session.
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